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HYPERTENSION
DISEASE OF CIVILIZATION
WHAT IS HIGH BLOOD PRESSURE
•Hypertension (HTN)
•Systolic blood pressure
•Diastolic blood pressure

•Systolic blood pressure (SBP) equal to or greater than 140 mmHg or a diastolic
pressure (DBP) equal to or greater than 90 mm Hg (extended period of time), or
taking antihypertensive medications

•Based on average of two or more blood pressure measurements taken in two or

more contacts with health care provider after an initial screening. (JNC 7)
TWO MAJOR TYPES
•Primary (essential
(essential or idiopathic)
•Secondary hypertension
•“the silent killer”
JNC 7 CLASSIFICATION
•Normal

•Pre Hypertension
•Hypertension
•Stage 1
•Stage 2
PATHOPHYSIOLOGY
•Blood pressure = total peripheral resistance + cardiac output
•Changes in arteriolar bed – increased peripheral vascular resistance
•Abnormally increased tone in sympathetic nervous system originates in
vasomotor system centers
•Increase in arteriolar thickening from genetic factors which leads to increased
peripheral resistance
•Abnormal renin release – angiotensin II which constricts arteriole and increases
volume
•Prolonged hypertension increases heart’s workload as resistance in left
ventricular ejection increases

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•To increase force of contraction the left ventricle gets larger (hypertrophy) –
raising heart’s oxygen demand and workload
•Promotes coronary atherosclerosis
•Vascular changes
•Secondary hypertension – patho related to underlying disease

TARGET ORGAN DAMAGE (COMPLICATIONS)

Heart
•Left Ventricular hypertrophy
•Angina /prior MI
•Heat failure
•Hypertensive Heart Disease

Brain
•Stroke or TIA
•Kidney
Chronic kidney disease
Nephrosclerosis
•Vascular
•PVD
Eyes
Retinopathy (retinal damage)

RISK FACTORS
•Cigarette Smoking
•Hyperlipidemia
•DM
•Age
•Gender
•Family history
•Obesity
•Refer to table 32-3, pg 781

Age Related Changes

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•Accumulation of atherosclerotic plaque

•Elastin replaced causing arterial stiffness & decreased vascular compliance
•Increased collagen deposits
•Impaired vasodilatation
•Aorta and large arteries are less able to accommodate the volume of blood
pumped out by heart and energy used to stretch the vessels used to elevate the
systolic BP
•Wide auscultatory gap

SIGNS & SYMPTOMS

•Physical exam – high blood pressure – 2 consecutive readings
•“Silent Killer” – asymptomatic until vascular changes
•Retinal changes
•Severe HPT
•Other SSx
MEDICAL HISTORY
•Patient history or symptoms of CHD
•Family Hx
•History of recent changes in weight, leisure time, physical activity, smoking
•Dietary assessment
•Rx and OTC meds & Herbal
•Psychosocial and environmental factors

Physical Exam
•Initial physical exam
•Person seated quietly for at least 5 minutes in a chair (rather than on exam
table) with feet on the floor and arm supported at heart level.
•2 measurements taken
•Verification in opposite arm (if values are different, higher value should
be used )
•Ht, Wt, Body mass index (BMI), waist circumference
•Funduscopic examination

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•Exam Neck

•Exam heart

•Exam abdomen

•Exam extremities

•Neurological assessment
RECOMMENDED LAB TESTS PRIOR TO ANTIHYPERTENSIVE THERAPY
•Hematocrit

•Blood chemistry: potassium, calcium, creatinine/GFR, fasting glucose, total

lipid panel (HDL, LDL, and triglycerides

•12-lead electrocardiogram

•Urinalysis
PREVENTIVE MEASURES
•Lifestyle modifications
•Nonpharmacologic Treatments
•Dietary Sodium
•Alcohol ingestion
•Electrolytes

NONPHARMACOLOGIC TREATMENTS (CONT.)

