Angina Pectoris Nursing Care Plan & Management


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  1. Angina is chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply.
  2. Angina is caused by an imbalance between oxygen supply and demand.
  3. Causes include obstruction of coronary blood flow because of atherosclerosis, coronary artery spasm, and conditions increasing myocardial oxygen consumption.
  4. The goal of treatment is to provide relief of an acute attack, correct the imbalance between myocardial oxygen supply and demand, and prevent the progression of the disease ad further attacks to reduce the risk of MI.

Angina Pectoris

Patterns of angina

1. Stable angina

  • Stable angina also called exertional angina.
  • Stable angina occurs with activities that involve exertion or emotional stress and is relieved with rest or nitroglycerin.
  • Stable angina usually has a stable pattern of onset, duration, severity, and relieving factors.

2. Unstable angina

  • Unstable angina also is called preinfarction angina.
  • Unstable angina occurs with an unpredictable degree of exertion or emotion and increases in occurrence, duration, and severity over time.
  • Pain may not be relieved with nitroglycerin.

3. Variant angina

  • Variant angina also is called Prinzmetal’s or vasospastic angina.
  • Variant angina results from coronary artery spasm.
  • Variant angina may occur at rest.
  • Attacks may be associated with ST segment elevation noted on the electrocardiogram.

4. Intractable angina is a chronic, incapacitating angina that is unresponsive to interventions.

5. Preinfarction angina

  • Preinfarction angina is associated with acute coronary insufficiency.
  • Preinfarction angina lasts longer than 15 minutes.
  • Preinfarction angina is a symptom of worsening cardiac ischemia.

6. Postinfarction angina occurs after an MI, when residual ischemia may cause episodes of angina.

Risk Factors
  • Atherosclerosis
  • Hypertension
  • Diabetes Mellitus
  • Thromboangitis Obliterans
  • Polycythemia Vera
  • Aortic Regurgitation

1. Pain

  1. Pain can develop slowly or quickly.
  2. Pain usually is described as mild or moderate.
  3. Substernal, crushing, squeezing, pain may occur.
  4. Pain may radiate to the shoulders, arms, jaw, neck, and back.
  5. Pain usually lasts less than 5 minutes, however, pain can last up to 15 to 20 minutes.
  6. Pain is relieved by nitroglycerin or rest.

2. Dyspnea
3. Pallor
4. Sweating
5. Palpitations and tachycardia
6. Dizziness and faintness
7. Hypertension
8. Digestive disturbances

Diagnostic Evaluation
  1. Electrocardiogram: Readings are normal during rest, with ST depression or elevation and/or T wave inversion during an episode of pain.
  2. Stress test: Chest pain or changes in the electrocardiogram or vital signs during testing may indicate ischemia.
  3. Cardiac enzymes and troponins: Findings are normal in angina.
  4. Cardiac catheterization: Catheterization provides a definitive diagnosis by providing information about the patency of the coronary arteries.
Primary Nursing Diagnosis
  • Altered tissue perfusion (myocardial) related to narrowing of the coronary artery(ies) and associated with atherosclerosis, spasm, or thrombosis
Other Diagnoses that may occur in Nursing Care Plans For Angina
  • Acute pain
  • Risk for decreased cardiac output
  • Anxiety
  • Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs
Medical Management

The goals of medical management are to decrease the oxygen demands of the myocardium and to increase the oxygen supply through pharmacologic therapy and risk factor control.

Surgical Management

Frequently, therapy includes a combination of medicine and surgery. Surgically, the goals of management include revascularization of the blood supply to the myocardium.

