Cardiac Surgery Flashcards
Go back to the CAD PP
Review!!!!!
medical procedure used to diagnose and treat certain heart conditions
Cardiac catheterization
If you are accessing a VEIN, where in the heart will it en up in?
Right side of the heart.
Right Atrium/Right ventricle
If you’re accessing an ARTERY, where in the heart will end up in?
LEFT side of the heart
In the cath lab, are patients awake?
- Not fully awake, but in a consicious sedation.
- Pt will be proteting their airway
What meds are used for these conscious sedations?
Benzos, opioids (Versed)
3 Timeframes for coronary tx (PCI)
- Emergent
- Urgent
- Scheduled
For patients with confirmed MI who are in crisis, what is the FIRST line of tx?
Emergent PCI (percutaneous coronary intervention)
* Straight to CATH LAB
* minimall invasive procedure
* heart treatment to open blocked blood vessels.
* Prof will refer these as CARDIAC CATHS in tests
Goal (time frame) to open blocked artery once pt arrives in facility
90 mins
True clot busters
Thrombolytics
f
- Requires prompt intervention (within 12-72 hours)
but may allow for time to optimize patient condition before going to cath lab (NSTEMI, Unstable Angina)
Urgent PCI
Outpatient or inpatient procedure (Positive
stress test, unexplained chest pain)
Scheduled PCI
Urgent PCI Preparation
- started on Heparin gtt: prevent further clots
- Nitroglycerin gtt: alleviate chest pain- check BP before!!!!!
- IV fluids (Before and/or after procedure)
-Prepare/flush kidneys from contrast - Hold Metformin for DM pts- 48 hrs before & after (oral diabetic med) **
-interacts with IV contrast - NPO after midnight
PCI PRE-Procedure Nurse duties
List 8
- 2 IV lines - pts at risk to deteriorate
- Mark peripheral pulses/establish baseline
-ALL OF THEM - Prep groin/wrist sites
- Continuous Telemetry
- Consents - Drs responsibility
- Foley catheter- ONLY if needed
- Heparin/Nitro drips , Aspirin
- TALK TO THE PATIENT AND FAMILY MEMBERS!! **
- Post expectations: laying FLAT for 6hrs, report bleeding , pain
POST-PCI Nursing Care
-
Keep affected limb straight/Flat-several hrs
-prevent damage/bleeding - Maintain bedrest or activity level per physician orders
- HOB needs to be elevated no more than 10 degrees (femoral approach)
- Check peripheral pulses, catheter insertion site, color and sensation of affected extremity per orders (ie. Q15 x4, Q30x2, Q1HR x 4) (Neurovascular checks 6 Ps - KNOW! **
- Frequently observe puncture site for hematoma, bleeding
- Monitor VS and EKG
-
Closely monitor for chest pain- make sure no re-blockage, monitor CLOSELY**
-(normal/”expected” discomfort vs. reperfusion vs. tamponade/STEMI)
6P’s will be checked on what extremitis after a PCI?
ONLY on the extremity where th sheath was inserted!
What are the 6 P’s?
(review)
What if your 6 P’s are not normal from the baseline. What will you do next?
Call the provider, make sure all other assessments are done prior.
Is it normal for patients to feel some DISCOMFORT after cath lab procedure?
Yes, Some discomfort is normal.
true chest pain- is NOT!
What is this called?
Trans-Radial Approach
- used instead of a FEMORAL sheath.
When pulling a sheth out, you hold PRESSURE for how long?
15 mins or more.
What med should ALWAYS be at the bedside when pulling out a sheath and why?
ATROPINE
(anticholinergic-blocks acetylcholine)
* due to pressure on sheath wound, may cause pt to vagal response (decrease bp) and lead to SYMPTOMATIC BRADYCARDIA
When removing a sheath patients can have a ___ response.
Vagal response.
- manipulation or pressure near the femoral artery can trigger a reflex involving the vagus nerve INDIRECTLY - decreases bp.
If patient vagus nerve is triggered, what heart symptom can patient start having?
SYMPTOMATIC bradycardia
- with symptoms- know how to treat
How would you treat SYMPTOMATIC bradycardia
- Assess
- O2
- IV access to Atropine- 0.5 mg IV push, Q3-5, max dose of 3 mg.
