The classic symptom of coronary artery disease (CAD) is angina—pain caused by loss of oxygen and nutrients to the myocardial tissue because of inadequate coronary blood flow. In most but not all patients presenting with angina, CAD symptoms are caused by significant atherosclerosis. Unstable angina is sometimes grouped with MI under the diagnosis of acute coronary syndrome. Angina has three major forms: (1) stable (precipitated by effort, of short duration, and easily relieved), (2) unstable (longer lasting, more severe, may not be relieved by rest/nitroglycerin; may also be new onset of pain with exertion or recent acceleration in severity of pain), and (3) variant (chest pain at rest with ECG changes due to coronary artery spasm). The AHCPR guidelines of May 1994 state that unstable angina is a transitory syndrome that causes significant disability and death in the United States.
CARE SETTING
Patients judged to be at intermediate or high likelihood of significant CAD are often hospitalized for further evaluation and therapeutic intervention. Classification of angina (provided by Canadian Cardiovascular Society Classification [CCSC]) aids in determining the risk of adverse outcomes for patients with unstable angina and, therefore, level of treatment needs. Class III angina is identified as occurring if the patient walks less than two blocks and normal activity is markedly limited, and class IV angina occurs at rest or with minimal activity and level of activity is severely limited.
These two classes may require inpatient evaluation/therapeutic adjustments.
RELATED CONCERNS
Cardiac surgery: postoperative care
Dysrhythmias
Heart failure: chronic
Myocardial infarction
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report: Sedentary lifestyle, weakness
Fatigue, feeling incapacitated after exercise
Chest pain with exertion or at rest
Awakened by chest pain
May exhibit: Exertional dyspnea
CIRCULATION
May report: History of heart disease, hypertension, obesity in self/family
May exhibit: Tachycardia, dysrhythmias
Blood pressure normal, elevated, or decreased
Heart sounds: May be normal; late S4 or transient late systolic murmur (papillary muscledysfunction) may be evident during pain
Moist, cool, pale skin/mucous membranes in presence of vasoconstriction
EGO INTEGRITY
May report: Stressors of work, family, others
May exhibit: Apprehension, uneasiness
FOOD/FLUID
May report: Nausea, “heartburn”/epigastric distress with eating
Diet high in cholesterol/fats, salt, caffeine, liquor
May exhibit: Belching, gastric distension
PAIN/DISCOMFORT
May report: Substernal or anterior chest pain that may radiate to jaw, neck, shoulders, and upper extremities (to left side more than right)
Quality: Varies from transient/mild to moderate, heavy pressure, tightness, squeezing, burning
Duration: Usually less than 15 min, rarely more than 30 min (average 3 min)
Precipitating factors: Physical exertion or great emotion, such as anger or sexual arousal; exercise in weather extremes; or may be unpredictable and/or occur during rest
or sleep in unstable angina
Relieving factors: Pain may be responsive to particular relief mechanisms (e.g., rest,
antianginal medications)
New or ongoing chest pain that has changed in frequency, duration, character, or
predictability (i.e., unstable, variant, Prinzmetal’s)
May exhibit: Facial grimacing, placing fist over midsternum, rubbing left arm, muscle tension,
restlessness
Autonomic responses, e.g., tachycardia, blood pressure changes
RESPIRATION
May report: Dyspnea worse with exertion
History of smoking
May exhibit: Respirations: Increased rate/rhythm and alteration in depth
TEACHING/LEARNING
May report: Family history or risk factors of CAD, hypertension, stroke, diabetes, cigarette smoking, hyperlipidemia
Use/misuse of cardiac, hypertensive, or OTC drugs
Regular alcohol use, illicit drug use, e.g., cocaine, amphetamines
Discharge plan DRG projected mean length of inpatient stay: 3.2–4.2 days
considerations: Alteration in medication use/therapy
Assistance with homemaker/maintenance tasks
Changes in physical layout of home
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
ECG: Often normal when patient at rest or when pain-free; depression of the ST segment or T wave inversion signifies
ischemia. Dysrhythmias and heart block may also be present. Significant Q waves are consistent with a prior MI.
24-hour ECG monitoring (Holter): Done to see whether pain episodes correlate with or change during exercise or activity. ST depression without pain is highly indicative of ischemia.
