Nursing Care and Interventions for Acute Coronary Syndrome

NURSING CARE OF CLIENT WITH
ACUTE CORONARY SYNDROME

NURSING DIAGNOSES AND COLLABORATIVE
INTERVENTIONS

Maria Carmela L. Domocmat, RN, MSN
Instructor
School of Nursing
Northern Luzon Adventist College

Common Nursing Diagnoses and
Collaborative Interventions

CLDomocmat 8/9/2012 2

Management

Maria Carmela L.Domocmat, RN, MSN 8/9/2012 3

Door to needle time
Door to balloon time


Goals of care

1. Treat the acute attack immediately
2. Determine location of myocardial infarction
3. Monitor for complications


cells in ischemic area – are salvageable if
reperfusion therapies and inotropic support is
promptly instituted (Schumacher &
Chernecky, 2006)
within 10 min of arrival of suspected AMI –
ingest aspirin and obtain baseline cardiac
serum markers, 12-lead ECG


Medical management
Reduce risk factors
Restore blood supply
Percutaneous transluminal coronary angioplasty
Directional coronary atherectomy
Laser ablation
Transmyocardial revascularization
Nursing management
Reduce risk factors
Restore blood supply
Surgical management
Cardiac surgery
Open heart surgery
Coronary artery bypass graft
Nursing management
before cardiac surgery
Phase I (In-hospital) Rehabilitation Programs
self-care
Phase 2 (Outpatient Exercise Training) Rehabilitation Programs
Phase 2 (Community) Rehabilitation Programs
Home exercise Rehabilitation Programs


Medical mgmt
first-line and initial treatment
(Schumacher & Chernecky, 2006; Smetzer, 2010)

Semi folwer’s position
O2 (2-4 lpm)
IV access
obtain 12-lead EKG
VS and pulse oximetry
labs (serum cardiac markers)
ECG monitoring
conduct hx and PE
reduce pain
administer meds

Medical mgmt
first-line and initial treatment cont.
admit to CCU
invasive line placement (arterial line, pulmo artery cath)
- to provide further data to monitor ventricular
dysfunction
IABP – intraaortic balloon pump
for severe L ventricular dysfunction
to assist ventricular ejection and promote CA perfusion
anticipate emergency PTCA or CABG
reperfusion procedures
if thrombolytics are either CI or unsuccessful


Nursing mgmt: Goals

Recognize and treat cardiac ischemia
Admin thrombolytic therapy as ordered, or
ready client for PTCA and observe for
complications
Recognize and treat potentially life-
threatening dysrhythmias


Nursing mgmt: Goals

Monitor for complications of reduced CO
Maintain a therapeutic critical care envt
Identify the psychosocial impact of AMI on
client and family
Educate the client in lifestyle changes and
rehabilitation


Nursing Diagnoses

Acute Pain
Ineffective Tissue perfusion (Cardiopulmonary)
Activity Intolerance
Ineffective Coping
Potential or dysrhythmias
Potential for heart failure
Potential for recurrent symptoms and extension
of injury

Acute Pain
related to imbalance between myocardial
oxygen supply and demand


Acute Pain

1. Obtain description of chest discomfort
2. Vital signs and cardiac monitoring
3. Check vascular access
4. Place in semi fowler’s position
5. 12 lead ECG
6. O2 inhalation


7. Provide pain meds and aspirin
a. Nitroglycerine – increases collateral blood flow,
redistributes blood flow toward the subendocardium and
causes dilation of the coronary arteries
b. Morphine sulfate – relieves MI pain, decreases
sympathetic stimulation which decreases O2
demand and reduces circulating catecholamines
8. Assess the client’s VS and intensity of pain 5
minutes after administration of meds
9. Notify physician if patients condition deteriorates