•Miscellaneous Dietary factors

•Smoking

•Exercise
PHARMACOLOGIC (DRUG) THERAPY
•Refer to Table 32-8, pg 787-790

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•Patient
does not reach goal blood pressure using lifestyle modifications, initiate
pharmacologic treatment.

•Otheragents – angiotensin-converting enzyme (ACE) inhibitors, angiotensin

receptor blockers, beta-adrenergic blockers, and calcium channel blockers may
be used

•Initially
with thiazide diuretics pts with a systolic BP ranging from 140 to 159
mm Hg and diastolic 90 to 99 mm Hg

•Two-drug combination pt with BP greater than 160/100

•Multidosetherapy pt with hypertension and other disease (heat failure, previous

MI, DM, CRF, stroke)

NURSING DIAGNOSIS
•Refer to table 32-11, pg. 793
•Altered/ineffective health maintenance r/t lack of knowledge of pathology,
complications & management of HTN
•Anxiety
•Altered sexuality R/T effects of antihypertensive medication
•Ineffective management of therapeutic regimen
•Body image disturbance R/T diagnosis of HTN
•Potential complication: Adverse effects from antihypertensive therapy
•Potential complication: Hypertensive crisis
•Altered cardiopulmonary, cerebral & renal tissue perfusion
•Potential complication: Cerebral vascular accident (stroke)

NURSING INTERVENTION
•Objective of nursing care for hypertensive patients focuses on lowering and
controlling the BP without adverse effects and without undue cost
•The nurse must support and teach the patient to adhere to the treatment
regimen by
•Implementing necessary lifestyle changes
•Taking meds as prescribed
•Scheduling regular follow-up appointments with health care provider

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•Monitor & manage potential complications

INCREASING KNOWLEDGE
•Understand disease process & how lifestyle changes and medications can
control hypertension
•Consult dietician to help develop a plan for weight loss
•Restrict sodium and fat intake
•Increasing intake of fruit and vegetables
•Implement regular physical activity
•Explain it will take 2-3 months for taste buds to adapt to changes in salt intake
(help them to adjust)

SELF-CARE
•Give written info about expected effects and side effects of medications
•Refer to Table 32-13, pg 794
•Need to understand importance of repo rting side-effects
•Rebound hypertension
•Inform that some meds (i.e. beta blockers may cause impotence or sexual
dysfunction), other meds are available
•Encourage & teach patients to take own BP at home
•Include family and caregivers in teaching program

GERONTOLOGICAL CONSIDERATIONS
•Compliance may be difficult for older adults - medication regimen difficult to
remember and expensive
•Monotherapy (tx with single agent) may simplify regimen
•Include family and caregivers in teaching program
•Nursing Alert - older adults more sensitive to extracellular volume depletion
caused by these meds, postural h ypote nsion
•Teach to change position slowly when moving from lying to sitting to
standing
•Use supportive devices, hand rails, walkers when necessary to prevent falls

EVALUATION
•How do I know that my interventions were effective?
•Expected patient outcomes refer to pg 864-865
•Maintain adequate tissue perfusion (achieve and maintain desired BP as defined

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for the individual)

•Compliance with self-care program (understand, except and implement
therapeutic plan)
•Has no complications (experience minimal or no unpleasant side effects of
therapy)
CARDIOVASCULAR DISORDERS
CORONARY ARTERY DISEASE (CAD)
ANGINA
UNCOMPLICATED INFARCTION (MI)
CORONARY ARTERY DISEASE (CAD)
•Atherosclerosis
•Loss of oxygen and nutrients to myocardial tissue – diminished blood flow
•Pathophysiology

Risk Factors
•Refer to Table 33-2,pg. 802
•Un modifiable
•Age
•Gender (men> women until 60 yr of age)
•Race ( African Americans < Whites)
•Genetic predisposition & family history of heart disease

