Coronary Artery Disease (CAD) is a prevalent condition characterized by the narrowing or blockage of the coronary arteries. These arteries are vital as they supply blood, oxygen, and nutrients to the heart muscle. CAD often stems from atherosclerosis, a process where fatty deposits, or plaques, accumulate within the arterial walls. This buildup leads to arterial narrowing, impeding blood flow and elevating the risk of serious cardiac events like angina and myocardial infarction.
CAD is not a sudden onset disease; it develops progressively over time. Often, individuals may not experience noticeable symptoms until the condition has significantly advanced. Symptoms, when they appear, can include angina, shortness of breath, and persistent fatigue.
When the blood flow through the coronary arteries is compromised, either partially or completely, it results in ischemia and, potentially, infarction of the heart muscle. Ischemia, a state of insufficient blood and oxygen supply to the myocardium, leads to decreased tissue perfusion. If ischemia is prolonged or severe, it can progress to necrosis or infarction, necessitating immediate medical intervention.
Nursing Process in CAD Management
Effective management of CAD is crucial and revolves around modifying risk factors to halt or slow down the disease’s progression. Given that CAD can be asymptomatic in its early stages, identifying individuals at risk is a key nursing responsibility.
Nurses play a pivotal role in health promotion, focusing on managing modifiable risk factors for CAD. Educating patients about the disease process, its progression, and the importance of lifestyle modifications is paramount in CAD prevention.
For patients presenting with symptoms such as chest pain or dyspnea, medical or surgical interventions might be necessary. Pharmacological treatments, including aspirin and cholesterol-lowering agents, are often prescribed to prevent blood clot formation, reduce the risk of heart attacks, and decrease plaque buildup. Surgical procedures like coronary angioplasty with stent placement may be indicated to physically remove blockages, widen the affected artery, and restore adequate blood flow to the heart. Coronary artery bypass grafting (CABG) is typically considered for patients with multiple severely narrowed coronary arteries.
Nursing Assessment for CAD
The nursing process begins with a comprehensive assessment, where nurses collect crucial physical, psychosocial, emotional, and diagnostic data. This section outlines the subjective and objective data relevant to coronary artery disease assessment, guiding the formulation of an accurate Acs Nursing Diagnosis when applicable, particularly in acute presentations of CAD.
Review of Health History
1. Elicit General Symptoms: Begin by inquiring about the patient’s overall symptoms. Document any complaints and general symptoms, such as:
- Chest pain: Characterize location, onset, duration, character, radiation, associated symptoms, relieving/aggravating factors.
- Shortness of breath (dyspnea): Note if it occurs at rest, during exertion, or in specific positions (orthopnea).
- Rapid breathing (tachypnea): Observe respiratory rate and depth.
- Orthopnea: Difficulty breathing when lying flat.
- Syncope: Fainting or lightheadedness.
- Palpitations: Awareness of heartbeats, racing or irregular.
- Lower extremity edema: Swelling in ankles, feet, legs.
- Lower extremity pain: Especially with activity, indicative of peripheral artery disease which often coexists with CAD.
- Difficulty with physical activities: Assess limitations and functional capacity.
2. In-depth Chest Pain Investigation: If the patient reports chest pain, delve deeper into its characteristics:
- Chest tightness, pressure, or heaviness: Describe the sensation.
- Squeezing or crushing feeling.
- Burning sensation.
- Pain related to physical activity: Angina pectoris.
- Triggers: Identify factors that provoke pain, such as stress, cold weather, or substance use.
- Radiation of pain: Note if pain extends to the jaw, neck, left arm, or back.
3. Risk Factor Assessment: Thoroughly evaluate both non-modifiable and modifiable risk factors for CAD.
Non-modifiable Risk Factors:
- Age: Risk increases significantly with advancing age due to natural arterial changes.
- Gender: Men generally have a higher risk earlier in life, but women’s risk escalates after menopause.
- Family history of ischemic heart disease: Strong family history (male relative <55 years, female relative <65 years) significantly increases risk.
- Race/ethnicity: Certain minority groups, including Hispanics and Blacks, exhibit a higher incidence of CAD.
Modifiable Risk Factors:
- Hypertension: Uncontrolled high blood pressure can stiffen and damage arteries, accelerating atherosclerosis.
