19014331 Angina Pectoris

8/8/2019 19014331 Angina Pectoris

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ANGINAANGINA

PECTORISPECTORISMarcos , Jose R.N


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Description/DefinitionDescription/Definition Chest pain caused by myocardial ischemia(cellChest pain caused by myocardial ischemia(cellhypoxia)hypoxia)

Deprivation of oxygen leads to anaerobic metabolismDeprivation of oxygen leads to anaerobic metabolismof the heart producing lactic Acid, which causes chestof the heart producing lactic Acid, which causes chestpain and other related clinical problemspain and other related clinical problems

A disease marked by brief paroxysmal attacks ofA disease marked by brief paroxysmal attacks ofchest pain precipitated by deficient oxygenation ofchest pain precipitated by deficient oxygenation ofthe heart musclesthe heart muscles


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AnatomyandPhysiologyAnatomyandPhysiology


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LayersoftheheartLayersoftheheart

EndocardiumEndocardium-- innermost layer consist of thininnermost layer consist of thinendothelial tissue lining the inner chambers andendothelial tissue lining the inner chambers andheart valves.heart valves.

MyocardiumMyocardium-- middle layer consist of striatedmiddle layer consist of striatedmuscle fiber ; actual muscle of the heart.muscle fiber ; actual muscle of the heart.

EpicardiumEpicardium

Visceral epicardiumVisceral epicardium-- covers the outer surface of thecovers the outer surface of the

heart; it adheres to the heart.heart; it adheres to the heart. Parietal epicardiumParietal epicardium-- encapsulates the visceralencapsulates the visceral

epicardium.epicardium.


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ChambersoftheheartChambersoftheheart

AtriaAtria-- upper collecting chambersupper collecting chambers

a.Righ

t atriuma.Righ

t atrium-- receives deoxygenated bloodreceives deoxygenated bloodb.Left atriumb.Left atrium-- receives oxygenated bloodreceives oxygenated blood

VentriclesVentricles-- lower pumping chamberslower pumping chambers

a.Right ventriclea.Right ventricle-- pumps blood into the lungspumps blood into the lungs

b.Left ventricleb.Left ventricle-- hearts largest, most muscular chamberhearts largest, most muscular chamberthat pumps blood into the systemic circulation.that pumps blood into the systemic circulation.


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FunctionsofthecardiovascularsystemFunctionsofthecardiovascularsystem

Electrophysiologic propertiesElectrophysiologic properties

a.a. ExcitabilityExcitability-- ability of the cardiac muscle cells toability of the cardiac muscle cells todepolarize in response to stimulus through the NAdepolarize in response to stimulus through the NA-- KK

pump and calcium ions.pump and calcium ions.b.b. Automacity/ rhythmicityAutomacity/ rhythmicity-- initiate an impulseinitiate an impulse

c.c. ContractilityContractility-- the contraction per secondthe contraction per second

d.d. RefractorinessRefractoriness-- inability to respond to a newinability to respond to a new stimulusstimuluswhile still in a state of depolarization fromwhile still in a state of depolarization from an earlieran earlierstimulusstimulus

e.e. ConductivityConductivity-- ability to propagate electricalability to propagate electrical impulsesimpulsesthrough the conduction systemthrough the conduction system

Cardiac cycle:Cardiac cycle: one cardiac cycle = one complete heartone cardiac cycle = one complete heart

beatbeat


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PredisposingF

actors:PredisposingF

actors: SexSex malemale Black raiseBlack raise

HyperlipidemiaHyperlipidemia SmokingSmoking

HypertensionHypertension

Diabetes mellitusDiabetes mellitus

Sedentary lifestyleSedentary lifestyle

StressStress


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PrecipitatingFactors:PrecipitatingFactors: EatingEating

EmotionEmotion

EffortEffort Extreme temperatureExtreme temperature

EliminationElimination


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SignsandSymptomsSignsandSymptoms An uncomfortable pressure, fullness, squeezing, or pain inAn uncomfortable pressure, fullness, squeezing, or pain in

the center of the chestthe center of the chest

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

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

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

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


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OthersymptomsmayoccurwithananginaOthersymptomsmayoccurwithanangina

attack:attack: Shortness of breathShortness of breath

LightheadednessLightheadedness

FaintingFainting

Anxiety or nervousnessAnxiety or nervousness

Sweating or cold, sweaty skinSweating or cold, sweaty skin

NauseaNausea

Rapid or irregularh

eart beatRapid or irregularh

eart beat Pallor (pale skin)Pallor (pale skin)

Feeling of impending doomFeeling of impending doom


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Priority1: AcutePainR/TdecreasePriority1: AcutePainR/Tdecrease

myocardialbloodflowmyocardialbloodflow


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AssessmentAssessment NursingNursing

DiagnosisDiagnosis

PlanningPlanning InterventionIntervention RationaleRationale EvaluationEvaluation

