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Adult Health Nursing II Block 7.0 Topic: Cardiovascular Nursing & EKG Monitoring, part 1 Module: 2.2.

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Presentation on theme: "Adult Health Nursing II Block 7.0 Topic: Cardiovascular Nursing & EKG Monitoring, part 1 Module: 2.2."— Presentation transcript:

1 Adult Health Nursing II Block 7.0 Topic: Cardiovascular Nursing & EKG Monitoring, part 1 Module: 2.2

2 Cardiovascular Nursing Selected Topics PT 1 It’s All About Cardiac Output Block 7.0 Module 2.2

3 Learning Outcomes a.k.a. “What’s On the Test?” See the Study Guides! Setting the Stage / Context for Cardiac Monitoring & EKGs AAA “It’s All About Cardiac Output”—EKGs Cardiac Monitoring: Selected Dysrhythmias, Recognition, Assessment, Nursing Interventions, Block 7.0 Module 2.2

4 Selected Topics in Cardiovascular Nursing_____ PATHOPHYSIOLOGY Myocardial Infarction Acute Coronary Syndrome Valvular Heart Disease Pacemakers CABG Abdominal Aortic Aneurysm Pericarditis Peripheral Vasc Disease (PVD) Fem-Pop Bypass Graft Shock / Fluid Deficit Raynaud’s Phenomenon Arrhythmias / Dysrhythmias PHARMACOLOGY Cardiac Glycosides ACE Inhibitors Beta Blockers Antiarrhythmics Catecholamines Anticoagulants ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation Cardiac Monitoring Lab Monitoring Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more… Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary Block 7.0 Module 2.2

5 Remember: It’s All About Cardiac Output = HR X SV C.O. = Heart Rate x Stroke Volume *More about this in Adult Health II Block 7.0 Module 2.2

6 It’s All About… Cardiac Output = HR X SV C.O. = Heart Rate x Stroke Volume *More about this in Adult Health II What FactorsAffectCardiac Output ? Block 7.0 Module 2.2

7 It’s All About… Cardiac Output = HR X SV C.O. = Heart Rate x Stroke Volume Sympathetic Nervous System (+) Parasympathetic Nervous System (-) *More about this in Adult Health II What FactorsAffectCardiac Output ? Block 7.0 Module 2.2

8 It’s All About… Cardiac Output = HR X SV C.O. = Heart Rate x Stroke Volume Sympathetic Nervous System Parasympathetic Nervous System Baroreceptors Chemoreceptors *More about this in Adult Health II What FactorsAffectCardiac Output ? Block 7.0 Module 2.2

9 It’s All About… Cardiac Output = HR X SV C.O. = Heart Rate x Stroke Volume Sympathetic Nervous System Parasympathetic Nervous System Blood Volume Blood Volume Baroreceptors Chemoreceptors *More about this in Adult Health II Viscosity Of Blood What FactorsAffectCardiac Output ? Block 7.0 Module 2.2

10 It’s All About… Cardiac Output = HR X SV C.O. = Heart Rate x Stroke Volume Sympathetic Nervous System Parasympathetic Nervous System Blood Volume Blood Volume Baroreceptors Chemoreceptors Medications Condition of Heart Valves *More about this in Adult Health II Viscosity Of Blood What FactorsAffectCardiac Output ? Block 7.0 Module 2.2

11 It’s All About… C.O. = Heart Rate x Stroke Volume Sympathetic Nervous System Parasympathetic Nervous System Blood Volume Blood Volume Baroreceptors Chemoreceptors Medications Preload, Afterload Condition of Cardiac Conduction System* Condition of Heart Valves Condition Of Myocardium *More about this in Adult Health II Viscosity Of Blood What FactorsAffectCardiac Output ? Block 7.0 Module 2.2

12 It’s All About… C.O. = Heart Rate x Stroke Volume Sympathetic Nervous System Parasympathetic Nervous System Blood Volume Blood Volume Baroreceptors Chemoreceptors Medications Preload, Afterload Condition of Cardiac Conduction System* Condition of Heart Valves Condition Of Myocardium *More about this in Adult Health II It’s All About Cardiac Output ! Viscosity Of Blood And, Many more factors ! What FactorsAffectCardiac Output ? Block 7.0 Module 2.2

