Nursing Care Management For Cardiovascular Patient After Percutaneous Coronary Intervention (PCI)

Goals of Nursing Care for PCI Patients

Discuss about the Nursing Care of a Post-PCI Patient.

The cardiovascular patient requiring nursing intervention is Mr. Philemon Jones. Mr. Jones is a 74-year-old African-American man who came to the hospital 16 hours ago with complaints of recurrent chest pain. The patient described the pain as squeezing and was located in the center of the chest. The pain radiated to the left jaw and the left arm. He also stated that he had had this pain several times before; the pain came after he engaged in strenuous activities like gardening and was relieved when he took a rest. However, on this particular occasion, the pain seemed to get worse even when he decided to rest. Lysing supine made the pain worse and caused him to become breathless. He had used two sublingual tablets that his family doctor prescribed to him but the pain had not subsided. He then took several tablets of aspirin before calling his daughter who called the ambulance. Of significance, Mr. Jones is a known hypertensive patient for the last 11 years on nifedipine. Mr. Jones also underwent an operation to evacuate a left parietal subdural hematoma three years ago. The medical team saw the patient immediately and made a diagnosis of an acute coronary syndrome. An Electrocardiogram (EKG) done at admission ruled out myocardial infarction. A cardiac enzyme profile also emphasized this finding. An echocardiogram conducted later showed hypertensive heart disease as evidenced by left ventricular hypertrophy. The medical team thus determined that the patient had unstable angina despite treatment with nifedipine, albeit for a different diagnosis altogether. They, thus, decided to intervene. The medical team first arranged for a coronary angiography to detect any narrowed segments in the coronary arteries; they determined partial occlusion of the circumflex branch of the left coronary artery. They prepared for a percutaneous balloon coronary angioplasty. In the operation, they used the left femoral artery to catheterize the patient. They then threaded the catheter to the site of the atherosclerotic plaque and used a balloon to expand it. They then removed the catheter but left the sheath in place to prevent bleeding. In the operation, they administered intravenous heparin and clopidogrel (Jneid et al., 2012). They then prescribed morphine for pain and clopidogrel to prevent restenosis (Genereux et al., 2015). The patient was to continue with their nifedipine.

The goal of nursing care in a patient who has undergone PCI is to ensure that the patient recuperates well and that the problem does not recur (Swearingen, 2016). To do this, the nurse works with several objectives in mind. These objectives include careful tracking of the patient’s vital signs; optimum control of pain; continuous EKG monitoring on the patient; early identification of the complications of the procedure; and prevention and early identification of restenosis (Hamon et al., 2013).

Assessment of Patient After PCI Procedure

Immediately after the operation, the patient is in the acute phase of rehabilitation and will need to be in the intensive care unit (ICU). On arrival at the patient, the first step of nursing care and management is assessment. The assessment has two steps: history taking and physical examination. In the history, the nurse should look to identify the patient correctly. Also, the nurse will identify the access site that the medical team used for the Percutaneous Coronary Intervention (PCI). Also, like in the case of Mr. Jones, the nurse should look to find out the dosage of anticoagulants that the patient is to receive and whether anticoagulants were administered during the procedure. Also, the nurse collaborates with the medical team and uses the patient’s records to find out the intraoperative findings, if any complications occurred during the procedure, and how these complications were managed (Naidu et al., 2012). Also, through interaction with the medical team and the patient’s records, the nurse determines any other medications given to the patient or those that have been ordered and their dosages.

While conducting a physical examination on Mr. Jones, the nurse will focus on the femoral puncture site. Here, the nurse will be looking for any signs of bleeding like oozing blood, hematoma formation or adjacent ecchymosis (Mert et al., 2012). Also, the nurse will assess the puncture site for evidence of infection. In case the nurse will identify any of these puncture complications, it is their duty to report to the medical team promptly and discuss with the medical team the best interventions for dealing with the complication. However, in case of frank bleeding, the nurse will attempt to achieve hemostasis by compressing the bleeding site and stopping the clopidogrel infusion until the physicians can review the patient (Genereux et al., 2015). It is also important for the nurse to assess a hematoma further in case they find one; this assessment will entail auscultating it for arterial bruits to differentiate it from a possible pseudoaneurysm (Hamon et al., 2013). By the time of the initial assessment, Mr. Jones had a sheath in situ and did not have any bleeding or hematoma at the puncture site. There was also no evidence of infection or inflammation at the site. The nurse should assess the puncture site every 30 minutes for the first four hours after the procedure and then hourly for the next few hours.

