Nursing mgmt of persons with problems with cardiac oxygenation and perfusion (PTCA, Stenting, CABG) Flashcards
Cardiac Catheterization
- Also known as angiogram
- Invasive Diagnostic procedure used to evaluate the presence and degree of CAD
- Involves the insertion of a cath into an artery (radial or femoral) and threading it to the heart and coronary arteries
- coronary artery narrowing and occlusions are identified by injection of contrast media under fluoroscopy
Dye shows area of blood flow through the arteries, with less blood flow through an artery indicates areas of stenosis
Contraindications for angiogram
- Those with impaired kidney function may need further assessment due to the nephrotoxic effects of the dye, pt can be put on dialysis as a result
- After procedure make sure to push PO fluids to help process the dye through the system
Nursing actions: Pre Coronary angiogram
- Ensure the pt understands the procedure, risks involved prior to signing informed consent
- Keep pt NPO for 8 hours prior to procedure
- Assess for iodine/shellfish allergy (For the contrast media but this is a myth but she taught it)
- Assess for latex allergy
- Ensure recent labs are done, notify provider if renal function is abnormal/impaired
- Start IVF if ordered
Nursing actions: Post coronary angio
- Assess the site for bleeding, hematoma, pulses
- Ensure any new med orders have been done.
- Admin IVF if ordered
- If no HF/ fluid overload, encourage PO fluids (Process the dye)
- If pt is found to need surgery, ensure meds have been reviewed by provider, antiplt might need to be stopped
Percutaneous Transluminal Coronary Angioplasty (PTCA)
- Balloon tipped cath, expands in areas of stenosis to allow blood flow, essentially pushing the atheroma against the walls
- Relieves Ischemia and ensures blood flow
- Used with pts with angina or as an intervention of ACS
- Can be used to open blocked bypass grafts (CABG)
- PTCA is done when the cardiologist thinks it can improve blood flow
Typically done in acute MI as a temp measure to save muscle
PTCA procedure
- Done in cardiac cath lab
- Hollow catheters (Sheaths) are inserted via femoral or radial to act as a conduit for other catheters
- Angiography is performed to determine area/extent of stenosis
- The balloon tipped catheters are then inserted and expanded at the area of stenosis to restore blood flow, due to the preseance of the sheath, multiple balloon tipped catheters with different purposes can be inserted and extracted depending on pt need
- Balloons are inflated with high pressure for several seconds and then deflated, this pressure can crack the atheroma (blocks blood flow during this time)
- the media and adventitia of the CA are also stretched
Conduit
Pipe or tube which something passes (Wire or wire)
Downsides of PTCA
- Technically a minimally invasive surgery
- Can break off chunks of atheroma, causing stroke or ischemia when blocking another artery downstream
- Bleeding
- High rate of stenosis
In emergency stenosis caused by PTCA may require emergent Bypass surgery
Middle layer of Coronary artery
Media
Outer layer of coronary artery
Adventia
Inner layer of coronary artery
Intima
During PTCA, what happens to the heart
Blood flow becomes blocked, causing the pt CP, and the EKG may show ST segment elevations temporarily
Goal of PTCA
- Reduction of stenosis to less than 10%
Reasons for restenosis: PTCA
- Injury to the intima, causing acute inflammatory response
- Release of mediators causing vasoconstriction, scar tissue formation and clotting
Coronary stent can be placed to prevent restenosis
Coronary artery stent/ Percutaneous Coronary Intervention (PCI)
- Metal mesh that provides support to the vessel, preventing acute closure
- Stent is placed over the angioplasty balloon, when the balloon is inflated it presses the stent against the walls of the artery holding it open, when the balloon is removed the stent stays in place
- Over time the endothelium covers the stent and it is incorporated into the artery
Bare metal stents
- Do not have any impregnated medications
- Allows pts to be off their antiplt sooner
- Sometimes preferred over DES so pts can receive certain medications that interact with the medications within the stent
Drug eluting stents (DES)
- Stents that are placed that are coated in medications (Sirolimus or Pacitaxel) that are meant to minimize the formation of thrombus in the lesion
- Prevents restenosis
Main medication given with Stents
- Dual antiplatelet therapy, ASA+plavix
- ASA is continued indefinitely
- Plavix is continued for one year
- Or orders may vary upon cardiologist, but dual anti plt therapy is good thing
- Med adherence is key or else restenosis will happen
Complications of Stents/PCI: During PCI
- Coronary artery dissection, perforation
- Vasospasm
- AMI, Arrhythmias, Cardiac arrest
May need emergency surgery to resolve these
Complications of Stents/PCI: Post PCI
- Abrupt closure of the artery
