Nursing Care and Primary Angioplasty of Thrombolysis - Term Paper Example

Nursing Care and Primary Angioplasty Vs. Thrombolysis The case of a 45 years old male who was brought to the hospital with severe central chest painis considered. ECG showed massive ST elevation in the antero-lateral leads. On arrival at the hospital, the patient’s signs and symptoms such as TPR (temperature, pulse and respiratory rate), blood pressure and blood glucose levels were recorded. Considering all the reports, he was advised to undergo emergency Primary Percutaneous Coronary Intervention (PPCI), also commonly known as Coronary Angioplasty, for left anterior descendent artery. Usually in such cases, as a first step once the patient is brought in, detailed history of the patient is taken by the hospital staff with the help of accompanying relatives while the patient is getting ready for the procedure. Details to be collected typically include – onset duration progress of cardiac symptoms, similar complaints in the past, any other major illnesses like diabetes, hypertension, medicines with dosage, previous surgeries, any allergies, etc. Details are provided to the respective physician and orders noted accordingly. Meanwhile the patient and the relatives are provided counseling and assurance. Coronary Angioplasty is planned in this patient to widen the occluded coronary artery. These arteries supply blood and oxygen to the heart muscles. These arteries get occluded due to fatty tissue or atheroma resulting in reduced blood supply to the heart causing chest pain. Angioplasty is performed to open up the blocked vessels by compressing fatty tissue against anterior coronary vessel wall. This procedure helps to improve blood flow through the vessels to the heart muscles and helps in relieving chest pain. Also, this procedure is advised when - a. Medicines like calcium channel blocker, beta adnergic blockers or nitrates fail to correct coronary heart disease symptoms (NICE technology appraisal guidance 71) or b. There is recurrence of chest pain post CABG (Coronary Artery Bypass Graft surgery). Coronary angioplasty can be planned procedure or an emergency procedure in the case of heart attack and unstable chest pain with acute myocardial infarction. (Coronary Angioplasty and Stents) This operation is performed either through radial artery or femoral artery. Radial route is more popular in recent times because radial artery is easily accessible and palpable. Its superficial location makes it easy to compress to achieve homeostasis later on. Normal Allen’s test ensures dual blood supply to hand. So in case of bruise to radial artery or radial blood flow shunt, hands will still receive perfusion through Ulnar artery without feeling any damage. There is less chance of nerve injury in radial method. This approach provides comfort to the patient as it allows them ability to mobilize. It is easier for the patient to notice and control any bleeding from the radial incision, the femoral artery lies deeper in leg, so compressing the artery is difficult and by the time hematoma is noted bleeding would be significant. Radial artery method is cost effective too. (Radial Approach to Cardiac Catheterisation). Coronary Angiography is performed with the Angioplasty in an emergency. Angiogram allows doctor to look inside coronary arteries and find out how severe and where the narrowed areas are. (Coronary Angioplasty and Stents) Patient is advised what medicines to be avoided on the day of the procedure, such as aspirin or any anti coagulant, which medicines should be stopped few days before the procedure and what additional medicines need to be taken. He/she is also informed about the details of the procedure along with the effect of anesthetic drugs during and after the procedure. Doctor explains about the nature of pain the patient may have. Nursing staff ensures that patient would not eat or drink anything 4 -5 hours before the procedure. Proper consent is taken from the patient and relatives informing them about the complication involved in it. Nursing staff prepares the patient for the procedure by checking TPR, BP and shaving the operative site on wrist. Primary Percutaneous Coronary Intervention (PPCI) procedure: PPCI is usually conducted in special well equipped lab called Catheterisation lab. Procedure usually takes half an hour to forty five minutes but may take longer depending on the prevailing conditions. Patient is given heparin (anticoagulant) during the procedure to rule out the chances of blood clotting. Patient’s wrist is sterilized, draped and hyper extended on arm rest. Local anesthesia is given to the site. A ‘Guide’ catheter is inserted through needle into the incision made over Radial Artery. Catheter is gently pushed upward towards heart. Low dose x rays are used to monitor the progress of the catheter tip. Catheter is pushed inside the coronary artery. Once it reaches its desired position, a colourless dye is injected. Dye contains iodine and as it passes through the vessels, it can be seen on x-ray. This contrast dye gives fair idea about