OR - Dopamine infusion (for hypotension and bradycardia)
- Epinephrine infusion (to increase heart rate and blood pressure)
know
PCI complications:
Most serious complication is
dissection of the newly dilated CORONARY artery
* the mechanical stress exerted by the balloon or other devices used to open the artery can cause a tear in the artery’s inner lining (intima).
* This tear creates a false passage or flap within the artery, called a dissection.
When coronary arteries rupture, what can occur?
- tamponade **
- ischemia- no blood to organs
- infarction
- decreased CO
- possibly death- pts can CODE very quickly!!
PCI complications:
Whats the timeframe where abrupt closure of the vessel can occur post-procedure?
In the first 24 hrs.
What is Restenosis
- the re-narrowing or re-blockage of an artery after it has been treated with procedures like angioplasty or stent placement.
- It usually occurs due to the regrowth of tissue at the site where the artery was previously widened bc body is trying to heal the site.
After PCI surgery, Restenosis risk is greates for the first ___ days
30 days
know
What meds can PREVENT restenosis?
Anti-platelets
(aspirin, P2Y12 Inhibitors (Plavix, Brilinta, Effient))
* these are NOT anticoags (heparing, warfarin)
What organ should we be monitoring for any future PCI patient?
Kidneys
* ALWAYS monitor renal function due to contrast given during procedure.
PCI complications:
3 MOST important complications after PCI’s
- Coronory vessel Dissection- leads to No.2
- Coronary Tamponade- decr. CO= death
- Vessel Restenosis- give anti-platelets
Review:
What is Coronary Tamponade
- the accumulation of fluid or blood in the pericardial sac surrounding the heart, which can compress the heart and impair its ability to pump blood effectively
- heart is STUCK in place
PCI Solutions:
What 3 signs do we assess for Cardiac Tamponade
It consists of three key signs: Becks Triad
“Three Ds”
- Decreased Hypotension: Due to impaired cardiac output caused by the compression of the heart, leading to reduced blood flow.
- Distended Jugular Venous (JVD): Elevated pressure in the jugular veins, observed as distension of the neck veins, is caused by the impaired filling of the heart and increased central venous pressure.
- Distant Muffled Heart Sounds: The sounds of the heart become muffled or distant upon auscultation, typically due to the fluid accumulation in the pericardial space which dampens the heart sounds.
Remember: DDD signs
What 2 types of medications are used for thrombus prophylaxis?
1 . Antiplatelet Medications: Prevent platelet aggregation; used for arterial clots.
- Examples: Aspirin, Clopidogrel (Plavix), Ticagrelor (Brilinta), Prasugrel (Effient)
2 . Anticoagulants: Prevent clot formation by inhibiting clotting factors; used for venous clots.
- Examples: Heparin, Warfarin (Coumadin)
PCI pts will be on a antiplatelet prophylaxis for how long?
rest of their lives (lifelong)
PCI solutions: Thrombus Prophylaxis
If ASPIRIN is used in conjunction with another anti-platelet medication it is called
dual-antiplatelet therapy
What other meds will be used with Aspirin?
- clopidogrel (Plavix) **
- ticagrelor (Brilinta)
- prasugrel (Effient)
-grel are anti-platellets
know
Other PCI complications
-
Coronary artery spasm prophylaxis-Vasodialators
* Nitrates
* Calcium Channel Blockers -
Assess for hematoma and/or possible retroperitoneal bleeding
-caused by blood leakage from femoral artery. -
Arrhythmias (“reperfusion” vs. lethal)
* Reperfussion: vtach or SVTs but very short- assess & report - Possible MI post-op
What is Retroperitoneal bleeding?
- bleeding in the retroperitoneal space, which is the anatomical area behind the peritoneum (the lining of the abdominal cavity).
- Blood collects in the peritoneal cavity and exerts pressures on tissues within the space
Reversal agents for Benzos
Flumazenil
know
Reversal agent for opioids
Naloxone (Narcan)
know
What 3 main areas of concerns should we be assessing POST PCI
- Hole in the skin (outward bleeding)
- Hole in the blood vessel accessed (hematoma/decreased limb perfusion)
- Coronary arteries (rupture/restenosis/spasm, etc.)
PCI Education will include
-
long-term management is largely aimed at
medication compliance and modifiable risk factors ** - Cardiach Rehab
- Rest/Recover & take it easy **
Type of surgical procedure used to treat severe coronary artery disease (CAD) by improving blood flow to the heart muscle
CABG
(coronary artery bypass grafting)
What is done during a CABG procedure?
