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Myocardial Infarction- Intracoronary stents, CABG, Laser ablation, Nursing management, complications

Intracoronary stents

Several different stent designs are available, but most are balloon –expandable or self expandables tubes that when placed in a coronary artery act as a mechanical scaffold to reopen the blocked artery. Coronary artery stents are made up of numerous materials, ranging from stainless steel to bio absorbable compounds. Once the coronary lesion is identified by angiography, the balloon catheter bearing the stent is inserted in to the coronary artery and stent is positioned at the site of the occlusion. a major concern related to stent placement is the prevention of acute thrombosis, especially the first several weeks after the procedure.

Laser ablation

Lasers are used with balloon angioplasty to vaporize atherosclerotic plaque. After the initial balloon angioplasty, a brief burst of radiation is administered and additional remaining plaque is removed. Complications include, coronary dissection, acute occlusion, perforation and embolism.

Coronary artery bypass graft (CABG)

CABG involves the bypass of a blockage in one or more of the coronary arteries using the saphenous vein, mammary artery, or radial artery as conduits or replacement vessels. Before surgery, coronary angiography precisely locates lesions and points of narrowing within the coronary arteries

During traditional CABG surgery, a median sternotomy incision is made through the sternum so that the heart and aorta can be seen. After being connected to the bypass, the heart is stopped (cardioplegia) using a solution of iced saline containing potassium. All bypasses were originally performed using saphenous vein from the leg as the new conduit. The distal end of the vein is sutured to the aorta, and the proximal end is sewn to coronary vessel distal to the blockage. The vein is reversed so that their valve do not interfere with blood flow.

Today the saphenous vein is used less often. More commonly, the internal mammary artery is grafted to a coronary artery. It is more routinely used to revascularize the portion of the myocardium supplied by the left anterior descending artery. The disadvantage of IMA is that more time is required to remove it and the mammary artery is shorter.

NURSING MANAGEMENT

NURSING ASSESSMENT

Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis).

Each symptom must be evaluated with regard to time, duration, the factors that precipitate the symptom and relieve it, and comparison with previous symptoms.

A precise and complete physical assessment is critical to detect complications and any change in patient status.

NURSING DIAGNOSIS

• Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow from coronary thrombus and atherosclerotic plaque

• Potential impaired gas exchange related to fluid overload from left ventricular dysfunction

• Potential altered peripheral tissue perfusion related to decreased cardiac output from left ventricular dysfunction

• Anxiety related to fear of death

• Deficient knowledge about post-MI self-care

POTENTIAL COMPLICATIONS

• Acute pulmonary edema

• Heart failure

• Cardiogenic shock

• Dysrhythmias and cardiac arrest

• Pericardial effusion and cardiac tamponade

• Myocardial rupture

NURSING GOALS

  • To get relief of pain
  • Absence of respiratory dysfunction
  • Maintenance or attainment of adequate tissue perfusion
  • To reduce anxiety
  • Adherence to the self-care program
  • Absence or early recognition of complications

NURSING INTERVENTIONS

RELIEVING PAIN

  • Oxygen administered by nasal cannula at rate of 2 to 4 L/min to maintain oxygen saturation levels of 96% to 100%
  • Vital signs assessed frequently
  • Physical rest in bed with the backrest elevated or in a cardiac chair to decrease chest discomfort and dyspnea.
  • Administer morphine for relief of pain
  • Revascularization with thrombolytic therapy or emergent PCI
  • Intravenous beta-blocker and nitroglycerin
  • Use of GPIIb/IIIa agent or heparin as prescribed

IMPROVING RESPIRATORY FUNCTION

  • Regular and careful assessment of respiratory function
  • Attention to fluid volume status to prevent overloading
  • Encourage patient to breathe deeply
  • Change position frequently helps keep fluid from pooling in thebases of the lungs.

PROMOTING ADEQUATE TISSUE PERFUSION

  •  Limiting the patient to bed or chair rest to reduce myocardial oxygen consumption
  •  Checkskin temperature and peripheral pulses frequently
  •  Oxygen is administered

REDUCING ANXIETY

  • Developing a trusting and caring relationship with the patient
  • Ensuring a quiet environment, preventing interruptions , using a caring and appropriate touch, teaching relaxation response, using humor and assisting the patient to laugh
  • Frequent opportunities are provided to share concerns and fears.
  • Music therapy is an effective method for reducing anxiety and managing stress

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include the following:

1. Relief of angina

2. No signs of respiratory difficulties

3. Adequate tissue perfusion

4. Decreased anxiety

5. Adherence to a self-care program

6. Absence of complications

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