- Hyperlipidemia/hypercholesterolemia: Elevated LDL (“bad”) cholesterol and low HDL (“good”) cholesterol levels are major contributors to plaque formation.
- Diabetes mellitus or insulin resistance: Diabetes promotes blood vessel damage and plaque buildup.
- Kidney disease: Impaired kidney function disrupts blood pressure regulation and increases cardiovascular risk.
- Tobacco use: Smoking (firsthand and secondhand) causes vasoconstriction and damages the endothelium, fostering atherosclerosis.
- Obesity: Excess weight contributes to hyperlipidemia, hypertension, and diabetes, all CAD risk factors.
- Physical inactivity: Lack of exercise elevates cholesterol and blood pressure.
- Diet: High saturated fat intake increases LDL cholesterol.
- Stress: Chronic stress triggers inflammation, which can narrow blood vessels.
- Alcohol use: Excessive alcohol consumption can weaken the heart muscle and affect blood clotting mechanisms.
- Lack of sleep: Poor sleep habits and insomnia are linked to increased stress and blood vessel constriction.
4. Medication and Treatment History Review: Certain medications (e.g., anthracyclines, anabolic steroids) and prior vascular surgeries can compromise blood vessel integrity and should be noted.
Physical Assessment
1. Vital Sign Monitoring: Closely monitor vital signs. Decreased oxygenated blood to the heart can lead to alterations, typically an increase, in pulse rate and blood pressure initially, though blood pressure may drop in severe cases.
2. Electrocardiogram (EKG) and Telemetry: Obtain an EKG immediately for patients reporting chest pain to detect arrhythmias or ischemic changes. Continuous telemetry monitoring is appropriate for patients with known cardiac history or suspected acute cardiac events.
3. Systemic Assessment: A comprehensive systemic assessment is crucial:
- Neck: Observe for jugular venous distention (JVD), indicating fluid overload and potential heart failure.
- Central Nervous System (CNS): Assess for acute distress, dizziness, lightheadedness, syncope, and lethargy, which may reflect reduced cerebral perfusion.
- Cardiovascular:
- Tachycardia or bradycardia
- Chest pain: Note characteristics.
- Abnormal heart sounds: Murmurs (especially at the apex), bruits (carotid arteries) upon auscultation.
- Irregular heartbeats (arrhythmias).
- Circulatory: Assess peripheral pulses for strength and equality; decreased pulses indicate reduced peripheral perfusion.
- Respiratory:
- Dyspnea, tachypnea, orthopnea.
- Abnormal breath sounds: Crackles (rales) may indicate pulmonary congestion from heart failure.
- Activity intolerance: Assess ability to perform activities of daily living without significant shortness of breath or fatigue.
- Gastrointestinal: Nausea and vomiting can occur, especially during acute cardiac events.
- Lymphatic: Assess for peripheral edema (lower extremities, sacral area).
- Musculoskeletal: Note complaints of neck, arm, back, jaw, or upper body pain; fatigue and weakness.
- Integumentary: Observe skin color (cyanosis, pallor), temperature (cold, clammy), and presence of diaphoresis (excessive sweating).
4. ASCVD Risk Score Calculation: Calculate the patient’s Atherosclerotic Cardiovascular Disease (ASCVD) risk score using established calculators. This score estimates the 10-year risk of a cardiovascular event based on factors like:
- Age
- Gender
- Race
- Blood pressure
- Cholesterol levels (total and HDL)
- Use of medications (e.g., statins)
- Diabetes status
- Smoking history
An ideal ASCVD risk score is low (<7.5% in 10 years). Higher scores necessitate more aggressive risk factor management.
Diagnostic Procedures
1. Arrhythmia Detection: CAD can disrupt the heart’s electrical activity, leading to arrhythmias. ECG monitoring should be scrutinized for:
- ST-segment changes: ST depression or elevation, indicating myocardial ischemia or injury.
- Other arrhythmias: Atrial fibrillation, bundle branch blocks, supraventricular tachycardia, ventricular arrhythmias.
2. Blood Work Analysis: Obtain and analyze blood samples for the following:
- Complete blood count (CBC) with differential: To assess for underlying infection (elevated WBC), blood clotting abnormalities (platelet count), and anemia (low RBC).
