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Nursing Priorities in Acute Coronary Syndromes. Keith Rischer RN, MA, CEN. Risk factors for CAD: Multifactorial. Unmodifiable Age: Increased age-CAD begins early and develops gradually. Gender: Highest for middle-aged white caucasian Race: Caucasian males highest risk Genetic : - PowerPoint PPT Presentation
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Nursing Priorities inAcute Coronary Syndromes
Keith Rischer RN, MA, CEN
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Risk factors for CAD: Multifactorial
UnmodifiableAge:
Increased age-CAD begins early and develops gradually.
Gender:Highest for middle-aged white caucasian
Race:Caucasian males highest risk
Genetic: Inherited tendencies for atherosclerosis
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Risk factors for CAD: Multifactorial
ModifiableSmoking Physical inactivityObesityStressGlucose IntoleranceElevated serum lipids Hypertension
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Types of Angina…Causative FactorsTypes of Angina…Causative Factors
Stable (classic)Stable (classic) Pain w/exertion-relief Pain w/exertion-relief
w/restw/rest
UnstableUnstable Pain onset w/restPain onset w/rest Precursor to AMIPrecursor to AMI
SilentSilent Unrecognized or Unrecognized or
truly silenttruly silent
Physical exertionPhysical exertion Temperature extremesTemperature extremes Strong emotionsStrong emotions Heavy mealHeavy meal Tobacco useTobacco use Sexual activitySexual activity StimulantsStimulants Circadian rhythm patternsCircadian rhythm patterns
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12 Lead EKG: Ischemic Changes
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12 Lead EKG: Old
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Myocardial InfarctionMyocardial Infarction
http://video.google.com/videoplay?docid=-861965134389078213&q=blocked+coronary+artery&total=19&start=10&num=10&so=0&type=search&plindex=3
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Zones of Injury
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Nursing Assessment: Manifestations Appearance
Anxious, restless, pallor, diaphoresis Blood Pressure/Pulses Breathing JVD (Jugular Vein Distension) Auscultation/heart and lung Abnormal heart sounds S3, S4
Shortness of Breath (SOB) Orthopnea
Chest Discomfort Pleuritic-point tenderness? Localized vs. diffuse
Palpitaion
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Ventricular EctopyVentricular Ectopy
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Areas of Damage
Inferior Right Coronary Artery Leads II, III, AVF
Anterior Left Anterior
Descending Leads V1-V4
Lateral Circumflex Leads I, AVL, V5, V6
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Diagnostic Assessments
12 Lead EKG Chest X-Ray:
Assessment of cardiac size and pulmonary congestion.
Treadmill exercise Stress Test on a
treadmill with EKG and B/P monitor
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STEMI vs. non-STEMI
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STEMI 12 Lead EKG
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nonSTEMI 12 Lead EKG
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Diagnostics: Cardiac enzymes
Enzyme Rises In Peaks In Remains Elevated For
CPK-MB 4- 8 hrs 12 – 24 hrs 1 day
Troponin 3 hrs 12-18 hours Up to 14 days
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Diagnostic Assessments
Angiogram: View coronary arteries Incr. risk if done after
MI Need creatinine
Dye can cause renal failure
Echocardiogram Safe, non-invasive, wall
motion abnormalities
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Nursing Diagnosis Priorities
Acute Pain R/T decreased myocardial oxygen supply
Ineffective tissue perfusion R/T myocardial damage, inadequate cardiac output and potential pulmonary congestion
Activity Intolerance R/T fatigue Anxiety R/T perceived threat to death, pain,
possible lifestyle changes Knowledge deficit
Smoking cessation, diet, medications, procedures
– Assess for dysrhthmias, heart failure, extension of MI
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Nursing Care Plan
Goals: Attain adequate pain control Maintain adequate tissue perfusion Expression of sense of well-being
