02.02 Angina

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Overview

Angina is chest pain resulting from inadequate blood flow to heart muscle. If flow is not restored, it can lead to further damage.

Nursing Points

General

  1. Most common cause – coronary artery disease (CAD) – atherosclerotic plaque ruptures – clot forms.
  2. Other causes
    1. Anemia
    2. Heart failure
    3. Stress/overexertion
    4. Abnormal rhythms.  
  3. Types
    1. Stable – With exertion. Relieved by nitroglycerin
    2. Unstable – At rest. Lasts longer. Unrelieved by nitroglycerin.
    3. Variant – Unpredictable.
  4. Desired Outcome
    1. Restored blood flow
    2. Decreased chest pain
    3. Improved activity tolerance.

Assessment

  1. Subjective Data
    1. Chest Pain
      1. Do full pain assessment (PQRST or OLDCARTS)
      2. Sternum, Left Shoulder, Left Arm, Jaw, Back
    2. Dyspnea on Exertion
    3. Ask –  nitroglycerin or aspirin?
  2. Objective Data
    1. Blood Pressure
      1. Hypotension – ↓ cardiac output
      2. Hypertension – ↑ stress on heart
    2. Arrhythmias
      1. Bradycardias -↓ cardiac output
      2. Supraventricular Tachycardia -↑ stress on heart
      3. Atrial Fibrillation – ↑ stress on heart
    3. Other
      1. Syncope
      2. Pale
      3. Diaphoretic

Therapeutic Management

  1. MONA
    1. Nitroglycerin first – 0.4 mg SL q5min x 3 doses total
      1. Coronary vasodilator
    2. Aspirin 325 mg
      1. Antiplatelet
    3. Morphine 2-4 mg IV
      1. ONLY if pain not relieved by first two
    4. Oxygen 2L NC
      1. ONLY if clinically relevant
  2. 12-Lead EKG
    1. Rule out STEMI
  3. 3- or 5-Lead EKG Monitoring
    1. Arrhythmias
  4. Monitor Vital Signs (HR, BP, SpO2)
    1. Monitor for changes
  5. Cardiac Enzymes
    1. Determine myocardial damage
  6. Cardiac Stress Test
    1. Determine myocardial stress point
  7. Cluster Care – Rest
    1. Decrease myocardial O2 demands

Patient Education

  1. Cluster Activities – allow for rest periods
  2. Take Aspirin daily as prescribed
  3. Nitroglycerin
    1. May take 3 doses, 5 minutes apart.
    2. Call 911 if pain not relieved 5 minutes after 1st dose.
      1. Take 2nd and 3rd dose while waiting
    3. Do NOT take if taken Viagra in last 24 hours
      1. Dangerous hypotension
  4. Lifestyle Changes
    1. Diet
      1. Reduce cholesterol and salt intake
      2. Lean meats, fruits, veggies
      3. Limit sugar/sweets
      4. Limit sodas/fast foods
    2. Exercise
      1. 30-60 minutes, 5-7 days/week
      2. Moderate to vigorous activity
    3. Weight Loss if necessary
    4. Stop smoking
    5. Reduce Stress (yoga, meditation
  5. Keep record of events

Reference Links

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Video Transcript

Today we’re going to be talking about Angina.

Angina is chest pain associated with a lack of adequate flow to the heart muscle. This might be because of Coronary Artery Disease, stress, anemia, heart failure, or even arrhythmias. Whatever the cause, the #1 goal is to restore flow to the myocardium. It often presents as midsternal chest pain, sometimes radiating to the arms (usually left) and the jaw.

Angina can be classified 3 ways, Stable, Unstable, and Variant. Refer to the Cheatsheet within this lesson to learn more about the three types. I want to talk specifically about what nursing actions are required for a patient with unstable angina.

In other words. If you’re a nurse working on the floor and your patient complains of chest pain – what do you do?

So let’s say you have a patient who begins complaining of chest pain. In this hypothetical situation, they’ve never complained of this before and don’t already have an order for Nitroglycerin. What do you do first?

Start with the nursing process. ADPIE – Assess, Diagnose, Plan, Implement, Evaluate. So if all you know is they are complaining of Chest Pain, we need more assessment information, don’t we? First, we need to know more about the pain itself. We can use a PQRST or OLDCARTS assessment for this. I like OLDCARTS. When did it start? Where is it located? How long has it lasted? What does the pain feel like? Does anything make it worse? Does anything make it better? Does it radiate anywhere? Is it associated with anything like eating or lying flat? Does it only come at certain times of the day And, how severe is it on a scale of 0-10? Once we have that information, we can possibly rule out things like indigestion or abdominal pain.

At that point, we want to get a set of vital signs. Specifically blood pressure, heart rate, and pulse oximetry. If your patient is in a monitored unit and you can access a 3- or 5-lead EKG easily, go ahead and attach that monitor as well to check for arrhythmias.

