Interventions for Critically Ill Clients with Acute Coronary Syndrome

Coronary Artery Disease Includes stable angina pectoris and acute coronary syndromes Includes stable angina pectoris and acute coronary syndromes Ischemia: oxygen supply insufficient to meet requirements of the myocardium Ischemia: oxygen supply insufficient to meet requirements of the myocardium Infarction: necrosis or cell death that occurs when severe ischemia is prolonged and irreversible damage to tissue results Infarction: necrosis or cell death that occurs when severe ischemia is prolonged and irreversible damage to tissue results

Stable Angina Pectoris A feeling of “strangling of the chest” A feeling of “strangling of the chest” Temporary imbalance between the coronary artery’s ability to supply oxygen and the cardiac muscle’s demand for oxygen Temporary imbalance between the coronary artery’s ability to supply oxygen and the cardiac muscle’s demand for oxygen Ischemia limited in duration and does not cause permanent damage to myocardial tissue Ischemia limited in duration and does not cause permanent damage to myocardial tissue Stable and unstable angina Stable and unstable angina

Acute Coronary Syndrome Atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation, thrombus formation, and vasoconstriction. Atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation, thrombus formation, and vasoconstriction. Between 10% and 30% of clients with unstable angina progress to having MI within 1 year. Between 10% and 30% of clients with unstable angina progress to having MI within 1 year. 29% die from MI within 5 years. 29% die from MI within 5 years.

Myocardial Infarction Most serious acute coronary syndrome Most serious acute coronary syndrome Occurs when myocardial tissue is abruptly and severely deprived of oxygen Occurs when myocardial tissue is abruptly and severely deprived of oxygen Dynamic process that does not occur instantly but evolves over several hours Dynamic process that does not occur instantly but evolves over several hours

Nonmodifiable Risk Factors Age Age Gender Gender Family history Family history Ethnic background Ethnic background

Modifiable Risk Factors Elevated serum cholesterol Elevated serum cholesterol Cigarette smoking Cigarette smoking Hypertension Hypertension Impaired glucose tolerance Impaired glucose tolerance Obesity Obesity Physical inactivity Physical inactivity Stress Stress

Pain Assessment Discomfort in the chest, epigastric area, jaw, back, or arm is noted. (Rate discomfort on scale of 0 to 10.) Discomfort in the chest, epigastric area, jaw, back, or arm is noted. (Rate discomfort on scale of 0 to 10.) Discomfort is often described as tightness, burning, pressure, or indigestion. Discomfort is often described as tightness, burning, pressure, or indigestion. Anginal pain improves with rest and nitroglycerine; MI does not. Anginal pain improves with rest and nitroglycerine; MI does not.(Continued)

Pain Assessment (Continued) Other manifestations include nausea and vomiting, diaphoresis, dizziness, weakness, palpitations, and shortness of breath. Other manifestations include nausea and vomiting, diaphoresis, dizziness, weakness, palpitations, and shortness of breath.

Diagnostic Assessment Electrocardiogram Electrocardiogram Stress test Stress test Myocardial perfusion imaging Myocardial perfusion imaging Magnetic response imaging Magnetic response imaging Cardiac catheterization Cardiac catheterization

Acute Pain Interventions include: Interventions include: –Provide pain relief modalities. –Decrease myocardial oxygen demand. –Increase myocardial oxygen supply.

Pain Management Nitroglycerine Nitroglycerine Morphine sulfate Morphine sulfate Oxygen Oxygen Position of comfort; semi-Fowler’s position Position of comfort; semi-Fowler’s position Quiet and calm environment Quiet and calm environment Deep breaths to increase oxygenation Deep breaths to increase oxygenation

Ineffective Tissue Perfusion (Cardiopulmonary) Interventions include: Interventions include: –Restoration of perfusion to the injured area often limits the amount of extension and improves left ventricular function. –Complete sustained reperfusion of coronary arteries in the first few hours after an MI has decreased mortality.

Thrombolytic Therapy Fibrinolytics dissolve thrombi in the coronary arteries and restore myocardial blood flow. Fibrinolytics dissolve thrombi in the coronary arteries and restore myocardial blood flow. Tissue plasminogen activator, APSAC, reteplase Tissue plasminogen activator, APSAC, reteplase Glycoprotein IIa/IIIb inhibitors Glycoprotein IIa/IIIb inhibitors

Identification of Coronary Artery Reperfusion Abrupt cessation of pain or discomfort Abrupt cessation of pain or discomfort Sudden onset of ventricular dysrhythmias Sudden onset of ventricular dysrhythmias A peak at 12 hours of markers of myocardial damage A peak at 12 hours of markers of myocardial damage

Oral Drug Therapy Aspirin Aspirin Beta-adrenergic blocking agents Beta-adrenergic blocking agents ACE inhibitors ACE inhibitors Calcium channel blockers Calcium channel blockers

Ineffective Coping Interventions Assess the client’s level of anxiety but allow expression of any anxiety and attempt to define its origin. Assess the client’s level of anxiety but allow expression of any anxiety and attempt to define its origin. Give simple explanations of therapies, expectations, and surroundings, and explanations of progress to help relieve anxiety. Give simple explanations of therapies, expectations, and surroundings, and explanations of progress to help relieve anxiety. Provide coping enhancement. Provide coping enhancement.

