CASE STUDY D (Angina Pectoris)

Study Questions

1. Distinguish between the symptoms of angina and MI.

ANGINA MYOCARDIAL INFARCTION

PALLIATIVE/PROVOCATIVE PALLIATIVE/PROVOCATIVE

 Precipitated by exertion or stress (or  Occurring without cause,

 rest in variant angina)  usually in the morning

 Relieved by nitroglycerin or rest  Relieved only by opioids

REGION AND RADIATION REGION AND RADIATION

 Substernal chest discomfort  Substernal chest pain/pressure

 Radiating to the left arm  Radiating to the left arm

 Pain or discomfort in jaw, back,

 shoulder, or abdomen

TIME TIME

 Lasting less than 15 minutes  Lasting 30 minutes or more

ASSOCIATED SYMPTOMS ASSOCIATED SYMPTOMS

 Few, if any, associated symptoms Frequent associated symptoms:

 Nausea/vomiting

 Diaphoresis

 Dyspnea

 Feelings of fear and anxiety

 Dysrhythmias
  Fatigue

 Palpitations

 Epigastric distress

 Anxiety

 Dizziness

 Disorientation/acute confusion

 Feeling “short of breath”

2. What are the signs and symptoms of stable angina?

 predictable angina

 often described as a squeezing, heavy, choking, or suffocating sensation

 angina is rarely sharp or stabbing, and it usually does not change with position or

breathing

 although most angina pain appears substernally, the sensation may occur in the neck

or radiate to various locations, including the lower jaw, the shoulders, and the arm

 often people complain of pain between the shoulder blades

 pain usually lasts for only 5 to 15 minutes and commonly subsides when the

precipitating factor is resolved

3. Define unstable angina. How it is diagnosed and treated?

Definition

It is a chest pain or discomfort that occurs at rest or with exertion and causes severe

activity limitation. A transitory syndrome falling between stable angina and acute

myocardial infarction (AMI); thrombus forms in an area of arterial stenosis but is

 subsequently fully or partially lysed by endogenous antithrombotic mechanisms.

Symptoms worsen such that the patient presents with the development of new onset

exertion angina, angina present at rest for longer than 20 minutes, or symptoms that have

accelerated in frequency, duration, or intensity.

Diagnosis

 Cardiac angiography (vessels assessed): patients most often show presence of stenotic

eccentric lesions, collateral circulation, and the absence of a totally occluded coronary

artery.

 Blood markers indicating myocardial damage are normal

 ECG changes, if present, are transitory and will return to normal.

Treatment

Medications

One of the first treatments which may be recommend by the physician is a blood thinner,

such as aspirin, heparin, or clopidogrel. When blood isn’t as thick, it can flow more freely

through your arteries. Other than that, these medications may also be prescribed to reduce

angina symptoms, including drugs that reduce blood pressure, cholesterol levels, anxiety

and arrhythmia symptoms.

Surgery

If a blockage or severe narrowing in an artery is present, the doctor may recommend

more invasive procedures. These include angioplasty, where they open up an artery that

was previously blocked. A small tube known as a stent to keep your artery open may also

be inserted. In severe instances, a heart bypass surgery may be essential. This procedure

reroutes blood flow away from a blocked artery to help improve blood flow to the heart
 Lifestyle modifications

Eating a healthier diet, lowering your stress, exercising more, losing weight if overweight

and quitting smoking if patient currently smokes.

4. Describe Prinzmetal (variant) angina.

It occurs when single or multiple sites in major coronary arteries and their large branches

have vasospasm. Most often the right coronary artery is involved. Sites of vasospasm

generally occur over eccentric lesions.

5. What does suggest the common noncardiac causes of chest pain?

NONCARDIC CHARACTER DURATION PRECIPITATING/AGGRAVATING

CAUSES FACTORS

Pulmonary  Pain - sharp, severe ≥ 30 min  Follows an infectious or noninfectious

(pneumonia, substernal or process (MI, cardiac surgery, cancer,

pulmonary epigastric arising immune disorders, uremia)

embolism, from inferior portion  Pleuritic pain increases with

spontaneous of pleura (referred to inspiration, coughing, movement, and

pneumothorax) as pleuritic pain) supine positioning

 Patient may be able to  Occurs in conjunction with

localize the pain community-acquired or nosocomial

lung infections (pneumonia) or deep

vein thrombosis (pulmonary

embolism)
Esophageal  pain - substernal 5-60  Recumbency, cold liquids,

disorders (hiatal sharp, burning or minutes exercise

hernia, reflux heavy

esophagitis or  Often mimics angina

spasm)  Can radiate to neck,

arm, or shoulders

Musculoskeletal  pain - Sharp or Hours - days  Most often follows respiratory tract