  • Coronary artery bypass surgery or minimally invasive direct coronary artery bypass (MIDCAB)
  • Percutaneous transluminal coronary angioplasty (PTCA) or percutaneous transluminal myocardial revascularization (PTMR)
  • Application of intracoronary stents and atherectomy to enhance blood flow
  • Lasers to vaporize plaques
  • Percutaneous coronary endarterectomy to extract obstruction.
Pharmacologic Intervention
  • Nitrates, the mainstay of therapy (nitroglycerin)
  • Beta-adrenergic blockers (metoprolol [Toprol])
  • Calcium ion antagonists and calcium-channel blockers (amlodipine [Norvase] and diltiazem [Cardizem])
  • Antiplatelet and anticoagulant medications (aspirin, clopidogrel (Plavix], ticlopidine [Ticlid], or heparin)
  • Oxygen therapy
Nursing Intervention
Immediate management
  1. Assess pain.
  2. Provide bed rest.
  3. Administer oxygen at 3 L/min by nasal cannula as prescribed.
  4. Administer nitroglycerin as prescribed to dilate the coronary arteries, reduce the oxygen requirements of the myocardium and relieve the chest pain.
  5. Obtain a 12-Lead electrocardiogram.
  6. Provide continuous cardiac monitoring.
Following acute episode:
  1. Instruct the client regarding the purpose of diagnostic medical and surgical procedures and the preprocedure and postprocedure expectations.
  2. Assist the client to identify angina precipitating events.
  3. Instruct the client to stop activity and rest if chest pain occurs and to take nitroglycerin as prescribed.
  4. Instruct the client to seek medical attention if pain persists.
  5. Instruct the client regarding prescribed medications.
  6. Provide diet instructions o the client, stressing that dietary changes are not temporary and must be maintained or life.
  7. Assist the client to identify risk factors that can be modified.
  8. Assist the client to set goals that will promote changes in lifestyle to reduce the impact of risk factors.
  9. Assist the client to identify barriers to compliance with therapeutic plan and to identify methods to overcome barriers.
  10. Provide community resources to the client regarding exercise, smoking reduction, and stress reduction.
Documentation Guidelines
  • Description of pain: Onset (sudden, gradual), character (aching, sharp, burning, pressure), precipitating factors, associated symptoms (anxiety, dyspnea, diaphoresis, dizziness, nausea, cyanosis, pallor), duration, and alleviating factors of the anginal episode
  • Response to prescribed medications
  • Reaction to bedrest or limitation in activity
Discharge and Home Healthcare Guidelines
  • PREVENTION. Teach the patient factors that may precipitate anginal episodes and the appropriate measures to control episodes. Teach the patient the modifiable cardiovascular risk factors and ways to reduce them. Manage risk factors, including hypertension, diabetes mellitus, obesity, and hyperlipidemia.
  • ACTIVITY. Each person has a different level of activity that will aggravate anginal symptoms. Most patients with stable angina can avoid symptoms during daily activities by reducing the speed of any activity.
  • MEDICATIONS. Be sure the patient understands all medications, including the dose, route, action, and adverse effects. If the patient’s physician prescribes sublingual nitroglycerin (NTG), instruct the patient to lie in semi-Fowler position and take up to three tablets 5 minutes apart to relieve chest discomfort. Instruct the patient that if relief is not obtained after ingestion of the three tablets, he or she should seek medical attention immediately. Remind the patient to check the expiration date on the NTG tablets and to replace the bottle, once it is opened, every 3 to 5 months.
  • COMPLICATIONS. Teach the patient the importance of not denying or ignoring angina episodes and of reporting them to the healthcare provider immediately.




Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed
Handbook for Brunner & Suddarth’s, Textbook of Medical-SurgicalNursing, 11th ed



Welcome to your MSN Exam for Angina Pectoris! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.


Exam Details

  • Number of Questions: 14 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!


Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Consider the American Diabetes Association's recommendations for treating hypoglycemia, which advise a specific range of simple carbohydrates to quickly raise blood sugar levels.

1 / 14

1. Nurse Lily attends to a disoriented and agitated female patient in the emergency department. The patient's medical history reveals type 1 diabetes mellitus, hypertension, and angina pectoris. Her symptoms include pallor, sweating, headaches, and severe hunger. An urgent blood glucose test shows a level of 42 mg/dl. After treating the patient for acute hypoglycemia and seeing her recover, Nurse Lily educates her on treating hypoglycemia at home by consuming:

💡 Hint

Consider the protocol for using nitroglycerine tablets in case of anginal pain, including the timing and when to seek emergency care.

