Jordan University of science and technology

Faculty of Nursing
Acute Care Nursing, Advanced Practice II: NUR 717
Major log
NSTMI POST CATHETERIZATION
Submitted to: DR. Jehad Rababa
DR. Anas aldomi
Prepared by: Hashim bani e’mar
University number: 150611

2/11/2022
Objectives

1- Develop a comprehensive, proficient nursing process and develop skills and

abilities.
2- Discuss the links between evidence-based knowledge and practice in the care
of patients with NSTMI post-catheterization.
3- Identify risk factors post-catheterization and how to manage it.
4- Determine the patient’s learning needs and compliance and consider the
patient’s limitations and strengths.
5- Demonstrate advanced physical examination for the patient and record
abnormal findings.

Patient demographic data:

Gender: male Age: 61 years

Place of birth: Irbid Marital status: married
Religion: Islamic Occupation: Army retired
Diagnosis: NSEMI Smoking 1 packet for 30 years

Chief Complaint:

The patient said “I have had sudden severe retrosternal chest pain radiated to right
arm last for 1 pm”
Hx of present illness:

 The patient 61-year-old male admitted a case of NSTMI complained of

severe tearing pain, and retrosternal chest pain radiating to the right arm and
right shoulder, the pain was continuous and progressive in intensity, and
lasted until 1 pm on the same day, the patient rated the pain 6/10 on the pain
scale, the pain occurred at rest and was increased with walking, the pain was
relieved by medication in the ER unit in KAUH. Chest pain also was
associated with shortness of breath and productive whitish color sputum.
The patient had the same symptoms 1 week ago that lasted for 1 hour and
resolved by its own without taking medications. According to the patient no
palpitation, intermittent claudication, no generalized weakness or fatigue
were reported. He has a normal appetite, no loss of consciousness or
dizziness or headache, no abdominal pain or diarrhea, or constipation.

Vital signs
Temperature 36.9 c
Blood pressure 165/95 his reading in ER was 140/88
Heart rate 88 beats/min
O2 saturation on room air 94%
Respiratory rate 19 breaths/min
Weight 70 kg
height 166 cm
Past medical and surgical History:

Hypertension for 15 years, DM not on medication, CVA in 2013 with right-sided

upper and lower limb weakness. IHD with a stent in 2014 in LCA.
Cholecystectomy, no history of trauma, previous hospitalization in 2014.

No known drug or food allergies.

Immunization According to immunization national program

Medication history: candesartan 16mg*1, aspirin 1oomg *1, atenolol 50mg *1

Subjective data:

The patient said, “Now I don’t have any chest pain at the moment after
catheterization but mild pain at the puncture insertion site, mild fatigue and worry
about post catheterization movement and complications”.

Objective data

The patient received on bed conscious oriented to time place persons, on full
monitoring, GCS 15 Braden scale 20 with no risk, vital signs reading above in
the table, patient on flat supine position post catheterization Morse fall scale:
the patient has < 50 on scale which mean a high risk for falling down related to
age and fatigue verbalized by the patient, safety procedures should be applied
as side rails, assist patient in movement, keep good lightening. Pt was permitted
to eat but he is now fasting.
Physical appearance:

Pt conscious oriented X3(place, time, person), GCS (15/15), normal facial

features with mild fatigue and mild pain in puncture site.

Pt normal speech with the appropriate word no mouth deviation or heaviness

in tongue

Mobility:

The patient was informed to stay flat position for 6 hours and then he will
need support during standing and walking.

Behavior:
The paient facial expressions are appropriate to the situation, grimes face
during pain, which is accepted in this situation, Pt cooperative during the
interview, the patient has clear and understandable articulation, clean and fit
the body clothing, and was good personal hygiene.

Measurement

* Weight: 70kg * height: 166 cm *BMI: 25.4 kg/m2

Neurologic system:
Pt doesn’t have a history of neurologic disorder, Pt continues oriented, no
limitation in speech, no dysarthria, no dysphasia, CN II -XII grossly intact. face
symmetric with no mouth droop. Appearance, behavior, and speech appropriate;
alert and oriented to person, place, and time; recent and remote memory intact.