- Vascular complications
1. Bleeding
2. Hematoma
3. Retroperitoneal bleeding
4. Arterial occlusion (Stroke/MI)
Retroperitoneal bleeding
Blood enters the space behind the peritoneum wall in the abdomen
Complications of Stents/PCI: Acute Kidney injury
- Extends from the nephrotoxic effects of the contrast media
- Manifested by decreased urine and increased BUN/Creatinine
Nursing actions: acute kidney injury
- Monitor I+O
- Monitor urine output, BUN, creatine, other electrolytes
- Provide hydration as ordered
- Admin renal protective agents (Acetylcysteine) Before and after procedure as ordered
Manifestations of Myocardial ischemia
- CP
- Arrhythmias
- ECG changes
Nursing actions: Myocardial ischemia
- O2+ nitro
- Obtain 12 lead EKG
- Notify provider
Manifestations of Bleeding, Hematoma
- Bleeding at the site
- Swelling, hard lump
- Pain
- Possible low BP
- Tachycardia
Nursing actions, Bleeding/hematoma
- keep PT on bed rest
- Apply manual pressure over the side
- Outline the hematoma with a marker to monitor size
- Notify provider
Manifestations, retroperitoneal hematoma
- Back, flank or abdominal pain
- Agitation
- Restlessness
- Low BP
- Tachycardia
Nursing actions: Retroperitoneal hematoma
- Notify provider
- Stop anticolag
- Admin IVF
- Anticipate CT (Check for hem stroke
- Possible intervention
Manifestations: Arterial occlusion
- Loss or weakened pulse
- Cool
- Cyanotic
- Painful
Nursing actions: Arterial occlusion
- Notify
- Anticipate
- Intervention
Manifestations: Pseudoaneurysm formation
- Swelling at site
- Pulsatile pass
Nursing actions: Pseudoaneurysm formation
- Notify
- Anticipate
- Intervention
Manifestations: Arteriovenous fistula formation
- Swelling at site
- Pulsatile mass
Nursing actions: Arteriovenous fistula formation
- Notify
- Anticipate
- Intervention
PCI/ Stent, Immediate post procedure period
- Similar to angiogram in care provided
- When PCI is performed emergent to treat ACS,pts are admitted for a couple days for observation
- During PCI pts recive IV heparin or a thrombin inhibitor, need to monitor closely for bleeding
- Femoral sheaths may be removed at the end of the procedure, At this point hemostasis can be achieved by applying heavy manual pressure or using a compression device
- Pts can come back to unit with the sheaths still in place, they are removed after the blood work comes back and says the clotting time is acceptable, usually a few hours later
PCI/stent, Nursing care in the post op period
- Pt must remain in bed and keep the leg straight until the sheaths are removed (Femoral artery), usually a couple hours after procedure
- Sheath removal and application of pressure on insertion site may cause vasovagal response. It should be transient but atropine is given if it persist, monitor
- Pts with unstable lesions are at risk for abrupt closure may be started on heparin or another blood thinner
- After hemostasis is achieved a pressure dressing is applied, pts resume self care and ambulate within a few hours of the procedure depending on sheath size, anticoagulant, Pt condition and providers preference
- The day after the site is inspected, the dressing is removed and the patient is instructed to monitor the site for bleeding or swelling
What is given for a continuous vagal response, post PCI
Atropine
Vasovagal response
Occurs due to some stimuli causing decreased HR and BP
Can lead to dizziness or syncope
Can you just put a stent in it
- No every case is complicated and a stent may not be fitting for every patient for a variety of reasons
- Don’t tell the pt the doc can just put a stent in it they might need CABG
PCI med adherence
- Is KEY need to understand the risks of restenosis and further dmg if med adherence is not taken seriously
Coronary Artery Bypass graft (CABG)
- Surgical procedure, blood vessel is grafted to a vessel before and after an occlusion so blood can flow past it
Main Indications for CABG
- Relief of angina not controlled with meds or PCI (Stent)
- Treatment for left main cononary stenosis (Widow maker)or multivessel CAD
- Prevention of, and treatment for MI, arrhythmias or HF
- Treatment for complications of an unsuccessful PCI (Stent)
Need for CABG is determined based on
- Number of diseased coronary vessels
- Degree of LV dysfunction
- Presence of other pt comorbidities
- Patients symptoms
- Any previous treatment
Done less on females; higher risk of complications and higher mortality (Older, more comorbidities)
Men and CABG
Do better than females and have better rate of graft patency and symptom relief
Normal EF
55-65%
Degree of stenosis needed for CABG
- 70% for arteries
- 50% for the left main
Artery must be patent past the area of blockage or CABG wont do anything as it dumps the blood onto another stenosed area
Why is CABG not done in lower degrees of stenosis (<70%)
If there is not significant stenosis, flow through the stenosed area will compete with the bypass, not improving the ischemic zone
Which vessels are prefered for CABG
