Nursing care Patients Acute Coronary Syndrome Dr.Sarinrut Sriprasong Department of Medical Nursing Faculty of Nursing, Mahidol University
Learning outcomes Can describe • Definition, Types, & Causes of CAD & ACS • Pathophysiology, Signs & Symptoms of ACS • Assess patients with ACS • Treatment & prevention CAD/ACS • Nursing care for patients with ACS • Analyze case and create care plan for ACS patient 11/01/61
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Glossary
• HT: Hypertension • ACS: Acute coronary • CO: Cardiac output syndrome • SV: Stroke volume • CAD: Coronary artery • HR: Heart rate disease • SVR: Systemic vascular • CVD: Cardio vascular resistance disease • EF: Ejection fraction • ESV: End systolic volume •IHD: Ischemia heart disease • EDV: End diastolic volume • STEMI: ST elevated Myocardial Infarction • NSTEMI: Non STEMI 11/01/61
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Glossary • EPS: Electrophysiology studies • EST: Exercise stress test • CAG: cardiac cath, cardiac catheterization, coronary angiogram • CABG: Coronary artery bypass graft
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• PCI: Percutaneous Coronary Intervention • PTCA: Percutaneous transluminal coronary angioplasty • DES: Drug-eluting stents • PTRA: Rotablation (Percutaneous Transluminal Rotational Atherectomy
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Heart structure
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1. Pericardium 2. Myocardium 3. Value 4. Coronary artery
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https://upload.wikimedia.org/wikipedia/commons/5/5f/Figure_40_03_02ab.png
Coronary artery 1. Left Coronary Artery: Left main (LM), Left anterior descending (LAD), Left circumflex(LCX) 2. Right coronary artery (RCA) https://www.hopkinsmedicine.org/healthlibrary/GetImage.aspx?ImageId=322243 11/01/61
Anterior wall,sarinrut.sri@mahidol.ac.th Septal wall, Lateral wall, Inferior wall, Posterior wall
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Incidence of CAD/CVD
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http://circ.ahajournals.org/content/circulationaha/133/4/e38/F14.large.jpg
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Incidence of CAD/CVD
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Definition • Coronary heart disease (CHD) is a condition and especially one caused by atherosclerosis that reduces blood flow through the coronary arteries to the heart and typically results in chest pain or heart damage — called also coronary artery disease (CAD) or ischemic heart disease (IHD) 11/01/61
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https://www.merriam-webster.com/dictionary/coronary%20heart%20disease
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High morbidity in patients with CAD because of ischaemic events • Patients with CAD are at risk of morbidity from non-fatal ischaemic events. • In the REACH registry 6.4% of patients with CAD were hospitalized for unstable angina and 4.6% for congestive heart failure in the first year of follow-up.
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https://www.thrombosisadviser.com/coronary-and-peripheral-artery-disease/
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Case study Patient E is a man, 54 years of age, who presented to clinic with complaints of chest pain. Upon arrival at the clinic, he was chest pain free. A 12-lead ECG was performed and showed no changes from previous ECGs. Vital signs : BP135/78 mmHg, HR 68 BPM & regular, R16 BPM & unlabored, T 36.7oC UD: HT, Smoking, Father had MI, Obesiy 1. What is the patient’s problem? 2. What is the causes of this problem? 11/01/61
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“Ischaemic Cardiac Chest Pain vs. Non-Cardiac Chest Pain (Davidson's Principles of Medicine, P540 #Med433�
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Signs & Symptoms of CAD S & S of myocardial ischemia • Chest pain (angina): feel pressure or tightness in chest, as if someone standing on your chest. This pain usually occurs on middle or left side of chest. Generally triggered by physical or emotional stress. • Pain usually goes away within minutes after stopping stressful activity. • In some people, especially women, this pain may be fleeting or sharp and felt in the neck, arm or back. 11/01/61
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Signs & Symptoms of CAD S & S of myocardial ischemia • Shortness of breath. If your heart can't pump enough blood to meet your body's needs, you may develop shortness of breath or extreme fatigue with exertion. • Diabetics or Elderly will develop this symptom. • Atypical chest pain: Flu-like symptoms, feeling of indigestion, Heartburn, Fatigue
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Modifiable & Non-modifiable Risk factors of CAD
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https://www.thrombosisadviser.com/coronary-and-peripheral-artery-disease/
Case study • Patient E had to go to hospital but he declined transport by EMS & insisted on driving himself to hospital. • In ER, Patient E developed an episode of chest pain. He rated the pain as 10 out of 10 & located pain on left side of his chest, substernal region. • He slightly diaphoretic with BP 170/90 mmHg, HR 110 BPM. 3. What is the problems of this patient? 4. What should a nurse perform more history taking/ physical exam/ other investigation? 11/01/61
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Acute coronary syndrome (ACS) • ACS is an umbrella term for situations where the blood supplied to the heart muscle is suddenly blocked resulting to myocardial ischemia, or dies (infarction) or unable to function properly — called also STEMI, NSTEMI, and unstable angina (heart attack) .
