FOURTH

EDITION

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Lewis’s
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Australia and New Zealand Edition
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medical–surgical
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nursing
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Assessment and Management

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of Clinical Problems
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Di Brown
Helen Edwards
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Lesley Seaton
Thomas Buckley
Sharon L. Lewis
Shannon Ruff Dirksen
Margaret McLean Heitkemper
Linda Bucher
 FOURTH EDITION
CHAPTER 30

Lewis’s
medical–surgical nursing

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Assessment and Management

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of Clinical Problems
Australia and New Zealand Edition

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EDITED BY
Di Brown RN, PhD, MACN, AFCHSM
Project Director, Sister Hospital Program, Royal Darwin Hospital, Darwin, NT,

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Australia and RSUP Sanglah, Denpasar, Bali, Indonesia
Professorial Fellow, Charles Darwin University, Brinkin, NT, Australia

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Helen Edwards RN, PhD, FACN, FAAN, OAM
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Professor and Assistant Dean (International and Engagement), Institute of Biomedical Innovation,
Queensland University of Technology, Brisbane, Qld, Australia

Lesley Seaton PhD, MN, BN, Grad Dip Adult Education, Dip Midwifery, ICcert, RN
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Senior Lecturer and Program Director (International), School of Nursing and Midwifery,
Griffith University, Brisbane, Qld, Australia
Adjunct Associate Professor, School of Health Sciences,
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Canterbury University, Christchurch, New Zealand

Thomas Buckley RN, BSc, MN, PhD

Senior Lecturer/Co-ordinator Master of Nursing (Clinical Nursing & Nurse Practitioner),
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Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia

Adjunct Associate Professor, School of Health and Human Sciences,
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Southern Cross University, Lismore, NSW, Australia

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Sharon L Lewis
Shannon Ruff Dirksen
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Margaret McLean Heitkemper

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Linda Bucher
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Sydney Edinburgh London New York Philadelphia St Louis Toronto

 Contents
CHAPTER 30

SECTION 1 SECTION 5

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Concepts in nursing practice Problems of oxygenation: Ventilation
1 The importance of nursing 2 22 Nursing assessment: Respiratory system 476

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2 Patient safety and clinical reasoning: 23 Nursing management: Upper respiratory
Thinking like a nurse 21 problems 500

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3 Health disparities and cultural care 32 24 Nursing management: Lower respiratory
problems 524

4 Pain management 48
5 Palliative care 81
6 Substance use and dependency 97
7 Rural and remote area nursing 125
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25 Nursing management: Obstructive
pulmonary diseases 564

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SECTION 6
SECTION 2 Problems of oxygenation: Transport

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Pathophysiological mechanisms of disease 26 Nursing assessment: Haematological
system 616
8 Nursing management: Inflammation
and wound healing
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144 27 Nursing management: Haematological
problems 637
9 Genetics and genomics 164
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10 Altered immune responses and  SECTION 7
transplantation 176
Problems of oxygenation: Perfusion
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11 Nursing management: Infection and

28 Nursing assessment: Cardiovascular
human immunodeficiency virus infection 200
system 692
12 Cancer 223
29 Nursing management: Hypertension 716
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13 Nursing management: Fluid, electrolyte

30 Nursing management: Coronary artery
and acid–base imbalances 262
disease and acute coronary syndrome 737
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SECTION 3 31 Nursing management: Heart failure 775

Perioperative care 32 Nursing management: ECG monitoring
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and arrhythmias 796

14 Nursing management: Preoperative care 294
33 Nursing management: Inflammatory
15 Nursing management: Intraoperative care 312 and structural heart disorders 820
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16 Nursing management: Postoperative care 330 34 Nursing management: Vascular disorders 843
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SECTION 4 SECTION 8
Problems related to altered sensory input
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Problems of ingestion, digestion, absorption

17 Nursing assessment: Visual and auditory and elimination
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systems 356
35 Nursing assessment: Gastrointestinal
18 Nursing management: Visual and auditory system 876
problems 375
36 Nursing management: Nutritional
19 Nursing assessment: Integumentary problems 900
system 411
37 Nursing management: Obesity 921
20 Nursing management: Integumentary
problems 425 38 Nursing management: Upper
gastrointestinal problems 941
21 Nursing management: Burns 449
CHAPTER 30
39 Nursing management: Lower
gastrointestinal problems 978
40 Nursing management: Liver, pancreas
and biliary tract problems 1024
SECTION 9
Problems of urinary function
41 Nursing assessment: Urinary system 1066
42 Nursing management: Renal and
urological problems 1086
43 Nursing management: Acute kidney
injury and chronic kidney disease 1124
SECTION 10
Problems related to regulatory and
reproductive mechanisms
44 Nursing assessment: Endocrine system 1160
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45 Nursing management: Diabetes mellitus 1181
46 Nursing management: Endocrine
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problems 1221
47 Nursing assessment: Reproductive
system 1250
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48 Nursing management: Breast disorders 1272
49 Nursing management: Sexually
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transmitted infections 1298
50 Nursing management: Female
reproductive problems 1315
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51 Nursing management: Male
reproductive problems 1348
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SECTION 11
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Problems related to movement and
coordination
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52 Nursing assessment: Nervous system 1376
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53 Nursing management: Acute intracranial
problems 1404
54 Nursing management: The patient
with a stroke 1436
55 Nursing management: Chronic
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neurological problems 1459
56 Nursing management: Delirium,
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depression and dementia 1492
57 Nursing management: Peripheral nerve
and spinal cord problems 1517
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58 Nursing assessment: Musculoskeletal
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system 1546
59 Nursing management: Musculoskeletal
trauma and orthopaedic surgery 1566
60 Nursing management: Musculoskeletal
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problems 1605
61 Nursing management: Arthritis and
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connective tissue diseases 1630
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SECTION 12
Nursing care in specialised settings
62 Nursing management: Critical care
environment 1670
63 Nursing management: Shock, systemic
inflammatory response syndrome and
multiple organ dysfunction syndrome 1706
64 Nursing management: Respiratory
failure and acute respiratory distress
syndrome 1730
65 Nursing management: Emergency
care situations 1751
66 Chronic illness and complex care 1780
APPENDICES
A Cardiopulmonary resuscitation and 
basic life support 1795
B Nursing diagnoses 1801
C Answer key to review questions 1803
D Image and text credits 1805
Index 1817
 Preface
The fourth Australian and New Zealand (ANZ) edition
of Lewis’s Medical–Surgical Nursing: Assessment and
Management of Clinical Problems builds on the combined
strengths of the third ANZ edition and the ninth US edition.
It has been written to address the needs of ANZ students and
educators. Professors Di Brown and Helen Edwards, and
Drs Lesley Seaton and Tom Buckley, led a team of nurse
clinicians and academic contributors from across ANZ to
develop this cutting-edge text.
The fourth edition has been thoroughly revised and
incorporates the most recent nursing knowledge in an engaging
and reader-friendly format. More than a textbook, this is a
comprehensive resource containing essential information
that students need in order to prepare for lectures, classroom
activities, examinations, clinical assignments and the
professional care of patients. In addition to its accessible
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writing style and quality illustrations, the text provides
special features—such as evidence-based practice boxes,
review questions and clinical reasoning exercises—to
facilitate student learning. Recurring topics include patient
teaching guides, gerontological advice, management of
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chronic diseases, multidisciplinary care, cultural and ethnic
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considerations, nutrition, community- and home-based care,
and nursing research.
The use of the nursing process as an organising frame­
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work for nursing practice has been retained and new content
has been added to reflect rapid changes in practice. Contributors
have been selected for their expertise in specific areas, and
clinical specialists have thoroughly reviewed each chapter
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to ensure accuracy, currency and regional relevance. From
the outset, the text firmly establishes the ANZ sociocultural
context and includes, for example, a chapter on current
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national patient safety priorities in ANZ (Ch 2), current
information on rural and remote area nursing (Ch 7), as well
as a framework for the management of chronic and complex
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conditions (Ch 66). In addition, this edition includes chapters
on contemporary health issues such as obesity (Ch 37) and
emergency and disaster nursing (Ch 65).
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Organisation
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The content is organised into 12 sections. Section 1 (Chs 1–7)
introduces key healthcare concepts within Australia and
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New Zealand. Sections 2–12 (Chs 8–66) present nursing
assessment and nursing management of medical and surgical
patient problems both within acute care settings and within
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the community. The focus of each section is across the whole
trajectory of healthcare, including health promotion, risk
assessment, management of acute and chronic conditions,
and the various nursing roles and responsibilities, as well as
the roles of the whole multidisciplinary healthcare team. The
various body systems are grouped to reflect their interrelated
functions. Each section is organised around two central
themes: assessment and management. Chapters dealing with
assessment of a body system include a discussion of the
following:
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1. a brief review of anatomy and physiology, focusing on
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information that will promote an understanding of
nursing care
2. health history and non-invasive physical assessment
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skills to expand the knowledge base on which decisions
are made
3. common diagnostic studies, expected results and related
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nursing responsibilities to provide easily accessible
information.
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Management chapters focus on the pathophysiology, signs
and symptoms, diagnostic study results, multidisciplinary
care and nursing management of various diseases and
disorders. The sections on nursing management are organised
into assessment, identification of priority care problems,
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planning, implementation and evaluation. To emphasise the
importance of patient care in various clinical settings, nursing
implementation of all major health problems is organised by
the following levels of care:
1. health promotion
3. ambulatory and community/home care.
Classic features
• Critical thinking, clinical judgement and clinical
reasoning (introduced in Ch 2) provide a framework
to enable students to think about patient situations
effectively. The use of multiple case studies at the end
of each section enables students to practise prioritising
care between a number of different patients. The
multiple case studies and the individual ones in the
assessment and management chapters are structured so
that students need to use their clinical reasoning and
judgement skills to plan and outline care priorities.
Key delegation decisions are included to enable the
student to begin to more clearly understand the
responsibilities of the registered nurse.
• National patient safety goals for both New Zealand
and Australia are introduced in the new Chapter 2 of the
text, which are then addressed in more detail in relevant
chapters throughout the text. Important patient safety
information such as drug interactions are highlighted
within specific chapters.
• Key epidemiological information is provided to enable
students to understand the incidence and prevalence
of the various conditions in the Australian and New
Zealand context.
• Priority care problems outlined in each of the
management chapters illustrate the multidisciplinary
nature of contemporary healthcare.
• Multidisciplinary care is further highlighted in special
multidisciplinary care sections in all management
chapters and more than 80 multidisciplinary care boxes
and tables throughout the text.
• The whole trajectory of care is included. Chapters
include prevention and health promotion, through the
 xxii PREFACE
acute care phase into rehabilitation and chronic disease
management where appropriate. These chapters have
been thoroughly updated to reflect current nursing
practice and include defining characteristics, expected
patient outcomes, specific nursing interventions with
rationales and multidisciplinary care. The book is
structured to enable students of nursing to gain a
comprehensive understanding of the nursing role and
the differences (and similarities) in nursing and other
healthcare roles and functions. The information and
structure of the chapters increases students’ understanding
about the multidisciplinary nature of current healthcare
practice and the roles that nurses play.
• Patient and carer education is an ongoing theme
throughout the text. Coverage includes more than
80 patient teaching guides throughout the text.
• Gerontological differences are included in each
chapter where the differences in assessment and the
effects of ageing are detailed. Chapter 56 provides a
thorough explanation about delirium, dementia and
depression in older adults who are admitted to an acute
care setting.
• Nutrition is highlighted throughout the book and
includes a separate chapter (Ch 36). Nutritional therapy
boxes and tables summarise nutritional interventions for
patients with various health problems.
• Complementary and alternative therapies boxes in
various chapters summarise what nurses need to know
about non-traditional therapies, such as herbal remedies
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and acupuncture.
• Nursing research boxes included throughout the text
demonstrate how clinical research and evidence can be
used to enhance clinical knowledge and nursing practice.
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• Culturally competent care is covered in Chapter 3, and
cultural information is integrated into other chapters
highlighting the risk factors and other important issues
related to the epidemiological incidence of various
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conditions and the associated nursing care as it relates to
different groups in the community.
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• Rural and remote area nursing is covered in Chapter 7
and is referenced throughout the text to highlight the
importance of this field of nursing in Australia and
New Zealand.
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• Current issues in healthcare, such as management of
the older person within acute care settings (addressed in
Ch 56) and management of chronic and complex illness
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(in Ch 66), provide students with a broad overview of
many of the key issues facing nursing and the community
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in the current healthcare system.
• Clinical practice boxes promote critical thinking about
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ethical dilemmas relating to timely and sensitive issues
that nursing students may deal with in clinical practice.
• Emergency management tables outline the emergency
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treatment of health problems that are most likely to
require emergency intervention.
• Common assessment abnormalities tables in assessment
chapters alert the nurse to frequently encountered
abnormalities and their possible aetiologies.
• Nursing assessment tables summarise the key subjective
and objective data related to common diseases. Subjective
data are organised by functional health patterns.
• Health history boxes and tables in assessment chapters
present key questions to ask patients related to a specific
disease or disorder.
• Student-friendly pedagogy includes the following:
Learning objectives and key terms at the beginning
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of each chapter help students to identify the key
content for each body system or disorder.
Key priority care problems are identified in
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individual chapters to illustrate the specific needs
of individual patients and their carers. Detailed
nursing care plans are available from the web-based
resources of the text.
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Evidence-based practice boxes present the evidence
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of results from research to improve patient outcomes
and the implications for nursing practice.
Several health disparities boxes highlight the genetic
basis, genetic testing and clinical implications for
genetic disorders that affect adults.
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Review questions at the end of each chapter help
students learn the important points in the chapter.
Answers are provided in Appendix C so that the
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review questions serve as a self-study tool. Further
questions can be found in the web resources.
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information about nursing and healthcare
organisations that provide patient teaching and disease
and disorder information. Resources include internet
sites to help students find current information online,
as well as to provide access to the best practice,
evidence-based guidelines developed by many of the
specialty clinical colleges and organisations within
Australia and New Zealand.
Ancillary website
LEARNING SUPPLEMENTS FOR THE STUDENT
AND INSTRUCTOR
The fourth edition Evolve website is available at http://evolve.
elsevier.com/AU/Brown/medsurg/ and features the following
valuable learning aids:
• review questions and answers with answer rationale
• key points from the chapters to provide a brief snapshot
of content
• quick quizzes
• concept map creator and concept map for case studies
• etables and efigures
• image collection, including all figures and tables from
the book
• videos and animations
• answer guidelines for case study clinical reasoning
questions
• additional case studies and answer guidelines
• fluids and electrolytes tutorial
• eNursing Care Plans
• PowerPoint slides

