Prevention is the best cure. Nurses play an important role in the treatment of CAD by offering and supplying comfort for anxiety and pain, minimizing symptoms and side effects, educating patients on the disease process, and helping to reduce risks and promote healthier lifestyles. Pathophysiology The heart is supplied blood, oxygen, and nutrients by the coronary arteries. When functioning normally, the coronary arteries ensure adequate oxygenation of the myocardium at all levels of cardiac activity (Klabunde, 2010).
CAD is a heart disease that is caused by impaired blood flow to or through the coronary arteries. Several disorders can arise from the disease ranging from myocardial ischemia to myocardial infarction. Blood flow through the coronary arteries is usually dictated by the heart’s need for oxygen. It is controlled by physical, metabolic and neural factors and uses 60 to 80% of the oxygen in the blood that flows through the coronary arteries (Porth, 2011). When this blood flow is interrupted, damage ensues.
Blood flow can be blocked by atherosclerosis, the buildup of fats and cholesterol in and on the artery walls (plaques) (Mayo Clinic, 2012). These buildups can be either stable and obstruct blood flow or unstable, “which can rupture and cause platelet adhesion and thrombus formation” (Porth, 2011). When the plaques are disrupted and a thrombus is formed, blood flow is obstructed and a myocardial infarction (MI) can occur. This obstruction starves the heart of oxygen and can cause angina (chest pain) and necrosis of the heart muscle.
Risk Factors There are modifiable and non-modifiable risk factors for CAD. Patient teaching should include modifiable risks that can be avoided such as smoking, obesity, uncontrolled hypertension, high LDL levels and low HDL levels, uncontrolled diabetes, high stress, and sedentary lifestyles (Mayo Clinic, 2012). Many of these can be controlled by diet, exercise, and smoking cessation. Non-modifiable risk factor include age, gender (men are more at risk for CAD but women’s risk increases after menopause), and family history.
According to the Mayo Clinic, the patient’s risk is highest if their father or brother was diagnosed with heart disease before age 55, or their mother or sister developed it before age 65. Since these factors cannot be controlled, it is extremely important to control the modifiable ones especially if the patient is at greater risk due to non-modifiable factors. Pathophysiology of MI Myocardial infarctions affect approximately ? million people each year in the US. 50% of the people affected die before reaching the hospital (KU, 2012).
MI is characterized by the ischemic death of myocardial tissue associated with CAD. This occurs when blood flow through the coronary arteries is significantly reduced or blocked and the heart muscle does not receive enough oxygen. A “heart attack” usually has a quick onset with chest pain being the significant symptom due to the lack of oxygen (Porth, 2011). Other symptoms can be fatigue, dyspnea, and heart palpitations. Treatment for CAD The goal in treating CAD is to restore adequate coronary perfusion.
If that is not possible, medications can be used to reduce the oxygen demand by the heart (Klabunde, 2011). Treatment options for CAD include reducing risk factors, use of medications, and surgery. Patients can slow the disease process by stopping smoking, eating healthier, and participating in more active lifestyles.
Medications that can be used are anti-platelets and anticoagulants that dissolve clots, or anti-angina drugs such as beta blockers (decrease myocardial oxygen consumption by decreasing the actions of the sympathetic nervous system), calcium channel blockers (decreases eart rate and strength of contraction and relaxes blood vessels, decreasing blood pressure), or nitroglycerin (dilates the arteries to increase blood flow, reducing myocardial oxygen consumption) (Smeltzer, S. , Hinkle J. , Bare, B. , & Cheever, K. 2010).
Usually cardiac catheterizations are done to determine blockage percentages (Appendix B). In extreme cases of CAD, stents can be implanted within the artery to restore blood flow or bypass grafts can be placed from an artery or vein elsewhere in the body to bypass the diseased segment (Klamunde, 2010). Nursing Diagnoses
CAD can be life threatening if the disease is allowed to progress. Therefore measures should be taken to prevent progression. Proper, thorough assessment and nursing interventions can help. The first priority nursing diagnosis for a patient with CAD would be: Ineffective cardiac tissue perfusion related to reduced coronary blood flow secondary to CAD as evidenced by chest pain, blood pressure of 164/88, and pulse ox of 90% on room air. This is the first priority because if the heart is not properly fed, the pump can fail and will result in inadequate circulation for the whole body which could cause death.