2 / 14

2. Nurse Olivia is conducting discharge education for Michael, who has been diagnosed with angina pectoris and prescribed nitroglycerine tablets. She wants to make sure Michael knows how to properly use the medication if he experiences anginal pain at home. What instruction should Nurse Olivia include?

💡 Hint

Consider which activity is most likely to cause the heart to demand more oxygen, thereby potentially triggering an anginal episode.

3 / 14

3. Nurse Clara is reviewing potential triggers of anginal episodes with Sarah, a 58-year-old patient diagnosed with stable angina. She wants to highlight an activity that is most likely to precipitate an angina episode. Which activity should Nurse Clara mention?

💡 Hint

Consider that stable angina is often triggered by any condition or activity that puts extra strain or demand on the heart. Which option encompasses multiple scenarios that could increase cardiac workload?

4 / 14

4. Nurse William is providing education to Karen, a patient diagnosed with stable angina. He explains that situations that demand extra oxygen from the heart can trigger her angina symptoms. In which of the following scenarios is Karen most likely to require additional cardiac oxygenation?

💡 Hint

Consider which option most accurately describes the unpredictability and increased risk associated with unstable angina.

5 / 14

5. Nurse Sarah is attending to Mr. Davis, a 54-year-old patient experiencing episodes of unstable angina. During patient education, she wants to accurately describe the pathophysiology causing Mr. Davis's unstable angina symptoms. What is the most accurate explanation?

💡 Hint

Consider the nature of angina symptoms, specifically whether they are chronic or temporary and what they typically consist of.

6 / 14

6. Nurse Michelle is providing educational material to Lisa, a new patient with cardiovascular issues. She wants to confirm Lisa's understanding about angina, specifically that angina pectoris refers to a temporary form of chest pain, pressure, or discomfort. Is this statement correct?

💡 Hint

Think about the skin characteristics that would facilitate the most effective absorption of the ointment.

7 / 14

7. Nurse Emily is about to administer nitroglycerine ointment to Susan, who has angina pectoris. Emily wants to ensure optimal percutaneous absorption of the medication. What factor is most crucial when choosing an application site for the ointment?

💡 Hint

Think about which side of the heart is responsible for pumping blood to the lungs and the rest of the body, and which side's failure would most likely result in systemic symptoms like weight gain and reduced urine output.

8 / 14

8. Nurse Olivia is assessing Sarah, a 65-year-old patient who has been complaining of weight gain, nausea, and a decrease in urine output. Which cardiac condition should Nurse Olivia most strongly consider based on these symptoms?

💡 Hint

Focus on the role of PKG and how it influences the state of smooth muscle cells in the context of organic nitrates.

9 / 14

9. Nurse Sarah is discussing the pharmacology of organic nitrates with Brian, a patient newly diagnosed with angina. She wants to clarify how these medications actually work at the cellular level to alleviate his symptoms. What is the mechanism of action of organic nitrates?

💡 Hint

Think about how vasodilators like organic nitrates work to relieve angina symptoms. Specifically, consider their impact on preload and blood pressure.

10 / 14

10. Nurse Emily is discussing medication options with Mark, a patient diagnosed with angina. She wants to inform him about the effects of organic nitrates on his cardiovascular system. What should Nurse Emily explain as the primary effects of this medication?

💡 Hint

Focus on the features that make unstable angina different from stable angina, especially concerning the state of the atherosclerotic plaque and blood flow.

11 / 14

11. Nurse Paul is educating Clara, a 54-year-old patient with cardiovascular issues, on the causes of unstable angina. What should Nurse Paul mention as the primary cause of this condition?

💡 Hint

Reflect on the two key factors that contribute to angina pain and how medication aims to address them.

12 / 14

12. Nurse Emily is taking care of Mrs. Smith, a 65-year-old patient who has been experiencing frequent angina episodes. As part of the patient education, Nurse Emily wants to clarify the primary objectives of drug therapy for treating angina. What should she identify as the main treatment goals?

💡 Hint

The goal of anti-anginal therapy is generally to decrease the workload on the heart while improving blood flow to ischemic tissues. Which option aligns best with these goals?

13 / 14

13. Nurse Rachel is educating Lisa, a 49-year-old patient with angina, about her new prescription for organic nitrates. What should Nurse Rachel explain as the primary anti-anginal effects of organic nitrates?

