Acute Coronary Syndrome

Acute Coronary Syndrome – Orientation Overview
Acute Coronary Syndrome
(Simulation in Nursing Education)
Debriefing/Guided Reflection Overview
In New Zealand the following is true:
Cardiovascular disease (heart, stroke and blood
vessel disease) is still the leading cause of death in
New Zealand, accounting for 30% of deaths
annually (2010 Ministry of Health Mortality data).
The CHD death rate is more than twice as high in
men as in women.
Mortality rates for Maori from cardiac related disease
are higher than non-Maori (2-4x higher). Therefore,
Maori need to be assessed 10 years earlier for risk
factors than non-Maori.
Pacific Island peoples do not have quite as high
cardiac risk as Maori, higher than non-Maori.
(New Zealand Health Information Service,
Non-modifiable risk factors:
o Family history of coronary heart disease
o Increasing age
o Gender
o Ethnicity
Modifiable risk factors:
o High serum lipids (LDL’S)
o Cigarette smoking
o Hypertension
o Diabetes Mellitus
o Physical inactivity
o Obesity
Management of care--management of coronary
clients involves the following nursing
Scenario Overview
Estimated scenario time: 15 minutes
Guided reflection time: 15 minutes
Target group: year 3 nursing students
Brief summary:
This case is a patient in the Emergency Department who
is complaining of chest pain. The student will be
expected to follow the standard protocols for the
treatment of chest pain suggestive of ischaemia and
appropriate protocols for ventricular tachycardia.
S1 2014
Report to student
Time: 1330
Carl Shapiro is a 54-year-old male who travels frequently
on business. He has had two previous heart attacks with
subsequent stents placed in his right and circumflex
arteries. He sought help in the ED and has been
transferred to your cardiac ward with complaints of dull
aching chest pain and shortness of breath. He is
currently visiting the area on business so has no local
GP. He has a 40 pk/year smoking history and drinks
alcohol occasionally. He describes work as ‘stressful.’
Additional information (medical history):
Identifies the primary nursing diagnosis
Patient data: male, age 54years, weight 110Kg, height
1.75 metres
Implements risk assessment
Implements patient safety measures
Evaluates patient assessment information including
vital signs
Hospital ID number: 256789
Implements therapeutic communication with team
and in ISBAR format
Implements direct communication to multidisciplinary team members
Past medical history: has a history of hypertension.
He states he takes ‘water pills’ for his blood pressure and
has been trying to exercise and lose weight but admits it
is very hard when he travels.
Demonstrates effective teamwork
Prioritises and implements doctors instructions
Scenario specific:
Recalls indications, contraindications, and potential
adverse effects of prescribed medications
Implements the ‘5 rights’ of medication
DOB: 19-07-XX
Recent medical history: has been really ‘pushing’
himself lately and feels the ‘stress’ is starting to get to
him. He has noticed this type of chest pain before but it
usually goes away when he rests. He became worried
when he began sweating and became short of breath.
Securing the airway and assessing oxygen
saturation. Starting oxygen at 4L/min. until
SpO2 is >92%
Administer Aspirin (chewed)
Evaluate pain and scale it (0-10)
Administer GTN (get history first and check
for medications for erectile dysfunction)
Monitor vital signs closely for hypotension
every 2-5 minutes
Morphine—only administered if not pain
free after GTN (3 doses every 5 minutes)
12-lead ECG obtained and evaluated within
10 min. of admission to the ward/unit
When ventricular tachycardia
CPR 30:2 when unresponsive
AED hooked up and shock
CPR 30:2 again
AED shock delivered
Adrenaline after 2nd shock (1mg
Recognises signs and symptoms of an adverse
Implements a focused respiratory assessment
Recalls indications and contraindications for oxygen
Initiates relevant cardiac and respiratory monitoring
Applies cardiac chest pain protocol according to
Acute Coronary Syndrome – Resources
Equipment checklist
Equipment to have in the room for this
Proposed correct treatment (outline)
Potential nursing problems
Gloves on
Acute pain related to cardiac ischaemia
Identify patient name from ID band (DOB, hospital
ID number)
Defining characteristics:
Verbal report
Standard precautions equipment
Obtain BP, pulse, RR, Temp, SpO2
Blood pressure cuff
Attach ECG monitor leads
SpO2 monitor and probe
Give oxygen
Assess pain utilising pain scale
Ineffective tissue perfusion, cardiopulmonary related
to interruption of flow (arterial)
Chest pain
ECG monitor and leads
Obtain 12-lead ECG if student has skills
Changes in BP, resp. rate, AP
Oxygen supply source
Notify medical team (involve MDT)
Oxygen delivery devices (nasal cannula, mask, and
ambu bag)
Administer medications per protocol MONA
Monitor cardiovascular and respiratory state every 25 min.