Patient safety and clinical reasoning:
Thinking like a nurse
Written by Di Brown
LEARNING OUTCOMES
1. Consider the relationship between national patient safety goals, nursing practice
and the use of effective clinical reasoning skills.
2. Explain why critical thinking and clinical reasoning are important nursing skills.
3. Analyse the key characteristics of the critical thinker.
4. Describe the relationship between critical thinking, clinical reasoning and clinical
judgement.
5. Explore the tools that can assist the application of clinical reasoning and clinical
judgement in the clinical setting.
6. Explain how ‘track and trigger’ tools can be used to assist the process of clinical
decision making.
7. Apply clinical reasoning skills to case study analysis.
The clinical care environment is increasingly complex and
turbulent. It requires nurses who are adaptable and intelligent,
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and who have sound knowledge, skills and understanding
relevant to the work that they carry out. We know that nurses
save lives.1–4 However, Gordon5 explains that nurses also
prevent suffering and provide cost-effective care. To do this
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effectively, nurses need to have the knowledge, skills and
confidence to be able to provide safe, high-quality care.
There has been increasing recognition in both New Zealand
and Australia of the need to improve the quality and safety
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of healthcare services. While the systems in both countries
are among the world’s best, the care environment in hospitals
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can still be risky. In Australia, it is estimated that about 10%
of patients will suffer adverse events while hospitalised. 6
In New Zealand, while the number of serious and sentinel
events has fallen since 2011, medication errors were the
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third leading cause of death or injury in hospitals in 2012.7 In
the United States, the Institute of Medicine8,9 estimates that
medical errors are among the top five leading causes of death
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in hospitalised patients.
To begin to address this issue in a systematic manner
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the Health Quality and Safety Commission New Zealand
(HQSC)7 was commissioned in November 2010 to lead quality
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and safety improvements in the health sector. The aim of the
Commission is to work with clinicians and health managers
to support and encourage quality and safety improvements,
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to identify areas where improvements can take place, and
to drive change. The Australian Commission on Safety and
Quality in Health Care (ACSQHC)10,11 was established in 2010
by the Australian federal, state and territory governments to
lead and coordinate national improvements in the safety and
quality of healthcare provision. The Commission engages in
collaborative work in the area of patient safety and healthcare
quality, which includes the development of the Australian
Charter of Healthcare Rights and the National Safety and
Quality Health Service Standards, and National Patient
21
Chapter 2
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KEY TERMS
clinical judgement, p 22
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clinical reasoning, p 22
critical thinking, p 22
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early warning systems, p 25
medical emergency team, p 24
national patient safety goals, p 21
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Safety Goals. The Commission has also developed a National
Safety and Quality Framework to improve the safety and
quality of the Australian health system.
Patient safety
WHY IS PATIENT SAFETY IMPORTANT?
Both the HQSC7 and the ACSQHC11,12 have identified similar
areas of focus for their national patient safety priorities to
ensure that people receive their healthcare without experienc­
ing preventable harm.
National patient safety goals in Australia and New Zealand
include consumer and patient involvement in care, 1,2,10–13
medication safety,7,11 reducing healthcare-associated infec­
tions, 7,10,11,14 management of falls, 7,11 pressure ulcers, 7,11
surgical safety,7,13,14 and recognising and responding to clinical
deterioration.11,15
While it is clear that preventing harm in any of these
priority areas is a multidisciplinary and collaborative
endeavour, there is much here that is part of the work of
nurses. Within this text, attention is given to the identified
national patient safety goals: medication safety (in all nursing
management chapters), wound care and the assessment and
management of decubitus ulcers (Ch 8), infection prevention
and control (Ch 11), and reducing perioperative harms (Chs 14,
15 and 16). Chapter 58 outlines the need for a sound falls
assessment and provides a useful assessment chart (Fig 58-7),
and Section 12 provides guidance on the assessment and
management of potential clinical deteriora­tion. As well, each
assessment chapter outlines nursing and multidisciplinary
responsibilities for patient assessment and the parameters
of relevant clinical observations. However, in order to apply
this essential knowledge about patient safety, the nurse needs
the skills of critical thinking, clinical reasoning and clinical
judgement. This chapter discusses the application of clinical
reasoning and clinical judgement to clinical practice and
 22 Section 1  Concepts in nursing practice
provides the novice nurse with a number of tools and ways of
thinking to assist them in developing this important skill.
PROVIDING PROFESSIONAL AND SAFE CARE
To support the increasing focus on quality and safety, modern
nursing has had to progressively embrace the need for multi­
disciplinary, patient-focused care. There is an overwhelming
body of research which attests to the benefits to patients in terms
of quality of patient outcomes and prevention of harm when
care is patient centred and collaborative.9–13 Similarly, there is
convincing evidence of the difference nurses can make to both
the quality of care and the quality of patient outcomes.1–5 Nurses
need to be competent in key dimensions of care which have
been found to influence patient safety. These key areas include:
(1) a focus on patients and families;7,9,10 (2) the importance of
teamwork;2,3,7,10,13,14 (3) the need to understand how to apply
evidence to clinical practice;2,12 and (4) the ability to function in a
safe manner,7–10 including the capacity to administer medications
safely7,11 to prevent healthcare-acquired infections7,11 and to
recognise when a patient’s condition may be deteriorating.15
To do this effectively, nurses must be knowledgeable and
be able to think critically and creatively about clinical care.
While the other chapters of this text consider key dimensions of
quality and safety—that is, developing the capacity to provide
patient-centred care, the importance of teamwork and the role
of multidisciplinary teams—as well as the evidence base for
clinical practice, this chapter focuses on how nurses need to
think about and analyse clinical practice. To do this they need
the skills of critical analysis and clinical reasoning, which lead
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to the making of sound and well-considered clinical judgements.
Clinical reasoning
The terms clinical reasoning, critical thinking and clinical
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judgement are often used interchangeably.16 Clinical reasoning is
a process of seeking relevant clinical information and making
clinical judgements based on patient cues and other evidence,
in order to decide which is the best course of action for this
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patient at this time.17 It also involves evaluating the care that
was provided and thinking about how care could be improved
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in future.18,19 It is very similar to clinical judgement which is
a result of ‘critical thinking in the clinical area’.16 However,
this definition of clinical judgement may not give the level of
guidance this is required by a novice nurse when they are first
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learning about the kind of thinking that is needed to provide
safe and effective care. However they are defined, the processes
of clinical reasoning, critical thinking and clinical judgement
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are what is meant when we talk about ‘thinking like a nurse’.18
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WHY DO WE NEED TO LEARN TO THINK LIKE
A NURSE, AND HOW IS THIS DIFFERENT FROM
EVERYDAY THINKING?
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Everyone thinks; it is human nature to do so. However, if we look
at our everyday actions—such as impulsively buying things we
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don’t really need, uncritically accepting the information given
by various media outlets, voting by habit for particular political
parties and so on—we can see that we sometimes ‘unthinkingly’
accept ideas, behaviours and practices that, on deeper reflection,
don’t sit well with our values or ideals. While this may not
matter very much in everyday living (although there is a lot
of evidence to say that it does), it is a topic that has fascinated
philosophers for generations. (Socrates, who lived more than
2000 years ago, is reported to have said that the unexamined
life is not worth living.)
Nurses who are unable to critically evaluate and reflect as
part of their clinical practice (i.e. are not critical thinkers) are a
danger to both their patients and their colleagues.2,12,15
WHAT DO WE MEAN BY ‘CRITICAL THINKING’?
Edward Glaser is recognised as one of the key researchers in this
area. In his seminal study20 on critical thinking and education,
Glaser argued that the ability to think critically involves three
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things: ‘(1) an attitude of being disposed to consider in a
thoughtful way the problems and subjects that come within the
range of one’s experiences, (2) knowledge of the methods of
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logical inquiry and reasoning, and (3) some skill in applying
those methods.’
Many researchers have agreed with him, 21–24 and the
consensus is that critical thinking is a disciplined intellectual
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process which requires individuals to consistently examine
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their beliefs, knowledge and attitudes in the light of evidence.
It means analysing, synthesising and evaluating information, as
well as considering underlying assumptions and values. Critical
thinking (see Table 2-1) requires a capacity to recognise and
formulate problems, then to gather information, and then to
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understand and evaluate its significance in order to develop
conclusions and/or actions. It is self-directed, self-disciplined,
self-monitored, and self-correcting.25
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TABLE 2-1  Key characteristic of the critical thinker
• Open-minded, having an appreciation of alternative perspectives,
being willing to respect the right of others to hold different
opinions, and understanding other cultural traditions to gain
perspectives on self and others.
• Inquisitive, curious and enthusiastic in wanting to acquire
knowledge, wanting to know how things work even when the
applications are not immediately apparent.
• Truth-seeking, courageous about asking questions to obtain the
best knowledge, even if such knowledge might fail to support
one’s perceptions, beliefs or interests.
• Analytical and using verifiable information, demanding the
application of reason and evidence, and the inclination to
anticipate consequences.
• Systematic, valuing organisation, and taking a focused and
diligent approach to problems at all levels of complexity.
• Self-confident, trusting one’s own reasoning and inclination to
utilise these skills rather than other strategies to respond to
problems—for example, making decisions based on scientific
evidence—and responding to the values and interests of
individuals and society.
HOW DO WE USE CRITICAL THINKING AND
CLINICAL REASONING EFFECTIVELY IN
NURSING PRACTICE?
While critical thinking and clinical reasoning are sometimes
considered to mean the same thing, critical thinking is a process
that can be used in all aspects of one’s daily life, whereas
clinical reasoning is a process that is used in nursing practice.
Both require a number of logical stages and steps. Both include:
• purposeful goal-directed thinking
• cue acquisition and hypothesis generation
• interpretation and evaluation
• judgements based on evidence rather than guesswork.
Both critical thinking and clinical reasoning are based
on the principles of scientific method—that is, maintaining
a questioning attitude, following an organised approach to
discovery and making sure the information is reliable.16,26 The
nursing process (see Ch 1, Fig 1-5, which is a tool based on
 Chapter 2  Patient safety and clinical reasoning: Thinking like a nurse 23

these principles, provides a basic foundation for nurses to assist
them in planning and carrying out care.
While this process looks relatively simple, nurses are work­
ing under conditions that demand rapid and accurate assess­
ments, an effective plan of action and a systematic way of
evaluating the effects of care activities. Newly graduated nurses
may find this process particularly stressful, especially if they are
called on to make independent decisions about patients under
their care. Early on in their careers, nurses may need to use
clinical reasoning or clinical decision-making tools17,18 to assist
them to make effective clinical judgements.
The two evidence-based models outlined here (Figs 2-1
and 2-2) provide frameworks to assist nurses to use critical
think­ing effectively to make clinical judgements about patients.
The models can also be used to assist students and others
to think about the case scenarios that are described in this

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Describe or list facts, Review current information (e.g. handover reports, patient
context, objects or history, patient charts, results of investigations and

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people. Consider nursing/medical assessments previously undertaken).
the patient Gather new information (e.g. undertake patient assessment).
situation Recall knowledge (e.g. physiology, pathophysiology,
pharmacology, epidemiology, therapeutics, best practice
evidence, culture, context of care, ethics law).

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Reflect on
process and
new learning

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Contemplate what
you have learned Collect cues/
from this process and information
what you could have
done differently.

Clinical

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Process Interpret: analyse data to come to an
information understanding of signs or symptoms;

reasoning
Evaluate compare normal vs abnormal.

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outcomes Discriminate: distinguish relevant
from irrelevant information;
recognise inconsistencies, narrow

cycle se down the information to what is most

Evaluate the
important and recognise gaps in
effectiveness of
cues collected.
outcomes and
Relate: discover new relationships or
actions. Ask: ‘Has the
patterns; cluster cues together to
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situation improved
identify relationships between them.
now?’
Infer: make deductions or form
Take action Identify opinions that follow logically by
problems/ interpreting subjective and objective
issues cues; consider alternatives and
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consequences.
Match current situation to past
Select a course of situations or current patient to past
action between Establish patients (usually an expert thought
different alternatives Describe what you want goal/s Synthesise facts and process).
available.
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to happen, a desired inferences to make a Predict an outcome (usually an

outcome and a time definitive diagnosis of expert thought process).
frame. the patient’s problem.
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Figure 2-1  The clinical reasoning process with descriptors.

Source: Levett-Jones, Hoffman, Dempsey, Jeong, et al, 2010.
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Noticing Interpreting Responding

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Expectations
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Reasoning patterns
Context
Analytical
Background Action
Intuitive
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Relationship
Narrative
Initial grasp
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Reflection-on-action and
clinical learning Reflection-in-action Outcomes

Reflecting

Figure 2-2  Clinical judgement model.

Source: Tanner, 2006.
 24 Section 1  Concepts in nursing practice

chapter and subsequent chapters of the textbook. The clinical
reasoning cycle illustrated in Figure 2-1 outlines the specific
steps involved in clinical reasoning. Each step summarises the
thinking and planning that is needed to enable the nurse to
form sound clinical judgements about a patient’s condition. It
illustrates the process of prioritising and planning care and then
outlines the stages of evaluation and reflection. While this may
look complicated to begin with, with practice and experience
observations they are not taking the action that is required to
prevent further harm.35,36
Because of the lack of consistency in recognising and
acting on changes in patient’s vital signs a number of clinical
tools have been developed to assist nurses in making the clinical
judgements necessary to act.37,38 Nevertheless, in order to act
properly, nurses need to have the clinical judgement skills to
assess what is needed for that particular patient at that time.

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the process will eventually become automatic.
MEDICAL EMERGENCY TEAMS
APPLYING CLINICAL REASONING SKILLS IN There is a growing body of research indicating that the use of

THE CLINICAL SETTING
Once nurses have become familiar with the logical steps required
to assess patients and plan and evaluate their care, they also need
to think about how clinical reasoning skills can be applied in
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well-structured guidelines and processes39,40 will assist nurses
and other health professionals to keep patients safe and protect
them from harm.
Figure 2-3 shows a simple ‘trigger’ tool outlining parameters

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the clinical setting. To do this: that can assist nurses to know when to report changes in a

1. They need to know what to expect: ‘What is normal for
this patient with this condition?’
2. Then they need to ask themselves: ‘What is going on
here? What else do I need to know?’
3. Finally, the nurse needs to pull all the information
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patient’s condition. (A trigger tool is one that sets clear guidelines
and standards to provide guidance about when to call for help.)
This kind of tool was initially used to enable nurses and junior
doctors concerned about a patient’s condition to call the hospital
medical emergency or rapid response team. 37,40 (A medical

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together into a synthesised whole in order to form a emergency team [MET] is designed to give an immediate
judgement about what action needs to be taken. This is response to at-risk patients in acute care hospitals.)
the use of clinical reasoning to make a clinical Medical emergency teams were first introduced as a

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judgement. response to research conducted in the 1990s in New Zealand,
Australia and the US which indicated that not only had the
IMPLICATIONS FOR NURSING PRACTICE
Nurses are the surveillance system of the hospital.3,4 They are
with the patients 24 hours a day and are generally the first
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outcomes from cardiac arrests in hospitals not improved over
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point of contact during a patient’s hospitalisation. As well as CLINICAL
providing comprehensive nursing care, the role of the nurse is
to keep patients safe and to be able to recognise and respond MEDICAL EMERGENCY TEAM
when things change or go wrong. There is a growing body of CALLING CRITERIA
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evidence3,27,28 about the nurse’s role in relation to recognising All Cardiac and Respiratory Arrests
and responding to clinical deterioration, and this provides a and all conditions listed below.
sound rationale for the essential role of critical thinking and ACUTE
clinical reasoning in nursing practice. PHYSIOLOGY
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CHANGES IN:
One of the first skills a nursing student learns is how to take
a patient’s vital signs. The technical skills of taking a tempera­ AIRWAY Threatened
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ture, pulse, respirations and blood pressure are often acquired BREATHING ALL RESPIRATORY ARRESTS
in the first or second semester of a nursing program,29,30 along Respiratory rate <5
with learning about how to wash patients and make their beds. Respiratory rate >36
Acute change in saturation <90%
Correct application of these assessment skills is fundamental
pr

despite oxygen
to becoming a competent registered nurse.
Accurate assessment and interpretation of findings saves CIRCULATION ALL CARDIAC ARRESTS
Pulse rate <40
patients’ lives. There is a body of convincing evidence in the Pulse rate >140
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literature which points to the presence of alterations in patients’ Systolic blood pressure <90
vital signs prior to a catastrophic event, with further evidence
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NEUROLOGY Sudden fall in level of

that if the changes had been picked up earlier then the patient consciousness
may not have had such a severe outcome.15,31–34 Abnormalities (Fall in GCS of >2 points)
m

or alterations in vital signs such as blood pressure, respiratory Repeated or prolonged seizures
rate, pulse and oxygen saturation are common prior to the RENAL Acute changes in urine output
occurrence of serious adverse events.15,31–34 This relationship to <50 mL in 4 hours
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between changes in vital signs and other physiological measures

Other Any patient who you are
and subsequent events means that nurses need to be able to seriously worried about that
assess the patient’s condition accurately and then take any does not fit the above criteria
necessary action in a timely manner. In other words, they need
to be able to recognise and respond to patients who are clinically To call the Medical Emergency Team, phone your Hospital Emergency
deteriorating. number and tell the operator where you are and the location of the patient
While this seems a relatively simple and obvious thing to
do, there is also a growing body of research which indicates Figure 2-3  Medical emergency team (MET) calling criteria.
that nurses are not carrying out these essential observations Source: Intensive Care Unit, Liverpool Hospital, South Western Sydney Local
as often as required,15,35,36 or that when they do carry out the Health District, Australia.
 Chapter 2  Patient safety and clinical reasoning: Thinking like a nurse 25
the last 20 years, but also that more than 10% of patients
experienced adverse events during their hospitalisation.41,42,43
Further, the findings indicated that about 50% of these events
were preventable.42,43 This gave rise to the introduction of the
MET approach to try and prevent the occurrence of adverse
events.
The MET was introduced based on five principles (outlined
in Table 2-2) that enabled any member of the ward staff to
activate the team (Fig 2-3). The goal of the MET was to rapidly
mobilise specially trained staff (generally from intensive care)
to deliver definitive and prompt care to patients who were
clinically deteriorating.40 The MET system aimed to reduce
cardiac arrests, morbidity and mortality.
Does it work? Chan, et al44 found that having an active
MET in a hospital reduces the cardiac arrest rate in both adult
and children’s hospitals by 30%, and reduces death rates in
children’s hospitals by 20% but made no difference in death
rates in adult hospitals. On the other hand, the MERIT study45
found that introducing a MET significantly reduced mortality
in adult hospitals. Do Campo, et al46 found a reduction in
unexpected adverse events in an acute medical ward and a
reduction in the number of unexpected deaths following the
introduction of an early warning system. A large Swedish study47
in 2010 of more than 275,000 patients admitted before and after
implementation of a MET found that in-hospital cardiac arrests
decreased and overall in-hospital mortality fell by 10% in the
2 years following the team’s implementation. However, a large
randomised control trial conducted in Australia in 2005 found
that there were no differences in patient outcomes in hospitals
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with MET.37 A number of reasons have been postulated for
this, including: (1) that the Australian study may not have had
the necessary power to be able to demonstrate change; and (2)
that vital signs were either not recorded accurately, or no action
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was taken when alterations were noted.48,49 Despite this result,
the research evidence to date has been convincing enough for
hospitals to maintain METs or rapid response teams to support
staff when patients are seen to have deteriorated unexpectedly.
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TABLE 2-2  Rationale for implementation of the
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MET system
• Principle 1: There is time for intervention, as there are warning
signs.
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Clinical deterioration is preceded by physiological deterioration
in vital signs.
These observations are easy to measure, inexpensive and
non-invasive (measuring them does not hurt the patient).
• Principle 2: There are effective treatments if dangerous
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conditions are recognised.
Examples include beta-blockers for myocardial ischaemia, fluid
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therapy for hypovolaemia, non-invasive ventilation and oxygen
for respiratory failure, and anticoagulation for thrombo-
m
embolic disease.
The majority of MET interventions are inexpensive, relatively
simple and non-invasive.
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• Principle 3: Any member of staff can activate the MET.
• Principle 4: Early intervention improves outcomes.
The assumption that early intervention saves lives has been
shown for the treatment of trauma as well as septic shock.
The hospital survival for cardiac arrest is at best 14%.
It is intuitive that sick people are easier to treat than dead people.
• Principle 5: The expertise exists and can be deployed.
Intensive care doctors and nurses are experts in the delivery of
advanced resuscitation.
The review of the critically ill patient is prompt.
Source: Adapted from Jones, Bellomo & Goldsmith, 2006.
EARLY WARNING SYSTEMS
Observation charts are the primary tool for recording informa­
tion about vital signs and other patient details. If the charts are
not well designed, this may contribute to the failure of staff to
readily recognise when a patient’s condition is deteriorating.15,49,50
As a result, many hospitals have now developed early warn­ing
systems (EWS) that help nurses and other health professionals
more easily identify if a patient’s condition is deteriorating.
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The observation chart (Fig 2-4) is one example of a ‘track and
trigger’ tool. It was developed by the Australian Commission
on Safety and Quality in Health Care based on work done in
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the UK and elsewhere.15,28 The guiding principle behind the
development of these tools is that they would assist nurses to
identify alterations to a patient’s condition and then to take
appropriate action.
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While this may seem a fairly simple and obvious approach
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to take, it is clear from the research38,44,49,50 that even with the use
of ‘track and trigger’ tools the outcomes in terms of improve­
ments in patient mortality have yet to be overwhelmingly
demonstrated.
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What role can nurses play in
improving practice?
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On the surface it seems that having clear parameters and know­
ing what is ‘normal’ would make it relatively simple for a
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nurse to recognise what is happening to a patient and therefore
to know when to call for help. However, Tait38 found that even
with risk assessment tools nurses may still be uncertain about
the criteria to be used when calling a medical emergency team.
In a number of studies,51,52 nurses are described as noticing
that ‘something was wrong’ with their patients even if they
were not able to articulate the problem clearly. Tait38 calls this
ability to detect subtle changes in a patient’s condition the
‘professional gaze’, whereas Benner51 calls it ‘intuition’ and
Tanner18 ‘noticing’. These researchers all comment that nurses
who are experienced in their specialty develop this skill over
time through seeing many similar cases and recognising patterns.
If this is true, then how do novice nurses develop this skill,
and how can they keep their patients safe from harm from their
first day on the job?
First, nurses need to know what is happening physiologically
with each patient. They then need to be able to recognise and
prioritise the patient cues in order to interpret the significance
of what they are seeing.38 To do this effectively, nurses need
to have the skills of critical thinking, clinical reasoning and
clinical judgement.16,53,54 Figure 2-5 illustrates the process and
outcomes of this thinking process.
Ideally, a new nurse will also understand the specific needs
of each patient. These needs will become clear as the nurse
elicits, through careful questioning, how the patient is feeling
about their situation. Even with little experience, a nurse will
know if they are feeling concerned about a particular patient. In
recognition of this, the parameter ‘worried’ has been added to
the ‘track and trigger’ observation charts developed in Australia
(Fig 2-4). This is when critical thinking and clinical reasoning
need to be used in practice.
While critical thinking is a habit that can be developed in
all spheres of life, it can be enhanced in the clinical setting by
considering it from three perspectives.16,53,54
1. Thinking ahead:54 This is a responsibility to anticipate
what might happen in particular situations. A newly
graduated nurse, for example, may know that she or he is
 Date MEWS Escalation
Time Time Weight
Kg MEWS 4 - 5 MEWS 6 - 7 MEWS 8 or
> 36 > 36 Greater
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31 – 35 31 – 35 Height cm
25 – 30 25 – 30
21 – 24 21 – 24 Contact RMO, to review within
15 – 20 15 – 20
0