Let’s review


Let’s review: Acute Pain

1. Obtain description of chest discomfort
2. Vital signs and cardiac monitoring
3. Check vascular access
4. Place in semi fowler’s position
5. 12 lead ECG
6. O2 inhalation
7. Provide pain meds and aspirin
8. Assess the client’s VS and intensity of pain 5
minutes after administration of meds
9. Notify physician if patients condition deteriorates

Ineffective Tissue perfusion

(Cardiopulmonary) related to
interruption of blood flow
• goal : to restore perfusion to the injured area
to reduce the size of the infarct and improve
left ventricular function


Ineffective Tissue perfusion (Cardiopulmonary)
related to interruption of blood flow



1. Thrombolytic therapy
2. Glycoprotein IIB/IIIA Inhibitors
3. Antiplatelets
Aspirin
Clopidogrel
4. Beta blockers
5. ACE Inhibitors



- Tissue plasminogen activator,
streptokinase, reteplase
- Indicated for patients who have chest pain
of greater than 30 minutes, unrelieved by
nitroglycerin and transmural MI (Q wave
MI)


Thrombolytic therapy

dissolves thrombus and promote
reperfusion
the golden period is 30 minutes from
“door to needle” or from onset of pain till
thrombolytic therapy within 30 minutes
or PTCA within 1 hour
Watch out for signs of bleeding and
hypersensitivity
hypersensitivity reaction ( Streptokinase )
IV infusion


- targets the platelet component of the
thrombus to prevent fibrinogen from
attaching to activated platelets at the
site of the thrombus
- Examples: Abciximab, Eptifibatide,
Abciximab, Eptifibatide,
Tirofiban
- Administered through IV


Glycoprotein IIB/IIIA
Inhibitors Examples: Abciximab,, Eptifibatide,, Tirofiban
Abciximab Eptifibatide


Aspirin

Swallow the tablets with a full glass of
water.
Taken as regular (not enteric-coated) low-
enteric- low-
dose aspirin.
Swallow the extended-release tablets whole with
a full glass of water. Do not break, crush, or chew
them.
Chewable aspirin tablets may be chewed, crushed,
or swallowed whole.
Drink a full glass of water, immediately after
taking these tablets.

Aspirin

If taking aspirin on a regular basis to prevent
heart attack or stroke, do not take ibuprofen
(Advil, Motrin) or other NSAIDs to treat pain
or fever (Ibuprofen can interfere with the anti-
platelet effect of low dose aspirin)
If need only a single dose of ibuprofen, take it
eight hours before or 30 minutes after taking
a regular (not enteric-coated) low-dose
aspirin.


Aspirin

Ask a doctor before giving aspirin to child or
teenager.
Aspirin may cause Reye's syndrome (a serious
condition in which fat builds up on the brain, liver,
and other body organs) in children and teenagers,
especially if they have a virus such as chicken pox
or the flu.


Clopidogrel

Plavix
when combined with
aspirin , more
effective in reducing
death, MI or stroke
when compared to
aspirin alone


Nrg Considerations: Aspirin and
Plavix
teach: may bleed more if having surgery,
easily or for a longer including dental
time than usual while surgery, tell doctor or
you are taking dentist that taking
clopidogrel. Be careful aspirin or Plavix
not to cut or hurt


Beta blockers – Metoprolol

reduces myocardial O2 requirement by
blocking beta receptors and slowing heart rate,
prolong diastole and increase myocardial
perfusion
aka: beta-adrenergic blocking agents
reduces myocardial O2 requirement by blocking
beta receptors and slowing heart rate, prolong
diastole and increase myocardial perfusion
Ex: Metoprolol, Acebutolol (Sectral), Atenolol
(Tenormin), Bisoprolol (Zebeta), Propranolol
(Inderal LA)

Let’s review


Angiotensin-converting enzyme (ACE)
Inhibitors
given within 48 hours of
MI prevents ventricular Benazepril (Lotensin)
remodeling and Captopril
development of CHF
Enalapril (Vasotec)
help relax blood vessels Fosinopril
Lisinopril (Prinivil, Zestril)
Moexipril (Univasc)
Perindopril (Aceon)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril (Mavik)


