BIODATA OF PATIENT

Name Minakshi devi

Age 68 yrs

Sex female

C.R No 32450

Marital Status married

Address Chakrata Road

Religion Hindu

Education Illiterate

Occupation Not working

Monthly Family income 2500-6000

Date of Admission

Diagnosis Coronary artery disease

Chief Complaints

H/O breathlessness on exertion x 8 months

Gradually progressing NYHA II to III

H/O giddiness x 2 days PTA

H/O headache x 4-5 days

No H/O palpitations/ fever / cough

History of Present Ilness

Minakshi Devi 68 yrs old female patient was admitted to CMI with complaints of
chest Pain on exertion since 2 Yrs but more significant since 8 months , more on left
pericardium squeezing type precipitated on exertion relieved by medication and rest.
She was taken to some local hospital from where she had echo and angiography done
which showed 80 % blockage in LAD and 50 % blockage in RCA narrowing from
Proximal to distal from where she was refered to CMI for treatment.

History of Past illness

H/O Diabetes X 5 Years on OHA

H/O Hypertension X 5 years on Atenolol 2.5 mg

Family History

Patiemt lives in joint Family. There are total 8 members in her family. There is no history
of DM/TB/HT or any other illness in family members.

Housing

Patient lives in her own pucca house. There are total 3 rooms. Indian toilet facility is
there. Source of drinking water is from tap and hand pump.

Patient’s sensitivity/allergy/precaution

Patient was not allergic to any drug, food material.

Personal History

Patient is vegetarian, usually had 3 meals per day. But due to fever and vomiting she had
anorexia for 4 to 5 days. She used to have 8 to 10 hrs of sleep at home.

Menstrual History

She had menopause at the age of 54 yrs.

Elimination:

Patient used to have normal bowel movement. She complaints of retention of urine
intermittently so required catheterization.
Mobility and exercise

She don’t have walking habits. Due to old age she had joint pains and was unable to
walk.

GENERAL PHYSICAL EXAMINATION

HEAD TO TOE ASSESSMENT

General Appearance: Moderate

Sensorium : Conscious

Posture : Normal

Vital Signs

Temp 38oc Pulse 90/min resp-18/min B.P- 126/90 mm of Hg

Skin: The condition of skin is dry and pale.

Hair: Hair are clean, grey and short . No pediculli or dandruff.

Eyes: Eyes are black in colour with no discharge, redness, swelling. Patient had
farsightedness and uses glasses

ENT: No discharge from ear or nose. No DNS. Patient has nasogastric tube.

Oral mucosa: Oral mucosa was healthy. Patient had dentures.

Glands: Lymph nodes are not enlarged

Chest: Patient had midsternal incision for surgery and was covered with dressing. No
dyspnea, orthopnea present. Chest movements were symmetrical. And crackles can be
heard.

Abdomen: Abdomen is flat , hard,& tender , due to constipation. Patient feels pain in
umbilical region.

Limbs:

Upper limbs: Restricted movements were there in the upper as well as in the lower
limbs.
Lower limbs: Patient had incision on left lower leg from where the graft has been taken.
And had dressing on it.

Back: Patient feels pain and discomfort in back due to prolonged bed rest. There is no
tenderness. Shape and curvature of spine is normal. No lordosis, kyphosis, scoliosis.

Systemic examination

Nervous system

Cranial nerves: All the cranial nerves are intact.

Motor system: Muscle tone and strength is decreased in the upper and lower limbs.

DTR’s are diminished

Respiratory system:

Bilateal breath sounds are equal. Crackles are heard in the left side. RR= 22/min

Circulatory system

S1 & S2 normal. Heart rate : 92/min

Gastrointestinal system

Bowel sounds are present. Patient feels tenderness at umbilical region.

No bruits present

Musculoskeletal system:

Restricted range of motion present in upper and lower limbs due to joint pain and
surgery.

Urinary system urinary retention present so patient is catheterized.

Description of disease

Definition :

 Coronary heart disease (or coronary artery disease) is a narrowing of the small
blood vessels that supply blood and oxygen to the heart (coronary arteries).

 Coronary artery disease leads to the interruption of blood flow to cardiac muscle
when the arteries are obstructed by plaque.

