1. PTCA (percutaneous transluminal coronary angioplasty)

  • One or more artery are dilated with a balloon catheter to open the vessel lumen and improve atrial blood flow
  • The client may experience re-occlusion after the procedure thus the procedure need to repeat
  • Re-occlusion
  • Artery dissection or rapture
  • Mobilization of plaque fragment
  • Spasm of the artery and acute MI
Life style modification
  • Reduce weight
  • Avoid fatty food
  • Avoid smoking
  • alter exercise pattern

Nursing responsibility pre opp
    • Take consent
    • Keep NPO
    • Assess any allergy to sea food or iodine
    • Monitor vital signs and peripheral pulses
    • Measure height and weight to determine the amount of die
    • Monitor s. creatinine and urea
    • Instruct the client that, when the catheter reaches the heart pt may feel desire to cough and may feel palpitation
    • Maintain patent IV line

After procedure
  • Monitor vital signs every 15 to30 minute
  • Provide bed rest 8 to 12 hr if femoral artery is used. If vein is used 6 t o 8 hr
  • Apply pressure over the site by using a sand bag
  • Apply cold pack to reduce bleeding and edema
  • Avoid flexion
  • Do not elevate head more than 30degree
  • Monitor for complication
  • Administer NTG ,IV to prevent coronary artery spasm
  • Administration of anticoagulant and anti platelet to prevent thrombus formation
  • Administrate calcium channel blocker to prevent contraction and spasm of the blood vessel
  • Take aspirin daily
  1. Laser assisted angioplasty

  • Laser probe is advanced through a cannula similar to that used to for PTCA.
  • It is used also for patient with small occlusion in the distal superficial femoral, proximal political, and common iliac artery
  • Heat from the laser vaporize the plaque and open the occlude artery
  • Coronary dissection
  • Coronary perforation
  • Acute occultation
  • Embolism
  • MI
  1. Coronary stent

  • It is used to eliminate the risk of acute coronary vessel occlusion ,
  • Balloon catheter bearing stent is inserted in to the coronary artery and poisoned at the site of occlusion
Post procedure management
  • Acute thrombosis can occur so the client placed on anti palette and anticoagulation therapy for several months following the procedure
  • Stent migration
  • Occultation
  • Coronary artery dissection
  • Bleeding caused buy anticoagulant
  1. Atherectomy

  • Remove the plaque from the artery by use of a cutting chamber on the inserted catheter. Or a rotating blade that remove plaque
  • It is used to improve blood flow to ischemic limb in individual with peripheral artery diseases
  • Arterial dissection, perforation
  • Embolism formation
  • Re occultation
  1. Trans- myocardial re-vasculation

  • It is used for the patient with widespread arthrosclerosis involving vessel that are too small and Nemours for replacement or balloon catheterization
  • It used high powered laser that create 15 to 30 holes or channel in the heart blood enter through this channel providing affected region with oxygenated blood
  • Opening surface of heart heals but main channel remain same
  • This procedure is perform through small chest incision
  1. Arterial revasculation

-it is perform to increase arterial blood flow to the affected limb. Graft material is sutured above and below occlusion to facilitate blood flow around the occlusion

Nursing responsibility pre opp
  • Assess base line vital signs and peripheral pulse
  • Insert IV line and urinary catheter
  • Maintain central venous, and arterial line if present
Post opp
  • Keep the extremity straight and limit movement to prevent bleeding
  • Provide bed rest for 24hr
  • Assess the vital sign
  • Prevent hypertension, because it my place stress on the graft and may cause clot formation
  • Prevent hypotension, to prevent collapse of the grafted portion
  • Monitor for warm, redness or edema, which are expected outcome because of increased blood flow
  • Monitor for graft occlusion Which occur within 24 hr, sharp increased pain which is the first indicator of graft occlusion
  • If sign of occlusion occur notify the physician
  • Encourage deep breathing and coughing exercise, and use of incentive spirometer to expand lung to prevent pneumonia
  • Use aseptic technique
  • Maintain NPO status
  • Assess insertion site for drainage warm or swelling
  • Monitor for bleeding
  • Monitor the area for hardness, tenderness, which may indicate infection
  • Encourage the client to modify the life style to prevent further plaque formation
  • Avoid smoking
  1. CABG (coronary artery bypass grafting )

  • Occluded coronary artery are bypassed with venous or atrial blood vessel,
  • Saphenous vein radial artery or LIMA (left internal mammary artery) are used to bypass in the coronary artery
pre operative intervention
  • Instruct the client how to splint the chest while cough and during deep breathing
  • Instruct to do arm and leg exercise
  • Inform the client to expect 2 to 3 sternal incision , possible arm or leg incision one or two chest tube , Foleys cath and IV line
  • Inform the client that he may be connected to a ventilator for 6 to 24 hr
  • He would not be able to talk. So use alternative method of communication
  • Medication are to be discontinued before surgery are
    • Diurites 2to 3day before surgery
    • Digitalis 12hr before surgery
    • Aspirin and anticoagulant 1 week before surgery
  • Medication to be given before surgery
      • Anti hypertensive
      • Anti arrhythmic
      • KCL
      • Antibiotics

