Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome NURSING CARE PLAN 34-1

833
Cardiovascular System

Patient with Acute Coronary Syndrome

NURSING DIAGNOSIS PATIENT GOAL
Pain Level
Acute pain related to myocardial ischemia as evidenced by severe chest pain and tightness, radiation of pain to the neck and arms

Reports relief of pain

OUTCOMES (NOC)
Reported pain ____
Measurement Scale
1 2 3 4 5 Severe Substantial Moderate Mild None

INTERVENTIONS (NIC) and RATIONALES

Cardiac Care: Acute

Evaluate chest pain (e.g., intensity, location, radiation, duration, and precipitating and alleviating factors) in order to accurately evaluate, treat, and prevent further ischemia.

Monitor effectiveness of oxygen therapy to increase oxygenation of myocardial tissue

and prevent further ischemia.

Administer medications to relieve/prevent pain and ischemia to decrease anxiety and

cardiac workload.

Obtain 12-lead ECG during pain episode to help differentiate angina from extension of
MI or pericarditis.

Pain Control

Monitor cardiac rhythm and rate and trends in blood pressure and hemodynamic parameters (e.g., central venous pressure and pulmonary artery wedge pressure) to monitor for hypotension and bradycardia, which may lead to hypoperfusion.

Uses preventive measures ____ Uses analgesics appropriately ____ Reports uncontrolled symptoms to health care
professional ____

Reports pain controlled ____

Measurement Scale
1 2 3 4 5 Never demonstrated Rarely demonstrated Sometimes demonstrated Often demonstrated Consistently demonstrated

NURSING DIAGNOSIS PATIENT GOAL

Ineffective tissue perfusion (cardiac) related to myocardial injury and potential pulmonary congestion as evidenced by decrease in BP, dyspnea, dysrhythmias, peripheral edema, and oliguria

Maintains stable signs of effective cardiac perfusion

OUTCOMES (NOC)
Cardiac Pump Effectiveness

INTERVENTIONS (NIC) and RATIONALES

Cardiac Care

1 2 3 4 5

Systolic blood pressure ____ Diastolic blood pressure ____ Apical heart rate ____ Urinary output ____

Monitor vital signs frequently to determine baseline and ongoing changes. Monitor for cardiac dysrhythmias, including disturbances of both rhythm and conduction, to identify and treat signicant dysrhythmias.

Monitor respiratory status for symptoms of heart failure to maintain appropriate levels of
oxygenation and observe for signs of pulmonary edema.

Measurement Scale
Severely compromised Substantially compromised Moderately compromised Mildly compromised Not compromised

Monitor uid balance (e.g., intake/output, daily weight) to monitor renal perfusion and
observe for uid retention.

Arrange exercise and rest periods to avoid fatigue and decrease the oxygen demand on
myocardium.

Peripheral edema ____ Dyspnea ____ Dysrhythmia ____

Measurement Scale
1 2 3 4 5 Severe Substantial Moderate Mild None

Continued

834
Cardiovascular System

Section 7

Problems of Oxygenation: Perfusion

NURSING CARE PLAN 34-1contd

Patient with Acute Coronary Syndromecontd

NURSING DIAGNOSIS
Anxiety related to perceived or actual threat of death, pain, possible lifestyle changes as evidenced by restlessness, agitation, and verbalization of concern over lifestyle changes and prognosis as substantiated by patients statement of What is going to happen when I die everyone relies on me

PATIENT GOAL

Reports decreased anxiety and increased sense of self-control

OUTCOMES (NOC)
Anxiety Self-Control

INTERVENTIONS (NIC) and RATIONALES

Anxiety Reduction

Monitors intensity of anxiety ____ Seeks information to reduce anxiety ____ Controls anxiety response ____ Uses relaxation techniques to reduce anxiety ____

Measurement Scale
1 2 3 4 5 Never demonstrated Rarely demonstrated Sometimes demonstrated Often demonstrated Consistently demonstrated

Observe for verbal and nonverbal signs of anxiety. Identify when level of anxiety changes since anxiety increases the need for oxygen. Use a calm, reassuring approach so as not to increase patients anxiety. Instruct patient in use of relaxation techniques (e.g., relaxation breathing, imagery) to enhance self-control. Encourage family to stay with patient to provide comfort. Encourage verbalization of feelings, perceptions, and fears to decrease anxiety and stress. Provide factual information concerning diagnosis, treatment, and prognosis to decrease fear of the unknown.

NURSING DIAGNOSIS PATIENT GOAL

Activity intolerance related to fatigue secondary to decreased cardiac output and poor lung and tissue perfusion as evidenced by fatigue with minimal activity, inability to care for self without dyspnea, and increased heart rate

Achieves a realistic program of activity that balances physical activity with energy-conserving activities

OUTCOMES (NOC)
Energy Conservation

INTERVENTIONS (NIC) and RATIONALES

Cardiac Care

Balances activity and rest ____ Recognizes energy limitations ____ Uses energy conservation techniques ____
Measurement Scale
1 2 3 4 5 Never demonstrated Rarely demonstrated Sometimes demonstrated Often demonstrated Consistently demonstrated

Monitor patients response to antiarrhythmic medications since these medications will affect BP and pulse prior to activity.

Arrange exercise and rest periods to avoid fatigue and to increase activity tolerance without rapidly increasing cardiac workload.

Energy Management

Assist patient to understand energy conservation principles (e.g., the requirement for restricted activity) to conserve energy and promote healing.

Teach patient and signicant other techniques of self-care that will minimize oxygen
consumption (e.g., self-monitoring and pacing techniques for performance of activities of daily living) to promote independence as well as minimize O2 consumption.