Potential for Dysrhythmias Dysrhythmias are the leading cause of death in most clients with MI who die before they can be hospitalized. Dysrhythmias are the leading cause of death in most clients with MI who die before they can be hospitalized. Interventions include: Interventions include: –Identify the dysrhythmias. –Assess hemodynamic status. –Evaluate for discomfort.

Potential for Heart Failure Interventions Assessment Assessment Monitoring for signs of poor organ perfusion Monitoring for signs of poor organ perfusion Hemodynamic monitoring Hemodynamic monitoring

Cardiogenic Shock Necrosis of more than 40% of the left ventricle Necrosis of more than 40% of the left ventricle Tachycardia Tachycardia Hypotension Hypotension Blood pressure < 90 mm Hg or 30 mm Hg < client’s baseline Blood pressure < 90 mm Hg or 30 mm Hg < client’s baseline Urine output < 30 mL/hr Urine output < 30 mL/hr(Continued)

Cardiogenic Shock (Continued) Cold, clammy skin Cold, clammy skin Poor peripheral pulses Poor peripheral pulses Agitation, restlessness, confusion Agitation, restlessness, confusion Pulmonary congestion Pulmonary congestion Tachypnea Tachypnea Continuing chest discomfort Continuing chest discomfort

Medical Management Pain relief and decreased myocardial oxygen requirements through preload and afterload reduction Pain relief and decreased myocardial oxygen requirements through preload and afterload reduction Intravenous morphine Intravenous morphine Oxygen, intubation, ventilation Oxygen, intubation, ventilation Intra-aortic balloon pump Intra-aortic balloon pump Immediate reperfusion Immediate reperfusion

Potential for Recurrent Symptoms and Extension of Injury Interventions Percutaneous transluminal coronary angioplasty (PTCA) Percutaneous transluminal coronary angioplasty (PTCA) Coronary artery bypass graft surgery (CABG) Coronary artery bypass graft surgery (CABG)

Percutaneous Transluminal Coronary Angioplasty Monitoring for acute closure of the vessel, bleeding from the insertion site, reaction to dye, hypotension, hypokalemia, and dysrhythmias Monitoring for acute closure of the vessel, bleeding from the insertion site, reaction to dye, hypotension, hypokalemia, and dysrhythmias Long-term nitrate, calcium channel blocker, and aspirin therapy Long-term nitrate, calcium channel blocker, and aspirin therapy Beta blocker and ACE inhibitor if MI Beta blocker and ACE inhibitor if MI Infusions of GPIIa/IIIb inhibitors Infusions of GPIIa/IIIb inhibitors

Coronary Artery Bypass Graft Surgery Postoperative care in cardiopulmonary bypass Postoperative care in cardiopulmonary bypass Management of fluid and electrolyte imbalance, hypotension, hypothermia, hypertension, bleeding, cardiac tamponade, altered levels of consciousness, and pain Management of fluid and electrolyte imbalance, hypotension, hypothermia, hypertension, bleeding, cardiac tamponade, altered levels of consciousness, and pain

Transfer from the Special Care Unit Ventilation provided for 3 to 6 hours postoperatively Ventilation provided for 3 to 6 hours postoperatively Supraventricular dysrhythmias commonly occur Supraventricular dysrhythmias commonly occur Sternal wound infections Sternal wound infections Mediastinitis Mediastinitis Postpericardiotomy syndrome Postpericardiotomy syndrome

Other Interventions Minimally invasive direct coronary artery bypass Minimally invasive direct coronary artery bypass Transmyocardial laser revascularization Transmyocardial laser revascularization Off-pump coronary artery bypass Off-pump coronary artery bypass Robotics Robotics

Health Teaching Smoking cessation Smoking cessation Diet control Diet control Complementary and alternative therapies Complementary and alternative therapies Physical activity Physical activity Sexual activity Sexual activity(Continued)

Health Teaching (Continued) Blood pressure, blood glucose control Blood pressure, blood glucose control Cardiac medications Cardiac medications Self-monitoring; seeking medical assistance if needed Self-monitoring; seeking medical assistance if needed