ACS AMI Facilitator

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI
Jimmy Kearns
Age: 68 Weight: 85 kg Base: Stan D. Ardman
Overview
Synopsis
This simulated clinical experience focuses on the emergent treatment of a patient who experiences an acute ST-segment elevation myocardial infarction (STEMI). The patient is within a two-to-four hour window from the time chest pain began and his arrival to the Emergency Department (ED) for treatment. While in the ED the patient experiences a recurrence of his chest pain as his condition rapidly progresses to cardiogenic shock. The patient is transported to the Cardiac Catheterization Laboratory for Percutaneous Coronary Interventions (PCI) and subsequently admitted to the Coronary Care Unit (CCU ) for post PCI observation and management. The SCE has four states that are transitioned manually at the facilitators discretion with the exception of State 2 Onset of Cardiogenic Shock that automatically transitions to State 3 Ventriculater Tachycardia after 90 seconds for a run of Ventricular Tachycardia. State 3 Ventriculater Tachycardia transitions back to State 2 Onset of Cardiogenic Shock after 10 seconds. With manual transitions, instructors should advance to the applicable state when appropriate interventions are performed. During State 1 Initial Assessment, the patient demonstrates a HR in the 100s, BP in the 90s/50s, RR in the low 20s and SpO2 in the high 90s on 2 LPM of oxygen via nasal cannula. Breath sounds are clear in all lobes. Heart sounds reveal S4 with the cardiac rhythm showing sinus rhythm with ST segment elevation that is characteristic of a STEMI. Bowel sounds are normoactive. His temperature is 37.5C with a capillary refill less than 3 seconds with normal skin color and warmth. If the learner requests blood results they are told White Blood Cells (WBC) 11.8, Red Blood Cells (RBC) 5.2, Hemaglobin (Hgb ) 15.4, Hematocrit (Hct) 47%, Platelets 350. Sodium (Na) 138, Potassium (K) 4.2, Chloride (Cl) 102, Carbon Dioxide Content (CO2 ) 30, Glucose 88, Blood Urea Nitrogen (BUN) 18, Creatinine (CK) 0.9. Cardiac Enzymes: Creatinine Kinase (CK) 457, Creatinine Kinase Specific for Myocardium (CK-MB ) 24.1, Troponin I 1.1. Urinalysis (UA) on dipstick within normal limits (WNL) with no results back yet for culture and sensitivity (C&S). Prothrombin Time (PT) 14, International Normalized Ratio (INR) 1.2 and Partial Thromboplastin Time (PTT) 33. He denies any chest pain. The learner is expected to perform an initial physical assessment interpreting and recording all vital signs and reporting abnormalities to the healthcare provider. The learner should undertake and implement all the healthcare providers orders and document as appropriate. All specimens (e.g., urinalysis and venepuncture) should be carried out in a safe manner, and when the results are returned, they should be passed to the healthcare provider. Oxygen and any medications should be calculated and administered according to the Six Rights. The patient should be prepared according to local protocol to undergo a Percutaneous Transluminal Coronary Angioplasty (PTCA). Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
2009 METI, Sarasota, FL

After the learner has completed the assessment, collected all specimens, administered all drugs as ordered and prepared the patient for a PTCA, the instructor should manually transition the patient to State 2 Onset of Cardiogenic Shock. In State 2 Onset of Cardiogenic Shock the patients condition deteriorates, with a HR in the 80s-100s, BP in the 60s-70s/40s, RR in the 20s and SpO2 initially in the high 90s but then decreases to the low 90s on 2 LPM of oxygen. The cardiac monitor displays a sinus rhythm with moderate ischemia with runs of Ventricular Tachycardia (VT), and breath sounds reveal crackles. The patients temperature is 37.8C. The patient is apprehensive and anxious and is slow to respond but states that his pain level is 5/10. The patient is slow to respond to questions. When the learners inquire, they are told that the patients pallor is dusky with cool skin and dry to touch. The rhythm strip shows 1.5 mm of ST-segment elevation with Premature Ventricular Contractions (PVC) greater than 6 per minute. The learner is expected to reassess the patient noting the cardiac rhythm changes and should notify the healthcare provider immediately. The learner should anticipate the management of a patient with increasing chest pain and an altered level of consciousness and assemble any emergency equipment (e.g., Code Cart.) The learner should document all findings and nursing care that has been given to the patient. In State 3 Ventriculater Tachycardia the patient demonstrates a rund of ventricular tachycardia for 10 seconds. After the learners have reassessed the patient and notified the healthcare provider of their findings and assembled the emergency equipment, the instructor should manually transition the patient to State 4 CCU Post PTCA. In State 4 CCU Post PTCA the patients condition improves, with a HR in the 70s, BP in the 120s/50s, RR in the low 20s and SpO2 in the high 90s on oxygen at 2 LPM via nasal cannula. Other clinical findings include a normal sinus cardiac rhythm, clear breath sounds and normal bowel sounds. The patient is alert and orientated with equal pupils. The patient has warm dry skin. His temperature is 38C with a capillary refill of less than three seconds. On checking the peripheral pulses of the left leg, the learner finds them 2+/4. The patient states that he has no pain (0/10 on the pain scale) and is asking questions such as What happened to me?, Did I really have a heart attack?, What does this mean for me now? and Will I have to take all these medications at home?. The learner is expected to assess the patient and interpret and monitor the pulse oximetry and cardiac rhythm. By demonstrating effective communication strategies with the patient and his family, the learner should identify the teaching needs and provide education at the appropriate level. All healthcare orders should be carried out in a safe manner (e.g., discontinuing the intravenous infusion and administering any medication using the Six Rights.) All care should be documented.
Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction

This SCE prepares the learner for the following items of the NCLEX-RN test format: NCLEX-RN Test Plan: X Safe and Effective Care Environment X Management of Care X Safety and Infection Control X Health Promotion and Maintenance X Psychosocial Integrity X Physiological Integrity X Basic Care and Comfort X Pharmacological and Parental Therapies X Reduction of Risk Potential Physiological Adaptations
Author
Original Author: Isaac Smith, Prairie View A & M University, Houston, Texas and Cheri Hernandez, California State University - Long Beach, Long Beach, California. Reviewer: Isaac Smith, Prairie VIew A & M University, Houston, Texas and Christie Pawley, METI. Sarasota, Florida 2008 and Amanda Wilford, METI Sarasota, Florida, 2009
Background
Patient History
Past Medical History: Unknown Allergies: No known drug allergies Medications: No medications Code Status: Full Code Social/Family History: He is a retired postal worker who is accompanied by his wife.
Handoff Report
The learner is expected to notify the healthcare provider of abnormal assessment findings where appropriate and necessary. The report should follow the SBAR format and include: Situation: The patient is a 68-year-old male who was admitted to the ED reluctantly by the paramedics from his home. At the scene, the paramedics administered sublingual (SL) nitroglycerin three times. While being transferred in the ambulance and following an ECG that showed an ST segment elevation of 2 mm, the paramedics commenced 2 LPM of oxygen via nasal cannula, asked the patient to chew 160 mg of aspirin and inserted an IV saline lock in the right forearm. The patient has been seen by the healthcare provider and orders have been written including to prepare him for a cardiac catheterization Background: 68-year-old man chest pain at home that on ECG indicates an acute myocardial infarction (AMI). He has been having crushing chest pain that radiates to his neck and jaw during the afternoon whilst cleaning out his garage. His wife reports that he appeared to be a horrible blue-grey color and the pain was not relieved until the paramedics arrived. The patient did not want to come to the hospital, and the paramedics needed to convince him. The time frame from initial onset to now is within the four-hour window. Assessment by the paramedics: HR 115, BP -106/68, RR 24, SpO2 95% on air, maintained now on oxygen at 2 LPM. General Appearance: Seems anxious. Cardiovascular: Cardiac Rhythm sows 2 mm ST-segment elevation Respiratory: Lungs clear GI: Bowel sounds normal GU: Not formally assessed Extremities: Not formally assessed Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction

Skin: Warm Neurological: Alert and oriented to person, place and time; Pupils equal, round and reactive to light and accommodation; no neurological deficits IVs: IV saline lock in right forearm. Labs: Need to be taken as per healthcare provider orders. Fall Risk: Needs to be assessed Pain: At the scene 4/10; on arrival to the ED 0/10 Recommendations: Please fully assess the patient and take all bloods particularly those for a Myocardial Infarct (MI) panel. Please administer all medications as prescribed noting for the effects and side effects and prepare the patient as per protocol for a cardiac catheterization and possible PTCA with stent placement.
Orders
Initial Orders Continuous cardiac monitor 12-lead ECG STAT and with complaints of chest pain MI Panel: CK, CK-MB, and Troponin I STAT and every 6 hours x3 CBC, Electrolytes, BUN, Creatinine, Glucose, PT/INR, PTT, UA C&S STAT Chest x-ray STAT NPO Saline lockpotential for thrombolytic therapy O2 at 2-6L PM by nasal cannulatitrate to maintain SpO2 greater than 92% Aspirin 325 mg chewed and swallowed STAT if not given by paramedics Nitroglycerin 50 mg/ 250 mL mixed with 5% Dextrose (D5W) IV at 5 mcg/minute, titrate for chest pain with SBP greater than 90 mmHg Morphine 2-10 mg Intravenous Push (IVP) as required if chest pain not relieved by nitroglycerin Metoprolol 5 mg slow IVP every 5 minutes for a total of 3 doses. Hold for HR less than 60 or SBP less than 90 mmHg Heparin 5000 units IVP and start continuous infusion at 1000 units/hr Vital signs every 15 minutes while titrating nitroglycerin, then every hour Foley catheter Weight on admission Intake and output Prepare for cardiac catheterization Obtain permit for cardiac catheterization and possible percutaneous transluminal coronary angiography (PTCA) with stent placement Notify healthcare provider of SBP less than 90 mmHg, HR less than 60, or PVCs greater than 6 per minute

State 2 Orders: Amiodarone 150 mg IV over 10 minutes, then 360 mg IV over 6 hours. Follow with maintenance infusion of 540 mg IV over 18 hours Dopamine IV infusion at 5 mcg/kg/minute. Titrate to keep SBP greater than 100 mmHg Notify Cardiac Catheter Laboratory of STAT transfer Before State 3 Orders: After the learner has administered the amiodarone and dopamine and the patient undergoes his PTCA, the following orders should be given. Transfer to the Coronary Care Unit Post PTCA orders for the next 8 hours: Complete bedrest with head of bed (HOB) at and left lower extremity straight HOB not to be elevated greater than 30 Sandbag over dressing to left groin Assess vital signs, left groin dressing and neurovascular status of left lower extremity every 15 minutes x 1 hour, every 30 minutes x 2 hours, every hour x 4 hours, then per Intensive Care Unit (ICU) routine Continuous cardiac monitoring Continuous SpO2 monitoring O2 at 2-6 LPM per nasal cannula to maintain SpO2 greater than 93% Dextrose 5% /0.45% NS infusing IV at 75 ml/hr: Convert to saline lock when stable and tolerating PO uids Cardiac diet 12-lead ECG in AM and prn chest pain Echocardiogram CBC, Electrolytes, BUN, Creatinine, Glucose PT/INT, PTT in AM Fasting lipid prole and liver function tests in AM Daily weight Intake and output every 8 hours Amiodarone 540 mg IV over 18 hours Dopamine IV infusion at 5 mcg/kg/min; titrate to keep SBP greater than 100 mmHg Enteric coated aspirin 325 mg PO daily Isosorbide dinitrate 10 mg PO 4 times a day Metoprolol 50 mg PO every 12 hours: Hold for HR less than 60 or SBP less than 100 Clopidogrel 300 mg PO for 1st dose, then 75 mg PO daily Captopril 12.5 mg PO every 8 hours: Hold for SBP less than 100 Diltiazem 30 mg PO every 6 hours Simvastatin 10 mg PO daily at HS Enoxaparin 1 mg/kg SQ every 12 hours Nitroglycerin 0.4 mg SL prn chest pain: May repeat every 5 minutes x 3 doses Morphine 1-5 mg IVP every 5 minutes for chest pain not relieved by nitroglycerin: Hold for SBP less than 90 Notify healthcare provider if chest pain is unrelieved by nitroglycerin Acetaminophen 650 mg PO every 4 hours prn for nonanginal minor pain Docusate sodium 100 mg PO daily unless diarrhea occurs: reevaluate daily Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction

Antacid 15 ml PO every 4 hours prn indigestion Laxative 30 ml PO daily prn constipation Promethazine 12.5 mg IV/PO every 4-6 hours prn nausea Temazepam 15 mg PO at HS prn, may repeat x1 Alprazolam 0.25-0.5 mg PO every 8 hours prn anxiety Cardiac Rehabilitation consult for activity progression Social Services consult
Preparation
Learning Objectives
Integrates theoretical knowledge from the sciences, humanities and nursing into Uses critical-thinking and the nursing process as a framework for clinical decision-making Designs an individualized plan of care for the nursing management of a patient with an
acute coronary syndrome (APPLICATION). (ANALYSIS). professional nursing practice (SYNTHESIS).
Learner Performance Measures