the location and extension of blockage in the vessel. As the guided wire reaches narrowed vessel, a small balloon is inflated slowly into the narrow area compressing the fatty tissue against arterial wall. This helps in widening of the vessel helping to increase blood flow to heart muscles. Sometimes, a stent (type of a wired mesh tube) is passed along with the balloon in a collapsed state inside the vessel. Along with the balloon inflation; stent expands like a scaffold to open the vessel and fits into the wall of narrowed vessel. After the proper positioning of the stent inside the artery, the balloon is slowly deflated and taken out. Stents are of two varieties bare metal stents and drug eluting stents. Drug eluting stents releases drugs slowly into the stream which will prevent artery from further blockage. After the procedure is done, radial sheath is removed. Homeostasis is achieved with slight pressure over the cut. Patient will not feel the catheter in the blood vessel. Patient’s heartbeats are monitored on ECG machine by placing the electrodes over his chest. Patient is given sedation before the test if he is very anxious. As the patient gets off the sedation, he is transferred out of the cath lab. (Coronary Angioplasty) Nowadays, drug eluting stents are frequently used to avoid chances of restenosis associated with inflammation process during Angioplasty procedure. Recent ones are polymer mix drug where the drug is held in a metallic frame and released slowly into surrounding tissue. Drug eluting stents are recommended only if the target vessel has less than 3 mm caliber or the lesion is longer than 15 mm. (NICE Technology appraisal Guidance 71). Risk factors for PPCI Although PPCI is commonly performed and is a safe procedure, at times some of the following complications are possible. (Angioplasty and Stent). – 1. Bruise at the site of the procedure is very common. 2. Bleeding from the punctured artery after the procedure. If it is severe, artery repair operation is needed. 3. Restenosis- vessel blockage or vessel rupture. This occurs due to recoil of the vessel after the balloon is deflated. This can occur immediately during or within 24 hours of the procedure. It may cause Acute Occlusive Dissection of the affected vessel. In such cases, patient is immediately transferred for Emergency CABG (Coronary Artery Bypass Grafting). In some cases, medium restenosis may occur in the same artery after some time of the procedure. Reasons are either contractions of the outer wall of the artery due to some procedural injury which may lead to occlusion of the artery or proliferation of the smooth muscle cells of the anterior wall of the artery. This may result in further restenosis. Procedure needs to be repeated in such cases. Re-intervention may be needed in some cases such as – a. Diabetes with tendency to atherosclerosis. Because, in such cases chances of recurrent stenosis are higher b. Patients having small calibers heart vessels (less than 3mm) c. Saphenous vein graft d. Long lesions (more than 15 mm) e. Cases where there is 100 percent occlusion (NICE Technology appraisal guidance 71) 4. Stent Thrombosis: There is a risk of Stent thrombosis associated with stent insertion. Patient needs to take anti platelet drug like Clopidogrel along with other anti coagulant drug for loner period to avoid Thrombosis. 5. Contrast dye allergy- Some patients can have allergy to the X ray dye injected during the procedure. It can cause renal impairment. It is a rare complication. Success rate of this procedure is very high and chances of complications are very less around 1-2 %. (Angioplasty and stent) Post Operative care: After the procedure, the patient is advised rest for some time till the sedation effect gets over. Nurses will observe the patient and maintain TPR BP chart every hour till the patient is discharged. Local examination of the wound will be performed to confirm no bleeding. The patient can also sit up and rest after the procedure. Nurse will make sure that there is someone accompanying the patient till the sedation effect gets over completely and the patient gets stable. Most of the time, the patient is discharged on the same day unless there some major prevailing conditions like heart attack before the procedure. Here, the patient will be monitored for some more time. Nurse will provide the post-discharge instructions for the patient such as – The list of medicine along with dosage intake that includes mainly anticoagulants, anti platelets drugs and rest systemic disease medication. Role of each medicine will be explained to the patient. Amount of activities / exercises permitted. No heavy weight lifting for about a week. Potential symptoms to be observed at the local site of procedure- any redness, swelling, bleeding, etc. Symptoms which need to immediate contacting the doctor to report such as any chest pain, breathing discomfort, signs of infection and fever. Guidance is given over Diet and Regimen. E.g. correction in food habits if any, stop smoking, exercise, reduction in weight, reduction in stress etc. Date is