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Complex Nursing Care of Patients with Coronary Artery Disease, Cardiac

Surgery, and Cardiac RehabilitationTina Zimmerman,

Professor of Nursing

Nursing 210

What is addressed in this class

Complex care of the patient with a myocardial infarction

Care of the patient following cardiac surgery

Care of the patient through cardiac rehabilitation

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Do you remember?

Kyra Smith, 58-years-old, is being treated for angina. She is currently taking metroprolol 50 mg q day, aspirin 81 mg q day, and nitro SL prn. She presents to the ED with worsening chest pain.

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QuestionMs. Smith is prescribed metropolol for

which of the following purposes?

a.To inhibit the conversion of angiotensin I to II

b.To decrease platelet aggregation

c.To reduce the workload of the heart

d.To increase the sympathetic response4

QuestionThe nurse is aware that the following

assessment finding will necessitate holding the beta blocker:

a.Blood pressure of 102/64

b.Pulse rate of 48

c.Blood pressure of 180/90

d.Pulse rate of 1005

QuestionMs. Smith is now pale, diaphoretic,

and c/o pain 9/10. What nursing intervention should be implemented first?

a.Start IV of 0.9% NS

b.Administer NTG SL

c.Obtain a 12 lead ECG

d.Assess the blood pressure 6

QuestionThe 12 lead ECG indicates injury to

the myocardium. What specific ECG finding supports the injury?

a.S-T segment depression

b.T wave inversion

c.Significant Q wave

d.S-T segment elevation7

QuestionMs. Smith is given NTG SL. The nurse

prepares her for which adverse effect that may occur?

a.Dizziness

b.Tinnitus

c.Diarrhea

d.Greenish-yellow visual changes8

QuestionMs. Smith is prescribed Tridil. What is a

primary goal of this medication?

a.Increase the force of myocardial contractions

b.Perfuse cardiac tissue by dilating coronary arteries

c.Relax cardiac musculature

d.Dilate cerebral vessels to prevent hypoxia9

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Complex Care Following MI Patient in critical care unitLiquid diet for first 24 hrsMonitor hemodynamic stabilityAdminister appropriate drugsMonitor for complicationsPrepare for rehabilitation

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Fibrinolytics (Thrombolytics)Goals of therapy:

decrease infarct sizedecrease mortalitypreserve heart functionrestore blood flow to heart

Time is MusclePreference is to administer

drug within 4 hoursMust be within 6 hoursDoor to needle time: hospitals

strive for 30 minutes13

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Selection CriteriaCP longer than 20 min. and

unrelieved w/ NTGECG evidenceLess than 6 hours from onset

of pain

Thrombolytics

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Contraindications Active bleeding Known bleeding disorder History of hemorrhagic stroke Uncontrolled HTN Recent major trauma or surgery Pregnancy Intracranial vessel malformation

Thrombolytics

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Thrombolytics

StreptokinaseTissue plasminogen

activators (tPA):–alteplase (Activase)–reteplase (Retavase)

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StreptokinaseAdvantages

Lower costDisadvantages

Antigenic Not fibrin specific Longer half life than other

thrombolytics

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tPAGeneral advantages

More clot specific Not antigenic Shorter half-life

General disadvantages More expensive With some – more bleeding

Thrombolytics

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Nursing Actions

Thorough historyEstablish all IV linesObtain baseline VS and blood

valuesNotify Dr. if SBP>180 or

DBP>110 – Hold medicationThrombolytics

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Nursing ActionsHeparin concurrent or after

fibrinolytic – different lineDo not elevate HOB above 15

degrees – especially with strepto.Place on telemetryObserve for bleeding

Thrombolytics

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Reperfusion

Relief of CPNormalization of ST

segmentsSinus tachycardia that is

transientFibrinolytics

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Complications

BleedingAllergic reactionDysrhythmias: slow VT is most

common

Fibrinolytics

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Follow-up CareHeparin infusion for 2-3 daysAspirin therapy perhapsCoumadin for at least 3 monthsPatient education: CoumadinPatient to report chest pain

immediatelyFibrinolytics

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Other Medications Post MI

Beta-blockersACE inhibitorsHeparinAspirinNTGMorphine

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Antiplatelet/Glycoprotein Inhibitors

tirofiban (Aggrastat) abciximab (ReoPro)eptifibatide (Integrilin)

