Angina

Angina is severe chest pain resulting from myocardial ischemia. It is caused by inadequate myocardial blood and oxygen supply, obstruction of coronary blood flow, coronary artery spasm, and a condition that increases myocardial oxygen demand. There is an imbalance between oxygen supply and demand.

The treatment is focused to provide relief of an acute attack, correct the imbalance between myocardial oxygen supply and demand, and prevent the progression of the disease and further attack to reduce risk of myocardial infarction.

Types of Angina:

1. Stable Angina: it is also called exertional angina, occurs with activities that involve exertion or emotional stress and is relieved with rest or nitroglycerin. It has stable pattern of onset, duration, severity, and relieving factors.
2. Unstable Angina: it is also called preinfarction angina, occurs with an unpredictable degree of exertion or emotion and increases in occurrence, duration and severity over time. The pain of this angina may not be relieved with nigroglycerin.
3. Variant Angina: it is also called Prinzmetal’s or vasospastic angina. It is results from coronary artery spasm and may occur at rest. ST segment elevation is noted on the electrocardiogram.
4. Intractable Angina: it is a chronic and incapacitating angina that is unresponsive to interventions.
5. Preinfarction Angina: It is associated with acute coronary insufficiency and lasts longer that 15 minutes. Preinfarction angina is a symptom of worsening cardiac ischemia.
6. Postinfarction Angina: It occurs after an myocardial infarction, when residual ischemia may cause episodes of angina.

Sign and Symptoms of Angina:

• Pain: slowly or quickly, mild or moderate, last lest than 4 minutes and relived by nitroglycerin or rest. Pain may radiate to the shoulders, arms, jaw, neck, and back. Pain is substernal, crushing, and squeezing.
• Pallor
• Dyspnea
• Sweating
• Dizziness and faintness
• Hypertension
• Palpitations and tachycardia
• Digestive disturbances

Diagnostic Procedures for Angina:

• Electrocardiogram: Normal during rest. ST depression or elevation and/or T wave inversion during an episode of attack.
• Stress Test: chest pain or changes in ECG or vital signs during testing indicate ischemia
• Cardiac Enzymes and Troponins: Normal in angina
• Cardiac Catheterization: to provide a definitive diagnosis.

Immediate Management:

• Assess pain
• Provide bed rest
• Oxygen at 3 L/min by nasal cannula
• Administer nitroglycerin as prescribed to dilate coronary arteries and relieve pain
• Obtain a 12-lead ECG
• Continuous cardiac monitoring

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Coronary Artery Disease

Coronary artery disease is a condition in which one or more coronary arteries become narrowed or obstructed. It can be result from atherosclerosis and an accumulation of lipid-containing plague in arteries. This condition causes decreases perfusion of myocardial tissue and inadequate myocardial oxygen supply. The goal of treatment is to alter the atherosclerotic progression.

Coronary artery disease leads to hypertension, angina, dysrhythmias, myocardial infarct, heart failure, and death.

Coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50% or if any major branch is reduced at least 75%.

Sign and Symptoms Coronary Artery Disease:

• Chest pain
• Palpitations
• Dyspnea
• Syncope
• Excessive fatigue
• Cough or hemoptysis
• Possibly normal findings during asymptomatic

Diagnostic Procedure for Patient with Coronary Artery Disease:

• Electrocardiogram: ST segment depression or T wave inversion when blood flow is reduced and ischemia occurs. ST segment elevation followed by T wave inversion when infarction occurs.
• Cardiac Catheterization: It will show the presence of atherosclerotic lesions.
• Blood Lipid Levels: may be elevated.

Nursing Interventions:

• Inform patient regarding the purpose of diagnostic medical and surgical procedures
• Assist and identify risk factors that can be modified
• Instruct the patient regarding a low-calorie, low sodium, los cholesterol, and low fat diet with an increase in dietary fiber
• Inform the patient that dietary changes are not temporary but maintained for life
• Instruct the patient regarding prescribed medications
• Instruct the patient regarding exercise, smoking reduction, and stress reduction

Surgical Procedures for Coronary Artery Disease:

• PTCA: to compress the plaque against the wall of the artery and dilate the vessel
• Laser angioplasty: to vaporize the plaque
• Vascular stent: to prevent the artery from closing and to prevent restenosis
• Atherectomy: to remove the plaque from the artery
• Coronary artery bypass graft: to improve blood flow to the myocardial tissue

Medications

• Nitrates: to dilate the coronary arteries and to decrease preload and afterload
• Cholesterol-lowering medications: to reduce the development of atherosclerotic plaques
• Calcium channel blockers: to dilate coronary arteries and reduce vasospasm
• Beta blocker: to reduce blood pressure

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CARDIAC TAMPONADE

Cardiac tamponade is compression of the heart due to critically increased volume of fluid in the pericardium. The space between the parietal and visceral layers of the pericardium are filled with fluid. Acute cardiac tamponade occurs when small volume (20-50 ml) of fluid accumulate in the pericardium.

Cardiac tamponade will restrict ventricular filling and cardiac output drops.

Signs and Symptoms of Cardiac Tamponade:

• Pulsus paradoxus
• Jugular venous distention with clear lungs
• Increased CVP
• Distant, muffled heart sounds
• Cardiac output is decreased

Intervention for Cardiac Tamponade:

• Place patient in a critical care unit for hemodynamic monitoring
• Administer fluid intravenously as prescribed
• Prepare patient for chest x-ray, echocardiogram, and pericardiocentesis (to draw pericardial fluid) if prescribed

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Rheumatic Fever

Rheumatic fever is a systemic inflammatory autoimmune disease occurring after a group A beta-hemolytic streptococcal infection: pharyngitis, strep throat, scarlet fever, tonsillitis, approximately 2-6 weeks prior. Rheumatic fever can involve the heart, joints, skin, and brain and most often seen in children and young adults.