- B-type natriuretic peptide (BNP): Elevated BNP levels suggest volume overload and possible heart failure of cardiac origin. Can be falsely elevated in kidney disease and lower in obese individuals.
- Cardiac enzymes (Troponin, Creatine Kinase-MB): Elevated levels of troponin and CK-MB are highly sensitive and specific indicators of acute myocardial ischemia and infarction.
- Lipid panel: To monitor for hypercholesterolemia (total cholesterol, LDL, HDL, triglycerides).
- Ultra-sensitive C-reactive protein (us-CRP) or high-sensitivity CRP (hs-CRP): Elevated levels indicate vascular inflammation, a risk factor for CAD.
- Liver function tests (LFTs): Evaluate liver function, which can be affected by CAD complications (e.g., hemochromatosis) and by cholesterol-lowering medications (statins).
3. Stress Testing: Stress testing is a non-invasive method to evaluate CAD by assessing the heart’s response to physical exertion.
4. Cardiac Catheterization (Angiography): Cardiac catheterization is the gold standard for visualizing coronary arteries. It is an invasive procedure using contrast dye to identify blockages.
5. Further Investigations: Other diagnostic tests may include:
- Echocardiogram: Ultrasound of the heart to assess structure, valve function, and ejection fraction; helps diagnose heart valve abnormalities and heart failure.
- Exercise treadmill test: For patients with a normal resting ECG who can exercise; assesses ECG changes during exercise.
- Nuclear stress test: Combines ECG with myocardial perfusion imaging at rest and during stress; useful for detecting ischemia.
- Stress imaging (Dobutamine stress echo or nuclear stress): For patients who cannot exercise or have difficult-to-interpret ECGs; uses pharmacological stress.
- Cardiac CT scans (Calcium scoring): Detects calcium buildup in coronary arteries, indicating plaque presence.
- CT coronary angiogram (CTCA): Uses contrast dye to provide detailed images of coronary arteries, less invasive than traditional angiography.
Nursing Interventions for CAD
Nursing interventions are crucial for patient recovery and long-term management of CAD. These interventions address symptom management, disease progression, and risk factor modification, contributing to improved patient outcomes and quality of life. Formulating appropriate ACS nursing diagnoses guides the selection and prioritization of these interventions.
Promote Myocardial Perfusion
1. Reduce Cholesterol Plaque Buildup: Administer cholesterol-lowering medications as prescribed. These may include:
- Statins (e.g., atorvastatin, simvastatin)
- Fibrates (e.g., gemfibrozil, fenofibrate)
- Niacin (nicotinic acid)
- Bile acid sequestrants (e.g., cholestyramine, colesevelam)
These medications work through different mechanisms to lower LDL cholesterol, raise HDL cholesterol, and reduce triglyceride levels, thus slowing plaque formation.
2. Prevent Blood Clot Formation: Administer antiplatelet medications as ordered, primarily aspirin. Low-dose aspirin therapy is often the cornerstone of primary and secondary prevention of CAD. In higher-risk patients, anticoagulant medications (e.g., clopidogrel, ticagrelor) may be added.
3. Revascularize Blocked Arteries: Interventional procedures to restore blood flow include:
- Coronary angioplasty and stent placement (Percutaneous Coronary Intervention – PCI): A minimally invasive procedure to open blocked coronary arteries using a balloon catheter and placing a stent to keep the artery open.
- Coronary artery bypass graft surgery (CABG): A more invasive surgical procedure that creates new pathways for blood flow around blocked coronary arteries using grafts from other blood vessels. CABG is indicated for patients with multi-vessel CAD or left main coronary artery disease.
4. Monitor Cholesterol Levels: Regularly monitor lipid profiles to assess medication effectiveness and guide adjustments in therapy.
Manage CAD Symptoms
1. Control Blood Pressure: Administer antihypertensive medications as prescribed. Common classes include:
- Beta-blockers (e.g., metoprolol, atenolol): Slow heart rate and lower blood pressure.
- Calcium channel blockers (e.g., amlodipine, diltiazem): Reduce blood pressure and may be used if beta-blockers are contraindicated.
- Angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril, enalapril) and Angiotensin II receptor blockers (ARBs) (e.g., losartan, valsartan): Lower blood pressure and provide cardioprotection.
