Nursing Care Plan for Angina

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Pathophysiology

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

Etiology

Most common cause is coronary artery disease (CAD). Other causes include anemia, heart failure, stress/overexertion, and abnormal rhythms.

Desired Outcome

Restore adequate blood flow to heart muscles as evidenced by decreased chest pain and improved activity tolerance.

Angina Nursing Care Plan

Subjective Data:

  • Chest Pain
  • Dyspnea on Exertion
  • Do full pain assessment (PQRST or OLDCARTS)
  • Ask about any doses of nitroglycerin or aspirin

Objective Data:

  • EKG changes (arrhythmias)
  • Hypotension
  • Tachycardia
  • Bradycardia
  • Decreased SpO2
  • Signs of decreased perfusion (cool, clammy, pale, diaphoretic)

Nursing Interventions and Rationales

  • Bedside EKG monitoring
    (3 or 5 Lead)

 

Apply a 3- or 5-lead EKG monitor to determine the presence of any arrhythmias.

Most common arrhythmias that cause angina include Atrial Fibrillation with Rapid Ventricular Response (AFib with RVR), Supraventricular Tachycardia (SVT), and Bradycardias.

 

  • 12-Lead ECG

    If initial 12-lead ECG indicates inferior MI, do a right-sided 12-lead ECG.

 

To rule out the presence of Myocardial Infarction. It takes 5-15 minutes to determine if the chest pain will subside with nitroglycerin. By checking a 12-lead EKG, a possible STEMI can be ruled out immediately. If STEMI is present, patient should be taken to the Cath Lab STAT.

Right sided 12 lead ECG shows the right side of the heart to assess for right ventricular ischemia.

 

  • MONA:
    • Morphine
    • Oxygen
    • Nitroglycerin
    • Aspirin (ASA)

    *note – this is only a mnemonic and not the correct order of administration – see rationale for details*

 

Initial treatment for acute coronary syndrome.

  • Morphine: given ONLY if aspirin and nitroglycerin do not relieve chest pain. Initial dose is 2-4 mg IV.
  • Oxygen: helps for you to remember to check oxygenation for chest pain – if under 94% or if patient is short of breath give 2L NC initially. Administer oxygen only when clinically relevant.
  • Nitroglycerin: This is the initial medication given, along with aspirin. This medication dilates the blood vessels to help allow any blood flow that might be impeded. Give 0.4 mg sublingual tab, wait 5 minutes, if the chest pain is not relieved administer another dose. This can happen 3 times total. Monitor a patient’s blood pressure, hold for a systolic BP of less than 90 mmHg.
  • Aspirin: given to thin the blood and decrease mortality risk. A total of 4 baby aspirin (81 mg each) can be given for a total of 324 mg, or a single 325 mg dose.

 

  • Insert Large Bore IV and draw initial Cardiac Enzymes

 

IV access is important for administration of medications, possible interventions if angina worsens, and any scans that may be needed to rule out thrombosis.

Cardiac enzymes further serve to rule out Myocardial Infarction and can give an indication to the extent of myocardial damage.

  • Troponin I
  • CK
  • CK-MB
  • Myoglobin

 

  • BP Monitoring
    • The measurement is determined by the doctor, who is determining this based on evidence based research married with patient factors.
    • It can be measured by the systolic BP or the Mean Arterial Pressure (MAP).

 

This is important because the higher the blood pressure, the more pressure is on a clot. It isn’t out of the question for someone to have more than one clot, and increased pressure could break free a clot lodge itself somewhere else either in the heart, lungs, brain, or extremity.  

It is also possible that the source of the angina is severe hypotension. This should be assessed and monitored and corrected as needed.

 

  • Monitor Cardiac Enzymes:
    • Troponin I
    • Creatine Kinase-MB (CKMB)

 

The values of these enzymes are based on your institutional laboratory technique. If they are elevated it indicates that the cardiac muscle is stressed out or injured.

  • Troponin I is an enzyme that helps the interaction of myosin and actin in the cardiac muscle. When necrosis of the myocyte happens, the contents of the cell eventually will be released into the bloodstream.
    • Troponin can become elevated 2-4 hours after in ischemic cardiac event and can stay elevated for up to 14 days.
  • Creatine Kinase MB: This enzyme is found in the cardiac muscle cells and catalyses the conversion of ATP into ADP giving your cells energy to contract. When the cardiac muscle cells are damaged the enzyme is eventually released into the bloodstream.
    • CKMB levels should be checked at admission, and then every 8 hours afterwards.

 

  • Cluster Care to allow for periods of rest

 

It is important in initial phases of treatment that patients get adequate rest. Clustering nursing care means doing multiple tasks in a short period of time and allowing longer breaks between interventions. This allows the patient to rest, thus decreasing their myocardial oxygen demands.

 


References

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