disorders stabbing; localized in infection with significant coughing,

(costochondritis) anterior chest vigorous exercise, or post trauma

 Most often unilateral  Some cases idiopathic

 Can radiate across  Exacerbated by deep inspiration,

chest to epigastrium coughing, sneezing, and movement of

or back upper torso or arms

Anxiety and panic  Pain - stabbing to dull Peaks in 10  Can occur at any time including

disorders ache minutes during sleep

 associated with  Can be associated with a specific

diaphoresis, trigger

palpitations, shortness

of breath, tingling of

hands or mouth,

feeling of unreality,

or fear of losing

control
6. List specific nursing measures regarding medications, diet, activity, lifestyle changes and

emotional support should be implemented for D.T.?

Diet

Consume sufficient calories for your body to include:

 Less than 7% from saturated fats

 Avoiding trans fatty acids

 Limit your cholesterol intake to less than 200mg/day.

 Limit your sodium intake as specified by your health care provider.

 Recommend DASH diet since patient has hypertension and this put him at more risk

to develop recurring angina. The diet includes a plant-based diet (green leafy), fruits,

lean protein sources like chicken, fish and beans. The diet is low in red meat, salt,

added sugars and fat. Encourage no more than 1 teaspoon (2,300 mg) of sodium per

day,

Activity

 If you are middle-aged or older or have a history of medical problems, check with

your health care provider before starting an exercise program.

 Engage in a regimen of physical conditioning with a gradual increase in activity

duration and then a gradual increase in activity intensity.

 Walk daily, increasing distance and time as prescribed.

 Monitor pulse rate during physical activity.

 Avoid physical exercise immediately after a meal.

 Alternate activity with rest periods (some fatigue is normal and expected during

convalescence).
  Engage in a daily program of exercise that develops into a program of regular

exercise for a lifetime

 If the patient has pain frequently or with minimal activity, patient’s activities must be

alternated with rest periods.

 Balancing activity and rest is an important aspect of the educational plan for the

patient and family.

 Avoid extremes of heat and cold and walking against the wind.

Lifestyle changes

 Stop smoking and use of tobacco; avoid secondhand smoke.

 Have your blood pressure checked regularly.

 Be compliant with taking Metropolol 100mg BID or follow doctor’s advise regarding

hypertensive medications.

 Continue to monitor blood pressure at regular intervals.

 Avoid severely restrictive or fad diets.

 Restrict intake of saturated fats, simple sugars, and cholesterol-rich foods.

 Increase physical activity

 Comply with the physician’s prescribed medications for chest pain.

Emotional support

Patients with angina often fear loss of their roles within society and the family. They may

also fear that the pain (or the prodromal symptoms) may lead to an MI or death.

 reduction methods - such as guided imagery or music therapy

 addressing the spiritual needs of the patient and family

 use a calm, reassuring approach to avoid increasing patient’s anxiety

  encourage verbalization of feelings, perceptions, and fears to decrease anxiety and

stress

 provide factual information concerning diagnosis, treatment, and prognosis to

decrease fear of the unknown

 assist the patient in identifying positive strategies to deal with limitations and manage

needed lifestyle or role changes

 help the patient to grieve and work through the losses of chronic illness

7. During his stay in the CCU, D.T. ask if he has to change his lifestyle, as he did not want

to have a “heart attack”. How would you respond?

I would say, “Yes sir. It is needed to prevent the angina or heart attack from recurring.

Making modifications (question number 6) in one’s lifestyle is not easy so you may do it

gradually until you get used to it.” Then I would inform him about the significance with

lifestyle change for his condition.

8. Discuss the nursing diagnosis of self-concept in regard to patients with angina. How does

this major problem impact their perception of self? Their relationship with others?

If a cardiovascular is acute, patient’s self-perception may be affected. Invasive diagnostic

procedures often lead to body image concerns for the patient. In D.T.’s case, he had

undergone coronary artery angioplasty (management). When it is chronic, patient may

not be able to identify what precipitates it but he or she can always describe the inability

to match up with previous levels of activity or accomplishments. This could also greatly

affect a person’s quality of life. Hence, identifying how the illness affects the person’s
life is essential. D.T. may express anger and may be directed at family, staff, or medical

regimen. He may show manifestations of withdrawal, crying, apathy.