Coronary Artery Disease

Priority #1 Priority #4
Key Problem / ND: Ineffective tissue Key Problem / ND: Noncompliance
perfusion related to blood flow
interruption Ineffective self-health management
related to patient refusing to adhere to
Supporting data: medication regimen as evidence by
statements from the patient.
Angina Supporting data:
Dyspnea
REASON FOR NEEDING HEALTH CARE
Fatigue Statements of refusing
Nausea Medical Diagnosis: Coronary Artery medication regimen by patient
Vomiting Comments regarding inability to
Disease
Fever pay for prescriptions
Tachypnea Co-morbidities: Hyperlipidemia

Key Assessments:

Angina
Dyspnea
Priority #2 Fatigue Priority #3
Key Problem / ND: Pain related to an Nausea Key Problem / ND: Anxiety related to
imbalance between myocardial oxygen Vomiting pain and fear of dying as evidence by
Fever
supply and demand. patients statements of I am scared I am
Tachypnea
going to die.
Statements of refusing
Supporting Data: medication regimen by patient
Supporting data:
Statements of fear of dying
Angina Statements of fear of dying
Dyspnea Dyspnea
Fatigue Angina
Nausea Key Assessments: Tachypnea
Vomiting Nausea
Fever
Tachypnea
Problem #1: Ineffective tissue perfusion related to blood flow interruption.
General Goal: Patient will maintain adequate tissue perfusion to vital organs.
Predictive Behavior Outcome Objective(s):The patient will have adequate blood flow through the coronary vasculature to maintain heart function within 4 to 6 hours.
Interventions Outcomes Rationale
1) Recommended by the American College of
1) Patient will verbalize increased comfort and less
1) Aspirin Therapy Cardiology and the AHA to inhibit platelet aggregation
pressure and oxygenation/tissue perfusion will increase
and vasoconstriction, decreasing risk of thrombosis.
2) Using fibrinolytics dissolves thrombin in coronary
2) Patient will verbalize increased comfort and less arteries and restores myocardial blood flow. Most
2) Thrombolytic Therapy
cardiac pressure sensation effective when delivered within the first six hours of a
coronary event.
3) Prevent fibrinogen from attaching to activated
3) Blood flow through coronary vasculature will be platelets at the site of thrombus. Maintains patency of
3)Glycoprotein IIb/IIIa inhibitors
adequate to maintain heart function artery after MI and for transluminal coronary
angioplasty.
4) A CAD patient is expected to tolerate walking 200
4) Patient will verbalize understanding of physical feet four times per day without chest discomfort or
4) Plan a program of cardiac rehabilitation with physical therapy as important part of cardiac rehab and will shortness of breath. Helps patient achieve and
therapy and patient participation willingly participate and adhere to planning and maintain a vital and productive life while remaining
implementation of program within the limits of the hearts ability to respond to
increases in activity and stress.
Evaluation: Patient will demonstrate functional or baseline ejection fraction, pulmonary wedge pressure, cardiac biomarkers, apical heart rate and systolic and diastolic
blood pressure as well as participation in rehabilitation planning and implementation before discharge.

Problem #2: Pain related to an imbalance between myocardial oxygen supply and demand.
General Goal:Patient will express markedly diminished or complete relief of pain and tightness in chest within HCP designated time specifications.
Predictive Behavior Outcome Objective(s): With pain relief measures, patient will describe/show no symptoms of pain or respiratory distress and vital signs will remain
stable and within acceptable ranges.
Interventions Outcomes Rationale
1) Maintain oxygen saturation of 95% and tissue
1) Administer 2-4 L oxygen via nasal cannula and teach 1) Patient will show balanced levels of oxygen perfusion which is threatened by Coronary Artery
patient to take several deep breaths when needed to saturation and tissue perfusion shortly after Disease. Evidence based practice determines that pain
increase oxygenation administration of oxygen will be markedly diminished with balanced oxygen
supply and demand.
2) Increases collateral blood flow, redistributes blood
2) Patient will show decreased anxiety levels due to flow toward the subendocardium and dilates the
2) Administer Nitroglycerin to relieve episodic angina
pressure and oxygen deprivation as well as some pain coronary arteries while decreasing myocardial oxygen
pain
relief demand by peripheral vasodilation to decrease preload
and afterload pressures.
 3) Patient will verbalize pain levels of less than 4/10 3) Management of pain in patients with MI increases
3) Administer morphine per HCP orders within 15 minutes of administration of medication oxygen supply and decreases myocardial oxygen
which will alleviate imbalances due to hyperventilation demand. Morphine relaxes smooth muscle and reduces
and anxiety regarding painful episode circulating catecholamines.

4) Often enhances comfort and tissue oxygenation to

4) Place patient in semi-fowlers position while offering
4) Patient will rest and present a calm demeanor be in semi-fowlers position. Relaxed environment
a quiet, calm environment to reduce anxiety.
reduces anxiety and ultimately pain.

Evaluation:Patient states that pain is relieved or below a 4/10 consistently with stable vital signs andspo2 levels before discharge.

Problem #3:#: Anxiety related to pain and fear of dying as evidence by patients statements of I am scared I am going to die

General Goal:Will have vital signs that reflect baseline or decreased sympathetic nervous system
1. Predictive Behavior Outcome Objective(s):The patient will identify, verbalize, and demonstrate techniques to control anxiety before discharge.

Interventions Outcomes Rationale

1) Assess patients level of anxiety and physical 1) Anxiety is a risk factor for major cardiac events in
1) Patient will discuss topics contributing to anxiety and
reactions to anxiety (using the Hamilton scale). verbalize understanding of healthy processes to persons with stable coronary artery disease.
alleviate stress
2) Information is empowering and reduces anxiety, also
2) Teach the client to identify signs of anxiety. 2) Patient will verbalize s/s leading to onset of anxiety
and explain actions which would decrease negative it can help the patient identify when she is anxious.
effects of stress/anxiety on patient
3) Teach client techniques and coping 3) Teaching relaxation techniques and coping
mechanisms to reduce anxiety (music, muscle mechanisms can help manage side effects with self-
3) Patient will demonstrate chosen techniques for self
relaxation techniques, relaxation breathing, care behaviors.
relaxation several times throughout the day
etc.).

4) These resources can help the patient manage and/or

4) Teach patient use of appropriate community 4) Patient will identify one support option to participate
reduce anxiety by sharing similar experiences and
resources in upon discharge
limitations with others

Evaluation: Patient has identified ways to relax when anxiety manifests and has contacted support groups within residential area.
 Problem #4: Ineffective self-health management related to patient refusing to adhere to medication regimen as evidence by statements from the
patient.

General Goal: Inform patient about medication regimen and the importance of adhering to medication schedule and dosages.
Predictive Behavior Outcome Objective(s):The patient will be informed about medications, their mode of action, and the benefits of taking them before discharge and
verbalize understanding
Interventions Outcomes Rationale
1) Assess patients context and meaning of 1) Improved symptom management and client
illness. 1) Client will explain pathophysiology of CAD in own satisfaction were noted as a result of interventions that
words and what this means to patient lifestyle focused on the needs of the client and the meaning and
perspective of their illness.
2) Teach patient about medications, their mode 2) The patient is more likely to adhere to her
of transmission, and how the directly assist 2) Patient will explain understanding of the purpose of medication regimen if she understands why she is
her throughout her disease process. each medication and the way that it helps relieve taking the medications and how they work.
etiology and discomfort of disease process

3) Coaching clients using telephone follow-up by expert

nurses and allied care professionals has proven
3) Use coaching methods such as telephone follow-up
3) Patient will willingly agree to discuss successes and effective in improving symptom management,
to reinforce learning. failures and understanding of shared management with increasing self-efficiency, and increasing client
health care coach on a routine basis satisfaction.

4) Advocating for the clients participation using a

4) Help the client appropriate follow-up resources for 4) Patient understands complications of unemployment community-based case management program has
continuing information and support. due to disability and identifies community office demonstrated improved clinical and financial outcomes
dedicated to assist and implement alternatives for for clients with complex chronic conditions.
financial and clinical assistance through social services

th
References: Understanding Pathophysiology, 4 edition, Huether, McCance, Brashers, Rote, 2008; Mosbys Nursing Drug Reference.
Pathophysiology of current illness:

Arteries that supply the myocardium are diseased and the heart cannot pump blood effectively to adequately perfuse vital organs and
peripheral tissues. The organs and tissues need oxygen in arterial blood for survival. When oxygenation and perfusion are impaired, the patient
can have life-threatening clinical manifestations and possible death. CAD includes chronic stable angina and acute coronary syndromes.
Ischemia and infarction of the myocardium may result from the blockage of blood, oxygen, and nutrients to the myocardial tissue.

Related health history assessment questions:

When did your symptoms first occur?

How long do symptoms last?

What is the location of your pain? Does it radiate to other areas?

Can you describe the pain?

Do you feel short of breath? Palpitations?

What alleviates/worsens symptoms?

MODIFIABLE RISK FACTORS

Do you smoke tobacco? How often? How long have you been a smoker?

Do you consume alcohol? How often? How much?

Does anyone in your household smoke tobacco?

Are you exposed to second hand smoke?

PHYSICAL ACTIVITY

Do you currently participate in physical exercise?

What type? How often? How long is each exercise session and how long have you participated in physical exercise?
OTHER FACTORS

Do have a history of hypertension?

Do you have or have you ever been diagnosed with diabetes mellitus?

Do you encounter daily stressors: at work or in your personal life?

What type of work do you do?

What are your hobbies?