786

SECTION 7 Problems of Oxygenation: Perfusion

NURSING CARE PLAN 34-1

Patient with Acute Coronary Syndrome

NURSING DIAGNOSIS

Acute pain related to an imbalance between myocardial oxygen supply and demand as evidenced by severe chest pain and
tightness, radiation of pain to the neck and arms, elevated cardiac markers, ECG changes
Reports relief of pain

PATIENT GOAL
OUTCOMES (NOC)
Pain Control

Uses preventive measures _____

Uses analgesics appropriately _____
Reports uncontrolled symptoms to health
care professional _____
Reports pain controlled _____
Measurement Scale

1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated

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.
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 changes in
cardiac output, hypotension, and bradycardia, which may lead to coronary hypoperfusion.

NURSING DIAGNOSIS

Decreased cardiac output related to myocardial injury as evidenced by decrease in BP, elevation in HR, dyspnea,
dysrhythmias, diminished pulses, peripheral edema, and pulmonary edema
Maintains stable signs of effective cardiac output

PATIENT GOAL
OUTCOMES (NOC)
Cardiac Pump Effectiveness

Angina _____
Peripheral edema _____
Dyspnea _____
Dysrhythmia _____
Pulmonary edema _____
Weight gain _____

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

INTERVENTIONS (NIC) AND RATIONALES

Cardiac Care
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 significant dysrhythmias.
Provide antidysrhythmic therapy according to unit policy to maintain cardiac output.
Monitor respiratory status for symptoms of heart failure to maintain appropriate levels of oxygenation
and observe for signs of pulmonary edema.
Monitor fluid balance (e.g., intake/output, daily weight) to monitor renal perfusion and observe
for fluid retention.
Arrange exercise and rest periods to avoid fatigue and decrease the oxygen demand on myocardium.

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 evidenced by patients statement of What if I die
everyone relies on me.
Reports decreased anxiety and increased sense of self-control

PATIENT GOAL
OUTCOMES (NOC)
Anxiety Self-Control

Monitors intensity of anxiety _____

Seeks information to reduce anxiety _____
Controls anxiety response _____
Uses relaxation techniques to reduce
anxiety _____

Measurement Scale

1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated

INTERVENTIONS (NIC) AND RATIONALES

Anxiety Reduction
Observe for verbal and nonverbal signs of anxiety in order to identify signs of stress and intervene
appropriately.
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 caregiver 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.

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. You need to provide the patient
with information regarding CAD, angina, precipitating factors
for angina, risk factor reduction, and medications.
You should deliver patient teaching in a variety of ways. Oneto-one contact between you and the patient is often the most effective approach. Time spent providing daily care (e.g., administering

medications) offers many teachable moments. Teaching tools such

as videotapes/CDs, heart models, and especially written information are important components of patient and caregiver teaching
(see Chapter 4).
Assist the patient to identify those factors that precipitate
angina (see Table 34-9). Give the patient instructions on how
to avoid or control precipitating factors. For example, teach the
patient to avoid exposure to extremes of weather and the consumption of large, heavy meals. If a heavy meal is eaten, instruct

CHAPTER 34 Coronary Artery Disease and Acute Coronary Syndrome

787

NURSING CARE PLAN 34-1contd

Patient with Acute Coronary Syndrome
NURSING DIAGNOSIS

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

PATIENT GOAL
OUTCOMES (NOC)
Activity Tolerance

Oxygen saturation with activity _____

Pulse rate with activity _____
Ease of breathing with activity _____
Walking pace _____
Ease of performing ADLs _____

Measurement Scale

1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

INTERVENTIONS (NIC) AND RATIONALES

Cardiac Care
Monitor patients response to cardiac medications since these medications often affect BP and
pulse.
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 caregiver 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.

NURSING DIAGNOSIS
PATIENT GOAL

Ineffective self-health management related to lack of knowledge of disease process, risk factor reduction, rehabilitation,
home activities, and medications as evidenced by frequent questioning about illness, management, and care after discharge
Describes the disease process, measures to reduce risk factors, and rehabilitation activities necessary to manage the therapeutic
regimen

OUTCOMES (NOC)
Knowledge: Cardiac Disease
Management
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 effects of medications _____
Measurement Scale

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.
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 significant support system.
Refer the patient to local community agencies/support groups so that the patient and caregiver 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.

1 = None
2 = Limited
3 = Moderate
4 = Substantial
5 = Extensive

the patient to rest for 1 to 2 hours after the meal because blood is
shunted to the GI tract to aid digestion and absorption.
Assist the patient to identify personal risk factors in CAD.
Once known, discuss the various methods of decreasing any
modifiable risk factors with the patient (see Table 34-3). Teach
the patient and caregiver about diets that are low in salt and saturated fats (see Tables 34-4 and 34-5). Maintaining ideal body
weight is important in controlling angina because excess weight
increases myocardial workload.
Adhering to a regular, individualized program of physical
activity that conditions rather than overstresses the heart is
important. For example, advise patients to walk briskly on a flat
surface at least 30 minutes a day, most days of the week, if not
contraindicated.8
It is important to teach the patient and caregiver the proper
use of NTG (see p. 776). NTG tablets, sprays, or ointments may
be used prophylactically before an emotionally stressful situation, sexual intercourse, or physical exertion (e.g., climbing a
long flight of stairs).
If needed, arrange for counseling to assess the psychologic
adjustment of the patient and caregiver 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 fill 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 (1) pain assessment and relief,
(2) physiologic monitoring, (3) promotion of rest and comfort,
(4) alleviation of stress and anxiety, and (5) understanding of
the patients emotional 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.16 Proper management of these priorities decreases
the oxygen needs of a compromised myocardium and reduces
the risk of complications. In addition, you should institute measures to avoid the hazards of immobility while encouraging rest.
Pain. Provide NTG, morphine sulfate, and supplemental
oxygen as needed to eliminate or reduce chest pain. Ongoing evaluation and documentation of the effectiveness of the