Nursing For Percutaneous Coronary Interventions – Clinical Practice Guidelines

Post-operative assessment and nursing care for PCIs

Discuss about the Nursing for Percutaneous Coronary Interventions.

In the simulation experience, the scenario of Mr. Bright has been demonstrated. Mr. Bright is a 65 years old male, with a history of hypertension and DMII, who have recently undergone an angioplasty. Being a simulation participant I have been asked to take care of the patient. In this context, I need to include post-operative or post-angioplasty assessment and proper nursing care to reduce side effects and maximise the heath care outcomes of angioplasty.

In this context, we need to present a set of nursing clinical practice guidelines for individuals undergoing percutaneous coronary interventions (PCIs), which has been provided in the article by (Rolley et al., 2011). The authors at first mentioned the need for “vital sign observation” of the patient, which is an important aspect of PCI care. In this context, ST segment elevation is an important aspect, which can detect acute ischemic changes. Thus, ECG and cardiac enzyme measurements should be done at proper intervals. In the case of patients with stable angina undergoing PCI, it is crucial to routinely screen c-troponin rise post-procedurally. In addition, patients should be monitored for the signs of localised puncture site complications including bleeding, swelling, haematoma, ecchymosis along with limb circulation observation (Khan et al., 2011). In addition, peripheral pulses, i.e. warmth, capillary return, colour and sensations should be monitored properly. Authors also provided sheath removal pain management interventions to control pain after sheath removal.

The study found strategies to achieve haemostasis for reducing post PCI vascular complication, which included arterial closure devices with standard compression. Patient’s positioning is another key aspect of post-angioplasty management (Wald et al., 2013). The guideline development process identified a preference for laying the patient flat, whereas other research found reduced back discomfort and reduced vascular complications, through patient’s position change regularly and head of bed slowly elevated to 30°. In secondary prevention of post-angioplasty complication guidelines, for chest pain action plan, the use of nitrate has been recommended after discharge along with seeking emergency assistance, when needed (Gallagher et al., 2011).

Therefore, from the above article, it has been found that the chest pain of Mr. Bright was significantly assessed in the simulation; soon it was reported by the patient. According to the recommendations in the paper, I have assessed ECG, troponin level and vital signs thoroughly. According to his medical documentations, it has been revealed that the patient has already experienced myocardial ischemia, which made the PCI difficult. Thus, his chest pain is related to PCI complications. These observations and assessment data are crucial in Mr. Bright’s care plan. On the other hand, I have also done the assessment of the wound has also been done during simulation, which has been indicated as a vital step in the guidelines provided by Rolley et al., (2011). The femoral puncture causes hematoma or haemorrhage, which can lead to significant blood loss. After surgery, I assessed Mr. Bright for the absence of ooze, redness, warmth and absence of bleeding. Pain at the femoral site and bilateral dorsalis pulse had been observed. However, I missed assessing sensation of two feet. After reporting the chest pain, I assessed swelling of the puncture site, measuring the bleeding size and presence of pain from the surgical wound (Bonati et al., 2012).

Importance of vital sign observations for PCIs

In the next article by Chang et al., (2016), neurovascular assessment is one of the important assessment criteria in the patient undergoing PCI to identify related complications and its proper resource. However, I have not performed the neurovascular assessment of Mr. Bright properly during the simulation. Femoral bleeding can cause hematoma formation, which can compress the femoral nerve. This nervous damage can be detected through a neurovascular assessment, i.e. capillary refill, skin colour, dosalis pulse, pain, discomfort, sensation and motor function observation are important in this assessment (Roffi et al., 2015). Although I have measured pain and surgical wound properly during simulation, other neurovascular assessments were not done. On the other hand, Mr. Bright is a diabetes type 2 patients, which also increases the chance of reduced rate of surgical wound recovery and can promote femoral nerve damage due to femoral bleeding (De Luca et al., 2013). Although his blood glucose level was normal, his medication order was not monitored whether these were withdrawn or not during simulation. It is because; all these symptoms together can adversely for promoting kidney damage (Rear, Bell & Hausenloy, 2016). Thus, it can be said that missed diagnosis might lead to misdiagnosis or increased severity of the disease.

Identify- Hi! This is Miss X., the RN of surgical ward QUT, I am the taking care of Mr. Bright, a post-angioplasty patient in the current shift. The patient was stable upon surgery with no pain or swollen surgical site. However, recently, I noticed a significant chest pain in the patient and I want to inform you about this post-surgical chest pain. His details are mentioned below:

