Medical – Surgical Nursing

(NUR 155) | BATCH 2023

COLLEGE OF NURSING – PHINMA UNIVERSITY OF PANGASINAN

ANGINA PECTORIS
NOCTURNAL ANGINA
- A clinical syndrome usually characterized by episodes of pain or - Associated with rapid eye movement (REM) sleep during
pressure in the anterior chest dreaming
- Usual cause is insufficient coronary blood flow which results in
imbalance between oxygen supply and demand ANGINA DECUBITUS
- Paroxysmal chest pain that occurs when the client reclines and
PATHOPHYSIOLOGY lessens when the client sits or stands up

Factors that increase oxygen demand on INTRACTABLE ANGINA

The heart or decreases blood flow to the heart - Chronic incapacitating angina, unresponsive to interventions
↓
Altered oxygen supply and demand of the heart POST-INFARCTION ANGINA
↓ - Occurs after MI when residual ischemia may cause episodes of
Myocardial Ischemia angina
↓
Decreased coronary tissue perfusion CLINICAL MANIFESTATIONS:
↓ 1. Transient paroxysmal attacking of substernal or precordial pain
Ischemic cells shift to anaerobic metabolism  Onset – quickly or slowly
↓
Accumulation of lactic acid  Location – retrosternal or slightly to the left of the sternum
↓  Radiation – left shoulder, arms, neck and jaw
Irritation of nerve endings  Duration – 10-15 minutes; may be more than 20 minutes but
↓ does not exceed 30 minutes
Chest pain/Angina
 Sensation – squeezing, burning, pressing, choking, aching pain
or feeling of gas, heartburn or indigestion
PATTERNS OF ANGINA
 Severity – mild to moderate
SILENT ANGINA  Relieved by rest or administration of nitroglycerine
- With objectives signs but patient reports no symptoms  Aggravated by continued activity
Exertion →Pain→Rest→Relief→Pattern
STABLE ANGINA 2. Dyspnea, palpitation
- Paroxysmal chest pain 3. Pallor, sweating
- Caused by predictable degree of exertion 4. Dizziness, fainting
5. Digestive disturbances
- Stable pattern of onset, duration, severity and relieving factor
DIAGNOSTICS:
UNSTABLE ANGINA
• ECG
- Preinfarction/Crescendo angina/Intermittent coronary syndrome
• Exercise Electrocardiography (Stress Testing)
- Paroxysmal chest pain
• Radioisotope Imaging
- Caused by unpredictable degree of exertion – occurs at night
• Coronary Angiography
- Unstable pattern with increased number, duration and severity
overtime
MEDICATIONS:
1. OPIATE ANALGESICS (i.e., Morphine Sulfate)
2. NITROGLYCERINE

VARIANT (PRINZMETAL’S ANGINA)

- Relieves pain within 1-5 minutes

- Occurs while at rest - Administered SL (tablet form)

- Attacks tend to happen in the early hours of the day (12MN-8AM) - Short-acting nitrate
- For acute attacks of angina

PADAWAN, ANGELIKA R.| 3BSN3

 Medical – Surgical Nursing
(NUR 155) | BATCH 2023
COLLEGE OF NURSING – PHINMA UNIVERSITY OF PANGASINAN

- Should be carried always and placed in its original container - Keep Vitamin K available
(dark glass bottle)
- Avoid foods rich in Vitamin K during therapy (e.g., green
- Observe for side effects: headache, flushed face, dizziness, leafy vegetables)
faintness and tachycardia; these are common during 1 st few
doses of the medication. Do not discontinue the drug
-
Minimally-Invasive Surgical Interventions:
- Nitroglycerin sublingual tablets usually give relief in 1-5
minutes. • Percutaneous transluminal coronary angioplasty (PTCA)

- However, if pain is not relieved, the patient may use a • Directional Coronary Atherectomy (DCA)
second tablet after 5 minutes after taking the first tablet. • Intracoronary Stents/Intravascular Stenting
- If the patient still has chest pain after a total of 3 tablets, the • Laser Ablation
patient must contact the doctor or go to a hospital ER
immediately. Surgical Interventions:
- • Coronary Artery Bypass Graft (CABG)
3. BETA-ADRENERGIC BLOCKERS • Transmyocardial Revascularization
- Assess PR before administration of the drug, withhold if
Bradycardia is present Nursing Responsibilities/Care:
- Administer with food to prevent GI upset Goals:
(1) Relieve acute pain;
- Examples: PropanOLOL (Inderal); AtenOLOL
(2) Restore coronary blood flow;
(Tenormin); MetropOLOL (Lopressor)
(3) Prevent further attacks to reduce the risk of AMI
1. Prevention and Control of Risk Factors. Avoid
4. CALCIUM-CHANNEL BLOCKERS
precipitating factors of angina
- Assess HR and BP 2. Diet: Low in Na and Fat; High in Fiber
- Administer 1 hour ac or 2 hours pc 3. Weight reduction and stress management techniques;
avoid overexertion
- Examples: Nifedipine (Calcibloc); Amlodipine (Norvasc); 4. Avoid smoking, alcohol and caffeine
Verapamil (Isoptin); Diltiazem(Cardizem)

5. ANTIPLATELETMEDICATION/
PLATELET AGGREGATION INHIBITORS
(e.g., aspirin/ticlopidine)
– advise the patient to take aspirin with food.

