Cardiovascular Treatment 2010

8/9/2019 Cardiovascular Treatment 2010

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CARDIOVASCULARCARDIOVASCULARSYSTEMSYSTEM

TREATMENTTREATMENT

MODALITIESMODALITIES


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PERCUTANEOUS TRANSLUMINALPERCUTANEOUS TRANSLUMINAL

CORONARY ANGIOPLASTYCORONARY ANGIOPLASTY

(PTCA)(PTCA)DESCRIPTIONDESCRIPTION

One or more arteries are dilated with aOne or more arteries are dilated with a

balloon catheter to open the vesselballoon catheter to open the vessellumen and improve arterial blood flowlumen and improve arterial blood flow

The client can experience reocclusionThe client can experience reocclusionafter the procedure, thus the procedureafter the procedure, thus the procedure

may need to be repeatedmay need to be repeated


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(PTCA)(PTCA)DESCRIPTIONDESCRIPTION

Complications can include arterialComplications can include arterialdissection or rupture, immobilization ofdissection or rupture, immobilization ofplaque fragments, spasm, and acuteplaque fragments, spasm, and acutemyocardial infarction (MI)myocardial infarction (MI)

Firm commitment is needed on theFirm commitment is needed on the

clients part to stop smoking, loseclients part to stop smoking, loseweight, alter exercise pattern, and stopweight, alter exercise pattern, and stopany behaviors that lead to progressionany behaviors that lead to progressionof artery occlusionof artery occlusion


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NORMAL ARTERY ANDNORMAL ARTERY AND

ATHEROSCLEROSISATHEROSCLEROSIS

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders


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(PTCA)(PTCA)

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.


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(PTCA)(PTCA)PREPROCEDUREPREPROCEDURE

Maintain NPO status after midnightMaintain NPO status after midnight

Prepare the groin area with antisepticPrepare the groin area with antisepticsoap and shave per institutionalsoap and shave per institutionalprocedure and as prescribedprocedure and as prescribed

Assess baseline VS and peripheralAssess baseline VS and peripheral

pulsespulses


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(PTCA)(PTCA)POSTPROCEDUREPOSTPROCEDURE

Monitor VS closelyMonitor VS closely

Assess distal pulses in both extremitiesAssess distal pulses in both extremitiesMaintain bed rest as prescribed, keepingMaintain bed rest as prescribed, keeping

the limb straight for 6 to 8 hoursthe limb straight for 6 to 8 hours

Administer anticoagulants andAdminister anticoagulants and

antiplatelets as prescribed to preventantiplatelets as prescribed to preventthrombus formationthrombus formation


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(PTCA)(PTCA)POSTPROCEDUREPOSTPROCEDURE

Monitor IV nitroglycerin that may beMonitor IV nitroglycerin that may beprescribed to prevent coronary artery spasmprescribed to prevent coronary artery spasm

Instruct the client in the administration ofInstruct the client in the administration ofnitrates, calcium channel blockers,nitrates, calcium channel blockers,antiplatelet agents, and anticoagulants asantiplatelet agents, and anticoagulants asprescribedprescribed

Instruct the client to take daily aspirinInstruct the client to take daily aspirinpermanently if prescribedpermanently if prescribed

Assist the client with planning lifestyleAssist the client with planning lifestylemodificationsmodifications


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LASERLASER--ASSISTEDASSISTED

ANGIOPLASTYANGIOPLASTY

DESCRIPTIONDESCRIPTION

A laser probe is advanced through aA laser probe is advanced through acannula similar to that used for PTCAcannula similar to that used for PTCA

Also used in clients with smallAlso used in clients with smallocclusions in the distal superficialocclusions in the distal superficialfemoral, proximal popliteal, andfemoral, proximal popliteal, and

common iliac arteriescommon iliac arteriesHeat from the laser vaporizes theHeat from the laser vaporizes the

plaque to open the occluded arteryplaque to open the occluded artery


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LASERLASER--ASSISTEDASSISTED