Incidence and prevalence

 Coronary artery diesease is the most common type of cardiovascular disease and
accounts for majority of deaths.

 There has been an alarming nine fold increase in the urban and over two fold
increase in CAD among rural population over the last four decades.

 A Delphi base study in late 90s revealed 9.5 percent prevalence of CAD, 10.2
percent among Indian immigrants in the US as compared to only 2.5 percent in
western based Framingham.

 Indians have more risk of developing CAD than Japanese by 20 times than
Chinese by 6 times than white Americans by four times.
 At present 25% death among Indians are attributable to CAD. With the present
trend mortality from CAD will increase by 103% in male and 90% in females from
1985 to 2015

 By 2015 CAD will account for 34 percent all male death and 32 percent all female
death in india.

Risk factors for CAD

Although the causes of CAD are not known, the evidence suggests that many factors
contribute to the onset of atherosclerosis.

Non modifiable risk factors

1. Heredity. Genetic factors contribute to four traits that increase the incidence of
atherosclerosis: hyoertension, dyslipidemia,diabetes and obesity.

2. Age: symptomatic CAD predominantly in clients over 40 years. However

clients in their 30’s and even their 20’s suffer angina attack or MI.

3. Sex: women of child bearing age displays one fourth the risk of developing
CAD compared with the men of same age. Women who take oral
contraceptive are more likely to develop CAD.

Modifiable risk factors

1. Smoking: clients who smoke have two to four times the risk of sudden cardiac
death. Male adult smokers have 70% higher mortality than do male nonsmokers.

2. BP : men over 45 years of age with blood pressure exceeding 140/90 and all adult
women with pressure above 160/95 have a 50 % higher chance of mortality.

3. Cholesterol. A client with serum cholesterol level greater than 259mg/dl is three
times more likely to develop CAD than with serum level of 200 mg/dl

4. D.M. A fasting blood sugar of more than 120mg/dl or routine blood sugar of 180
mg/dl increased the risk of developing CAD.
 5. Physical Inactivity: lack of physical activity increases the chances of obesity and
CAD

6. Obesity: obesity places an extra burden on heart requiring the muscle to work
harder to support added tissue mass.

7. Personality: Type A behavior is Characterized by aggressiveness, ambition,

competitiveness, and it may be a significant factor in working woman

Related anatomy and physiology

Coronary arteries

Two coronary arteries-right and left – branch from the ascending aorta.

The left coronary artery

passes inferior to the left
auricle and divides into the
interventricular and
circumflex branches.

The anterior interventricular

branch or left anterior
descending(LAD) artery is
in the anterior
interventricular sulcus and
supplies oxygenated blood
to the walls of both
ventricles and the interventricular septum.

The circumflex branch lies in the coronary sulcus and distributes oxygenated
blood to the walls of left ventricle and left atrium.

The right coronary artery supplies small branches to the right atrium. It
continues inferior to the right auricle and divides into the posterior interventricular
and marginal branches.
 The posterior interventricular branch follows the posterior interventricular sulcus
and supplies the walls of two ventricles and the intervetricular septum with
oxygenated blood.

The marginal branch in the coronary sulcus transports oxygenated blood to the
myocardium of the right ventricle.
Depending on the degree to which an artery is blocked the tissue that receives blood
from it is at risk for ischemia, injury, or infarction

If the LAD is occluded the anterior wall of left ventricle, the interventriclular
septum,the right bundle branch and right bundle branch and left anterior fasiculus of the
left bundle branch may become ischemic, injured or infracted

If RCA is occluded the right atrium and ventricle and part of the left ventricle may
become ischemic, injured or infracted.

