Nursing Care Plan (NCP) for Angina
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Outline
Lesson Objective for Angina Nursing Care:
- Understanding Angina:
- Develop a comprehensive understanding of angina, including its pathophysiology, triggers, and manifestations, to facilitate accurate assessment and targeted interventions.
- Managing Acute Episodes:
- Learn effective strategies for managing acute episodes of angina, including prompt recognition of symptoms, administration of prescribed medications, and implementation of lifestyle modifications to alleviate ischemic chest pain.
- Preventing Complications:
- Explore preventive measures to reduce the risk of complications associated with angina, such as myocardial infarction (heart attack). Emphasize the importance of adherence to prescribed medications and lifestyle modifications.
- Implementing Lifestyle Changes:
- Understand and advocate for lifestyle changes that can positively impact angina, including a heart-healthy diet, regular physical activity, smoking cessation, and stress management techniques.
- Promoting Medication Adherence:
- Focus on strategies to promote medication adherence, ensuring individuals understand the purpose and potential side effects of prescribed medications for angina. Encourage open communication with healthcare providers regarding concerns or challenges.
Pathophysiology of Angina:
- Coronary Artery Disease (CAD):
- Angina is primarily associated with coronary artery disease, a condition where the coronary arteries, responsible for supplying blood to the heart muscle, become narrowed or blocked by atherosclerosis. Atherosclerosis involves the buildup of plaque composed of cholesterol, fats, and inflammatory cells on the arterial walls.
- Myocardial Ischemia:
- Reduced blood flow to the myocardium (heart muscle) due to narrowed coronary arteries results in myocardial ischemia. Insufficient oxygen and nutrients reaching the heart muscle can lead to chest pain or discomfort, known as angina.
- Triggering Factors:
- Angina symptoms are often triggered by increased demands on the heart, such as physical exertion, emotional stress, or exposure to cold temperatures. These triggers exacerbate the imbalance between myocardial oxygen supply and demand.
- Stable vs. Unstable Angina:
- Stable angina occurs predictably and is often relieved by rest or nitroglycerin. Unstable angina is characterized by more frequent, severe, or unpredictable episodes, posing a higher risk of progressing to a heart attack (myocardial infarction).
- Vasospasm and Microvascular Dysfunction:
- In addition to atherosclerosis, vasospasm (abnormal constriction of blood vessels) and microvascular dysfunction may contribute to angina. These mechanisms further compromise blood flow, intensifying myocardial ischemia and symptomatology.
Etiology of Angina:
- Coronary Artery Disease (CAD):
- The primary cause of angina is coronary artery disease (CAD), characterized by the buildup of atherosclerotic plaques within the coronary arteries. These plaques narrow the arteries, reducing blood flow to the heart muscle and leading to myocardial ischemia.
- Risk Factors:
- Multiple risk factors contribute to the development of CAD and angina, including hypertension, hyperlipidemia (elevated cholesterol levels), diabetes mellitus, smoking, and a family history of cardiovascular disease. Addressing these risk factors is essential in angina management.
- Aging and Genetics:
- Advancing age is associated with an increased likelihood of developing CAD and angina. Genetic factors also play a role, as individuals with a family history of cardiovascular disease may have a higher predisposition.
- Obesity and Sedentary Lifestyle:
- Lifestyle factors, such as obesity and a sedentary lifestyle, contribute to the development and progression of CAD. Physical inactivity and poor dietary choices can exacerbate risk factors like high blood pressure and cholesterol levels.
- Microvascular Dysfunction and Vasospasm:
- Beyond traditional CAD, angina may also result from microvascular dysfunction or vasospasm, where blood vessels constrict abnormally, reducing blood flow. These conditions may be independent or coexist with atherosclerosis.
Desired Outcome for Angina Nursing Care:
- Symptom Control:
- Achieve effective control of angina symptoms, minimizing the frequency, intensity, and duration of episodes. The goal is to provide individuals with a better quality of life and reduce the impact of chest pain on daily activities.
