Assessment

Subjective Cue:
My chest is really
in pain right now.
The pain even
travels along my
neck and left
arm., as
verbalized by the
patient
Objective Cues:
Pain scale of
8/10
Cool clammy
skin
Facial
grimace
Placing fist
over midsternum
Rubbing left
arm
Restlessness
Vital Signs:
Pulse:
121bpm
Blood
Pressure:
150/100mmH
g

Diagnosis
Acute Pain
related to
decreased
myocardial
blood flow as
evidenced by
reports of pain
and
distraction
behaviours

Planning
Objective:
After 8 hours
of nursing
intervention,
the patient will
be free from
pain
complaint.

Intervention
Independent
1. Instruct to notify
nurse immediately
when chest pain
occurs.

2. Assess reports of
pain in jaw, neck,
shoulder, arm or
hand.
3. Place patient at
complete bed rest
during angina
attacks.

4. Elevate head of
bed if patient is
short of breath.

5. Monitor heart rate

and blood
pressure.

6. Maintain calm and

comfortable

Rationale

Evaluation
After 8 hours
Pain and
of nursing
decreased
intervention,
cardiac output the patient
may stimulate reported no
the
signs of pain.
sympathetic
Pain scale of
nervous
0/10.
system to
release
excessive
amounts of
norepinephrin
e which may
lead to
coronary
artery
vasospasm.
Cardiac pain
may radiate.
Reduces
myocardial
oxygen
demand to
minimize risk
of tissue
injury/necrosis
.
Facilitates gas
exchange to
decrease
hypoxia and
resultant
shortness of
breath.

environment.

7. Provide light
meals.

Collaborative
1. Provide
supplementary
oxygen as
indicated.

2. Administer
anti-anginal
medications as
indicated.

Patients with
unstable
angina have
an increased
risk of acute
lifethreatening
dysrhythmias,
which occur in
response to
ischemic
changes
and/or stress.
Blood
pressure may
initially rise
because of
sympathetic
stimulation,
and then fall if
cardiac output
is
compromised.
Mental or
emotional
stress
increases
myocardial
workload.
Have patient
rest for 1 hour
after meals. It
decreases
myocardial
workload
associated
with work of
digestion,
reducing risk

of angina
episodes.

Increases
oxygen
available after
myocardial
uptake or
reversal of
ischemia.
Nitroglycerin
has a
vasodilator
effect and can
be used as a
prophylactic
preparation to
prevent or
abort angina
attacks. Beta
blockers
reduce angina
by reducing
the hearts
workload.
Calcium
channel
blockers
produce
relaxation of
coronary
vascular
smooth
muscle.