Angina Pectoris

ANGINA PECTORIS Marcos , Jose R.N

Description/ Definition 

Chest pain caused by myocardial ischemia(cell hypoxia)



Deprivation of oxygen leads to anaerobic metabolism of the heart producing lactic Acid, which causes chest pain and other related clinical problems



A disease marked by brief paroxysmal attacks of chest pain precipitated by deficient oxygenation of the heart muscles

Anatomy and Physiology

Layers of the heart 





Endocardium- innermost layer consist of thin endothelial tissue lining the inner chambers and heart valves. Myocardium- middle layer consist of striated muscle fiber ; actual muscle of the heart. Epicardium 



Visceral epicardium- covers the outer surface of the heart; it adheres to the heart. Parietal epicardium- encapsulates the visceral epicardium.

Chambers of the heart 

Atria- upper collecting chambers a.Right atrium- receives deoxygenated blood b.Left atrium- receives oxygenated blood



Ventricles- lower pumping chambers a.Right ventricle- pumps blood into the lungs b.Left ventricle- heart’s largest, most muscular chamber that pumps blood into the systemic circulation.

Functions of the cardiovascular system 



Electrophysiologic properties a. Excitability- ability of the cardiac muscle cells to depolarize in response to stimulus through the NAK pump and calcium ions. b. Automacity/ rhythmicity- initiate an impulse c. Contractility- the contraction per second d. Refractoriness- inability to respond to a new stimulus while still in a state of depolarization from an earlier stimulus e. Conductivity- ability to propagate electrical impulses through the conduction system Cardiac cycle: one cardiac cycle = one complete heart beat

Predisposing Factors:        

Sex – male Black raise Hyperlipidemia Smoking Hypertension Diabetes mellitus Sedentary lifestyle Stress

Precipitating Factors:     

Eating Emotion Effort Extreme temperature Elimination

Factors that decrease supply: 

 

Coronary vessel disorders Circulating disorders Blood disorders

Factors that increase demand:  

Increase cardiac output Increase myocardial need for oxygen

Signs and Symptoms 

An uncomfortable pressure, fullness, squeezing, or pain in the center of the chest



It may also feel like tightness, burning, or a heavy weight.



The pain may spread to the shoulders, neck, or arms.



It may be located in the upper abdomen, back, or jaw.



The pain may be of any intensity from mild to severe.

Other symptoms may occur with an angina attack:         

Shortness of breath Lightheadedness Fainting Anxiety or nervousness Sweating or cold, sweaty skin Nausea Rapid or irregular heart beat Pallor (pale skin) Feeling of impending doom

Priority 1: Acute Pain R/T decrease myocardial blood flow

Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation

Objective: >Facial Grimace >Guarding pain >Clinched fist >irritable >diaphoresis >Narrowed Focus >Disturbed Sleep >pain scale of 7/10

Pain R/T decrease myocardial blood flow

After the shift, the patient will report a decrease in pain as evidence by a pain scale of 1/10

•

Instructed client to notify nurse immediately when chest pain occurs.

•

Assessed and document client response of medication

Pain and decreased cardiac output may stimulate the sympathetic nervous system to release excessive amounts of Norepinephrine ,w/c increases platelet aggregation •

The goal was met, after the shift the patient verbalized decrease in pain with a pain scale of 1/10

•

Identified precipitating event frequency, duration, intensity, and location of pain •

Provides information about disease progression . Helps differentiate this chest pain, and aids in evaluating possible progression to unstable angina •

Decrease cardiac output stimulates sympathetic/para sympathetic nervous system, causing a variety of vague sensations •

Observed for associated symptoms of dyspnea, nausea/vomiting, dizziness, palpitations, dsire to micturate •

Placed client at complete rest during angina episodes •

Reduces myocardial oxygen demand to minimize risk of tissue injury •

Facilitates gas exchange to decrease hypoxia •

Elevated head of bed , if client is short of breath

•

Monitored vital signs every 5 min. during initial angina attack

•

•

Blood pressure may initially rise because of sympathetic stimulation

•

Maintained quiet, comfortable environment, restrict visitors as necessary

Mental/ emotional stress increases myocardial workload

•

Provided light meals. Have client rest for 1 hr

Decreases myocardial workload associated with workload of digestion, reducing risk of angina attack •

