Objectives

CARE OF CLIENTS WITH  define the angina pectoris

ANGINA PECTORIS  list the etiology and clinical manifestations of

angina pectoris

 explain the pathophysiology of angina pectoris

 explain the collaborative management of clients

with angina pectoris
Norfidah Binti Mohamad
 determine the nursing care of clients with
angina pectoris

Definition
 Chest pain resulting from reduced
coronary blood flow causing a temporary
imbalance between myocardial blood
supply and demand

 Due to CHD, atherosclerosis or vessel

constriction that impairs blood supply to
myocardium

Precipitating factors Pathophysiology

 Hypermetabolic conditions such as  Temporary and reversible myocardial
ischemia caused by partial obstruction of
 Exercise coronary artery, coronary artery spasm or
 Thyrotoxicosis, hyperthyroidism thrombus
 Stimulant abuse (cocaine)
 Emotional stress  Cells in region supplied by artery are
deprived of essential oxygen and nutrients
for metabolic processes compromising
 Factors affecting blood and oxygen cellular processes
supplies
 Anemia
 Heart failure

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 Cells switch to anaerobic metabolism
causing lactic acid to build up in cells
 Cell membranes release histamine, kinins,
specific enzymes stimulating nerve fibers
in cardiac muscle that send pain impulses
to CNS
Types of angina
1.Stable angina:
 Most common and predictable angina;
occurs with predictable amount of
activity or stress
 Common manifestation of CHD
 Pain radiates to upper body because heart
shares same dermatome as this region
 Return of adequate circulation provides
nutrients and clears away waste products
 > 30 minutes of ischemia irreversible
damages myocardial cells or necrosis
 Occurs when work of heart
is increased by physical
exertion, exposure to cold,
stress
 Relieved by rest and
nitrates
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 Manifestations
2.Unstable angina 1. Chest pain
 Typically precipitated by identifiable event such
 Occurs with increasing frequency,
as physical activity, strong emotion, stress,
severity, duration eating a heavy meal, exposure to cold

 Pain is unpredictable and occurs with  Classic sequence: activity: pain, rest: relief
rest, low activity, stress

 At risk for myocardial infarction

 Description of pain: tight, squeezing, 2.Other

heavy pressure, constricting sensation manifestations:
beginning beneath sternum and may dyspnea,
radiate to jaw, neck, or arm pallor,
 Pain may just be in jaw, epigastric region, tachycardia,
or back great anxiety
 Pain usually lasts < 15 minutes; relieved
or fear
by rest

