Angina Pectoris

Introduction
Angina pectoris is a symptom of ischemic heart disease characterized by paroxysmal and usually recurring substernal or precordial chest pain or discomfort. The term comes from the Latin words meaning "choking of the chest." About 10 million Americans experience angina, and approximately 350,000 new cases of angina occur every year. Angina pectoris is caused by varying combinations of increased myocardial demand and decreased myocardial perfusion. The imbalance between supply and demand is caused either by a primary decrease in coronary blood flow or by a disproportionate increase in myocardial oxygen requirements. Blood flow through the coronary arteries is partially or completely obstructed because of coronary artery spasm, fixed stenosing plaques, disrupted plaques, thrombosis, platelet aggregation, and embolization. Angina can be classified as chronic exertional (stable, typical) angina, variant angina (Prinzmetal's), unstable or crescendo angina, or silent ischemia (Table 8). Chronic exertional angina is usually caused by obstructive coronary artery disease that causes the heart to be vulnerable to further ischemia whenever there is increased demand or workload. Variant angina may occur in people with normal coronary arteries who have cyclically recurring angina at rest, unrelated to effort. Unstable angina is diagnosed in patients who report a changing character, duration, and intensity of their pain. Experts are also recognizing that not all ischemic events are perceived by patients, even though such events, called silent ischemia, may have adverse implications for the patient.

I. Assessment
1. HISTORY. Ask the patient to describe past chest discomfort in terms of quality (aching, sharp, tingling, knifelike, choking, squeezing), location and radiation, precipitating factors (activity), duration, alleviating factors (relieved by rest), and associated signs and symptoms during the attack (dyspnea, anxiety, diaphoresis, nausea). Obtain information regarding medications, family history, and modifiable risk factors such as eating habits, lifestyle, and physical activity. If chest discomfort is present at the time of the interview, delay collection of historical data until you implement appropriate interventions for ischemic chest pain and the patient is pain free. The Canadian Cardiovascular Society grading scale is used to classify the severity of angina: Class I: angina only during strenuous or prolonged physical activity; Class II: slight limitation, with angina only during vigorous physical activity; Class III: symptoms with everyday living activities; Class IV: inability to perform any activity without angina or angina at rest. 2. PHYSICAL EXAM. During anginal attacks, chest discomfort is often described as an ache rather than an actual pain and may be characterized as a heaviness, pressure, tightness, squeezing sensation, or indigestion. The discomfort is typically located in the substernal region or across the anterior upper

chest. Often, the area of pain is the size of a clenched fist and the patient may place his or her fist over the area of discomfort (Levine's sign). The sensation may radiate to the neck, jaw, or tongue; to either arm, elbow, wrist, or hand; or to the upper abdomen. Anginal discomfort is typically of short duration, usually 3 to 5 minutes, but can last up to 30 minutes or longer. The discomfort may have been brought on by physical or emotional stress, exposure to extreme temperatures, or eating a heavy meal. Termination of the precipitating factor may bring about alleviation of the discomfort. Frequently, the patient is anxious, pale, diaphoretic, lightheaded, dyspneic, tachycardiac, and nauseated. Upon auscultation, the patient may have atrial or ventricular gallops (S3, S4). 3. PSYCHOSOCIAL. Patients often rationalize that their symptoms are the result of indigestion or overexertion. Denial can interfere with identification of a symptom and be harmful to the patient. Chest pain and all the surrounding implications can be extremely stressful and anxiety-producing to the patient and family.

II. Primary Nursing Diagnosis

Acute pain related to decreased myocardial blood flow.

III. Planning and Intervention

COLLABORATIVE For any patient who is experiencing an acute anginal episode, pain management is the priority not only for patient comfort but also to decrease myocardial oxygen consumption. The physician orders selected therapies that either decrease myocardial oxygen demand or increase coronary blood and oxygen supply. These therapies may include short-term bedrest; oxygen therapy; cardiac monitoring to prevent potential complications; and small, frequent, easily digested meals. Diet. A collaborative effort among the patient, dietitian, physician, and nurse plans for a diet low in cholesterol, fat, calories, and sodium. Drinks in the coronary care unit or step-down unit are usually decaffeinated and not too hot or cold. Vital signs. During unstable periods, the nurse and physician closely monitor the patient's vital signs and her or his response to pain-relieving therapies (narcotics, nitrates). Often the patient is placed on a cardiac monitor to determine if life-threatening dysrhythmias occur during an anginal episode, particularly if the angina may be a symptom that the patient is having an MI.

Independent To decrease oxygen demand, encourage the patient to maintain bedrest until the pain subsides; even though bedrest is usually short term, a sheepskin, air mattress, foam pad, foot cradle, or heel pads can reduce the risk of skin breakdown and increase patient comfort.

IV. Evaluation
Description of pain: Onset ,character, precipitating factors, associated symptoms, duration, and alleviating factors of the anginal episode Response to prescribed medications Reaction to bedrest or limitation in activity

5 Priority Nursing Diagnoses

1. 2. 3. 4. 5. Acute pain related to decreased myocardial blood flow. Activity intolerance related imbalance between oxygen supply and demand. Anxiety related to situational crises. Deficient knowledge relatedto misinterpretation. Risk for decreased cardiac output