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For years, aPTT was the clotting factor that was used to monitor for heparin therapy. Research is now showing that there is a better way to monitor clotting time. This is called, the anti Xa factor. Research shows that the anti Xa factor is more effective because there is a shorter time to therapeutic anti-coagulation, longer maintenance of therapeutic levels fewer lab test, and less heparin dose changes.

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White: Assessment and Patient Problem
Pink: Pathophysiology
Yellow: Patient Current and History of Medical problem
Green: Nursing Care and Teaching
Blue: Medications
Purple: Labs and Diagnostics

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My patient was very surprise to learn that she had Afib and coronary artery disease due to not having a family history of cardiac problems. Research has shown that patient's with type 2 diabetes are at a higher risk of developing Afib because diabetes can lead to other cardiac problems (hypertension and damaging heart and blood vessels) that contributes to Afib. Diabetics developing Afib is greater if the patient is noncompliant with controlling glucose levels. When blood sugars are not controlled, blood vessels become damaged and clots form. This leads to poor blood flow to the heart, which damages the heart and contributes to Afib and heart failure. A diabetic patient is also at risk for stoke as well because of Afib not efficiently pumping blood. Other risk factors that contributed to my patient's Afib are, obesity and advanced age.

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*Used to assess for clot formation related to Afib
*A probe goes down into the esophagus where sound waves are sent to the heart and is then translated as pictures onto a screen.
*Medications for numbing and anxiety are given before procedure.
*Patient may have a sore throat afterwards

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Is a synchronized countershock that is performed to restore Afib back into Normal Sinus Rhythm
*Used for new on-set Afib
*TEE (transesophageal echocardiogram) is performed if on new on-set Afib to assess for clot formation in left atrium
*Will be given a anesthetic for sedation
*Two electrodes are placed on the patient and a machines will "shock" heart back into normal rhythm
*After cardioversion- patient's response and heart rhythm will be assessed and therapy may be repeated until desired results  or alternative therapies are considered (Pacemaker)
*Patient may have chest burns from electrodes
*Nurse will assess vitals, airway, dysrhythmias, and provide emotional support.

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A catheter is placed through either the radial or femoral vein and navigated to the heart where contrast dye is injected from a catheter. X-Ray imaging will show if there is blockage in the arteries.
*Patient will be NPO 6-8 hours before heart cath
*Let doctor know if allergic to iodine
*Patient will need someone to drive home after procedure
*Will be given sedation/anxiety meds and a local anesthetic.
After....
*Patient will keep effected leg (femoral) or arm (radial) straight and remain bedrest
*Nurse will monitor vitals
*Report any bleeding, swelling, pain at the site. Report any chest pain

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*Type II Diabetes

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*Major Depressive Disorder
*Type II Diabetes
*Hypothyroidism

Surgeries
*Hysterotomy
*Total Hip Replacement

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Multiple rapid impulses from many atrial foci depolarize the atria in a disorganized manner at a rate of 350-600 times per minute. This results in a chaotic rhythm with no clear P waves, no atrial contractions, a loss of atrial kick, and an irregular ventricular response. The ventricles beat with a rapid rate in response to the many atrial impulses. The rapid and irregular ventricular rate decreases filling in the ventricles, resulting in decreased cardiac output. This causes blood to pool and placing the patient at risk for clotting.

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*An ECG is performed so that the provider can view and examine the electrical activity of the heart. The provider will be able to tell if the heart is having electrical problems, is stressed, or has damaged.
*The patient will wear loose fitting clothing (preferably a hospital gown)
*Electrodes (sticky pads) will be attached to the patient's chest, shoulders, and legs.
*The patient will be asked to lay still so that the machine can get an accurate reading.
*The test takes about 10-15 mins

Patient's Results: Showed Atrial Fib at admission. Currently in Normal Sinus Rhythm after cardioconversion

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Hsu, J.-C., Yang, Y.-Y., Chuang, S.-L., Yu, C.-C., & Lin, L.-Y. (2021). Higher long-term visit-to-visit glycemic variability predicts new-onset atrial fibrillation in patients with diabetes mellitus. Cardiovascular Diabetology, 20(1). https://doi.org/10.1186/s12933-021-01341-3

Ignatavicius, D., Workman, L., Rebar, C., & Heimgartner, N. (2021). Medical Surgical Nursing Concepts for Interprofessional Collaborative Care (10th ed.) [Review of Medical Surgical Nursing Concepts for Interprofessional Collaborative Care]. Elsevier.

