Acute Coronary Syndrome and Acute Myocardial Infarction

Si mul ated Cl i ni cal Experi ence (SCE) Over vi ew Lear ni ng Obj ecti ves
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 oor, 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 SpO
2
95% He stated his chest pain was 4/10. Paramedics administered
nitroglycerin 0.4mg SL x2 every ve 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 2LPM 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 ne 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
O
2
at 2-6LPM by nasal cannulatitrate to maintain SpO
2
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
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).
1 Learner
Program for Nursing Curriculum Integration (PNCI

)
2 Learner
i
S
t
a
n

P
r
o
g
r
a
m

f
o
r

N
u
r
s
i
n
g

C
u
r
r
i
c
u
l
u
m

I
n
t
e
g
r
a
t
i
o
n

(
P
N
C
I

)

A
c
u
t
e

C
o
r
o
n
a
r
y

S
y
n
d
r
o
m
e

a
n
d

A
c
u
t
e

M
y
o
c
a
r
d
i
a
l

I
n
f
a
r
c
t
i
o
n

2
0
0
8

M
E
T
I
,

S
a
r
a
s
o
t
a
,

F
L
;


O
r
i
g
i
n
a
l

A
u
t
h
o
r
:

I
s
a
a
c

S
m
i
t
h
,

P
r
a
i
r
i
e

V
I
e
w

A

&

M

U
n
i
v
e
r
s
i
t
y

a
n
d

C
h
e
r
i

H
e
r
n
a
n
d
e
z
,

C
a
l
i
f
o
r
n
i
a

S
t
a
t
e

U
n
i
v
e
r
s
i
t
y

-

L
o
n
g

B
e
a
c
h
.
R
e
v
i
e
w
e
r
:

I
s
a
a
c

S
m
i
t
h
,

P
r
a
i
r
i
e

V
I
e
w

A

&

M

U
n
i
v
e
r
s
i
t
y

a
n
d

C
h
r
i
s
t
i
e

P
a
w
l
e
y
,

M
E
T
I
.

v
.
2

A
u
g
u
s
t

2
0
0
8
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
suddarths textbook of medical-surgical nursing. Pennsylvania: Lippincott.
Taniguchi, R. (2004). Combined measurements of cardiac troponin T and N-terminal
pro-brain natriuretic peptide in patients with heart failure. Circulation 12, 1160-1164.
Vacek, J.L. (2002). Classic O wave myocardial infarction. Practical Peer Review
Journal for Primary Care Physicians 112(1), 71-77.
Questi ons to Prepare f or the Si mul ated Cl i ni cal Experi ence:
Ref erences
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 circumex 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 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 benet? What are the nursing implications and management of the patient
receiving thrombolytic therapy?
13. 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.
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 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