💡 Hint

Consider the classic symptoms and triggers for this type of chest pain, which often include physical activity or emotional stress and can be relieved by rest or medication.

14 / 14

14. Nurse James is educating Tina, a 45-year-old woman, about her cardiac symptoms. He wants to properly identify the term that refers to her chest pain, which is induced by either physical exertion or emotional stress and is alleviated by rest or medication. What is the appropriate term to describe Tina's condition?

Nursing Care Plan

Nursing Diagnosis: Acute Pain

May be related to

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

Possibly evidenced by

  • Reports of pain varying in frequency, duration, and intensity (especially as 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
  • 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 Interventions
  • 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 to 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.
  • Observe for associated symptoms: dyspnea, nausea and vomiting, dizziness, palpitations, desire to micturate.
    • Rationale: Decreased cardiac output (which may occur during ischemic myocardial episode) stimulates sympathetic and 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. Pain is often referred to more superficial sites served by the same spinal cord nerve level.
  • Place patient at complete rest during anginal episodes.
    • Rationale: Reduces myocardial oxygen demand to minimize risk of tissue injury.
  • 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 and 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 and/or prolong ischemic pain. Presence of nurse can reduce feelings of fear and helplessness.
  • Maintain quiet, comfortable environment. Restrict visitors as necessary.
    • Rationale: Mental/emotional stress increases myocardial workload.
  • 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.
  • Provide supplemental oxygen as indicated.
    • Rationale: Increases oxygen available for myocardial uptake and reversal of ischemia.

Administer antianginal medication(s) promptly as indicated:

  • Nitroglycerin: sublingual (Nitrostat), buccal, or oral tablets, metered-dose spray.
    • 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.
  • sublingual isosorbide dinitrate (Isordil)
    • Rationale: Rapid vasodilator effect lasts 10–30 min and can be used prophylactically to prevent, as well as abort, anginal attacks.
  • Sustained-release tablets, caplets:(Nitrong, Nitrocap T.D.), chewable tablets (Isordil, Sorbitrate), patches, transmucosal ointment (Nitro-Dur, Transderm-Nitro)
    • Rationale: 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. Reduces frequency and severity of attack by producing continuous vasodilation.
  • Beta-blockers:  acebutolol (Sectral), atenolol (Tenormin), nadolol (Corgard), metoprolol (Lopressor), propranolol (Inderal)
    • Rationale: Reduces angina by reducing the heart’s workload. Note: Often these drugs alone are sufficient to relieve angina in less severe conditions.
  • Calcium channel blockers: bepridil (Vascor), amlodipine (Norvasc), nifedipine (Procardia), felodipine (Plendil), isradipine (DynaCirc), diltiazem (Cardizem)
    • Rationale: Produces relaxation of coronary vascular smooth muscle; dilates coronary arteries; decreases peripheral vascular resistance.
  • Analgesics:  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.

Nursing Diagnosis:  Deficient Knowledge

May be related to

  • Lack of exposure
  • Inaccurate/misinterpretation of information
  • Unfamiliarity with information resources

