NCP Angina Pectoris

Angina Pectoris
- Nursing Diagnoses/Collaborative Problems

Angina pectoris is transient chest pain or discomfort that is caused by an imbalance between myocardial oxygen supply and demand. The discomfort typically occurs in the retrosternal area; may or may not radiate; and is described as a tight, heavy, squeezing, burning, or choking sensation. The most common cause of angina pectoris is decreased coronary blood supply due to atherosclerosis of a major coronary artery. The atherosclerosis causes narrowing of the vessel lumen and an inability of the vessel to dilate and supply sufficient blood to the myocardium at times when myocardial oxygen needs are increased. Other conditions that can compromise coronary blood flow (e.g., spasm and/or thrombosis of a coronary artery, hypovolemia) and conditions that reduce oxygen availability and/or increase myocardial workload and oxygen demands (e.g., anemia, smoking, exercise, heavy meals, increased altitude, exposure to cold, stress) may precipitate or increase the frequency of angina attacks by widening the gap between oxygen needs and availability.

The two major types of angina pectoris are stable (classic exertional) angina and unstable angina. Stable angina, the most common type, is usually precipitated by physical exertion or emotional stress, lasts 3 to 5 minutes, and is relieved by rest and nitroglycerin. Unstable angina is characterized by an increasing frequency and/or severity of attacks that occur with less provocation or at rest. It is considered to be an acute coronary syndrome, which is associated with thrombus formation in a coronary artery. Persons with unstable angina are usually hospitalized and treated with heparin and antiplatelet agents while decisions regarding medical versus surgical treatment are made. A third type of angina is Prinzmetal's variant angina. It is less common than stable or unstable angina and is caused by severe focal spasm of a coronary artery.

This care plan focuses on the adult client hospitalized during an episode of chest pain/discomfort suspected to be unstable angina.

Angina Pectoris
- Description

1. Risk for decreased cardiac output
2. Acute pain: radiating or nonradiating chest pain/discomfort
3. Potential complications
1. cardiac dysrhythmias
2. myocardial infarction
4. Fear/Anxiety
5. Deficient knowledge, Ineffective therapeutic regimen management, or Ineffective health maintenance

NURSING DIAGNOSIS: Risk for decreased cardiac output

related to mechanical and/or electrical dysfunction of the heart associated with severe or prolonged myocardial ischemia.
Desired Outcome
The client will maintain adequate cardiac output as evidenced by:

1. B/P within normal range for client
2. apical pulse regular and between 60-100 beats/ minute
3. absence of gallop rhythm
4. absence of fatigue and weakness
5. unlabored respirations at 12-20/minute
6. clear, audible breath sounds
7. usual mental status
8. absence of dizziness and syncope
9. palpable peripheral pulses
10. skin warm and usual color
11. capillary refill time less than 2-3 seconds
12. urine output at least 30 ml/hour
13. absence of edema and jugular vein distention.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of decreased cardiac output:
1. variations in B/P (may be increased because of pain or a compensatory response to low cardiac output; may be decreased when compensatory mechanisms and pump fail)
2. tachycardia (may also be a response to pain)
3. presence of gallop rhythm
4. fatigue and weakness
5. dyspnea, tachypnea
6. crackles (rales)
7. restlessness, change in mental status
8. dizziness, syncope
9. diminished or absent peripheral pulses
10. cool extremities
11. pallor or cyanosis of skin
12. capillary refill time greater than 2-3 seconds
13. oliguria
14. edema
15. jugular vein distention (JVD)
16. chest x-ray results showing pulmonary vascular congestion, pulmonary edema, or pleural effusion
17. abnormal blood gases
18. a significant decrease in oximetry results.
2. Monitor for and report the following:
1. ECG readings showing dysrhythmias or findings indicative of ischemia (e.g., ST segment depression or elevation, inverted T waves)
2. an elevation in cardiac enzymes (e.g., CK-MB, troponin).
3. Implement measures to help maintain an adequate cardiac output:
1. perform actions to improve myocardial blood flow and oxygenation and subsequently reduce damage to the myocardium:
1. maintain oxygen therapy as ordered
2. administer the following medications if ordered:
1. nitrates (e.g., nitroglycerin, isosorbide) to dilate the coronary and peripheral (primarily venous) blood vessels, thereby improving myocardial blood flow and reducing cardiac workload and myocardial oxygen consumption
2. beta-adrenergic blocking agents (e.g., atenolol, nadolol, metoprolol, propranolol) to reduce myocardial oxygen requirements by decreasing the heart rate and force of myocardial contractility
3. calcium-channel blockers (e.g., verapamil, diltiazem, amlodipine, bepridil, nicardipine) to dilate the coronary arteries and also reduce cardiac workload by dilating peripheral vessels
4. anticoagulants (e.g., intravenous heparin, dalteparin, enoxaparin) and antiplatelet agents (e.g., low-dose aspirin, glycoprotein IIb/IIIa receptor inhibitor [e.g., tirofiban, eptifibatide, abciximab], clopidogrel) to prevent obstruction of the coronary artery(ies) by thrombosis
3. prepare client for percutaneous coronary intervention (e.g., balloon angioplasty, atherectomy, intracoronary stenting) or coronary artery bypass grafting (CABG) if planned
2. perform additional actions to reduce cardiac workload:
1. implement measures to promote emotional and physical rest (e.g., maintain a calm, quiet environment; limit the number of visitors; maintain activity restrictions)
2. instruct client to avoid activities that create a Valsalva response (e.g., straining to have a bowel movement, holding breath while moving up in bed)
3. discourage excessive intake of beverages high in caffeine such as coffee, tea, and colas (caffeine is a myocardial stimulant and can increase myocardial oxygen consumption)
4. discourage smoking (nicotine has a cardiostimulatory effect and causes vasoconstriction; the carbon monoxide in smoke reduces oxygen availability)
5. increase activity gradually as allowed and tolerated.

NURSING DIAGNOSIS: Acute pain: radiating or nonradiating chest pain/discomfort

related to decreased myocardial oxygenation (an insufficient oxygen supply forces the myocardium to convert to anaerobic metabolism; the end products of anaerobic metabolism act as irritants to myocardial neural receptors).
Desired Outcome
The client will experience relief of chest pain/discomfort as evidenced by:

1. verbalization of same
2. relaxed facial expression and body positioning
3. increased participation in activities
4. stable vital signs.

Nursing Actions and Selected Purposes/Rationales

1. Assess for signs and symptoms of pain/discomfort (e.g., verbalization of pain; grimacing; rubbing neck, jaw, or arm; reluctance to move; clutching chest; restlessness; diaphoresis; increased B/P; tachycardia).
2. Assess client's perception of the severity of the pain/discomfort using an intensity rating scale.
3. Assess the client's pattern of pain/discomfort (e.g., location, quality, onset, duration, precipitating factors, aggravating factors, alleviating factors).
4. Implement measures to relieve pain/discomfort:
1. administer nitroglycerin as ordered
2. maintain oxygen therapy as ordered to increase the myocardial oxygen supply
3. maintain client on bed rest in a semi- to high Fowler's position
4. administer a narcotic (opioid) analgesic (e.g., morphine sulfate) as ordered if pain/discomfort is unrelieved by rest and nitroglycerin within 15-20 minutes (narcotic analgesics are usually administered intravenously because intramuscular injections are poorly absorbed if tissue perfusion is decreased; intramuscular injections also elevate some serum enzyme levels, which makes assessment of myocardial damage more difficult)
5. provide or assist with nonpharmacologic measures for relief of discomfort (e.g., position change, relaxation techniques, restful environment).
5. Consult physician if pain/discomfort persists or worsens.
6. Implement measures to help maintain an adequate cardiac output (see Diagnosis 1, action c) in order to improve myocardial blood flow and oxygenation and subsequently prevent recurrent episodes of angina.

