Coronary artery disease (CAD) is a prevalent condition affecting the arteries that supply the heart with essential nutrients, blood, and oxygen. It is crucial for healthcare professionals, especially nurses, to understand CAD, its management, and the relevant nursing diagnoses to provide optimal patient care.
Atherosclerosis, a primary cause of CAD, involves the accumulation of lipid deposits within the arterial walls. These plaques cause narrowing of the arteries, impeding blood flow and significantly increasing the risk of angina and myocardial infarction. CAD is a progressive disease that often develops insidiously over many years. Patients may not experience noticeable symptoms such as angina, shortness of breath, and fatigue until the condition is quite advanced.
When the flow of blood through the coronary arteries is significantly reduced or completely blocked, it leads to ischemia and infarction of the heart muscle. This lack of sufficient blood and oxygen supply (ischemia) to the myocardium results in decreased tissue perfusion and necrosis (infarction), necessitating prompt medical intervention.
Nurses play a vital role in the holistic management of CAD, from health promotion and risk factor modification to acute care and rehabilitation. This article will delve into the nursing process for CAD, focusing on key nursing assessments, interventions, and care plans, with a particular emphasis on Cad Nursing Diagnosis.
Nursing Process in CAD Management
Managing CAD effectively involves a multi-faceted approach centered on modifying risk factors to prevent or slow disease progression. Given the often silent nature of early CAD, identifying individuals at risk is paramount. Nurses are at the forefront of health promotion efforts aimed at controlling modifiable risk factors for CAD. Patient education on the disease process, its progression, and the importance of lifestyle modifications is crucial in preventing CAD and managing existing conditions.
For patients presenting with symptoms like chest pain or dyspnea, pharmacological or surgical interventions may be necessary. Medications such as aspirin and cholesterol-lowering agents are commonly prescribed to prevent blood clot formation, reduce the risk of heart attacks, and minimize plaque buildup in the arteries. Surgical procedures, including coronary angioplasty with stent placement and coronary artery bypass grafting (CABG), may be indicated to remove blockages, widen arteries, and restore adequate blood flow to the heart. CABG is typically considered for patients with multiple severely narrowed coronary arteries.
Nursing Assessment for CAD
The foundation of effective nursing care is a thorough nursing assessment. This involves gathering comprehensive physical, psychosocial, emotional, and diagnostic data. For patients with or at risk for CAD, a detailed assessment is essential to identify current problems, potential complications, and individual needs. This section outlines the subjective and objective data relevant to coronary artery disease assessment.
Review of Health History
1. Elicit General Symptoms: Begin by inquiring about the patient’s overall symptoms. Document any complaints, such as:
- Chest pain (angina): Characterize location, duration, intensity, and relieving/aggravating factors.
- Shortness of breath (dyspnea): Note onset, duration, severity, and associated factors (e.g., exertion, rest).
- Rapid breathing (tachypnea): Observe respiratory rate and depth.
- Difficulty breathing while lying down or sitting (orthopnea): Determine the number of pillows used for comfortable breathing.
- Fainting or lightheadedness (syncope or presyncope): Assess frequency, triggers, and associated symptoms.
- Palpitations: Ask about awareness of heartbeats, rhythm irregularities.
- Lower extremity edema: Note location, severity, and timing (e.g., worse at the end of the day).
- Leg pain, especially with exertion (claudication): Determine location, onset, and relieving factors.
- Difficulty performing physical activities: Assess limitations and impact on daily life.
2. In-depth Chest Pain Investigation: If the patient reports chest pain, delve deeper into its characteristics:
- Description: Tightness, squeezing, heaviness, burning sensation, pressure.
- Pain triggers: Physical activity, emotional stress, cold weather, large meals.
- Radiation: Pain radiating to the jaw, neck, left arm, or back.
- Associated symptoms: Nausea, sweating, shortness of breath.
- Duration and frequency of episodes.
- Relief measures: Rest, nitroglycerin.
3. Risk Factor Assessment: Thoroughly assess both non-modifiable and modifiable risk factors for CAD.
Non-modifiable Risk Factors:
- Age: Increased risk with advancing age due to natural arterial changes.
- Gender: Men generally have a higher risk until women reach menopause, after which their risk increases.
- Family history of premature ischemic heart disease: Significant risk if a male relative (father or brother) had heart disease before age 55 or a female relative (mother or sister) before age 65.
