CAD Nursing Diagnosis Care Plan: A Comprehensive Guide for Nurses

Coronary artery disease (CAD) is a prevalent and serious condition affecting the arteries that supply blood, nutrients, and oxygen to the heart. Understanding CAD, its progression, and effective nursing interventions is crucial for healthcare professionals. This article provides a comprehensive overview of CAD, focusing on nursing diagnoses and care plans to optimize patient care in English-speaking healthcare settings.

CAD is often rooted in atherosclerosis, a process where fatty deposits, or plaques, accumulate within the arterial walls. These plaques narrow the arteries, hindering blood flow and elevating the risk of serious cardiac events such as angina and myocardial infarction. This condition typically develops gradually over time, often reaching an advanced stage before noticeable symptoms like angina, shortness of breath, and fatigue manifest.

When coronary artery blood flow is compromised—partially or completely blocked—ischemia and infarction can occur in the heart muscle. Myocardial ischemia, a state of insufficient blood and oxygen supply, leads to decreased tissue perfusion and, if prolonged, necrosis (infarction), necessitating prompt medical intervention.

This guide delves into the nursing process for CAD, emphasizing risk factor modification to slow disease progression and prevention strategies. Early identification of at-risk individuals is paramount, as symptoms are not always immediately apparent. Nurses play a vital role in health promotion, educating patients about CAD, its progression, and the importance of lifestyle modifications.

For patients experiencing symptoms like chest pain or dyspnea, medical or surgical interventions may be necessary. Common medications include aspirin and cholesterol-lowering agents to prevent clot formation, reduce heart attack risk, and decrease plaque buildup. Surgical options range from coronary angioplasty and stent placement to restore blood flow, to coronary artery bypass grafting (CABG) for patients with multiple severely narrowed arteries.

Nursing Assessment for CAD

The cornerstone of effective nursing care is a thorough nursing assessment. This involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic. Let’s explore the subjective and objective data collection relevant to coronary artery disease.

Review of Health History

1. Elicit General Symptoms: Begin by asking the patient about any general symptoms they’ve experienced. Key complaints may include:

• Chest pain (angina)
• Shortness of breath (dyspnea), both at rest and during exertion
• Rapid breathing (tachypnea)
• Orthopnea (difficulty breathing while lying down)
• Syncope (fainting)
• Palpitations
• Lower extremity edema
• Lower extremity pain
• Difficulty performing physical activities

2. Detailed Chest Pain Investigation: If chest pain is reported, delve deeper into its characteristics:

• Nature of pain: tightness, squeezing, heaviness, burning
• Pain triggers: physical activity, stress, substance use
• Radiation: pain extending to the jaw, neck, left arm, or back

3. Risk Factor Assessment: Evaluate both non-modifiable and modifiable risk factors:

Non-modifiable Risk Factors:

• Age: Arterial damage and narrowing are more likely with increasing age.
• Gender: Men are generally at higher risk, but women’s risk increases post-menopause.
• Family History: Significant risk exists if a male relative (father/brother) had heart disease before 55 or a female relative (mother/sister) before 65.
• Race/Ethnicity: Certain minority groups, including Hispanics and Blacks, have a higher CAD incidence.

Modifiable Risk Factors:

• Hypertension: Uncontrolled high blood pressure can stiffen and rigidify arteries, impeding blood flow.
• Hyperlipidemia/Hypercholesterolemia: Elevated LDL (“bad” cholesterol) or decreased HDL (“good” cholesterol) increases atherosclerosis risk.
• Diabetes or Insulin Resistance: These conditions promote blood vessel hardening and plaque buildup.
• Kidney Disease: Impaired kidney function affects blood pressure regulation.
• Tobacco Use: Smoking (firsthand and secondhand) causes blood vessel constriction.
• Obesity: Contributes to elevated cholesterol and plaque formation, narrowing blood vessels.
• Physical Inactivity: Lowers HDL cholesterol levels.
• Diet: High saturated fat intake raises LDL cholesterol.
• Stress: Increases inflammatory markers, contributing to blood vessel narrowing.
• Alcohol Use: Can weaken heart muscle and affect blood clot formation.
• Lack of Sleep: Poor sleep and insomnia elevate stress, leading to vasoconstriction.

4. Medication and Treatment History Review: Certain medications (anthracyclines, anabolic steroids) and prior vascular surgeries can compromise blood vessel integrity.

Physical Assessment

1. Vital Signs Monitoring: Decreased oxygenated blood to the heart can alter vital signs, notably increasing or changing pulse rate and blood pressure.

2. EKG and Telemetry: An EKG is crucial for patients presenting with chest pain to detect dysrhythmias. Continuous telemetry monitoring is appropriate for those with a known cardiac history.