Modifiable Major Risk Factors

•Modif iable
•Major
•Cigarette smoking
•Hypertension
•Elevated lipid level
•Obesity
•Physical inactivity
•Contributing
•Hyperglycemia (DM)
•Stressful lifestyle (aggressive, hostility, Type A coronary prone)
•Use of oral contraceptives
•Infection (gingivitis)
•Geography - industrialized regions
regions

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Signs & Symptoms

•Angina (classic sign)
•Burning, squeezing or tightness in chest, radiates to left arm, neck, jaw or
shoulder blade
•Nausea & Vomiting – results from reflex stimulation of vomiting centers by
pain
•Cool extremities & pallor – sympathetic stimulation
•Diaphoresis – sympathetic stimulation
•Xanthelasma – result from hyperlipidemia

ATYPICAL PRESENTATION
•Weakness or fatigue
•Shortness of Breath (dyspnea)
•May experience no chest pain
•Are more common in women, Blacks, Hispanics, diabetics, & elderly
•Diabetics
•Central neuropathies – no chest pain
•Sympathetic stimulation (cool extremities, diaphoresis, N & V)

Stable Angina
•Refers to chest pain occurring intermittently over a long time with the same
pattern of onset, duration, and intensity of symptoms; pain is predictable
predictable in
frequency & duration
•Relieved by rest or cessation of activity and nitroglycerin

Unstable Angina
•Progressive or perinfarction angina
•Unpredictable (change in pattern)
•Occurs during minimal or no exercise or exertion, during sleep, or at rest
•Ass. With deterioration of once stable atherosclerotic plaque; rupture

Prinzmetal’s or Variant Angina

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•Occurs at rest; not related to physical exercise or emotional stress

•Pain caused by spasm of coronary artery
•Symptoms – pain & marked ST segment elevation on ECG
•Rare form of angina, may occur in absence of CAD
•Triggered by smoking

Abnormal Lab Findings

•Lipid levels – may be elevated indicating atherosclerotic involvement
•Cardiac enzymes
•C-reactive protein (CRP)
Test to Help Diagnosis CAD
•ECG – Measures heart’s electrical activity; may show parts of heart muscle
damage
• Exercise or pharmacological stress test
•Echocardiography
•Coronary angiogram – shows any blockages &/or narrowing
•CXR – detect heart enlargement, cardiac calcification & pulmonary congestion
•Nuclear imaging
•PET scan

Decreasing Risk Factors for CAD

•Refer to Table 33-3, pg. 805
•Lifestyle changes, include reducing saturated fat and cholesterol in the diet
•Other therapies - Omega-3 polyunsaturated fatty acids (derived from fish oil)
and flax seed oil, olive oil (recently approved by FDA)
•Refer to natural lipid-lowering agents, pg. 809
•American Heart Association Diet
•Use AHA Step I or II diet pg. 807
•Limit total fat intake to 25% to 35% total calories each day
•Calories should come from carbohydrates such as bread, cereal, rice and
grains. 15% from proteins, meat, fish eggs, or beans
•Exercise
•Weight control

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•Don’t smoke
•Limit alcohol intake
•Eat 20 to 30 grams of soluble fiber every day

