Primary Nursing Diagnosis

Altered tissue perfusion (myocardial) related to narrowing of the coronary artery(ies) associated with atherosclerosis, spasm, and/or thrombosis

OUTCOMES. Cardiac pump effectiveness; circulation status; comfort level; pain control behavior; pain level; tissue perfusion: cardiac

INTERVENTIONS. Cardiac care; Cardiac precautions; Oxygen therapy; Pain management; Medication administration; Circulatory care; Positioning

U PLANNING AND IMPLEMENTATION Collaborative

INVASIVE PROCEDURES. Several invasive but nonsurgical procedures can be used to manage CAD. Percutaneous coronary intervention (PCI) includes balloon catheter angioplasty and stenting. A balloon catheter angioplasty involves an invasive radiographic procedure that is performed under local anesthesia. A balloon-tipped coronary catheter is introduced into a coronary vessel and inflated and deflated in quick succession. The atheroma (fatty lesion) is compressed against the vessel wall, and the stenosis is dilated, which increases coronary blood flow. During the stent procedure, the cardiologist places a small, hollow metal (mesh) tube or "stent," in the artery to keep it open following a balloon angioplasty.

Coronary Artery Disease (Arteriosclerosis) 251

CORONARY ARTERY BYPASS GRAFTING (CABG). A patent blood vessel from another part of the body is grafted to the affected coronary artery distal to the lesion. The new vessel bypasses the obstruction. Unfortunately, unless reduction of risks and modification of the lifestyle accompany this procedure, the grafted vessels will also eventually occlude. Vessels commonly used for grafting are the greater or lesser saphenous veins, basilic veins, and right and left internal mammary arteries.

Managing the patient after heart surgery involves complex collaborative strategies among the nurse, surgeon, and respiratory therapist. Usually, a patient leaves the operating room with a systemic arterial and pulmonary artery catheter in place. Fluids and medications are administered according to the patient's hemodynamic response to the surgery. Monitoring for complications is also an essential role. Early complications from heart surgery include hypotension or hypertension (lowered or raised blood pressure), hemorrhage, dysrhythmias, decreased cardiac output, fluid and electrolyte imbalance, pericardial bleeding, fever or hypothermia, poor gas exchange, gastric distension, and changes in level of consciousness.

If the patient has a large amount of drainage from mediastinal tubes, the nurse may initiate autotransfusion. In the immediate postoperative period, patients will need airway management with an endotracheal tube and breathing support with mechanical ventilation. Some patients will also require temporary cardiac pacing through epicardial pacing wires that are inserted during the surgery. Patients will often need fluid therapy with blood, colloids, or crystalloids to replace lost fluids or bleeding.

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