ACE Inhibitors

In some people the first dose can cause a drop in blood
pressure immediately. The following is advice for
starting ACE inhibitors:
If taking a diuretic (water tablet), may be advised not to take it
for a day or so before starting an ACE inhibitor.
After the very first dose, on the first day start an ACE inhibitor:
Stay indoors for about four hours, as occasionally some people
feel dizzy.
If you do feel dizzy, sit or lie down and it will usually ease off.
If you become very dizzy, contact your doctor immediately.
Thereafter, there is no need to take any special precautions.

http://www.patient.co.uk/health/ACE-Inhibitors.htm CLDomocmat 8/9/2012 39

ACE Inhibitors


Let’s review:
3. Antiplatelets
Aspirin
Clopidogrel
4. Beta blockers
5. ACE Inhibitors


related to imbalance between oxygen
supply and demand



1. Bed rest with commode privilege for only 24-
24-
48 hours unless with complications.
2. Explain that the purpose of CCU confinement
is for continuous monitoring and safety during
the early recovery period.
3. Administer diazepam as ordered
4. Provide psychosocial support to the patient
and his family. Calmness and competency are
extremely reassuring.

Cardiac Rehabilitation

actively assisting the client in achieving and
maintaining a vital and productive life while
remaining within the limits of the hearts ability to
respond to increases in activity and stress
begins the moment a client is admitted to the
hospital
3 Phases
1. From acute illness and ends with discharge from
the hospital
2. After discharge and continues through
convalescence at home
3. Long term conditioning


Program of Physical Activity

1. Increase activities gradually after the first 24-
24-
48 hours
2. Early mobilization after an MI. May be allowed
to sit on a chair for increasing periods of time
and begins ambulation on the 4th or 5th day
3. Monitor V/S before activities.
4. An exercise session is terminated if any one of
the following occurs:cyanosis, cold sweats,
occurs:cyanosis,
faintness, extreme fatigue, severe dyspnea,
pallor, chest pain, PR > 100, dysrhythmias, Bp
> 160/90


5 Physical Activity: Sexual intercourse

4-6 weeks post MI or when
a patient with
uncomplicated MI is
capable of walking 2 flights
of stairs without difficulty
nitroglycerine before sex
avoid concomitant use with
Sildenafil

Sexual intercourse

Perform sexual activity in a cool, familiar
environment
Refrain from sexual activity during a fatiguing
day, after eating a large meal, or after drinking
alcohol
If dyspnea, chest pain, dizziness or palpitations
occur, moderation should be observed. If
symptoms persist stop sexual activity.


Sexual intercourse

assume position with less strain
Ex: woman on top, side lying


Ineffective Coping

related to effects of acute illness, major
changes in lifestyle or loss of control
over a body part
1. Anxiolytics during the acute phase of illness
2. Provide opportunity for the patient and family
to explore their concerns
3. Identify clients coping mechanism
1. denial, anger and depression


Promote Nutrition and
Elimination
Provide small frequent feedings
Low calorie, low cholesterol, low sodium
Avoid stimulants
Avoid taking very hot or very cold beverages and
gas forming foods to prevent vasovagal
stimulation
Use of bedpan and straining at stool should be
avoided. Avoid valsalva maneuver
Bedside commode
Administer stool softeners as ordered


Potential for recurrent symptoms
& extension of injury
Goal: minimal angina while engaging in ADLs
and exercise program
Ix
Percutaneous Transluminal coronary angioplasty
(PTCA)
Coronary artery Bypass graft surgery (CABG)
Minimally invasive Direct coronary artery bypass
(MIDCAB)
Transmyocardial Laser Vascularization
Of-pump Coronary Artery Bypass (OPCAB)
Robotics


Complications of MI
Dysrhythmias
Cardiogenic shock
Thromboembolism
Pericarditis
Rupture of the myocardium
Ventricular aneurysm
CHF