Rate
9– 14
m 9– 14
1
30 minutes. Inform Team Leader
and start fluid balance chart

Respiration
5–8 5–8
<5 <5
2
MEWS RR After 60 minutes if patient not
Flow Rate Flow rate 3 reviewed and MEWS not decreased
Oxygen

Modified Early
Warning Score
Delivery Device Device MET/4
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If the amount of oxygen the patient is getting needs to be increased then they MUST be reviewed by a medical officer Contact Registrar and RMO, Registrar to review
Oxygen Devices:
> 93
90 – 92
e > 93
90 – 92 RA= room air
in 30 minutes. Notify Consultant. Inform Team
Leader and start fluid balance chart
85 – 89 85 – 89 NP= nasal prongs

SpO2
< 85 < 85 HM= Hudson mask
MEWS SpO2 NRBM= non- After 60 minutes if patient not
>39.5 >39.5 Rebreather reviewed and MEWS not decreased
38.6 – 39.5 38.6 – 39.5 High Flow Oxygen
38 – 38.5 38 – 38.5 Humidified Oxygen
Contact Registrar and Consultant Registrar to review in 10 minutes. No
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37 – 37.9 37 – 37.9 response from the page or the treatment, the MEWS has not decreased,
36.1 – 36.9 36.1 – 36.9 consider MET/ICU consult. Inform Team Leader and start fluid balance chart
35.1-36 35.1-36

Temperature
34.1 - 35 34.1 - 35
< 34 < 34 BP MEWS table: Usual BP: ___________(Circle Usual BP for patient)
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26 Section 1  Concepts in nursing practice

MEWS Temperature USUAL BP → 190 180 170 160 150 140 130 120 110 100 90 80
200 & more 200 & more 0 0 1 1 2 2 2 3 3 4 5 5
190-199 190-199 0 0 0 1 1 1 2 2 3 3 4 4
180-189 180-189 0 0 0 0 0 1 1 2 2 3 3 4
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170-179 170-179 1 0 0 0 0 1 1 2 2 3 3 3
160-169 160-169 1 1 0 0 0 0 0 1 1 2 2 2
150-159 150-159 1 1 1 0 0 0 0 0 1 1 2 2
140-149 140-149 2 1 1 1 0 0 0 0 0 1 1 1 Score the MEWS for Systolic
130-139
@ 130-139 2 2 1 1 0 0 0 0 0 0 0 1 Blood Pressure using the usual
120-129 120-129 2 2 2 1 1 0 0 0 0 0 0 0 BP circled column and compare
110-119 110-119 3 2 2 2 1 1 0 0 0 0 0 0 to the current Systolic BP reading
100-109 100-109 3 3 3 2 2 2 1 1 0 0 0 0

Source: Used with permission, ACT Health: Canberra Hospital & Health Service, 2011.
90-99 90-99 4 3 3 3 2 2 2 2 1 1 0 0
80-89 80-89 1 0
70-79 70-79
CURRENT SYSTOLIC BP

60-69 60-69
50-59 50-59
MET
40-49 40-49

> < Blood Pressure & Heart Rate (●)

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30-39 30-39

Figure 2-4  Example of a modified early warning system adult observation chart.
20-29 20-29
MEWS HR
MEWS BP Sedation Score
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0 0 0=awake & alert
MET Criteria
1 1 1=normally asleep, responds to stimuli Dial “8” or use Code Blue
2=mild, occasionally drowsy, easy to rouse
2 2 3=moderate, frequently drowsy, easy to rouse but unable to Button

score
3 3 maintain wakeful state

Sedation
• All respiratory & cardiac arrests
4 4 4= severe, somnolent, difficult to rouse
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Sedation MEWS Urine Output • Threatened Airway, RR in purple zone
(RR< 5 or > 36 breaths per minute)
> 800 ≥ 800 • Calculate the urine output for the previous 4 hours and
120 - 799 120 - 799 write the volume and then calculate the MEWS. • Pulse Rate in purple zone

for 4

Urine
hours
80 - 119 80 - 119 If not on a fluid balance chart “N/A” (< 40 or > 140 beats per minute)

Output
•
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< 79 < 79 • If MEWS 4 or more start fluid chart
• Systolic BP in purple zone
MEWS Urine Output
(< 90 mmHg)
TOTAL MEWS • Sudden fall in level of consciousness
Weight Weight All patients with a MEWS of 4 or more must also have:
• Fall of GCS > 2
BGL BGL • A review by the Team Leader • Repeated or prolonged seizures
Pain Score Pain Score • A Fluid Balance Chart
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Bowels Bowels • Any patient you are seriously worried about
• Increased frequency of observations (see back for that does not fit the above criteria
details)

Initial Initial
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60205(0912)
tra
lia


Complete details or affix label

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MODIFIED EARLY WARNING SCORES (MEWS)
*60201* MRN:
* 6 0 2 0 1 *
m Surname: To calculate the MEWS:
Canberra Hospital & Health Service
Given name:
• Record a full set of vital sign observations on the patient
General Observation Chart – Adult • Note whether the observation falls into the shaded areas and score accordingly
DOB: Gender:
• Total the scores from each observation attended to achieve the MEWS score
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Pain Score Urinalysis
e Date A MEWS score of 4 or more will trigger an action (see flow chart on other side)
Should be documented with each set
Time
of vital signs • Increase frequency of vital signs
(Verbal Numerical Rating Scale) Leucocytes
No pain – 0 Nitrate
• Half hourly for 1 hour
Worst pain – 10 Urobilinogen • Hourly for 4 hours
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Protein • 4 hourly for 24 hours
pH
Blood VARIANCE TO MEWS
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Specific
Gravity Where a patient has a pre-existing condition that requires a variance from the normal scoring
Ketones of MEWS, this must be documented in the allocated section of this chart after agreement with
Bilirubin the admitting Consultant or Registrar. This Variance must also include a “valid until” date.
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Glucose For chronic conditions this may be for the entire hospital stay.
Variance to MEWS
If abnormal observations are accepted, write the vital sign ranges below:
Respiratory Rate to
@
Name Consultant / Registrar
SpO2 to
Signature
=0
Heart Rate to
Date / / Time__:__ Valid Until / /
Sedation score to VARIANCE TO MET

Variances to the MET criteria may also be done in the allocated section of this chart. Indicate
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parameter(s) to be varied and the range for MET
Variance to MET
Indicate parameter(s) to be varied and range for MET activation Document reason for variance.
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- Note when to call a MET (e.g- accept SBP down to 80 mmHg as long as alert, warm, passing urine and heart rate

Figure 2-4  Example of a modified early warning system adult observation chart—cont’d
General Observation Chart – Adult
not greater than 100 beats/min)
Reason for Variance
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Communication for MEWS 4 or greater
Date/Time MEWS Action if MEWS ≥ 4 Signature
ESCORT OFF WARD AREA
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If the patient requires movement to another clinical area, the following escort should
accompany the patient.

 MEWS > 4 Registered Nurse

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 MEWS > 6 Registered Nurse & JMO
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 MEWS > 8 Registered Nurse & Registrar
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Chapter 2  Patient safety and clinical reasoning: Thinking like a nurse 27

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 28 Section 1  Concepts in nursing practice
PROCESS RESULT
Clinical judgement
Critical thinking
(conclusion, decision,
and clinical reasoning
opinion, action)
Figure 2-5  Process and outcome of critical thinking and clinical
reasoning.
Source: Alfaro-LeFevre, 2012.
going to work on an acute surgical ward where the
majority of patients have orthopaedic procedures. It is
their responsibility, therefore, to revise what they know
about the care of orthopaedic patients and to think about
the types of medications patients may be taking. The
nurse also needs to review relevant ward policies and
procedures, and to plan the type of care that may be
required by patients.
2. Thinking in action:54 This is the ability to ‘think on your
feet’ and tends to be ‘rapid, dynamic reasoning that
considers several cues and priorities at once’ (p 4).54 This
type of thinking will improve with time as the nurse gains
more experience and is able to think back to other similar
cases. Nevertheless, it is an important skill for a nurse and
can be improved by, for example, taking part in clinical
simulation activities and being exposed to online, real-
time testing of knowledge, skills and decision making.
Tanner calls this ‘reflection in action’.18
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3. Thinking back (reflecting):54 Every situation can be
used as a learning experience; whether something went
well or badly, lessons can be learned for use in the future.
In many hospitals, debriefing sessions are held following
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major adverse events, but not in relation to the day-to-day,
normal care activities of the ward. For the individual
nurse, it is important to develop the habit of critically
reviewing what they have done and learned each day in
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order to improve and to be able to take better action in
future. Each person will do this in different ways—some
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will keep a journal, others will use a mentor or more
senior nurse to assist, while still others will discuss what
has happened with friends or via discussion boards on the
internet. The critical factor is to learn to tease out the
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themes or underlying assumptions that caused you to
respond in the ways that you did. What could you have
done differently? Why did you act in the way you did?
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What was the outcome for the patient, the family and
other members of the healthcare team?
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Benner, et al 53 talk of ‘clinical forethought’ in which
nurses (or other health professionals) develop specific habits
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of thinking, including: (1) future think, (2) clinical forethought
about specific patient problems, (3) anticipation of risks for
particular patients, and (4) seeing the unexpected. These are
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complicated cognitive skills that can be acquired and improved
only with practice. A newly graduated nurse will need to
consciously practise these ways of thinking while in the clinical
field to ensure that they develop the highly attuned, holistic
approach of the expert nurse as quickly as possible.
While thinking critically about clinical care issues is
challenging and difficult, it is a crucial skill for all levels of
nurse. It is as important as technical ability. Tanner18 provides a
succinct summary of the relationship between clinical judgement
and patient safety, as shown in Box 2-1.
BOX 2-1  The relationship between clinical
judgement, patient safety and good nursing practice
Clinical judgement is tremendously complex. It is required in
clinical situations that are, by definition, underdetermined,
ambiguous, and often fraught with value conflicts among
individuals with competing interests. Good clinical judgement
requires a flexible and nuanced ability to recognise salient
aspects of an undefined clinical situation, interpret their
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meanings and respond appropriately. Good clinical judgements
in nursing require an understanding of not only the
pathophysiological and diagnostic aspects of a patient’s clinical
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presentation and disease, but also the illness experience for
both the patient and the family and their physical, social, and
emotional strengths and coping resources.
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Source: Tanner, 2006.
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As with many things in nursing, the capacity to think
critically is not immediately visible to a person watching a
nurse practise, but it will become evident in the way that nurses
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respond to changes in patients’ conditions. Students in nursing,
and indeed all nurses, have a responsibility to improve their
capacity to think critically about life and clinical care. Thinking
vi
critically about life events will enable nurses to transfer their
skills to the clinical field, thus ensuring that patients, as far as
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is possible, are not harmed as a result of their interaction with
the healthcare system. As Florence Nightingale said, ‘The very
first requirement in a hospital … is that it should do the sick
no harm …’55
The following case study is based on the clinical reasoning
cycle and provides a way for nurses to think about nursing care
in a structured manner, using skills in clinical reasoning and
clinical judgement. The case also provides a framework that
students can use to work through this textbook and learn about
becoming a nurse.
CASE STUDY
Les Green is an 86-year-old man who fell from
a ladder. He has sustained two fractured ribs
on his right side and one fractured rib on the
left side. He presented to ED last night
complaining of pain in his chest.
Les Green has mild asthma. Twenty years
ago he underwent a left inguinal hernia repair.
Otherwise, he is a healthy gentleman. His only
Source: Shutterstock/ medication is a bronchodilator.
PathDoc.
Consider the patient situation
Les Green was admitted to the ward last night. You have
commenced your shift and at handover are told that Les Green
had IV patient-controlled analgesia (PCA) in situ and he was using
it appropriately. He didn’t seem to be in too much pain. He has
some bruising around his chest area. His wife will be visiting this
morning to bring in his pyjamas. The night nurse also told you
that his medication chart hasn’t been written up yet and so he
self-administered his bronchodilator at around 5 am.
Think about what other information you need from Les Green or
the night nurse to plan his care.
Collect cues
You commence your shift and check his charts. He currently has a
vital signs chart and a patient-controlled analgesia (PCA) chart.
 Chapter 2  Patient safety and clinical reasoning: Thinking like a nurse 29
His vital signs at 0730 are:
Temperature 37°C, pulse 110 bpm, respirations 22 pm, BP 90/60,
O2 saturation 98%.
His patient-controlled analgesia is running at 10 mcg of
Fentanyl/mL. His pain levels have not been recorded.
He also has a medication chart, but you remember that he has
been self-administering his bronchodilator. You note that the
doctor needs to see Les Green when he gets to the hospital to
chart his medication.
When you go to Les Green’s bedside you notice that he has not
eaten breakfast. He says he doesn’t feel like eating but would like to
have a shower. However, he has great difficulty in moving, and
when you ask him if he wants to go to the toilet before his shower
he declines. While you assist him to shower, you notice there is
quite a lot of bruising around his rib cage. After you have dried him
he tries to stand up, but says that he feels dizzy. You let him sit for a
few minutes. After dressing him, you assist him into a wheelchair to
go back to bed. He sleeps for the rest of the morning.
Process the information
Look at Les Green’s vital signs (above for 0730 obs). At 1200 his
temperature is 37°C, pulse is 120 bpm, respiratory rate is 25 pm,
BP is 90/50, O2 saturation is 94%.
Are these signs what you would consider ‘normal’ for a generally
well 86-year-old man? What do you think is going on here? What
relationships can you establish between Les Green’s vital signs and
other things you noticed while he was out of bed? What physiological
reasons might account for these vital signs?
Identify the problem
After processing the information you have collected and talking
to Les Green further, you find that he is in pain. He is complaining
that his pain level is eight on a visual analogue scale.
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Establish goals
What are the most important short-term goals for Les Green
considering his current condition? Why?
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Take action
Make a list of nursing actions you would take and explain the
rationale behind each of these.
(You ring the doctor, who tells you to give Les Green his
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pain relief and see if this will settle him. He tells you to ‘keep
an eye on him’.)
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Evaluate
It is now one hour since you have given Les Green some
breakthrough pain relief. He tells you that his pain score has
dropped from eight down to four, and says he is ‘feeling a lot
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better’. (The doctor has added Les Green’s bronchodilator to the
medication chart.)
Consider the patient situation
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Les Green continues to doze in bed. You wake him at 1400 hours
to take his vital signs and notice a worrying trend. His pulse and
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respiratory rates have increased and his blood pressure is slightly
lower than it was at 1200.
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Collect cues
What other cues could you collect to assist you in identifying any
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problem?
Continue to evaluate
You decide to complete a physical assessment of Les Green.
Your findings are:
• He is pale.
• He is complaining that his mouth is dry and he feels thirsty.
• You ask him if he has urinated this shift. He tells you that he
used a urine bottle in ED when he was admitted but hasn’t
done so since then.
• He has no palpable bladder.
Process the information
What is going on here?
Identify the problem
What is Les Green’s problem?
Establish goals
What are the most important short-term goals to achieve?
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Take action
What actions would you take to improve Les Green’s condition?
Evaluate
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You continue to monitor Les Green for the rest of the shift and
notice that by 1545 he is starting to look a little less pale and has
urinated 120 mL.
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Reflection and review
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1. What have you learned from this case study?
2. What could nursing staff have done to prevent Les Green’s
deterioration?
Source: Chest & Rudolph, 2010.
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Answers available at http://evolve.elsevier.com/AU/Brown/medsurg.
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REVIEW QUESTIONS
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1. A colleague asks you to describe clinical reasoning. How do
you respond? Clinical reasoning is
a. a way of carrying out nursing care that is safe and
effective.
b. always being critical about ideas and looking to find what
is wrong with them.
c. analysing, synthesising and evaluating situations.
d. analysing, synthesising and evaluating situations, as well
as considering underlying assumptions and values.
2. Critical thinking in clinical practice is an important skill
because it ensures that (select all that apply)
a. nurses will plan and evaluate care efficiently.
b. nurses will be able to consider individual patient cues
and problems and act accordingly.
c. nurses will be able to reflect on their practice and
consider how they can improve in future.
d. nurses will recognise when things are going wrong with
patients.
3. Your hospital wants to introduce a MET. You are asked to
outline the rationale for this to other staff on your ward. You
explain that
a. MET is an effective way of increasing the input of ICU
specialists for very sick ward patients.
b. clinical deterioration can be seen before patients arrest.
c. it can only be initiated by specially trained staff.
d. it can only be used in cases of cardiac arrest.
4. The advantages of using early warning systems for clinical
observations include (select all that apply)
a. clear guidelines and parameters.
b. information about medication history.
c. information about when to call a medical officer.
d. patient diagnosis.
5. The nurse explains to the patient that she or he will take
regular observations of the patient’s condition and ensure,
as far as possible, that the patient is kept safe. The patient
asks how this differs from what the doctor does. The
 NURSING MANAGEMENT:

Chapter 30
Coronary artery disease and
acute coronary syndrome

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Written by Linda Bucher and Sharmila Johnson
Adapted by John Rolley

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LEARNING OUTCOMES KEY TERMS
1. Describe the aetiology and pathophysiology of coronary artery disease, angina and acute coronary syndrome (ACS), p 757

s
acute coronary syndrome. angina, p 750
2. Identify risk factors for coronary artery disease and the nursing role in the promotion atherosclerosis, p 738

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of therapeutic lifestyle changes in patients at risk. chronic stable angina, p 750
3. Compare and contrast the precipitating factors, signs and symptoms, collateral circulation, p 739
multidisciplinary care and nursing management of the patient with coronary artery coronary artery disease (CAD), p 738
disease and chronic stable angina. coronary revascularisation, p 756
4. Describe the signs and symptoms, complications, diagnostic study results and metabolic equivalent (MET), p 769

er
multidisciplinary care of the patient with acute coronary syndrome. myocardial infarction (MI), p 757
percutaneous coronary intervention
5. Describe the pathophysiology of myocardial infarction from the onset of injury to (PCI), p 756
the healing process.

