NURSING INTERVENTION IN

REPERFUSION THERAPI
PATIENT ACS

Malang, 10 Oktober 2010

Lulu Lusyana,SKp,CVRN
 Introductio
n
Acute Myocardial Infarction (AMI) is a leading cause of
mortality and morbidity

TIME IS MUSCLE

Early intervension ( reperfusion therapi) can

saved high mortality and morbidity
DEFINISI

Acute Coronary Syndrome (SKA)

adalah gabungan gejala klinik yang
menandakan iskemia miokard akut
terdiri dari infark miokard akut
dengan elevasi segmen ST
( STEMI), infark miokard akut tanpa
elevasi ST (NSTEMI) dan Angina
pektoris tidak stabil (UAP)
TYPICAL PROGRESSION OF CORONARY ATHEROTHROMBOSIS
Initial Management Chest pain in ED
Nurses
 Common chief complaints : chest pain (Judith A, 2008)

P Q R S T
Provocative Quality or Region or Severity Timing
or palliative quantity radiation
How severe is the When did the
What provokes What does the Where in the chest pain? How pain begin ?
or relives the pain feel like chest the pain would you rate it Was the onset
chest pain occur ? on a scale of 0 to sudden or
Are you having
10, with 10 being gradual
What makes the pain right now? Does the pain
the most severe ? How often
the pain If so, is it more or appear in
does the pain
worsen less severe than other regions Does the pain
occur?
usual as well ? If so seem to be How long does
where ? diminishing,
To what degree it last ?
intensifying, or
does chest
staying about the
pain affect your
same ?
normal activities
Electrocardiography Harus direkam dan dibaca
dalam waktu 10 menit
Understanding ECG leads
NSTEMI STEMI

Locating myocardial damage

Wall affected Leads Artery involved
Anterior V2 , V3, V4 LCA, LAD

Anterolateral I,aVL, V3 to V6 LAD, LCx

Anteroseptal V1, V2, V3, V4 LAD

Inferior II, III, aVF RCA

Lateral I,aVL, V5, V6 LCx, Branch LAD

Posterior V8, V9 RCA, LCx

CHARACTERISTICS OF SERUM CARDIAC MARKERS FOR
THE DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION
SERUM CARDIAC MARKERS TEST PEAK
FIRST LEVEL
BECOMES ( Hours)
POSITIVE
(HOURS)
Cretinin Kinase
Single assay 3-8 12 - 24
Serial assay

Creatine Kinase- MB
Single assay 4-6 12 - 24
Serial assay
Troponin I and T
Measure 4 hours after onset of chest pain 4 - 10
Measure 10 hours after onset of chest pain 8 - 28

SKA harus ditegakan tanpa menunggu hasil enzym

WHO: D/STEMI ( 2 hal ): Nyeri dada tipikal,
EKG ST Elevasi, Peningkatan Enzym
The goal of nursing care

Manage chest pain/disconfort

Use consistent and standardized of assessing pain/ disconfort
Detect and prevent complication ( maintenance ecg monitoring,
hemodynamic monitoring closely
Teach the patient and familly the importance of reporting
ischemic pain, make them aware of the benefit of
reporting pain and treating recurrent ischemia
Physical activity is limited for the first 12 hours
Use nitrates and intravenous morphine sulfate as
necessary. Nitrates reduce afterload & preload
For recurent ischemia pain/disconfort perform approriate
assessment (ECG 12 lead and treating nitrates &
morphine as necessary )
 ST Segment Monitoring
(AACN practice)

ST segment monitoring can detect silent

ischemia in asymptomatic pt
Monitoring ST segment change in 12 lead
provides the most accurate data for
identification of ischemia events
If only two lead are available for ST
segment monitoring use leads III and V3
( Lead III best inferior lead and shows
reciprocal change with lateral MI and V3
best anterior lead
 How its treated
For patients with angina reduce myocardial demand
or increase oxygen supply
Nitrates reduce myocardial oxygen compsumption
Beta-adrenergic blockers reduce the workload and
oxygen demand of the heart
Angina cause by coronary artery spasm , calsium
channel blockers
Antiplatelet drugs minimize platelet aggregation and
the danger of coronary occlusion
Antilipemic drugs reduce elevated serum cholesterol
or triglyceride
CABG or PTCA
 How its treated
For patients with MI to relive pain, stabilIze heart rhythm,
Revascularitation the coronary artery, preserve myocardial
tissue and reduce cardiac workload
Thrombolytic theraphy shoud be started within 6
hours of
the onset of symptoms ( unless contraindications
exist )
PTCA or stent placement are option for opening
blocked
or narrowed arteries
Oxygen is administered to increase oxygenation of
the
blood
Nitroglycerin is administrated sublingually to relive
chest
pain, unless systolic blood pressure is less than
90 mmHg or heart rate is less than 50 or greater than
 Cont..

