ASKEP ANGINA PECTORIS

ANGINA PECTORIS

A.    DEFINITIONS

Angina pectoris is chest pain due to ischemic infarction ditimbukan and temporary or reversibl. (Russ, 2006)

Angina pectoris is a chronic syndrome in which the client had an attack of typical chest pain is like a button, or feel heavy in the chest that sometimes spreads to the left arm which arise at the time and soon lost when the activity stops. (Prof. Dr.. HM Sjaifoellah Noer, 1996)

Angina pectoris is a term used to describe the type of discomfort is usually located in the region retrosternum. (Penuntun Praktis Kardiovaskuler). (Chung, 1996)

B.     ETIOLOGY

1.      Ateriosklerosis

2.      Coronary artery spasm

3.      Severe anemia

4.      Arthritis

5.      Aortic insufficiency

C.    RISK FACTORS

·         Mutable (modified)

1)   Diet (hyperlipidemia)

2)   Cigarette

3)   Hypertension

4)   Stress

5)   Obesity

6)   Less activity

7)   Diabetes Mellitus

8)   Use of oral contraceptives

·         Can not be changed

1)   Age

2)   Gender

3)   Race

4)   Hereditary

5)   Type A Personality

D.    TRIGGER FACTORS ATTACKS

Precipitating factors that can cause attacks include:

1)   Emotion

2)   Stress

3)   Heavy physical work

4)   Eve is too hot and humid

5)   Too full

6)   Many smoking

E.     CLINICAL FEATURES

1.      Substernal chest pain retrosternal ataru to the neck, throat, internal regions of the left scapula, or arm.

2.      Quality of pain like a heavy pressure, such as pressing, hot, sometimes just a bad feeling in the chest (chest discomfort).

3.      Duration of pain lasting 1 to 5 minutes, no more daari 30 minutes.

4.      Pain lost (reduced) when a break or the administration of nitroglycerin.

5.      Symptoms: shortness of breath, feeling tired, sometimes appear cold sweat, palpitations, dizzines.

6.      EKG: ST segment depression, inverted T wave seen.

7.      EKG is often normal at the time of attack did not arise.

F.     TYPE ATTACKS

1.    Stable angina pectoris

·      Onset is classically associated with exercise or activity that increases oxygen demand niokard.

·      Pain go away with rest or cessation of activity.

·      The duration of pain 3-15 minutes.

2.    Unstable angina pectoris

·      The nature, location and spread of chest pain can be similar to stable angina pectoris.

·      Adurasi attacks can occur for longer than stable angina pectoris.

·      Triggers can occur in a state of rest or light activity on tigkat.

·      Less responsive to nitrate.

·      More often found depresisegmen ST.

·      Can be caused by atherosclerotic plaque rupture, spasmus, thrombus or platelet aggregate.

3.    Prinzmental angina (variant angina).

·      Chest pain or pain occur at rest, often in the morning.

·      Pain caused by spasmus koroneraterosklerotik vessels.

·      ECG showed ST segment elevaasi.

·      Likely to evolve into acute myocardial infaark.

·      Arrhythmias may occur.

G.    PATHOPHYSIOLOGY AND PATHWAYS

The mechanism of occurrence of angina pectoris based on inadequate supplied oxygen to the myocardium cells resulting from arterial rigidity and narrowing of the lumen of the coronary arteries (coronary arteriosclerosis). It is not known exactly what causes arteriosclerosis, it is clear that no single factor was responsible for the development of arteriosclerosis. Ateriosklerosis is coronary arteries are most often found. As the workload of a network increases, the oxygen demand is also increasing. If demand increases in the healthy heart coronary artei drain dilated and more blood and oxygen to muscle heart. However, if the coronary artery has narrowed due to rigidity or arteriosclerosis and can not be dilated in response to increased need for oxygen, then there is ischemic (lack of blood supply) myocardium.

Presence of endothelial injury resulting in loss of production NO (Nitrate Oksida) which serves to inhibit a variety of reactive substances. In the absence of this function can menyababkan smooth muscle to contract and arising spasmus aggravate coronary luminal narrowing due to a myocardial oxygen supply is reduced. Narrowing or block is not cause symptoms that are so visible when not reached 75%. If the narrowing is more than 75% and is triggered by excessive activity of the coronary blood supply to be reduced. myocardium cells use anaerobic glycogen to meet their energy needs. metabolite is lactic acid which lowers the yield pH of the myocardium and cause pain. If the energy kenutuhan heart cells decreases, the oxygen supply becomes inadequate and muscle cells again oxidative phosphorylation to form energy. This process does not produce lactic acid. With the loss of lactic acid pain will subside.