- Prevention of Complications:
- Prevent the progression of angina to more severe cardiovascular complications, such as myocardial infarction (heart attack) or heart failure. This involves addressing underlying risk factors and promoting a heart-healthy lifestyle.
- Improved Exercise Tolerance:
- Enhance the individual’s exercise tolerance by implementing a structured cardiac rehabilitation program and encouraging regular, tailored physical activity. Improved cardiovascular fitness contributes to overall well-being.
- Medication Adherence:
- Promote adherence to prescribed medications, including anti-anginal drugs and medications for managing underlying cardiovascular risk factors. This helps maintain optimal blood flow to the heart and reduces the risk of adverse events.
- Enhanced Quality of Life:
- Work towards an improved overall quality of life for individuals with angina by addressing physical symptoms, providing emotional support, and empowering them to actively participate in their healthcare. This includes education on self-management strategies and coping mechanisms.
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 Assessment for Angina:
- Clinical History:
- Obtain a comprehensive clinical history, including the onset, duration, and characteristics of angina symptoms. Inquire about any recent changes in the frequency or intensity of episodes.
- Risk Factor Assessment:
- Evaluate and document cardiovascular risk factors such as hypertension, hyperlipidemia, diabetes, smoking, family history of heart disease, and lifestyle factors (diet, exercise). Identify modifiable risk factors for targeted interventions.
- Physical Examination:
- Perform a thorough physical examination, focusing on cardiovascular parameters. Assess blood pressure, heart rate, respiratory rate, and signs of heart failure. Examine for peripheral edema and signs of poor perfusion.
- Pain Assessment:
- Use a validated pain assessment tool to quantify and characterize chest pain. Explore factors that alleviate or exacerbate pain, and assess the impact of pain on the individual’s daily activities.
- Exercise Tolerance:
- Evaluate exercise tolerance by assessing the individual’s ability to engage in physical activity without triggering angina symptoms. Determine any limitations or challenges related to exercise.
- Medication History:
- Review the individual’s medication history, ensuring adherence to prescribed anti-anginal medications and other cardiovascular medications. Inquire about any side effects or challenges with medication management.
- Psychosocial Assessment:
- Assess the psychosocial impact of angina on the individual’s mental health, emotional well-being, and overall quality of life. Explore coping mechanisms, stressors, and support systems.
- Educational Needs:
- Identify educational needs related to angina management. Assess the individual’s understanding of the condition, prescribed medications, lifestyle modifications, and the importance of seeking prompt medical attention for worsening symptoms.
Implementation for Angina Nursing Care:
- Medication Administration:
- Administer prescribed anti-anginal medications, such as nitroglycerin, beta-blockers, or calcium channel blockers, as directed.
- Educate the individual on the proper use of nitroglycerin for acute symptom relief and when to call for medical support
- Lifestyle Modification Support:
- Provide guidance and support for lifestyle modifications, including dietary changes, regular physical activity as tolerated, smoking cessation, and stress management. Collaborate with the individual to develop a personalized plan for cardiovascular health.
- Cardiac Rehabilitation Referral:
- Refer the individual to cardiac rehabilitation programs to enhance exercise tolerance and promote overall cardiovascular fitness. Monitor participation and progress in rehabilitation activities.
- Patient Education:
- Conduct ongoing education on angina management, including the importance of adhering to prescribed medications, recognizing and responding to symptoms, and adopting a heart-healthy lifestyle. Ensure understanding of self-care strategies.
- Monitoring and Follow-up:
- Implement regular monitoring of symptoms, blood pressure, and heart rate. Schedule follow-up appointments to assess progress, address concerns, and make necessary adjustments to the care plan. Encourage open communication between the healthcare team and the individual.
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 ECGIf 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 the 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 catalyzes 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 afterward.
- Cluster Care to allow for periods of rest
It is important in the 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.
Evaluation for Angina Nursing Care:
- Symptom Control Assessment:
- Evaluate the effectiveness of interventions in controlling angina symptoms. Assess the frequency, intensity, and duration of episodes compared to baseline data.
