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Interventions for Critically Ill
Clients with Acute Coronary
Syndrome
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

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

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.

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

Nonmodifiable Risk Factors
Age
 Gender
 Family history
 Ethnic background

Modifiable Risk Factors
Elevated serum cholesterol
 Cigarette smoking
 Hypertension
 Impaired glucose tolerance
 Obesity
 Physical inactivity
 Stress

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)
Pain Assessment (Continued)

Other manifestations include nausea
and vomiting, diaphoresis, dizziness,
weakness, palpitations, and
shortness of breath.
Diagnostic Assessment
Electrocardiogram
 Stress test
 Myocardial perfusion imaging
 Magnetic response imaging
 Cardiac catheterization

Acute Pain

Interventions include:
– Provide pain relief modalities.
– Decrease myocardial oxygen demand.
– Increase myocardial oxygen supply.
Pain Management
Nitroglycerine
 Morphine sulfate
 Oxygen
 Position of comfort; semi-Fowler’s
position
 Quiet and calm environment
 Deep breaths to increase
oxygenation

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.
Thrombolytic Therapy
Fibrinolytics dissolve thrombi in the
coronary arteries and restore
myocardial blood flow.
 Tissue plasminogen activator, APSAC,
reteplase
 Glycoprotein IIa/IIIb inhibitors

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

Oral Drug Therapy
Aspirin
 Beta-adrenergic blocking agents
 ACE inhibitors
 Calcium channel blockers

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.

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.
Potential for Heart Failure
Interventions
Assessment
 Monitoring for signs of poor organ
perfusion
 Hemodynamic monitoring

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)
Cardiogenic Shock (Continued)
Cold, clammy skin
 Poor peripheral pulses
 Agitation, restlessness, confusion
 Pulmonary congestion
 Tachypnea
 Continuing chest discomfort

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

Potential for Recurrent Symptoms and
Extension of Injury Interventions
 Percutaneous transluminal coronary
angioplasty (PTCA)
 Coronary artery bypass graft surgery
(CABG)
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

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

Transfer from the Special
Care Unit
Ventilation provided for 3 to 6 hours
postoperatively
 Supraventricular dysrhythmias
commonly occur
 Sternal wound infections
 Mediastinitis
 Postpericardiotomy syndrome

Other Interventions
Minimally invasive direct coronary
artery bypass
 Transmyocardial laser
revascularization
 Off-pump coronary artery bypass
 Robotics

Health Teaching
Smoking cessation
 Diet control
 Complementary and alternative
therapies
 Physical activity
 Sexual activity

(Continued)
Health Teaching (Continued)
Blood pressure, blood glucose control
 Cardiac medications
 Self-monitoring; seeking medical
assistance if needed

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