CAUSES

·       Atherosclerosis: The main cause of CAD. It involves lipid deposits within artery walls, forming plaques that narrow the arteries and obstruct blood flow

RISK

·       Increased Risk: Plaques in the arteries raise the likelihood of angina (chest pain) and myocardial infarction (heart attack)

PROGRESSION

·       Slow Development: CAD develops gradually over time and may not show symptoms until advanced.

·       Symptoms: Angina, shortness of breath, and fatigue are common symptoms once the disease progresses.

COMPLICATIONS

·       Ischemia: Partial or complete blockage of coronary arteries reduces blood and oxygen supply to the heart muscle, leading to ischemia.

·       Infarction: Without adequate intervention, ischemia can progress to tissue death (infarction) in the heart muscle due to decreased tissue perfusion.

NURSING PROCESS

MANAGEMENT GOALS

·       Modify Risk Factors: Prevent and slow the progression of CAD.

·       Identify At-Risk Individuals: Important since symptoms may not always be present

NURSING ROLE

·       Health Promotion: Focus on controlling modifiable risk factors for CAD through patient education.

·       Patient Education: Teach about the disease process, progression, and necessary lifestyle changes to prevent CAD.

·       Symptom Management: For patients with symptoms like chest pain or dyspnea, medications or surgical interventions may be needed.

MEDICATIONS

·       Aspirin: Prevents blood clots and heart attacks.

·       Cholesterol-lowering Agents: Reduce plaque buildup in arteries.

SURGICAL INTERVENTIONS

·       Coronary Angioplasty and Stent Placement: Remove blockages, widen the artery, and restore blood flow to the heart.

·       Coronary Artery Bypass Grafting (CABG): Used for patients with multiple narrowed arteries.

GENERAL SYMPTOMS

·       Chest pain

·       Shortness of breath (dyspnea)

·       Rapid breathing (tachypnea)

·       Difficulty breathing while lying down (orthopnea)

·       Fainting (syncope)

·       Palpitations

·       Lower extremity edema

·       Pain in the lower extremity

·       Difficulty performing physical activities

CHEST PAIN

·       Chest tightness

·       Squeezing sensation

·       Heaviness

·       Burning sensation

·       Pain during physical activity

·       Triggers like stress or substance use

·       Pain radiating to the jaw, neck, left arm, or back

RISK FACTORS

NON-MODIFIABLE

·       Age: Increased risk with age.

·       Gender: Men are at greater risk; risk increases for women after menopause.

·       Family History: Higher risk if an immediate male relative had heart disease before age 55 or a female relative before age 65.

·       Race/Ethnicity: Higher incidence in minority groups such as Hispanics and Blacks.

MODIFIABLE

·       Hypertension: Can lead to stiff and narrowed arteries.

·       Hyperlipidemia/Hypercholesterolemia: Increases risk of atherosclerosis.

·       Diabetes/Insulin Resistance: Leads to hardening of blood vessels and plaque buildup.

·       Kidney Disease: Impairs blood pressure regulation.

·       Tobacco Use: Increases blood vessel constriction.

·       Obesity: Contributes to cholesterol buildup and narrowed vessels.

·       Physical Inactivity: Increases cholesterol levels.

·       Diet: High in saturated fat raises LDL "bad" cholesterol.

·       Stress: Increases inflammatory levels, causing vessel narrowing.

·       Alcohol Use: Weakens heart muscle and affects blood clot formation.

·       Lack of Sleep: Poor sleep habits increase stress levels, leading to vessel constriction

MEDICATION AND TREATMENT HISTORY

·       Review medications such as anthracyclines and anabolic steroids, and any previous vascular surgeries that may compromise blood vessel integrity.

VITAL SIGNS

·       Monitor for changes in pulse rate and blood pressure due to decreased oxygen supply to the heart.

EKG AND TELEMETRY MONITORING

·       Conduct an EKG immediately for chest pain to assess for dysrhythmias.

·       Continuous telemetry monitoring for patients with a known cardiac history.

SYSTEMIC ASSESSMENT

·       Neck: Check for distended jugular veins.

·       CNS: Look for signs of acute distress, dizziness, syncope, and lethargy.

·       Cardiovascular: Assess for tachycardia, chest pain, abnormal heart sounds, and irregular heartbeats.

·       Circulatory: Check for decreased peripheral pulses.

·       Respiratory: Assess for dyspnea, tachypnea, orthopnea, and abnormal lung sounds.

·       Gastrointestinal: Monitor for nausea and vomiting.

·       Lymphatic: Check for peripheral edema.

·       Musculoskeletal: Assess for pain in the neck, arms, back, jaw, and upper body, along with fatigue.