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Glycoprotein Inhibitors

Prevent platelets from binding togetherAdministered IVAssess patient for bleeding &

hypersensitivity reaction

Glycoprotein InhibitorsMust assess creatinine clearance –

Dosing chart will specify for creatinine clearance >50 and also <50

Usually 2 bolus doses 10 minutes apart

IV infusion is weight basedNOT compatible with furosemide

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Glycoprotein InhibitorsContraindicators (some):

Severe hypertension SBP>200 or

DBP >110 Major surgery w/in preceding 6 weeks Stroke w/in 30 days History of hemorrhagic stroke Active bleeding w/in previous 30 days

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MI Complications

DysrhythmiasType of MI can often determine type of dysrhythmia

VT is dreaded complicationNecrotic cells are silent

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MI Complications

Heart blockTemporary or permanent pacemaker may be needed

Heart FailureMyocardium does not contract normally

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MI ComplicationsPulmonary Embolism

CP, SOB, Tachypnea, HemoptysisMyocardial Rupture

Rare Cardiac Tamponade

• JVD, muffled heart sounds

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MI Complications

Cardiogenic ShockLethal complicationMust prevent from occurring

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Cardiogenic ShockMost often caused by MIHigh mortality: 65-100%Heart’s pumping ability so

compromised that CO is not maintained

Usually more than 40% of left ventricle is damaged

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Cardiogenic Shock

Pulse: tachycardiaBP: hypotensionSkin: cold, clammy, pale,

moistRespiration: tachypnea,

crackles, dyspnea

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Cardiogenic Shock

LOC: anxious lethargicRenal: output less than

30cc/hrElevated wedge pressure

36PA Catheter

Pulmonary Artery Catheter

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Pulmonary Catheter

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PA CatheterGives an accurate measurement

of left ventricular functionPAWP = pulmonary artery

wedge pressurePAWP mean pressure is

between 4.5 and 13 mmHg (will vary among agencies)

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Nursing Actions: PA CatheterHOB elevated about 45 degreesInflate with about 1mL of airAfter PAWP, immediately

deflate the balloon – do NOT aspirate the airLook for correct waveformMonitor for infection

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Interventions for Cardiogenic ShockMedications

Inotropic and vasopressors: increase contractility, BP, SV, CO•dopamine, dobutamine, digoxin

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Interventions for Cardiogenic ShockMedications

Morphine NTG

Oxygen May need mechanical

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Interventions for Cardiogenic Shock

Monitor vital signs Goal is to keep SBP above 90

Sodium bicarbonateMechanical Assistive Device

Intra-aortic balloon pump

Cardiogenic shock

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IABPIABP Ballon Pump

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CABGRestores blood flow to

ischemic areas of heartSaphenous vein, mammary

artery, and/or radial artery usedTraditional & alternative

techniques

CABG 45

CABG

CABG 46

CABG 47

CABG PROCEDURE

CABG 48

Off-Pump CABG

No CPBBB given to slow heart rateStabilizer used on heartLess complications

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Off-Pump CABG

Stabilizer

CABG 51

CABG: Nursing CarePre-op teaching:

Critical care unit Endotracheal tube in place 2-24 hrs. Will have many tubes in place Increase activity gradually TC&DB and use of IS Don’t forget family

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Post CABGMajor nursing goals & actions

Maintain hemodynamic stability & cardiac output

Thorough assessments Monitor & manage complications Assist patient & family through

recovery

Monitor for Complications

Patient must be continually assessed for impending complications such as decreased CO, fluid volume imbalance, pain, etc .

Read in textbook!53

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Altered Tissue Perfusion

Palpate all pulsesHypotension

SBP<90: vein graft may collapse

May need to increase fluidsCardiac surgery

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Altered Tissue PerfusionHypertension

SBP>140-150: may promote leakage from graft site

Titrate tridil or nipride

Cardiac surgery

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HypothermiaMonitor temperature using same

site – avoid rectal & oral for first 8 hrs.