Post operative intervention
  • Monitor HR, rhythm, neurological status, pulmonary artery, and arterial pressure
  • Connect the patient with ventilator and administer o2
  • Provide semi fowler’s position
  • Monitor mediasternal drainage tube and report if drainage exceeding 100 to 150 ml/hr
  • Monitor pericardial pace wire, and should be guarded properly
  • Monitor fluid and electrolyte balance, restrict fluid 1.5 to 2 lit/day
  • Maintain Kcl level b/w 4 to 5 mcq/lit
  • Control BP, prevent hypotension to prevent collapse of graft
  • Prevent hypertension, because increased pressure promote leakage from the suture line and may cause bleeding
  • Monitor temperature, initiate rewarming produced by using thermal blanket
  • If the temperature drop below 96.80 F rewarm the patient. But not faster than 1.80F/hr to prevent increase pulsate
  • During surgery initiate hypothermia, to decrease metabolism, decrease pulse rate, and to decrease work load of heart
  • Monitor for cardiac tamponade which will include sudden cessation of previously heard heart sound, pulse paradox, heavily mediasternal drainage, jugular vein distension and clear lung sound
  • Monitor for pain and differentiate sternotomy pain from angina pain, because angina pain indicate graft failure
After acute care
    • Monitor vital sign, level of consciousness , and peripheral perfusion
    • Monitor for cardiac arrhythmia
    • Monitor respiratory status, temperature, and WBC , increase in WBC after 3 -4 days indicate infection
    • Provide adequate fluid to liquify the secretion
    • Sutured line should be checked for signs of infection
    • Guide the client to resume activity gradually.
    • Assess the client for tachycardia, postural hypertension, and fatigue before and during activity
    • Discontinue activity if BP drops more than 10 -20 mmof hg from the baseline


Home care
  • Inform the client that incision will heal within 6 to 8 week
  • Limit pushing or pulling activity for six week following discharge and progressively return to activity at home
  • Avoid crossing the leg
  • Wear elastic hose until edema subside
  • Elevate the limb when sitting in a chair
  • Take prescribed medication provided
  • Increased protein diet, and restrict fat rich diet
  • Sexual intercourse will resume after exercise tolerance is assessed
  • If the client can walk one block or two flight of stair without symptom, he or she can resume sexual intercourse safely
  1. Heart transplantation

From an individual of an compatible body weight and ABO compatibility is transmitted to a recipient with in 6 hr of obtain.

  • Remove the diseased heart by leaving the posterior portion of the atria to serve as a anchor for the new heart
  • Because of the portion of the atria is remain in the patient, two unrelated P waves are noted in b/w the two consecutive QRS on ECG
  • Transplanted heart is unresponsive to vagus stimulation so client does not experience angina pain
  • Monitor symptoms of heart rejection, like hypo tension, arrhythmia, weakness, fatigue
  • Need immuno suppressive therapy to prevent rejection
  1. Cardioversion

  • The synchronized counter shock to convert an undesirable rhythm to a stable rhythm
  • It is an elective procedure usually performed by the physican
  • Defibrillator is synchronized (pre-set) to the client R wave to avoid discharging the shock during vulnerable period. On T wave
  • If it is not synchronized it could discharge on T wave and cause VT
  • The energy in the cardio version is 50j to 200j
Nursing responsibility pre procedure
  • Written consent
  • Administrate sedative
  • Hold the digoxin 48 hr pre procedure
  • To prevent post Cardioversion ventricular irritability
  • Ensure that skin is clean and dry before procedure
  • Stop O2 to prevent hazard of fire
  • Be sure that no one is touching the patient and his bed
Post procedure
  • Maintain patent airway
  • Assess vital sign specially peripheral pulse
  • Assess the LOC
  • Monitor cardiac rhythm
  1. Defibrillation

  • An asynchronous  counter shock used to terminate pulse less  VT and VF
  • Three rapid consecutive shock are delivered at an energy of 200j , if unsuccessful shock is repeated at 300j and 360j
  • Use of paddle electrodes
  • Apply conductive pads
  • Apply one paddle placed at 3rd intercostal space to the right of the sternum; the other is placed at 5th intercostal space on the left midaxillary line
  • Apply firm pressure with the pad
  • Make sure that no one is touching the pt or bed, when delivering the shock
  1. Automated external defibrillator (AED)

  • B it is used by an expert person (lay person ) and emergency medical technician for pre hospital cardiac arrest
  • We have to provide affirm dry place, and stop CPR, ensure that no one is touching the client
  • Place the electrode paddle at the correct position on the client chest
  • Press the analysis button to identify the rhythm. which may take 30 sec .
  • The machine will advice whether the shock is necessary or not
  • Shock are recommended only for pulse less VT and VF
  • If shock is recommended, it initially deliver an energy of 200j. if unsuccessful repeat at 300j and 360j.
  • If unsuccessful start CPR continue for few minute provide a serious 3 shock again
  1. Implantable cardioverted defibrillator

