What are the reasons why a cardiac catheterization procedure would be performed?
- Acute MI
- Prior to valve replacement surgery
What is the cardiac catheter procedure?
- Puncture into radial OR femoral artery
- Insertion of a catheter that is advanced into the heart
- Contrast dye injected to provide information on the status of the coronary arteries, ventricular function, valvular disease, and intracardiac pressures
- Anti-anixety and pain meds used pre-procedure
- Bedrest post procedure for 4-12 hours per order
What is important to tell the patient about the contrast dye that is injected during cardiac catheterization?
Will feel warm when the dye is injected
Should patients' routine medications be given on the day of a cardiac catheter?
Check with the cardiologist
Special caution with diabetics, patients on cardiac meds, or anticoagulants
What should the nurse be assessing post cardiac catheterization?
- Monitor insertion site for bleeding, hematoma
- Assess distal pulses
- Maintain IV fluid (usually NS 1L over 4-8 hours)
- Apply pressure on femoral puncture during turning, eating, coughing, or bedpan use
How does nursing care differ if the radial artery is used VS femoral artery for cardiac catherization?
- CMS checks of involved hand
- BP on alternate arm
- Increased mobility as ambulation will not be restricted
- Shorter recovery time
What is Holter Monitoring (Ambulatory ECG)?
Recording EKG for 24-48 hours and correlating rhythm changes with symptoms recorded in a diary
What are the nursing responsibilities of Holter Monitoring (Ambulatory ECG)?
Normal activity is encouraged. Explain the importance of keeping a diary of symptoms. No bathing or showering during monitoring.
What is the Exercise Treadmill Test?
Evaluates the effect of exercise tolerance on myocardial function. Includes continuous monitoring of VS and EKG for ischemic changes.
What are the three types of echocardiogram?
- Transthoracic Echo (TTE)
- Transesophageal Echo (TEE)
- Stress Echo
What is a Transthoracic Echo (TTE)?
Involves an ultrasound of the heart that records direction and flow of blood through the heart.
What is a Transesophageal Echo (TEE)?
What is a stress echo?
What is Nuclear Cardiology?
IV injection of a radioactive isotope used to evaluate myocardial contractility perfusion and for acute injury.
What are the nursing responsibilities for nuclear cardiology?
Light meal between scan , all caffeine and theophylline products are held
What are biochemical markers?
Enzymes that are released following a MI
What are nursing responsibilites for biochemical markers?
Serial levels to be assessed q8 hours X 3 sets
What is electrophysiology study?
Records intracardiac electrical activity using catheters inserted into the femoral vein. Catheters are advanced into the right side of the heart. Dysrhythmias can be induced by this procedure.
What are the nursing responsibilties for electrophysiology study?
Ensure written consent is completed
Anti-arrhythmic meds may be held
Keep patient NPO 6-8 hours before procedure
Premedicate for relaxation
Why are serum lipid levels checked?
Elevated lipid levels are considered a risk factor for development of coronary artery disease (CAD)
Why are cholesterol levels checked?
Elevated cholesterol is a risk factor for ASHD
Why are triglycerides checked?
Elevated triglycerides are a risk factor for CV disease
Why are lipoproteins checked?
High density lipoproteins (HDL) protects heart against development of CAD
Low density lipoprotein (LDL) increases risk of CAD development
What should be assessed for cardiac patients?
- Cardiac rhythm
- Assess heart sounds - regular/irregular
- Auscultate heart sounds
- Assess for orthostatic BP and HR changes
- Assess for apical-radial pulse deficit
- Assess peripheral pulses
- Assess color, temperature, cap refill
Where and when is S1 heard?
S1 is heard at the apex of the heart.
S1 is associated with the closing of the mitral and tricuspid valves
End of diastole, beginning of systole
Where and when is S2 heard?
Best heard at the base of the heart.
Associated with the closing of the aortic and pulmonic valves.
End of systole, beginning of diastole
What to be assessed in terms of dyspnea for cardiac assessment?
Does the dyspnea occur with activity or rest?
Does the patient have orthopnea or paroxysmal nocturnal dyspnea? (PND)
How many pillows does the patient sleep with?
Can be cardiac or pulmonary in origin. Diseased heart is unable to compensate the increase in blood volume returning to the heart.
Patient's skin and mucuous membrane color
Auscultate lung sounds
Diagnostic tests: ABG, CXR
What is syncope?
Transient loss of consciousness due to decreased blood flow to the brain
What questions should be asked during cardiac assessment?
- Any palpitations?
- Any hx of syncope?
