Review of the Heart and

Blood Vessels

Pericardium
Epicardium
Myocardium
Endocardium
Atria
Ventricles
Coronary Arteries
Arteries/Veins
Fat

Sequence of blood flow

Heart Beats & Valves

Lubb - Dubb
-Corresponds to valves
closing
Atrioventricular (AV)
Valves
-Tricuspid and Mitral
valve
Semilunar Valves

Cardiac Cycle

Cardiac Conduction System

Describes how electric
signalling makes its
way through the heart
in a coordinated
fashion automaticity
Sinoatrial (SA) node
Atrioventricular (AV)
node
AV Bundle
Purkinje Fibers

Cases of
Cardiovascular
Diseases

Myocardial
Infarction

Maria Ericka B. Santos

BSN III

What is Myocardial
Infarction?

 Myocardial infarction (MI), commonly

known as a heart attack, is the
interruption of blood supply to part of the
heart, causing some heart cells to die.

I. Assessment of Client with

MI

II. Diagnostic and Laboratory

Procedures of Client with MI

Patient History
Electrocardiogram (ECG)
Echocardiogram
Laboratory Tests
Creatine Kinase and its Isoenzymes
Myoglobin
Troponin

Electrocardiogram (ECG)

Laboratory Tests

Pathophysiology of MI

Medical-Surgical Nursing
Management of clients with
MI
Pharmacologic Therapy
Thrombolytics
Analgesics
Angiotensin-Converting Enzyme Inhibitors

Emergent Percutaneous Coronary

Intervention
Cardiac Rehabilitation
Invasive Coronary Artery Procedures

Cardiac Rehabilitation
The goals of rehabilitation of the patient who has had
an MI are to extend life and improve the quality of life.
Objectives of treatment:
To limit the effects and progression of atherosclerosis
Return the patient to work
Pre-illness lifestyle
Enhance the psychosocial and vocational status
Prevent another cardiac event

Cardiac Rehabilitation
Phase 1
Begins with the diagnosis of
atherosclerosis, which may occur
when the patient is admitted to the
hospital for ACS.
Consists of low- level activities and
initial education for the patient and
family.

 Phase 2
Occurs after the patient has been
discharged.
It usually lasts for 4 to 6 weeks but
may last as long as 6 months.
This outpatient program consists of
supervised, often ECG monitored,
exercise training that is individualized
based on the results of an exercise
stress test.

 Phase 3
Focuses on maintaining
cardiovascular stability and longterm conditioning.

NURSING RESPONSIBILITIES

Invasive Coronary
Procedures
Percutaneous Transluminal

Coronary Angioplasty (PTCA)

An invasive interventional procedure, a
balloon tipped catheter is used to open
blocked coronary vessels and resolve
ischemia.
Catheter-based interventions can also be
used to open blocked CABGs.

 Coronary Artery Stent

The intima of the coronary artery has been injured
and responds by initialling an acute inflammatory
process. This process may include release of
mediators that lead to vasoconstriction, clotting,
and scar tissue formation. A coronary artery stent
is placed to overcome these risks.
A stent is a metal mesh that provides structural
support to a vessel at risk of acute closure.
Some stents are coated with medications, such as
sirolimus or paclitaxel, which may minimize the
formation of thrombi or scar tissue within the
stent. These drug-eluting stents have increased
the success of PCI.

 Atherectomy
Atherectomy is an invasive interventional
procedure that involves the removal of the
atheroma, or plaque, from a coronary artery
by cutting, shaving, or grinding.
Rotational atherectomy uses a catheter
with diamond chips impregnated on the tip
(called a bur) that rotates like a dentist's drill.

 Brachytherapy
Brachytherapy reduces the recurrence of
obstruction, preventing vessel restenosis by
inhibiting smooth muscle cell proliferation.
Involves the delivery of gamma or beta
radiation by placing a radioisotope close to
the lesion.

Complications
Complications that can occur during a PCI
procedure include:
Dissection
Perforation
Abrupt closure
Vasospasm of the coronary artery
Acute MI
Acute dysrhythmias (eg, ventricular tachycardia)
Cardiac arrest.
These may require emergency surgical treatment.

Complications after the procedure may

include:
Abrupt closure of the coronary artery
Vascular complications
o
o
o
o
o
o
o

Bleeding at the insertion site

Retroperitoneal bleeding
Hematoma
Pseudoaneurysm
Arteriovenous fistula
Arterial thrombosis
Distal embolization

Acute renal failure

Posprocedure Care
Many patients are admitted to the hospital
the day of the PCI.
Those with no complications go home the
next day.
When the PCI is performed emergently to
relieve ACS, the patient will usually go to a
critical care unit and stay in the hospital for
a few days.

 During the PCI, patients receive IV heparin and are

monitored closely for signs of bleeding.
Patients may also receive a GPIIb/IIIa agent (eg,
eptifibatide [Integrilin]) for several hours following
the PCI to prevent platelet aggregation and
thrombus formation in the coronary artery.
Hemostasis is achieved, and femoral sheaths may
be removed at the end of the procedure by using a
vascular closure device (eg, AngioSeal, VasoSeal)
or a device that sutures the vessels.

NURSING RESPONSIBILITIES
Nursing responsibilities before cardiac
catheterization include the following:
The patient is instructed to fast, usually for 8 to 12
hours, before the procedure. If catheterization is to
be performed as an outpatient procedure, a friend,
family member, or other responsible person must
transport the patient home.
The patient is informed of the expected duration of
the procedure and advised that it will involve lying
on a hard table for less than 2 hours.
The patient is reassured that mild sedatives or
moderate sedation will be given IV.

