Presented by: Jessaly Joyce Sioson

Care and Management of the Client

with Cardiac Alterations
 Acute Coronary Syndrome and
Myocardial Infarction
• ACS is an emergent situation characterized by an
acute onset of myocardial ischemia that results in
myocardial death (ie, MI) if definitive interventions
do not occur promptly.
• This includes unstable angina, non-St segment
elevation MI (NSTEMI), and ST-segment elevation MI
(STEMI).
Facts:
• Each year in the US nearly 1 million
people have acute MIs; one fourth of
theses people die as a result.

• Half of those die never reach the

hospital.
Clinical Manifestations
Chest Pain that occurs suddenly and continues despite rest and
medication is the presenting symptom in most patients with
ACS syndrome.
• Patient may present combination of symptoms:
- shortness of breath -cool, pail and moist skin
-indigestion - HR and RR may be faster
-nausea than normal
-anxiety
Assessment and Diagnostic Findings
• Presenting signs and symptoms
• 12-lead ECG
• Laboratory tests (eg, serial cardiac biomarkers) are
performed to clarify whether the patient has
unstable angina, NSTEMI, or STEMI.
• Prognosis depends on the severity of coronary
obstruction and the presence and extent of
myocardial damage
• Physical exam is always conducted, but the
examination alone does not confirm the diagnosis
Patient History