13 Cardiovascular Nursing Selected Topics PT 1 Atrial Fibrillation Complicated Patient Block 7.0 Module 2.2

14 James H. 68 y.o. R/O MI, Atrial Fibrillation Kam H. 48 y.o. AAA Haynes H. 55 y.o. PVD S/P Femoral-Popliteal Bypass Page R. 78 y.o. Sick Sinus Syndrome S/P Pacemaker Insertion Renee C. 29 y.o. Pericarditis Admission Pending Pre-Op CABG CARDIAC MONITORING Block 7.0 Module 2.2

15 Patient Record History & Physical Dr’s Orders Labs & Dx M.A.RM.A.R. V.S. & Graphics Name: I & O Assessments Consults Nurse’s Notes TreatmentsMISC Name: James H. Age: 68 y.o Male Occupation: Architect Adm: Date DX: R/O MI, R/O CVA, S/P CABG X 4 date OTHER DX: DM, AAA, PVD, Atrial Fibrillation James H. Reports

16 Dr’s Orders 1.Admit to Telemetry Unit; continuous cardiac monitoring 2.DX: R/O MI, R/O Embolic CVA 3.Activity: BR, BSC 4.Diet: Clear Liquids, adv as tol to 1500 calorie ADA Diet 5.FSBG q ac & hs with Moderate SSRI Coverage 6.Meds: Humulin 70/30 35 units sq q am / 20 units sq q pm Digoxin mg po daily Amiodarone 400 mg po bid Colace 200 mg po daily Heparin IV per weight-based protocol NTG 0.4 mg sl q5 min x 3, PRN CP Morphine SO4 2 mg IVP PRN CP Lidocaine 2 mg / minute IV / continuous 7.IV: Saline Lock 8.Labs / Diagnostics: Continue Serial Cardiac Enzymes; BMP q day; CBC; Coag studies per heparin weight-based protocol; schedule for CT of brain 9.Telemetry Protocols; ACLS Protocols 10. Daily EKG; EKG with any chest pain What are your concerns about the patient? What is the cause of the concern? What are you going to do about it? What is the patient experiencing? Block 7.0 Module 2.2

17 History & Physical Block 7.0 Module 2.2 Admitted 2/10/2009 after c/o crushing, substernal chest pain rated as 9 on a scale of (Presented with Cardiac Rhythm as noted on ( ER rhythm strip #1 and ER rhythm strip #2 );ER rhythm strip #1 ER rhythm strip #2 ( later, developed (Rhythm strip #3) while being transported from the Emergency Department to the telemetry unit.) Also was noted to have rhythm noted on Rhythm strip #4. Rhythm strip #5 is attached for your enlightenment.(Rhythm strip #3) Rhythm strip #4.Rhythm strip #5 Client was successfully resuscitated, including use of ACLS protocols and Defibrillation with 360 joules x 2. Converted to atrial fibrillation w/controlled ven- tricular response. After defibrillation and transfer to the nursing unit, pt exhibited s/s disorientation-see Rhythm Strip #6.Rhythm Strip #6 Five hours after admission to the telemetry floor, became agitated and c/o (R)-side chest pain: See Nurse’s Notes.Nurse’s Note Surgical history includes 4 vessel CABG in 1/2008; PTCA with 3 stents in 2002; Laparascopic Cholecystectomy in Other pertinent Medical History includes diagnosis of DM in 1990; blood sugars controlled moderately well with Humulin 70/30 35 units q am / 20 units q pm. Long history of atrial fibrillation with concomitant control via digoxin 0.25 mg daily. CO = HR & R X SV BP = CO X SVR

18 Awake and alert; BP= 112/72 RHYTHM STRIP #1 The Patient airway, breathing, LOC Block 7.0 Module 2.2

19 RHYTHM STRIP #2 Awake & Alert C/O Chest Pressure and Feeling Nervous BP = 106/68 Check The Patient airway, breathing, LOC Block 7.0 Module 2.2

