The classic symptom of coronary artery disease (CAD) is angina—pain caused by loss of oxygen and nutrients to the myo¬cardial tissue because of inadequate coronary blood flow. In most but not all patients presenting with angina, CAD symptoms are caused by significant atherosclerosis. Unstable angina is sometimes grouped with MI under the diagnosis of acute coronary syndrome.
Angina has three major forms:
Stable (precipitated by effort, of short duration, and easily relieved)
Unstable (longer lasting, more severe, may not be relieved by rest/nitroglycerin; may also be new onset of pain with exertion or recent acceleration in severity of pain), and
Variant (chest pain at rest with ECG changes due to coronary artery spasm). The AHCPR guidelines of May 1994 state that unstable angina is a transitory syndrome that causes significant disability and death in the United States.
Nursing Care Plan for Coronary Artery Disease (Angina) | Nursing Priorities; Discharge Goals
Nursing Priorities |Nursing Care Plan for Coronary Artery Disease (Angina)
Prevent/minimize development of myocardial complications.
Provide information about disease process/prognosis and treatment.
Support patient/SO in initiating necessary lifestyle/behavioral changes.
Report anginal episodes decreased in frequency, duration, and severity.
Demonstrate relief of pain as evidenced by stable vital signs, absence of muscle tension and restlessness
Nursing Care Plan for Coronary Artery Disease (Angina) | Nursing Interventions for Coronary Artery Disease
Nursing Care Plan for Coronary Artery Disease (Angina) | Nursing Interventions for Coronary Artery Disease (Angina) and Rationale;
Nursing Interventions for Coronary Artery Disease (Angina) and Rationale
Pain Management (NIC)
Nursing Interventions for Coronary Artery Disease (Angina) (Independent) | Nursing Care Plan for Coronary Artery Disease (Angina)
Instruct patient to notify nurse immediately when chest pain occurs. Rationale: Pain and decreased cardiac output may stimulate the sympathetic nervous system to release excessive amounts of norepinephrine, which increases platelet aggregation and release of thromboxane A2. This potent vasoconstrictor causes coronary artery spasm, which can precipitate, complicate, and/or prolong an anginal attack. Unbearable pain may cause vasovagal response, decreasing BP and heart rate.
Assess and document patient response/effects of medication. Rationale: Provides information about disease progression. Aids in evaluating effectiveness of interventions, and may indicate need for change in therapeutic regimen.
Identify precipitating event, if any; frequency, duration, intensity, and location of pain. Rationale: Helps differentiate this chest pain, and aids in evaluating possible progression to unstable angina. (Stable angina usually lasts 3–15 min and is often relieved by rest and sublingual nitroglycerin (NTG); unstable angina is more intense, occurs unpredictably, may last longer, and is not usually relieved by NTG/rest.)
Observe for associated symptoms, e.g., dyspnea, nausea/vomiting, dizziness, palpitations, desire to micturate. Rationale: Decreased cardiac output (which may occur during ischemic myocardial episode) stimulates sympathetic/parasympathetic nervous system, causing a variety of vague sensations that patient may not identify as related to anginal episode.
Evaluate reports of pain in jaw, neck, shoulder, arm, or hand (typically on left side). Rationale: Cardiac pain may radiate, e.g., pain is often referred to more superficial sites served by the same spinal cord nerve level.
Pain Management (NIC)
Nursing Interventions for Coronary Artery Disease (Angina) (Independent) – Continuation
Place patient at complete rest during anginal episodes. Rationale: Reduces myocardial oxygen demand to minimize risk of tissue injury/necrosis.
Elevate head of bed if patient is short of breath. Rationale: Facilitates gas exchange to decrease hypoxia and resultant shortness of breath.
Monitor heart rate/rhythm. Rationale: Patients with unstable angina have an increased risk of acute life-threatening dysrhythmias, which occur in response to ischemic changes and/or stress.
Monitor vital signs every 5 min during initial anginal attack. Rationale: Blood pressure may initially rise because of sympathetic stimulation, then fall if cardiac output is compromised. Tachycardia also develops in response to sympathetic stimulation and may be sustained as a compensatory response if cardiac output falls.
Stay with patient who is experiencing pain or appears anxious. Rationale: Anxiety releases catecholamines, which increase myocardial workload and can escalate/prolong ischemic pain. Presence of nurse can reduce feelings of fear and helplessness.
Provide light meals. Have patient rest for 1 hr after meals. Rationale: Decreases myocardial workload associated with work of digestion, reducing risk of anginal attack.
Nursing Interventions for Coronary Artery Disease (Angina) (Collaborative) | Nursing Care Plan for Coronary Artery Disease (Angina)
Provide supplemental oxygen as indicated. Rationale: Increases oxygen available for myocardial uptake/reversal of ischemia.
Administer antianginal medication(s) promptly as indicated:
Nitroglycerin: sublingual (Nitrostat), buccal, or oral tablets, metered-dose spray; or sublingual isosorbide dinitrate (Isordil). Rationale: Nitroglycerin has been the standard for treating and preventing anginal pain for more than 100 yr. Today it is available in many forms and is still the cornerstone of antianginal therapy. Rapid vasodilator effect lasts 10–30 min and can be used prophylactically to prevent, as well as abort, anginal attacks. Long-acting preparations are used to prevent recurrences by reducing coronary vasospasms and reducing cardiac workload. May cause headache, dizziness, light-headedness—symptoms that usually pass quickly. If headache is intolerable, alteration of dose or discontinuation of drug may be necessary. Note: Isordil may be more effective for patients with variant form of angina.
Sustained-release tablets, caplets (Nitrong, Nitrocap T.D.), chewable tablets (Isordil, Sorbitrate), patches, transmucosal ointment (Nitro-Dur, Transderm-Nitro). Rationale: Reduces frequency and severity of attack by producing prolonged/continuous vasodilation.
Beta-blockers, e.g., acebutolol (Sectral), atenolol (Tenormin), nadolol (Corgard), metroprolol (Lopressor), propranolol (Inderal). Rationale: Reduces angina by reducing the heart’s workload. (Refer to ND: Cardiac Output, risk for decreased, following, p. 000.) Note: Often these drugs alone are sufficient to relieve angina in less severe conditions.
Analgesics, e.g., acetaminophen (Tylenol). Rationale: Usually sufficient analgesia for relief of headache caused by dilation of cerebral vessels in response to nitrates.
Morphine sulphate (MS). Rationale: Potent narcotic analgesic may be used in acute onset because of its several beneficial effects, e.g., causes peripheral vasodilation and reduces myocardial workload; has a sedative effect to produce relaxation; interrupts the flow of vasoconstricting catecholamines and thereby effectively relieves severe chest pain. MS is given IV for rapid action and because decreased cardiac output compromises peripheral tissue absorption.
Monitor serial ECG changes. Rationale: Ischemia during anginal attack may cause transient ST segment depression or elevation and T wave inversion. Serial tracings verify ischemic changes, which may disappear when patient is pain-free. They also provide a baseline against which to compare later pattern changes.
Further reading for coronary artery disease at Wikipedia.
This is a sample of Nursing Care Plan for Coronary Artery Disease (Angina).