Potential or dysrhythmias

Identify
Assess hemodynamic status
Monitor cardiac rhythm and CR
Evaluate for discomfort


Dysrhythmias

most common complication and most major
cause of death among clients with MI
When Dysrhythmias develop the cardiac nurse
must:
1. Identify the Dysrhythmias
2. Assess the client’s hemodynamic status
3. Evaluate the client for chest
discomfort
4. attach to cardiac monitor

Inferior Wall MI
- bradycardia – atropine
- second degree AV block – Pacemaker

Anterior Wall MI
- 3rd degree AV block – Pacemaker
- Ventricular irritability
- PVC’s – the most common dysrhythmia in MI
- notify physician if more than 6 PVC’s
occur per minute and client is
symptomatic (hypotensive, chest pain)
(hypotensive,


Potential for heart failure

Goal: regain hemodynamic stability as
evidenced by:
BP and PR – within client’s acceptable range and
adequate for metabolic demands
Adequate UO
Mental alertness
Clear lungs o auscultation
Palpable peripheral pulses


Potential for heart failure (HF)

Manage L ventricular failure
Assess and monitor
Classfication of Post MI HF (Killip I, II, III, IV)
Relieve pain
Decrease myocardial O2 reqt
Morphine
O2
Intra-aortic balloon pump
Immediate reperfusion (L sided heart cath; PTCA,
CABG)


Potential for heart failure (HF)

Manage R ventricular failure
Enhance R ventricular preload
IFI – as much as 200 ml/hr
Monitor CO
Note: prevent dev L side HF :
Aucultate lungs
PAWP


Decreased Cardiac output

Heart Failure is a relatively common
complication after an MI
results from left ventricular dysfunction,
rupture of the intra-ventricular septum,
intra-
papillary muscle rupture with valvular
dysfunction or cardiogenic shock


Medical Management for Killip IV

Goal is to relieve pain and decrease myocardial O2
demand through preload and possibly after load reduction
1. IV morphine
2. O2 therapy – intubation and mechanical ventilation
3. Preload reduction – nitroglycerin, nitroprusside,
nitroprusside,
diuretics – monitor BP constantly
4. Vasopressor and Inotropes – dopamine, dobutamine –
used to maintain organ perfusion but can increase O2
consumption and can worsen ischemia
5. IABP


Intra-
Intra-aortic Balloon Pump (IABP)

used when clients do not respond to drug
therapy
invasive intervention that is used to improve
myocardial perfusion during an acute MI,
reduce after load and facilitate left ventricular
emptying
inflation of balloon during diastole increases
diastolic pressure and improves coronary
perfusion
deflation of the balloon before diastole reduces
after load at the time of systolic contraction


http://www.fda.gov/ucm/groups/fdagov-
public/documents/image/ucm064550.gif


☺ Let’s watch how it works!

Video animation of
IABP
YouTube - IABP Intraaortic Ballon Pump.flv

Video of IABP in
G:E CARMELA
OR
video downloadsvideos cardi

http://www.fda.gov/ucm/groups/fdagov-
public/documents/image/ucm064550.gif


IABP:
IABP What precautions to take?

See handout

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/med
sun/news/printer.cfm?id=602

http://www.fda.gov/ucm/groups/fdagov-public/documents/image/ucm064550.gif CLDomocmat 8/9/2012 64

PAWP


Thromboembolism:
Thromboembolism: Pulmonary Embolism
r/t phlebitis of the leg & pelvic veins


Collaborative Management
Anticoagulants
Thrombolytics
Move legs, avoid placing pressure under the knees,
elastic stockings
Early ambulation
Observe for signs and symptoms indicative of
pulmonary embolism
Sudden onset of dyspnea
Chest pain
Coughing
Hemoptysis
Rapid weak pulse
Pallor


Pericarditis

28% of post MI patients
2-4 days post MI
inflamed areas of infarction rubs against the
pericardial surface causing it to lose
lubricating fluid


