Coronary artery disease (CAD) is the leading cause of death and illness in Western societies. A number of conditions result from coronary artery disease, including angina, congestive heart failure, and sudden cardiac death. Coronary artery diseaseresults when decreased blood flow through the coronary arteries causes inadequate delivery of oxygen and nutrients to the myocardium. The lumens of the coronary arteries become narrowed from either fatty fibrous plaques or calcium plaque deposits, thus reducing blood flow to the myocardium, which can lead to chest pain or even myocardial infarction (MI) and sudden cardiac death.
Plaque buildup in the coronary arteries is a result of arteriosclerosis, defined as thickening of the arterial walls’ inner aspect and a loss of elasticity. Arterial walls may develop calcifications, which diminish the ability of the vessels to transport blood adequately. Atherosclerosis, the most common form of arteriosclerosis, produces yellowish plaques made up mostly of cholesterol and lipids that line the inner arterial wall. The process of atherosclerosis may be initiated by damage to the arterial endothelium. Plaque accumulation reduces the inner arterial lumen and leads to wall thickening, calcification, and reduced blood supply. Aging results in increased streaking of fatty substances and fibrous change in the arteries.
Atherosclerosis is the most common cause of CAD and is linked to many risk factors—primarily elevated serum cholesterol levels, elevated blood pressure, and cigarette smoking. Blood levels of cholesterol and low-density lipoproteins (LDLs) have been associated with increased risk of CAD. Hypertension places chronic stress on the blood vessels and may initiate plaque deposition. Because smoking increases myocardial oxygen requirements, blood pressure, and heart rate, cigarette smokers are twice as likely to have an MI and four times as likely to have sudden cardiac death. Other risk factors include heredity, obesity, lack of physical activity, stress, and diabetes mellitus.
Nursing care plan assessment and physical examination
Patients with CAD describe symptoms of myocardial ischemia. A careful description of the pain, including location, severity, and precipitating factors, is essential. The most common symptom is angina, but some individuals remain asymptomatic. Cardiac pain is usually described as a diffuse aching pain or pressure that is relieved by rest or administration of nitroglycerin. The pain is usually substernal but may radiate to either arm, the neck, or between the shoulder blades. Often, the pain is precipitated by extra physical or emotional demands. Atypical pain may originate in the elbow, jaw, or shoulder. The patient may have no pain sensation but may complain of being short of breath or having nausea, vomiting, lightheadedness, or sweating.
Physical examination may reveal nothing abnormal. Labored breathing, pallor, and profuse sweating suggest that chest pain may be caused by MI. There may be evidence of flat or slightly raised yellowish tumors, most frequently found on the upper and lower lids (xanthelasma), or flat, slightly elevated, soft, rounded plaques or nodules, usually on the eyelids (xanthoma). Auscultate the heart sounds carefully to identify accompanying cardiac problems such as valvular dysfunction or heart failure.
Because the stress in one’s life has long been associated with the development of CAD, problem solving to reduce stress is an important nursing function. Occupational stress or the obligations from multiple roles may vary for female and male patients. Individuals whose work involves heavy lifting may require vocational rehabilitation counseling in order to return to work. Continuation of a fulfilling sexual expression requires thoughtful assessment and teaching.
Nursing care plan primary nursing diagnosis: Altered tissue perfusion (myocardial) related to narrowing of the coronary artery(ies) associated with atherosclerosis, spasm, and/or thrombosis.
Nursing care plan intervention and treatment plan
Several invasive but nonsurgical procedures can be used to manage CAD. Percutaneous coronary intervention (PCI) includes balloon catheter angioplasty and stenting. A balloon catheter angioplasty involves an invasive radiographic procedure that is performed under local anesthesia. A balloon-tipped coronary catheter is introduced into a coronary vessel and inflated and deflated in quick succession. The atheroma (fatty lesion) is compressed against the vessel wall, and the stenosis is dilated, which increases coronary blood flow. During the stent procedure, the cardiologist places a small, hollow metal (mesh) tube or “stent,” in the artery to keep it open following a balloon angioplasty.
CORONARY ARTERY BYPASS GRAFTING (CABG). A patent blood vessel from another
part of the body is grafted to the affected coronary artery distal to the lesion. The new vessel bypasses the obstruction. Unfortunately, unless reduction of risks and modification of the lifestyle accompany this procedure, the grafted vessels will also eventually occlude. Vessels commonly used for grafting are the greater or lesser saphenous veins, basilic veins, and right and left internal mammary arteries.
Managing the patient after heart surgery involves complex collaborative strategies among the nurse, surgeon, and respiratory therapist. Usually, a patient leaves the operating room with a systemic arterial and pulmonary artery catheter in place. Fluids and medications are administered according to the patient’s hemodynamic response to the surgery. Monitoring for complications is also an essential role. Early complications from heart surgery include hypotension or hypertension (lowered or raised blood pressure), hemorrhage, dysrhythmias, decreased cardiac output, fluid and electrolyte imbalance, pericardial bleeding, fever or hypothermia, poor gas exchange, gastric distension, and changes in level of consciousness.
If the patient has a large amount of drainage from mediastinal tubes, the nurse may initiate autotransfusion. In the immediate postoperative period, patients will need airway management with an endotracheal tube and breathing support with mechanical ventilation. Some patients will also require temporary cardiac pacing through epicardial pacing wires that are inserted during the surgery. Patients will often need fluid therapy with blood, colloids, or crystalloids to replace During episodes of chest pain, encourage complete rest and allay the patient’s anxiety by remaining close at hand. Monitor the blood pressure and heart rate, and initiate collaborative interventions such as administering nitroglycerin and oxygen. If the pain does not subside, notify the physician. When the episode is over, ask the patient to grade the severity of the pain (1 is low pain and 10 is severe pain), and document it in detail.
lost fluids or bleeding.
Explain strategies to reverse coronary artery disease through a program that includes a very low fat diet, aerobic exercise, and stress-reduction techniques. Information about resumption of sexual activity acceptable for the medical condition is helpful. Patient information literature is abundant and available from cardiac rehabilitation programs, as well as the American Heart Association. Although many patients will be admitted on the day of surgery, preoperative teaching about the intensive care unit environment, the procedure, postoperative coughing and breathing exercises, and postoperative expectations of care is essential. The surgery is a family crisis that may lead to a long recovery, patient dysfunction, and even death. The family needs emotional support and constant information about the patient’s progress.