If circumflex artery is blocked the lateral walls of the left ventricle, the left atrium and
the left posterior fasiculus of the left bundle branch may become ischemic, injured or
infracted
 Pathophysiology of CAD

Risk factors( hypertension, DM, High blood cholesterol,)

Atherosclerotic plaque formation in the lumen of coronary arteries

Stimulate the platelet aggregation and thrombus formation

Narrowing of lumen of coronary artery

Ischemia to myocardial cells

Anaerobic metabolism of glycogen

Acculmulation of hydrogen ions and lactate

Acidosis

if perfusion not restored within about 20 min

myocardial necrosis

scar tissue replaces healthy tissue

impaired myocardial contractility

decreased cardiac output

stimulate the sympathetic nervous system decreased renal perfusion

release of epi and nor epi stimulate the release of renin release ofADH

angiotensin and aldosterone

increase the heart rate, blood pressure vasoconstriction sod and water reabsorb

increases after load increseaes the preload

increases the myocardial demand for oxygen

increases the workload of heart

Clinical Manifestations

According to book According to patient

Heaviness, squeezing, pressure, tightness in chest pain was present squeezing type on
upper chest exertion
Indigestion or gas Present
Radiation to neck, jaw, shoulders and arms Present

Associated symptoms Present

Dyspnea, Diaphoresis, Dizziness, N/V, Breathlessness on exertion , dyspnea
Anxiety
Feeling of weakness or numbness in arms, Not present
wrists or hands
Choking or smothering sensation Not present

Investigations

According to book According to patient

ECG Done
ST segment elevation, T wave inversion, and an abnormal Q wave.
Chest X ray Done Cardiomyopathy
Echocardiography Done
Mild MR mild PR, LVD dysfunction, EF 50%
Angiography Done RCA 80 % LAD 70 %

Lab tests: Done .high levels of serum cholesterol, triglyceride levels

Medical management:

According to book According to patient

HMG- CoA Reductase inhibitors Tab. Atorvas 20 mg

Antiplatelets Tab. Ecosprin 150 mg

Adenosine diphosphate receptor Tab clopivas 75 mg

antagonists
Vasodilators Tab Imdur 30 mg

Beta adrenergic blockers Tab metoprolol 5 mg

ACE inhibitors not prescribed
Glycoprotein II b/Iia inhibitors not prescribed

Fibrinolytic therapy not prescribed

Oxygen therapy on venturi mask at 6 l/min

Drug presentation

NAME: Atorvas

CLASSIFICATION: HMG CoA Inhibitors

ACTION: HMG CoA inhibitors (alo called statins) inhibit the enzyme HMG
CoA reductase that is invloved in the synthesis of cholestrol. These
agents decreases the concentratiom of total and LDL cholestrol and
triglycerides and increases the concentration of HDL cholesterol. It is
effective in controlling the lipid levels.

INDICATIONS: hypercholestrolemia, dyslipidemia reduction of lipids/cholesterol to

reduce the risk of MI and stroke sequelae and to decrease the need
for byepass procedure

ROUTE AND DOSAGE: PO: 10 to 20 mg once daily initially; may be increased q

2-4 wk upto 80 mg/day
PHARMACOKINETICS: Absorption: it is rapidly absorned but undergoes
extensive GI and hepatic metabolism reulting in 14 % bioavailability.

DISTRIBUTION : it probably enters the breast milk

METABOLISM AND EXCRETION : it is metabolized by liver and excreted in bile

and faeces.

HALF LIFE: 14 hrs

ADVERSE EFFECTS: CNS: headache, insomnia, weaknes

ENT: Rhinitis

Resp: bronchitis

GI: abdominal cramps, constipation, diarrhea, flatus,

heartburn, altered taste, drug induced hepatitis, dyspepsia,
elevated liver enzymes, nausea

Derm: Rashes

Musculoskeletal: arthralgia, myalgia

Misc : Hypersenstivity reactions

NURSING RESPONSIBILITIES:

 Record the clients complete health, diet family medication and exercise history

 Weigh the client and examine the skin for xanthomas

 Monitor serum cholesterol, triglyceride levels, LFTs

 Monitor the client for GI symptoms and constipation

CLIENT EDUCATION

 Take the medication exactly as directed and donot skip doses. Take daily dose in
the evening to maximize the drug effect.
 Follow a low fat, low cholesterol diet and control sugar intake.
  Eat foods that are high in fiber, and drink atleast 6-8 glasses of fluids a day to
prevent constipation
 Follow an exercise program
 Restrict alcohol and stop smoking to reduce the risk of CAD
 Report muscle pain and serious GI side effects to the primary care providers
 If surgery is planned inform the surgeon of medication regimen
 Schedule regular appointments with health care professionals for reevaluation and
ongoing lab studies
SURGICAL MANAGEMENT

CORONARY ARTERY BYEPASS GRAFTING

• Coronary artery bypass grafting is open heart surgery which creates a new path for
blood to flow around a blocked artery

( caused by CAD).

