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Nursing Priorities in Acute Coronary Syndromes

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Presentation on theme: "Nursing Priorities in Acute Coronary Syndromes"— Presentation transcript:

1 Nursing Priorities in Acute Coronary Syndromes
Keith Rischer RN, MA, CEN Largest killer of Americans 1 of 5 deaths CV disease #1 cause of death in US-CAD is most common subtype… Defined as heart disease due to impaired coronary blood flow usually atherosclerosis 1.2 million americans will have MI and ¼ will die in ED or before reaching a hospital Mortality rate decreased 26% from CAD leading cause of death of both men and women-responsible for 1/3 of all deaths

2 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 Age: Increased age-CAD begins early and develops gradually. Gender: Highest for middle-aged white men. After age 65 it equalizes: Evidence suggests that women develop MI earlier due to stress, high B/P, smoling & use of estrogen. Race: Inc. risk for white males Genetic Inheritance: Inherited tendencies for weak arterial wall.

3 Risk factors for CAD: Multifactorial
Modifiable Smoking Physical inactivity Obesity Stress Glucose Intolerance Elevated serum lipids Hypertension Elevated serum lipids: One of the four most firmly established risk factors for CAD. Total cholesterol prefer to be ,200mg/dl and fasting triglycerides,150mg/dl. HDLvs.LDL ratio is important: LDL (<100 LDL carries mostly cholesterol; HDL carries much less cholesterol. You want HDL (the “good” cholesterol to be higher). Modifiable Elevated serum lipids HDL improves w/ exercise Hypertension: 2nd major risk factor in CAD, inc. salt intake=fluid retention=inc. systemic vascular resistance to the cardiac workload Smoking: Risk of developing CAD is 2-6x higher in smokers than non-smokers. Risk is proportional to the number of cigarettes smoked Second hand smoke Obesity: Inc. body mass=Inc. workload of the heart. Diet= fat and triglycerides. Physical inactivity: Physically active people found to have Inc. HDL. Exercise 3x/week for at least 30 minutes (causing perspiration and an Inc. HR (by BPM) Stress: Type A (competitive, aggressive, ambitious, pre-occupied schedules, time, #s, deadlines, details) CHD 2x higher. Glucose intolerance: Diabetics Mechanism unclear: Insulin reacts to lipid metabolism and artery changes. Why is smoking so bad to heart??? Increases rate of atherosclerosis by incr LDL, decr HDL, nicotine stimulates release of catecholamines which incr HR and BP which incr cardiac workload and demand, when heart needs more O2 supply of extraction is decr due to CO in smoke, incr vessel inflammation and thrombosis through polycythemia In women decreases estrogen…benefits of cessation immediate and mortality rates drop to those of nonsmokers in 12 months Physical inactivity- lack of regular exercise on regular basis…what is true exercise???brisk walk for 30” 5x week causing perspiration and incr HR bpm Incr HDL, enhances fibrinolytic activity, encourages collateral circulation Obesity defined as BMI >30…incr LDL-triglycerides, HTN 3x more likely to develop than normal weight…abd fat correlates w/higher incidence of CAD

4 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 Stable- Usually stable plaque that is occlusive at least 75%-CP transient lasting 3-5” onset w/activity-relief w/rest…if blood flow restored no permanent damage Relief w/rest or NTG…if unrelieved may be AMI Occurs intermittently with same pattern-duration-intensity of sx Unstable- rupture of plaque-incomplete occlusion of vessel- Silent no CP-may be just fatigue, dyspnea, epigastric burning Incr w/elderly, diabetes as well as w/those who have had CABG Stable angina: No change during previous 60 days “Unstable”: Change in pattern within previous 60 days 4

5 12 Lead EKG: Ischemic Changes

6 12 Lead EKG: Old

7 Myocardial Infarction
Acute coronary syndomes-encompasses UA and AMI STEMI vs nonSTEMI 80-90% of all MI due to thrombus MI leading cause of death of all cardiovascular diseases. Almost half of US mortality due to CVD; accounts for more deaths than cancer, respiratory diseases and accidents combined. MI causes 56% of CV deaths. Annual incidence of MI is about 1.5 million. Approximately 490,000 MI victims die each year before they reach the hospital. On an average most people wait 3 hours before going to the hospital thinking that “symptoms will pass”. Patients need to know importance of when to go to the hospital or call 911. Atherosclerosis “hardening of the arteries” Synonymous terms: Arteriosclerotic Heart Disease (AHD), Cardiovascular Heart Disease (CVHD), Ischemic Heart Disease (IHD), Coronary Heart Disease (CHD) Disease Process: plaque formation, artheromatous deposits and coronary occlusions 7

