BROAD OBJECTIVE At the end of this presentation, learners should be able to manage the patient with angina pectoris.
OUTLINE1. Define and describe the classification of angina pectoris2. Explain the etiology and pathophysiology of angina pectoris3. Describe the clinical manifestation of angina pectoris4. Describe the diagnostic evaluation of the angina pectoris5. Explain the nursing assessment and its diagnosis6. Explain the nursing management of angina pectoris7. Explain the medical/ surgical management of angina pectoris8. Outline the complications of angina pectoris
Definition It is commonly called “angina” It is the chest pain that is due to ischemia of the heart muscle, generally due to obstruction or spasm of the coronary arteries
TYPES OF ANGINA PECTORIS The most three types of angina include: Stable angina- It is triggered by a predictable degree of physical exertion or motion but can be improved after rest.- It is the most common type of angina Unstable angina- It is triggered by unpredictable degree which may occur at night- It is more dangerous and requires emergency treatment and is often a sign that heart attack can occur soon Variant angina- this is a rare form that is caused by a spasm in coronary artery
ETIOLOGY AND PATHOPHYSIOLOGY Angina pectoris is as a result of ischemia of the heart which is due to antherosclerosis of the coronary arteries which restricts blood flow to the myocardium. Due to myocardium ischemia, the myocardial tissues are deprived of oxygen and nutrients for the aerobic metabolism. As a result there is an inclusion of anaerobic metabolism which leads to accumulation of lactic acid
Due to increase of lactic acid, myocardial nerve fibers are irritated and this transmit a pain message to the cardiac nerves and upper thoracic posterior nerve roots And all this leads to cardiac pain which is the angina pectoris
DIAGNOSTIC EVALUATION Electrocardiography (ECG)- an ECG recorded in the presence of pain may record transient ischemic attacks.- it also suggest coronary artery’s involvement and the extent of the myocardium affected by the ischemic event Exercise electrocardiography- This involves the client exercising on a treadmill or stationery bicycle until reaching a maximum of 85% heart rate. If any change in the ECG or vital signs may indicate the presence of ischemia
Radioisotope- this involves the use of different nuclear imaging techniques to evaluate heart muscles.- regions of ischemia appear as areas of diminished activity Ultrafast computed tomography- it enables detection of the amount of calcium in the coronary arteries. High coronary calcium rate is associated with obstructive coronary disease.
Coronary angiography- it detect the percentage of blockage in coronary artery- it remains the most accurate test Chest x-ray- it allows the detection of cardiomegaly and non cardiac causes of chest pain e.g pneumonia
NURSING ASSESSMENTSUBJECTIVE DATAPast health history- previous history of cardiac artery disease, angina, myocardial infarction, anemia and heart failureMedications- use of aspirin, calcium channel blockers and antihypertensiveFamily history- history of heart disease, tobacco useNutritional history- heart burn, nausea, vomitingCoping stress mechanism- anger, anxiety, depression and stressful life style
OBJECTIVE DATAGeneral- anxiety, fear, restlessnessIntegumentary- cool, clammy, pale skinCardivascular- tachycardia or bradycardia, dysrhythmias, low Bp or hypertensionPossible findings- increase in white blood cell count, positive exercise stress test, ST segment and T wave abnormalities on ECG, cardiac enlargement, pulmonary congestion on chest x-ray and positive coronary angiography.
NURSING DIAGNOSIS Acute pain related to myocardial ischemia as evidenced by severe chest pain and tightness Ineffective tissue perfusion related to myocardial injury as evidenced by dyspnea, decrease in Bp. Anxiety related to perceived or actual threat of death, pain and possible life style changes as manifested by restlessness and patient asking too much questions Activity intolerance related to fatigue secondary to decreased cardiac output and poor lung and tissue perfusion as manifested by increased heart rate
Ineffective therapeutic regimen management related to lack of knowledge of disease process as evidenced by frequent questioning about the illness and management after discharge
NURSING MANAGEMENT- evaluate chest pain e.g location in order to accurately evaluate, treat and prevent further ischemia- promote bed rest in semi fowlers position, it relaxes the muscles of the chest cavity- monitor vital signs after every 5 minutes on each attack to review the effectiveness of the care given
- Monitor fluid balance (e.g. monitor input and output, daily weight ) to monitor renal perfusion and observe for fluid retention- Provide factual information concerning the disease process to decrease fear of the unknown- administer prescribed medication to relieve pain and ischemia to decrease anxiety and cardiac workload e.g. Nitroglycerin-which dilates the coronary arteries and increases the supply of oxygen to the myocardium
MEDICAL MANAGEMENT It focuses on three goals1. Relief of the acute pain. The major drugs used to reduce acute pain are opioid analgesics e.g nitroglycerin2. Restore coronary blood flow. Administer vasodilators e.g propanolol, calcium channel blockers such as felodipine.3. Prevent further attacks-this is done through education and counselling regarding modification of risk factors of the disease.
This reduce the progression of coronary heart disease.
Complications of Angina Pectoris Angina pectoris can lead to:-• Heart failure• Acute renal failure• Myocardial infarction• Cardiac arrest• Death
References1. Black J. M. and Hawks J (2009) Medical – surgical Nursing, Clinical Management for positive outcomes (8th edition) saunders, Elsevier2. Lewis S. M., Heitkemper M. M and Dirksen S. R (2007) Medical /Surgical Nursing. Assessment and management of clinical problems. (7th edition) St Louis: C.V. Mosby3. http://www.servier.co.uk