Cardiac/Vascular Nurse Exam Secrets Study Guide (28 page)

Carotid endocardiectomy

Carotid endocardiectomy is a common procedure that removes plaque buildup within the carotid artery that serves cerebral blood flow. The procedure involves clamping of the carotid artery and then removal of the plaque buildup to restore blood flow. In an effort to monitor blood flow to the brain, Doppler and electroencephalogram may be used during the procedure.

Carotid endarterectomy is indicated for patients with severe asymptomatic or symptomatic carotid stenosis, ulcerated or intermediate degrees of stenosis that are not effectively treated with anticoagulation therapy and severe stenosis with contralateral internal carotid occlusion.

Carotid endocardiectomy is contraindicated in patients with thick circular calcification, completely blocked arteries, and other cardiovascular comorbid conditions that may be better treated with percutaneous transluminal angioplasty or stent procedure.

Complications associated with carotid endocardiectomy include thrombus formation, embolism, transient ischemic attack, stroke, cranial nerve injury, infection, hematoma, intracranial hemorrhage, restenosis, and/or sudden death. Other complications may arise due to the presence of other cardiovascular comorbid conditions such as diabetes, congestive heart failure, hypertension, or hyperlipidemia as well as due to patient’s overall health status. Elderly or severely ill patients with cardiovascular comorbid conditions should be monitored closely pre-and post-carotid endocardiectomy.

Prior to carotid endocardiectomy, practicing clinicians should take a patient’s medical history, perform a physical examination, and evaluate a patient’s overall health. Patients should be screened for drug-drug interactions, allergies, vital signs such as heart rate and blood pressure and cardiovascular blood indicators such as potassium levels, prothrombin time, and hematocrit and creatinine levels. Patients should also undergo an electrocardiogram and echocardiogram prior to procedure. Additionally, they should take prophylactic antibiotic therapy and undergo a chest x-ray. Overall, a full cardiovascular work-up should be conducted prior to the procedure. Additionally, patient’s neurological status should be assessed as well.

During carotid endocardiectomy, patients should only receive medications via an intravenous route, except for aspirin, which is given orally prior to the procedure. Postprocedure, practicing clinicians should perform an electrocardiogram, echocardiogram, perform a physical assessment, monitor peripheral blood flow and look for swelling and evaluate cardiac pain. Neurological assessment including level of consciousness, vocal cord functioning, reflexes, motor strength, level of sensation, pupil size, and reaction to light should be made every 1 to 2 hours postsurgery.

Hospital protocols for aftercare should be followed. Hemodynamic blood flow should be monitored and patients should be assessed for hemorrhagic shock. Doppler evaluation of vessels may also be completed. Prior to patient release, practicing clinicians should perform additional physical assessments such as assess patient’s heart sounds and laboratory tests such as hematocrit, potassium levels, creatinine levels, and cardiac enzymes. Overall, a full cardiovascular work-up should be conducted postsurgically and prior to releasing the patient.

Patients should be instructed to follow-up with their practicing clinician 1 week post procedure and then follow-up after 3 months should be done. At 3 months, Doppler evaluation should be performed to assess artery patency. At 6 months and then yearly, Doppler evaluation should be performed to assess for restenosis. Elderly patients should be checked on a regular basis for risk of infection, heart sounds, and cardiac risk factors. Patients at risk for other cardiovascular complications should be monitored on a regular basis. Patients should also be assessed for other cardiovascular risk factors and managed for these risks.

Peripheral thromboembolectomy

Peripheral thromboembolectomy is a procedure that uses a balloon catheter to remove an arterial embolism and restore blood flow through the peripheral circulation. For aortic or iliac occlusions, bilateral ventricle groin incisions followed by embolectomy balloon catheter approach is typically performed. The procedure can be performed on both legs once the initial clot is removed from the occlusion.