2. Relieve Chest Pain (Angina): Administer nitroglycerin as prescribed for acute angina episodes. Nitroglycerin dilates coronary arteries and veins, improving blood flow and reducing preload.
3. Identify Angina Triggers: Educate patients to recognize and avoid angina triggers, such as:
- Physical exertion
- Emotional stress
- Cold weather
- Heavy meals
Maintaining a diary of angina episodes and triggers can be helpful.
4. Manage Chronic Ischemic Angina: For chronic angina, ranolazine may be prescribed in combination with other antianginal medications, including:
- Beta-blockers
- Calcium channel blockers
- Nitrates
- Antiplatelet agents
- Lipid-lowering medications
5. Maintain Target Blood Pressure: Emphasize the importance of maintaining blood pressure below 140/90 mmHg for most patients with CAD. However, caution is advised with diastolic blood pressure below 60 mmHg, as it can worsen angina in some individuals.
Cardiac Rehabilitation
1. Encourage Adherence to Cardiac Rehabilitation: Cardiac rehabilitation programs are tailored to individual patient needs and include:
- Supervised exercise training
- Education on heart-healthy lifestyle modifications
- Emotional support and counseling
2. Prevent Complications and Readmissions: Cardiac rehabilitation is proven to improve outcomes after CAD events and reduce the risk of complications and hospital readmissions.
3. Refer to Home and Community Health Services: Facilitate ongoing cardiac rehabilitation after hospital discharge through home-based programs or community healthcare facilities. Typical programs last 6-10 weeks.
4. Motivate Program Adherence: Emphasize the benefits of cardiac rehabilitation, including improved exercise capacity, lipid profiles, psychological well-being, and quality of life, as well as reduced mortality.
Lower CAD Risk: Prevention Measures
1. Promote Regular Physical Activity: Encourage patients to engage in at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity aerobic exercise per week, combined with strength training exercises twice a week.
2. Achieve and Maintain Ideal Body Mass Index (BMI): Educate patients about the importance of weight management. Weight loss can improve blood pressure, cholesterol levels, and metabolic health.
3. Patient Education: Provide comprehensive patient education on:
- CAD disease process
- Risk factors
- Medications
- Lifestyle modifications
- Importance of adherence to treatment plans
- When to seek medical attention
4. Stress Management Techniques: Teach stress reduction techniques such as:
- Yoga
- Guided imagery
- Deep breathing exercises
- Meditation
- Mindfulness
5. Comorbidity Management: Emphasize the importance of managing comorbidities like diabetes, hypertension, and hyperlipidemia to improve long-term outcomes in CAD.
6. Emphasize When to Seek Medical Attention: Instruct patients to seek immediate medical attention for symptoms suggestive of heart attack or stroke, such as:
- Severe chest pain, especially if not relieved by nitroglycerin
- Sudden onset of shortness of breath
- Weakness or numbness on one side of the body
- Slurred speech
7. Lifestyle Modification Education: Reinforce the importance of adopting a heart-healthy lifestyle, including:
- Heart-healthy diet (low in saturated and trans fats, cholesterol, and sodium; rich in fruits, vegetables, and whole grains)
- Smoking cessation and avoidance of secondhand smoke
- Limiting alcohol intake
- Managing stress
- Addressing depression and anxiety
8. Omega-3 Fatty Acids: Discuss the potential benefits of omega-3 fatty acids, obtained through diet (fatty fish, flaxseeds, soybeans) or supplements, in reducing inflammation and CAD risk.
9. Alternative Medicine Considerations: Advise patients to consult with their healthcare provider before using herbal supplements, as some may interact with prescribed medications. Some herbs purported to lower cholesterol and blood pressure include garlic, barley, oats, and psyllium.
10. Cardiology Follow-up: Stress the importance of regular follow-up appointments with a cardiologist for monitoring, testing, and treatment plan adjustments. Recommended follow-up is typically every 3-6 months for diagnosed CAD patients.
Ensure Patient Safety
1. Caution with Blood Thinners: When patients are on anticoagulant therapy, educate them about the increased risk of bleeding.
