17.10: Acute Coronary Syndrome V: Nursing Management

Nursing Assessment:

Nursing management of acute coronary syndrome (ACS) involves taking the patient's history, focusing on primary complaints such as chest pain, dyspnea, and excessive sweating (diaphoresis), as well as other symptoms like back or jaw pain, nausea, vomiting, palpitations, dizziness, and fatigue. The nurse also reviews the patient's history of cardiac events, risk factors such as hypertension, diabetes, smoking, family history, and current medications.

In the objective assessment, vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, are continuously monitored, focusing on detecting hemodynamic instability such as hypotension or tachycardia.

The physical examination includes a thorough cardiovascular assessment, noting abnormal heart sounds like S3 or S4, murmurs, or friction rubs. It also includes respiratory assessments for pulmonary congestion or edema and peripheral vascular checks for poor perfusion.

Diagnostic tests, including a 12-lead ECG to identify ischemic changes or arrhythmias, cardiac biomarkers such as troponins and CK-MB, complete blood count, lipid profile, electrolytes, and imaging studies like echocardiograms or chest X-rays, are performed as indicated to complete the assessment.

Diagnoses:

Based on a comprehensive assessment, the nursing diagnoses are formulated, such as:

• Acute chest pain related to myocardial ischemia secondary to coronary obstruction, as evidenced by patient reports of severe, crushing chest pain that may radiate to the left arm.
• Ineffective breathing patterns related to pulmonary edema secondary to decreased myocardial contractility, as evidenced by shortness of breath and labored breathing.

The patient's primary goals include relief of pain or ischemic signs, preventing myocardial damage, and maintaining effective respiratory function.

To achieve these goals, the nurse plans interventions:

Administer Medications:

• Administer prescribed medications such as nitroglycerin to relieve chest pain and improve blood flow.
• Provide aspirin as ordered to reduce platelet aggregation.
• Administer morphine as prescribed for pain management while closely monitoring for hypotension and respiratory depression.

Monitor Vital Signs:

• Regularly check blood pressure, heart rate, respiratory rate, and oxygen saturation.
• Monitor for signs of hypotension or bradycardia after medication administration.

Provide Oxygen Therapy:

• Administer supplemental oxygen if oxygen saturation is below 90% to maintain a saturation range of 90-94%.

Positioning:

• To improve chest expansion and comfort and facilitate breathing, position the patient in a semi-Fowler's position (45-degree angle) and lean forward if tolerated.

ECG Monitoring:

• Continuously monitor the patient's cardiac rhythm with an electrocardiogram (ECG).
• Alert the healthcare team of any significant changes in the ECG.

Monitor Fluid Balance:

• Strictly monitor input and output to manage fluid status.
• Weigh the patient daily to assess fluid retention.

Encourage Effective Breathing Techniques:

• Teach and promote the use of diaphragmatic breathing and pursed-lip breathing to improve ventilation.
• Encourage frequent deep breathing and coughing exercises.

Emotional Support:

• Provide reassurance and a calm environment to reduce anxiety.
• Explain all interventions and procedures to the patient and family.

Evaluation:

Lastly, the treatment plan should be evaluated by regularly assessing patient outcomes, including pain levels, respiratory function, and hemodynamic stability. Based on these evaluations, the care plan should be modified to ensure optimal patient recovery.