For femoral and popliteal occlusions, incisions in the distal common femoral artery followed by embolectomy balloon catheter approach are typically performed. If thromboembolectomy fails, then adjuvant balloon dilatation and/or atherectomy may also be performed. However, anticoagulation therapy may be initiated prior to peripheral thromboembolectomy.

Peripheral thromboembolectomy is indicated for patients with acute symptomatic arterial occlusion as well as patients with gangrene to achieve lower level amputation.

Contraindications of peripheral thromboembolectomy include advanced ischemia up to 2 days. Patients with advanced ischemia after 48 days have a higher risk of amputation. Complications associated with peripheral thromboembolectomy include thrombus formation, vessel vasospasm, hemorrhage, bleeding, hematoma formation, artery dissection, compartment syndrome, venous thrombosis, edema, hyperkalemia, cardiac arrhythmia, renal failure, and rhabdomyolysis. Complications may arise due to the presence of other cardiovascular comorbid conditions such as diabetes, congestive heart failure, hypertension, or hyperlipidemia as well as due to the patient’s overall health status.

Prior to peripheral thromboembolectomy, practicing clinicians should take a patient’s medical history, perform physical examination, and evaluate the patient’s overall health. Patients should be screened for drug-drug interactions, allergies, vital signs such as heart rate and blood pressure and cardiovascular blood indicators such as potassium levels, prothrombin time, hematocrit, and creatinine levels. Patients should also undergo electrocardiogram and echocardiogram prior to procedure. Additionally, they should take prophylactic antibiotic therapy and undergo a chest x-ray. Overall, a full cardiovascular work-up should be conducted prior to the procedure. Additionally, patients should be administered heparin prior to the procedure.

During peripheral thromboembolectomy, patients should only receive medications via an intravenous route, except for aspirin, which is given orally prior to the procedure.

Postprocedure, practicing clinicians should perform an electrocardiogram, echocardiogram, perform a physical assessment, perform pedal pulse assessment with Doppler and/or ankle brachial indices, monitor peripheral blood flow, look for swelling, and evaluate cardiac pain.

Hospital protocols for aftercare should be followed. Hemodynamic blood flow should be monitored and patients should be assessed for hemorrhagic shock. Doppler evaluation of vessels may also be completed. Prior to patient release, practicing clinicians should perform additional physical assessments such as assess patient’s heart sounds and laboratory tests such as hematocrit, potassium levels, creatinine levels, and cardiac enzymes. Overall, a full cardiovascular work-up should be conducted postsurgically and prior to releasing the patient.

Patients should be instructed to follow-up with their practicing clinician 1 week postprocedure and then follow-up with Doppler and/or duplex ultrasound evaluation should be performed. Elderly patients should be examined on a regular basis for risk for infection, heart sounds, and cardiac risk factors. Other patients at risk for other cardiovascular complications should be monitored on a regular basis. Patient should also be assessed for other cardiovascular risk factors and managed for these risks. Patients should also be referred to a podiatrist or foot surgeon to address any additional limb and/or foot complications.

Cardiac transplantation

Cardiac transplantation involves the replacement of a patient’s own heart with a donor heart. The procedure is performed in patients with progressive end stage cardiovascular disease. Cardiac transplantation is indicated for patients with class III or IV end stage cardiovascular disease, with life expectancy of less than 1 year, under 65 years of age, medically stable, and with no underlying comorbid conditions such as systemic infection, irreversible renal insufficiency, irreversible pulmonary insufficiency, irreversible hepatic insufficiency, active peptic ulcer, or recent pulmonary embolism.

Practicing clinicians and nurses need to work as a team to prepare a patient for cardiac transplantation. Preoperative care focuses on immunosuppression, acute renal failure, bradycardia, and right ventricular dysfunction.

Long-term complications associated with cardiac transplantation include rejection, infection, transplant coronary artery disease, nephrotoxicity, hypertension, hyperlipidemia, transplant lymphoproliferative disease, and malignancy. Long-term pharmacologic management to prevent these complications includes use of immunosuppressive agents, antibiotics, antihypertensive agents, diuretics, and lipid-lowering agents.

