Download Cardiovascular Alterations

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Unit 5A - PROBLEMS OF CARDIAC OUTPUT AND TISSUE PERFUSION
Cardiovascular Alterations
STUDY GUIDE 5A-Discussion
Cardiovascular Alterations
1. You are taking care of a 58-year-old post-MI patient brought back to the unit because of recurrent
chest pain, shortness of breath, and the need for IV NTG.
a. Prioritize your actions at this time.
Immediately upon arrival connect him to the bedside monitor (cardiac, NIBP cuff, and pulse
oximetry). Assess his chest pain asking him to rate it on the 0-10 scale. Also assess what type of
pain it is (burning, crushing, pressure, etc.), what he was doing when the pain started, how long
ago did the pain start, does it radiate, and does anything make it better or worse. Assure that he is
on oxygen via nasal cannula at 2 to 4 L/pm. Assure he has at least 2 patent IVs. If not done on the
telemetry unit, obtain 12-lead EKG. Start the NTG drip if not already infusing. Draw labs: CBC,
chemistries, and cardiac enzymes. Notify the physician of his arrival at the critical care unit.
Report to the physician what the pain rating was, the infusion rate of the NTG, and how long the
pain has been present. Ask for an order for morphine IV, and ask for NTG titration parameters.
Provide the patient with a calm, quiet environment; notify his family members if not already done.
b. What assessment findings regarding MI would concern you?
The patient has shortness of breath along with his chest pain, this could indicate an evolving MI.
Assess patient's pain rating and whether or not the IV NTG is helping to relieve the chest pain. He
was diagnosed 3 days ago with an MI; this should concern the nurse because he could have
another MI.
c. What pertinent information from the patient’s history would you want to obtain?
The nurse should assess the patient's lifestyle (smoking, ETOH use, diet, and exercise program if
any). The nurse should obtain a thorough medical history noting high blood pressure, high
cholesterol, previous episodes of chest pain, and what prescription medicines the patient is taking.
d. What diagnostic tests do you anticipate?
The patient will have 12-lead ECG performed. The patient will have a set of cardiac enzymes
drawn usually every 8 hours × three sets. The physician may order a stress test (Dobutamine stress
test) but given the history probably a nuclear scan (Thallium scan) should be ordered to ascertain
the amount of heart muscle involvement. The patient will probably be scheduled for a cardiac
catheterization.
2. Many patients now come into the hospital the same day that cardiac surgery is performed. Discuss
methods for teaching patients effectively given this situation.
Strategies for preoperative teaching in the outpatient setting BEFORE same day admission are
essential. The anxiety and stress of surgery are factors that impair learning immediately before the
procedure. Teaching strategies include group teaching, videotapes, reading materials, and the
computer. Strategies should be based on the patient's learning style, education, etc. Visiting the critical
care unit before surgery is also an effective teaching strategy for patients and their families so that
they visualize what to expect. Patients should also practice postoperative procedures before surgery,
such as incentive spirometry (Tri-flow or Voldyne) and coughing and deep breathing.
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3. You are caring for a 63-year-old woman who has just returned to the cardiac care unit after PTCA
and stent placement to the right coronary artery. Her proximal right coronary artery had a 90%
occlusive lesion. She has her arterial sheath in place to the right femoral artery. She is receiving IV
NTG and eptifibatide (Integrilin).
a. What type of arrhythmia would you anticipate if her right coronary artery were to reocclude?
Bradycardia, AV blocks, junctional dysrhythmias.
b. Prioritize your actions on her arrival.
Immediately upon arrival, connect her to the bedside monitor (cardiac rhythm, noninvasive blood
pressure cuff, and pulse oximetry). Assure the arterial sheath is marked clearly denoting that it is
arterial and not venous. Connect the arterial sheath to a pressure bag and transducer for
intraarterial monitoring. Level and zero the transducer. Obtain baseline/admission rhythm strip
and post in the medical record. Perform any STAT orders that accompany her from the cath lab.
Perform an assessment of her; particularly the cardiovascular system. Check and mark pedal
pulses in both lower extremities. Educate the patient regarding chest pain, low back pain, and pain
in general; reinforce the need to call the nurse at the first sign of chest pain, especially if it is the
same type of chest pain that brought her to the hospital. Assure the call light is within easy reach.
c. What type of assessment would you perform regarding the sheath?
Assess the site of insertion, looking for more than one puncture site that may denote a difficult
stick. If the sheath was inserted with difficulty, then she should be closely monitored for additional
bleeding from those sites. Assess connections to the transducer, assuring they are not overly tight.
Assess the transducer tubing for air and flush out as needed. Level and zero the transducer. Assure
the arterial sheath is clearly marked, so that all of the staff will know that it is arterial. Assess and
mark the pedal pulses in both lower extremities. Ascertain if the sheath is to be removed or left in
place. If the plan is to remove it, then activated clotting time (ACT) should be done every hour
until an acceptable ACT (< 150 seconds) is achieved. If the sheath is to be left in place, the patient
is reminded not to bend the leg at the knee; this can be accomplished by placing a folded sheet
over the knee of the lower extremity that has the arterial sheath.
4. Mr. Phillips has been hospitalized three times in the past 2 months for chronic HF. What teaching and
interventions can you implement to prevent rehospitalization after discharge?
Teaching and/or education should involve the patient and his significant other. The patient should be
educated on his medication regimen, diet modification, weight management, and an exercise program.
Interventions after discharge should focus on prevention of worsening of the heart failure symptoms
and treatment of co-morbidities. The patient should be taught to weigh himself at the same time
during the day and to be consistent with it. Weight gain parameters for notifying a health care
professional should be established.