3. Systemic Assessment Approach:

• Neck: Assess for jugular vein distention.
• CNS: Note acute distress, dizziness, lightheadedness, syncope, lethargy.
• Cardiovascular: Monitor for tachycardia, chest pain, murmurs (apex), bruits (carotid artery), arrhythmias.
• Circulatory: Check for decreased peripheral pulses.
• Respiratory: Assess for dyspnea, tachypnea, orthopnea, crackles, activity intolerance.
• Gastrointestinal: Note nausea and vomiting.
• Lymphatic: Observe for peripheral edema.
• Musculoskeletal: Evaluate neck, arm, back, jaw, and upper body pain, fatigue.
• Integumentary: Assess skin for cyanosis, pallor, and excessive sweating.

4. ASCVD Risk Score Calculation: Calculate the patient’s atherosclerotic cardiovascular disease (ASCVD) risk score using factors like age, gender, race, blood pressure, cholesterol, medications, diabetes, and smoking status. A low score (<<7.5%) is ideal.

Diagnostic Procedures

1. Arrhythmia Detection: CAD-related blockage of heart blood flow can cause arrhythmias. Monitor for ST segment changes on ECG, which may indicate ischemia, as well as other arrhythmias like atrial fibrillation or bundle branch blocks.

2. Blood Work Analysis:

• Complete Blood Count (CBC) with differential: To assess for infection (WBC), clotting response (platelets), and anemia (RBC).
• B-type Natriuretic Peptides (BNP): To detect volume overload of cardiac origin (though may be falsely elevated in kidney conditions or low in obesity).
• Cardiac Enzymes (Troponin, CK): To identify acute ischemia.
• Lipid Panel: To monitor hypercholesterolemia.
• Ultra-sensitive C-reactive protein (us-CRP): To assess vascular inflammation.
• Liver Function Tests (LFTs): To evaluate liver and heart function concurrently, especially in conditions like hemochromatosis, and to monitor liver function during cholesterol medication use.

3. Stress Testing: Useful for noninvasive CAD evaluation, assessing the heart’s response to physical exertion.

4. Cardiac Catheterization Preparation: Explain that cardiac catheterization (angiogram) is the gold standard for visualizing heart blood vessels, while noting it is invasive and uses contrast dye.

5. Further Investigations:

• Echocardiogram: To visualize heart structure and valve function, useful for detecting valve abnormalities or heart failure.
• Exercise Treadmill Test: For patients with normal resting ECGs who can exercise.
• Nuclear Stress Test: Combines ECG with blood flow images to the heart muscle at rest and during stress.
• Stress Imaging: For patients revascularized, with difficult ECGs, or exercise limitations.
• Cardiac CT Scans: To show calcium buildup and blockages.
• CT Coronary Angiogram: Similar to CT scan but uses contrast for detailed imaging.

Nursing Interventions for CAD

Nursing interventions are vital for patient recovery and management of CAD. These interventions focus on promoting perfusion, managing symptoms, cardiac rehabilitation, risk reduction, and ensuring patient safety.

Promoting Perfusion

1. Reduce Cholesterol Plaque Buildup: Administer cholesterol-lowering medications (statins, fibrates, niacin, bile acid sequestrants) as prescribed to decrease LDL cholesterol and reduce plaque formation.

2. Prevent Blood Clots: Utilize aspirin therapy to thin the blood and prevent clot formation. Low-dose aspirin is often a primary prevention strategy. Anticoagulants may be added for higher-risk patients.

3. Address Blocked Arteries:

• Coronary Angioplasty and Stent Placement (PCI): Explain this procedure to open blocked arteries using a stent.
• Coronary Artery Bypass Grafting (CABG): Describe this surgical option for creating new pathways for blood flow around blockages, especially for multi-vessel disease.

4. Cholesterol Level Monitoring: Regularly monitor cholesterol levels, especially in high-risk patients, to ensure early CAD detection and management.

Symptom Management

1. Blood Pressure Control: Administer medications to manage hypertension:

• Beta-blockers: To slow heart rate and lower blood pressure.
• Calcium Channel Blockers: As an alternative if beta-blockers are contraindicated.
• ACE Inhibitors and ARBs: To lower blood pressure.

2. Chest Pain Relief: Use nitroglycerin to dilate veins and improve blood flow to relieve angina.

3. Angina Trigger Identification: Educate patients to track angina triggers (exercise, stress, meals, rest) to aid in care planning.

4. Ischemic Angina Management: Treat chronic angina with ranolazine, often in combination with antihypertensives, nitrates, antiplatelets, and lipid-lowering agents.