The second priority nursing diagnosis would be: Acute pain related to ischemia secondary to CAD as evidenced by restlessness, increased blood pressure, 143/88, and verbal report of pain in left shoulder and left jaw of 8/10 (on a numeric 1-10 scale) that has been unrelieved by over the counter medications. If pain is not managed, the body systems will continue to respond increasing vasoconstriction which in turn increases BP which could eventually lead to a cardiovascular accident or death.
The third nursing diagnosis for a patient with CAD that is a smoker and has an unhealthy diet is: Risk prone health behavior related to inadequate comprehension of disease process as evidenced by patient smoking ? a pack of cigarettes a day and eating fast food and fried foods regularly. These behaviors are both modifiable risk factors and should be included in the patient teaching. Nursing Goals For the priority nursing diagnosis of Ineffective Cardiac Tissue Perfusion, he goals would be:
Patient will attain adequate tissue perfusion and cellular oxygenation as evidenced by a pulse ox of 96% or above on 2L oxygen by nasal cannula within 8 hours
Patient will verbalize an understanding of the disease process and the therapy regimen by discharge.
The goals for the diagnosis of Acute Pain would be:
Patient will verbally describe the level (using a numeric 1-10 scale) and characteristics of their pain every 2 hours
Patient will report pain goal of <3 on a numeric 1-10 scale is reached within 1 hour of analgesic administration.
The goals for Risk prone health behavior are:
Patient will demonstrate an increasing interest and participation in self health care by beginning a smoking cessation program immediately
By end of shift, patient will list five foods that should be avoided such as fatty cuts of meat, butter, egg yolks, ice cream, and processed grain products (cookies, cakes, muffins, and pastries).
These are all foods that are high in fat and/or cholesterol (Scherer, 2012).
Nursing Implementations and Rationales
Nursing implementations and rationales included in the diagnosis of Ineffective Cardiac Tissue Perfusion to help the patient meet the goals are:
Monitor ABG – low hemoglobin levels reduce the uptake of oxygen and oxygen delivery to the tissues
Monitor vital signs and heart rhythm at beginning of shift and every 4 hours – to determine baseline and detect changes
Collaborate in treatment of underlying conditions such as administering anti-coagulants and oxygen per doctor’s order– to correct or treat disorders that could affect perfusion
Assess self-care history- to identify risks for potential problems
Encourage smoking cessation – smoking decreases oxygen delivery
Auscultate lungs every 4 hours – to check for abnormalities that could represent heart failure
Check pulse ox every 2 hours – to check progression or needs
O2 at 2L nasal cannula per doctor’s orders – improve oxygenation
Encourage use of spirometer every 2 hours – patient is on bed rest, this will encourage deep breathing
Have patient turn every 2 hours – patient is on bed rest, his will help avoid pressure ulcers
Assist in ambulation to toilet – to avoid over-exerting the heart
Check apical pulse and peripheral pulses every 2 hours – to check progression or regression
Explain to patient and family the disease process and therapy regimen for controlling disease – to educate patient and family on disease process and medications. Implementations and rationales for an acute pain diagnosis are:
Have patient state characteristics of pain and level of pain on a numeric 1-10 scale at beginning of shift and every two hours – establishes a baseline for assessing improvement and change and notifies nurse of needs for medications
Administer nitroglycerin tablets 0. mg SL q5minutes X3 per doctor’s orders for chest pain –dilates vessels for better blood flow
1-10 mg Morphine slow IVP, titrate for pain relief per doctor’s orders- to maintain acceptable levels of pain
Accept client’s description of pain – pain is subjective
Observe non-verbal cues – observations may be incongruent with verbal reports
Monitor vital signs - blood pressure, heart rate and respirations are usually altered in acute pain
Determine pain goal and tolerance – varies with individual
Note when pain occurs – to medicate prophylactically as appropriate
Provide comfort measures such as a quiet environment, low lighting, and calm activities - to promote non-pharmacologic pain measures
Evaluate and document patient’s response to medications – check for effectiveness
Encourage adequate rest periods – to prevent fatigue and over-exertion of the heart.
