Republic of the Philippines CAVITE STATE UNIVERSITY DON SEVERINO DE LAS ALAS CAMPUS Indang, Cavite

College Of Nursing

Critical Care Nursing

Cardiovascular System: Acute Coronary Syndrome

Submitted by: Losoloso, Bethlehem E. BSN 4-1 Submitted to: Mrs. Mary Antoinette Viray RN, MAN Clinical Instructor

Introduction
The circulatory system is an organ system that permits blood and lymph circulation to transport nutrients (such as amino acids and electrolytes), oxygen, carbon dioxide, hormones, blood cells, etc. to and from cells in the body to nourish it and help to fight diseases, stabilize body temperature and pH, and to maintain homeostasis.

This system may be seen strictly as a blood distribution network, but some consider the circulatory system as composed of the cardiovascular system, which distributes blood, and the lymphatic system, which returns excess filtered blood plasma from the interstitial fluid (between cells) as lymph. While humans, as well as other vertebrates, have a closed cardiovascular system (meaning that the blood never leaves the network of arteries, veins and capillaries),

some invertebrate groups have an open cardiovascular system. The more primitive, diploblastic animal phyla lack circulatory systems. The lymphatic system, on the other hand, is an open system providing an accessory route for excess interstitial fluid to get returned to the blood.

The essential components of the human cardiovascular system are the heart, blood, and blood vessels. It includes: the pulmonary circulation, a "loop" through the lungs where blood is oxygenated; and the systemic circulation, a "loop" through the rest of the body to provide oxygenated blood. An average adult contains five to six quarts (roughly 4.7 to 5.7 liters) of blood, accounting for approximately 7% of their total body weight. Blood consists of plasma, red blood cells, white blood cells, and platelets. Also, the digestive system works with the circulatory system to provide the nutrients One of which are problems in relation to the pumping action of the heart, ventricular contraction, thrombosis, stenosis, so also with the different structures of the heart that causes an impairment of its normal function.

ACUTE CORONARY SYNDROME

Acute Coronary Syndrome 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. (Although the terms coronary occlusion, heart attack and MI are used synonymously, the preferred term is MI.) The spectrum of ACS includes unstable angina, non-ST segment elevation MI (NSTEMI), and ST-segment elevation MI (STEMI).

Risk Factors
Genetics (hypertension, diabetes, abdominal aortic aneurysm, carotid artery disease) Environmental and Chemical Factors (smoking, alcohol) Lifestyle (sedentary, no exercise) Dietary Intake (increase ingestion of fatty foods,) Biologic Factors (elevated low-density lipoproteins, decreased high-density lipoprotein, systolic blood pressure) Increasing Age Inflammatory Response Disorders (high levels of C-reactive protein) Prothrombotic state (high fibrinogen level) Obesity Gender Race

Causes
Atherosclerosis - abnormal accumulation of lipid or fatty substance, and fibrous tissue in the lining of arterial blood vessel wall. Vulnerable plaque - a plaque that has the tendency to rupture and can formed into a hemorrhage which leads to thrombus formation. Unstable Angina - reduced blood flow in a coronary artery Abnormal Electrocardiogram changes

Clinical Manifestations
Usually the patient under these disorder manifests chest pain that occurs suddenly and continuous despite rest and medication is the presenting symptom in most patient with ACS. Some of these patients have prodromal symptoms or a previous diagnosis of Coronary Artery Disease but about half report no previous symptom. Patients may present with a combination of symptoms, including chest pain, shortness of breath, indigestion, nausea, and anxiety. They may have cool, pale and moist skin. Their heart rate and respiratory rate may be faster than the normal rate. These signs and symptoms, which are caused by the stimulation of sympathetic nervous system may be present for only a short time or may persist. In many cases, the signs and symptoms of MI cannot be distinguished from those of unstable angina, hence, the evolution of the term ACS.