State 1 Initial Assessment: Performs an initial physical assessment on a 68-year-old male Identies abnormalities in assessment and reports those abnormalities to the healthcare provider Documents all ndings appropriately Reviews orders and implements the healthcare providers plan of care Formulates a plan of care Establishes ECG monitoring Repeats assessment, evaluates data and documents ndings Assesses and analyzes the cardiac rhythm Monitors pulse oximetry Inserts urinary catheter using sterile technique sending urine specimen to the lab Documents the catheter insertion Documents characteristics of urine: color, clarity, amount and odor Records output correctly Assesses for potential thrombolytic therapy Noties healthcare provider of lab results and assessment data Prepares for PTCA Draws labs using appropriate technique and lab tubes Calls lab for results and then calls results to healthcare provider Veries the correct oxygen setting Initiates the second IV for nitroglycerin therapy Administers the nitroglycerin infusion and ensures the accuracy of dose Administers the correct dose of metoprolol times three doses Administers heparin infusion and ensures the accuracy of the dose State 2 Onset of Cardiogenic Shock: Performs a physical assessment Identies the abnormalities in assessment and reports those abnormalities to the healthcare provider Assesses and analyzes the cardiac rhythm Monitors the pulse oximetry Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction

Identies the rhythm correctly and the need for antidysrhythmic medication Identies potential medical orders or nursing measures that may be appropriate for the
patient with cardiac pain Evaluates vital signs and explains abnormals Documents all ndings appropriately Noties the healthcare provider of changes in assessment Evaluates chest pain and documents appropriately Anticipates and prepares for emergency intervention Remains with patient Evaluates patients level of responsiveness Increases oxygen Ensures the code cart is at bedside Documents characteristics of urine: color, clarity amount and odor Records output correctly
State 2 Following Healthcare Providers Orders: Repeats assessment, evaluates data and documents ndings Reassesses cardiac rhythm Medicates patient, demonstrating the Six Rights Correctly administers medication amiodarone and dopamine Administers (drug-route) using the correct technique Documents on medication administration record (MAR) Anticipates and monitors for side effects of medication Prepares for STAT the transfer to Cardiac Catheter Laboratory when stable hemodynamically State 4 CCU Post PTCA: Performs a physical assessment Identies and prioritizes teaching needs Evaluates pain and documents appropriately Reassesses cardiac rhythm Monitors the pulse oximetry Assesses the level of social support Assesses the readiness to learn and provides appropriate education Communicates effectively with patient and family members Monitors IV infusion and site Converts IV to saline lock when taking oral fluids Instructs the patient to post-PTCA care Offers uids orally Evaluates assessment ndings. Documents ndings and intervenes appropriately Administers medications using the Six Rights Begins discharge teaching appropriate for patient with acute myocardial infarction (AMI)
Acute Coronary Syndrome and Acute Myocardial Infarction PNCI Preparation Questions
What is Acute Coronary Syndrome (ACS)? Describe the etiology and pathophysiology of ACS. What are the differences between a transmural (e.g., full thickness) myocardial infarction How are these differences depicted on the ECG? What are the areas of infarction? Correlate the location and area involved with the part of the coronary circulation involved: Right coronary artery Left anterior descending artery Left circumex artery Why does the younger person who has a severe MI usually have more serious impairment
(MI) and a subendocardial (e.g., partial thickness) MI?
than an older person? Why is it common for the temperature to rise in the rst 24 hours following an AMI? What is the most common complication following an AMI? Why? Correlate the area of infarction and the side effects/complications most commonly seen: Inferior wall damage Lateral wall damage Anterior wall damage Posterior wall damage What are the serum cardiac markers used in diagnosing an AMI? When do their levels peak? When do their levels return to normal? Thrombolytic therapy should be instituted within how many hours of the onset of pain to be of most benet? What are the nursing implications and management of the patient receiving thrombolytic therapy? What are the major drug classications the nurse would anticipate a patient with ACS receiving? For each of the classications, identify the action and key nursing implications. Outline the components of a teaching plan for a patient with ACS and successful revascularization via PCI. What is the half-life of amiodarone? Why is this important to know?
10
Acute Coronary Syndrome and Acute Myocardial Infarction PNCI Equipment and Supplies
IV Supplies Transparent dressing (2) IV pumps (4) IV pump tubing (4) Distilled water 250 mL (labeled Nitroglycerin 50 mg in 250 mL 5% Dextrose, Heparin 25,000 units in 250 mL 0.9% Sodium Chloride, Dopamine 200 mg in 250 ml 5 % Dextrose) (3) Distilled water 100 mL (labeled 5 % Dextrose) (2) Distilled water 500 mL (labeled 5 % Dextrose) IV Piggy Back (PB) tubing (3) Saline lock 20ga IV catheter (2) Supplies Simulated pills (labeled Aspirin 325 mg, clopidogrel 300 mg, metoprolol 50 mg, quinapril 2.5 mg, captopril 12.5 mg, isosorbide 10 mg, diltiazem 30 mg, simvastatin 10 mg, acetaminophen 325 mg x2, docusate 100 mg, promethazine 12.5 mg, temazepam 15 mg, alprazolam 0.25 mg, alprazolam 0.5 mg) Distilled water 10 ml vial (labeled Metroprolol 10 mg/10 mL) Empty nitroglycerin bottle with baby aspirin (labeled NTG 0.4 mg) Distilled water 1 mL vial (labeled Morphine Sulfate 5 mg / mL, promethazine 25 mg/ mL, heparin 10,000 units/ mL) Distilled water 10 mL vial (labeled Amiodorone 50 mg/ mL x2) 60 mL bottle (labeled antacid, labeled Laxative) 3 mL syringe Plastic medication cup Prelled 1 mL syringe lled with 1 ml distilled water (labeled Exonaparin 100 mg /mL) Oxygen, Airway and Ventilation Supplies Oxygen owmeter Oxygen source Nasal cannula Non-rebreather mask Oxygen connection tubing Water to humidify oxygen (if needed) Genitourinary Supplies 14 Fr urinary catheter with drainage bag Urimeter Distilled water 1000 mL with 2 mL of yellow food coloring for urine source
11

