Interventions for Critically Ill Clients with Acute Coronary Syndrome

Coronary Artery Disease Includes stable angina pectoris and acute coronary syndromes 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

Stable Angina Pectoris 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 Ischemia limited in duration and does not cause permanent damage to myocardial tissue Stable and unstable angina Sentences and phrases

Acute Coronary Syndrome 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. 29% die from MI within 5 years. Sentence and phrases

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

Nonmodifiable Risk Factors Age Gender Family history Ethnic background

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

Pain Assessment 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. Anginal pain improves with rest and nitroglycerine; MI does not. (Continued) Sentence and phrases

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

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

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

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

Ineffective Tissue Perfusion (Cardiopulmonary) 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. Tissue plasminogen activator, APSAC, reteplase Glycoprotein IIa/IIIb inhibitors Sentence and phrases

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

Oral Drug Therapy Aspirin Beta-adrenergic blocking agents ACE inhibitors 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. Give simple explanations of therapies, expectations, and surroundings, and explanations of progress to help relieve anxiety. Provide coping enhancement. Sentences and phrase

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

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

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

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

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

Potential for Recurrent Symptoms and Extension of Injury Interventions Percutaneous transluminal coronary angioplasty (PTCA) 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 Long-term nitrate, calcium channel blocker, and aspirin therapy Beta blocker and ACE inhibitor if MI Infusions of GPIIa/IIIb inhibitors

Coronary Artery Bypass Graft Surgery Postoperative care in cardiopulmonary bypass 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 Supraventricular dysrhythmias commonly occur Sternal wound infections Mediastinitis Postpericardiotomy syndrome

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

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

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