20 The Patient airway, breathing, LOC Awake and alert; BP= 88/40 C/O “Feeling Funny” RHYTHM STRIP #3 Block 7.0 Module 2.2

21 The Patient (!) airway, breathing, LOC RHYTHM STRIP #4 NON-RESPONSIVE BP= CO = HR&R x SV BP = CO x SVR Block 7.0 Module 2.2

22 TREAT THE PATIENT, NOT THE MONITOR ! RHYTHM STRIP #5 AWAKE & ALERT BP = 112/78 CHEST LEAD RECONNECTED (It fell off…) (Oops, MY BAD!) The Patient (!) Airway, breathing, LOC Block 7.0 Module 2.2

23 The Patient airway, breathing, LOC RHYTHM STRIP # 6 BP = 112/72 Speech slurred (Check cranial nerves) II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial IX, X Glossopharyngeal Vagus Block 7.0 Module 2.2

24 Nurse’s Notes 0700: Unable to initiate additional peripheral IV line, attempts x 3. VS: P=90, irregular; R=22, unlabored; BP= 118/78; SaO2=95%. Monitor displaying atrial fibrillation with occasional PVC. Physician notified re: IV; will continue Lidocaine 2 mg/min per available site on (L) forearm; Heparin infusion per WBP on hold until additional IV site accessed. Consult for central line placement pending J. Nurse, RN 0900: C/O sharp pain, pointing to area (R) thorax; became agitated and dis- oriented. VS: BP = 90/50; P = 110, irregular; R = 32, labored; T =98*; SaO2 = 86 %. ABG’s obtained, results pending. O2 increased to 4L/NC. Note absent breath sounds, RLL;Cardiac monitor: Atrial fibrillation w/ rapid ventricular response. Physician notified and enroute to hospital. Will continue to Monitor J. Nurse, RN 0920: Non-responsive; VS: BP = 80/40, P = 156, irreg, R = 10, SaO2 = 80%; central cyanosis noted. Intubated and ventilated with 100% 02. Absent lung sounds RLL & RML. Cardiac monitor shows atrial fibrillation w/ uncontrolled ventricular response. Report provided to ICU nurse, Transported via gurney to ICU for ventilator support J. Nurse, RN What are your concerns about the patient? What is the cause of the concern? What are you going to do about it? What is the patient experiencing? SEE CONCEPT MAP Block 7.0 Module 2.2

25 MED DX: MI Atrial Fib CVA PE NSG DX #1: PAIN, ACUTE NSG DX #2: Ineffective Tissue Perfusion, Cardio- pulmonary NSG DX #3: Ineffective Tissue Perfusion, Cerebral Other Nursing DX: 4. Decreased Cardiac Output 5. IMPAIRED SWALLOWING 6. RISK for INJURY 7. Self-Care Deficit 8. Impaired Communication KEY ASSESSMENTS PAIN VS O2 Sats ABG’s LOC Cranial Nerve Assmt Capillary Refill Breath Sounds Swallowing / Gag Reflex NSG DX #4: Impaired Gas Exchange CONCEPT MAP James H. Block 7.0 Module 2.2

26 Cardiovascular Nursing Selected Topics PT 2 Abdominal Aortic Aneurysm Block 7.0 Module 2.2

27 Patient Record NAME: Kam H. AGE: 48 y.o. OCCUPATION: Attorney ADM: DX: AAA Pre-Op: AAA Repair NAME: Kam H. AAA

28 AAA Abdominal Aortic Aneurysm S/S FREQUENTLY: ASYMPTOMATIC Gnawing, constant, abdominal, flank, and groin pain Pulsating abdominal mass Bruit RUPTURE Sudden onset “tearing,” “ripping,” or “stabbing” abdominal or back pain Shock (Hypovolemic) GRAFT OCCLUSION Changes in Pulses Coolness & cyanosis of extremities below graft Severe Pain Decreased Urine Output Block 7.0 Module 2.2