To have a successful outcome for the diagnosis of Risk Prone Health Behavior, implementations and rationales should include:
Encourage immediate smoking cessation – smoking constricts vessels therefore decreasing blood flow
Teach patient about risks associated with smoking and CAD – to educate patient
Supply patient with a low fat/low cholesterol diet, per doctor’s orders – to reduce risk from fat/cholesterol
Educate patient on risks of high fat and cholesterol diets – to educate patient
Teach patients which foods are high in fats and cholesterol – to educate patient.
To evaluate the success of the goals requires assessment and communication. To evaluate the goals for Ineffective Cardiac Tissue Perfusion, the nurse should check pulse ox levels and have the patient verbalize what they know about CAD. If pulse ox has reached 96% or above while on 2L O2 nasal cannula within 8 hours, then the goal has been met. If not, the plan will need to be modified. Patient teaching should begin as soon as the patient is admitted so the second goal of the patient being able to verbalize an adequate understanding of the disease process and therapy regimen should be successful by discharge. This can be judged by having the patient state factors of the disease and proper uses of the medications.
To evaluate the success of Acute Pain goals, documentation should be available for anytime pain is reported (level and characteristics) and when Morphine or Nitroglycerin is given. Anytime a medication is given, there should be documentation of how effective the medication was and if the pain goal was reached. If the documentation is done correctly, it should measure whether the goal was met or not. If pain persists, treatment should be modified. The goals for risk prone health behavior will be assessed by patient’s verbal report of knowledge of high fat/ high cholesterol foods and witnessed increased participation in self health care of patient joining a smoking cessation program.
If the goal would have been total smoking cessation, the goal would have only been partially met by joining a smoking cessation program. Patient and Family Education Patient education is one of the most important facets for a patient with CAD. Accurate patient education about modifiable risk factors (such as smoking, unhealthy diet, and obesity) and immediate treatments can reduce the risks for myocardial infarction. Knowing the risks can help encourage a healthier lifestyle.
Educating patients about the early signs and symptoms of CAD can provide the information needed for knowing when to acquire medical help and may help with an immediate accurate diagnosis and treatment plan being developed and instituted. Patients also need to be educated about he medications that are available and proper use of medications such as Nitroglycerin. Educating the patient can also help reduce anxiety about the disease. (Appendix A). References BCS Heart, (2012). Cardiac Catheterization.
Interventional Cardiology and Cardiovascular Services.
Retrieved October 2, 2012 from BCS website information. http://bcsheart. com/for_patients_patient_education_cardiac_catheterization. php
Gulanick, M., Myers, J. (2011). Cardiac and Vascular Plans. Nursing Care Plans (209). St. Louis, MS: Wiley-Blackwell Publishing. Klabunde, R. (2010). Retrieved October 2, 2012 from Cardiovascular Physiology Concepts. Coronary Artery Disease. http:// www.vphysiology. com/CAD/CAD001.htm
KU Medical Center, (2012). Retrieved October 3, 2012 from KU Medical Center online information, http://classes.kumc. edu/cahe/respcared/cybercas/cabg2/stevmi.html
Mayo Clinic, (2012). Retrieved October 4, 2012. Coronary Artery Disease, http://www. mayoclinic. com/health/arteriosclerosis-atherosclerosis/DS00525 http://www. mayoclinic. com/health/coronary-artery-disease/DS00064/DSECTION=risk-factors National Heart, Lung, and Blood Institute (NHI).
(2011, July). Coronary Artery Disease. Retrieved October 5, 2012. NHI article on MedlinePlus Web site: http://www. nlm. nih. gov/medlineplus/coronaryarterydisease. tml#cat3
Porth, C. M. (2011). Coronary Artery Disease. H. Surrena & S. Loht (Eds. ), Essentials of Pathophysiology (450-461). Philadelphia: Lippincott Williams & Wilkins. Rimmerman, C. (2011). Diseases and Conditions: Coronary Artery Disease. Retrieved October 5, 2012, Cleveland Clinic Web site: http://my. clevelandclinic. org/heart/disorders/cad/understandingcad. aspx
Scherer, E. (2012) Retrieved October 2, 2012 from Discovery Fit and Health online information, http://health. howstuffworks. com/wellness/food-nutrition/facts/foods-high-in-saturated-fat-and-cholesterol. htm
Smeltzer, S. , Hinkle J. , Bare, B. , & Cheever, K. (2010). Coronary