Review of Unstable Angina (Nursing)

00:01 Now this one is the big medical emergency, right? This is unstable angina.

00:07 Our patient likely has had chronic stable angina, but you can sometimes see a patient present in the ER, this is their first event that they become aware of.

00:17 The changes have been happening in their vessels that they were unaware of, but this is now when they first become aware there's a problem.

00:23 The reason it's a supply ischemia is because this unstable angina usually involves a thrombus or a clot, right? That's just a fancy word that we use for it. So it's a medical emergency.

00:34 It can be a severe coronary artery disease, it's been complicated by some type of vasospasm or a clot.

00:40 But either way, we've got a significant blockage in the blood supply.

00:44 So the clot may have happened because that plaque ruptured, and then all the plaque is stuck to that side of the wall.

00:51 As the platelets are flowing by, they stick to it, and that's how you end up with a bigger and bigger and bigger clot, or thrombus, until it completely, or almost completely blocks off the artery.

01:02 Okay, so, by now, I'm pretty sure you're saying, why are we taking so much time to explain the differences between these types of anginas? Okay, I'm right with you.

01:13 Here's why it makes a difference.

01:16 Because understanding the difference between unstable angina and infarcting will help you really understand how we treat it differently, and what you need to do differently as a nurse.

01:27 Okay, if I had chronic stable angina and you got me to rest, that should resolve the pain.

01:34 Not so in unstable angina.

01:37 Even if somewhat rest, although it's hard to do that when having chest pain, it doesn't relieve the pain for the patient, because why? You've got a clot, right? That's what's happening in infarct.

01:47 You've got a blocked vessel.

01:50 Now, you might see patients that this is new onset exertional angina for them, or it might be somebody who's had angina before, but it is much more intense, it is different.

02:00 So, I want you to know that people can and present in the ER to the hospital setting in multiple different ways.

02:08 They may have never had chest pain before and now they're having a heart attack.

02:12 They may have a history of chest pain that's been controlled by nitrates, but now it's different.

02:17 Or they were doing something that exerted themselves, increased their demand, and now they're having this unstable angina.

02:24 So they can come at you from all different perspectives.

02:27 That's why an excellent nurse always asks questions.

02:32 Ask what was going on, ask them to describe the chest pain, ask them if they've ever had it before, what they used to treat it, make sure you get a number on a scale of 1 to 10 that tells you how intense the chest pain is.

02:44 That also helps us assess throughout the process as we try different medical interventions, are we getting better or worse, or are they getting better or worse? Okay, so the goals of treatment in unstable angina is we want to decrease that oxygen demand and increase that oxygen supply because, why? Look at that red box, we want to prevent infarction.

03:09 So we've got the tiniest bit of time to respond to this.

03:12 So, make sure you circle and highlight that that our goal in unstable angina is to prevent infarction.

03:19 We want to make the scales level and balanced again.

03:23 Okay, the ambulance is on this slide, not by accident.

03:27 We put it there as a giant reminder to you that this is an emergency.

03:32 And in the red box, I want you to star that, what's our goal? Prevent infarction.

03:37 These are our immediate priorities.

03:39 Now, you may or may not have heard this before, but MONA is just a term we use to help us remember: morphine, oxygen, nitrates, and aspirin.

03:49 These are our immediate priorities in an emergency situation like this.

03:53 So, likely they've started this in the ambulance, but if they haven't, patient came to us by a private car, these are going to be our top priorities when they roll into ER.

04:03 Let's start with morphine. Now this used to be a Class Ia, meaning just about everybody got it.

04:09 But now it's been moved to a Class IIa, still really important, but not necessarily given across the board.

04:15 These recommendations are by the American College of Cardiology and the American Heart guidelines that were updated in 2012.

04:22 So, now we use it if the pain is not relieved by nitroglycerin.

04:26 So, nitroglycerin is our go-to.

04:28 That's going to be the one that we try first to relieve the pain.

04:32 If that doesn't work, then we move on to morphine.

04:36 Oxygen. You know that the whole reason we're in this unstable angina is because the patient's heart is not getting enough oxygen supplied to it.

04:45 So the current AHA guidelines say that oxygen therapy is indicated only if the oxygen saturation is below 90%.

04:53 So if their sat is < 90%, that's pretty severe.

04:58 If they're in respiratory distress or they have some other risk features of being poorly oxygenated, or hypoxemia.

05:05 So, while we used to put oxygen on everybody, we're treating it a little differently now.

05:11 Now we put oxygen on if their sat is < 90%, they're in respiratory distress, or they have some other high risk opportunity for having low blood oxygen, or hypoxemia.

05:24 Nitrates are given to everybody, so that's the N.

05:27 So that's definitely a procedure that every patient will receive or medication that every person will receive, and aspirin.

05:34 So when you think of MONA, morphine, if nitro doesn't relieve the pain; oxygen, if they're showing you signs of respiratory distress or a sat that's less than 90%, nitrates and aspirin.