Angina Pectoris

Description
1. Angina is chest pain resulting from myocardial ischemia caused by inadequate myocardial
blood and oxygen supply.
2. Angina is caused by an imbalance between oxygen supply and demand.
3. Causes include obstruction of coronary blood flow because of atherosclerosis, coronary artery
spasm, and conditions increasing myocardial oxygen consumption.
4. The goal of treatment is to provide relief of an acute attack, correct the imbalance between
myocardial oxygen supply and demand, and prevent the progression of the disease ad further
attacks to reduce the risk of MI.

Patterns of angina
1.Stable angina
Stable angina also called exertional angina.
Stable angina occurs with activities that involve exertion or emotional stress and is relieved with
rest or nitroglycerin.
Stable angina usually has a stable pattern of onset, duration, severity, and relieving factors.
2. Unstable angina
Unstable angina also is called preinfarction angina.
Unstable angina occurs with an unpredictable degree of exertion or emotion and increases in
occurrence, duration, and severity over time.
Pain may not be relieved with nitroglycerin.
3. Variant angina
Variant angina also is called Prinzmetals or vasospastic angina.
Variant angina results from coronary artery spasm.
Variant angina may occur at rest.
Attacks may be associated with ST segment elevation noted on the electrocardiogram.
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4. Intractable angina is a chronic, incapacitating angina that is unresponsive to interventions.

5. Preinfarction angina
Preinfarction angina is associated with acute coronary insufficiency.
Preinfarction angina lasts longer than 15 minutes.
Preinfarction angina is a symptom of worsening cardiac ischemia.
6. Postinfarction angina occurs after an MI, when residual ischemia may cause episodes of angina.
Risk Factors
Atherosclerosis
Hypertension
Diabetes Mellitus
Thromboangitis Obliterans
Polycythemia Vera
Aortic Regurgitation

Assessment
1. Pain
a. Pain can develop slowly or quickly.
b. Pain usually is described as mild or moderate.
c. Substernal, crushing, squeezing, pain may occur.
d. Pain may radiate to the shoulders, arms, jaw, neck, and back.
e. Pain usually lasts less than 5 minutes, however, pain can last up to 15 to 20 minutes.
f. Pain is relieved by nitroglycerin or rest.
g. Pain intensity is unaffected by inspiration and expiration.
2. Dyspnea
3. Pallor
4. Sweating
5. Palpitations and tachycardia
6. Dizziness and faintness
7. Hypertension
8. Digestive disturbances
Diagnostic Evaluation
1. Electrocardiogram: Readings are normal during rest, with ST depression or elevation and/or T
wave inversion during an episode of pain.
2. Stress test: Chest pain or changes in the electrocardiogram or vital signs during testing may
indicate ischemia.
3. Cardiac enzymes and troponins: Findings are normal in angina.
4. Cardiac catheterization: Catheterization provides a definitive diagnosis by providing
information about the patency of the coronary arteries.
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Primary Nursing Diagnosis

Altered tissue perfusion (myocardial) related to narrowing of the coronary artery(ies) and
associated with atherosclerosis, spasm, or thrombosis
Other Diagnoses that may occur in Nursing Care Plans For Angina
Acute pain
Risk for decreased cardiac output
Anxiety
Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and
discharge needs

Medical Management
The goals of medical management are to decrease the oxygen demands of the myocardium and to
increase the oxygen supply through pharmacologic therapy and risk factor control.
Pharmacologic Intervention

Nitrates, the mainstay of therapy (nitroglycerin)

Beta-adrenergic blockers (metoprolol [Toprol])
Calcium ion antagonists and calcium-channel blockers (amlodipine [Norvase] and diltiazem
[Cardizem])
Antiplatelet and anticoagulant medications (aspirin, clopidogrel (Plavix], ticlopidine [Ticlid],
or heparin)
Oxygen therapy