• CABG surgery restores blood flow to heart tissue that

has been deprived of blood because of coronary artery
disease

INDICATIONS

Coronary angiogram shows >50% stenosis in the

presence of any of the following: -

1. Severe angina unrespoonsive to medical therapy

2. Marked S-T depression in Tread Mill Test.

3. Left main stem stenosis.

4. Severe triple vessel disease.

5 .Angina with left ventricular dysfunction.

Benefit of CABG
 • CABG significantly improves symptoms of angina, exercise capacity and reduce
the need for medications.

• Overall quality of life improves significantly.

• It reduces chance of further heart attack.

• It significantly improves long term survival (10

yrs).

Types of graft

Saphenous vein

saphenous vein) for the bypass is harvested through a

long incision along the calf of the lower leg.

The vein is sewn in above and below the blockage in

the coronary artery.

Radial graft

Radial incision on plantar side of forearm is made and

radial artery for graft is harvested

Internal mammary artery graft

Most commonly the left ITA is left attached at its origin

from the left subclavian artery and the distal end is
dissected away from the chest wall, swung over, and its
distal end is attached with sutures to the side of the left
anterior descending (LAD) coronary artery.

Types of CABG

• Traditional ( with heart lung machine)

 • Minimally Invasive Direct CABG (MIDCAB)

Procedure

 The patient is brought to the operating room and moved on to the operating table.

 General anaesthesia is given to the patient.

 An endotracheal tube is inserted and secured by the anaestheist and mechanical

ventilation is started.

 The chest is opened via a median sternotomy .

 The byepass grafts are harvested – frequent

conduits are the internal thoracic arteries,
radial arteries and saphenous veins.

 When harvesting is done the patient is given

heparin is given to prevent the blood from
clotting.

 In case, of “off- pump” the surgeon sutures

cannulae into the heart and instructs the
perfusionist to start cardiopulmonary byepass.

 Once the CPB is established the surgeon places the aortic cross clamp across the
aorta
and instructs the perfusionist to deliver cardioplegia to stop the heart.

 one end of each graft is sewn onto the coronary arteries beyond the blockage and
the other end is attached to the aorta.

 The heart is restarted or in the off pump surgery the stabilizing devices are
removed.

 The sternum is wired together and the incisions are sutured closed.
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYEPASS
(MIDCAB)

 It is a surgical treatment for coronary heart disease that is less invasive method of
coronary artery byepass grafting.

 MIDCAB gains surgical access to the

heart with a smaller incision than other
types of CABG

 It is sometimes referred to as keyhole

heart surgery because the procedure is
analogous to operating through a keyhole.

 MIDCAB is a form of off pump coronary

artery byepass surgery performed off
pump without the use of cardiopulmonary
byepass.

 The surgeon enters the chest cavity through a mini thoracotomy (a 2 to 3 inch
incision between the ribs)

 The MIDCAB approach is usually reserved for cases requiring one or two
byepasses, typically byepassing arteries on the front of the heart such as LAD
coronary artery.

 Patients requiring more than one or two byepass conduit are usually not candidates
for MIDCAB because of limited access to vessels on the back side of heart.

POST OP COMPLICATIONS

CABG associated complications:

1.Postperfusion syndrome ( pumphead) a transient neurocognitive impairment

associated with cardiopulmonary bypass surgery.
2. Nonunion of the sternum

3. Myocardial infarction due to hypoperfusion, early graft occlusion, or graft failure.

Others

1. Late graft stenosis, particularly of saphenous vein grafts due to atherosclerosis

causing recurrent angina or myocardial infarction
2. Acute renal failure due to hypoperfusion.
3. Stroke, secondary to aortic manipulation or hypoperfusion
4. Thrombophlebitis/ pulmonary embolism
5. CCF
6. Memory deficits

General surgical complications

1. Infection at incision sites or sepsis.

2. Deep vein thrombosis (DVT)
3. Anesthetic complications such as malignant hyperthermia.
4. Keloid scarring
5. Chronic pain at incision sites
6. Chronic stress related illnesses
7. Death
8. Heart attack
9. Circulatory problems including poor circulation to the intestines, liver, legs

Postpericardiotomy syndrome:

It occurs within the first 4 days to two weeks which causes a patient to be constantly
tired with achy painful joints .