- Race/ethnicity: Certain minority groups, including Hispanics and African Americans, have a higher CAD incidence.
Modifiable Risk Factors:
- Hypertension: Uncontrolled high blood pressure can stiffen and damage arteries, accelerating atherosclerosis.
- Hyperlipidemia/hypercholesterolemia: Elevated LDL (“bad”) cholesterol and decreased HDL (“good”) cholesterol contribute to plaque formation.
- Diabetes mellitus and insulin resistance: These conditions promote blood vessel hardening and fatty plaque buildup.
- Chronic Kidney Disease: Kidney disease impairs blood pressure regulation and contributes to cardiovascular risk.
- Tobacco use: Smoking (both firsthand and secondhand) causes blood vessel constriction and damages the endothelium.
- Obesity: Excess weight, particularly abdominal obesity, is linked to elevated cholesterol, hypertension, and diabetes.
- Physical inactivity: Lack of exercise contributes to poor cholesterol profiles and overall cardiovascular risk.
- Unhealthy diet: High intake of saturated and trans fats elevates LDL cholesterol.
- Stress: Chronic stress can increase inflammation and contribute to vasoconstriction.
- Excessive alcohol consumption: Can weaken the heart muscle and increase blood clot formation.
- Lack of sleep and sleep disorders (e.g., insomnia): Poor sleep habits increase stress and can lead to vasoconstriction.
4. Medication and Treatment History: Review the patient’s current medications and past treatments. Certain medications, such as anthracyclines and anabolic steroids, and a history of vascular surgery can compromise blood vessel integrity.
Physical Assessment
1. Monitor Vital Signs: Assess vital signs regularly. Decreased oxygenated blood supply to the heart can lead to alterations in vital signs, particularly heart rate and blood pressure. Expect possible increases or irregularities.
2. EKG and Telemetry Monitoring: Perform an electrocardiogram (EKG) immediately if the patient reports chest pain to assess for arrhythmias and ischemic changes. Continuous telemetry monitoring is appropriate for patients with a known cardiac history or those at high risk.
3. Systemic Physical Examination: Conduct a comprehensive systemic assessment:
- Neck: Inspect for jugular venous distention (JVD), indicating fluid overload or heart failure.
- Central Nervous System (CNS): Assess level of consciousness, noting any acute distress, dizziness, lightheadedness, syncope, or lethargy.
- Cardiovascular System: Auscultate heart sounds for tachycardia, murmurs (at the apex or carotid arteries), bruits, and irregular heartbeats (arrhythmias). Assess for chest pain.
- Peripheral Circulation: Palpate peripheral pulses (radial, pedal) to assess strength and equality. Diminished pulses may indicate decreased tissue perfusion.
- Respiratory System: Assess respiratory rate, depth, and effort. Note dyspnea, tachypnea, orthopnea, and adventitious breath sounds (e.g., crackles) upon auscultation, which may indicate heart failure and pulmonary congestion. Assess activity tolerance.
- Gastrointestinal System: Inquire about nausea and vomiting, which can be associated with myocardial ischemia.
- Lymphatic System: Assess for peripheral edema, particularly in the lower extremities.
- Musculoskeletal System: Note any reports of neck, arm, back, jaw, or upper body pain, and fatigue.
- Integumentary System: Observe skin color for pallor, cyanosis, and diaphoresis (excessive sweating), which can indicate poor perfusion and sympathetic nervous system activation.
4. ASCVD Risk Calculation: Calculate the patient’s 10-year ASCVD (atherosclerotic cardiovascular disease) risk score using established risk calculators. Factors typically included are:
- Age
- Gender
- Race
- Blood pressure
- Cholesterol levels (total and HDL)
- Diabetes status
- Smoking history
A low ASCVD risk score is ideal (<7.5%). Higher scores indicate increased risk and guide preventive and treatment strategies.
Diagnostic Procedures
1. Arrhythmia Detection: Monitor for arrhythmias on EKG. CAD-related ischemia can disrupt the heart’s electrical activity, leading to various arrhythmias. Look for ST-segment changes (elevation or depression), T-wave inversions, atrial fibrillation, bundle branch blocks, and supraventricular tachycardia. ST-segment changes are particularly concerning as they may indicate acute myocardial ischemia or injury.