Laboratory Supplies Blood tubes (4) Vacutainer and needle (or equivalent) 2 x 2 gauze Tape Sterile Specimen Cup Blood gas syringe with 21 gauge needle Miscellaneous Stethoscope BP cuff adapted for use with simulator Non-sterile gloves (one box) Sharps container Patient identification band Patient chart with appropriate forms and order sheets 4 x 4 gauze 5 x 9 dressing 5 lb sandbag Audio and visual recording devices Monitors Required ECG NIBP SPO2 Temperature
12
Notes
Facilitator Notes
This SCE was created with the patient Jimmy Kearns, and only this patient can be used. The physiological values documented indicate appropriate and timely interventions. Differences will be encountered when care is not appropriate or timely. If using the Muse platform, dont hit Run until you are ready to start the scenario. If using the HPS6 platform, open the patient and scenario directory. Do not open the scenario until you are ready to start the simulated clinical experience. Learners should perform an appropriate physical exam, and the facilitator or patient should verbalize physical findings the learner is seeking but not enabled by the simulator (such as pain on palpation). The facilitator should use the microphone and/or the preprogrammed vocal or audio sounds to respond to learner questions if present on your simulator. Where appropriate, do not provide information unless specifically asked by learner. In addition, ancillary study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them. If the patient becomes unconscious in the SCE, remember the patient stops speaking. It is important to moulage the simulator to enhance the fidelity, or realism, of the simulated clinical experience. For this patient, dress the simulator in casual clothing. At the end of State 2, place a pressure dressing and sandbag over the left groin. When the learner initiates cardiac monitoring, the tracing and heart rate appear on a real ECG monitor for those simulators with this feature. For simulators without ECG monitoring, have the learner apply ECG electrodes to the mannequin and attach leads. Once all 3 or 5 leads are in place, reval the TouchPro or Waveform display ECG tracing. Prime the Genitourinary system per simulator feature. Leave the indwelling catheter in place to the drainage bag if the patient already has a urinary catheter in place. Remove the catheter if the learner is to insert a urinary catheter. Add one drop of yellow food coloring to 1000 mL of distilled water, and pre-fill a urinary catheter bag to simulate that the patient has already drained an additional 50 mL of urine. Place a code cart either outside the room or away from the patient area in the room to allow the secondary nurse to retrieve it and bring it to the bedside, if needed. Have a code cart and either an automated external defibrillator or a defibrillator with the code cart. Simulation center personnel should play the following roles: Healthcare provider Laboratory technician Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
13

