Acute Coronar y Syndrome and Acute Myocardial Infarction

S imul ate d Cl i nic a l Ex per ie nc e (SC E ™ ) O v e r v i e w L e a r n i n g O b j e c ti v es

Location: Coronary Care Unit
History/Information:
This patient is a 68-year-old retired postal worker who developed substernal “crushing” chest pain,
which radiated to the left side of his neck and jaw while cleaning out his garage earlier this afternoon. His
wife came outside to check on his progress and found him sitting on the floor, holding his arm and with a
“horrible blue-gray color” in his face. He told her the pain had been occurring since about 30 minutes after he
started cleaning out the garage. “I thought it would go away, but it just keeps getting worse.”
1. Integrates theoretical knowledge from the sciences, humanities and nursing
into professional nursing practice (SYNTHESIS).
2. Uses critical thinking and the nursing process as a framework for clinical
decision-making (ANALYSIS).
3. Designs an individualized plan of care for the nursing management of
a patient with an acute coronary syndrome (APPLICATION).

On arrival of the paramedics at the scene, the patient was responsive to all questions. His initial vital
signs
were HR 115, BP 108/68, RR 24 and SpO 2 95% He stated his chest pain was 4/10. Paramedics administered
nitroglycerin 0.4mg SL x2 every five minutes without relief. Five minutes after administering the third nitroglycerin,
the patient stated his chest pain was now “almost gone.” Paramedics had to convince him to come to
the Emergency Department. They did an ECG en route, which showed 2mm ST-segment elevation, indicating
an acute myocardial infarction (AMI). The paramedics started oxygen at 2LPM by nasal cannula,
administered
160mg of chewable aspirin, and started a right forearm saline lock. He had no chest pain en route, and on
arrival, he states he is pain free. He states, “I am just fine now, and I don’t know why I am here.”

Healthcare Provider’s Emergency Department Orders:

Continuous cardiac monitor
12-lead ECG STAT and with complaints of chest pain
MI Panel: CK, CK-MB, and Troponin I STAT and every 6 hours x3
CBC, Electrolytes, BUN, Creatinine, Glucose, PT/INR, PTT, UA C&S STAT
Chest x-ray STAT
NPO
Saline lock—potential for thrombolytic therapy
O2 at 2-6LPM by nasal cannula—titrate to maintain SpO2 greater than 92%
Aspirin 325mg chewed and swallowed STAT if not given by paramedics
Nitroglycerin 50mg/250 ml D5W IV at 5 mcg/minute; Titrate for chest pain with SBP greater than 90
Morphine 2-10mg IVP prn chest pain not relieved by nitroglycerin
Metoprolol 5 mg slow IVP every 5 minutes for a total of 3 doses; Hold for HR less than 60 or SBP less than 90
Heparin 5000 units IVP and start continuous infusion at 1000 units/hr
Vital signs every 15 minutes while titrating nitroglycerin, then every hour
Foley catheter
Weight on admission
Intake and output
Prepare for cardiac catheterization
Obtain permit for cardiac catheterization and possible percutaneous transluminal coronary angiography (PTCA)
with stent placement
Notify healthcare provider of SBP less than 90, HR less than 60, or PVCs greater than 6 per minute

Batam National Health Training Centre – Acute Coronary Syndrome and Acute Myocardial Infarction Learner 1
Q u e s ti o n s t o P rep are f or t h e Sim ul ate d C l i nic a l Exp e ri e nce : Re fer enc es

