CHAPTER 29 / Nursing Care of Clients with Coronary Heart Disease 817
NURSING CARE OF THE CLIENT HAVING CORONARY ANGIOGRAPHY
BEFORE THE PROCEDURE
• Assess the client’s and family’s knowledge and understanding
of the procedure. Provide additional information as needed.
Explain that the client will be awake during the procedure,
which takes 1 to 2 hours to complete. A sensation of warmth
(a “hot flash”) and a metallic taste may occur as the dye is in-
jected. A rapid pulse or a few “skipped beats,” also are com-
mon and expected during the procedure. A good understand-
ing of the procedure and expected sensations reduces anxiety
and improves cooperation during the procedure.
• Provide routine preoperative care as ordered (see Chapter 7).
Although the client remains awake, sedation may be given.
Signed consent is required, and preprocedure fasting may be
ordered.
• Administer ordered cardiac medications with a small sip of
water unless contraindicated. Regularly ordered medications
are continued to prevent cardiac compromise or dysrhythmias
during the procedure.
• Assess for hypersensitivity to iodine, radiologic contrast me-
dia, or seafood. An iodine-based radiologic contrast dye is typi-
cally used for an angiogram. Iodine or seafood allergy increases
the risk for anaphylaxis and requires an alternative dye or spe-
cial precautions.
• Record baseline assessment data, including vital signs,
height, and weight. Mark the locations of peripheral pulses;
document their equality and amplitude. The data provide a
baseline for evaluating changes after the procedure.
• Instruct to void prior to going to the cardiac catheterization
laboratory, to promote comfort.
AFTER THE PROCEDURE
• Assess vital signs, catheterization site for bleeding or
hematoma, peripheral pulses, and neurovascular status every
the initial treatment of angina. They are used cautiously in clients
with dysrhythmias, heart failure, or hypotension.
The nursing implications of antianginal medications are
summarized on p. 000.
Aspirin
The client with angina, particularly unstable angina, is at risk
for myocardial infarction because of significant narrowing of
the coronary arteries. Low-dose aspirin (80 to 325 mg/day) is
often prescribed to reduce the risk of platelet aggregation and
thrombus formation.
Revascularization Procedures
Several procedures may be used to restore blood flow and
oxygen to ischemic tissue. Nonsurgical techniques include
transluminal coronary angioplasty, laser angioplasty, coro-
nary atherectomy, and intracoronary stents. Coronary artery
bypass grafting (CABG) is a surgical procedure that may be
used.
15 minutes for first hour, every 30 minutes for the next hour,
then hourly for 4 hours or until discharge. The data provide
vital information about the client’s status and potential compli-
cations such as bleeding, hematoma, or thrombus formation.
• Maintain bed rest as ordered, usually for 6 hours if the femoral
artery is used, or 2 to 3 hours if the brachial site is used. The
head of the bed may be raised to 30 degrees. Bed rest reduces
movement of and pressure in the affected artery, reducing the
risk of bleeding or hematoma.
• Keep a pressure dressing, sandbag, or ice pack in place over
the arterial access site. Check frequently for bleeding (if the
access site is in the groin, check for bleeding under the but-
tocks). Arteries are high-pressure systems. The risk for significant
bleeding after an invasive procedure is high.
• Instruct to avoid flexing or hyperextending the affected ex-
tremity for 12 to 24 hours. Minimizing movement of the af-
fected joint allows the artery to effectively seal and promotes
blood flow, reducing the risk of bleeding, hematoma, or throm-
bus formation.
• Unless contraindicated, encourage liberal fluid intake. An in-
creased fluid intake promotes excretion of the contrast medium,
reducing the risk of toxicity (particularly to the kidneys).
• Promptly report diminished peripheral pulses, formation of a
new hematoma or enlargement of an existing one, severe
pain at the insertion site or in the affected extremity, chest
pain, or dyspnea. While the risk of complications is low, myocar-
dial infarction or insertion site complications may occur. These
necessitate prompt intervention.
• Provide instructions about dressing changes, follow-up ap-
pointments, and potential complications prior to discharge.
Percutaneous Coronary Revascularization
Percutaneous coronary revascularization (PCR) are procedure
used to restore blood flow to the ischemic myocardium in
clients with CHD. Approximately 600,000 PCR procedures
are done annually in the United States. PCR is used to treat
clients with:
• Moderately severe, chronic stable angina unrelieved by med-
ical therapy.
• Mild angina but objective evidence of coronary ischemia.
• Unstable angina.
• Acute myocardial infarction (Braunwald et al., 2001).
PCR procedures are similar to the procedure used for coro-
nary angiography. A catheter introduced into the arterial circula-
tion is guided into the opening of the narrowed coronary artery.
A flexible guidewire is inserted through the catheter lumen into
the affected vessel. The guidewire is then used to thread an an-
gioplasty balloon, arterial stent, or other therapeutic device into
the narrowed segment of the artery. The procedure is performed