CASE STUDY
Cardiovascular Alterations
Mr. Smith was admitted to the emergency department (ED) by the emergency medical service with a
complaint of sudden onset of substernal chest pain while he was mowing his lawn. The paramedics have
placed Mr. Smith on oxygen at 2 L per minute by nasal cannula. They have started an 18-gauge
intravenous (IV) line in his left antecubital area with normal saline to be kept open. They have given Mr.
Smith aspirin and three sublingual nitroglycerin tablets en route. Mr. Smith states that his pain has gone
from a 7, on a 0 to 10 scale, to a 3 now. Jane, the ED nurse, places Mr. Smith on the heart monitor and
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notes that he is in sinus rhythm with frequent premature ventricular contractions (PVCs). The paramedic
states that Mr. Smith was diaphoretic, cool, and clammy on arrival of the emergency medical service at
the scene. Mr. Smith is now warm and drier, although he still appears quite pale. Mr. Smith’s blood
pressure is 154/88 mm Hg, his pulse is 95 beats per minute, and respirations are 24 breaths per minute and
nonlabored. While awaiting the arrival of the ED physician to examine Mr. Smith, Jane starts a second IV
line, gives Mr. Smith another nitroglycerin tablet, and then proceeds to obtain a brief history from Mr.
Smith.
Mr. Smith is a 63-year-old white man, 220 lb, 6’2’’, and he has been married for 41 years. He is
hypertensive and diabetic, and he continues to smoke 1½ packs of cigarettes per day. He is allergic to
penicillin.
While Jane is obtaining the history from Mr. Smith, she looks at the monitor and notices ventricular
fibrillation. She begins cardiopulmonary resuscitation. The code team arrives, and Mr. Smith is
defibrillated with 200 Js. His rhythm is now regular sinus with frequent PVCs. His blood pressure is
92/56 mm Hg, his pulse is thready, and he is diaphoretic. His pupils are 4 mm, equal and reactive. His
respiration rate is 16 breaths per minute and shallow, and his oxygen saturation is 92%. He has developed
crackles in his lower and middle lung fields bilaterally. He is not fully awake at this time, but he is
moving all his extremities. A 150-mg bolus of amiodarone is given over 10 minutes, and a drip is started
at 1 mg per minute. Emergency laboratory tests and arterial blood gases (ABGs) are ordered, along with a
12-lead electrocardiogram. A request for an emergency consultation is placed to the cardiologist on call.
Mr. Smith’s cardiac enzymes return: creatine kinase, 456 units/L; creatine kinase-myocardial band, 52%
of creatine phosphokinase; and troponin T, 151 mcg/L. Electrolytes are sodium, 143 mEq/L; potassium,
3.4 mEq/L; chloride, 109 mEq/L; carbon dioxide, 34 mEq/L; glucose, 354 mg/dL; and magnesium, 1.5
mEq/L. ABGs are pH, 7.32; PaCO2, 49 mm Hg; PaO2, 77 mm Hg; and bicarbonate, 24 mEq/L. His
hemoglobin is 16.9 g/dL, and his hematocrit is 47.2%. A 12-lead electrocardiogram shows ST elevation in
leads V2, V3, and V4. Mr. Smith is diagnosed with an acute anterior myocardial infarction. Mr. Smith’s
oxygen is increased to 6 L by nasal cannula. Based on these study results, tissue plasminogen activator (tPA) is administered.
Questions
1. What do Mr. Smith’s cardiac enzyme values indicate about the time and extent of his myocardial
infarction?
Mr. Smith's troponin T is significantly elevated; however, a true determination of size of infarct
cannot be made by the measurement of cardiac enzymes. The significant elevation of the troponin T
and moderate elevation of the CK indicates that the infarct is only a few hours old.
2. What would you expect his repeat cardiac enzyme values to show at the following times after his heart
attack?
a. 8 hours
b. 24 hours
c. 4 days
One would expect his CKs to continue to rise at 8 hours and to peak at 24 hours. At 4 days there
would probably be no elevation of the CKs. The troponin T will be elevated at 8 hours, 24 hours, and
at 4 days.
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3. What complications may be anticipated for Mr. Smith related to the infusion of t-PA? What
parameters would the nurse need to monitor?
Mr. Smith should be monitored for bleeding at all points where his skin has been invaded. This
includes not only the obvious incisional and needle stick sites, but also any skin tears that he may have
incurred while doing yard work, shaving, or any bruises that he may have. Large hematomas can
develop over existing bruises when a patient receives any of the thrombolytic drugs. Sites where
automatic blood pressure cuffs have been in place for prolonged periods have been known to develop
bruising and bleeding. The nurse monitors Mr. Smith’s lab results for decreases in hemoglobin,
hematocrit, and/or platelets. Monitoring includes observing for signs of hemorrhage (including subtle
changes in vital signs), flank pain, alteration in oxygenation, alterations in sensorium, and signs of
frank bleeding. All pulses are assessed. Interventions include protecting skin from injury, preventing
unnecessary needle sticks, applying pressure to any bleeding sites, notifying MD for any changes in
condition suggesting bleeding.
4. What assessments would indicate that the t-PA was effective?
The 12-lead ECG should show improvement in ST-segment elevation (e.g., return to baseline).
Reperfusion dysrhythmias may occur once blood flow to the myocardium is established. Continuous
monitoring of cardiac rhythm is warranted. The patient should have improvement or alleviation of
chest pain and other related signs and symptoms