    • ICD monitor cardiac rhythm and detect and terminate VT and VF
    • It delivered 20j, 30j and maximum of 50j, up to 4 time if necessary
    • ICD is used in client with episode of spontaneous VT or VF which is unrelated to an MI or in client whose medication therapy has been unsuccessful
    • Electrodes are placed at Rt atrium, Rt ventricle and epical pericardium and generator is implanted in the abdominal wall

Instruction to the patient
  • Instruct pt to perform cough CPR
  • Teach the patient how to take pulse and should take pulse daily
  • Maintain a diary of daily pulse rate
  • Wear loose fitting cloth
  • Avoid strain full activity
  • Monitor for any infection at the insertion site
  • Report the symptom of fainting, nausea, weakness, blackouts (loss of consciousness) and tachycardia
  • During the shock client may feel fainting or shortness of breath
  • Instruct the client to sit or lie down if he or she feels a shock
  • Teach the family members to give CPR if necessary
  • Patient should avoid electromagnetic field directly over the ICD because they can inactivate the demand
  • Keep ID or media alert bracelet
  • Instruct the patient to move away from the magnetic field immediately if beeping sound are heard and should be notified to the physician
  1. Pace maker

  • Temporary or permanent device that provide impulse or electrical stimulation and maintain the heart rate when the client intrinsic pacemaker fail to provide a perfusing rhythm
  • Synchronous or demand pace maker

    – it sense the pt rhythm and pace, only  give its pace, If the client intrinsic rate fall below the set pace maker rate

  • Asynchronous or fixed rate pace maker :-

    paces at a preset rate regardless of the client’s intrinsic rhythm

  • Overdrive pacing pace maker:-

    to suppress the underlying rhythm in tachydysrhythmias so that the sinus node will regain control of the heart

Temporary pacemaker

  1. Noninvasive temporary pace maker :-
  • it is used an emergency measure or when a patient is being transported and when the risk of bradydysrhythmia present
  • electrode patch is placed on the chest and back. Not necessary to shave the area
  • do not apply alcohol or tinctures to the skin
  • place the posterior electrode b/w the spine and left scapula behind the heart, avoid placing over the bone
  • place anterior electrode between V2 andV5 position over the heart
  • do not place the anterior electrode over the female breast tissue; rather, displace breast tissue and place under the breast
  • do not take pulse or BP on the left side, the result will not be accurate because of the muscle twitching and the electrical current
  • ensure that electrode are in good contact with skin


  1. transvenous invasive temporary pacing
    • pacing led wire is placed through antecubital, femoral, jugular, or subclavin vein in to the right atrium for atrial pacing or through the right ventricle, and positioned in contact with the endocardium
    • monitor the cardiac rhythm continuously
    • monitor vital signs
    • monitor pace maker insertion site
    • restrict the patient movement to prevent lead wire displacement


epicardial invasive temporary pacing

  • applied by using a transthoracic approach
  • the led wire are loosely threaded on the epicardial surface of the heart after surgery
nursing responsibility
  • to reduce the risk of microshock use approved equipment
  • insulate exposed portion of wire with plastic or rubber material
  • ground all electrical equipment with 3 way pin plug
  • wear gloves when handling exposed wire
  • keep dressing dry
permanent pacemakers
  • pulse generator is internal and surgically implanted in a subcutaneous pocket under the clavicle or abdominal wall
  • the leads are passed transvenously via the cephalic or subclavian vein to the endocardium on the right side of the heart


  • single chambered :- in which lead wire is placed in the chamber to  be paced
  • dual chambered :- in which lead wire placed in the atrium and right ventricle

this program can be reprogram if necessary by noninvasive transmission from an external progrmer in to the implanted generator

life span of pacemaker  it is depend on the battery on use; lithium battery-10yrs; nuclear battery – 20yrs

health education after pacemaker implantation
  • teach the patient about signs of battery failure and it should be notify to the doctor
  • Incision site should be monitor for swelling, tenderness, redness and fever
  • Report signs of dizziness, weakness, fatigue, chest pain, and shortness of breathing
  • Keep pacemaker identification card in the wallet and wear a medic-alert bracelet
  • Wear loose fitting cloths
  • Instruct the client to take pulse daily and note on a diary
  • Avoid contact sports
  • Report airport security that he has a pacemaker, because the pacemaker may set off by the security detector
  • Inform the health care provider that the pacemaker is implanted
  • Instruct the client that most electrical appliance can be used without any interference with the functioning of the pacemaker; however advice the client not to use electrical appliance directly over the pacemaker site
  • Avoid transmitter tower
  • If any unusual feeling occur when near any electrical device, move 5 to 10 feet away and check pulse
  • pacemaker function can be checked in the clinic by a pacemaker programmer or from home, using telephone transmitter device
  • client may be provided a device that placed over the pacemaker generator with an attachment of telephone, the HR can be transmitted to the clinic by this method


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