5. Maintain Target Blood Pressure: Advise patients with CAD to maintain blood pressure below 140/90 mmHg, with caution advised for diastolic pressure below 60 mmHg, which can worsen angina.

Cardiac Rehabilitation

1. Cardiac Rehab Adherence: Emphasize the importance of cardiac rehabilitation programs tailored to individual needs for exercise, education, and support for long-term lifestyle changes.

2. Complication Prevention: Highlight cardiac rehab’s role in recovery and reducing the risk of complications and hospital readmissions.

3. Home and Community Health Services Referral: Facilitate ongoing cardiac rehabilitation post-discharge through home or community-based programs, typically lasting 6-10 weeks.

4. Patient Motivation and Adherence: Encourage adherence to cardiac rehab plans, noting that it improves outcomes, reduces mortality, and enhances quality of life in CAD patients.

Risk Reduction and Prevention

1. Promote Ambulation and Exercise: Encourage regular physical activity (150 minutes of moderate-intensity exercise weekly) to lower cardiovascular event risk.

2. Achieve Ideal BMI: Advise weight loss to reduce fatty deposits in arteries and improve blood pressure, cholesterol, and metabolic function.

3. Patient Education: Educate patients on medications, treatments, and lifestyle changes to enhance adherence and promote patient-centered care.

4. Stress Management: Teach stress reduction techniques (yoga, meditation, deep breathing) to mitigate stress-induced vasoconstriction and CAD risk.

5. Comorbidity Management: Emphasize the importance of managing comorbidities like diabetes and hypertension for better CAD outcomes.

6. Recognize When to Seek Medical Attention: Instruct patients to seek immediate medical help for suspected heart attack or stroke symptoms and for angina unresponsive to nitroglycerin.

7. Lifestyle Modification Education: Educate on key lifestyle changes: heart-healthy diet, exercise, smoking cessation, limited alcohol intake, and stress management.

8. Omega-3 Fatty Acids: Discuss the potential benefits of omega-3 fatty acids in reducing vascular inflammation and CAD risk.

9. Alternative Medicine Considerations: Advise caution and consultation with healthcare providers before using herbal supplements, mentioning garlic, barley, oats, and psyllium as examples known to affect cholesterol and blood pressure.

10. Cardiologist Follow-Up: Recommend regular follow-up visits with a cardiologist (every 3-6 months) and routine testing to ensure treatment effectiveness.

Ensuring Safety

1. Cautious Use of Blood Thinners: Highlight the bleeding risk associated with anticoagulant therapy often used in CAD management.

2. Bleeding Precautions Implementation: Advise on bleeding precautions: soft toothbrushes, electric razors, avoiding forceful nose blowing, preventing constipation, and avoiding contact sports.

3. Medical Identification Reminder: Recommend medical identification bracelets or necklaces to alert emergency responders to CAD history and anticoagulant use.

Nursing Care Plans for CAD

Nursing care plans help prioritize assessments and interventions for both short and long-term care goals once nursing diagnoses are identified. Here are examples of nursing care plans for common CAD-related diagnoses.

Acute Pain

Nursing Diagnosis: Acute Pain related to increased cardiac workload and decreased myocardial blood flow.

As evidenced by: Reports of chest pain, diaphoresis, facial grimacing, guarding behavior, altered vital signs.

Expected Outcomes: Pain relief demonstrated by absence of pain behaviors and stable vital signs; patient verbalizes appropriate actions for chest pain and when to seek emergency help.

Assessments:

1. Monitor vital signs: Tachycardia and hypertension may be initial signs; hypotension and bradycardia may develop with worsening cardiac output.
2. Assess pain characteristics: Differentiate chest pain from other causes; unstable angina is more intense, unpredictable, and less responsive to rest or nitroglycerin.
3. Review diagnostic studies (ECG): Identify signs of ischemia (ST depression, T-wave inversion) or infarction (ST-elevation, abnormal Q waves).

Interventions:

1. Administer supplemental oxygen: Maintain SpO2 ≥ 90% if needed.
2. Administer medications promptly: Nitroglycerin, morphine sulfate, beta-blockers as ordered.
3. Elevate head of bed: Promotes comfort and reduces myocardial oxygen demand.
4. Maintain quiet environment: Reduces anxiety and myocardial workload.
5. Help patient identify triggers: Assist in recognizing activities or events that precipitate chest pain.

Anxiety

Nursing Diagnosis: Anxiety related to situational crisis, pain, pathophysiological response, and threat to health status.

As evidenced by: Distress, insecurity, awareness of physiological symptoms, feelings of helplessness, palpitations, fear of death, altered respiratory pattern, increased vital signs, sweating.