Objective:Objective:

>Facial Grimace>Facial Grimace

>Guarding pain>Guarding pain

>Clinched fist>Clinched fist>irritable>irritable

>diaphoresis>diaphoresis

>Narrowed>Narrowed

FocusFocus

>Disturbed>DisturbedSleepSleep

>pain scale of>pain scale of

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Pain R/TPain R/T

decreasedecrease

myocardialmyocardial

blood flowblood flow

After theAfter the

shift, theshift, the

patientpatient

willwillreport areport a

decreasdecreas

e in paine in pain

asas

evidenceevidence

by a painby a pain

scale ofscale of

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1.1.Instructed client to notifyInstructed client to notify

nurse immediately whennurse immediately when

chest pain occurs.chest pain occurs.

2.2.Assessed and documentAssessed and document

client response ofclient response of

medicationmedication

3.3.Identified precipitatingIdentified precipitating

event frequency, duration,event frequency, duration,

intensity, and location ofintensity, and location of

painpain

4.4.Observed for associatedObserved for associated

symptoms of dyspnea,symptoms of dyspnea,

nausea/vomiting,nausea/vomiting,

dizziness, palpitations,dizziness, palpitations,

dsire to micturatedsire to micturate

5.5.Placed client at completePlaced client at complete

rest during anginarest during angina

episodesepisodes

6.6.Elevated head of bed , ifElevated head of bed , if

client is short of breathclient is short of breath

7.7.Monitored vital signsMonitored vital signs

every 5 min. during initialevery 5 min. during initialangina attackangina attack

8.8.Maintained quiet,Maintained quiet,

comfortable environment,comfortable environment,

restrict visitors asrestrict visitors as

necessarynecessary

yyPain and decreased cardiac outputPain and decreased cardiac output

may stimulate the sympatheticmay stimulate the sympathetic

nervous system to releasenervous system to release

excessive amounts ofexcessive amounts of

Norepinephrine ,w/c increasesNorepinephrine ,w/c increases

platelet aggregationplatelet aggregation

yyProvides information about diseaseProvides information about disease

progression .progression .

yyHelps differentiate this chest pain,Helps differentiate this chest pain,

and aids in evaluating possibleand aids in evaluating possible

progression to unstable anginaprogression to unstable angina

yyDecrease cardiac output stimulatesDecrease cardiac output stimulates

sympathetic/para sympatheticsympathetic/para sympathetic

nervous system, causing a variety ofnervous system, causing a variety of

vague sensationsvague sensations

yyReduces myocardial oxygenReduces myocardial oxygen

demand to minimize risk of tissuedemand to minimize risk of tissue

injuryinjury

yyFacilitates gas exchange toFacilitates gas exchange to

decrease hypoxiadecrease hypoxia

yyBlood pressure may initially riseBlood pressure may initially rise

because of sympathetic stimulationbecause of sympathetic stimulation

yyMental/ emotional stress increasesMental/ emotional stress increases

myocardial workloadmyocardial workload

yyDecreases myocardial workloadDecreases myocardial workload

associated with workload ofassociated with workload of

digestion, reducing risk of anginadigestion, reducing risk of angina

The goalThe goal

was met,was met,

after theafter the

shift theshift thepatientpatient

verbalizedverbalized

decreasedecrease

in painin pain

with a painwith a pain

scale ofscale of1/101/10


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Priority2: RiskforDecreaseCardiacOutputPriority2: RiskforDecreaseCardiacOutput

R/Talteredheartrate/rhythmR/Talteredheartrate/rhythm


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DiagnosisDiagnosis


ObjectiveObjective::

>edema>edema

>weight>weight gaingain>dysnea>dysnea

>Clammy>Clammy

skinskin

>decreased>decreased

peripheralperipheralpulsespulses

>tachycardia>tachycardia

Risk forRisk for

decreasedecrease

cardiaccardiacoutputoutput

related torelated to

alteredaltered

heartheart

rate/rhythmrate/rhythm

After theAfter the

shift, theshift, the

patientpatientwillwill

ParticipaParticipa

te inte in

activitiesactivities

thatthatreducereduce

thethe

workloaworkload of thed of the

heart.heart.

1.Maintained bed rest1.Maintained bed rest

in position of comfortin position of comfort

during acuteduring acuteepisodesepisodes

2.Auscultated breath2.Auscultated breath

sounds and heartsounds and heart

sounds .sounds .

3.Provided adequate3.Provided adequate

rest periods .rest periods .