Treatment for Angina

•Nitrates – Dilate peripheral blood vessels, coronary arteries & collateral
vessels which lowers peripheral vascular resistance (afterload)
•Nit roglycerin (sublingual, IV, spray, ointment, transdermal controlled-
release)
•Isosorbide dinitrate (SL or oral)
•Isosorbide monotrate (oral)
•Beta-Adren ergic bloc king age nts ; inhibit sympathetic stimulation of beta
receptors in heart decreases heart rate and force of myocardial contraction thus
decreasing myocardial oxygen consumption (e.g. Tenormin, Lopressor, Inderal).
•Calcium Chan nel blocking agen ts – prevent the movement of extracellular
calcium into the cell resulting in coronary and peripheral artery dilation (e.g.
Norvasc, Cardizem, Isoptin, Procardia).
•Antiplatelet & A nticoagulant first line pharmacologic intervention: ( e.g.
Aspirin, intolerance of ASA (use ticLid, plavix), Heparin, Lovenox, fragmin
•Heparin infusion -
DRUG THERAPIES
•Antilipedemic drugs – reduce serum cholesterol or triglyceride
• Niacin (Nicotinic Acid, Vit B3)
•Lowers LDL and triglycerides & raises HDL
•Cause itching and flushed face. Take an aspirin 30 mins before taking niacin
•Bile acid sequetrants (colestipol, cholestyraine) -
•Bind cholesterol in the bowels and get rid of it in the stool; used to lower
LDL and raise HDL
• May cause diarrhea and gas

DRUG THERAPIES
•Statins (HMG CoA reductase inhibitors (lovastatin [Mevacor], pravastatin
[Pravachol], fluvastatin [ Lescol], simvistatin [Zocar], atorvastatin [Lipotor]
•Lower LDL and triglyceride levels and in some patients can raise HDL
•Diarrhea, nausea, vomiting & leg cramps. Require liver function studies
(work in liver)
•Muscle tenderness or weakness (rhabdomyoloysis)
•Anti-hypertensive meds – control BP

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•Estrogen replacement therapy – reduce risk CAD in post menopausal women

DRUG THERAPIES
•Gemfibrozil (Lopid)
•Lowers TG, minimal or no effect on chol.
•Used to treat hypertriglyceridemia to prevent pancreatitis
•Major S. E.: GI complaints, myopathy, HA, dizziness, fatigue, blurred vision
•Monitor fasting lipid profile, liver enzymes, FBS
•Don’t use with statins, this might damage muscle and cause gall stones
Treatment
•Coronary artery bypass graft (CABG)
•Surgery to restore blood flow by bypassing an occluded artery using another
vessel –Internal mammary artery (chest); Saphenous Vein (from leg)
•Fig 33-18, pg 822
•“Key-hole” – minimally invasive surgery
•Precutaneous transluminal coronary Angioplasty (PTCA) or angioplasty &
Stenting – minimally invasive tx to open blocked arteries; with or without
stent placement – hold artery open
•Drug-eluting stent placement (Taxus) - holds a reopened artery open &
minimize the risk of restenosis

PTCA
Nursing Diagnosis and Client Goals, Angina
•Nursing Diagnosis
•Acute Pain
•Ineffective myocardial tissue perfusion
•Anxiety R/T fear of death
•Activity intolerance
•Knowledge deficit about disease and methods to avoid complications
•Noncompliance, ineffective management of therapeutic regimen R/T failure
to accept necessary lifestyle changes
•Client goals (outcomes)
•Pain relief & absence of return of pain
•Reduction of anxiety
•Awareness of underlying nature of disorder
•Understanding Rx care
•Adherence to self care program
•Modify risk factors
•Absence of complications

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Nursing Management CAD

•Identify persons at risk for CAD
•Obtain personal and family hx
•Environmental factors – eating habits, type of diet, level of exercise
•Psychosocial hx – smoking habits, alcohol ingestion, type A behavior, recent
life-stressing events, sleeping habits, presence of anxiety or depression
•Identify pt attitude & benefits of health & illness
•Educational background
•Once high risk person identified – preventive measures taken – modifiable risk
factors
ASSESSMENT, ANGINA & MI
•Gather info about symptoms & activities, those that precede and precipitate
attack
•Refer Table 33-15, pg 825
•See Table 28-4 pg 723, ask questions using the PQRST format, also see
handout
Nursing Management
•If nurse present during an angina attack, do this
•Administer oxygen
•Assess Vital Signs
•12-lead EKG
•Nitrate followed by narcotic analgesic if needed; prompt pain relief
•Physical assess of chest
•Position pt comfortably