- Arteries over veins due to the structural differences, not developing atherosclerotic changes as quickly and remaining patent longer
- Left internal mammary (Thoracic) arteries are prefered due to them remaining patent for a long time and reducing complications
- Thoracic arteries may be too short for CABG so they may use the saphenous veins instead
If the thoracic arteries are too short what are used instead
- Mix of venous and arterial grafts are used
- Great and lesser saphenous veins are used, harvested endoscopically (Lower leg edema still occurs)
- However within 5-10 years atherosclerotic changes often develop in vein grafts
Traditional CABG procedure
- Pt under anesthesia
- Median sternotomy (Crack the chest open)
- Cardiopulmonary bypass (CPB) machine
- Bypass completed
- CPB is discontinued
- Chest tubes and epicardial pacing wires are placed
- Sternotomy incision is closed
- pt is transferred to critical care unit
Cardiopulmonary Bypass (CPB), On pump
- Mechanical circulation and oxygenation of blood bypassing heart and lungs
- Maintains perfusion to the body
- Allows the surgeon to perform the anastomoses (Graft) in a motionless bloodless surgical field
- Hypothermia is maintained during CPB, blood is cooled and returned to the body, decreasing tissue demand for O2 after surgery the blood is warmed by the CPB
- Urine, electrolytes and Blood counts, ABG and coagulation studies are monitored throughout the procedure
higher graft patency and reduction of long term mortality
I referred to it as traditional as well
What temp is the body maintained at during CPB
82.4F, 28 C
Off pump coronary artery bypass surgery (OPCAB)
- Normal bypass but without the CPB
- Heart is beating, but slowed (Using a BB)
- Heart stabilization device is used to hold the site for the graft onto the coronary artery while it still beats
- Reduced incidence of post op morbidity such as stroke
Criteria when deciding between CABG and PCI(Graft)
Surgical mortality
* Individual characteristics (heavier or skinny)
* Anatomic complexity of coronary lesions (Do you have one area of stenosis or 100)
* Ability to achieve revascularization
Age, sex, diabetes, HTN, LVEF, arrhythmias, previous CV history and interventions, disease complexity, concomitant valve disease
Pre Op CABG
Prevents complications and improves outcomes
* Use of ASA, BB statins, preop are associated with better outcomes
* BB 24 hours prior to reduce afib
* Statins reduce the rates of potop MI, AFIB, neuro dysfunction, renal dysfunction, infection and death
Preop Assessment CABG
- Thorough and well documented history, to serve as a baseline to compare against post op
- What meds they are on, otc, herbal, tobacco, alc
- Cognitive status needs to be assessed, altered or impaired cognition will need more assistance post op
- Pt and family education
- pt’s function level, coping mechanisms, available support, discharge planning and rehab
- Allow pt and family time to express fear and anxiety
- Attention to pt glucose control if diabetic, poor control places increased risk of complications
Two comorbidities that place increased risk of complications for CABG
- Diabetes: Special attention is made to pt glucose control as it can affect post op
- Lung disease
Pt education pre op CABG
- With the history make sure that you educate that you need to know all herbal, otc, alc, nicotine
- Allow pt+fam to express anxiety and fear
- Shower with chlorhexidine prior to surgery, apply mupirocin calcium to each nostril to prevent infections from staph cultured in the nose, reducing staph infections post op
- Educate regarding tubes, lines, equipment, chest tubes, cath, ventilator
- Cough and deep breathing
- Incentive spiro
- Splinting sternotomy incision
- Foot exercises
- Early ambulation
- Need for analgesics, pts don’t want to take pain meds, Pain limits lung expansion slowing recovery
Intraoperative complications of CABG
- Low CO
- Arrhythmias
- Hemorrhage
- MI
- Organ failure from shock
- Thrombolytic events (Stroke)
Intraoperative mgmt of CABG
- Before the chest is closed, chest tubes are inserted to evacuate air and drainage from mediastinum and thorax
- Temp epicardial pacemaker electrodes may be implanted on the RA+RV, connected to a temp external pacemaker if the pt has persistent bradycardia during surgery
- The temp pacemaker leads are left in typically till right before the pt goes home for the concern of emergent brady
Epicardial pacing
- Wires are inserted during CABG on the RA/RV for an external pacemaker device sewn into the epicardium
- Terminal wires are pulled through the skin and sutured before the chest is closed
- These remain until the pt goes home for emergent bradycardia,
Post op CABG: Nursing mgmt
- Initial post op care focuses on maintaining hemodynamic stability and recovery from general anesthesia
- ECG electrodes to monitor heart and rhythm
- Endotracheal tube for mechanical ventilation and suctioning
