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NSG 478 > Nursing mgmt of persons with problems with cardiac oxygenation and perfusion (PTCA, Stenting, CABG) > Flashcards

Nursing mgmt of persons with problems with cardiac oxygenation and perfusion (PTCA, Stenting, CABG) Flashcards

1
Q

Cardiac Catheterization

A
  • 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

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2
Q

Contraindications for angiogram

A
  • 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
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3
Q

Nursing actions: Pre Coronary angiogram

A
  • 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
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4
Q

Nursing actions: Post coronary angio

A
  • 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
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5
Q

Percutaneous Transluminal Coronary Angioplasty (PTCA)

A
  • 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

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6
Q

PTCA procedure

A
  1. Done in cardiac cath lab
  2. Hollow catheters (Sheaths) are inserted via femoral or radial to act as a conduit for other catheters
  3. Angiography is performed to determine area/extent of stenosis
  4. 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
  5. Balloons are inflated with high pressure for several seconds and then deflated, this pressure can crack the atheroma (blocks blood flow during this time)
  6. the media and adventitia of the CA are also stretched
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7
Q

Conduit

A

Pipe or tube which something passes (Wire or wire)

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8
Q

Downsides of PTCA

A
  • 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

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9
Q

Middle layer of Coronary artery

A

Media

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10
Q

Outer layer of coronary artery

A

Adventia

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11
Q

Inner layer of coronary artery

A

Intima

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12
Q

During PTCA, what happens to the heart

A

Blood flow becomes blocked, causing the pt CP, and the EKG may show ST segment elevations temporarily

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13
Q

Goal of PTCA

A
  • Reduction of stenosis to less than 10%
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14
Q

Reasons for restenosis: PTCA

A
  • 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

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15
Q

Coronary artery stent/ Percutaneous Coronary Intervention (PCI)

A
  • 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
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16
Q

Bare metal stents

A
  • 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
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17
Q

Drug eluting stents (DES)

A
  • 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
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18
Q

Main medication given with Stents

A
  • 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
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19
Q

Complications of Stents/PCI: During PCI

A
  • Coronary artery dissection, perforation
  • Vasospasm
  • AMI, Arrhythmias, Cardiac arrest

May need emergency surgery to resolve these

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20
Q

Complications of Stents/PCI: Post PCI

A
  • Abrupt closure of the artery
  • Vascular complications
    1. Bleeding
    2. Hematoma
    3. Retroperitoneal bleeding
    4. Arterial occlusion (Stroke/MI)
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21
Q

Retroperitoneal bleeding

A

Blood enters the space behind the peritoneum wall in the abdomen

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22
Q

Complications of Stents/PCI: Acute Kidney injury

A
  • Extends from the nephrotoxic effects of the contrast media
  • Manifested by decreased urine and increased BUN/Creatinine
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23
Q

Nursing actions: acute kidney injury

A
  • 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
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24
Q

Manifestations of Myocardial ischemia

A
  • CP
  • Arrhythmias
  • ECG changes
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25
Q

Nursing actions: Myocardial ischemia

A
  • O2+ nitro
  • Obtain 12 lead EKG
  • Notify provider
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26
Q

Manifestations of Bleeding, Hematoma

A
  • Bleeding at the site
  • Swelling, hard lump
  • Pain
  • Possible low BP
  • Tachycardia
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27
Q

Nursing actions, Bleeding/hematoma

A
  • keep PT on bed rest
  • Apply manual pressure over the side
  • Outline the hematoma with a marker to monitor size
  • Notify provider
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28
Q

Manifestations, retroperitoneal hematoma

A
  • Back, flank or abdominal pain
  • Agitation
  • Restlessness
  • Low BP
  • Tachycardia
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29
Q

Nursing actions: Retroperitoneal hematoma

A
  • Notify provider
  • Stop anticolag
  • Admin IVF
  • Anticipate CT (Check for hem stroke
  • Possible intervention
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30
Q

Manifestations: Arterial occlusion

A
  • Loss or weakened pulse
  • Cool
  • Cyanotic
  • Painful
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31
Q

Nursing actions: Arterial occlusion

A
  • Notify
  • Anticipate
  • Intervention
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32
Q

Manifestations: Pseudoaneurysm formation

A
  • Swelling at site
  • Pulsatile pass
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33
Q

Nursing actions: Pseudoaneurysm formation

A
  • Notify
  • Anticipate
  • Intervention
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34
Q

Manifestations: Arteriovenous fistula formation

A
  • Swelling at site
  • Pulsatile mass
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35
Q

Nursing actions: Arteriovenous fistula formation

A
  • Notify
  • Anticipate
  • Intervention
36
Q

PCI/ Stent, Immediate post procedure period

A
  • 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
37
Q

PCI/stent, Nursing care in the post op period

A
  • 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
38
Q

What is given for a continuous vagal response, post PCI

A

Atropine

39
Q

Vasovagal response

A

Occurs due to some stimuli causing decreased HR and BP
Can lead to dizziness or syncope

