Nursing diagnoses for patients undergoing cardiac catheterization procedure:

Plavix)toreduceriskofin-stentrestenosispostPCI.Additionally,drug-elutingstentsfurtherreduceriskofrestenosis.Anantirestenoticmedication

containedwithinthepolymerofthesestentsisreleasedoveraperiodof

timetomodifythehealingresponsethatwouldresultinrestenosis.

ComplicationsofPCIincludebleeding,acutein-stentthrombosis,vascular

injury,infection,MI,stroke,contrast-inducednephropathy,allergicreaction

tomedicationsorcontrast,anddeath.

Cardiaccatheterizationisdiscussedlaterinthissection,andCABGisdiscussed

inChapter18,“CardiacSurgery,”p.149.

Nursing Diagnosis:

Deficient Knowledge

related to unfamiliarity with relaxation techniques effective for stress reduction

Desired Outcome:

The patient reports subjective relief of stress after using a relaxation technique.

ASSESSMENT/INTERVENTIONS RATIONALES

Assessthepatient’sstresslevel.Discusstheimportanceofrelaxation

forpatientswithCADifappropriate.

Relaxationdecreasesnervoussystemtone(sympathetic),energy

requirements,andO2consumption.Knowledgeablepatientsare

morelikelytoadheretotechniquesthatpromoterelaxation.

Introducemethodsofrelaxation,suchasmusic,imagery,massage,art

therapy,biofeedback.

Relaxationmethodsmaydecreaseenergyrequirements.

Encouragethepatienttopracticerelaxationtechniqueswheneverfeeling

stressedortense.

Thesetechniquescanbecomepartofthepatient’slifestyle,reducing

stressonadailylevel.

Nursing diagnoses for patients undergoing cardiac catheterization procedure:

Nursing Diagnosis:

Deficient Knowledge

related to unfamiliarity with the catheterization procedure and postcatheter-ization regimen

Desired Outcome:

Before the procedure, the patient verbalizes knowledge about cardiac

catheterization and the postcatheterization plan of care.

PART I: Medical-Surgical Nursing

Assessthepatient’shealthcareliteracy(language,reading,

comprehension).Assesscultureandculturallyspecificinformation

needs.

Thisassessmenthelpsensurethatinformationisselectedand

presentedinamannerthatisculturallyandeducationally

appropriate.

Assessthepatient’sknowledgeaboutthecatheterizationprocedure.As

appropriate,reinforcethehealthcareprovider’sexplanation,and

answeranyquestionsorconcerns.Describethecatheterizationlab

andsensationsthepatientmayexperience.

Knowledgeabouttheprocedureandwhattoexpectmayhelpreduce

anxiety.

Beforecardiaccatheterization,havethepatientpracticetechniquesthat

willbeusedduringtheprocedure.

Valsalva’smaneuver,coughing,anddeepbreathingmayberequired

duringthecardiaccatheterization,andmanypeopleareunfamiliar

withthepropertechnique.

Explainthata“flushing”feelingmayoccurwhendyeininitiallyinjected. Dyeinjectioncausesvasodilation,whichofteninducesflushing.

Explainthepostcatheterizationregimenandcautionthatflexingthe

insertionsiteiscontraindicated,oftenfor4-6hrpostprocedure.

Aftertheprocedurebedrestwillberequiredandvitalsigns,circulation,

andtheinsertionsitewillbecheckedatfrequentintervalstoensure

integrity.Flexingtheinsertionsite(armorgroin)iscontraindicated

topreventbleeding.

Stresstheimportanceofpromptlyreportingsignsandsymptomsof

concern.

Groin,leg,orbackpain;dizziness;chestpain;orshortnessofbreath

maysignalhemorrhageorembolizationofthestent.Prompt

reportingenablesrapidintervention.

Nursing Diagnosis:

Risk for Decreased Cardiac Tissue Perfusion

related to interrupted arterial flow occurring with the cardiac catheterization procedure

Desired Outcome:

Within 1 hr after the procedure, the patient has adequate perfusion as evidenced by HR regular and within 20 bpm of baseline HR; apical/radial pulse equality; BP within 20 mm Hg of baseline BP; peripheral pulse amplitude greater than 2+ on a 0-4+ scale;

warmth and normal color in the extremities; no significant change in mental status; and orientation to person, place, and time.

ASSESSMENT/INTERVENTIONS RATIONALES

AssessBPq15minuntilstableon3successivechecks,q2hforthenext

12hr,andq4hfor24hrunlessotherwiseindicated.

TheseassessmentsmonitorBPtrend.

Note:Iftheinsertionsitewastheantecubitalspace,measureBPinthe

unaffectedarm.

Thismeasurepreventsbleedingorbloodvesselinjury.

Ifthefemoralarterywastheinsertionsite,maintainHOBatnogreater

thana30-degreeelevation.

Thismeasurepreventsacutehipjointflexion,whichcouldcompromise

arterialflow.

IftheSBPdrops20mmHgormorebelowpreviousrecordings,lower

theHOBandnotifythehealthcareprovider.

