Interventions for Critically Ill Clients with Acute Coronary Syndrome

Interventions for Critically Interventions for Critically Ill Clients with Acute Ill Clients with Acute Coronary SyndromeCoronary Syndrome

Coronary Artery Disease Coronary Artery Disease

Includes stable angina pectoris Includes stable angina pectoris and acute coronary syndromesand acute coronary syndromes

Ischemia: oxygen supply Ischemia: oxygen supply insufficient to meet requirements insufficient to meet requirements of the myocardiumof the myocardium

Infarction: necrosis or cell death Infarction: necrosis or cell death that occurs when severe ischemia that occurs when severe ischemia is prolonged and irreversible is prolonged and irreversible damage to tissue resultsdamage to tissue results

Stable Angina PectorisStable Angina Pectoris

A feeling of “strangling of the chest”A feeling of “strangling of the chest” Temporary imbalance between the Temporary imbalance between the

coronary artery’s ability to supply coronary artery’s ability to supply oxygen and the cardiac muscle’s oxygen and the cardiac muscle’s demand for oxygendemand for oxygen

Ischemia limited in duration and does Ischemia limited in duration and does not cause permanent damage to not cause permanent damage to myocardial tissuemyocardial tissue

Stable and unstable anginaStable and unstable angina

Acute Coronary Acute Coronary Syndrome Syndrome

Atherosclerotic plaque in the Atherosclerotic plaque in the coronary artery ruptures, coronary artery ruptures, resulting in platelet aggregation, resulting in platelet aggregation, thrombus formation, and thrombus formation, and vasoconstriction.vasoconstriction.

Between 10% and 30% of clients Between 10% and 30% of clients with unstable angina progress to with unstable angina progress to having MI within 1 year.having MI within 1 year.

29% die from MI within 5 years.29% die from MI within 5 years.

Myocardial InfarctionMyocardial Infarction

Most serious acute coronary Most serious acute coronary syndromesyndrome

Occurs when myocardial tissue is Occurs when myocardial tissue is abruptly and severely deprived abruptly and severely deprived of oxygenof oxygen

Dynamic process that does not Dynamic process that does not occur instantly but evolves over occur instantly but evolves over several hoursseveral hours

Nonmodifiable Risk Nonmodifiable Risk FactorsFactors

AgeAge GenderGender Family historyFamily history Ethnic backgroundEthnic background

Modifiable Risk FactorsModifiable Risk Factors

Elevated serum cholesterolElevated serum cholesterol Cigarette smokingCigarette smoking HypertensionHypertension Impaired glucose toleranceImpaired glucose tolerance ObesityObesity Physical inactivityPhysical inactivity Stress Stress

Pain AssessmentPain Assessment Discomfort in the chest, Discomfort in the chest,

epigastric area, jaw, back, or epigastric area, jaw, back, or arm is noted. (Rate discomfort arm is noted. (Rate discomfort on scale of 0 to 10.)on scale of 0 to 10.)

Discomfort is often described as Discomfort is often described as tightness, burning, pressure, or tightness, burning, pressure, or indigestion.indigestion.

Anginal pain improves with rest Anginal pain improves with rest and nitroglycerine; MI does not.and nitroglycerine; MI does not.

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Pain AssessmentPain Assessment

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Other manifestations include Other manifestations include nausea and vomiting, nausea and vomiting, diaphoresis, dizziness, diaphoresis, dizziness, weakness, palpitations, and weakness, palpitations, and shortness of breath.shortness of breath.

Diagnostic AssessmentDiagnostic Assessment

ElectrocardiogramElectrocardiogram Stress testStress test Myocardial perfusion imagingMyocardial perfusion imaging Magnetic response imagingMagnetic response imaging Cardiac catheterizationCardiac catheterization

Acute Pain Acute Pain

Interventions include:Interventions include:– Provide pain relief modalities.Provide pain relief modalities.– Decrease myocardial oxygen Decrease myocardial oxygen

demand.demand.– Increase myocardial oxygen supply.Increase myocardial oxygen supply.

Pain ManagementPain Management

NitroglycerineNitroglycerine Morphine sulfateMorphine sulfate OxygenOxygen Position of comfort; semi-Position of comfort; semi-

Fowler’s positionFowler’s position Quiet and calm environmentQuiet and calm environment Deep breaths to increase Deep breaths to increase

oxygenationoxygenation

Ineffective Tissue Ineffective Tissue Perfusion Perfusion

(Cardiopulmonary)(Cardiopulmonary) Interventions include:Interventions include:

– Restoration of perfusion to the Restoration of perfusion to the injured area often limits the amount injured area often limits the amount of extension and improves left of extension and improves left ventricular function.ventricular function.

– Complete sustained reperfusion of Complete sustained reperfusion of coronary arteries in the first few coronary arteries in the first few hours after an MI has decreased hours after an MI has decreased mortality.mortality.

Thrombolytic Therapy Thrombolytic Therapy

Fibrinolytics dissolve thrombi in Fibrinolytics dissolve thrombi in the coronary arteries and restore the coronary arteries and restore myocardial blood flow.myocardial blood flow.

