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Chapter 3

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NURS 287
Rick Nilson

Chapter 3: Drug Therapy  Initial management of the patient with chest pain includes aspirin, sublingual nitroglycerin, morphine sulfate for pain unrelieved by nitroglycerin, and oxygen.  IV nitroglycerin, aspirin, -adrenergic blockers, and systemic anticoagulation with either low molecular weight heparin given subcutaneously or IV unfractionated heparin (UH) are the initial drug treatments of choice for ACS.  IV antiplatelet agents (e.g., glycoprotein IIb/IIIa inhibitor) may also be used if percutaneous coronary intervention (PCI) is anticipated.  ACE inhibitors help prevent ventricular remodeling and prevent or slow the progression of HF. They are recommended following anterior wall MIs or MIs that result in decreased left ventricular function (ejection fraction [EF] less than 40%) or pulmonary congestion and should be continued indefinitely. For patients who cannot tolerate ACE inhibitors, angiotensin receptor blockers should be considered.  Calcium channel blockers or long-acting nitrates can be added if the patient is already on adequate doses of -adrenergic blockers or cannot tolerate -adrenergic blockers, or has Prinzmetal’s angina.  Stool softeners are given to facilitate and promote the comfort of bowel evacuation. This prevents straining and the resultant vagal stimulation from the Valsalva maneuver. Vagal stimulation produces bradycardia and can provoke dysrhythmias.  Initially, patients may be NPO (nothing by mouth) except for sips of water until stable (e.g., pain free, nausea resolved). Diet is advanced as tolerated to a low-salt, low-saturated-fat, and low-cholesterol diet. Surgical Therapy  Coronary revascularization with coronary artery bypass graft (CABG) surgery is recommended for patients who (1) fail medical management, (2) have left main coronary artery or three-vessel disease, (3) are not candidates for PCI (e.g., lesions are long or difficult to access), or (4) have failed PCI with ongoing chest pain.  Minimally invasive direct coronary artery bypass (MIDCAB) surgery can be used for patients with single-vessel disease.  The off-pump coronary artery bypass (OPCAB) procedure uses full or partial sternotomy to enable access to all coronary vessels. OPCAB is also performed on a beating heart using mechanical stabilizers and without cardiopulmonary bypass (CPB).  Transmyocardial laser revascularization (TMR) is an indirect revascularization procedure used for patients with advanced CAD who are not candidates for traditional bypass surgery and who have persistent angina after maximum medical therapy. Nursing Management: Chronic Stable Angina and Acute Coronary Syndrome  The following nursing measures should be instituted for a patient experiencing angina: (1) administration of supplemental oxygen, (2) determination of vital signs, (3) 12-lead ECG, (4) prompt pain relief first with a nitrate followed by an opioid analgesic if needed, (5) auscultation of heart sounds, and (6) comfortable positioning of the patient.  Initial treatment of a patient with ACS includes pain assessment and relief, physiologic monitoring, promotion of rest and comfort, alleviation of stress and anxiety, and understanding of the patient’s emotional and behavioral reactions. o Nitroglycerin, morphine sulfate, and supplemental oxygen should be provided as needed to eliminate or reduce chest pain. o Continuous ECG monitoring is initiated and maintained throughout the hospitalization. o Frequent vital signs, intake and output (at least once a shift), and physical assessment should be done to detect deviations from the patient’s baseline parameters. Included is an assessment of lung sounds and heart sounds and inspection for evidence of early HF (e.g., dyspnea, tachycardia, pulmonary congestion, distended neck veins).  Bed rest may be ordered for the first few days after an MI involving 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.  It is important to plan nursing and therapeutic actions to ensure adequate rest periods free from interruption. Comfort measures that can promote rest include frequent oral care, adequate warmth, a quiet atmosphere, use of relaxation therapy (e.g., guided imagery), and assurance that personnel are nearby and responsive to the patient’s needs.  Cardiac workload is gradually increased through more demanding physical tasks so that the patient can achieve a discharge activity level adequate for home care.  Anxiety is present in all patients with ACS to various degrees. The nurse’s role is to identify the source of anxiety and assist the patient in reducing it.  The emotional and behavioral reactions of a patient are varied and frequently follow a predictable response pattern. The role of the nurse is to understand what the patient is currently experiencing, to assist the patient in testing reality, and to support the use of constructive coping styles. Denial may be a positive coping style in the early phase of recovery from ACS.  The major nursing responsibilities for the care of the patient following PCI involves monitoring for signs of recurrent angina; frequent assessment of vital signs, including
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