Perfusion

OCTOBER 21, 2021

N3015 HEALTH ALTERATIONS II
ASHLEY CRANE
Concept: Perfusion
Interrelated Concepts
 Extra Exemplars

 Atrial Fibrillation
 Valve Disorders
 Endocarditis
 Pulmonary Hypertension
 Hypertension
 Aneurysm
 Shock
 Electrocardiogram
https://www.youtube.com/w
atch?v=ocWk8zD8ZPk
Electrocardiogram, Lead Placement
 Angina Pectoris

 Chest pain resulting from myocardial ischemia

 Lasts 3-5 minutes
 Supply versus demand issue – stat O2
Types of Angina (Chart 29-2)
Stable, Unstable, Variant (Prinzmetal’s Angina)
 Angina: Diagnostic Tests
 ECG
 ST depression and T-wave inversion
 ST elevation
 Abnormal Q-wave
 Stress Test
 Cardiac Catheterization/Coronary Angiography
 Treatment Goals
 Decrease myocardial oxygen demand and restore
coronary blood flow
 Relieve acute pain
 Reduce risk of acute Myocardial Infarction
 Nursing Care
 Stop activity, rest
 History &Physical Assessment (VS)
 ECG (12-lead), cardiac monitor
 Apply O2 (2-4L NP)
 IV, blood work:
 Cardiac enzymes
 Electrolytes
 Coagulation
 Renal Function
 Lipid Profile
 Reduce anxiety
 Chest Pain Protocol (CPP)
 Medications
 Oxygen
 Aspirin
 Nitro (Chest Pain Protocol)
 Morphine
 Beta-blockers (Metoprolol, Atenolol, etc.)
 CA channel blocking agents (Cardizem, Adalat, Norvasc, etc.)
 Chest Pain Protocol
 Assess pain
 Check vital signs (if hypotensive or bradycardic, notify physician)
 Give nitroglycerin
 O2 3L via nasal prongs (or 28% Venturi mask)
 Wait 3 minutes after 1st nitro, recheck vitals. If pain not relieved and BP stable, administer second
nitro dose
 Wait another 3 mins, if pain not relieved, BP stable, give 3rd dose nitro
 If pain not relieved after 3 tablets/spray, do 12-lead ECG and notify physician
 If frequency of episodes or severity of angina increases or changes, notify physician

*If patient becomes unstable (decrease BP, decreased pulse, call physician immediately)*
 Cardiac Enzymes
 CK (creatinine kinase)
 20-160 IU/L (higher CK more damage to myocardium)
 Myoglobin
 1.0-3.5 nmol/L (<90 Mcg/L)
 CK-MB
 0-6%
 Troponin T
 <0 .1 Mcg/L
 Troponin I
 < 0.35 Mcg/L
Cardiac Enzymes
Test Onset Peak Returns to
Normal
CK 3-6h 18h 2-3 days

My 1-3h 4-12h 12h

CK-MB 3-6h 12-24h 12-48h

T 3-4h 4-24h
Measured q6h, until peaks 1-3 weeks
(80%)
 Stress Test
 https://www.youtube.com/watch?v=PXay0q1kJVw
 If not able to complete test can do a chemical stress test
 No smoking, caffeine, or ETOH before test
 Rest night before
 Some places ask to fast 2-4 hr pre
 During test: Monitor ECG, BP, chest pain, shortness of breath, dizziness
 Cardiologist accessible
 Cardiac Catheterization
 Dye is injected into heart to visualize blockages
 Catheter is inserted to measure:
 Function of heart chambers
 Patency of Coronary arteries
 Radial, brachial or femoral approach
 30-45 minutes

 Central Venous Pressure (CVP: 2-6 mm Hg)

 Pulmonary Arterial Wedge Pressure (PAWP: 6-15 mm Hg)
 Cardiac Output (CO: 3-6 L/min)
Balloon Angioplasty
Coronary Artery PTCA & Stent: Reperfusion

https://www.youtube.com/watch?v=pSbln3qgZ2A
 Cardiac Cath: Pre-Procedure
 Pre–op checklist  Education
 NPO 8 hrs  Mild sedation
 Monitor VS
 Incision in groin/arm for
 Peripheral pulses (mark)
catheter
 Informed consent
 Feels warm and flushed once
 Check for allergies (Iodine/shellfish)
 Note any meds on hold (metformin) dye injected
 Blood work (BUN, Creat., PT/PTT, Hgb, platelets,  Pounding in chest during
electrolytes)
procedure
 Cardiac Cath: Post-Procedure

VS
 (q 15min X4, Q 30min X 2, Q1hr X 4, Q4h X 24hr)
2-6 hr bed rest

Keep leg straight if femoral site used

HOB 30-45

Circulation Assessment: Temp, color, sensation, capillary refill, peripheral pulses

Watch for bleeding, hypotension, hematoma, infection, labs (Coag, CBC, Creat.),

arrhythmias, chest pain (have resuscitation equipment ready)
Administer anticoagulant meds as prescribed

Document urine output

Monitor compression device (Angioseal, Hemoband, pressure dressing)

 Patient Education
 First 24 hrs, no bending, heavy lifting (<10
 No driving 1-2 days pounds)

 Hard No bathtub
surface 2 hrs post-op


 If stent inserted, anticoagulant therapy for 6-8

 Pressure dressing weeks
 Take med same time each day
 Discuss fears and anxiety  Labs to adjust dose
 DB &C  Avoid activities cause bleeding
 Cardiac diet
 Report chest pain,  No ETOH or smoking
bleeding, infection (temp)  Exercise
 Help getting out of bed
first time
 Complications

 Cardiac tamponade (emergency)

 Artery dissection
 Allergic reaction
 Embolism
 Acute kidney injury
 Hematoma formation
 Clot reforms
 Retroperitoneal bleed (bleeding into abd from femoral arterial puncture)
 Acute Myocardial Infarction
(Acute Coronary Syndrome)
 Causes:
 Atherosclerosis  rupture of plague  occluded artery
 Vasospasm
 Decreased oxygen supply (acute blood loss, anemia, or low blood pressure)
 Increased demand for oxygen (rapid heart rate, thyrotoxicosis, or ingestion of drugs)

 Acute onset ischemia

 Unstable angina
 NSTEMI
 STEMI

 Early intervention and treatment!