Make a patient chart with the appropriate written order forms, MARs, diagnostic results, etc. for learners to utilize. The chart should include the specific patient identification information. Begin simulation with the offgoing nurse providing verbal handoff to the oncoming nurse using SBAR. Have the learners roleplay inter-professional communication by reporting the patients response to interventions. If the data presented is disorganized or missing vital components, have the healthcare provider become inappropriate in response. Emphasize the importance of data organization and completeness when communicating. Roleplay intra-professional communication by having the learner hand off to the admitting or transferring unit or have the learner hand off to the next shift. When learners apply and/or titrate oxygen, the facilitator should open the Oxygen Intervention Option or Treatment Scenario and choose the appropriate flow rate. If using the HPS, no software command is necessary when real oxygen is applied. When learners provide pharmaceutical interventions, the facilitator should open the Medication Intervention Option or Treatment Scenario and choose the appropriate medication. If using the drug recognition feature of the HPS, no software command is necessary when a drug is administered using that system. When learners provide IV fluid interventions, the facilitator should open the Intervention Option or Treatment Scenario and choose the appropriate fluid and volume to be administered. Debriefing and instruction after the scenario are critical. Learners and instructors may wish to view a videotape of the scenario afterward for instructional and debriefing purposes.
Debriefing Points
The facilitator should begin by introducing the process of debriefing: Introduction: Discuss faculty role as a facilitator, expectations, confidentiality, safediscussion environment Personal Reactions: Allow students to recognize and release emotions, explore student reactions Discussion of Events: Analyze what happened during the SCE, using video playback if available Summary: Review what went well and what did not, identify areas for improvement and evaluate the experience
14

Questions to be asked during debriefing: What was the experience like for you? What happened and why? What did you do and was it effective? Discuss your interventions (technical and non-technical). Were they performed appropriately and in a timely manner? How did you decide on your priorities for care and what would you change? How did patient safety concerns influence your care? What did you overlook? In what ways did you personalize your care for this patient and family members (recognition of culture, concerns, anxiety)? Discuss your teamwork. How did you communicate and collaborate? What worked, what didnt work and what will you do differently next time? What are you going to take away from this experience?
Teaching Q&A
State 1 Initial Assessment: Is this patient a candidate for thrombolytic therapy? Yes, must be symptomatic for less than six hours, have pain for 20 minutes unrelieved by nitroglycerin and have a ST segment elevation greater than or equal to 1 mm in two or more continuous leads and no contraindications for thrombolytic therapy Contraindications include: previous hemorrhagic stroke at any time, other strokes or CVA within past one year, known intracranial neoplasms, active bleeding or suspected aortic dissection Should this patient develop chest pain, what is the rationale behind each of the modalities ordered? ECG: To be interpreted by healthcare provider for extension of current MI or development of right ventricular infarctions Nitroglycerin SL: Immediate relief of ischemic pain of AMI; increases coronary perfusion (vasodilation); caution should be used in administering nitroglycerin to patients with inferior or right ventricular infarctions Nitroglycerin drip: Initiated after SL nitroglycerin for titration to relief of ischemic pain Morphine IV: When symptoms are not immediately relieved with nitroglycerin or when acute pulmonary congestion is present; induces modest arterial and venous dilation resulting in reduced myocardial oxygen demands from its effect on afterload and preload Call healthcare provider if chest pain is not relieved by nitroglycerin: Warrants intervention What is the rationale for oxygen administration? Assists myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarctions; assists in maintaining oxygenation
15

What lab results are indicative of ACS? CK Total: Levels rise within three to eight hours after myocardial injury and returns to baseline within three to four days CK-MB: Typically detectable four to six hours after the onset of ischemia, peaks in 12 to 24 hours and normalizes in two to three days. Does not predict infarction size but can be used to detect early reinfarction Troponin: Preferred markers of myocardial injury because of higher specicity and sensitivity to myocardial damage than CK-MB: Can be detected between three to six hours after onset of symptoms Myoglobin: Can be detected as early as two hours after myocardial necrosis occurs What is Troponin I, and what are the normal values? Troponins are biochemical markers for cardiac diseases especially for the diagnosis of Acute Myocardial Infarction. Troponin I is cardiac specic The normal is 0.1-0.5ng/ml Suspicious myocardial injury - 0.5-2.0 ng/ml What is the signicance of S4? S4 is an atrial gallop that occurs with decreased compliance of the ventricle. What do the current guidelines from the American Heart Association indicate for the management of acute coronary syndrome? All patients with ST-segment elevation should receive aspirin, beta-blockers (in the absence of contraindications) and an antithrombin (particularly ifalteplase or reteplase is used for brinolytic therapy) Heparin use in patients receiving nonselective brinolytic agents remains controversial Patients treated within 12 hours and eligible for brinolytics should expeditiously receive either brinolytic therapy or be considered for primary PTCA Primary PTCA is also considered when brinoltyic therapy is absolutely contraindicated Coronary Artery Bypass Graft (CABG) may be considered if it is less than six hours from onset of symptoms Individuals treated after 12 hours should receive the initial medical therapy noted above and, on an individual basis, may be candidates for reperfusion ]therapy or ACE inhibitors What preparations need to be made for a PTCA? Teach the patient and family members about the procedure Check for a history of allergies If allergic to shellsh, iodine or contrast media, notify the healthcare provider Ensure the consent is signed Restrict food and uids for at least six hours before the procedure Ensure the results of the coagulation studies CBC, Electrolytes, blood type and cross are on the chart Ensure patency of IV
16

