post mi and cabg.2012.2013 multimedia
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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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