Coronary Artery Disease Nursing Diagnosis: A Comprehensive Guide

Coronary Artery Disease (CAD) stands as a prevalent heart condition, significantly impacting global health. It arises when the arteries supplying blood, oxygen, and vital nutrients to your heart become compromised. This article delves into the essential aspects of CAD, focusing on nursing diagnosis, a critical component in patient care. As a dedicated resource for automotive diagnostics at xentrydiagnosis.store, we understand the importance of expert knowledge and precise interventions. Similarly, in healthcare, accurate diagnosis and tailored care are paramount, especially in managing conditions like CAD.

Understanding Coronary Artery Disease

Coronary Artery Disease (CAD), often referred to as heart disease, is primarily caused by atherosclerosis. This condition involves the buildup of plaques composed of cholesterol, fats, and other substances within the artery walls. Over time, these plaques harden and narrow the coronary arteries. This narrowing reduces blood flow to the heart muscle, a condition known as ischemia. This diminished blood supply can lead to a range of complications, from chest pain (angina) to heart attack (myocardial infarction).

Alt text: Illustration depicting atherosclerosis, showing plaque buildup narrowing a coronary artery, a key factor in coronary artery disease.

CAD is a progressive disease, often developing silently over many years. Individuals may be unaware of their condition until significant narrowing has occurred, and symptoms manifest. These symptoms can include angina, shortness of breath (dyspnea), and unexplained fatigue, particularly during physical exertion. In critical situations, complete or near-complete blockage of coronary arteries can result in myocardial ischemia and infarction, necessitating immediate medical intervention to restore blood flow and minimize heart muscle damage.

Nursing Process in CAD Management

Effective management of CAD hinges on a structured nursing process, beginning with a thorough assessment to identify individuals at risk and those experiencing symptoms. Nurses play a pivotal role in health promotion, focusing on modifiable risk factors to prevent or slow the progression of CAD. Patient education is crucial, empowering individuals to understand the disease process and adopt necessary lifestyle modifications.

For patients exhibiting symptoms like chest pain or dyspnea, nursing interventions extend to medication administration and preparing patients for surgical interventions. Medications such as aspirin and cholesterol-lowering agents are commonly prescribed. Surgical options like coronary angioplasty, stent placement, and coronary artery bypass grafting (CABG) are considered for patients requiring more invasive treatments to restore adequate blood flow to the heart.

Nursing Assessment for Coronary Artery Disease

The cornerstone of effective nursing care for CAD is a comprehensive nursing assessment. This process involves gathering subjective and objective data across physical, psychosocial, emotional, and diagnostic domains.

Review of Health History: Subjective Data

Obtaining a detailed health history is crucial for identifying potential CAD and associated risk factors.

1. General Symptom Inquiry: Begin by asking the patient about any general symptoms they may be experiencing. Key symptoms to note include:

• Chest pain: Characterize location, intensity, duration, and provoking/relieving factors.
• Shortness of breath (dyspnea): Assess onset, duration, severity, and relation to activity or rest.
• Rapid breathing (tachypnea): Observe respiratory rate and depth.
• Difficulty breathing while lying or sitting (orthopnea): Determine the number of pillows needed for comfortable breathing.
• Fainting (syncope): Inquire about preceding symptoms and circumstances surrounding fainting episodes.
• Palpitations: Ask about the frequency, duration, and triggers of heart palpitations.
• Lower extremity edema: Assess for swelling in ankles, feet, and legs, noting severity and timing.
• Lower extremity pain: Investigate location, character, and factors that exacerbate or relieve the pain.
• Difficulty performing physical activities: Evaluate limitations in daily activities due to cardiac symptoms.

2. Detailed Chest Pain Investigation: If the patient reports chest pain, delve deeper into its characteristics:

• Description: Is it tightness, squeezing, heaviness, or burning?
• Location: Where is the pain located? Does it radiate?
• Triggers: Is it associated with physical activity, stress, cold weather, or eating?
• Radiation: Does the pain extend to the jaw, neck, left arm, or back?
• Duration: How long does the pain typically last?
• Relieving factors: Does rest or nitroglycerin alleviate the pain?

