Cardiac Case
Study
John Watson
56 years old
Barbara Durham, DNP, RN, CNE, CHSE
1
Scenario
WHAT DATA ARE RELEVANT AND HAVE CLINICAL
SIGNIFICANCE FOR THE NURSE?
• S- John Watson, a 56-year-old male, was admitted to
your telemetry floor from the emergency department
(ED) with a medical diagnosis of “cardiomyopathy,
coronary artery disease, probable MI.”
• B- Mr. Watson has a past health history of
hyperlipidemia, hypertension, chronic renal
insufficiency, and a recently diagnosed 4 cm suprarenal
abdominal aortic aneurysm. His wife brought him to
the ED after he reported unrelieved “indigestion.”
2
Scenario
• O2 @ 4L/NC to keep sats > 94%
ASA 325 mg PO was given
• IV #1 with LR @ 75 ml/hr; IV#2 Nitroglycerin @ 5 mcg/min (50 mg/250ml)
P-Q-R-S-T Pain Assessment (5th VS)
CURRENT VS
Temp:
99.1 F/37.3 C
Provoking/Palliative
Unknown
HR:
94 irreg
Quality:
Sharp
RR:
24
Region/Radiation:
Chest
BP:
202/124
Severity:
9/10
O2 Sat:
93%
Timing:
Continuous
WHAT VS DATA ARE RELEVANT AND HAVE CLINICAL
SIGNIFICANCE FOR THE NURSE?
3
What is your priority?
PLANNING
•At this time, what are 3 priority goals for the
telemetry RN assigned to Mr. Watson based
on his admitting diagnosis and PMH? Place
them in the order of priority.
1. _____________
2. _____________
3. _____________
4
What is your priority?
•What are 3 priority interventions for the
telemetry RN assigned to Mr. Watson based
on goals identified on the previous slide?
Place them in the order of priority.
1. _____________
2. _____________
3. _____________
INTERVENTIONS
BREAK OUT GROUPS
5
Chest Pain
• WHAT MEDICATIONS DO YOU ANTICIPATE STARTING AND
WHY?
• IS MR. WATSON A CANDIDATE FOR TPA?
• What is the major risk?
• STAT LABS RESULTS HAVE RETURNED
• Review the characteristics of stable versus unstable
angina and acute coronary syndrome.
6
Comparison: Clinical Manifestations
• Angina – chest pain lasting 2-5 minutes, usually
relieved by rest
• Dyspnea, pallor, tachycardia, anxiety, fear
• Women have atypical symptoms
• ACS (Unstable angina) – more severe chest pain lasting
10-20 minutes, can occur at rest
• Above plus diaphoresis, cool skin, hypotension,
lightheaded
• AMI – sudden onset of continuous pain that is
unrelieved (>20 min)
• Sustained ischemia; necrosis occurs over 4-6 hrs
• Above plus a sense of impending doom, S&S of HF
• Women have worse outcomes
7
Acute Coronary Syndrome
Etiology and Pathophysiology
• When ischemia is prolonged and is not immediately reversible, acute
coronary syndrome (ACS) develops.
Deterioration
of once stable
plague
Rupture
Platelet
aggregation
Thrombus
• Result
• Partial occlusion of coronary artery: UA or NSTEMI
• Total occlusion of coronary artery: STEMI
8
STEMI vs NSTEMI
STEMI
NSTEMI
• ST elevation
• Progression to Q wave
• Full blockage of coronary
artery
• ST depression
• No progression to Q wave
• Partial blockage of coronary
artery
• Positive troponin
• More URGENT
• Positive troponin
• Due to NECROSIS =
permanent damage
• Severe ISCHEMIA = reversible
• Fibrinolytics may be
harmful
• Fibrinolytics are beneficial • Heparin is often prescribed
9
Pharmacology:
• ONAM:
• Oxygen, nitro, aspirin, morphine
• Lower cholesterol
• Statins, bile acid sequestrants, nicotinic acid, fibric acid
derivatives
• Treat angina
• Nitrates, beta-blockers, calcium-channel blockers, aspirin
• Treat myocardial infarction
• Analgesics, fibrinolytics, antidysrhythmic, antiplatelet
10
Fibrinolytics
• Breaks down/dissolves blood clots
• Nursing considerations:
• Must know contraindications
• Recent surgery or trauma, bleeding disorder, uncontrolled HTN
• Monitor for signs of bleeding
• No invasive procedures
• Evaluate response to treatment: Normalized ST segments,
relief of chest pain
• Stay on bedrest for 6 hours
• Monitor for manifestations of reocclusion
11
Chart Review:
WHAT LAB DATA ARE RELEVANT AND HAVE
CLINICAL SIGNIFICANCE FOR THE NURSE?
Lab Result
K
Na
Cl
Glu
BUN
Cr
4.3 mEq/L
139 mEq/L
108 mEq/L
159 mg/dL
23 mg/dL
1.4 mg/dL
Lab
Cholesterol
Triglycerides
HDL
LDL
Troponin T
CK-MB
BNP
Mg
Result
225 mg/dL
186 mg/dL
25 mg/dL
160 mg/dL
3.2 ng/mL
10%
78 pg/ml
1.8 mEq/L
12
Mr. Watson continues to report chest pain and a 12-lead ECG
is ordered STAT.
WHAT IS YOUR INTERPRETATION AND NURSING
INTERVENTIONS?
The ECG tech hands you Mr. Watson’s 12-lead
ECG results…
13
Coronary Arteries:
14
ECG Changes Associated With
Acute Coronary Syndrome (ACS)
ISCHEMIA
INJURY