Prep area (if ordered) Give sedation as ordered Take baseline peripheral pulses in all extremities
State 2 Onset of Cardiogenic Shock What is the appropriate sequence of interventions for a patient having chest pain? STAT ECG to assess for ischemic changes or nding consistent with pericarditis Immediate set of vital signs Assess for new murmurs or friction rubs Increase FiO2 Give nitroglycerin SL or morphine sulfate for chest pain unrelieved by nitroglycerin Notify healthcare provider for chest pain unrelieved by nitroglycerin What response(s) would cause the nurse to alter this sequence? If systolic BP falls below 90 and unable to give nitroglycerin or morphine sulfate If rapid decline of condition Immediately call healthcare provider and start ACLS protocol Is uid resuscitation appropriate in this patient? Why or why not? No, the problem is not volume Heart has lost its pumping ability to adequately eject blood (volume) secondary to damage from AMI What has caused this dramatic change in condition? Cardiogenic shock What is this patient most at risk for now? Increasing infarction size Circulatory collapse Possible right ventricular infarct What is the treatment indicated to prevent the progression of the shock state? Aggressive approach to treat underlying cause Enhance effectiveness of the pump Improve tissue perfusion Inotropic agents to increase cardiac output and maintain adequate BP and peripheral perfusion Diuretics for preload reduction Once BP has been stabilized, vasodilating agents are used for preload and afterload reduction Antidysrhythmic agents are used to suppress dysrhythmias that can affect cardiac output Intubation and mechanical ventilation may be necessary to support oxygenation Possible intraortic balloon pump to augment coronary artery perfusion and decrease myocardial oxygen demand by reducing afterload Strict glucose control (80-110) Revascularization Program for Nursing Curriculum Integration (PNCI) Acute Coronary Syndrome and Acute Myocardial Infarction
17

What is the rationale for amiodarone? Indicated for suppression of ventricular arrhythmias Prolongs myocardial cell action potential and refractory period by direct action on all cardiac tissue, decreasing aortic valve conduction and sinus node function What is the rationale for dopamine? What unexpected effects should be monitored for? Dopamine is a positive inotrope agent acting primarily on beta1-adrenergic receptors to increase the contractile force of the heart Causes increased cardiac output leading to increased BP and tissue perfusion Dopamine is also a positive inotrope at 5-10mcg/ kg/minute, but tends to increase HR (release of norepinephrine) and thus increase myocardial oxygen demand What is the rationale for nitroglycerin? What are contraindications for nitroglycerin? For the relief of ischemic pain and to increase coronary perfusion by vasodilation Contraindicated with hypotension or uncorrected hypovolemia, constrictive pericarditis and pericardial tamponade, severe anemia and previous reaction to drug What is the nursing management of each of these drugs? Amiodarone: Assess BP and apical pulse immediately before drug administered Hold if HR below 60 or systolic blood pressure is less than 90 Monitor for symptoms of pulmonary toxicity Monitor ECG for cardiac changes (widening QRS, prolonged PR interval, and QT) Monitor liver enzymes Dopamine: Continuous cardiac monitor to assess for arrhythmias Hourly urine output If extravasation occurs at IV site, take corrective action per hospital policy immediately Monitor cardiac outpit (CO), BP, and central venus pressure (CVP) or pulmonary arterial occlusion pressure (PaOP) if available Monitor CO, BP, and CVP or PAWP if available Assess peripheral circulation Nitroglycerin: Record onset, type, radiation, location, intensity and duration of anginal pain and precipitating factors Assess BP and apical pulses before administration and periodically after dose Continuous ECG monitoring for IV administration Instruct to rise slowly from lying to sitting position and dangle legs before standing; may cause headache State 4 CCU Post PTCA: What is the nursing management of weaning off oxygen? Wean slowly by 1 to 2 LPM/hour Continuously monitor RR and effort as well as oxygen saturation
18

