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Nursing Priorities in
Acute Coronary Syndromes
Keith Rischer RN, MA, CEN
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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
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Risk factors for CAD: Multifactorial
Modifiable
 Smoking
 Physical
inactivity
 Obesity
 Stress
 Glucose
Intolerance
 Elevated serum lipids
 Hypertension
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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
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12 Lead EKG: Ischemic Changes
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12 Lead EKG: Old
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Myocardial Infarction
http://video.google.com/videoplay?docid=861965134389078213&q=blocked+coronary+artery&total=19&start=10&num=10&
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so=0&type=search&plindex=3
Zones of Injury
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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




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Ventricular Ectopy
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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

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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
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STEMI vs. non-STEMI
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STEMI 12 Lead EKG
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nonSTEMI 12 Lead EKG
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Diagnostics: Cardiac enzymes
Enzyme
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
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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
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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
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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
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
Nursing Interventions:Priorities
DECREASE WORKLOAD OF THE
HEART
Preload reduction
Afterload reduction
HR reduction

Pain Relief:


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


Oxygen, Morphine
Amiodorone
Provide emotional support
Spiritual care
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Nursing Interventions:MI
 Fluid
status
 Monitor
for any symptoms of fluid overload, I&O
 Emotional
 Explain
support to patient and S.O.
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
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Collaborative Care

Percutaneous
Transluminal
Coronary Angioplasty
(PTCA)

Stent Placement

Coronary Artery
Bypass Graft (CABG)
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Collaborative Care:Drug Therapy
Antiplatelet agent:
First line of interventionASA, 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”
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Complications of Acute MI







Dysrhythmias
Cardiogenic shock
Myocardial rupture (of ventricle)
L.V. Aneurysm
Pericarditis
Venous Thrombosis
Psychological Adjustments
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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
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Admission 12 Lead EKG
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Myocardial Revascularization:
CABG
Coronary Artery Bypass
Graft
 Pre-operative Care




Baseline diagnostic
data
CXR
Coagulation studiesclotting, time,
prothrombin time,
fibrinogen, platelets
CBC, UA
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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
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CABG Nursing Interventions:Post op

Usually stays in ICU 1 or 2 days
–




assess for post-op pain
administer ordered pain meds
Cardiac tamponade
Monitor electrolytes
–

K+
Assess for dysrhythmias
–

Vented 3-6 hours after surgery
Atrial fib most common
Chest tubes
–
–
Milking q 1-2 hours
Assess amount/color drainage
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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
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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 placedminimal u/o
 Encephalopathy-MRI neg, EEG shows diffuse cerebral
dysfunction-restless, does not follow commands
 NG for tube feeding

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