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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
7/107/10
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
1/101/10
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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AssessmentAssessment NursingNursing
DiagnosisDiagnosis
PlanningPlanning InterventionIntervention RationaleRationale EvaluationEvaluation
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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AssessmentAssessment NursingNursing
DiagnosisDiagnosis
PlanningPlanning InterventionIntervention RationaleRationale EvaluationEvaluation
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
DischargedPlanningDischargedPlanning
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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
DischargedPlanningDischargedPlanning
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