Morphine is administrated as analgesia

Aspirin and antiplatelet drugs to inhibit platelet aggregation
I.V Heparin to increase the chances of patency in the
affected coronary artery
Physical activity is limited for the first 12 hours to reduce
cardiac workload
I.V Nitroglycerin for 24 -48 hours to reduce afterload,
preload and relieve chest pain
I.V Beta adrenergic blockers is administrated early to patie
with evolving acute MI, followed by oral to reduce HR,
contractibility, reduce myocardial oxygen requirement
CCU Nursing Management
Monitor & record ECG,BP,HR,T, heart & breath sound closely assess
and record the severity, location,type and duration pain
Be alert for indications suggesting CO,(BP ,HR,PAP/PAWP )
Assess U/O
Monitor Oxygen saturation
During chest pain monitor closely (ECG,BP,frequent monitor arrhytmia)
Serial cardiac enzyme
Diet : salt, cholesterol, chalorie, avoid alcohol and smoking
Stress management
Early Mobilisation ( 12-24 hours)
Nursing education (risk factors, ACS)
Observe crackles, cough,tachipnoe ( indicated LVHF)
Stool softener to prevent straining during defecation
Management of STEMI
Reperfusion goal
Fibrinolytic clock start at door of hospital
PCI clock start at first contact with
medical personal

DOOR TO NEEDLE < 30

MINUTE
DOOR TO BALLOON < 90
MINUTE
 REPERFUSION THERAPI
There are 3 main classes of aggressive
coronary reperfusion therapy

Bypass surgery
Percutaneous transluminal coronary
angioplasty (PTCA)
Fibrinolitic drug therapy (tissue
plasminogen activator (t-PA).
Fibrinolytic drug therapy
Ischemic symptoms, onset < 12
hours
ECG:
- ST elevation of 1mm or more in
least two contiguous lead
- New LBBB
THROMBOLYTIC AGENT
Non Fibrin Selective: Streptokinase,
urokinase

Relatively Fibrin selective : r TPA,

Staphylokinase
 Contraindication
Absolute:
- Active internal bleeding
- History of CVA ( Cerebro Vascular Attack)
- Recent intracranial bleeding or neoplasm -
Aortic dissection
Relative: - Severe uncontrolled hypertension
- Known bleeding disorder
- Current use of terapeutic anticoagulants
- Active peptic ulceekser
- Pregnancy
- Recent trauma within yhe past 2-4 weeks
- Hystory prolong CPR > 10 mnt
- Recent internal bleeding
 Nursing action
Continuous ECG monitoring
Prepare for EMG trolley
Initiation at least 2 to 3 IV lines
Assesment of neurological status
Assesment for changes in ECG and
hemodynamic
 PTCA
Percutaneous Transluminal Coronary Angioplasty (PTCA) is
an invasive procedure used to eliminate stenosis in
the coronary arteries by insertion,a catheter through the
skin and moving forward through the artery, a balloon
catheter is inserted in the coronary arterial lesion and
the balloon is inflated at the level of occlusion to open
the lumen.

Elective
Cito - Primary
- Immediate
- Resque (failled fibrinolisys)
Primary
Evolution of Angioplasty
Percutaneus radial artery approach
Radial anatomical characteristic
: superficial, double blood
supply to the hand
Patient can immediately walk
back to his chair or bed
No bed rest recommended
Compression force just until
bleeding stops and gradual
decrease of compression by the
nurse.
bandage can be removed early
comfortable decompression
Patient can observe puncture
site by himself through
transparent dressing
Reduced bleeding complication
Reduce LOS and cost
Improved pt comfort
Radial Approach
 Responsibilities of the nurse
involved in the care of the
patient undergoing
interventional therapy

Prevention and early diagnosis of

potential complications
Education of the patient and the
family
Rehabilitation.
 Nursing organisation for
primary PCI
Nursing staff may call in a second nurse for
assistance if the case is anticipated to be
particularly complex.
The primary PCI team must have current
Advanced Life Support and be proficient in
assisting with Intra Aortic Balloon Pump (IABP)
Prepare for temporary pacing (TPM)
Nursing staff must also be assessed by the
nurse unit manager with regard to their
safety, speed and knowledge
 Preparation
Previous labs data ( coagulation study, electrolyte,
BUN, creatinin)
Physical examination, vital sign, assess pheriperal
pulse
Apply ECG monitoring , IV access
Perify allergic reaction
Describe the procedure to the pt & family
Informed consent
Patient should be NPO
Antiplatelets agents
Skin preparation as policy/Shave
Allens Test
To determine patency of the radial artery
Interpretation of Allens test normal <7
Negative Allens test not suitable procedure
 During Procedures
Monitoring Vital sign, dysrhytmias