Tissue plasminogen activator, Tissue plasminogen activator, APSAC, reteplaseAPSAC, reteplase

Glycoprotein IIa/IIIb inhibitorsGlycoprotein IIa/IIIb inhibitors

Identification of Identification of Coronary Artery Coronary Artery

ReperfusionReperfusion Abrupt cessation of pain or Abrupt cessation of pain or

discomfortdiscomfort Sudden onset of ventricular Sudden onset of ventricular

dysrhythmiasdysrhythmias A peak at 12 hours of markers of A peak at 12 hours of markers of

myocardial damagemyocardial damage

Oral Drug Therapy Oral Drug Therapy

AspirinAspirin Beta-adrenergic blocking agentsBeta-adrenergic blocking agents ACE inhibitorsACE inhibitors Calcium channel blockersCalcium channel blockers

Ineffective Coping Ineffective Coping InterventionsInterventions

Assess the client’s level of anxiety Assess the client’s level of anxiety but allow expression of any anxiety but allow expression of any anxiety and attempt to define its origin.and attempt to define its origin.

Give simple explanations of Give simple explanations of therapies, expectations, and therapies, expectations, and surroundings, and explanations of surroundings, and explanations of progress to help relieve anxiety.progress to help relieve anxiety.

Provide coping enhancement.Provide coping enhancement.

Potential for Potential for DysrhythmiasDysrhythmias

Dysrhythmias are the leading Dysrhythmias are the leading cause of death in most clients cause of death in most clients with MI who die before they can with MI who die before they can be hospitalized.be hospitalized.

Interventions include:Interventions include:– Identify the dysrhythmias.Identify the dysrhythmias.– Assess hemodynamic status.Assess hemodynamic status.– Evaluate for discomfort.Evaluate for discomfort.

Potential for Heart Potential for Heart Failure InterventionsFailure Interventions

AssessmentAssessment Monitoring for signs of poor Monitoring for signs of poor

organ perfusionorgan perfusion Hemodynamic monitoringHemodynamic monitoring

Cardiogenic Shock Cardiogenic Shock

Necrosis of more than 40% of the Necrosis of more than 40% of the left ventricleleft ventricle

TachycardiaTachycardia HypotensionHypotension Blood pressure < 90 mm Hg or Blood pressure < 90 mm Hg or

30 mm Hg < client’s baseline30 mm Hg < client’s baseline Urine output < 30 mL/hrUrine output < 30 mL/hr

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Cardiogenic Shock Cardiogenic Shock (Continued)(Continued)

Cold, clammy skinCold, clammy skin Poor peripheral pulsesPoor peripheral pulses Agitation, restlessness, Agitation, restlessness,

confusionconfusion Pulmonary congestionPulmonary congestion TachypneaTachypnea Continuing chest discomfortContinuing chest discomfort

Medical ManagementMedical Management

Pain relief and decreased Pain relief and decreased myocardial oxygen requirements myocardial oxygen requirements through preload and afterload through preload and afterload reductionreduction

Intravenous morphineIntravenous morphine Oxygen, intubation, ventilationOxygen, intubation, ventilation Intra-aortic balloon pumpIntra-aortic balloon pump Immediate reperfusionImmediate reperfusion

Potential for Recurrent Symptoms Potential for Recurrent Symptoms and Extension of Injury and Extension of Injury

InterventionsInterventions Percutaneous transluminal Percutaneous transluminal

coronary angioplasty (PTCA)coronary angioplasty (PTCA) Coronary artery bypass graft Coronary artery bypass graft

surgery (CABG)surgery (CABG)

Percutaneous Percutaneous Transluminal Coronary Transluminal Coronary

AngioplastyAngioplasty Monitoring for acute closure of the Monitoring for acute closure of the vessel, bleeding from the insertion vessel, bleeding from the insertion site, reaction to dye, hypotension, site, reaction to dye, hypotension, hypokalemia, and dysrhythmiashypokalemia, and dysrhythmias

Long-term nitrate, calcium channel Long-term nitrate, calcium channel blocker, and aspirin therapyblocker, and aspirin therapy

Beta blocker and ACE inhibitor if MIBeta blocker and ACE inhibitor if MI Infusions of GPIIa/IIIb inhibitorsInfusions of GPIIa/IIIb inhibitors

Coronary Artery Bypass Coronary Artery Bypass Graft SurgeryGraft Surgery

Postoperative care in Postoperative care in cardiopulmonary bypasscardiopulmonary bypass

Management of fluid and Management of fluid and electrolyte imbalance, electrolyte imbalance, hypotension, hypothermia, hypotension, hypothermia, hypertension, bleeding, cardiac hypertension, bleeding, cardiac tamponade, altered levels of tamponade, altered levels of consciousness, and painconsciousness, and pain

Transfer from the Transfer from the Special Care UnitSpecial Care Unit

Ventilation provided for 3 to 6 Ventilation provided for 3 to 6 hours postoperativelyhours postoperatively

Supraventricular dysrhythmias Supraventricular dysrhythmias commonly occurcommonly occur

Sternal wound infectionsSternal wound infections MediastinitisMediastinitis Postpericardiotomy syndromePostpericardiotomy syndrome

Other InterventionsOther Interventions

Minimally invasive direct Minimally invasive direct coronary artery bypasscoronary artery bypass

Transmyocardial laser Transmyocardial laser revascularizationrevascularization

Off-pump coronary artery bypassOff-pump coronary artery bypass Robotics Robotics

Health TeachingHealth Teaching

Smoking cessationSmoking cessation Diet controlDiet control Complementary and alternative Complementary and alternative

therapiestherapies Physical activityPhysical activity Sexual activitySexual activity

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Health Teaching Health Teaching (Continued)(Continued)

Blood pressure, blood glucose Blood pressure, blood glucose controlcontrol

Cardiac medicationsCardiac medications Self-monitoring; seeking medical Self-monitoring; seeking medical

assistance if neededassistance if needed