Chronic Stable Angina Pectoris

Essentials of Diagnosis:

Precordial chest pain, usually precipitated by stress or exertion, relieved rapidly

by rest or nitrates.

Electrocardiographic or scintigraphic evidence of ischemia during pain or stress

testing.

Angiographic demonstration of significant obstruction of major coronary vessels.

Chronic Stable Angina Pectoris

Clinical Findings: History

Circumstances that precipitate and relieve angina.

Characteristics of the discomfort.

Location and radiation:

In 80 to 90 % of cases, the discomfort is felt behind or slightly to the left of the

mid-sternum.

Angina may radiate to any dermatome from C8 to T4; most often, it radiates to
the left shoulder and upper arm, frequently moving down the inner volar aspect of
the arm to the elbow, forearm, wrist, or fourth and fifth fingers.

Occasionally, it may be felt initially in the lower jaw, back of the neck, the
interscapular area, high in the left back, or in the volar aspect of the wrist.

Chronic Stable Angina Pectoris

Clinical Findings: History

Duration of attacks:

Short duration and subsides completely without residual discomfort.

If attack if precipitated by exertion and patient promptly stops to rest, it usually

lasts less than 3 minutes.

Attacks following a heavy meal or brought on by anger often last 15 to 20

minutes.
 Attacks lasting more than 30 minutes are unusual.

Effects of nitroglycerin

Risk factors

Signs

Significant elevation in systolic and diastolic blood pressure.

Gallop rhythm.

Apical systolic murmur indicating transient mitral regurgitation.

Differential diagnosis:

Anterior chest wall syndrome (Tietzes syndrome)

Intercostal neuritis; cervical or thoracic spine disease

Peptic ulcer disease; GERD

Spontaneous pneumothorax

Pulmonary embolization

Laboratory findings:

Serum lipid levels should be determined in all patients.

Anemia and diabetes may also be investigated if clinically appropriate.

Electrocardiography:

Resting ECG is normal in 25% of patients.

Abnormalities include old myocardial infarction, non-specific ST-T wave changes,

atrioventricular or intraventricular conduction defects, and changes of left
ventricular hypertrophy.

During anginal episodes, there is horizontal or downsloping ST segment

depression that reverses after ischemia disappears.

Exercise ECG:

Precautions and risks

Indications:
 Confirm diagnosis of angina.

Determine the severity of limitation of activity due to angina.

Assess the prognosis in patients with known coronary artery disease.

Evaluate responses to therapy.

Screen asymptomatic populations for silent coronary disease.

Scintigraphic assessment of ischemia

Echocardiography

Coronary angiography

Definitive diagnostic procedure for CAD.

Should be performed in the following groups:

Patients being considered for revascularization.

Patients deemed at high risk for future infarction.

Patients with aortic valve disease who also have angina pectoris.

Patients who have had recurrence of symptoms despite revascularization.

Patients with cardiac failure in whom a surgically correctable lesion is suspected.

Patients surviving sudden death or those with symptoms of life-threatening

arrhythmia.

Patients with chest pain of uncertain cause, or cardiomyopathy of unknown

cause.

Treatment

Acute attack:

Sublingual nitroglycerin

Nitroglycerin buccal spray

Prevention of further attacks:

Aggravating factors

Nitroglycerin and long-acting nitrates

 Beta-blockers

Calcium-entry blocking agents

Platelet-inhibiting agents

Risk reduction

Revascularization

Chronic Stable Angina Pectoris: Revascularization

Indications:

Unacceptable symptoms despite medical therapy.

Left main coronary stenosis greater than 50% with or without symptoms.

Three-vessel disease with left ventricular dysfunction.

Unstable angina

Post-MI patients.

Types:

Coronary artery bypass grafting (CABG)

Percutaneous transluminal coronary angioplasty (PTCA)

 Acute Myocardial Infarction

Essentials of Diagnosis:

Sudden but not instantaneous development of prolonged (>30 minutes)

anterior chest discomfort (sometimes felt as gas) that may produce
arrhythmias, hypotension, shock, or cardiac failure.

Rarely painless, masquerading as acute congestive heart failure, syncope,

cerebral vascular accident, or unexplained shock.

ECG ST segment elevation or depression, evolving Q waves, symmetric

inversion of T waves.

Elevation of cardiac enzymes.

Appearance of segmental wall abnormality by imaging techniques.

Clinical Findings

Symptoms:

Premonitory pain

Pain of infarction

Associated symptoms:

Diaphoresis / cold sweats

Weakness and apprehension

Light-headedness, syncope

Sense of impending doom

Abdominal bloating

Dyspnea, orthopnea, cough, wheezing

Nausea

Painless infarction

Sudden death and early arrhythmias

 Signs:

General:

Anxiety and diaphoresis

Heart rate: from markedly bradycardic to tachycardia

Blood pressure: hypertension or hypotension

Respiratory distress

Fever appears after 12 hours and persists for days

Chest:

Clear lung fields are a good prognostic sign

Basilar crackles common

Heart:

May be unimpressive or very abnormal

Soft heart sounds; S4 indicating atrial gallops

Transient murmurs

Extremities:

Edema is usually not present.

Cyanosis and cold temperature indicate low output.

Peripheral pulses should be noted.

Laboratory findings:

Leukocytosis on the second day and resolves after a week.