4.Assess for signs4.Assess for signs

and symptoms ofand symptoms of

Heart failureHeart failure

5.Evaluated mental5.Evaluated mental

status, notingstatus, noting

development ofdevelopment of

confusion,confusion,disorientationdisorientation

6.Noted skin color6.Noted skin color

and presence ofand presence of

pulsespulses

7.Administered7.Administered

supplemental oxygensupplemental oxygenas neededas needed

yyDecreases oxygenDecreases oxygen

consumption/ demand,consumption/ demand,

reducing myocardialreducing myocardialworkload and risk ofworkload and risk of

decompensationdecompensation

yyS3, S4, or crackles canS3, S4, or crackles can

occur with cardiacoccur with cardiacdecompensation.decompensation.

yy

Conserve energy, reducesConserve energy, reducescardiac workloadcardiac workload

yyDisease may compromiseDisease may compromise

cardiac function to point ofcardiac function to point of

decompensationdecompensation

yyReduced perfusion of theReduced perfusion of the

brain can producebrain can produce

observable changes inobservable changes insensoriumsensorium

yyPeripheral circulation isPeripheral circulation is

reduced when cardiac outputreduced when cardiac output

falls, giving a skin pale orfalls, giving a skin pale or

gray color and diminishinggray color and diminishing

the strength of peripheralthe strength of peripheral

pulsespulses

yyIncrease ox en availableIncrease ox en available

Goal wasGoal was

met,met,

The patientThe patienthad activelyhad actively

participatedparticipated

in activitesin activites

that helpthat help

reduce thereduce theworkload ofworkload of

the heartthe heart


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Priority3: AnxietyR/T ChangeinHealthPriority3: AnxietyR/T ChangeinHealthStatusStatus


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DiagnosisDiagnosis


Objective:Objective:

>poor eye>poor eye

contactcontact>restless>restless

>irritable>irritable

>difficulty>difficulty

concentratinconcentratin

gg

>increased>increased

tensiontension

Anxiety R/TAnxiety R/T

Change inChange in

HealthHealthStatusStatus

After theAfter the

shift theshift the

patientpatientwillwill

identifyidentify

healthyhealthy

ways toways to

deal withdeal with

andand

expressexpress

anxiety.anxiety.

1.1.Explained purpose ofExplained purpose of

test and procedurestest and procedures

2.2.EncouragedEncouraged

expression of feelingsexpression of feelings

and fearsand fears

3.3.Encouraged familyEncouraged family

and friends to treatand friends to treat

client as beforeclient as before

4.4.Tell client theTell client the

medical regimen hasmedical regimen has

been designed tobeen designed to

reduced attacks andreduced attacks andincrease cardiacincrease cardiac

stability.stability.

5.5.AdministeredAdministered

sedatives,sedatives,

tranquilizers, astranquilizers, as

indicatedindicated

yyReduces anxietyReduces anxiety

attributable to fear ofattributable to fear of

unknown diagnosis andunknown diagnosis andprognosis.prognosis.

yyVerbalization of concernsVerbalization of concerns

reduces tension, verifiesreduces tension, verifies

level of coping, andlevel of coping, and

facilitates dealing withfacilitates dealing with

feelings.feelings.

yyReassures client that theReassures client that the

role in the family androle in the family and

business has not beenbusiness has not been

altered.altered.

yyEncourages client to testEncourages client to test

symptom control, tosymptom control, to

increase confidence inincrease confidence in

medical program, andmedical program, andintegrate abilities intointegrate abilities into

perceptions of selfperceptions of self

yyMay be desired to helpMay be desired to help

client relax until physicallyclient relax until physically

able to reable to re--establishestablish

adequate copingadequate coping

strategies.strategies.

Goal wasGoal was

met, themet, the

patientpatientidentifiedidentified

healthyhealthy

ways toways to

deal withdeal with

andand

expressedexpressed

anxiety.anxiety.


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Exercise:Exercise:

--Increase walking time by 5min/week untilIncrease walking time by 5min/week untilwalking 20walking 20--30min 330min 3--4 times a week4 times a week

--ankle flexion and extension exercises.ankle flexion and extension exercises.

DischargedPlanningDischargedPlanning


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Treatment:Treatment:

--Surgical interventions are used to increase coronarySurgical interventions are used to increase coronary

perfusion and myocardial oxygen supply such

as:perfusion and myocardial oxygen supply such

as:

a. PTCAa. PTCA-- Percutaneous TransluminarCoronaryPercutaneous TransluminarCoronaryAngioplasty.Angioplasty. The insertion of aThe insertion of a

balloon tip catheterballoon tip catheter

b. CABGb. CABG-- Coronary Artery Bypass Grafting.Coronary Artery Bypass Grafting.--rerouting of coronary arteryrerouting of coronary artery



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Health teaching:Health teaching:

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

-- do not lift, push or pull anything greater than 10pounds for 4do not lift, push or pull anything greater than 10pounds for 4--6 weeks6 weeks

-- Return to work as prescribed the medical doctorReturn to work as prescribed the medical doctor

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

-- bring medications everyday everywhere.bring medications everyday everywhere.

-- Avoid strenuous activitiesAvoid strenuous activities



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19014331 Angina Pectoris