ANGIOPLASTYANGIOPLASTY

PREPROCEDURE ANDPREPROCEDURE ANDPOSTPROCEDURE CAREPOSTPROCEDURE CARE

Similar to the PTCASimilar to the PTCAMonitor for complications of coronaryMonitor for complications of coronary

dissection, acute occlusion, perforation,dissection, acute occlusion, perforation,embolism, and MIembolism, and MI


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CORONARY ARTERYCORONARY ARTERY

STENTSSTENTS


Used instead of PTCA to eliminate theUsed instead of PTCA to eliminate therisk of acute coronary vessel closurerisk of acute coronary vessel closureand to improve longand to improve long--term patency ofterm patency ofthe vesselthe vessel

A balloon catheter bearing the stent isA balloon catheter bearing the stent is

inserted into the coronary artery andinserted into the coronary artery andpositioned at the site of occlusionpositioned at the site of occlusion

When placed in the coronary artery, theWhen placed in the coronary artery, thestent reopens the blocked arterystent reopens the blocked artery


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STENTSTENT

From Monahan FD, Neighbers M: Medical-surgical nursing: foundations for

clinical practice, ed. 2, Philadelphia, 1998, W.B. Saunders.


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STENTSSTENTS

POSTPROCEDUREPOSTPROCEDURE

Acute thrombosis is a major concernAcute thrombosis is a major concernfollowing the procedure, and the clientfollowing the procedure, and the clientis placed on antiplatelet andis placed on antiplatelet andanticoagulation therapy for severalanticoagulation therapy for severalmonths following the proceduremonths following the procedure

Monitor for complications of theMonitor for complications of theprocedure, such as stent migration orprocedure, such as stent migration orocclusion, coronary artery dissection,occlusion, coronary artery dissection,and bleeding due to anticoagulationand bleeding due to anticoagulation


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ATHERECTOMYATHERECTOMY


Removes plaque from an artery by theRemoves plaque from an artery by theuse of a cutting chamber on theuse of a cutting chamber on theinserted catheter or a rotating bladeinserted catheter or a rotating bladethat pulverizes the plaquethat pulverizes the plaque

Used to improve blood flow to ischemicUsed to improve blood flow to ischemic

limbs in individuals with peripherallimbs in individuals with peripheralarterial diseasearterial disease

POSTPROCEDUREPOSTPROCEDURE

Monitor for complications of perforation,Monitor for complications of perforation,

embolus, and reocclusionembolus, and reocclusion


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ATHERECTOMYATHERECTOMY

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3, St. Louis: Mosby.


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TRANSMYOCARDIALTRANSMYOCARDIAL

REVASCULARIZATIONREVASCULARIZATION

Used for clients with widespreadUsed for clients with widespreadatherosclerosis involving vessels thatatherosclerosis involving vessels thatare too small and numerous forare too small and numerous for

replacement or balloonreplacement or ballooncatheterizationcatheterization

Uses a highUses a high--powered laser thatpowered laser thatcreates 15 to 30 holes (channels) increates 15 to 30 holes (channels) inthe heart; blood enters these smallthe heart; blood enters these smallchannels providing the affectedchannels providing the affectedregion of the heart with oxygenatedregion of the heart with oxygenatedbloodblood


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ARTERIALARTERIAL

REVASCULARIZATIONREVASCULARIZATIONDESCRIPTIONDESCRIPTIONPerformed to increase arterial blood flowPerformed to increase arterial blood flow

to the affected limbto the affected limb

Inflow procedures involve bypassing theInflow procedures involve bypassing thearterial occlusion above the superficialarterial occlusion above the superficialfemoral arteriesfemoral arteries

Outflow procedures involve bypassingOutflow procedures involve bypassing

the arterial occlusions at or below thethe arterial occlusions at or below thesuperficial femoral arteriessuperficial femoral arteries

Graft material is sutured above andGraft material is sutured above andbelow the occlusion to facilitate bloodbelow the occlusion to facilitate blood

flow around the occlusionflow around the occlusion


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ARTERIALARTERIAL

REVASCULARIZATIONREVASCULARIZATIONPREOPERATIVEPREOPERATIVE

Assess baseline VS and peripheralAssess baseline VS and peripheralpulsespulses

Insert an IV and urinary catheter asInsert an IV and urinary catheter asprescribedprescribed