29 AAA Procedure Block 7.0 Module 2.2

30 AAA Block 7.0 Module 2.2

31 Nursing Care: AAA Repair ? NSG DX #1: Fear / Anxiety Abdominal Aortic Aneurysm (Pathophysiology) KEY ASSESSMENTS? ? ? Other Nursing Diagnoses That May Apply: ? Block 7.0 Module 2.2

32 AAA: Pathophysiology An abdominal aortic aneurysm is an abnormal dilation of the wall of the abdominal aorta. The aneurysm usually develops in the segment of the vessel that is between the renal arteries and the iliac branches of the aorta. The most common cause of an abdominal aortic aneurysm is atherosclerosis. The plaque that forms on the wall of the artery causes degenerative changes in the medial layer of the vessel. These changes lead to loss of elasticity, weakening, and eventual dilation of the affected segment. Some other causes of abdominal aortic aneurysm include inflammation (arteritis), trauma, infection, congenital abnormalities of the vessel, and connective tissue disorders that cause vessel wall weakness. Most abdominal aortic aneurysms are asymptomatic and are discovered during a routine physical examination (signs include palpation of a pulsatile mass in the abdomen and/or auscultation of a bruit over the abdominal aorta) or during a review of x-ray results of the abdomen or lower spine. The presence of symptoms such as mild to severe abdominal, lumbar, or flank pain and/or lower extremity arterial insufficiency is usually indicative of a large aneurysm that is exerting pressure on surrounding tissues or an aneurysm that is leaking. Surgical repair of an aneurysm is usually performed if the aneurysm is growing rapidly and/or reaches a size of 5-6 cm or larger or if the client experiences symptoms. The procedure often involves the use of a synthetic graft, which is inserted to replace or support the weakened vessel. Ulrich & Canale: (2006) Nursing Care Planning Guides: For Adults in Acute, Extended, and Home Care Settings, 6th Edition Block 7.0 Module 2.2

33 NURSING DIAGNOSIS: Fear/Anxiety related to: 1. unfamiliar environment and separation from significant others; 2. lack of understanding of diagnostic tests, surgical procedure, and postoperative care; 3. anticipated loss of control associated with effects of anesthesia; 4. risk of disease if blood transfusions are necessary; 5. anticipated postoperative discomfort and potential change in sexual functioning; 6. possibility of death. Desired Outcome The client will experience a reduction in fear and anxiety Nursing Actions and Selected Purposes/Rationales 1. Preoperative Care Plan, for measures related to the assessment and reduction of fear and anxiety. 2. Implement additional measures to reduce fear and anxiety: a. orient client to critical care unit if appropriate b. describe and explain the rationale for equipment and tubes that may be present postoperatively (e.g., cardiac monitor, ventilator, intravenous and intra-arterial lines, nasogastric tube, urinary catheter) c. explain that B/P may be taken in both arms and thighs in order to better evaluate circulatory status d. reinforce physician's explanations and clarify misconceptions client has about effects of the surgery on sexual functioning (impotence can result from diminished blood flow in the mesenteric or internal iliac arteries during or after surgery and/or from nerve damage during surgery). Block 7.0 Module 2.2

34 COLLABORATIVE DIAGNOSIS: Potential complication: hypovolemic shock R/T related to excessive blood loss if the aneurysm ruptures. Desired Outcome: The client will not develop hypovolemic shock as evidenced by: 1. usual mental status 2. stable vital signs 3. skin warm and usual color 4. palpable peripheral pulses 5. urine output at least 30 ml/hour. NURSING ACTIONS: (next page) Block 7.0 Module 2.2