AdropinBPcouldsignifyacutebleedingorshock.LoweringtheHOB

aidsperfusiontotheheartandbrain.

AssessHR,andnotifythehealthcareproviderifdysrhythmiasoccur.If

thepatientisnotonacardiacmonitor,auscultateapicalandradial

pulseswitheveryBPcheck,andreportirregularitiesorapical/radial

discrepancies.

Dysrhythmiasandapical/radialdiscrepanciesmaybesignsofcardiac

ischemia.

Bealerttoandreportcoolextremities,decreasedamplitudeof

peripheralpulses,cyanosis,changesinmentalstatus,decreased

levelofconsciousness,andshortnessofbreath.

Theseareindicatorsofdecreasedperfusion.

PART I MEDICAL-SURGICALNURSING:Cardiovascular Care Plans RiskforIneffectivePeripheralTissuePerfusion

Coronary Artery Disease

161

CardiovascularCarePlans

PART I: Medical-Surgical Nursing

Nursing Diagnoses:

Risk for Bleeding/

Risk for Deficient Fluid Volume

related to the potential for hemorrhage caused by arterial puncture and/or osmotic diuresis caused by the contrast dye

Desired Outcomes:

The patient remains normovolemic as evidenced by HR 100 bpm or less;

BP 90/60 mm Hg or greater (or within 20 mm Hg of baseline range); no significant change in mental status; and orientation to person, place, and time. The dressing is dry, and there is no swelling at the puncture site.

ASSESSMENT/INTERVENTIONS RATIONALES

AssessvitalsignsandpromptlyreportadecreaseinBP,increaseinHR,

anddecreasinglevelofconsciousness(LOC).

Theseareindicatorsofhemorrhageand/orshock.Rapidreporting

enablespromptintervention.

Inspectthedressingonthegroinorantecubitalspaceatfrequent

intervals,andreportsignificantfindings.

Thismeasuredetectspresenceoffrankbleedingorhematoma

formation(fluctuatingswelling),whichwouldnecessitateprompt

intervention.

Assessforandreportdiminishedamplitudeorabsenceofdistalpulses,

delayedcapillaryrefill,coolnessoftheextremities,andpallor.

Thesesignsofdecreasedperipheralperfusionmaysignalembolization

orhemorrhagicshock.

Cautionthepatientaboutflexingtheelboworhipmorethan30degrees

for6-8hr,orasprescribed.

Theserestrictionsminimizeriskofbleedingandcirculationcompromise.

Ifbleedingoccurs,maintainpressureattheinsertionsiteas

prescribed,usually1inchproximaltothepuncturesiteorintroducer

insertionsite.

Pressurestabilizesbleeding.Typicallythisisdonewithapressure

dressingora2-to5-lbsandbag.

Nursing Diagnosis:

Risk for Ineffective Peripheral Tissue Perfusion

related to interrupted arterial flow in the involved limb occurring with embolization

Desired Outcome:

Within 1-2 hr following intervention, the patient has adequate perfusion in the involved limb as evidenced by peripheral pulse amplitude greater than 2 + on a 0-4+

scale; normal color, sensation, and temperature; and brisk capillary refill (less than 2 sec).

ASSESSMENT/INTERVENTIONS RATIONALES

Assessperipheralperfusionbypalpatingperipheralpulsesq15minfor

30min,thenq30minfor1hr,thenhourlyfor2hr,orperprotocol.

Promptrecognitionofadiminishedorabsentpulseisessentialto

preventlimbdamage.

Bealerttoandreportfaintnessorabsenceofpulse;coolnessofthe

extremity;mottling;decreasedcapillaryrefill;cyanosis;and

complaintsofnumbness,tingling,andpainattheinsertionsite.

Instructthepatienttoreportanyoftheseindicatorspromptly.

Thesearesignsofembolizationintheinvolvedlimb.Promptrecognition

willresultinrapidintervention.

Ifthereisnoevidenceofanembolusorthrombusformation,instruct

thepatienttomovethefingersortoesandrotatethewristorankle.

Thesemeasurespromotecirculationintheinvolvedlimbs.

Ensurethatthepatientmaintainsbedrestfor4-6hrorasprescribed. Bedrestorimmobilityenablesthepuncturesitetostabilize,thereby

avoidingbleeding.

PART I: Medical-Surgical Nursing

Risk for Ineffective Renal Perfusion

related to interrupted blood flow occurring with decreased cardiac output or reaction to contrast dye

Desired Outcome:

The patient has adequate renal perfusion as evidenced by a stable blood urea nitrogen (BUN)/creatinine, urinary output of at least 30 mL/hr (0.5 mL/kg/hr), specific gravity less than 1.030, good skin turgor, and moist mucous membranes.

ASSESSMENT/INTERVENTIONS RATIONALES

Assessforindicatorsofdehydration,suchaspoorskinturgor,dry

mucousmembranes,andhighurinespecificgravity(1.030ormore).

