Page 247 - ACCCN's Critical Care Nursing

224 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

are above the therapeutic range. Weight-adjusted treatment of complications, comfort and pain control, psy-
heparin (100 units/kg) is usually used during PTCA to chosocial support and teaching and discharge planning.
prevent thrombus formation, and glycoprotein IIb/ Reduction of myocardial workload includes ensuring the
IIIa inhibitors such as abciximab may be used to patient has bedrest, providing support with activities and
prevent platelet aggregation and thrombus formation limiting stress. A calm, caring manner during nursing care
for patients at high risk of occlusion. is essential to lower patient and family stress levels. Indi-
● Bedrest (2–6 hours) is used to discourage the patient vidual evaluation of the patient and the family is neces-
from moving the joint of the insertion site to prevent sary to determine the most appropriate management of
clot displacement and haematoma formation. Ini- visiting. ECG monitoring (preferably including ST moni-
tially the patient should lie relatively flat if femoral toring) and evaluation of heart rate, shortness of breath,
artery access has been used, then progress to sitting. chest discomfort and blood pressure are essential to deter-
The period of rest has been demonstrated to be safely mine ischaemia, treatment effects, myocardial workload
reduced to 1 hour in low-risk patients (normotensive and complications. This monitoring should occur hourly
and normal platelet count). 29 during the acute phase, reducing as the patient recovers.
● Pain relief is used primarily to promote comfort for Provision of oxygen by mask or nasal cannulae in the
patients who find bedrest to cause pain and discomfort. first 6 hours is standard practice to raise SaO 2 levels in
● Urine output. Adequate urine output is essential as the myocardium, although there is no evidence of patient
radiographic IV contrast is cleared by the kidneys, so benefit if heart failure is not present. Oxygen saturation
it is vital that nurses ensure good hydration and levels should be routinely assessed concomitantly.
monitor initial urine output.
● Oral antiplatelet drugs, such as clopidogrel or ticlopi- Symptom relief should be provided, including analgesia
dine, may be given prior to the procedure to prevent for pain. Analgesia management should be conducted by
later reocclusion in the stent. Usually patients will be nurses because of their continued contact and thus more
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discharged on this medication to continue for up to accurate assessment and treatment of pain. It is essential
3 months while endothelium lines the stent/injured to treat pain, not only for the distress it causes patients
area. Unless contraindicated, all patients will take but also because pain causes stimulation of the sympathetic
aspirin for the rest of their lives. 30,31 nervous system (SNS). SNS responses include elevated
heart rate and potential for arrhythmias, peripheral vaso-
constriction and increased myocardial contractility and,
Practice tip therefore, an overall increase in myocardial oxygen
demand. Effective treatments for pain include IV morphine
Increased hydration can aggravate problems with urination and nitrates. The IV route is preferable, as absorption is
when on bedrest, particularly in older men with prostate predictable and additional punctures in thrombolysed
enlargement. If a femoral access site is used in these patients, patients are not required. Morphine has the additional
it is easier for the patient to urinate while turned on the side, benefit of reducing anxiety in a distressing situation and
using pillow support to maintain the position. should be initially provided at a dose of 2.5–5 mg at 1 mg/
min, followed by 2.5 mg doses as indicated. While there
is little randomised controlled trial evidence to support
Practice tip this particular practice, it is generally accepted to be appro-
priate. A standardised method of pain evaluation and
If a femoral access site has been used, bleeding may track charting should be used to ensure consistent assessment
between the patient’s legs and pool, and this will be invisible and treatment. An antiemetic such as metoclopramide
to a cursory inspection, particularly if the patient is obese. should be given concurrently to lessen and prevent nausea.
Always move the patient’s thigh during regular inspections. Other drugs, such as beta-blockers and nitrates, decrease
myocardial workload, contributing to pain reduction.
Many patients find the PTCA procedure and confirmation Nursing care for thrombolysis
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of CHD diagnosis stressful. It is an important nursing Patients receiving thrombolytics require constant obser-
role to provide patients with preparatory information vation, regular non-invasive blood pressure measurement
about the procedure and care required during recovery. for hypotension, and monitoring for allergic reactions
As family members provide valuable support and remind- to streptokinase. Continuous ECG monitoring for
ers about recovery, these people should be included in arrhythmias and ST segment changes is essential. Some
any information sessions. The patient and family need to arrhythmias, particularly idioventricular arrhythmias, are
be provided with information about the possibility of associated with reperfusion and tend to be benign. ST
restenosis, mobility restrictions at home and the lifestyle segment monitoring and assessment of pain help evalu-
changes needed to reduce the risk of worsening CHD. ate the effectiveness of the thrombolysis. Thrombolysis is
considered to have failed if the patient is still in pain and
Nursing management of ACS and MI the ST segment has not resolved within 60–90 minutes.
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The nursing role in patients with ACS and MI includes reduc- If thrombolysis fails, patients are at high risk for other
ing myocardial workload and maximising cardiac output, interventions, so repeat thrombolysis is often the only
provision of treatments, careful monitoring to determine treatment option. Salvage or rescue angioplasty may be
the effects of treatment and detect complications, rapid undertaken if available at the site.