35 Nursing Actions and Selected Purposes/Rationales 1. Assess for and immediately report signs and symptoms of conditions that indicate impending aneurysm rupture: A. Leaking aneurysm: a. increasing abdominal girth b. ecchymosis of flank area or perineum c. frank or occult gastrointestinal bleeding (occurs if the aneurysm ruptures into the duodenum) d. decreasing RBC, Hct, and Hgb levels e. new or increased reports of lumbar, flank, abdominal, pelvic, or groin pain (accumulation of blood in the peritoneum and/or retroperitoneal spaces causes irritation of and pressure on the tissues and nerves) f. diminishing or absent peripheral pulses g. further decline in thigh B/P as compared with B/P in arm (thigh B/P is usually slightly lower than B/P in arm of a client with an abdominal aortic aneurysm) B..Expanding aneurysm: a. new or increased reports of lumbar, flank, or groin pain (results from pressure on lumbar nerves) b. increased size of pulsating mass in abdomen c. increasing sense of abdominal and/or gastric fullness (results from pressure on duodenum) d. decreasing motor or sensory function of lower extremities (results from pressure on lumbar and/or sacral nerves). C. Assess for and report signs and symptoms of hypovolemic shock: a. restlessness, agitation, confusion, or other change in mental status b. significant decrease in B/P c. postural hypotension d. rapid, weak pulse e. rapid respirations f. cool skin g. pallor, cyanosis h. diminished or absent peripheral pulses i. urine output less than 30 ml/hour. Block 7.0 Module 2.2

36 D. Implement measures to decrease risk of aneurysm rupture: a. instruct client to avoid elevating legs when in bed, using knee gatch, and crossing legs in order to prevent restriction of blood flow to the lower extremities and subsequent increase in vascular pressure at the aneurysm site b. perform actions to prevent an increase in blood pressure: c. limit client's activity as ordered d. nstruct client to avoid activities that create a Valsalva response (e.g., straining to have a bowel movement, holding breath while moving up in bed, lifting heavy objects) E. implement measures to reduce fear and anxiety (see Preoperative Diagnosis 1) F. administer antihypertensives if ordered to reduce pressure in the dilated vessel. G. If signs and symptoms of hypovolemic shock occur: a. place client flat in bed unless contraindicated b. monitor vital signs frequently c. administer oxygen as ordered d. administer blood and/or volume expanders as ordered (these need to be used with caution since increased vascular pressure can extend a tear at site of rupture) e. prepare client for insertion of hemodynamic monitoring devices (e.g., central venous catheter, intra-arterial catheter) if indicated f. prepare client for emergency surgical repair of aneurysm if indicated. Block 7.0 Module 2.2

37 NURSING DIAGNOSIS: Risk for imbalanced fluid and electrolytes Third-spacing of fluid related to: 1. increased capillary permeability in surgical area associated with the inflammation that occurs following extensive dissection of tissue during major abdominal surgery 2. increased vascular hydrostatic pressure associated with excess fluid volume if present 3. hypoalbuminemia associated with the escape of proteins from the vascular space into the peritoneum (a result of increased capillary permeability in the surgical area); Excess fluid volume related to: 1. vigorous fluid replacement Fluid retention associated with: 1. increased secretion of antidiuretic hormone (output of ADH is stimulated by trauma, pain, and anesthetic agents) 2. renal insufficiency (can occur if there is inadequate blood flow to the kidneys during or after surgery) 3. reabsorption of third-space fluid (occurs about the 3rd postoperative day); Deficient fluid volume related to restricted oral fluid intake before, during, and after surgery; blood loss; and loss of fluid associated with nasogastric tube drainage; Electrolyte Imbalance: hypokalemia, hypochloremia, and metabolic alkalosis related to loss of electrolytes and hydrochloric acid associated with nasogastric tube drainage. Block 7.0 Module 2.2

38 Desired Outcome The client will experience resolution of third-spacing as evidenced by: 1. absence of ascites 2. B/P and pulse within normal range for client and stable with position change. Block 7.0 Module 2.2

39 Cardiovascular Nursing Selected Topics PT 3 Peripheral Vascular Disease Block 7.0 Module 2.2

40 Patient Record NAME: Haynes H. AGE: 55 y.o. OCCUPATION: Registered Nurse ADM: DX: Peripheral Vascular Disease Procedure: Femoral-Popliteal Bypass NAME: Haynes H. PVD

41 Peripheral Arterial Disease Pathophysiology PAD results from atheroclerosis in the arteries of the lower extremities, characterized by inadequate blood flow (ischemia). Intermittent Claudication: pain caused by insufficient arterial blood supply Block 7.0 Module 2.2