Systemic Approach to Nursing Assessment

Next, the nursing assessment focuses on a systemic approach. This examination attempts to determine the general state of the patient and if there are any systemic complications. The most important part of this examination is the determination of vital signs. Immediately after the PCI procedure, it is important to take the blood pressure, pulse rate, and respiratory rate of the patient every 30 minutes and the temperature every four hours (Mert et al., 2012). Also important is to assess the SpO₂ of the patient and their pain quotient every four hours.

The systemic assessment attempts to identify systemic complications of the procedure earlier. Among these complications is retroperitoneal hemorrhage. To assess the possibility of retroperitoneal hemorrhage, the nurse will determine the patient’s vital signs (Mert et al., 2012). The nurse will then conduct an abdominal exam while carefully looking for bruising or discoloration on the flanks or along the inguinal ligament. Also, the nurse will assess for any areas of tenderness on the abdomen. A diagnosis of retroperitoneal hemorrhage is certain if the patient has abdominal pain ipsilateral to the puncture site (Subherwal et al., 2012; Rao et al., 2013). Also, it is important to asses for diaphoresis and cold temperature of extremities which are consistent with circulatory shock – a dreaded complication of unrecognized retroperitoneal hemorrhage. The patient’s general status is also an important marker of their circulatory status. A patient who is agitated and restless could be going into circulatory shock. Where the nurse suspects that the patient is having retroperitoneal or any other form of massive hemorrhage, it is important for the nurse to do a random hemoglobin assay to confirm it. After that, the nurse should move swiftly to notify the medical team about their suspicion and contribute in decision making; the nurse major contribution here will be to let the medical team know the patient’s vital signs as these will help the medical team to determine the best approach for the patient.

Another important complication of balloon coronary angioplasty as a PCI option that the nurses should be awake to in their assessment of the patient is the possibility of thromboembolism. For Mr. Jones, thrombosis is more likely in the left lower limb. Therefore, the nurse, assess the limb for any edema, change in temperature, tenderness, pulse strength, mobility, and sensation. In case the nurse suspects arterial occlusion due to distal pallor or weakness of distal pulses, it is important for them to check the tightness of the occlusive dressing for the puncture site as a very tight dressing can precipitate such a state. If the perfusion of the limb does not improve with relief of the tightness of the occlusive dressing, then the nurse goes ahead to report their findings to the physicians, and helps them to make a decision of how to address the issue. In case the nurse suspects venous thrombosis, she should also assess the patient for a possibility of thromboembolism, especially to the pulmonary vasculature; she can this assessment by determining the patient’s respiratory rate, pulse rate, blood pressure, and SpO₂ (Pedersen et al., 2014).  Of note is that while discussing the therapeutic options for Mr. Jones, in case a diagnosis of thromboembolism is certain, the nurse has to remember to remind the medical team that thrombolysis is not a good option for the patient. This is because he is a high risk of bleeding; the fact that he has positive history of subdural hemorrhage reveals that he is likely to bleed (Rao et al., 2013).

Complications of PCI to be Monitored

Also importantly, patients who have undergone PCI are at a high risk of developing arrhythmias. This complication is even more likely in patients who had diseases that predispose them to arrhythmias before undergoing the procedure. Mr. Jones, for instance, had hypertensive heart disease which causes hypertrophy of some of the chambers of the heart; the hypertrophy is an important predisposition to arrhythmia. To assess for arrhythmia, the nurse will need to compare a print out of the pre-PCI EKG with the EKG recording at the time of assessment (Price et al., 2011). In other words, it is the duty of the nurse to interact closely with the physicians to ensure that the patient has EKG monitoring at all times while they are still in ICU. The other importance of constant EKG monitoring is that it will help in early identification of restenosis. Patients with arrhythmias might also report palpitations and could have an irregular pulse. In some arrhythmias such as atrial fibrillation, the patients will have a pulse deficit in addition to an irregularly irregular pulse (Pedersen et al., 2014). In case arrhythmias arise, the nurse should know when to intervene immediately and when to take things insidiously by opting to inform the medical team first. However, in post-PCI patients, the nurses should consider any arrhythmia as a medical emergency and thus move with the necessary speed. The nurse has a duty to inform the medical staff about the nature of the arrhythmia and the status of the patient.