Exercise or pharmacological stress electrocardiography: Provides more diagnostic information, such as duration and level of activity attained before onset of angina. A markedly positive test is indicative of severe CAD. Note:
Studies have shown stress echo studies to be more accurate in some groups than exercise stress testing alone.
Cardiac enzymes (AST, CPK, CK and CK-MB; LDH and isoenzymes LD1, LD2): Usually within normal limits (WNL); elevation indicates myocardial damage.
Chest x-ray: Usually normal; however, infiltrates may be present, reflecting cardiac decompensation or pulmonary complications.
PCO2, potassium, and myocardial lactate: May be elevated during anginal attack (all play a role in myocardial ischemia and may perpetuate it).
Serum lipids (total lipids, lipoprotein electrophoresis, and isoenzymes cholesterols [HDL, LDL, VLDL]; triglycerides; phospholipids): May be elevated (CAD risk factor).
Echocardiogram: May reveal abnormal valvular action as cause of chest pain.
Nuclear imaging studies (rest or stress scan): Thallium-201: Ischemic regions appear as areas of decreased thallium uptake.
MUGA: Evaluates specific and general ventricle performance, regional wall motion, and ejection fraction.
Cardiac catheterization with angiography: Definitive test for CAD in patients with known ischemic disease with angina or incapacitating chest pain, in patients with cholesterolemia and familial heart disease who are experiencing chest pain, and in patients with abnormal resting ECGs. Abnormal results are present in valvular disease, altered contractility, ventricular failure, and circulatory abnormalities. Note: Ten percent of patients with unstable angina have normal-appearing coronary arteries.
Ergonovine (Ergotrate) injection: On occasion, may be used for patients who have angina at rest to demonstrate hyperspastic coronary vessels. (Patients with resting angina usually experience chest pain, ST elevation, or depression and/or pronounced rise in left ventricular end-diastolic pressure [LVEDP], fall in systemic systolic pressure, and/or high-grade coronary artery narrowing. Some patients may also have severe ventricular dysrhythmias.)
NURSING PRIORITIES
1. Relieve/control pain.
2. Prevent/minimize development of myocardial complications.
3. Provide information about disease process/prognosis and treatment.
4. Support patient/SO in initiating necessary lifestyle/behavioral changes.
DISCHARGE GOALS
1. Achieves desired activity level; meets self-care needs with minimal or no pain.
2. Free of complications.
3. Disease process/prognosis and therapeutic regimen understood.
4. Participating in treatment program, behavioral changes.
5. Plan in place to meet needs after discharge.
CARE SETTING
Patients judged to be at intermediate or high likelihood of significant CAD are often hospitalized for further evaluation and therapeutic intervention. Classification of angina (provided by Canadian Cardiovascular Society Classification [CCSC]) aids in determining the risk of adverse outcomes for patients with unstable angina and, therefore, level of treatment needs. Class III angina is identified as occurring if the patient walks less than two blocks and normal activity is markedly limited, and class IV angina occurs at rest or with minimal activity and level of activity is severely limited.
These two classes may require inpatient evaluation/therapeutic adjustments.