• treated with ibuprofen

complications found in different research studies

1. Abnormal lab value

2. Fluid volume imbalance

3. Respiratory System
 – Tachypnea (43%)

– Dyspnea 65%

– Pneumonia

– Atelectasis

– Pleural effusion

– Bronchitis

4. Central Nervous System

– Altered mental status

– stroke 1-2%

Cardio vascular system

• Dysarrhythmias 95%

• Hypotension 40%

• Hypertension

• Angina

• Myocardial infarction

• Cardiac Temponade

• Persistent Bleeding

• Excessive blood loss

• Thrombophlelibitis

• Deep Vein Thrombosis

6. Gastrointestinal System

• Nausea 10%

• Vomiting 13%
 • Diarrhoea

• Constipation 100%

7. Genitourinary System
– Urinary tract infection 3%

– Altered urine output 35%

– Renal failure

8 Systemic

– Sternal wound infection

– Leg wound infection

– Throat infection

– Fever 65%

– Weakness/Lethargic 93%

9 Drug (Narcotic e.g. morphine, tramadol) Induced withdrawl symptoms

– Nausea

– Headache

– Vomiting

– Bodyache

Care of patient

Preoperative interventions

 Explain surgical procedure to the patients as well its expected outcomes and
complications
 Get informed consent from patient or nearest relative after explaining in
vernacular language if necessary.
 Follow institutional protocol regarding following –
 1. Shaving & preparing surgical site

2. Pre op medication ( as ordered)

3. Arrange at least 4 bottles of cross matched blood.

4. Ready patient in OT clothes

Post operative interventions

NURSING PRIORITIES

1. Support hemodynamic stability/ventilatory function.

2. Promote relief of pain/discomfort.
3. Promote healing.
4. Provide information about postoperative expectations and treatment regimen.
 NURSING CARE PLAN

S. NURSING GOAL PLANNING INTERVENTION RATIONALE EVALUATION

N DIAGNOSIS
o.

1. Decreased To It is *Monitor cardiac This will Cardiac putput

cardiac mainta planned to status for help in is maintained.
output in monitor hemodynamic maintenance
related to cardia cardiac stability of cardiac
blood loss c status & including output.
&compromi output monitor readings of BP,
sed ECG pulmonary artery
myocardial pattern. pressure, central
function. venous pressure,
cardiac output,
cardiac rhythm
and rate.

*Monitor ECG
pattern for
cardiac
dysrythmias

*Assess cardiac
enzyme test
results

*Measure urine
output every ½
. hrly to 1 hr

*Observe buccal
mucosa nailbeds,
lips, earlobes
and extremities
for cyanosis
which may
 indicate
decreased
cardiac output.

*Assess skin
temperature and
color as cool
moist skin
indicate
casoconstriction
and decreased
cardiac output.
Observe for
persistent
bleeding, steady
continous
drainage of
blood,
hypotension, low
CVP,
tachycardia

2. Impaired *Maintain It will lead Proper gas

gas To It is mechanical to improved exchange is
exchange impro planned to ventilation until gas maintained.
related to ve gas provide the patient is exchange.
trauma of excha mechanical able to breathe
extensive nge ventilation independently.
chest abg
surgery monitoring *Monitor Presence of
Arterial blood hypoxia
gases, tidal indicates
volume, peak need for
inspiratory supplementa
pressures. l
oxygenation
*Auscultate for
breath sounds
 *Promote deep
breathing forced
expiratory
technique and
turning.

*Encourage use
of the incentive
spirometer and
compliance with
breathing
treatments.
.
*Teach
incisional
splinting with a
“cough pillow”
to decrease
discomfort
during deep
breathing.

