Now this one is the big medical
This is unstable angina.
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.
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.
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.
It can be a severe coronary artery disease,
it's been complicated by some
type of vasospasm or a clot.
But either way, we've got a significant
blockage in the blood supply.
So the clot may have happened
because that plaque
ruptured, and then all the plaque is
stuck to that side of the wall.
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.
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.
Here's why it makes a difference.
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.
Okay, if I had chronic stable angina
and you got me to rest,
that should resolve the pain.
Not so in unstable angina.
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.
You've got a blocked vessel.
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.
So, I want you to know that people can
and present in the ER to
the hospital setting
in multiple different ways.
They may have never had chest pain before
and now they're having a heart attack.
They may have a history of chest pain
that's been controlled by nitrates,
but now it's different.
Or they were doing something that exerted
themselves, increased their demand,
and now they're having this unstable angina.
So they can come at you from
all different perspectives.
That's why an excellent nurse
always asks questions.
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.
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.
So we've got the tiniest bit of
time to respond to this.
So, make sure you circle and
highlight that that our goal
in unstable angina is
to prevent infarction.
We want to make the scales
level and balanced again.
Okay, the ambulance is on
this slide, not by accident.
We put it there as a giant reminder
to you that this is an emergency.
And in the red box, I want you to star that,
what's our goal? Prevent infarction.
These are our immediate priorities.
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.
These are our immediate priorities
in an emergency situation like this.
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.
Let's start with morphine. Now
this used to be a Class Ia,
meaning just about everybody got it.
But now it's been moved to a
Class IIa, still really important,
but not necessarily given across the board.
These recommendations are by the
American College of Cardiology
and the American Heart guidelines
that were updated in 2012.
So, now we use it if the pain is
not relieved by nitroglycerin.
So, nitroglycerin is our go-to.
That's going to be the one that
we try first to relieve the pain.
If that doesn't work, then we
move on to morphine.
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.
So the current AHA guidelines say
that oxygen therapy is indicated
only if the oxygen saturation is below 90%.
So if their sat is < 90%, that's pretty severe.
If they're in respiratory distress or they
have some other risk features of being
poorly oxygenated, or hypoxemia.
So, while we used to put oxygen on everybody,
we're treating it a little differently now.
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.
Nitrates are given to everybody,
so that's the N.
So that's definitely a procedure
that every patient will receive
or medication that every person
will receive, and aspirin.
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.