2. Implement Bleeding Precautions: Instruct patients on bleeding precautions, such as:
- Using a soft-bristled toothbrush
- Using an electric razor
- Avoiding forceful nose blowing
- Preventing constipation and straining during bowel movements
- Avoiding contact sports and activities with high risk of injury
3. Medical Identification: Advise patients to wear medical identification (bracelet, necklace, or card) indicating their CAD diagnosis and anticoagulant use, alerting emergency responders to their condition.
Nursing Care Plans for CAD
Nursing care plans are essential for organizing and prioritizing nursing care for patients with CAD. They are guided by ACS nursing diagnoses and help to define short-term and long-term goals of care, along with appropriate assessments and interventions. Examples of nursing care plans relevant to CAD are provided below.
Acute Pain related to Myocardial Ischemia
CAD-related chest pain, or angina, arises from insufficient blood supply to the heart muscle due to arterial blockage. Patients often describe this pain as pressure, tightness, or a heavy sensation in the chest.
Nursing Diagnosis: Acute Pain
Related to:
- Increased cardiac workload
- Decreased myocardial blood flow
As evidenced by:
- Reports of chest pain or tightness (duration, frequency, intensity)
- Diaphoresis
- Distraction behaviors (e.g., pacing, restlessness)
- Facial grimacing
- Guarding or protective posture
- Positioning to alleviate pain
- Altered vital signs (e.g., increased heart rate, blood pressure)
Expected Outcomes:
- Patient will report pain relief, as evidenced by a pain score of ≤ 3 on a 0-10 scale and absence of pain behaviors.
- Patient will verbalize understanding of actions to take during chest pain and when to seek emergency assistance.
Assessments:
1. Monitor Vital Signs: Vital signs can fluctuate with pain. Initially, tachycardia and hypertension may be present. However, as cardiac output declines, hypotension, hypoxemia, and bradycardia may develop.
2. Pain Characterization: Conduct a thorough pain assessment (PQRST – Provoking factors, Quality, Region/Radiation, Severity, Timing). Differentiate cardiac chest pain from other causes like heartburn or musculoskeletal pain. Unstable angina is typically more severe, unpredictable, longer-lasting, and less responsive to rest or nitroglycerin compared to stable angina.
3. Diagnostic Study Review: Review ECG results. ST-segment depression or T-wave inversion may be present during angina, indicating ischemia. ST-elevation or new Q waves may indicate myocardial infarction.
Interventions:
1. Administer Supplemental Oxygen: Provide oxygen to maintain SpO2 ≥ 90%. Oxygen is indicated for hypoxemia but should be used judiciously as it can have adverse effects if used unnecessarily in normoxemic patients.
2. Prompt Medication Administration: Administer prescribed medications:
- Nitroglycerin: To dilate coronary arteries and improve blood flow.
- Morphine sulfate: For pain relief, smooth muscle relaxation, and reduced myocardial oxygen demand.
- Beta-blockers: To reduce heart rate and myocardial workload.
3. Elevate Head of Bed: Semi-Fowler’s or high-Fowler’s position promotes comfort, reduces myocardial oxygen demand, and facilitates gas exchange.
4. Quiet and Comfortable Environment: Minimize environmental stressors to reduce anxiety and pain. Stress increases myocardial workload and pain.
5. Trigger Identification: Help the patient identify activities or situations that precipitate chest pain (e.g., exertion, stress). Activity cessation upon pain onset can help determine if further evaluation is needed.
Patient experiencing chest pain
Anxiety related to Cardiac Event
Anxiety is a common response to a cardiac event or CAD diagnosis. Excessive anxiety can negatively impact overall health and cardiac function.
Nursing Diagnosis: Anxiety
Related to:
- Situational crisis or stressors (cardiac event, diagnosis)
- Pain
- Pathophysiological response
- Perceived threat to health status
As evidenced by:
- Verbalization of distress, worry, or insecurity
- Awareness of physiological symptoms of anxiety (e.g., palpitations)
- Feelings of helplessness or fear
- Palpitations, tachycardia
- Nausea
- Fear of death
- Physiological manifestations: Altered respiratory pattern, flushing, increased blood pressure, heart rate, sweating
Expected Outcomes:
- Patient will verbalize recognition of anxiety and healthy coping mechanisms.
