Angina Pectoris Sharina

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Angina Pectoris

Introduction

Angina pectoris is a symptom of ischemic heart disease characterized by paroxysmal and usually

recurring substernal or precordial chest pain or discomfort. The term comes from the Latin words

meaning "choking of the chest." About 10 million Americans experience angina, and approximately

350,000 new cases of angina occur every year. Angina pectoris is caused by varying combinations of

increased myocardial demand and decreased myocardial perfusion. The imbalance between supply and

demand is caused either by a primary decrease in coronary blood flow or by a disproportionate increase

in myocardial oxygen requirements. Blood flow through the coronary arteries is partially or completely

obstructed because of coronary artery spasm, fixed stenosing plaques, disrupted plaques, thrombosis,

platelet aggregation, and embolization.

Angina can be classified as chronic exertional (stable, typical) angina, variant angina (Prinzmetal's),

unstable or crescendo angina, or silent ischemia (Table 8). Chronic exertional angina is usually caused by

obstructive coronary artery disease that causes the heart to be vulnerable to further ischemia whenever

there is increased demand or workload. Variant angina may occur in people with normal coronary

arteries who have cyclically recurring angina at rest, unrelated to effort. Unstable angina is diagnosed in

patients who report a changing character, duration, and intensity of their pain. Experts are also

recognizing that not all ischemic events are perceived by patients, even though such events, called silent

ischemia, may have adverse implications for the patient.

I. Assessment

1. HISTORY. Ask the patient to describe past chest discomfort in terms of quality (aching, sharp, tingling,

knifelike, choking, squeezing), location and radiation, precipitating factors (activity), duration, alleviating

factors (relieved by rest), and associated signs and symptoms during the attack (dyspnea, anxiety,

diaphoresis, nausea). Obtain information regarding medications, family history, and modifiable risk

factors such as eating habits, lifestyle, and physical activity. If chest discomfort is present at the time of

the interview, delay collection of historical data until you implement appropriate interventions for

ischemic chest pain and the patient is pain free.

The Canadian Cardiovascular Society grading scale is used to classify the severity of angina: Class I:

angina only during strenuous or prolonged physical activity; Class II: slight limitation, with angina only

during vigorous physical activity; Class III: symptoms with everyday living activities; Class IV: inability to

perform any activity without angina or angina at rest.

2. PHYSICAL EXAM. During anginal attacks, chest discomfort is often described as an ache rather than an

actual pain and may be characterized as a heaviness, pressure, tightness, squeezing sensation, or

indigestion. The discomfort is typically located in the substernal region or across the anterior upper


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chest. Often, the area of pain is the size of a clenched fist and the patient may place his or her fist over

the area of discomfort (Levine's sign). The sensation may radiate to the neck, jaw, or tongue; to either

arm, elbow, wrist, or hand; or to the upper abdomen. Anginal discomfort is typically of short duration,

usually 3 to 5 minutes, but can last up to 30 minutes or longer. The discomfort may have been brought

on by physical or emotional stress, exposure to extreme temperatures, or eating a heavy meal.

Termination of the precipitating factor may bring about alleviation of the discomfort. Frequently, the

patient is anxious, pale, diaphoretic, lightheaded, dyspneic, tachycardiac, and nauseated. Upon

auscultation, the patient may have atrial or ventricular gallops (S3, S4).

3. PSYCHOSOCIAL. Patients often rationalize that their symptoms are the result of indigestion or

overexertion. Denial can interfere with identification of a symptom and be harmful to the patient. Chest

pain and all the surrounding implications can be extremely stressful and anxiety-producing to the

patient and family.

II. Primary Nursing Diagnosis

Acute pain related to decreased myocardial blood flow.

III. Planning and Intervention

COLLABORATIVE

For any patient who is experiencing an acute anginal episode, pain management is the priority not only

for patient comfort but also to decrease myocardial oxygen consumption. The physician orders selected

therapies that either decrease myocardial oxygen demand or increase coronary blood and oxygen

supply. These therapies may include short-term bedrest; oxygen therapy; cardiac monitoring to prevent

potential complications; and small, frequent, easily digested meals.

Diet.A collaborative effort among the patient, dietitian, physician, and nurse plans for a diet low in

cholesterol, fat, calories, and sodium. Drinks in the coronary care unit or step-down unit are usually

decaffeinated and not too hot or cold.

Vital signs.During unstable periods, the nurse and physician closely monitor the patient's vital signs and

her or his response to pain-relieving therapies (narcotics, nitrates). Often the patient is placed on a

cardiac monitor to determine if life-threatening dysrhythmias occur during an anginal episode,

particularly if the angina may be a symptom that the patient is having an MI.

Independent

To decrease oxygen demand, encourage the patient to maintain bedrest until the pain subsides; even

though bedrest is usually short term, a sheepskin, air mattress, foam pad, foot cradle, or heel pads can

reduce the risk of skin breakdown and increase patient comfort.


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IV. Evaluation

Description of pain: Onset ,character, precipitating factors, associated symptoms, duration, andalleviating factors of the anginal episode

Response to prescribed medications Reaction to bedrest or limitation in activity

5 Priority Nursing Diagnoses

1. Acute pain related to decreased myocardial blood flow.2. Activity intolerance related imbalance between oxygen supply and demand.3. Anxiety related to situational crises.4. Deficient knowledge relatedto misinterpretation.5. Risk for decreased cardiac output

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Angina Pectoris Sharina