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Nursing Priorities inAcute Coronary Syndromes

Keith Rischer RN, MA, CEN

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Risk factors for CAD: Multifactorial

UnmodifiableAge:

Increased age-CAD begins early and develops gradually.

Gender:Highest for middle-aged white caucasian

Race:Caucasian males highest risk

Genetic: Inherited tendencies for atherosclerosis

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Risk factors for CAD: Multifactorial

ModifiableSmoking Physical inactivityObesityStressGlucose IntoleranceElevated serum lipids Hypertension

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Types of Angina…Causative FactorsTypes of Angina…Causative Factors

Stable (classic)Stable (classic) Pain w/exertion-relief Pain w/exertion-relief

w/restw/rest

UnstableUnstable Pain onset w/restPain onset w/rest Precursor to AMIPrecursor to AMI

SilentSilent Unrecognized or Unrecognized or

truly silenttruly silent

Physical exertionPhysical exertion Temperature extremesTemperature extremes Strong emotionsStrong emotions Heavy mealHeavy meal Tobacco useTobacco use Sexual activitySexual activity StimulantsStimulants Circadian rhythm patternsCircadian rhythm patterns

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12 Lead EKG: Ischemic Changes

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12 Lead EKG: Old

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Myocardial InfarctionMyocardial Infarction

http://video.google.com/videoplay?docid=-861965134389078213&q=blocked+coronary+artery&total=19&start=10&num=10&so=0&type=search&plindex=3

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Zones of Injury

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Nursing Assessment: Manifestations Appearance

Anxious, restless, pallor, diaphoresis Blood Pressure/Pulses Breathing JVD (Jugular Vein Distension) Auscultation/heart and lung Abnormal heart sounds S3, S4

Shortness of Breath (SOB) Orthopnea

Chest Discomfort Pleuritic-point tenderness? Localized vs. diffuse

Palpitaion

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Ventricular EctopyVentricular Ectopy

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Areas of Damage

Inferior Right Coronary Artery Leads II, III, AVF

Anterior Left Anterior

Descending Leads V1-V4

Lateral Circumflex Leads I, AVL, V5, V6

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Diagnostic Assessments

12 Lead EKG Chest X-Ray:

Assessment of cardiac size and pulmonary congestion.

Treadmill exercise Stress Test on a

treadmill with EKG and B/P monitor

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STEMI vs. non-STEMI

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STEMI 12 Lead EKG

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nonSTEMI 12 Lead EKG

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Diagnostics: Cardiac enzymes

Enzyme Rises In Peaks In Remains Elevated For

CPK-MB 4- 8 hrs 12 – 24 hrs 1 day

Troponin 3 hrs 12-18 hours Up to 14 days

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Diagnostic Assessments

Angiogram: View coronary arteries Incr. risk if done after

MI Need creatinine

Dye can cause renal failure

Echocardiogram Safe, non-invasive, wall

motion abnormalities

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Nursing Diagnosis Priorities

Acute Pain R/T decreased myocardial oxygen supply

Ineffective tissue perfusion R/T myocardial damage, inadequate cardiac output and potential pulmonary congestion

Activity Intolerance R/T fatigue Anxiety R/T perceived threat to death, pain,

possible lifestyle changes Knowledge deficit

Smoking cessation, diet, medications, procedures

– Assess for dysrhthmias, heart failure, extension of MI

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Nursing Care Plan

Goals: Attain adequate pain control Maintain adequate tissue perfusion Expression of sense of well-being

Evaluation: Compare progress as a result of nursing interventions Effectiveness of pain control VS stable: skin color improved If interventions unsuccessful – need to make

modifications of NCP

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Nursing Interventions:Priorities

DECREASE WORKLOAD OF THE HEART

Preload reductionAfterload reductionHR reduction Pain Relief:

Oxygen, Morphine Decrease demand for oxygen consumption

Bedrest, limit visitors, avoid large meals, Oxygen supplement complete bed bath/commode avoid straining during BM Music Therapy, Relaxation Tapes

Watch for dysrhythmias: Increasing PVC’s, VT Amiodorone

Provide emotional support Spiritual care

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Nursing Interventions:MI

Fluid statusMonitor for any symptoms of fluid overload, I&O

Emotional support to patient and S.O.Explain procedures/technology, relieve anxiety

Document based on unit guidelinesPatient education/prevention

Assess needs early, referrals (SS, cardiac rehab), others (risk factor management, psychological adjustment

Complimentary/alternative therapy

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Collaborative Care

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Stent Placement

Coronary Artery Bypass Graft (CABG)

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Collaborative Care:Drug Therapy

Antiplatelet agent:

First line of intervention-ASA, Plavix

Beta-adrenergic blockers: Prophylactic for angina Inderal, Lopressor,

(decrease in myocardial contractility

Lowers HR & B/P…reduces myocardial O2 demand

ACE Inhibitors Improve ventricular

“remodeling”

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Complications of Acute MI

Dysrhythmias Cardiogenic shock Myocardial rupture (of ventricle) L.V. Aneurysm Pericarditis Venous Thrombosis Psychological Adjustments

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Cardiogenic Shock: ICU Case Study

78yr female PMH: CAD, smokes 1ppd, CRI HPI: awoke w/CP, nausea, diaphoresis. Seen in small

community ED… See 12 lead…, Troponin 0.9 Received ½ dose TPA…airlifted to ANW level 1

In transport HR dropped to 20’s-Epi & Atropine & CPR x1” Angio: occluded prox. LAD-opened x3 stents BP-78/46

– Dopamine & Epinephrine gtts started– IABP placed-transfer to ICU

ICU: progressive resp failure-intubated– u/o 30cc last 4 hours– Stat echo…EF 25%– Labs: creat 2.1, K+ 5.7, BNP 1488, Trop 2.6

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Admission 12 Lead EKG

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Myocardial Revascularization: CABG

Coronary Artery Bypass Graft

Pre-operative Care Baseline diagnostic

data CXR Coagulation studies-

clotting, time, prothrombin time, fibrinogen, platelets

CBC, UA

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CABG Nursing Interventions: Pre op

Surgical pre-op teaching – to help reduce anxiety

procedure – video of surgery ICU post op pain meds Incentive spirometer-Cough-deep breathe chest tubes endotracheal tube Foley catheter Emotional/spiritual support Shower/bath w/Hibiclens Pre-op Abx

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CABG Nursing Interventions:Post op

Usually stays in ICU 1 or 2 days– Vented 3-6 hours after surgery

assess for post-op pain administer ordered pain meds Cardiac tamponade Monitor electrolytes

– K+ Assess for dysrhythmias

– Atrial fib most common Chest tubes

– Milking q 1-2 hours– Assess amount/color drainage

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Chest Tube: Nursing Priorities

Assess resp. status closely Check water seal for

bubbling Milk NOT strip every 2

hours Assess color-amount

drainage Call MD if >100cc/hr x2

hours first 24 hours Sterile guaze/occlusive

dressing at bedside

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CABG Complications: Case Study

68yr male s/p AVR & CABG PMH: CAD, AS, HTN

Post-op Complications: Resp. failure/aspiration req. ongoing vent support…likely

trach CV: hypotension-vasopressor support, fluid overload ARF-on CRRT and central dialysis catheter placed-

minimal u/o Encephalopathy-MRI neg, EEG shows diffuse cerebral

dysfunction-restless, does not follow commands NG for tube feeding