Contrastdyeforcardiaccatheterizationmaycauseosmoticdiuresis.

Assessintakeandoutput. Thisassessmentdeterminesifurineoutputissufficient.

Notifythehealthcareproviderifurinaryoutputislessthan30mL/hr

(0.5mL/kg/hr)inthepresenceofadequateintake.

Afallinurinaryoutputisasignofdehydrationorrenalinsufficiency.

MonitorBUNandcreatininedaily. Ariseintheserenalmarkersmaysignifyrenalinsufficiencyoracute

renalfailure.SeeAppendixB,“LaboratoryTestsDiscussedinThis

Manual:NormalValues,”p.754,foroptimalvalues.

Ifurinaryoutputisinsufficientdespiteadequateintake,restrictfluids. Thismeasurehelpspreventfluidoverload.

Bealerttoandreportcrackles(rales)onauscultationoflungfields,

distendedneckveins,andshortnessofbreath;notifythehealthcare

provideraboutsignificantfindings.

Thesesignsareotherindicatorsoffluidoverload.Promptdetectionand

reportingenablerapidintervention.

Ifthepatientdoesnotexhibitsignsofcardiacorrenalfailure,

encouragedailyintakeof2-3Loffluidsorasprescribed.

Increasinghydrationhelpsflushcontrastdyeoutofthesystemmore

quickly.

ADDITIONAL NURSING DIAGNOSES/PROBLEMS:

“PsychosocialSupport” p.72

“PsychosocialSupportforthePatient’sFamilyand

SignificantOthers” p.84

“PulmonaryEmbolus,”Risk for Bleedingrelatedto

anticoagulationtherapy p.130

“CardiacSurgery”foradiscussionofCABG p.149

“DysrhythmiasandConductionDisturbances” p.164

PATIENT-FAMILY TEACHING AND DISCHARGE PLANNING

When providing patient-family teaching, focus on sensory information, avoid giving excessive information, and initiate a visiting nurse referral for necessary follow-up teaching.

Include verbal and written information about the following:

✓

Signs and symptoms necessitating immediate medical attention, including chest pain unrelieved by NTG, decreased exercise tolerance, increasing shortness of breath, increased leg edema or pain (postcatheteriza-tion), and loss of consciousness.

✓ Importance of reporting to the health care provider any

change in pattern or frequency of angina.

✓ Importance of follow-up with the health care provider;

confirm date and time of next appointment.

✓ Importance of getting BP checked at regular intervals

(at least monthly if the patient is hypertensive).

✓ Pulse monitoring: how to self-measure pulse, including

parameters for target heart rates and limits.

✓ Avoiding strenuous activity for at least 1 hr after meals

to help prevent excessive O

2

demands.

✓ Medications, including drug name, dosage, purpose,

schedule, precautions, and potential side effects.

Also discuss drug-drug, food-drug, and herb-drug inter-actions (see appropriate Deficient Knowledge). Explain the potential for headache and dizziness after NTG administration. Caution the patient about using NTG more frequently than prescribed and notifying the health care provider if three tablets do not relieve angina.

✓ Importance of reducing or eliminating intake of

caf-feine, which causes vasoconstriction and increases HR.

✓ Dietary changes: low saturated fat, low sodium, low

cho-lesterol, and need for weight loss if appropriate.

Encour-age use of food labels to determine caloric, cholesterol,

fat, and sodium content of foods.

PART I MEDICAL-SURGICALNURSING:Cardiovascular Care Plans RiskforIneffectiveRenalPerfusion

Coronary Artery Disease

163

CardiovascularCarePlans

PART I: Medical-Surgical Nursing

✓

Prescribed exercise program and importance of main-taining a regular exercise schedule, with referral to a cardiac rehabilitation program, in which individualized exercise programs are outlined for the patient.

✓

Practice of stress reduction techniques.

✓

Elimination of smoking and tobacco use. Refer patient to a “stop smoking” program as appropriate. The follow-ing Internet resources support and describe methods and reasons to advise patients to stop smoking:

•

http://smokefree.gov/

•

http://www.cancer.gov/cancertopics/tobacco/smoking

• Importance of involvement and support of significant others in patient’s lifestyle changes.

• Availability of community and medical support, such as American Heart Association at www.americanheart

.org.

• The Heart and Stroke Foundation at

www .heartandstroke.com.

Conduction Disturbances 20

OVERVIEW/PATHOPHYSIOLOGY

Dysrhythmias are abnormal rhythms of the heart caused by conditions that alter electrical conduction. Dysrhythmias originate in different areas of the conduction system, such as the sinus node, atrium, atrioventricular (A-V) node, His-Purkinje system, bundle branches, and ventricular tissue.

Many conditions and diseases may cause dysrhythmias; the most common are coronary artery disease (CAD) and myocardial infarction (MI). Other causes include fluid and electrolyte imbalance, hormonal imbalance, changes in oxy-genation, medications, and drug toxicity. Cardiac dysrhyth-mias may result from the following mechanisms:

Disturbances in automaticity: May involve an increase