- Patient will demonstrate two effective relaxation techniques.
- Patient will report reduced anxiety to a manageable level (e.g., anxiety score ≤ 4 on a 0-10 scale).
Assessments:
1. Stress Level Assessment: Evaluate the patient’s stress level and sources of stress, as stress can exacerbate CAD symptoms and increase cardiac workload.
2. Vital Sign Monitoring: Differentiate between physiological responses to anxiety and medical causes. Both can manifest as rapid pulse, diaphoresis, and hyperventilation.
Interventions:
1. Encourage Expression of Feelings: Provide a safe space for the patient to express fears and concerns. Unexpressed emotions can contribute to anxiety and worsen CAD.
2. Reassurance and Calm Presence: Offer reassurance and a calm demeanor to reduce anxiety and promote a sense of security.
3. Medication Administration (if prescribed): Administer anxiolytics (e.g., benzodiazepines) as ordered to help manage acute anxiety.
4. Provide Accurate Information: Educate the patient about CAD, treatment plans, and prognosis. Knowledge reduces uncertainty and anxiety.
5. Promote Relaxation Techniques: Teach and encourage relaxation techniques:
- Deep breathing exercises
- Meditation
- Distraction (e.g., reading, music)
- Positive self-talk
Decreased Cardiac Output related to Myocardial Ischemia
CAD can lead to reduced cardiac output, resulting in inadequate tissue oxygenation and perfusion.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Inotropic changes (myocardial ischemia, infarction)
- Altered heart rate or rhythm (arrhythmias)
As evidenced by:
- Tachycardia or bradycardia
- ECG changes (arrhythmias, ST-segment changes)
- Angina
- Activity intolerance
- Fatigue
- Restlessness, anxiety
Expected Outcomes:
- Patient will report fewer episodes of angina, dyspnea, and arrhythmias.
- Patient will participate in activities that reduce cardiac workload.
Assessments:
1. Monitor Heart Rate, Blood Pressure, and Rhythm: Tachycardia may be compensatory for decreased cardiac output, pain, anxiety, or hypoxemia. Blood pressure changes (hypotension or hypertension) reflect cardiac function.
2. Auscultate Breath and Heart Sounds: Crackles in lungs may indicate pulmonary edema from heart failure. Abnormal heart sounds (gallop rhythms – S3 or S4, murmurs) also suggest heart failure.
3. Skin Color and Peripheral Pulses: Pallor, cyanosis, and diminished peripheral pulses indicate reduced peripheral perfusion due to decreased cardiac output.
Interventions:
1. Adequate Rest Periods: Schedule rest periods to reduce myocardial oxygen demand and workload.
2. Avoid Valsalva Maneuver: Instruct patients to avoid straining during bowel movements or holding breath during activities, as Valsalva maneuver can impair cardiac output.
3. Medication Administration: Administer medications as prescribed, such as:
- Inotropes (e.g., digoxin, dobutamine) to enhance myocardial contractility and cardiac output.
- Antiarrhythmics to control heart rhythm disturbances.
4. Prepare for Diagnostic Procedures: Prepare patient for:
- Echocardiogram: To assess cardiac function and structure.
- Cardiac catheterization: To visualize coronary arteries and assess for blockages.
Ineffective Peripheral Tissue Perfusion related to Arterial Obstruction
CAD-related atherosclerosis can cause ineffective tissue perfusion due to narrowed or blocked arteries, reducing blood supply to peripheral tissues.
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Related to:
- Arterial plaque formation and obstruction
- Vasospasm of coronary arteries
- Ineffective cardiac muscle contraction
- Conditions compromising blood supply
As evidenced by:
- Decreased or absent peripheral pulses
- Prolonged capillary refill (>3 seconds)
- Cool, clammy skin
- Pallor or cyanosis
- Edema (peripheral)
- Chest pain (angina)
- Dyspnea
- Orthopnea
- Tachypnea
- Altered level of consciousness
- Restlessness
- Fatigue
- Activity intolerance
- Claudication (leg pain with exercise)
- Numbness or tingling in extremities
Expected Outcomes:
- Patient will demonstrate palpable peripheral pulses and capillary refill ≤ 2 seconds.
- Patient will exhibit warm, dry skin without edema.