Evaluation: Compare progress as a result of nursing interventions Effectiveness of pain control VS stable: skin color improved If interventions unsuccessful – need to make
modifications of NCP
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Nursing Interventions:Priorities
DECREASE WORKLOAD OF THE HEART
Preload reductionAfterload reductionHR reduction Pain Relief:
Oxygen, Morphine Decrease demand for oxygen consumption
Bedrest, limit visitors, avoid large meals, Oxygen supplement complete bed bath/commode avoid straining during BM Music Therapy, Relaxation Tapes
Watch for dysrhythmias: Increasing PVC’s, VT Amiodorone
Provide emotional support Spiritual care
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Nursing Interventions:MI
Fluid statusMonitor for any symptoms of fluid overload, I&O
Emotional support to patient and S.O.Explain procedures/technology, relieve anxiety
Document based on unit guidelinesPatient education/prevention
Assess needs early, referrals (SS, cardiac rehab), others (risk factor management, psychological adjustment
Complimentary/alternative therapy
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Collaborative Care
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Stent Placement
Coronary Artery Bypass Graft (CABG)
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Collaborative Care:Drug Therapy
Antiplatelet agent:
First line of intervention-ASA, Plavix
Beta-adrenergic blockers: Prophylactic for angina Inderal, Lopressor,
(decrease in myocardial contractility
Lowers HR & B/P…reduces myocardial O2 demand
ACE Inhibitors Improve ventricular
“remodeling”
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Complications of Acute MI
Dysrhythmias Cardiogenic shock Myocardial rupture (of ventricle) L.V. Aneurysm Pericarditis Venous Thrombosis Psychological Adjustments
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Cardiogenic Shock: ICU Case Study
78yr female PMH: CAD, smokes 1ppd, CRI HPI: awoke w/CP, nausea, diaphoresis. Seen in small
community ED… See 12 lead…, Troponin 0.9 Received ½ dose TPA…airlifted to ANW level 1
In transport HR dropped to 20’s-Epi & Atropine & CPR x1” Angio: occluded prox. LAD-opened x3 stents BP-78/46
– Dopamine & Epinephrine gtts started– IABP placed-transfer to ICU
ICU: progressive resp failure-intubated– u/o 30cc last 4 hours– Stat echo…EF 25%– Labs: creat 2.1, K+ 5.7, BNP 1488, Trop 2.6
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Admission 12 Lead EKG
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Myocardial Revascularization: CABG
Coronary Artery Bypass Graft
Pre-operative Care Baseline diagnostic
data CXR Coagulation studies-
clotting, time, prothrombin time, fibrinogen, platelets
CBC, UA
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CABG Nursing Interventions: Pre op
Surgical pre-op teaching – to help reduce anxiety
procedure – video of surgery ICU post op pain meds Incentive spirometer-Cough-deep breathe chest tubes endotracheal tube Foley catheter Emotional/spiritual support Shower/bath w/Hibiclens Pre-op Abx
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CABG Nursing Interventions:Post op
Usually stays in ICU 1 or 2 days– Vented 3-6 hours after surgery
assess for post-op pain administer ordered pain meds Cardiac tamponade Monitor electrolytes
– K+ Assess for dysrhythmias
– Atrial fib most common Chest tubes
– Milking q 1-2 hours– Assess amount/color drainage
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Chest Tube: Nursing Priorities
Assess resp. status closely Check water seal for
bubbling Milk NOT strip every 2
hours Assess color-amount
drainage Call MD if >100cc/hr x2
hours first 24 hours Sterile guaze/occlusive
dressing at bedside
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CABG Complications: Case Study
68yr male s/p AVR & CABG PMH: CAD, AS, HTN
Post-op Complications: Resp. failure/aspiration req. ongoing vent support…likely
trach CV: hypotension-vasopressor support, fluid overload ARF-on CRRT and central dialysis catheter placed-
minimal u/o Encephalopathy-MRI neg, EEG shows diffuse cerebral
dysfunction-restless, does not follow commands NG for tube feeding