42 PTA : Percutaneous Transluminal Angioplasty Block 7.0 Module 2.2

43 An intraoperative photograph of a right femoral to posterior tibial artery bypass using the greater saphenous vein to correct peripheral arterial disease. Block 7.0 Module 2.2

44 Nursing Considerations Post Femoral-Popliteal Bypass Hemorheologic Drugs: pentoxifyline (Trental) increases RBC flexibility, decreases viscosity Antiplatelet Agents: ASA, clopidogrel (Plavix) Pedal Pulses (palpated or Doppler) Color, temp., capillary refill, pain (warmth, redness, & edema are EXPECTED OUTCOMES of the revascularlization). Graft Occlusion NOTIFY PHYSICIAN Compartment Syndrome NOTIFY PHYSICIAN Acute Arterial Occlusion NOTIFY PHYSICIAN MEDS ASSESSMENT COMPLICATIONS THE 6 P’s of Ischemia: PAIN, PALLOR, PULSELESSNESS, PARESTHESIA, PARALYSIS, POIKILOTHERMIA Block 7.0 Module 2.2

45 PAD Buerger’s Disease thromboangiitis obliterans Raynaud’s Disease Raynaud’s phenomenon Block 7.0 Module 2.2

46 Patient Record NAME: Page R. AGE: 78 y.o. OCCUPATION: Retired Teacher ADM: DX: Sick Sinus Syndrome Procedure: Pacemaker Insertion today NAME: Page R. Pacemaker

47 Cardiac Pacemakers PathophysiologyNursing Considerations Block 7.0 Module 2.2

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49 Cardiac Pacemakers IMMEDIATELY POST-OP: Monitor heart rate & rhythm Minimize shoulder movement w/ sling for 24 hrs; Gentle passive ROM after 24 hrs Indications: Symptomatic bradycardia Complete Heart Block Sick Sinus Syndrome Sinus arrest Asystole Atrial tachydysrhythmias Ventricular tachydysrhythmias Block 7.0 Module 2.2

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51 Pacemaker Complications Failure to Capture— Pacemaker initiates a stimulus, but depolarization of the myocardium does not occur Stimulation of Chest Wall or Diaphragm Hiccoughs Cardiac Tamponade Block 7.0 Module 2.2

52 Pending Admission Patient Record NAME: DX: CAD, 4-Vessel Pre-Op: Coronary Artery Bypass Graft (CABG) CABG PTCA Block 7.0 Module 2.2

53 Cardiovascular Nursing Selected Topics PT 5 PTCA & CABG Block 7.0 Module 2.2

54 James H. 68 y.o. R/O MI, Atrial Fibrillation Kam H. 48 y.o. AAA Haynes H. 55 y.o. PVD S/P Femoral-Popliteal Bypass Page R. 78 y.o. Sick Sinus Syndrome S/P Pacemaker Insertion Renee C. 29 y.o. Pericarditis Admission Pending Pre-Op CABG CARDIAC MONITORING Block 7.0 Module 2.2

55 Pending Admission Patient Record NAME: DX: CAD, 4-Vessel Pre-Op: Coronary Artery Bypass Graft (CABG) CABG PTCA LVAD Block 7.0 Module 2.2

56 Left Ventricular Assist Device (LVAD) A left ventricular assist device (LVAD) is implanted under the skin via “open heart” surgery. It helps pump blood from the left ventricle of the heart and on to the rest of the body. A control unit and battery pack are worn outside the body and are connected to the LVAD through a port in the skin. This is a typically a temporary measure while the patient is awaiting a heart transplant, though in some cases it may be used for the long term when the patient is not a good heart transplant candidate. Block 7.0 Module 2.2

57 Intra-Aortic Balloon Pump IABP The IABP can be used along with interventional cardiology procedures and medical therapy (medications). Indications for IABP use include: Failure to wean from cardiopulmonary bypass. Cardiogenic shock. Heart failure. Acute heart attack. Support during high-risk percutaneous transluminal coronary (balloon) angioplasty, and coronary stent placement. Block 7.0 Module 2.2