 Signs & Symptoms
 Chest pain
 BP, HR, Resps
 SOB
 Jugular venous distension
 Nausea & vomiting
 Cool, clammy, diaphoretic
 Fear & anxiety
 Diagnostic Tests

 Patient history
 Physical assessment
 ECG
 Cardiac biomarkers
 Myoglobin
 CK-MB
 Troponin I & T
 Based on EKG: 3 diagnoses
 Unstable Angina
 Clinical signs of ischemia
 ECG & labs negative
 ST-Elevation Myocardial Infarction (STEMI)
 Caused by a sudden complete (100%) blockage of a heart artery (coronary artery).
 ECG changes in 2 continuous leads ST elevation > 1mm
 Non-ST-Elevation Myocardial Infarction (NSTEMI)
 Usually caused by a severely narrowed artery, but the artery is usually not completely blocked
 Increased biomarkers BUT no ST-elevation on ECG
 Management

STEMI
 Complete blockage, ST-elevation
 Cardiac cath lab
 Door to drug time 30 min
 Door to balloon time 60-90 min
 Thrombolytic
NSTEMI
 Partial blockage
 No ST-elevation
 May go to cath lab but not as urgent (to
see damage or identify cause)
 Pharmacological management first
 The Nursing Care: Immediately
 History and physical
 Cardiac monitor
 EKG
 O2
 IV, Labs (cardiac biomarkers, electrolytes, coagulation, renal function)
 Meds
 Psychosocial Support
 PFO cath lab or thrombolytic therapy (if STEMI)
 Medications
 Aspirin – chew and swallow
 Vasodilators (nitroglycerin)
 Morphine
 Beta Blockers, ACE Inhibitors
 Thrombolytic therapy for STEMI (Alteplase, TNKase)
 30 min on arrival
 Dissolve thrombus to allow blood flow
 Must be given 6hr or less from onset of CP
 Antiplatelet (Aspirin, Plavix)
 Antiocoagulants (Heparin, Lovenox)
 Glycoprotein inhibitors
 Nursing Care: Continued
 Bed rest 12-24 hrs
 Cardiac rehabilitation: Education
 Diet
 Gradual increase in activity
 Adherence to prescribed regimes (meds, keeping appointments)
 Report any concerns immediately
 Psychosocial support & stress management
 Monitoring for complications of meds
 Similar to angina - no straining, lifting, no smoking
 Routine blood work
Coronary Artery Bypass Grafting
Saphenous vein
 Pre-op Care
DiscussPFO meds (e.g stop anticoag)
Address PFO risk factors
Smoking, drinking, eating, rest
See CV surgeon & Anesthesia
Informed consent
Psychological Support
 Pre-op Teaching
 NPO after midnight
 Pre-op shower
 Sedative
 DBC, “the pillow” (splint incision)
 Imp. to move ASAP
 Length of surgery
 Pain management
 CVICU  special care unit  nursing unit
 Activity level
 Lifestyle changes
 Going home will need supports
 Pre-op Teaching
 What to expect post-op
 IV lines
 Central lines
 Endotracheal tube & mechanical ventilation (can’t speak)
 Chest tubes (multiple)
 Incisions
 Foley catheter
 Arterial lines
 ICU (environment)
 Pacemaker wires
Can be off or on pump
• CPB System “pump”
• Circulates & oxygenates blood for the body
while bypassing the heart & lungs
• Hypothermic (28-320 C)
• Heart stopped
• Heparin in circuit (reversed: protamine
sulfate at end)
 Post OP: Intensive Care
 System Assessment: head to toe
 Encourage movement ASAP
 Airway: Respiratory therapist, wean off ventilator (ABG’s, extubate ASAP)
 Neuro: LOC, caution Stroke
 VS, arterial line, hemodynamic monitoring, rhythms, maintain body temperature, watch for
infection, check dressings, pulses
 Chest tubes
 Nasogastric tubes
 Urine output (intake and output)
 Monitor labs
System
Assessment
CVP 2-6 mm
HG
 CABG Post-Op
 Pain management
 Monitor for Complications:
 Bleeding
 Care of chest tubes
 Atelectasis
 Pacing wires
 Hypo/hyperthermia  NG
 Wound dehiscence, infection  Foley
 Delirium  Diet
 Vasospasm
 Cardiac Tamponade

 Stress (family)
 Tissue Perfusion
 Check Peripheral Pulses for occlusion (may need to use Doppler)
 Compression stockings
 Assess for pain and LOC
 No crossing legs
 No pillows under knees
 Move
 Some meds to increase BP can decrease perfusion to kidneys so watch output and renal function
 References

El Hussein, M., & Osuji, J. (2019). Brunner & Suddarth’s textbook of Canadian medical-surgical

nursing (4th ed.). Wolters Kluwer/Lippincott Williams & Wilkins.

Giddens, J. F. (2017). Concepts for nursing practice (2nd ed.). Elsevier.