2. Blood Work Analysis: Obtain and analyze blood samples for the following:
- Complete Blood Count (CBC) with differential: Assess for signs of infection (elevated WBC count), blood clotting abnormalities (platelet count), and anemia (low RBC count).
- B-type Natriuretic Peptide (BNP): Elevated BNP levels can indicate volume overload of cardiac origin, as seen in heart failure. Note that BNP can be falsely elevated in kidney disease and lower in obese individuals.
- Cardiac Enzymes (Troponin and Creatine Kinase-MB (CK-MB)): Elevated troponin and CK-MB levels are highly specific indicators of myocardial damage and acute ischemia (myocardial infarction).
- Lipid Panel: Assess cholesterol levels (total cholesterol, LDL, HDL, triglycerides) to monitor for hyperlipidemia.
- High-sensitivity C-reactive protein (hs-CRP) or ultra-sensitive CRP (us-CRP): Elevated levels indicate systemic vascular inflammation, which is a significant risk factor for CAD.
- Liver Function Tests (LFTs): Evaluate liver function, particularly if considering statin therapy (cholesterol-lowering medications) or to rule out conditions like hemochromatosis (iron overload) that can affect both liver and heart.
3. Stress Testing: Prepare and assist patients undergoing stress tests. Stress testing is a non-invasive method to evaluate the heart’s response to physical exertion and detect ischemia.
4. Cardiac Catheterization Preparation: Prepare patients for cardiac catheterization (angiography), the gold standard for visualizing coronary arteries. Explain the procedure, including the use of contrast dye and associated risks.
5. Further Investigations: Prepare patients for or assist with the following diagnostic tests as indicated:
- Echocardiogram: Ultrasound of the heart to assess heart structure, valve function, and ejection fraction. Helps detect structural abnormalities and heart failure.
- Exercise Treadmill Test: Stress test performed on a treadmill, suitable for patients with normal resting EKGs and ability to exercise.
- Nuclear Stress Test: Combines EKG monitoring with nuclear imaging to assess blood flow to the heart muscle at rest and during stress. Useful for detecting areas of ischemia.
- Stress Imaging (Dobutamine Stress Echo or Nuclear Stress Test with pharmacological stress): For patients unable to exercise adequately, pharmacological agents like dobutamine are used to simulate the effects of exercise on the heart.
- Cardiac CT Scans: Detect calcium buildup in coronary arteries and assess for blockages.
- CT Coronary Angiography: CT scan using contrast dye to provide detailed images of coronary arteries, identifying stenosis and plaques.
Nursing Interventions for CAD
Nursing interventions are critical for managing CAD, alleviating symptoms, promoting perfusion, and preventing disease progression.
Promote Myocardial Perfusion
1. Reduce Cholesterol Plaque Buildup: Administer cholesterol-lowering medications as prescribed. Statins are the primary drugs to reduce LDL cholesterol and plaque formation. Other classes include fibrates, niacin, and bile acid sequestrants.
2. Prevent Blood Clots: Administer antiplatelet medications, typically aspirin, to reduce blood clot formation. For higher-risk patients, anticoagulants may be added.
3. Restore Blood Flow in Blocked Arteries:
- Coronary Angioplasty and Stent Placement (Percutaneous Coronary Intervention – PCI): Prepare patients for PCI, a minimally invasive procedure to open blocked coronary arteries using a balloon catheter and stent. Provide pre- and post-procedure care, including monitoring puncture site, vital signs, and for signs of bleeding or complications.
- Coronary Artery Bypass Graft Surgery (CABG): Prepare patients for CABG, a surgical procedure to bypass blocked arteries using grafts, usually from the patient’s own vessels. Provide comprehensive pre- and post-operative care, including wound care, pain management, respiratory care, and hemodynamic monitoring.
4. Cholesterol Level Monitoring: Regularly monitor cholesterol levels and educate patients on the importance of adherence to lipid-lowering therapy and lifestyle modifications.
Symptom Management
1. Blood Pressure Control: Administer antihypertensive medications as ordered to manage hypertension, a major risk factor for CAD. Common classes include:
- Beta-blockers: Reduce heart rate and blood pressure.
- Calcium channel blockers: Used if beta-blockers are contraindicated or not tolerated.
- Angiotensin-converting enzyme (ACE) inhibitors and Angiotensin II receptor blockers (ARBs): Lower blood pressure and provide cardioprotective effects.