8 Zones of Injury

9 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 80 y.o. male with S4 = abnormal

10 Ventricular Ectopy Ectopic pacemaker is an excitable focus outside the SA node PVC’s-caffeine-ETOH, nicotine, dig, lyte imbalances-K-Mg-stress CAD, MI, HF VT-MI, lyte imbalance, cardiomyopathy, 10

11 Areas of Damage Inferior Anterior Lateral Right Coronary Artery
Leads II, III, AVF Anterior Left Anterior Descending Leads V1-V4 Lateral Circumflex Leads I, AVL, V5, V6

12 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 12 lead EKG May be normal when the patient comes to the ER w/complaint of chest pain; but within a few hours it indicates damage or infarct. Must be sequential; not always definitive in 15-25% of cases

13 STEMI vs. non-STEMI

14 STEMI 12 Lead EKG

15 nonSTEMI 12 Lead EKG

16 Diagnostics: Cardiac enzymes
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 Used in conjunction with CK-MB findings CK MB norm 0-7 >7 positive (Combined elevation of Trop and CK-MB indicate that coronary artery blood flow has been sufficiently obstructed to cause myocardial necrosis). Normal range is 0-1.9

17 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 Echo-est. extension of infarction, detect complications, i.e. LV aneurysms, pappilary muscle dysfunction, free wall rupture, mural thrombus, pericardial effusion.

18 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 Instruct patient to take NTG before intercourse to prevent CP

19 Nursing Care Plan Goals: Evaluation: 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

20 Nursing Interventions:Priorities
DECREASE WORKLOAD OF THE HEART Preload reduction Afterload reduction HR 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

21 Nursing Interventions:MI
Fluid status Monitor for any symptoms of fluid overload, I&O Emotional support to patient and S.O. Explain 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

22 Collaborative Care Percutaneous Transluminal Coronary Angioplasty (PTCA) Stent Placement Coronary Artery Bypass Graft (CABG) Important to implement life-style changes after intervention: no smoking exercise, diet (low fat), and stress management. Percutaneous Transluminal Coronary Angioplasty (PTCA): A balloon is placed next to the plaque, blocking the artery-balloon is inflated crushing the plaque. May be performed as the first line of treatment Stent-a small, expandable wire-mesh stent is permanently inserted into the artery during angioplasty. The balloon is placed inside the stent and inflated, which opens the stent and pushes it into place against the artery wall to keep the narrowed artery open. Because the stent is meshlike, the cells lining the blood vessel grow through and around the stent to help secure it. CABG-Usually recommended for patients with unstable angina who demonstrate poor response to traditional Rx. Grafts use: saphenous vein or internal mammary artery. Provides the patient with improved outcomes, quality of life and survival. Nursing Role: Teaching Pre-Op-location/purpose of post-op tubes (chest tubes) and when they will be removed. Encourage support groups to help quit smoking, manage stress etc; low fat diet, exercise at every opportunity. Take Aspirin regularly to reduce chances of having an MI. MD Role: Risks/Complications of symptoms; modifying regimen; nature and procedures of symptoms.

23 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” Nitroglycerin: Relieves pain (can also be used prophylactic ally to prevent pain, e.g. before intercourse). Remember: Side Effects can include decreased B/P, flushing and throbbing headaches. Side effects

24 Complications of Acute MI
Dysrhythmias Cardiogenic shock Myocardial rupture (of ventricle) L.V. Aneurysm Pericarditis Venous Thrombosis Psychological Adjustments Dysrhythmias 95% show in first 2 to 3 days Cardiogenic shock Peripheral circulatory failure, cyanosis, dulled sensorium, oliguria, lowered O2 Myocardial rupture (of ventricle) Can lead to cardiac tamponade  death L.V. Aneurysm - contributes to CHF Pericarditis Venous Thrombosis - originate from deep leg veins  pulm. Emboli Psychological Adjustments “cardiac cripple” Encourage to exercise within capacity like taking short walks in hallway, etc.

25 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

26 Admission 12 Lead EKG

27 Myocardial Revascularization: CABG
Coronary Artery Bypass Graft Pre-operative Care Baseline diagnostic data CXR Coagulation studies-clotting, time, prothrombin time, fibrinogen, platelets CBC, UA to provide blood flow beyond the occluded vessel involves a graft from saphenous vein; internal mammary artery remains a palliative treatment for CAD and not a cure

28 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 provide emotional support shower with use of bacteriostatic soap administer parenteral antibiotics as ordered

29 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 Refer to study guide p.21

30 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 Check water seal for bubbling…IF YOU CLAMP THE TUBING CLOSE TO THE PT-IT STOPS…WHAT DOES THIS TELL YOU?

31 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


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