given for next follow up (Coronary Angioplasty information leaflet) It is important for patient and relatives to know that discharge from the hospital not only marks end of the acute care episode but also the start of new adjustment period wherein patient and relatives need to manage their own care. (Primary angioplasty and health information provision, NHS improvement) Thrombolysis Vs PPCI They key to improve coronary heart disease condition is to improve coronary blood flow as quickly as possible to minimize heart muscle damage. There have been lots of discussions going on regarding the benefits of PPCI over Thrombolysis. Thrombolysis is a process in which drugs are administered to break up or dissolve blood clots which are the causative factors for heart attack and stroke (Definition Thrombolysis). Long term benefits of PPCI are being noticed by the clinicians over thrombolysis and following conclusions are formed Most of the patients are suitable for Primary Angioplasty procedure in emergency hospital admissions. Risks factors like heart attack or stroke are much reduced with PPCI than Thrombolysis. In 20-30% of the Thrombolysis cases, coronary artery renarrows causing recurrence of symptoms. Beneficiary effect of Primary Angioplasty in STEMI (ST elevation myocardial infarction) patients is remarkably reduced if the procedure is not conducted within 90 minutes of STEMI symptom detection because this time lapse results in significant damage to heart muscle. If thrombolysis and PPCI take place in the same time frame, success rate of PPCI is higher than thrombolysis, thereby reducing mortality rates and improving long term outcomes Thrombolytic treatment gets started by the paramedics when they come in contact with the patient. This has an advantage of the treatment in early phase of heart attack. Effectivity of PPCI is reduced due to time lost in the patient seeking medical help. (Thrombolysis and primary Angioplasty) It is observed that overall effectiveness of both these methods solely depends upon the timely application of either procedures National plan to cover primary angioplasty in UK focusing on south west England Considerable progress has been made across the nation in delivering prompt service to STEMI patients since Oct 2008 to April 2010. All 28 cardiac and stroke units are now getting prepared to deliver quality PPCI service to the eligible population. This will be achieved by – Minimising door to balloon time by ensuring maximum patients are diagnosed by paramedics and taken directly to the PPCI centre. Minimising door to balloon time by preparing PPCI centres Developing strategies for managing more than one patient at a same time with the help of neighbouring PPCI centres with minimal time wastage. (NHS improvement interim report) NHS Plans for PPCI Services in South West England Geography Peninsula – (Population 1.6 million) – a small population of North Devon and Cornwall may receive Thrombolysis because of the long distance travel to PPCI centre. A PPCI service has been established for North Devon which will commence very soon. South Devon patients are receiving 24/7 Thrombolysis treatment but very soon they will be provided with 24/7 PPCI service with the help of referral pathways to Derriford, Royal Devon, and Exeter foundation trust hospitals. Dorset – (Population 0.78 million) Patients are being provided with day time PPCI service and Thrombolysis for after hours. Plan is to achieve 100% population coverage by November 2011. Avon, Gloucestershire, Somerset, Wiltshire – (Population 2.8 million) 56% of the population is covered by PPCI service and plan is to achieve 100% coverage by the end of 2011(NHS improvement interim report). Together working with other clinical networks and NHS organisation across England, NHS improvement helps to deliver and build sustainable improvements across the entire pathway of care in diagnostic services. Work Cited “Radial Approach to Cardiac Cathetersation” Cardiology HD. UK. March 2009.Web.19 May 2011.< http://www.cardiologyhd.com/invasive-education/radial-approach-to-cardiac-catheterisation> “Coronary Angioplasty and Stents” British heart Foundation. n.p. n.d. Web 17 May 2011 NICE Technology appraisal guidance 71”Drug-eluting stents for the treatment of coronary artery disease” July 2008. Part review. April 2009.PDF file “Angioplasty and Stent” Circulation foundation.org.uk.Circulation foundation UK .n.d. Web 16 May 2011 “Coronary Angioplasty” Patient.co.in .n.d. Reviewed on 22 Feb 2010. Web 19 May 2011 National Coronary Angioplasty Audit.NHS.2007.Web19 May 2011 NHS improvement interim report. “National Roll-out of primary PCI for patients with ST segment elevation myocardial infarction” NHS .n.d. PDF. “Thrombolysis and Primary Angioplasty” Department of Health. National Archives.7/4/2010.Web.16 May 2011. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/Coronaryheartdisease/Thrombolysisandprimaryangioplasty/index.htm “Definition Thrombolysis” Online Web Dictionary n.d. Web. “Primary Angioplasty and Health information Provision” NHS improvement. n.d. PDF Read More