58 IABP The IABP is a polyethylene balloon mounted on a catheter, which is generally inserted into the aorta through the femoral artery in the leg. The balloon is guided into the descending aorta, approximately 2 cm from the left subclavian artery. At the start of diastole, the balloon inflates, augmenting coronary perfusion. At the beginning of systole, the balloon deflates; blood is ejected from the left ventricle, increasing the cardiac output by as much as 40 percent and decreasing the left ventricular stroke work and myocardial oxygen requirements. Block 7.0 Module 2.2

59 PTCA percutaneous transluminal coronary angioplasty Patient has had a history of CAD for several years. Underwent PTCA with stent placement x 1 year ago Increasing angina PTCA last week shows near occlusion of four coronary arteries Block 7.0 Module 2.2

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61 Nursing Care After PTCA Monitor Cardiac Rhythm Maintain Bedrest for Specified time Frequent assessment of affected leg / groin site for bleeding Frequent assessment of affected leg for tissue perfusion distal to cath insertion site Block 7.0 Module 2.2

62 The goal of treatment for heart disease is to maximize cardiac output. Surgically this may be done by improving myocardial muscle function and blood flow through procedures such as the traditional CABG (or via less invasive procedures such as MIDCAB, percutaneous transmyocardial revascularization [PTMR], and/or port access requiring four small incisions under the left breast), wrapping the latissimus dorsi muscle around the heart, and/or repair or replacement of defective valves. Of the three types of cardiac surgery— (1) reparative (e.g., closure of atrial or ventricular septal defect, repair of mitral stenosis), (2) reconstructive (e.g., CABG, reconstruction of an incompetent valve), and (3) substitutional (e.g., valve replacement, cardiac transplant)—reparative surgeries are more likely to produce cure or prolonged improvement. Block 7.0 Module 2.2

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64 An open heart bypass surgery is performed under general anesthesia, which requires that the patient be on a ventilator during surgery. Surgery begins with harvesting the blood vessels that will become the grafts. The saphenous vein in the leg is commonly used because it is long enough to create multiple grafts. If the saphenous vein cannot be used, vessels from the arm can be used instead. The left internal mammary artery is used for a single graft and is taken once the chest is opened for surgery. Once the saphenous vein has been recovered, the chest is opened by making an incision along the sternum, or breastbone. The surgeon then cuts the sternum, allowing the chest cavity to be opened, giving the surgeon access to the heart. In the traditional CABG procedure, the heart is stopped with a potassium solution so the surgeon is not attempting to work on a moving vessel, and the blood is circulated by a heart-lung machine. At this time the heart- lung machine does the work of the heart and the lungs, and the ventilator is not used. Block 7.0 Module 2.2

65 The surgeon places the grafts, either rerouting blood around the blockage, or removing and replacing the blocked vessel. The amount of time on the heart-lung bypass machine is determined by the speed at which the surgeon is able to work, primarily, how many grafts are needed. Once the grafts are complete, the heart is started and provides blood and oxygen to the body. The sternum is returned to its original position and closed using surgical wire, to provide strength the bone needs to heal, and the incision is closed. Block 7.0 Module 2.2

66 Coronary Artery Bypass Graft CABG Block 7.0 Module 2.2

67 Sternal Wires Block 7.0 Module 2.2

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69 Care Planning NURSING PRIORITIES 1. Support hemodynamic stability/ventilatory function. 2. Promote relief of pain/discomfort. 3. Promote healing. 4. Provide information about postoperative expectations and treatment regimen. DISCHARGE GOALS 1. Activity tolerance adequate to meet self-care needs. 2. Pain alleviated/managed. 3. Complications prevented/minimized. 4. Incisions healing. 5. Postdischarge medications, exercise, diet, therapy understood. 6. Plan in place to meet needs after discharge. Block 7.0 Module 2.2