Collaborative Care Diagnostic Tests

1. Pain relief 1. Diagnosis based on
 Past medical history and family history

2. Restoration of coronary blood flow  Comprehensive description of pain

 Physical assessment findings

 Laboratory tests confirm presence of risk

factors

 Diagnostic tests: information about overall

cardiac function

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Electrocardiography
 Resting ECG: may be normal, show nonspecific
changes in ST segment and T wave; signs of
previous myocardial infarction
 ECG changes consistent with anginal episodes:
ST segment is depressed or downsloping; T wave
flattened or inverted
 Ischemic changes reverse when ischemia is
relieved
Nursing care of client having coronary
angiography
Before procedure
 Assessment of allergy to contrast media,
iodine, seafood; renal function tests
 Baseline assessment including peripheral
pulses
 Teaching regarding procedure, sense of
warmth and metallic taste with injection of
dye, lying flat post procedure
Coronary angiography
 Evaluation of coronary arteries; guided by
fluoroscopy,
 catheter introduced into femoral or
brachial artery and threaded into coronary
arteries and dye injected;
 main coronary branches are visualized
Post procedure
 Maintenance of bedrest with head elevated 30o;
monitoring vital signs, catheterization site for
bleeding, hematoma, peripheral pulses,
neurovascular status per protocol; report
significant deviations
 Minimal flexion or hyperextension of affected
extremity
 Maintenance of adequate fluid intake (IV and/or
oral)
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Medications
To reduce oxygen demand and increase
oxygen supply to myocardium
1. Nitrates
 Includes nitroglycerine (GTN) (sublingual
or buccal spray for acute angina relief)
and longer-acting nitrate preparations
(prevention of angina)
 Improves oxygenation by dilating
collateral blood vessels
 Longer acting preparations are available
as oral tablets, ointment, transdermal
patches to prevent angina
 The drug starts to work within 2 minutes
and goes on working for up to 30 minutes
 If the first nitrate dose does not relieve
angina within 5 minutes, take a second
dose
 After 5 more minutes, patient may take a
third dose if needed
Description
 Sublingual
 Drug of choice to treat acute angina
 Acts within 1 – 2 minutes
 Decreases myocardial work and oxygen
demand through arterial and venous
dilation
Health teaching
 Nitroglycerin is used to prevent chest pain
(angina). It works by relaxing the blood vessels
to the heart, so the blood flow and oxygen supply
to the heart is increased
 To use the tablets, instruct patient to place a it
under their tongue and allow it to dissolve.
 Do not swallow the tablet.
 Try not to swallow saliva too often until the tablet
dissolves.
 Patient may experience a burning
sensation under the tongue and develop a
transient headache when they take the
drug. The headache will diminish over
time
 Use caution when standing from a sitting
position, GTN may make the patient
lightheaded
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Beta-Blockers (e.g. propranolol) Calcium Channel Blockers (e.g. diltiazem)
 First-line drugs to treat stable angina
 Description
 Reduces myocardial oxygen demand
 Description
 Blocks cardiac-stimulating effects of
norepinephrine and epinephrine  Increases myocardial blood and oxygen
 Prevents anginal attacks by reducing heart supply
rate, myocardial contractility, and blood
pressure  Acts by lowering blood pressure and
 Reduces myocardial oxygen demand heart rate
 Contraindicated for clients with asthma or
severe COPD (severe bronchospasm)
 Reduces myocardial contractility

Revascularization Procedures
Aspirin Percutaneous Coronary Revascularization (PCR)
 Invasive procedures used to restore blood flow to
 Low dose prescribed to reduce risk of
ischemic myocardium
platelet aggregation and thrombus
formation
 Used to treat moderately severe, chronic, stable
angina unrelieved by medication; coronary
ischemia; unstable angina; acute myocardial
infarction

 Catheter introduced into narrowed coronary

artery and procedure performed to restore
circulation

Percutaneous Coronary Revascularization Percutaneous Transluminal Balloon

Angioplasty (PTCA)
(PCR)
 Balloon positioned across area of narrowing and
inflated to decrease vessel obstruction to less
that 50% of arterial lumen

 Usually used in combination with stent placement

(metallic scaffolds to maintain an open arterial
lumen, in 70 – 80 % PCR procedures)

 Antiplatelet medications (aspirin and ticlopidine)

to reduce thrombus formation

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Coronary Artery Bypass Grafting (CABG)

 Surgery involves using section of vein or

artery to create connection between aorta
and coronary artery beyond obstruction,
i.e. revascularization

 Blood perfuses ischemic sections of heart

 Internal mammary artery in chest and

saphenous vein from legs are vessels
commonly used for cardiac bypass grafts

 Surgery involves medial sternotomy; heart often

stopped during surgery and circulation is
maintained by cardiopulmonary bypass pump,
which oxygenates blood and perfuses organs
while heart is stopped

 Hypothermia during surgery reduces metabolic

rate and need for oxygen

 Grafting done by anastomosis of graft to aorta

and coronary artery distal to occlusion; internal
mammary artery (IMA) has only distal end
excised and anastomosed to coronary artery

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 Nursing Diagnoses for clients with
 Administer prescribed O2 via n/prong
angina (supplemental oxygen reduces myocardial
Ineffective Tissue Perfusion: Cardiac hypoxia

 Assess the location, severity and quality of  Space activity to allow rest between them
the client’s pain (to allow early (activity increase cardiac work and may
intervention and reduce the risk of further precipitate angina
damage

 Give GTN as prescribed ( GTN reduces  Instruct to take sublingual GTN before
cardiac work and may improve myocardial engaging in activities that precipitate
blood flow angina (this prophylactic dose help
maintain cardiac perfusion

Risk for Ineffective Therapeutic Regimen

Management Home Care
 Assess pt’s knowledge Education
 Understand angina and management
 Provide teaching, written and verbal
construction- esp. medication  Lower risk factors for CHD
 Medications
 Stress the importance of taking chest
pains seriously while maintaining a positive  Participation in rehabilitation
attitude

 Refer- rehabilitation program