ANGINA

Case :

Mr. N is 50 years old, entered the hospital with complaints of chest pain
radiating to the neck and shoulders accompanied by shortness of breath. This
complaint occurs when the client helped her neighbors to lift items for moving
house. When clients complain assessment of chest pain is still felt to the neck and
shoulders. The neck also felt the pinch and burning, pain lasts 30 minutes, for 5
minutes when the client complains of chest pain shortness of breath also feels,
Physical examination of the results obtained during the assessment of BP:
140/100 mmHg, Pulse : 96 x / min, RR: 30 x / min, Temperature: 36.5 C. Clients
complained of chest pain is felt since the age of 5 years ago, which is where the
pain often occurs after the client to do the heavy work, the client had not
previously been hospitalized.

Nursing Problem :
1. Acute Pain relate to myocardial ischemia
2. Anxiety relate to Fear to the Death
3. Activity intolerance relate to imbalance of myocardial oxygen supply and
the needs of the client

Aims :
1. After get nursing caring for 3 x 24 hours, expected decrease pain or
relieved by criteria results :
- demonstrate relaxation techniques like take a deep breathe to increase
comfort
- patients can express that pain is reduced / lost verbal and oral
- Overview ECG ST segment no elevanted / depression
- Vital signs in normal range (blood pressure, pulse, respiration).
 2. After get nursing caring for 3 x 24 hours, expected normal cardiac output
by criteria results :
- no angina pain
- Clients tolerating activity.
- Vital signs in normal range (blood pressure, pulse, respiration)

3. After get nursing caring for 2 x 24 hours, expected Patients intolerant of

activity by Criteria Results :
- Participating in physical activity without an increase in blood pressure,
pulse, and RR
- Able to perform daily activities (ADLs) independently
- The balance of activity and rest
Nursing Intervention :
1. Acute pain

Instruct patient to notify nurse immediately when chest pain occurs.

Observe for associated symptoms: dyspnea, nausea and vomiting, dizziness,
palpitations, desire to micturate.
Evaluate reports of pain in jaw, neck, shoulder, arm, or hand (typically on left side).
Monitor heart rate and rhythm.
Monitor vital signs every 5 minutes during initial anginal attack.
Stay with patient who is experiencing pain or appears anxious.
Provide light meals. Have patient rest for 1 hr after meals.
Provide supplemental oxygen as indicated.
Place patient at complete rest during anginal episodes.
Elevate head of bed if patient is short of breath.
Identify precipitating event, if any: frequency, duration, intensity, and location of
pain.
Maintain quiet, comfortable environment. Restrict visitors as necessary.
Assess and document patient response to medication.

2. Anxiety
 Maintain bed or chair rest in position of comfort during acute episodes.
Monitor vital signs and cardiac rhythm.
Auscultate breath sounds and heart sounds. Listen for murmurs.
Push family to help patient for more relas
Teach relaxation technique, take a deep breath
Evaluate mental status, noting development of confusion, disorientation.

3. Activity intolerance

Maintain bed rest in a comfortable position.

Provide adequate rest periods, aids in the fulfillment of self-care activities as

indicated.

Note skin color and pulse quality.

Increase client activity on a regular basis.

ECG Monitor with frequently