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Interventions for Critically Ill
Clients with Acute Coronary
Coronary Artery Disease
Includes stable angina pectoris and
acute coronary syndromes
 Ischemia: oxygen supply insufficient
to meet requirements of the
 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
 Occurs when myocardial tissue is
abruptly and severely deprived of
 Dynamic process that does not occur
instantly but evolves over several
Nonmodifiable Risk Factors
 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
 Anginal pain improves with rest and
nitroglycerine; MI does not.
Pain Assessment (Continued)
Other manifestations include nausea
and vomiting, diaphoresis, dizziness,
weakness, palpitations, and
shortness of breath.
Diagnostic Assessment
 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
 Morphine sulfate
 Oxygen
 Position of comfort; semi-Fowler’s
 Quiet and calm environment
 Deep breaths to increase
Ineffective Tissue Perfusion
Interventions include:
– Restoration of perfusion to the injured
area often limits the amount of
extension and improves left ventricular
– 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,
 Glycoprotein IIa/IIIb inhibitors
Identification of Coronary
Artery Reperfusion
Abrupt cessation of pain or
 Sudden onset of ventricular
 A peak at 12 hours of markers of
myocardial damage
Oral Drug Therapy
 Beta-adrenergic blocking agents
 ACE inhibitors
 Calcium channel blockers
Ineffective Coping
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
 Monitoring for signs of poor organ
 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
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
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
 Supraventricular dysrhythmias
commonly occur
 Sternal wound infections
 Mediastinitis
 Postpericardiotomy syndrome
Other Interventions
Minimally invasive direct coronary
artery bypass
 Transmyocardial laser
 Off-pump coronary artery bypass
 Robotics
Health Teaching
Smoking cessation
 Diet control
 Complementary and alternative
 Physical activity
 Sexual activity
Health Teaching (Continued)
Blood pressure, blood glucose control
 Cardiac medications
 Self-monitoring; seeking medical
assistance if needed
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