Discuss about the Catheterization and Cardiovascular Interventions.
In the present case, Mr Bright has undergone a coronary angioplasty for treating the stenotic coronary arteries of the heart. Angioplasty is referred to the minimally invasive endovascular procedure undertaken for widening obstructed or narrowed veins or arteries, usually for treating arterial atherosclerosis (Wald, 2013). A Percutaneous coronary intervention (PCI) has been performed with stable coronary artery disease for the reduction of chest pain (Levine et al., 2013). A possible medical complication related to angioplasty is impaired tissue perfusion related to haematoma formation or bleeding. Bleeding occurring in relation to procedures like angioplasty and stent insertion for treating coronary syndromes is common in many cases, and this has emerged as a major issue in the management of patients who have coronary syndromes (Sanborn et al., 2015). Bleeding after angioplasty holds significant implications for prognosis, patient outcomes and healthcare costs. Evidences point out that patients who have major bleeding episodes are at a high risk of major complications and even death in the following months if not checked (Sanborn et al., 2013). Different mechanisms underlie the relation between, blood transfusion, femoral bleeding and increased mortality. Relentless haemorrhage directly increases the risk of death by virtue of hemodynamic compromise, and this is witnessed more in patients who have a poor cardiac reserve and other rigorous comorbidities (Aradi et al., 2015).
It is pivotal for the health care professionals to carry out a suitable nursing assessment on the patient in relation with impaired tissue perfusion and bleeding. The most important assessment that is to be done for identifying signs of bleeding is the assessment of the puncture site for bruises. Any bruise appearing at the puncture site and around it is a serious problem and is an indication of femoral artery leakage (Al Azzoni et al., 2017). People have chances of bleeding to death from such kind of bleeding and therefore are to be presented to the emergency room.
The second most important assessment for the patient would be an assessment for numbness and/or weakness in the extremities in the legs and arms where the catheter had been inserted. Such swelling and numbness in the legs or arms may be signs of improper blood circulation and hematoma (Kaplow, 2015). A patient suffering from type II diabetes has major implications for bleeding. Hyperglycemia, or increased blood glucose level is highly associated with enhanced platelet activation, thrombin formation and fibrin clot in patients having acute coronary syndrome. Several mechanisms have been related to the disadvantageous impact of hyperglycemia in patients with acute myocardial ischemia such as the activation of blood coagulation and blood platelets, increased oxidative stress, increased inflammation, and dysfunction of endothelial cell (Bhatty et al., 2011). In the present scenario, the patient Mr Bright had been successfully assessed by the nurses for any presenting bruises and swelling or numbness in the feet as the patient had been subjected to the angioplasty procedure with the stent being inserted in the leg. Mr.Bright is found to be suffering from Type II Diabetes Mellitus. The patient was therefore correctly assessed for blood glucose level that forms a major element of patient assessment after angioplasty pertaining to blood clotting.
Significant bleeding occurring at the puncture site is an indication of major complication and needs instantaneous assessment and proper treatment. Computed Tomography (CT) is the imaging modality advised for the detection of size and location of hematomas (Harris, 2016). A hematoma is referred to the collection of blood clotting outside a certain blood vessel. It takes place when the blood vessel’s wall, capillary, vein or artery has been subjected to damage and blood has come out into the nearby surrounding (Almenawer et al., 2014). CT is done for identifying resultant significant bleeding that requires surgical intervention. The bleeding can spread in a number of ways, and the most common ones are retroperitoneal and groin bleeding. The spread of the bleeding can lead to further complications in the patient. It is, therefore, necessary to conduct a CT for assessing the size and location of hematoma since hematoma is usually not visible. Oozing from the puncture site indicates potential bleeding, and therefore the patient needs to be assessed for oozing from the puncture site. The patient needs to be assessed for the vital signs at regular intervals. The rationale behind this is that bradycardia, fluctuating blood pressure response and hypertension is all signs of retroperitoneal bleeding. Such bleeding refers to the accumulation of blood in the retroperitoneal space (Sanborn et al., 2015). In the present case, CT is a key nursing assessment that was not performed on Mr Bright in relation to bleeding and hematoma. In addition, the patient was also not checked for pressure dressing for bleeding or oozing from the puncture site. Moreover, the vital signs of the patient were also not recorded after the angioplasty procedure that is an essential part of the nursing assessment for a patient.
As a nurse at the ward in a tertiary healthcare facility where the patient, Mr Harry Bright has been admitted after undergoing an angioplasty this communication is regarding the patient’s need for consultation for a doctor after complaining of chest pain.
The patient has undergone an angioplasty procedure to his left coronary artery. The patient is now suffering from chest pain and needs immediate interventions.
Recurrent angina that is chest pain or chest discomfort may occur after the stent implantation in coronary artery angioplasty in certain cases. Mr Bright is suffering such recurrent angina. This may be due to severe coronary spasm. Due to stent implantation, the blood vessels are dilated and extensively stretched. As a result, they are sored, and inflammation occurs like a cut in the skin. Until complete healing takes place, the vessels may undergo spasm since there are massive irritation and inflammation. The patient, in this case, must be having bouts of coronary spasm, giving rise to angina. The chest pain after the coronary intervention is most likely to be of benign character. The pain may also be indicative of acute coronary artery closure or myocardial infarction. However, chances are there that the chest pain that the patient has been suffering is due to local coronary artery trauma. A distinction done between these two conditions is vital for optimal care delivery (Olson, 2014). Commonly, patients undergoing percutaneous transluminal coronary angioplasty (PTCA) and exhibiting chest pain have distinct lesion sites that suggest that the pain is either due to coronary arterial wall stretching or due to coronary artery spasm. The frequency of the chest pain after implantation of the stent may be higher that prior to the stenting (Monreal & Blevins-McNaughton, 2017). The chest pain for Mr Bright is without any signs of ischemia. However, ischemia was indicated at the time of angioplasty. Non-ischemic chest pain after insertion of a stent is due to the severe stretching of the arterial wall as a result of the stent being inserted at the position. The reason is the minimised elastic recoiling after PTCA.