Pericarditis

Dressler’s syndrome (Late Pericarditis)- 6
Pericarditis)
weeks to months after MI
The client presents with fever lasting 1 week or
longer, pericardial chest pain, pericardial friction
rub, and occasional pericardial effusion
self limiting
Bed rest, aspirin, prednisone, opioid analgesics


Rupture of the myocardium

Mitral Regurgitation,
VSD and Ventricular
Aneurysm


Mitral Regurgitation ,VSD and
Ventricular Aneurysm
MR due to rupture of papillary muscle
of LV
thinning , ballooning and hypokinesia of
the left ventricular wall after a
transmural MI
the dysfunctional area often becomes filled
with necrotic debris and clot


Mitral Regurgitation ,VSD and
Ventricular Aneurysm
the aneurysm may rupture causing
cardiac tamponade and death
usually 7-10 days post MI
7-
report presence of new murmur
PVC’s-
PVC’s- due to irritability of necrotic
tissue


Management

arteriolar vasodilation - to lower systemic
pressure
IABP
surgery-
surgery- 4-6 weeks post MI
excise ventricular aneurysm
replace mitral valve
repair VSD
pericardiocentesis for tamponade

SURGICAL TREATMENT


Surgical Treatment

PCI or PTCA
Coronary artery Bypass graft surgery
Off-pump Coronary Artery Bypass
Minimally invasive Direct coronary artery
bypass
Transmyocardial Laser revascularization
Open heart surgery


Percutaneous Coronary
Interventions (PCI)


PCI

AKA: Percutaneous transluminal coronary
angioplasty
Balloon angioplasty
Laser with balloon angioplasty
Stent
Atherectomy
Brachytherapy


PTCA

an invasive procedure used to eliminate
stenosis in the coronary arteries by
insertion a catheter through the skin and
moving forward through the veins. At the
last stage,a balloon catheter is inserted in
the coronary arterial lesion and the balloon
is inflated at the level of occlusion to open
the lumen


PTCA: types

1. Percutaneous Coronary Laser
Angioplasty or Laser with balloon
angioplasty
2. Placement of Percutaneous
Coronary Stent
3. Percutaneous Coronary
Atherectomy
4. Brachytherapy

Angioplasty stent

http://www.youtube.com/watch?v=77fPzbExkxA&feature=related

PTCA: Lasers with balloon
angioplasty
creates a smoother
lumen of the blood
vessel

Video:
Lasers angioplasty


PTCA: Directional coronary
atherectomy

G:E CARMELA
Atherectomy

video


Nursing Management

Same Preop prep
Consent for procedure
NPO 8 hrs
Skin prep – shave bilateral groins
etc


Nursing Management: Post-op

VS, monitor for complications
(AMI,Spasm)
Assess for development of crackles,
wheezes, tachypnea, frothy sputum, S3
heart sound
Administer medications as ordered
Anti-coagulation with aspirin/heparin
SL Nifedipine – to prevent coronary spasm
Glycoprotein IIb/IIIA – prevent restenosis


Nursing Management: Post-op

Monitor for signs of poor organ perfusion
Change in LOC
Oliguria
Cool, clammy extremities with decreased pulses
Unusual fatigue
Recurrent chest pain
Monitor right atrial pressure , pulmonary
artery wedge pressure (measure of preload)
by using the Swan Ganz catheter
if < 18mmHg do volume infusion or administer
inotropes

Nursing Management

Nursing care of client having PCI Adobe Acrobat
Document


Coronary artery Bypass graft
surgery (CABG)


CABG
bypass of a blockage in artery
use of saphenous vein or internal
mammary artery (graft of choice because it
has a 90% patency rate after the procedure)
reduces 80-90% of symptoms
80-
indicated when clients do not respond to
medical management of CAD or when
disease progression is evident
cardiopulmonary bypass needed


