PRADEEP'S_ Angina

8/6/2019 PRADEEP'S_ Angina

1/35


2/35

ANGINA PECTORIS:

INTRODUCTION:

Angina is usually caused by artherosclerotic disease.Almost

invariably, angina is associated with a significantobstruction of a major coronary artery.

DEFINITION:

Angina Pectoris is a clinical syndrome characterised byepisodes or paroxysms of pain or pressure in theanterior chest.


3/35

ETIOLOGY:

(1) PHYSICAL EXERTION- It may precipitate an attack byincreasing myocardial oxygen demand.

(2) EXPOSURE TO COLD- It can cause vasoconstriction &

an elevated blood pressure, with increased oxygendemand.

(3) EATING A HEAVY MEAL- It increases the blood flow tothe mesentric area for digestion which in turn reduces thrblood supply available to the heart muscle.

(4) STRESS OR ANY EMOTION- It causes the release ofadrenaline which in turn increases the blood pressure whichmay accelerate the heart rate & increase myocardialworkload.


4/35

It is not typically associated with thelisted factors, it may also occur at rest.


5/35

CANADIAN CARDIOVASCULARSOCIETY CLASSIFICATION OF

ANGINA:

CLASS ACTIVITYEVOKING

ANGINA

LIMITS TOACTIVITY

1 Prolongedexertion

None

2 Walking > 2

blocks

Slight

3 Walking < 2blocks

Marked

4 Minimal or rest Severe


6/35

PATHOPHYSIOLOGY:The cause is usually-

Insufficient coronary blood flow

Decreased oxygen supply to meet anincreased myocardial demand foroxygen

Need of oxygen exceeds the supply

Reduces the blood supply to the heart muscle.

Pain ( ANGINA )


7/35

TYPES OF ANGINA:

Angina is mainly of 5 types as follows:

Stable Angina: Its a predictable &consistent pain that occurs on exertion &

relieved on rest.

Unstable Angina (preinfarction orcrescendo angina): Its symptoms occurmore frequently & last longer than stableangina. The threshold for pain is lower & painmay occur at rest.

Intractable or refractory angina: Its a

severe incapacitating chest pain.


8/35

CONTINUE.

Variant or Prinzetals Angina: Its pain atrest with ST- Segment elevation; thoughtto be caused by coronary arteryvasospasm.

Silent Ischemia: Its an objective evidenceof ischemia (such as EEG changes with astress test) but patient reports nosymptoms.


9/35

CLINICAL MANIFESTATIONS:

Pain- which is often felt deep in the chest behind theupper or middle third of the sternum (RetrosternalArea)

Typically the pain or discomfort is poorlylocalised & may radiate to neck, jaw, shoulders &inner aspects of the upper arms usually the left arm.

The patient often feels tightness or a heavy, chokingor strangling sensation that has a viselike insistentquality

The patient with Diabetes Mellitus may not havesevere pain with angina because the neuropathythat accompanies diabetes can interfere withneuroreceptors, dulling the patients perception ofpain.


10/35

Continue

~

A feeling of weakness or numbness inthe arms, wrists &hands mayaccompany the pain as may

shortness of breath

diaphoresisdizziness

light headedness

nausea & vomiting

An important characteristic of angina isthat it abates or subsides with rest or

nitroglycerin.


11/35

DIAGNOSTIC EVALUATION:

1. ECG, Echocardiogram & blood laboratory valueshelp in making the diagnosis.

2. Coronary Artery Angiograpy (CAD)- to diagnosethe inflammation of the arterial endothelium.

3. C-Reactive protein (CRP)- is a marker for theinflammation of vascular endothelium.

High blood levels ofCRP have beenasssociated with increased coronary artery

calcification & risk of an acute cardiovascularevent (e.g. MI)

4. An elevated blood level of homocystiene, anamino acid, has also been proposed as anindependent risk factor for cardiovascular

disease.


12/35

MANAGEMENT:

MEDICAL:The objective of the medical management of

angina is to decrease the oxygen demand of themyocardium & to increase the oxygen supply.

Among medications used to control angina are:

Nitroglycerin.

Beta-Adrenergic blocking agents.