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Prinzmetal’s angina, p 751
6. Identify commonly used drug therapy in treating patients with coronary artery silent ischaemia, p 751
disease and acute coronary syndrome. stent, p 756
coronary syndrome and coronary revascularisation procedures.
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7. Identify key issues to include in the rehabilitation of patients recovering from acute

8. Describe the precipitating factors, clinical presentation and multidisciplinary care of

sudden cardiac death (SCD), p 771
unstable angina (UA), p 757
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patients who are at risk of or have experienced sudden cardiac death.
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Cardiovascular disease, which incorporates ischaemic heart
disease and other vascular conditions, is the major cause of
death in Australia,1 and the second leading cause of death
in New Zealand2 (see Fig 30-1). Coronary artery disease
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symptoms of CAD and are termed acute coronary syndrome
(ACS). In 2009, 63% of Australians having a heart attack
survived, compared to 47% in 1997.1 In 2012 it was estimated
that nearly 700,000 Australians have CAD;1 and in New

(CAD), or ischaemic heart disease, is the most common type Zealand, each day approximately 15 people die as the result
of cardiovascular disease.1,2 Although the mortality rate from of ischaemic heart disease.2
CAD has decreased by more than 60% in the last few decades Multiple causal factors contribute to CAD. A number of
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due to advances in prevention, assessment and treatment, modifiable risk factors contribute to around 90% of the risk
it remains the leading cause of all cardiovascular disease of myocardial infarction observed worldwide: blood lipid
deaths and thus deaths in general. Patients with CAD can abnormalities, smoking, hypertension, diabetes mellitus,
pr

be asymptomatic or develop chronic stable angina. Unstable abdominal obesity, psychosocial factors, physical inactivity,
angina (UA) and myocardial infarction (MI) are more serious and inadequate intake of fruits and vegetables.3 Given that
e
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Australia
100
New Zealand
m

80
Deaths (%)

60
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40%
40 36%
28% 29%

18% 21%
20 7.5% 7%
6.5% 7%

0
A B C D E

Figure 30-1  Leading causes of death for men and women, Australia and New Zealand.
A, Total cardiovascular diseases. B, Cancer. C, Respiratory disease. D, Accidents and poisoning. E, All other.
Source: AIHW, 2012; NZMOH, 2009.

737
 738 Section 7  Problems of oxygenation: Perfusion

cardiovascular disease is largely preventable, Australian and (QGRWKHOLXP ,QWLPD

New Zealand primary care guidelines3,4 emphasise compre­ &KURQLFHQGRWKHOLDOLQMXU\
hensive risk assessment to enable the effective management ‡+\SHUWHQVLRQ
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of identified risk factors through lifestyle changes (e.g. weight ‡+\SHUOLSLGDHPLD
management, smoking cessation and increasing physical ‡+\SHUKRPRF\VWHLQDHPLD
activity) and pharmacological therapy (e.g. anti-platelet agents, ‡'LDEHWHV
blood pressure-lowering agents and lipid-modifying agents). ‡,QIHFWLRQV
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(See Figs 30-4 and 30-5, later in this chapter, for Australian

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CORONARY ARTERY DISEASE ‡/LSLGVDFFXPXODWHDQGPLJUDWH
Coronary artery disease (CAD) is a type of blood vessel disorder LQWRVPRRWKPXVFOHFHOOV
that is included in the general category of atherosclerosis. The
term atherosclerosis comes from two Greek words: athere,

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meaning ‘fatty mush’, and skleros, meaning ‘hard’. This

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combination implies that atherosclerosis begins as soft deposits
of fat that harden with age. Consequently, atherosclerosis is %
commonly referred to as ‘hardening of the arteries’. Although )LEURXVSODTXH
this condition can occur in any artery in the body, the atheromas ‡&ROODJHQFRYHUVWKHIDWW\VWUHDN
(fatty deposits) prefer the coronary arteries. The terms ‡9HVVHOOXPHQLVQDUURZHG

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arteriosclerotic heart disease, cardiovascular heart disease, ‡%ORRGIORZLVUHGXFHG
ischaemic heart disease, coronary heart disease and CAD all ‡)LVVXUHVFDQGHYHORS

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describe this disease process.

AETIOLOGY AND PATHOPHYSIOLOGY se &

Atherosclerosis is the major cause of CAD. It is characterised by &RPSOLFDWHGOHVLRQ
deposits of lipids within the intima of the artery. The genesis of ‡3ODTXHUXSWXUH
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plaque formation is the result of complex interactions between ‡7KURPEXVIRUPDWLRQ
‡)XUWKHUQDUURZLQJRUWRWDO
the components of the blood and the elements forming the RFFOXVLRQRIYHVVHO
vascular wall.5,6 Endothelial injury and inflammation7 play a
central role in the development of atherosclerosis.
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The endothelium (the inner lining of the vessel wall)

is normally non-reactive to platelets and leukocytes, as '
well as coagulation, fibrinolytic and complement factors.
However, the endothelial lining can be injured as a result of
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Figure 30-2  Pathogenesis of atherosclerosis.

tobacco use, hyperlipidaemia, hypertension, toxins, diabetes, A, Damaged endothelium. B, Fatty streak and lipid core formation.
hyperhomocysteinaemia and infection, causing a local inflam­ C, Fibrous plaque. Raised plaques are visible: some are yellow; others are
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matory response (Fig 30-2, A).5,6,8
C-reactive protein (CRP), a protein produced by the liver,
is a non-specific marker of inflammation and is increased in
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white. D, Complicated lesion: thrombus is red; collagen is blue. Plaque is
complicated by red thrombus deposition.
Fibrous plaque

many patients with CAD.9 The level of CRP rises when there
is systemic inflammation. Chronic elevations of CRP are
The fibrous plaque stage is the beginning of progressive changes
associated with unstable plaques and the oxidation of low-
in the endothelium of the arterial wall. These changes can
density lipoprotein (LDL) cholesterol.4,10
appear in the coronary arteries by age 30 and increase with age.
e

Developmental stages Normally the endothelium repairs itself immediately

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except in the person with CAD. LDLs and growth factors from
CAD is a progressive disease that develops over many years. platelets stimulate smooth muscle proliferation and thickening
When it becomes symptomatic, the disease process is usually of the arterial wall. Once endothelial injury has taken place,
m

well advanced. The stages of development in atherosclerosis are: lipoproteins (carrier proteins within the bloodstream) transport
(1) fatty streak, (2) fibrous plaque, and (3) complicated lesion. cholesterol and other lipids into the arterial intima. Collagen
sa

Fatty streak
Fatty streaks, the earliest lesions of atherosclerosis, are
characterised by lipid-filled smooth muscle cells. As streaks
of fat develop within the smooth muscle cells, a yellow tinge
appears (Fig 30-2, B).8 Fatty streaks can be seen in the coronary
arteries by age 15 and involve an increasing amount of surface
area as one ages. Yet, atherosclerotic plaque has been found in
fetuses and infants, particularly where the mother smoked.11
Treatment that lowers LDL cholesterol may reverse this process.
covers the fatty streak and forms a fibrous plaque with a greyish
or whitish appearance.5,6 These plaques can form on one portion
of the artery or in a circular fashion involving the entire lumen.
The borders can be smooth or irregular with rough, jagged
edges.6 The result is a narrowing of the vessel lumen and a
reduction in blood flow to the distal tissues (Fig 30-2, C).
Complicated lesion
The final stage in the development of the atherosclerotic
lesion is the most dangerous. As the fibrous plaque grows,
 Chapter 30  NURSING MANAGEMENT: Coronary artery disease and acute coronary syndrome 739
A B C than 6.2 mmol/L), elevated systolic blood pressure (BP) (greater
Figure 30-3  Vessel occlusion with collateral circulation.
A, Open, functioning coronary artery. B, Partial coronary artery closure
with collateral circulation being established. C, Total coronary artery
occlusion with collateral circulation bypassing the occlusion to supply
blood to the myocardium.
continued inflammation can result in plaque instability,
ulceration and rupture. Once the integrity of the artery’s inner
wall is compromised, platelets accumulate in large numbers,
leading to a thrombus. The thrombus may adhere to the wall
of the artery, leading to further narrowing or total occlusion of
the artery. Activation of the exposed platelets causes expression
of glycoprotein Ilb/IIIa receptors that bind fibrinogen. This, in
turn, leads to further platelet aggregation and adhesion, further
enlarging the thrombus. At this stage the plaque is referred to
as a complicated lesion (Fig 30-2, D).
Collateral circulation
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Normally some arterial anastomoses or connections, termed
collateral circulation, exist within the coronary circulation.
Two factors contribute to the growth and extent of collateral
@
circulation: (1) the inherited predisposition to develop new blood
vessels (angiogenesis) and (2) the presence of chronic ischaemia.
When a plaque occludes the normal flow of blood through a
coronary artery and the resulting ischaemia is chronic, increased
fs
collateral circulation develops (Fig 30-3). When occlusion of
the coronary arteries occurs slowly over a long period, there is
a greater chance of adequate collateral circulation developing,
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and the myocardium may still receive an adequate amount of
blood and oxygen. However, with rapid-onset CAD (e.g. familial
hypercholesterolaemia) or coronary spasm, time is inadequate
pr
for collateral development. Consequently, a diminished blood
flow results in a more severe ischaemia or infarction.
CAD develops over many years, and signs and symptoms
will not be apparent in the early stages of the disease. Therefore,
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it becomes extremely important to identify people at risk so that
therapeutic lifestyle changes and some treatment strategies can
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be initiated early.
Risk factors for coronary artery
m
disease
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Risk factors are characteristics or conditions that are associated
with a high incidence of a disease. Risk factors in different
populations may vary. For example, major risk factors for CAD
in Australia and New Zealand, such as high serum cholesterol
and hypertension, are more prevalent in Indigenous Australians,
Māori, Pacific Islander peoples and those from the Indian
subcontinent (see Figs 30-4 and 30-5).1,2,3
Many risk factors have been associated with CAD and are
categorised as non-modifiable and modifiable (Table 30-1).
Non-modifiable risk factors are age, gender, ethnicity, family
history and genetics. Modifiable risk factors include elevated
serum lipids, elevated blood pressure, tobacco use, physical
inactivity, obesity, diabetes, metabolic syndrome, psychological
states (depression and anxiety) and elevated homocysteine level.
Data on risk factors for CAD come from several major
studies. In the Framingham study (one of the first and most
widely known), men and women were observed for 20 years.
Over time, it was noted that elevated serum cholesterol (greater
lia
than 160 mmHg), and tobacco use (one or more packets a
day) were positively correlated with an increased incidence
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of CAD.12
NON-MODIFIABLE RISK FACTORS
Age, gender and ethnicity
s
The incidence of CAD is almost twice as high among men
Au
as women in Australia and New Zealand.1,2 After 65 years,
the incidence in men and women equalises, although cardio­
vascular disease causes more deaths in women than men.1,2,13
Additionally, CAD is present in Australian Indigenous women
er
at rates higher than their non-Indigenous counterparts.1 (See
Table 30-2 for the recommended age to start cardiovascular
disease and diabetes risk assessment.)
vi
Heart disease kills almost 10 times more women than breast
cancer. Even though cardiovascular disease remains the lead­ing
se
cause of death in women and the mortality rate for women with
CAD has remained relatively constant in recent years, just 15%
of women consider CAD their greatest health risk.13 It is only
recently that there has been research focusing on the symptoms
and course of CAD in women. Women tend to manifest CAD
10 years later in life than men. This is thought to be related to
the loss of the cardio-protective effects of natural oestrogen
with the onset of menopause. Most women have symptoms of
angina rather than MI when presenting with their initial cardiac
event (see the Gender Differences box on CAD).
Genetic link
Genetic predisposition is an important factor in the occurrence
of CAD. Family history is a risk factor for CAD and MI. Most
times, patients with angina or MI can name a parent or sibling
who died of CAD.
The genetic basis of CAD/MI is complex and, to date,
poorly understood. It is estimated that the genetic contribution
to CAD/MI is as high as 40% to 60%. This proportion relates
mainly to genes that control known risk factors (e.g. lipid
metabolism).5 (Genes known to contribute to CAD risk are
listed in eTable 30-1, available on the website for this chapter.)
(See the Genetics in Clinical Practice box.)
MAJOR MODIFIABLE RISK FACTORS
Elevated serum lipids
An elevated serum lipid level is one of the four most firmly
established risk factors for CAD.3,8,11 The various types of serum
lipids are presented in Figure 30-6. The risk of CAD is associated
with a serum cholesterol level of more than 5.2 mmol/L or
a fasting triglyceride level of more than 3.7 mmol/L. (See
Table 28-6 for normal serum lipid values.)
For lipids to be used and transported by the body, they must
become soluble in blood by combining with proteins. Lipids
combine with proteins to form lipoproteins. Lipoproteins
are vehicles for fat mobilisation and transport, and vary in
composition. They are classified as high-density lipoproteins
 120

4 5 6 7 8 4 5 6 7 8

Total cholesterol:HDL ratio

740 Section 7  Problems of oxygenation: Perfusion

Risk level women

Risk level
No diabetes Diabetes (for women
Non-smoker Smoker Non-smoker Smoker and men)
5-year cardiovascular
180 180 disease (CVD) risk
(fatal and non-fatal)
160 160
Age
>30%
140 65–74 140
Very high 25–30%

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120 120
20–25%
180 180

Systolic blood pressure (mmHg)

Systolic blood pressure (mmHg)

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High 15–20%
160 160
Age
Moderate 10–15%
140 55–64 140

120 120
5–10%

s
Mild 2.5–5%
180 180

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<2.5%
160 160
Age
140 45–54 140

120 120

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180 180

Age

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160 160

140
35–44 140

120

4 5 6 7 8 4 5 6 7 8 4
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5 6 7 8 4 5 6 7 8
120

Total cholesterol:HDL ratio Total cholesterol:HDL ratio

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Risk level men
Risk level
No diabetes Diabetes
@

(for women
Non-smoker Smoker Non-smoker Smoker
and men)
180 5-year cardiovascular 180
disease (CVD) risk
160 (fatal and non-fatal) 160
Age
fs

140 >30% 65–74 140

120 Very high 25–30% 120

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20–25%
180 180
Systolic blood pressure (mmHg)

Systolic blood pressure (mmHg)

160 High 15–20% 160

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Age
140 Moderate 10–15% 55–64 140

120 120
5–10%
e

180 Mild 2.5–5% 180

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160 <2.5% 160

Age
140 45–54 140
m

120 120
sa

180 180

160 160
Age
140 35–44 140

120 120

4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8

Total cholesterol:HDL ratio Total cholesterol:HDL ratio

Figure 30-4  New Zealand cardiovascular risk assessment levels.

Source: New Zealand Guidelines Group, 2009.
 Total cholesterol:HDL ratio

* In accordance with Australian guidelines, patients with systolic

considered at increased absolute risk of CVD.
Chapter 30  NURSING MANAGEMENT: Coronary artery disease and acute coronary syndrome 741

People without diabetes

Risk level for
Women Men 5-year
Non-smoker Smoker Non-smoker Smoker cardiovascular
(CVD) risk
179* 179*
High risk
160 160
Age ≥30%
140 65–74 140
25–29%
120 120

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20–24%

179* 179* 16–19%

Systolic blood pressure (mmHg)

Systolic blood pressure (mmHg)

160 160 Moderate risk

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Age
140 55–64 140 10–15%

120 120 Low risk

5–9%

s
179* 179*
<5%

Au
160 160
Age
140 45–54 140

120 120

er
179* 179*

160 160 Charts in this age

Age bracket are for use in
140 140

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35–44 Indigenous populations
120 120 only.
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8

Total cholesterol:HDL ratio*

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Total cholesterol:HDL ratio*
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People with diabetes
Women Men
@

Non-smoker Smoker Non-smoker Smoker

179* 179*
Adults over the age
160 160 of 60 with diabetes
Age are equivalent to
65–74
fs

140 140 high risk (>15%),

120 120
regardless of their
calculated risk
Systolic blood pressure (mmHg)

Systolic blood pressure (mmHg)

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level. Nevertheless,
179* 179*
reductions in risk
160 160 factors in this age
Age
group can still
140 55–64 140
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lower overall
120 120
absolute risk.