2. Angina Relief: Administer nitroglycerin as prescribed for angina. Educate patients on proper administration (sublingual tablets or spray), expected effects (headache, flushing), and when to seek emergency care (if pain is unrelieved after 3 doses).
3. Angina Trigger Identification: Help patients identify and avoid angina triggers. Encourage them to keep a diary to track activities or situations that provoke chest pain (e.g., physical exertion, stress, cold exposure, heavy meals).
4. Management of Chronic Ischemic Angina: Administer ranolazine, if prescribed, for chronic angina. Educate patients about this medication and its common use in combination with other antianginal and cardiovascular medications.
5. Blood Pressure Target Maintenance: Emphasize the importance of maintaining blood pressure below 140/90 mmHg for CAD patients. Caution patients about excessively low diastolic blood pressure (below 60 mmHg), which can worsen angina in some individuals.
Cardiac Rehabilitation
1. Cardiac Rehabilitation Program Adherence: Encourage and support patient participation in cardiac rehabilitation programs. Explain the benefits of structured exercise, education, and support in improving cardiovascular health and recovery.
2. Complication Prevention: Emphasize that cardiac rehabilitation helps prevent complications, reduce hospital readmissions, and improve overall outcomes after CAD events or procedures.
3. Home and Community Health Services Referral: Facilitate referrals to home health or community-based cardiac rehabilitation programs for continued support after hospital discharge.
4. Patient Motivation and Adherence: Motivate patients to actively participate in and adhere to their cardiac rehabilitation plan. Highlight the positive impact of adherence on mortality, exercise capacity, risk factor modification, and quality of life.
Risk Reduction and Prevention
1. Promote Physical Activity: Advise patients on the importance of regular physical activity. Recommend at least 150 minutes of moderate-intensity aerobic exercise per week, incorporating strength training.
2. Weight Management: Encourage patients to achieve and maintain a healthy body weight. Explain that weight loss, if overweight or obese, improves blood pressure, cholesterol, and metabolic parameters.
3. Patient Education: Provide comprehensive patient education on CAD, risk factors, medications, lifestyle modifications, and warning signs. Effective education enhances medication adherence, self-management, and patient-centered care.
4. Stress Management Techniques: Educate patients on stress reduction techniques such as yoga, meditation, deep breathing exercises, and guided imagery. Explain the link between stress and increased heart rate, blood pressure, and vasoconstriction.
5. Comorbidity Management: Emphasize the importance of managing comorbidities such as diabetes and hypertension to improve long-term outcomes and prevent complications.
6. Recognition of Emergency Symptoms: Educate patients on when to seek immediate medical attention. Instruct them to call emergency services (911 in the US) for suspected heart attack or stroke symptoms. For angina patients, advise seeking help if chest pain is unrelieved by nitroglycerin.
7. Lifestyle Modification Education: Reinforce the importance of lifestyle modifications for CAD prevention and management:
- Regular exercise
- Heart-healthy diet (low in saturated and trans fats, rich in fruits, vegetables, and whole grains)
- Smoking cessation and avoidance of secondhand smoke
- Moderate alcohol intake (if any)
- Stress management
- Management of depression or anxiety
8. Omega-3 Fatty Acid Considerations: Discuss the potential benefits of omega-3 fatty acids in reducing inflammation and CAD risk. Advise patients to obtain omega-3s through diet (fatty fish, flaxseeds, soybeans) or supplements, after consulting their healthcare provider.
9. Alternative Medicine Awareness: Advise patients to discuss any herbal supplements or alternative therapies with their healthcare provider due to potential interactions with prescribed medications. Mention that some herbs like garlic, barley, oats, and psyllium are purported to have cholesterol-lowering effects.
10. Cardiologist Follow-up: Emphasize the importance of regular follow-up appointments with a cardiologist for monitoring, testing, and treatment plan adjustments. Recommend follow-up every 3-6 months for diagnosed CAD patients.
Safety Measures
1. Anticoagulant Therapy Precautions: If patients are on anticoagulants, educate them about the increased risk of bleeding and necessary precautions.
2. Bleeding Precautions Implementation: Instruct patients on bleeding precautions:
- Use a soft-bristled toothbrush.
- Use an electric razor for shaving.
- Avoid forceful nose blowing.
- Prevent constipation and straining during bowel movements.
- Avoid contact sports or activities with high risk of injury.