6. ANTICOAGULANTS
MYOCARDIAL INFARCTION
Heparin Sodium - Also known as coronary occlusion or “Heart Attack”
- Inactivates thrombin and other clotting factors inhibiting - Usually follows sudden coronary occlusion and the abrupt
conversion of fibrinogen to fibrin (stable clot) cessation of blood flow to the
myocardium
- Assess for s/sx of bleeding
- Considered as the endpoint of CAD
- Monitor PTT or aPTT levels
- A profound imbalance between oxygen demand and supply
- Keep protamine sulfate available
- One of the leading causes of death in the world
Warfarin Sodium (Coumadin)
- Inhibit hepatic synthesis of Vitamin K Etiology:
- Monitor PT or INR - Coronary atherosclerosis/CAD

PADAWAN, ANGELIKA R.| 3BSN3

 Medical – Surgical Nursing
(NUR 155) | BATCH 2023
COLLEGE OF NURSING – PHINMA UNIVERSITY OF PANGASINAN

- Coronary occlusion by embolus or thrombus  Inferior Wall Infarct – RCA

- Coronary stenosis or spasms
Classifications of MI:
- Conditions that increase oxygen demand or decrease oxygen
supply
 Transmural Infarct – extends from endocardium to epicardium
 Subendocardial infarct – affects the endocardial muscles
PATHOPHYSIOLOGY  Intramural infarct – patchy areas of the myocardium and is
Changes in the Coronary Artery associated with long standing angina
↓
Inadequate coronary blood flow Clinical Manifestations
↓ • Chest pain – heavy, crushing, knifelike, severe and prolonged (>30
Myocardial Ischemia minutes); not relieved by rest or NTG or position changes
(Zone of Ischemia) • Feelings of doom or restlessness
↓
• Shock
Alterations in heart’s functions
↓ • Oliguria
Autonomic responses • Fever
↓Exacerbates imbalance between oxygen supply and demand • Indigestion
↓ • Acute pulmonary edema
Persistent ischemia results to Injury
(Zone of Injury)
↓
LABORATORY/DIAGNOSTICS
Further deprivation of blood supply would
o ECG
Result necrosis
(Zone of infarction) o T wave depression (Ischemia)
↓ o ST segment elevation (Injury)
Scar formation o Pathologic Q wave (Infarction)
↓ o Blood Tests
Permanent loss of myocardial contractility o Leukocytosis (↑WBC)
o Increased ESR

Complications:
 Dysrhythmias
 Heart failure
 Pulmonary Edema
 Cardiogenic shock
 Pulmonary embolism
 Recurrent MI
 Ventricular Aneurysm
 Pericarditis
 Mitral regurgitation
 Sudden Cardiac Death

Sites of MI:
 Anterior Wall Infarct – LADA
 Posterior Wall Infarct - RCA/Circumflex artery

PADAWAN, ANGELIKA R.| 3BSN3

 Medical – Surgical Nursing
(NUR 155) | BATCH 2023
COLLEGE OF NURSING – PHINMA UNIVERSITY OF PANGASINAN

CPK MB (Creatine Phosphokinase – MB)

- Onset (3 to 6 hours)
- Peak (12 to 18 hours)
- Normal (3 to 4 days)

LDH (Lactate Dehydrogenase)

TROPONIN I and T
Onset (7 to 14 hours)
Normal (5-7 days)

MYOGLOBIN
Medical Management:
Goals:
• Minimize myocardial damage
• Preserve myocardial function
• Prevent complication

Morphine
Oxygen
Nitroglycerine
Aspirin

If not relieved by MONA, patient most likely undergoes emergency

surgery.

CARDIAC MARKERS

PADAWAN, ANGELIKA R.| 3BSN3

 Medical – Surgical Nursing
(NUR 155) | BATCH 2023
COLLEGE OF NURSING – PHINMA UNIVERSITY OF PANGASINAN

Other meds:
 Thrombolytics
 Anticoagulants
 ACE inhibitors
 Diuretics

NURSING MANAGEMENT:
 Activate EMS and start a code
 Implement CBR without BRPs as ordered
 Allay anxiety
 Identify s/sx of heart failure and other complications

HEALTH TEACHINGS:
 Emphasize lifelong lifestyle modifications
 Resumption of ADLs

CARDIAC REHABILITATION (4 PHASES):

Promoting self-care and independence
• Phase 1 (inpatient)
• Phase 2 (post-discharge – psychological and educational
interventions)
• Phase 3 (Structured Exercise and rehabilitation)
• Phase 4 (long term maintenance)

PADAWAN, ANGELIKA R.| 3BSN3