CK-MB and LDH

Troponin-T and troponin-I

Electrocardiography:

ST-segment elevation and depression

Peaked T waves
 T wave inversion

Q waves

Chest x-ray

Echocardiography

Scintigraphic studies

Hemodynamic measurements

Treatment
Thrombolytic therapy:
o t-PA
o Streptokinase / urokinase
o Anisoylated plasminogen streptokinase activator complex (APSAC)
Anti-platelet drugs
Acute PTCA
General measures:
o CCU monitoring
o Bed rest
o Progressive ambulation after 24 to 72 hours
o Low-flow oxygen therapy and liquid diet (1 st 24 hours)
Analgesia
Antiarrhythmia prophylaxis
Beta-adrenergic blocking agents
Nitrates
ACE-inhibitors
Calcium-entry blocking agents
Anticoagulation

Acute Myocardial Infarction: Complications

Infarct extension and post-infarction ischemia

Arrhythmias
Myocardial dysfunction

Acute Myocardial Infarction: Nursing Management

Objectives:
o To maintain adequate circulatory function.
o To prevent death from arrhythmia, asystole, and cardiogenic shock.
o To limit the size of the infarct.
o To provide healing for the myocardium.
 o To facilitate rehabilitation.
To provide constant nursing surveillance during the critical stage of the illness:
o Admit patient to the CCU.
o Lift patient from stretcher to bed and place in position of comfort.
o Start IV infusion running slowly.
o Be vigilant for occurrence of any type of premature ventricular beats.
Correct arrhythmia immediately.
Lidocaine may be given prophylactically.
Other antiarrhythmic drugs procainamide, quinidine, propranolol,
atropine.
Prepare patient for prophylactic pacing if indicated.
To provide constant nursing surveillance during the critical stage of the illness:
o Provide continuing nursing assessment of peripheral perfusion:
Attach ECG monitoring electrodes.
Measure and record vital signs.
Count respirations.
Monitor body temperature, assess skin temperature and color.
Auscultate for breath sounds, rales.
Auscultate the heart for gallops, friction rub, murmus.
Assess neck veins for distention.
Assess for changes in mental status.
Evaluate urine output
To provide constant nursing surveillance during the critical stage of
the illness:
Utilize hemodynamic monitoring for critically ill patients.
Place patient at rest.
Oxygen supplementation by nasal cannula.
Relieve patients pain and anxiety.
Give analgesics (morphine or meperidine).
Give in small IV doses every 15 to 20 minutes until relief is obtained
(if vital signs are within safe parameters)
Monitor blood pressure, pulse and respiration before giving
narcotics.
Administer anti-anxiety drugs

PYELONEPHRITIS acute or chronic inflammation of renal pelvis leading to tubular

destruction, intestinal abscesses and renal failure

A. PREDISPOSING FACTORS
1. Microbial invasion
 E. coli
Streptococcus
2. Urinary retention/ stagnation
3. pregnancy
4. DM
5. Exposure to renal toxins/ use of nephrotoxic agents
6. Obesity

B. S/SX
1. Acute Pyelonephritis
Urinary frequency and urgency
Costovertebral angle pain and tenderness
Fevers and chills, anorexia, general body malaise
Burning upon urination
Dysuria, nocturia, hematuria
2. Chronic Pyelonephritis
Fatigue and/or weakness
Weight loss
Polyuria
Polydypsia
HPN

C. DIAGNOSTICS
1. Urine CS: (+) cultured microorganisms (E.coli and strep)
2. Urinalysis: elevated WBC, CHON, pus cells
3. Cystoscopic exam: (+) urinary obstruction

NURSING MANAGEMENT
1. Provide CBR especially during acute attack
2. Forced fluids
3. Provide an acid ash in the diet
4. Provide warm sitz bath for comfort
5. Administer medications as ordered
Nitrofurantoin
SE: GIT irritation, give with food, peripheral neuropathy, hemolytic anemia (initial sx:
fever), discoloration of teeth
Urinary analgesics
Pyridium

6. prevent complications
renal failure
NEPHROLITHIASIS/UROLITHIASIS formation of stones elsewhere in the urinary
tract

TYPES OF STONES
1. calcium
2. oxalate
3. uric acid

B. PREDISPOSING FACTORS
1. diet high in calcium and oxalate
2. hereditary (like gout)
3. hyperparathyroidism (Hypercalcemia)
4. obesity
5. sedentary lifestyle

C. S/SX
1. Renal colic
2. Cool, moist skin
3. Burning upon urination
4. Dysuria, Nocturia
5. Hematuria

D. DIAGNOSTICS
1. Urinalysis (+) RBC, WBC, Pus cells
2. KUB: reveal site or location of stones
3. Stone analysis: reveals composition of stone
4. Cystoscopic exam: urinary obstruction
5. IVP: reveals obstruction

E. NURSING MANAGEMENT
1. Forced fluids to prevent further crystallization
2. Alternate warm and cold compress
3. Administer isotonic fluids as ordered
4. Strain all urine using gauze pad
5. Warm sitz bath for comfort
6. Meds as ordered
Narcotic analgesics morphine
Allopurinol (zyloprim)
7. Provide dietary intake:
If (+) to ca stones: acid ash
If (+) to oxalate stones: alkaline ash (milk, tea, vegetables)
If (+) to uric acid: avoid purine rich food like anchovies, legumes, organ meat, nuts
8. Assist
Litholapoxy surgical removal of 2/3 stone
Nephrectomy removal of kidney stagnation
Lithotripsy extracorporeal shockwave
No incision, early discharge
Too costly
Stones can recur
Post-op: strain urin
9. Prevent complications renal failure