Presentation on theme: "Nursing Priorities in Acute Coronary Syndromes"— Presentation transcript:
1 Nursing Priorities in Acute Coronary Syndromes Keith Rischer RN, MA, CENLargest killer of Americans1 of 5 deathsCV disease #1 cause of death in US-CAD is most common subtype… Defined as heart disease due to impaired coronary blood flow usually atherosclerosis1.2 million americans will have MI and ¼ will die in ED or before reaching a hospitalMortality rate decreased 26% fromCAD leading cause of death of both men and women-responsible for 1/3 of all deaths
2 Risk factors for CAD: Multifactorial UnmodifiableAge:Increased age-CAD begins early and develops gradually.Gender:Highest for middle-aged white caucasianRace:Caucasian males highest riskGenetic:Inherited tendencies for atherosclerosisAge: 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 malesGenetic Inheritance: Inherited tendencies for weak arterial wall.
3 Risk factors for CAD: Multifactorial ModifiableSmokingPhysical inactivityObesityStressGlucose IntoleranceElevated serum lipidsHypertensionElevated 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).ModifiableElevated serum lipidsHDL improves w/ exerciseHypertension:2nd major risk factor in CAD, inc. salt intake=fluid retention=inc. systemic vascular resistance to the cardiac workloadSmoking:Risk of developing CAD is 2-6x higher in smokers than non-smokers.Risk is proportional to the number of cigarettes smokedSecond hand smokeObesity: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:DiabeticsMechanism 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 polycythemiaIn women decreases estrogen…benefits of cessation immediate and mortality rates drop to those of nonsmokers in 12 monthsPhysical inactivity- lack of regular exercise on regular basis…what is true exercise???brisk walk for 30” 5x week causing perspiration and incr HR bpmIncr HDL, enhances fibrinolytic activity, encourages collateral circulationObesity 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/restUnstablePain onset w/restPrecursor to AMISilentUnrecognized or truly silentPhysical exertionTemperature extremesStrong emotionsHeavy mealTobacco useSexual activityStimulantsCircadian rhythm patternsStable- 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 damageRelief w/rest or NTG…if unrelieved may be AMIOccurs intermittently with same pattern-duration-intensity of sxUnstable- rupture of plaque-incomplete occlusion of vessel-Silent no CP-may be just fatigue, dyspnea, epigastric burningIncr w/elderly, diabetes as well as w/those who have had CABGStable angina: No change during previous 60 days“Unstable”: Change in pattern within previous 60 days4
7 Myocardial Infarction Acute coronary syndomes-encompasses UA and AMISTEMI vs nonSTEMI80-90% of all MI due to thrombusMI 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 occlusions7
9 Nursing Assessment: Manifestations AppearanceAnxious, restless, pallor, diaphoresisBlood Pressure/PulsesBreathingJVD (Jugular Vein Distension)Auscultation/heart and lungAbnormal heart sounds S3, S4Shortness of Breath (SOB)OrthopneaChest DiscomfortPleuritic-point tenderness?Localized vs. diffusePalpitaion80 y.o. male with S4 = abnormal
10 Ventricular EctopyEctopic pacemaker is an excitable focus outside the SA nodePVC’s-caffeine-ETOH, nicotine, dig, lyte imbalances-K-Mg-stressCAD, MI, HFVT-MI, lyte imbalance, cardiomyopathy,10
11 Areas of Damage Inferior Anterior Lateral Right Coronary Artery Leads II, III, AVFAnteriorLeft Anterior DescendingLeads V1-V4LateralCircumflexLeads I, AVL, V5, V6
12 Diagnostic Assessments 12 Lead EKGChest X-Ray:Assessment of cardiac size and pulmonary congestion.Treadmill exerciseStress Test on a treadmill with EKG and B/P monitor12 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
16 Diagnostics: Cardiac enzymes Rises InPeaks InRemains Elevated ForCPK-MB4- 8 hrs12 – 24 hrs1 dayTroponin3 hrs12-18 hoursUp to 14 daysUsed in conjunction with CK-MB findingsCK 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 arteriesIncr. risk if done after MINeed creatinineDye can cause renal failureEchocardiogramSafe, non-invasive, wall motion abnormalitiesEcho-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 supplyIneffective tissue perfusion R/T myocardial damage, inadequate cardiac output and potential pulmonary congestionActivity Intolerance R/T fatigueAnxiety R/T perceived threat to death, pain, possible lifestyle changesKnowledge deficitSmoking cessation, diet, medications, proceduresAssess for dysrhthmias, heart failure, extension of MIInstruct patient to take NTG before intercourse to prevent CP