COLLABORATIVE DIAGNOSIS: Potential complications

1. cardiac dysrhythmias related to myocardial irritability associated with myocardial hypoxia;
2. myocardial infarction related to prolonged myocardial ischemia.

Desired Outcome
The client will maintain normal sinus rhythm as evidenced by:

1. regular apical pulse at 60-100 beats/minute
2. equal apical and radial pulse rates
3. absence of syncope and palpitations
4. ECG showing normal sinus rhythm.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of cardiac dysrhythmias (e.g., irregular apical pulse; pulse rate below 60 or above 100 beats/ minute; apical-radial pulse deficit; syncope; palpitations; abnormal rate, rhythm, or configurations on ECG).
2. Implement measures to help maintain an adequate cardiac output (see Diagnosis 1, action c) in order to improve myocardial blood flow and oxygenation and subsequently reduce the risk for dysrhythmias.
3. If cardiac dysrhythmias occur:
1. initiate cardiac monitoring if not already being done
2. administer antidysrhythmics (e.g., lidocaine, procainamide, amiodarone, esmolol, adenosine, diltiazem, verapamil) if ordered
3. restrict client's activity based on his/her tolerance and severity of the dysrhythmia
4. maintain oxygen therapy as ordered
5. assess cardiovascular status frequently and report signs and symptoms of inadequate cardiac output (see Diagnosis 1, action a)
6. have emergency cart readily available for cardioversion, defibrillation, or cardiopulmonary resuscitation.

Desired Outcome
The client will not experience a myocardial infarction as evidenced by:

1. resolution of chest pain within 15-20 minutes
2. stable vital signs
3. cardiac enzymes within normal range
4. absence of ST segment depression or elevation, T wave inversion, and abnormal Q waves on ECG.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of a myocardial infarction (e.g., chest pain that lasts longer than 20 minutes; increase in pulse rate; significant change in B/P; labored respirations; elevation of cardiac enzymes [e.g., CK-MB, troponin]; ST segment depression or elevation, T wave inversion, and/or abnormal Q waves on ECG [ST segment elevation can also occur in Prinzmetal's angina]).
2. Implement measures to help maintain an adequate cardiac output (see Diagnosis 1, action c) in order to improve myocardial blood flow and oxygenation and subsequently reduce the risk for a myocardial infarction.
3. If signs and symptoms of a myocardial infarction occur:
1. initiate cardiac monitoring if not already being done
2. maintain client on strict bed rest in a semi- to high Fowler's position
3. maintain oxygen therapy as ordered
4. administer the following medications if ordered:
1. morphine sulfate to reduce pain and anxiety and decrease cardiac workload
2. nitrates to improve coronary blood flow and reduce myocardial oxygen requirements
3. beta-adrenergic blocking agents to reduce myocardial oxygen requirements by decreasing the heart rate and force of myocardial contractility
5. prepare client for the following procedures that may be performed to improve myocardial blood flow:
1. injection of a thrombolytic agent (e.g., streptokinase, alteplase [tPA], anistreplase [APSAC, Eminase], reteplase, tenecteplase [TNK-tPA])
2. percutaneous coronary intervention (e.g., balloon angioplasty, atherectomy, intracoronary stenting) or coronary artery bypass grafting [CABG]
3. insertion of an intra-aortic balloon pump (IABP).

NURSING DIAGNOSIS: Fear/Anxiety

related to discomfort during angina attack and threat of recurrent attacks; lack of understanding of diagnostic tests, diagnosis, and treatment plan; unfamiliar environment; and effect of angina pectoris on future lifestyle and roles.
Desired Outcome
The client will experience a reduction in fear and anxiety as evidenced by:

1. verbalization of feeling less anxious
2. usual sleep pattern
3. relaxed facial expression and body movements
4. stable vital signs
5. usual perceptual ability and interactions with others.