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CAD & ACS
https://www.thrombosisadviser.com/coronary-and-peripheral-artery-disease/ 11/01/61
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Acute Coronary Event Risk --ACS--
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http://circ.ahajournals.org/content/125/9/1147/tab-figures-data
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Diagnosis criteria for ACS Diagnostic criteria 1. History Taking Chest pain 2. ECG 12 leads ST, T change 3. Lab Cardiac marker, Troponin T, I 1. History taking
Chief C.
Chest pain Angina
Non cardiac
2.ECG
3
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1. History taking of ACS : PQRST • • • • •
P = Provoked, Precipitating, Palliative Q = Quality, Characteristic R = Region / Radiation S = Severity (pain scale 1 to 10) T = Timing
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1. History taking of ACS Myocardial Infarction Angina • P: Precipitation by – exertion / Stress • Q: Substernal Chest discomfort • R: Radiation Left arm • R: Relieved by – NTG/ Rest • S: Few symptoms • S: pain score 5-6 • T: Lasting for < 15 min 11/01/61
• P: precipitated 10 am in morning after meal • Q: Substernal Chest pressure • R: Radiation Left arm, back, jaw • R: Relieved – Opioids • S: pain score 10/10 • S: Many Symptoms : Nausea, Vomiting, Diaphoresis, Fear, Anxiety, Palpitation, Sweating, shortness of breath • T : Lasting for > 30 min up
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1. History taking of ACS
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https://tomhitchens.com/wp-content/uploads/2015/06/Heart-Attack-Pain-Diagram2.jpg
1. History taking of ACS â&#x20AC;˘ S & S Heart attack
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2. ECG 12 leads: Unstable angina/ NSTEMI •ST segment depression and/or T wave inversion subendocardial infarction
https://image.slidesharecdn.com/myocardialinfarction-copy-13061822212311/01/61 sarinrut.sri@mahidol.ac.th 26 phpapp02/95/acute-myocardial-infarction-36-638.jpg?cb=1428399393
2. ECG 12 leads: STEMI • ST segment elevation, followed by T wave inversion & Q wave Transmural infarction
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3. Laboratory: Cardiac markers
Fatty Acid-Binding Protein (FABP) 11/01/61 sarinrut.sri@mahidol.ac.th 28 http://www.int.laborundmore.com/archive/852368/The-earliest-plasma-marker-for-myocardialinfarction.html
Special investigation Anatomical assessment • Echocardiography • Coronary arteriography (CAG) • • • • • •
Coronary Tomographic arteriography (CTA) MR angiography Coronary artery calcium (CAC) Intravascular ultrasound (IVUS) Optical coherence tomography Carotid intima thickness measurement
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Echocardiography â&#x20AC;˘ Graphic outline of heart's movement by ultrasound (high-frequency sound waves) from a hand-held wand (Transducer) placed on chest provides pictures of heart's valves and chambers and evaluate pumping action of heart. â&#x20AC;˘ Echo is often combined with Doppler ultrasound and color Doppler to evaluate blood flow across the heart's valves.