Activity Tolerance

Oxygen saturation with activity ____ Pulse rate with activity ____ Ease of breathing with activity ____
Measurement Scale
1 2 3 4 5 Severely compromised Substantially compromised Moderately compromised Mildly compromised Not compromised

Adhering to a regular, individualized program of physical activity that conditions the heart rather than overstresses the myocardium is important. Most patients can be advised to walk briskly on a at surface at least 30 minutes a day, 5 or more days a week.8 It is important to teach the patient and the family in the proper use of nitroglycerin (see pp. 000). Nitroglycerin tablets or ointments may be used prophylactically before an emotionally stressful situation, sexual intercourse, or physical exertion (e.g., climbing a long ight of stairs). Counseling should be provided to assess the psychologic adjustment of the patient and the family to the diagnosis of CAD and

the resulting angina. Many patients feel a threat to their identity and self-esteem and may be unable to ll their usual roles in society. These emotions are normal and real.

Nursing Implementation Acute Coronary Syndrome Acute Intervention. Priorities for nursing interventions in the

initial phase of ACS include pain assessment and relief, physiologic monitoring, promotion of rest and comfort, alleviation of stress and anxiety, and understanding of the patients emotional

Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome NURSING CARE PLAN 34-1contd

835
Cardiovascular System

Patient with Acute Coronary Syndromecontd

NURSING DIAGNOSIS
Ineffective therapeutic regimen management related to lack of knowledge of risk factors, disease process, rehabilitation, home activities, and medications as evidenced by frequent questioning about illness, management, and care after discharge

PATIENT GOAL

Describes risk factors, the disease process, and rehabilitation activities necessary to manage the therapeutic regimen

OUTCOMES (NOC)
Knowledge: Cardiac Disease Management

INTERVENTIONS (NIC) and RATIONALES

Teaching: Disease Process

Appraise the patients current level of knowledge related to myocardial infarction to obtain information on patients teaching needs.

Description of usual course of disease

process ____ Description of symptoms of worsening disease ____ Description of ways to manage controllable risk factors ____ Description of importance of completing recommended cardiac rehabilitation program ____ Description of energy conservation techniques ____ Description of effects of medications ____ Description of options in assistance with medical emergencies ____

Explain the pathophysiology of the disease and how it relates to anatomy and physiology
to individualize the information and to increase understanding.

Discuss lifestyle changes that may be required to prevent further complications and/or
control disease process to get the cooperation of the patients signicant support system.

Refer the patient to local community agencies/support groups so that the patient and
family have resources and support available.

Teaching: Prescribed Medication

Instruct the patient on the purpose and action of each medication. Instruct the patient on the dosage, route, and duration of each medication so that patient
understands the reason for taking the medication and will be less likely to refuse to take medications.

Measurement Scale
1 2 3 4 5 None Limited Moderate Substantial Extensive

and behavioral reactions. Research has shown that patients with increased anxiety levels have a greater risk for adverse outcomes such as recurrent ischemic events and dysrhythmias.48 Proper management of these priorities decreases the oxygen needs of a compromised myocardium and reduces the risk of complications. In addition, the nurse should institute measures to avoid the hazards of immobility while encouraging rest. Pain. Nitroglycerin, morphine sulfate, and supplemental oxygen should be provided as needed to eliminate or reduce chest pain. Ongoing evaluation and documentation of the effectiveness of the interventions is important. Once pain is relieved, the nurse may have to deal with denial in a patient who interprets the absence of pain as an absence of cardiac disease. Monitoring. A patient has continuous ECG monitoring while in the ED and intensive care unit and usually after transfer to a stepdown or general unit. The nurse should be educated in ECG interpretation so that dysrhythmias causing further deterioration of the cardiovascular status can be identied and treated. During the initial period after MI, ventricular brillation is the most common lethal dysrhythmia. In many patients, this dysrhythmia is preceded by premature ventricular contractions or ventricular tachycardia. The nurse should also monitor the patient for the presence of silent ischemia by monitoring the S-T segment for shifts above or below the baseline of the ECG. Silent ischemia occurs without clinical symptoms such as chest pain, but its presence places a patient at higher risk for adverse outcomes and even death.48 If episodes of silent ischemia are seen on the monitor, the physician should be notied. (See Chapter 36 for a complete discussion of ECG monitoring.)

In addition to frequent vital signs, intake and output should be evaluated at least once a shift, and physical assessment should be carried out to detect deviations from the patients baseline parameters. Included is an assessment of lung sounds and heart sounds and inspection for evidence of early HF (e.g., dyspnea, tachycardia, pulmonary congestion, distended neck veins). Assessment of the patients oxygenation status is important, especially if the patient is receiving oxygen. Also, the nares should be checked for irritation or dryness, which can cause considerable discomfort if the nasal route is used for oxygen administration. Rest and Comfort. With a severe insult to the myocardium, as in the case of ACS, it is important for the nurse to promote rest and comfort. Bed rest may be ordered for the rst few days after an MI involving a large portion of the ventricle. A patient with an uncomplicated MI (e.g., angina resolved, no signs of complications) may rest in a chair within 8 to 12 hours after the event. The use of a commode or bedpan is based on patient preference. When sleeping or resting, the body requires less work from the heart than it does when active. It is important to plan nursing and therapeutic actions to ensure adequate rest periods free from interruption. Comfort measures that can promote rest include frequent oral care, adequate warmth, a quiet atmosphere, use of relaxation therapy (e.g., guided imagery), and assurance that personnel are nearby and responsive to the patients needs. It is important that the patient understand the reasons why activity is limited. However, in spite of this limitation, the patient is not completely restricted. Gradually the cardiac workload is increased through more demanding physical tasks so that the patient