179* 179*
e

160 160
Age
pl

140 45–54 140

120 120
m

179* 179*

160
Age 160 Charts in this age
sa

35–44 bracket are for use in

140 140
Indigenous populations
120 120 only.
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8

Total cholesterol:HDL ratio Total cholesterol:HDL ratio

* In accordance with Australian guidelines, patients with systolic blood pressure ≥ 180 mmHG, or total cholesterol of >7.5 mmol/L, should be
considered at increased absolute risk of CVD.

Figure 30-5  Australian cardiovascular risk assessment levels.

Source: Heart Foundation, 2014.
Risk level for
5-year
cardiovascular
(CVD) risk
 742 Section 7  Problems of oxygenation: Perfusion

TABLE 30-1  Risk factors for coronary artery disease
Non-modifiable risk factors
Age
Gender (men > women until
60 years of age)
Ethnicity (Indigenous
Australians, Māori, Pacific
Islanders and people from
Modifiable risk factors
Major
Serum lipids: elevated
triglycerides and LDL
cholesterol; decreased HDL
cholesterol*
Nutrition
(HDLs), LDLs and very-low-density lipoproteins (VLDLs).
(See Fig 30-7, which illustrates the types of dietary fat.)
HDLs contain more protein by weight and fewer lipids than
any other lipoprotein. HDLs carry lipids away from arteries
and to the liver for metabolism. This process of HDL transport
prevents lipid accumulation within the arterial walls. Therefore,
high serum HDL levels are desirable and lower the risk of CAD.
There are two types of HDLs: HDL2 and HDL3. They differ by

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Indian subcontinent > other Hypertension: ≥130/85 mmHg* their density and apolipoprotein composition. Apolipoproteins
Australians and New Tobacco use are found on lipoproteins and activate enzyme or receptor sites
Zealanders) Alcohol intake** that promote the removal of fat from plasma. Several types of

Genetic predisposition and
family history of heart disease
Physical inactivity
Obesity: waist circumference
>102 cm in men and >88 cm
in women*
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apolipoproteins exist (e.g. apo A-I, apo B-100, apo C-I). Women
produce more apo A-I than men, and premenopausal women
have HDL2 levels approximately three times greater than men.
This is thought to be related to the protective effects of natural

s
Social history
Related conditions oestrogen. After menopause, women’s HDL2 levels decrease

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Diabetes mellitus and quickly approach those of men.
Fasting blood sugar In general, HDL levels are higher in women, decrease
>6.4 mmol/L* with age, and are low in people with CAD. Physical activity,
Kidney function: microalbumin moderate alcohol consumption, and oestrogen administration
+/– urine protein, eGFR
increase HDL levels. LDLs contain more cholesterol than any

er
45mL/min/1.73 m2
Familial hypercholesterolaemia of the lipoproteins and have an attraction for arterial walls.
Homocysteine levels VLDLs contain both cholesterol and triglycerides, and may
Evidence of atrial fibrillation deposit cholesterol directly on the walls of arteries. Elevated

vi
*Three or more of these risk factors meet the criteria for metabolic LDL levels correlate closely with an increased incidence of
syndrome as defined by the National Heart Lung and Blood Institute atherosclerosis and CAD. Therefore, low serum LDL levels
and American Heart Association.
**Alcohol is a risk factor for elevated BP (which itself is a major
determinant of risk for atherosclerotic disease), stroke and
se are desirable.14,15
Certain diseases (e.g. type 2 diabetes, chronic kidney
disease), drugs (e.g. corticosteroids, hormone therapy) and
cardiomyopathy.
El
HDL, high-density lipoprotein; LDL, low-density lipoprotein genetic disorders have been associated with elevated triglyceride
Source: Adapted from New Zealand Cardiovascular Guidelines Handbook, levels. Lifestyle factors that can contribute to elevated
2012; Australian National Vascular Disease Prevention Alliance, 2012. triglycerides include high alcohol consumption, high intake of
Available from www.health.govt.nz/publication/new-zealand-primary- refined carbohydrates and simple sugars, and physical inactivity.
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care-handbook-2012, accessed 11 May 2014.

When a high triglyceride level is combined with a high LDL
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TABLE 30-2  Recommended age to start cardiovascular disease and diabetes risk assessment
Group Men* Women* Australian guidelines**
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Asymptomatic people without known risk factors Age 45 years Age 55 years All adults over 45 years
Māori, Pacific Islander peoples or people from the Indian subcontinent (NZ)*
†
Age 35 years Age 45 years Age 35 years
Aboriginal and Torres Strait Islander peoples (Aus)**
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People with other known cardiovascular risk factors or at high risk of developing Age 35 years Age 45 years Age 35 years
diabetes
Family history risk factors
• Diabetes in first-degree relative (parent, brother or sister)
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• Premature coronary artery disease or ischaemic stroke in a first-degree relative

(father or brother <55 years, mother or sister <65 years)
pl

Personal history risk factors

• People who smoke (or who have quit in only the last 12 months)
• Gestational diabetes, polycystic ovary syndrome
m

• Prior blood pressure >160/85 mmHg (NZ); >180 mmHg systolic or >100 mmHg
(Aus)
• Prior TC:HDL ratio >7 (NZ), serum total cholesterol >7.5 mmol/L (Aus)
sa

• Known IGT (impaired glucose tolerance) or IFG (impaired fasting tolerance)