Nursing Intervention
Immediate management
1. Assess pain.
2. Provide bed rest.
3. Administer oxygen at 3 L/min by nasal cannula as prescribed.
4. Administer nitroglycerin as prescribed to dilate the coronary arteries, reduce the oxygen
requirements of the myocardium and relieve the chest pain.
5. Obtain a 12-Lead electrocardiogram.
6. Provide continuous cardiac monitoring.
Following acute episode:
1. Instruct the client regarding the purpose of diagnostic medical and surgical procedures and the
preprocedure and postprocedure expectations.
2. Assist the client to identify angina precipitating events.
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3. Instruct the client to stop activity and rest if chest pain occurs and to take nitroglycerin as
prescribed.
4. Instruct the client to seek medical attention if pain persists.
5. Instruct the client regarding prescribed medications.
6. Provide diet instructions o the client, stressing that dietary changes are not temporary and
must be maintained or life.
7. Assist the client to identify risk factors that can be modified.
8. Assist the client to set goals that will promote changes in lifestyle to reduce the impact of risk
factors.
9. Assist the client to identify barriers to compliance with therapeutic plan and to identify
methods to overcome barriers.
10. Provide community resources to the client regarding exercise, smoking reduction, and stress
reduction.

Documentation Guidelines
Description of pain: Onset (sudden, gradual), character (aching, sharp, burning, pressure),
precipitating factors, associated symptoms (anxiety, dyspnea, diaphoresis, dizziness, nausea,
cyanosis, pallor), duration, and alleviating factors of the anginal episode
Response to prescribed medications
Reaction to bedrest or limitation in activity

Discharge and Home Healthcare Guidelines

PREVENTION. Teach the patient factors that may precipitate anginal episodes and the
appropriate measures to control episodes. Teach the patient the modifiable cardiovascular risk
factors and ways to reduce them. Manage risk factors, including hypertension, diabetes
mellitus, obesity, and hyperlipidemia.
ACTIVITY. Each person has a different level of activity that will aggravate anginal
symptoms. Most patients with stable angina can avoid symptoms during daily activities by
reducing the speed of any activity.
MEDICATIONS. Be sure the patient understands all medications, including the dose, route,
action, and adverse effects. If the patients physician prescribes sublingual nitroglycerin
(NTG), instruct the patient to lie in semi-Fowler position and take up to three tablets 5
minutes apart to relieve chest discomfort. Instruct the patient that if relief is not obtained after
ingestion of the three tablets, he or she should seek medical attention immediately. Remind
the patient to check the expiration date on the NTG tablets and to replace the bottle, once it is
opened, every 3 to 5 months.
COMPLICATIONS. Teach the patient the importance of not denying or ignoring angina
episodes and of reporting them to the healthcare provider immediately.

Nitrates (Nitroglycerin)
What does this medication do?
Nitrates can be used to prevent chest pain (angina), limit the number of angina attacks that you have,
relieve the pain of a current attack, or treat the symptoms of heart failure. Nitroglycerin is a type of
nitrate.
How does it work?
Nitrates are vasodilators, which means they help widen (dilate) your blood vessels, making it easier
for blood to flow through and let more oxygen-rich blood reach your heart. Better blood flow means
your heart doesn't have to work as hard. Nitrates also relax the veins so less blood is returned to the
heart, which can reduce the workload on your heart.

Q.1) What are the anti-aginal actions of organic nitrates?

