Coronary artery disease (CAD) is a term used to describe conditions that affect the arteries that provide nutrients, blood, and oxygen to the heart.
Atherosclerosis, a known cause of CAD, is characterized by lipid deposits within the walls of the arteries. These plaques narrow arteries, obstructing blood flow. This increases the risk of angina and myocardial infarction.
CAD is a progressive disease that develops over time. The condition is often advanced before the patient begins exhibiting symptoms like angina, shortness of breath, and fatigue.
When blood flow through the coronary arteries becomes partially or completely blocked, ischemia and infarction in the heart muscles occur. When there is insufficient blood and oxygen supply (ischemia) to the myocardium, decreased tissue perfusion and necrosis (infarction) will develop, requiring immediate intervention.
The nonmodifiable risk factors of CAD include:
- Gender (men are at greater risk, but the risk increases for women after menopause)
- Family history
Modifiable risk factors include:
- Tobacco use
- Physical inactivity
- Alcohol use
Several tests are used to diagnose CAD including electrocardiogram (ECG), echocardiogram, chest x-ray, cardiac catheterization, coronary angiogram, stress tests, and coronary artery calcium scan.
The Nursing Process
The management of CAD involves modifying risk factors to prevent and slow disease progression. Since symptoms may not always be evident, it is important to identify people who are at risk for CAD.
Nurses provide health promotion efforts that are directed toward controlling the modifiable risk factors for CAD. Patient education about the disease process and progression along with necessary lifestyle changes is important in preventing CAD.
For patients who present with symptoms such as chest pain or dyspnea, medications or surgical interventions may be indicated. Medications like aspirin or cholesterol-lowering agents are prescribed to prevent blood clots and heart attacks and reduce plaque buildup in the arteries. Surgical interventions like coronary angioplasty and stent placement may be indicated to remove blockages, widen the artery, and restore blood flow to the heart. Coronary artery bypass grafting (CABG) is indicated for patients who have multiple narrowed arteries.
Nursing Care Plans Related to Coronary Artery Disease
Acute Pain Care Plan
CAD may cause chest pain, known as angina. Pain occurs when there is decreased blood supply to the heart muscles due to blocked arteries. Chest pain in CAD is often described as pressure or tightness and the patient may describe it as something “sitting on my chest.”
Nursing Diagnosis: Acute Pain
- Increased cardiac workload
- Decreased blood flow to the myocardium
As evidenced by:
- Reports of chest pain or tightness varying in duration, frequency, and intensity
- Distraction behavior
- Facial grimace
- Guarding or protective behavior
- Positioning to ease pain
- Altered physiologic parameters or vital signs
- The patient will demonstrate pain relief as evidenced by the absence of pain behaviors and stable vital signs.
- The patient will verbalize what to do when chest pain occurs and when to seek emergency assistance
Acute Pain Assessment
1. Assess and monitor vital signs.
Vital signs may be altered with the presence of pain. Tachycardia and hypertension may present initially. However, with the progression of poor cardiac output, hypotension, hypoxemia, and bradycardia may develop.
2. Assess pain characteristics.
Rapid pain assessment of a patient reporting or exhibiting chest pain is crucial. It is important to differentiate chest pain from other possible causes such as heartburn or indigestion. Unstable angina is more intense, unpredictable, lasts longer, and is not relieved with rest or sublingual nitroglycerin compared to stable angina.
3. Assess diagnostic studies.
ECG results can identify both the presence and the location of infarction or angina. During angina, ST depression or T-wave inversion may be present. When there is infarction, ECG results will reveal ST-elevation MI, non-ST-elevation MI, and an abnormal Q wave.
Acute Pain Interventions
1. Provide supplemental oxygen as needed.
Supplemental oxygen can help maintain arterial oxygen saturation of 90% or higher. Oxygen should only be administered if SpO2 levels are below normal limits, as it can have a counterproductive effect.
2. Administer medications promptly as indicated.
Nitroglycerin dilates coronary arteries to increase blood flow. Morphine sulfate may be ordered to promote comfort, relax smooth muscles, and decrease myocardial oxygen demand. Beta-blockers reduce the workload of the heart.
3. Raise the head of the bed.
This position promotes comfort and reduces myocardial oxygen demand. Raising the head of the bed will facilitate gas exchange to minimize hypoxia and resultant shortness of breath.
4. Maintain a quiet and comfortable environment.
This can help reduce anxiety and reduce chest pain. Mental and emotional stress can increase myocardial workload and pain.
5. Help the patient recognize triggers.
Chest pain is often precipitated by a stressful or emotional event or exercise. Stopping the activity that is causing the chest pain can help the patient identify if the chest pain requires further assessment.
Decreased Cardiac Output Care Plan
CAD can lead to decreased cardiac output which results in inadequate oxygenation and perfusion to meet the demands of the body.