Postpericardiotomy syndrome (PPS)

Postpericardiotomy syndrome is an inflammatory response most often occurring when a patient has undergone a surgical procedure involving the pericardium. Symptoms can develop 1–6 weeks after surgery. The key symptom is high fever (even if the patient has no other complaints of illness). Other symptoms might include malaise, chest or lung pain, trouble breathing, joint pain, irritability and lack of appetite. Physical examination and testing will often exhibit friction rubs, pleural effusions, lung inflammation and cardiac tamponade. Laboratory testing results show negative cultures, but high erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and anti-heart antibodies. Treatment involves pericardial draining and anti-inflammatory medications.

Evaluation

Complications and prognosis

Raynaud’s phenomenon

Raynaud’s phenomenon is typically not severe, but can lead to digit deformity due to lack of proper oxygenation and blood flow to digits. Other complications include skin ulcers, infection, and gangrene. Patients with Raynaud’s phenomenon should address any cuts or scrapes in the affected areas to prevent infection. A clinical practitioner should address any cuts or scrapes that do not heal properly or in a timely manner. In severe cases of Raynaud’s phenomenon, patients may have to undergo surgery and/or have digits amputated.

In terms of prognosis, primary Raynaud’s phenomenon is rarely life threatening and more often annoying and a cause of discomfort. Over time, with proper management and care, the phenomenon typically improves. However, secondary Raynaud’s phenomenon may be a sign of a rheumatic condition and should be monitored closely by a specialist.

Buerger’s disease

Buerger’s disease is a rare disorder involving inflammation and subsequent blockage of the veins and arteries. It mainly affects men younger than 40 of Middle Eastern or Far Eastern descent. It causes patchy numbness, cold, burning or tingling of one or more limbs and eventually causes necrosis in the tissues surrounding blocked areas. The principal cause is always tobacco use, therefore of primary concern to the healthcare provider is facilitating smoking and tobacco (of any kind) cessation in order to halt the disease process. Other areas of concern might be pain control, stress management and lifestyle changes that encourage tobacco abstinence. Other less effective treatment options include medications and compression devices to increase blood circulation. If circulation cannot be maintained and infection occurs, amputation of the affected limb may be needed.

Cardiomyopathy

The prognosis of cardiomyopathy varies by the type and extent of disease. Current treatments reduce symptoms and complications of disease. However, in some patients the disease can progress rapidly and result in serious complications such as heart attack and death.

The complications of cardiomyopathy include congestive heart failure, arrhythmias, heart murmur, endocarditis, cardiac arrest, and sudden death. Blood clots may also occur, which can lead to heart attacks and strokes. Patients need to be aware of these complications and manage these risks effectively with self-care, proper pharmacologic regimens, and clinical follow-up on a regular basis.

Congestive heart failure

Complications of congestive heart failure include end organ system dysfunction such as renal failure, pulmonary edema, liver dysfunction due to fluid buildup, and insufficient absorption of nutrients and pharmacologic agents by the small intestines.

Congestive heart failure is typically a progressive disease. The prognosis of the disease varies by the degree and extent of progression. Current treatments reduce symptoms and complications of disease. However, in some patients the disease can progress rapidly, while in others the disease can become chronically maintained.

Factors that determine prognosis include underlying comorbid conditions, symptoms, response to pharmacologic management, and degree and severity of the end organ system involvement

Cor pulmonale

The prognosis of cor pulmonale depends on the underlying cause of disease. The more severe the underlying cause, the greater the risk for complications, and the lower the chance of survival. The administration of supplemental oxygen is typically effective in increasing survival and improving quality of life.

Complications of cor pulmonale include severe fluid retention, life-threatening shortness of breath, shock, and/or death. Other complications include syncope, hypoxia, pedal edema, and/or hepatic congestion. Additionally, complications associated with underlying disease leading to cor pulmonale may arise.