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https://my.clevelandclinic.org/health/diagnostics/16947-echocardiogram
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Echocardiography •Assess overall heart function •Determine myocardial, valve, pericardial disease, infective endocarditis, cardiac masses & congenital heart disease •Follow progress of valve disease over time •Evaluate effectiveness of medical or surgical treatments 11/01/61
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https://my.clevelandclinic.org/health/diagnostics/16947-echocardiogram
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Echocardiography ชชชื่อ -สกกุ ล .................................... Sex: Male Age: 66 years 6 mo. Method: Adult TTE(IPD) HN: …………………………… …….Tape No: ………………… Date: 30 Jun 2017 BW: 70Kg. Ht: 165 cm. BSA: 1.77sgm. Dimension: -M-Mode: IVSd: 7.18mm LVDd: 64.78mm PWd: 9.09mm EDV (Teich) 214.30ml IVSs : 9.39mm LVDs: 56.89 mm PWs: 9.91mm ESV (Teich) 159.30 ml IVSd/PWd : 0.79 EF (Teich) : 25.66% PA/Ao: Pa=Ao RA/LA: RA<LA RV/LV: RV < LV -LV Volume: Modified Simpson’s method EDV (ml) 161.00 ESV (ml): 108.00 EF(%) 33.28 ES(%)12.18
Note: LV mass Index 123 g/sgm. RWT 0.28 LA Volume Index 65 ml/sqm. RV function : TV Lat S vel 7.51 cm/s
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EF: Ejection fraction
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Echocardiography Valve: - MV excursion: Good excursion -MR severity : Severe (4+)
ERO(sqmm) : 56.79
Regurg. Vol (ml): 59.63
Cause of MR: Rupture Chordae -AoV excursion: Good excursion
AoV (cusp) : 3 cusps
-AoV Peak grad (mmHg): 5.66
Mean Grad (mmHg) : 2.93 AVA (sq.cm): 2.00
Stroke volume (ml) at LVOT :39.20 -AR Severity : Mild
AoV calcify: Yes
Cardiac output (L/min) at LVOT : 3.10
Jet/LVOT (%) :44.00
-PV excursion: Good excursion -PR Severity : Mild
PA diastolic pressure (mmHg) : 21.00
-TV excursion: Good excursion -TR Severity : Mild
RAP (mmHg) : 15.00
RVSP (mmHg) : 60.00
Note: PAP 60/21 mmHg, Mean PAP (Abba’s formula) 39 mmHg. Diastolic: E (cm/s): 155.00
A (cm/s): 52.10
E/A :3.00
DT (ms): 153.00
-Type of diastolic function: Restrictive filling Note: TDI Mitral annulus: Med S Vel 5.65 cm/s, Med E’ vel 7.9 cm/s, Med A’ Vel 5.41 cm/s, Lat E’vel 7.51 cm/s, E/avge’ 20 11/01/61
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Echocardiography
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Coronary Angiogram (CAG) • Invasive diagnostic procedure investigate structure & function of heart. • During procedure, a long, thin & flexible tube (catheter) inserted into femoral/ radial. • Using X-ray images as guide, tip of catheter passed up to aorta, heart & coronary arteries • A special type of dye called contrast medium is injected into the catheter and X-ray images (angiograms) are taken. 11/01/61 sarinrut.sri@mahidol.ac.th https://www.nhs.uk/conditions/coronary-angiography/
http://www.privatecardiology.co.uk/w pcontent/uploads/2015/06/angio2.jpg
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Coronary Angiogram (CAG) â&#x20AC;˘ Contrast medium visible on angiograms, showing blood vessels that fluid travels through. highlights --narrowed or blocked. â&#x20AC;˘ The procedure usually carried out under local anesthetic, so patient will be awake while procedure carried out, but area where catheter is inserted will be numbed. 11/01/61 sarinrut.sri@mahidol.ac.th https://www.nhs.uk/conditions/coronary-angiography/
https://www.aviva.co.uk/library/images/med _encyclopedia/cfhg360corang_001.gif
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Coronary Angiogram (CAG) Allen test
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radial & ulnar artery sarinrut.sri@mahidol.ac.th
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Pre-Catheterization 1. Teaching plan individualized to fit patient's needs. 2. Advise patient: time procedure, check pre-cath. orders, allergies, cardiac cath. permit, verify counseling by physician, and to establish that patients knowledge level. Important to alleviate any fears and to provide opportunity to answer questions. 3. Laboratory: BUN Cr GFR in DM/CKD 4.Check status of peripheral pulses/ Allen test http://micunursing.com/cardiaccathpreandpostcare.htm 11/01/61
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Post-Catheterization Assessment • vital signs, O2 sat, distal pulses q 15 min. X 4, q 30 min. X 2, then q hour X 2, then routine. • neurovascular status, if change notified. • Urine output, cardiac, respiratory, pulmonary, gastrointestinal, & gentle urinary assessment. • Peripheral vascular assessment of lower extremities. • If sedation, close monitor LOC 11/01/61
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http://micunursing.com/cardiaccathpreandpostcare.htm
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Post-Catheterization http://micunursing.com/cardiaccathpreandpostcare.htm
Interventions:
• Bed rest with head <30 degrees. The affected extremity must be kept straight. • patient fully awake, encourage to drink at least 2L of fluid during first 12 hrs post cardiac cath. • Monitor hourly intake & output. • If bleeding at puncture site, hold pressure above insertion site until bleeding stopped. Do not hold pressure directly on departure site. Notify physician. • If re-bleeds at catheter site: find pulse above insertion site & hold pressure with gauze sponge until hemostasis achieved. Note: do not totally obliterate 11/01/61 sarinrut.sri@mahidol.ac.th 41 distal pulses.