Possibly evidenced by

  • Questions; statement of concerns
  • Request for information
  • Inaccurate follow-through of instructions
Desired Outcomes
  • Participate in learning process.
  • Assume responsibility for own learning, looking for information and asking questions.
  • Verbalize understanding of condition/disease process and potential complications.
  • Verbalize understanding of /participate in therapeutic regimen.
  • Initiate necessary lifestyle changes.
Nursing Interventions
  • Discuss pathophysiology of condition. Stress need for preventing and managing anginal attacks.
    • Rationale: Patients with angina need to learn why it occurs and what they can do to control it. This is the focus of therapeutic management to reduce likelihood of myocardial infarction and promote healthy heart lifestyle.
  • Review significance of cholesterol levels and differentiate between LDL and HDL factors. Emphasize importance of periodic laboratory measurements.
    • Rationale: Although recommended LDL is ±160 mg/dL, patients with two or more risk factors (smoking, hypertension, diabetes mellitus, positive family history) should keep LDL ±130 mg/dL, and those with diagnosis of CAD need to keep LDL below 100 mg/dL. HDL below 35–45 is considered a risk factor; a level above 60 mg/dL is considered an advantage.
  • Encourage avoidance of situations that may precipitate anginal episode (stress, intense physical exertion, large heavy meals especially during bedtime, exposure to extreme temperatures).
    • Rationale: Doing so would reduce the incidence or severity of ischemic episodes.
  • Assist patient and/or SO to identify sources of physical and emotional stress and discuss ways that they can be avoided.
    • Rationale: This is a crucial step in preventing anginal attacks.
  • Review importance of weight control, cessation of smoking, dietary changes, and exercise.
    • Rationale: Knowledge of the significance of risk factors provides patient with opportunity to make needed changes. Patients with high cholesterol who do not respond to 6-month program of low-fat diet and regular exercise will require medication.
  • Encourage patient to follow prescribed reconditioning program; caution to avoid exhaustion.
    • Rationale: Fear of triggering attacks may cause patient to avoid participation in activity that has been prescribed to enhance recovery (increase myocardial strength and form collateral circulation).
  • Discuss impact of illness on desired lifestyle and activities, including work, driving, sexual activity, and hobbies. Provide information, privacy, or consultation, as indicated.
    • Rationale: Patient may be reluctant to resume usual activities because of fear of anginal attack or death. Patient should take nitroglycerin prophylactically before any activity that is known to precipitate angina.
  • Demonstrate how to monitor own pulse and BP during and after activities, and to schedule activities, avoid strain and take rest periods.
    • Rationale: Allows patient to identify those activities that can be modified to avoid cardiac stress and stay below the anginal threshold.
  • Discuss steps to take when anginal attacks occur, (cessation of activity, keeping “rescue” NTG on hand, administration of prn medication, use of relaxation techniques).
    • Rationale: Being prepared for an event takes away the fear that patient will not know what to do if attack occurs.
  • Review prescribed medications for prevention of anginal attacks:
    • Rationale: Angina is a complicated condition that often requires the use of many drugs given to decrease myocardial workload, improve coronary circulation, and control the occurrence of attacks.
  • Lipid-lowering agents: bile acid sequestrants, cholestyramine (Questran), colestipol (Colestid);
    • Rationale: These drugs are considered first-line agents for lowering serum cholesterol levels. Note: Questran and Colestid may inhibit absorption of fat-soluble vitamins and some drugs such as Coumadin, Lanoxin, and Inderal.
  • nicotinic acid, and HMG-CoA reductase inhibitors: lovastatin (Mevacor), simvastatin (Zocor)
    • Rationale: The HMG-CoA reductase inhibitors may cause photosensitivity.
  • Stress importance of checking with physician before taking OTC drugs.
    • Rationale: OTC drugs may potentiate or negate effects of prescribed medications.
  • Discuss ASA and other antiplatelet agents as indicated.
    • Rationale: May be given prophylactically on a daily basis to decrease platelet aggregation and improve coronary circulation.
  • Review symptoms to be reported to physician: increase in frequency of attacks, changes in response to medications.
    • Rationale: May prolong survival rate of patients with unstable angina. Knowledge of expectations can avoid undue concern for insignificant reasons or delay in treatment of important symptoms.
  • Discuss importance of follow-up appointments.
    • Rationale: Angina is a symptom of progressive coronary artery disease that should be monitored and may require occasional adjustment of treatment regimen.

Nursing Diagnosis:  Anxiety

May be related to

  • Situational crises
  • Threat to self-concept (altered image/abilities)
  • Underlying pathophysiological response
  • Threat to or change in health status (disease course that can lead to further compromise, debility, even death)
  • Negative self-talk

