1. Interventions for Critically Ill Clients with Acute Coronary Syndrome

3. 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

4. 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
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5. 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.
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6. 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

8. Nonmodifiable Risk Factors
Age
Gender
Family history
Ethnic background

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

10. 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)
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11. Pain Assessment (Continued)
Other manifestations include nausea and vomiting, diaphoresis, dizziness, weakness, palpitations, and shortness of breath.

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

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

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

15. 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.

16. Thrombolytic Therapy
Fibrinolytics dissolve thrombi in the coronary arteries and restore myocardial blood flow.
Tissue plasminogen activator, APSAC, reteplase
Glycoprotein IIa/IIIb inhibitors
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17. 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

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

19. 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.
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20. 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.

21. Potential for Heart Failure Interventions
Assessment
Monitoring for signs of poor organ perfusion
Hemodynamic monitoring
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22. 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)
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23. Cardiogenic Shock (Continued)
Cold, clammy skin
Poor peripheral pulses
Agitation, restlessness, confusion
Pulmonary congestion
Tachypnea
Continuing chest discomfort

24. 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

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

27. 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

29. 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

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

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

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

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