40
Q

Can you just put a stent in it

A
  • 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
41
Q

PCI med adherence

A
  • Is KEY need to understand the risks of restenosis and further dmg if med adherence is not taken seriously
42
Q

Coronary Artery Bypass graft (CABG)

A
  1. Surgical procedure, blood vessel is grafted to a vessel before and after an occlusion so blood can flow past it
43
Q

Main Indications for CABG

A
  • 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)
44
Q

Need for CABG is determined based on

A
  • 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)

45
Q

Men and CABG

A

Do better than females and have better rate of graft patency and symptom relief

46
Q

Normal EF

A

55-65%

47
Q

Degree of stenosis needed for CABG

A
  • 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

48
Q

Why is CABG not done in lower degrees of stenosis (<70%)

A

If there is not significant stenosis, flow through the stenosed area will compete with the bypass, not improving the ischemic zone

49
Q

Which vessels are prefered for CABG

A
  • 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
50
Q

If the thoracic arteries are too short what are used instead

A
  • 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
51
Q

Traditional CABG procedure

A
  1. Pt under anesthesia
  2. Median sternotomy (Crack the chest open)
  3. Cardiopulmonary bypass (CPB) machine
  4. Bypass completed
  5. CPB is discontinued
  6. Chest tubes and epicardial pacing wires are placed
  7. Sternotomy incision is closed
  8. pt is transferred to critical care unit
52
Q

Cardiopulmonary Bypass (CPB), On pump

A
  • 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

53
Q

What temp is the body maintained at during CPB

A

82.4F, 28 C

54
Q

Off pump coronary artery bypass surgery (OPCAB)

A
  • 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
55
Q

Criteria when deciding between CABG and PCI(Graft)

A

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

56
Q

Pre Op CABG

A

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

57
Q

Preop Assessment CABG

A
  • 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
58
Q

Two comorbidities that place increased risk of complications for CABG

A
  • Diabetes: Special attention is made to pt glucose control as it can affect post op
  • Lung disease
59
Q

Pt education pre op CABG

A
  • 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
60
Q

Intraoperative complications of CABG

A
  • Low CO
  • Arrhythmias
  • Hemorrhage
  • MI
  • Organ failure from shock
  • Thrombolytic events (Stroke)
61
Q

Intraoperative mgmt of CABG

A
  • 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
62
Q

Epicardial pacing

A
  • 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,
63
Q

Post op CABG: Nursing mgmt

A
  • 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

64
Q

Post op CABG: Nursing assessment

A
  • COMPLETE assessment Q 4 hrs
  • Neuro status
  • Cardiac status
  • Resp status
  • Peripheral vascular status
  • Renal function
  • Fluids and electrolytes
  • Pain
  • Assessment for delirium
65
Q

Post op CABG: Nursing assessment: Neuro status

A
  • Level of response
  • pupil size
  • reaction to light
  • facial symmetry
  • extremity movement
  • grip strength
66
Q

Post op CABG: Nursing assessment: Cardiac status

A

All Vs readings from monitoring devices

67
Q

Post op CABG: Nursing assessment: Resp status

A

Breath sounds
Vent readings

68
Q

Post op CABG: Nursing assessment: Peripheral vascular status

A
  • Pulses
  • Color from skin
  • Nail beds
  • Lips
  • Condition of dressings
  • Invasive line sites
69
Q

Post op CABG: Nursing assessment: Renal function

A
  • Urine
  • Serum BUN
  • Creatinine
70
Q

Post op CABG: Nursing assessment: Fluids and electrolyte status

A
  • I+O of all IVF
  • all drainage tubes
  • labs
71
Q

Post op CABG: Nursing assessment: Pain

A
  • Nature
  • Type
  • Location
  • Duration
  • Apprehension
  • Response to meds
72
Q

Post op CABG: Nursing assessment: Assessment for delirium

A

Signs include
* Transient perceptual illusions (Visual or auditory)
* Disorientation
* Paranoia

73
Q

Complications of CABG: Decreased CO

A
  • Comes from bleeding problems
  • Preload and afterload changes
  • Arrhythmias
  • Changes in VS
74
Q

Complications of CABG: Maintaining CO

A
  • 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
75
Q

Complications of CABG: Maintaining fluid and electrolyte balance

A
  • Careful I+O
  • Hemodynamics
  • Lab work
  • Indications of dehydration
  • Fluid overload or electrolyte abnormalities report promptly
76
Q

Complications of CABG: Impaired gas exchange

A
  • 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
77
Q

Complications of CABG: Promoting gas exchange

A
  • 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
78
Q

Complications of CABG: Impaired cerebral circulation

A
  • 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
79
Q

Complications of CABG: Minimizing confusion

A
  • 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
80
Q

Complications of CABG: Pain

A
  • 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
81
Q

Complications of CABG: Maintaining adequate tissue perfusion

A
  • 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
82
Q

Complications of CABG: Maintaining normal body temp

A
  • 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
83
Q

Complications of CABG: Postpericardiotomy syndrome

A
  • 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
84
Q

CABG discharge instructions

A
  • 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
85
Q

Benefit of on pump CABG vs off pump

A
  • 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

NSG 478 (23 decks)

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