Coronary angioplasty or percutaneous coronary intervention refers to the procedure that is used to open clogged blood vessels, primarily the arteries. The procedure involves temporary insertion and inflation of a tiny balloon at regions where a clog is located in the artery. This helps in widening the artery. In other words, it can be defined as a therapeutic procedure that is used for treating stenotic coronary arteries that are located in the heart (M?kikallio et al. 2016). Occurrence of such stenotic segments in the blood vessels can be attributed to buildup or accumulation of plaques that are made up of cholesterol deposition, due to onset of artherosclerosis. Upon administration of this therapeutic intervention is found to reduce chest pain or angina in the patients. However, the associated risk of myocardial infarction does not get reduced. In the case scenario, the procedure of coronary angioplasty was implemented upon the patient Elizabeth Green, following her reports of sudden pain in the chest and left shoulder. The essay will elaborate on hematoma, a potential problem that can arise post-coronary angioplasty. Furthermore, it will also illustrate the underlying aspects of anatomy and physiology to facilitate treatment of the potential problems.
Hematoma refers to the localized accumulation of blood outside the blood vessels. This can be attributed to trauma or disease, in addition to injury following a surgery. The physiological abnormality involves seepage of blood from broken capillaries. Hematoma is most commonly observed after coronary angioplasty and occurs in liquid form, following which it gets spread among different tissues, in addition to the sacs that are present between the tissues (Kleber et al. 2015). Upon reaching the tissue spaces, coagulation and solidification often occurs, before reabsorption of blood in the vessels. While most hematomas are often visible under the skin surface that are commonly called bruises, some are also felt in the form of lumps or masses (Almenawer et al. 2014). The lumps are found to be direct manifestation of blood limitation to the sacs or spaces of subcutaneous and intramuscular tissue that are isolated by certain fascial planes. Hence, lump formation is considered as a major anatomical feature that works by preventing injuries from leading to huge blood loss. However, in most cases, such hematoma that grows in the form of a blood sac is found to eventually dissolve (Rodriguez?Luna et al. 2013). However, research studies have also provided evidence that demonstrates continuous growth of hematoma due to blood seepage (Sanidas et al. 2014). Failure of the blood sac to disappear is often treated by performing a surgery that cleans or repairs it. Furthermore, this potential problem often involves reabsorption at a slow rate that allows movement of the broken blood cells and the blood pigment hemoglobin, towards the connective tissues (Pancholy et al. 2014). Furthermore, hematoma is considered as a major problem, post conduction of coronary angioplasty due to the fact that on articulation, it can often reduce mobility of a patient and a misdiagnosis in the vertebra can also lead to buildup of cells or hemangioma.
Hematoma development, following coronary angioplasty is considered as the most common complication. Research evidences suggest that most patients who have experienced hematoma demonstrate a reduced quality of life. Furthermore, hematoma leads to several inconvenience, the most common of which are walking impairment, mobility problems, and unpleasant or tingling sensation in the legs (Saw et al. 2016). Aortic intramural hematoma might arise in the patient, 8 hours after undergoing coronary angioplasty. The aorta is the largest blood vessel (artery) present in the human body. It is found to originate from the left ventricle of the heart that acts as the major chamber, which pumps out blood from the heart. The potential problem related to aortic intramural hematoma is considered dangerous for the patient as the condition is often characterized by leakage of blood through the innermost layers of the walls of the aorta (Bakhshi et al. 2014). A tear in the aortic wall might not contribute to this blood leakage. Thus, it might become difficult to immediately diagnose any such abnormality in the patient. Furthermore, buildup of hematoma might also lead to disruption of blood supply to different parts of the body, thereby resulting in oxygen deprivation and worsening the patient condition (Chhatriwalla et al. 2013). Thus, hematoma or internal bleeding after catheterization is considered as a major health concern, afrer a coronary angioplasty in the patient Elizabeth Green owing to the fact that it might lead to the development of groin pain at the location of acess, which in turn will be accompanied by focal bruising, swelling, and potential hemodynamic compromise. This is often related to tachycardia and hypotension. Furthermore, additional complications might also arise from this hematoma, such as, compression of femoral nerve, owing to its proximity to the nerve that is typically associated with weakness in the quadriceps (Tweet et al. 2014). Therefore, efforts need to be taken for minimizing the chances of formation of hematoma, by providing meticulous attention to the access site and the region of entry with the use of fluoroscopy.
In addition to cardiac catherterisation, occasionally hematoma might also arise spontaneously, as a direct manifestation of action of blood thinning medications. Blood thinners, commonly referred to as anticoagulants are chemicals that are administered to reduce or prevent blood coagulation, thereby increasing the clotting time (?zcan et al. 2013). Anticoagulant therapy is most often implemented in cases of unstable angina, with the aim of preventing progression of subocclusive coronary thrombus, thereby reducing risks of myocardial infarction and associated death. Research evidences have also suggested that administration of medication such as, plavix (clopidogrel), coumadin (warfarin), and aspirin are found to result in an increased likelihood of developing hematoma in the blood vessels, when compared to individuals not under these medications (Aspegren et al. 2013). They play an important role in hematoma development by causing impairment on the ability of the blood to clot. Thus, it becomes more difficult to repair minor damages that have occurred in the blood vessels, thereby resulting in hematoma formation (De Bonis et al. 2013). Furthermore, research evidences have also emphasized on association between extensive anticoagulant therapy in case of cardiovascular disorders with subdural hematoma and subarachnoid bleeding. Evidences also suggest that low doses of aspirin are related to reduced risks of hematomal bleed, thereby elaborating on the underlying pharmacology of hematoma (Kuramatsu et al. 2015).