Cranial Nerve I: normal sense of smell bilaterally

Cranial Nerve II: visual acuity 20/40 Pt has vision problem (aging process) not
related to the neurogenic problem.

Cranial Nerve III: pupils size 4 reactive to light bilateral.

Cranial Nerve V: patient clenches teeth. Muscles equally strong on both sides and
can’t separate the jaw by pushing down on the shin, Corneal Reflex normal
response
Blink his eye bilaterally.

Cranial Nerve IV and VI: patient turn eyes downward, temporally, and nasally

Cranial Nerve VII (Facial): symmetry and mobility of face patient smile, frown,
close eyes, lift eyebrows, show teeth and puff cheeks., escape equally from both
sides.

Cranial Nerve VIII: tests hearing acuity. Done by whispered voice test Pt
understood voice and repeat it.
Cranial Nerve IX (Glossopharyngeal) and X (Vagus): the gag reflex is present and
the voice sounds smooth and not strained.

Cranial Nerve XI (Spinal Accessory): shrug shoulders against resistance. The Pt

movements felt equally strong on both sides.

Cranial Nerve XII (Hypoglossal): Inspect the tongue no wasting of the tongue or
deviation

Skin: skin surface warm and moist non-tender, good in turgor, no edema seen in
upper and lower extremities, normal color. Catheterization insertion site skin has
been checked no signs of bleeding no swelling no hematoma.

Eyes: external eye structure looks normal eyebrows and eyelids. The patient has
problems with vision, long-sightedness, which is normal at this age stage. No
pain, no redness no nystagmus, Snellen chart 30/40 on both eyes, corneal light
reflex symmetric bilaterally diagnostic position test shows extraocular muscles
intact no ptosis, conjunctiva clear sclera white No lesions. Patients, Red reflex
present bilaterally, pupils brisk reactive size 4 bilateral to light.

Mouth and Throat;

The normal color of mouth mucosa and soft palate (pink color) uvula appeared on
the midline of posterior mouth no deviation, tongue appeared normal color (pink)
and shape no lesion or swelling, no bleeding gums, no toothache, no sores or
lesion in mouth, no dysphagia or sore throat. Normal tonsils size.

Respiratory system: no chest deformity seen, AP less than the transverse

diameter, respiration 19 breath per min relaxed Chest expansion symmetrical.
Tactile fremitus equals bilaterally, no tenderness to palpation, no lumps or lesions.
Resonant to percussion over lung fields. vesicular breath sound clear over lung
fields, no abnormal sound heard (wheezes, crackles…) no chest pain, pt smoker 20
cigarette daily for 30 years ago, no Environmental exposure,

Cardiovascular system: no chest pain, no palpation, no cyanosis, no fatigue,

normal S1, S2, no murmurs, Apical impulse in 5 th ICS, at left midclavicular line,
no thrill. Heart rate 88 beats per min, regular. Bp (145/85), no jugular vein
distention, Pt has HTN but it’s in control
Pt takes regular antihypertensive medication and most of the reading is within the
normal range.

No family history of cardiac disease.

musculoskeletal system:

moderate range of motions, muscle strength for all body checked grade 3/5, no
history of muscle or bone disease. No bone or joint deformity.
Peripheral vascular:

Extremities have pink color without redness, cyanosis, or any skin lesion.
Extremities symmetric bilaterally Temperature is warm bilaterally. All pulses
present 2+ and bilaterally, capillary refill normal less than 2 seconds, lower limbs
no varicose vein seen bilateral, sensation in lower limbs existed, no ulcer, no
edema bilateral. Lower extremity dorsalis pedis, posterior tibial normal bilaterally.
 Labs test
Test Finding Interpretation/significance

* CBC:

WBC= 9.6

Hgb= 12.3 Decreased (14-18)

Plts = 300

MCV= 89

HCT = 34.5 Decreased (39-54)