Maintain central venous catheter and orMaintain central venous catheter and or

arterial line if insertedarterial line if inserted


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ARTERIALARTERIAL

REVASCULARIZATIONREVASCULARIZATIONPOSTOPERATIVEPOSTOPERATIVE

Assess VSAssess VS

Monitor the blood pressure and notifyMonitor the blood pressure and notifythe physician if changes occurthe physician if changes occur

Monitor for hypotension, which mayMonitor for hypotension, which mayindicate hypovolemiaindicate hypovolemia

Monitor for hypertension, which mayMonitor for hypertension, which mayplace stress on the graft and facilitateplace stress on the graft and facilitateclot formationclot formation

Maintain bed rest for 24 hours asMaintain bed rest for 24 hours as

prescribedprescribed


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ARTERIALARTERIAL

REVASCULARIZATIONREVASCULARIZATIONPOSTOPERATIVEPOSTOPERATIVE Instruct the client to keep affectedInstruct the client to keep affected

extremity straight, limit movement, andextremity straight, limit movement, and

avoid bending the knee and hipavoid bending the knee and hipMonitor for warmth, redness, andMonitor for warmth, redness, and

edema, which are often expectededema, which are often expectedoutcomes due to increased blood flowoutcomes due to increased blood flow

Monitor for graft occlusion, which oftenMonitor for graft occlusion, which oftenoccurs within the first 24 hoursoccurs within the first 24 hours

Assess peripheral pulses and forAssess peripheral pulses and foradverse changes in color andadverse changes in color and

temperature of the extremitytemperature of the extremity


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ARTERIALARTERIAL

REVASCULARIZATIONREVASCULARIZATIONPOSTOPERATIVEPOSTOPERATIVEMonitor for a sharp increase in pain,Monitor for a sharp increase in pain,

since pain is frequently the firstsince pain is frequently the first

indicator of postoperative graftindicator of postoperative graftocclusionocclusion

If signs of graft occlusion occur, notifyIf signs of graft occlusion occur, notifythe physician immediatelythe physician immediately

Encourage coughing and deep breathingEncourage coughing and deep breathingand the use of incentive spirometryand the use of incentive spirometry

Maintain NPO status with progression toMaintain NPO status with progression toclear liquids as prescribedclear liquids as prescribed

Use strict aseptic technique when inUse strict aseptic technique when in


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ARTERIALARTERIAL


Assess the incision for drainage,Assess the incision for drainage,warmth, or swellingwarmth, or swelling

Monitor for excessive bleeding (a smallMonitor for excessive bleeding (a smallamount of bloody drainage is expected)amount of bloody drainage is expected)

Monitor the area over the graft forMonitor the area over the graft for

hardness, tenderness, and warmth,hardness, tenderness, and warmth,which may indicate infection; if thiswhich may indicate infection; if thisoccurs, notify the physician immediatelyoccurs, notify the physician immediately


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ARTERIALARTERIAL


Instruct the client about proper footInstruct the client about proper footcare and measures to prevent ulcercare and measures to prevent ulcerformationformation

Instruct the client to take medicationsInstruct the client to take medicationsas prescribedas prescribed

Instruct the client how to care for theInstruct the client how to care for theincisionincision

Assist the client in modifying lifestyle toAssist the client in modifying lifestyle toprevent further plaque formationprevent further plaque formation


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BYPASS GRAFT (CABG)BYPASS GRAFT (CABG)

DESCRIPTIONDESCRIPTIONThe occluded coronary arteries areThe occluded coronary arteries are

bypassed with the clients own venousbypassed with the clients own venous

or arterial blood vesselsor arterial blood vesselsThe saphenous vein, radial artery, orThe saphenous vein, radial artery, or

internal mammary artery is used tointernal mammary artery is used tobypass lesions in the coronary arteriesbypass lesions in the coronary arteries

Performed when the client does notPerformed when the client does notrespond to medical management ofrespond to medical management ofcoronary artery disease (CAD) or whencoronary artery disease (CAD) or whendisease progression is evidentdisease progression is evident


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BYPASS GRAFT (CABG)BYPASS GRAFT (CABG)

From Lewis SM, Heitkemper M, Dirksen S: Medical-Surgical Nursing: Assessment

and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.


