Nursing Diagnosis : Acute Pain
Goal: pain is reduced / resolved.
Patient states / shows the pain is relieved,
Patient reported angina episodes decreased in frequency, duration and severity.
1. Instruct the patient to notify nurse quickly in the event of chest pain.
Rationale: Pain and decreased cardiac output can stimulate the sympathetic nervous system to release large amounts of nor epinephrine, which increases platelet aggregation and thromboxane A2 issued. Pain can not be detained cause vasovagal response, reducing BP and heart rate.
2. Identification of the precipitating factors, if any: frequency, duration, intensity and location of pain.
Rationale: Helps distinguish chest pain early and the possibility of progress evaluation tool becomes unstable angina (stable angina usually ends 3 to 5 minutes while unstable angina longer and can last more than 45 minutes.
3. Evaluation report pain in the jaw, neck, shoulder, hand or arm (especially on the left side).
Rationale: cardiac pain may spread to the sample surface pain more often innervated by the same spinal level.
4. Instruct the patient on bed rest during episodes of angina.
Rationale: Reduce myocardial oxygen demand to minimize the risk of tissue injury or necrosis.
5. Elevate the head of the bed when the patient is short of breath.
Rationale: Facilitate the exchange of gases to reduce repetitive hypoxia and shortness of breath.
6. Monitor the speed or rhythm of the heart.
Rationale: Patients with unstable angina have increased life-threatening dysrhythmias in acute, which occurs in response to ischemia and or stress.
7. Monitor vital signs every 5 minutes during an attack of angina.
Rational: BP can rise early with respect to sympathetic stimulation, then dropped when the cardiac output is affected.
8. Maintain a calm, comfortable environment, limit the visitor when necessary.
Rationale: mental or emotional stress increase myocardial work.
9. Give soft foods. Let the patient rest for 1 hour after eating.
Rationale: Reduces Myocardial work in connection with the work of digestion, manurunkan risk of angina attacks
10. Give antianginal as indicated.
Rationale: For the treatment and prevent angina pain.