70 Cardiovascular Nursing Selected Topics PT 6 Pericarditis Block 7.0 Module 2.2

71 James H. 68 y.o. R/O MI, Atrial Fibrillation Kam H. 48 y.o. AAA Haynes H. 55 y.o. PVD S/P Femoral-Popliteal Bypass Page R. 78 y.o. Sick Sinus Syndrome S/P Pacemaker Insertion Renee C. 29 y.o. Pericarditis Admission Pending Pre-Op CABG CARDIAC MONITORING Block 7.0 Module 2.2

72 Patient Record NAME: Renee C. AGE: 29 y.o. Occupation: Graduate Student DX: Pericarditis, Mitral Valve Prolapse Pericarditis Block 7.0 Module 2.2

73 Overview: Pericarditis Pericarditis - inflammation of the lining surrounding the heart (the pericardial sac). Pericardial effusion - a collection of fluid in the pericardial sac. This fluid may be produced by inflammation. The etiology of pericarditis in most patients is unknown, although many diseases can cause pericarditis. The diagnosis of pericarditis is made by history and physical examination including presence of a pericardial friction rub. It may confirmed by EKG and echocardiogram. Pericarditis is treated with anti-inflammatory medications and by treating any underlying disease. Pericardial tamponade occurs when enough fluid accumulates in the sac to compromise the heart's ability to adequately pump blood. Tamponade is treated by pericardiocentesis, removing the fluid with a needle. Block 7.0 Module 2.2

74 Etiology Idiopathic The cause of the illness is not identified (although often it's the result of a minor viral illness or "cold") Mechanical injury to the heart Heart attack (myocardial infarction) and Dressler's syndrome Heart surgery and post pericardiotomy syndrome Trauma Infection Bacterial Viral Fungal Tumors or cancer Primary (rare) Metastatic Connective Tissue Disease Rheumatoid arthritis Systemic Lupus Erythematosus (SLE) Sarcoidosis Scleroderma Metabolic diseases Uremia (kidney failure) Hypothyroidism Medication Reactions (next page) Block 7.0 Module 2.2

75 Etiology Side effects of certain medications can cause an immune response causing an inflammation of the pericardial sac and pericarditis. Medicines that have been implicated include phenytoin (Dilantin), hydralazine (Apresoline) and procainamide (Pronestyl, Procan-SR, Procanbid). Block 7.0 Module 2.2

76 Symptoms Chest pain is the most common symptom of pericarditis. The pain is usually sharp and stabbing. It can arise slowly or suddenly and can radiate directly to the back, to the neck or to the arm. The pain can be made worse with deep breaths (pleuritic). The pain is frequently positional and made worse when lying flat and better when leaning forward. The most common physical finding that almost always confirms the diagnosis is a pericardial friction rub. Block 7.0 Module 2.2

77 Medicines that reduce inflammation are the primary treatment for pericarditis. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, are used to decrease the inflammation and fluid accumulation in the pericardial sac. process. Occasionally, a short course of narcotic pain medication [codeine, hydrocodone (Vicodin) or oxycodone (OxyContin, Roxicodone)] will be needed. In recurrent cases, especially in immunologically-mediated causes, corticosteroids are often very effective. Treatment of the underlying cause of pericarditis is essential and will be based on the disease Block 7.0 Module 2.2

78 Cardiac tamponade If there is enough fluid in the pericardia sac, there may be enough pressure on the outside of the heart to prevent it from beating adequately to push blood to the body and lungs. The pressure within the sac itself needs to be higher than the pressure within the heart chambers, but symptoms gradually progress as the heart function is compromised. Treated by pericardiocentesis, a procedure where a long needle is inserted through the chest wall into the pericardial sac and fluid is removed. This relieves the pressure within the sac and temporarily resolves the acute emergency. A plastic tube or catheter may be left in the chest until the underlying illness that cause the tamponade is addressed and further accumulation of fluid in the pericardium is prevented. Block 7.0 Module 2.2

79 Pericarditis Cardiac Tamponade: Most serious complication of pericarditis Pulsus Paradoxus Pulsus Paradoxus (PP) is an exaggeration of the normal variation in the pulse during the inspiratory phase of respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales. It is a sign that is indicative of several conditions including cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease (e.g. asthma, COPD). Block 7.0 Module 2.2

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