Activity intolerance related to imbalance between
oxygen supply/demand
Medication and fluids:
Normal saline 1000ml infusing at 75ml/hour
Aspirin 300mg in a bottle
Number of participants:
1 student—recorder and calling SBAR ROLE
GTN sublingual spray 0.4mg
Morphine sulphate 10mg/10ml vial
1 student—doing primary assessment, giving
1 student—Vital signs and airway management
1 student—family member
Documentation forms:
Doctors instructions/DHB protocols
Observation record, medication sheet, nursing notes
Diagnostic equipment:
AED machine with pads that stick
Preparation of SimMan simulator:
Location: cardiac ward hospital
Dress SimMan in male clothing
Sitting up on the bed (semi-fowlers)
Secure ID band with patient name, DOB, and
hospital ID number
Defining characteristics:
Verbal report of fatigue
Electrocardiographic changes
Exertional discomfort
Acute Coronary Syndrome – Scenario
SIM MAN settings
Patient/manikin actions
Initial state (0-2 minutes)
Lung sounds: clear bilaterally
Heart rate: 140/minute
Peripheral pulses: strong
Respiratory rate: 24/min.
Vocal sounds: “It feels like an elephant
sitting on my chest. The pain is ‘8!’”
BP: 158/92
Rates pain as ‘8’ on scale of 1-10
SpO2: 94%
Temp. 37 C
Student interventions
Student should do the following:
Gloves on
Introduce self, identify patient
Obtain vital signs & assess pain
Apply ECG leads
Apply oxygen 4L/min.
Obtain 12-lead ECG
Give first dose NTG
Administer Aspirin
Role member providing cue: patient
Administer 2nd dose of GTN & record
Continue to monitor pain and vital
signs continuously
Check for responsiveness
Call for help
Commence CPR 30:2
Apply pads AED
Press charge on AED
State, “Shock advised, stand clear,
shocking now”
Deliver shock—check for
CPR again 30:2
Role member to provide cue: patient
Adrenaline 1mg every 2nd cycle
Provide fluid bolus for ↓BP (500ml)
Communicate therapeutically with
patient when back to NSR
Monitor and record vital signs (BP,
AP, SpO2,) continuously
Call ISBAR to physician and obtain
Role member to provide cue: primary
care provider
ECG: 140/min. sinus tachycardia
Vocal sounds: “The pain is ‘5’ out of 10
now.’ (after 1st dose of GTN)
2-5 minutes
GTN trend:
Vocal sounds: “The pain is getting
worse” (after 2nd dose of GTN)
BP: Not obtainable
SpO2: not obtainable
HR: 150/min.
Resp. rate: Not breathing
ECG: VTACH this frame after
7-10 minutes
Heart rate: 90/min..
BP: 90/50
ECG: 90/min. Sinus rhythm
BP: 90/7O,
Resp: 28/min.
Vocal sounds (with hypotension):—“I feel
really light-headed and I see black spots
in front of my eyes.”
Vocal sounds: Eyes roll back and client
groans. Patient becomes unconscious.
Cue: if student does not apply oxygen
patient will say,
“It feels like an elephant is sitting on my
chest. Can you do something to help
the pain?”
“When will the doctor take a look at
me? What do you think is happening
Cue: if nurse does not notify doctor when
space allows, family member will ask,
“What is going to happen next? Is he
Cue (final orders):
Transfer to CCU
Call when blood results are available
(Troponin-T, CK-MB, Myoglobin)
Ventricular fibrillation and pulseless ventricular tachycardia are included in the Pulseless Arrest Algorithm. This is the most important algorithm in ACLS,
and one that should be mastered. Both are shockable rhythms, in contrast to PEA and asystole, which fall on the right side of the algorithm.
The ventricular fibrillation and pulseless ventricular tachycardia algorithm can be found here. The high resolution PDF for member download can be found
Ventricular fibrillation is the most common rhythm experienced by patients who experience cardiac arrest. This is why so much emphasis in ACLS is placed
upon learning and memorizing this rhythm and its treatment. Evidence reveals that rapid treatment of ventricular fibrillation using the ACLS pulseless arrest
algorithm is the best way to achieve return of spontaneous circulation (ROSC).
The following points are essential to remember when treating a patient using the Pulseless Arrest Algorithm for ventricular fibrillation and pulseless ventricular
1. Until the defibrillator is attached to the patient, high quality CPR should be performed.
2. Interruptions in chest compressions should be minimized.
3. Rapid use of the defibrillator is the key component of treatment for VF and VT.
4. Use of an AED may involve prolonged interruptions in chest compressions for analysis of the rhythm and administration of shock. Use a manual
defibrillator if available.
o Stacked shocks are no longer used.
o CPR should be resumed for five cycles between each shock.
Defibrillation and Shock
We will be using AEDs as students have not been trained in defibrillation with paddles at this point. Paramedicine has advised use of AEDs due to lack of
previous skill training with paddles.
Definition: A vasopressor is a medication that produces constriction of the blood vessels, with a subsequent rise in blood pressure.
In the treatment of ventricular fibrillation and pulseless ventricular tachycardia, the vasopressors used in the ACLS algorithm are Adrenaline and vasopressin.
While Adrenaline is primarily used for its vasoconstrictor effects, vasopressin increases blood flow to the brain and heart, and has vasoconstrictor effects similar
to those of Adrenaline.
Amiodarone, lidocaine, and magnesium are the antiarrhythmic medications used in the pulseless arrest algorithm. More detailed information about these
medications is located here. Rhythm checks should be limited to 10 seconds and should be performed after 5 cycles of CPR, to minimize interruptions in
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