Emily Grange, Ora Despain, Adam Hyatt, Ashleigh Turner (Group 3)
Acute Coronary Syndrome
1. Assessment
a. Physical
i. Temp 37.3, Pulse 54 reg, RR 20, BP 148/92, 02 sats 95% RA
ii. Respers clear, unlabored, and equal bilat; skin pale/pink, cool
& moist, no edema, 3+ pulses in all extremities, S1S2 heart
sounds; A&O x4; Abd soft & non-tender, active BS in all quads,
voiding w/o difficulty, urine clear and yellow; Skin integrity
intact
b. Diagnostic
i. 12 lead ECG reveals ST elevation in leads II, III, AVF
ii. Troponin T (norm 0-0.03): 1.2 ng/mL
iii. CK/CK-MB (norm 0-10): 32 u/L
c. Knowledge
I know
I
I know
I
Patient Knowledge of Coronary Artery
nothing know a good know
Disease
a
amount a lot
little
Meds that help Coronary Artery Disease
(CAD)
Meds that hurt CAD
Foods that should be avoided with CAD
Your goal Blood Pressure
Understanding Tx options
Symptoms of CAD
How CAD is measured and diagnosed
Function of the heart
Knowledge about why you have been sent
to a cardiologist
2. Goals
a. Prevent chest pain
i. Nitro
ii. Rest
iii. Seek help if can not control
iv. Reduce stress in life
v. Proper use of O2 therapy when needed.
b. Prevent complications: MI, thrombus
i. Meds and lifestyle changes
c. Increase or maintain daily activity
i. DASH Diet
ii. Loose weight
iii. Identify techniques to enhance activity intolerance.
iv. Pt will participate in desired activities and ADLs.
v. Improve self-esteem.
d. Properly use prescribed medication.
i. Understand side effects, report any unusual side effects, or
signs of allergic reaction.
ii. Do not stop abruptly.
iii. Monitor weight and BP.
e. Gain knowledge about condition, risk factors, treatments, and
potential outcomes.
i. Stop smoking
ii. Lower BP
iii. Recognized worsening condition, call if you believe you are
having a MI.
iv. Pt will increase their perfusion and demonstrate behaviors to
improve circulation.
f. Maintain perfusion to the heart, prevent ischemic attacks.
Increase cardiac output, decrease the heart’s demand for O2.
i. Medications lowering lipids, lower BP, use prescribed blood
thinners and anticoagulants.
ii. Decrease the workload on the heart.
g. Maintain normal lab values.
i. CK-MB 0-3.9%
ii. Mg 1.6-2.4 mEq/L, K 3.5- 5.2 mEq/L
iii. Total cholesterol <200 mg/dL
iv. HDL >= 35 or >= 60 mg/dL if high risk.
v. LDL 65-180 mg/dL
vi. Triglycerides <150 mg/dL
vii. CRP 0- 1.0mg/L or less than 10mg/L
viii. D dimer <= 250 ng/mL
ix. Troponin <0.04
3. Outline
a. Disease Process: Acute Coronary Syndrome is an emergency
situation in which ischemia of the myocardium sets in causing acute
chest pain. If ACS goes untreated it may eventually lead to a
myocardial tissue death otherwise known as a heart attack. ACS is a
spectrum syndrome that may range anywhere from angina (chest
pain) to a full blown STEMI (heart attack with ST segment elevation
noticed on an EKG). When blood flow through a coronary artery is
slowed due to plaque build up, the heart muscle cannot obtain the
amount of oxygen it needs to function. As cells are deprived of oxygen
they begin to die off causing chest pain. This slowed rate of blood flow
and lack of oxygen delivery is known as ischemia. This situation is
Acute Coronary Syndrome. Should the artery become completely
blocked and oxygen delivery no longer exists, a heart attack would
occur. The complete blockage of the artery is known as an infarction
which is why the technical term for a heart attack is a Myocardial
Infarction.
b. Medications
i. Lisinopril
1. Dosage: initial dosage will be 10mg once daily then
advance to 20-40mg once daily with a max dose of
80mg/day.
2. Frequency: daily
3. Instruction: take your blood pressure before taking
medication, take at night before bed to avoid dizziness,
change position slowly.
4. Reason for use: inhibits vasoconstriction to keep blood
pressure down.
ii. Atenolol
1. Dosage: Initial dose of 50mg/day orally then increased
to 100mg/day.
2. Frequency: daily
3. Instruction: Take your BP and HR before taking drug,
change position slowly, take at bed time.
4. Reason for use: blocks beta receptors to decrease blood
pressure and heart rate.
iii. Glyburide
1. Dosage: 2.5-5.0mg/day titrated down by no more than
2.5mg/week.
2. Frequency: daily
3. Instruction: take med at same time every day. If you
miss a dose, take asap. Do NOT take if you cannot eat
shortly after.
4. Reason for use: stimulates insulin release to lower
blood sugar.
iv. Prilosec
1. Dosage: 20mg/day
2. Frequency: daily for 4 weeks.
3. Instruction: notify physician of persistent abdominal
pain.
4. Reason for use: decreases acid reflux by preventing the
build up of acid in the stomach.
v. Simvastatin
1. Dosage: initial dose of 40mg/day in the evening. 540mg/day.
2. Frequency: Daily in the evening.
3. Instruction: have liver enzymes monitored closely.
4. Reason for use: Lowers cholesterol including LDL and
triglycerides. Also helps to raise HDL. Helps to prevent
the progression of coronary atherosclerosis.
c. Lifestyle changes necessary: remaining physically active (when
angina presents rest and then continue ADL or activity when gone and
gradually increase activity over time), smoking cessation, diet
modification (hyperlipidemia, HTN, and DMII) ensure understands
needs to choose low sodium, low fat, and understands carb exchange
for diabetes.
d. skills necessary for self-care: no mental deficits or sensory deficits
noted in case study. patient can dress without assistance and may
need assistance getting from bed to bathroom while on nitro. Patient
understands medication effects and takes appropriate measures to
not let adverse effects cause problems (like lightheadedness - giving
time to equalize prior to standing)
e. When to notify the provider: notify the provider if pain increases or
persists with rest and medication, if any adverse medication effects
are hindering quality of life (can re-evaluate regimen if needed), have
emergency plan in place if cardiac arrest was to occur, if any signs of
bleeding (unexplained bruising, persistent bloody nose, petechiae,
uncontrolled bleeding)
4. Specify how you will teach your patient:
a. Brochures
b. Videos
c. Whiteboard
d. Demonstration
e. Question and Answer
f. Explanation
g. Teach back using spinner
5. Determine how you will assess the patient’s learning:
a. Level of patient learning will be demonstrated through using the teach
back method with the spinner provided as well as the patients future
admissions to the hospital, fewer future admissions indicates
sufficient knowledge and compliance with treatment regimen.