- Exercise Tolerance Improvement:
- Measure improvements in exercise tolerance through objective assessments and feedback from the individual. Evaluate the ability to engage in physical activity without triggering angina symptoms.
- Medication Adherence and Side Effects:
- Assess the individual’s adherence to prescribed medications and inquire about any side effects experienced. Adjust the medication regimen as needed to optimize symptom management and minimize adverse effects.
- Quality of Life Enhancement:
- Gauge the impact of nursing interventions on the individual’s overall quality of life. Evaluate improvements in daily functioning, emotional well-being, and the ability to participate in meaningful activities.
- Educational Effectiveness:
- Determine the effectiveness of educational interventions by assessing the individual’s understanding of angina, adherence to lifestyle modifications, and ability to recognize and respond to worsening symptoms. Reinforce education as necessary.
References
- https://acls.com/free-resources/knowledge-base/acute-coronary-syndrome/mona-morphine-oxygen-nitroglycerin-and-aspirin
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900358/
- http://www.heart.org/HEARTORG/Conditions/HeartAttack/AboutHeartAttacks/About-Heart-Attacks_UCM_002038_Article.jsp#.WQvquVMrIzY
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941782/
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Transcript
Hey guys, today, we’re going to take a look at angina and its associated care plan.
So in this lesson, we’ll take a look at what angina is and the different types of angina. We’re also going to take a look at additional things like subjective and objective data that your patient may present with and also the necessary nursing interventions and rationales for those interventions.
Okay. Let’s jump in. So, the pathophysiology behind angina is pretty simple. Basically angina is chest pain, which your patient feels because of inadequate blood flow to the heart. This is super important because if blood flow is not restored, more damage can occur. So what is the etiology or cause behind the angina? So, the most common cause is coronary artery disease or CAD. We also see angina in patients with anemia, heart failure, abnormal heart rhythms, or even stress and overexertion.
So, the desired outcome for these patients is to increase or restore blood flow to the heart, to decrease chest pain and improve activity tolerance.
Okay. So here you can see an example of a care plan. Let’s walk through this so you can see exactly how a care plan for angina would be completed. So, at the top here, you can see the medical diagnosis. Below, let’s think of some of the subjective data your patient may present with. Now, remember subjective data is based on the patient’s opinion or feelings, and really cannot be measured by you. So, subjective data for this will include chest pain, dyspnea on exertion or shortness of breath. Included in this objective data, should be a full pain assessment, maybe using a scale like OLDCARTS. Also super important, ask the patient if they have taken any aspirin or nitroglycerin. Objective data will include EKG changes, hypotension, tachycardia, bradycardia, decreased Sp02, and finally signs of decreased perfusion like cool clammy pale skin.
So, nursing interventions are such an important part of a care plan. So, let’s take a look at those next. Bedside EKG monitoring (three or five lead) is critical to see if the patient has any arrhythmias because arrhythmias like Afib with RVR, SVT, and also bradycardia commonly cause angina. Another nursing intervention will include a 12 lead EKG to rule out an MI. It takes five to 15 minutes to determine if chest pain will be relieved by nitroglycerin. So, by checking a 12 lead, a possible STEMI can be ruled out immediately. If your patient does in fact have a STEMI, the patient must go to the cath lab stat.
Okay, a super important Pneumonic we use for the treatment of angina is MONA. M stands for medicine for pain, O is for oxygen, N is for nitroglycerin and A is for aspirin. So, this is the initial treatment for acute coronary syndrome. Now remember, MONA is not the correct order of administration, just an easy way to remember the components of this treatment. Okay. So M used to be used for morphine if both aspirin and nitroglycerin did not relieve chest pain, but morphine isn’t really used anymore as it increases mortality. So, for the M and Mona, think medicine because some type of medication will be given for pain. Oxygen, reminds you to check your oxygenation for chest pain. If the patient is short of breath or has a sat of less than 94%, start two liters Nasal Cannula. Now remember though, only use or administer oxygen if it is clinically necessary.