*Suction
tracheobronchial
secretions as
needed using
strict aseptic
techniques.
Assist in
weaning and
endotracheal
tube removal

3. Risk for To It is Maintain fluid Fluid &

deficient mainta planned to and electrolyte It will help electrolyte
fluid in maintain balance by:- in balance is
volume and fluid input maintenance maintained.
electrolyte & output *Maintain strict of fluid &
imbalance electro chart & intake and electrolyte
 related to lyte measure output charting. imbalance.
alteration in balanc postoperati
blood e ve chest *Record urine
volume drainage. volume every ½
hr to 4 hrs.

*Assess the
following
parameters in
patient-
pulmonary artery
pressure,
CVP,blood
pressure,
JVP,tissue turgor
,urine output and
nasogastric tube
drainage.

*Measure
postoperative
chest drainage.
Ensure patency
and integrity of
the drainage
system.

*Monitor the
changes in
electrolyte levels
especially
potassium,
magnesium,
sodium and
calcium.
Disturbed To
4. It is *Use measures Patient has
sensory relieve planned to to prevent post It will help calm sleep &
perception
anxiet explain cardiotomy in relieving no anxiety.
related to
y procedure psychosis: from anxiety
excessive &prov & & will
environmen ide comfortabl *Explain all provide
tal comfo e procedures and comfortable
stimulation, environme the need for sleep.
rtable
sleep nt patient
deprivation, enviro &relaxatio cooperation.
electrolyte nment. n technique
imbalance. to patient. *Plan nursing
care to provide
for periods of
uninterrupted
sleep with
patients normal
day night
pattern.

*Decrease sleep
preventing
environmental
stimuli as much
as possible.

*Orient to time
and place
frequently.

*Encourage
family to visit
regularly.

*Assess for
medications that
may contribute
to delirium.

*Teach
relaxation
technique and
diversions.Obser
ve for perceptual
 distortions,
hallucinations,
disorientations,
and paranoid
delusions.
To
5. Acute pain relieve It is
*Assess nature,
planned to Pain is
related to pain
provide type, location, It will help relieved.
surgical comfortabl in relieving
intensity and
e position of pain.
trauma
& duration of pain.
assessment
of pain
*Assist the
location &
patient to
type
differentiate
between surgical
pain and angina
pain.

*Encourage
routine pain
medication for
the first 24 to 72
hrs and observe
for side effects
of lethargy,
hypotension,
tachycardia,
respiratory
depression.

To
provid
6. Deficient e It is *Develop Patient is
knowledge planned to teaching plan for It will help having
knowl
related to provide patient and the patient knowledge of
self care edge knoeledge family. after self care
activities regarding discharge, activities.
relatd
exercise, *Provide how to
to self medication specific perform self
, instructions for care
care
temperatur the following- activities
activit e daily weight and after
monitoring diets, activity discharge.
ies
. progression,
exercise, deep
breathing,lung
expansion,exerci
se,temperature
monitoring,
medication
regimen,need for
medic alert
identification.

*Provide verbal
and written
instructions;
provide several
teaching sessions
for
reinforcement
and answering
questions.

*Involve family
in all teaching
sessions.

*Provide
information
regarding follow
up visit with
 cardiologist.

*Make
appropriate
referral: home
care agency,
cardiac
rehabilitation
program,
community
support groups .

Cardiac rehabilitation

Process of actively assisting the client with cardiac disease to achieve and maintain a
vital and productive life within the limitations of the heart disease.

Patient Education and Health Maintenance

Instruct Patient and Family About CAD

 Review the chambers of the heart and the coronary artery system, using a diagram
of the heart.
 Show patient a diagram of a clogged artery; explain how the blockage occurs;
point out on the diagram the location of the patient's lesions.
 Explain what angina is (a warning sign from the heart that there is not enough
blood and oxygen because of the blocked artery or spasm).
 Review specific risk factors that affect CAD development and progression;
highlight those risk factors that can be modified and controlled to reduce risk.
 Discuss the signs and symptoms of angina, precipitating factors, and treatment for
attacks. Stress to patient the importance of treating angina symptoms at once.
 Distinguish for patient the different signs and symptoms associated with stable
angina versus preinfarction angina.

