NURSING PROCESS: THE PATIENT WITH ANGINA PECTORIS
The nurse gathers information about the patient’s symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. Appropriate questions are identified in Table 28-4, using a PQRST format. Other helpful questions may be asked. How long does the angina usually last? Does nitroglycerin relieve the angina? If so, how many tablets or sprays are needed to achieve relief? How long does it takes for relief to occur?
The answers to these questions form a basis for designing a log-ical program of treatment and prevention. In addition to assessing angina pectoris or its equivalent, the nurse also assesses the patient’s risk factors for CAD, the patient’s response to angina, the patient’s and family’s understanding of the diagnosis, and adherence to the current treatment plan.
Based on the assessment data, major nursing diagnoses for the pa-tient may include:
· Ineffective myocardial tissue perfusion secondary to CAD, as evidenced by chest pain or equivalent symptoms
· Anxiety related to fear of death
· Deficient knowledge about the underlying disease and methods for avoiding complications
· Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes
Potential complications that may develop include the following:
· Acute pulmonary edema
· Congestive heart failure
· Cardiogenic shock
· Dysrhythmias and cardiac arrest
· MI (described later)
· Myocardial rupture
· Pericardial effusion and cardiac tamponade
The major patient goals include immediate and appropriate treat-ment when angina occurs, prevention of angina, reduction of anxiety, awareness of the disease process and understanding of the prescribed care, adherence to the self-care program, and absence of complications.
If the patient reports pain (or the individual’s equivalent to pain), the nurse takes immediate action. When a patient experiences angina, the nurse should direct the patient to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen re-quirements of the ischemic myocardium. The nurse assesses the pa-tient’s angina, asking questions to determine whether the angina is the same as the patient typically experiences. A difference may in-dicate a worsening of the disease or a different cause. The nurse then continues to assess the patient, measuring vital signs and observing for signs of respiratory distress. If the patient is in the hospital, a 12-lead ECG is usually obtained and scrutinized for ST-segment and T-wave changes. If the patient has been placed on cardiac monitoring with continuous ST-segment monitoring, the ST segment is assessed for changes.
Nitroglycerin is administered sublingually, and the patient’s re-sponse is assessed (relief of chest pain and effect on blood pressure and heart rate). If the chest pain is unchanged or is lessened but still present, nitroglycerin administration is repeated up to three doses.
Each time, blood pressure, heart rate, and the ST segment (if the patient is on a monitor with ST segment monitoring capability) are assessed. The nurse administers oxygen therapy if the patient’s respiratory rate is increased or the oxygen saturation level is de-creased. Although there is no documentation of its effect on out-come, oxygen is usually administered at 2 L/min by nasal cannula, even without evidence of respiratory distress. If the pain is signif-icant and continues after these interventions, the patient is usually transferred to a higher-acuity nursing unit.
Patients with angina often fear loss of their roles within society and the family. They may also be fearful that the pain may lead to an MI or death. Exploring the implications that the diagnosis has for the patient and providing information about the illness, its treatment, and methods of preventing its progression are im-portant nursing interventions. Various stress reduction methods should be explored with the patient. For example, music therapy, in which patients are given the opportunity to listen to selected music through headphones for a predetermined duration, has been shown to reduce anxiety in patients who are in a coronary care unit and may serve as an adjunct to therapeutic communi-cation (Chlan & Tracy, 1999; Evans, 2002). Addressing the spir-itual needs of the patient and family may also assist in allaying anxieties and fears.
The nurse reviews the assessment findings, identifies the level of activity that causes the patient’s pain, and plans the patient’s ac-tivities accordingly. If the patient has pain frequently or with minimal activity, the nurse alternates the patient’s activities with rest periods. Balance of activity and rest is an important aspect of the educational plan for the patient and family.
Learning about the modifiable riskfactors that contribute to the continued development of CAD and resulting angina is essential. Exploring with the patient and family what they see as their priority in managing the disease and developing a plan based on their priorities can assist with patient adherence to the therapeutic regimen. It is important to explore with the patient methods to avoid, modify, or adapt the triggers for anginal pain. The teaching program for the patient with angina is designed so that the patient and family can explain the illness, identify the symptoms of myocardial ischemia, state the actions to take when symptoms develop, and discuss methods to prevent chest pain and the advancement of CAD. The goals of the educational program are to reduce the frequency and severity of anginal attacks, to delay the progress of the underlying disease, if possible, and to prevent any complications. The factors out-lined in the accompanying checklist Chart 28-5 are important in educating the patient with angina pectoris.
The self-care program is prepared in collaboration with the patient and family or friends. Activities should be planned to minimize the occurrence of angina episodes. The patient needs to understand that any pain unrelieved within 15 minutes by the usual methods (see Chart 28-4) should be treated at the closest emergency center; the patient should call 911 for assistance.
Expected patient outcomes may include:
1) Reports that pain is relieved promptly
a) Recognizes symptoms
b) Takes immediate action
c) Seeks medical assistance if pain persists or changes in quality
2) Reports decreased anxiety
a) Expresses acceptance of diagnosis
b) Expresses control over choices within medical regimen
c) Does not exhibit signs and symptoms that indicate a high level of anxiety
3) Understands ways to avoid complications and demonstrates freedom from complications
a) Describes the process of angina
b) Explains reasons for measures to prevent complications
c) Exhibits normal ECG and cardiac enzyme levels
d) Experiences no signs and symptoms of acute MI
4) Adheres to self-care program
a) Takes medications as prescribed
b) Keeps health care appointments
c) Implements plan for reducing risk factors
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