*CARDIOVASCULAR > Chest pain or discomfort not relieved by rest or nitroglycerin preparations. Heart sounds may include S3 and S4 and new onset of murmurs. > Increase jugular venous distention if MI has caused heart failure. > Blood pressure may be elevated because of sympathetic stimulation; decreased because of decreased contractility impending cardiogenic shock or medication.

*RESPIRATORY > Shortness of breath, dyspnea, tachypnea, and crackles if MI has caused congestion. Pulmonary edema may be present.

*GASTROINTESTINAL > Nausea and vomiting

* GENITOURINARY > A decreased urinary output may indicate cardiogenic shock

* INTEGUMENTARY (SKIN) > Cool, clammy, diaphoretic and pale appearance due to sympathetic stimulation indicate a cardiogenic shock.

* NEUROLOGIC > Anxiety, restlessness, and lightheadedness, may indicate increased sympathetic stimulation ; decreased because of decreased contractility and cerebral oxygenation.

*PSYCHOLOGICAL > Fear with feeling of impending doom, or denial that anything is wrong.

Non-pharmacological Management Assessment

It is one of the important aspect of care for the patient with ACS - it establishes the baseline for the patient so that any deviations may be identified, systematically identifies the patients 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, difficulty of breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). 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 symptom. A precise and complete physical assessment is critical to detect complications and any changes in patients status. IV sites are examined frequently. 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 patients condition stabilizes, IV lines may be changed to a saline lock to maintain IV access.

Nursing Diagnoses
Ineffective cardiac tissue perfusion related to reduced coronary blood flow Risk for imbalanced fluid volume Risk for ineffective peripheral tissue perfusion related to decreased cardiac output from left ventricular dysfunction Death anxiety related to cardiac event Deficient knowledge about post-ACS self care

Nursing Interventions
Relieving pain and other signs and symptoms of ischemia

Balancing myocardial oxygen supply with demand (eg. As evidenced by the relief of chest pain), is the top priority in the care of patient with ACS. Collaboration among the patient, nurse and the physician is critical in assessing patients response to therapy and in altering the interventions accordingly. Oxygen should be administered along with medication therapy to assist with relief of symptoms. Administration of oxygen even in low doses, 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 is also documented. A flow rate of 2 to 4 L/min is usually adequate to maintain oxygen saturation levels of 96 % to 100 % unless chronic pulmonary disease is present. Vital signs are assessed frequently as long as the patient is experiencing pain and other signs and symptoms of acute ischemia. Physical rest in bed with the backrest elevated or in a supportive chair helps decrease chest discomfort and dyspnea. Elevation of the head and torso is beneficial for the following response: > Tidal volume improves because of reduced pressure from abdominal contents on the diaphragm and better lung expansion. > Drainage of the upper lung lobe improves. > Venous return to the heart (preload) decreases, reducing the work of the heart.

Improving the respiratory function Regular and careful assessment of the respiratory function detects early signs of pulmonary

complications. The nurse monitors fluid volume status to prevent overloading the heart and lungs and encourages the patient to breathe deeply and change position frequently to help keep fluid from pooling from the bases of 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. It is important to check skin temperature and peripheral pulse frequently to monitor tissue perfusion.

Reducing anxiety Alleviating anxiety and decreasing fear are important nursing functions that reduce the

sympathetic stress response. Decreased sympathetic stimulation, decreases the workload of the heart, which may relieve pain and other signs and symptoms of ischemia. 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 acre and greatly assists in creating a positive relationship. Ensuring a quiet environment, preventing interruptions that disturb sleep, using a caring and appropriate touch, teaching relaxation techniques, using humor and providing spiritual support consistent with the patients beliefs. Provide opportunities for the patient to verbalize concerns and fear.

Monitoring and managing potential complications 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, sensorium, ECG changes, and laboratory values. And reporting to the physician immediately if there is changes to patients conditions and institute emergency measures if necessary.