PT & FAMILY TEACHING

•Reassure long, productive life is possible
•Teaching tools – one-to-one on daily care, pamphlets, films at beside, heart
model, written info
•Assist to identify factors that precipitate angina & instructions on how to avoid
•Help to identify risk factors
•Teach about diet low in Na & saturated fats maintaining ideal body weight;

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exercise program
•Counseling R/T threat to identity & self esteem
Myocardial Infarction (Heart Attack)
•Reduced blood flow through one of coronary arteries results I myocardial
ischemia and necrosis
•Mortality high if treatment is delayed
•Occlusion stem from atherosclerosis, thrombosis, platelet aggregation or
coronary artery stenosis or spasm
•Prolonged ischemia longer than 20 minutes – irreversible cell damage and
muscle death – site depends on vessel involved

Myocardial Infarction Pathophysiology

•Site of occlusion depends on vessel involved
•Circumflex branch left coronary artery – lateral wall infarction
•Anterior descending branch left coronary artery – anterior wall infarction
•Right coronary artery or its branches – True posterior or inferior wall
infarction; also right ventricular infarction and cause right sided heart failure

Pathophysiology
•Central area of necrosis or infarction surrounded by area potentially viable
hypoxic injury – recover if revascularization occurs (circulation restored in 6
hours)
•Change s that occur in MI
•Cardiac enzymes and proteins released by infarcted myocardial cells – used
in diagnosis of MI
•In 24 hours infarcted muscle becomes edematous and cyanotic
•Next several days leukocytes infiltrate the necrotic area & begin to remove
dead cell thinning ventricular wall

Causes (Predisposing Risk Factors)

•Family Hx of MI
•Gender (men, postmenopausal women more susceptible)
•Hypertension
•Smoking
•Elevated triglycerides, cholesterol, & LDL
•Obesity
•Excess intake of saturated fats

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•Sedentary lifestyle
•Aging
•Stress or type A personality
•Drug use (cocaine & amphetamines)

Signs & Symptoms - MI

•Hallmark – severe. Immobilizing CP unrelieved by rest or nitrate
•CP not evident in all patients ( may present with weakness, indigestion SOB)
•Nausea & Vomiting (reflex stimulation of vomiting center by severe pain)
•CNS stimulation – increased catecholamines (norepinephrine and epinephrine
released ) result in diaphoresis and vasoconstriction pf peripheral blood vessels;
skin ashen, clammy & cool (“cold sweat”)
•Fever – day after MI – inflammatory response
•Changes in vital signs
•Jugular vein distention reflects ventricular dysfunction and pulmonary
congestion
•S3 & S4 heart sounds – ventricular dysfunction
•Loud murmur in apex
•Reduced urine output – reduced renal perfusion and increased aldosterone and
antidiuretic hormone

Diagnosis – MI
•Serial measurement of cardiac markers (Q 8 hrs X’s 3) – show characteristic
rise and fall
•Creatine kinase (CK) – rises within 4-6 hrs of MI (maybe skeletal, brain, or
heart)
•CK-MB- starts to rise within 10-30 mins; rises within 4-6 hrs after acute
MI & peaks in 24 hours
•Indication of MI - > 7.5 ng/ml
•Troponin – starts & peaks same as CK-MB and remains elevated up to 3
weeks
•Troponin I highly specific to cardiac tissue
•WBC – elevated
•Increased FBS – release of catecholamines
•C-reactive protein & Erythrocyte sedimentation rate from inflammation
•Myoglobin – helps determine MI
Diagnosis
•ECG - in specific leads T-wave inversion (ischemia), ST segment elevation

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(injured cardiac tissue), & abnormal Q wave - 12 lead

•ECHO – show ventricular wall motion abnormalities
•CXR show left-sided heart failure or cardiomegaly form ventricular dilation
•Nuclear imaging scanning
•Cardiac catheterization - info about which coronary artery is blocked

