Acute Complex Care (Health- nursing)

Acute complex care: Angina Pectoris
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Introduction
Acute complex care is an important aspect of contemporary nursing practice, as health care teams need to work together and assess the usefulness of their interventions. Coronary artery disease is one of the major causes of increased mortality and morbidity in the developed world (Cassar et al., 2009). Complex health problem require extra care and this has a direct impact on both carers and patients. Acutely ill patients provide a challenge to the healthcare profession as they are more vulnerable and hence there is a need to ensure that there is quality of care for critically ill patients. Similarly, advancement in the medical field and technological improvement have led patient care to be more complex than ever before, necessitating the need for acute complex care. In any case, implementation of acute care is necessary to assess the success of managing critically ill patients, while also looking into both professional and legal aspects of acute complex care. This paper highlights on aetiology, pathology, clinical presentation, assessment and current evidence based treatments of angina pectoris.
In looking at the aim of interventions in treating angina, Danchin et al (2011) point out that lowering the frequency of angina attacks and severity should be a top priority as well as preventing death from angina complications. Consequently, the role agents that lower the heart rate through therapy or beta blockers receive more attention. Other than these, other agents including nicorandil, metabolic agents, long acting nitrates and dihydropyridine calcium-channel blockers become the other options being complimentary (Danchin et al., 2011). The authors point out that Trimetazidine, which has a complementary role to heart rate lowering agents, is one of the most effective given that it improves exercise performance and lowers the likelihood of angina attacks with little effect on hemodynamic parameters.
Aetiology
Angina pectoris typically known as angina and is a pain that occurs because of ischemia (Gore, 2010). This involves a lack of blood supply to the heart muscle which is in turn related to blockage of coronary arteries as this typically precedes the onset of angina (Gore , 2010). Severity of angina determines the risk of cardiac arrest, but there is weak correlation between lack of oxygen in the heart muscles and the severity of pain. Deficiency of blood supply is most likely to cause pain during physical activities as the heart typically requires more oxygen. Similarly, reducing the level of activities most likely reduces the level of pain among angina patients unlike other categories of chest pains.
There are various causes of angina, but coronary artery disease is one of the main causes (Ueda et al., 2010). Essentially, this takes place after the coronary arteries of the heart become narrow resulting to the obstruction of blood and oxygen in the heart (Ueda et al., 2010). Narrowing of the coronary arteries is mainly caused by fatty deposits. Consequently, the heart is not able to handle the passage of blood, and this strains the heart. In any case, the fall in the level of blood oxygen results to the pain experienced by sufferers of angina as the nervous system tries to sends signals in response to reduced blood flow. The other main cause of angina is atherosclerotic plaque build-up which also obstructs the coronary artery. Nonetheless, there are various risk factors that increase susceptibility to angina. Hypertension, smoking, diabetes, high blood cholesterol levels and sedentary lifestyles are some of the risk factors.
Chest pains are typically transmitted through nerve fibres, where the pain travels through the receptors of free nerve endings mechanically or chemically. However, expounding on the possible causes of angina and other chest pains remain a challenge because the pains may precede the onset of heart attacks and ischemia. Similarly, pains may not necessarily come from the heart but from other organs. In any case there may be different types of pain in the same area making it difficult to correctly assess the cause of chest pains. Thus, the cause of chest pain and transmission to other areas may be indistinguishable from the sources which cause the pain.
Pathology
Exertion typically precedes angina and the pain recurs in a pattern, in a way that results to recognition of the problem after several episodes have occurred. In essence, this type of angina is the most common and is referred as stable angina (Thakkar, 2010). However, severe angina may occur for a long period of time and is discomforting. Similarly, angina may appear as one severe episode or may be recurring episodes. On the other hand, angina may appear through predicable patterns than only differ slightly and this is unstable angina when patients appear to have heart attacks. Patients with severe angina may also not experience blockage on coronary arteries, but narrowing of the arteries also causes chest pains.
The need to manage angina emanates from the fact that chronic stable angina affects many people in the developed countries in comparisons to other ischemic heart diseases (Tarkin & Kaski, 2013). Consequently, improving the quality of life and lowering mortality requires more focus on the pathology of angina. The onset of angina pectoris occurs because of the imbalance between myocardial oxygen supply and demand. Thus, the therapeutic approaches seek to reduce oxygen imbalance as well as integrate a holistic approach that includes lifestyle change and reducing the prevalence of risk factors (Tarkin & Kaski, 2013).
Clinical presentation
The clinical presentation of angina highlights on the history of this type of chest pain and extends to manifestations of the condition. In most cases, patients suffering angina have discomforts rather than pain, but acute complex care is necessary because of the risks involved for more severe cases. Additionally, the discomfort is typically characterised as pressure and a choking sensation, but the pain experienced by patients may extend to the neck, jaw, back, shoulder and even shoulders(Newson , 2010). Chest pains which occur for short periods of time like in seconds are not part of angina, and the intensity of angina remains largely unchanged. Thus, taking care of angina patients requires focusing on the history and frequency of angina.
It is necessary to differentiate the signs and symptoms of various coronary heart diseases as they to ensure adequate management. For instance the pathophisiology of angina and acute myocardial infarction (AMI) are different (Kimble et al., 2011). Nonetheless, the health complications of both conditions have similar transmission of chest pain through the chest walls. The chest pain from AMI can be intense, and patients can also have intense pain through chronic occurrences. Consequently, people suffering from chronic angina typically report different symptoms from those suffering from AMI. However, differentiation of symptoms may at times be difficult resulting to problems in making decisions on chest pains. Consequently, Kimble et al (2011) highlight the importance of clinical assessment that takes into account multiple symptoms, including dysponea, fatigue and frequency of chest pain.
Assessment
According to McCaffery (2009) the management of angina has tended to highlight on symptoms of the condition because of patient complaint. Thus, assessment of angina typically involves focus on history, risks of cardiovascular complications and tests, which may reveal ischemia. In the case of stable angina the ECG stress test is the most commonly used. Other tests that are applicable depend on the resources available, stress perfusion, stress echo and other modalities applicable (McCaffery, 2009). The modalities may involve motion imaging, PET and the cardiac magnetic resonance. However, in cases of severe angina where patients are non- responsive to therapy, then use of angiography helps to present more accurate diagnosis, and this precedes angioplasty. Registered nurses need to collaborate information from specialists when taking care of patients suffering from angina as the severity of the symptoms requires different levels of attention.
For patients under acute complex care assessment of pain and communication of the diagnosis to a healthcare team is critical for effective pain management (Hughes, 2012). For patients in palliative care this is even more critical to control symptoms, and helps to give directions to healthcare teams on pain relief. At the same time, it is necessary to spend time with patients with the aim of promoting therapeutic measures that can relieve pain as well as improve relationship with the patient (Hughes, 2012). Patients with angina can communicate well and this enables them to self report during diagnosis. Thus, patient history provides a snapshot of health status of patients, and patient history can also be collaborated with pain scores.
Nonetheless, assessment of angina pectoris occurs through use of coronary angiography (CAG) since in most cases the heart is the underlying cause of chest pains (Burchardt et al., 2009). Many patients may show normal signs even before use of CAG, and patients who suffer a recurrence of chest pains require assurance that the condition is manageable. Thus, even when there is negative CAG it is important to reassure patients, but assessment of other possible causes of chest pain is important to rule out the impact of these other factors. Other cardiac conditions may weaken the heart muscle and this increases susceptibility to chest pains. Nurses should situate that patients do not follow rigorous exercise regimes that may trigger chest pain through assessment of the intensity of physical activities.