·       Integumentary: Look for cyanotic or pale skin and excessive sweating

ARRHYTHMIA MONITORING

·       Check for ST segment changes indicating cardiac ischemia. Look for other arrhythmias such as atrial fibrillation, bundle branch block, and supraventricular tachycardia.

BLOOD WORK

·       Complete Blood Count (CBC): Check for infection, clotting response, and anemia.

·       B-type Natriuretic Peptides (BNP): Identify volume overload of cardiogenic origin.

·       Cardiac Enzymes: Troponin and CK levels indicate acute ischemia.

·       Lipid Panels: Monitor cholesterol levels.

·       Ultra-sensitive C-reactive Protein (us-CRP): Assess vascular inflammation.

·       Liver Function Tests (LFT): Evaluate liver function, especially in patients taking cholesterol medications.

STRESS TEST

Useful for non-invasive evaluation of CAD, assessing the heart’s response to physical activity.

CARDIAC CATHETERIZATION

The most reliable method for visualizing heart blood vessels, though it is invasive and involves risks.

FURTHER INVESTIGATION

·       Echocardiogram: Shows heart structure and valve function.

·       Exercise Treadmill Test: Used for physically competent patients with a normal resting ECG.

·       Nuclear Stress Test: Combines ECG recordings with blood flow images.

·       Stress Imaging: For patients with revascularization or physical limitations.

·       Cardiac CT Scan: Shows calcium buildup and blockages in the arteries.

·       CT Coronary Angiogram: Provides detailed imaging with contrast dye.

PROMOTE PERFUSION

·       Reduce Cholesterol Plaque Buildup: Administer cholesterol-lowering medications (e.g., statins, fibrates, niacin, bile acid sequestrants) to decrease LDL cholesterol and reduce plaque formation in arteries.

·       Prevent Blood Clots: Administer daily low-dose aspirin to prevent blood clots. Anticoagulant medications may be added for patients at higher risk.

·       Fix Blocked Arteries: Coronary Angioplasty and Stent Placement: Facilitate procedures that open clogged arteries using stents to restore blood flow.

·       Coronary Artery Bypass Graft Surgery (CABG): Assist in procedures that create a new path for blood flow in patients with multiple vessel damage.

·       Monitor Cholesterol Levels: Regularly monitor the patient's cholesterol levels to detect early signs of CAD, especially in high-risk patients

MANAGE SYMPTOMS

·       Control Blood Pressure

o   Administer medications such as beta-blockers, calcium channel blockers, ACE inhibitors, and ARBs to manage blood pressure in CAD patients.

·       Relieve Chest Pain

o   Use nitroglycerin to dilate veins and improve blood flow, thus alleviating chest pain (angina).

·       Identify Angina Triggers

o   Educate patients to monitor and document activities or conditions that trigger chest pain, aiding in treatment planning

·       Improve Ischemic Angina

o   Administer ranolazine, often combined with hypertensive medications, nitrates, antiplatelets, and lipid-lowering drugs to treat chronic and ischemic angina.

·       Maintain Optimal Blood Pressure

o   Ensure patients maintain a blood pressure below 140/90 mmHg.

o   Caution should be exercised if diastolic BP falls below 60 mmHg, as it may worsen angina.

CARDIAC REHABILITATION

·       Adhere to the Rehabilitation: Plan Encourage participation in a personalized cardiac rehabilitation program that includes support, exercise, and education.

·       Prevent Complications: Promote cardiac rehabilitation to aid recovery, lower the risk of complications, and reduce hospital readmissions.

·       Refer to Home and Community Health Services: Facilitate continued cardiac rehabilitation post-discharge, either at home or in community healthcare settings.

·       Motivate Adherence: Stress the importance of adhering to the rehabilitation plan, as it significantly improves outcomes, including exercise capacity, psychological well-being, and quality of life.

LOWER THE RISK: PREVENTION MEASURES

·       Promote Ambulation: Encourage 150 minutes of physical activity weekly to reduce cardiovascular risk.

·       Aim for an Ideal BMI: Support weight loss to improve blood pressure, cholesterol, and metabolic health.

·       Educate the Patient: Provide education to improve medication adherence and lifestyle changes.

·       Coping with Stress: Teach stress reduction techniques like yoga and meditation.

·       Manage Comorbidities: Help manage conditions such as diabetes and hypertension.

·       Seek Medical Attention: Educate on seeking immediate care for heart attack or stroke symptoms.

·       Promote Lifestyle Modification: Advocate for regular exercise, a heart-healthy diet, smoking cessation, and moderate alcohol intake.

·       Consider Omega-3 Fatty Acids: Suggest omega-3s from fish, flaxseeds, or soybeans to reduce inflammation.

·       Acknowledge Alternative Medicine: Recommend consulting healthcare providers before using herbal supplements.