H.    DIAGNOSTIC EXAMINATION

1.      ECG Characteristics of ischemia: ST depression and inverted T waves.

2.      Fortable ECG Holter Monitor ECG monitor which is 24 hours - patients still do daily activities

3.      Coronary angiography to see a narrowing / blockage through a catheter inserted into the coronary vessels.

4.      Images in Thorax Photo thoracic Angina pectoris is usually normal. Thoracic photos more frequently show abnormalities in myocardial infarction or patients with chest pain who are not from the heart

5.      Examination stress (stress testing) ·

6.      pedaling a stationary bicycle or walking on treatmill, ECG recorded during the examination of the risk of myocardial infarction mortality risk

I.    COMPLICATION

a)    An acute myocardium infarction (heart attack)

b)   Sudden cardiac death

c)    Cardiach arrhythmias

J.   MEDICAL MANAGEMENT

Prevention of low dose aspirin, for example Angettes 75 which may reduce the tendency of red blood cells and helps prevent the formation and arrangement of platelets.

1.  Glyseril trinitrate, placed under the tongue or a spray can relax the arteries of the heart and can reduce angina attacks

2. Nitrate, nitrate movement can be used to reduce the frequency of angina attacks. Can be either tablets or medicine pieces, and very effective. Side effects from the use of nitrates is headache. But after use in a few weeks, this headache will be rare

3. Beta blockers, gives effect to the hormone, so that the pulse will beat the slow and low blood pressure. This will make the heart to reduce the amount of oxygen required and improve the blood supply to the heart muscle. In addition, beta blockers is also important to protect the heart when exposed to attacks

4. Calcium antagonists, in general function is to reduce coronary arterial pressure on the muscles. Calcium antagonists are a few types, such as verapamil (cordilox), and nifedipine (righteousness).

5. Treatment in general, which may be required to control or know the symptoms and improve conditions without any side effects from the treatment itself. The treatment is tailored to the needs of each patient.

K.    ASSESSMENT

Ø  Subjective data that may arise:

·         The client complains of chest pain

·         Clients complain of shortness of

·         Clients complain of weakness

Ø  Objective data that may arise:

·         Clients look pale

·         TTV abnormal

·         The client looks uneasy

·         Client's skin cold

·         Obtained an EKG ST segment depression and inverted T waves

L.     NURSING DIAGNOSIS THAT MAY ARISE

1.      Acute pain associated with ischemic infarction.

2.      Activity intolerance associated with reduced cardiac output.

3.      Anxiety associated with fear of the threat of sudden death.

4.      Lack of knowledge (learning needs) regarding Events, treatment needs related to the lack of information.

M.   FOCUS INTERVENTION

A.       Acute pain associated with ischemic infarction.

Intervention :

·      Review the description and the factors that aggravate the pain.

·      Put the client on bed rest during episodes of angina (the first 24-30 hours) with a semi-Fowler position.

·      Observation of vital signs every 5 minutes every attack of angina.

·      Create a peaceful environment, limit the visitor when necessary.

·      Give soft foods and let the client rest 1 hour after meals.

·      Stay with clients who are experiencing pain or appears anxious.

·      Teach distraction and relaxation techniques.

·      Collaborative treatment.

B.       Activity intolerance related to lack of cardiac output.

Intervention :

·      Maintain bed rest in a comfortable position.

·      Provide adequate rest periods, aids in the fulfillment of self-care activities as indicated.

·      Record kualittas skin color and pulse.

·      Increase the clients activities on a regular basis.

·      Monitor the ECG with frequently.

C.       Anxiety associated with fear of the threat of sudden death.

Intervention :

·      Explain all procedures act.

·      Increase the expression of feelings and fear.

·      Encourage family and friends separately consider the client as before.

·      Notify the client of medical programs that have been made ​​to reduce / limit the attack will come and increase the stability of the heart.

·      Collaboration.

D.       Lack of knowledge (learning needs) on the condition, treatment needs related to the lack of information.

Intervention :

·      Emphasize the need to prevent angina attacks.

·      Push to avoid the factors / situations as the originator of episodes of angina.

·      Assess the importance of weight control, smoking cessation, dietary changes and exercise.

·      Show / encourage clients to monitor their own pulse during activity, avoid tension.

·      Discuss the steps taken when an attack of angina.

·      Encourage the client to follow a predetermined program.

 

REFERENCES

Corwin, Elizabeth, Buku Saku Patofisiologi, Jakarta, EGC, 2000.

Chung, EK,  Penuntun Praktis Penyakit Kardiovaskuler, Jakarta, EGC, 1996

Doenges, Marylinn E, Rencana Asuhan Keperawatan, Jakarta, EGC, 1998

Engram, Barbara, Rencana Asuhan Keperawatan Medikal Bedah volume 2, Jakarta, EGC, 1998

Long, C, Barbara, Perawatan Medikal Bedah 2,  Bandung, IAPK, 1996

Noer, Sjaifoellah, Buku Ajar Ilmu Penyakit Dalam, Jakarta, FKUI, 1996

Price, Sylvia Anderson, Patofisiologi Buku I Jakarta, EGC, 1994

Russ, Roy D, Cardiovaskular System, Philadelphia, ELSEVIER, 2006

Tucker, Susan Martin,  Standar Perawatan Pasien Volume I,  Jakarta, EGC, 1998

Underwood, J C E, Pathologi Volume 1 , Jakarta, EGC, 1999