Nursing Assessment after Percutaneous Coronary Intervention - Case Study Example

Running title: PCI AFTER MYOCARDIAL INFARCTION Nursing Assessment after Percutaneous Coronary Intervention: Based on a Case Study Name: Affiliation: Date:   Cannon & O’Gara (2006) has emphasized importance of careful management of symptoms during and post percutaneous coronary intervention (PCI). Patients undergoing PCI are kept overnight in the hospital. Jowett, Thompson and Boyle (2007) state that the interventions are focused on a patient’s physical, Psychological and social well being. These factors are of particular importance for Mr Casey since he is recently divorced and is also under stress of uncertainty about his job. The correct interventions must aim to slow down or even reverse the progression of coronary artery disease and reduce morbidity and mortality. These interventions should be according to the British association of cardiac rehabilitation (BACR UK). The lifestyle, risk factors and therapeutic care management are important components. It is absolutely necessary that MI patients should avoid smoking, control obesity, serum cholesterol levels and high blood pressure. The present patient also has diabetes as a risk factor and the intervention requires that evidence based drugs prescriptions should be fulfilled. These are usually aspirins, beta blockers, ACE inhibitors and lipid lowering agents. Patients with ongoing pain ischemic ECG changes, haemodynamic instability, left ventricular failure or raised troponin are high risk group. The initial inquiry about patient’s condition and history serves two purposes: Is it an acute coronary syndrome requiring reperfusion Are there any contraindications for thrombolysis. The answer to both these is yes in our present case. Jowett, Thompson and Boyle (2007) further state that nitrates are given to those with ST –elevation myocardial infarction (STEMI) to lessen vasospasm and anginal pain. Intravenous (IV) nitrates are given to patient with anterior infarcts and hypertension. For immediate pain relief IV diamorphine or morphine sulphate is given which relieves both pain and anxiety and increases cardiac work. IV beta blockers or nitrates may be added to diamorphine, if pain relief is not sufficient. The side effects may be nausea or vomiting which can be relieved by giving antiemetic metoclopramide. The acute pain is due to ischaemia but still functional myocardium. Mr casey is also showing ischaemia as his blood supply and hence oxygen are disrupted to myocardium as a result he is administered both morphine sulphate and nitrates. The STEMI is further confirmed by cardiac markers such as CK-MB and troponin but these are not highly elevated in reports of Mr Casey. According to Jowett, Thompson and Boyle (2007) ST elevation occurs in acute myocardial infarction. Initially the ST segment straightens losing its normal concavity. As the T-wave broadens ST becomes convex upward. Without reperfusion these ST-T wave changes may take hours or days to resolve. Mr Casey’s ECG shows ST-elevation in leads II ,III, V5 and V6. ECG helps find the site of coronary occlusion. Three major coronary vessels are Right coronary artery (RCA), Left Anterior Descending Artery (LAD) and Left Circumflex Artery. Conover (2003) stated that in inferio-lateral acute myocardial infarction (AMI) ST –elevation occurs in leads II, III and aVF and in lateral leads I, aVL and V5-V6 (Fig 1). The RCA occlusion is shown by the ST segment higher in III than in II Fig 1. Summary of electrocardiographic leads, corresponding coronary arteries, and myocardium supplied (From Shoulders-Odom, 2008) In patients undergoing balloon angioplasty alone aspirin 80 to 325 mg daily is recommended for secondary prevention of coronary events. In patients receiving coronary stent, clopidogrel (or any other antiplatelet agent) is loaded pre –procedure followed by 75 mg for one year to prevent stent thrombosis Cannon & O’gara (2006) . (Shoulders-Odom, 2006) finds stents as useful devices in preventing abrupt closure and restenosis. These can be inserted directly decreasing the length of procedure and vessel injury. But incase of Mr Casey the stenting was done after the balloon angioplasty. As an absolute 1, 3, or 6 months bare metal, sirolimus coated or paclitaxel coated stent is needed. PCI patients should receive 1 to 2 L of one-half normal saline. In case of renal insufficiency and CHF, there is need of intravenous furosemide. How renal function seems undisturbed in the present case. In absence of angiographic complications patients do not require anticoagulation after PCI. The sheaths should be removed when ACT is about 150 seconds. The vascular closure device which are normally used after PCI allow ambulation 4-6 hrs after the procedure. The patient can be discharged home the following morning if there is no bleeding (Cannon & O’gara (2006) . The nursing intervention should include Mr Casey’s diabetes as additional risk factor. Since the clinical outcomes in diabetic patients are less favourable compared to the non-diabetics and there are higher incidents of restenosis after balloon angioplasty and stenting. These are due to aggressive intimal hyperplasia resulting in lumen loss and decreased lumen area. Diabetes increases rate of revascularization by 50% in one year follow up. The diabetics with tight glycemic control had only 15% revascularization compared to 34% in those having sugar above 7.0 as HbA1c. Other factors aggravating the intimal hyperplasia are hypertension and high LDL levels. Both of these are also risk factors in case of Mr Casey. Drug-eluting stents likely to reduce stenosis in diabetic ( Kornowski & Fuchs, 2004). However it is not clear whether bare metal or drug –eluting stents were inserted into the RCA of Mr Casey. Since because of his Diabetes , our present patient is under increased threat of restenosis and thrombosis so a little more description is requires here about these. Restenosis occurs when body tries to heal up the wound caused by mechanical injury of the procedure. As a result the lumen may become narrow again. Restenosis typically occurs after 3-12 month’s of the procedure and is suspected if angina occurs (Baim, 2006). Untreated angina may lead to AMI. Restenosis may be found out by stress test or confirmed by repeat angiography. Two beneficial treatments of restenosis are brachytherapy and drug-eluting stents (Shoulders-Odom, 2006). Stent thrombosis (Shoulders-Odom, 2006) occurs suddenly and is suspected when patient shows acute ischaemic events and ECG changes leading invariably to AMI (Baim, 2006). Stent thrombosis may occur within 24 hrs (acute) or 30 days (sub-acute). Diabetes is a risk factor for stent thrombosis. It can occur in case of drug- eluting stents particularly the late stent thrombosis, i. e. after 3 yrs. The cause of concern is that it can occur even after the patient has completed clopidogrel (or Ticlopidine) and continues aspirin. An emergency angioplasty or thrombectomy is treatment of choice in such cases. A standard regimen of antiplatelet therapy is prescribed to decrease the risk of thrombosis. Typical antiplatelet agents include inhibitors of the glycoprotein IIb/IIIa complex (GPIIb-IIIa), thienopyridines, and aspirin. GPIIb-IIIa inhibitors, abciximab, bind to the GPIIb-IIIa receptor sites, blocking the final common pathway of platelet aggregation and thus decreasing the incidence of acute thrombosis (Baim, 2006). Abciximab along with oral dose of aspirin and heparin intravenously have proved to be effective in reducing ischaemic events associated with coronary angioplasty as these induce reperfusion. Further studies certainly are needed about superiority of bare metal and drug –eluting stents. The patient should be educated to remain watchful of stent thrombosis and restenosis. NURSING MANAGEMENT: Patient education: Key topics include site assessment, potential complications, activity limitations, follow-up care, when to seek medical assistance, medication therapy, and modification of risk factors. All incidents of chest pain post –PCI must be promptly reported. The chest may be due to unsual stent sensation, acute thrombosis, sudden vessel closure, temporary coronary spasms, side branch blockade or distal embolisation of waste. Regular ECG monitoring is useful in assessing ischaemic events. The PCI assess site should be observed for bleeding .haematoma, ecchymosis, tenderness, pulsations. Patients with restless leg syndrome and extremity immobilization need to be treated with an immobilizer (Shoulders-Odom, 2006). Shoulders-Odom (2006) advice that patients should be explained about the small hard lump if conspicuous in the groin region would subside gradually. Ecchymosis due to hematoma, however may take some time to resolve. Patients should also be informed that the discoloration will most likely spread out and change from dark blue to greenish yellow before disappearing. If femoral nerve compression occurred, leg weakness may persist for long time, up to months. Exercise: Patients should be advised to avoid strenuous activity the week after the PCI procedure, but they may resume walking in 48 hours. They should avoid lifting weight more than 10 pounds for next 48 hrs and driving a car for 72 hrs, post PCI. Patient should be counseled to look for rebleeding from access site or redness and tenderness. At times pseudo aneurysms develops after discharge and a low threshold ultrasound