1. What is Acute Coronary Syndrome (ACS)? Kee, J.L. (2009). Prentice hall handbook of laboratory and diagnostic tests with
2. Describe the etiology and pathophysiology of Acute Coronary Syndrome. nursing implications. (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
3. What are the differences between a transmural (e.g., full thickness) MI and a
subendocardial (e.g., partial thickness) MI? Keeley, E.C. and Grines, C.L. (2004). Primary coronary intervention for acute
4. How are these differences depicted on the ECG? myocardial infarction. JAMA 291, 6, 736-739
5. What are the areas of infarction?
6. Correlate the location and area involved with the part of the coronary circulation Kowalak, J.P., Hughes, A.S. and Mills, J.E. (2003). Best practices: A guide to
involved: excellence in nursing care. Philadelphia: Lippincott.
a. Right coronary artery
b. Left anterior descending artery Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P.G. and Nucher, L. (2007).
c. Left circumflex artery Medical-surgical nursing: Assessment and management of clinical problems. St.
7. Why does the younger person who has a severe MI usually have more serious Louis: Mosby.
impairment than an older person?
8. Why is it common for the temperature to rise in the first 24 hours following an AMI? Mahaffey, K.W. et al (2005). High-risk patients with acute coronary syndromes
9. What is the most common complication following an AMI? Why? treated with low-molecular-weight or unfractionated heparin. JAMA 294, 20.
10. Correlate the area of infarction and the side effects/complications most commonly
seen: McGee, S. (2007). Evidence-based physical diagnosis (2nd ed.). Philadelphia:
a. Inferior wall damage Saunders.
b. Lateral wall damage
c. Anterior wall damage Morton, P.G., Fontaine, D.K., Hudak, C.M. and Gallo, B.M. (2005). Critical care
d. Posterior wall damage nursing: A holistic approach (8th ed.). Philadelphia: Lippincott.
11. What are the serum cardiac markers used in diagnosing an AMI? When do their levels
peak? When do their levels return to normal? Mosby Staff. (2004). Mosby’s drug consult for healthcare professions 2006. St. Louis:
12. Thrombolytic therapy should be instituted within how many hours of the onset of pain Mosby.
to be of most benefit? What are the nursing implications and management of the
patient receiving thrombolytic therapy? Nettina, S. M. (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia:
13. What are the major drug classifications the nurse would anticipate a patient with Lippincott.
ACS receiving? For each of the classifications, identify the action and key nursing
implications. Pifarre, R. (2001). Evidence-based management of the acute coronary syndrome (1st
14. Outline the components of a teaching plan for a patient with Acute Coronary Syndrome ed.). Philadelphia: Hanley and Belfus.
and successful revascularization via Percutaneous Coronary Intervention (PCI).
15. What is the half life of amiodarone? Why is this important to know? Registered Nurses Association of Ontario. (2002). Assessment and management of
pain. Toronto: RNAO.

References: Rippe, J.M. (2003). Intensive care medicine (5th ed.). Boston: Little.
Best practices: Evidence-based nursing procedures (2nd ed.). (2006). Philadelphia:
Lippincott. Smeltzer, S.C., Bare, B.G., Hinkle, J.L. and Cheever, K.H. (2008). Brunner and
suddarth’s textbook of medical-surgical nursing. Pennsylvania: Lippincott.
Fenton, D. (2004). Acute coronary syndrome. Postgraduate Medicine 1, 1-33.
Taniguchi, R. (2004). Combined measurements of cardiac troponin T and N-terminal
Fonarow, G.C., Wright, R.S., Spencer, F. A., Fredrick, P. D., Dong, W., Every, N. et al. (2005). pro-brain natriuretic peptide in patients with heart failure. Circulation 12, 1160-1164.
Effect of statin use within the first 24 hours of admission for acute myocardial infarction on
early morbidity and mortality. The American Journal of Cardiology 86(5), 611-615. Vacek, J.L. (2002). Classic O wave myocardial infarction. Practical Peer Review
Journal for Primary Care Physicians 112(1), 71-77.
Hani, J., (2003, May). Aspirin and clopidogrel in acute coronary syndromes. Arch Intern
Med 163, 1143-1151.

Joanna Briggs Institute for Evidence Based Nursing and Midwifery. (2007). Best Practice:
Vital Signs. Retrieved March 25, 2008 from http://www.joannabriggs.edu.au/best_practice/
bp8.php?win=NN

Batam National Health Training Centre - Acute Coronary Symdrome and Acute Myocardial Infarction Learner 2