Possibly evidenced by
Questions, statement of concerns
Request for information
Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will
Participate in learning process.
Assume responsibility for own learning, looking for information and asking questions.
Knowledge: Cardiac Disease Management
Verbalize understanding of condition, disease process, and potential complications.
Verbalize understanding of and participate in therapeutic regimen.
Initiate necessary lifestyle changes.
Nursing care plan intervention with rationale:
1. Discuss pathophysiology of condition. Stress need for preventing and managing anginal attacks.
Rationale: Clients with angina need to learn why it occurs and what they can do to control it. This is the focus of therapeutic management to reduce likelihood of MI and promote heart-healthy lifestyle.
2. Review significance of cholesterol levels and differentiate between LDL and HDL factors. Emphasize importance of periodic laboratory measurements and use of cholesterol- lowering drugs.
Rationale: Although the American Heart Association recommended LDL is 130 mg/dL, clients with two or more risk factors, including smoking, hypertension, diabetes mellitus, and positive family history, should keep LDL 100 mg/dL, and those with diagnosis of CAD need to keep LDL below 100 mg/dL. HDL below 35 to 45 is considered a risk factor; a level above 60 mg/dL is considered an advantage. Note: The National Cholesterol Education Program Guidelines now state that all adult high-risk clients with LDL of 100 mg/dL should be treated with drug therapy.
3. Encourage avoidance of factors or situations that may precipitate anginal episode, such as emotional stress, extensive or intense physical exertion, ingestion of large or heavy meal (especially close to bedtime), and exposure to extremes in environmental temperature.
Rationale: May reduce incidence or severity of ischemic episodes. Helps client manage symptoms.
4. Assist client or SO to identify sources of physical and emotional stress and discuss ways that they can be avoided.
Rationale: This is a crucial step in limiting or preventing anginal attacks.
5. Encourage client to follow prescribed reconditioning program; caution client to avoid exhaustion.
Rationale: Fear of triggering attacks may cause client to avoid participation in activity that has been prescribed to enhance recovery by increasing myocardial strength and forming collateral circulation. Cardiac rehabilitation programs provide a phased approach to increasing client’s activity and exercise tolerance.
6. Discuss impact of condition on desired lifestyle and activities, including work, driving, sexual activity, and hobbies. Provide information, privacy, or consultation, as indicated.
Rationale: Client may be reluctant to resume or continue usual activities because of fear of anginal attack or death. Client should take nitroglycerin prophylactically before any activity that is known to precipitate angina. Note: ED can be sign of CAD or diabetes in men. Use of Viagra, or similar drugs, is contraindicated with nitrates, which are usually used with angina.
7. Demonstrate how and encourage client to monitor own pulse and BP during and after activities, when appropriate, and to schedule and simplify activities, avoid strain, and take rest periods.
Rationale: Allows client to identify those activities that can be modified to avoid cardiac stress and stay below the anginal threshold.
8. Discuss steps to take when anginal attacks occur, such as cessation of activity, keeping “rescue” NTG on hand, administration of PRN medication, and use of relaxation techniques.
Rationale: Being prepared for an event takes away the fear that client will not know what to do if attack occurs.
9. Review prescribed medications for control and prevention of anginal attacks as previously presented:
Rationale:Angina is a complicated condition that often requires the use of many drugs to decrease myocardial workload, improve coronary circulation, and control the occurrence of attacks.
a). ASA and other antiplatelet agents
Rationale: May be given prophylactically on a daily basis to decrease platelet aggregation and improve coronary circulation. May prolong survival rate of clients with unstable angina.
b). Lipid-lowering agents: bile acid sequestrants, such as cholestyramine (Questran), colestipol (Colestid), and nicotinic acid (Niacin); fibrates, such as fenofibrate (Tricor) and gemfibrozil (Lopid); and HMG-CoA reductase inhibitors, such as lovastatin (Lipitor), fluvastatin (Lescol),
pravastatin (Pravachol), and simvastatin (Zocor)
Rationale: These drugs are considered first-line agents for lowering serum cholesterol levels. Note: Questran and Colestid may inhibit absorption of fat-soluble vitamins and some drugs,
such as Coumadin, Lanoxin, and Inderal. The HMG-CoA reductase inhibitors may cause photosensitivity. Most lipid-lowering agents are inhibited by grapefruit juice.
10. Stress importance of checking with physician before taking OTC drugs.
Rationale: OTC drugs may potentiate or negate effects of prescribed medications.
11. Discuss use of herbals such as ginseng, garlic, ginkgo, hawthorn, and bromelain, as indicated.
Rationale: Some herbals, such as ginkgo, ginseng, and bromelain can affect bleeding and clotting, especially when added to medications such as Plavix or Coumadin, which increase
bleeding. Others, such as hawthorn, can increase the effects of certain heart medications.
12. Review symptoms to be reported to physician, particularly an increase in frequency and duration of attacks and changes in response to medications.
Rationale: Knowledge of expectations can avoid undue concern for insignificant reasons or delay in treatment of important symptoms.
13. Discuss importance of follow-up appointments.
Rationale: Angina is a symptom of progressive CAD that should be monitored and may require occasional adjustment of treatment regimen.
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