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CORONARY ARTERY BYPASSCORONARY ARTERY BYPASS

GRAFT (CABG)GRAFT (CABG)PREOPERATIVEPREOPERATIVE

Familiarize the client and family with theFamiliarize the client and family with thecardiac surgical critical care unitcardiac surgical critical care unit

Instruct the client how to splint theInstruct the client how to splint thechest incision, cough and deep breathe,chest incision, cough and deep breathe,and perform arm and leg exercisesand perform arm and leg exercises

Instruct the client to inform the nurse ofInstruct the client to inform the nurse ofany postoperative pain, as painany postoperative pain, as painmedication will be availablemedication will be available


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GRAFT (CABG)GRAFT (CABG)

PREOPERATIVEPREOPERATIVE

Inform the client to expect a sternalInform the client to expect a sternalincision, possible arm or leg incision(s),incision, possible arm or leg incision(s),one or two chest tubes, a Foleyone or two chest tubes, a Foleycatheter, and several IV fluid catheterscatheter, and several IV fluid catheters

Inform the client that an endotrachealInform the client that an endotracheal(ET) tube will be in place and connected(ET) tube will be in place and connectedto a ventilator for 6 to 24 hoursto a ventilator for 6 to 24 hours

Advise the client to breathe with theAdvise the client to breathe with theventilator and not fight itventilator and not fight it


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Inform the family that the client will notInform the family that the client will notbe able to talk while the ET tube is inbe able to talk while the ET tube is inplaceplace

Note that prescribed medications are toNote that prescribed medications are tobe discontinued preoperativelybe discontinued preoperatively(diuretics 2 to 3 days prior to surgery,(diuretics 2 to 3 days prior to surgery,digitalis 12 hours prior to surgery, anddigitalis 12 hours prior to surgery, andaspirin and anticoagulants 1 week prioraspirin and anticoagulants 1 week priorto surgery)to surgery)


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Administer medications as prescribed,Administer medications as prescribed,which may include potassium chloride,which may include potassium chloride,antihypertensives, antidysrhythmics,antihypertensives, antidysrhythmics,and antibioticsand antibiotics

Encourage the client and family toEncourage the client and family todiscuss anxieties and fears related todiscuss anxieties and fears related tosurgerysurgery


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CARDIAC SURGICAL UNITCARDIAC SURGICAL UNIT

Maintain mechanical ventilation for 6 toMaintain mechanical ventilation for 6 to24 hours as prescribed24 hours as prescribed

Monitor heart rate and rhythm,Monitor heart rate and rhythm,pulmonary artery and arterial pressures,pulmonary artery and arterial pressures,and neurological statusand neurological status

Monitor mediastinal and pericardialMonitor mediastinal and pericardialtubes and water seal drainage system,tubes and water seal drainage system,and report drainage exceeding 100 toand report drainage exceeding 100 to150 ml per hour150 ml per hour


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Ground epicardial pacer wiresGround epicardial pacer wires

Assess fluid and electrolyte balanceAssess fluid and electrolyte balanceRestrict fluids as prescribed to 1500 toRestrict fluids as prescribed to 1500 to

2000 ml because the client usually has2000 ml because the client usually hasedemaedema

Monitor for hypotension, which canMonitor for hypotension, which cancause collapse of a vein graftcause collapse of a vein graft


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Monitor for hypertension becauseMonitor for hypertension becauseincreased pressure promotes leakageincreased pressure promotes leakagefrom the suture line and may causefrom the suture line and may causebleedingbleeding

