Interventions for Critically Ill Clients with Acute Coronary Syndromes

Coronary Artery Disease

Description Is narrowing or obstruction of one or more coronary arteries as a result as Atherosclerosis, an accumulation of lipidcontaining plaque in the arteries Causes decreased perfusion of myocardial tissue & inadequate myocardial O2 supply Leads to HPN, angina, dysrhythmias, MI, heart failure, & death Collateral circulation, more than one artery supplying a muscle with blood, is normally present in the coronary arteries, especially in older persons.

 Symptoms occur when the coronary artery is

occluded to the point that inadequate blood supply to the muscle occurs, causing ischemia Coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50%, or if any major branch is reduced at least 75% The goal of treatment : Is to alter the atherosclerotic progression.

Assessment
Possibly normal findings during asymptomatic

periods Chest pain Palpitations Dyspnea Syncope Cough or hemoptysis Excessive fatigue

Diagnostic studies
1.

Electrocardiogram When blood flow is reduced & ischemia occurs, ST segment depression or T wave inversion is noted; the ST segment returns to normal when the blood flow returns With infarction, cell injury results in ST segment elevation, followed by T wavee inversion

2. Cardiac Catheterization Provides the most definitive source for diagnosis Shows the presence of atherosclerotic lesions. 3. Blood lipid levels Blood lipid levels may be elevated Cholesterol lowering drugs reduce the development of atherosclerotic plaques

Intervention
Medical management: A. Drugs 1. Nitrates : to dilate the coronary arteries & to decrease preload and afterload 2. Calcium channel blockers: to dilate coronary arteries & reduce vasospasm 3. Cholesterol lowering : to reduce the development of artherosclerotic plaques 4. Beta blockers : to reduce BP in individuals who are hypertensive

Surgical Management 1. Percutaneous Transluminal Coronary Angioplasty or PTCA To compress the plaque against the walls of the artery & dilate the vessel 2. Coronary Artery Bypass Graft To improve blood flow to the myocardial tissue that is at risk for ischemia or infarction because of the occluded artery

Angina Pectoris
Description Transient, paroxysmal chest pain produced by insufficient blood flow to the myocardium resulting in myocardial ischemia Is caused by an imbalance between O2 supply and demand Risk factors CAD, atherosclerosis, hypertension, DM, aortic insufficiency, severe anemia

Causes - obstruction of coronary blood flow because of atherosclerosis - coronary artery spasm - conditions increasing myocardial O2 consumption Precipitating factors Physical exertion *Strong emotions Consumption of heavy meal * Cigarette smoking Extremely cold weather * Sexual activity

Goal of treatment
1. To provide relief of an acute attack. 2. To correct the imbalance between myocardial O2 supply and demand 3. To prevent the progression of the disease & further attacks to reduce the risks of MI.

Patterns of Angina
Stable Angina or exertional angina Occurs with activities that involve exertion or emotional stress & is relieved with rest or Nitroglycerin Usually has a stable pattern of onset, duration, severity and relieving factors 2. Unstable Angina or Pre Infarction angina Occurs with an unpredicatable degree of exertion or emotion & increases in occurrence, duration & severity over time. Pain may not be relieved with Nitroglycerine
1.

Assessment
1.

Pain Pain can develop slowly or quickly Is usually described as mild or moderate Substernal ,crushing, squeezing pain May radiate to the shoulders, arms, jaw, neck & back Usually lasts less than 5 minutes; however, pain can last up to 15 to 20 minutes Is relieved by Nitroglycerine or rest

2. Dyspnea 3. Pallor 4. Sweating 5. Palpitations and tachycardia 6. Dizziness and faintness 7.Hypertension 8. Digestive disturbance

Diagnostic studies
1.

2. 3. 4.

Electrocardiogram : readings are normal during rest, with ST depression or elevation &/or T wave inversion during an episode of pain. Stress test : chest pain or changes in ECG or vital signs during testing may indicate ischemia Cardiac enzymes & Troponins : findings are normal in angina Cardiac Catheterization : provides definitive diagnosis by providing information about patency of the coronary arteries.

Medical management
Drug therapy Nitrates Beta- adrenergic blocking agents Calcium-blocking agents Lipid reducing ( elevated cholesterol) Percutaneous transluminal coronary angioplasty or PTCA Surgery: CABG

Nursing Intervention
1. Administer oxygen/ semi to high fowlers 2. 3.

4. 5

position Prompt pain relief with nitrates or narcotic analgesics as ordered Monitor VS, status of cardiopulmonary function Monitor 12 lead ECG Provide emotional support

6. Provide client teaching & discharge planning concerning : a. Proper use of Nitrates 1. Nitroglycerine tablets ( Sublingual ) a. Allow tablet to dissolve b. Relax for 15 minutes after tking tablet to prevent dizziness c. If no relief with 1 tablet, take additional tablets at 5minute intervals, but no more than 3 tablets within a 15 minute period d. Transient headache is frequent side effect

e. Keep bottle tightly capped and prevent exposure to air, light , heat f. Ensure tablets are within reach at all times g. Check shelf life, expiration date of tablets 2. Nitroglycerine Ointment ( topical ) a. Rotate sites to prevent dermal inflammation b. Remove previously applied ointment c. Avoid massaging/ rubbing as this increases absorption & interferes with drugs sustained action.