3. Risk Factor Assessment: Thoroughly evaluate both non-modifiable and modifiable risk factors for CAD:

• Non-modifiable Risk Factors:

  • Age: Risk increases significantly with age, particularly after 45 for men and 55 for women.
  • Gender: Men generally have a higher risk until women reach menopause, after which their risk increases.
  • Family history: A strong family history of early heart disease (before age 55 in male relatives and 65 in female relatives) significantly elevates risk.
  • Race/Ethnicity: Certain minority groups, including African Americans and Hispanics, experience a higher incidence of CAD.

• Modifiable Risk Factors:

  • Hypertension: Uncontrolled high blood pressure damages arteries and accelerates atherosclerosis.
  • Hyperlipidemia/Hypercholesterolemia: High LDL (“bad”) cholesterol and low HDL (“good”) cholesterol levels contribute to plaque formation.
  • Diabetes Mellitus: Diabetes significantly increases CAD risk by damaging blood vessels and promoting plaque buildup.
  • Insulin Resistance: Often precedes type 2 diabetes and contributes to similar vascular damage.
  • Chronic Kidney Disease: Impaired kidney function disrupts blood pressure regulation and increases cardiovascular risk.
  • Tobacco Use: Smoking in any form severely damages blood vessels, promoting constriction and plaque formation.
  • Obesity: Excess body weight, especially abdominal obesity, contributes to high cholesterol, high blood pressure, and diabetes.
  • Physical Inactivity: Lack of regular exercise worsens cholesterol profiles and increases overall cardiovascular risk.
  • Unhealthy Diet: Diets high in saturated and trans fats, cholesterol, and sodium elevate LDL cholesterol and blood pressure.
  • Stress: Chronic stress contributes to inflammation and blood vessel constriction.
  • Excessive Alcohol Use: Heavy alcohol consumption can weaken the heart muscle and increase blood pressure.
  • Lack of Sleep: Insufficient sleep or poor sleep quality increases stress hormones and blood pressure.

4. Medication and Treatment History Review: Document all current medications, including over-the-counter drugs and supplements. Certain medications, such as anthracyclines and anabolic steroids, and a history of vascular surgery can impact blood vessel integrity and increase CAD risk.

Physical Assessment: Objective Data

A comprehensive physical examination provides crucial objective data.

1. Vital Signs Monitoring: Monitor vital signs closely. In CAD, expect potential alterations such as:

• Elevated or decreased heart rate: Tachycardia or bradycardia may be present.
• Elevated or decreased blood pressure: Hypertension or hypotension can occur depending on the stage and severity of CAD and compensatory mechanisms.
• Increased respiratory rate: Tachypnea may indicate respiratory distress secondary to cardiac issues.
• Oxygen saturation: Monitor for hypoxemia.

2. EKG and Telemetry Monitoring:

• Electrocardiogram (EKG): Obtain an EKG immediately for any patient reporting chest pain to assess for arrhythmias, ST-segment changes, or other ischemic indicators.
• Telemetry Monitoring: Continuous telemetry monitoring is essential for patients with known or suspected CAD, especially during hospitalization or acute episodes.

