1. 1 Nursing Priorities in Acute Coronary Syndromes Keith Rischer RN, MA, CEN

2. 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

3. 3 Risk factors for CAD: Multifactorial Modifiable  Smoking  Physical inactivity  Obesity  Stress  Glucose Intolerance  Elevated serum lipids  Hypertension

4. 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

5. 5 12 Lead EKG: Ischemic Changes

6. 6 12 Lead EKG: Old

7. 7 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

8. 8 Ventricular Ectopy

9. 9 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

10. 10 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

11. 11 Diagnostics: Cardiac enzymes EnzymeRises InPeaks InRemains Elevated For CPK-MB4- 8 hrs12 – 24 hrs1 day Troponin3 hrs12-18 hoursUp to 14 days

12. 12 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

13. 13 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

14. 14 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

15. 15 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

16. 16 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

17. 17 Collaborative Care  Percutaneous Transluminal Coronary Angioplasty (PTCA)  Stent Placement  Coronary Artery Bypass Graft (CABG)

18. 18 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”

19. 19 Complications of Acute MI  Dysrhythmias  Cardiogenic shock  Myocardial rupture (of ventricle)  L.V. Aneurysm  Pericarditis  Venous Thrombosis  Psychological Adjustments

20. 20 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

21. 21 Myocardial Revascularization: CABG Coronary Artery Bypass Graft  Pre-operative Care Baseline diagnostic data CXR Coagulation studies- clotting, time, prothrombin time, fibrinogen, platelets CBC, UA

22. 22 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

23. 23 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

24. 24 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