3. Medical Identification: Recommend that patients wear medical identification (bracelet, necklace, or card) indicating their CAD diagnosis, anticoagulant use, and potential risks of heart attack or stroke.
Nursing Care Plans for CAD
Nursing care plans provide a structured framework for organizing and delivering patient care. They help prioritize nursing diagnoses, assessments, interventions, and expected outcomes. Here are examples of nursing care plans for common CAD nursing diagnoses:
Acute Pain related to Myocardial Ischemia
CAD-related chest pain, or angina, arises from reduced blood supply to the heart muscle due to arterial blockage. Patients often describe it as pressure, tightness, or a heavy sensation in the chest.
Nursing Diagnosis: Acute Pain
Related Factors:
- Increased cardiac workload
- Decreased myocardial blood flow
Evidenced by:
- Reports of chest pain (location, duration, intensity, characteristics)
- Diaphoresis
- Distraction behaviors (e.g., restlessness, moaning)
- Facial grimacing
- Guarding or protective posture
- Positioning to alleviate pain
- Changes in vital signs (e.g., increased heart rate, blood pressure)
Expected Outcomes:
- Patient will report pain relief or reduction to a tolerable level within a specified timeframe.
- Patient will demonstrate non-verbal indicators of pain relief (relaxed facial expression, calm demeanor).
- Patient will verbalize understanding of angina triggers and appropriate actions to take when chest pain occurs.
Nursing Assessments:
- Monitor Vital Signs: Assess heart rate, blood pressure, respiratory rate, and oxygen saturation. Changes may indicate pain, anxiety, or compromised cardiac function. Tachycardia and hypertension may initially be present, followed by hypotension and bradycardia with worsening cardiac output.
- Pain Assessment: Conduct a thorough pain assessment using PQRST or similar mnemonic. Differentiate angina from other types of chest pain (e.g., musculoskeletal, gastrointestinal). Unstable angina is typically more intense, unpredictable, prolonged, and less responsive to rest or nitroglycerin compared to stable angina.
- Diagnostic Study Review: Review EKG findings. Assess for ST-segment depression or T-wave inversion (ischemia) or ST-segment elevation or new Q waves (myocardial infarction).
Nursing Interventions:
- Oxygen Administration: Administer supplemental oxygen as needed to maintain SpO2 ≥ 90%. Oxygen should be used judiciously, only if SpO2 is below target range.
- Medication Administration: Promptly administer prescribed medications:
- Nitroglycerin: Sublingual or IV as ordered to dilate coronary arteries and improve blood flow.
- Morphine sulfate: For severe pain, to promote comfort, reduce myocardial oxygen demand, and relax smooth muscles.
- Beta-blockers: To reduce heart rate and myocardial workload.
- Positioning: Elevate the head of the bed to semi-Fowler’s or high-Fowler’s position to promote comfort, reduce myocardial oxygen demand, and improve gas exchange.
- Environment Management: Provide a calm, quiet, and comfortable environment to reduce anxiety and minimize stimuli that can exacerbate pain.
- Trigger Identification and Education: Assist the patient in identifying angina triggers (e.g., exertion, stress). Educate on avoiding triggers and appropriate actions to take if pain occurs.
Anxiety related to Perceived Threat to Health Status
Anxiety is a common emotional response to cardiac events and the diagnosis of CAD. Excessive anxiety can negatively impact patient well-being and cardiovascular health.
Nursing Diagnosis: Anxiety
Related Factors:
- Situational crisis (cardiac event, new diagnosis)
- Pain and discomfort
- Underlying pathophysiological changes
- Perceived threat to health status and life
Evidenced by:
- Verbalization of distress, worry, or insecurity
- Awareness of physiological symptoms (e.g., palpitations)
- Feelings of helplessness or fear
- Expressed fear of death
- Physical manifestations of anxiety: restlessness, agitation, increased heart rate, increased respiratory rate, diaphoresis, facial flushing.
Expected Outcomes:
- Patient will verbalize recognition of anxiety and feelings associated with CAD.
- Patient will identify and utilize effective coping mechanisms to manage anxiety.
- Patient will report a reduction in anxiety to a manageable level.
- Patient will demonstrate relaxation techniques.
Nursing Assessments:
- Stress Level Assessment: Assess the patient’s perceived stress level and sources of stress related to their CAD diagnosis and health status.
