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.
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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.
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Coronary Artery Disease163
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 or decrease in automaticity in the sinus node (e.g., sinus tachycardia or sinus bradycardia). Premature beats may arise from the atria, A-V junction, or ventricles. Abnormal rhythms, such as atrial or ventricular tachycardia, also may occur.
Disturbances in conductivity:
Conduction may be too rapid, as in conditions caused by an accessory pathway (e.g., Wolff-Parkinson-White syndrome), or too slow (e.g., A-V block). Reentry occurs when a stimulus reexcites a conduction pathway through which it already has passed. Once started, this impulse may circulate repeatedly. For reentry to occur, there must be two different pathways for conduction: one with slowed conduction and one with unidirectional block.
Combinations of altered automaticity and conductivity:
Several dysrhythmias occur together, for example, a first- degree A-V block (disturbance in conductivity) and prema- ture atrial contractions (disturbance in automaticity).
HEALTH CARE SETTING
Primary care, acute care, and intensive/coronary care unit (ICU/CCU)
ASSESSMENT
Signs and symptoms:
Can vary from absence of symptoms to complete cardiopulmonary collapse. General indicators include alterations in level of consciousness (LOC), vertigo, syncope, seizures, weakness, fatigue, activity intolerance, shortness of breath, dyspnea on exertion, chest pain, palpita- tions, sensation of “skipped beats,” anxiety, and restlessness.
Physical assessment:
Increases or decreases in heart rate (HR), blood pressure (BP), and respiration rate (RR); changes
skin; decreased urine output; weakened and paradoxical pulse;
and abnormal heart sounds (e.g., paradoxical splitting of S
1and S
2).
Electrocardiogram (ECG) results:
Changes with dysrhyth- mias include abnormalities in rate, such as sinus bradycardia or sinus tachycardia, irregular rhythm such as atrial fibrilla- tion, extra beats such as premature atrial contractions (PACs) and premature junctional contractions (PJCs), wide and bizarre-looking beats such as premature ventricular contrac- tions (PVCs) and ventricular tachycardia (VT), a fibrillating baseline such as ventricular fibrillation (VF), and a straight line as with asystole.
History and risk factors:
CAD, recent MI, electrolyte dis- turbances, substance abuse, drug toxicity, obesity, diabetes mellitus, obstructive sleep apnea, advanced age, genetic factors, thyroid problems, certain medications and supple- ments, and hypertension.
DIAGNOSTIC TESTS
12-lead ECG:
To detect dysrhythmias and identify possible origin.
Serum electrolyte levels:
To identify electrolyte abnormali- ties that can precipitate dysrhythmias. The most common are potassium and magnesium abnormalities.
Drug levels:
To identify toxicities (e.g., of digoxin, quini- dine, procainamide, aminophylline) that can precipitate dys- rhythmias, or to determine substance abuse that can affect heart rate and rhythm, such as cocaine.
Ambulatory monitoring (e.g., Holter monitor or cardiac event recorder):
To identify subtle dysrhythmias, associate abnor- mal rhythms by means of patient’s symptoms, and assess response to exercise.
Electrophysiology study:
Invasive test in which two to three catheters are placed into the heart, giving it a pacing stimulus at varying sites and of varying voltages. The test determines origin of dysrhythmia, inducibility, and effective- ness of drug therapy in dysrhythmia suppression.
Exercise stress testing:
Used in conjunction with Holter
monitoring to detect advanced grades of PVCs (those caused
by ischemia) and to guide therapy. During the test, ECG and
BP readings are taken while the patient walks on a treadmill
or pedals a stationary bicycle; response to a constant or
increasing workload is observed. The test continues until the
patient reaches target heart rate or symptoms such as chest
pain, severe fatigue, dysrhythmias, or abnormal BP occur.
Decreased Cardiac Output
Dysrhythmias and Conduction Disturbances165
Cardiovascular Care Plans
PART I: Medical-Surgical Nursing
Nursing Diagnosis:
Decreased Cardiac Output
related to altered rate, rhythm, or conduction or to negative inotropic changes
Desired Outcome:
Within 1 hr of treatment/intervention, the patient has improved cardiac output as evidenced by BP 90/60 mm Hg or higher, HR 60-100 bpm, and normal sinus rhythm on ECG.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s heart rhythm continuously on a monitor. This assessment will reveal whether dysrhythmias occur or increase in occurrence.
Assess BP and symptoms when dysrhythmias occur.
Report significant findings to the health care provider.
Signs of decreased cardiac output include decreased BP and symptoms such as unrelieved and prolonged palpitations, chest pain, shortness of breath, weakened and rapid pulse (more than 150 bpm), sensation of skipped beats, dizziness, and syncope.
Decreased cardiac output should be reported promptly for timely intervention, because it may be life threatening.
If symptoms of decreased cardiac output occur, prepare to transfer the patient to intensive care.
Transfer to a specialized intensive care unit for continual monitoring is essential.
Document dysrhythmias with a rhythm strip, using a 12-lead ECG as necessary.
