Nursing Priorities in Acute Coronary Syndromes Keith Rischer

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

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

Risk factors for CAD: Multifactorial Unmodifiable q Age: ü Increased age-CAD begins early and

Risk factors for CAD: Multifactorial Unmodifiable q Age: ü Increased age-CAD begins early and develops gradually. q Gender: ü Highest for middle-aged white caucasian q Race: ü Caucasian males highest risk q Genetic: ü Inherited tendencies for atherosclerosis 2

Risk factors for CAD: Multifactorial Modifiable q Smoking q Physical inactivity q Obesity q

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

Types of Angina…Causative Factors Stable (classic) q Pain w/exertion-relief w/rest Unstable q q Pain

Types of Angina…Causative Factors Stable (classic) q Pain w/exertion-relief w/rest Unstable q q Pain onset w/rest Precursor to AMI Ø Ø Ø Silent q Ø Unrecognized or truly silent Ø Physical exertion Temperature extremes Strong emotions Heavy meal Tobacco use Sexual activity Stimulants Circadian rhythm patterns 4

12 Lead EKG: Ischemic Changes 5

12 Lead EKG: Ischemic Changes 5

12 Lead EKG: Old 6

12 Lead EKG: Old 6

Myocardial Infarction http: //video. google. com/videoplay? docid=861965134389078213&q=blocked+coronary+artery&total=19&start=10&num=10& 7 so=0&type=search&plindex=3

Myocardial Infarction http: //video. google. com/videoplay? docid=861965134389078213&q=blocked+coronary+artery&total=19&start=10&num=10& 7 so=0&type=search&plindex=3

Zones of Injury 8

Zones of Injury 8

Nursing Assessment: Manifestations Appearance ü Anxious, restless, pallor, diaphoresis q Blood Pressure/Pulses q Breathing

Nursing Assessment: Manifestations Appearance ü Anxious, restless, pallor, diaphoresis q Blood Pressure/Pulses q Breathing q JVD (Jugular Vein Distension) q Auscultation/heart and lung q Abnormal heart sounds S 3, S 4 Shortness of Breath (SOB) q Orthopnea Chest Discomfort q Pleuritic-point tenderness? q Localized vs. diffuse Palpitaion q Ø Ø Ø 9

Ventricular Ectopy 10

Ventricular Ectopy 10

Areas of Damage Ø Inferior Right Coronary Artery q Leads II, III, AVF q

Areas of Damage Ø Inferior Right Coronary Artery q Leads II, III, AVF q Ø Anterior Left Anterior Descending q Leads V 1 -V 4 q Ø Lateral Circumflex q Leads I, AVL, V 5, V 6 q 11

Diagnostic Assessments Ø Ø 12 Lead EKG Chest X-Ray: q Ø Assessment of cardiac

Diagnostic Assessments Ø Ø 12 Lead EKG Chest X-Ray: q Ø Assessment of cardiac size and pulmonary congestion. Treadmill exercise q Stress Test on a treadmill with EKG and B/P monitor 12

STEMI vs. non-STEMI 13

STEMI vs. non-STEMI 13

STEMI 12 Lead EKG 14

STEMI 12 Lead EKG 14

non. STEMI 12 Lead EKG 15

non. STEMI 12 Lead EKG 15

Diagnostics: Cardiac enzymes Enzyme Rises In Peaks In Remains Elevated For CPK-MB 4 -

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 16

Diagnostic Assessments Angiogram: q View coronary arteries q Incr. risk if done after MI

Diagnostic Assessments Angiogram: q View coronary arteries q Incr. risk if done after MI q Need creatinine ü Dye can cause renal failure Echocardiogram ü Safe, non-invasive, wall motion abnormalities 17

Nursing Diagnosis Priorities q q q Acute Pain R/T decreased myocardial oxygen supply Ineffective

Nursing Diagnosis Priorities q q q 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 ü Smoking cessation, diet, medications, procedures – Assess for dysrhthmias, heart failure, extension of MI 18

Nursing Care Plan Goals: Attain adequate pain control q Maintain adequate tissue perfusion q

Nursing Care Plan Goals: Attain adequate pain control q Maintain adequate tissue perfusion q Expression of sense of well-being q Evaluation: Compare progress as a result of nursing interventions q Effectiveness of pain control q VS stable: skin color improved q If interventions unsuccessful – need to make modifications of NCP 19 q

Nursing Interventions: Priorities DECREASE WORKLOAD OF THE HEART Preload reduction Afterload reduction HR reduction

Nursing Interventions: Priorities DECREASE WORKLOAD OF THE HEART Preload reduction Afterload reduction HR reduction q Pain Relief: ü q Decrease demand for oxygen consumption ü ü q q 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 ü q Oxygen, Morphine Amiodorone Provide emotional support Spiritual care 20