Another complication of PCI that can occur in a patient like Mr. Jones is restenosis (Pedersen et al., 2014). The nurse has an important role in preventing and early identification of restenosis. To prevent restenosis due to thrombus formation in the coronary artery, the nurse should ensure that the patient receives any antiplatelet drugs prescribed and in the right dosages (Wit et al., 2012). For the case of Mr. Jones, he was to receive clopidogrel for an unspecified period. In the acute setting, the nurse helps the patient to take the drug. However, as part of the preparation for discharge, the nurse will ensure that the patient is aware where they will need to go for a refill of their drugs and, if possible, to link up with the community nurse in the locality where Mr. Jones stays (Muthusamy et al., 2013). Also, the nurse will check for the ability of the patient to tolerate the drug and attempt to identify any side effects of the drug. At the time of discharge, the nurse will hold an in-depth discussion with the patient about the effects of the drug that the patient should watch out for and report to the hospital immediately. Among the effects that Mr. Jones should look to notify the physician or the nurse at their refill facility are constant headaches, dizziness, abdominal pain, epistaxis, and increased bleeding on slight bruising (Rossello et al., 2015; Alexopoulos et al., 2012). In terms of helping in early identification of restenosis, the nurse should always be aware of the pain status of the patient as the ischemia that comes with restenosis can cause acute typical chest pain. Also, the nurse should ensure continued EKG tracing and always note any new abnormalities; whenever such abnormalities are present, the nurse should notify the medical team promptly (Price et al., 2011).

Importance of EKG monitoring

Additionally, an important part of nursing care is direct participation in the various phases of cardiac rehabilitation (Mampuya, 2012). The nurse plays the most important role in the first phase of rehabilitation while the patient is still in the hospital environment (Wenger, 2008; Lear & Ignaszewski, 2001). The nurse identifies the various needs of the patient and their self-care deficit and attempts to cover up for this deficit. In the acute phase after the operation, the nurse provides a majority of self-care needs for the patient; as the patient rehabilitates and their deficit decreases – the work of the nurse decreases.

The most important aspect of nursing care at the point of discharge is health education. Apart from the discussion of medication, the nurse needs to share with Mr. Jones a little more information about his condition. The nurse is the person who can tell Mr. Jones about his conditions, the risk factors for the condition, and how to avoid these risk factors (Sandesara et al., 2015). The nurse will also need to tell Mr. Jones about his future prognosis and advise him to change his lifestyle to enhance his future prognosis. In the process of health education, the nurse will also determine the socioeconomic status of Mr. Jones and help him achieve the best outcomes in that environment. Among many other benefits, patient education helps to alleviate anxiety which past studies have associated with poor mortality outcomes (Celano et al., 2015; Park et al., 2015).

Conclusion

Mr. Jones is an example of a typical patient with an acute coronary syndrome that requires surgical intervention. Mr. Jones, however, is a special patient as he is at risk of bleeding since he has a prior history of subdural hemorrhage. For this reason, thrombolysis is not a good option for the patient. His previous history also means that Mr. Jones is at significant risk bleeding at the puncture site and intracranial bleeding following the administration of heparin and antiplatelet drugs during the balloon coronary angioplasty. For this reason, apart from covering for the patient’s self-care deficit and looking to identify the other complications early, a rigorous search of internal and external hemorrhage should be an important part of nursing care for Mr. Jones. In addition, as Mr. Jones’s case reveals, the collaboration between nurses and the other professionals is important for the patient (Naidu et al., 2012). Being closer to patients, nurses can identify complications of the PCI much earlier and alert the medical team.

Identification and Management of Post-Procedure Complications

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