Kristin Hinkle

NSC 386

Coronary Artery Disease pt. 2

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Other Care for ACS 1. Coronary Artery Bypass Graft (CABG)-open heart surgery Placement of new passages (vessels) between the aorta, or other major arteries, beyond the obstructed coronary arteries Most commonly used grafts= internal mammary artery and saphenous vein Antiplatelet therapy improves vein graft patency Done when cant use balloon or stent to open blockage A large incision is made, saw through sternum, heart is stopped and pt. is on cardio/pulmonary bypass, pts. temp is cooled to 82-89*F Aspirin is given after surgery to improve patency of the new graft 10% of cases will re-occlude within 10 years of surgery (with no lifestyle change) CABG Other Care for ACS 2. Minimally Invasive Direct Coronary Artery Bypass For patients needing bypasses in one or 2 coronary arteries on the anterior surface of the heart cant be posterior Several small incisions are made between the ribs, the heart is slowed with beta-blockers, and the graft is sutured to the LAD or RCA Advantages= decreased cost and Length Of Stay, shorter recovery No sternal incision! No cardio/ pulmonary by-pass Other Care for ACS #3. Fibrinolytic (clot buster) Therapy medication that is given IV For facilities that do not have an interventional cardiac cath. Lab (cant do balloon angioplasty or stents) Dissolves the coronary artery thrombus Should be given within the first 6 hours (ideally within the first hour) of onset of pain, dyspnea Blood thinner- thins blood but cant bust clot; fibrinolytic can bust clots Fibrinolytic Therapy Inclusion Criteria: 1, chest pain typical of MI (< or = 6 hrs in duration) 2. EKG finding consistent with MI (has ST elevation-look like tombstones) 3. No conditions that predispose the pt. to hemorrhage Contraindicated with: Active PUD (peptic ulcer disease-bleeding), pregnancy, hx of hemorrhagic cva (stroke), known malignant brain tumor, recent surgery(within past 3 weeks), or severe uncontrolled HTN BP 180/110 Nursing Care with Fibrinolytics 1. Draw blood for baseline lab values- will check again after- PTT, PT INR, CBC (platelets), HNH 2. Insert 2-3 IV lines- cant give other stuff through line fibrinolytics are going through- establish lines first because they can bleed afterward. 3rd line foe blood draws 3. Do all invasive procedures before infusion started- Foley, NG tube.. 4. Monitor hearth rhythm, vital signs & O2 Sat Watch for reperfusion dysrhythmias (mostly ventricle- PVCs, VTac, V-Fib

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Kristin Hinkle

NSC 386

Coronary Artery Disease pt. 2

ST elevation should return to normal Rush of blood to area not used to it so the heart freaks outmostly PVCs 5. Monitor Heparin Drip- preventative- to keep another clot from forming 6. Watch for bleeding Can experience minor bleeding Notify MD. If BP, HR (*hallmark sign of internal bleeding), change in LOC (sleepy, confused, slurred speech) bloody urine or stool Check @ 15 minutes 7. Monitor Biomarkers CK-MB increases and peaks early Nursing Diagnoses Related to MI Acute pain r/t myocardial ischemia Decreased cardiac output r/t myocardial injury Ineffective tissue perfusion (cardiac) r/t myocardial injury Anxiety r/t pain & perceived threat of death Activity intolerance r/t decreased cardiac output & poor lung perfusion Complications of MI 1. Dysrhythmias (most common complication after MI) in @ 80% of pts. 2. Heart Failure loses effective pumping ability 3. Cardiogenic Shock (severe left ventricular dysfunction) Medical Emergency! O2 perfusion, very high mortality rate 4. Papillary Muscle Dysfunction Medical Emergency! Papillary muscle attaches to the mitral valve ( on lt. side between Lt. atria & Lt. ventricle) opens & closes mitral valve- rapid deterioration; can hear new systolic murmur can be heard 5. Pericarditis Can affect ventricular filling/emptying within 2-3 days of MI : Inflammation to pericardial area 6. Dressler Syndrome = pericarditis with effusion (collection of fluid) and fever 4-6 weeks after MI. this fluid can get infected- chest pain, fever, friction rub (sounds like sandpaper rubbing) Nursing Care After an Acute MI Provide Education: Pt. needs to change their ways! Cardiac rehabilitation- financial, occupational, emotional, physical Proper use of Nitroglycerin (NTG) Dietary Teaching- Sodium, Saturated Fats Maintain ideal body weight- if not at ideal, help them try to get there Exercise- no too much. Listen to your body. Stop if you have symptoms Emotional support- increased rates of depression; lost of lifestyle changes hard Resumption of sexual activity- after 7-10 days; do not use meds for erectile dysfunction with nitrates-NTG, Imdur- can cause unsafe drop in BP #3. Sudden Cardiac Death (SCD) MOST SERIOUS!! Cardiac arrest, respiratory arrest Unexpected death from cardiovascular causes No CO, No blood to brain Usual culprit = Acute Ventricular dysrhythmias: V-Tac, V-Fib

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Kristin Hinkle

NSC 386

Coronary Artery Disease pt. 2

2 categories: 1. No history of MI (majority)- heart failure, P.E., Rhythm disturbances 2. Prior acute MI- chest pain, symptoms of dyspnea Most commonly happens at HOME Sudden Cardiac Death- VERY TRAUMATIC Risk Factors: Strongest predictors= EF < 30% and ventricular dysrhythmias EF=Ejection Fraction- should be 55-65% EF is % of blood that is pumped out of the ventricles with each beat; How much blood is emptied vs. How much blood remains Male gender- esp. African Americans Family history of premature atherosclerosis Tobacco use- any DM- diabetes Hypercholesterolemia HTN hypertension Cardiomyopathy enlarged heart How should the nurse respond after a sudden cardiac death experience? Deal with Families: Presence/touch- be there, be available, hand on back, hold hand Allow for expression of feeling from family members- Anger is most common emotion Allow for moments of silence- let things sink in Be honest & direst- avoid medical jargon This must be very difficult for you Allow the family to have closure Sudden Cardiac Death Treatment for survivors of SCD ICD (most common approach) Antiarrythmics used in conjunction (Amiodarone) Psychosocial Needs- may need counciling time bomb pt. thinks: it happened once, it could happen again Patients may be reluctant to resume normal activities Loneliness/withdrawal/ depressed OR pt. may feel as if they have been given a 2nd chance and decide to REALLY live their lives now PT is asking about DNR: Make sure pt. knows exactly what you will/ wont do if they code need signed order by physician after pt. has decided Involve family- make sure they know pts wishes and understand what will happen Other resources; Hospice, end of life care, chaplin

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