A. Increase O2 consumption; redistribution of coronary flow to infarct areas; relief of coronary
spasm; improve perfusion to other organs
B. Decrease O2 consumption; redistribution of coronary flow to ischemic areas; relief of
coronary spasm; improve perfusion
C. Decrease O2 consumption; redistribution of coronary flow to infarct areas; relief of coronary
spasm; improve perfusion

Q.3) An agitated, confused female client arrives in the emergency department. Her history includes
type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis,
headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated
for an acute hypoglycemic reaction. After recovery, nurse Lily teaches the client to treat
hypoglycemia by ingesting:
A. 2 to 5 g of a simple carbohydrate.
B. 10 to 15 g of a simple carbohydrate
C. 18 to 20 g of a simple carbohydrate.
D. 25 to 30 g of a simple carbohydrate
Explanation
To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a
simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6
tsp), or 4 oz of fruit juice. If necessary, this treatment can be repeated in 15 minutes. Ingesting only 2
to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than
15 g may raise it above normal, causing hyperglycemia.
Q.4) Which of the following conditions is most closely associated with weight gain, nausea, and a
decrease in urine output?
A. Angina pectoris
B. Cardiomyopathy
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C. Left-sided heart failure

D. Right-sided heart failure
Explanation
Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure.
Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure
causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesnt cause
weight gain, nausea, or a decrease in urine output.
Q.5) A patient with stable angina is more likely to experience chest pain when the heart needs extra
oxygen. During which of the following situations does the heart need extra oxygen?
A. Smoking a cigarette
B. Eating and digesting a heavy meal
C. Running up the stairs or other physical activity
D. All of the above
Explanation
The heart needs extra oxygen when someone smokes a cigarette, eats a heavy meal, runs up the stairs
or engages in other physical activity. Someone with stable angina is more likely to experience chest
pain during any of these activities.
Q.6) Which of the following terms refers to chest pain brought on by physical or emotional stress and
relieved by rest or medication?
A. angina pectoris
B. atherosclerosis
C. atheroma
D. ischemia
Explanation
Angina pectoris is a symptom of myocardial ischemia.Atherosclerosis is an abnormal accumulation of
lipid deposits and fibrous tissue within arterial walls and lumens. Atheromas are fibrous caps
composed of smooth muscle cells that form over lipid deposits within arterial vessels. Ischemia is
insufficient tissue oxygenation and may occur in any part of the body.
Q.7) What are the effects of organic nitrates?
A. Vasodilation; dilation of large veins results in decreased after-load and decreased cardiac output
B. Vasodilation; dilation of large veins results in decreased pre-load and decreased cardiac
output
C. Vasodilation; dilation of large veins results in decreased pre-load and decreased blood pressure
Q.8) Angina (angina pectoris) is a type of temporary chest pain, pressure or discomfort.
A. True
B. False
Q.9) What is the mechanism by which organic nitrates exert their effects?
A. Increased PKG which causes relaxation of smooth muscle
B. Increased PKG which causes relaxation of large veins and arteries
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C. Decreased PKG which causes relaxation of smooth muscle