Chemistry: Normal value

* Na= 144 mmol/l

K 4.9 mmol/l

CA=9.1 mmol/l
Cl= 109 mmol/l

Mg = 2.1 mmol/l

Cr= 0.9 mmol/l

BUN = 11 mmol/l

PT: 13s Normal finding

PTT:30s

INR:1.2

Lipid profile Normal

LDL 4.08 mmol/l

CHOLESTEROL 6.4 mmol/l

TRYGLCERIDES 0.9 mmol/l

Troponin I 20. 03 Highly increased rt MI

CK 1687 High

CK-MB 171 High

 Diagnostic procedure

Test Finding Interpretatio

n/
significance.
 PTCA

Catheterization report LM: NORMAL 2.5*14*12

atm balloon.
LAD: mid 50%, distal 50% plaques.
Dissection
LCX: cx: dominant, patent cx stents
after PTCA,
pre stent 30% plaque
normal
OM: mid 90% stenosis, distal diffuse. flow,

RCA: nondominant, disease. couldn’t

Summary: ACS, NSTEMI. advance

stent due to
Recommendation:
dissection.

ECHO  Infero wall akinesia Check for

 Sclerotic aortic valve signs of

edema and
 G I MR
SOB
 Echo in 2014 E.F 60%, LVH

ECG ST depression in leads V3 V4 V5 Monitor

Chest x ray normal frequent

ECG
 Current medication

NAMEOF ROUTE FREQUEN CLASSIFICATION Nursing

MEDICATION CY CONSIDERATION
metoprolol P.O *1 Beta blockers. May cause
100mg Metoprolol is a drowsiness

cardioselective Monitor v/s

beta-1-adrenergic Assess for an

receptor inhibitor allergy to beta-

that competitively blockers.

blocks beta1- Assess for chest

receptors with pain by having the

minimal or no patient rate on a

effects on beta-2 scale of 1-10, and

receptors at oral describe

doses of less than characteristics,

100 mg in adults. It duration, and

decreases cardiac frequency.

output by negative Monitor for signs

 inotropic and of worsening CHF

chronotropic such as shortness

effects. of breath or

adventitious lung

sounds.

Assess the

patient’s blood

pressure and heart

rate to ensure the

medication is safe

to administer and

will not worsen

hypotension or

bradycardia.

B.aspirin p.o *1 Antiplatelet, Do not use if

100mg NSAIDS sensitive to other
NSAIDs or
salicylates. Can
cause renal or
liver impairment.
Excessive
bleeding may
 occur if used with
another
anticoagulant.
Omeprazole p.o *1 Proton pump Assess possible
20mg inhibitor side effects
nausea, diarrhea
Atorvastatin p.o *1 antihyperlipidemia Evaluate serum
cholesterol and
40mg
triglyceride levels
before initiating,
after 2–4 wk of
therapy, and
periodically
thereafter.
If patient develops
muscle tenderness
during therapy,
CPK levels should
be monitored. If
CPK levels are
>10 times the
upper limit of
normal or
myopathy occurs,
therapy should be
discontinued.
May cause ↑ in
fasting serum
glucose levels and
in HbA1c.
May cause ↑ AST,
ALT and creatine
phophokinase.
May cause
 hyperkalemia.
Clexan s.c 70mg *1 Anticoagulant Monitor signs of

anemia, including

unusual fatigue,

shortness of

breath with

exertion, bruising,

and pale skin.

Notify physician

or nursing staff

immediately if

these signs occur.

Monitor signs of

high plasma

potassium levels

(hyperkalemia),

including

bradycardia,

fatigue, weakness,

numbness, and
 tingling.

Amlodipine P.O 5mg *2 Calcium channel Monitor B.P H.R

blockers Dysarrhthmi
Antagonist of the Increased
Brilinta( ticagl p.o P2Y₁₂ receptor.
bleeding risk thus
erol) *1 antiplatelet
90mg monitor pt PTT
INR
isoket
po 20mg *2 A vasodilator.
Monitoring of
Isosorbide
vital signs
mononitrate is an
(including
anti-anginal agent
respiratory rate,
and vasodilator that
Heart rate, Blood
relaxes vascular
pressure and
smooth muscle to
oxygen
prevent and
saturations for all
manage angina
clients with chest
pectoris. The
pain is essential.
pharmacological
A medical officer
action is mediated
should be
by the active
consulted as soon
metabolite, nitric
as possible
oxide, which is
released when
isosorbide
mononitrate is
 metabolized