All right, guys, nitroglycerin is the initial medication given along with aspirin. Nitroglycerin works as a dilator to help allow blood flow that might be disrupted. You’re going to give 0.4 milligrams sublingual. You’re going to wait five minutes and if chest pain isn’t relieved, administer another dose, no more than three doses. Make sure that the patient’s blood pressure is being monitored. Hold the dose if the systolic blood pressure is less than 90 milligrams mercury. Finally guys, aspirin is given because it decreases mortality by thinning the patient’s blood. A single dose of 325 milligrams may be given or four baby aspirin, which are 81 milligrams each can be given to total 324 milligrams. Okay, IV access, as you can imagine, is super important to be able to administer medications, and also for other interventions, if angina worsens, or even for scans to rule out thrombosis. Additionally cardiac enzymes should be drawn to rule out myocardial infarction, and even to help show the extent of myocardial damage. These cardiac enzymes include Troponin 1, CK, CK-MB and myoglobin.
So, your patient should have the blood pressure monitoring because the higher the blood pressure, the more pressure will be exerted on a clot, or even severe hypotension could cause angina. The blood pressure parameters are determined by the physician and the systolic BP, or even the mean arterial pressure or map will be used.
So, not only do we draw cardiac enzymes, but they also need to be monitored. Troponin 1 is an enzyme that helps with the interaction of myosin and actin in the cardiac muscle. So, troponin can become elevated two to four hours after an ischemic cardiac event, and can even stay elevated for up to 14 days. When we talk about CK-MB, which is creatinine kinase, MB is also an enzyme that is found in cardiac muscle. So, when cardiac muscle cells are damaged, this enzyme is released into the bloodstream.
So CK-MB should be measured at admission and then every eight hours after. Finally, for these patients an important intervention is clustering care. This allows the patient to rest by doing multiple things in a short time to allow for longer breaks for the patient. Clustering care decreases their myocardial oxygen demands.
All right guys, here is a look at the completed care plan for angina.
All right, before we end this lesson, it’s important to mention that there are different types of angina that do exist that include: stable, unstable and variant angina. Stable angina usually occurs with stress or exertion. It lasts less than five minutes and is usually predictable and is relieved with rest or nitroglycerin. Unstable angina usually occurs with stress, exertion and also rest. It lasts up to 30 minutes, is unpredictable and may be relieved with nitroglycerin, but it may not be. Variant angina occurs at rest at different durations, is unpredictable and may or may not be relieved with nitroglycerin. So, be sure to refer to the angina cheat sheet that we have for more information.
Okay. So let’s take a final look at the components of the angina care plan. So, remember angina is chest pain due to decreased blood flow to the heart, which can be caused by coronary artery disease, heart failure, stress, and also dysrhythmias.
Subjective data includes chest pain, using a pain assessment like OLDCARTS, also dyspnea on exertion, and ask them if aspirin or nitro has been taken.
Objective data includes hypotension, tachycardia, bradycardia, decreased sats, signs of decreased perfusion like cool pale clammy skin or diaphoretic skin.
Nursing interventions include a three or five lead EKG to assess for any arrhythmias and also a 12 lead to rule out an MI. MONA is a critical nursing intervention for the initial treatment of coronary artery syndrome. Some type of medicine for pain is given. If nitroglycerin and aspirin do not relieve chest pain, oxygenate the patients if clinically necessary. Nitroglycerin sublingual is the initial treatment to relieve chest pain, to increase blood flow to the necessary areas of the heart. And finally, aspirin is given to thin the blood, which increases patient decreases, excuse me, patient mortality. Blood pressure monitoring is important to determine and treat hyper or hypotension, and cardiac enzymes, including Troponin 1, CK CK-MB and myoglobin should be drawn to rule out EMI and determine cardiac damage.
That’s it guys for this lesson. Go out and be your best self today and as always, happy nursing!
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