Page 144 - Critical Care Nursing Demystified
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Chapter 3 CARE OF THE PATIENT WITH CRITICAL CARDIAC AND VASCULAR NEEDS 129
Treatment
Stop all activity.
Administer oxygen.
Give medications (ASA, anticoagulants, Lopressor, nitrates, thrombolytics).
Prepare for coronary arteriogram, angioplasty, or open-heart surgery (OHS)
if needed.
Nursing Diagnoses for ACS Expected Outcomes
Acute pain due to coronary artery The patient will have 0 pain on a
blockage 1–10 scale
Ineffective tissue perfusion, cardiac due The patient will have normal VS,
to blockage of coronary arteries CO, and peripheral pulses
Nursing Interventions
Have patient stop all activity immediately and place patient on bedrest to
decrease workload and energy demand upon the heart.
Monitor the patient’s vital signs (VS) at least every 15 minutes, especially if
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Auscultate lung fields and heart sounds frequently to determine if heart
failure is occurring due to MI.
Monitor the patient’s telemetry because dysrhythmia disturbances often
occur in ACS, and they can lead to cardiac arrest or cardiogenic shock.
Assess ECGs periodically and when chest pain reoccurs to see if the infarc-
tion has extended into other ventricular tissues.
Continue ongoing pain assessments to evaluate if therapy is effective or more
advanced cardiac measures are needed like IABP, PAC, angioplasty, etc. (Refer
to these sections in this chapter.)
Perform venipunctures for cardiac enzymes and possible electrolytes and
check medication level as needed to see if ECG or electrolyte changes (i.e.,
low potassium or calcium) have occurred that can be treated.
Place the patient in a semi-Fowler’s position to allow the patient to breathe
easier.
Start at least one IV to allow for emergency administration of drugs. If the
patient is to receive thrombolytic therapy, three separate IV lines may be
needed.
Administer aspirin to help prevent platelets from sticking together.
