Page 575 - Cardiac Nursing

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C HAPTER 2 3 / Interventional Cardiology Techniques: Percutaneous Coronary Intervention 551
nitroglycerin drip until pain free or as directed. Notify cardiolo- inhibitors, vessel trauma from the intravascular sheaths for me-
gist of significant changes in vital signs, ECG, or escalation of chanical interventions place the patient at risk for arterial access
chest pain pattern. Maintain anticoagulant infusions to prevent bleeding. Bleeding at puncture sites occurs from delayed or inad-
myocardial ischemia as prescribed and monitor ordered coagula- equate hemostasis after diagnostic angiography or interventions.
tion tests. Re-occlusion of the stenotic coronary artery or intra- This type of access bleeding is a risk for all patients receiving some
coronary stent is signaled by sudden onset of chest pain and re- type of interventional cardiac therapy because aggressive intraop-
turn of ST-segment elevation on the ECG. Lead selection for erative and postprocedure anticoagulation and antiplatelet thera-
continuous ECG monitoring should be based on knowledge of pies result in delayed clot formation. Access-site bleeding ranges
the involved vessels to allow early detection of ST-segment from oozing at the site of puncture to hematoma formation or
changes that may occur in the absence of chest pain. Treatment is retroperitoneal bleeding if the femoral approach is used.
the same as described for the patient with myocardial ischemia.
Goals
Outcome Criteria To prevent, detect early, and treat ECF deficit. To prevent, detect
Outcome criteria include patient remains free of chest pain and early, and treat bleeding at puncture sites.
ECG manifestations of acute injury, and coagulation tests remain
within therapeutic range. Chest pain, and ECG and hemodynamic Interventions
changes are noted and reported within 15 minutes of onset. Evaluate serum electrolytes, blood pressure, heart rate and
rhythm, urine output, central pressures (central venous pressure,
Risk of Decreased Cardiac Output pulmonary artery wedge pressure if possible) or jugular venous
Related to Arrhythmias distension, or reports of dizziness/lightheadedness when standing.
Infuse intravenous fluids (normal saline, lactated Ringer’s) as or-
Cardiac ischemia, reperfusion, injection of contrast, and fluctuat- dered and provide oral rehydration with electrolyte-containing
ing fluid and electrolyte status place patients receiving interven- fluids unless contraindicated. Evaluate patient complaints of
tional cardiac therapies at risk for cardiac arrhythmias. The sever- thirst. Check postural blood pressures before ambulating postpro-
ity of the drop in cardiac output determines the patient’s response cedure (Chapters 7 and 10). Prevent access site bleeding by leav-
to arrhythmias. Some arrhythmias are well tolerated and require ing arterial and venous sheaths in place until heparin or a direct
only identification, assessment of hemodynamic response, and thrombin inhibitor can be interrupted or discontinued and ACT
documentation. returns to normal. Systematic monitoring and assessment of ac-
cess sites for bleeding and serial laboratory evaluation of patient
Goals platelet count, hemoglobin, and hematocrit aid in detection of
To detect early, identify, and treat arrhythmias, and assess and bleeding. Care is also guided by institutional protocols and stand-
treat hemodynamic responses to arrhythmias. ing orders specific to each type of intervention.
Interventions Outcome Criteria
Continuously monitor cardiac rhythm to detect arrhythmias after Outcome criteria are absence of changes in heart rate and rhythm,
PCI. Identify and document the arrhythmia and associated he- blood pressure, central pressures, urine output, dizziness, or light-
modynamic responses. The most common reperfusion arrhythmia headedness. There are no reliable laboratory indicators of ECF
is accelerated idioventricular rhythm; it usually requires no addi- deficit. Signs of ECF deficit and bleeding are detected early and
tional intervention. Ventricular tachycardia, atrial arrhythmias, reported.
bradycardia, and atrioventricular block may occur after reperfu-
sion and intervention. Specific therapies are determined by the
type of arrhythmia and severity of alteration in cardiac output. REFE R E NC ES
1. Gruentzig, A. R., & Meier, B. (1983). Percutaneous transluminal coronary
Outcome Criteria angioplasty. The first five years and the future. International Journal of
Cardiology, 2(3–4), 319–323.
Outcome criteria include detection at onset of arrhythmias and 2. King, S. B., III, Aversano, T., Ballard, W. L., et al. (2007). ACCF/
accompanying hemodynamic responses, and immediate institu- AHA/SCAI 2007 update of the clinical competence statement on cardiac
tion of appropriate interventions to stop the arrhythmia or stabi- interventional procedures: A report of the American College of Cardiology
lize hemodynamic parameters. Foundation/American Heart Association/American College of Physicians
Task Force on Clinical Competence and Training (writing Committee to
Update the 1998 Clinical Competence Statement on Recommendations for
the Assessment and Maintenance of Proficiency in Coronary Interventional
ECF DEFICIT RELATED TO CONTRAST- Procedures). Journal of the American College of Cardiology, 50(1), 82–108.
INDUCED DIURESIS, RESTRICTED 3. Smith, S. C., Jr., Feldman, T. E., Hirshfeld, J. W., Jr., et al. (2006).
ACC/AHA/SCAI 2005 guideline update for percutaneous coronary inter-
ORAL INTAKE, HEMORRHAGE vention-summary article: A report of the American College of Cardiol-
FROM DELAYED COAGULATION ogy/American Heart Association Task Force on Practice Guidelines
(ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for
Percutaneous Coronary Intervention). Journal of the American College of
7
7
An ECF deficit may further compound myocardial ischemia, and Cardiology, 47(1), 216–235.
hemodynamic and rhythm instability. There is a risk of bleeding 4. King, S. B., III, Smith, S. C., Jr., Hirshfeld, J. W., Jr., et al. (2008). 2007
or hemorrhage related to delayed clot formation secondary to an- focused update of the ACC/AHA/SCAI 2005 guideline update for percu-
taneous coronary intervention: A report of the American College of Car-
ticoagulant and antiplatelet agents, or groin complications. Ag- diology/American Heart Association Task Force on Practice guidelines.
gressive anticoagulation, antiplatelet agents, or direct thrombin Journal of the American College of Cardiology, 51(2), 172–209.