Post Coronary Angiogram At radial: • Physician remove Sheath from radial artery & put TR Band above insertion site for 4 hours • Affected extremity must be kept straight but can move fingers for 6 hours • If feel numbness, pain a tip of fingers, notify Physician • Can sit but put sling arm 11/01/61
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Coronary Angiogram (CAG)
RCA 95%
1.
LCX 80%
Korean Circ J. 2011 Jul;41(7):417-420. English. 11/01/61
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Case study • Patient E received 325 mg of aspirin with instructions to chew it before swallowing. He was also given sublingual nitroglycerin, & supplemental oxygen at 2 L per nasal cannula. • 12-lead ECG showed ST-segment depression with positive troponin T • physician ordered LWMH sc inj., 600 mg of clopidogrel , low dose of beta blocker & drip NTG, • Patient E was taken to cardiac catheterization laboratory for diagnostic coronary angiography & possible PCI. Cardiac catheterization : blockage in right coronary artery. PCI with placement of a bare-metal stent was performed.
5. What is the treatment and nursing intervention? 6.11/01/61 Discharge planning for patent E? sarinrut.sri@mahidol.ac.th
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Management ACS
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https://www.nursingtimes.net/pic 45 tures/1180xany/3/2/9/3026329_ ACS_Fig2_150217_NEW.jpg
Management ACS Pharmacological management • Pain relief: sublingual NTG, NTG infusion or IV Morphine, small doses q few minutes until pain free. • Oxygen: if present with hypoxia or heart failure. There is some evidence that giving supplemental oxygen to patients with uncomplicated MI can be harmful (Stub et al, 2015).
• Antiplatelet agents: ASA, P2Y12 antagonist group --potentially life-threatening bleeding • Anticoagulation agents: SC LMWH in NSTEMI, UA 11/01/61 sarinrut.sri@mahidol.ac.th 46 https://www.nursingtimes.net/pictures/1180xany/3/2/9/3026329_ACS_Fig2_150217_NEW.jpg
Management ACS Pharmacological management (cont.) • Beta-blockers started as early as possible if no hypotension, signs of heart failure, bradycardia or heart block. To reduce workload on heart, decrease ischaemia and limit development and/or size of an infarct • ACE inhibitors (ramipril, lisinopril & enalapril) started as early as possible – normally within 24 hrs. reduced incidence of major adverse CVD events when given within first days of ACS onset, improvement in left ventricular ejection fraction (LVEF), reducing risk of heart failure
• Statins, aimed at lowering cholesterol, 11/01/61
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https://www.nursingtimes.net/pictures/1180xany/3/2/9/3026329_ACS_Fig2_150217_NEW.jpg
Management ACS
Coronary reperfusion strategies : STEMI • PCI within 12 hours of symptom onset within 2 hours to restore coronary arterial flow & salvage myocardium (NICE, 2013a). PCI performed through radial artery, although femoral artery used in 10-15% of cases (Macdonald et al, 2016).
received PCI within 90 minutes of arrival in hospital.
• If Hospital can not do PCI Treat with thrombolytics drugs 11/01/61
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Management ACS
Coronary reperfusion strategies : STEMI • Nursing pt. receive Thrombolytic drugs 1. Monitor indication of Cerebrovascular bleeding. 2. Observe all IV sites for bleeding & patency. 3. Monitor clotting studies. 4. Observe signs of internal bleeding: Hct & Hb. 5. Test stool, urine & emesis for occult blood. 6. Monitor for indication of coronary reperfusion : abrupt cessation of chest pain/discomfort, sudden onset of Ventricular dysrhythmias, ST depress & 11/01/61 49 reduce marker oversarinrut.sri@mahidol.ac.th 12 hours.