Medical Management
The goals of management are to minimize myocardial damage, preserve myocardial function, and prevent complication. These goals may be achieved by reperfusing the area with emergency use of thrombolytic medications or PCI. Maintaining myocardial damage is also accomplished by reducing myocardial demand and increasing oxygen supply with medications, oxygen administration, and bed rest. The resolution of pain and ECG changes indicate that demand and supply are in equilibrium; they may also indicate reperfusion.

Pharmacologic Therapy The patient with MI is given aspirin, nitroglycerin, morphine, an IV beta-blocker and other

medications as indicated while the diagnosis is being confirmed. Patients should continue the betablocker throughout hospitalizations and after discharge because long term therapy with beta-blockers can decrease the incidence of future cardiac events. Unfractionated heparin is prescribed along with platelet-inhibiting agents to prevent further clot formation. Non-steroidal Anti-Inflammatory Drugs may be discontinued because of their association of adverse cardiac events.

Analgesics The analgesic of choice for acute MI is morphine sulfate administration in IV boluses to

reduce pain and anxiety. It also reduces preload and after load, which decreases the workload of the heart and relaxes bronchioles to enhance oxygenation. The cardiovascular response to morphine is monitored carefully, particularly the blood pressure, which can decrease, and respiratory rate which can be depressed. Because morphine decreases the sensation of pain. ST-segment elevation may be a better indicator of subsequent ischemia than reported pain.

Angiotensin-Converting Enzyme Inhibitors ACE inhibitors prevent the conversion of angiotensin 1 to angiotensin 2. In the absence of

angiogenesis II, the blood pressure decreases and the kidneys excrete fluid and sodium (diuresis), decreasing the oxygen demand of the heart. It is important to ensure that the patient is not hypotensive, hyponatremic, hypovolemic, hyperkalemic, Before administering ACE inhibitors Blood pressure, urine output, serum sodium, potassium, and creatinine levels need to be monitored closely.

Thrombolytics Thrombolytics are used to treat some patients with acute MI. These agents are administered IV

according to a specific protocol. The purpose of thrombolytics is to dissolve (ie lyse), the thrombus in a coronary artery (thrombolysis), allowing blood to flow through the coronary artery again (reperfusion), minimizing the size of the infarction, and preserving ventricular contraction. Use of thrombolytics does not affect the atherosclerotic lesion, the patient is still advise for cardiac catheterization and other invasive interventions. These drugs, also called clotbusters, help dissolve a blood clot that's blocking blood flow to your heart. If you're having a heart attack, the earlier you receive a thrombolytic drug

after a heart attack, the greater the chance you will survive and lessen the damage to your heart. However, if you are close to a hospital with a cardiac catheterization laboratory, you'll usually be treated with emergency angioplasty and stenting instead of thrombolytics. Clotbuster medications are generally used when it will take too long to get to a cardiac catheterization laboratory, such as in rural communities.

Nitroglycerin. This medication for treating chest pain and angina temporarily widens narrowed blood vessels, improving blood flow to and from your heart.

Beta blockers. These drugs help relax your heart muscle, slow your heart rate and decrease your blood pressure, which decreases the demand on your heart. These medications can increase blood flow through your heart, decreasing chest pain and the potential for damage to your heart during a heart attack.

Calcium channel blockers. These medications relax the heart and allow more blood to flow to and from the heart. Calcium channel blockers are generally given if symptoms persist after you've taken nitroglycerin and beta blockers.

Cholesterol-lowering drugs. Commonly used drugs known as statins can lower your cholesterol levels, making plaque deposits less likely, and they can stabilize plaque, making it less likely to rupture.

Clot-preventing drugs. Medications such as clopidogrel (Plavix) and prasugrel (Effient) can help prevent blood clots from forming by making your blood platelets less likely to stick together. However, clopidogrel increases your risk of bleeding, so be sure to let everyone on your health care team know that you're taking it, particularly if you need any type of surgery.

References: Medical-Surgical Nursing, Brunner and Suddarths volume 1 and 2

http://www.mayoclinic.com/health/acute-coronary-syndrome/DS01061/DSECTION=treatments-and-drugs