SURGICAL MANAGEMENT

Nursing Interventions for AnginaAdminister, as ordered:OxygenMeds (Nitroglycerine)RestDietLow fat, low Na, low cholesterol dietAvoid saturated fatsRead food labelsActivity restriction within patients limitationWeight loss

Myocardial Infarction

Ischemic myocardial cell necrosisCaused by coronary artery obstruction due to:Rupture of an atheromatous plaque causing distal obstruction to blood flowProgressive development of atherosclerosisCoronary artery spasmEmbolism

Myocardial infarction is defined if the following criteria are satisfied:Rise and gradual fall of Troponin T or I and/orA more rapid rise and fall of Creatinine KinaseAnd at least one of the following:Typical ischemic chest painPathological Q waves on ECGST elevation or depression on ECGCoronary occlusion on angiography

Angina vs. Myocardial Infarction

ProvocativeNo relation to activity No relief from rest / NTGQualityHeavy crushing dullRegionOver sternum, epigastric area, jaw, back, shoulderSeverity Mild to severe often includes feeling of doom, nausea and vomiting , diaphoresisTiming Lasts longer than 15 minsManifestations

ComplicationsDysrhythmias major cause of death after an MICardiogenic ShockHeart FailurePulmonary EmbolismPericarditis Dresslers syndrome late Pericarditis; occurs 6 wks to months after MI

Diagnostic StudiesEnzymes and Serum Markers:Troponin I elevates in 2 to 4 hoursMyoglobin elevates in 1 hourCPK-MB elevates in 2 to 4 hours AST peaks in 24 to 36 hoursLDH1 peaks in 48 to 72 hours.GPBB elevates in 1 to 3 hours

ECG changes:ST elevation = myocardial injury large Q waves = Infarction / NecrosisNew LBBB

GoalsStabilizing the patient's condition Relieving ischemic painProviding antithrombotic

Collaborative Management"O BATMAN!":

O - xygenB - eta blockerA - SAT - hrombolytics M - orphineA - CE inhibitorsN - itroglycerinOther meds:Anti dysrrhythmicsAnticoagulantsSedativesStool softener Lactulose

PHARMACOLOGIC MANAGEMENT OF NON ST ELEVATION MYOCARDIAL INFARCTION(NONSTEMI)

AspirinClopidogrelUnfractionated heparin Lowmolecular weight heparin (LMWH)Intravenous platelet glycoprotein IIb/IIIa complex blockers (eg, tirofiban, eptifibatide)Beta blocker

MANAGEMENT OF ST ELEVATION MYOCARDIAL INFARCTION

What is the priority nursing problem?

Chest PAIN!

May cause SHOCK!

Drug of Choice?

2. Blood clot!

Percutaneous Coronary Intervention

Thrombolytics

t-PA, streptokinase, urokinase, alteplase

AnticoagulantsHeparin and Warfarin

Side effects

WOF any sign of bleeding!!!

Nursing InterventionsAdminister, as ordered:OxygenMorphine sulfateIVF to run KVOCBRMonitor:vital signs every 1 to 2 hours.cardiac rhythm for dysrhythmias signs of congestive heart failure

DietProvide small frequent feedingsFull liquid diet with gradual increase to softProvide low cholesterol, low sodium dietAvoid stimulantsAvoid taking very hot or very cold beverages and gas forming foods. vaso-vagal stimulation may occur thereby bradycardia and cardiac arrest

Use of bedpan and straining at stool should be avoided. Valsalva maneuver causes changes in BP and HR and may trigger dysrhythmias, ischemia, or cardiac arrestUse bedside commode.Administer stool softener as ordered.

Exercises/ActivitiesFollow physicians instructions regarding progression of activity.Start slowly and pace activities for the first few weeks,

Stop activity if extreme fatigue, weakness, SOB, dizziness, or chest pain occurDiscuss resuming sexual activity.Resumption of sexual activity after 4 weeks from discharge, if appropriate. Or when the client with uncomplicated MI (no dysrhythmias, shock or CHF) is capable of walking two flights of stair w/o difficulty.