Nursing diagnosis:

1. Ineffective cardiac tissue perfusion r/t disease process AMB catheterization

report.
2. Risk for ineffective peripheral tissue perfusion r/t catheterization
complication and clot formation.
3. Risk for Ineffective Therapeutic Regimen Management related to
insufficient knowledge of medication regime and post-op care as evidenced
by the patient and wife verbalizing these concerns.
4. Anxiety related to the outcome of diseases AMP pt. verbalization.

Desired outcomes:

1. Patient will maintain cardiopulmonary perfusion as evidenced by normal

sinus heart rhythm, heart rate within normal limits, and no complaints of
shortness of breath
2. Patient will maintain adequate peripheral perfusion as evidenced by strong
pedal pulses, warm skin temperature, and intact skin without edema.
3. Patient will demonstrate appropriate lifestyle modifications to support

adequate tissue perfusion, post-op care related surgical site and

complications.
4. Patient will verbalize decreased anxiety level and other disease concerns.
 Nursing interventions:
1. Assess for sudden changes. Note the presence of sudden chest pain,
diaphoresis, respiratory distress, and SOB, alteration in consciousness.
2. Assess vital signs and ECG. Closely monitor blood pressure, heart rate,
respiration, and changes in cardiac rhythms. Use this data to compare to
baseline information to identify changes in condition. 
3. Monitor hemoglobin levels. Hemoglobin is a red blood cell component that
carries oxygen through the body. If hemoglobin is decreased, less oxygen
will be perfused through the body and tissues.
4. Assess capillary refill. Capillary refill assesses circulation and peripheral
perfusion. If capillary refill time is sluggish, the client may be hypovolemic
and lack blood volume to support the circulatory system with adequate
oxygenation.
5. Administer medications to improve blood flow.
Vasodilators open blood vessels to improve blood flow such as nitroglycerin
for chest pain, or hydralazine for high blood pressure. 
6. Provide oxygen as required. To support oxygenation and perfusion oxygen
may be needed to ensure gas exchange. 
7. Surgical Intervention. Conditions that impede blood flow such as blockages
may require coronary angioplasty or bypass surgeries. The nurse is vital in
educating the patient and family on procedures and monitoring for
complications post-op.
8. Teach signs of a heart attack. Symptoms of a heart attack are different for
men and women. Men may have direct chest pain while women usually have
indirect symptoms such as nausea and jaw, back, or arm pain.
9. Provide a thorough skin assessment. Take note of edema, wounds or
ulcerations, skin color, temperature, hair loss, and thickened nails.
10. Assess peripheral pulses. Monitor for absent or weak pulses which indicate
poor perfusion.
11. Assess for pain and numbness. Patients with conditions such as diabetes,
PAD or PVD may lack circulation to extremities. They may experience pain
or dulled sensations from poor blood flow.
12. Use a doppler if needed to assess blood flow. If peripheral pulses are
difficult to palpate, a doppler can assist in locating a pulse.
13. Apply anti-embolism stockings. Patients with edema or poor circulation to
the lower legs may require compression stockings to increase circulation.
14. Discourage sitting for long periods or crossing ankles. This impedes blood
flow and venous return.
15. Encourage lifestyle behaviors to improve blood flow. Quitting smoking,
diet control to manage diabetes, and proper exercise are necessary to control
chronic diseases.
16. Prevent exposure to cold. Raynaud’s disease results in poor blood flow to
smaller arteries, usually the fingers in response to cold or stress. Teach
patients to stay inside in cold weather, and use gloves or mittens
 Vital sign changes may reveal blood
17.Monitor vital signs every 15 minutes for 4, every 30
loss and with internal bleeding may be
minutes for 3 hours, then every 4 hours.
the first indicator of health problem.

18.Gather baseline laboratory results Provides comparative data for post-

from pre-catheterization assessment. catheterization assessment.