PKG protein)
Q.10) A patient with angina pectoris is being discharged home with nitroglycerin tablets. Which of the
following instructions does the nurse include in the teaching?
A. When your chest pain begins, lie down, and place one tablet under your tongue. If the pain
continues, take another tablet in 5 minutes.
B. Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.
C. Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro
tablets one every 5 minutes for 15 minutes, then go lie down.
D. Place one Nitroglycerin tablet under the tongue every five minutes for three doses. Go to the
hospital if the pain is unrelieved.
Explanation
Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving
nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 5
mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary
occlusion that requires immediate medical attention.
Q.11) To enhance the percutaneous absorption of nitroglycerin ointment, it would be MOST important
for the nurse to select a site that is
A. muscular.
B. near the heart.
C. non-hairy.
D. over a bony prominence.
Explanation
Nitroglycerine: used in treatment of angina pectoris to reduce ischemia and relieve pain by decreasing
myocardial oxygen consumption; dilates veins and arteries. Side effects: throbbing headache,
flushing, hypotension, tachycardia. Nursing responsibilities: teach appropriate administration, storage,
expected pain relief, side effects. Ointment applied to skin; sites rotated to avoid skin irritaion.
Prolonged effect up to 24 hours.
Q.12) What causes unstable angina?
A. Atherosclerosis which ruptures, thrombus forms on top, often leading to complete occlusion
B. Atherosclerosis which reduces O2 to tissue
C. Atherosclerosis which ruptures, thrombus forms on top, always followed by breaking up and
embolus formation leading to complete occlusion and infarction
Q.15) What are the drug therapy targets for angina treatment?
A. Decrease heart rate; increase activation of RAAS system
B. Increase cardiac output; decrease body fluid volume
C. Improve myocardial perfusion; reduce metabolic demand
A client in the emergency department complains of squeezing substernal pain that radiates to the left
shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the
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nurse do?
Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual
nitroglycerin.
RATIONALES: Cardiac chest pain is caused by myocardial ischemia. Administering supplemental
oxygen increases the myocardial oxygen supply. Cardiac monitoring helps detect life-threatening
arrhythmias. Ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest
pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac
catheterization team before completing the initial assessment is premature.
A client is admitted to the hospital with a diagnosis of angina. As part of the discharge plan, a nurse
should include which of the following instructions to reduce the risk of angina?
Take frequent rest breaks during the day.
RATIONALES: Taking frequent rest breaks during the day will help decrease oxygen demand which
may reduce the risk of angina. Although exercise is encouraged, the appropriate amount of exercise
should be discussed with the physician. Smoking cigarettes with less tar and nicotine does not reduce
the risk of angina. Smoking cessation should be encouraged. Activity shouldn't be limited to sitting in
a chair. A carefully planned cardiac rehabilitation program with gradual exercise increases would be
more appropriate.
Which of the following signs and symptoms should the nurse expect to find in a client with angina?
Chest tightness
Chest pressure
Jaw pain
RATIONALES: Chest tightness, chest pressure, and jaw pain are all symptoms of angina. General
muscle aching is not associated with angina. Respirations and heart rate typically increase, not
decrease, with anginal attacks.
A client is admitted for treatment of Prinzmetal's angina. When developing the plan of care, the nurse
keeps in mind that this type of angina is triggered by:
coronary artery spasm.
A client with angina complains that the anginal pain is prolonged and severe and occurs at the
same time each day, most often at rest in the absence of precipitating factors. How would the
nurse best describe this type of anginal pain?
1.Stable angina
2.Variant angina
3.Unstable angina
4.Nonanginal pain
Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day,
most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets.
Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor
of myocardial infarction.