Re-warming for temp. below 96.8 F (36 C) – re-warm slowly

Thermal blanket, lights, warmed IV

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PainBoth CW and harvested siteDifferentiate between sternal

incision pain and anginal painIncision pain: localized, no

radiation, worse with coughing and breathing; sharp

Cardiac surgery

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Pain

Encourage routine pain medication dosing for 1st 24 to 72 hours

PCA: Patient Controlled AnalgesiaSupport incision

Cardiac surgery

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Risk for Bleeding

Monitor H & HMonitor VSAssess for bleedingMonitor chest drainage: should

be less than 200 mL/h during first 4 to 6 hours

Cardiac surgery

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Cardiac Tamponade: risk for Accumulation of fluid in

pericardial sac leading to compression of the heart

Sudden decrease in chest drainage may be indicator

Pericardiocentesis: removal of fluid

Cardiac surgery

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Cardiac Tamponade: S/S Decreasing SBPNarrow pulse pressureRising venous pressure (JVD, can

be with clear lung soundsDistant heart soundsPulsus paradoxus: pp 823 & 842

Cardiac surgery

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Fluid & Electrolyte ImbalanceCheck levels frequentlyHypokalemia is most commonI & ORecord chest tube drainage

hourly

Cardiac surgery

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DysrhythmiasAtrial fibrillation most commonAmiodarone may be ordered

pre-operativelyBeta-blocker or calcium

channel blocker may also be used to control rateTemporary pacemaker - maybe

Cardiac surgery

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Sensory-Perception Imbalance

Changes due to anesthesia, CPB, and/or hypothermia

Memory loss, confusion, wide-eyed look, slow to arouse

Report s/s that might indicate stroke

Most changes resolve within 8 hours Cardiac surgery

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Sensory-Perception Imbalance

Monitor neurological status very frequently Every 30 minutes in first hour Then hourly for next 8 hours Then every 2 hours for next 8

hours Then every 4 hours for next 8

hours Cardiac surgery

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Risk for InfectionSterile techniquePostpericardiotomy syndrome may

develop between 5 days & several weeks post-op

Monitor labs, color of drainage, temperature, malaise

Cardiac surgery

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Gas Exchange

Atelectasis – most commonMechanical ventilation – 2-24 hrsSuction as neededUse incentive spirometer

Every 1-2 hours

TCDBCardiac surgery

Recovery from CABGSutures removed from chest prior to

discharge and from leg after 7 to 10 days

Elastic support stockings during day for first 4-6 weeks after surgery; keep leg elevated when sitting

Not to lift anything more than 10 lbs 68

Recovery from CABGAdvised not to drive for the first four

weeks Normal sexual activity as long as

positions doesn’t put significant weight on the chest or upper arms.

Return to work after 6 weeksExercise stress testing done 4-6 weeks

after CABG surgery 69

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Critical Care Nursing Issues

Can be a stressful environmentDepersonalization of both

patients and healthcare providersPrognosis of patients

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Mental Health StressorsMainly for MI Patient

AnxietyDenialDepression

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Cardiac Rehab Goals Promote

optimal healingMaintain

and/or achieve productive lifestyle

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Phase OneFrom admission to dischargePromote restCardiac progressionTeach: CAD process, risk

factors, diet, meds, etcRehab

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Phase TwoFrom discharge to about 4-6

weeksSupervised out-patient programBP and ECG monitoringGroup educational sessions

Rehab

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Phase Three

Life-longMaintain CV stability and

conditioningPatient now self-directed

Rehab

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Teaching HintsAlways have an objectiveDon’t overwhelm patientPay attention to non-verbal cluesAlways evaluate learningUse media, pamphlets,

brochures, etcRehab

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Teaching PointsAllowed to use one flight of steps

2-3 times a day for the first 2 weeksCan usually drive within 2 weeks

of dischargeAverage time to return to work

depends on extent of MIRehab

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Teaching PointsRemain at home for 2 weeksStart aerobic exercise programCan usually resume sexual activity

2 weeks after discharge Indicator: can climb 2 flights of stairs

without chest painRehab

Any Questions?

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