•

Increases oxygen available for

•

Priority 2: Risk for Decrease Cardiac Output R/T altered heart rate/rhythm

Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation

Objective: >edema >weight gain >dysnea >Clammy skin >decreased peripheral pulses >tachycardia

Risk for decrease cardiac output related to altered heart rate/rhythm

After the shift, the patient will Participa te in activities that reduce the workloa d of the heart.

1.Maintained bed rest in position of comfort during acute episodes

•

Decreases oxygen consumption/ demand, reducing myocardial workload and risk of decompensation

Goal was met, The patient had actively participated in activites that help reduce the workload of the heart

2.Auscultated breath sounds and heart sounds . 3.Provided adequate rest periods .

S3, S4, or crackles can occur with cardiac decompensation. •

Conserve energy, reduces cardiac workload •

4.Assess for signs and symptoms of Heart failure 5.Evaluated mental status, noting development of confusion, disorientation 6.Noted skin color and presence of pulses 7.Administered supplemental oxygen as needed

Disease may compromise cardiac function to point of decompensation •

Reduced perfusion of the brain can produce observable changes in sensorium •

Peripheral circulation is reduced when cardiac output falls, giving a skin pale or gray color and diminishing the strength of peripheral pulses •

Increase oxygen available for myocardial uptake to improve contractility, reduce ischemia, and reduce lactic •

8.Monitored pulse oxymetry/ ABG as indicated

Priority 3: Anxiety R/T Change in Health Status

Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation

Objective: >poor eye contact >restless >irritable >difficulty concentratin g >increased tension

Anxiety R/T Change in Health Status

After the shift the patient will identify healthy ways to deal with and express anxiety.

•

Explained purpose of test and procedures

•

Reduces anxiety attributable to fear of unknown diagnosis and prognosis.

•

Encouraged expression of feelings and fears

•

Goal was met, the patient identified healthy ways to deal with and expressed anxiety.

•

Encouraged family and friends to treat client as before

•

•

Tell client the medical regimen has been designed to reduced attacks and increase cardiac stability.

•

Administered sedatives, tranquilizers, as indicated

•

•

Verbalization of concerns reduces tension, verifies level of coping, and facilitates dealing with feelings. Reassures client that the role in the family and business has not been altered. Encourages client to test symptom control, to increase confidence in medical program, and integrate abilities into perceptions of self May be desired to help client relax until physically able to re-establish adequate coping strategies.

Discharged Planning 

Medication:

- Continue medications as per advised by the medical doctor. - Common medications for the treatment of Angina Pectoris to decrease the workload of the heart and increase myocardial perfusion: a. Nitrates (NTG SL, PO, Spray, Patch and IV) b. Beta Blockers (atenolol, metoprolol) c. Calcium Channel Blocker (verapamil HCL)

Discharged Planning 

Exercise:

-Increase walking time by 5min/week until walking 20-30min 3-4 times a week -ankle flexion and extension exercises.

Discharged Planning 

Treatment:

-Surgical interventions are used to increase coronary perfusion and myocardial oxygen supply such as: a. PTCA- Percutaneous Transluminar Coronary Angioplasty. – The insertion of a balloon tip catheter b. CABG- Coronary Artery Bypass Grafting.rerouting of coronary artery

Discharged Planning 

Health teaching:

-teach the patient to do the following after discharged: -

do not lift, push or pull anything greater than 10pounds for 4-6 weeks

-

Return to work as prescribed the medical doctor

-

resume sexual activity when physical exercises is tolerated well (ex: able to climb 2 flights of stairs comfortably.)

-

bring medications everyday everywhere.

-

Avoid strenuous activities

Discharged Planning 

Out-patient:

- Regular follow-up check-up - Update administration of medication that are prescribe by the physician 

Diet

-Avoid processed food & Low salt, Low Fat and high in fiber foods.