Download Section 7 Problems of Oxygenation: Perfusion NURSING

Cardiovascular System
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Section 7
Problems of Oxygenation: Perfusion
through the patent channels extending from the outside of the heart
to the interior of the left ventricle, optimal results are not seen until
the formation of new blood vessels that arise from laser channels
and begin to supply the myocardium. Optimal results are seen at
about 3 to 6 months.
NURSING MANAGEMENT
CHRONIC STABLE ANGINA AND ACUTE CORONARY
SYNDROME
■ Nursing Assessment
Subjective and objective data that should be obtained from a patient with ACS are presented in Table 34-15.
■
Nursing Diagnoses
Nursing diagnoses for the patient with ACS may include, but are
not limited to, those presented in Nursing Care Plan (NCP) 34-1.
■
Planning
The overall goals for a patient with ACS include (1) relief of pain,
(2) preservation of myocardium, (3) immediate and appropriate
treatment, (4) effective coping with illness-associated anxiety,
(5) participation in a rehabilitation plan, and (6) reduction of risk
factors.
■
Nursing Implementation
TABLE
34-15
NURSING ASSESSMENT
Acute Coronary Syndrome
Subjective Data
Important Health Information
Past health history: Previous history of CAD, angina, MI, aortic stenosis, heart failure, or cardiomyopathy; hypertension, diabetes, anemia, lung disease; hyperlipidemia
Medications: Use of aspirin, nitrates, -adrenergic blockers, calcium
channel blockers, angiotensin-converting enzyme inhibitors; antihypertensive drugs; cholesterol-lowering drugs; vitamin and herbal
supplements
Functional Health Patterns
Health perception–health management: Family history of heart disease;
sedentary lifestyle; tobacco use
Nutritional-metabolic: Indigestion, heartburn, nausea, belching,
vomiting
Elimination: Desire to void, straining at stool
Activity-exercise: Palpitations, dyspnea, dizziness, weakness
Cognitive-perceptual: Substernal chest pain or pressure (squeezing,
constricting, aching, sharp, tingling), possible radiation to jaw,
neck, shoulders, back, or arms
Coping–stress tolerance: Stressful lifestyle, depression; anger, anxiety;
feeling of impending doom
Objective Data
General
Anxiety, fear, restlessness
Integumentary
Cool, clammy, pale skin
■
Chronic Stable Angina
Health Promotion. Behaviors to reduce the risk for CAD are
presented in Table 34-3 and discussed on pp. 000 to 000.
Acute Intervention. If a nurse is present during an anginal attack, the following measures should be instituted: (1) administration of supplemental oxygen, (2) determination of vital signs,
(3) 12-lead ECG, (4) prompt pain relief first with a nitrate followed
by a opioid analgesic if needed, (5) auscultation of heart sounds,
and (6) comfortable positioning of the patient. The patient will
most likely appear distressed and have pale, cool, clammy skin.
The BP and HR will probably be elevated and an atrial gallop (S4)
sound may be heard. If a ventricular gallop (S3) is heard, it may
indicate left ventricular dysfunction. A murmur may be heard during an anginal attack secondary to ischemia of a papillary muscle
of the mitral valve. The murmur is likely to be transient and disappear with the cessation of symptoms.
The nurse should ask the patient to rate the pain on a scale of
0 to 10 before and after treatment to evaluate the effectiveness of
the interventions. It is important to use the same words that patients use to describe their pain. Some patients may not always
verbalize pain. The nurse must be attuned to other manifestations
of pain, such as restlessness, elevated HR, respiratory rate or BP,
clutching of the bedclothes, or other nonverbal cues. Supportive
and realistic assurance and a calm, soothing manner help reduce
the patient’s anxiety during an anginal attack.
Ambulatory and Home Care. The patient with a history of angina should be reassured that a long, productive life is possible.
Prevention of angina is preferable to its treatment, and this is
where teaching is important. The patient should be provided information regarding CAD, angina, precipitating factors for angina,
risk factor reduction, and medications.
Patient teaching can be handled in a variety of ways. One-toone contact between the nurse and the patient is often the most ef-
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Cardiovascular
Tachycardia or bradycardia, pulsus alternans (alternating weak and
strong heartbeats), dysrhythmias (especially ventricular), S3, S4,
↑ or ↓ BP, murmur
Possible Findings
Negative or positive serum cardiac markers, ↑ serum lipids; ↑ WBC
count; positive exercise stress test and thallium scans; ST segment
and T wave abnormalities on ECG; cardiac enlargement, calcifications, or pulmonary congestion on chest x-ray; abnormal wall motion with stress echocardiogram; positive coronary angiography
BP, Blood pressure; CAD, coronary artery disease; ECG, electrocardiogram; MI,
myocardial infarction; WBC, white blood cell.
fective procedure. The time spent in providing daily care is often
an ideal teaching period. Teaching tools such as pamphlets, videotapes, heart models, and especially written information are necessary components of patient and family teaching (see Chapter 5).
The patient should be assisted in identifying factors that precipitate angina (see Table 34-9). The patient should be given instruction on how to avoid or control precipitating factors. For example, the patient should be taught to avoid exposure to extremes
of weather and the consumption of large, heavy meals. If a heavy
meal is ingested, adequate rest should be planned for 1 to 2 hours
after eating because blood is shunted to the GI tract to aid digestion and absorption.
The patient should be assisted in identifying personal risk factors in CAD. Once these are known, various methods of decreasing
any modifiable risk factors should be discussed (see Table 34-3).
Teaching the patient and the family about diets that are low in
sodium and reduced in saturated fats may be appropriate (see Tables 34-4 and 34-5). Maintaining ideal body weight is important in
controlling angina because weight above this level increases the
myocardial workload.
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