Possibly evidenced by

  • Expressed concern regarding changes in life events
  • Increased tension/helplessness
  • Apprehension, uncertainty, restlessness
  • Association of diagnosis with loss of healthy body image, loss of place/influence
  • View of self as noncontributing member of family/society
  • Fear of death as an imminent reality
Desired Outcomes
  • Verbalize awareness of feelings of anxiety and healthy ways to deal with them.
  • Report anxiety is reduced to a manageable level.
  • Express concerns about effect of disease on lifestyle, position within family and society.
  • Demonstrate effective coping strategies/problem-solving skills.
Nursing Interventions
  • Explain purpose of tests and procedures: stress testing.
    • Rationale: Reduces anxiety attributable to fear of unknown diagnosis and prognosis.
  • Promote expression of feelings and fears. Let patient/SO know these are normal reactions.
    • Rationale: Unexpressed feelings may create internal turmoil and affect self-image. Verbalization of concerns reduces tension, verifies level of coping, and facilitates dealing with feelings. Presence of negative self-talk can increase level of anxiety and may contribute to exacerbation of angina attacks.
  • Encourage family and friends to treat patient as before.
    • Rationale: Reassures patient that role in the family and business has not been altered.
  • Tell patient the medical regimen has been designed to limit future attacks and increase cardiac stability.
    • Rationale: Encourages patient to test symptom control, to increase confidence in medical program, and to integrate abilities into perceptions of self.
  • Administer sedatives, tranquilizers, as indicated.
    • Rationale: May be desired to help patient relax until physically able to reestablish adequate coping strategies.

Nursing Diagnosis: Risk for Decreased Cardiac Output

Risk factors may include

  • Inotropic changes (transient/prolonged myocardial ischemia, effects of edications)
  • Alterations in rate/rhythm and electrical conduction
Desired Outcomes
  • Report/display decreased episodes of dyspnea, angina, and dysrhythmias.
  • Demonstrate increased activity tolerance.
  • Participate in behaviors/activities that reduce the workload of the heart.
Nursing Interventions
  • Maintain bed or chair rest in position of comfort during acute episodes.
    • Rationale: Decreases oxygen demand therefore reducing myocardial workload and risk of decompensation.
  • Monitor vital signs and cardiac rhythm.
    • Rationale: Tachycardia may be present because of pain, anxiety, hypoxemia, and reduced cardiac output. Changes may also occur in BP (hypertension or hypotension) because of cardiac response. ECG changes reflecting dysrhythmias indicate need for additional evaluation and therapeutic intervention.
  • Auscultate breath sounds and heart sounds. Listen for murmurs.
    • Rationale: S3, S4, or crackles can occur with cardiac decompensation or some medications (especially beta-blockers). Development of murmurs may reveal a valvular cause for chest pain (aortic stenosis, mitral stenosis) or papillary muscle rupture.
  • Provide for adequate rest periods. Perform self-care activities, as indicated.
    • Rationale: Conserves energy, reduces cardiac workload.
  • Stress importance of avoiding straining down, especially during defecation.
    • Rationale: Valsalva maneuver causes vagal stimulation, reducing heart rate (bradycardia), which may be followed by rebound tachycardia, both of which may impair cardiac output.
  • Encourage immediate reporting of pain for prompt administration of medications as indicated.
    • Rationale: Timely interventions can reduce oxygen consumption and myocardial workload and may minimize cardiac complications.
  • Monitor and documents effects or adverse response to medications, noting BP, heart rate, and rhythm.
    • Rationale: Desired effect is to decrease myocardial oxygen demand by decreasing ventricular stress. Drugs with negative inotropic properties can decrease perfusion to an already ischemic myocardium. Combination of nitrates and beta-blockers may have cumulative effect on cardiac output.
  • Assess for signs and symptoms of heart failure.
    • Rationale : Angina is only a symptom of underlying pathology causing myocardial ischemia. Disease may compromise cardiac function to point of decompensation.
  • Evaluate mental status, noting development of confusion, disorientation.
    • Rationale: Reduced perfusion of the brain can produce observable changes in sensorium.
  • Note skin color and presence and quality of pulses.
    • Rationale: Peripheral circulation is reduced when cardiac output falls, giving the skin a pale or gray color (depending on level of hypoxia) and diminishing the strength of peripheral pulses.
  • Administer supplemental oxygen as needed.
    • Rationale: Increases oxygen available for myocardial uptake to improve contractility, reduce ischemia, and reduce lactic acid levels.
  • Monitor pulse oximetry or ABGs as indicated.
    • Rationale: Determines adequacy of respiratory function and/or Otherapy.
  • Measure cardiac output and other functional parameters as indicated.
    • Rationale: Cardiac index, preload/afterload, contractility, and cardiac work can be measured noninvasively through various means, including thoracic electrical bioimpedance (TEB) technique. Useful in evaluating response to therapeutic interventions and identifying need for emergency care. Note: Evaluation of changes in heart rate, BP, and cardiac output requires consideration of patient’s circadian hemodynamic variability.