Full name- Mr. Harry Bright

DOB- 20^th May, 1950

URN-

• Situation- Mr. Bright reported a chest pain during recovery and he was administered with nitroglycerin spray sublingually X 1, which resolved the pain. Currently, he is not experiencing pain. Upon his transfer to the ward, he reported severe pain, which was radiating from left hand to his back.
• Background- Mr. Bright is a 65 years old male with the medical history of type 2 diabetes and hypertension. Hypertension and diabetes mellitus symptoms are well controlled through medications and diet. He is also a chain smoker, i.e. smoking 20 cigarettes per day and has habits of alcohol consumption. Recently, he has experienced unstable angina. His medical history indicated 3/12 unstable angina while doing gardening and watching TV. The pain radiates from left arm to left jaw. The patient has been admitted to QUT hospital for performing a PTCI on 16^th Jan 2016. On assessment, his blood pressure was shown to be slight high, i.e. 150/90 and BGL was 10 mmol/l, in the normal range. In the operation theatre, the PTCI was performed, where his right femoral artery was punctured by the use of 6 French sheaths, where a drug eluting Stent was placed in the right coronary artery, with 10 % residual stenosis at the site. It was reported that the procedure was difficult and recommended for continuous ECG monitoring. In recovery, his sheath on the right Femoral surgical wound was removed in recovery, when he reported chest pain. After informing the doctor, he was administered with nitroglycerin spray sublingually X 1, which resolved the pain. He returned to the ward at 16.50 hours; he was conscious and alert. At that time, he was assessed and no pain at the site was revealed, no swelling or haematoma and very small wound ooze were revealed. His pulse rate was also observed. He has got normal saline IV line with a rate of 100 ml/hr. I performed an ECG, which showed normal results. According to the nursing care plan, I was monitoring his vital signs over every 30 minutes.
• Assessment- Mr. Bright reported chest pain against at 17.30 hours. I measured his pain score, which was 6 and blood pressure was high, i.e. 170/100, his pulse was also deteriorated with increased heart rate, HR was 26 and body temperature was 37.3° In this context, when I assessed his surgical site, no hematoma, colour change or pain had been observed. He also reported nausea and pain radiation towards the back (Benner, Hooper-Kyriakidis & Stannard, 2011). I also attempted to consider his position; I did not allow him to sit straight, as at his situation it is not recommended to sit patient at an angle greater than 30 degrees.
• Recommendations- At this situation, I am going to administer nitroglycerin spray and complete his neurovascular assessment after the routine interval. I will attempt to keep Mr Bright’s airway clear. In addition, I will thoroughly assess his pain with the pain scale and attempt to inform doctor, when the pain score is increased or decreased. To reduce pain, with the consultation of the doctor, I would administer morphine and metoclopramide, based on Mr. Bright’s assessment (Abid et al., 2015). As he is having significant pain radiating towards the back, I assumed that he might have hematoma or bleeding, which I need to assess. For this, I suggest ordering further diagnostic tests including an ECG, Doppler, angiography or troponin. Finally, a doctor visit would be confirmed. It is required for ensuring that the nursing diagnosis and care procedures are appropriate for improving Mr. Bright’s condition and what more advanced care procedures should be implemented for Mr. Bright’s recovery.

Reference List

Abid, S., Shuaib, W., Ali, S., Evans, D. D., Khan, M. S., Edalat, F., & Khan, M. J. (2015). Chest pain assessment and imaging practices for nurse practitioners in the emergency department. Advanced Emergency Nursing Journal, 37(1), 12-22. doi: 10.1097/TME.0000000000000048

Benner, P. E., Hooper-Kyriakidis, P. L., & Stannard, D. (2011). Clinical wisdom and interventions in acute and critical care: A thinking-in-action approach. Springer Publishing Company.

Bonati, L. H., Lyrer, P., Ederle, J., Featherstone, R., & Brown, M. M. (2012). Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. The Cochrane Library.

Chang, C. C., Chen, Y. C., Ong, E. T., Chen, W. C., Chang, C. H., Chen, K. J., & Chiang, C. W. (2016). Chest pain after percutaneous coronary intervention in patients with stable angina. Clinical Interventions in Aging, 11, 1123.

De Luca, G., Dirksen, M. T., Spaulding, C., Kelbæk, H., Schalij, M., Thuesen, L., … & Chechi, T. (2013). Impact of Diabetes on Long-Term Outcome After Primary Angioplasty. Diabetes Care, 36(4), 1020-1025.

Gallagher, K. A., Meltzer, A. J., Ravin, R. A., Graham, A., Shrikhande, G., Connolly, P. H., … & McKinsey, J. F. (2011). Endovascular management as first therapy for chronic total occlusion of the lower extremity arteries: comparison of balloon angioplasty, stenting, and directional atherectomy. Journal of Endovascular Therapy, 18(5), 624-637.

Khan, N., Dodd, R., Marks, M. P., Bell-Stephens, T., Vavao, J., & Steinberg, G. K. (2011). Failure of primary percutaneous angioplasty and stenting in the prevention of ischemia in Moyamoya angiopathy. Cerebrovascular Diseases, 31(2), 147-153.

Rear, R., Bell, R. M., & Hausenloy, D. J. (2016). Contrast-induced nephropathy following angiography and cardiac interventions. Heart (British Cardiac Society), 102(8), 638-648. doi:10.1136/heartjnl-2014-306962

Roffi, M., Patrono, C., Collet, J. P., Mueller, C., Valgimigli, M., Andreotti, F., … & Gencer, B. (2015). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European heart journal, ehv320.

Rolley, J. X., Salamonson, Y., Wensley, C., Dennison, C. R., & Davidson, P. M. (2011). Nursing clinical practice guidelines to improve care for people undergoing percutaneous coronary interventions. Australian Critical Care, 24(1), 18-38.

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.