1. Complex Nursing Care of
Patients with Coronary
Artery Disease, Cardiac
Surgery, and Cardiac
Rehabilitation
Tina Zimmerman,
Professor of Nursing
Nursing 210 1
2. What is addressed in this class
Complex care of the patient
with a myocardial infarction
Care of the patient following
cardiac surgery
Care of the patient through
cardiac rehabilitation 2
3. Do you remember?
Kyra Smith, 58-years-old, is
being treated for angina. She is
currently taking metroprolol 50
mg q day, aspirin 81 mg q day,
and nitro SL prn. She presents to
the ED with worsening chest
pain. 3
4. Question
Ms. Smith is prescribed metropolol for
which of the following purposes?
a.To inhibit the conversion of angiotensin
I to II
b.To decrease platelet aggregation
c.To reduce the workload of the heart
d.To increase the sympathetic response
4
5. Question
The nurse is aware that the following
assessment finding will necessitate
holding the beta blocker:
a.Blood pressure of 102/64
b.Pulse rate of 48
c.Blood pressure of 180/90
d.Pulse rate of 100
5
6. Question
Ms. Smith is now pale, diaphoretic,
and c/o pain 9/10. What nursing
intervention should be implemented
first?
a.Start IV of 0.9% NS
b.Administer NTG SL
c.Obtain a 12 lead ECG
d.Assess the blood pressure 6
7. Question
The 12 lead ECG indicates injury to the
myocardium. What specific ECG
finding supports the injury?
a.S-T segment depression
b.T wave inversion
c.Significant Q wave
d.S-T segment elevation
7
8. Question
Ms. Smith is given NTG SL. The nurse
prepares her for which adverse effect
that may occur?
a.Dizziness
b.Tinnitus
c.Diarrhea
d.Greenish-yellow visual changes
8
9. Question
Ms. Smith is prescribed Tridil. What is a
primary goal of this medication?
a.Increase the force of myocardial
contractions
b.Perfuse cardiac tissue by dilating coronary
arteries
c.Relax cardiac musculature
d.Dilate cerebral vessels to prevent hypoxia
9
11. Complex Care Following MI
Patient in critical care unit
Liquid diet for first 24 hrs
Monitor hemodynamic stability
Administer appropriate drugs
Monitor for complications
Prepare for rehabilitation 11
12. Fibrinolytics (Thrombolytics)
Goals of therapy:
decrease infarct size
decrease mortality
preserve heart function
restore blood flow to heart
12
13. Time is Muscle
Preference is to administer
drug within 4 hours
Must be within 6 hours
Door to needle time: hospitals
strive for 30 minutes
13
14. Selection Criteria
CP longer than 20 min. and
unrelieved w/ NTG
ECG evidence
Less than 6 hours from onset
of pain
Thrombolytics 14
15. Contraindications
Active bleeding
Known bleeding disorder
History of hemorrhagic stroke
Uncontrolled HTN
Recent major trauma or surgery
Pregnancy
Intracranial vessel malformation 15
Thrombolytics
18. tPA
General advantages
More clot specific
Not antigenic
Shorter half-life
General disadvantages
More expensive
With some – more bleeding 18
Thrombolytics
20. Nursing Actions
Heparin concurrent or after
fibrinolytic – different line
Do not elevate HOB above 15
degrees – especially with strepto.
Place on telemetry
Observe for bleeding
Thrombolytics 20
21. Reperfusion
Relief of CP
Normalization of ST segments
Sinus tachycardia that is
transient
Fibrinolytics 21
23. Follow-up Care
Heparin infusion for 2-3 days
Aspirin therapy perhaps
Coumadin for at least 3 months
Patient education: Coumadin
Patient to report chest pain
immediately
Fibrinolytics 23
26. Glycoprotein Inhibitors
Prevent platelets from binding
together
Administered IV
Assess patient for bleeding &
hypersensitivity reaction
26
27. Glycoprotein Inhibitors
Must assess creatinine clearance –
Dosing chart will specify for
creatinine clearance >50 and also <50
Usually 2 bolus doses 10 minutes
apart
IV infusion is weight based
NOT compatible with furosemide 27
28. Glycoprotein Inhibitors
Contraindicators (some):
Severe hypertension SBP>200 or
DBP >110
Major surgery w/in preceding 6 weeks
Stroke w/in 30 days
History of hemorrhagic stroke
Active bleeding w/in previous 30 days
28
29. MI Complications
Dysrhythmias
Type of MI can often determine
type of dysrhythmia
VT is dreaded complication
Necrotic cells are silent
29
30. MI Complications
Heart block
Temporary or permanent
pacemaker may be needed
Heart Failure
Myocardium does not contract
normally 30
33. Cardiogenic Shock
Most often caused by MI
High mortality: 65-100%
Heart’s pumping ability so
compromised that CO is not
maintained
Usually more than 40% of left
ventricle is damaged
33
38. PA Catheter
Gives an accurate measurement
of left ventricular function
PAWP = pulmonary artery
wedge pressure
PAWP mean pressure is
between 4.5 and 13 mmHg
(will vary among agencies) 38
39. Nursing Actions: PA Catheter
HOB elevated about 45 degrees
Inflate with about 1mL of air
After PAWP, immediately
deflate the balloon – do NOT
aspirate the air
Look for correct waveform
Monitor for infection 39
40. Interventions for Cardiogenic Shock
Medications
Inotropic and vasopressors:
increase contractility, BP, SV, CO
• dopamine, dobutamine, digoxin
40
44. CABG
Restores blood flow to
ischemic areas of heart
Saphenous vein, mammary
artery, and/or radial artery
used
Traditional & alternative
techniques 44
51. CABG: Nursing Care
Pre-op teaching:
Critical care unit
Endotracheal tube in place 2-24 hrs.