- During CABG, a healthy artery or vein from another part of the body is connected or grafted to the blocked coronary artery
- this when we can NOT fix the arteries of heart any longer
- Full chest is opened during surgery!!
Is CABG a cure for coronary artery disease (CAD)?
- CABG improves blood flow to the heart but does NOT cure coronary artery disease.
- Must Be accompanied by treatment of modifiable risk factors such as: smoking, diet, DM, cholesterol,
Education starts
on admissions!
Why do POST-OP CABG patients require incredibly close monitoring?
Their condition can change QUICKLY
How is staffing organized for a patient after CABG surgery?
- The primary RN typically has no other patients
- During the first few hours after surgery, care requires multiple caregivers, including:
-MD (Physician)
-Nurse Practitioner (NP)
-Respiratory Therapist (RT)
-Charge RN - This ensures close monitoring and rapid intervention if the patient’s condition changes.
Multiple parameters will be closely assessed but more emphezised on 2 specific parameters. What are they?
Cardiac Output and Cardiac Index
Why do we care about cardiac output and cardiac index?
Perfussion!!
amount of blood the heart pumps to the body each MINUTE
cardiac output
What other assessments are done IMMEDIATELY after a CABG surgery?
- Strict I & O
- Urinary output q 1 hr- this is how often you report it
- Drain output- from ALL drains (bleeding!)
- Tight glycemic control (Insulin drip)
- all about healing and long term outcomes
know
When will you contact HCP for pt who is post-op CABG surgery?
- Urine < 30ml/hr x 2hr - need perfusion to kidneys
- B/P too high or too low
- Chest tube drainage > 150ml/hr or > 250ml in 2hrs- may include internal bleeding (hemorrhage)
- Lab Abnormalities (low H&H, low K, high WBC, high BUN/Creat)
- Severe agitation/difficulty extubating
- Any S/S of complications
For Cardiac surgery, do we expect large or small amounts of drainage?
SMALL- should resolve within 1st or 2nd day.
If we have chest tubes for a chest trauma, do we expect large or small amounts of drainage?
Large- for trauma large amounts of drainage is an ‘expected’ abnormal.
What are these used for?
Temporary pacing leads
* (temporary electrodes are screwed into the epicardium (not inside the heart) from outside prior to closing the chest). Sometimes heart needs an EXTRA KICK while it recovers from shock of surgery
If a temporary pacing lead is accidentally pulled out, what are the pts at risk for?
Possible Tamponade
(lead goes thru pericardium, then pericardial space, and sits in epicardium space.
Pts will stay in bed for at least ___ AFTER REMOVAL of temporary pacing leads
1 hour.
- after one hr and no complications, then tamponade may not occur
CABG POST-Op priorites/teachings will include
-
Early mobilization
-out of bed by end of surgery - Sternal percautions- heart pillow
-
Pulmonary excercises
-IS, Flutter valves, TCDB - Pain control
Home care instructions POST CABG:
How to care for incision on legs and sternum
- Watch for redness, swelling or drainage.
- Clean with soap & water. Pat dry– no tub soaking
How is the skin bonded after CABG
Dermabond (skin glue)
Home care instructions to patient regarding Dermabond (skin glue)
- will start itching 10-14 days out
- DONT SCRATCH- can get infected!
Other Home Care Instructions for POST CABG surgery
- Limit pushing, pulling, lifting activities until directed by HCP (Sternal Precautions)
- Discuss driving with HCP, may be limited until sternum heals
- Wear TED hose, elevate legs when sitting, avoid crossing legs (vein harvest)
- Lifestyle changes
What is the recommended diet after CABG surgery
- low fat
- low sodium
- smoking cessation
- exercise program
- weight loss (if needed)
Any patient after a surgery (including CABG) may experience
POST-OP cognitive dysfunction (POCD)
-memory problems, difficulty concentrating, or general confusion.
-several factors play role: pts age (older), meds, long procedures, infection- all can affect brain.
What should the nurse do if POST-OP Cognitive Dysfunction occurs?