Jones & Bartlett Learning. (2021). Nurse’s drug handbook 2021 (20th ed.). Jones & Bartlett Learning.

Williams-Norwood, T., Caswell, M., Milner, B., Vescera, J. C., Prymicz, K., Ciszak, A. G., Ingle, C., Lacey, C., & Stavrou, E. X. (2020). Design and Implementation of an Anti–Factor Xa Heparin Monitoring Protocol. AACN Advanced Critical Care, 31(2), 129–137. https://doi.org/10.4037/aacnacc2020132

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Patient is to be transferred to Lincoln for a CABG, after her surgery, she will be referred to cardiac rehab. She should be able to return home and will need to practice a hearth healthy life style such as eating a cardiac diet and exercising. A possible challenge would be a lack of support from her husband and being noncompliant to treatment. Both the patient and her husband will need to be educated about her condition. My patient should expect to have regular follow up appointments.

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The goal of teaching is to help the patient prevent heart failure and embolus formation.
*Be compliant with drug therapy. Do not stop any medication suddenly because many heart meds have harmful withdraw affects. (See med teaching for more info)
*Develop an appropriate exercise routine (approved by provider)
*Eat a cardiac diet and control BS related to diabetes (see Diet and Nutrition teaching) Diabetes is a risk factor for heart disease and developing Afib.
-Consider quitting smoking
*Monitor pulse and BP daily and report and change in heart rhythm.
*Attend Cardiac rehab, support groups, and follow appointments
*Meet with a diabetic specialist for education on controlling BS

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*Wear for 1 hour several times a day to prevent clotting due to immobility and Afib.

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Teaching for Hospital and New Medications related to AFIB

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Teaching for Hospital and New Medications related to AFIB

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*Heparin: Risk for bleeding. No contact sports, use assistive devices, and declutter walking area to prevent falls. Also, use electric razors and soft brushes to prevent bleeding. Must get regular lab draws to monitor aPTT.
*Lispro: Must be administered 10-15 mins before meals. Monitor for hypoglycemia
*Hydrocloraothiazide: Take in the mornings to avoid nocturia, Monitor I&Os, BP, and daily weight. Check bs often. Increase potassium, and monitor fluid and electrolytes and kidney labs.
*Metoprolol: Take with food at the same time each day. Check HR and BP before taking. Do not stop taking suddenly.
* Nitroglycerin/Nitrostat: Recognize signs and symptoms of angina. Take 5 mins apart. If chest pain doesn't subside after the third dose, call 911. Carry on hand at all times in original brown bottle. Move slowly to prevent orthostatic hypotension.
* Lipitor/Atorvastatin: Drink plenty of fluids. Report signs of infection. Monitor bs and for signs of hypoglycemia

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Patient is a 74 yr old female. Full Code. Allergy to penicillin. Pt is A&O x4. Speech is clear and appropriate. PERRLA. Strength and movement of all extremities. Full ROM x4. Does c/o of mild tingling in the legs due to diabetic neuropathy. She has an unsteady gait and is a 1A with a GB and walker. Fall risk precautions in place. HEENT-Facial symmetry intact, sclera is white. Mucous membranes moist, pink, and intact. Has top teeth intact and bottom partials intact. No swollen lymph nodes. Skin is dry. Has mild redness under breast and abdominal folds. Normal skin turgor. Resp-Bilateral clear and diminished lung sounds throughout. Breathing is non-labored and even.  Cardiac: Pt is on tele. Strip reads: Normal Sinus rhythm. (had a cardioversion two days prior) Rate is reg. pulses- Apical: 73 bpm, Radial: equal, bilateral-72 bpm. Pedal equal, bilateral rate: reg. at 70bpm. Cap refills <2 all four extremities. non-pitting edema throughout. GI-Bowels active x4. Abd flat, soft, non-tender. No c/o nausea, vomiting, diarrhea, c/o constipation. Patient uses BR and is continent. Urine is clear, yellow, and no odor.