Sexual activity Assume a less fatiguing position.The non-MI partner takes the active role.Perform sexual activity in a familiar environment.Take nitroglycerine before the activity.Refrain from sexual activity during a fatiguing day, after a large meal, or after drinking alcohol.If dyspnea, chest pain, dizziness or palpitations occur, moderation should be observed; If symptom persist, stop sexual activity.Develop other means of sexual expression.

Treatment/LifestyleDiscontinue smokingControl hypertension with continued medical supervision.Avoid stress

Follow-up careCardiac rehabilitationStarts upon admissionEducationSupport

Heart Failure

Classifications of Heart Failure

Left versus Right sided Ventricular failure

Framingham Criteria for CHF

Major CriteriaMinor CriteriaPNDHepatomegalyNVEExtremity edemaRalesNight coughCardiomegalyDOB on exertionAcute pul.edemaPleural effusionS3 gallop Dec.vital capacityInc.venous pressure >16cm H20Tachycardia >120bpm+ hepatojugular reflex

Diagnosis of CHF requires the simultaneous presence of at least 2 major criteria or 1 major criterion in conjunction with 2 minor criteria.

New York Heart Association Functional Classification

Class 1No limitation on physical activityClass 2Slight limitationClass 3Marked limitationClass 4Unable to carry on any physical activity with discomfort

CVP MonitoringR atriumRSHF2 -12 mm HgMeasure at level of the right atrium at 4th intercostal space

Swan Ganz Catheterization4 lumensLSHFOnly inflate the balloon when doing PCWP reading

MUGA Scan

Medical Management

4 Ds + BDigitalis = Improve Ventricular Pump Performance Diuretics = Reduce myocardial workload and fluid retentionvasoDilators = Reduce after load Diet = Reduce fluid retentionBeta blockers = improves mortality rate

Signs of Digitalis Toxicity Normal .5 2meq/LLateHalo vision &Orange / green vision common to elderlyDysrhythmia fatal Early (BANDAV)B bradycardiaA anorexiaN nauseaD diarrheaA abdominal painV vomiting

Dry PhlebotomyPooling of blood in the lower extremities, thereby reducing preload

Occlude 3 extremities at a timeRotate tourniquets clockwise every 15 minutesEach extremity is occluded for a maximum of 45 minutesRemove tourniquet one at a time every 15 minutesPerform neurovascular check distal to the tourniquet application

Surgical Management

Cardiac TransplantArtificial heart

N.I.D.I.A

Priority Nursing DiagnosesDecreased cardiac outputFluid volume excessActivity intolerance

Nursing ManagementProviding oxygenationPromote rest and activityFacilitating fluid balance Provide skin carePromote nutrition Promote elimination

Vascular Disorders

What is hypertension ? Systolic BP 140 mmHg Diastolic BP 90 mmHg * based on the average of > 2 BP measurements taken on different occasions14090

Blood pressure category Normal 100Blood pressure (mmHg)

SystolicDiastolicClassification of Blood Pressure for Adults (JNC 7)

HEART

KIDNEY

RETINA OF THE EYE

BRAIN

Hypertension is classified into:1. Primary or Essential Hypertension2. Secondary Hypertension3. Malignant Hypertension4. White coat Hypertension

Collaborative Management1. Lifestyle modifications2. Pharmacologic

ANEURYSM

Collaborative ManagementHypertension controlSurgeryResection of the aneurysm and replacement with a Teflon/Dacron graft

Nursing InterventionsAdvise client to prevent increased IAPPrevent flexion of hip and knees to eliminate pressure on the arterial wall.Apply abdominal binders Narcotics as ordered Monitor intake and output Watch out for signs of shock (ruptured aneurysm)

PERIPHERAL VASCULAR DISEASE

Peripheral Arterial Occlusive DiseaseA chronic occlusive arterial disease that affect the femoral, popliteal, aorta, and iliac arteries.Occurs most often in men 50-70 y.o

Clinical ManifestationsIntermittent claudicationRest painDependent ruborElevation pallorWeak or absent peripheral pulsesMottled skinUlceration/gangrene

The Six Ps of arterial occlusion Pain early Paresthesias Poikilothermia (coolness) PallorParalysis Pulselessness late

Drug TherapyVasodilators Pentoxifylline Analgesics AnticoagulantsLipid-reducing drug

