M2P10.pdf

1/16/24, 10:31 PM Realizeit for Student NURSING PROCESS The Patient With Acute Coronary Syndrome Assessment One of the most important aspects of care of the patient with ACS is the assessment. It establishes the patient’s baseline, identifies the patient’s needs, and helps determine the priority...

1/16/24, 10:31 PM Realizeit for Student NURSING PROCESS The Patient With Acute Coronary Syndrome Assessment One of the most important aspects of care of the patient with ACS is the assessment. It establishes the patient’s baseline, identifies the patient’s needs, and helps determine the priority of those needs. Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, dyspnea (difficulty breathing), palpitations, unusual fatigue, syncope (faintness), or other possible indicators of myocardial ischemia. Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. A focused physical assessment is critical to detect complications and any change in patient status. Two IV lines are typically placed for any patient with ACS to ensure that access is available for administering emergency medications. Medications are administered IV to achieve rapid onset and to allow for timely adjustment. After the patient’s condition stabilizes, IV lines may be changed to a saline lock to maintain IV access. Diagnosis NURSING DIAGNOSES Based on the clinical manifestations, history, and diagnostic assessment data, major nursing diagnoses may include: •Acute pain associated with increased myocardial oxygen demand and decreased myocardial oxygen supply •Risk for impaired cardiac function associated with reduced coronary blood flow •Risk for hypovolaemia •Impaired peripheral tissue perfusion associated with impaired cardiac output from left ventricular dysfunction •Anxiety associated with cardiac event and possible death •Lack of knowledge about post-ACS self-care https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 1/12 1/16/24, 10:31 PM Realizeit for Student COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: •Acute pulmonary edema •Heart failure •Cardiogenic shock •Arrhythmias and cardiac arrest •Pericardial effusion and cardiac tamponade Planning and Goals The major goals for the patient include relief of pain or ischemic signs (e.g., ST-segment changes) and symptoms, prevention of myocardial damage, maintenance of effective respiratory function, maintenance or attainment of adequate tissue perfusion, reduced anxiety, adherence to the self-care program, and early recognition of complications. Care of the patient with ACS who has an uncomplicated MI is summarized in the Plan of Nursing Care. Nursing Interventions Relieving pain and other signs and symptoms of ischemia Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the patient with an ACS. Although administering medications as described previously is required to accomplish this goal, nursing interventions are also important. Collaboration among the patient, nurse, and primary provider is critical in evaluating the patient’s response to therapy and in altering the interventions accordingly. Oxygen should be given along with medication therapy to assist with relief of symptoms. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. The route of administration (usually by nasal cannula) and the oxygen flow rate are documented. A flow rate of 2 to 4 L/min is usually adequate to maintain oxygen saturation levels of at least 95% unless chronic pulmonary disease is present. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 2/12 1/16/24, 10:31 PM Realizeit for Student Vital signs are assessed frequently as long as the patient is experiencing pain and other signs or symptoms of acute ischemia. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. Elevation of the head and torso is beneficial for the following reasons: •Tidal volume improves because of reduced pressure from abdominal contents on the diaphragm and better lung expansion. •Drainage of the upper lung lobes improves. •Venous return to the heart (preload) decreases, reducing the work of the heart. The pain associated with an acute MI reflects an imbalance in myocardial oxygen supply and demand or ineffective myocardial tissue perfusion. The pain also results in increases in heart rate, respiratory rate, and blood pressure. Promptly relieving the pain helps to reestablish this balance, thus decreasing the workload of the heart and minimizing damage to the myocardium. Relief of pain also helps to reduce the patient’s anxiety level, which in turn reduces the sympathetic stress response, leading to a decrease in workload of the already stressed heart. Improving Respiratory Function Regular and careful assessment of respiratory function detects early signs of pulmonary complications. The nurse monitors fluid volume status to prevent fluid overload and encourages the patient to breathe deeply and change position frequently to maintain effective ventilation throughout the lungs. Pulse oximetry guides the use of oxygen therapy. Promoting Adequate Tissue Perfusion Bed or chair rest during the initial phase of treatment helps reduce myocardial oxygen consumption. This limitation on mobility should remain until the patient is pain free and hemodynamically stable. Skin temperature and peripheral pulses must be checked frequently to monitor tissue perfusion. Reducing Anxiety Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Less sympathetic stimulation decreases the workload of the heart, which may relieve pain and other signs and symptoms of ischemia. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 3/12 1/16/24, 10:31 PM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 4/12 1/16/24, 10:31 PM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 5/12 1/16/24, 10:31 PM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 6/12 1/16/24, 10:31 PM Realizeit for Student The development of a trusting and caring relationship with the patient is critical in reducing anxiety. Providing information to the patient and family in an honest and supportive manner encourages the patient to be a partner in care and greatly assists in developing a positive relationship. Other interventions that can be used to reduce anxiety include ensuring a quiet environment, preventing interruptions that disturb sleep, and providing spiritual support consistent with the patient’s beliefs. The nurse provides frequent opportunities for the patient to privately share concerns and fears. An https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 7/12 1/16/24, 10:31 PM Realizeit for Student atmosphere of acceptance helps the patient know that these concerns and fears are both realistic and normal. Alternative therapies such as pet therapy can help certain patients relax and reduce anxiety (Waite, Hamilton, & O’Brien, 2018). Many hospitals have developed infection control and safety procedures pertaining to the animals, their handlers, and the patients eligible for pet therapy. Monitoring and Managing Potential Complications Complications that can occur after acute MI are caused by the damage that occurs to the myocardium and to the conduction system from reduced coronary blood flow. Because these complications can be life-threatening, close monitoring for and early identification of their signs and symptoms are critical. The nurse monitors the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, skin color and temperature, mental status, ECG changes, and laboratory values. Any changes in the patient’s condition must be reported promptly to the primary provider and emergency measures instituted when necessary. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. The most effective way to increase the probability that the patient will implement a self-care regimen after discharge is to identify the patient’s priorities, provide adequate education about heart-healthy living, and facilitate the patient’s involvement in a cardiac rehabilitation program (Ibanez et al., 2018). Patient participation in the development of an individualized program enhances the potential for an effective treatment plan. Continuing and Transitional Care. Depending on the patient’s condition and the availability of family assistance, home, community-based, or transitional, care may be indicated. The nurse making a home visit can assist the patient with scheduling and keeping follow-up appointments and with adhering to the prescribed cardiac rehabilitation regimen. The patient may need reminders about follow-up monitoring, including periodic laboratory testing, as well as ongoing assessment of cardiac status. In addition, the home health nurse monitors the patient’s adherence to dietary restrictions and to prescribed medications. If the patient is receiving home oxygen, the nurse ensures that the patient is using the oxygen as prescribed and that appropriate home safety measures are maintained. If the patient has evidence of heart failure secondary to an MI, appropriate home care guidelines for the patient with heart failure are followed. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 8/12 1/16/24, 10:31 PM Realizeit for Student Evaluation Expected patient outcomes may include: 1.Experiences relief of angina 2.Has stable cardiac and respiratory status 3.Maintains adequate tissue perfusion 4.Exhibits decreased anxiety 5.Adheres to a self-care program 6.Has no complications Example YouTube: An Osmosis Video: Heart Attack Explained YouTube: Heart attack (myocardial infarction) pathophysiology | NCLEX-RN | Khan Academy https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 9/12 1/16/24, 10:31 PM Realizeit for Student Summary Myocardial infarction (MI) is used synonymously with coronary occlusion and heart attack. Yet, MI is the most preferred term as myocardial ischemia causes acute coronary syndrome (ACS) that can result in myocardial death. In an MI, an area of the myocardium is permanently destroyed because plaque rupture and