Signs and Symptoms:

• Fever
• Joint pain, migratory polyarthritis
• Joint swelling; redness, or warmth
• Abdominal pain
• Skin rash (erythema marginatum)
• Aschoff bodies, inflammatory hemorrhagic bullous lesions located on the myocardium usually found on autopsy
• Sydenham’s chorea also called St.Vitus Dance—emotional instability, muscular weakness and rapid, uncoordinated jerky movements affecting primarily the face, feet, and hands
• Epistaxis (nosebleeds)
• Carditis
• Subcutaneous nodules located on extensor surfaces of knees, elbows, and knuckles
• Cardiac murmur

Treatments:

• Anti-inflammatory medications such as aspirin or corticosteroids;
• Antibiotic therapy (penicillin, erythromycin), includes the continuous use of low dose antibiotics to prevent recurrence; supportive therapy for other symptoms

Nursing Interventions:

• Assess and monitor for risk factors
• Monitor vital sign
• Assess laboratory values for elevated erythrocyte sedimentation rate, C-reactive protein
• Assess and monitor heart sounds and ECG
• Administer pain medication as prescribed
• Administer antibiotics as prescribed
• Maintain bed rest during acute stage
• Maintain fluid balance
• Provide emotional support
• Provide client and family education especially for prophylactic antibiotic therapy to reduce the risk of recurrent rheumatic fever
• Instruct client and family in proper and prompt treatment of strep throat and scarlet fever
• Provide client and family education

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Endocarditis

Endocarditis is the infection of the endocardial suface of the heart including the valves. Most people who develop endocarditis have underlying valvular heart disease. The disease due to rheumatic heart disease, prostatic heart valve, IV drug use, mitral valve prolapsed, and infection by bacteria (Streptococci, Enterococci, or Staphylococcus aureous). Infective endocarditis has a 20-30% mortality rate.

Endocarditis can be diagnosed by positive blood cultures and presence or valvular vegetations on echocardiogram.

Signs and Symptoms:

• Anorexia
• Malaise
• Fever
• Fatigue
• Night sweats
• Heart murmurs
• Wight loss
• Elevated ESR and WBC

Treatments:

1. Antibiotic to eliminate all microorganism and prevent complication
2. Surgical repair or replacement of damaged valves.

Nursing Interventions:

• Assess and monitor vital signs and heart sound (the presence of murmurs)
• Administer IV antibiotics as prescribed
• Monitor for side effects of antibiotic (renal or ototoxicity)
• Assess and monitor signs of heart failure, embolic event, or dysrhythmias
• Provide adequate rest
• Teach patient to avoid recurrence of infections
• Teach patient to avoid excessive fatigue and to stop activities that result in chest pain, faintness, or dyspnea
• Teach patient the importance of completing medication schedule and side effects of medication

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Myocarditis

Myocarditis is the inflammation of the myocardium. Generally myocarditis is due to infection from virus, bacteria, protozoa or helminthes, toxins, systemic disease, radiation, and drugs. The inflammatory process causes edema and damage to the cell of the heart that results in weakening anf the heart muscle and then decreases its contractility. Mycardtis has a 20% to 30 % mortality rate.

Signs and Symptoms of Patient with Mycarditis:

• Anorexia
• Malaise
• Fatigue
• Fever
• Weight loss
• Night Sweats
• Heart murmurs
• Elevated ESR and WBC
• Positive blood cultures, reflecting an infectious or inflammatory

Nursing Intervention for Patient with Myocarditis:

• Monitor vital sign and assess for presence of murmus
• Administer antibiotics as prescribed and monitor for side effects
• Assess and monitor for signs of heart failure
• Assess for signs of embolic or dysrhythmias
• Provide adequate rest periods for patient

Special Teaching for Patient with Myocarditis:

• Teach patient how to avoid recurrence of infection: using antibiotic prophylaxis for dental or urological procedures.
• Teach patient the side effects of each myocarditis mediction.
• Teach patient how to modify lifestyle to avoid excessive fatigue and to stop activities that result in chest pain, faintness, or dyspnea.
• Teach patient the importance of completing mycarditis medication schedules.

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Pericarditis

Pericarditis is the inflammation of the layers of the pericardium. It may involve the diaphragm and can be primary or secondary to other disease. Pericardium is the fibrous sac surrounding the heart.

Pericarditis may result from bacterial, viral, or fungal infections, immunologic disorders, connective tissue disease, neoplasms, renal failure, myocardial infarction, myocardial injury, radiation, or drugs.

Patient with pericarditis will show up the signs and symptoms as followed as here:

• Chest pain that worsens when deep breathing or lying in a supine position and improves when sitting up taking shallow breaths (this is one means to discriminate from acute MI since chest pain in MI is usually not effected by change in position)
• Dyspnea
• Malaise
• Fever
• Cough
• Elevated ESR and WBC
• Pericardial friction rub heard most commonly on expiration

Nursing Interventions for patients with pericarditis:

• Assess and monitor vital signs and heart sound.
• Administer pain medication to treat malaise and other flulike symptoms as prescribed.
• Administer NSAIDs as prescribed.
• Give patient time for rest.
• Assess and monitor the signs of decreases cardiac output.
• Comfort patient: increased fluids, rest periods, and distraction technique.
• Teach patient to adhere to medication schedules.
• Guide patient to adopt ways to modify lifestyle especially to conserves energy and reduce fatique during acute episode of illness.
• Teach patient how to recognize signs of recurrence: chest pain, malaise, and fever.

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