should be undertaken in cases of such complaints. Since atherosclerosis is lifelong disease, The LDL-C should be lowered to 70 mg/Dl in all patients through aggressive dietary and pharmacologic approaches(Shoulders-Odom, 2006; Cannon & Ogara (2006) ). A good exercise plan is best option for the person’s who had myocardial infarction. Khan (2005) suggests that Patient should begin a lifelong aerobic exercise plan Moderate exercise may be resumed within a week of discharge. Patient may enroll in a cardiac rehabilitation progamme and exercise three times a week for 20-40 min at the 75-80% of their baseline maximal heart rate. Or begin a walking programme at home The exercise should begin with a 5 min warm up and end with a 5 min cool down period. The walking should begin for 10 min after 1 week of discharge. At slow steady pace. Keep on adding 10 min to it every 2-3 days till it becomes 60 min walking . Khan (2005) outlines some contraindications to exercise to post myocardial infarction patients, as : Patients with suspected ischemia, Inability to maintain 5 METs (metabolic equivalents) at 3 to 6 week stress testing, New left bundle branch block, Systolic BP less than 100 mm Hg, Uncontrolled systolic hypertension, Suspected left ventricular systolic dysfunction Medications: The drugs prescribed to Mr Casey are the usual medications given after AMI. Mehta & Sketch (2004) state that secondary prevention include appropriate medical therapies such as aspirin, beta-blockers, angiotensin converting enzyme inhibitors (ACE-I), aggressive lipid-lowering agents, tight glycemic and blood pressure control. Besides, the lifestyle changes require smoking cessation, weight control, diet and exercise are the only opportunities for management of coronary artery disease in the diabetics. Aspen & Beard (1999) found ace inhibitors as preferred anti hypertensive drug for diabetic since these increase insulin sensitivity but these may cause some renal insufficiency. Beta blockers such as metoprolol may aggravate lipids and decrease insulin sensitivity. But they improve long term morbidity and mortality in diabetcs with MI. Antman & Givertz (2006) emphasize that patients are discharged on aspirin after the MI. ACE-I is given to patients with congestive heart failure, hypertension or diabetes. Beta-blockers are prescribed to all patients in absence of any contraindication to manage angina and blood pressure at 130/80 mm Hg. The cholesterol is to be maintained at less than 100 mg/dL . Statins are preferred to lowering LDL-C. Mr Casey has diabetes with other comorbidies such as hypertension and obesity. He is put on all these drugs as well as the drug for glycemic control. Patients should seek medical assistance if they have expansion of and/or pulsation in the groin swelling, new or significantly worsening discoloration, leg weakness, numbness, or pallor, redness, warmth at the access site, or puslike drainage from the site. (Shoulders-Odom, 2006) also acknowledge the fact that nurses are in a distinctive position to educate patients on the importance of modifying cardiovascular risk factors. Smoking cessation, medical therapy, diet, and regular exercise are key areas which should ideally be addressed with patients and their families. In Mr Casey’s case however the family is limited sso a good rapport with the patient is necessary. References Antman, E. M. & Givertz, M. M. (2006). Cardiovascular therapeutics: a companion to Braunwald's Heart disease. Elsevier Health Sciences Aspen  , J. G. and Beard, S. (1999). Diabetes management: clinical pathways, guidelines, and patient education. Jones & Bartlett Publishers Baim D.S. (2006). Grossman’s Cardiac Catheterization, Angiography, and Interventions. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins Cannon, C.P. & O'Gara, P. T. (2008). Critical pathways in cardiovascular medicine. 2nd ed, Lippincott Williams & Wilkins Conover, M. B. (2003). Understanding electrocardiography. 8 th ed. Elsevier Health Sciences  Jowett, N. I., Thompson, D.R. and Boyle, R. (2007). Comprehensive Coronary Care, 4th ed, Elsevier Health Sciences. Khan , M. I. G. (2005). Heart disease diagnosis and therapy: a practical approach. 2nd ed. Human Press Kornowski, R. & Fuchs, S. (2004). Optimization of glycemic control and restenosis prevention in diabetic patients undergoing percutaneous coronary interventions. J Am Coll Cardiol , 43,15-17. Mehta, R. & Sketch, M. H. (2004). Percutaneous Coronary Revascularization in Diabetic Patients with Multivessel Coronary Artery Disease: Importance and Feasibility .J. Invasive Cardiol.  16, (3) . Shoulders-Odom, B. (2008). Management of Patients After Percutaneous Coronary Interventions. Critical Care Nurse. 28, 26-40 . Read More