Will have many tubes in place
Increase activity gradually
TC&DB and use of IS
Don’t forget family
CABG 51
52. Post CABG
Major nursing goals & actions
Maintain hemodynamic stability &
cardiac output
Thorough assessments
Monitor & manage complications
Assist patient & family through
recovery
52
53. Monitor for Complications
Patient must be continually
assessed for impending
complications such as
decreased CO, fluid volume
imbalance, pain, etc .
Read in textbook!
53
54. Altered Tissue Perfusion
Palpate all pulses
Hypotension
SBP<90: vein graft may
collapse
May need to increase fluids
Cardiac surgery 54
56. Hypothermia
Monitor temperature using same
site – avoid rectal & oral for first
8 hrs.
Re-warming for temp. below 96.8
F (36 C) – re-warm slowly
Thermal blanket, lights, warmed
IV 56
57. Pain
Both CW and harvested site
Differentiate between sternal
incision pain and anginal pain
Incision pain: localized, no
radiation, worse with coughing
and breathing; sharp
Cardiac surgery 57
58. Pain
Encourage routine pain medication
dosing for 1st 24 to 72 hours
PCA: Patient Controlled Analgesia
Support incision
Cardiac surgery 58
59. Risk for Bleeding
Monitor H & H
Monitor VS
Assess for bleeding
Monitor chest drainage: should
be less than 200 mL/h during
first 4 to 6 hours
Cardiac surgery 59
60. Cardiac Tamponade: risk for
Accumulation of fluid in
pericardial sac leading to
compression of the heart
Sudden decrease in chest drainage
may be indicator
Pericardiocentesis: removal of
fluid Cardiac surgery 60
61. Cardiac Tamponade: S/S
Decreasing SBP
Narrow pulse pressure
Rising venous pressure (JVD, can
be with clear lung sounds
Distant heart sounds
Pulsus paradoxus: pp 823 & 842
Cardiac surgery 61
62. Fluid & Electrolyte Imbalance
Check levels frequently
Hypokalemia is most common
I&O
Record chest tube drainage
hourly
Cardiac surgery 62
63. Dysrhythmias
Atrial fibrillation most common
Amiodarone may be ordered
pre-operatively
Beta-blocker or calcium channel
blocker may also be used to
control rate
Temporary pacemaker - maybe
Cardiac surgery 63
64. Sensory-Perception Imbalance
Changes due to anesthesia, CPB,
and/or hypothermia
Memory loss, confusion, wide-
eyed look, slow to arouse
Report s/s that might indicate
stroke
Most changes resolve within 8
hours Cardiac surgery 64
65. Sensory-Perception Imbalance
Monitor neurological status very
frequently
Every 30 minutes in first hour
Then hourly for next 8 hours
Then every 2 hours for next 8
hours
Then every 4 hours for next 8
hours Cardiac surgery 65
66. Risk for Infection
Sterile technique
Postpericardiotomy syndrome may
develop between 5 days & several
weeks post-op
Monitor labs, color of drainage,
temperature, malaise
Cardiac surgery 66
67. Gas Exchange
Atelectasis – most common
Mechanical ventilation – 2-24 hrs
Suction as needed
Use incentive spirometer
Every 1-2 hours
TCDB
Cardiac surgery 67
68. Recovery from CABG
Sutures removed from chest prior to
discharge and from leg after 7 to 10
days
Elastic support stockings during day
for first 4-6 weeks after surgery; keep
leg elevated when sitting
Not to lift anything more than 10 lbs
68
69. Recovery from CABG
Advised not to drive for the first four
weeks
Normal sexual activity as long as
positions doesn’t put significant weight
on the chest or upper arms.
Return to work after 6 weeks
Exercise stress testing done 4-6 weeks
after CABG surgery 69
70. Critical Care Nursing Issues
Can be a stressful environment
Depersonalization of both
patients and healthcare providers
Prognosis of patients
70
76. Teaching Hints
Always have an objective
Don’t overwhelm patient
Pay attention to non-verbal clues
Always evaluate learning
Use media, pamphlets,
brochures, etc
Rehab 76
77. Teaching Points
Allowed to use one flight of steps
2-3 times a day for the first 2 weeks
Can usually drive within 2 weeks
of discharge
Average time to return to work
depends on extent of MI
Rehab 77
78. Teaching Points
Remain at home for 2 weeks
Start aerobic exercise program
Can usually resume sexual activity
2 weeks after discharge
Indicator: can climb 2 flights of stairs
without chest pain
Rehab 78