Surgical InterventionsSymphatectomy

Saphenous vein grafting from the femoral artery to the area below the obstruction

Nursing DiagnosesAltered Tissue PerfusionDisturbed sensory perceptionRisk for Impaired skin Integrity

Nursing InterventionsAssess for 6 Ps of ischemiaProtect from injuryDependent positioningAvoid elevationPromote vasodilationNever apply direct heat source to the extremities.Provide insulating warmth.Keep room temperature comfortably warmStop smokingTeach to avoid constricting garments such as knee-high stockings

STRESS the Importance of foot care, immediately taking care of cuts, wounds, injuries!

Buergers Disease vs. Raynauds Disease

General Nursing Interventions for Arterial ProblemsProvide health teaching and discharge planning concerning:Importance of stopping smoking.Need to avoid trauma to the affected to the affected extremity.Need to maintain warmth, especially in cold weather.Avoid exposure to coldDecrease stressAvoid contraceptive pillsAdminister vasodilators and CCBs as ordered

Deep Vein Thrombosis vs. Varicose Veins

General Nursing Interventions for Venous DisordersProvide bed rest, elevating involved extremity to increase venous return and decrease edema.Apply continuous warm, moist soaks to decrease lymphatic congestionAdminister coagulants as orderedHeparinWarfarin.DO NOT MASSAGE the extremityMonitor for chest pain or SOB possible pulmonary embolism.

Provide client teaching and discharge planning:Avoid prolonged standing and sitting, constrictive clothing, crossing legs, smoking, oral contraceptives.Elevate legs for 10-20 minutes every few hours each dayEncourage adequate hydration to prevent hypercoagulability.Use of elastic stocking when ambulatory.Plan rest periods with elevation of the feet.

Thanks!

Post Cardiac Surgery assess for signs of hemodynamic compromise such as severe hypertension, decreased cardiac output and shockPost CABG avoid lifting objects > 20 pounds. Most common complications PE, impaired renal function

*ManifestationsProvocativeNo relation to activity ,No relief from rest / NTGQualityHeavy crushing dullRegionOver sternum, epigastric area, jaw, back, shoulderSeverity Mod to severe often includes feeling of doom, nausea and vomiting , diaphoresisTiming Lasts longer than 15 mins

glycogen phosphorylase isoenzyme BB elevates*Altered tissue perfusion*AnalgesicsFor relief of painDOC = Morphine sulfateWOF = MORPHINE TOXICITY !RESPIRATORY DEPRESSION PINAKA IMPORTANTE!!!PIN POINT PUPILSCONSTIPATIONURINARY RETENTIONCNS DISTURBANCESAntidote: Naloxone (Narcan)

*Activate plasminogen and generate plasminGolden Period is 3 to 6 hours after the initial infarction has occurred. Detect for allergies and occult bleeding during and after thrombolytic therapyGiven as IV dripAntidoteAminocaproic acidUsed only in acute ,life threatening conditions

*Used for thrombosis, pulmonary embolism and MIAnticoagulants prevent the extension and formation of clots by inhibiting factors in the clotting cascade and decreasing blood coagulability.Started after thrombolytic therapyHeparin sodiumPrevents thrombin from converting fibrinogen to fibrinMonitored by the PTT or aPTT NURSING INTERVENTIONS IN DRUG THERAPYAvoid IM injection ( IV or SQ)/ Avoid aspirationAvoid same site (rotate to avoid lipodystrophy)Avoid massage.Apply pressureAvoid aspirin/dipyridamole (OTC containing aspirin)Avoid alcohol intakeThe antidote to heparin toxicity is protamine sulfate!Warfarin Sodium (Coumadin)Suppresses coagulation by acting as an antagonist of vitamin KUsed for long term anticoagulationProlongs clotting time and is monitored by the prothrombin time (PT)NURSING INTERVENTIONS IN DRUG THERAPYAvoid aspirinAvoid/minimize green leafy vegetables.Administer in advance 3 days before discontinuation of heparin therapy.Assess for s/sx of bleeding / report hematuria, epistaxis, melena, hematocheziaUse soft bristled tooth brushThe antidote for warfarin toxicity is Vitamin K (phytonadione, Aquamephyton)