CABG

G:E CARMELA G:E CARMELA
video downloadsvideos cardi video downloadsvideos cardi
Let us watch! Let us watch!
Animation of Heart Bypass CABG in the OR
Surgery (CABG)

http://video.about.com/heartdisease/OPCAB.htm CLDomocmat 8/9/2012 91

Heart-lung bypass machine or
Extracorporeal circulation (ECC)


Extracorporeal circulation


Extracorporeal circulation
(ECC)


Nursing care of client undergoing CABG Adobe Acrobat
Document


Off-pump Coronary Artery
Bypass (OPCAB)
"beating heart" surgery

http://video.about.com/heartdisease/OPCAB.htm

OPCAB

http://www.qualityhealth.com/health-encyclopedia/surgeries-procedures/heart-bypass-surgery-series

OPCAB


Minimally Invasive Direct
Coronary Artery Bypass
(MIDCAB)


Minimally invasive Direct
coronary artery bypass
(MIDCAB)
indicated for clients with a lesion of the left
anterior descending artery
left thoracotomy incision with removal of 4th rib
dissection of the left IMA and attached to the
still beating heart below the level of the lesion in
the LAD
no cardiopulmonary bypass needed

TECAB

Totally Endoscopic,
Minimally Invasive
Coronary Bypass
Surgery : High-
Precision Robotic
Surgery Without any
Opening of the Chest
The da Vinci robot's
"wristed"
instruments provide
a greater range of
motion than the
human hand while
eliminating
physician tremor.


TECAB

http://www.umm.edu/heart/tecab.htm CLDomocmat 8/9/2012 107

TransMyocardial
Laser Revascularization
(TMLR)
Laser ablation


TMLR
a procedure used to relieve severe angina or chest pain in
very ill patients who aren't candidates for bypass surgery or
angioplasty.

Procedure
a surgeon makes an incision on the left breast to expose the
heart.
Then, using a laser, the surgeon drills a series of holes from the
outside of the heart into the heart's pumping chamber.
From 20 to 40 mm laser channels are placed during the
procedure.
Bleeding from the laser channels on the outside of the heart
stops after a few minutes of pressure from the surgeon's finger.
In some patients TMR is combined with bypass surgery. In
those cases an incision through the breastbone is used.
http://www.americanheart.org/presenter.jhtml?identifier=4782 109
CLDomocmat 8/9/2012

TMLR

How does it work?
How TMR reduces angina still isn't fully understood.
The laser may stimulate new blood vessels to grow,
called angiogenesis
It may destroy nerve fibers to the heart, making
patients unable to feel their chest pain.
http://www.americanheart.org/presenter.jhtml?identifier=4782

The heart feeds itself by taking blood from within its
chambers, just like in reptiles, whose hearts have no
coronary arteries. http://www.texheartsurgeons.com/TMLR.htm


Indications
people who are high-risk candidates for a second
bypass or angioplasty.
people whose blockages are too diffuse to be
treated with bypass alone.
some patients with heart transplants who develop
atherosclerosis after their transplant.


TMLR: Before

http://www.texheartsurgeons.com/Images/TMLRchanls.jpg


TMLR: After

http://www.texheartsurgeons.com/Images/TMLRchanls.jpg


TMLR


Transmyocardial
revascularization

G:E CARMELA
An animation of the transmyocardial
revascularization procedure


Other sources
Cardiac surgery/Open heart surgery
http://www.medicalvideos.us/play.php?vid=1297
http://video.about.com/heartdisease/Heart-Lung-Machine.htm
Atherosclerosis
http://www.youtube.com/watch?v=OHE1ig4k64M&feature
=related
Heart Attack
http://www.youtube.com/watch?v=EQVEdFSlUGU&featur
e=channel
Coronary Artery Angioplasty (PCI, Heart Stent
Surgery)
http://www.youtube.com/watch?v=N7nghr9TpSU&f
eature=related