·       Follow Up with a Cardiologist: Schedule regular follow-ups every 3-6 months to adjust treatment plans.

PROVIDE SAFETY

·       Use Blood Thinners with Caution: Monitor for bleeding signs in patients on anticoagulants.

·       Implement Bleeding Precautions: Advise using a soft-bristle toothbrush, avoiding manual razors, and preventing bowel straining.

·       Remind About Medical Identification: Recommend wearing a medical ID bracelet or tag to alert responders to CAD history and anticoagulant use.

RELATED TO

·       Increased cardiac workload

·       Decreased blood flow to the myocardium

AS EVIDENCED BY

·       Reports of chest pain or tightness

·       Diaphoresis

·       Guarding or protective behavior

·       Altered vital signs (e.g., tachycardia, hypertension)

EXPECTED OUTCOMES

·       The patient will demonstrate pain relief as evidenced by stable vital signs and the absence of pain behaviors.

·       The patient will verbalize what to do when chest pain occurs and when to seek emergency assistance.

ASSESSMENT

·       Monitor Vital Signs: Assess for changes such as tachycardia, hypertension, hypotension, hypoxemia, and bradycardia associated with pain.

·       Assess Pain Characteristics: Rapidly assess the pain to differentiate between angina and other causes such as indigestion.

·       Review Diagnostic Studies: Evaluate ECG results to identify angina or infarction. Look for ST depression, T-wave inversion, or ST-elevation

INTERVENTIONS

·       Provide Supplemental Oxygen: Administer oxygen to maintain SpO2 levels at 90% or higher, especially if oxygen saturation is below normal.

·       Administer Medications Promptly: Administer nitroglycerin to dilate coronary arteries, morphine sulfate for pain relief, and beta-blockers to reduce heart workload.

·       Raise the Head of the Bed: Position the patient to promote comfort, improve gas exchange, and reduce myocardial oxygen demand.

·       Maintain a Quiet Environment: Create a calm environment to reduce anxiety and myocardial workload, thereby minimizing chest pain.

·       Help the Patient Recognize Triggers: Educate the patient to identify activities or stressors that precipitate chest pain for better management.

RELATED TO

·       Situational crisis or stressors

·       Pain

·       Threat of change in health status

AS EVIDENCED BY

·       Expression of distress and insecurity

·       Fear of death

·       Physiological manifestations like increased blood pressure, heart rate, and sweating

EXPECTED OUTCOMES

·       The patient will verbalize awareness of anxiety and coping strategies.

·       The patient will demonstrate two effective relaxation strategies.

·       The patient will report reduced anxiety to a manageable level.

ASSESSMENT

·       Assess Stress Levels: Determine the impact of stress on the patient's condition, as it can exacerbate CAD symptoms.

·       Monitor Vital Signs: Differentiate between medical and emotional responses, both of which can present with rapid pulse, diaphoresis, and hyperventilation.

INTERVENTIONS

·       Encourage Expression of Feelings: Provide opportunities for the patient to express fears and anxieties, which can help in reducing anxiety.

·       Provide Reassurance: Reassure the patient about their safety and maintain a calm presence to reduce anxiety.

·       Administer Medications as Indicated: Use medications such as benzodiazepines (e.g., alprazolam) to help the patient relax and manage anxiety.

·       Provide Accurate Information: Educate the patient about their condition to reduce fear and promote active participation in treatment.

·       Encourage Relaxation Techniques: Teach and encourage the use of coping strategies such as deep breathing exercises, meditation, and positive self-talk.

RELATED TO

·       Transient or prolonged myocardial ischemia

·       Altered heart rate and rhythm

AS EVIDENCED BY

·       Tachycardia

·       EKG changes

·       Angina

·       Fatigue

·       Restlessness

EXPECTED OUTCOMES

·       The patient will report fewer episodes of angina, dyspnea, and dysrhythmias.

·       The patient will participate in activities that reduce myocardial workload.

ASSESSMENT

·       Assess Heart Rate, Blood Pressure, and Rhythm: Monitor for tachycardia, changes in blood pressure, and abnormal cardiac rhythms that may indicate decreased cardiac output.

·       Assess Breath and Heart Sounds: Listen for crackles in the lungs and abnormal heart sounds (e.g., S3, S4) that may signal heart failure.

·       Assess Skin Color and Pulse: Check for signs of poor peripheral circulation, such as pallor, cyanosis, and diminished pulses.

INTERVENTIONS

·       Allow Adequate Rest Periods: Encourage rest to reduce oxygen consumption and myocardial workload.

·       Stress the Importance of Avoiding Straining: Advise against activities like the Valsalva maneuver, which can impair cardiac output by causing vagal stimulation and rebound tachycardia.

·       Administer Medications as Indicated: Use inotropic agents (e.g., digoxin) to strengthen heart contractions and improve cardiac output.

·       Prepare for Diagnostic Tests: Assist in preparing the patient for echocardiograms, cardiac catheterizations, or angiograms to assess heart function and identify blockages.

RELATED TO

·       Formation of plaque

·       Narrowed or obstructed arteries

·       Rupture of unstable plaque

·       Vasospasm of coronary arteries

·       Conditions that compromise the blood supply

·       Increased workload on the heart

·       Inadequate blood supply to the heart

·       Ineffective cardiac muscle contraction

AS EVIDENCED BY

·       Decreased blood pressure (hypotension)

·       Decreased peripheral pulses Increased central venous pressure (CVP)

·       Tachycardia Dysrhythmias

·       Decreased oxygen saturation

·       Chest pain (angina)

·       Difficulty breathing (dyspnea)

·       Orthopnea (difficulty breathing when lying down)

·       Alteration in level of consciousness

·       Restlessness

·       Fatigue Activity intolerance

·       Cold, clammy skin

·       Prolonged capillary refill time

·       Pallor or cyanosis

·       Edema

·       Claudication (pain in lower extremities)

·       Numbness or pain in the lower extremities

·       Tachypnea (rapid breathing)

EXPECTED OUTCOMES

·       Patient will display palpable peripheral pulses and capillary refill time < 3 seconds.

·       Patient will manifest skin that is warm to the touch without edema.

·       Patient will maintain an alert, conscious, and coherent level of consciousness.

ASSESSMENT

·       Determine vascularization status: Assess for signs of inadequate tissue perfusion, especially in chronic conditions like peripheral vascular disease.

·       Calculate ankle-brachial index: Compare blood pressure in the arms and ankles to assess for poor blood flow in the legs.

·       Assess skin color, capillary refill, and sensations: Monitor for signs such as edema, poor ulceration or wound healing, skin color changes, and decreased peripheral pulses.

·       Use Doppler ultrasound: Perform a noninvasive assessment of blood flow and tissue perfusion, particularly in the lower extremities.

INTERVENTIONS

·       Administer medications: Provide vasodilators (e.g., nitroglycerin, hydralazine) to improve blood flow.

·       Prepare for surgery: Ready the patient for procedures like PCI or CABG.

·       Start aspirin therapy: Give aspirin to prevent clot formation and enhance blood flow.

·       Instruct on activity: Educate on avoiding prolonged sitting, crossing legs, and tight clothing; encourage ROM exercises and ambulation.

·       Refer to cardiac rehab: Suggest cardiac rehab to boost exercise tolerance and overall heart health.

RELATED TO

·       Plaque formation

·       Narrowed or obstructed arteries

·       Rupture of unstable plaque

·       Coronary vasospasm

·       Ineffective cardiac muscle contraction

·       Increased workload on the heart

·       Inadequate blood supply to the heart

·       Difficulty in effective contraction and relaxation

AS EVIDENCED BY

A risk diagnosis is not evidenced by signs and symptoms, as the problem has not yet occurred. The goal is to prevent unstable blood pressure

EXPECTED OUTCOMES

·       Patient will maintain blood pressure within prescribed parameters.

·       Patient will be able to sit or stand without significant fluctuation in blood pressure.

·       Patient will avoid complications of unstable blood pressure, such as myocardial ischemia or stroke.

ASSESSMENT

·       Track blood pressure: Monitor for hypertension, which can damage blood vessels and lead to plaque rupture.

·       Assess for signs and symptoms: Look for symptoms like angina, dyspnea, fatigue, and dizziness, which may indicate unstable blood pressure.

·       Determine risk factors: Assess for factors like high blood sugar, inactivity, high triglycerides, high sodium intake, and alcohol consumption, which increase the risk of hypertension.

·       Assess body fat: Monitor for obesity, which can elevate blood pressure due to fat accumulation around the kidneys.

INTERVENTIONS

·       Advise caution with exertional activities: Recommend limiting physical activities that may cause significant increases in blood pressure.

·       Administer medications as prescribed: Provide beta-blockers, ACE inhibitors, or antiplatelet/anticoagulant medications to manage blood pressure and reduce cardiac workload.

·       Educate on blood pressure control: Instruct the patient on maintaining a blood pressure within normal limits and recognizing their target blood pressure based on cardiovascular history.

·       Emphasize lifestyle modifications: Encourage dietary changes, exercise routines, and other lifestyle modifications like smoking cessation to control blood pressure.

·       Assist with stress testing: Prepare the patient for an exercise stress test to evaluate for exertional hypotension or hypertension and guide treatment plans.