Nursing Actions and Selected Purposes/Rationales

1. Assess client for signs and symptoms of fear and anxiety (e.g., verbalization of feeling anxious, insomnia, tenseness, shakiness, restlessness, diaphoresis, tachycardia, elevated blood pressure, self-focused behaviors).
2. Implement measures to reduce fear and anxiety:
1. provide care in a calm, supportive, confident manner
2. if client is having severe pain:
1. do not leave him/her alone during period of acute distress
2. perform actions to relieve pain (see Diagnosis 2, action d)
3. once period of acute distress has subsided:
1. orient client to environment, equipment, and routines; include an explanation of cardiac monitoring equipment
2. keep cardiac monitor out of client's view and the sound turned as low as possible
3. introduce client to staff who will be participating in care; if possible, maintain consistency in staff assigned to his/her care
4. assure client that staff members are nearby; respond to call signal as soon as possible
5. encourage verbalization of fear and anxiety; provide feedback
6. explain all diagnostic tests
7. reinforce physician's explanations and clarify misconceptions the client has about angina pectoris, the treatment plan, and prognosis; stress to client that he/she has not had a "heart attack"
8. reinforce physician's explanation of percutaneous coronary intervention procedures (e.g., balloon angioplasty, atherectomy, intracoronary stenting) if planned
9. initiate preoperative teaching if heart surgery is planned
10. provide a calm, restful environment
11. instruct client in relaxation techniques and encourage participation in diversional activities
12. provide information based on current needs of client at a level he/she can understand; encourage questions and clarification of information provided
13. assist client to identify specific stressors and ways to cope with them
14. allow client to discuss concerns about future lifestyle and roles; focus on the need for alteration in rather than elimination of activities
15. encourage significant others to project a caring, concerned attitude without obvious anxiousness
16. include significant others in orientation and teaching sessions and encourage their continued support of the client
17. administer prescribed antianxiety agents if indicated.
3. Consult appropriate health care provider (e.g., psychiatric nurse clinician, physician) if above actions fail to control fear and anxiety.

NURSING DIAGNOSIS: Deficient knowledge, Ineffective therapeutic regimen management, or Ineffective health maintenance*

*The nurse should select the diagnostic label that is most appropriate for the client's discharge teaching needs.
Desired Outcome
The client will verbalize a basic understanding of angina pectoris.
Nursing Actions and Selected Purposes/Rationales
Explain angina pectoris in terms that client can understand. Utilize teaching aids (e.g., pamphlets, diagrams) whenever possible.
Desired Outcome
The client will identify factors that may precipitate angina attacks and ways to control these factors.
Nursing Actions and Selected Purposes/Rationales

1. Ask client if there is a pattern to angina attacks and precipitating factors.
2. Inform the client of factors that may precipitate angina pectoris (e.g., strenuous or isometric exercises, change in usual sexual habits and/or partner, consumption of a large meal, exposure to extreme cold, strong emotions, smoking).
3. Provide the following instructions regarding ways to reduce risk of precipitating an angina attack:
1. take nitroglycerin before strenuous activity or sexual intercourse and during times of high emotional stress
2. gradually increase activity by engaging in a regular aerobic exercise program (e.g., walking, biking, swimming)
3. avoid strenuous exercise and activities that involve pushing or lifting heavy objects (e.g., weight lifting)
4. avoid exercising for at least an hour after eating and exercise with caution at higher altitude and when the environmental temperature is extremely hot or cold
5. avoid tobacco use before exercise
6. rest between activities
7. stop any activity that causes shortness of breath, palpitations, dizziness, or extreme fatigue or weakness
8. begin a cardiovascular fitness program if recommended by physician
9. adhere to the following precautions regarding sexual activity:
1. avoid intercourse for at least 1-2 hours after a heavy meal or alcohol consumption and when fatigued or stressed
2. engage in sexual activity in a familiar environment and in a position that minimizes exertion (e.g., side-lying, partner on top); recognize that a new sexual relationship can be started but may result in greater energy expenditure initially
3. avoid hot or cold showers just before and after intercourse.

