Nursing diagnosis: Angina pectoris related to increased cardiac workload and oxygen consumption; decreased myocardial blood flow, tissue ischemia.
Possibly evidenced by
Reports of pain varying in frequency, duration, and intensity, especially as condition worsens
Distraction behaviors, such as moaning, crying, pacing, or restlessness
Autonomic responses, such as diaphoresis, BP and pulse rate changes, pupillary dilation, increased or decreased respiratory rate
Desired Outcomes/Evaluation Criteria—Client Will
Report anginal episodes decreased in frequency, duration, and severity.
Demonstrate relief of pain as evidenced by stable vital signs and absence of muscle tension and restlessness.
Nursing care plan with intervention:
1. Instruct client to notify nurse immediately when chest pain occurs.
Rationale: Pain and decreased cardiac output may stimulate the sympathetic nervous system to release excessive amounts of norepinephrine, which increases platelet aggregation, and release of thromboxane A2. This potent vasoconstrictor causes coronary artery spasm, which can precipitate, complicate, and prolong an anginal attack. Unbearable pain may cause vasovagal response, thus decreasing BP and heart rate.
2. Assess and document client response and effects of medication.
Rationale: Provides information about disease progression. Aids in evaluating effectiveness of interventions and may indicate need for change in therapeutic regimen.
3. Identify precipitating event, if any; identify frequency, duration, intensity, and location of pain.
Rationale: Helps differentiate chest pain and aids in evaluating possible progression to unstable angina. Stable angina usually lasts 3 to 15 minutes and is often relieved by rest and sublingual
nitroglycerin (NTG); unstable angina is more intense, occurs unpredictably, may last longer, and is not usually relieved by NTG or rest.
4. Observe for associated symptoms, such as dyspnea, nausea, vomiting, dizziness, palpitations, and desire to urinate.
Rationale: Decreased cardiac output, which may occur during ischemic myocardial episode, stimulates sympathetic or parasympathetic nervous system, causing a variety of vague sensations that client may not identify as related to anginal episode.
5. Evaluate reports of pain in jaw, neck, shoulder, arm, or hand (typically on left side).
Rationale: Cardiac pain may radiate; for example, pain is often referred to more superficial sites served by the same spinal cord nerve level.
6. Place client at complete rest during anginal episodes.
Rationale: Reduces myocardial oxygen demand to minimize risk of tissue injury and necrosis.
7. Elevate head of bed if client is short of breath.
Rationale: Facilitates gas exchange to decrease hypoxia and resultant shortness of breath.
8. Monitor heart rate and rhythm.
Rationale: Clients with unstable angina have an increased risk of acute life-threatening dysrhythmias, which occur in response to ischemic changes and stress.
9. Monitor vital signs every 5 minutes during initial anginal attack.
Rationale:BP may initially rise because of sympathetic stimulation and then fall if cardiac output is compromised. Tachycardia also develops in response to sympathetic stimulation and may be sustained as a compensatory response if cardiac output falls.
10. Stay with client who is experiencing pain or appears anxious.
Rationale: Anxiety releases catecholamines, which increase myocardial workload and can escalate or prolong ischemic pain. Presence of nurse can reduce feelings of fear and helplessness.
11. Maintain quiet, comfortable environment; restrict visitors as necessary.
Rationale: Mental or emotional stress increases myocardial workload.
12. Provide light meals. Have client rest for 1 hour after meals.
Rationale: Decreases myocardial workload associated with work of digestion, reducing risk of anginal attack.
13. Provide supplemental oxygen, as indicated.
Rationale: Increases oxygen available for myocardial uptake and reversal of ischemia.
14. Administer anti-anginal medication(s) promptly, as indicated, for example:
Nitrates: NTG sublingual (Nitrostat, NitroQuick); extended release tablets and capsules, such as Nitrong and Nitrogard SR; metered-dose spray (Nitrolingual); transdermal patch (Minitran, Nitrodisc); transdermal ointment (Nitrol, Nitro-Bid); isosorbide (Isordil, Imdur).
Rationale: NTG has been the standard for treating and preventing anginal pain for more than 100 years. Today, it is available in many forms and is still the cornerstone of anti anginal therapy. Rapid vasodilator effect lasts 10 to 30 minutes and can be used prophylactically to prevent, as well as abort, anginal attacks. Long-acting preparations are used to prevent recurrences by reducing coronary vasospasms and reducing cardiac workload. May cause headache, dizziness, and light-headedness—symptoms that usually pass quickly. If headache is intolerable, alteration of dose or discontinuation of drug may be necessary. Note: Isordil may be more effective for clients with variant form of angina.
15. Beta blockers, such as atenolol (Tenormin), carteolol (Cartrol), labetalol (Normodyne), nadolol (Corgard), metroprolol (Tropol XL), and propranolol (Inderal).
Rationale: Reduce angina by reducing the heart’s workload. (Refer to ND: risk for decreased Cardiac Output following.) Note: Often, these drugs alone are sufficient to relieve angina in less severe conditions.
16. Calcium channel blockers, such as bepridil (Vascor), amlodipine (Norvasc), nicardipine (Cardene), nifedipine (Procardia), felodipine (Plendil), isradipine (DynaCirc), and diltiazem (Cardizem).
Rationale: Produce relaxation of coronary vascular smooth muscle, dilate coronary arteries, and decrease peripheral vascular resistance.
17. Analgesics, such as acetaminophen (Tylenol).
Rationale: Usually sufficient analgesia for relief of headache caused by dilation of cerebral vessels in response to nitrates.
18. Morphine sulfate (MS)
Rationale: Potent opioid analgesic may be used in acute onset because of its beneficial effects. Such effects include peripheral vasodilatation and reduced myocardial workload; sedation,
which produces relaxation; and interrupted flow of vasoconstricting catecholamines, thereby effectively relieving severe chest pain. MS is given intravenously (IV) for rapid action and because decreased cardiac output compromises peripheral tissue absorption.
19. Monitor serial ECG changes.
Rationale: Ischemia during anginal attack may cause transient ST-segment depression or elevation and T-wave inversion. Serial tracings verify ischemic changes, which may
disappear when client is pain free. They also provide a baseline against which to compare later pattern changes.