Let’s say the patient’s blood pressure is 103/67, heart rate is 142, and sats are 93%. Do I now have enough information to move on from assessment in my nursing process? Yes, I do. I can “diagnose” that there is some perfusion issue happening because their heart rate is so high, as well as possible oxygenation issues based on their sats.

So what are the main interventions for angina and at what point do you need to call the physician?
MONA is the mnemonic we use, it stands for Morphine, Oxygen, Nitroglycerin, and Aspirin. This is not the order we give these in, but just a way to remember them. Of those 4 interventions, which one can you do without having to call the doctor first? Oxygen! Since the patient’s O2 was 93%, it’s appropriate to apply 2L NC before calling the doctor.

So we’ve done that and now we’ve called the doctor. What other interventions should we anticipate? This can be part of your planning stage. Well, medication-wise we always start with Nitroglycerin to determine whether it helps to relieve the pain. We should also expect a 12-lead EKG to rule out a Myocardial Infarction and cardiac enzymes to determine the extent of damage to the heart muscle.

We get an order for aspirin 324 mg chewable PO x 1 dose and nitroglycerin sublingual 0.4 mg every 5 minutes x 3 doses total. We administer the aspirin and the first dose of nitroglycerin. If the nitroglycerin doesn’t provide pain relief after 5 minutes, we will give a 2nd dose. But at this point, notify your provider that it isn’t working – he or she will want to come assess the patient themselves. If the nitroglycerin doesn’t work x 3 doses, the doctor will order Morphine for pain control – and it can also help decrease the workload on the heart.

Now, we have to evaluate. In the case of this patient, let’s say the nitro didn’t work and now the 12-lead EKG is showing that the patient is in Supraventricular Tachycardia at a rate of 164 At this point, we have to treat the cause of the angina. So we would notify the doctor and anticipate the move to some sort of cardioversion to address the SVT.

Ultimately the goal with treatment of angina is to reverse the cause and restore blood flow to the heart muscle. If we don’t act quickly, unstable angina can easily advance and become a myocardial infarction. Knowing what to do, in what order, helps us to be proficient and get the patient the help they need quickly.

When a patient is having chest pain, a thorough pain assessment and getting a set of vital signs will help you to gain a better picture of what’s happening with your patient before you call the provider.
Anticipate what they will order. If you know they will likely order labs and a 12-lead, go ahead and start gathering the necessary equipment.
Unstable angina is usually not responsive to nitroglycerin and probably has a deeper cause that needs to be addressed.
As always, follow your nursing process and be confident with which interventions need to happen first in order to get the best outcomes.

The scenario we just discussed was what I like to call an NCLEX world scenario. What that means is it was one where you could only do one intervention at a time and couldn’t multitask or have anyone else do things for you, right? In the real world, as soon as I think I have a significant angina issue, I’m asking the secretary or charge nurse to call the doctor for me while I finish my assessment and apply oxygen. I’ve likely also asked someone to grab lab tubes to draw cardiac enzymes, and maybe even call for the EKG tech or EKG machine. That’s the beautiful thing about nursing and why we love it so much, we function as a team to get many things done in a short period of time. Because in the end, we’re all there for the best interest of the patient.

Read more

  • Question 1 of 10

The nurse is assessing a client who is coughing so hard that his chest hurts. The client is holding his chest and asking for pain medications. What is the priority for this client?

  • Question 2 of 10

A nurse must administer nitroglycerin 0.4 mg sublingually to a client experiencing chest pain. Which best describes how nitroglycerin works to relieve chest pain?

  • Question 3 of 10

The nurse is caring for a client with a chief complaint of angina. Which lab panel does the nurse anticipate being ordered?

  • Question 4 of 10

A 60-year-old client is seeking care for chest pain and the nurse has an order to place a nitroglycerin patch. Which implications must the nurse consider when administering this medication? Select all that apply.

  • Question 5 of 10

The nurse is getting report from the emergency department on a client admitted for unstable angina. The ED nurse states that everything has come back negative and the plan of care is for the client to have a cardiac stress test later today. Which question is a priority question to ask the ED nurse during report?

  • Question 6 of 10

During an initial assessment of a client with coronary artery disease, the nurse wants to assess the client’s dietary intake to determine if diet is contributing to his health condition. Which question would most likely give the nurse an idea of the client’s everyday diet?

  • Question 7 of 10

Which of the following medications lower blood pressure by reducing cardiac cell excitability?

  • Question 8 of 10

A nurse is caring for a client with stable angina. The nurse understands that stable angina is which of the following?

  • Question 9 of 10

Four clients in the emergency room have complaints of chest pain. The nurse should see the client with which of the following first?

  • Question 10 of 10

The nurse is caring for a client who was just administered an antianginal agent in the form of a nitrate. The nurse knows that this helps angina by which of the following mechanisms?