Ways to minimize precipitating events

1. Reduce stress & anxiety ( relaxation

techniques/ guided imagery) 2. Avoid overexertion & smoking 3. Maintain low- cholesterol, low saturated fat diet & eat small, frequent meals 4. Avoid extremes of temperature/ dress warmly in cold weather

Myocardial Infarction
Description: 1. Occurs when myocardial tissue is abruptly & severely deprived of O2 2. Ischemia can lead to necrosis of myocardial tissue if blood flo is not restored 3. Infarction does not occur instantly but evolves over several hours 4. Obvious physical changes do not occur in the heart until 6 hours after the infarction, when the infarcted area appears blue & swollen

5. After 48 hours the infarct turns gray with yellow streaks as neutrophils invade the tissue 6. By 8 to 10 days after infarction, granulation tissue forms 7. Over 2 to 3 months, the necrotic area develops into a scar : scar tissue permanently changes the size & shape of the entire left ventricle 8. Not all clients experience the classic symptoms of MI 9. Women may experience atypical discomfort, shortness of breath, or fatigue 10. An older client may experience SOB, pulmonary edema, dizziness, altered mental status or dysrhythmia

Location of Myocardial Infarction

1. Obstruction of the left anterior descending

artery results in anterior or septal MI or both 2. Obstruction of the circumflex artery results in posterior wall MI or lateral wall MI 3. Obstruction of the right coronary artery results in inferior wall MI

Risk factors
1. 2. 3. 4. 5. 6. 7. 8. 9.

Atherosclerosis Coronary artery disease or CAD Elevated cholesterol levels/ hyperlipidemia Smoking Hypertension Obesity Physical inactivity Impaired glucose tolerance Stress

Diagnostic studies
Total creatine kinase level Level rises within 3 hrs. After the onset of chest pain Level peaks within 24 hrs after damage & death of cardiac tissue 2. CK-MB Isoenzyme a. Peak elevation occurs 18 to 24 hrs. after the onset of chest pain b. Level returns to normal 48 to 72 hrs later 3. Troponin level a. Level rises within 3 hours b. Level remains elevated for up to 7 days
1. a. b.

4. Myoglobin : level rises within 1 hour after cell death, peaks in 4 to 6 hrs, & returns to normal within 24 to 36 hrs or less 5. LDH level a. Level rises 24 hrs after MI b. Level peaks between 48 & 72 hrs & falls to normal in 7 days c. Serum level of LDH isoenzyme rises higher than serum level of LDH 6. White blood cell count : An elevated WBC of 10,000 to 20,000 appears on the 2nd dy following the MI & lasts up to a week

7. Electrocardiogram a. Shows ST segment elevation, T wave inversion,& an abnormal Q wave b. Hours to days after the MI, ST and T wave changes will return to normal but the Q wave usually remains permanently 8. Diagnostic tests following the acute stage a. Exercise tolerance test or stress test to assess ECG & ischemia & to evaluate for medical therapy or identify clients who may need invasive therapy.

b. Thallium scans may be prescribed to assess for ischemia or necrotic muscle tissue c. Multigated cardiac blood pool imaging scans may be used to evaluate left ventricular function d. Cardiac catheterization is performed to determine the extent & location of obstructions of the coronary arteries.

Assessment
1. 2. 3. 4. 5. 6. 7. 8.

Pain usually substernal with radiation to the neck, arm, jaw or back: severe, crushing, viselike with sudden onset: unrelieved by rest or nitrates Nausea & vomiting Dyspnea Skin: cool, clammy, ashen Elevated temperature Initial increase in BP & pulse, with gradual drop in BP Restlessness occasional findings : rales or crackles; presence of S4 : pericardial friction rub : split S1 S2

Nursing intervention
1. 2. 3. 4. 5. 6. 7. 8.

Establish a patent IV line Provide pain relief; Morphine Sulfate IV O2 to relieve dyspnea & prevent arrhythmias Bed rest on semi-fowlers positionn to decrease cardiac workload Monitor ECG & hemodynamic proccedure Administer antiarrhythmias as ordered Perform complete lung/cardiovascular assessmnet Monitor urinary output& report of less than 30ccml/hr ; indicates decreased cardiac output

9. Maintain full liquid diet with gradual increase to soft low sodium 10.Maintain quiet environment 11. Stool softeners as ordered to facilitate bowel evacuation & prevent straining 12. Administer as ordered: anticoagulants, thrombolytics , Streptokinase and monitor side effects: bleeding

13. Provide client teaching & discharge planning concerning: a. Effects of MI , healing process & treatment regimen b. Medication regimen including name, purpose, schedule, dosage, side effect c. Risk factors, with necessary lifestyle modifications d. Dietary restrictions: low sodium, low cholesterol, avoidance of caffeine e. Importance of participation in a progressive activity program

f. Resumption of sexual activity according to physicians orders ( usually 4-6 weeks) g. Need to report the following symptoms: increased persisitent chest pain, dyspnea,, weakness, fatigue, persistent palpitations, light-headedness h. Enrollment in cardiac rehabilitation program