• BMI >30 or truncal obesity (waist circumference >100 cm in men (NZ), 102 cm
(Aus), or >90 cm in women (NZ), 88 cm (Aus)
• eGFR <60 mL/min/1.73 m2 (NZ), <45 mL/min/1.73 m2 (Aus)
People with diabetes Annually from diagnosis
†
People from Indian subcontinent = Indian, including Fijian Indian, Sri Lankan, Afghani, Bangladeshi, Nepalese, Pakistani, Tibetan.
Source:* New Zealand cardiovascular guidelines handbook, 2009. Available from www.nzgg.org.nz/guidelines/0154/CVD_handbook_june_2009_
update.pdf.
** Source: Australian National Vascular Disease Prevention Alliance. Guidelines for the assessment of absolute cardiovascular disease risk, 2009.
Available from www.heartfoundation.org.au/SiteCollectionDocuments/A_AR_Guidelines_FINAL%20FOR%20WEB.pdf.
 Chapter 30  NURSING MANAGEMENT: Coronary artery disease and acute coronary syndrome 743
Men
Coronary artery disease
• Initial cardiac event for men
is more often MI than
angina.
• Men report more typical
signs and symptoms of
angina and MI.
• Men receive more evidence-
based therapies (e.g. aspirin,
statins, diagnostic
catheterisation, PCI) when
acutely ill from CAD (e.g. MI)
than women.
• Mortality rates from CAD
have fallen more rapidly for
men than women.
Acute coronary syndrome
• Incidence of MI is highest
among middle-aged men.
• After age 65, the incidence
of MI in men and women
equalises.
• Men present more
frequently than women with
an acute MI as the first
symptom of CAD.
• Men develop greater
collateral circulation than
women.
• Men have larger-diameter
coronary arteries than
fs
women; vessel diameter is
inversely related to risk of
restenosis after
oo
interventions.
• Standard screening for risk
of sudden cardiac death
(e.g. EP studies) is more
pr
predictive in men.
e
pl
m
sa
ACS, acute coronary syndrome; CAD, coronary artery disease;
EP, electrophysiology; HDL, high-density lipoprotein; LDL, low-density
lipoprotein; MI, myocardial infarction; PCI, percutaneous coronary
intervention; UA, unstable angina.
GENDER DIFFERENCES GENETICS IN CLINICAL PRACTICE
Women Familial hypercholesterolaemia
Genetic basis
• Women experience the • Autosomal dominant disorder.
onset of heart disease
• Mutation in low-density lipoprotein receptor (LDLR) gene.
approximately 10 years later
• Gene codes for low-density lipoprotein (LDL) receptor that
binds to LDLs.
lia
than men.
• CAD is the leading cause of • LDLs are the primary carriers of cholesterol in the blood. By
removing LDLs from the bloodstream, the LDL receptors play a
death for women, regardless
critical role in regulating cholesterol levels.
of ethnicity.
• Exists in both heterozygous (most common) and homozygous
tra
• Initial cardiac event for forms.
women is more often angina
than MI.
Incidence
• More women than men with • Heterozygotes: 1 in 500
s
MI die of sudden cardiac
death before reaching the
• Homozygotes: rare
Au
hospital.
Genetic testing
• Before menopause, women • Disorder is characterised by elevated serum LDLs.
have higher HDL cholesterol
levels and lower LDL
• Serum lipid profile can be used to measure total cholesterol,
triglycerides, LDLs and high-density lipoproteins (HDLs).
cholesterol levels than men.
• DNA testing is available.
er
After menopause LDL levels
increase.
Clinical implications
• Common genetic disease.
vi
• High cholesterol levels are a result of defective function of the
• Women are older than men LDL receptors.
• Plasma levels of LDLs elevated throughout life.
when seen with first MI and
often have more
comorbidities.
• Women delay longer in
se• Develop severe atherosclerosis in early to middle years.
• Xanthomas (fatty deposits under the surface of the skin) can
occur (see eFig 30-1, available on the website for this chapter).
• Treatment strategies include low-fat diet, exercise and lipid-
El
seeking care and are often
more ill on presentation lowering medications.
than men. • Homozygous familial hypercholesterolaemia is much more
• Once a woman reaches severe than the heterozygous form. Cholesterol levels may
exceed 600 mg/dL in these patients.
@
menopause, her risk for an
MI quadruples.
• Fewer women than men
manifest the ‘classic’ signs
and symptoms of UA or MI.
• Fatigue is often the first
symptom of ACS in women. Lipids
• Women experience more
‘silent’ MIs compared with
men.
• Among those who have an Cholesterol Triglycerides Phospholipids
MI, women are more likely to
suffer a fatal cardiac event
within 1 year than men.
• Women report more Chylomicrons Fatty acids
disability after a cardiac
event than men.
• Women who have coronary
artery bypass graft surgery
VLDL HDL Saturated Unsaturated
have a higher mortality rate
and more complications
after surgery than men.
LDL
Monounsaturated Polyunsaturated
• Oleic acid • Omega-3
• Omega-6
• Linoleic acid
Figure 30-6  Types of serum lipids.
HDL, high-density lipoprotein; LDL, low-density lipoprotein;
VLDL, very-low-density lipoprotein.
 744 Section 7  Problems of oxygenation: Perfusion
Saturated Monounsaturated
(Use sparingly)
CANOLA
OIL
• Animal fat (bacon, lard, • Fish oil
egg yolk, dairy fat) • Oils (canola, peanut,
• Oils (coconut, palm oil) olive)
• Butter • Avocado
• Cream cheese • Nuts (almonds, peanuts,
• Sour cream pecans)
• Olives (green, black)
Figure 30-7  Types of dietary fat.
level, a smaller, denser LDL particle is formed, which favours
se
El
deposition on arterial walls. People with insulin resistance often
have this pattern.
The current national guidelines for treating elevated LDL
cholesterol are based on a person’s 10-year risk of having a non-
@
fatal MI or dying from a coronary event and LDL levels. Risk
scores are calculated based on information about the follow­
ing: (1) age; (2) gender; (3) use of tobacco; (4) systolic BP;
(5) use of BP medications; (6) total cholesterol; and (7) HDL
fs
cholesterol level.16,13 In general, people with only 0–1 risk
factors are considered low risk for the development of CAD
oo
and the LDL goal is less than 4.14 mmol/L. People at very
high risk have CAD and multiple risk factors. The LDL goal
for these patients is less than 1.8 mmol/L.13,17,18 Treatment goals
and strategies are summarised in Table 30-3. Risk profiles are
pr
outlined in Figures 30-4 and 30-5.
Hypertension
e
The second major risk factor in CAD is hypertension, which is
defined as a BP greater than 140/90 mmHg (greater than 130/80
pl
mmHg if the patient has diabetes or chronic kidney disease)
or current use of antihypertensive medication.19 Hypertension
m
increases the risk of death from CAD 10-fold in all people.
In postmenopausal women, hypertension is associated with
a higher incidence of CAD than in men and premenopausal
sa
women.
Blood pressure is classified as normal when the BP is
less than 120/80 mmHg. Hypertension is graded 1–3. (See
Table 29-2, which outlines classification of the different
levels.19) The cause of hypertension in 90% of those affected is
unknown, but it is usually controllable with diet and/or drugs.
Therapeutic lifestyle changes should begin in people at risk
of hypertension. Those with stage 1 or 2 hypertension often
require more than one drug to reach therapeutic goals9 (see
Ch 29 and Table 29-5). Teach all people with elevated systolic
Polyunsaturated
(Use primarily)
Olive
lia
Oil
s tra
Au
• Vegetable oils (safflower,
corn, soybean, flaxseed,
cottonseed)
• Some fish oil, shellfish
• Nuts (walnuts)
er
• Seeds (pumpkin, sunflower)
• Margarine
vi
or diastolic BP the importance of achieving and maintaining
target BP goals.
The stress of an elevated BP increases the rate of
atherosclerotic development. This relates to the shearing
stress that causes endothelial injury. Atherosclerosis, in turn,
causes narrowed, thickened arterial walls and decreases the
distensibility and elasticity of vessels. More force is required to
pump blood through diseased arteries, and this increased force
is reflected in a higher BP. This increased workload results in
left ventricular hypertrophy and decreased stroke volume with
each contraction. Excessive salt intake positively correlates with
elevated BP, adding volume and increasing systemic vascular
resistance (SVR) to the cardiac workload. (See Ch 29 for a
complete discussion of hypertension.)
Tobacco use
A third major risk factor in CAD is tobacco use. The risk
of developing CAD is two to six times higher in those who
smoke tobacco or use smokeless tobacco than in those who do
not. Further, tobacco smoking decreases oestrogen levels,
placing premenopausal women at greater risk for CAD. Risk is
proportional to the number of cigarettes smoked. Changing to
lower-nicotine or filtered cigarettes does not affect risk.
Nicotine in tobacco smoke causes catecholamine (i.e.
adrenaline, noradrenaline) release. These neurohormones
cause an increased heart rate (HR), peripheral vasoconstriction
and increased BP. These changes increase the cardiac
workload. Tobacco smoke is also related to an increase in
LDL level, a decrease in HDL level, and release of toxic oxygen
radicals. All of these add to vessel inflammation and thrombosis.8
Carbon monoxide, a by-product of combustion found
in tobacco smoke, affects the oxygen-carrying capacity of
haemoglobin by reducing the sites available for oxygen
transport. Thus the effects of an increased cardiac workload,
combined with the oxygen-depleting effect of carbon monoxide,
 Chapter 30  NURSING MANAGEMENT: Coronary artery disease and acute coronary syndrome 745
PATIENT TEACHING GUIDE
TABLE 30-3  Reducing risk factors for coronary artery
disease
When teaching the patient and/or carer about risk reduction for
coronary artery disease, include the following information.
Risk factor Health-promoting behaviours
Hypertension • Monitor home blood pressure (BP) and attend
regular check-ups.
• Take prescribed medications for BP control.
• Reduce salt intake (see eTable 29-1, available on
the website for this chapter).
• Stop tobacco use. Avoid exposure to
environmental tobacco (second-hand) smoke.
• Control or reduce weight.
• Move as much as possible, and walk for
30 minutes a day.
Elevated • Reduce total fat intake.
serum lipids • Reduce animal (saturated) fat intake.
• Take prescribed medications for lipid reduction.
• Adjust total intake to achieve and maintain ideal
body weight.
• Engage in daily physical activity.
• Increase amount of complex carbohydrates, fibre
and vegetable proteins in diet.
Tobacco use* • Begin a program to quit smoking.
• Change daily routines associated with smoking
to reduce desire to smoke.
• Substitute other activities for smoking.
El
• Ask carers to support efforts to stop smoking.
• Avoid exposure to environmental tobacco
smoke.
Physical • Develop and maintain at least 30 minutes of
@
inactivity moderate physical activity daily (minimum 5 days
a week).
• Increase activities to a fitness level.
fs
Psychological • Increase awareness of behaviours that are
state harmful to health.
• Alter patterns that are conducive to stress
oo
(e.g. get up 30 minutes earlier so breakfast is not
eaten on the way to work).
• Set realistic goals for self.
• Reassess priorities in light of health needs.
pr
• Learn effective stress management strategies.
• Seek professional help if feeling depressed,
angry, anxious, etc.
• Plan time for adequate rest and sleep.
e
Obesity† • Change eating patterns and habits.
pl
• Reduce energy intake to achieve body mass
index of 18.5–24.9 kg/m2.
• Increase physical activity to increase energy
m
expenditure.
• Avoid fad and crash diets, which are not effective
over time.
sa
• Avoid large, heavy meals. Consider smaller, more
frequent meals.
Diabetes‡ • Follow the recommended diet.
• Control or reduce weight.
• Take prescribed antidiabetic medications.
• Monitor blood glucose levels regularly.
*Smoking cessation is discussed in Chapter 6 and Tables 6-3 to 6-6.
†
See Chapter 37 for additional health-promoting behaviours.
‡
See Chapter 45 for additional health-promoting behaviours.
significantly decrease the oxygen available to the myocardium.
There is also some indication that carbon monoxide is a chemical
irritant and causes injury to the endothelium.
The benefits of smoking cessation are dramatic and almost
immediate. CAD mortality rates drop to those of non-smokers
within 12 months. However, nicotine is highly addictive, and
often intensive intervention is required to assist people to quit.
Individual and group counselling sessions, nicotine replacement
lia
therapy, smoking cessation medications (e.g. bupropion,
varenicline), and hypnosis are examples of smoking cessation
strategies. (See Ch 6, Tables 6-3 to 6-6, for information on
tra
smoking cessation.)
Chronic exposure to environmental tobacco (second-hand)
smoke also increases the risk of CAD.15 People who live in the
same household as the patient should be encouraged to stop
s
smoking. This reinforces the individual’s effort and decreases
Au
the risk of ongoing exposure to environmental smoke. Pipe and
cigar smokers, who often do not inhale, have an increased risk of
CAD similar to those exposed to environmental tobacco smoke.
Physical inactivity
er
Physical inactivity is the fourth major modifiable risk factor.
Physical inactivity implies a lack of adequate physical exercise
on a regular basis. An example of health-promoting regular
vi
physical activity is brisk walking (5 to 6.5 kilometres per hour)
for at least 30 minutes five or more times a week.8
se The mechanism by which physical inactivity predisposes
a person to CAD is mostly still unknown. Physically active
people have increased HDL levels. Exercise improves thrombo­
lytic activity, thus reducing the risk of clot formation. Exercise
may also encourage the development of collateral circulation
in the heart.
Exercise training for those who are physically inactive
decreases the risk of CAD through more efficient lipid
metabolism, increased HDL production, and more efficient
oxygen extraction by the working muscles, thereby decreasing
the cardiac workload. For those individuals with CAD, regular
physical activity reduces symptoms, improves functional
capacity, and improves other risk factors such as insulin
resistance and glucose intolerance.
Obesity
The mortality rate from CAD is statistically higher in obese
people. Obesity is defined as a body mass index (BMI) of greater
than 30 kg/m2. A waist measurement of more than 100 cm in
men (NZ), 102 cm (Aus), or more than 90 cm in women (NZ),
88 cm (Aus) increases the risk of CAD.
The increased risk for CAD is proportional to the degree of
obesity. Obese people may produce increased levels of LDLs
and triglycerides, which are strongly related to atherosclerosis.
Obesity is often associated with hypertension. There is also
evidence that people who tend to store fat in the abdomen (an
‘apple’ figure) rather than in the hips and buttocks (a ‘pear’
figure) have a higher incidence of CAD (see Table 37-2). As
obesity increases, the heart grows and uses more oxygen. In
addition, there is an increase in insulin resistance in obese
individuals.8
CONTRIBUTING MODIFIABLE RISK FACTORS
Diabetes mellitus
The incidence of CAD is two to four times greater among
people who have diabetes, even those with well-controlled
 746 Section 7  Problems of oxygenation: Perfusion
blood glucose levels, than the general population. The patient
with diabetes manifests CAD not only more frequently but also
at an earlier age.9 There is no age difference between male or
female patients with diabetes in the onset of symptoms of CAD.
Diabetes virtually eliminates the lower incidence of CAD in
premenopausal women.
Undiagnosed diabetes is frequently discovered at the time
a person has an MI. The person with diabetes has an increased
tendency towards endothelial dysfunction. This may account
for the development of fatty streaks in these patients. Diabetic
patients also have alterations in lipid metabolism and tend to
have high cholesterol and triglyceride levels. Management of
diabetes should include lifestyle changes and drug therapy to
achieve a haemoglobin A1C (HbA1C) level of less than 7%.14
Metabolic syndrome
Metabolic syndrome refers to a cluster of risk factors for
CAD whose underlying pathophysiology may be related
to insulin resistance. These risk factors include obesity as
defined by increased waist circumference, hypertension,
abnormal serum lipids and an elevated fasting blood glucose
(see Table 37-8).8 These interrelated risk factors of metabolic
origin appear to promote the development of CAD. (Chapter 37
discusses metabolic syndrome.)
Psychological states
The Framingham study provided early evidence that certain
behaviours and lifestyles contribute to the development of CAD.
El
Several behaviour patterns correlated with CAD. However,
the study of these behaviours remains controversial and
complex. One type of behaviour, referred to as type A, includes
perfectionism and a hardworking, driven personality. The type A
@
person often suppresses anger and hostility, has a sense of time
urgency, is impatient, and creates stress and tension. This person
may be more prone to MIs than a type B person, who is more
easy going, takes upsets in stride, knows personal limitations,
fs
takes time to relax, and is not an overachiever. However, findings
from studies about these relationships are inconsistent.
oo
Studies now are focusing on specific psychological risk
factors thought to increase risk of CAD. These include
depression, acute and chronic stress (e.g. poverty, serving
as a carer), anxiety, hostility and anger, and lack of social
pr
support.20,21 In particular, depression is a risk factor for both
the development and worsening of CAD. Depressed patients
have elevated levels of circulating catecholamines that may
e
contribute to endothelial injury and inflammation and platelet
activation. Higher levels of depression are also associated
pl
with an increased number of adverse cardiac events.20 More
research on the treatment of depression and other negative
m
psycho­logical states (e.g. anger) in patients with or at risk
for CAD is needed to improve these patients’ emotional and
physical health.
sa
Stressful states correlate with the development of CAD.22
Sympathetic nervous system (SNS) stimulation and its effect
on the heart are the physiological mechanism by which stress
predisposes one to the development of CAD. SNS stimulation
causes an increased release of catecholamines (i.e. adrenaline,
noradrenaline). This stimulation increases HR and intensifies
the force of myocardial contraction, resulting in increased
myocardial oxygen demand. Also, stress-induced mechanisms
can cause elevated lipid and glucose levels and changes in blood
coagulation, which can lead to increased atherogenesis.
Homocysteine
High blood levels of homocysteine have been linked to an
increased risk for CAD and other cardiovascular diseases.23
Homocysteine is produced by the breakdown of the essential
amino acid methionine, which is found in dietary protein. High
homocysteine levels possibly contribute to atherosclerosis by:
(1) damaging the inner lining of blood vessels, (2) promoting
plaque build-up, and (3) altering the clotting mechanism to
lia
make clots more likely to occur (see Table 28-6).
Research is ongoing to determine whether a decline in
homocysteine can reduce the risk of heart disease. B-complex
tra
vitamins (B 6, B 12, folic acid) have been shown to lower
blood levels of homocysteine. Generally, a screening test for
homocysteine is limited to those suspected of having elevated
levels, such as older patients with pernicious anaemia or people
s
who develop CAD at an early age.
Au
Substance abuse
The use of illicit drugs, such as cocaine and methampheta­
mine, can produce coronary spasm resulting in myocardial
ischaemia and chest pain. Most people who are seen in the ED
er
with drug-induced chest pain are initially indistinguishable
from those with CAD. Although MI can occur, these patients
vi
more often have sinus tachycardia, high BP, angina and
anxiety.24
se
NURSING AND MULTIDISCIPLINARY
MANAGEMENT: CORONARY ARTERY DISEASE
Health promotion
The appropriate management of risk factors in CAD may
prevent, modify or slow the progression of the disease. Over the
past 30 years, there has been a gradual and persistent decline in
cardiovascular-related deaths. The decline relates to people’s
efforts to become generally healthier, as well as advances
in drugs and technology to treat CAD. Prevention and early
treatment of heart disease must involve a multifaceted approach
and needs to be ongoing throughout the life span.
Identification of high-risk people
Signs and symptoms of CAD are not apparent in the early
stages of the disease. Therefore, regardless of the healthcare
setting, it is extremely important to identify people at risk for
CAD. Risk screening involves obtaining a thorough health
history. Question the patient about a family history of heart
disease in parents and siblings. Note the presence of any
cardiovascular symptoms. Assess environmental factors, such
as eating habits, type of diet and level of exercise, to elicit
lifestyle patterns. Include a psychosocial history to determine
tobacco use, alcohol ingestion, recent stressful events (e.g. loss
of a spouse), and any negative psychological states (e.g. anxiety,
depression, anger). The place and type of employment provide
important information on the kind of activity performed,
exposure to pollutants or noxious chemicals, and the degree
of stress associated with work.
Identify the patient’s attitudes and beliefs about health
and illness. This information can give some indication of how
disease and lifestyle changes may affect the patient and can
reveal possible misconceptions about heart disease. Knowledge
of the patient’s educational background can help to decide the
level needed for teaching. If the patient is taking medications,
it is important to know the names and dosages and if the patient
is compliant with the drug regimen.
 Chapter 30  NURSING MANAGEMENT: Coronary artery disease and acute coronary syndrome 765
TABLE 30-14  Acute coronary syndrome
Subjective data
Important health information
Past health history: Previous history of CAD, chest pain/angina, MI,
valve disease (e.g. aortic stenosis), heart failure or cardiomyopathy;
hypertension, diabetes, anaemia, lung disease; hyperlipidaemia
Medications: Use of antiplatelets or anticoagulants, nitrates,
angiotensin-converting enzyme inhibitors, β-adrenergic blockers,
calcium channel blockers; antihypertensive drugs; lipid-lowering
drugs; over-the-counter drugs (e.g. vitamin and herbal
supplements)
History of present illness: Description of events related to current
illness, including any self-treatments and response (see Table 30-8)
Functional health patterns
Health perception–health management: Family history of heart
disease; sedentary lifestyle; tobacco use; exposure to environmental
smoke
Nutritional–metabolic: Indigestion, heartburn, nausea, belching,
vomiting
Elimination: Urinary urgency or frequency, straining at stool
Activity–exercise: Palpitations, dyspnoea, dizziness, weakness
Cognitive–perceptual: Substernal chest pain or pressure (squeezing,
constricting, aching, sharp, tingling), possible radiation to jaw, neck,
shoulders, back or arms (see Table 30-7)
Coping–stress tolerance: Stressful lifestyle, depression; anger, anxiety;
feeling of impending doom
BP, blood pressure; CAD, coronary artery disease; ECG, electrocardiogram; MI, myocardial infarction; WBC, white blood cell.
El
ness of the interventions (see Table 30-8). It is important to use
the same words that patients use to describe their pain. Some
patients may not report pain. Assess for other symptoms of pain,
such as: restlessness; ECG changes; elevated HR, respiratory
@
rate or BP; rocking or other non-verbal cues. Supportive and
realistic assurance and a calm approach help reduce the patient’s
anxiety during an anginal attack.
fs
Ambulatory and home care
Reassure the patient with a history of angina that a long, active
oo
life is possible. Prevention of angina is preferable to its treat­
ment, and this is why teaching is important. Provide the patient
with information regarding CAD, angina, precipitating factors
for angina, risk factor reduction, and medications.
pr
Patient teaching can be done in a variety of ways. One-
on-one contact between the nurse and the patient is often the
most effective approach. Time spent providing daily care (e.g.
e
administering medications) offers many teachable moments.
Teaching tools such as DVDs or CDs, heart models and printed
pl
information are important components of patient and carer
teaching (see Resources at the end of the chapter).
m
Assist the patient to identify factors that precipitate angina
(see Table 30-9). Educate the patient about how to avoid or
control precipitating factors. For example, teach the patient to
sa
avoid exposure to extremes of weather and the consumption
of large, heavy meals. If a heavy meal is eaten, explain to the
patient that it is best 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 for
CAD. Then discuss the various methods of decreasing any
modifiable risk factors (see Table 30-3). Teach the patient
and carer about diets that are low in salt and saturated fats
(see Tables 30-4 and 30-5). Maintaining ideal body weight is
NURSING ASSESSMENT
Objective data
General
Anxious, fearful, restless, distressed
Integumentary
Cool, clammy, pale skin
lia
Cardiovascular
Tachycardia or bradycardia, pulsus alternans (alternating weak and
strong heartbeats), pulse deficit, arrhythmias (especially
ventricular), S3, S4, ↑ or ↓ BP, murmur
tra
Possible diagnostic findings
Positive serum cardiac markers, ↑ serum lipids; ↑ WBC count; positive
exercise or pharmacological stress test and thallium scans;
pathological Q wave, ST-segment elevation, and/or T wave
s
abnormalities on ECG; cardiac enlargement, calcifications, or
pulmonary congestion on chest X-ray; abnormal wall motion with
Au
stress echocardiogram; positive coronary angiography
er
vi
se
important in control­ling angina because excess weight increases
myocardial workload.
Adhering to a regular, individualised 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
(minimum 5) if not contraindicated.14
It is important to teach the patient and carer the proper
use of GTN (see p 753). NTG may be used prophylactically
before an emotionally stressful situation, sexual intercourse or
physical exertion (e.g. climbing a long flight of stairs).
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. If they persist or cause problems in a
patient’s life, the patient may need to be referred for specialised
counselling.
Nursing implementation: Acute coronary
syndrome
Acute intervention
Priorities for nursing interventions in the initial phase of ACS
include: (1) pain assessment and relief, (2) physiological
monitoring, (3) promotion of rest and comfort, (4) alleviation
of stress and anxiety, and (5) understanding of the patient’s
emotional and behavioural reactions. Patients with increased
anxiety levels have a greater risk for adverse outcomes such
as recurrent ischaemic events and arrhythmias.8,22 Proper
management of these priorities decreases the oxygen needs of
a compromised myocardium and reduces the risk of complica­
tions. In addition, institute measures to avoid the hazards of
immobility while encouraging rest.
Pain  Provide NTG, morphine and supplemental oxygen as
needed to eliminate or reduce chest pain. Ongoing evaluation
 766 Section 7  Problems of oxygenation: Perfusion
and documentation of the effectiveness of the interventions are
important. Once pain is relieved, you may have to deal with
denial in a patient who interprets the absence of pain as an
absence of cardiac disease.
Monitoring  Maintain continuous ECG monitoring while
the patient is in the ED and intensive care unit and after
transfer to a step-down or general unit. Arrhythmias need to be
identified quickly and treated. During the initial period after MI,
ventricular fibrillation is the most common lethal arrhythmia.
In many patients, premature ventricular contractions or
ventricular tachycardia precedes this arrhythmia. Monitor
the patient for reinfarction or ischaemia by monitoring the ST
segment for shifts above or below the baseline of the ECG.
Silent ischaemia can occur without clinical symptoms such
as chest pain. Its presence places a patient at higher risk for
adverse outcomes and even death. If you note ST segment
changes, notify the doctor. (See Ch 32 for a complete discussion
of ECG monitoring.)
Perform a physical assessment to detect deviations from the
patient’s baseline findings. Assess heart and breath sounds and
any evidence of early HF (e.g. dyspnoea, tachycardia, pulmonary
congestion, distended neck veins). In addition to routine vital
signs, monitor intake and output at least once a shift.
Assessment of the patient’s oxygenation status is important,
especially if the patient is receiving oxygen. If a nasal cannula is
used to deliver oxygen, check the nares for irritation or dryness,
which can cause considerable discomfort.
El
Rest and comfort  It is important to promote rest and comfort
with any degree of myocardial injury. Bed rest may be ordered
for the first few days after an MI that involves 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
fs
the heart than it does when active. It is important to plan nursing
and therapeutic interventions to ensure adequate rest periods
oo
free from interruption. Comfort measures that can promote rest
include a quiet environment, use of relaxation techniques (e.g.
relaxation breathing, guided imagery), and assurance that staff
are nearby and responsive to the patient’s needs.
pr
It is important that the patient understand the reasons why
activity is limited but not completely restricted. Gradually
increase the patient’s cardiac workload through more demand­
e
ing physical tasks so that the patient can achieve a discharge
activity level adequate for home care. Box 30-2 outlines the
pl
phases of cardiac rehabilitation.
m
Anxiety  Anxiety is present in all patients with ACS to some
degree. It is the nurse’s role to identify the source of anxiety
and assist the patient in reducing it. If the patient is afraid of
sa
being alone, allow a carer to sit quietly nearby or to check in
with the patient frequently. If a source of anxiety is fear of the
unknown, explore these concerns with the patient. For anxiety
caused by lack of information, provide teaching based on the
patient’s stated need and level of understanding. Answer the
patient’s questions with clear, simple explanations.
It is important to start teaching at the patient’s level rather
than to present a prepackaged program. For example, patients
generally are not ready to learn about the pathology of CAD.
The earliest questions usually relate to how the disease affects
BOX 30-2  Phases of rehabilitation after coronary
syndrome
Phase I: Hospital
• Occurs while the patient is still hospitalised.
• Activity level depends on severity of angina or MI.
• Patient may initially sit up in bed or chair, perform range-of-
motion exercises and self-care (e.g. washing, shaving), and
progress to ambulation in hallway and limited stair climbing.
lia
• Attention focuses on management of chest pain, anxiety,
arrhythmias and complications.
tra
Phase II: Early recovery
• Begins after the patient is discharged.
• Usually lasts 2–12 weeks and is conducted as an outpatient.
• Activity level is gradually increased under the supervision of the
cardiac rehabilitation team and with ECG monitoring.
s
• Team may suggest that physical activity (e.g. walking) be
Au
initiated at home.
• Information about risk factor reduction is provided during this
phase.
Phase III: Late recovery
• Long-term maintenance program.
er
• Individual physical activity programs are designed and
implemented at home, a local gym or as an outpatient.
• Patient and carer possibly restructure lifestyles and roles.
vi
• Therapeutic lifestyle changes should become lifelong habits.
• Medical supervision is still recommended.
se
ECG, electrocardiogram; MI, myocardial infarction.
perceived control and independence. Examples include the
following:
• When will I leave the coronary care unit?
• When can I get out of bed?
• When will I be discharged?
• When can I return to work?
• How many changes will I have to make in my life?
• Will this happen again?
Tell the patient that a more complete teaching program will
begin once they are feeling stronger. Frequently the patient may
not be able to ask the most serious concern of ACS patients:
Am I going to die? Even if a patient denies this concern, it is
helpful for you to start a conversation by remarking that fear
of dying is a common concern among most patients who have
experienced ACS. This gives the patient ‘permission’ to talk
about an uncomfortable and fearful topic.
Emotional and behavioural reactions  Patients’ emotional
and behavioural reactions vary but frequently follow a predict­
able response pattern (Box 30-3). The nurse’s role is to under­
stand what the patient is currently experiencing and to support
the use of constructive coping styles. Denial may be a positive
coping style in the early phase of recovery from ACS.
Assess the support structure of the patient and carer. Help
to determine how you can help maximise the support system.
Often the patient is separated from the most significant support
system at the time of hospitalisation. The nurse’s role includes
talking to the patient’s family and informing them about the
patient’s condition and progress, allowing the patient and
key family members to interact as necessary, and supporting
those who will provide the necessary support to the patient.
Open visiting is helpful in decreasing anxiety and increasing
support for the patient with ACS.38 Social isolation has been
 Chapter 30  NURSING MANAGEMENT: Coronary artery disease and acute coronary syndrome 767
BOX 30-3  Psychosocial responses to acute coronary
syndrome
Denial
• May have history of ignoring signs and symptoms related to
heart disease
• Minimises severity of medical condition
• Ignores activity restrictions
• Avoids discussing illness or its significance
Anger and hostility
• Is commonly expressed as, ‘Why did this happen to me?’
• May be directed at family, staff or medical regimen
Anxiety and fear
• Fears long-term disability and death
• Overtly manifests apprehension, restlessness, insomnia,
tachycardia
• Less overtly manifests increased verbalisation, projection of
feelings to others, hypochondriasis
• Fears activity
• Fears recurrent chest pain, heart attacks and sudden death
Dependency
• Is totally reliant on staff
• Is unwilling to perform tasks or activities unless approved by
healthcare provider
• Wants to be monitored by ECG at all times
• Is hesitant to leave the intensive care or telemetry unit or
hospital
Depression
• Mourns loss of health, altered body function and changes in
lifestyle
El
• Realises seriousness of situation
• Begins to worry about future implications of health problem
• Shows symptoms of withdrawal, crying, apathy
• May be more evident after discharge
@
Realistic acceptance
• Focuses on optimum rehabilitation
• Plans changes compatible with altered cardiac function
• Actively engages in lifestyle changes to address modifiable risk
fs
factors
oo
ECG, electrocardiogram.
associated with negative outcomes following MI in both men
pr
and women. It is important for the health team to assist the
patient to identify additional support systems (e.g. rehabilitation
programs, community support programs [see Resources at the
e
end of the chapter]) that can assist after discharge.
pl
Coronary revascularisation
Patients with ACS may undergo coronary revascularisation with
m
PCI or CABG surgery. The major nursing responsibilities for
patient care after PCI involve monitoring for signs of recurrent
angina; frequent assessment of vital signs, including HR and
sa
rhythm; evaluation of the catheter insertion site for signs of
bleeding; neurovascular assessment of the involved extremity;
and maintenance of bed rest per institution policy.
For patients having CABG surgery, care is provided in
the intensive care unit for the first 24 to 36 hours. Ongoing
and intensive monitoring of the patient’s haemodynamic
status is critical. The patient will have numerous invasive
lines for monitoring cardiac status and other vital organs (see
Ch 62). These include: (1) a pulmonary artery catheter for
measuring CO and other haemodynamic parameters, (2) an
DELEGATION DECISIONS
Cardiac catheterisation and percutaneous coronary
intervention (PCI)
Role of registered nurse (RN)
Preprocedure
• Assess for allergies, especially to contrast medium. Perform
baseline assessment, including vital signs, pulse oximetry, heart
lia
and breath sounds, neurovascular assessment of extremities
(e.g. distal pulses, skin temperature, skin colour, sensation).
• Teach patient and carer about procedure and postprocedure
care.
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Postprocedure
• Perform assessment and compare to baseline: vital signs, pulse
oximetry, heart and breath sounds, neurovascular assessment
s
of extremity used for procedure, assessment of catheter
insertion site for haematoma or bleeding.
Au
• Monitor ECG for arrhythmias or other changes (e.g. ST segment
elevation).
• Monitor patient for chest pain and other sources of pain or
discomfort.
• Monitor IV infusions of anticoagulants, antiplatelets.
• Teach patient and carer about discharge medications (e.g.
er
aspirin, prasugrel, antianginal medications).
vi
Role of the enrolled nurse
• Take vital signs and report increases or decreases in heart rate
or blood pressure to RN.
se
• Report decreases in pulse oximetry to the RN.
• Administer medications before and after the procedure
(consider applicable Nursing Practice Act and agency policy).
• Assess neurovascular status of involved extremity every
15 minutes for the first hour, then according to agency policy
(consider applicable Nursing Practice Act and agency policy).
• Check for bleeding at catheter insertion site every 15 minutes
for the first hour, then according to agency policy.
• Report changes in neurovascular status of involved extremity or
any bleeding to the RN.
Role of personal care assistants
• Report patient complaints of chest pain, shortness of breath,
and/or any other discomfort or distress to RN.
• Assist with oral hygiene, hydration, meals and toileting.
intraarterial line for continuous BP monitoring, (3) pleural
and mediastinal chest tubes for chest drainage, (4) continuous
ECG monitoring to detect arrhythmias, (5) an endotracheal
tube connected to mechanical ventilation, (6) epicardial pacing
wires for emergency pacing of the heart, (7) a urinary catheter
to monitor urine output, and (8) a nasogastric tube for gastric
decompression. Most patients are extubated within 6 hours and
transferred to a step-down unit within 24 hours for continued
monitoring of cardiac status.
Many of the postoperative complications that develop after
CABG surgery relate to the use of CPB. Major consequences of
CPB are systemic inflammation, which includes complications
of bleeding and anaemia from damage to red blood cells and
platelets; fluid and electrolyte imbalances; hypothermia as blood
is cooled as it passes through the CPB machine; and infections.
Focus nursing care on assessing the patient for bleeding (e.g.
chest tube drainage, incision sites), haemodynamic monitoring,
checking fluid status, replacing electrolytes as needed, and
restoring temperature (e.g. warming blankets).
Postoperative arrhythmias, specifically atrial arrhythmias,
are common in the first 3 days after CABG surgery. Post­operat­
ive atrial fibrillation (AF) occurs in 20% to 50% of patients.36
 768 Section 7  Problems of oxygenation: Perfusion
β-Adrenergic blockers should be restarted as soon as possible
after surgery (unless contraindicated) to reduce the incidence
of AF. Discharge is often delayed in these patients in order to
begin anticoagulation therapy. (See Ch 32 for information on
treatment of AF.)
Nursing care for the patient with a CABG also involves
caring for the surgical sites (e.g. chest, arm, leg). Care of the
radial artery harvest site includes monitoring sensory and
motor function of the distal hand. The patient with radial artery
harvest should take a calcium channel blocker for approximately
3 months to decrease the incidence of arterial spasm at the
arm or anastomosis site.
Care of the leg incision is minimal since endoscopy is
used to harvest the vein. Management of the chest wound,
which involves a sternotomy, is similar to that of other chest
surgery (see Ch 24). Other interventions include strategies to
manage pain and prevent venous thromboembolism (e.g. early
ambulation, sequential compression device) and respiratory
complications (e.g. use of incentive spirometer, splinting during
coughing and deep-breathing exercises). (See Ch 16 for care of
the postoperative patient.)
Postoperatively, patients may experience some cognitive
dysfunction. This includes impairment of memory, concentra­
tion, language comprehension and social integration. Patients
may cry or become teary. Postoperative cognitive dysfunction
(POCD) can manifest days to weeks after surgery and may
remain a permanent disorder. It is seen in 40% of patients several
months after cardiac surgery.39 (POCD is discussed in Ch 16.)
In the older patient, elective CABG is generally well tolerated.
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However, the incidence of postoperative complications,
including arrhythmias, stroke and infection, is high. Although
the benefits of treatment may outweigh risks in this population,
complications are higher than in younger individuals.
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Postoperative nursing care of the patient with a MIDCAB or
OPCAB procedure is similar to that for CABG surgery patients.
Pain management is important regardless of the procedure.
Patients report higher levels of pain with thoracotomy incisions
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than a sternotomy incision. The recovery time is somewhat
shorter with these procedures, and patients often resume routine
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activities sooner than patients who have CABG surgery.
Ambulatory and home care
Cardiac rehabilitation is the restoration of a person to an
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optimal state of function in six areas: physiological, psycho­
logical, mental, spiritual, economic and vocational. Many
people recover from ACS physically, yet they may never attain
e
psychological wellbeing. All patients (e.g. patients with ACS,
chronic stable angina, cardiac surgery) need to be referred to
pl
a cardiac rehabilitation program. In considering rehabilitation,
the patient must recognise that CAD is a chronic disease. It
m
is not curable, nor will it disappear by itself. Therefore, basic
changes in lifestyle must be made to promote recovery and
future health. These changes often are needed at a time when
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a person is middle aged or older. The patient must realise that
recovery takes time. Resumption of physical activity after ACS
or CABG surgery is slow and gradual. However, with appropriate
and adequate supportive care, recovery is more likely to occur.
Patient teaching  Patient teaching needs to occur at every stage
of the patient’s hospitalisation and recovery (e.g. ED, telemetry
unit, home care). The purpose of teaching is to give the patient
and carer the tools they need to make informed decisions about
their health. For teaching to be meaningful, the patient must be
EVIDENCE-BASED PRACTICE
Do exercise-based cardiac rehabilitation programs
improve outcomes?
Clinical question
In patients with coronary heart disease (P), do exercise-based
cardiac rehabilitation programs (I) versus usual care (C) reduce
mortality and morbidity and improve quality of life (O)?
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Best available evidence
Systematic review of randomised controlled trials (RCTs)
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Critical appraisal and synthesis of evidence
• 47 RCTs (n = 10,794) of patients with myocardial infarction (MI),
angina pectoris, coronary artery bypass graft (CABG) or
percutaneous transluminal coronary angioplasty (PTCA).
s
Exercise-based cardiac rehabilitation was exercise alone or with
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psychosocial or educational interventions. Usual care included
standard medical care and drug therapy with no structured
exercise training.
• Exercise-based rehabilitation reduced overall and
cardiovascular mortality, decreased hospital admissions and
improved quality of life.
er
• Cardiac rehabilitation did not reduce risk of recurrent MI or
revascularisation (CABG or PTCA).
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Conclusion
• Exercise-based cardiac rehabilitation reduces risk of dying from
heart disease.
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Implications for nursing practice
• Provide assistance in accessing cardiac rehabilitation programs.
• Reinforce benefits of adhering to recommended physical
activity.
• Reduce program dropout rates by motivating patients to stay
engaged.
Reference for evidence
Heran B, Chen J, Ebrahim S, et al. Exercise-based cardiac
rehabilitation for coronary heart disease. Cochrane Database
Syst Rev 2011;7:CD001800.
P, patient population of interest; I, intervention or area of interest;
C, comparison of interest or comparison group; O, outcomes of
interest; T, timing (see p 16).
aware of the need to learn. Careful assessment of the patient’s
learning needs helps them to set goals that are realistic.
The timing of the teaching is important. When patients and
carers are in crisis (either physiological or psychological), they
may not be interested in learning new information. Answer the
patient’s questions in simple, brief terms. The answers often
require repetition. When the shock and disbelief accompanying
a crisis subside, the patient and carer are better able to focus on
new and more detailed information.
Limit use of medical terminology. For example, explain
that the heart, a four-chambered pump, is a muscle that needs
oxygen, like all other muscles, to work properly. When blood
vessels supplying the heart muscle with oxygen are blocked by
plaque, less oxygen is available to the muscle. As a result, the
heart cannot pump normally. It helps to have a model of the
heart or to sketch a picture of what is being explained.
Anticipatory guidance involves preparing the patient
and carer for what to expect in the course of recovery and
rehabilitation. By learning what to expect during treatment and
recovery, the patient gains a sense of control over his or her life.
 Chapter 30  NURSING MANAGEMENT: Coronary artery disease and acute coronary syndrome 769