3. Systemic Assessment: Conduct a systematic head-to-toe assessment, focusing on cardiovascular and related systems:

• Neck: Observe for jugular venous distention (JVD), indicating fluid overload and potential heart failure.
• Central Nervous System (CNS): Assess for:
  • Acute distress: Anxiety, restlessness, agitation.
  • Dizziness, lightheadedness, syncope: May indicate decreased cerebral perfusion.
  • Lethargy: Suggests reduced cardiac output and systemic perfusion.
• Cardiovascular:
  • Heart rate and rhythm: Auscultate for tachycardia, bradycardia, or irregular rhythms (arrhythmias).
  • Heart sounds: Listen for abnormal heart sounds like murmurs (especially at the apex, suggesting mitral regurgitation) or bruits over the carotid arteries, indicating turbulent blood flow and potential atherosclerosis.
  • Chest pain: Observe for signs of chest pain, even if nonverbal (e.g., guarding, grimacing).
• Circulatory:
  • Peripheral pulses: Palpate and compare pulses in all extremities, noting any diminished or absent pulses, which indicate impaired peripheral circulation.
• Respiratory:
  • Respiratory rate and pattern: Assess for dyspnea, tachypnea, and orthopnea.
  • Breath sounds: Auscultate lungs for abnormal sounds like crackles (rales), indicating pulmonary edema, a sign of heart failure.
  • Activity intolerance: Observe for shortness of breath or fatigue with minimal exertion.
• Gastrointestinal:
  • Nausea and vomiting: Can be associated with pain, anxiety, or reduced cardiac output.
• Lymphatic:
  • Peripheral edema: Assess for edema in the extremities, noting location, severity, and pitting.
• Musculoskeletal:
  • Pain: Inquire about pain in the neck, arm, back, jaw, or upper body, which can be referred cardiac pain.
  • Fatigue: Evaluate the severity and impact of fatigue on daily life.
• Integumentary:
  • Skin color: Observe for pallor (paleness) or cyanosis (bluish discoloration), indicating poor perfusion and oxygenation.
  • Excessive sweating (diaphoresis): May be associated with pain, anxiety, or reduced cardiac output.
  • Skin temperature: Assess for cold and clammy skin, indicative of poor peripheral perfusion.

4. ASCVD Risk Score Calculation: Calculate the patient’s 10-year ASCVD (Atherosclerotic Cardiovascular Disease) risk score using online calculators or clinical tools. This score estimates the risk of heart attack or stroke in the next 10 years and is based on factors such as:

• Age
• Gender
• Race
• Blood pressure
• Cholesterol levels (total and HDL)
• Medication use (e.g., statins)
• Diabetes status
• Smoking status

An ideal ASCVD risk score is considered low (<7.5%). Higher scores indicate increased risk and guide treatment strategies.

Diagnostic Procedures

Various diagnostic procedures aid in confirming CAD and assessing its severity.

1. Arrhythmia Detection (EKG/Holter Monitoring): CAD can disrupt the heart’s electrical activity, leading to arrhythmias.

• EKG: Look for ST-segment changes (elevation or depression), T-wave inversions, or Q waves, which may indicate ischemia or infarction.
• Holter monitor: 24-48 hour continuous EKG monitoring to detect intermittent arrhythmias not captured on a standard EKG. Common arrhythmias in CAD include atrial fibrillation, bundle branch blocks, and supraventricular tachycardia.

2. Blood Work Analysis: Specific blood tests provide valuable information:

• Complete Blood Count with Differential (CBC with diff):
  • White Blood Cell count (WBC): Elevated WBC may suggest an underlying infection or inflammatory process.
  • Platelet count: Assesses blood clotting ability.
  • Red Blood Cell count (RBC) and Hemoglobin/Hematocrit: Detects anemia, which can exacerbate cardiac ischemia.
• B-type Natriuretic Peptide (BNP): Elevated BNP levels indicate volume overload and potential heart failure of cardiac origin. Note that BNP can be falsely elevated in kidney disease and lower in obese individuals.
• Cardiac Enzymes (Troponin, CK-MB): Troponin and CK-MB levels are crucial for detecting acute myocardial ischemia and infarction. Elevated levels indicate heart muscle damage.
• Lipid Panel: Measures cholesterol levels (total cholesterol, LDL, HDL, triglycerides) to monitor hypercholesterolemia and guide lipid-lowering therapy.
• Ultra-sensitive C-reactive protein (us-CRP) or High-sensitivity CRP (hs-CRP): Elevated hs-CRP levels indicate vascular inflammation, a significant risk factor for CAD.
• Liver Function Tests (LFTs): Evaluate liver function, especially important as liver disease and hemochromatosis (iron overload, a CAD complication) can affect both liver and heart. Also, monitor liver function in patients taking cholesterol-lowering medications, as some can affect the liver.

3. Stress Testing: Stress testing evaluates the heart’s response to physical exertion, helping to identify ischemia.

• Exercise Stress Test (Treadmill): The most common type, involving walking on a treadmill while EKG, heart rate, and blood pressure are monitored.
• Pharmacological Stress Test: Used for patients unable to exercise, medications are used to simulate the effects of exercise on the heart.

