NURSING DIAGNOSIS: Acute pain: radiating or nonradiating chest pain/discomfort related to decreased myocardial oxygenation (an insufficient oxygen supply forces the myocardium to convert to anaerobic metabolism; the end products of anaerobic metabolism act as irritants to myocardial neural receptors).
The client will experience relief of chest pain/discomfort as evidenced by: 1. verbalization of same
2. relaxed facial expression and body positioning
3. increased participation in activities
4. stable vital signs. Nursing Actions and Selected Purposes/Rationales
1. Assess for signs and symptoms of pain/discomfort (e.g., verbalization of pain; grimacing; rubbing neck, jaw, or arm; reluctance to move; clutching chest; restlessness; diaphoresis; increased B/P; tachycardia).
2. Assess client's perception of the severity of the pain/discomfort using an intensity rating scale.
3. Assess the client's pattern of pain/discomfort (e.g., location, quality, onset, duration, precipitating factors, aggravating factors, alleviating factors).
4. Implement measures to relieve pain/discomfort:
1. administer nitroglycerin as ordered
2. maintain oxygen therapy as ordered to increase the myocardial oxygen supply
3. maintain client on bed rest in a semi- to high Fowler's position
4. administer a narcotic (opioid) analgesic (e.g., morphine sulfate) as ordered if pain/discomfort is unrelieved by rest and nitroglycerin within 15-20 minutes (narcotic analgesics are usually administered intravenously because intramuscular injections are poorly absorbed if tissue perfusion is decreased; intramuscular injections also elevate some serum enzyme levels, which makes assessment of myocardial damage more difficult)
5. provide or assist with nonpharmacologic measures for relief of discomfort (e.g., position change, relaxation techniques, restful environment).
5. Consult physician if pain/discomfort persists or worsens.
6. Implement measures to help maintain an adequate cardiac output (see Diagnosis 1, action c) in order to improve myocardial blood flow and oxygenation and subsequently prevent recurrent episodes of angina. __________________|
NURSING DIAGNOSIS: Fear/Anxiety
related to discomfort during angina attack and threat of recurrent attacks; lack of understanding of diagnostic tests, diagnosis, and treatment plan; unfamiliar environment; and effect of angina pectoris on future lifestyle and roles.
The client will experience a reduction in fear and anxiety as evidenced by: 1. verbalization of feeling less anxious
2. usual sleep pattern
3. relaxed facial expression and body movements
4. stable vital signs
5. usual perceptual ability and interactions with others. Nursing Actions and Selected Purposes/Rationales
1. Assess client for signs and symptoms of fear and anxiety (e.g., verbalization of feeling anxious, insomnia, tenseness, shakiness, restlessness, diaphoresis, tachycardia, elevated blood pressure, self-focused behaviors).
2. Implement measures to reduce fear and anxiety:
1. provide care in a calm, supportive, confident manner
2. if client is having severe pain:
1. do not leave him/her alone during period of acute distress
2. perform actions to relieve pain (see Diagnosis 2, action d)
3. once period of acute distress has subsided:
1. orient client to environment, equipment, and routines; include an explanation of cardiac monitoring equipment
2. keep cardiac monitor out of client's view and the sound turned as low as possible
3. introduce client to staff who will be participating in care; if possible, maintain consistency in staff assigned to his/her care
4. assure client that staff members are nearby; respond to call signal as soon as possible
5. encourage verbalization of fear and anxiety; provide feedback
6. explain all diagnostic tests
7. reinforce physician's explanations and clarify misconceptions the client has about angina pectoris, the treatment plan, and prognosis; stress to client that he/she has not had a...
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