Following angioplasty in the patient Elizabeth Green, who reported discomfort in her chest and shoulder, several nursing care procedures must be followed in order to avoid further health complications related to hematoma, myocardial infarction or arrhythmia.
- Upon removal of the tube or stent from the arms or legs, it is required to apply direct pressure for duration of 15 minutes or longer at the region where the catheter has been inserted. This will be done to ensure reduction of all chances that might lead to internal bleeding (Greenberg and Kornowski 2013).
- The patient will be checked for presence of hepatic infusion, followed by insertion of catheters in the artery in a groin that is found to directly link to the liver.
- Efforts will be taken to assess the patient for signs and symptoms that relate to intravascular volume depletion. Intravascular volume refers to the amount of blood present in the circulatory system and generally encompasses the blood plasma component of the entire body (Bateman et al. 2013).
- Assessments will be conducted to determine presence of physiological abnormalities that pertain to tachycardia, hypotension, delayed CRT, widened pulse, agitation and reduced peripheral infusion.
- Hematoma will be ausculated by listening to the internal sounds to reveal presence of systolic bruit or pulse. This would indicate presence of pseudoaneurysm (Rodriguez-Leor et al. 2013).
- Pressure will also be applied above the catheter insertion site, with the use of gauze for achieving haemostasis. Successful haemostasis will encompass a process that leads to stop of bleeding, by restricting blood within the vessels that have been damaged (Omori et al. 2013).
- The patients’ vital signs will be monitored, with an emphasis on blood pressure and heart rate. Signs of orthostatic hypotension or decrease in systolic pressure of 20 mmHg and diastolic pressure of 10 mmHg will be observed. Orthostasis will indicate a reduction in the circulating fluids. Efforts will be taken to administer medications such as, fludrocortisone, midodrine, and pyridostigmine for managing the condition (Ricci, De Caterina and Fedorowski 2015).
- Immediate care plan will also include preventing administration of any medication that can create an effect on hemostasis. Use of anticoagulants, NSAIDs and salicylates will be stopped for preventing further health complications that might arise from internal bleeding. NSAIDs and salicylates have been found to inhibit the activity of cyclooxygenase 1 or COX-1 enzyme that promotes aggregation of platelets. Protamine sulfate and vitamin K will be administered for counteracting the effects of blood thinners. This will also reduce the chances of developing embolism (Koster et al. 2014).
- Laboratory tests will be conducted for evaluating the coagulation status of a patient. The platelet count, PT/INR ratio (prothrombin time/international normalised), bleeding time, fibrinogen count, thromboplastin time (aPTT), vitamin K, and activated coagulation time will be evaluated. This can be related to the fact that cascade that involves blood clotting forms an integral system that requires several extrinsic and intrinsic factors. Derangements in any of the aforementioned factors can directly create an effect on the clotting ability of a person. Hence, conduction of these clotting tests after coronary angioplasty is essential in retrieving information about the bleeding potential and coagulation status of Elizabeth Green.
- The urine (hemastix) and stool (guaiac) will be checked for occult blood. These tests will help in distinguishing bleeding from the urinary or gastrointestinal tracts.
- The skin and mucous membrane will also be assessed for identifying signs of brusing, petechiae, blood oozing and hematoma formation. Mrs. Green will be administered emollient lip balms and normal saline based nasal sprays. This will help in reducing cracking and drying of the mucous membrane, thereby limiting risks of bleeding (Nunes, Rego and Nunes 2014).
- Rectal suppositories, enemas, thermometers, tampons and vaginal douches will be avoided in order to prevent trauma that these invasive devises can cause to the mucous membranes.
- Blood products such as, plasma derivatives and blood components that are prepared at blood transfusion centres will be used to increase the oxygen carrying capacity of the RBCs.
- Educating the patient and her family members about the risk factors.
The Standard 7 of the Standards of Practice for Registered Nurses emphasizes on evaluating outcomes of the patient that will create provisions for an informed nursing practice, which in turn is integral to effect several changes across a healthcare setting. One of the major aspects that are encompassed by this standard of practice encompasses evaluating and monitoring progress of a patient towards the intended goals or outcomes. The aforementioned nursing care plan, following coronary angioplasty involves identification and monitoring the vital signs of the patient, in addition to assessing his skin and mucous membrane for recognizing development of hematoma or other health complications related to internal bleeding. Thus, the nursing care plan is consistent with the first standard of practice. Monitoring the blood pressure and heart rate of the patient will also help in determining effectiveness of the angioplasty procedure and will enhance the quality of life of the patient, thereby providing evidence for health progress. The standard 7.2 focuses on making revisions in the plan, following an evaluation of the patient (nursingmidwiferyboard.gov.au 2018).
The nursing care plan stated earlier states that presence of hematoma signs and symptoms will be assessed, following which all kinds of medication that encompass anticoagulant therapy will be stopped. Thus, on observing internal bleeding, the nursing care plan will be revised by removing administration of blood thinners, with the aim of reducing health complications. Hence, the care plan also demonstrates accordance to the second standard. The standard 7.3 involves determining, documenting and communicating goals, priorities and outcomes with relevant individuals (nursingmidwiferyboard.gov.au 2018). The care plan will involve efforts to increasing awareness of Elizabeth Green and her children regarding the measures that must be taken to eliminate the risk factors that might deteriorate her health.
To conclude, it can be stated that there is a need to conduct a thorough assessment of the patient Mrs. Green in order for treating the angina symptoms that are reported by her. Performing a coronary angioplasty was essential for removing blockade from the blood vessel. The nursing care plan shows adherence to the standards of practice. Hence, appropriate intervention and care plan will help in improving the overall health and wellbeing of the patient.
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