Monitoring minor and major

complications
Post Procedural Management

Assess the pt vital sign,O2 sat every 15 for the 1 st

hour
Administer iv fluid, anticoagulant as indicated
Assess peripheral pulse distal to the catheter
insertion site ( color, sensation, temperature,
capillary refill)
Monitor cardiac rhythm continuously and
hemodynamic monitoring closely for change
( Temperature !!!!!)
Monitor 12 lead ECG ST segment change
indicated ischemia/injury
Instruct the pt immobilization 8 hours ( femoral
sheath)
Elevated head 30o

Cont

Immediately report MD sign and symptoms

present :Chest pain, ECG change. fluid overload
(tachypnoe, dyspnoe , edema)
Apply direct pressure (15-30) after removed
catheter
Documentation ( respons pt, vital sign,
hemodynamic parameter, puncture site, ECG,
extremitas distal, complication

MANUAL COMPRESSION OPERATOR DEPENDENT

POOR TECHNIQUE = POOR HEMOSTASIS=POOR
OUTCOME
Teaching the pt after PCI
Site assessment
Instruct the pt to hold firmly if need to
cough or sneeze
Any discomfort in
chest,SOB,nausea,weakness
Potensial Complication
Activity limitation
Follow up care
When to seek medical doctor
Medication th/
Modification risk factor
 Major Complications
Acut MI

Stroke

Death
 Post Procedures, complications
Access site complication: AV vistula,
retroperitoneal bleed, pseudoaneurysm
Cardiac tamponade
Contrast nephropathy
Vasovagal reaction
Arrhythmias
Acute pulmonary edema
Cardiogenic shock
Stroke
Dissection
Stent thrombosis
CLINICAL PRESENTATION
Chest pain : due to abrupt vessel
( dissection, periprocedural MI, stent
trombosis, post procedure pain)
Hypotension: hypovolemia, vasovagal
reaction, cardiac tamponade,
retroperitoneal bleeding
Dissected
Short of breath: pulmonary edema due to
contrast or ischemia
Renal problem
CLINICAL PRESENTATION , cont
Mental status change: TIA, stroke
Decrease urine output: may cause by
contrast nephropathy
Groin back pain: can be due to
retroperitoneal bleeding or presense
of a pseudo aneurysm
Nursing Intervension
Monitoring hemodynamic
Physical exam
Serial ECG, enzym
Monitoring site insertion for bleeding and
hematoma
Check peripheral pulsation, colour, acral
Monitoring mental status change
Check Urine output and renal function
Groin/ back pain can be due to retroperitoneal
bleeding
Administer fluid, pain reduce, psychological
approach
 Nursing intervention for minimize
bleeding
Avoid IM injection and invasive lines
Monitor for all body fluid
Minimize traumatic procedures
Monitor vital sign and labs
Asses neurological status regularly
Bee allert for posible retroperitoneal
bleeding
 MEDICAL MANAGEMENT
Trombotic occlusion: emergent
vascular surgery consultation
AV fistula: may require surgical repair
Vascular examination ( dopller)
Periprocedural MI: if pain is present
and ECG changes should repeat cath
Stroke: neurologic exam or
consultation and CT scan
MEDICAL MANAGEMENT, cont
Arrhythmias : vasovagal reaction may
caused increase groin pressure, pain,
anxiety, hypovolemia. Administer
fluid, pain release
Renal failure: hidration, utilizing low
osmolar contrast agent
Cardiac tamponade: Echo should be
done rapidly to rule out complication
Cardiac Rehabilitation

Cardiac rehabilitation is a
comprehensive, multidisciplinary,
long term service program,
involving medical evaluation,
exercise, cardiac risk factor
modification, pt education and
counseling and behavioral
intervention.
( 3 phase)
 CONCLUTION
Medical management of AMI has
changed significantly over the part
two decades and has resulted in
dramatic decreaseds in early infarc
mortality
Primary angioplasty are high
successs rates, low complication
rates, wide applicability and lower
mortalityr ates
Nurse as a team should to improve
Thank you for u attention