*Left Sided HFDyspnea-Most frequent symptomCheyne-stokes respirationCoughOrthopneaParoxysmal nocturnal dyspneaCardiomegalyS3gallop-single most reliable sign of LVFCerebral hypoxia,fatigue,muscular weakness

Right Sided HFPeripheral edemaHepato-splenomegalyAbdominal painCardiac cirrhosisLeg varicosities, Internal hemorrhoidsJugular vein distention*Diagnosis of CHF requires the simultaneous presence of at least 2 major criteria or 1 major criterion in conjunction with 2 minor criteria.

**CVPIV accessMonitoring PAP (20-30mmHg) and PCWP (8 13 mmHg)Inflation and deflation of balloonO2 saturation*A MUGA scan (Multi Gated Acquisition Scan) is a time-proven yet dated nuclear medicine test designed to evaluate the function of the right and left ventricles of the heart, thus allowing informed diagnostic intervention in heart failure. It is also called radionuclide angiography, as well as gated blood pool imaging. This modality uniquely provides a cine image of the beating heart, and allows the interpreter to determine the efficiency of the individual heart valves and chamber. At a high level, the MUGA test involves the introduction of a radioactive marker into the bloodstream of the patient. The patient is subsequently scanned to determine the circulation dynamics of the marker, and hence the blood.

*DigitalisMajor therapy in HFPositive inotropic, negative chronotropic and dromotropic effectsAssess HR before giving the drugMonitor serum potassium levelshypokalemia enhances digitalis toxicityAssess for S/Sx of digitalis toxicity

Toxicity may be treated with gastric lavage, activated charcoal or digoxin-Fab fragment ( Digibind ) which is the antidote

Examples: Lanoxin (Digoxin), Crystodigin (Digitoxin), Lanatoside (Cedilanid C), Deslanoside (Cedilanid D)

Diuretic TherapyTo decrease cardiac workload by reducing circulating volume and thereby reduce preloadAssess for signs of hypokalemia especially when administering thiazides and loop diureticsGive potassium supplements or food rich in potassiumGive diuretics in the morningVasodilators To decrease after load by decreasing resistance to ventricular emptyingExample ACE inhibitors first lineNitroprussideHydralazine

*Occlude 3 extremities at a timeRotate tourniquets clockwise every 15 minutesEach extremity is occluded for a maximum of 45 minutesIf Bp compression cuff is used as tourniquet inflate up to slightly above diastolic pressure (10-40mmHg). This allows occlusion of venous return but arterial pressure remainsPerform neurovascular check distal to the tourniquet application:Skin colorSkin temperaturePresence of pulsePresence of numbness or tinglingIf tourniquet application is too tight, tissue ischemia may occurAssess for signs and symptoms of thrombosis and embolismRemove tourniquet one at a time every 15 minutes

If Bp compression cuff is used as tourniquet inflate up to slightly above diastolic pressure (10-40mmHg). This allows occlusion of venous return but arterial pressure remainsPerform neurovascular check distal to the tourniquet application:Skin colorSkin temperaturePresence of pulsePresence of numbness or tinglingIf tourniquet application is too tight, tissue ischemia may occurAssess for signs and symptoms of thrombosis and embolism

*Most common complications post heart surgery CVA, pulmonary embolism, tissue rejectionPost heart transplant fever signifies rejectionMeds given post heart surgeryNitroprusside to control BpIsoproterenol to enhance cardiac contractionDopamine to improve contractility and renal perfusionImmunisupressantsAntibiotics*Providing oxygenation O2 at 2-6 L/min as orderedEvaluate ABGsSemi fowlers positionPromote rest and activityAssess for signs of activity intolerance such as dyspnea, fatigue, and increased PRBed rest or limit activity during acute phaseActivities should progress through dangling, sitting up in a chair and then walking in increased distances under close supervisionFacilitating fluid balance limit sodium intake ( no added salt)Limit fluid to < 1.2 L/dayDiureticsI and O, weight, V/SDry phlebotomyProvide skin careEdematous skin is poorly nourished and susceptible to pressure soresFrequent change in positionAssess sacral area regularlyEgg crate mattressPromote nutrition Bland, low calorie, low-residue with vitamin supplement during the acute phaseSmall frequent feedingsPromote eliminationAdvise to avoid straining at defecation which involves Valsalvas manuever. It increases cardiac workload.Laxatives as orderedBedside commode