What would be assessed to determine not only readiness but also success? Readiness assessed by SpO2 greater than 98% on 2 to 4 LPM oxygen Success indicated by ability of patient to sustain SpO2 greater than 92% on room air and RR within normal limits How would the nurse assess this patients readiness to learn? Once stable, validating readiness with patient Patients expression of interest in care and follow-up Questions asked by patient with regard to treatment and therapies Willingness to listen Decreased stress and anxiety levels Following PTCA, what is important for the nurse to assess? Assess vital signs every 15 minutes for the rst hour, then every 30 minutes for four hours, unless condition warrants more frequent checking Assess peripheral pulses distal to the catheter insertion site as well as the color, sensation, temperature and capillary rell of the affected extremity (compromised blood ow) Assess catheter site for hematoma, ecchymosis and hemorrhage Monitor ECG rhythm and arterial pressures Monitor the ECG for ST and T-wave changes (coronary artery spasm) Be alert for early symptoms of ischemia (coronary artery dissection may occur with no early symptoms, but can cause restenosis of the vessel) What are the potential complications following revascularization? Persistent coronary spasms Coronary artery dissection Acute coronary thrombosis Bleeding and hematoma at site of cannulation Compromised blood ow to involved extremity Contrast-induced renal failure Dysrhythmias Vagal response during manipulation or removal of introducer sheaths Restenosis What are the priorities in this patients discharge teaching? Recognition of signs and symptoms of ACS and appropriate actions to take Goals for secondary prevention (maintenance of BP at or below 120/80; smoking cessation, at least 30 minutes of physical activity three to four days/week; weight management) Need for antiplatelet medication (warning to avoid ibuprofen), ACE inhibitors and betablockers Lipid management through diet (low saturated fat and cholesterol) and drug therapy Possible cardiac rehabilitation Restriction and resumption of physical and sexual activity Healthcare provider follow-up care
19

Who should be involved in this and why? Patient, wife and any other interested family members For support, encouragement and reinforcement of information What are possible referrals for this patient? Cardiologist Cardiac rehabilitation program CPR training program for family Dietician What concerns might the nurse anticipate this patient and his wife having with discharge? Anxiety regarding change of lifestyle to promote health Fear of reoccurrence of chest pain, AMI or sudden death Fear of resumption of sexual activity
References
Fenton, D. (2004). Acute coronary syndrome. Postgraduate Medicine 1, 1-33. Fonarow, G.C., Wright, R.S., Spencer, F. A., Fredrick, P. D., Dong, W., Every, N. et al. (2005). Effect of statin use within the rst 24 hours of admission for acute myocardial infarction on early morbidity and mortality. The American Journal of Cardiology 86(5), 611-615. Hani, J., (2003). Aspirin and clopidogrel in acute coronary syndromes. Arch Intern Med 163, 1143-1151. Kee, J.L. (2009). Prentice hall handbook of laboratory and diagnostic tests with nursing implications. (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Keeley, E.C. and Grines, C.L. (2004). Primary coronary intervention for acute myocardial infarction. JAMA 291, 6, 736-739 Kowalak, J.P., Hughes, A.S. & Mills, J.E. (2003). Best practices: A guide to excellence in nursing care. Philadelphia: Lippincott Williams & Wilkins. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., OBrien, P.G. & Nucher, L. (2007). Medical- surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Mosby. Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs. International Journal of Evidence Based Healthcare 2(6), 207-230. Mahaffey, K.W., Cohen, M., Garg, J., Antman, E., Kleiman, N.S., Goodman, S.G., et al (2005). High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin. JAMA 294, 20. McGee, S. (2007). Evidence-based physical diagnosis (2nd ed.). Philadelphia: Saunders.
20

Morton, P.G., Fontaine, D.K., Hudak, C.M. & Gallo, B.M. (2005). Critical care nursing: A holistic approach (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Mosby Staff. (2004). Mosbys drug consult for healthcare professions 2006. St. Louis, MO: Mosby. Nettina, S. M. (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Pifarre, R. (2001). Evidence-based management of the acute coronary syndrome (1st ed.). Philadelphia: Hanley and Belfus. Registered Nurses Association of Ontario. (2002). Assessment and management of pain. Toronto: RNAO. Rippe, J.M. (2003). Intensive care medicine (5th ed.). Boston: Little. Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2008). Brunner and suddarths textbook of medical-surgical nursing. Pennsylvania: Lippincott Williams & Wilkins. Springhouse (Eds). Best practices: Evidence-based nursing procedures (2nd ed.). (2006).
21

ACS AMI Facilitator

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

ACS AMI Facilitator

Uploaded by

Copyright:

Available Formats

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Learner Performance Measures

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

Acute Coronary Syndrome and Acute Myocardial Infarction PNCI

You might also like