Monitor the temperature and initiateMonitor the temperature and initiaterewarming procedures using warm orrewarming procedures using warm orthermal blankets if the temperaturethermal blankets if the temperaturedrops below 96.8drops below 96.8 F; rewarm the clientF; rewarm the clientno faster than 1.8no faster than 1.8 F per hour toF per hour to

prevent shivering, and discontinue whenprevent shivering, and discontinue when


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CARDIAC SURGICAL UNITCARDIAC SURGICAL UNITAdminister potassium IV as prescribedAdminister potassium IV as prescribed

to maintain the potassium level betweento maintain the potassium level between

4 and 5 mEq/L to prevent dysrhythmias4 and 5 mEq/L to prevent dysrhythmiasMonitor for signs of cardiac tamponade,Monitor for signs of cardiac tamponade,

which will include sudden cessation ofwhich will include sudden cessation ofpreviously heavy mediastinal drainage,previously heavy mediastinal drainage,

jugular vein distention with clear lungjugular vein distention with clear lungsounds, and pulsus paradoxussounds, and pulsus paradoxus

Monitor pain, differentiating sternotomyMonitor pain, differentiating sternotomypain from anginal pain, which wouldpain from anginal pain, which wouldindicate graft failureindicate graft failure


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TRANSFER FROM THE CARDIACTRANSFER FROM THE CARDIACSURGICAL UNITSURGICAL UNIT

Monitor VS, level of consciousnessMonitor VS, level of consciousness(LOC), and peripheral perfusion(LOC), and peripheral perfusion

Monitor for dysrhythmiasMonitor for dysrhythmias

Auscultate lungs and assessAuscultate lungs and assessrespiratory statusrespiratory status

Encourage the client to splint theEncourage the client to splint theincision, cough and deep breathe, andincision, cough and deep breathe, and

use an incentive spirometer to raiseuse an incentive spirometer to raise


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Monitor temperature and WBC count,Monitor temperature and WBC count,which if elevated after 3 to 4 days,which if elevated after 3 to 4 days,indicates infectionindicates infection

Provide adequate fluids and hydrationProvide adequate fluids and hydrationas prescribed to liquefy secretionsas prescribed to liquefy secretions

Assess suture line and chest tubeAssess suture line and chest tubeinsertion sites for redness, purulentinsertion sites for redness, purulentdischarge, and signs of infectiondischarge, and signs of infection


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Assess sternal suture line forAssess sternal suture line forinstability, which may indicate aninstability, which may indicate aninfectioninfection

Guide the client to gradually resumeGuide the client to gradually resume

activityactivityAssess the client for tachycardia;Assess the client for tachycardia;

orthostatic hypotension; and fatigueorthostatic hypotension; and fatiguebefore, during, and after activitybefore, during, and after activity

Discontinue activities if the BP dropsDiscontinue activities if the BP drops


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Progression with activities at homeProgression with activities at homeLimit pushing or pulling activities forLimit pushing or pulling activities for6 weeks following discharge6 weeks following discharge

Incisional care and to record signs ofIncisional care and to record signs ofredness, swelling, or drainageredness, swelling, or drainage

Sternotomy incision heals in about 6Sternotomy incision heals in about 6to 8 weeksto 8 weeks

Avoid crossing legs, wear elasticAvoid crossing legs, wear elastichose as prescribed until edemahose as prescribed until edemasubsides, and elevate surgical limbsubsides, and elevate surgical limb

when sitting in a chairwhen sitting in a chair

HOME CARE INSTRUCTIONS FOLLOWINGHOME CARE INSTRUCTIONS FOLLOWINGCARDIAC SURGERYCARDIAC SURGERY


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HOME CARE INSTRUCTIONSHOME CARE INSTRUCTIONS

FOLLOWING CARDIACFOLLOWING CARDIAC

SURGERYSURGERYUse of prescribed medicationsUse of prescribed medications

Dietary measures including the avoidanceDietary measures including the avoidanceof saturated fats and cholesterol and theof saturated fats and cholesterol and the

use of saltuse of salt

Sexual intercourse can be resumed on theSexual intercourse can be resumed on theadvice of the physician after exerciseadvice of the physician after exercisetolerance is assessed; if the client cantolerance is assessed; if the client can

walk one block or climb two flights ofwalk one block or climb two flights ofstairs without symptoms, they can safelystairs without symptoms, they can safelyresume sexual activityresume sexual activity

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Cardiovascular Treatment 2010

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