Calcium channel blockers.

Antiplatelet agents.


13/35

(a) NITROGLYCERIN:

A vasoactive agent, nitroglycerin (Nitrostat, Nitrol,Nitrobid IV)

Reduces myocardial oxygen consumption

Decreases ischemia

Relieves pain.

It helps to increase coronary blood flow bypreventing vasospasm & increasing perfusionthrough the colateral vessels.


14/35

(b)BETA-ADRENERGIC BLOCKINGAGENTS:

Beta-blockers such as propranolol (Inderal),metoprolol (Lopressor, Toprol) & atenolol(Tenormin)

Blocks the Beta-Adrenergic sympathetic stimulation to

the heart.

Reduces myocardial oxygen consumption

Decreases ischemia

Relieves pain.


15/35

(c) CALCIUM CHANNEL BLOCKERS:

Dilate the smooth muscle wall of the coronaryarterioles

Reduces systematic arterial pressure

Decrease myocardial oxygen demand

Reduces the workload of the heart.


16/35

(d) ANTIPLATELET & ANTICOAGULANTMEDICATIONS:

Antiplatelet & anticoagulant medications areadministered

to prevent platelet aggregation which impedesblood flow

e.g. Aspirin, Clopidogrel, Ticlopidine, Heparin etc.


17/35

OXYGEN ADMINISTERATION:

Oxygen therapy is usually initiated at the onset ofchest pain

Increase the amount of oxygen delivered to themyocardium

Decrease pain.


18/35

REVASCULARIZATIONPROCEDURES:

Revascularization procedures are to restore the blood

supply

to the myocardium.It includes Percutaneous Coronary

Inventional (PCI) procedures[ e.g PercutaneousTransluminal

Coronary Angioplasty (PTCA)], intracoronary stents &

artherectomy, CABG & Percutaneous TransluminalMyocardial

Revascularization (PTMR)


19/35

NURSINGMANAGEMENT:

ASSESSMENT:

Gather information about the patients symptoms &activities,

especially those that precede & precipitate attacks of Angina

Pectoris. Appropriate questions are identified using a PQRST format

i.e.

CONTINUE


20/35

ASSESSMENT OF ANGINA:

ACROMYN FACTORS ABOUTPAIN THAT NEED

TO BE ASSESED

ASSESSMENT

QUESTIONS

P Position/Location

Provocation

(1)Where is thepain? Can u point to

it?

(2)What were u

doing when the painbegan?

Q Quality (3)How would u

describe pain?

(4)Is it like the painu had before?


21/35

CONTINUE..

ACROMYN FACTORS ABOUT

PAIN THAT NEED

TO BE ASSESSED

ASSESSMENT

QUESTIONS

Q Quantity (5)Has the painbeen constant?

R Radiation

Relief

(6)Can u feel the

pain anywhere

else?

(7)Did anything

make the pain

better?


22/35

CONTINUE

ACROMYN FACTORS ABOUTPAIN THAT NEED TO

BE ASSSSED

ASSESSMENT

QUESTIONS

S Severity

Symptoms

(8)How would urate the pain on a

0-10 scale with 0

being no pain & 10

being the most

amount of pain?

(9)Did u notice

any other

symptom with the

pain?


23/35

CONTINUE

ACROMYN FACTORS ABOUT

PAIN THAT NEED

TO BE ASSESSED

ASSESSMENT

QUESTIONS

T Timing (10) How long ago

did the pain start?


24/35

CONTINUE

Other helpful questions may be asked like:

How long the angina usually start?

Does Nitroglycerin relieve the angina?If, so howmany tablets or sprays are needed to achieverelief?

How long does it take for relief to occur?


25/35

NURSING DIAGNOSIS:

Based on the assessment data major nursing diagnosis for thepatient may include:

(a) Discomfort related to pain as manifested by facialexpressions.

GOAL: To relieve the pain.

NURSING INTERVENTIONS:

(1)To assess the quality, frequency, attitude, site & othercharacteristics of pain.

(2)To review the assessment findings & identify the level ofactivity that causes the patients pain & plans the patientsactivity thoroughly.