subsequent thrombus formation result in complete occlusion of the artery. The spectrum of ACS includes unstable angina, non-ST-segment elevation MI, and ST-segment elevation MI. Patients experiencing an acute MI may present with symptoms in any environment, including the hospital emergency room, a physician's office, an ambulatory clinic, and any other department within the hospital. With this in mind, it is important for nurses in a variety of settings to be familiar with the basics of an acute MI. They should be able to recognize the signs and symptoms of acute MI and be prepared to take immediate action. This course provides nurses with essential information regarding an acute MI. It explains signs and symptoms, describes ST elevation on a 12-lead electrocardiogram (EKG), summarizes nursing interventions and pharmacologic management, and outlines associated emotional and psychosocial issues related to acute MI. Information on patient education is also presented (https://www.nursece.com/courses/80-stemi-alertrapid-response-to-acute-myocardial-infarction) https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 10/12 1/16/24, 10:31 PM Realizeit for Student Review Acute Myocardial Infarction (MI) is one condition in a spectrum of illnesses known as acute coronary syndrome. The cause of acute MI can be traced to several causes, but the main perpetrator of a "heart attack" is coronary artery disease (CAD). ACS is usually triggered by the rupture of an atherosclerotic plaque in the wall of a coronary artery; this causes activation, adhesion, and aggregation of platelets and the clotting systems, leading to the formation of a thrombus. If the thrombus completely occludes the coronary artery, the section of the myocardium supplied by that artery is starved of oxygen, leading to myocardial cell necrosis, and typical ST elevation changes are seen on an electrocardiogram. In addition, cardiac enzymes are released from damaged myocardial cells (troponin I and T, creatinine kinase MB isoenzyme), which can be measured in the blood. Patients typically present with central chest pain or tightness described as dull or crushing; it can radiate to the jaw or down the left arm and normally lasts for >15 minutes. Some patients, such as those with diabetes, older people, or women, may not have chest pain. Mnemonics, such as SOCRATES, can be used to assess patients’ chest pain: S – site of pain O – onset of pain C – character of the pain R – any radiation A – associated factors T – timing of the pain E – exacerbating/alleviating factors; for example, position or inspiration https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 11/12 1/16/24, 10:31 PM Realizeit for Student S – severity of the pain using a rating scale of 1-10 (10 being the worst pain) Shortness of breath, palpitations, syncope, or autonomic symptoms, such as sweating, nausea, tachycardia, or vomiting, may also occur (with or without chest pain). Close attention to vital signs is critical as patients can deteriorate and become hemodynamically unstable or develop heart failure and arrhythmias. Diagnosis and nursing care A thorough clinical history and physical examination should be undertaken and supported by an EKG. Keeping clear and comprehensive notes is crucial to ensure all nurses caring for patients with ACS know the patients’ clinical status, areas of concerns, and management plan. Nurses caring for patients who recently had coronary angiography should monitor radial or femoral access sites and be able to recognize complications. General priorities for patients with ACS are hemodynamic monitoring and close observation of vital signs. A review of fluid status can provide information about renal perfusion, as some patients may present with or develop heart failure. Symptom monitoring is important to achieve pain relief with Nitroglycerine or morphine. Swift recognition of any cardiac changes on the serial EKGs is also a key aspect of nursing care. Patients considered at high risk should be managed where continuous cardiac monitoring is available as they are at risk of arrhythmias, which can precede a cardiac arrest. Patients at intermediate risk may be managed in a medical assessment unit, where they are likely to receive serial EKGs. Nurses caring for patients with ACS should have ECG interpretation skills, as EKG changes or arrhythmias are signs of potential deterioration. Other elements of nursing care include ongoing management of IV cannulas, central venous pressure lines, urinary catheters, and wounds and dressings. Patients are likely to be anxious and frightened. Nurses should be calm, reassuring, and ensure pain and other symptoms are well controlled. They play a central role in providing psychosocial support; when possible, they should give patients a chance to speak about their experiences, address their concerns and relay these to the multidisciplinary team. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2f… 12/12