ACS-Cardiac-2-0f-41
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Transcript ACS-Cardiac-2-0f-41
Nursing Priorities in
Acute Coronary Syndromes
Keith Rischer RN, MA, CEN
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Risk factors for CAD: Multifactorial
Unmodifiable
Age:
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
Modifiable
Smoking
Physical
inactivity
Obesity
Stress
Glucose
Intolerance
Elevated serum lipids
Hypertension
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Types of Angina…Causative Factors
Stable (classic)
Pain w/exertion-relief
w/rest
Unstable
Pain onset w/rest
Precursor to AMI
Silent
Unrecognized or
truly silent
Physical exertion
Temperature extremes
Strong emotions
Heavy meal
Tobacco use
Sexual activity
Stimulants
Circadian rhythm patterns
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12 Lead EKG: Ischemic Changes
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12 Lead EKG: Old
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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 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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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 reduction
Afterload reduction
HR reduction
Pain Relief:
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
Oxygen, Morphine
Amiodorone
Provide emotional support
Spiritual care
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Nursing Interventions:MI
Fluid
status
Monitor
for any symptoms of fluid overload, I&O
Emotional
Explain
support to patient and S.O.
procedures/technology, relieve anxiety
Document
based on unit guidelines
Patient 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 interventionASA, 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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Myocardial Revascularization:
CABG
Coronary Artery Bypass
Graft
Pre-operative Care
Baseline diagnostic
data
CXR
Coagulation studiesclotting, 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
–
assess for post-op pain
administer ordered pain meds
Cardiac tamponade
Monitor electrolytes
–
K+
Assess for dysrhythmias
–
Vented 3-6 hours after surgery
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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