19. Keep pressure dressing on the catheterization site

and assess every 30 minutes for bleeding. If Direct constant pressure on site is
bleeding does occur, apply continuous direct needed to avoid bleeding; no
pressure 1 inch above the puncture site and bleeding, even oozing, should happen.
immediately report to the physician.

Bed rest avoids strain to catheterization

site which otherwise might hasten
20. Maintain bed rest for 6 hours
bleeding; an elevation of the head (45-
post-catheterization as ordered.
degree) and bend at the knees are
acceptable.

Allows for expression and interaction

21. Encourage patient and his family to engage
without physical stress; provides a
in quiet activities such as storytelling, music.
distraction for comfort.

22. Inform patient and family of the need for Promotes understanding
periodic monitoring and for bed rest. and cooperation.

23. Instruct patient and his family to observe and notify

any sign of bleeding immediately. Educate patient
that pressure dressing will be removed after 24 Increases close monitoring of the site.
hours and that they should continue to assess the site
and report to the physician if any bleeding is noted.
24.Converse using a simple When experiencing moderate to severe anxiety, patients
language and brief statements. may be unable to understand anything more than simple,
clear, and brief instruction

25. instruct patient to apply deep

breathing relaxation training” Best way to lower anxiety and relaxation.
meditation, autogenic
training….)

The presence of someone the patient trusts provides

26. Be present Stay with the
positive encouragement to handle situations. Being
patient during levels of high
present also helps ensure the patient’s safety
anxiety or “panic attacks”

27. Establish trust with the patient

Listen to their concerns, avoid establishing trust can help the patient calm down and
giving immediate suggestions, Be make treatment more effective.
respectful of patient’s space.

28. Recognize awareness of the Since a cause of anxiety cannot always be identified, the

patient’s anxiety. patient may feel as though the feelings being experienced

are counterfeit.
Evaluations:

Goals were met patient didn’t complain of signs of insufficient cardiac perfusion
signs like chest pain during my shift, no complication occurs related to peripheral
perfusion it was patent no signs of bleeding or infection, patient and his wife were
rephrasing instructions related to medications, quit smoking and modification of
lifestyles and future cardiac problems, he has relaxed and reported anxiety is
reduced to a manageable level.

CNS ROLE

supporting patients through integrated care across primary and secondary care
teams. by supporting cardiologists with diagnosis, providing support and
information to people newly diagnosed with HF, and supervising patients starting a
new medicine, coordinating tailored care for each patient, thus promoting a
multidisciplinary approach.
1. assist in ensuring that care is evidence-based and that drug regimens are
optimized and this can be done through locally agreed protocols.
2. assisting the patient with self-management, and providing education to
patients, their families, and their careers.
3. It is essential that CNS is accessible to patients, their families, and careers,
which is often a limitation in most services where the nurse is only available
during office hours.
4. play a large part in ongoing follow-up care. They can provide support and
counseling to patients, act as the patient’s advocate, and promote
communication between primary and secondary care and also within the
multidisciplinary team. By assisting in professional education and
development they should be considered as a resource to other professionals.
5. give good assessment and full management for all the following:
Objective measurement of dyspnea severity:
Respiratory rate, dyspnea severity scale, tolerance of lying prone, the effort of
breathing, oxygen saturation

Hemodynamic status: Systolic and diastolic blood pressure monitoring

Heart rhythm: Heart rate and rhythm, 12-lead electrocardiogram

Cardiac output: Body temperature, peripheral perfusion, urine output, mental

status.

Clinical examination for signs of congestion: Pulmonary rales, peripheral edema,

jugular venous pressure.

Laboratory blood tests: Full blood count, urea, creatinine, electrolytes, glucose,
troponin, natriuretic peptide level.

Anxiety levels: Using an objective assessment tool.