Ignatavicious & Workman, 2016
Management ACS Coronary reperfusion strategies : NSTEMI • All NSTEMI receive antiplatelet & anticoagulation Tx. • Patients at intermediate or high risk evaluate by GRACE or TIMI offered coronary angiography, followed by PCI if needed, within 72 hours of admission. • Patients with NSTEMI or unstable angina who are clinically unstable should have angiography (followed by PCI if indicated) within 24 hours of becoming clinically unstable (NICE, 2014). 11/01/61
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Nursing care priorities General priorities for patients with ACS • Promote rest & provide assistance in ADL • Haemodynamic & ECG monitoring • Close observation of vital signs. • Review of fluid status renal perfusion, HF • Diabetes, capillary BS levels regularly checked 11/01/61
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Nursing care priorities General priorities for patients with ACS • Symptom monitoring --pain relief with NTG or morphine. • Swift recognition of cardiac changes on serial ECGs • Patients at high risk should continuous cardiac monitoring • Patients at intermediate risk managed in a medical assessment unit, -receive serial ECGs. • Nurses have ECG interpretation skills, as ECG changes or arrhythmias are signs of potential deterioration. 11/01/61 sarinrut.sri@mahidol.ac.th 52
Low Molecular Weight Heparin (LMWH) (Enoxaparin)
0. Preparation 1. Sites 2. Injection 3. Needle & syringe 4. Caring after Injection
Nursing care patient with LMWH • Given SC • Rotate sites with administration • Pressure must be applied to site for 5 min. after admin (very important to prevent bruising!!!) • Do not massage site • Use syringe and do not push air • Apply cold pack before injection 30 min.
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Low Molecular Weight Heparin (LMWH) (Enoxaparin)
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Low Molecular Weight Heparin (LMWH) (Enoxaparin)
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Low Molecular Weight Heparin (LMWH) (Enoxaparin)
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Nursing care ACS • Patients are likely to be anxious and frightened. • Nurses should be calm & reassuring, and ensure pain and other symptoms are well controlled. • Nurses play central role in providing psychosocial support; when possible, they should give patients a chance to speak about their experiences, address their concerns and relay these to the multidisciplinary team. • Stress management: relaxation, guided imagery, music therapy, pet therapy. https://www.nursingtimes.net/clinical-archive/cardiology/diagnosis-managementand-nursing-care-in-acute-coronary-syndrome/7015584.article 11/01/61
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Ignatavicious & Workman, 2016
Nursing Diagnosis ๏ Acute Pain may be related to decreased myocardial blood flow/ or increased cardiac workload/oxygen consumption ๏ (risk for) Low cardiac output related to ineffective myocardial contraction/ arrhythmia ๏ (Risk to) Hypoxia related to ineffective gas exchange) ๏ (Risk to) ineffective gas exchange relate to pulmonary edema ๏ Excess water related to ineffective myocardial contraction ๏ 11/01/61 Fear /Anxiety with sarinrut.sri@mahidol.ac.th illness 58
Nursing activities: keep O2 balance O2 Supply
Dependent roles
• O2 2 - 4 L/M •keep Sat O2 92% •Antiplatelet: ASA, … •Nitrate, NTG •Fowlers' position •CCB Multidis ciplinary 11/01/61
O 2 Demand • Bed rest • pain, Morphine, • Stress reduction • Soft diet • Laxative • Assist activities
Independent roles sarinrut.sri@mahidol.ac.th
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CO = SV X HR Bed rest EDV Veins
Preload
Blood vol.
+
-
+
ESV
TX & Nrg
+
Heart
Arteries
Contractility
O2
-blocker Control HR
O2
Afterload
Vasodilators, ACE-I, ARB
•control volume: •Diuretic, •Restrict fluid, Keep O Reperfusio 2 11/01/61 sarinrut.sri@mahidol.ac.th •Low Na n Tx, PCI Balance
Inotrope Dobutamine 60
Triller, 2004
Danger Complications Acute ACS/ MACE
Cardiac failure
Cardiogenic shock
Embolism
VSD Rupture of chordae tendidae
Heart Sound
Cardiac arrhythmia
Cardiac Rupture Pericarditis 61
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Discharge Planning METHOD M = Medication E = Environment & Economic T = Treatment H = Health O = Outpatient referral D = Diet 11/01/61
Assessment • Mortality risk Exercise Stress Test : EST Max MET = ….