Nursing Interventions: MI q Fluid status ü Monitor for any symptoms of fluid overload,

Nursing Interventions: MI q Fluid status ü Monitor for any symptoms of fluid overload, I&O q Emotional ü Explain support to patient and S. O. procedures/technology, relieve anxiety q Document based on unit guidelines q Patient education/prevention ü Assess needs early, referrals (SS, cardiac rehab), others (risk factor management, psychological adjustment q Complimentary/alternative therapy 21

Collaborative Care Ø Percutaneous Transluminal Coronary Angioplasty (PTCA) Ø Stent Placement Ø Coronary Artery

Collaborative Care Ø Percutaneous Transluminal Coronary Angioplasty (PTCA) Ø Stent Placement Ø Coronary Artery Bypass Graft (CABG) 22

Collaborative Care: Drug Therapy Antiplatelet agent: First line of intervention. ASA, Plavix Beta-adrenergic blockers:

Collaborative Care: Drug Therapy Antiplatelet agent: First line of intervention. ASA, Plavix Beta-adrenergic blockers: ü Prophylactic for angina ü Inderal, Lopressor, (decrease in myocardial contractility ü Lowers HR & B/P…reduces myocardial O 2 demand ACE Inhibitors ü Improve ventricular “remodeling” 23

Complications of Acute MI Ø Ø Ø Ø Dysrhythmias Cardiogenic shock Myocardial rupture (of

Complications of Acute MI Ø Ø Ø Ø Dysrhythmias Cardiogenic shock Myocardial rupture (of ventricle) L. V. Aneurysm Pericarditis Venous Thrombosis Psychological Adjustments 24

Cardiogenic Shock: ICU Case Study Ø 78 yr female PMH: CAD, smokes 1 ppd,

Cardiogenic Shock: ICU Case Study Ø 78 yr female PMH: CAD, smokes 1 ppd, CRI q HPI: awoke w/CP, nausea, diaphoresis. Seen in small community ED… q See 12 lead…, Troponin 0. 9 q Received ½ dose TPA…airlifted to ANW level 1 q In transport HR dropped to 20’s-Epi & Atropine & CPR x 1” ü Angio: occluded prox. LAD-opened x 3 stents BP-78/46 ü – Dopamine & Epinephrine gtts started – IABP placed-transfer to ICU ü ICU: progressive resp failure-intubated – u/o 30 cc last 4 hours – Stat echo…EF 25% – Labs: creat 2. 1, K+ 5. 7, BNP 1488, Trop 2. 6 25

Admission 12 Lead EKG 26

Admission 12 Lead EKG 26

Myocardial Revascularization: CABG Coronary Artery Bypass Graft q Pre-operative Care Baseline diagnostic data ü

Myocardial Revascularization: CABG Coronary Artery Bypass Graft q Pre-operative Care Baseline diagnostic data ü CXR ü Coagulation studiesclotting, time, prothrombin time, fibrinogen, platelets ü CBC, UA ü 27

CABG Nursing Interventions: Pre op Ø Surgical q pre-op teaching – to help reduce

CABG Nursing Interventions: Pre op Ø Surgical q pre-op teaching – to help reduce anxiety procedure – video of surgery ü ICU post op ü pain meds ü Incentive spirometer-Cough-deep breathe ü chest tubes ü endotracheal tube ü Foley catheter ü Emotional/spiritual support ü Shower/bath w/Hibiclens ü Pre-op Abx ü 28

CABG Nursing Interventions: Post op ü Usually stays in ICU 1 or 2 days

CABG Nursing Interventions: Post op ü Usually stays in ICU 1 or 2 days – ü ü assess for post-op pain administer ordered pain meds Cardiac tamponade Monitor electrolytes – ü K+ Assess for dysrhythmias – ü Vented 3 -6 hours after surgery Atrial fib most common Chest tubes – – Milking q 1 -2 hours Assess amount/color drainage 29

Chest Tube: Nursing Priorities Ø Ø Ø Assess resp. status closely Check water seal

Chest Tube: Nursing Priorities Ø Ø Ø Assess resp. status closely Check water seal for bubbling Milk NOT strip every 2 hours Assess color-amount drainage q Call MD if >100 cc/hr x 2 hours first 24 hours Sterile guaze/occlusive dressing at bedside 30

CABG Complications: Case Study Ø 68 yr male s/p AVR & CABG q Ø

CABG Complications: Case Study Ø 68 yr male s/p AVR & CABG q Ø PMH: CAD, AS, HTN Post-op Complications: Resp. failure/aspiration req. ongoing vent support…likely trach q CV: hypotension-vasopressor support, fluid overload q ARF-on CRRT and central dialysis catheter placedminimal u/o q Encephalopathy-MRI neg, EEG shows diffuse cerebral dysfunction-restless, does not follow commands q NG for tube feeding q 31