Nursing Priorities in Acute Coronary Syndromes: Risk Factors, Assessment, and Care

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

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

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. 12 Lead EKG: Ischemic Changes

6. 12 Lead EKG: Old

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. Ventricular Ectopy

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. 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. Diagnostics: Cardiac enzymes

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

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

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. 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. 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. 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. 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