(3)If the patient has pain frequently or with minimal activity, thenurse must alternates the activities with rest periods.

(4)Balance of activity &rest is an important aspect of theeducational plan for the patient & family.


26/35

(b) Ineffective myocardial tissue perfusion secondaryto CAD related to coronary blood flow asmanifested by chest pain or equivalent

symptoms.GOAL: To stabilize the coronary blood flow.


(1) Initially to assess, document & report to the

physician the following: Patients description of chest discomfort including

location, intensity, duration & factors that effectit.

The effect of chest discomfort on cardiovascular

perfusion-to the heart (e.g. change in BP, heartsounds), to the brain (e.g. changes in LOC), tothe kidneys (e.g. decrease in urine output) & tothe skin (e.g. colour, temperature.)


27/35

CONTINUE.

(2) Obtain ECG recording during the symptomatic events asprescribed, to determine extension of infarction.

(3) Administer oxygen as prescribed.

(4) Ensure physical rest, use of bedside commade assistance,backrest elevated to promote comfort, diet as tolerated, armssupported during upper extremity activity & use of stoolsoftners to prevent straining of stool.

(5) Provide a restful environment & allay fears & anxiety by beingsupportive, calm & competent.

(6)Administer medication therapy as prescribed & evaluate the

patients response continuously.


28/35

(c) Anxiety related to fear of death as manifested byfacial expressions & questions asked by thepatient.

GOAL: To relieve the anxiety.


(1) To assess, document & report to the physicianthe patients & familys level of anxiety & copingmechanisms.

(2) Allow patient & family to express anxiety & fear;

By showing genuine interest & concern.

By facilitating communication (listening,reflecting & guiding.)

By answering questions.


29/35

CONTINUE

(3) To assess the need for spiritual counseling & refer

as appropriate.(4) Use of flexible visiting hours allows the presence

of a supportive family to assist in reducing thepatients level of anxiety.

(5)Encourage active participation in a cardiacrehabilitation program.

(6) Teach stress reduction techniques.


30/35

(d) Deficient knowledge about the underlying disease, methodsof avoiding complications & self care activities as manifestedby asking questions.

GOAL: To make the patient & family knowledgeable.


(1)To develop a teaching plan for the patient & family. Providespecific instructions for the following:

Diet & daily weights. Activity progression.

Exercise.

Deep breathing, coughing & lung expansion exercises.

Temperature monitoring.

Medication regimen.

Pulse taking.

CPR, if appropriate for the family to learn.

Need for the Medical Alert identification.


31/35

CONTINUE.

(2) To provide written & verbal instructions; provideseveral teaching sessions for reinforcement &answering questions.

(3) Involve family in teaching sessions.

(4) Provide information regarding follow-up, phone callto surgeon, cardiologist or liaison nurse.

(5)Make appropriate refferals; home care agency,cardiac rehabilitation program, community supportgroups & Mended Heart Club.


32/35

COMPLICATIONS:

Acute pulmonary edema.

Congestive heart failure.

Cardiogenic shock.

Dysrhythmias & cardiac arrest.

Myocardial infarction.

Myocardial rupture.

Pericardial effusion & cardiac tamponade.


33/35

BIBLIOGRAPHY:

~ JUDITH K. SANDE, PANELA.E. DENNISON,CLINICAL MANUALOF MEDICAL-SURGICALNURSING, ELSIEVER PUBLISHERS,P-725.

~ JOYCE M.BLACK & HANKS JANE HOKANSON,

MEDIC

AL-SURG

ICAL

NURSING,

Ist ED

ITION,SAUNDERS PUBLISHERS, NEW DELHI,2005, Pg-

589.

~ BASAVANTHAPPA BT,MEDICAL-SURGICALNURSING 7th EDITION, JAYPEE PUBLISHERS,NEW

DELHI, P-121-22.

~ SUZANNE C.SMELTZER & BRTENDABARE,:TEXTBOOK OF MEDICAL-SURGICALNURSING, 10th EDITION, ELSIEVER

PUBLISHERS, P-723-30.


34/35


35/35

PRADEEP'S_ Angina

Documents

Transcript of PRADEEP'S_ Angina