4. Cardiac Catheterization (Angiogram): Considered the “gold standard” for visualizing coronary arteries.

• An invasive procedure where a catheter is inserted into an artery (usually femoral or radial) and guided to the coronary arteries. Contrast dye is injected to visualize blockages or narrowing on X-ray.
• Risks include bleeding, infection, allergic reaction to contrast dye, and rarely, stroke or heart attack.

5. Further Investigations:

• Echocardiogram: Uses ultrasound to visualize heart structure and function, assessing valve function, heart muscle strength, and identifying structural abnormalities or heart failure.
• Nuclear Stress Test: Combines stress testing with nuclear imaging to assess blood flow to the heart muscle at rest and during stress, identifying areas of ischemia.
• Stress Imaging (Dobutamine Stress Echocardiogram): For patients unable to exercise or with difficult-to-interpret EKGs. Dobutamine medication is used to stress the heart, and echocardiography assesses heart wall motion.
• Cardiac CT Scans: Non-invasive imaging to detect calcium buildup in coronary arteries (calcium score) and identify blockages.
• CT Coronary Angiogram (CTCA): A more detailed CT scan using contrast dye to visualize coronary arteries, similar to cardiac catheterization but less invasive.

Nursing Interventions for Coronary Artery Disease

Nursing interventions are crucial for managing CAD, promoting patient recovery, and preventing disease progression.

Promoting Perfusion

1. Reduce Cholesterol Plaque Buildup: Administer cholesterol-lowering medications as prescribed.

• Statins: Primary drugs for lowering LDL cholesterol and reducing plaque formation.
• Fibrates, Niacin, Bile Acid Sequestrants: May be used in combination with statins or as alternatives depending on lipid profile and patient tolerance.

2. Prevent Blood Clots: Implement strategies to prevent thrombus formation.

• Aspirin Therapy: Low-dose aspirin is often prescribed for primary and secondary prevention of CAD due to its antiplatelet effect.
• Anticoagulant Medications: May be indicated in specific situations to further reduce clot risk.

3. Address Blocked Arteries: Prepare and care for patients undergoing revascularization procedures.

• Coronary Angioplasty and Stent Placement (Percutaneous Coronary Intervention – PCI): A minimally invasive procedure to open blocked arteries using a balloon catheter and placing a stent to maintain patency.
• Coronary Artery Bypass Graft Surgery (CABG): A surgical procedure to bypass blocked arteries using grafts from other blood vessels (e.g., leg veins or mammary artery). Indicated for multi-vessel CAD or complex lesions.

4. Monitor Cholesterol Levels: Regularly monitor lipid profiles to assess medication effectiveness and adherence to therapy.

Managing Symptoms

1. Control Blood Pressure: Administer antihypertensive medications as ordered.

• Beta-blockers: Reduce heart rate and blood pressure, decreasing myocardial workload.
• Calcium Channel Blockers: May be used if beta-blockers are contraindicated or ineffective.
• Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs): Lower blood pressure and provide cardioprotective effects.

2. Relieve Chest Pain (Angina): Manage angina episodes promptly.

• Nitroglycerin: Administer sublingually or intravenously as prescribed to dilate coronary arteries and relieve chest pain. Educate patients on proper nitroglycerin use and storage.

3. Identify Angina Triggers: Educate patients to recognize and avoid angina triggers. Common triggers include:

• Physical exertion
• Emotional stress
• Cold weather
• Heavy meals

4. Manage Ischemic Angina: Administer medications for chronic angina management.

• Ranolazine: An antianginal medication often used in combination with other cardiac medications.

5. Maintain Recommended Blood Pressure: Educate patients on target blood pressure goals and the importance of adherence to antihypertensive therapy. For CAD patients, blood pressure should ideally be maintained below 140/90 mmHg. Exercise caution with diastolic blood pressure below 60 mmHg, as it can worsen angina in some individuals.