Vitals: 135/91 (106), T-97.1 degrees tympanic, SATS 97% on RA, HR 73, Resp 20. pain 0/10

Ht: 5'7 Weight: 161.6 kg

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ED Admit Report
Pt is a 74 yr old female. Went to work at 8am and had acute chest heaviness with SOB and racing pulse.

*AFIB with RVR
*NSTEMI
*Coronary Artery Disease
*Morbid Obesity
*Hypothyroidism
*Hypertension
*Hyperlipidemia
*Type II Diabetes
*Major Depressive Disorder

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At the start of the shift, my patient was NPO because she was preparing for a heart cath that day. It is recommended that patients remain NPO for a cath lab procedure because the patient will be given anesthetics which increases the risk of aspirating. After her heart cath, she was prescribed a cardiac diet due to the resent findings of a clogged artery and having a high risk of having an MI. Bad cholesterol, such as Low-density lipoprotein, causes fatty deposits to grow and eventually clogs arteries and prevents blood flow to the heart. *The purpose of a cardiac diet is to lower cholesterol and prevent/manage heart disease. The diet consist of foods low in sodium (2g or less per day), avoiding saturated and trans fat. And avoiding foods high in cholesterol. My patient should aim to eat meals that includes vegetables, fiber, and non-red meats (chicken and turkey) It is also recommended to eat fish (salmon or tuna) that are have healthy Omega-3 fats. My patient should also consider a diet low in carbs and sugars due to being a type II diabetic to control her high blood sugars. Controlling blood sugars will also help keep the heart healthy as well. My patient has a BMI of 55.8 (morbib obesity) Due to my patient's age, it is recommended that she have a BMI of 25-27.

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*ECG: Showed AFib on admission. Patient was cardioverted and is now in Normal Sinus Rhythm
*Heart Cath: Showed 90% blockage in right coronary artery

It's important to monitor platelets, Hct, Hgb because the patient is on a heparin drip and is at an increase risk of bleeding. If there is a decrease in these labs, that can indicate bleeding

*High Hct: studies show that a high hematocrit is a risk factor of developing  heart disease

*Low Heparin Anti-Xa Level: Heparin levels are low and the nurse will need to adjust the rate.

*High Glucose: Patient is a type II diabetic and is not making enough insulin to control glucose levels

Because the patient is a diabetic, it is important to monitor kidney function (BUN and Creatinine). A kidney that is not excreting waste will build too much fluid and electrolytes.

*High Troponin: Indicates damage to the heart

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*Atenolol/Tenormin (Beta Blocker) 50mg PO QDAY-to treat hypertension
*Rosuvastatin/Crestor (Statin) 10mg PO QDAY- to treat high cholesterol
*Glimepiride/Amaryl (Sulfonylurea) 2mg PO QDAY- to treat high blood sugars
*Metformin/Fortamet (Biguanides) UNKNOWN dose-to treat high blood sugars
*Potassium Chloride (supplement) 10mEq Capsule PO, QDAY-to treat low potassium levels
*Acetylsalicylic acid/Aspirin (NSAID)--81 mg Tablet, Delayed Release PO QDaily-to prevent heart attack and stroke
* Levothytoxine/Synthroid (Thyroid Hormone Agent)- 137 mcg PO, QAM- for hypothyroidism

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*Human Lispro (Insulin) Sliding Scale Units, SUBCUT, ACHS SCH -For controlling high blood sugars related to diabetes.
* Acetylsalicylic Acid/Aspirin (NSAID/Blood thinner) 81mg PO, DAILY- for reducing clots related to Afib
*Hydrocloraothiazine/Hydrodiuril (diuretic) 25mg PO, QAM- to reduce edema
*Metoprolol/Lopressor (Beta-Blocker) 50mg PO, BID- for high BP and rate control.
*Heparin/Sodium Cloride (blood thinner)-25,000 Units in 250 mLs @ 17.187 mLs/hr IV-continuous until D/C-Prevents blood clots related to Afib.
* Levothytoxine/Synthroid (Thyroid Hormone Agent)- 137 mcg PO, QAM- for hypothyroidism
* Nitroglycerin/Nitrostat (vasodilator)0.4 mg sublingual, Q5MIN, PRN -for chest pain,
* Ondansetron/Zofran (antiemetic)-4 mg IV, PRN for nausea,
* Lipitor/Atorvastatin (statin) 80mg PO, QPM to treat high lipid levels
*Acetaminophen/Tylenol (Analgesic)-500mg PO, Q8H/PRN-for pain.