RELATED CONCERNS
Cardiac surgery: postoperative care
Dysrhythmias
Heart failure: chronic
Myocardial infarction
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report: Sedentary lifestyle, weakness
Fatigue, feeling incapacitated after exercise
Chest pain with exertion or at rest
Awakened by chest pain
May exhibit: Exertional dyspnea
CIRCULATION
May report: History of heart disease, hypertension, obesity in self/family
May exhibit: Tachycardia, dysrhythmias
Blood pressure normal, elevated, or decreased
Heart sounds: May be normal; late S4 or transient late systolic murmur (papillary muscledysfunction) may be evident during pain
Moist, cool, pale skin/mucous membranes in presence of vasoconstriction
EGO INTEGRITY
May report: Stressors of work, family, others
May exhibit: Apprehension, uneasiness
FOOD/FLUID
May report: Nausea, “heartburn”/epigastric distress with eating
Diet high in cholesterol/fats, salt, caffeine, liquor
May exhibit: Belching, gastric distension
PAIN/DISCOMFORT
May report: Substernal or anterior chest pain that may radiate to jaw, neck, shoulders, and upper extremities (to left side more than right)
Quality: Varies from transient/mild to moderate, heavy pressure, tightness, squeezing, burning
Duration: Usually less than 15 min, rarely more than 30 min (average 3 min)
Precipitating factors: Physical exertion or great emotion, such as anger or sexual arousal; exercise in weather extremes; or may be unpredictable and/or occur during rest
or sleep in unstable angina
Relieving factors: Pain may be responsive to particular relief mechanisms (e.g., rest,
antianginal medications)
New or ongoing chest pain that has changed in frequency, duration, character, or
predictability (i.e., unstable, variant, Prinzmetal’s)
May exhibit: Facial grimacing, placing fist over midsternum, rubbing left arm, muscle tension,
restlessness
Autonomic responses, e.g., tachycardia, blood pressure changes
RESPIRATION
May report: Dyspnea worse with exertion
History of smoking
May exhibit: Respirations: Increased rate/rhythm and alteration in depth
TEACHING/LEARNING
May report: Family history or risk factors of CAD, hypertension, stroke, diabetes, cigarette smoking, hyperlipidemia
Use/misuse of cardiac, hypertensive, or OTC drugs
Regular alcohol use, illicit drug use, e.g., cocaine, amphetamines
Discharge plan DRG projected mean length of inpatient stay: 3.2–4.2 days
considerations: Alteration in medication use/therapy
Assistance with homemaker/maintenance tasks
Changes in physical layout of home
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
ECG: Often normal when patient at rest or when pain-free; depression of the ST segment or T wave inversion signifies
ischemia. Dysrhythmias and heart block may also be present. Significant Q waves are consistent with a prior MI.
24-hour ECG monitoring (Holter): Done to see whether pain episodes correlate with or change during exercise or activity. ST depression without pain is highly indicative of ischemia.
Exercise or pharmacological stress electrocardiography: Provides more diagnostic information, such as duration and level of activity attained before onset of angina. A markedly positive test is indicative of severe CAD. Note:
Studies have shown stress echo studies to be more accurate in some groups than exercise stress testing alone.
Cardiac enzymes (AST, CPK, CK and CK-MB; LDH and isoenzymes LD1, LD2): Usually within normal limits (WNL); elevation indicates myocardial damage.
Chest x-ray: Usually normal; however, infiltrates may be present, reflecting cardiac decompensation or pulmonary complications.
PCO2, potassium, and myocardial lactate: May be elevated during anginal attack (all play a role in myocardial ischemia and may perpetuate it).
Serum lipids (total lipids, lipoprotein electrophoresis, and isoenzymes cholesterols [HDL, LDL, VLDL]; triglycerides; phospholipids): May be elevated (CAD risk factor).
Echocardiogram: May reveal abnormal valvular action as cause of chest pain.
Nuclear imaging studies (rest or stress scan): Thallium-201: Ischemic regions appear as areas of decreased thallium uptake.
MUGA: Evaluates specific and general ventricle performance, regional wall motion, and ejection fraction.
Cardiac catheterization with angiography: Definitive test for CAD in patients with known ischemic disease with angina or incapacitating chest pain, in patients with cholesterolemia and familial heart disease who are experiencing chest pain, and in patients with abnormal resting ECGs. Abnormal results are present in valvular disease, altered contractility, ventricular failure, and circulatory abnormalities. Note: Ten percent of patients with unstable angina have normal-appearing coronary arteries.
Ergonovine (Ergotrate) injection: On occasion, may be used for patients who have angina at rest to demonstrate hyperspastic coronary vessels. (Patients with resting angina usually experience chest pain, ST elevation, or depression and/or pronounced rise in left ventricular end-diastolic pressure [LVEDP], fall in systemic systolic pressure, and/or high-grade coronary artery narrowing. Some patients may also have severe ventricular dysrhythmias.)
NURSING PRIORITIES
1. Relieve/control pain.
2. Prevent/minimize development of myocardial complications.
3. Provide information about disease process/prognosis and treatment.
4. Support patient/SO in initiating necessary lifestyle/behavioral changes.
DISCHARGE GOALS
1. Achieves desired activity level; meets self-care needs with minimal or no pain.
2. Free of complications.
3. Disease process/prognosis and therapeutic regimen understood.
4. Participating in treatment program, behavioral changes.
5. Plan in place to meet needs after discharge.
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