- Nasogastric tube to decompress stomach
- Mediastinal and pleural chest tubes
- Radial arterial line
- Central venous or pulmonary artery cath (Swan cath)
- Pulse Ox
- Foley cath
Can usually eat the next day
Post op CABG: Nursing assessment
- COMPLETE assessment Q 4 hrs
- Neuro status
- Cardiac status
- Resp status
- Peripheral vascular status
- Renal function
- Fluids and electrolytes
- Pain
- Assessment for delirium
Post op CABG: Nursing assessment: Neuro status
- Level of response
- pupil size
- reaction to light
- facial symmetry
- extremity movement
- grip strength
Post op CABG: Nursing assessment: Cardiac status
All Vs readings from monitoring devices
Post op CABG: Nursing assessment: Resp status
Breath sounds
Vent readings
Post op CABG: Nursing assessment: Peripheral vascular status
- Pulses
- Color from skin
- Nail beds
- Lips
- Condition of dressings
- Invasive line sites
Post op CABG: Nursing assessment: Renal function
- Urine
- Serum BUN
- Creatinine
Post op CABG: Nursing assessment: Fluids and electrolyte status
- I+O of all IVF
- all drainage tubes
- labs
Post op CABG: Nursing assessment: Pain
- Nature
- Type
- Location
- Duration
- Apprehension
- Response to meds
Post op CABG: Nursing assessment: Assessment for delirium
Signs include
* Transient perceptual illusions (Visual or auditory)
* Disorientation
* Paranoia
Complications of CABG: Decreased CO
- Comes from bleeding problems
- Preload and afterload changes
- Arrhythmias
- Changes in VS
Complications of CABG: Maintaining CO
- Report S+S decreased CO promptly
- Data is used to determine the cause of the problem
- Provider and RN work together to restore CO and prevent further complications
- This can be done through
1. Fluids
2. Diuretics
3. Antiarrhythmics
4. Blood components
5. Vasodilators/ pressors are given
Complications of CABG: Maintaining fluid and electrolyte balance
- Careful I+O
- Hemodynamics
- Lab work
- Indications of dehydration
- Fluid overload or electrolyte abnormalities report promptly
Complications of CABG: Impaired gas exchange
- Pt stable postop can be extubated 2-4 hours postop
- Some unstable pts take days after surgery to be extubated
- Following extubation aggressive pulmonary interventions are implemented, such as turning, coughing and deep breathing, early ambulation to prevent atelectasis and pneumonia
Complications of CABG: Promoting gas exchange
- Assess patency of endotracheal tube, suction prn
- ABG are drawn and reported
- When hemodynamics stabilize, T/P Q 1-2 hrs to provide optimal pulmonary vent and perfusion, allowing the lungs to expand fully
Complications of CABG: Impaired cerebral circulation
- Hypoperfusion or microemboli may produce injury to the brain
- S+S of hypoxia
1. Confusion
2. restlessness
3. Hypotension - Frequent neuro checks are done to monitor for changes, report changes to provider
Complications of CABG: Minimizing confusion
- Delirium appears 2-5 days in the icu
- Correct metabolic and electrolytes
- Frequently orientate
- Uninterrupted sleep
- Explain all procedures, welcome the pts family, continuity of care
Complications of CABG: Pain
- Pts might be in pain around area of incision, and throughout the chest
- Shoulders and back irritation might be from pleura and chest tubes
- Encourage pt to accept meds regularly
- Use of adjunct pain relieves such as nsaids or muscle relaxers are encouraged
- Decrease use of opioids if possible
- Splint incision
Complications of CABG: Maintaining adequate tissue perfusion
- Assess pulses
- Thromboembolic events from vascular site
- Air embolism can result from Cardiopulmonary bypass (CPB)
- S+S depends on site usual sites are;
1. Lungs
2. Coronary arteries
3. Mesentery
4. Spleen
5. Extremities
6. Kidneys
7. Brain - Observe for CP, dyspnea, abdominal or back pain, neuro changes, assess for venous thromboembolism (DVT/PE) use compression devices, don’t cross legs
Complications of CABG: Maintaining normal body temp
- Risk of fever as result of tissue inflammation or infection (Increases tissue O2 demands and cardiac workload)
- Reposition pt, cough and deep breath ambulate and discontinue lines asap to prevent infection
- Common sites of infection
1. Lungs
2. Urinary tract
3. Incisions
4. Cath
Complications of CABG: Postpericardiotomy syndrome
- Inflammatory response causing pain
- May occur post op
S+S include - Fever
- Pericardial pain
- Pleural pain
- SOB
- Pericardial effusion
- Arthralgias
- Occurs days to weeks post op
- Use of colchicine and nsaids to relieve symptoms
CABG discharge instructions
- Activity, limitations, driving (Don’t carry a fridge)
- Bathing, incision care (Gently wash each day with soap and water)
- meds (Med adherence is key)
- Medical and surgical follow-up
- Diet
- What to be aware of, and to notify provider
Benefit of on pump CABG vs off pump
- On pump is associated with higher graph patency and long term mortality might be decreased
- Off pump has a reduced short term morbidity such as stroke