 The patient is informed about certain sensations that will

be experienced during the catheterization. Knowing what
to expect can help the patient cope with the experience.
The nurse explains that an occasional pounding sensation
(palpitation) may be felt in the chest because of extra
systoles that almost always occur, particularly when the
catheter tip touches the myocardium. The patient may be
asked to cough and to breathe deeply, especially after the
injection of contrast agent. The injection of a contrast
agent into either side of the heart may produce a flushed
feeling throughout the body and a sensation similar to the
need to void, which subsides in 1 minute or less.
The patient is encouraged to express fears and anxieties.
The nurse provides teaching and reassurance to reduce
apprehension.

NURSING RESPONSIBILITIES
Nursing responsibilities after cardiac catheterization may
include the following:
The catheter access site is observed for bleeding or
hematoma formation. Peripheral pulses in the affected
extremity (dorsalis pedis and posterior tibial pulses in the
lower extremity, radial pulse in the upper extremity) are
assessed every 15 minutes for 1 hour, and then every 1 to
2 hours until the pulses are stable.
Temperature and color of the affected extremity are
evaluated, as well as any patient complaints of pain,
numbness, or tingling sensations, to detect arterial
insufficiency. Any changes are reported promptly.

Dysrhythmias are carefully assessed by observing the

cardiac monitor or by assessing the apical and peripheral
pulses for changes in rate and rhythm. A vasovagal
reaction, consisting of bradycardia, hypotension, and
nausea, can be precipitated by a distended bladder or by
discomfort during removal of the arterial catheter,
especially it a femoral site has been used. Prompt
intervention is critical; this includes raising the feet and
legs above the head, administering IV fluids, and
administering IV atropine.

The patient is instructed to report chest pain and

bleeding or sudden discomfort from the catheter insertion
sites immediately.

Bed rest must be maintained for 2 to 6 hours after the

procedure. If manual or mechanical pressure is used
without vascular closure devices, the patient must remain
on bed rest for up to 6 hours with the affected leg straight,
and the head elevated to 30 degrees. For comfort, the
patient, may be turned from side to side with the affected
extremity straight. If the cardiologist used deployed closure
devices or patches, the nurse checks local nursing care
standards and anticipates that the patient will have fewer
activity restrictions, such as elevation of the head of the
bed, and that the patient will be allowed to ambulate in 2
hours or less. Analgesic medication is administered as
prescribed for discomfort.
Safety is ensured by instructing the patient to ask for help
when getting out of bed the first time after the procedure,
because orthostatic hypotension may occur and the patient
may feel dizzy and lightheaded.

 The patient is monitored for contrast

agent-induced renal failure that may be
suspected if there is an increase in the
BUN and creatinine levels. An accurate
record of intake and output must be
maintained, and both oral and IV fluids are
encouraged to increase urinary output and
flush the agent from the urinary tract.

Self-Management After
Cardiac Catheterization
After discharge from the hospital for cardiac
catheterization, guidelines for self-care include the
following:
For the next 24-hours, do not bend at the wait (to
lift anything), strain, or lift heavy objects.
Avoid tub baths, but shower as desired.
Talk with your physician about when you may
return to work, drive, or resume strenuous
activities.

 Call your physician if any of the following occur:

bleeding, swelling, new bruising or pain from your
procedure site, temperature of (38.6 *C) or more.
If test results show that you have coronary artery
disease, talk with your physician about options for
treatment, including cardiac rehabilitation
programs in your community.
Talk with your physician and nurse about lifestyle
changes to reduce your risk for further or future
heart problems, such as quitting smoking,
lowering your cholesterol level, initiating dietary
changes, beginning an exercise program, or
losing weight.

Surgical Procedures: Coronary

Artery Revascularization
Traditional Coronary Artery Bypass
Graft
The traditional CABG procedure is
performed with the patient under general
anesthesia.
The surgeon makes a median sternotomy
incision and connects the patient to the
cardio-pulmonary bypass (CPB) machine.

Cardio Pulmonary Bypass

 Alternative Coronary Artery Bypass

Graft Techniques
A number of alternative CABG techniques
have been developed that may have fewer
complications for some groups of patients.
Off-pump CABG (OPCAB) surgery has
been used successfully in many patients
since the 1990s. OPCAB involves a
standard median sternotomy incision, but
the surgery is performed without CPB.

Complications of Coronary
Artery Bypass Graft
CABG may result in complications such as:
MI
Dysrhythmias
Hemorrhage
Although most patients improve symptomatically following
surgery,
CABG is not a cure for CAD, and angina, exercise intolerance, or
other symptoms experienced before CABG may recur.
Medications required before surgery may need to be continued.
Lifestyle modifications recommended before surgery remain
important to treat the underlying CAD and for the continued
viability of the newly implanted grafts.

QUESTIONS???

References:
Brunner & Suddarths Textbook of MedicalSurgical Nursing 11ed volume 1 by 11th Ed
by Smeltzer, Bare, Hinkle, Cheever
Essentials of Pathophysiology, 2 nd Ed by
Carol Porth
http://emedicine.medscape.com/article/15
5919-overview
http://www.webmd.com/heart-disease/under
standing-heart-attack-basics
http://youtube.com