The nurse in the medical unit is assigned to provide discharge teaching to a client with a
diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to
minimize the effects of the disease process. The client continually changes the subject during the
teaching session. The nurse interprets that this client's behavior is most likely related to which
problem?
1.Anxiety related to the need to make lifestyle changes
2.Boredom resulting from having already learned the material
3.An attempt to ignore or deny the need to make lifestyle changes
4.Lack of understanding of the material provided at the teaching session and embarrassment
about asking questions
Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by
refusal to discuss what has happened. Denial is a common early reaction associated with chest
discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of
sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to
interpret the client's behavior as boredom or as either understanding or not understanding the material
provided at the teaching session.
The nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The
client is receiving oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is
necessary. The nurse should provide which information to the client?
1.Oxygen has a calming effect.
2.Oxygen will prevent the development of any thrombus.
3.Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle.
4.The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells.
The pain associated with angina results from ischemia of myocardial cells. The pain often is
precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will
help to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent
thrombus formation and does not directly calm the client.
A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns
to the nursing unit after the procedure, and the nurse provides instructions to the client regarding
home care measures. Which statement, if made by the client, indicates an understanding of the
instructions?
1."I need to cut down on cigarette smoking."
2."I am so relieved that my heart is repaired."
3."I need to adhere to my dietary restrictions."
4."I am so relieved that I can eat anything I want to now."
After angioplasty, the client needs to be instructed regarding the specific dietary restrictions that must
be followed. Making the recommended dietary and lifestyle changes will assist in preventing further
atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are
not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.
The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris
who takes nitroglycerin for chest pain at home. During the assessment the client complains of
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chest pain. The nurse should immediately ask the client which question?
1."Where is the pain located?"
2."Are you having any nausea?"
3."Are you allergic to any medications?"
4."Do you have your nitroglycerin with you?"
If a client complains of chest pain, the initial assessment question would be to ask the client about the
pain intensity, location, duration, and quality. Although options 2, 3, and 4 all may be components of
the assessment, none of these questions would be the initial assessment question with this client.
A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going
up two flights of stairs or after walking four blocks. What type of angina should the nurse
determine that the client is experiencing?
1.Stable
2.Variant
3.Unstable
4.Intractable
Stable angina is triggered by a predictable amount of effort or emotion. Variant angina is triggered by
coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early
in the day and at rest. Unstable angina is triggered by an unpredictable amount of exertion or emotion
and may occur at night; the attacks increase in number, duration, and severity over time. Intractable
angina is chronic and incapacitating and is refractory to medical therapy.
The nurse is teaching the client with angina pectoris about disease management and lifestyle
changes that are necessary to control disease progression. Which statement by the client indicates
a need for further teaching?
1."I will avoid using table salt with meals."
2."It is best to exercise once a week for 1 hour."
3."I will take nitroglycerin whenever chest discomfort begins."
4."I will use muscle relaxation to cope with stressful situations."
Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target
heart rate. Other healthful habits include limiting salt and fat in the diet and using stress management
techniques. The client also should be taught to take nitroglycerin before any activity that previously
caused the pain and to take the medication at the first sign of chest discomfort.
The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's
(variant) angina. What should the nurse plan to teach the client about this type of angina?
1.It is most effectively managed by b-blocking agents.
2.It has the same risk factors as stable and unstable angina.
3.It can be controlled with a low-sodium, high-potassium diet.
4.Generally it is treated with calcium-channel-blocking agents
Prinzmetal's angina results from spasm of the coronary vessels and is treated with calcium-channel
blockers. b-Blockers are contraindicated because they may actually worsen the spasm. The risk
factors are unknown, and this type of angina is relatively unresponsive to nitrates. Diet therapy is not
specifically indicated.
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Which information given by a patient admitted with chronic stable angina will help the nurse
confirm this diagnosis?
a.The patient rates the pain at a level 3 to 5 (0-10 scale).
b.The patient states that the pain "wakes me up at night."
c.The patient indicates that the pain is resolved after taking one sublingual nitroglycerin
tablet.
d.The patient says that the frequency of the pain has increased over the last few weeks.
Rationale: Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level
of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased
frequency is typical of unstable angina.
Which of the following tests is used most often to diagnose angina?
12-lead electrocardiogram (ECG)
The 12-lead ECG will indicate ischemia, showing T-wave inversion. In addition, with variant angina,
the ECG shows ST-segment elevation. A chest x-ray will show heart enlargement or signs of heart
failure, but isnt used to diagnose angina.
A client admitted with angina complains of severe chest pain and suddenly becomes unresponsive.
After establishing unresponsiveness, which of the following actions should the nurse take first?
Activate the resuscitation team
Immediately after establishing unresponsiveness, the nurse should activate the resuscitation team. The
next step is to open the airway using the head-tilt, chin-lift maneuver and check for breathing
(looking, listening, and feeling for no more than 10-seconds). If the client isnt breathing, give two
slow breaths using a bag mask or pocket mask. Next, check for signs of circulation by palpating the
carotid pulse.

When the patient diagnosed with angina pectoris complains that

he is experiencing chest pain more frequently even at rest, the
period of pain is longer, and it takes less stress for the pain
to occur, the nurse recognizes that the patient is describing
which type of angina?
a) Variant
b) Refractory
c) Intractable
d) Unstable
Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in
treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond
to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation
and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe,
incapacitating chest pain that does not respond to conventional treatment.

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