- Do symptoms occur at the same time
- How much caffeine do you consume?
- Tabbacco use?
- Any changes in the amount of stress?
- Illicit drug use?
What data is collected during a PAIN assessment in a cardiac patient?
O: Onset of symptoms. How long ago did symptoms start?
P: Precipitating events - What was the patient doing when symptoms began?
Q: Quality of pain - sharp, aching, etc
S: Severity: rate on a scale of 0-10
T: Timing - Has the pain changed over time?
Avoid the use of the word pain. Use alternative wording such as discomfort, achiness, dull, pressure
Any additional symptoms such as SOB, palpitations, dizziness, sweating
Is the pain like pain with previous MIs?
What special considerations should be taken for diabetics regarding a pain assessment?
Often no pain
1st symptom may be SOB, dyspnea
What special considerations should be taken for patients with obstructive sleep apnea regarding cardiac pain?
Snoring intereferes with sleep and is a risk factor for HTN
What special considerations should be taken for women regarding cardiac pain?
Atypical angina symptoms
Often report discomfort in the back, epigastric region, jaw, and arms
Often report no pain, fatigue, N/V, diaphoresis, palpitations
What is ischemia?
Hypoxia of tissues
It is painful
What are the labatory/diagnostic tests done for rest/sleep/comfort regarding cardiac assessment
12 lead ECG
What are the laboratory/diagnostic tests done for oxygen assessment regarding cardiac assessment?
12 lead ECG
Serum lipid levels
What are the laboratory/diagnostic tests done for fluid intake and urinary elimination during a cardiac assesment?
What are the laboratory/diagnostic tests done for activity during a cardiac assessment?
Cardiac Stress Test
What data should be collected regarding activity during a cardiac assessment?
- Possible events that may have triggered the symptoms
- Factors that alleviate the symptoms
- Symptoms of fatigue or intolerance of normal activity. Fatigue that occurs after mild activity may indicate decreased cardiac function.
- What is your current activity level and has it recently changed?
- How far can you walk before you are fatigued?
- Symptoms of fatigue
- Inability to perform ADLs
What data should be collected from the patient regarding fluid intake and urinary elimination during a cardiac assessment?
- Assess for c/o weight gain (fluid retention)
- Assess for c/o edema
- Assess nutritonal nintake for excessive sodium intake
- Assess and monitor lung sounds
- Assess for jugular vein distention (fluid backup)
- Monitor weight daily
- Assess urinary output and I&Os
- Assess for peripheral edema
What is the purpose of telemetry monitoring?
Telemetry monitoring is the observation of a patient's HR and rhythm at a site distant from the patient. The use of this technology can help rapidly diagnose dysrhythmia, ischemia, infarction. The RN must frequently assess all monitored patients for signs and symptoms of cardiac instability such as chest pain, hypotension, tachycardia
What are leads?
The lead selected to monitor the cardiac rhythm allows the RN to view the electrical activity from different positions based on the direction of the flow of electrical activity. Three common leads monitored includ Lead I, II, and III.
The lead appearance P, QRS, T waves will thus change based on the lead selected to monitor cardiac rhythm.
Why are telemetry units useful?
Telemetry units allow the patient to be more mobile on the unit while the RN is able to continuously monitor the heart's electrical activity. Usually there are 5 leads.
Where do the 5 leads go for a 5 lead telemetry unit?
White is right (shoulder)
Clouds over trees (white over green)
Green goes on right abdomen (near ribs)
Smoke over fire (black over red)
Black goes on left shoulder
Red goes on left abdomen (near ribs)
Chocolate close to the heart
Brown goes over heart
What is the difference between telemetry and a hard-wired monitor?
Hard wired: Tethers patient to bed. Used in peds and/or critical care setting where patient is non-ambulatory
Telemetry: Allows for patient mobility
Both: measure HR and rhythm
What should be documented with telemetry?
- Date and time monitoring begins and name of the lead used
- 6 rhythm strip every 4-8 hours or with changes in the patient's condition
- Rhythm strips are automatically labeled with patient name, room #, date & time
- Identify essential measurements (HR, PR, QRS, rhythm)
Where should the transmitter be on the patient?
Place transmitter in a pouch and securely attach pouch strings to patient's neck or waist, or other appropriate area. Change transmitter pouch whenever soiled.
What teaching should you do for the patient on telemetry?
Why they are on it and the purpose of the transmitter and how it works
When should electrodes be replaced?
Every 48 hours and as needed. Remove all unused electrodes. When attaching electrodes be sure that the gel is moist.
What should you do upon initiating telemetry monitoring?