- Vital Sign Monitoring: Monitor vital signs, recognizing that both anxiety and cardiac events can cause similar physiological responses (tachycardia, tachypnea, diaphoresis). Differentiate between emotional and physiological causes of vital sign changes.
Nursing Interventions:
- Encourage Verbalization: Encourage the patient to express feelings, fears, and concerns openly. Active listening and providing a safe space for expression can be therapeutic.
- Reassurance and Support: Provide reassurance and emotional support. Reiterate that they are in a safe environment and receiving appropriate care. Maintain a calm and reassuring presence.
- Medication Administration: Administer anti-anxiety medications (e.g., benzodiazepines) as prescribed, particularly in the acute phase, to help manage severe anxiety.
- Patient Education: Provide accurate and understandable information about CAD, treatment plan, and prognosis. Education reduces uncertainty and empowers patients to participate in their care.
- Coping Strategy Promotion: Teach and encourage relaxation techniques such as deep breathing exercises, meditation, guided imagery, and progressive muscle relaxation. Encourage the use of positive self-talk and distraction techniques.
Decreased Cardiac Output related to Altered Contractility
CAD can impair myocardial contractility due to ischemia and infarction, leading to decreased cardiac output and inadequate tissue perfusion.
Nursing Diagnosis: Decreased Cardiac Output
Related Factors:
- Myocardial ischemia and infarction
- Altered heart rate and rhythm (arrhythmias)
- Inotropic changes (reduced contractility)
Evidenced by:
- Tachycardia
- EKG changes (arrhythmias, ischemic changes)
- Angina
- Fatigue
- Activity intolerance
- Restlessness
- Signs of poor peripheral perfusion (pallor, cool extremities, diminished pulses)
- Pulmonary congestion (crackles, dyspnea)
- Edema
Expected Outcomes:
- Patient will maintain adequate cardiac output as evidenced by stable vital signs, palpable peripheral pulses, warm and dry skin, and absence of edema.
- Patient will report reduced frequency and severity of angina and dyspnea episodes.
- Patient will participate in activities that reduce cardiac workload.
Nursing Assessments:
- Cardiovascular Assessment: Monitor heart rate, blood pressure, and cardiac rhythm. Assess for tachycardia, bradycardia, arrhythmias, and hypotension. Changes may indicate worsening cardiac output.
- Auscultate Heart and Breath Sounds: Listen for abnormal heart sounds (gallops, murmurs) and adventitious breath sounds (crackles), which can indicate heart failure and fluid overload.
- Peripheral Perfusion Assessment: Assess skin color, temperature, capillary refill, and peripheral pulses. Pallor, cyanosis, cool skin, delayed capillary refill, and diminished pulses suggest reduced cardiac output and peripheral vasoconstriction.
Nursing Interventions:
- Promote Rest: Ensure adequate rest periods to reduce myocardial oxygen demand and cardiac workload. Schedule activities to allow for rest and recovery.
- Avoid Valsalva Maneuver: Instruct patients to avoid straining during bowel movements or breath-holding, as Valsalva maneuvers can impair cardiac output.
- Medication Administration: Administer medications as prescribed to improve cardiac output:
- Inotropic agents (e.g., digoxin, dobutamine): To enhance myocardial contractility.
- Diuretics: To reduce fluid overload and preload.
- Vasodilators: To reduce afterload and improve cardiac output.
- Prepare for Diagnostic Procedures: Prepare patients for diagnostic tests such as echocardiograms and cardiac catheterization to assess cardiac function and coronary artery anatomy.
Ineffective Peripheral Tissue Perfusion related to Arterial Obstruction
CAD affects blood flow to the heart muscle, and generalized atherosclerosis can also impair peripheral tissue perfusion.
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Related Factors:
- Arterial obstruction due to plaque formation and atherosclerosis
- Reduced cardiac output
- Vasospasm of coronary or peripheral arteries
Evidenced by:
- Decreased or absent peripheral pulses
- Cool, pale, or cyanotic extremities
- Delayed capillary refill time (>3 seconds)
- Edema
- Skin changes (thin, shiny, hairless skin; thickened nails)
- Pain in extremities (claudication, rest pain)
- Numbness or tingling in extremities
- Slow or non-healing wounds or ulcers
Expected Outcomes:
- Patient will demonstrate improved peripheral tissue perfusion as evidenced by palpable peripheral pulses, warm and dry extremities, normal skin color, and capillary refill ≤ 2 seconds.