• Knowledge deficit for modify behaviors
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Nursing Goals
Risk Factors
> 36 in (>90 cm) > 32 in (>80 cm) LDL
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ï&#x201A;³ 100 mg/dL
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Topics for education Diagnosis and arrangements for follow-up Include in every discharge summary: • Confirmation of acute MI diagnosis • Investigation results • Future management plans • Secondary prevention advice
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Topics for education Advise patients about CR and encourage them to attend. CR consists of:: • Physical activity • Travel and health advice • Psychological and social support • Advice on sexual activity • Support with lifestyle changes 11/01/61
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Topics for education Cardiac risk factors and lifestyle changes: • Control blood pressure • Reduce LDL cholesterol • Maintain glycemic control • Stop smoking • Maintain a healthy diet (Low Na & Fat) • Take up appropriate physical activity • Restrict alcohol use to safe levels • Maintain a healthy weight 11/01/61
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Topics for education Drug therapy for secondary prevention - Offer all of the following drugs: • • • • •
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Understand dosages ACE inhibitor/ARB & administration Dual platelet therapy routes Beta-blocker Statin Ensure the GP is aware of the timing of drug titration and the need to monitor renal function and blood pressure sarinrut.sri@mahidol.ac.th
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Education/continuing care • Report abnormal symptoms: chest pain, dyspnea, palpitation • how to use NTG SL • how to use Antithrombotic drug • Limit Intake/ Decrease salt • Preserve energy for activities level • Record pulse
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Evaluation
1. Level of conscious, vital signs, O2 sat, I/Oď&#x192; Modified early warning score (MEWS)
4. ECG monitoring
3. Physical exam: Heart & Lung
5. Laboratory 11/01/61
2. Assess behaviors mood express
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6. Specialty investigation EST, CAG, MRI 69
Cardiac investigation Exercise stress test (EST) Electrocardiogram (ECG) Transthoracic echocardiogram (TTE) Trans-esophageal echocardiogram (TEE) Tilt table test Ambulatory ECG (AECG/ Holter monitoring) • Implantable loop recorder • Electrophysiological study (EPS) • Magnetic resonance imaging (MRI) sarinrut.sri@mahidol.ac.th •11/01/61 Coronary Angiogram (CAG) • • • • • •
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Coronary Artery Disease CAD Angina, dyspnea, syncope
Atherosclerosis Plaque Age, Gender, HDL, HT, DM, Smoke
Nursing care • Control/manage chest pain • Medication adherence • Lifestyle modification • Prevent serious complication 11/01/61
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Diagnoses
- ECG, EST, CAG, Echocardiography, Cardiac enzymes, Thallium scan, MRI, Medications • Antiplatelet, • Nitrates • Beta-blockers, • Calcium antagonists, • ACEI, • ARB: Angiotensin 71 receptor blockers.
Acute coronary syndrome Plaque rupture
ACS Severe Angina, dyspnea, syncope, sweating
UA, NSTEMI
Nursing care
STEMI
• Identify STEMI, Relief of chest pain, Tx life-threatening : VF, VT • Prevention of major adverse cardiac events (MACE) • Balance O2 demand-supply • Prevent re- infarction • Mediation adherence, sarinrut.sri@mahidol.ac.th Lifestyle 11/01/61 modification
Diagnosis
- ECG, - Cardiac enzymes, - Echo, CAG Medications • MONA: ASA, Oxygen, Morphine, Nitrates • Antiplatelet, • Anticoagulants, • Antithrombotics • Beta-blockers, • ACEI, ARB 72 • Statin
Booklets for cardiac patients • Cardiac rehabilitation https:// www.bhf.org.uk/publications/heart-conditions/cardiac-rehabilitation
• Medicines for my heart https://www.bhf.org.uk/publications/heart-conditions/medicines-for-your-heart
• Heart Attack booklet https://www.bhf.org.uk/publications/large-print/heart-attack---large-print
• https://www.bhf.org.uk/heart-health
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Interesting website
• https://www.thrombosisadviser.com/coronary-and-peripheral-ar tery-disease / • https:// my.clevelandclinic.org/health/diagnostics/16947-echocardiogr am • http://micunursing.com/cardiaccathpreandpostcare.htm • https:// www.nursingtimes.net/clinical-archive/cardiology/diagnosismanagement-and-nursing-care-in-acute-coronary-syndrome/701 584.article • https://www.rnpedia.com/nursing-notes/medical-surgical-nursi ng-notes/coronary-artery-disease / 11/01/61
sarinrut.sri@mahidol.ac.th
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