4 Angina Pectoris (Chest Pain) Nursing Care Plans

Acute Pain

Angina pectoris literally means “strangling of the chest”. It is a general medical term used to define types of chest pain caused by myocardial ischemia. Due to plaque build-up and atherosclerosis, the myocardium can become deprived of blood and oxygen. Thrombus formation and further plaque formation eventually narrow the coronary arteries, causing ischemia and death of myocardial tissue. Ischemia occurs if the demand for oxygen exceeds its supply.

Nursing Diagnosis

• Acute Pain

May be related to

• Decreased myocardial blood flow
• Increased cardiac workload/oxygen consumption
• Tissue ischemia

Possibly evidenced by

• Reports of pain varying in frequency, duration, and intensity (especially as the condition worsens)
• Narrowed focus
• Distraction behaviors (moaning, crying, pacing, restlessness)
• Autonomic responses, e.g., diaphoresis, blood pressure, and pulse rate changes, pupillary dilation, increased/decreased respiratory rate

Desired Outcomes

• The client will report anginal episodes decreased in frequency, duration, and severity.
• The client will demonstrate relief of pain as evidenced by stable vital signs, absence of muscle tension, and restlessness

Nursing Assessment and Rationales

1. Assess and document the client’s response to medication.
This provides information about disease progression and aids in evaluating the effectiveness of interventions and may indicate the need for change in the therapeutic regimen. A microvascular spasm is a form of coronary spasm that is often unresponsive to short-acting nitrates. Treatment of coronary microvascular spasms is difficult and often empiric, and differentiation from other types of angina can only be made during invasive provocation testing.

2. Identify precipitating events, if any, as well as frequency, duration, intensity, and location of the pain.
This helps differentiate this chest pain and aids in evaluating possible progression to unstable angina. An important reason to ask questions about chest pain is to differentiate between stable and unstable angina. The change from stable to unstable angina is potentially life-threatening for the client.

3. Observe associated symptoms such as dyspnea, nausea, vomiting, dizziness, palpitations, and desire to micturate.
Decreased cardiac output (which may occur during the ischemic myocardial episode) stimulates the sympathetic and parasympathetic nervous system, causing a variety of vague sensations that the client may not identify as related to the anginal episode. A feeling of weakness or numbness in the arms, wrists, and hands, as well as shortness of breath, pallor, diaphoresis, dizziness, lightheadedness, and nausea and vomiting, may accompany the pain.

4. Monitor alterations in the cardiac monitor closely.
Silent ischemia describes a situation in which objective evidence of ischemia is observed on an ECG monitor but the person does not complain of anginal symptoms. One-third of clients who are having a heart attack do not report chest pain as a symptom.

5. Evaluate reports of pain in the jaw, neck, shoulder, arm, or hand (typically on the left side).
Cardiac pain may radiate. Pain is often referred to as more superficial sites served by the same spinal cord nerve level. The pain may be accompanied by severe apprehension and a feeling of impending death. It is often felt deep in the chest behind the sternum or the retrosternal area. Typically, the pain or discomfort is poorly localized and may radiate to the neck, jaw, shoulders, and inner aspects of the upper arms, usually the left arm.

6. Monitor vital signs every five minutes during the initial anginal attack.
Tachycardia is common in persons diagnosed with acute coronary syndrome and acute myocardial infarction. Heart rate irregularity may signal the presence of atrial fibrillation or frequent supraventricular or ventricular ectopic beats. High or low blood pressure may be noted. Blood pressure may initially rise because of sympathetic stimulation, then fall if cardiac output is compromised. Hypotension often reflects hemodynamic compromise and is a predictor of poor outcomes (Shah & Ali, 2021).

7. Auscultate heart sounds. Monitor heart rate and rhythm.
Clients with unstable angina have an increased risk of acute life-threatening dysrhythmias, which occur in response to ischemic changes and/or stress. An S4 gallop is a common early finding. The presence of an S3 is an indication of reduced left ventricular function. Heart murmurs, particularly those of mitral regurgitation and ventricular septal defect, may be found after the initial presentation; their presence indicates a grave prognosis (Shah & Ali, 2021). 

8. Monitor serial ECG changes.
Ischemia during an anginal attack may cause transient ST segment depression or elevation and T wave inversion. Serial tracings verify ischemic changes, which may disappear when the client is pain-free. They also provide a baseline against which to compare later pattern changes.

