Interventions for Critically Ill Patients With Coronary Syndrome

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Interventions for Critically IllClients with Acute Coronary

Syndromes

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Coronary Artery Disease

Description

♦ Is narrowing or obstruction of one or more coronary arteriesas a result as Atherosclerosis, an accumulation of lipid-containing 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 amuscle with blood, is normally present in the coronaryarteries, especially in older persons.

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♦ Symptoms occur when the coronary artery isoccluded to the point that inadequate blood supplyto the muscle occurs, causing ischemia

♦

Coronary artery narrowing is significant if thelumen diameter of the left main artery is reduced atleast 50%, or if any major branch is reduced at least75%

♦

The goal of treatment : Is to alter the atherosclerotic progression.

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Assessment

♦ Possibly normal findings during asymptomatic

 periods

♦ Chest pain

♦ Palpitations

♦ Dyspnea

♦ Syncope

♦ Cough or hemoptysis

♦ Excessive fatigue

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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

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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

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Intervention

Medical management:

A. Drugs

1.  Nitrates : to dilate the coronary arteries & todecrease preload and afterload

2. Calcium channel blockers: to dilate coronaryarteries & reduce vasospasm

3. Cholesterol –lowering : to reduce thedevelopment of artherosclerotic plaques

4. Beta – blockers : to reduce BP in individuals whoare hypertensive

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Surgical Management

1. Percutaneous Transluminal CoronaryAngioplasty or PTCA

♦ To compress the plaque against the walls of theartery & dilate the vessel

2. Coronary Artery Bypass Graft

♦ To improve blood flow to the myocardial tissue

that is at risk for ischemia or infarction becauseof the occluded artery

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Angina

PectorisDescription

♦ 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

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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

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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.

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Patterns of Angina

1. Stable Angina or exertional angina

♦ Occurs with activities that involve exertion or emotionalstress & is relieved with rest or Nitroglycerin

♦ Usually has a stable pattern of onset, duration, severity

and relieving factors2. 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

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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 lastup to 15 to 20 minutes

♦ Is relieved by Nitroglycerine or rest

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2. Dyspnea

3. Pallor 

4. Sweating

5. Palpitations and tachycardia6. Dizziness and faintness

7.Hypertension

8. Digestive disturbance

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Diagnostic studies 

1. Electrocardiogram : readings are normal during rest, withST depression or elevation &/or T wave inversion duringan episode of pain.

2. Stress test : chest pain or changes in ECG or vital signs

during testing may indicate ischemia3. Cardiac enzymes & Troponins : findings are normal in

angina

4. Cardiac Catheterization : provides definitive diagnosis by providing information about patency of the coronaryarteries.

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Medical management

Drug therapy

♦ Nitrates

♦ Beta- adrenergic blocking agents

♦ Calcium-blocking agents

♦ Lipid reducing ( elevated cholesterol)

♦ Percutaneous transluminal coronary angioplasty or 

PTCA♦ Surgery: CABG

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 Nursing Intervention

1. Administer oxygen/ semi to high fowlers position

2. Prompt pain relief with nitrates or narcotic

analgesics as ordered3. Monitor VS, status of cardiopulmonary

function

4. Monitor 12 lead ECG5 Provide emotional support

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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 preventdizziness

c. If no relief with 1 tablet, take additional tablets at 5-minute intervals, but no more than 3 tablets within a 15minute period

d. Transient headache is frequent side effect

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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 drug’s sustained action.

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Ways to minimize precipitating events

1. Reduce stress & anxiety ( relaxationtechniques/ guided imagery)

2. Avoid overexertion & smoking

3. Maintain low- cholesterol, low saturatedfat diet & eat small, frequent meals

4. Avoid extremes of temperature/ dress

warmly in cold weather 

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Myocardial Infarction

Description:

1. Occurs when myocardial tissue is abruptly & severelydeprived of O2

2. Ischemia can lead to necrosis of myocardial tissue if 

 blood flo is not restored3. 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

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5. After 48 hours the infarct turns gray with yellow streaks as neutrophilsinvade 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 MI9. 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

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Location of Myocardial Infarction

1. Obstruction of the left anterior descendingartery results in anterior or septal MI or  both

2. Obstruction of the circumflex arteryresults in posterior wall MI or lateral wallMI

3. Obstruction of the right coronary arteryresults in inferior wall MI

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Risk factors

1. Atherosclerosis

2. Coronary artery disease or CAD

3. Elevated cholesterol levels/ hyperlipidemia

4. Smoking5. Hypertension

6. Obesity

7. Physical inactivity

8. Impaired glucose tolerance9. Stress

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Diagnostic studies

1. Total creatine kinase level

a. Level rises within 3 hrs. After the onset of chest pain

 b. 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

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4. Myoglobin : level rises within 1 hour after cell death, peaksin 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 7days

c. Serum level of LDH isoenzyme rises higher than serumlevel of LDH

6. White blood cell count : An elevated WBC of 10,000 to20,000 appears on the 2nd dy following the MI & lasts upto a week 

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7. Electrocardiogram

a. Shows ST segment elevation, T wave inversion,& anabnormal 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 identifyclients who may need invasive therapy.

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 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 functiond. Cardiac catheterization is performed to determine

the extent & location of obstructions of the

coronary arteries.

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Assessment

1. Pain usually substernal with radiation to the neck, arm, jaw or back: severe, crushing, viselike with sudden onset:unrelieved by rest or nitrates

2.  Nausea & vomiting

3. Dyspnea

4. Skin: cool, clammy, ashen

5. Elevated temperature

6. Initial increase in BP & pulse, with gradual drop in BP

7. Restlessness

8. occasional findings : rales or crackles; presence of S4 : pericardial friction rub : split S1 S2

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 Nursing intervention

1. Establish a patent IV line

2. Provide pain relief; Morphine Sulfate IV

3. O2 to relieve dyspnea & prevent arrhythmias

4. Bed rest on semi-fowlers positionn to decrease cardiac

workload

5. Monitor ECG & hemodynamic proccedure

6. Administer antiarrhythmias as ordered

7. Perform complete lung/cardiovascular assessmnet

8. Monitor urinary output& report of less than 30ccml/hr ;indicates decreased cardiac output

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9. Maintain full liquid diet with gradual increase to

soft low sodium

10.Maintain quiet environment

11. Stool softeners as ordered to facilitate bowelevacuation & prevent straining

12. Administer as ordered: anticoagulants,

thrombolytics , Streptokinase and monitor sideeffects: bleeding

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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

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f. Resumption of sexual activity according to

 physician’s 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