Question

ADULT/GENERAL - Care of the Patient with CARDIAC problems: Concepts include; Myocardial Infarction, Heart Failure, Pulmonary Edema, MAP, CABG, Cardiac Medications, Cardiac Catherization, Inflammatory Conditions of the heart (Pericarditis, Cardiac Tamponade).

1. Develops a plan of care for patients undergoing invasive cardiac diagnostic procedures such as cardiac catheterization and angiography.

2. Apply the nursing process/ ADPIE (assessment, planning, diagnosis, implementation of interventions and evaluation) in the care of patients with cardiac problems.

3. Describe pharmacologic information, for medications used for patients with cardiac problems.

4. Prioritize care for patients with acute coronary syndromes (ACS), focusing on care of the patient in the ER, cardiac treatment unit (cath lab), and critical care units.

Answer 1

Q)1) Develops a plan of care for patients undergoing invasive cardiac diagnostic procedures such as Cardiac catheterization and Angiography?

Ans) Essentials: Cardiac catheterization / Angiography is indicated for evaluation of patients with coronary, valvular and congenital heart disease in whom diagnostic or Therapeutic decisions can not be made on the basis of noninvasive tests.

Most patients presenting for cardiac catheterization have CAD, catheterization and coronary Angiography are integral parts of interventional treatments for pts experiencing Ischemic coronary syndromes.

Indications: Coronary artery disease,

- valvular disease,

- congenital disease,

- pericardial disease,

- congestive heart failure,

- Pulmonary vascular Disease.

Care plans for this invasive procedures : Preparing the patient : Pre catheterization Evaluation should consists of a careful history and examination, particularly aimed at eliciting details of prior cardiac procedures, reactions to contrast medium, renal function, peripheral vascular status, and hemostatic function,

- The patient carefully advised of the indications,alternatives, risks,discomforts and expected benefits of the procedure,

Vascular access : made a vasucular access is via a cutdown near the antecubital fossa, with isolation and mobilization of the brachial or antecubital vein and the brachial artery for right and left heart catheterization there by allowing arterial and venous access,

- after the procedure the arterial entry site is repaired by suture and the vein is usually tied off,

- this approach has the advantage of enabling early post procedure ambulation and security of direct arterial closure in anticoagulated patients,

- prepare plan for vascular access is acheived by direct puncture with a needle through which a flexible spring guide wire is passed into the vessel,

- Prepare and hand over data to Cath Lab personnel,

- be ready with all diagnostic and radiology investigations reports,

- read the vitals and same inform to provider if any abnormal findings.

Complications of cardiac catheterization : Death within 24hr,

Death between 24 h and 30days,

Stroke,

Transient cerebral ischemia,

Myocardial Infraction,

Peripheral arterial embolism,

Access site complications,

Cardiac tamponade,

Ventricular fibrillation,

Arrythmia,

Primary hypotension,

Reaction to contrast medium,

Arterial perforation or dissection.

After procedure, kindly assess above factors also.

Q)2) Apply the Nursing process / ADPIE ( assessment, Planning, diagnosis, Implementation of interventions and evaluation) in case of patients with cardiac problems?

Ans) Assessment : for complications of cardiac / vascular dysfunction, mainly assesses for :

- complications for bleeding,

- complications for decreased out put,

- Complications for dysarrthmias,

- complications of pulmonary edema,

- complications of hypovolemia,

- complications of compartment syndrome,

- complications of pulmonary and coronary embolism.

Planning : plan should be , the nurse will manage and minimize bleeding episodes,

- monitor and manage episodes of decreased cardiac output,

- manage and minimize dysarythmatic episodes,

- manage and minimize the episodes of pulmonary edema,

- minimize the complications of DVT,

- minimize hypovolemic episodes,

- compartment syndromes,

Minimize the PE.

Diagnosis: It depends on the significant Laboratory and diagnostic assessment criteria: Estimation of cardiac enzymes and proteins, creatinine kinase, isoenzymes, Troponins, BNP, C- reactive protein, Electrolytes,CBP, ABG, coagulation studies, ECG, ECHO, Doppler ultrasonic flow meter,cardiac catheterization,CT,MRI, Perfusion imaging, infract imaging, Angiography, Holter monitoring, Inflatable loop monitor.

Implementation of Interventions and evaluation :

1. Monitor fluid status, surgical site, monitor for throbolytic therapy, signs of bleeding from venous sites, monitor signs and symptoms for shock

2.Monitor for signs and Symptoms of decreased cardiac output by irregular pulse rate, respiratory rate, decreased bld pressure,abnormal heart sound,neck vein distention,

3. Change of abnormal rate and Rhytham etc.

Q)3) and) Few cardiovascular drugs are like Adenosine, adrenaline and throbolytics are exclusive emergency drugs,

Drugs	PREPARATIONS
Adenosine	Amp 2ml (6mg)
Atropine,	Amp 1ml ( 0.6mg)
Amidarone,	Amp 3 ml ( 150mg)
Digoxin,	Amp 2ml ( 0.5 mg)
Dilitiazem	Vial 5 ml ( 5mg/ml)
Dopamine	Amp 5 ml ( 40mg/ml)
Dobutamine	Amp 5 ml (50 mg/ml)
Epinephrine	Amp 1ml ( 1mg 0.1 mg)
Frusemide	amp 2ml ( 20 mg)
Isoprenaline	Amp 1ml (2mg)
Ibutilide	Amp : 1 ml ( 1mg)
Isoprenaline	Amp 1 ml (2 mg)
Metoprolol	amp 5 ml (5mg/ml)
Morphine	Amp 2ml (15mg)
Nicorandil	Amp 1ml (2mg)
NTG	Amp 5ml ( 5 mg/ml)
Nitroprusside	Amp 5ml ( 50 mg/ml)
Norepinephrine	Amp 2 ml (4mg)
Protamine	Amp 5 ml ( 10mg/ml)
Verapamil	Amp 2ml (10mg)

Q)4)ans) ACS is precipitated by an atheromatous plaque, resulting in in increased obstruction to perfusion and ischemia or infraction in the territory supply by the affected vessel,,

- the clinical consequences range from salient episode to profound ischemia complicated by progressive infraction, heart failure and risk of sudden death,

- - the choice and timing of acute management depends on three elements:

1. Unstable angina,

2. NSTEMI,

3. STEMI.

Diagnosis by ECG and Biomarkers for necrosis,

MANAGEMENT: An acute reperfusion startagy (PCI) or Thrombolysis with tissue plasminogen activators,

Effective analgesia for pain relief,

Special attention for sudden cardiac arrest with CPR and Defibrillation,

Management of artythmatic and heamodynamic complications including heart failure.