EVIDENCE-BASED PRACTICE PATIENT TEACHING GUIDE

Jamie Boaz is a 56-year-old man who is being discharged from
hospital after having a myocardial infarction (MI) 4 days ago. You
know that he is struggling with the lifestyle changes he must
make, including how to kick his cigarette habit. While you are
discussing the importance of smoking cessation with him, you
explain the best available evidence and use your clinical
expertise. In addition, you describe a variety of smoking cessation
BOX 30-4  Acute coronary syndrome
When teaching the patient and/or carer about acute coronary
syndrome, include the following information.
• Signs and symptoms of angina and MI and what to do should
they occur (e.g. take glyceryl trinitrate)*
• When and how to seek help (e.g. contact ambulance services)

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interventions that he could choose. • Anatomy and physiology of the heart and coronary arteries
• Cause and effect of CAD
Best available Patient preferences • Definition of terms (e.g. CAD, angina, MI, sudden cardiac death,
heart failure)

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evidence* Clinician expertise and values
• Identification of and plan to decrease risk factors* (see
Combination You have heard After reviewing all Tables 30-2, 30-3 and 30-4)
strategies (e.g. from several the information, • Rationale for tests and treatments (e.g. ECG monitoring, blood
medication plus patients who have Jamie Boaz informs tests, angiography), activity limitations and rest, diet and

s
behavioural successfully you that he is medications*
support) work best stopped smoking • Appropriate expectations about recovery and rehabilitation

Au
willing to start
to help patients that they tried with the nicotine (anticipatory guidance)
stop smoking. more than one patch but does • Resumption of work, physical activity, sexual activity
intervention at a not want to do • Measures to promote recovery and health
time to stop anything else at • Importance of the gradual, progressive resumption of activity*
smoking (e.g. this time.

er
medication plus *Identified by patients as most important to learn before discharge.
support group, CAD, coronary artery disease; ECG, electrocardiogram;
hypnotherapy plus EMS, emergency medical services; MI, myocardial infarction.

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support group).

Your decision and action

As his nurse, you respect and support his decision. You document
your teaching and JB’s response. You ask his doctor for a
prescription for the nicotine patch before he is discharged from
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on maximal oxygen uptake, increasing CO, decreasing
blood lipids, decreasing BP, increasing blood flow through
the coronary arteries, increasing muscle mass and flexibility,
El
hospital. improving the psychological state, and assisting in weight loss
and control. A regular schedule of physical activity, even after
References
Carpenter MJ, Hughes JR, Gray KM, et al. Nicotine therapy
many years of sedentary living, is beneficial.25
One method of identifying levels of physical activity is
@

sampling to induce quit attempts among smokers unmotivated

to quit: A randomized clinical trial. Arch Intern Med
2011;171:1901.
Joseph AM, Fu SS, Lindgren B, et al. Chronic disease management
for tobacco dependence: A randomized, controlled trial. Arch
fs
through metabolic equivalent (MET) units: 1 MET is the amount
of oxygen needed by the body at rest—3.5 mL of oxygen per
kilogram per minute. The MET determines the energy costs
of various exercises (Box 30-5). In hospital, activity level is

Intern Med 2011;171:1894. gradually increased so that by the time of discharge the patient
can tolerate moderate-energy activities of 3 to 6 METs. Many
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patients with UA that has resolved or an uncomplicated MI are

The idea of perceived control is operationalised as the process in hospital for approximately 3 or 4 days. By day 2, the patient
by which the patient exercises choice and makes decisions can ambulate in the hallway and begin limited stair climbing
by cutting back. Cutting back is one way of minimising the (e.g. three or four steps). Many cardiologists order low-level
pr

psychological and physiological losses after MI (or any other exercise stress tests before discharge to assess readiness for
life-changing event). For example, a middle-aged man who discharge, optimal HR for an exercise program, and potential
smokes two packets of cigarettes a day, is 15 kg overweight, for ischaemia or reinfarction. If tests are positive (i.e. ischaemia
e

and gets no physical exercise has a seemingly overwhelming at a low level of energy expenditure), the patient is evaluated for
task. He may decide that he can live with a weight reduction cardiac catheterisation before discharge. If the test is negative,
pl

plan and will get more exercise (although perhaps not daily) a catheterisation may still be done before discharge or several
but that it is not possible for him to quit smoking. He reasons weeks after discharge. Because of the short hospital stay, it
m

that because he is modifying two of the three risk factors, he is critical to give the patient specific guidelines for physical
will be healthier. Ideally, the tobacco risk factor should be a activity so that overexertion will not occur. It is important to
priority for this patient. If the information regarding risks and tell the patient to ‘listen to what your body is saying’—the most
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effects of tobacco use is not accepted, the patient’s lifestyle
choices are, in the end, up to each individual.
In addition to teaching the patient and carer what they wish
to know, several types of information are essential in achieving
optimal health. Box 30-4 presents a teaching guide for the
patient with ACS.
Physical activity  Physical activity, an integral part of reha­
bilitation, is necessary for optimal physiological functioning
and psychological wellbeing. It has a direct, positive effect
important aspect of recovery.
Teach patients to check their pulse rate. The patient should
know the limits within which to exercise. Tell the patient the
maximum HR that should be present at any point. If the HR
exceeds this level or does not return to the rate of the resting
pulse within a few minutes, instruct the patient to stop and rest.
Also instruct the patient to stop exercising and rest if chest pain
or shortness of breath occurs.
In a normal, healthy person the minimum threshold
for improving cardiopulmonary fitness is 60% of the age-
 770 Section 7  Problems of oxygenation: Perfusion

PATIENT TEACHING GUIDE PATIENT TEACHING GUIDE

BOX 30-5  Energy expenditure in metabolic BOX 30-6  FITT activity guidelines after acute
equivalents coronary syndrome
Activity When teaching the patient and/or carer after an acute coronary
Metabolic equivalents (METs) for selected METs METs syndrome, include the following information.
activities* (min) (max)
Warm-up/cool-down

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METs for leisure activities
• Educate the patient to perform mild stretching for 3–5 minutes
Aerobics 6 9 before the physical activity and 5 minutes after the activity.
Activity should not be started or stopped abruptly.
Cycling

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8 km per hour 2 3 Frequency
16 km per hour 5 6 • Encourage the patient to perform physical activity on most days
21 km per hour 8 9 of the week.
Music, playing an instrument 2.5 4

s
Intensity
Dancing, ballroom 4 5 • Activity intensity is determined by the patient’s HR. If an

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Gardening exercise stress test has not been performed, the HR of the
Mowing lawn (pushing) 3 6 patient recovering from an MI should not exceed 20 beats/
Weeding/cultivating 4 5 minute over the resting HR.

Running Type of physical activity

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General light jogging 6 9 • Physical activity should be regular, rhythmic and repetitive,
Training 10 km per hour 8 11 using large muscles to build up endurance (e.g. walking,
Skipping <80/min 8 10 cycling, swimming, rowing).