Meds given at the Cath Lab:
*Fentanyl/Duragesic (Opioid)- 100 Mcg/2ml IV, One Dose- used for pain and sedation,
*Naloxone/Narcan (Opioid antagoist) 0.4 mg IV, PRN- antidote for fentanyl
*Midazolam/Versed (benzo) 2mg/2ml IV-One Dose- used for sedation.
*Flumazenil/Romazicon (Gaba receptor antagoist) 0.5 mg IV, PRN- antidote for Midazolam.
*Iohexol/Omnipaque (contrast dye) 15,000 mg IV  used in xray for diagnosing blockages in arteries,
* Lidocaine/Xylocaine (local anestetic) 2% 20 mL IV, One Dose- used to numb the catheter incision site,
*Nitroglycerin-Dextrose/Nitrostat (vasodilator) 25mg/250 MI in D5W- use as directed- used to treat and prevent coronary vasospasms and increase blood flow.
*Verapamil/Verelan (calcium channel blocker) 5 mg IV, one dose- used to prevent radial artery spasms

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*Monitor vital signs every 4 hours
*Give medications in a timely manner. Monitor for side effects and if meds were effective.
*Continuous telemetry monitoring-watch for changes in rhythm and dysrhythmias.
*Apply Sequential Compression Device to prevent clotting.
*Assess for signs of decreased cardiac output (hypotension, syncope, increased HR) and signs of heart failure (dyspnea, productive cough, edema)
*Give oxygen if needed for signs of HF
*Assess for signs of PE
*Educated patient and family about diagnose and how to make life style changes.

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Treatment Goal is to prevent clotting and prevent heart failure.
*Drug Therapy- drugs that slow ventricular conduction (Calcium Channel Blockers and Beta Blockers) or antidysrhythmic drugs that convert Afib back into normal sinus rhythm (flecainide, dofetilide, propafenone, and ibutilide) Long-term anticoagulation therapy (rivatoxaban) to prevent clot formation.
*Non Surgical Interventions- *Electrical Cardioversion: synchronized countershock that may be performed to restore back to a normal rhythm. Used for new on-set Afib
Other interventions include: Radiofrequency catheter ablation, biventricular pacing, left atrial appendage closure.
-Surgery: Maze procedure-an open-chest surgical technique often performed with coronary artery bypass grafting
*Preventatives (see diagnosis teaching)

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*12-Lead Electrocardiogram (ECG)-Allows the provider to view the heart's electrical activity from different views.

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My patient  is a 74 year old female. She currently works at a bank teller in Grand Island. Is currently living in Grand Island, NE with her husband. They have three sons. One son lives nearby. Patient has never been a smoker and does not drink alcohol or use illegal drugs. She is independent at home and does not need help with ADL's. She claims she has no financial burdens and no life stressors other than her currently diagnosed heart condition. She was surprised of the diagnosis since there is no family history of heart problems. She is a catholic and she and her husband go to church every Sunday. She states that she doesn't eat a very healthy diet but wishes to. She finds it hard to eat healthy because her husband is not supportive of trying to eat healthier. Erikson Stage: 8 despair. The patient knows she is overweight and doesn't eat right even though she has diabetes. She feels regret that she didn't take better care of herself and that it lead to her heart problems.

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1. Decreased Cardiac Output (See NJMM)
2. Impaired Tissue Perfusion (See NJMM)
3. Risk for Clot- r/t Afib and Coronary Artery Disease. S/S: SOB, heart palpitations, fatigue. EKG reading and heart cath results.
4. Impaired skin Integrity- r/t obesity and diabetes. S/S: unhealing redness under breast and skin folds
5. Deficient Knowledge- r/t Lack of interest in learning. S/S: Patient was educated about a cardiac diet and within a few minutes she called to order a cheeseburger and French fries. She needed to be reeducated and stated, “I know it’s bad for my heart, but a cheeseburger sounds so good”

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>Irregular apical pulse
>Increased HR
>Signs of poor perfusion
*Fatigue
*Weakness
*Shortness of Breathe
>Dizziness
*Anxiety
>Syncope
*Palpitations
>Chest Discomfort
>Pain
>Hypotension