Cardiac Rehabilitation

1. Cardiac Rehabilitation Program Adherence: Encourage and support patient participation in cardiac rehabilitation programs.

• Cardiac rehab is a structured program involving exercise training, education, and counseling tailored to individual patient needs.

2. Prevent Complications and Readmissions: Emphasize the role of cardiac rehab in reducing the risk of complications, improving functional capacity, and preventing hospital readmissions.

3. Home and Community Health Services Referral: Facilitate transition to home-based or community-based cardiac rehabilitation programs post-discharge.

4. Patient Motivation and Adherence: Motivate patients to actively participate in and adhere to all aspects of their cardiac rehabilitation plan to maximize benefits and improve long-term outcomes.

Lowering Risk: Prevention Measures

1. Promote Ambulation and Physical Activity: Encourage regular exercise. Recommend at least 150 minutes of moderate-intensity aerobic exercise per week, including strength training.

2. Achieve and Maintain Ideal BMI: Educate patients on the benefits of weight management. Weight loss can improve blood pressure, cholesterol levels, and metabolic health.

3. Patient Education: Provide comprehensive education on CAD, risk factors, lifestyle modifications, medications, and self-management strategies. Effective education enhances medication adherence and promotes patient-centered care.

4. Stress Management: Teach stress reduction techniques. Techniques like yoga, meditation, deep breathing exercises, and guided imagery can help manage stress and reduce its impact on cardiovascular health.

5. Manage Comorbidities: Emphasize the importance of managing co-existing conditions like diabetes, hypertension, and kidney disease. Effective comorbidity management improves overall health and CAD outcomes.

6. Recognize When to Seek Medical Attention: Educate patients on recognizing symptoms requiring immediate medical attention, such as:

• Chest pain unrelieved by rest or nitroglycerin
• Symptoms of heart attack or stroke

7. Lifestyle Modifications: Counsel patients on essential lifestyle changes:

• 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
• Moderate alcohol intake (if any)
• Stress management
• Management of depression and anxiety

8. Omega-3 Fatty Acids: Discuss the potential benefits of omega-3 fatty acids. Sources include fatty fish, flaxseeds, soybeans, and fish oil supplements. Omega-3s may reduce inflammation and improve lipid profiles.

9. Alternative Medicine Considerations: Advise caution and consultation with healthcare providers before using herbal supplements. Some herbs, like garlic, barley, oats, and psyllium, are purported to have cholesterol-lowering effects, but evidence is variable, and interactions with medications are possible.

10. Cardiologist Follow-Up: Emphasize the importance of regular follow-up appointments with a cardiologist and routine testing to monitor CAD progression and treatment effectiveness. Typically recommended every 3-6 months for diagnosed CAD patients.

Providing Safety

1. Caution with Blood Thinners: If patients are on anticoagulant therapy, educate them about the increased risk of bleeding and necessary precautions.

2. Implement Bleeding Precautions: Educate patients on bleeding precautions to minimize injury risk:

• 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 injury risk.

3. Medical Identification: Recommend wearing medical identification (bracelet, necklace, or ID tag) indicating CAD diagnosis, anticoagulant use (if applicable), and risk of heart attack or stroke.

Coronary Artery Disease Nursing Diagnoses and Care Plans

Nursing diagnoses provide a framework for individualized care planning. Common nursing diagnoses for CAD include:

Acute Pain

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

As evidenced by:

• Reports of chest pain or tightness (varying duration, frequency, intensity)
• Diaphoresis
• Distraction behavior (restlessness, moaning)
• Facial grimace, guarding behavior
• Positioning to ease pain
• Altered vital signs (tachycardia, hypertension, tachypnea)

Expected Outcomes:

• Patient will report pain relief or reduction to a tolerable level within a specified timeframe.
• Patient will verbalize understanding of angina triggers and appropriate actions during chest pain episodes, including when to seek emergency care.

Assessments:

1. Monitor vital signs: Assess for changes (tachycardia, hypertension initially, potentially hypotension and bradycardia with worsening cardiac output).
2. Assess pain characteristics (PQRST): Provoking factors, Quality, Region/Radiation, Severity, Timing. Differentiate angina from other chest pain causes (e.g., musculoskeletal, gastrointestinal). Unstable angina is more severe, unpredictable, and less responsive to rest or nitroglycerin than stable angina.
3. Review diagnostic studies: EKG findings (ST depression, T-wave inversion during angina; ST-elevation, non-ST-elevation, Q waves in infarction).

Interventions:

1. Administer supplemental oxygen: Maintain SpO2 ≥ 90%. Administer oxygen judiciously, only if saturation is below target, as unnecessary oxygen can be harmful.
2. Administer medications promptly: Nitroglycerin (vasodilator), morphine sulfate (pain relief, reduces myocardial oxygen demand), beta-blockers (reduce cardiac workload).
3. Elevate head of bed: Promotes comfort, reduces myocardial oxygen demand, and facilitates gas exchange.
4. Maintain quiet, comfortable environment: Reduces anxiety and myocardial workload.
5. Help patient identify and avoid triggers: Educate on common angina triggers (exertion, stress, cold) and encourage activity modification.

Anxiety

Nursing Diagnosis: Anxiety related to situational crisis (cardiac event), pain, underlying pathophysiological response, and threat to health status.

As evidenced by:

• Expression of distress, worry, insecurity
• Awareness of physiological symptoms (palpitations, shortness of breath)
• Feelings of helplessness, fear of death
• Heart pounding, nausea
• Physiological manifestations: altered respiratory pattern, facial flushing, increased BP, increased HR, diaphoresis

Expected Outcomes:

• Patient will verbalize recognition of anxiety and healthy coping mechanisms.
• Patient will demonstrate relaxation techniques.
• Patient will report reduced anxiety to a manageable level.

Assessments:

1. Assess stress levels: Use anxiety scales if appropriate. Identify stressors.
2. Monitor vital signs: Differentiate between physiological responses to anxiety vs. cardiac condition (both can cause tachycardia, diaphoresis, hyperventilation).

Interventions:

1. Encourage expression of feelings: Provide a safe space for patients to verbalize fears and concerns.
2. Provide reassurance: Reassure patient of safety and care being provided. Maintain a calm and supportive presence.
3. Administer anxiolytics as prescribed: Benzodiazepines (e.g., alprazolam) may be used short-term to manage acute anxiety.
4. Provide accurate information: Educate patient about CAD, treatment plan, and prognosis to reduce uncertainty and fear.
5. Teach coping and relaxation techniques: Breathing exercises, meditation, distraction, positive self-talk, guided imagery.

Decreased Cardiac Output

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

As evidenced by:

• Tachycardia, EKG changes (arrhythmias)
• Angina
• Activity intolerance, fatigue
• Restlessness, altered mental status
• Dyspnea, orthopnea
• Peripheral edema
• Weak peripheral pulses

Expected Outcomes:

• Patient will report reduced angina, dyspnea, and arrhythmias.
• Patient will participate in activities that reduce cardiac workload.
• Patient will maintain adequate cardiac output as evidenced by stable vital signs, palpable peripheral pulses, and absence of edema.

Assessments:

1. Assess heart rate, BP, cardiac rhythm: Monitor for tachycardia, bradycardia, arrhythmias, hypotension, hypertension.
2. Assess breath and heart sounds: Crackles in lungs (pulmonary edema), abnormal heart sounds (gallop rhythm – S3 or S4), murmurs.
3. Assess skin color and pulses: Pallor, cyanosis, diminished peripheral pulses indicate reduced cardiac output and peripheral perfusion.

Interventions:

1. Provide adequate rest periods: Reduce myocardial oxygen demand and workload.
2. Avoid Valsalva maneuver: Instruct patients to avoid straining during bowel movements as it can impair cardiac output.
3. Administer medications as prescribed: Inotropes (e.g., digoxin) to increase contractility, diuretics to reduce fluid overload, antiarrhythmics to manage rhythm disturbances.
4. Prepare for diagnostic tests/procedures: Echocardiogram, cardiac catheterization to assess cardiac function and coronary arteries.

Ineffective Tissue Perfusion (Peripheral, Cardiopulmonary, Cerebral)

Nursing Diagnosis: Ineffective Tissue Perfusion (specify type: Peripheral, Cardiopulmonary, Cerebral, etc.) related to plaque formation, narrowed/obstructed arteries, and decreased cardiac output.

As evidenced by:

• Decreased blood pressure (hypotension) or hypertension
• Decreased or absent peripheral pulses
• Increased central venous pressure (CVP) (in fluid overload)
• Tachycardia, dysrhythmias
• Decreased oxygen saturation (SpO2)
• Chest pain (angina), dyspnea, orthopnea, tachypnea
• Altered level of consciousness, restlessness, fatigue
• Activity intolerance
• Cold, clammy skin; prolonged capillary refill
• Pallor or cyanosis
• Edema
• Claudication, numbness, pain in lower extremities

Expected Outcomes:

• Patient will demonstrate palpable peripheral pulses and capillary refill time within normal limits.
• Patient will exhibit warm, dry skin without edema.
• Patient will maintain alert and oriented level of consciousness.
• Patient will report reduced symptoms of ischemia (angina, claudication).

Assessments:

1. Assess vascularization status: Evaluate peripheral pulses, skin color, temperature, capillary refill, presence of edema, wounds, or ulcers.
2. Calculate Ankle-Brachial Index (ABI): Ratio of ankle systolic BP to brachial systolic BP to assess for peripheral artery disease.
3. Assess skin color, capillary refill, sensation: Note edema, ulceration, wound healing, skin color/temperature, hair loss, nail changes, pulses, pain, sensation changes, claudication.
4. Use Doppler ultrasound: Assess blood flow in peripheral arteries, especially lower extremities.

Interventions:

1. Administer vasodilators: Nitroglycerin, hydralazine, calcium channel blockers as prescribed to improve blood flow.
2. Prepare for surgical procedures: PCI, CABG to restore blood flow.
3. Initiate aspirin therapy: As prescribed, for antiplatelet effect.
4. Educate on mobility and activity: Avoid prolonged sitting, leg crossing, constrictive clothing. Encourage ROM exercises, ambulation as tolerated, leg elevation when sitting.
5. Refer to cardiac rehabilitation: For risk factor modification, exercise training, and education.

Risk for Unstable Blood Pressure

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

As evidenced by:

• (Risk diagnoses are not evidenced by signs and symptoms because the problem has not yet occurred. Evidence is the presence of risk factors.)

Risk Factors (Related to):

• Plaque formation, narrowed/blocked arteries
• Coronary vasospasm
• Ineffective cardiac muscle contraction
• Conditions compromising blood supply
• Increased cardiac workload
• Inadequate myocardial blood supply
• Inability of heart muscle to contract/relax effectively

Expected Outcomes:

• Patient will maintain blood pressure within prescribed parameters.
• Patient will tolerate positional changes (sitting, standing) without significant BP fluctuations.
• Patient will not experience complications of unstable blood pressure (myocardial ischemia, cerebrovascular accident).

Assessments:

1. Track blood pressure trends: Monitor for hypertension, hypotension, orthostatic hypotension.
2. Assess for symptoms of unstable BP: Angina, dyspnea, fatigue, dizziness, lightheadedness.
3. Determine risk factors for unstable BP: Hypertension, diabetes, obesity, smoking, sedentary lifestyle, high-sodium diet, excessive alcohol intake.
4. Assess body fat distribution: Excess abdominal fat increases hypertension risk.

Interventions:

1. Advise caution with exertion: Instruct patients to avoid strenuous activities that may excessively elevate BP.
2. Administer antihypertensive medications: Beta-blockers, ACE inhibitors, ARBs, diuretics as prescribed to manage blood pressure.
3. Educate on blood pressure control: Emphasize the importance of medication adherence, lifestyle modifications, and regular BP monitoring.
4. Emphasize lifestyle modifications: Diet (DASH diet), exercise, weight management, smoking cessation, stress reduction, limiting alcohol intake.
5. Assist with stress testing: Monitor BP response to exercise to identify exertional hypotension or hypertension.

References

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