Expected Outcomes: Patient verbalizes anxiety awareness and healthy coping mechanisms; demonstrates relaxation strategies; reports manageable anxiety levels.

Assessments:

1. Assess stress levels: Identify stressors that may exacerbate CAD symptoms.
2. Monitor vital signs: Differentiate between medical and emotional responses (tachycardia, diaphoresis, hyperventilation).

Interventions:

1. Encourage expression of feelings: Facilitate verbalization of fears and anxieties.
2. Provide reassurance: Offer calm presence and reinforce patient safety.
3. Administer medications: Benzodiazepines as prescribed for anxiety relief.
4. Provide disease information: Educate patient about CAD and treatment plan.
5. Encourage coping methods: Teach and reinforce relaxation techniques (breathing exercises, meditation).

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to inotropic changes due to myocardial ischemia and altered heart rate/rhythm.

As evidenced by: Tachycardia, ECG changes, angina, activity intolerance, fatigue, restlessness.

Expected Outcomes: Patient reports fewer angina, dyspnea, and dysrhythmia episodes; participates in activities to reduce cardiac workload.

Assessments:

1. Assess heart rate, BP, rhythm: Monitor for tachycardia, blood pressure changes, and arrhythmias.
2. Assess breath and heart sounds: Listen for crackles (pulmonary congestion), gallops (heart failure).
3. Assess skin color and pulses: Check for pallor, cyanosis, diminished peripheral pulses.

Interventions:

1. Provide rest periods: Reduce oxygen demand and myocardial workload.
2. Avoid Valsalva maneuver: Prevent vagal stimulation and rebound tachycardia.
3. Administer medications: Inotropes like digoxin to improve cardiac output.
4. Prepare for diagnostic tests: Echocardiograms, cardiac catheterization.

Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion related to plaque formation, narrowed/obstructed arteries, and ineffective cardiac muscle contraction.

As evidenced by: Hypotension, decreased peripheral pulses, tachycardia, dysrhythmias, chest pain, dyspnea, altered LOC, fatigue, cold/clammy skin, prolonged capillary refill, pallor/cyanosis, edema, claudication.

Expected Outcomes: Palpable peripheral pulses, normal capillary refill; warm, non-edematous skin; alert and coherent level of consciousness.

Assessments:

1. Determine vascularization status: Assess for peripheral vascular disease and impaired circulation.
2. Calculate ankle-brachial index (ABI): Assess for poor lower extremity blood flow.
3. Assess skin color, capillary refill, sensation: Note edema, ulceration, skin color/temperature, pulses, pain, claudication.
4. Use Doppler ultrasound: Assess blood flow in lower extremities.

Interventions:

1. Administer vasodilators: As prescribed (nitroglycerin, hydralazine).
2. Prepare for surgical procedures: PCI (stent), CABG.
3. Initiate aspirin therapy: As ordered, to improve blood flow and reduce clotting risk.
4. Educate on mobility and contraindications: Avoid prolonged sitting, leg crossing, constrictive clothing; encourage ROM exercises and leg elevation.
5. Refer to cardiac rehab: For risk factor modification, exercise, medication adherence, and diet control.

Risk for Unstable Blood Pressure

Nursing Diagnosis: Risk for Unstable Blood Pressure related to plaque formation, narrowed arteries, and ineffective cardiac muscle contraction.

As evidenced by: (Risk diagnosis, no defining signs/symptoms present yet; interventions aimed at prevention).

Expected Outcomes: Patient maintains blood pressure within prescribed parameters; tolerates positional changes without significant BP fluctuations; avoids complications of unstable BP.

Assessments:

1. Track blood pressure: Monitor for hypertension, which can exacerbate CAD.
2. Assess for signs/symptoms: Monitor for tachycardia, angina, dyspnea, fatigue, dizziness.
3. Determine risk factors: Identify factors increasing hypertension risk (diet, inactivity, comorbidities).
4. Assess body fat: Obesity is a significant risk factor for hypertension.

Interventions:

1. Advise caution with exertion: Avoid activities that significantly increase blood pressure.
2. Administer medications: Beta-blockers, ACE inhibitors as prescribed.
3. Educate on BP control: Emphasize lifestyle modifications and medication adherence.
4. Emphasize lifestyle modifications: Diet, exercise, smoking cessation for BP management.
5. Assist with stress testing: Evaluate BP response to exercise.

These comprehensive nursing care plans provide a framework for managing patients with CAD, addressing key nursing diagnoses, and promoting optimal patient outcomes. By focusing on thorough assessment, targeted interventions, and patient education, nurses can significantly impact the care and management of individuals with coronary artery disease.