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Swimming Time
Breast stroke 8 9 • Physical activity sessions should be at least 30 minutes long.
Freestyle
Tennis
9
4
10
9
se Educate the patient to begin slowly at personal tolerance
(perhaps only 5–10 minutes) and build up to 30 minutes.
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Walking HR, heart rate; MI, myocardial infarction.
1–3 km per hour 1 3
3–6 km per hour 3 6
METs for activities of daily living
@

Carrying heavy groceries 5 7 beginning an exercise program should do so under supervision

whenever possible.
Cleaning windows 3 4
The more important factor is the patient’s response to
Cooking 2 3 physical activity in terms of symptoms rather than absolute HR,
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General housework 3 4 especially since many patients are taking β-adrenergic blockers
and may not be able to reach a target HR. This point cannot
Grocery shopping 2 4
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be overstressed. Basic physical activity guidelines for patients

Loading/unloading washing machine 4 5 after ACS follow the FITT formula (Box 30-6).
Mowing by hand 5 7 The basic categories of physical activity are isometric (static)
and isotonic (dynamic). Most daily activities are a mixture of
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Painting/decorating 4 5
the two. Isometric activities involve the development of tension
Sexual intercourse 3 5 during muscular contraction but produce little or no change in
Showering 3 4 muscle length or joint movement. Lifting, carrying and pushing
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heavy objects are isometric activities. Because the HR and BP

Vacuuming 3 3.5
increase rapidly during isometric work, exercise programs
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Walking up stairs 4 7 involving isometric exercises should be limited.

Washing a car 6 7 Isotonic activities involve changes in muscle length and
m

joint movement with rhythmic contractions at relatively low

Washing dishes 2 3
muscular tension. Walking, jogging, swimming, bicycling and
jumping rope are examples of activities that are predominantly
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* 1 MET equals oxygen consumption at rest, which is about 3.5 mL/kg

of body weight per minute. An individual exercising at 2 METs is
consuming oxygen at twice the resting rate.
Source: New Zealand Primary Care Handbook, 2012. Appendix D.
Available from www.health.govt.nz/publication/new-zealand-
primary-care-handbook-2012.
predicted maximum HR (calculate by subtracting the person’s
age from 220). The ideal training target HR is 80% of maximum
HR. The patient who has been physically inactive and is just
isotonic. Isotonic exercise can put a safe, steady load on the
heart and lungs and improve the circulation in many organs.
Discuss participation in an outpatient cardiac rehabilitation
program with all patients (see Box 30-2). These programs are
beneficial, but not all patients choose or are able to participate
in them (e.g. location and travel limitations). Home-based
cardiac rehabilitation programs can provide an alternative.
Physical activity guidelines are developed for the patient, and
staff maintain ongoing contact with the patient (e.g. during
rehabilitation programs, or via the telephone, exercise logs,
 Chapter 30  NURSING MANAGEMENT: Coronary artery disease and acute coronary syndrome 771
email). Maintaining contact with the patient is one key to the
success of these programs.
Older women (65 years or older) who experience MI may
frequently have poor adherence to a regular physical activity
program. Often these women describe continued fatigue post-MI
that is poorly understood. Another factor that has been linked
to poor adherence to a physical activity program after MI is
depression. Depression is common among patients with CAD,
especially in women.40 Routinely screen for depression in all
patients with CAD and recommend treatment as appropriate.
Resumption of sexual activity  It is important to include
sexual counselling for cardiac patients and their partners. This
often-neglected area of discussion may be difficult for both
patients and healthcare providers to approach. However, the
patient’s concern about resumption of sexual activity after
hospitalisation for ACS often produces more stress than the
physiological act itself. Most of these patients change their
sexual behaviour not because of physical problems, but because
they are concerned about sexual inadequacy, death during
intercourse, and impotence. A concerned and knowledgeable
healthcare professional can clarify any misperceptions and
increase the patient’s knowledge.
Before providing guidelines on resumption of sexual
activity, it is important to know the patient’s physiological
status, the physiological effects of sexual activity and the
psychological effects of having a heart attack.
When educating patients it is helpful to consider sex as
a physical activity and to discuss or explore feelings in this
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area when other physical activities are discussed. One helpful
approach is, ‘Many people who have had a heart attack wonder
when they will be able to resume sexual activity. Has this been
@
of concern to you?’ It is important to emphasise that sexual
activity is like other forms of activity and should be gradually
resumed after MI. If a patient’s ability to perform sexually is
concerning them, tell them that the energy used is no more
fs
than that required to walk briskly or climb two flights of stairs.
This type of non-threatening explanation allows the patient
to explore their feelings, and gives the patient an opportunity
oo
to raise questions with you or another healthcare provider.25
Common guidelines are presented in Box 30-7.
The patient needs to know that the inability to perform
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sexually after MI is common and that sexual dysfunction
usually disappears after several attempts. Reinforce the idea
that patience and understanding usually solve the problem.
However, with the availability of drugs to correct erectile
e
dysfunction, many male patients may be interested in using
pl
them. Caution the patient that these drugs are not to be used
with nitrates because severe hypotension and even death have
been reported.28 Encourage patients to discuss the use of these
m
drugs with their treating doctor.
It is common for a patient who experiences chest pain on
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physical exertion to have some angina during sexual stimu­la­
tion or intercourse. The patient may be instructed to take GTN
prophylactically.28 It is also helpful to have the patient avoid sex
soon after a heavy meal or after excessive ingestion of alcohol,
when extremely tired or stressed, or with unfamiliar partners.
Initially, patients should avoid anal intercourse because of the
likelihood of eliciting a vasovagal response.
Tell the patient that resumption of sex depends on the
patient and his or her partner’s emotional readiness and on the
doctor’s assessment of the extent of recovery. It is generally
PATIENT TEACHING GUIDE
BOX 30-7  Sexual activity after acute coronary
syndrome
When teaching the patient and/or partner after an acute coronary
syndrome, include the following information.
• Sexual activity should be resumed at a level that corresponds to
sexual activity before experiencing acute coronary syndrome.
lia
• Physical training may improve the physiological response to
intercourse; therefore, daily physical activity during recovery
should be encouraged.
• Consumption of food and alcohol should be reduced before
tra
intercourse is anticipated (e.g. waiting 3–4 hours after ingesting
a large meal before engaging in sexual activity).
• Familiar surroundings and a familiar partner reduce anxiety.
• Masturbation may be a useful sexual outlet and may reassure
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the patient that sexual activity is still possible.
• Hot or cold showers should be avoided just before and after
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intercourse.
• Foreplay is desirable because it allows a gradual increase in
heart rate before orgasm.
• Positions during intercourse are a matter of individual choice.
• Orogenital sex places no undue strain on the heart.
er
• A relaxed atmosphere free of fatigue and stress is optimal.
• Prophylactic use of nitrates to decrease chest pain during sexual
activity may be recommended.
vi
• Use of erectile agents (e.g. sildenafil) is contraindicated if taking
nitrates in any form.
• Anal intercourse should be avoided because of the possibility of
se inducing a vasovagal response.
safe to resume sexual activity 7 to 10 days after an uncompli­
cated MI.31
Evaluation
eNursing Care Plan 30-1 (found on the website for this chapter)
presents the expected outcomes for the patient with an ACS.
SUDDEN CARDIAC DEATH
Sudden cardiac death (SCD) is unexpected death resulting from
a variety of cardiac causes. Classification of SCD is not clear;
however, an estimated 30,000 Australians experience sudden
cardiac arrest each year. Most of these events occur outside the
hospital and survival is still quite poor.41
AETIOLOGY AND PATHOPHYSIOLOGY
In SCD a sudden disruption in cardiac function produces an
abrupt loss of CO and cerebral blood flow. The affected person
may or may not have a known history of heart disease. SCD
is often the first sign of illness for 25% of those who die of
heart disease.42
Acute ventricular arrhythmias (e.g. ventricular tachycardia,
ventricular fibrillation) cause the majority of cases of SCD.
Structural heart disease accounts for 10% of the cases of
SCD. Patients in this group include those with left ventricular
hypertrophy, myocarditis and hypertrophic cardiomyopathy.
Hypertrophic cardiomyopathy is a risk factor for SCD, especially
in young, athletic people.
Approximately 10% to 12% of cases of SCD among people
less than age 45 occur in the absence of structural heart disease.
These involve disturbances in the conduction system (e.g.
prolonged QT syndrome, Wolff-Parkinson-White syndrome).
 772 Section 7  Problems of oxygenation: Perfusion

It is difficult to know who is at high risk for SCD. However,
left ventricular dysfunction (EF less than 30%) and ventricular
arrhythmias following MI have been found to be the strongest
predictors.43 Other risk factors include history of syncope, left
ventricular outflow tract obstruction (e.g. aortic stenosis), male
gender, and family history of ventricular arrhythmias.
also may need to deal with additional issues such as possible
driving restrictions, role reversal and change in occupation. The
grief response varies. Be attuned to the specific needs of the
patient and family members and teach them accordingly while
providing appropriate emotional support.

SIGNS, SYMPTOMS AND COMPLICATIONS CASE STUDY

lia
People who experience SCD because of CAD fall into two Myocardial infarction
groups: (1) those who did not have an acute MI; and (2) those who Patient profile
did have an acute MI. The first group accounts for the majority

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Darrell Masters, a 51-year-old, successful
of cases of SCD.42 These victims usually have no warning signs business executive, is rushed to the hospital
or symptoms. Patients who survive are at risk for another SCD by ambulance after experiencing crushing
event because of the continued electrical instability of the heart substernal chest pain that radiates down his

s
that caused the initial event to occur. left arm. He also complains of dizziness and
nausea.
The second, smaller group of patients includes those who

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have had an MI and have suffered SCD. Such patients usually Subjective data
have prodromal symptoms, such as chest pain, palpitations and • Has a history of chronic stable angina and
dyspnoea. Death usually occurs within 1 hour of the onset of Source: hypertension
acute symptoms. iStockphoto/ • States he is ‘borderline diabetic’
• Overweight but recently lost 5 kg

er
Thinkstock.
NURSING AND MULTIDISCIPLINARY • Rarely exercises
• Has three teenage children who are causing ‘problems’
MANAGEMENT: SUDDEN CARDIAC DEATH • Recently experienced loss of best friend and business partner,

vi
People who survive an episode of SCD require a diagnostic who died from cancer
workup to determine whether they have had an MI. Thus, serial
analysis of cardiac markers and ECGs are done, and the patient
is treated accordingly. (See section on multidisciplinary care of
ACS.) In addition, because most people with SCD have CAD,
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Objective data
Physical examination
• Diaphoretic, short of breath, nauseous
• BP 165/100 mmHg, pulse rate 120/min, respiratory rate 26/min
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cardiac catheterisation is indicated to determine the possible
location and extent of coronary artery occlusion. PCI or CABG Diagnostic studies
surgery may be indicated.
• 12-lead ECG shows sinus tachycardia with ST elevation in
leads II, III, aVf, V5, V6 with occasional premature ventricular
Most SCD patients have a lethal ventricular arrhythmia contractions
@

that is associated with a high incidence of recurrence. Thus, it • Cardiac-specific troponin I level elevated
is useful to know when those people are most likely to have a • Cholesterol 9.1 mmol/L
recurrence and what drug therapy is the most effective treat­ment. • HbA1C 0.09
Assessment of arrhythmias in these patients includes 24-hour • Infero-lateral wall MI
fs

Holter monitoring or other type of event recorder, exercise Multidisciplinary care

stress testing, signal-averaged ECG, and electrophysiology Emergency department
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study (EPS).42 • Oxygen 6 L/min via Hudson mask, titrate to keep O2 saturation
EPS is performed under fluoroscopy. Pacing electrodes are above 93%
placed in selected intracardiac areas, and stimuli are selectively • Continuous ECG monitoring
used to attempt to produce arrhythmias. The patient’s response • Given aspirin 325 mg (chewable)
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to various antiarrhythmic medications is determined and • Clopidogrel 600 mg orally

• Weight-based heparin IV (unless PCI is available, then this is
monitored in a controlled environment (see Ch 32). contraindicated)
The most common approach to preventing a recurrence is • Glyceryl trinitrate IV, titrate to relieve chest pain; don’t give if
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the use of an implantable cardioverter-defibrillator (ICD). It has systolic BP below 100 mmHg
been shown that an ICD improves survival compared with drug • Morphine 2 to 4 mg IV every 5 minutes, PRN for chest pain
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therapy alone.42,43 (Chapter 32 discusses ICDs.) Drug therapy unrelieved by glyceryl trinitrate
with amiodarone may be used in conjunction with an ICD to • Vital signs, pulse oximetry every 10 minutes or more frequently
if unstable
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decrease episodes of ventricular arrhythmias. • Preparation of patient for transfer to cardiac catheterisation
Teaching people about the symptoms of impending laboratory for possible PCI
cardiac arrest and the actions to take can save lives. Rapid
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cardiopulmonary resuscitation (CPR) (see Appendix A) and Clinical reasoning

defibrillation with an automatic external defibrillator (AED),  
combined with early advanced cardiac life support, have greatly
improved long-term survival rates for a witnessed arrest.  
When caring for these patients, be alert to the patient’s
psychosocial adaptation to this sudden ‘brush with death’.
Many of these patients develop a ‘time bomb’ mentality. They  
fear the recurrence of cardiac arrest and may become anxious,
 
angry and depressed. Their partners and family members are
likely to experience the same feelings. Patients and families
1. Which coronary artery(ies) is (are) most likely occluded in
Darrell Masters’ coronary circulation?
2. Explain the pathogenesis of CAD. What risk factors contribute
to its development? What risk factors were present in Darrell
Masters’ life?
3. What is angina? How does chronic stable angina differ from
angina associated with acute coronary syndrome?
4. Explain the pathophysiological basis for the signs and
symptoms that Darrell Masters exhibited.
 Chapter 30  NURSING MANAGEMENT: Coronary artery disease and acute coronary syndrome 773
 5. Explain the significance of the results of the laboratory tests
and the 12-lead ECG findings.
 6. Provide a rationale for each treatment measure ordered for
Darrell Masters.
 7. Priority decision: Based on the assessment data presented,
what are the priority care problems? Identify any other care
problems.
 8. Priority decision: What are the priority nursing interventions
for Darrell Masters immediately after his MI? Immediately
after his PCI?
 9. Delegation decision: Identify activities that can be delegated
to a patient care assistant.
10. Evidence-based practice: Two days after an uncomplicated
PCI and the placement of two stents, Darrell Masters wants to
know what the most effective strategies are to prevent
another MI. Based on his clinical situation, what would you
tell him?
Answers and a corresponding concept map are available at http://
evolve.elsevier.com/AU/Brown/medsurg.
REVIEW QUESTIONS
1. In teaching a patient about coronary artery disease, the nurse
explains that the changes that occur in this disorder include
which of the following (select all that apply)?
a. diffuse involvement of plaque formation in coronary veins.
b. abnormal levels of cholesterol, especially low-density
lipoproteins.
El
c. accumulation of lipid and fibrous tissue within the
coronary arteries
d. development of angina due to a decreased blood supply
to the heart muscle
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e. chronic vasoconstriction of coronary arteries leading to
permanent vasospasm
2. After teaching about ways to decrease risk factors for CAD,
the nurse recognises that additional instruction is needed
fs
when the patient says,
a. ‘I would like to add weight lifting to my exercise program.’
oo
b. ‘I can only keep my blood pressure normal with
medication.’
c. ‘I can change my diet to decrease my intake of saturated
fats.’
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d. ‘I will change my lifestyle to reduce activities that increase
my stress.’
3. A hospitalised patient with a history of chronic stable angina
e
tells the nurse that she is having chest pain. The nurse bases
his actions on the knowledge that ischaemia
pl
a. will always progress to myocardial infarction.
b. will be relieved by rest, glyceryl trinitrate, or both.
m
c. indicates that irreversible myocardial damage is
occurring.
d. is frequently associated with vomiting and extreme
sa
fatigue.
4. The nurse is caring for a patient who is 2 days post-MI. The
patient reports that she is experiencing chest pain. She states,
‘It hurts when I take a deep breath.’ Which of the following
actions would be a priority?
a. Notify the doctor immediately and obtain a 12-lead ECG.
b. Obtain vital signs and auscultate for a pericardial friction
rub.
c. Apply high-flow oxygen by face mask and auscultate
breath sounds.
d. Medicate the patient with PRN analgesic and re-evaluate
in 30 minutes.
5. A patient is admitted to the ICU with a diagnosis of unstable
angina. Which of the following medications would the nurse
expect the patient to receive (select all that apply)?
a. ACE inhibitor
b. antiplatelet therapy.
c. thrombolytic therapy.
lia
d. prophylactic antibiotics
e. intravenous glyceryl trinitrate
6. A patient is recovering from an uncomplicated MI. Which
tra
rehabilitation guideline is a priority to include in the teaching
plan?
a. Refrain from sexual activity for a minimum of 3 weeks.
b. Plan a diet program that aims for a 0.5 kg to 1 kg weight
s
loss per week.
Au
c. Begin an exercise program that aims for at least five
30-minute sessions per week.
d. Consider the use of erectile agents and prophylactic GTN
before engaging in sexual activity.
7. The most common finding in individuals at risk for sudden
er
cardiac death is
a. aortic valve disease.
b. mitral valve disease.
vi
c. left ventricular dysfunction.
d. atherosclerotic heart disease.
se
Answers to the questions are found in Appendix C. For rationales
to these answers, visit http://evolve.elsevier.com/AU/Brown/
medsurg.
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RESOURCES
Australasian Cardiovascular Nursing College
www.acnc.net.au
Australian Cardiovascular Health and Rehabilitation Association
www.acra.net.au
Cardiac Society of Australia and New Zealand
www.csanz.edu.au
Heart Foundation (Australia)
www.heartfoundation.org.au
http://heartmoves.heartfoundation.org.au/
Heart Foundation (New Zealand)
www.heartfoundation.org.nz
www.heartfoundation.org.nz/programmes-resources/pacific-health/
pacific-heartbeat-programme
World Heart Federation
www.world-heart-federation.org
See the Evolve site for more great resources at
http://evolve.elsevier.com/AU/Brown/medsurg/