• -Description of the presenting signs and symptoms

(eg. Pain),
• History of previous cardiac and other illnesses
• Family history should also include information about
the patient’s risk factors of the disease.
Electrocardiogram
• This should be obtained within 10
minutes from the time a patient reports
pain or arrives in the ER.
• The classic ECG changes are T wave
inversion, ST-segment elevation, and
the development of abnormal Q wave.
 Assessing for Acute Coronary Syndrome (ACS) or
Acute Myocardial Infacrtion (MI)
• Cardiovascular -blood pressure maybe
-chest pain or discomfort not elevated or decreased
relived by rest or -irregular pulse may indicate
nitroglycerine palpitations. atrial fibrillation.
-heart sounds may include S3, - In addition to ST-segment
S4 and new set of murmur and T-wave changes, ECG
-increased jugular venous may show tachycardia,
distention may be seen if bradycardia or other
the MI has caused heart dyrhythmias.
failure.
 Assessing for Acute Coronary Syndrome (ACS) or
Acute Myocardial Infacrtion (MI)
• Respiratory • Skin
-shortness of breath, dyspnea, -cool, clammy, diaphoretic and pale
tachycardia, and crackles if MI appearance due to sympathetic
has caused pulmonary stimulation may indicate
congestion. cardiogenic shock.
-Pulmonary edema may be present • Neurologic
• Gastrointestinal -anxiety, restlessness, and
-nausea and vomiting lightheadedness
• Genitourinary • Psychological
-decreased urinary output may - Fear with feeling of impending
indicate cardiogenic shock doom, or denial that anything is
wrong.
• Unstable Angina: The patient has clinical
manifestation of coronary ischemia, but
ECG and cardiac biomarkers show no
evidence of acute MI.
• STEMI: The patient has ECG evidence of
acute MI with characteristic changes in 2
contiguous leads on a 12-lead ECG.
-there is significant damage to the
myocardium.
• NSTEMI: elevated cardiac biomarkers but
no definite ECG evidence of acute MI.
• Creatinine Kinase isoenzyme
- CK-MB (heart muscle)
- Increases only when there has been
damage to these cells.
- Increase within few hours and peaks
within 24 hours of an MI.
Myoglobin
• Is a heme protein that helps transport
oxygen. Like CK-MB enzyme, myoglobin
is found in cardiac and skeletal muscle.
The myoglobin level starts to increase
within 1 to 3 hoursand peaks within 12
hours after the onset of symptoms.
• Not very specific
Troponin
• -a protein found in the myocardium, regulates the
myocardial contractile process.
• Troponin I and T are specific for cardiac muscle.
• -reliable and critical markers of myocardial injury
• An increase in level of troponin in the serum can
be detected within a few hours during acute MI.
• Remains elevated for a long period, often as long
as 3 weeks.
• Can detect recent myocardial damage.
Medical Management
• Goal of medical management are to
minimize myocardial damage, preserve
myocardial function and prevent
complications.
Pharmacologic Therapy
• Suspected MI- Aspirin, nitroglycerin, morphine and
IV-beta- blockers.
• Continue beta-blocker throughout hospitalization
and after discharge to decrease incidence of future
cardiac events.
• Unfractionated Heparin or LMWH is prescribed
along with platelet-inhibiting agents to prevent
further clot formation.
• NSAIDS- may be discontinued because of
association of their association with adverse
cardiac events.
• Analgesics
-DOC: morphine administered in IV boluses to reduce
pain and anxiety. Reduces preload and after load.
-WOF: morphine sulfate toxicity
• Angiotensin Converting Enzyme Inhibitors
- To decrease blood pressure and excretion of
Sodium and fluid, decreasing oxygen demand of
the heart.
• Thrombolytics
- To dissolve the thrombus in coronary artery.
- Should not be used if the patient has formed
protective clot elsewhere, such as major surgery
or hemorrhagic stroke.
Treatment Guidelines for Acute
Myocardial Infarction
• Use rapid transit to the hospital
• Obtain 12 –lead ECG to be read within
10 minutes
• Laboratory blood specimens of cardiac
biomarkers including troponin.
• Obtain other diagnostics to clarify
diagnosis.
• Begin routine medical interventions:
-Supplemental oxygen
-Nitroglycerin
-Morphine
-Aspirin 162 to 325 mg
-Beta-blocker
-ACE inhibitor within 24 hours
-Anticoagulation with heparin and platelet
inhibitors
• Evaluate for indications for reperfusion
therapy
-Percutaneous coronary intervention
-Thrombolytic therapy
• Continue therapy as needed:
- intravenous heparin, low-molecular
weight heparin, bi-valirudin or
fondaparinux
-Clopidogrel (Plavix)
-Glycoprotein llb/lla inhibitor
• Bed rest for a minimum of 12 to 24 hours
Administration of Thrombolytic
Therapy
Indications:
• Chest pain for longer than 20 minutes,
unrelived by nitroglycerin
• St segment elevation in atleast 2 leads
that face the same area of the heart
• Less than 6 hours from the onset of
pain.
Contraindication:
• Active bleeding
• Known bleeding disorder
• History of hemorrhagic stroke
• Hx of intracranial vessel malformation
• Recent major history trauma
• Uncontrolled hypertension
• Preganancy
Nursing Cosniderations:
• Minimize the number of times the patient’s kin is
punctured.
• Avoid IM injections
• Draw blood for laboratory test when starting IV line
• Start IV lines before thrombolytic therapy, designate 1
line to use for blood draws.
• Avoid continual use of noninvasive BP cuff
• Monitor cardiac dysrrhythmias and hypotension
• Monitor for reperfusion resolution of angina or acute
ST segment changes
• Check signs and symptoms of bleeding, decrease
hematocrit and hemoglobin values, decrease in
blood pressure, increase in HR, oozing or bulging
at invasive procedure sites, back pain, muscle
weakness, change in LOC, complaints of headache.
• Treat major bleeding by discontinuing
thrombolytic therapy and any anticoagulants;
apply direct pressure and notify the physician
immediately.
• Treat minor bleeding by applying direct bleeding
by applying direct pressure if accessible and
appropriate continue to monitor.
Emergent Percutaneous Coronary
Intervention
• Patient with STEMI may be taken
directly to the cardiac catheterization
laboratory for an immediate PCI.
• Is used to open occluded coronary
artery and promote reperfusion to the
area.
• Should be done less than 60 minutes
from the patient’s arrival in the ERD.
Phases of Cardiac Rehabilitation
• Phase I
- Begin with the diagnosis of artherosclerosis
which may occur when the patient is admitted
to the hospital for ACS. (eg, unstable angina or
acute MI)
- Teaching of essentials of self-care
- Teaching of signs and symptoms when to seek
emergency assistance, medication regimen,
rest-activity balance, follow-up appointments
• Phase II
-occurs after the patient has been
discharged.
Attends session 3 time a week for 4 to 6
weeks but may continue for as long as six
months, ECG monitoring, exercise training,
support and guidance related to the
treatment of the disease.
-Outpatient cardiac rehabilitation programs
are designed to encourage patients and
families to support each other.
• Phase III
- Long-term outpatient program that
focuses on maintenance cardiovascular
stability and long term conditioning.
Nursing Process
• Assessment- history taking
• Nursing Diagnoses
- Ineffective cardiac tissue perfusion related
to reduced coronary blood flow
- Risk for imbalnce fluid voume
- Risk for ineffective perepheral tuuse
perfusion related to decreased CO from
left ventricular dysjunction
- Death anxiety related to cardiac event
• Planning and Goals
-Relief of pain or ischemic signs (St- segment
changes) and symptoms prevention of
myocardial damage, absence of respiratory
dysfunction, maintenance or attainment of
adequate tissue perfusion, reduced
anxiety, adherence to the self-care
program and absence or early recognition
of complications.
Nursing Interventions
• Balancing the myocardial oxygen supply
with demand (eg, as evidenced by the
relief of chest pain) is the top priority in
the care of the patient with ACS.
• Administer oxygen thru nasal cannula.
Flow rate of 2 to 4 L/min is usually
adequate.
• O2 Sat of 96 to 100% unless chronic
pulmonary disease is present.
• Vital signs are assessed frequently

Improving Respiratory Function

-regular and careful assessment of
respiratory function detects early signs of
pulmonary complications.
-monitor fluid volume status to prevent over
loading of the heart and lungs.
-Encourage deep breathing exercise and
change position frequently
• Promoting Adequate Tissue Perfusion
-bed or chair rest during the initial phase
of treatment helps reduce myocardial
oxygen consumption.
• Reducing Anxiety
- Alleviating anxiety and decreasing fear
are important nursing functions that
reduces sympathetic stress response.
• Monitoring and Managing Potential
Complications
-Close monitoring for and early identification
of signs and symptoms are critical.
- Monitor changes in cardiac rate, respiratory
status, urinary output, skin color and
temperature, sensorium, ECG changes and
laboratory values.
Promoting Home and Community-Based
Care
-teaching patients self-care