C H A P T E R 4 6
Antianginal agents
721
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.