Identify Suitable Activity Level to Prevent Angina

Advise the patient about the following:

 Participate in a normal daily program of activities that do not produce chest

discomfort, shortness of breath, and undue fatigue. Spread daily activities out over
 the course of the day, avoid doing everything at one time. Begin regular exercise
regimen as directed by health care provider.
 Avoid activities known to cause anginal pain â sudden exertion, walking against
the wind, extremes of temperature, high altitude, emotionally stressful situations;
these may accelerate heart rate, raise BP, and increase cardiac work.
 Refrain from engaging in physical activity for 2 hours after meals. Rest after each
meal if possible.
 Do not perform activities requiring heavy effort (eg, carrying heavy objects).
 Try to avoid cold weather if possible; dress warmly and walk more slowly. Wear
scarf over nose and mouth when in cold air.
 Reduce weight, if necessary, to reduce cardiac load.

Instruct About Appropriate Use of Medications and Adverse Effects

 Carry nitroglycerin at all times.

o Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and
time.
o Keep nitroglycerin in original dark glass container, tightly closed to prevent
absorption of drug by other pills or pillbox.
o Nitroglycerin should cause a slight burning or stinging sensation under the
tongue when it is potent.
 Place nitroglycerin under the tongue at first sign of chest discomfort.
o Stop all effort or activity; sit, and take nitroglycerin tablet ”relief should be
obtained in a few minutes.
o Bite the tablet between front teeth and slip under tongue to dissolve if quick
action is desired.
o Repeat dosage in a few minutes for total of three tablets if relief is not
obtained.
o Keep a record of the number of tablets taken to evaluate change in anginal
pattern.
o Take nitroglycerin prophylactically to avoid pain known to occur with
certain activities.
 Demonstrate for patient how to administer nitroglycerin paste correctly.
o Place paste on calibrated strip.
o Remove previous paste on skin by wiping gently with tissue.
o Rotate site of administration to avoid skin irritation.
o Apply paste to skin; use plastic wrap to protect clothing if not provided on
strip.
o Have patient return demonstration.
 Instruct patient on administration of transdermal nitroglycerin patches.
o Remove previous patch; wipe area with tissue to remove any residual
medication.
o Apply patch to a clean, dry, nonhairy area of body.
o Rotate administration sites.
o Instruct patient not to remove patch for swimming or bathing.
o If patch loosens and part of it is nonadherent, it should be discarded and a
new patch applied.
 Teach patient about adverse effects of other medications.
o Constipationâ”verapamil (Calan)
o Ankle edema ”nifedipine (Procardia)
o Heart failure (shortness of breath, weight gain, edema)â”beta-adrenergic
blockers or calcium channel blockers
o Dizzinessâ vasodilators, antihypertensives

 Ensure that patient has enough medication until next follow-up appointment or trip
to the pharmacy. Warn against abrupt withdrawal of beta-adrenergic blockers or
calcium channel blockers to prevent rebound effect.

 Inform patient of methods of stress reduction, such as biofeedback and relaxation

techniques.
 Review low-fat and low-cholesterol diet. Explain AHA guidelines, which
recommend eating fish at least twice a week, especially fish high in omega-3 oils.
o Omega-3 oils have been shown to improve arterial health and decrease BP,
triglycerides, and the growth of atherosclerotic plaque.
o Omega-3 oils can be found in fatty fish, such as mackerel, salmon, sardines,
herring, and albacore tuna.
o Suggest available cookbooks (AHA) that may assist in planning and
preparing foods.
o Have patient meet with dietitian to design a menu plan.
 Inform patient of available cardiac rehabilitation programs that offer structured
classes on exercise, smoking cessation, and weight control.
 Avoid excessive caffeine intake (coffee, cola drinks), which can increase the heart
rate and produce angina.
 Do not use diet pills nasal decongestants, or any over-the-counter medications that
can increase the heart rate or stimulate high BP.
 Avoid the use of alcohol or drink only in moderation (alcohol can increase
hypotensive adverse effects of drugs).
 Encourage follow-up visits for control of diabetes, hypertension, and
hyperlipidemia.