- Patient will maintain alert and oriented level of consciousness.
Assessments:
1. Vascularization Status: Assess peripheral vascular status, noting signs of reduced blood flow, particularly in lower extremities. Consider coexisting peripheral artery disease.
2. Ankle-Brachial Index (ABI): Calculate ABI to assess for peripheral artery disease and reduced blood flow to legs.
3. Skin Assessment and Sensory Evaluation: Assess:
- Skin color, temperature, and texture
- Capillary refill time
- Presence of edema, ulceration, or delayed wound healing
- Hair loss on extremities
- Thickened toenails
- Peripheral pulse strength (pedal, posterior tibial, femoral)
- Pain (especially claudication)
- Sensation (numbness, tingling)
4. Doppler Ultrasound: Use Doppler ultrasound to assess blood flow in peripheral arteries, especially if pulses are weak or non-palpable.
Interventions:
1. Medications to Improve Blood Flow: Administer vasodilators as prescribed:
- Nitroglycerin for angina
- Hydralazine for hypertension
2. Prepare for Revascularization Procedures: Prepare patient for potential:
- Percutaneous Coronary Intervention (PCI) with stent placement
- Coronary Artery Bypass Grafting (CABG)
3. Aspirin Therapy: Administer aspirin as ordered to reduce platelet aggregation and improve blood flow.
4. Mobility and Positioning Instructions: Educate patient to:
- Avoid prolonged sitting or standing
- Avoid crossing legs
- Avoid constrictive clothing
- Perform active and passive range of motion exercises
- Ambulate as tolerated
- Elevate legs when sitting to promote venous return
5. Cardiac Rehabilitation Referral: Refer patient to cardiac rehabilitation to improve risk factors, exercise tolerance, and medication adherence.
Risk for Unstable Blood Pressure related to CAD
CAD can lead to unstable blood pressure due to arterial narrowing and reduced cardiac function.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Plaque formation in coronary arteries
- Arterial narrowing and obstruction
- Coronary vasospasm
- Ineffective myocardial contraction
- Conditions compromising blood supply
- Increased cardiac workload
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention.
Expected Outcomes:
- Patient will maintain blood pressure within prescribed parameters (e.g., SBP 90-140 mmHg, DBP 60-90 mmHg).
- Patient will tolerate positional changes (sitting, standing) without significant blood pressure fluctuations (orthostatic hypotension).
- Patient will not experience complications of unstable blood pressure (e.g., myocardial ischemia, cerebrovascular accident).
Assessments:
1. Blood Pressure Monitoring: Regularly monitor blood pressure in various positions (supine, sitting, standing) to detect instability and orthostatic changes. High blood pressure is a major risk factor for CAD progression and complications.
2. Assess for Signs and Symptoms: Monitor for symptoms of unstable blood pressure:
- Hypotension: Dizziness, lightheadedness, syncope, fatigue
- Hypertension: Headache, blurred vision, chest pain, shortness of breath
- Tachycardia
3. Risk Factor Assessment: Identify and manage modifiable risk factors for hypertension, such as:
- High sodium diet
- Physical inactivity
- Obesity
- Excessive alcohol intake
- Uncontrolled diabetes
4. Body Fat Assessment: Assess BMI and waist circumference, as excess body weight and obesity contribute to hypertension.
Interventions:
1. Caution with Exertional Activities: Advise patient to avoid strenuous activities that could exacerbate blood pressure instability. Monitor blood pressure response to activity.
2. Medication Administration: Administer antihypertensive medications as prescribed:
- Beta-blockers
- ACE inhibitors
- ARBs
- Calcium channel blockers
- Diuretics
3. Patient Education on Blood Pressure Control: Educate patient about:
- Importance of blood pressure management
- Medications (purpose, dosage, side effects)
- Lifestyle modifications for blood pressure control (diet, exercise, stress management)
- Regular blood pressure monitoring at home
4. Lifestyle Modification Emphasis: Reinforce lifestyle modifications:
- Low-sodium, heart-healthy diet
- Regular exercise
- Weight management
- Smoking cessation
- Stress reduction
5. Assist with Stress Testing: Prepare patient for and assist with stress testing (exercise or pharmacological) to assess blood pressure response to exertion and identify exertional hypotension or hypertension.
