2.3 Nursing patients with Acute Coronary Syndrome (ACS)

During the acute phase of ACS there is a need for continuous monitoring of vital signs and therefore patients should be treated in a specialist cardiac unit. Specialist nurses should observe and assess the patient continuously during this acute phase and liaise regularly with the multi professional team. The aim is to implement nursing interventions to reduce cardiac muscle oxygen demand and to increase the oxygen supply to the heart. In the acute phase it is important to implement nursing care to assist the patient’s in their activities of daily living whilst encouraging self-care. The nurse should guide the patient and family about the long term implications of coronary heart disease whilst supporting the patient to maintain their autonomy and independence.

Observations

• Observe respiratory rate, depth and pattern. Patients experiencing ACS may be hypoxic with dyspnoea therefore oxygen therapy should be considered.
• Prescribed oxygen can be administered to increase the oxygen saturation levels in the blood and can limit ischaemic damage. In some cases where patients have developed cyanosis, pulmonary oedema and possibly shock, they may require greater amounts of oxygen. Patients will be confined to bed for one to two days to reduce the oxygen requirements of the damaged myocardium.
• Pulse oximetry should be recorded to assess oxygen demand
• There should be regular observations of blood pressure, pulse, skin, temperature, fluid balance to assess the effectiveness of treatment (nitrates, beta blockers and diuretics) and any complications.

The nurse should  administer and observe the effectiveness of the following prescribed medications:

• Analgesics should be administered as prescribed and the effectiveness of the medication monitored. Chest pain and infarction pain are associated with severe pain.

• Chest pain causes stimulation of the sympathetic nervous system which increases heart rate, elevates blood pressure, thereby increasing oxygen demand with increased risk of myocardial ischaemia and increased risk of arrhythmias. It is important that the patient’s pain relief is optimised to mitigate these reactions in the body and reduce patient anxiety associated with chest pain. Morphine is the most commonly used analgesic for chest pain due to both  its analgesic effect and effectiveness in reducing anxiety. Additionally morphine has a parasympathetic effect which causes dilatation of veins and reduces resistance in the pulmonary circulation, which in turn reduces the oxygen consumption and thus overall cardiac demand. Morphine is administered intravenously by a healtcare practitioner, with a maximum effect after 8-10 minutes and this can be optionally repeated upto 5 to 10 minutes. The effectiveness of the analgesia should be observed and the nurse should liaise with the medical team to discuss the patient’s progress.

• Nitrates cause a vasodilation of coronary vessels and peripheral vessels. This reduces the venous return to the heart and thus the cardiac workload. This means reduced oxygen demand and reduces the risk of heart failure. The medication is usually administered intravenously on the first day of treatment and, then administered in tablet form or transdermal patch that  is gradually scaled down. It is important that following administration of nitrates the patient’s blood pressure is monitored. A low dose should be prescribed initially which is increased gradually until it reaches the optimal effect on pain and blood pressure. In significant hypotension the nurse should promptly report this to the medical team, reduce the supply of medicine, tilt bed end and possibly administer fluid therapy.

When the patient is pain free sitting out of bed, they can begin to mobilise and will hopefully be able to be discharged home between 5- 7 days. During this phase the nurse must offer appropriate support with activities of daily living.

Patient education/Cardiac Rehabilitation
Following an episode of ACS patients should be referred to a cardiac rehabilitation programme, Cardiac rehabilitation aims to support patients to modify risk factors, increase physical activity and offers psychosocial counselling when necessary.  In most cases patients should be well enough to resume normal activities at 4 – 6 weeks post discharge with a return to work usually after 12 weeks.

More information about cardiac rehabilitation programmes can be accessed by the link below:

https://www.bhf.org.uk/heart-health/living-with-a-heart-condition/cardiac-rehabilitation