ETC…


Cardiac tamponade
is pressure on the heart that occurs when blood or fluid
builds up in the space between the heart muscle
(myocardium) and the outer covering sac of the heart
(pericardium).
Cardiac tamponade is a condition involving compression of
the heart caused by blood or fluid accumulation in the
space between the myocardium (the muscle of the heart)
and the pericardium (the outer covering sac of the heart).
Blood or fluid collects within the pericardium. This prevents
the ventricles from expanding fully, so they cannot
adequately fill or pump blood. Cardiac tamponade is an
emergency condition that requires hospitalization.


pulsus paradoxus

an abnormal inspiratory decrease in arterial
blood pressure, seen in cardiac tamponade
and caused by a decreased pulmonary venous
return.

http://medical-dictionary.thefreedictionary.com/pulsus+paradoxus


inotropic agent

any of a class of agents affecting the force of
muscle contraction, particularly a drug
affecting the force of cardiac contraction;
positive inotropic agents increase, and
negative inotropic agents decrease the force
of cardiac muscle contraction.


Drugs affect the function of the heart in three
main ways. They can affect the force of
contraction of the heart muscle (inotropic
effects); they can affect the frequency of the
heartbeat, or heart rate (chronotropic
effects); or they can affect the regularity of
the heartbeat (rhythmic effects).

http://www.britannica.com/EBchecked/topic/171942/drug/233954/Drug
s-affecting-the-heart?anchor=ref295300


Inotropic agents
A drug may be classified by the chemical type of the active ingredient or
by the way it is used to treat a particular condition. Each drug can be
classified into one or more drug classes.
Inotropic agents affect the contraction of the heart muscle. Positive
inotropes stimulate and increase the strength of heart muscle
contraction causing the heart rate to increase. Negative inotropic
agents weaken the force of muscular contractions.
Inotropic state depends on the amount of calcium in the cytoplasm of
the heart muscle wall, as contractility of the heart depends on control of
intracellular calcium i.e. control of calcium entry into the cell membrane
and calcium storage in the sarcoplasmic reticulum. The main factors
controlling calcium entry are activity of voltage gated calcium channels
and sodium ions, which affects calcium/sodium ion exchange.
Positive inotropes usually increase the level of intracellular calcium and
negative inotropes decrease it.


Inotropic agents

Digoxin
Dobutamine
Milrinone


pulsus paradoxus
also paradoxic pulse or paradoxical pulse, is defined as an
abnormally large decrease in systolic blood pressure and
pulse wave amplitude during inspiration.
The normal fall in pressure is less than 10 mmHg or 10 torr.
When the drop is more than 10mm Hg, it is referred to as
pulsus paradoxus.
has nothing to do with pulse rate or heart rate. The normal
variation of blood pressure during breathing/respiration is a
decline in blood pressure during inhalation/inspiration and
an increase during exhalation/expiration.
is a sign that is indicative of several conditions, including
cardiac tamponade, pericarditis, chronic sleep apnea,
croup, and obstructive lung disease (e.g. asthma, COPD).
http://en.wikipedia.org/wiki/Pulsus_paradox
us

CTT


Pleur-evacⓇ
Adult/Pediatric Chest
Drainage Model A-
6000. The Pleur-evac
Chest Drainage
Systems have been the
world's most popular
units since their
inception in 1967.
(Courtesy of Deknatel,
Inc., Fall River, MA.)


1. Standard percutaneous access to the
venous system is performed.


2. The Trellis catheter is advanced through
the clot over a standard 0.035" guidewire.


3. The distal occluding balloon is inflated.


4. After the proximal occluding balloon is
inflated, delivery of the thrombolytic agent
begins.


5. The Trellis dispersion wire is activated with
the motor drive unit.


6. Clot dispersion continues.


7. After clot is dispersed, remaining material
is aspirated through the Trellis catheter.


8. The Trellis catheter and guidewire are
withdrawn when treatment is complete.


Nursing Care and Interventions for Acute Coronary Syndrome

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