I.

Nursing Management

Nursing Management

Initially assess, document, and report

to the physician the following:

Rationale

These data assist in determining the

cause and effect of the chest
discomfort and provide a baseline
with which post-therapy symptoms
can be compared.

a. The patients description of

a. There are many conditions

chest discomfort, including

associated with chest

location, intensity, radiation,

discomfort. There are

duration, and factors that affect

characteristic clinical findings

it; other symptoms such as

of ischemic pain and

nausea, diaphoresis, or

symptoms.

complaints of unusual fatigue

b. The effect of the coronary

b. Acute coronary syndrome

ischemia on perfusion to the

(ACS) decreases myocardial

heart (e.g., change in blood

contractility and ventricular

pressure, heart rhythm), to the

compliance and may produce

brain (e.g., changes in level of

dysrhythmias. Cardiac output

consciousness), to the kidneys

is reduced, resulting in reduced

(e.g., decrease in urine output),

blood pressure and decreased

and to the skin (e.g., color,

organ perfusion.

temperature)

Obtain a 12-lead ECG recording

during symptomatic events, as

prescribed, to assess for ongoing

useful in the diagnosis of ongoing

ischemia.

ischemia.

Administer oxygen as prescribed.

An ECG during symptoms may be

supply to the myocardium.

Administer medication therapy as

prescribed, and evaluate the patients

Oxygen therapy increases oxygen

Medication therapy (nitroglycerin,

morphine, beta-blocker, aspirin) is the

response continuously.

first line of defense in preserving

myocardial tissue.

Ensure physical rest; head of bed

elevated to promote comfort; diet as

Physical rest reduces myocardial

tolerated; the use of bedside

oxygen consumption. Fear and anxiety

commode; the use of stool softener to

precipitate the stress response; this

prevent straining at stool. Provide a

results in increased levels of

restful environment, and allay fears

endogenous catecholamines, which

and anxiety by being calm and

increase myocardial oxygen

supportive. Individualize visitation,

consumption.

based on patient response.

Initially, every 4 hours, and with chest

These data are useful in diagnosing

discomfort or symptoms, assess,

left ventricular failure. Diastolic

document, and report to the physician

filling sounds (S3 and S4) result from

abnormal heart sounds (S3 and S4

decreased left ventricular compliance

gallop or new murmur), abnormal

associated with ACS. Papillary muscle

breath sounds (particularly crackles),

dysfunction (from infarction of the

decreased oxygenation, and activity

papillary muscle) can result in mitral

tolerance.

regurgitation and a reduction in stroke

volume. The presence of crackles
(usually at the lung bases) may
indicate pulmonary congestion from
the increased left heart pressures. The
association of symptoms and activity
can be used as a guide for activity
prescription and a basis for patient

Initially, every 4 hours, and with chest

discomfort, assess, document, and
report to the physician the following:
a. Hypotension
b. Tachycardia and other
dysrhythmia
c. Activity tolerance
d. Mentation changes (use family
input)
e. Reduced urine output (<0.5
mL/kg/h)
f. Cool moist, cyanotic

education.
These data are useful in determining a
low cardiac output state.

extremities, decreased
peripheral pulses, prolonged

capillary refill
Assess, document, and report to the

These data provide information about

physician the patients and familys

psychological well-being. Causes of

level of anxiety and coping

anxiety are variable and individual,

mechanisms.

and may include acute illness,

hospitalization, pain, disruption of
activities of daily living at home and
at work, changes in role and selfimage due to illness, and financial
concerns. Because anxious family
members can transmit anxiety to the
patient, the nurse must also identify
strategies to reduce the familys fear
and anxiety.

Assess the need for spiritual

counseling and refer as appropriate.

If a patient finds support in a religion,

spiritual counseling may assist in
reducing anxiety and fear.

Social services can assist with

posthospital care and financial

Assess the need for social service

referral.

concerns.