19 Nursing Care Plan Goals: Evaluation: Attain adequate pain control Maintain adequate tissue perfusionExpression of sense of well-beingEvaluation:Compare progress as a result of nursing interventionsEffectiveness of pain controlVS stable: skin color improvedIf interventions unsuccessful – need to make modifications of NCP
20 Nursing Interventions:Priorities DECREASE WORKLOAD OF THE HEARTPreload reductionAfterload reductionHR reductionPain Relief:Oxygen, MorphineDecrease demand for oxygen consumptionBedrest, limit visitors, avoid large meals,Oxygen supplementcomplete bed bath/commode avoid straining during BMMusic Therapy, Relaxation TapesWatch for dysrhythmias: Increasing PVC’s, VTAmiodoroneProvide emotional supportSpiritual care
21 Nursing Interventions:MI Fluid statusMonitor for any symptoms of fluid overload, I&OEmotional support to patient and S.O.Explain procedures/technology, relieve anxietyDocument based on unit guidelinesPatient education/preventionAssess needs early, referrals (SS, cardiac rehab), others (risk factor management, psychological adjustmentComplimentary/alternative therapy
22 Collaborative CarePercutaneous Transluminal Coronary Angioplasty (PTCA)Stent PlacementCoronary 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 treatmentStent-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, PlavixBeta-adrenergic blockers:Prophylactic for anginaInderal, Lopressor, (decrease in myocardial contractilityLowers HR & B/P…reduces myocardial O2 demandACE InhibitorsImprove 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 DysrhythmiasCardiogenic shockMyocardial rupture (of ventricle)L.V. AneurysmPericarditisVenous ThrombosisPsychological AdjustmentsDysrhythmias95% show in first 2 to 3 daysCardiogenic shockPeripheral circulatory failure, cyanosis, dulled sensorium, oliguria, lowered O2Myocardial rupture (of ventricle)Can lead to cardiac tamponade deathL.V. Aneurysm - contributes to CHFPericarditisVenous Thrombosis -originate from deep leg veins pulm. EmboliPsychological Adjustments“cardiac cripple”Encourage to exercise within capacity like taking short walks in hallway, etc.
25 Cardiogenic Shock: ICU Case Study 78yr femalePMH: CAD, smokes 1ppd, CRIHPI: awoke w/CP, nausea, diaphoresis. Seen in small community ED…See 12 lead…, Troponin 0.9Received ½ dose TPA…airlifted to ANW level 1In transport HR dropped to 20’s-Epi & Atropine & CPR x1”Angio: occluded prox. LAD-opened x3 stents BP-78/46Dopamine & Epinephrine gtts startedIABP placed-transfer to ICUICU: progressive resp failure-intubatedu/o 30cc last 4 hoursStat echo…EF 25%Labs: creat 2.1, K+ 5.7, BNP 1488, Trop 2.6
27 Myocardial Revascularization: CABG Coronary Artery Bypass GraftPre-operative CareBaseline diagnostic dataCXRCoagulation studies-clotting, time, prothrombin time, fibrinogen, plateletsCBC, UAto provide blood flow beyond the occluded vesselinvolves a graft from saphenous vein; internal mammary arteryremains a palliative treatment for CAD and not a cure
28 CABG Nursing Interventions: Pre op Surgicalpre-op teaching – to help reduce anxietyprocedure – video of surgeryICU post oppain medsIncentive spirometer-Cough-deep breathechest tubesendotracheal tubeFoley catheterEmotional/spiritual supportShower/bath w/HibiclensPre-op Abxprovide emotional supportshower with use of bacteriostatic soapadminister parenteral antibiotics as ordered
29 CABG Nursing Interventions:Post op Usually stays in ICU 1 or 2 daysVented 3-6 hours after surgeryassess for post-op painadminister ordered pain medsCardiac tamponadeMonitor electrolytesK+Assess for dysrhythmiasAtrial fib most commonChest tubesMilking q 1-2 hoursAssess amount/color drainageRefer to study guide p.21
30 Chest Tube: Nursing Priorities Assess resp. status closelyCheck water seal for bubblingMilk NOT strip every 2 hoursAssess color-amount drainageCall MD if >100cc/hr x2 hours first 24 hoursSterile guaze/occlusive dressing at bedsideCheck 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 & CABGPMH: CAD, AS, HTNPost-op Complications:Resp. failure/aspiration req. ongoing vent support…likely trachCV: hypotension-vasopressor support, fluid overloadARF-on CRRT and central dialysis catheter placed-minimal u/oEncephalopathy-MRI neg, EEG shows diffuse cerebral dysfunction-restless, does not follow commandsNG for tube feeding