Planning and Goals

Major patient goals include immediate and appropriate treatment 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.
Nursing Interventions
Treating Angina
If the patient reports pain (or the person’s prodromal symptoms suggest anginal ischemia, which may
include sensations of indigestion or nausea, choking, heaviness, weakness or numbness in the upper
extremities, dyspnea, or dizziness), the nurse takes immediate action. When a patient experiences
angina, the patient is directed to stop all activities and sit or rest in bed in a semi-Fowler’s position to
reduce the oxygen requirements of the ischemic myocardium. The nurse assesses the patient’s angina,
asking questions to determine whether the angina is the same as the patient typically experiences. A
change may indicate 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 STsegment 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 response 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 if the oxygen
saturation
level is decreased. Oxygen is usually administered at 2 L/min by nasal cannula, even without evidence
of
respiratory distress, although there is no documentation of its effect on outcome. If the pain is
significant
and continues after these interventions, the patient is further evaluated for acute MI and may be
transferred to a higher-acuity nursing unit.
Reducing Anxiety
Patients with angina often fear loss of their roles within society and the family. They may also fear
that the
pain (or the prodromal symptoms) 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 important nursing interventions. Various stress reduction methods, such
as
guided imagery or music therapy, should be explored with the patient. Addressing the spiritual needs
of
the patient and family may also assist in allaying anxieties and fears.
Preventing Pain
The nurse reviews the assessment findings, identifies the level of activity that causes the patient’s pain
or
prodromal symptoms, and plans the patient’s activities accordingly. If the patient has pain frequently
or
with minimal activity, the nurse alternates the patient’s activities with rest periods. Balancing activity
and
rest is an important aspect of the educational plan for the patient and family.
Promoting Home and Community-Based Care
TEACHING PATIENTS SELF-CARE. The teaching program for the patient with angina is designed
so that the
patient and family understand 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 education are to reduce the frequency and severity of anginal attacks, to delay the
progress of the underlying disease if possible, and to prevent complications. The factors outlined in
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, including nitroglycerin (see Chart 28-3),
should
be treated at the closest emergency center; the patient should call 911 for assistance.

CONTINUING CARE. Arrangements are made for a home care nurse when appropriate. The home
care
nurse assists the patient with scheduling and keeping follow-up appointments. The patient may need
reminders about follow-up monitoring, including periodic blood laboratory testing and ECGs. In
addition,
the home care nurse may monitor the patient’s adherence to dietary restrictions and to prescribed
antianginal medications, including nitroglycerin. If the patient has severe anginal symptoms, the nurse
may assess the home environment and recommend modifications that diminish the occurrence of
anginal
episodes. For instance, if a patient cannot climb stairs without experiencing ischemia, the home care
nurse may help the patient plan daily activities that minimize stair climbing. Some patients may
benefit
from moving the bedroom to a lower level in the home.
Evaluation
Expected Patient Outcomes
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 is free of complications
a. Describes the process of angina
b. Explains reasons for measures to prevent complications c. Exhibits normal ECG and cardiac
biomarkers
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 to reduce risk factors
Acute Coronary Syndrome and
Myocardial Infarction
ACS is an emergent situation characterized by an acute onset of myocardial ischemia that results in
myocardial death (ie, MI) if definitive interventions do not occur promptly. (Although the terms
coronary
occlusion, heart attack, and MI are used synonymously, the preferred term is MI.) The spectrum of
ACS
includes unstable angina, non–STsegment elevation MI (NSTEMI), and ST-segment elevation MI
(STEMI).