Question

The Case:

The home health care nurse is visiting Mr. Saleh, a 62-year-old man with a significant history of angina pectoris. During the visit, the nurse assesses Mr. Saleh’s current status, including his vital signs, activity level, and dietary intake. Mr. Saleh’s medications include sublingual nitroglycerin as needed for chest pain, metoprolol, Cardizem, and ticlopidine.

Questions:

1. What are the rationales for the prescribed medications?

2. Mr. Saleh continues to smoke despite his disease process. How does smoking increase Mr. Saleh’s chances of angina episodes?

3. The nurse reviews the correct procedure for taking nitroglycerin for chest pain, and includes what information?

4. The nurse uses the PQRST acronym to assess for symptoms of angina. What is the nurse assessing?

Answer 1

1) Rationale for precribed medication

Sublingual nitroglycerin is given because,nitroglycerin is potent vasodilator, so it can dilate the coronary artery and increase the blood flow to the myocardium.

Metoprolol is a cardioselective beta-blocker. Beta-blockers prevent the heart from getting too excited or overworked. They do this by blocking off the beta receptors in the blood and heart.

When the receptors are inaccessible, compounds that would usually excite the heart, such as epinephrine, cannot act on them and cause these effects. As a result, this may help keep the blood vessels relaxed.

Cardizem is called a calcium channel blocker. It works by relaxing blood vessels in the body and heart and lowers the heart rate.

ticlopidine is a platelet aggregation inhibitor, so inhibit the formation of platelet plug, so that the blood flow to the heart is maintained.

2)Smoking also increases the stiffness of the blood vessels making it harder for them to expand and contract as needed and more likely to split. These changes to the arteries can cause  angina.

3)

Confirm the patient has no known allergy to nitroglycerin.

Confirm the patient has NOT recently taken a phosphodiesterase inhibitor like Sildenafil (Viagra) or Tadalafil (Cialis)this can lead to severe hypotension or even death.

It’s not for patients with increased intracranial pressure.

Confirm patient’s vital signs (especially blood pressure) is within parameters.

When giving nitroglycerin (sublingual or as oral spray) have the patient sit down because this medication causes dizziness.

1. fter administration of the first dose, monitor the patient’s blood pressure very closely and their chest pain rating. Is it decrease or increasing?
2. If chest pain is still present and blood pressure is within parameters, after 5 minutes you may administer a 2nd dose.
3. Again monitor the patient’s blood pressure very closely and chest pain rating. If chest pain is still present and blood pressure is within parameters, after 5 minutes you may administer a 3rd dose.
4. No more than 3 doses are given. Contact the physician for further order

4)The PQRST method of assessing pain is a valuable tool to accurately describe, assess and document a patient’s pain. The method also aids in the selection of appropriate pain medication and evaluating the response to treatment.

P = Provocation/Palliation

What were you doing when the pain started? What caused it? What makes it better or worse? What seems to trigger it? Stress? Position? Certain activities?

What relieves it? Medications, massage, heat/cold, changing position, being active, resting?

Q = Quality/Quantity

What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching.

R = Region/Radiation

Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around? Did it start elsewhere and is now localized to one spot?

S = Severity Scale

How severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?

T = Timing

When/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first experienced it? When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally.