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Nursing Diagnosis Care Plan for Coronary Artery Disease (CAD)

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Coronary Artery Disease (CAD) encompasses conditions that affect the arteries responsible for delivering vital nutrients, blood, and oxygen to the heart muscle. Atherosclerosis, the primary culprit behind CAD, is characterized by the accumulation of lipid deposits within the arterial walls. These plaques lead to the narrowing of arteries, impeding blood flow and significantly elevating the risk of angina and myocardial infarction.

CAD is typically a progressive condition that develops gradually over an extended period. Often, individuals may not experience noticeable symptoms like angina, shortness of breath, and fatigue until the disease has advanced considerably. When the flow of blood through the coronary arteries is significantly reduced or completely blocked, it results in ischemia and infarction of the heart muscle. This insufficient supply of blood and oxygen (ischemia) to the myocardium leads to decreased tissue perfusion and necrosis (infarction), necessitating prompt medical intervention.

In managing CAD, a crucial aspect is modifying risk factors to both prevent and slow down the progression of the disease. Given that symptoms may not always be apparent, identifying individuals at risk of CAD is paramount. Nurses play a vital role in health promotion, focusing on controlling modifiable risk factors for CAD. Educating patients about the disease process, its progression, and the importance of necessary lifestyle adjustments is essential in CAD prevention.

For patients presenting with symptoms such as chest pain or dyspnea, medical or surgical interventions may be required. Medications like aspirin and cholesterol-lowering agents are commonly prescribed to prevent blood clots, heart attacks, and reduce plaque buildup in the arteries. Surgical procedures, including coronary angioplasty and stent placement, may be indicated to remove blockages, widen the arteries, and restore adequate blood flow to the heart. Coronary artery bypass grafting (CABG) is typically considered for patients with multiple severely narrowed arteries.

Nursing Assessment for Coronary Artery Disease

The initial step in providing nursing care is a thorough nursing assessment. This involves gathering comprehensive data encompassing the patient’s physical, psychosocial, emotional, and diagnostic aspects. This section will detail the subjective and objective data pertinent to coronary artery disease.

Reviewing Health History

1. Inquire about General Symptoms. Document the patient’s reported symptoms, such as:

  • Chest pain or discomfort
  • Shortness of breath (dyspnea), both at rest and during exertion
  • Rapid breathing (tachypnea)
  • Difficulty breathing when lying down or sitting (orthopnea)
  • Fainting or lightheadedness (syncope)
  • Heart palpitations
  • Swelling in the lower extremities (edema)
  • Leg pain, especially during activity (claudication)
  • Difficulty performing usual physical activities

2. Deep Dive into Chest Pain Characteristics. If chest pain is reported, explore its characteristics in detail:

  • Describe the sensation: tightness, squeezing, heaviness, burning.
  • Is the pain related to physical activity?
  • Identify triggers: stress, substance use, cold weather, large meals.
  • Does the pain radiate? (jaw, neck, left arm, or back)

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

Non-modifiable Risk Factors:

  • Age: The risk of CAD increases significantly with age as arteries naturally become more prone to damage and narrowing over time.
  • Gender: Men generally have a higher risk of CAD at a younger age. However, women’s risk increases after menopause due to the decrease in estrogen, which has protective effects on blood vessels.
  • Family History: A strong family history of premature ischemic heart disease (before age 55 in male relatives and before age 65 in female relatives) significantly elevates an individual’s risk.
  • Race/Ethnicity: Certain minority groups, including African Americans, Hispanics, and Native Americans, experience a higher incidence of CAD, often linked to socioeconomic factors and disparities in healthcare access.

Modifiable Risk Factors:

  • Hypertension: Uncontrolled high blood pressure puts excessive strain on artery walls, leading to stiffness, rigidity, and accelerated atherosclerosis.
  • Hyperlipidemia/Hypercholesterolemia: Elevated levels of “bad” cholesterol (LDL) and low levels of “good” cholesterol (HDL) contribute directly to plaque formation in arteries.
  • Diabetes Mellitus and Insulin Resistance: Diabetes promotes hardening of blood vessels and the accumulation of fatty plaques, increasing CAD risk substantially.
  • Chronic Kidney Disease: Kidney disease disrupts blood pressure regulation and is frequently associated with other CAD risk factors.
  • Tobacco Use: Smoking, both firsthand and secondhand, is a major CAD risk factor. Nicotine constricts blood vessels, damages the endothelium (inner lining of arteries), and promotes clot formation.
  • Obesity: Excess weight, particularly abdominal obesity, is linked to high cholesterol, high blood pressure, and diabetes, all of which exacerbate CAD.
  • Physical Inactivity: Lack of regular exercise contributes to elevated cholesterol levels, obesity, and poor cardiovascular health.
  • Unhealthy Diet: Diets high in saturated and trans fats, cholesterol, and sodium promote LDL cholesterol elevation and contribute to atherosclerosis.
  • Stress: Chronic stress triggers inflammatory responses in the body, which can damage blood vessels and promote plaque development.
  • Excessive Alcohol Consumption: Heavy alcohol use can weaken the heart muscle (cardiomyopathy) and increase blood pressure.
  • Sleep Deprivation: Insufficient sleep and conditions like insomnia elevate stress hormones and blood pressure, negatively impacting cardiovascular health.

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 Examination

1. Monitor Vital Signs. Changes in vital signs, particularly increased heart rate (tachycardia) and blood pressure, or significant alterations from baseline, can indicate the heart’s response to reduced oxygen supply. Hypotension may also be present in severe cases.

2. Electrocardiogram (EKG) and Telemetry Monitoring. An EKG is crucial for any patient reporting chest pain to immediately assess for arrhythmias or ST-segment changes indicative of ischemia or infarction. Continuous telemetry monitoring is warranted for patients with known cardiac conditions or those at high risk.

3. Systemic Physical Assessment:

  • Neck: Observe for jugular vein distention (JVD), which can indicate heart failure or fluid overload.
  • Central Nervous System (CNS): Assess for signs of reduced cerebral perfusion: acute distress, dizziness, lightheadedness, syncope, lethargy, confusion.
  • Cardiovascular System:
    • Auscultate heart sounds for tachycardia, murmurs (especially at the apex, potentially indicating mitral regurgitation or stenosis), or bruits over the carotid arteries (suggesting carotid artery disease).
    • Palpate for irregular heartbeats (arrhythmias).
    • Evaluate for chest pain upon palpation of the chest wall (to differentiate cardiac from musculoskeletal pain).
  • Peripheral Circulation: Assess peripheral pulses (radial, dorsalis pedis, posterior tibial) for strength and equality. Diminished or absent pulses can indicate reduced peripheral perfusion.
  • Respiratory System:
    • Observe respiratory rate and effort (dyspnea, tachypnea, orthopnea).
    • Auscultate lung sounds for abnormal sounds like crackles (rales), which may indicate pulmonary edema secondary to heart failure.
  • Gastrointestinal System: Assess for nausea and vomiting, which can be associated with myocardial infarction due to vagal nerve stimulation.
  • Lymphatic System: Check for peripheral edema, particularly in the lower extremities, which can be a sign of heart failure.
  • Musculoskeletal System: Inquire about pain in the neck, arm, back, jaw, or upper body, and assess for generalized fatigue.
  • Integumentary System: Observe skin color for pallor (paleness) or cyanosis (bluish discoloration), and assess for diaphoresis (excessive sweating), which can be signs of reduced cardiac output and stress response.

4. Calculate ASCVD Risk Score. Utilize risk calculators, such as the ASCVD (Atherosclerotic Cardiovascular Disease) risk estimator, to quantify the patient’s 10-year risk of cardiovascular events. Factors considered typically include:

  • Age
  • Gender
  • Race
  • Systolic and Diastolic Blood Pressure
  • Total Cholesterol and HDL Cholesterol
  • Use of Statin Medication
  • Presence of Diabetes
  • Smoking Status

Alt text: Healthcare provider uses heart model to educate patient about coronary artery disease, emphasizing prevention and lifestyle changes.

Diagnostic Procedures

1. Arrhythmia Detection. CAD disrupts the heart’s electrical activity due to reduced blood flow, leading to arrhythmias. Monitor ECG readings for:

  • ST-segment changes (elevation or depression), indicating cardiac ischemia or injury.
  • Other arrhythmias such as atrial fibrillation, bundle branch blocks, supraventricular tachycardia, ventricular tachycardia, and heart blocks.

2. Blood Work Analysis. Obtain and analyze blood samples for:

  • Complete Blood Count (CBC) with differential:
    • White Blood Cell (WBC) count: Elevated WBCs may suggest underlying infection or inflammation.
    • Platelet count: Assesses blood clotting ability.
    • Red Blood Cell (RBC) count and Hemoglobin/Hematocrit: Detect anemia, which can exacerbate cardiac ischemia.
  • B-type Natriuretic Peptide (BNP): Elevated BNP levels often indicate volume overload associated with heart failure of cardiac origin. Note that BNP can be falsely elevated in kidney disease and lower in obesity.
  • Cardiac Enzymes (Troponin, Creatine Kinase-MB (CK-MB)): Troponin is highly specific for myocardial damage and is the gold standard for detecting myocardial infarction. CK-MB is another cardiac enzyme that rises with heart muscle injury.
  • Lipid Panel: Measures cholesterol levels (total cholesterol, LDL, HDL, triglycerides) to assess hyperlipidemia risk.
  • High-Sensitivity C-Reactive Protein (hs-CRP) or Ultra-sensitive C-Reactive Protein (us-CRP): Elevated levels indicate vascular inflammation, a key process in atherosclerosis and CAD progression.
  • Liver Function Tests (LFTs): Evaluate liver function, especially important in patients with potential hemochromatosis (iron overload, a rare CAD complication). Also, monitor liver function as statin medications can sometimes affect liver enzymes.

3. Stress Testing. Stress tests evaluate the heart’s response to increased workload and are crucial for non-invasive CAD assessment. Types include:

  • Exercise Stress Test (Treadmill or Bicycle): ECG monitoring during exercise to detect ischemia.
  • Pharmacological Stress Test: For patients unable to exercise, medications like adenosine or dobutamine are used to simulate exercise stress while ECG and imaging are performed.

4. Cardiac Catheterization (Angiogram). This invasive procedure is the gold standard for visualizing coronary arteries. A catheter is inserted into an artery (usually femoral or radial) and guided to the heart. Contrast dye is injected to visualize blockages or narrowings under fluoroscopy.

5. Further Investigations. Additional diagnostic tools include:

  • Echocardiogram: Ultrasound imaging of the heart to assess heart structure, valve function, and ejection fraction (heart’s pumping efficiency). Can identify wall motion abnormalities suggestive of ischemia or infarction.
  • Nuclear Stress Test (Myocardial Perfusion Imaging): Combines stress testing with radioactive tracer injection to visualize blood flow to the heart muscle at rest and during stress. Detects areas of reduced blood flow (ischemia).
  • Stress Echocardiography: Echocardiogram performed before and immediately after exercise or pharmacological stress to assess for wall motion abnormalities indicating ischemia.
  • Cardiac Computed Tomography (CT) Scans:
    • Calcium Score CT: Measures calcium buildup in coronary arteries, a marker of atherosclerosis.
    • CT Coronary Angiography (CTCA): Uses contrast dye to provide detailed images of coronary arteries, similar to invasive angiography but less invasive.

Nursing Interventions for Coronary Artery Disease

Nursing interventions are crucial in managing CAD, focusing on promoting perfusion, symptom management, cardiac rehabilitation, risk reduction, and ensuring patient safety.

Promoting Myocardial Perfusion

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

  • Statins: (e.g., atorvastatin, simvastatin) Primary drugs to lower LDL cholesterol.
  • Fibrates: (e.g., gemfibrozil, fenofibrate) Primarily lower triglycerides and raise HDL cholesterol.
  • Niacin (Nicotinic Acid): Can lower LDL and triglycerides and raise HDL, but with significant side effects (flushing).
  • Bile Acid Sequestrants: (e.g., cholestyramine, colesevelam) Lower LDL cholesterol by binding bile acids in the gut.
  • Cholesterol Absorption Inhibitors: (e.g., ezetimibe) Reduce cholesterol absorption in the small intestine.
  • PCSK9 Inhibitors: (e.g., alirocumab, evolocumab) Potent LDL-lowering agents, typically used for high-risk patients.

2. Prevent Thrombus (Blood Clot) Formation. Administer antiplatelet and anticoagulant medications as ordered:

  • Aspirin: Low-dose aspirin (75-162 mg daily) is often recommended for primary and secondary prevention of CAD events due to its antiplatelet effects.
  • P2Y12 Inhibitors: (e.g., clopidogrel, ticagrelor, prasugrel) More potent antiplatelet agents, often used after PCI or in acute coronary syndromes.
  • Anticoagulants: (e.g., heparin, enoxaparin, warfarin, direct oral anticoagulants (DOACs)) May be used in specific CAD situations like atrial fibrillation or post-MI with high thromboembolic risk.

3. Revascularize Blocked Arteries. Prepare patients for and provide post-procedure care for revascularization procedures:

  • Percutaneous Coronary Intervention (PCI) – Coronary Angioplasty and Stent Placement: A minimally invasive procedure to open blocked coronary arteries. A balloon catheter is inflated to widen the artery, and a stent (mesh tube) is typically deployed to maintain patency.
  • Coronary Artery Bypass Grafting (CABG): Open-heart surgery to bypass blocked arteries using grafts from other blood vessels (e.g., saphenous vein, internal mammary artery). Indicated for multi-vessel CAD or left main coronary artery stenosis.

4. Monitor Lipid Profiles Regularly. Routine monitoring of cholesterol and lipid levels is essential to assess treatment effectiveness and adjust medications as needed.

Managing CAD Symptoms

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

  • Beta-blockers: (e.g., metoprolol, atenolol) Reduce heart rate and contractility, lowering blood pressure and myocardial oxygen demand.
  • Calcium Channel Blockers: (e.g., amlodipine, diltiazem) Relax blood vessels and reduce heart rate, effective for angina and hypertension, especially when beta-blockers are contraindicated.
  • Angiotensin-Converting Enzyme (ACE) Inhibitors: (e.g., lisinopril, enalapril) Block the renin-angiotensin-aldosterone system, lowering blood pressure and providing cardioprotective effects.
  • Angiotensin II Receptor Blockers (ARBs): (e.g., losartan, valsartan) Similar to ACE inhibitors, used when ACE inhibitors are not tolerated.
  • Diuretics: (e.g., hydrochlorothiazide, furosemide) Reduce fluid volume, lowering blood pressure.

2. Chest Pain (Angina) Relief. Manage angina with medications and lifestyle advice:

  • Nitroglycerin: Sublingual nitroglycerin for acute angina relief. Dilates coronary arteries and reduces preload. Educate patients on proper use, storage, and potential side effects (headache, hypotension). Long-acting nitrates (isosorbide mononitrate, isosorbide dinitrate) for angina prevention.
  • Ranolazine: Anti-anginal medication that can be used for chronic angina, often in combination with other anti-anginal drugs.

3. Angina Trigger Identification. Educate patients to identify and avoid angina triggers:

  • Physical exertion
  • Emotional stress
  • Cold weather
  • Heavy meals
  • Smoking
  • Caffeine
  • Sudden temperature changes

4. Ischemic Angina Management. Treat chronic stable angina comprehensively:

  • Combination therapy often involves:
    • Antianginals (Nitrates, Beta-blockers, Calcium channel blockers, Ranolazine)
    • Antiplatelets (Aspirin, P2Y12 inhibitors)
    • Lipid-lowering medications (Statins)
    • Blood pressure medications (ACE inhibitors, ARBs, Beta-blockers, Calcium channel blockers)

5. Maintain Optimal Blood Pressure. Target blood pressure goals for CAD patients are generally <140/90 mmHg, but individual targets may vary based on comorbidities and risk factors. Be cautious with diastolic blood pressure <60 mmHg, as it can sometimes worsen angina in CAD patients.

Cardiac Rehabilitation

1. Cardiac Rehabilitation Program Adherence. Encourage and support patient participation in cardiac rehabilitation programs. These programs provide structured exercise, education, and support tailored to individual needs.

2. Prevent Complications and Readmission. Emphasize the role of cardiac rehab in improving recovery, reducing the risk of future cardiac events, and lowering hospital readmission rates.

3. Home and Community-Based Cardiac Rehab Referral. Facilitate transition to home-based or community-based cardiac rehabilitation programs post-discharge to ensure continuity of care.

4. Patient Motivation and Adherence. Motivate patients to actively engage in and adhere to all aspects of their cardiac rehabilitation plan for optimal outcomes. Highlight the benefits of cardiac rehab in improving exercise capacity, quality of life, and long-term survival.

Risk Factor Modification and Prevention

1. Promote Regular Physical Activity. Advise patients to engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week, along with muscle-strengthening activities at least two days a week.

2. Achieve and Maintain a Healthy Body Weight. Encourage weight loss if overweight or obese to achieve a BMI in the healthy range (18.5-24.9 kg/m²).

3. Patient Education. Provide comprehensive education on CAD, risk factors, medications, lifestyle modifications, and warning signs. Emphasize patient-centered care and shared decision-making.

4. Stress Management Techniques. Educate patients on stress-reduction techniques:

  • Relaxation techniques (deep breathing, meditation, yoga, guided imagery)
  • Mindfulness practices
  • Time management
  • Healthy coping mechanisms
  • Seeking social support

5. Comorbidity Management. Aggressively manage co-existing conditions like diabetes, hypertension, hyperlipidemia, and kidney disease, as they significantly impact CAD progression.

6. Recognize and Respond to Warning Signs. Educate patients on recognizing symptoms requiring immediate medical attention:

  • New onset or worsening chest pain (angina)
  • Chest pain not relieved by nitroglycerin
  • Shortness of breath
  • Palpitations
  • Dizziness or syncope
  • Symptoms of stroke (sudden weakness, numbness, speech difficulty)

7. Lifestyle Modifications. Reinforce the importance of long-term lifestyle changes:

  • Heart-healthy diet (low in saturated and trans fats, cholesterol, sodium, and added sugars; rich in fruits, vegetables, whole grains, lean protein)
  • Smoking cessation (provide resources and support)
  • Avoidance of secondhand smoke
  • Moderate alcohol intake (if any)
  • Stress management
  • Treatment of depression and anxiety

8. Omega-3 Fatty Acids. Discuss the potential benefits of omega-3 fatty acids from fish or supplements in reducing inflammation and improving lipid profiles.

9. Alternative Medicine Considerations. Advise patients to discuss any herbal supplements or alternative therapies with their healthcare provider due to potential interactions with prescribed medications. Some herbs (garlic, barley, oats, psyllium) may have mild cholesterol-lowering effects, but evidence is limited, and they are not a substitute for conventional treatment.

10. Regular Cardiologist Follow-up. Emphasize the importance of regular follow-up appointments with a cardiologist, typically every 3-6 months for established CAD, and adherence to recommended testing and blood work.

Ensuring Patient Safety

1. Caution with Anticoagulants and Antiplatelets. Be vigilant about the increased bleeding risk associated with medications like aspirin, clopidogrel, warfarin, and DOACs.

2. Implement Bleeding Precautions. Educate patients on bleeding precautions:

  • Use soft-bristled toothbrushes
  • Use electric razors
  • Avoid forceful nose blowing
  • Prevent constipation and straining during bowel movements
  • Avoid contact sports and activities with high injury risk
  • Report any signs of unusual bleeding or bruising

3. Medical Identification. Advise patients to wear medical identification (bracelet or necklace) indicating their CAD diagnosis, medications (especially anticoagulants), and allergies, so emergency responders are aware of their condition.

Nursing Care Plans for Coronary Artery Disease

Nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term care goals for patients with CAD. Here are examples of nursing diagnosis care plans for coronary artery disease.

Nursing Care Plan: Acute Pain

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

Defining Characteristics:

  • Reports of chest pain or tightness (angina), varying in duration, frequency, and intensity.
  • Diaphoresis (sweating).
  • Distraction behaviors (restlessness, moaning).
  • Facial grimacing.
  • Guarding or protective posture.
  • Positioning to minimize pain.
  • Altered vital signs (increased heart rate, blood pressure).

Expected Outcomes:

  • Patient will report pain reduction or relief to a tolerable level within a specified timeframe (e.g., within 30 minutes of intervention).
  • Patient will verbalize understanding of angina triggers and appropriate actions to take when chest pain occurs, including when to seek emergency medical assistance.
  • Patient will demonstrate non-pharmacological pain management techniques.

Nursing Assessments:

  1. Monitor Vital Signs: Assess heart rate, blood pressure, respiratory rate, and oxygen saturation. Rationale: Vital sign changes (tachycardia, hypertension initially, potentially hypotension and bradycardia with worsening cardiac output) are indicators of pain and physiological stress.

  2. Pain Assessment (PQRST): Evaluate pain characteristics thoroughly:

    • Provoking factors: What triggers the pain? (exertion, stress, rest?)
    • Quality: Describe the pain (sharp, dull, pressure, squeezing, burning).
    • Radiation: Does the pain radiate to other areas (jaw, arm, back)?
    • Severity: Pain scale rating (0-10).
    • Timing: Onset, duration, frequency of pain episodes.
      Rationale: Detailed pain assessment helps differentiate angina from other pain sources and monitor pain response to interventions. Unstable angina is characterized by more intense, unpredictable, and prolonged pain, less responsive to rest or nitroglycerin compared to stable angina.

  3. Review Diagnostic Studies: Examine ECG results and cardiac enzyme levels. Rationale: ECG changes (ST-segment depression or T-wave inversion during angina; ST-elevation, non-ST-elevation, or Q waves with infarction) and elevated cardiac enzymes (troponin, CK-MB) provide objective data about myocardial ischemia or infarction.

Nursing Interventions:

  1. Administer Oxygen Therapy: Apply supplemental oxygen as needed to maintain SpO2 > 90%. Rationale: Supplemental oxygen increases oxygen availability to the myocardium, reducing ischemia and pain. Oxygen is only indicated if SpO2 is below normal limits.

  2. Medication Administration: Administer prescribed medications promptly:

    • Nitroglycerin (sublingual, IV, topical): Rationale: Dilates coronary arteries, increasing blood flow and reducing preload and afterload, thus decreasing myocardial oxygen demand.
    • Morphine Sulfate (IV): Rationale: Provides analgesia, reduces anxiety, promotes vasodilation, and decreases myocardial oxygen demand.
    • Beta-blockers (oral or IV): Rationale: Reduce heart rate and contractility, decreasing myocardial workload and oxygen demand.

  3. Positioning: Elevate the head of the bed to a semi-Fowler’s or high-Fowler’s position. Rationale: Promotes chest expansion, reduces preload, and eases breathing, decreasing myocardial oxygen demand.

  4. Environment Management: Create a calm and restful environment. Rationale: Reduces anxiety and stress, which can exacerbate chest pain and increase myocardial workload. Minimize noise and interruptions.

  5. Patient Education on Angina Triggers and Management. Help the patient identify personal angina triggers and strategies to avoid them. Teach them to stop activity and rest if chest pain occurs and when to seek medical attention (if pain is unrelieved by rest and nitroglycerin, or if symptoms worsen). Rationale: Empowers patients to manage their condition effectively and seek timely help when needed.

Nursing Care Plan: Anxiety

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

Defining Characteristics:

  • Verbalization of distress, worry, and insecurity.
  • Awareness of physiological symptoms (palpitations, shortness of breath).
  • Feelings of helplessness and fear.
  • Heart pounding or racing.
  • Nausea.
  • Fear of death or serious illness.
  • Physiologic manifestations: altered respiratory pattern, facial flushing, increased blood pressure, increased heart rate, diaphoresis.

Expected Outcomes:

  • Patient will verbalize recognition of anxiety feelings and identify healthy coping mechanisms.
  • Patient will demonstrate at least two effective relaxation techniques to manage anxiety.
  • Patient will report a reduction in anxiety to a manageable level (e.g., anxiety scale rating decreases by 2 points).

Nursing Assessments:

  1. Assess Anxiety Level: Use a standardized anxiety scale (e.g., GAD-7, visual analog scale) to quantify anxiety. Rationale: Provides a baseline and allows for monitoring anxiety levels over time and in response to interventions.

  2. Monitor Vital Signs: Track heart rate, blood pressure, and respiratory rate. Rationale: Differentiate between physiological responses to anxiety versus cardiac events. Both can manifest with tachycardia, diaphoresis, and hyperventilation. However, context and other assessment findings are crucial.

  3. Identify Stressors: Explore potential stressors contributing to anxiety: diagnosis of CAD, chest pain, fear of the unknown, hospitalization, changes in lifestyle. Rationale: Understanding the root causes of anxiety enables targeted interventions.

Nursing Interventions:

  1. Encourage Expression of Feelings: Provide a safe and supportive environment for the patient to verbalize fears and concerns. Actively listen and validate their feelings. Rationale: Unexpressed emotions can intensify anxiety. Open communication facilitates emotional processing and reduces feelings of isolation.

  2. Provide Reassurance and Emotional Support. Offer calm reassurance and empathy. Explain procedures and treatments clearly and honestly. Rationale: Reduces uncertainty and fear, fostering a sense of security and trust. A calm demeanor can be contagious and help reduce patient anxiety.

  3. Administer Anxiolytic Medications (if prescribed). Administer benzodiazepines (e.g., alprazolam, lorazepam) or other anxiolytics as ordered by the physician. Rationale: Medications can provide temporary relief from acute anxiety, allowing the patient to engage in coping strategies and learn relaxation techniques. Use judiciously and in conjunction with non-pharmacological methods.

  4. Provide Accurate Information and Education. Educate the patient about CAD, treatment plan, prognosis, and self-management strategies. Address misconceptions and provide reliable information. Rationale: Knowledge reduces fear of the unknown and empowers patients to take an active role in their care. Accurate information can dispel inaccurate beliefs that contribute to anxiety.

  5. Teach Relaxation Techniques: Instruct and encourage the patient to practice relaxation techniques:

    • Deep breathing exercises
    • Progressive muscle relaxation
    • Meditation or mindfulness
    • Guided imagery
    • Music therapy
    • Aromatherapy
      Rationale: These techniques promote physiological relaxation, reduce sympathetic nervous system activity, and provide patients with self-management tools to cope with anxiety.

  6. Promote Coping Skills: Help the patient identify and utilize effective coping mechanisms they have used in the past. Encourage positive self-talk and problem-solving strategies. Rationale: Strengthens resilience and self-efficacy in managing anxiety-provoking situations.

  7. Referral to Support Services: Consider referral to counseling, therapy, support groups, or chaplaincy services as needed. Rationale: Provides access to specialized professional support for managing anxiety and emotional distress, particularly for patients experiencing significant or persistent anxiety.

Nursing Care Plan: Decreased Cardiac Output

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

Defining Characteristics:

  • Tachycardia or bradycardia.
  • ECG changes (arrhythmias, ST-segment changes).
  • Angina.
  • Activity intolerance.
  • Fatigue.
  • Restlessness, anxiety, confusion.
  • Hypotension or hypertension.
  • Dyspnea, orthopnea, cough.
  • Peripheral edema, jugular vein distention.
  • Decreased peripheral pulses, cool and clammy skin.
  • Decreased urine output.

Expected Outcomes:

  • Patient will maintain adequate cardiac output as evidenced by stable vital signs, absence of chest pain or dyspnea at rest, palpable peripheral pulses, and appropriate urine output.
  • Patient will participate in activities that reduce cardiac workload within their tolerance level.
  • Patient will verbalize understanding of factors that affect cardiac output and strategies to optimize it.

Nursing Assessments:

  1. Assess Heart Rate, Rhythm, and Blood Pressure: Monitor apical pulse, peripheral pulses, ECG rhythm, and blood pressure regularly (frequency depends on patient stability). Rationale: Tachycardia is an initial compensatory response to decreased cardiac output; bradycardia can occur with severe ischemia or heart block. Hypotension indicates severely compromised cardiac output. Arrhythmias can further impair cardiac output.

  2. Auscultate Heart and Breath Sounds: Listen for abnormal heart sounds (murmurs, gallops [S3, S4]), and lung sounds (crackles, wheezes). Rationale: Gallops and murmurs can indicate valve dysfunction or heart failure. Crackles suggest pulmonary edema due to left ventricular failure.

  3. Assess Peripheral Perfusion: Evaluate skin color, temperature, capillary refill, peripheral pulses (strength and equality), and presence of edema. Rationale: Reduced cardiac output leads to decreased peripheral circulation, manifesting as pallor, cyanosis, cool skin, delayed capillary refill, diminished pulses, and edema.

  4. Monitor for Signs of Decreased Tissue Perfusion: Assess for changes in level of consciousness (restlessness, confusion, lethargy), dizziness, syncope, decreased urine output, and angina. Rationale: These signs indicate inadequate oxygen delivery to vital organs due to reduced cardiac output.

  5. Review Hemodynamic Monitoring (if applicable): Monitor central venous pressure (CVP), pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), and cardiac output/cardiac index (CO/CI). Rationale: Provides direct measures of cardiac function and fluid status in critically ill patients.

Nursing Interventions:

  1. Promote Rest and Reduce Cardiac Workload: Schedule rest periods between activities. Assist with activities of daily living (ADLs) as needed. Limit strenuous activities and emotional stress. Rationale: Rest reduces myocardial oxygen demand and workload, conserving energy and minimizing cardiac strain. Activities should be paced to prevent overexertion.

  2. Positioning: Position the patient in semi-Fowler’s or high-Fowler’s position unless contraindicated. Elevate legs slightly if edema is present. Rationale: Promotes venous return, reduces preload, and eases breathing. Leg elevation helps reduce peripheral edema.

  3. Fluid Management: Monitor fluid balance closely (intake and output, daily weights, edema assessment). Administer intravenous fluids cautiously as prescribed, avoiding fluid overload. Restrict sodium intake as ordered. Rationale: Maintaining optimal fluid balance is crucial for cardiac output. Both fluid deficit and overload can compromise cardiac function. Sodium restriction helps prevent fluid retention.

  4. Medication Administration: Administer medications as prescribed to improve cardiac output:

    • Inotropic agents (e.g., digoxin, dobutamine, dopamine): Rationale: Increase myocardial contractility, enhancing stroke volume and cardiac output.
    • Vasodilators (e.g., nitroglycerin, nitroprusside): Rationale: Reduce afterload and preload, decreasing cardiac workload and improving cardiac output in some situations.
    • Diuretics (e.g., furosemide, bumetanide): Rationale: Reduce fluid volume overload, decreasing preload and pulmonary congestion.
    • Antiarrhythmics (e.g., amiodarone, metoprolol): Rationale: Treat or prevent arrhythmias that impair cardiac output.

  5. Monitor ECG Continuously: Continuously monitor ECG for arrhythmias and ST-segment changes. Report significant changes promptly. Rationale: Early detection and treatment of arrhythmias are essential to maintain cardiac output and prevent complications.

  6. Prepare for Diagnostic and Therapeutic Procedures: Prepare the patient for echocardiography, cardiac catheterization, PCI, or CABG as indicated. Provide pre- and post-procedure care. Rationale: Diagnostic procedures help identify the underlying cause of decreased cardiac output. Therapeutic procedures aim to improve myocardial perfusion and cardiac function.

  7. Patient Education on Self-Management: Educate the patient about:

    • Medications (purpose, dosage, side effects, adherence)
    • Diet (sodium restriction, heart-healthy diet)
    • Activity limitations and pacing
    • Warning signs and symptoms to report to healthcare provider
    • Importance of regular follow-up appointments
      Rationale: Empowers patients to actively participate in their care and optimize cardiac output at home.

Nursing Care Plan: Ineffective Peripheral Tissue Perfusion

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to plaque formation, narrowed or obstructed arteries, and decreased cardiac output secondary to CAD.

Defining Characteristics:

  • Decreased or absent peripheral pulses (radial, dorsalis pedis, posterior tibial).
  • Cool or cold extremities.
  • Pallor or cyanosis of extremities.
  • Prolonged capillary refill time (>3 seconds).
  • Edema in extremities.
  • Pain in lower extremities (claudication, rest pain).
  • Numbness or tingling in extremities.
  • Skin changes (thin, shiny skin; hair loss; thick nails; ulceration; delayed wound healing).
  • Decreased blood pressure in affected limbs (measured by ankle-brachial index).
  • Restlessness, changes in level of consciousness (in severe cases of global hypoperfusion).

Expected Outcomes:

  • Patient will demonstrate improved peripheral tissue perfusion as evidenced by palpable peripheral pulses, warm and dry extremities, normal skin color, capillary refill time < 3 seconds, and absence of edema or pain in extremities.
  • Patient will maintain an alert and oriented level of consciousness.
  • Patient will verbalize understanding of factors that improve peripheral circulation and strategies to promote tissue perfusion.

Nursing Assessments:

  1. Vascular Assessment: Assess peripheral pulses (rate, rhythm, quality) in all extremities bilaterally. Use Doppler ultrasound if pulses are weak or impalpable. Rationale: Diminished or absent pulses indicate reduced arterial blood flow to the periphery.

  2. Skin Assessment: Evaluate skin color (pallor, cyanosis, rubor), temperature (coolness or coldness), moisture (dry or clammy), and integrity (presence of ulcers, lesions). Rationale: Changes in skin color and temperature reflect reduced blood flow and oxygenation. Skin breakdown is a risk with chronic ischemia.

  3. Capillary Refill Time: Assess capillary refill in nail beds of fingers and toes. Rationale: Prolonged capillary refill (>3 seconds) indicates poor peripheral perfusion.

  4. Edema Assessment: Check for peripheral edema, particularly in lower extremities. Grade edema if present (1+ to 4+). Rationale: Edema can be associated with both arterial and venous insufficiency, but in the context of CAD, it may indicate heart failure contributing to poor peripheral perfusion.

  5. Pain Assessment: Assess for leg pain, including claudication (pain with activity, relieved by rest) and rest pain (pain at rest, often worse at night). Characterize pain (location, intensity, quality, aggravating/relieving factors). Rationale: Claudication and rest pain are hallmark symptoms of peripheral artery disease and indicate ischemic pain due to insufficient blood flow.

  6. Ankle-Brachial Index (ABI): Measure systolic blood pressure in the brachial artery and both dorsalis pedis and posterior tibial arteries. Calculate ABI (ankle SBP / brachial SBP). Rationale: ABI is a non-invasive test to quantify the degree of peripheral artery disease. An ABI < 0.9 is abnormal and indicates peripheral artery disease.

  7. Neurological Assessment: Assess level of consciousness, orientation, and presence of neurological deficits. Rationale: In severe cases of global hypoperfusion, cerebral tissue perfusion may be compromised, leading to changes in mental status.

Nursing Interventions:

  1. Positioning: Position the patient to promote arterial blood flow to extremities. Avoid crossing legs or prolonged sitting. Elevate legs slightly when sitting to promote venous return (unless contraindicated in severe arterial insufficiency). Rationale: Proper positioning can optimize blood flow and reduce venous stasis. Crossing legs and prolonged sitting can impede circulation.

  2. Temperature Management: Keep patient warm and avoid exposure to cold temperatures. Provide warm blankets and socks. Rationale: Cold temperatures cause vasoconstriction, further reducing peripheral blood flow. Warmth promotes vasodilation.

  3. Promote Circulation:

    • Encourage regular, moderate exercise (walking, cycling) as tolerated, after medical clearance. Rationale: Exercise improves collateral circulation and overall cardiovascular health.
    • Instruct on active and passive range-of-motion (ROM) exercises, especially for lower extremities. Rationale: ROM exercises prevent venous stasis and promote blood flow.
    • Advise against constrictive clothing or stockings. Rationale: Constrictive clothing can impede circulation.

  4. Smoking Cessation: Strongly advise and assist with smoking cessation. Provide resources and support. Rationale: Nicotine is a potent vasoconstrictor and damages blood vessels, severely impairing peripheral circulation. Smoking cessation is critical for improving tissue perfusion.

  5. Medication Administration: Administer medications as prescribed to improve blood flow:

    • Vasodilators (e.g., cilostazol, pentoxifylline): Rationale: Cilostazol is a phosphodiesterase inhibitor that improves walking distance in patients with claudication by vasodilation and antiplatelet effects. Pentoxifylline improves red blood cell flexibility and blood flow.
    • Antiplatelet agents (e.g., aspirin, clopidogrel): Rationale: Reduce platelet aggregation and thrombus formation, improving blood flow.
    • Anticoagulants (e.g., heparin, warfarin, DOACs) – may be used in specific situations like acute arterial occlusion. Rationale: Prevent clot propagation and allow for improved blood flow.

  6. Skin Care: Provide meticulous skin care to prevent skin breakdown and infection, especially in lower extremities. Keep skin clean and dry. Apply moisturizing lotion to prevent dryness and cracking. Protect from injury. Rationale: Ischemic tissues are vulnerable to injury and infection. Good skin care is essential to prevent complications.

  7. Foot Care Education: Educate patients on proper foot care:

    • Inspect feet daily for any cuts, blisters, redness, or swelling.
    • Wash feet daily with mild soap and lukewarm water. Dry thoroughly, especially between toes.
    • Apply moisturizing lotion (avoiding between toes).
    • Wear comfortable, well-fitting shoes and socks.
    • Avoid walking barefoot.
    • Trim toenails straight across or seek podiatry care.
    • Avoid soaking feet in hot water.
    • Seek immediate medical attention for any foot injuries or signs of infection.
      Rationale: Proper foot care is crucial to prevent complications in patients with peripheral vascular disease. Even minor injuries can become serious in the presence of poor circulation.

  8. Referral to Vascular Specialist or Cardiac Rehabilitation: Refer to a vascular specialist for further evaluation and management if needed. Refer to cardiac rehabilitation for exercise training and risk factor modification. Rationale: Specialized care may be required for advanced peripheral artery disease. Cardiac rehabilitation programs can improve exercise tolerance and overall cardiovascular health.

Nursing Care Plan: 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 associated with CAD.

Defining Characteristics:

A risk nursing diagnosis does not have defining characteristics as the problem has not yet occurred. The goal of interventions is prevention.

Risk Factors (Related Factors):

  • Plaque formation in coronary arteries.
  • Narrowed or blocked coronary arteries.
  • Coronary artery vasospasm.
  • Ineffective cardiac muscle contraction (ischemia-induced myocardial dysfunction).
  • Conditions compromising blood supply to the heart (CAD itself).
  • Increased cardiac workload.
  • Inadequate blood supply to the heart muscle.
  • Inability of the heart muscle to contract and relax effectively.
  • Underlying hypertension, diabetes, hyperlipidemia, obesity, smoking, stress, sedentary lifestyle.

Expected Outcomes:

  • Patient will maintain blood pressure within prescribed parameters (individualized based on patient’s condition and physician orders).
  • Patient will remain asymptomatic of unstable blood pressure (no dizziness, syncope, angina, stroke symptoms).
  • Patient will verbalize understanding of factors contributing to unstable blood pressure and strategies for blood pressure management.
  • Patient will demonstrate lifestyle modifications to promote blood pressure control.

Nursing Assessments:

  1. Monitor Blood Pressure Regularly: Assess blood pressure in both arms in supine, sitting, and standing positions initially and at regular intervals (as per patient’s condition and unit protocol). Note postural changes (orthostatic hypotension). Rationale: Frequent blood pressure monitoring detects trends and fluctuations. Orthostatic hypotension is common in patients with cardiovascular disease and medication side effects.

  2. Assess for Signs and Symptoms of Unstable Blood Pressure: Monitor for dizziness, lightheadedness, syncope, angina, palpitations, headache, visual changes, fatigue, and stroke symptoms (weakness, numbness, speech difficulty). Rationale: These symptoms can indicate hypotension or hypertension or fluctuations in blood pressure.

  3. Identify Risk Factors for Unstable Blood Pressure: Review patient’s medical history, medications, lifestyle factors, and lab results to identify modifiable and non-modifiable risk factors for hypertension and hypotension. Rationale: Identifying risk factors guides targeted interventions and patient education.

  4. Assess Medication History: Review current medications, including antihypertensives, diuretics, vasodilators, inotropes, and any medications that can affect blood pressure (e.g., some antidepressants, decongestants, NSAIDs). Rationale: Medications can be a primary cause or contributing factor to unstable blood pressure.

  5. Evaluate Lifestyle Factors: Assess diet (sodium intake, caffeine, alcohol), smoking status, physical activity level, stress levels, and sleep patterns. Rationale: Lifestyle factors significantly impact blood pressure control.

Nursing Interventions:

  1. Administer Antihypertensive Medications as Prescribed: Administer antihypertensive medications (ACE inhibitors, ARBs, beta-blockers, calcium channel blockers, diuretics) as ordered and monitor for effectiveness and side effects (hypotension, dizziness, bradycardia, electrolyte imbalances). Rationale: Medications are often necessary to manage hypertension and reduce cardiovascular risk. Adherence and monitoring for side effects are crucial.

  2. Educate on Blood Pressure Control: Provide comprehensive patient education on:

    • Importance of blood pressure control in managing CAD and preventing complications (stroke, heart attack, kidney disease).
    • Target blood pressure goals and individualization.
    • Medications (purpose, dosage, administration, side effects, importance of adherence).
    • Lifestyle modifications (diet, exercise, weight management, smoking cessation, stress reduction).
    • How to monitor blood pressure at home (if appropriate), proper technique, and when to report readings.
    • Warning signs and symptoms of hypo- and hypertension and when to seek medical attention. Rationale: Empowered patients are more likely to adhere to treatment plans and achieve blood pressure control. Education should be tailored to the patient’s understanding and needs.

  3. Promote Lifestyle Modifications: Reinforce and support lifestyle changes:

    • Dietary Modifications: Recommend a heart-healthy diet (DASH diet or Mediterranean diet) low in sodium, saturated and trans fats, and cholesterol; rich in fruits, vegetables, whole grains, and lean protein. Advise on reducing caffeine and alcohol intake. Rationale: Dietary changes are fundamental for long-term blood pressure management.
    • Regular Exercise: Encourage regular physical activity (at least 150 minutes of moderate-intensity aerobic exercise per week). Rationale: Exercise lowers blood pressure and improves cardiovascular health.
    • Weight Management: Assist with weight loss if overweight or obese. Rationale: Weight loss significantly reduces blood pressure in overweight individuals.
    • Stress Reduction Techniques: Teach and encourage stress management techniques (relaxation exercises, mindfulness, yoga, meditation). Rationale: Stress contributes to hypertension and can make blood pressure control more challenging.
    • Smoking Cessation: Provide strong encouragement and support for smoking cessation. Rationale: Smoking elevates blood pressure and increases cardiovascular risk.
    • Limit Alcohol Intake: Advise limiting alcohol consumption to recommended guidelines (if any). Rationale: Excessive alcohol intake can raise blood pressure.

  4. Prevent Orthostatic Hypotension: Implement measures to prevent orthostatic hypotension:

    • Advise patient to change positions slowly, especially from lying to sitting or standing.
    • Instruct patient to sit at the edge of the bed for a few minutes before standing.
    • Encourage adequate hydration.
    • Advise patient to avoid prolonged standing or sitting.
    • Assess for dizziness or lightheadedness when changing position.
    • Monitor blood pressure in different positions.
    • Consult with physician about adjusting medications if orthostatic hypotension is persistent or symptomatic. Rationale: Orthostatic hypotension can cause falls and injuries, especially in older adults and those taking antihypertensive medications.

  5. Monitor for and Manage Hypotension: If hypotension occurs, assess for cause (medications, dehydration, bleeding, cardiac dysfunction). Implement measures to raise blood pressure as ordered (IV fluids, Trendelenburg position, vasopressors if severe). Rationale: Hypotension can compromise tissue perfusion and lead to dizziness, syncope, and organ damage.

  6. Monitor for and Manage Hypertension: If hypertension is present or worsening, assess for contributing factors (pain, anxiety, fluid overload, medication non-adherence). Administer antihypertensive medications as ordered and monitor response. Rationale: Uncontrolled hypertension increases cardiac workload and risk of cardiovascular events.

  7. Assist with Stress Testing: Prepare patient for and assist with stress testing (exercise or pharmacological stress test) as ordered to evaluate blood pressure response to exertion and identify exertional hypertension or hypotension. Rationale: Stress testing can reveal abnormal blood pressure responses to activity and guide management.

By implementing these comprehensive nursing care plans, nurses can effectively address the diverse needs of patients with coronary artery disease, promoting optimal health outcomes and quality of life.

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