- Patient will report reduced pain and discomfort in extremities.
- Patient will maintain intact skin without ulceration.
Nursing Assessments:
- Vascular Assessment: Assess peripheral pulses (pedal, posterior tibial, femoral, radial) for presence, strength, and equality.
- Ankle-Brachial Index (ABI): Measure ABI as indicated to assess for peripheral artery disease.
- Skin Assessment: Assess skin color, temperature, texture, and integrity of extremities. Note any edema, ulcerations, or signs of ischemia (pallor, cyanosis, coolness).
- Doppler Ultrasound: Use Doppler ultrasound to assess blood flow in peripheral arteries if pulses are weak or non-palpable.
Nursing Interventions:
- Medication Administration: Administer medications to improve blood flow and reduce vasoconstriction:
- Vasodilators (e.g., nitrates, calcium channel blockers): To dilate blood vessels and improve perfusion.
- Antiplatelet agents (e.g., aspirin, clopidogrel): To prevent clot formation and improve blood flow.
- Lipid-lowering agents (statins): To reduce atherosclerosis progression.
- Prepare for Procedures: Prepare patients for procedures to improve peripheral perfusion:
- Percutaneous transluminal angioplasty (PTA) and stenting: To open blocked peripheral arteries.
- Peripheral artery bypass surgery: To bypass blocked segments of peripheral arteries.
- Aspirin Therapy: Ensure aspirin therapy is initiated and maintained as ordered to reduce the risk of thrombotic events and improve blood flow.
- Mobility and Positioning Education: Instruct patients on positions and activities that promote venous return and arterial blood flow. Advise against prolonged sitting, crossing legs, and constrictive clothing. Encourage regular exercise and leg elevation when sitting.
- Cardiac Rehabilitation Referral: Refer patients to cardiac rehabilitation programs that include exercise training and education to improve peripheral circulation and overall cardiovascular health.
Risk for Unstable Blood Pressure related to Cardiovascular Dysfunction
CAD-related cardiovascular dysfunction can lead to instability in blood pressure, both hypertension and hypotension, increasing the risk of complications.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related Factors:
- Plaque formation in coronary arteries
- Narrowed or blocked arteries
- Myocardial ischemia and infarction
- Coronary vasospasm
- Ineffective myocardial contraction
- Cardiovascular regulatory mechanism dysfunction
Evidenced By:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. The goal is prevention.
Expected Outcomes:
- Patient will maintain blood pressure within prescribed parameters.
- Patient will not experience significant fluctuations in blood pressure (orthostatic hypotension, hypertensive episodes).
- Patient will not develop complications associated with unstable blood pressure (myocardial ischemia, stroke).
Nursing Assessments:
- Blood Pressure Monitoring: Regularly monitor blood pressure in various positions (supine, sitting, standing) to assess for orthostatic hypotension or hypertension.
- Symptom Assessment: Assess for symptoms associated with unstable blood pressure, such as dizziness, lightheadedness, syncope, chest pain, shortness of breath, fatigue, and headache.
- Risk Factor Identification: Identify and assess risk factors that contribute to unstable blood pressure, including hypertension, diabetes, obesity, smoking, and medication non-adherence.
- Body Fat Assessment: Assess body mass index (BMI) and waist circumference, as excess weight and abdominal obesity are linked to hypertension.
Nursing Interventions:
- Activity Precautions: Advise patients to avoid strenuous activities that could excessively elevate blood pressure or cause hypotension. Instruct them to change positions slowly to prevent orthostatic hypotension.
- Medication Administration: Administer antihypertensive medications as prescribed to maintain blood pressure within target range. Monitor for side effects and effectiveness.
- Blood Pressure Control Education: Educate patients on the importance of blood pressure control, lifestyle modifications for blood pressure management (diet, exercise, weight management, stress reduction), and medication adherence.
- Lifestyle Modification Counseling: Counsel patients on lifestyle modifications to manage blood pressure, including:
- Dietary Approaches to Stop Hypertension (DASH) diet.
- Regular physical activity.
- Weight loss if overweight or obese.
- Smoking cessation.
- Stress reduction techniques.
- Stress Test Assistance: Assist with stress testing as ordered to evaluate blood pressure response to exercise and identify exertional hypertension or hypotension.
References
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