Administer medications as indicated:

  • Calcium channel blockers: diltiazem (Cardizem), nifedipine (Procardia), verapamil (Calan), bepridil (Vascor), amlodipine (Norvasc), felodipine (Plendil), isradipine (DynaCirc)
    • Rationale: Although differing in mode of action, calcium channel blockers play a major role in preventing and terminating ischemia induced by coronary artery spasm and in reducing vascular resistance, thereby decreasing BP and cardiac workload.
  • Beta-blockers: atenolol (Tenormin), nadolol (Corgard), propranolol (Inderal), esmolol (Brevibloc);
    • Rationale: These medications decrease cardiac workload by reducing heart rate and systolic BP. Note: Overdosage produces cardiac decompensation.
  • Acetylsalicylic acid (ASA), other antiplatelet agents: ticlopidine (Ticlid); glycoprotein IIb/IIa, abciximab (ReoPro), eptifibatide (Integrilin)
    • Rationale: Useful in unstable angina, ASA diminishes platelet aggregation and clot formation. For patients with major GI intolerance, alternative drugs may be indicated. New antiplatelet medications are being used IV in conjunction with angioplasty. Oral forms are under investigation.
  • IV heparin
    • Rationale: Bolus, followed by continuous infusion, is recommended to help reduce risk of subsequent MI by reducing the thrombotic complications of plaque rupture for patients diagnosed with intermediate or high-risk unstable angina. Note: Use of low-molecular-weight heparin is increasing because of its more efficacious and predictable effect with fewer adverse effects (less risk of bleeding) and longer half-life. It also does not require anticoagulation monitoring.
  • Monitor laboratory studies: PTT, aPTT.
    • Rationale: Evaluates therapy needs and effectiveness.
  • Discuss purpose and prepare for stress testing and cardiac catheterization, when indicated.
    • Rationale: Stress testing provides information about the health and strength of the ventricles.
  • Prepare for surgical intervention, angioplasty with/without intracoronary stent placement, valve replacement, CABG, if indicated.
    • Rationale: Angioplasty (also called percutaneous transluminal coronary angioplasty [PTCA]) increases coronary blood flow by compression of atheromatous lesions and dilation of the vessel lumen in an occluded coronary artery. Intracoronary stents may be placed at the time of PTCA to provide structural support within the coronary artery and improve the odds of long-term patency. This procedure is preferred over the more invasive CABG surgery. CABG is the recommended treatment when testing confirms myocardial ischemia as a result of left main coronary artery disease or symptomatic three-vessel disease, especially in those with left ventricular dysfunction. Note: Stent placement may also be effective for the variant form of angina where periodic vasospasms impair arterial flow.
  • Prepare for transfer to critical care unit if condition warrants.
    • Rationale: Prolonged chest pain with decreased cardiac output reflects development of complications requiring more emergency interventions.

Other Possible Nursing Care Plans

  • Activity intolerance—may be related to imbalance between O2 supply and demand, possibly evidenced by exertional dyspnea, abnormal pulse/BP response to activity, and ECG changes.
  • Decreased cardiac output—may be related to inotropic changes, alterations in rate and rhythm possibly evidenced by changes in hemodynamic readings, dyspnea, restlessness, decrease tolerance for activity, fatigue, diminished peripheral pulses, cool/pale skin, changes in mental status, and continued chest pain.
  • Risk for sedentary lifestyle—risk factors may include lack of training or knowledge of specific exercise needs, safety concerns, and fear of myocardial injury.
  • Risk for prone-health behavior—risk factors may include condition requiring long-term therapy/change in lifestyle, multiple stressors, assault to self-concept, and altered locus of control.