- This usually improves with time
- Goal is to get clients back into pre-surgery env as quickly as possible
- Help orient pt using clocks, calendars, photos
For heart transplant (or any transplant) patients are on __ for life.
immunosupressants
Pacemakers are usually indicated for clients who
need correction of a SLOW of irregular heart rate/rhythm
Pacemakers shows up on an EKG as a
pacer “spike”
Internal pacemaker placement will only pace the ___ side of the heart
RIGHT side
(RA or RV)
What type of pacing is this
Atrial Pacing (pacemaker= single chamber)
- will show on P wave
What type of pacing is this?
Ventricular Pacing
- These look like PVC but PVC are events not rhythms- not consistent through EKG
- Spike shows before QRS **
know
What type of pacing is on this EKG strip?
Atrial Pacing
What type of pacing is showing here?
AV sequential pacemaker (dual chamber)
What type of pacing is shown here?
Ventricular Pacing
Type of pacemaker malfunction where the pacemaker generates an electrical stimulus, but the heart does not respond so it does not contract.
“Failure to capture”
- Essentially, the pacemaker is “firing” but failing to cause the heart muscle to contract
Type of pacemaker malfunction where pacemaker doesn’t correctly detect the heart’s natural beats. As a result, it may send electrical signals when it’s not needed or fail to send them when they are needed, dysrupting hearts normal rhythm.
“Failure to sense”
Which pacemaker malfunction am I?
Failure to capture
know
Which pacemaker malfunction am I?
Failure to Sense
- you will see pacerspikes all over the place
know
POST-OP Care for PERMANENT pacemaker insertion
- Obtain baseline EkG Recording
- Compare your EKG to patients PULSE
- Assess incision for bleeding/hematoma
- Observe SITE for temp elevation/pain
- Post-insertion Chest X-Ray
POST-OP:
After permanent pacemaker is inserted an arm immobilizer is used for how long
FIRST 12-24 hrs
Why does the patient use an arm immobilizer?
List 3 reasons.
- prevent movement of the arm on the side where the pacemaker leads were placed (usually the left arm)
- prevent lead dislodgment
- Allows heart to heal around pacemaker.
Client/Family Teaching:
What precautions should a patient with a pacemaker take regarding magnets and security detectors?
Avoid close proximity to large generators or magnets
* Ex: MRI machines (most pacemakers are NOT MRI compatible)
What can an MRI do to a pacemaker?
can change the settings of pacemaker and/or interfere with its function
Will Home appliances, cell phones, electronic devices affect pacemakers?
They should not.
WHat is used to program/change the setting on a pacemaker?
Magnets- this is why MRIs are not used for patients with pacemakers.
Review:
A defibrillator is used for what types of dysrhythmias?
- VFIB (always pulseless)
- Pulseless VTACH- this can be pulse or pulseless
“NEVER defibrillate a pulse”
“DEFIB a VFIB”
Pts who HAVE suffered from VFib/Vtach, but also pts who are at HIGH risk for these events use what type of pacemaker?
IMPLANTABLE CARDIOVERTER-
DEFIBRILLATOR (ICD)
What is an ICD’s main job and what’s the voltage amount it should deliver?
detect and correct most life-threatening dysrhythmias
- delivers <25 joules (due to closeness of heart)
What should healthcare workers do if an ICD delivers shocks during an inpatient code?
- Allow the ICD to deliver shocks as needed.
- Continue CPR and other resuscitation efforts without interruption, as the ICD does not replace the need for manual interventions in a code situation.
Defibrillator and CPR are still done!!!– KNOW
What happens if a magnet is placed over an IMPLANTABLE CARDIOVERTER- DEFIBRILLATOR (ICD)? This one is different.
Placing a magnet over an ICD will stop the defibrillation feature.
What happens if a magnet is placed over a “COMBO” device that functions as both an ICD and a pacemaker?
The magnet will not turn off the pacemaker function of the “combo” device.
- It will ONLY turn off the defibrillator function
ICD- Family/Client Teaching should include:
List 4
- Family should learn CPR **
- Driving may not be allowed – depends on state law
- Shock is painful – some describe it like a kick to the
chest - ID Card / Medical Alert Bracelet
ICD Pt/Fam teaching:
If ICD fires ONCE what should pt/family do?
Call HCP immediately
- can mean many things
- Not a true medical emergency
ICD Pt/Fam teaching:
If ICD fires MORE THAN ONCE and pt feels bad or loses consciousness what should they do next?
CALL EMS!!
- this is a medical emergency