*. Primary or Essential Hypertensionreason for elevated BP is unknownseen in 90 to 95% of hypertensives2. Secondary Hypertensionthere is an identifiable cause e.g. renal artery stenosis, pheochromocytoma

*Lifestyle Modifications for HypertensionPrevention & ManagementLose weight if overweight.Limit alcohol intake.Increase aerobic physical activity.Reduce sodium intake.Maintain adequate intake of dietary potassium & magnesium.Stop smoking and reduce dietary intake of saturated fat & cholesterol.Diuretics 1st line of treatment Beta-Blockers ACE inhibitors Angiotensin receptor blockers (ARBs) Calcium channel blockers Alpha blockersFor best results most patients need 2 or more drugs

*AneurysmLocalized , irreversible dilatation and distention of an artery due the weakening and stretching of the arterial wallMay involve only one layer or all layers of the arterial wallRepresents surgical emergency if rupturedCommon among white males 50 70 y.o.CausesAtherosclerosis The jet effect of streaming blood across a plaque produce turbulence Congenital Marfans syndromeSyphilisTraumaRisk FactorsHypertensionObesityStressHypercholesterolemiaCigarette Smoking

Classification of AneurysmAccording to Shape Fusiform More common than saccular Entire circumference of the artery wall is dilated Saccular Pouch like projection at one side of the arteryFalse The vessel wall is disrupted, blood escapes into surrounding area but is held in place by surrounding tissueAccording to LocationThoracic AneurysmAscending aorta occurs above the aortic valveAortic ArchDescending aorta occurs beyond the left subclavian arteryAbdominal Aortic Aneurysm Originate beneath the renal arteries The most common site = iliac arteriesThoracoabdominal AneurysmInvolves a thoracic aneurysm extending down to the abdominal aorta

Thoracic Aortic Aneurysm SubjectiveMaybe asymptomatic the first sign might be the danger signPain resulting from pressure against the nerves or vertebraeDyspneaDysphagiaObjectiveHoarseness, aphonia d/t impingement of the laryngeal nerveCoughUnequal pulses and arterial pressure in upper extremitiesTrachea maybe displaced from midline d/t adhesion between trachea and aneurysm

Abdominal Aortic Aneurysm (AAA)SubjectiveMaybe asymptomatic the first sign might be the danger sign already such as potentially life threatening situation such as rupture, acute thrombosis or embolization.Lower back or abdominal pain (severe)Digestion difficulties d/t duodenal obstruction from large aneurysmSensory changes in the lower extremity if aneurysm rupturesA feeling of heart beating in the abdomenObjective HypertensionPulsating abdominal mass umbilical region, left to midlineIncreased abdominal gain/circumferenceRupturing Aneurysms - HEMORRHAGEHypotensionDiaphoresisMental obtundationOliguriaDysrrhythmiaHematoma on flanks

Apply abdominal binders to provide support when the client is coughing, deep breathing or ambulating.Monitor intake and output renal failure may occur Watch out for signs of shock (ruptured aneurysm)Monitor the vital signs and pulses of all extremities.Monitor CVP frequently*Vasodilators - to improve arterial circulationPentoxifylline reduced blood viscosisty; s/e GI upsetAnalgesics to relive ischemic pain.Anticoagulants to prevent thrombus formationLipid-reducing drug

Post-op care Monitor v/s frequently because shock may occurChange position gradually because dizziness maybe a problemApply elastic bandages as ordered.

Post-op careAssess circulation of involved extremity including neurologic functions.Observe for signs of hemorrhageAmbulate as ordered; sitting should be avoided to prevent graft dislodgement.

Promote vasodilationNever apply direct heat source to the extremities.Provide insulating warmth with gloves and socks.Keep room temperature comfortably warm. Prevent client from being chilled.Teach patient to avoid vasoconstrictive agents like nicotine from smoking.Teach to avoid constricting garments such as knee-high stockings

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