Nursing Diagnosis: Decreased Cardiac Output
- Inotropic changes like transient or prolonged myocardial ischemia
- Altered heart rate and rhythm
As evidenced by:
- EKG changes
- Activity intolerance
- The patient will report decreased episodes of angina, dyspnea, and dysrhythmias.
- The patient will participate in activities that reduce the workload of the heart.
Decreased Cardiac Output Assessment
1. Assess heart rate, blood pressure, and cardiac rhythm.
Tachycardia may be present because of pain, hypoxemia, anxiety, and reduced cardiac output. Changes in blood pressure may also occur because of cardiac response.
2. Assess breath and heart sounds.
Crackles in the lungs can occur with cardiac decompensation. Abnormal heart rhythms or heart sounds such as a gallop or S3 or S4 heart sound signal heart failure.
3. Assess skin color and pulse.
When cardiac output is compromised, peripheral circulation is reduced, manifesting as pallor, cyanosis, and diminished peripheral pulses.
Decreased Cardiac Output Interventions
1. Allow adequate rest periods.
Rest periods decrease oxygen consumption and demand, reduce the risk of decompensation, and minimize myocardial workload.
2. Stress the importance of avoiding bearing down or straining.
Valsalva maneuver can cause vagal stimulation which reduces heart rate and is followed by rebound tachycardia; both of these can impair cardiac output.
3. Administer medications as indicated.
Inotropic medications like digoxin can raise cardiac output by making heart contractions stronger.
4. Prepare for tests and procedures.
Echocardiograms show how blood moves through the heart and valves and can identify weak areas. Cardiac catheterizations or angiograms use guided catheters and dye to visualize blockages.
Anxiety Care Plan
Anxiety is a normal response to stressful situations like a cardiac event but can be detrimental to the patient’s overall health if it is present in excess. Timely and accurate identification, management, and treatment of both anxiety and CAD are essential.
Nursing Diagnosis: Anxiety
- Situational crisis or stressors
- Underlying pathophysiological response
- Threat of change in health status
As evidenced by:
- Expression of distress and insecurity
- Awareness of physiological symptoms
- Feelings of helplessness
- Heart pounding
- Fear of death as an impending reality
- Physiologic manifestations like altered respiratory pattern, facial flushing, increased blood pressure, increased heart rate, and increased sweating
- The patient will verbalize awareness of feelings of anxiety and healthy ways to cope with them
- The patient will demonstrate two effective relaxation strategies
- The patient will report that anxiety has been reduced to a manageable level
1. Assess stress levels.
Stress can aggravate the patient’s condition. It can increase blood pressure levels, which increases cardiac workload.
2. Monitor vital signs.
Attempt to decipher between medical and emotional responses. Both can result in rapid pulse, diaphoresis, and hyperventilation.
1. Encourage the patient to express feelings and fears.
Unexpressed feelings and fears tend to develop into anxiety, affecting the patient’s overall health and aggravating existing health conditions like CAD.
2. Provide reassurance to the patient.
Reassuring the patient can help relieve anxiety. Reiterate that they are safe. Present a calm presence to invoke a sense of control.
3. Administer medications as indicated.
Benzodiazepines like alprazolam can help the patient relax until physically able to rebuild adequate coping strategies.
4. Provide accurate information about the disease.
Patient education is vital because it allows the patient to understand what is happening and what to expect. It will also allow the patient to actively participate in the treatment regimen.
5. Encourage coping methods for relaxation.
Remind and encourage the patient to practice coping strategies to decrease anxiety such as breathing exercises, meditation, distraction, and positive talk.
References and Sources
- Celano, C. M., Daunis, D. J., Lokko, H. N., Campbell, K. A., & Huffman, J. C. (2016). Anxiety Disorders and Cardiovascular Disease. Current psychiatry reports, 18(11), 101. https://doi.org/10.1007/s11920-016-0739-5
- Coronary Artery Disease. National Heart, Lung, and Blood Institute. Last updated on March 24, 2022. https://www.nhlbi.nih.gov/health/coronary-heart-disease
- Coronary Artery Disease: Prevention, Treatment, and Research. Copyright © 2022. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronary-artery-disease-prevention-treatment-and-research
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Ramadhani, F. B., Liu, Y., Jing, X., Qing, Y., Rathnayake, A. K., Kara, W., & Wu, W. (2019). Investigating the Relevance of Nursing Caring Interventions Delivered to Patients with Coronary Artery Disease at a Teaching Hospital in China: A Retrospective Study. Cureus, 11(5), e4672. https://doi.org/10.7759/cureus.4672
- Shahjehan RD, Bhutta BS. Coronary Artery Disease. [Updated 2022 Feb 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564304/