McKenna's Pharmacology for Nursing, 2e

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C H A P T E R 4 6 Antianginal agents

S.W. did not have elevated troponin levels. The chest pain subsided within 3 minutes after she received another sublingual glyceryl trinitrate. It was decided that S.W. should stay in the emergency department (ED) for a few hours for observation. The diagnosis of an acute angina attack was made. CRITICAL THINKING What care interventions are appropriate for S.W. while she is still in the ED? Consider the progression of coronary artery disease (CAD) and the ways in which that progression can be delayed and chest pain avoided. What teaching points should be stressed with this person? What type of guilt may the daughter experience after the disagreement with S.W.? What interventions would be useful in dealing with mother and daughter during this crisis? Should any further tests or treatments be addressed with S.W. when discussing her heart disease? DISCUSSION S.W.’s vital signs should be monitored closely while she is in the ED. If her attack subsides, she will be discharged, and teaching points about CAD will be reviewed with her. It would be a good time to discuss angina with S.W. and her daughter, explaining the pathophysiology of the disease and ways to avoid disrupting the supply-and-demand ratio in the heart muscle. Because S.W. took four glyceryl trinitrate tablets with no effect before coming to the ED, it would be important to find out the age and potency of her drug. Review the storage requirements for the drug, ways to tell whether it is potent, and the importance of replacing the pills at least every 6 months. S.W. and her daughter should be encouraged to air their feelings about this episode; for example, guilt or anger may be precipitated by this scare. They should have the opportunity to explore other ways of handling their problems, try to pace activities to avoid excessive demand for oxygen and plan what to do if this happens again. They should both receive support and encouragement to cope with the angina and its implications. Written information, including drug information, should be given to S.W. Once her condition is stabilised, further studies may be indicated to monitor the progress of her disease. The use of dietary interventions, avoidance of smoking as appropriate, blood pressure control and monitoring of activity should be considered. CARE GUIDE FOR S.W.: ANTIANGINAL NITRATES Assessment: History and examination Assess S.W. for allergies to any nitrates, renal or hepatic dysfunction, pregnancy and breastfeeding (if appropriate), early MI, head trauma, hypotension and hypovolaemia.

Focus the physical examination on the following areas: Cardiovascular: blood pressure, pulse, perfusion, ECG Neurological (CNS): orientation, affect, reflexes, vision Skin: colour, lesions, texture Respiratory system: respiratory rate and character, adventitious sounds GI: abdominal examination, bowel sounds Laboratory tests: liver and renal function tests, full blood count, haemoglobin Implementation Ensure proper administration of drug, and protect the drug from heat and light. Provide comfort and safety measures: • Offer environmental control for headaches. • Give drug with food if GI upset occurs. • Provide skin care as needed. • Taper dose after long-term use. Provide support and reassurance to deal with drug effects. Provide teaching regarding drug, dosage, adverse effects, what to report and safety precautions. Evaluation Evaluate drug effects: relief of signs and symptoms of angina, prevention of angina. Monitor for adverse effects: headache, dizziness; arrhythmias; GI upset; skin reactions; hypotension; and cardiovascular effects. Monitor for drug–drug interactions as indicated for each drug. Evaluate the effectiveness of the teaching program and comfort and safety measures. TEACHING FOR S.W. • A nitrate is given to people with chest pain that occurs because the heart muscle is not receiving enough oxygen. The nitrates act by decreasing the heart’s workload and thus its need for oxygen, which it uses for energy. This relieves the pain of angina. • Besides taking the drug as prescribed, you can also help your heart by decreasing the work that it must do. For example, you can do the following: • Reduce weight, if necessary. • Decrease or avoid the use of coffee, cigarettes or alcoholic beverages. • Avoid going outside in very cold weather; if this cannot be avoided, dress warmly and avoid exertion while outside. • Avoid stressful activities, especially in combination. For example, if you eat a big meal, do not drink coffee or alcoholic beverages with that meal. If you have just eaten a big meal, do not climb stairs; rest for a while. • Determine which social interactions are stressful or anxiety producing; then find ways to limit or avoid these situations.