INFARCTION
16
17
Interpret these 12-lead ECGs
18
THE HCP PLANS FOR AN EMERGENT PCI.
Mr. Watson is awaiting a cardiac
catheterization…
WHAT TEACHING WILL YOU PROVIDE REGARDING THE
PROCEDURE?
• Benefits of PCI:
• Locate and open blocked artery
• Determine presence of collateral circulation
• Evaluate left ventricular function
• What complications can be anticipated as a result of
the procedure?
19
Nurses role with Cardiac Cath: BEFORE
• Allergy to contrast dye
• NPO 6-12 hr before procedure
• Teaching expectations with the procedure
• Sedatives will be given
• BASELINE assessment
• VS, SpO2, heart/lung sounds, CMS, Labs
20
Balloon angioplasty
STENT
LAD
Circumflex
21
Scenario progression:
• Several hours later, Mr. Watson returns from the
cardiac catheterization lab. The catheterization
report shows 50% occlusion of the proximal left
anterior descending coronary artery (LAD), 50%
occlusion of the distal LAD, 95% occlusion of the
distal right coronary artery (RCA), and old inferior
infarction with an ejection fraction of 37%.
WHAT POST PROCEDURE NURSING INTERVENTIONS WILL
YOU PERFORM?
WHAT IS YOUR INTERPRETATON OF THESE RESULTS?
22
Nurses role with Cardiac Cath: AFTER
• Keep patient on bedrest
• Assess CMS, frequently to extremity
• Observe insertion site for signs of bleeding or hematoma over
arterial site (q15min x4)
• Monitor VS, ECG, dysrhythmias, respiratory distress (PE)
• Monitor for chest pain
• Monitor IV infusions
23
Closure Devices
Angio-seal
24
Closure Devices
FemoSTOP
TR BAND
25
AMI-1 Aspirin on arrival
AMI-2,5, 10 Aspirin, Beta blocker, and Statin
prescribed on discharge
AMI-3 ACEI or ARB for LVSD
AMI-4 Smoking cessation counselling
AMI-7 Time to Thrombolytics = 30 min
AMI-8 Time to PCI = 90 min
26
Scenario progression:
• About an hour after the procedure, you perform a
brief nursing assessment and find that Mr. Watson
now has a loud grade III/IV systolic ejection
murmur at the cardiac apex with palpable thrill,
crackles bilaterally in the lung bases, and trace
pitting edema of his feet and ankles. Except for a
soft systolic murmur, these findings were not
present before the catheterization. You get a
prescription to draw a CBC and complete
metabolic panel.
WHAT DO THE CHANGES IN THE PATIENT STATUS SUGGEST?
27
Chart Review:
WHAT LAB DATA ARE RELEVANT AND HAVE
CLINICAL SIGNIFICANCE FOR THE NURSE?
Lab
Hgb
BNP
BUN
Cr
Result
8.8 g/dL
189 pg/mL
33 mg/dL
3.1mg/dL
28
Pathophysiology-Heart Failure
Neurohormonal Responses
SNS Stimulation
Epi/norepi release, inc MO2
demand and workload
RAAS, ADH, proinflammatory cytokines
Counter regulatory: BNP is release to
vasodilate and enhance diuresis, NO also
dilates and dec afterload
• How is the heart going to compensate for the low cardiac output and
impending failure?
Ventricular dilation
(remodeling)
Initially adaptive, then becomes
inadequate
Ventricular Hypertrophy
Response to beat harder, results in poor
contractility, high O2 needs, and inc risk
for dysrhythmias
29
Mr. Watson goes into heart failure and requires an
IABP while waiting for surgery. A Swan-Ganz
catheter is inserted.
Result
CVP
13 mmHg
PAP
38/23 mmHg
PAWP 21 mmHg
SVR
1623 dynes/sec
CI
1.8 L/min
HOW DO YOU INTERPRET THE RESULTS OF THE SWAN-GANZ
CATHETER?
WHAT IS THE NURSES ROLE IN CARING FOR PATIENTS WITH AN IABP?
30
Intraaortic Balloon Pump
(IABP)
• Balloon inserted into
femoral artery and
placed in thoracic aorta
• Confirm placement with
x-ray
• Inflate balloon with
helium in conjunction
with ECG
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Intraaortic Balloon Pump
(IABP)
• Complications of IABP therapy
• Vascular injuries
• Thrombus and embolus formation
• Thrombocytopenia
• Ischemia to periphery, kidneys, bowel
• Infection
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Intraaortic Balloon Pump
(IABP)
• To decrease risks of IABP therapy
• Frequent assessments
• Keep patient immobile and limited to
side-lying or supine positions with
HOB <45 degrees
• Wean from IABP by gradually
reducing assist ratio
Copyright © 2017, Elsevier Inc. All Rights Reserved.
HF-1 Discharge Instructions*
 Activity , Diet , Follow-up , Medications , Symptoms
Worsening , Weight Monitoring
HF-2 Evaluation of LV Function*
 Assessed before or during hospital stay
 Or documentation that LV will be assessed p/DC
HF-3 Add ACEI or ARB
 LV systolic dysfunction = EF < 40%
HF-4 Adult Smoking Cessation Counseling*
34
35