Desired Outcome
The client will identify modifiable cardiovascular risk factors and ways to alter these factors.
Nursing Actions and Selected Purposes/Rationales

1. Inform client that certain modifiable factors such as elevated serum lipids, a sedentary lifestyle, hypertension, and smoking have been shown to increase the risk for coronary artery disease.
2. Assist client to identify changes in lifestyle that can help him/her to eliminate or reduce the above risk factors and help to manage angina (e.g., dietary modification, physical exercise on a regular basis, moderation of alcohol intake, smoking cessation).
3. Encourage client to limit daily alcohol consumption (daily alcohol intake exceeding 1 oz of ethanol may contribute to the development of hypertension and some forms of heart disease). Current recommendations are no more than 2 drinks/day for men and no more than 1 drink/day for women and lighter weight persons. A "drink" is considered to be ½ oz of ethanol (e.g., 1½ oz of 80-proof whiskey, 12 oz of beer, 5 oz of wine).

Desired Outcome
The client will verbalize an understanding of the rationale for and components of a diet designed to lower serum cholesterol and triglycerides.
Nursing Actions and Selected Purposes/Rationales

1. Explain the rationale for a diet low in saturated fat and cholesterol.
2. Provide instructions on ways the client can reduce intake of saturated fat and cholesterol:
1. reduce intake of meat fat (e.g., trim visible fat off meat; replace fatty meats such as fatty cuts of steak, hamburger, and processed meats with leaner products)
2. reduce intake of milk fat (avoid dairy products containing more than 1% fat)
3. reduce intake of trans fats (e.g., avoid stick margarine and shortening and foods such as commercial baked goods that are prepared with these products)
4. use vegetable oil rather than coconut or palm oil in cooking and food preparation
5. use cooking methods such as steaming, baking, broiling, poaching, microwaving, and grilling rather than frying
6. restrict intake of eggs (recommendations about the number of whole eggs allowed per week vary depending on the client's lipid levels).
3. Encourage client to increase intake of omega-3 fatty acids (e.g., flaxseed, cold water ocean fish such as salmon and halibut) to help lower triglycerides and increase high density lipoproteins (HDLs).

Desired Outcome
The client will demonstrate accuracy in counting pulse.
Nursing Actions and Selected Purposes/Rationales

1. Teach client how to count his/her pulse, being alert to the regularity of the rhythm.
2. Allow time for return demonstration and accuracy check.

Desired Outcome
The client will verbalize an understanding of medications ordered including rationale, food and drug interactions, side effects, schedule for taking, and importance of taking as prescribed.
Nursing Actions and Selected Purposes/Rationales