Check that the batteries are functioning and also throughout monitoring. When telemetry is discontinued, recycle used transmitter batteries according to agency policy.
What should you do before removal of telemetry?
Obtain an order before removal of transmitter prior to patient shower or travel off unit. Some patients may need continous monitoring. The patient may need to be attached to a portable monitor if transported beyond the range of the telemetry
How should the nurse collaborate regarding telemetry monitoring?
Daily with physician/practitioner regarding continuation or discontinution of monitoring. There may be telemetry orders that indicate monitoring may be discontinued when set criteria are met.
What are some safety hazards involving telemetry monitoring?
Damaged cables, wires, monitors
What should you observe in the patient on telemetry monitoring?
Patient's rhythm should be frequently observed and report deviations from patient's normal rhythm to physician/practitioner
What should the nurse do if an alarm sounds on the telemetry monitor?
Compare the monitor display and rhythm printout with a clinical assessment of the patient's condition. Also, artifact can be caused by disturbing electrodes, close proximity of other electrical equipment, poor conduction, a faulty electrode or wire, muscle tremor, decreased humidity less than 40%, improper grounding of bed, or static electricitiy
What does a flat trace mean in any lead?
A flat trace in any lead shows that the electrocardiograph is detecting no electrical activity. This could be caused by a disconnected of the cable from the patient or the machine, or by a break in the cable itself. Check that all electrodes, connections, and cables are secure and free of damage. Always check the patient first as this may be asystole (death)
What is a muscle artifact?
A muscle artifact is a fine, somewhat irregular distortion of the baseline and QRS complexes. It is often due to fine muscle tremor of poorly supported or tense muscles and can be mimicked by loose, dry, outdated electrodes, a loose lead wire or cable connections, or inadequate skin preparation. Check that both the patient and the electrodes are positioned correctly and that the patient is lying quietly and not talking.
What is a wandering baseline?
A wandering baseline is a broad swing of the ECG trace, most often observed during deep inhalations and expirations of respiration. Check position of electrodes and possibly reposition
What is electromagnetic interference?
Originates from outside the patient and is caused by interference from electrical sources such as AC power cables. Ensure that power cables are not touching or lying near to the patient cables and check the patient lead wires and cables for observable damage. Make sure that all electrical equipment has hospital standard 3 prong plug.
What is a 12 lead ECG?
The 12 lead ECG differs from continuous ECG monitoring in that it records views of the heart's electrical acitivity from 12 different angles at one point in time. The 12 lead ECG is used to diagnosis dysrhythmias, ischemia, or infarction of the heart based on ECG changes within specific leads.
Where are the 10 electrodes placed in 12 lead ECG?
4 extremity and 6 chest leads
4 extremities: inner surface of L and R wrists, inner surface of the L and R legs near the ankle, as these areas provide a flat surface for good electrode skin contact
What are the nursing responsibilites for skin preparation on a 12 lead ECG?
- Skin is a poor conductor of electricity. To reduce the resistance (known as impedance) from the patient to the electrocardiography, ensure that there is good contact between the electrode and the patient's skin
- Ensure that the patient's skin is clean and dry. Perspiration, dead skin cells, hair, and wound dressings can all decrease conductivity, and it may be necessary to wipe or shave a small area or remove wound dressings to enable electrodes to adhere
- Fat tissue, breast tissue, a large thorax or a large muscle mass increase impedance and can hinder the ability of the leads to record the ECG. However, efforts should be made to place electrodes in the correct position
- Breast tissue is a poor conductor of electrcity. Avoid placing electrodes over it. Placement will usually be underneath the breasts in women
- Pre-prepared adhesive electrodes are used which contain a conductive gel. Check the expiration date of the packet of electrodes and each gel pad for moistness prior to application. Dry gel pads will not word. Do not expose to air because it will dry out conductive gel. Keep in sealed package until needed
- Ask patient if they have any skin reactions or allergies to adhesive tapes. Consider obtaining hypoallergenic pre-prepared adhesive electrodes for use as an alternative for those with sensitive skin.
- Check to see that the patient's arms are not touching the body and that the legs are not touching each other, as this will interfere with the transmission of impulses.
What additional steps are required when preparing a child for cardiac catheterization?
- Measure and record height for catheter length
- Measure and record weight for contrast or medciation dose calculation
- Assess the skin for diaper rash (radial artery is not big enough, femoral is used...if diaper rash could introduce infection)
When a child is to undergo a cardiac catheterization and is placed NPO, what should the RN assess?
Blood glucose level.
Hypoglycemia can occur due to NPO status and an IV of D5W is often indicated