ACE inhibitors
 May develop persistent,
dry cough







Angiotensin II receptor
blockers
-Adrenergic blockers
Diuretics
Vasodilators
Positive Inotrope
(Digitalis)
Antidysrhythmics
CAM - Hawthorne

Nursing Considerations:
 Monitor BP, weight, check





pulse
Careful with position
changes
Keep hydrated; don’t take
diuretics after 5pm
Monitor for S&S dig
toxicity and hypokalemia
Be careful with OTC meds
Notify HCP if experience
any changes, keep follow
up appointments
Diet and weight reduction: Individualize
recommendations and consider cultural
background
 Recommend Dietary Approaches to Stop
Hypertension (DASH) diet.
 Sodium is usually restricted to 1.5 – 2 g per day.
 Fluid restriction not generally required
 Daily weights are important

 Same time, same clothing each day

Weight gain of 3 lb (1.4 kg) over 2 days or a 3- to
5-lb (2.3 kg) gain over a week should be
reported to health care provider.

36

One day later, Mr. Watson begins to report
sharp, severe stabbing chest pain. It is worse on
inspiration.
WHAT ADDITIONAL ASSESSMENTS DO YOU WANT TO
DO?
HOW DO YOU TREAT THE PAIN?
HOW DO YOU POSITION THE PATIENT NOW?
WHAT ARE COMPLICATIONS ASSOCIATED WITH THIS
CONDITION? HOW WOULD YOU KNOW THE
COMPLICATION HAS OCCURRED?
37

Caused by inflammation around
pericardial sac
 Normally has a lubrication function
(10-15 ml)

Clinical Manifestations:
 Severe, sharp, stabbing chest pain
 Worse on inspiration and supine
 Pain can be referred to trapezius
muscle
 Pericardial friction rub