1. Explain the rationale for, side effects of, and importance of taking the medications prescribed. Inform client of pertinent food and drug interactions.
2. If client is discharged on sublingual or transmucosal nitroglycerin tablets or nitroglycerin translingual spray, instruct to:
1. limit intake of alcoholic beverages
2. have tablets or spray readily available at all times
3. take a tablet or use spray before strenuous activity and in emotionally stressful situations
4. take one tablet or spray 1-2 metered doses into mouth when chest pain occurs and repeat every 5 minutes up to a total of 3 times if necessary; notify physician or obtain emergency medical assistance if pain persists
5. place sublingual tablet under tongue or transmucosal tablet between the gum and cheek (buccal cavity) or gum and upper lip and allow to dissolve completely; do not chew or swallow tablets
6. store tablets in a tightly capped, dark-colored glass container away from heat and moisture
7. replace tablets 6 months after the container is opened or sooner if they do not relieve discomfort
8. avoid rising to a standing position quickly after taking nitroglycerin in order to reduce dizziness associated with its vasodilatory effect
9. recognize that dizziness, flushing, and mild headache may occur after taking nitroglycerin
10. report fainting, persistent or severe headache, blurred vision, or dry mouth.
3. If nitroglycerin skin patches are prescribed:
1. provide instructions about correct application, skin care, need to rotate sites and remove old patch, and frequency of change; explain that the patch should be removed for an 8-12 hour period of time each day per physician's instructions in order to help prevent the development of nitrate tolerance
2. caution client that activities that increase blood flow to the skin (e.g., hot bath or shower, sauna) can cause a sudden reduction in blood pressure
3. instruct client to limit intake of alcoholic beverages
4. instruct client to notify health care provider if faintness, dizziness, or flushing occurs following application or if persistent redness or itching occurs at patch site.
4. If client is discharged on a beta-adrenergic blocking agent (e.g., propranolol, metoprolol, atenolol, nadolol), instruct to:
1. take the medication at the same time every day
2. check pulse before taking medication; consult health care provider if pulse rate is unusually slow (it is expected that pulse will be lower than normal)
3. avoid skipping doses, trying to make up for missed doses, altering the prescribed dose, and discontinuing medication without first discussing with health care provider
4. change from a lying to a sitting or standing position slowly if dizziness or lightheadedness is a problem
5. limit intake of alcoholic beverages
6. monitor blood glucose on a regular basis if a diabetic (beta blockers may affect blood sugar and mask symptoms of hypoglycemia)
7. wear a medical alert identification bracelet or tag specifying the name of the medication being taken
8. report the following:
1. persistent lightheadedness or dizziness
2. significant weight gain, night cough, difficulty breathing, or swelling of feet or ankles (may be indicative of heart failure)
3. cold, painful toes or fingers
4. persistent fatigue, depression, insomnia, or sexual dysfunction
5. worsening of any symptoms of chronic respiratory disease.
5. If client is discharged on a calcium-channel blocker (e.g., amlodipine, bepridil, nicardipine, verapamil, diltiazem), instruct to:
1. avoid skipping doses, altering the prescribed dose, and discontinuing medication without first discussing it with health care provider
2. change from a lying to a sitting or standing position slowly in order to prevent dizziness
3. report any increase in frequency, duration, or severity of angina
4. report persistent dizziness, lightheadedness, or headache; swelling of feet or ankles; shortness of breath; or weight gain of more than 2 pounds in a day
5. check pulse before taking medication if taking verapamil or diltiazem and report pulse rate that is unusually slow (e.g., less than 50 beats per minute)
6. avoid operating dangerous equipment and driving as long as dizziness is present (common in the early treatment period).
6. Instruct client to take lipid-lowering agents (e.g., HMG-CoA reductase inhibitors ["statins"], gemfibrozil, ezetimibe, niacin) and antiplatelet agents (e.g., aspirin, clopidogrel) as prescribed.
7. Instruct client to consult physician before taking other prescription and nonprescription medications.
8. Instruct client to inform all health care providers of medications being taken.

Desired Outcome
The client will state signs and symptoms to report to the health care provider.
Nursing Actions and Selected Purposes/Rationales
Stress the importance of reporting the following signs and symptoms:

1. chest, arm, neck, or jaw discomfort unrelieved by rest and/or nitroglycerin taken every 5 minutes for 15 minutes
2. shortness of breath
3. irregular pulse or a resting pulse less than 56 or greater than 100 beats/minute (the rate the client should report may vary depending on the medication[s] prescribed, the client's baseline pulse, and physician's preference)
4. fainting spells
5. diminished activity tolerance
6. swelling of feet or ankles
7. increase in severity or frequency of angina attacks.

Desired Outcome
The client will identify community resources that can assist in making necessary lifestyle changes and adjusting to the effects of angina pectoris.
Nursing Actions and Selected Purposes/Rationales

1. Provide information about community resources that can assist client in making lifestyle changes and adjusting to effects of angina pectoris (e.g., weight loss, smoking cessation, and stress management programs; American Heart Association; counseling services).
2. Initiate a referral if indicated.

Desired Outcome
The client will verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider.
Nursing Actions and Selected Purposes/Rationales

1. Reinforce the importance of keeping follow-up appointments with health care provider.
2. Implement measures to improve client compliance:
1. include significant others in teaching sessions if possible
2. encourage questions and allow time for reinforcement and clarification of information provided
3. provide written instructions regarding future appointments with health care provider, dietary modifications, activity level, medications prescribed, and signs and symptoms to report.