DRUG THERAPY FOR MI

•Morphine sulfate (MSO4) is given for acute chest pain relief b/c it reduces
anxiety and fear and decreases the cardiac workload by lowering myocardial
oxygen consumption
•IV nitroglycerin (Tridil) may be used in the initial therapeutic tx
•Antiarrhythmic drugs – arrhythmias are the most common complication after an
MI
•Positive Inotropic drugs – that increase the heart’s contractility may be used in
patient with acute MI (e.g. Dobutrex, digitalis, amrinone (Inocor).
•Beta-Adrenergic blockers – used in acute phase of the MI and during a 1 year
follow-up regimen, can decrease morbidity (Drug choice and dose depend on the
MD)
•Calcium Channel blockers – may be used in the TX of MI where the pt also
underwent PTCA to restore perfusion

DRUG THERAPY
•Angioten sin – converting enzyme ( ACE) inhib itors – may be used
following MIs – help prevent ventricular remodeling and prevent or slow the
progression of heart failure (e.g. captopril (Capoten) and enalapril (Vasotec)
•Stool soften ers – After an MI the pt is predisposed to constipation as result
of bed rest and narcotic administration. Given to facilitate and promote comfort
of bowel evacuation; prevents straining and resultant vagal stimulation from the
Valsalva’s maneuver
•Fibrinolytics (streptokinase, t-PA, reteplase (Retavase) given to dissolve or
lyses the thrombus Chart 28-7, pg 727; Not used after major surgery or
hemorrhagic stroke
•Major complication - _____________
•IV Heparin – pt’s who have received fibrinolytic therapy to increase chances
of patency in affected coronary artery
•Monitor Partial Prothrombin time (PTT) – 1-2 times normal
•Complication - bleeding

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Nutritional Therapy
•Diet is restricted in saturated fats and cholesterol and sodium to prevent fluid
retention. The patient may have a clear liquid diet the first day is there is
nausea
Treatment
•Assessment of pt in emergency department within 10 minutes of symptoms
onset
•“T im e is muscl e” reflect urgency of appro priate treatm ent
•Oxygen – 2-3 LMP/NC – increase blood oxygenation
•Nitroglycerin SL or IV to relieve chest pain (parameters – BP systolic less than
90 mm Hg or heart rate less than 50 or greater than 100)
•Morphine or meperidine – analgesia – pain sympathetic nervous system, leading
to in increase in heart rate & vasoconstriction
•Aspirin Q day indefinitely – inhibit platelet aggregation
•Continuous cardiac monitoring – detect arrhythmias and ischemia
•IV fibrinolytic therapy – beneficial within 3 hours after symptoms start
•IV heparin – Patients who have received fibrinolytic therapy to increase
chances of patency in affected coronary artery (Monitor PTT – 1-2 times
normal)
•PTCA
•Glycoprotein IIb/IIIa receptor blocking agents – strongly inhibit platelet
aggregation
•Limit physical activity for first 12 hours to reduce cardiac workload; limiting
area of necrosis
•Be prepared to administer ACLS
•Atropine, epinephrine, amiodarone, defibrillator, pacing)
•Risk modification program
•Lipid lowering agents
CABG
•CABG procedure – main surgical tx for CAD to produce new pathway beyond
the occluded coronary artery
•AIM – area distal to obstruction continue to receive blood flow
•Uses blood vessels to go around (bypass) clogged coronary heart arteries
•Internal mammary artery (chest)
•Saphenous Vein (from leg)

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•Fig 33-18, pg 822

Cardiac Rehab Phases

oRefer to Table 33-16, pg. 829
oPlan individualized care (by phases)
Phase I – predominately during admission to the hospital. Low-level
activities & initial education for pt & family
Phase 2 – pt discharged. Lasts 4-6 weeks or up to 6 months.
Supervised exercise training I individualized based on
results of exercise stress test
Phase 3 – Maintain CV stability & long-term conditioning. Pt usually
self-directed during this phase & no supervised program
required
Phase 4 – time of recovery and maintenance – involve community
rehab program