Nursing Management:
 Elevate HOB 45 o
 Anti-inflammatory meds
38

Complications:
 Pericardial Effusion –
▪ Dyspnea, distant heart sounds, cough,
hiccups, hoarseness
 Cardiac tamponade
▪ Beck’s triad
▪ Muffled heart sounds**, hypotension with a
narrowing pulse pressure, and JVD
▪ Pulsus paradoxus - drop>10 mm Hg SBP during
inspiration
▪ Confused, restless, anxious, CP, dec CO
39
Scenario progression:
• Two days later, Mr. Watson undergoes coronary
artery bypass surgery of 2 coronary arteries (CABG
X 2).
WHAT ARE SOME COMPLICATIONS RELATED TO CARDIOPULMONARY BYPASS?
REVIEW TYPES OF SURGERY FOR BYPASS.
DISCUSS THE NURSING INTERVENTIONS FOR A PATIENT POST
BYPASS SURGERY.
40
Internal Mammary Artery and
Saphenous Vein Grafts
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Management
Acute Coronary Syndrome
• Coronary revascularization: CABG
ICU for first 24–36 hours
Pulmonary artery catheter
 Intraarterial line
 Pleural/mediastinal chest tubes
 Continuous ECG
 ET tube with mechanical ventilation
 Epicardial pacing wires
 Urinary catheter
 NG tube


Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Management
Acute Coronary Syndrome
• Complications related to CPB
 Bleeding and anemia from damage to
RBCs and platelets
 Fluid and electrolyte imbalances
 Hypothermia as blood is cooled as it
passes through the bypass machine
 Infections
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Management
Acute Coronary Syndrome
• CABG: postoperative nursing care
 Assess patient for bleeding
 Monitor hemodynamic status
 Assess fluid status
 Replace blood and electrolytes PRN
 Restore temperature
 Monitor for atrial fibrillation (which is
common)
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Management
Acute Coronary Syndrome
• CABG: postoperative nursing care
 Surgical site care
• Radial artery harvest site
• Leg incisions
• Chest incision
 Pain management
 DVT prevention
 Pulmonary hygiene
 Cognitive dysfunction
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Scenario progression:
• After 3 days in the heart center, Mr. Watson’s
condition is stable and he is returned to the
telemetry floor. Now, 5 days later, he is ready to
go home and you are preparing him for discharge.
WHAT SHOULD BE INCLUDED IN THE DISCHARGE
INSTRUCTIONS POST AMI, PCI, AND CABG?
46
Nursing Management
Acute Coronary Syndrome
• Ambulatory Care
 Cardiac rehabilitation
 Patient and caregiver teaching
 Physical activity
• METs scale
• Monitor heart rate
• Low-level stress test before discharge
• Isometric versus isotonic activities
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Management
Acute Coronary Syndrome
• Ambulatory Care
 Resumption of sexual activity
• Teach when discuss other physical activity
• Erectile dysfunction drugs contraindicated
with nitrates
• Prophylactic nitrates before sexual activity
• When to avoid sex
• Typically 7–10 days post MI or when patient
can climb two flights of stairs
Copyright © 2017, Elsevier Inc. All Rights Reserved.
Nursing Management
Acute Coronary Syndrome
• Dietary Considerations
 Low cholesterol (<200 mg/day)
 Low in saturated fats (<7% of calories)
 DASH diet for HTN (reduced salt/Na)
 Inc fiber, fruits and vegetables
National Guidelines
for treating high LDL
Risk scores are calculated based
on
•
Age
•
Gender
•
Use of tobacco
•
Systolic BP
•
Use of BP medications
•
Total cholesterol
•
HDL cholesterol level
• Framingham Heart Study
Treatment
• Therapeutic lifestyle
changes (TLC)
Diet
 Physical activity
 Weight management

•
Drug therapy
• DHHS NIH NHLBI
50
National Guidelines
for treating high LDL
DHHS NIH NHLBI
Healthy People Goals
•
Less than 7 % of your daily calories
from saturated fat
•
Achieve and maintain a healthy
weight
•
Less than 200 mg a day of cholesterol
•
Reduce salt and sodium intake
•
25–35 % of daily calories from total fat
•
Increase level of physical activity
•
Diet options you can use for more LDL
lowering
 Plant stanols or sterols
 Soluable fiber
•
Avoid use of all tobacco products
•
Limit alcohol intake to small to
moderate amounts (12 oz beer, 4 oz
wine, 1 oz hard liquor)
•
Only enough calories to reach or
maintain a healthy weight
•
•
At least 30 minutes of a moderate
intensity physical activity, such as
brisk walking, on most, and preferably
all, days of the week.
Chose a diet that is low in dietary
cholesterol and total and saturated
fat, and high in fruits and vegetables
51