Page 269 - ACCCN's Critical Care Nursing

246 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

complications arising. Important principles covered in ● Heart failure:
this chapter are summarised below. ● May affect either the left, right or both ventricles,
● Coronary heart disease: resulting in different symptoms being displayed by
● Incorporates myocardial ischaemia, angina and the patient.
acute coronary syndrome. ● Diagnosis is usually made on the basis of echo-
● Early patient assessment and diagnosis is essential cardiography, ECG, chest X-ray, full blood count,
electrolytes, liver function tests and urinalysis.
to facilitate prompt intervention. ● In acute heart failure, CPAP or BiPAP may be neces-
● Initial diagnosis is based on history, clinical assess- sary to improve hypoxaemia
ment, electrocardiographic and biochemical exam- ● Pharmacological therapy of acute heart failure con-
ination, with coronary angiography, exercise testing sists of: morphine, nitrates and diuretics. Positive
and chest radiography available to provide later inotropes may also be used such as IV dopamine
detail. and dobutamine to improve renal perfusion and
● Early restoration of blood flow – including reperfu- contractility
sion therapy and coronary angioplasty – to reduce ● Many patients with heart failure will also have a
myocardial damage is a core component of pacemaker with cardiac resynchronisation therapy
treatment. and/or a defibrillator to improve cardiac function
● Other goals of care include reducing plaque and and reduce the incidence of sudden death
clot formation in coronary arteries, reducing the ● Patient care must be lifelong and coordinated
workload of the heart, controlling symptoms, between all members of the healthcare team. Broad
providing psychosocial support to the patient interventions, including medications, diet and life-
and family, and educating the patient about the style modification, may be appropriate for some
disease process, lifestyle and future responses to patients, while palliative care might be more
illness. appropriate for other patients.

Case study
Mrs See is a 69-year-old woman who presented to the emergency had a slightly globular configuration. There was no evidence of a
department with intermittent chest pain. She presented to her pericardial effusion.
general practitioner (GP) two days ago complaining of chest pain
lasting 2–3 hours. An ECG was done showing old q waves anteriorly Within a short time her acute pulmonary oedema was stabilised
and ST depression V5 & V6. A troponin-I was done by her GP that and so she was considered for a primary PTCA. Coagulation profiles
was 0.16 µg/L. and a brief history of, and contraindications to, fibrinolytic treat-
ment were collected. Preparation for PTCA included locating,
Her past medical history included: smoker for the past 50 years of assessing and marking peripheral pulses in both right leg and right
10–20 cigarettes a day, diabetes mellitus type 2, infrarenal abdomi- arm. The coronary angiogram report stated: moderate to severe
nal aortic aneurysm, asthma/COPD, peripheral vascular disease, reduction in left ventricular function, ejection fraction 30%; intact
left internal carotid artery aneurysm, hypercholesterolaemia and left circumflex artery, intact left main coronary artery with minor
hypertension. Her medications consisted of: diamicron 60mg daily, irregularities (30%) in left anterior descending artery; and severe
glargine 26 units nocte, perindopril 5 mg daily, seretide and ven- localised 70–80% stenosis within the proximal third of the right
tolin puffers and lipitor 20 mg daily. coronary artery and collaterals from the left coronary artery. Her
right coronary artery was the dominant vessel. This stenosis was
Two days after visiting her GP, she presented to emergency depart- dilated by PTCA with resulting TIMI 3 flow, and a paclitaxel drug-
ment with further intermittent chest pain. Initial 12-lead ECG eluting stent was placed.
showed ST elevation in leads II, III and aVF. She was also feeling
tired and nauseated at times. She denied any chest pain. She was Post-PTCA, Mrs See was admitted to CCU with oxygen via mask,
afebrile, BP 143/96, pulse 120 bpm and regular, respiratory rate PTCA access site and sheath in her right groin. Her observations
33 bpm, and O 2 sat 93% on room air. Her respirations were laboured included: BP 100/60 mmHg, HR 80 beats/min, RR 20/min. She was
and her skin was cool and clammy. On chest auscultation there free of pain. Her ECG was normal except for T inversion in lead III
were bibasal crackles to midzones. Her jugular venous pressure with a generalised widened QRS (200 msecs). Post PTCA she expe-
was +6 and peripheral oedema to mid calves. She had dual heart rienced short runs of ventricular tachycardia. These were initially
sounds (S1S2) and a third heart sound (S3). Blood test results: thought to be due to reperfusion arrhythmias. However, the short
U&E-Na 134 mmol/L, K 5.1 mmol/L, urea 5.2 mmol/l, creatinine intermittent runs of ventricular tachycardia continued. Her blood
86 µmol/L, ctroponin-I 2.0 µg/L, CK 590 U/L and random glucose test results were: Na 137 mmol/L, K 4.6 mmol/L, urea 8.8 mmol/L,
10.6 mmol/L. Her FBE and LFTs were normal. Fast-track treatment creatinine 99 μmol/L, calcium 2.37 mmol/L, magnesium
was commenced, including administering aspirin 300 mg orally, 0.96 mmol/L. Fasting cholesterol profile: total cholesterol
oxygen via face mask, glyceryl trinitrate patch, morphine 2.5 mg 4.3 mmol/L, HDL-C 1.91 mmol/L, LDL-C 2.1 mmol/L, triglycerides
IV, metoclopramide 10 mg IV and frusemide 40 mg IV. Chest X-ray 0.7 mmol/L, cholesterol/HDL-C 2.3 mmol/L. Her liver function and
showed horizontal linear interstitial opacities at both bases, which full blood examination tests were normal. She was commenced on
were not present on a previous X-ray taken six months ago, which an intravenous amiodarone infusion and considered for an ICD
was consistent with the clinical impression of pulmonary oedema. with CRT, in light of her newly diagnosed heart failure (evident on
There was also a marked increase in size of the heart which also coronary angiogram) and NYHA class III symptoms.