Appropriate measures are to be taken for controlling the chest pain suffered by the patient. The patient is to be administered Nitroglycerin for the treatment of high blood pressure and controlling chances of heart attack. Nitroglycerin is a nitrate acting by widening or relaxing the blood vessels. Chest pain results from a deficit of oxygen and widening of the blood vessels would allow easy flow of blood. The patient is not allergic to any food or medication and therefore can be prescribed nitroglycerin. The prescribed medications administered to the patient are Metformin, Aspirin and Clopidogrel and therefore their interaction with nitroglycerin is to be assessed. The patient does not suffer from anaemia, low blood volume or low blood pressure. Nitroglycerin may lead to light-headedness, blurred vision or dizziness. Interventions are to be provided for checking these symptoms (Bellchambers et al., 2016).
Vital signs are to be monitored at regular intervals and recorded accurately. The patient is to be assessed for signs of chills, fever, numbness, tingling or coolness in the leg where the puncture has been done. The stimulus triggering increased pain are to be identified and avoided. Morphine may be administered if required (Macdonald et al., 2016). The patient is to be given a healthy diet to promote healing and recovery. Antacids may be given to relieve pain. The patient is also to be supported with mobility in order to facilitate recovery. Repositioning may be considered for relieving pain (Matthews, 2017).
References
Al Azzoni, A. M., Macrae, E., Renu, S., Alzayer, H., Patel, C., Schwalm, J. D., … & Natarajan, M. (2017). Assessment of the safety of performing coronary angioplasty without interrupting oral anticoagulants. Journal of the American College of Cardiology, 69(11), 1156.
Almenawer, S. A., Farrokhyar, F., Hong, C., Alhazzani, W., Manoranjan, B., Yarascavitch, B., … & Singh, S. (2014). Chronic subdural hematoma management: a systematic review and meta-analysis of 34829 patients.
Aradi, D., Kirtane, A., Bonello, L., Gurbel, P. A., Tantry, U. S., Huber, K., … & Siller-Matula, J. M. (2015). Bleeding and stent thrombosis on P2Y12-inhibitors: collaborative analysis on the role of platelet reactivity for risk stratification after percutaneous coronary intervention. European heart journal, 36(27), 1762-1771.
Bellchambers, J., Deane, S., & Pottle, A. (2016). Diagnosis and management of angina for the cardiac nurse. British Journal of Cardiac Nursing, 11(7), 324-330
Bhatty, S., Cooke, R., Shetty, R., & Jovin, I. S. (2011). Femoral vascular access-site complications in the cardiac catheterization laboratory: diagnosis and management. Interventional Cardiology, 3(4), 503-514
Harris, K. (2016). Cardiac Rehabilitation for Heart Failure Patients: An Evaluation of Knowledge and Practice Patterns of Nurse Practitioners.
Kaplow, R. (2015). Cardiac surgery essentials for critical care nursing. Jones & Bartlett Publishers.
Levine, G. N., Bates, E. R., Blankenship, J. C., Bailey, S. R., Bittl, J. A., Cercek, B., … & Khot, U. N. (2013). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. Catheterization and Cardiovascular Interventions, 82(4), E266-E355.
Macdonald, N., Jones, J., & Leslie, S. J. (2016). Acute coronary syndromes—the role of the CCU nurse. Part I: Initial management. British Journal of Cardiac Nursing, 11(9), 453-458.
Matthews, R. (2017). Surgical procedure and nursing care for coronary heart disease. benefits, 10, 32.
Monreal, D., & Blevins-McNaughton, J. (2017). Case Presentation for Percutaneous Transluminal Coronary Angioplasty and Coronary Artery Disease. In International Journal of Exercise Science: Conference Proceedings (Vol. 2, No. 9, p. 105).
Olson, K. (Ed.). (2014). Oxford handbook of cardiac nursing. Oxford University Press.
Sanborn, T. A., Mehran, R., Genereux, P., Witzenbichler, B., Brener, S., Kirtane, A. J., … & Nikolsky, E. (2013). Tct-292 reduced bleeding complications and increased event-free survival with femoral vascular closure device use and bivalirudin in stemi patients undergoing primary angioplasty in the horizons-ami trial. Journal of the American College of Cardiology, 62(18), B95.
Sanborn, T. A., Tomey, M. I., Mehran, R., Généreux, P., Witzenbichler, B., Brener, S. J., … & Nikolsky, E. (2015). Femoral vascular closure device use, bivalirudin anticoagulation, and bleeding after primary angioplasty for STEMI: Results from the HORIZONS?AMI trial. Catheterization and Cardiovascular Interventions, 85(3), 371-379.
Wald, D. S., Morris, J. K., Wald, N. J., Chase, A. J., Edwards, R. J., Hughes, L. O., … & Oldroyd, K. G. (2013). Randomized trial of preventive angioplasty in myocardial infarction. New England Journal of Medicine, 369(12), 1115-1123.
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