Nursing Interventions and Rationales

1. Instruct the client to notify the nurse immediately when chest pain, pressure, or heaviness occurs.
Pain and decreased cardiac output may stimulate the sympathetic nervous system to release excessive amounts of norepinephrine, which increases platelet aggregation and the release of thromboxane A₂. This potent vasoconstrictor causes coronary artery spasms, which can precipitate, complicate, and/or prolong the anginal attack. Unbearable pain may cause vasovagal response, decreasing BP and heart rate. The term chest pain is not to be used exclusively because some clients describe their angina as “pressure” or “heaviness”. These complaints must be evaluated quickly because they are indicators of myocardial ischemia.

2. Place the client at complete rest during anginal episodes.
This reduces myocardial oxygen demand to minimize the risk of tissue injury. A mismatch between myocardial oxygen supply and demand can result in myocardial ischemia or infarction. Infarct results in irreversible damage to the myocardium (Boyette & Manna, 2022).

3. Elevate the head of the bed if the client is short of breath or during nitrates administration.
This facilitates gas exchange to decrease hypoxia and resultant shortness of breath. Maintain the client in a recumbent position with the head of the bed no higher than 30 degrees during angina. This position minimizes the potential for headache or hypotension by enabling better blood return to the heart and head.

4. Maintain a calm environment and stay with the client who is experiencing pain or appears anxious.
Anxiety releases catecholamines, which increase myocardial workload and can escalate and/or prolong ischemic pain. The presence of a nurse can reduce feelings of fear and helplessness. The nurse may be faced with the challenge of ensuring that the elements of a calm environment that can alleviate the client’s fear and anxiety are maintained while being ready at all times to respond to an acute emergency.

5. Provide light meals with decreased saturated fats, decreased cholesterol, decreased sodium, and refined sugar. Have the client rest for one hour after meals.
This decreases the myocardial workload associated with the work of digestion, reducing the risk of anginal attack. Reducing the dietary saturated fat and decreasing cholesterol intake is effective in lowering the risk of heart and blood vessel disease. Refined sugars are empty calories that can convert to fat stores. Increased sodium intake leads to water retention, which increases vascular volume and cardiac workload.

6. Provide supplemental oxygen as indicated.
Increases oxygen available for myocardial uptake and reversal of ischemia. All clients with acute ischemic pain are administered supplemental oxygen to increase myocardial oxygenation. Hypoxia is common because of the decreased perfusion which adds stress to the compromised myocardium.

7. Administer antianginal medication(s) promptly as indicated.

• 7.1. Nitrates such as nitroglycerin and isosorbide (sublingual, buccal, or oral tablets, metered-dose spray)
  Nitroglycerin has been the standard for treating and preventing anginal pain for more than 100 years. Today it is available in many forms and is still the cornerstone of antianginal therapy. A combination of intravenous and sublingual nitroglycerin is used to vasodilate the coronary arteries and decrease pain. After administration, observe the client closely for the potential development of side effects such as hypotension and headache. Isosorbide dinitrate has a rapid vasodilator effect that lasts 10 to 30 minutes and can be used prophylactically to prevent, as well as abort, anginal attacks.
  
• 7.2. Sustained-release tablets, caplets, chewable tablets, patches, and transmucosal ointment
  Long-acting preparations are used to prevent recurrences by reducing coronary vasospasms and reducing cardiac workload. They may cause headaches, dizziness, light-headedness, and symptoms that usually pass quickly. If the headache is intolerable, alteration of dose or discontinuation of the drug may be necessary. 
  
• 7.3. Beta-blockers such as acebutolol, atenolol, nadolol, metoprolol, and propranolol (Inderal)
  Beta-blockers reduce angina by reducing the heart’s workload. Note: Often these drugs alone are sufficient to relieve angina in less severe conditions. The negative chronotropic and inotropic effects lead to a decreased oxygen demand; that is how angina improves after beta-blocker usage (Farzam & Jan, 2022).
  
• 7.4. Calcium channel blockers such as bepridil, amlodipine, nifedipine, felodipine, isradipine, and diltiazem
  These agents produce relaxation of coronary vascular smooth muscle, dilate coronary arteries, and decrease peripheral vascular resistance. The calcium channel blocker amlodipine relaxes the coronary smooth muscles and produces coronary vasodilation, which in turn improves myocardial oxygen delivery (Shah & Ali, 2021).
  
• 7.5. Analgesics such as morphine sulfate
  Morphine (2 to 4 mg given intravenously) is the analgesic opiate of choice for preinfarction angina. It relieves pain and decreases fear and anxiety. After administration, the critical care nurse assesses the client for pain relief and the development of unwanted side effects such as hypotension and respiratory depression.