Physical Activity
Refer to Table 33-20, pg 832
Physical exercise
Gradual increase in activity level
Watch symptoms rather than HR
Resumption of sexual activity
Refer to Table 33-21, pg. 832
Resume after 1st phase of recovery and being discharged from hospital
Inability to perform sex is common
Discuss feeling in this area
May need prophylactic nitroglycerin
Avoid heavy meal before sex (wait 1-3 hours after eating a full meal – allow
digestion)
Avoid anal intercourse

Assessment, MI
•Assess level of consciousness
•Evaluate chest pain
•Assess heart rate and rhythm; dysrhythmias may indicate not enough oxygen to
the myocardium
•Assess heart sounds; S3 can be an early sign of impending left ventricular

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failure
•Measure blood pressure to determine response to pain and TX; note pulse
pressure which may narrow after MI
•Assess peripheral pulses, rate, rhythm and volume
•Evaluate skin color and temperature
•Auscultate lung fields at frequent intervals
•Assess bowel motility
•Observe urinary output and check for edema

NURSING DIAGNOSES & CLIENT GOALS – MI

•Acute pain
•Decreased myocardial perfusion R/T reduced coronary blood flow
•Potential impaired gas exchange R/T fluid overload
•Risk for ineffective peripheral tissue perfusion R/T decreased cardiac output
•Anxiety R/T fear of death
•Knowledge deficit about MI, self-care
•Relief of symptoms of ischemia (chest pain, ST segment changes)
•Absence of respiratory difficulties
•Adequate tissue perfusion
•Reduced anxiety
•Adherence to self-care program
•Prevention or early recognition of complications

Nursing Interventions
•Top p rior ity – pain relief, once airway, pain relief breathing and circulation
have been stabilized
•Administer oxygen and other medications as directed
•Monitor at least every hour for indications of decreased cardiac output–
sustained HR>20 BPM over baseline, lowered BP, decreased urine output
•Monitor cardiac rhythm, continuous ECG for premature ventricular contractions
(PVCs) (the most common dysrhythmia), or ventricular tachycardia (VT) which
precede ventricular fibrillation (lethal arrhythmia)
•Monitor lung sounds fro crackles, wheezes, consolidation
•Maintain patent IV line
•Maintain restful environment
•Bedrest first few days – severe MI
•Rest in chair 12-24 hours after event – uncomplicated MI
•Give brief explanations for all procedures, tests, and equipment and encourage
verbalization of feelings & relieve anxiety

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•Morphine given PRN (rate on pain scale 1-10)

•Frequent VS, I & O (Q 4-8 hrs)
•Anxiety
•Table 33-17 emotional behavioral responses
•Denial, Anger, Anxiety & fear, dependency, depression, realistic acceptance
•Patient teaching starts on admit (CCU), assess learning needs

Home care regarding client education

•Short and long- acting nitrates, how to administer and store them
•Sublingual nitrates – take SL NTG at pain onset, then x2 at five-minute
intervals, if pain persists, call for assistance and transport to ER
•Store in dry, dark bottle and obtain new bottle every 6 months, shelf life is 3
to 6 months once bottle is opened; a tingling under the tongue indicates
potency of med
•Transdermal nitrates – rotate sites in non-hairy areas above the knees or
elbows and wash site after patch removed

Patient Education
•How to increase activity level slowly
•How to weigh daily
•Diet changes – low fat, low cholesterol, moderate to low salt
•When sexual activity can resumed
•If stents have been placed – cannot remove (treatment is lifelong) must stay on
Plavix
•Evaluate for medication effectiveness
•How to take radial pulse daily, best before getting out of bed
•What adverse reactions would require medical assistance, such as persistent
anorexia, N/V, or change in vision

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