Page 553 - Cardiac Nursing

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C HAPTER 22 / Acute Coronary Syndromes 529
5. Consider ST-segment monitoring to detect silent ischemia or to DISPLAY 22-2 Selected Therapies to Reduce Ischemia
evaluate the relation between patient care activities and ischemia.
6. Report the findings of the above assessment to the physician. Decrease Myocardial O 2 Consumption
For Goal 2 Narcotic analgesics
1. Immediately reduce the patient’s physical activity to the level -Blocking agents
before occurrence of the discomfort. Maintain BP within normal limits
2. Administer oxygen, morphine sulfate if ordered, and NTG or Maintain normal sinus rhythm with medications, pacing,
other medications as ordered, and continuously evaluate the or cardioversion
patient’s response to therapy. Selected diet (initially clear liquids followed by small,
frequent, easily digested meals)
3. Provide a restful environment and maximize; and promote the
Stress reduction techniques
patient’s physical comfort by elevating the head of the bed to 20
Anxiolytics as indicated
to 30 degrees or higher and by individualizing basic patient care.
Maintain quiet environment
For Goal 3 Stool softeners and laxatives
1. Provide care in a calm, competent manner. Rest with backrest elevation 20 to 30 degrees
2. Provide a restful, quiet environment. Gradually increase physical activity
3. Provide small portions of easily digestible food. Increase Myocardial O 2 Supply
4. Assist the patient with activities of daily living.
5. Teach patient to exhale with physical movement (to avoid Val- Oxygen
salva maneuver), and as necessary, offer stool softeners and lax- NTG
atives to prevent straining. Aspirin
Anticoagulants
6. Teach patient to recognize precipitating factors and alter be- Reperfusion
havior accordingly. Thrombolytics
7. Teach patient to practice relaxation techniques. PCI
CABG
Outcome Criteria
Goal 1: Chest discomfort, 12-lead ECG changes indicative of is-
chemia, and changes in vital signs and hemodynamic responses
are detected at the onset.
Goal 2: Within 5 minutes of the intervention, patient states to improve this imbalance. Interventions to meet each goal
that chest discomfort is relieved or reduced; patient appears com- include:
fortable, heart and respiratory rates and BP are returning or have For Goal 1
returned to the baseline level before the onset of chest discomfort, 1. The patient’s heart rate and rhythm should be monitored fre-
ST segments and T waves revert to pattern seen before the onset quently during the acute phase of MI. Assess and document
of chest discomfort, and skin is warm and dry. cardiac rhythm every 1 to 4 hours depending on patient con-
Goal 3: Patient denies chest discomfort, patient appears com- dition, before and after each dose of antiarrhythmic or vasoac-
fortable, heart and respiratory rates and BP are within patient’s tive drug (or any drug with cardiovascular effects), and when
normal range, and skin is warm and dry (Display 22-2).
patient status indicates. Assess BP and obtain 12-lead ECG
with changes in cardiac rhythm or if patient complains of pal-
Decreased Myocardial Tissue pitations.
Perfusion 2. If the patient experiences arrhythmias, perform a cardiovascu-
lar examination; obtain venous blood for electrolytes, hemo-
Diagnosis globin, and, if appropriate, drug levels; obtain arterial blood for
Decreased myocardial tissue perfusion related to an imbalance be- blood gas analysis; and obtain a chest radiograph as ordered by
tween myocardial oxygen supply and demand and manifested by the physician.
chest discomfort, arrhythmias, conduction disturbances, and/or 3. Initially, every 4 to 8 hours, and during chest discomfort, as-
heart failure. Refer to previous diagnosis of chest discomfort for sess, document, and report to the physician the following: new
goals, interventions, and outcome criteria for chest discomfort.
S 3 or S 4 gallops or a new murmur of mitral regurgitation, new
or increasing crackles, and reduced activity tolerance.
Goals
1. To detect early manifestations (specify) and etiologies of de- For Goal 2
creased myocardial tissue perfusion. 1. Immediately reduce patient’s physical activity to the level of ac-
2. To reduce or eliminate manifestations (specify) of decreased tivity before occurrence of manifestations of decreased myocar-
myocardial tissue perfusion. dial tissue perfusion.
3. To prevent, when possible, manifestations (specify) of de- 2.Administer oxygen and antiarrhythmic and other medications
creased myocardial tissue perfusion and extension of MI or (positive inotropic, afterload-reducing, and preload-reducing
progression to infarction in patients with angina. agents) as ordered and continuously evaluate the patient’s re-
sponse to therapy.
Interventions 3. Provide a restful environment; and promote the patient’s phys-
Interventions are designed to detect the manifestations of the ical comfort by elevating head of bed to 20 to 30 degrees or
imbalance between myocardial oxygen supply and demand and higher and providing individualized basic nursing care.