ACUTE CORONARY SYNDROME

Location: Coronary Care Unit

History/Information:

This patient is a 68-year-old retired postal worker who developed substernal

crushing chest pain, which radiated to the left side of his neck and jaw
while cleaning out his garage earlier this afternoon. His wife came outside to
check on his progress and found him sitting on the floor, holding his arm and
with a horrible blue-gray color in his face. He told her the pain had been
occurring since about 30 minutes after he started cleaning out the garage. I
thought it would go away, but it just keeps getting worse.
On arrival of the paramedics at the scene, the patient was responsive to all
questions. His initial vital signs were HR 115, BP 108/68, RR 24 and SpO2
95%.
He stated his chest pain was 4/10. Paramedics administered
nitroglycerin 0.4mg SL 2x every five minutes without relief. Five minutes
after administering the third nitroglycerin, the patient stated his chest pain
was now almost gone.
Paramedics had to convince him to come to the Emergency Department.
They did an ECG en route, which showed 2mm ST-segment elevation,
indicating an acute myocardial infarction (AMI). The paramedics started
oxygen at 2 LPM by nasal cannula, administered 160mg of chewable aspirin,
and started a right forearm saline lock. He had no chest pain en route, and
on arrival, he states he is pain free. He states, I am just fine now, and I dont
know why I am here.
Healthcare Providers Emergency Department 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 2-6LPM by nasal cannulatitrate to maintain SpO2 greater than 92%
Aspirin 325mg chewed and swallowed STAT if not given by paramedics
Nitroglycerin 50mg/250 ml D5W IV at 5 mcg/minute; Titrate for chest pain
with SBP greater than 90
Morphine 2-10mg IVP prn 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
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, HR less than 60, or PVCs
greater than 6 per minute.
Learning Outcome :
1. Integrates theoretical knowledge from the sciences, humanities and
nursing
into professional nursing practice (SYNTHESIS).
2. Uses critical thinking and the nursing process as a framework for clinical
decision-making (ANALYSIS).
3. Designs an individualized plan of care for the nursing management of a
patient with an acute coronary syndrome (APPLICATION).
Questions for preparing simulation :
1. What is Acute Coronary Syndrome (ACS)?
2. Describe the etiology and pathophysiology of Acute Coronary Syndrome.
3. What are the differences between a transmural (e.g., full thickness) MI and a
subendocardial (e.g., partial thickness) MI?
4. How are these differences depicted on the ECG?
5. What are the areas of infarction?
6. Correlate the location and area involved with the part of the coronary circulation
involved:
a. Right coronary artery
b. Left anterior descending artery
c. Left circumfl ex artery
7. Why does the younger person who has a severe MI usually have more serious
impairment than an older person?
8. Why is it common for the temperature to rise in the fi rst 24 hours following an
AMI?
9. What is the most common complication following an AMI? Why?

10. Correlate the area of infarction and the side effects/complications most
commonly
seen:
a. Inferior wall damage
b. Lateral wall damage
c. Anterior wall damage
d. Posterior wall damage
11. What are the serum cardiac markers used in diagnosing an AMI? When do their
levels
peak? When do their levels return to normal?
12. Thrombolytic therapy should be instituted within how many hours of the onset
of pain
to be of most benefi t? What are the nursing implications and management of the
patient receiving thrombolytic therapy?
13. What are the major drug classifi cations the nurse would anticipate a patient
with
ACS receiving? For each of the classifi cations, identify the action and key nursing
implications.
14. Outline the components of a teaching plan for a patient with Acute Coronary
Syndrome
and successful revascularization via Percutaneous Coronary Intervention (PCI).
15. What is the half life of amiodarone? Why is this important to know?

References :
Best practices: Evidence-based nursing procedures (2nd ed.). (2006). Philadelphia:
Lippincott.
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 fi 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, May). Aspirin and clopidogrel in acute coronary syndromes. Arch
Intern
Med 163, 1143-1151.
Joanna Briggs Institute for Evidence Based Nursing and Midwifery. (2007). Best
Practice:
Vital
Signs.
Retrieved
March
25,
2008
from
http://www.joannabriggs.edu.au/best_practice/
bp8.php?win=NN
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. and Mills, J.E. (2003). Best practices: A guide to
excellence in nursing care. Philadelphia: Lippincott.
Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., OBrien, P.G. and Nucher, L. (2007).
Medical-surgical nursing: Assessment and management of clinical problems. St.
Louis: Mosby.
Mahaffey, K.W. 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.
Morton, P.G., Fontaine, D.K., Hudak, C.M. and Gallo, B.M. (2005). Critical care
nursing: A holistic approach (8th ed.). Philadelphia: Lippincott.
Mosby Staff. (2004). Mosbys drug consult for healthcare professions 2006. St. Louis:
Mosby.
Nettina, S. M. (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia:
Lippincott.
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. and Cheever, K.H. (2008). Brunner and