Research article
Abstract:
Background: Cardiac catheterization is the most diagnostic and interventional
procedure found now used by cardiologists using a catheter through groin or
jugular area to the heart with x-ray images. The prevalence of post-cath
complication is up to 9%, complication ranges from mild to severe and life-
threatening complications. Mild which may be bleeding, reaction to medications or
dye, allergic skin reaction to latex or tape, bruising, abnormal heartbeats,
temporary pain, minor infections, nausea and vomiting. Those severe which
involve bleeding, hematoma, heart or lung problems such as irregular heart
rhythms and lung or heart failure, stroke, heart attack, blood vessel or nerve
damage, blood clots in the legs or lungs, failure of medical equipment, and renal
failure, with possible dialysis needed. in patients whose ages were more than 70
years, female, and had renal failure has the highest risks.
Nurse’s main role is to assess the patient for any unwanted signs of a change in
condition, safe transport, giving medication, assist in basic personal care needs,
controlling of bleeding, maintenance of hemostasis. Using evidenced protocol of
care that is based upon the different educational needs of nurses and considers
other relevant factors will help the patients to cope successfully with their
condition and minimizing their vascular complications. Caring of patients post-
cardiac catheterization needs knowledge about its complications and the related
factors. Moreover, nurses should have good knowledge when preparing patients
for the procedure and when giving care after procedure that consists close
observation, continuous monitoring, and maintenance of hemodynamic stability. A
good prepared unit with environment of safety, demonstrated clinical quality
results, and high internal/external client satisfaction scores to evade the dangers
associated with a less reliable unit.
Though, the nurse should know and interpret significant potential and/or existing
postcatheterization complications. Nursing care of the patient post this procedure is
vital to the successful completion of the test. Since any invasive procedure can lead
to complications, quick and accurate nursing assessment and action are essential.

It may lead to several minor and more serious complications which may
contribute to morbidity and mortality. The responsibility of the cardiac
catheterization team is ensuring good patient care, safety without accidental harm
as a result of a health care encounter.
Aim: This study was conducted to assess cardiac nurses knowledge and practice
regarding patient's safety post cardiac catheterization.
Design: A descriptive-correlational design was used.
Setting: within cardiac care units, intermediate cardiac care unit and cardiac and
chest surgery departmentat University Hospital, at Shebien El koom, Menoufia
Governorate, Egypt.
Sample: A convenience sample of 40 cardiac nurses were involved.
Tools: Semi-structured questionnaire and observational chick list were developed
to assess the knowledge and practice of cardiac nurses.
Results: This study revealed that the mean score of knowledge of nurses more than
five years of experience was better than those less than five years of experience.
The mean practice score of nurses more than five years of experience was better
than those less than five years of experience. Baccalaureate nurses had higher
mean score of knowledge than that of diploma and technical institute nurses also
the mean practice score of Baccalaureate nurses was better than institute and
diploma nurses. There was relationship between staff nurses practice and
knowledge with their years of experience.
Conclusion: knowledge level and practice of cardiac catheterization staff nurses
regarding patient's safety increase with years of experience.
Recommendations: Administrative and nursing leaders can provide relevant
educational seminars, offer a standardized protocol for caring of patient in
simulation labs, and assess the competency of new staff nurses caring for patients
after cardiac catheterization to ensure high-quality nursing care. It also important
to teach and involve the nursing students in post cath wards and give educational
sessions within faculty labs to enhance knowledge.
 References
Henedy, W. M., & El-Sayad, H. E. S. (2019). Nurses' Knowledge and practice

regarding patient's safety Post Cardiac Catheterization. Journal of Nursing

and Health Science, 8(3), 43-52.

Degavi G. (2013) effectiveness of planned teaching programme (PTP) on

Knowledge Regarding Cadiac Rehabilitation among staff Nurses working in

ICCU of Heart Foundation of KLEs Dr. Prabhakar Kore Hospital & MRC

Belgaum (Doctoral dissertation, KLE UniversityBelgaum, Karnataka)

Thabet, O. F., Ghanem, H. M., Ahmed, A. A., & Abd-ElMouhsen, S. A. (2019).

Effect of developing and implementing nursing care standards on outcome

of patients undergoing cardiac catheterization. IOSR Journal of Nursing and

Health Science (IOSR-JNHS), 8(01), 42-54.

McCaffrey, R., & Taylor, N. (2005). Effective anxiety treatment prior to diagnostic

cardiac catheterization. Holistic nursing practice, 19(2), 70-73.