This assessment will identify dysrhythmias and their general trend.
Monitor the patient’s laboratory data, particularly electrolyte and digoxin levels.
Serum potassium levels less than 3.5 mEq/L or more than 5.0 mEq/L can cause dysrhythmias. Digoxin toxicity may cause heart block or dysrhythmias.
Administer antidysrhythmic agents as prescribed; note patient’s response to therapy based on action of the following classifications:
Class IA: sodium channel blockers: quinidine, procainamide, disopyramide Decrease depolarization moderately and prolong repolarization.
Class IB: sodium channel blockers: phenytoin, mexiletine, tocainide Decrease depolarization and shorten repolarization.
Class IC: sodium channel blockers: encainide, flecainide, propafenone Significantly decrease depolarization with minimal effect on repolarization.
Class II: beta-blockers: propranolol, metoprolol, atenolol, acebutolol Slow sinus automaticity, slow conduction via A-V node, control ventricular response to supraventricular tachycardias, and shorten the action potential of Purkinje fibers.
Class III: potassium channel blockers: amiodarone, sotalol, ibutilide, dofetilide
Increase the action potential and refractory period of Purkinje fibers, increase ventricular fibrillation threshold, restore injured myocardial cell electrophysiology toward normal, and suppress reentrant dysrhythmias.
Class IV: calcium channel blockers: verapamil, diltiazem, nifedipine Depress automaticity in the sinoatrial (S-A) and A-V nodes, block the slow calcium current in the A-V junctional tissue, reduce conduction via the A-V node, and are useful in treating tachydysrhythmias because of A-V junction reentry. This class of drugs also vasodilates.
Monitor corrected QT interval (QTc) when initiating drugs known to cause QT prolongation (e.g., sotalol, propafenone, dofetilide, flecainide).
When QTc is prolonged, it can increase risk of dysrhythmias. QTc equals QT (in seconds) divided by the square root of the R-to-R interval (in seconds).
Provide humidified O2 as prescribed. O2 may be beneficial if dysrhythmias are related to ischemia or are causing hypoxia. Humidity helps prevent oxygen’s drying effects on oral and nasal mucosa.
Maintain a quiet environment, and administer pain medications promptly. Both stress and pain can increase sympathetic tone and cause dysrhythmias.
continued
PART I: Medical-Surgical Nursing
If life-threatening dysrhythmias occur, initiate emergency procedures and cardiopulmonary resuscitation (as indicated by advanced cardiac life support [ACLS] protocol).
This action provides circulation to vital organs and restores the heart to normal or viable rhythm.
When dysrhythmias occur, stay with the patient; provide support and reassurance while performing assessments and administering treatment.
This action reduces stress and provides comfort, which optimally will decrease dysrhythmias.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the mechanism by which dysrhythmias occur and lifestyle implications
Desired Outcome:
Within the 24-hr period before hospital discharge, the patient and signifi- cant other verbalize knowledge about causes of dysrhythmias and implications for the patient’s lifestyle modifications.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs.
This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate.
Discuss causal mechanisms for dysrhythmias, including resulting symptoms. Use a heart model or diagrams as necessary.
This information increases the patient’s knowledge about health status. Visual aids augment understanding of verbal information.
A knowledgeable patient is more likely to adhere to the therapeutic regimen.
Teach signs and symptoms of dysrhythmias that necessitate medical attention.
Indicators such as unrelieved and prolonged palpitations, chest pain, shortness of breath, rapid pulse (more than 120 bpm), dizziness, and syncope are serious and should be reported promptly for timely intervention.
Teach the patient and significant other how to check pulse rate for a full minute.
Checking the pulse rate for a full minute ensures a better average of rate and rhythm than if it were measured for 15 seconds and multiplied by 4.
Teach about medications that will be taken after hospital discharge, including drug name, purpose, dosage, schedule, precautions, and potential side effects. Also discuss drug-drug, food-drug, and herb-drug interactions.
See Decreased Cardiac Output, earlier, for a description of these medications and their actions.
The more knowledgeable the patient is, the more likely he or she is to adhere to therapy and report side effects and complications promptly for timely intervention.
Stress that the patient will be taking long-term antidysrhythmic therapy and that it could be life threatening to stop or skip these medications without health care provider involvement.
Stopping or skipping these drugs may decrease blood levels effective for dysrhythmia suppression.
Advise about the availability of support groups and counseling; provide appropriate community referrals. Explain that anxiety and fear, along with periodic feelings of denial, depression, anger, and confusion, are normal following this experience.
Patients who survive sudden cardiac arrest may experience nightmares or other sleep disturbances at home.
Stress the importance of leading a normal and productive life. If the patient is going on vacation, advise taking along sufficient medication and investigating health care facilities in the vacation area.
This concept may be difficult to implement for patients who fear breakthrough of life-threatening dysrhythmias and alter their lives accordingly.
Advise the patient and significant other to take cardiopulmonary resuscitation classes; provide addresses for community programs.
Emergency life-saving procedures may be necessary in the future.