Priority #1 Key Problem / ND: Ineffective tissue perfusion related to blood flow interruption Supporting data: Angina Dyspnea

Dyspnea Fatigue Nausea Vomiting Fever Tachypnea

Coronary Artery Disease

Priority #4 Key Problem / ND: Noncompliance Ineffective self-health management related to patient refusing to adhere to medication regimen as evidence by statements from the patient. Supporting data:

REASON FOR NEEDING HEALTH CARE

Medical Diagnosis: Coronary Artery Disease Co-morbidities: Hyperlipidemia Key Assessments: Angina Dyspnea Fatigue Nausea Vomiting Fever Tachypnea Statements of refusing medication regimen by patient Statements of fear of dying

Statements of refusing medication regimen by patient Comments regarding inability to pay for prescriptions

Priority #2 Key Problem / ND: Pain related to an imbalance between myocardial oxygen supply and demand. Supporting Data: Angina Dyspnea Fatigue Nausea Vomiting Fever Tachypnea

Priority #3 Key Problem / ND: Anxiety related to pain and fear of dying as evidence by patients statements of I am scared I am going to die. Supporting data: Statements of fear of dying Dyspnea Angina Tachypnea Nausea

Key Assessments:

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) Aspirin Therapy 1) Patient will verbalize increased comfort and less pressure and oxygenation/tissue perfusion will increase 2) Patient will verbalize increased comfort and less cardiac pressure sensation 1) Recommended by the American College of Cardiology and the AHA to inhibit platelet aggregation and vasoconstriction, decreasing risk of thrombosis. 2) Using fibrinolytics dissolves thrombin in coronary arteries and restores myocardial blood flow. Most effective when delivered within the first six hours of a coronary event. 3) Prevent fibrinogen from attaching to activated platelets at the site of thrombus. Maintains patency of artery after MI and for transluminal coronary angioplasty. 4) A CAD patient is expected to tolerate walking 200 feet four times per day without chest discomfort or shortness of breath. Helps patient achieve and maintain a vital and productive life while remaining within the limits of the hearts ability to respond to increases in activity and stress.

2) Thrombolytic Therapy

3)Glycoprotein IIb/IIIa inhibitors

3) Blood flow through coronary vasculature will be adequate to maintain heart function

4) Plan a program of cardiac rehabilitation with physical therapy and patient participation

4) Patient will verbalize understanding of physical therapy as important part of cardiac rehab and will willingly participate and adhere to planning and implementation of program

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) Administer morphine per HCP orders

3) Patient will verbalize pain levels of less than 4/10 within 15 minutes of administration of medication which will alleviate imbalances due to hyperventilation and anxiety regarding painful episode 4) Patient will rest and present a calm demeanor

3) Management of pain in patients with MI increases oxygen supply and decreases myocardial oxygen demand. Morphine relaxes smooth muscle and reduces circulating catecholamines. 4) Often enhances comfort and tissue oxygenation to be in semi-fowlers position. Relaxed environment reduces anxiety and ultimately pain.

4) Place patient in semi-fowlers position while offering a quiet, calm environment to reduce anxiety.

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 1) Assess patients level of anxiety and physical reactions to anxiety (using the Hamilton scale). Outcomes 1) Patient will discuss topics contributing to anxiety and verbalize understanding of healthy processes to alleviate stress 2) Patient will verbalize s/s leading to onset of anxiety and explain actions which would decrease negative effects of stress/anxiety on patient Rationale 1) Anxiety is a risk factor for major cardiac events in persons with stable coronary artery disease.

2) Teach the client to identify signs of anxiety.

2) Information is empowering and reduces anxiety, also it can help the patient identify when she is anxious.

3) Teach client techniques and coping mechanisms to reduce anxiety (music, muscle relaxation techniques, relaxation breathing, etc.).

3) Patient will demonstrate chosen techniques for self relaxation several times throughout the day

3) Teaching relaxation techniques and coping mechanisms can help manage side effects with selfcare behaviors.

4) Teach patient use of appropriate community resources

4) Patient will identify one support option to participate in upon discharge

4) These resources can help the patient manage and/or reduce anxiety by sharing similar experiences and 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 1) Client will explain pathophysiology of CAD in own satisfaction were noted as a result of interventions that illness. 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 2) Patient will explain understanding of the purpose of of transmission, and how the directly assist medication regimen if she understands why she is each medication and the way that it helps relieve her throughout her disease process. 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 effective in improving symptom management, increasing self-efficiency, and increasing client satisfaction.

3) Use coaching methods such as telephone follow-up to reinforce learning.

3) Patient will willingly agree to discuss successes and failures and understanding of shared management with health care coach on a routine basis

4) Help the client appropriate follow-up resources for continuing information and support.

4) Patient understands complications of unemployment due to disability and identifies community office dedicated to assist and implement alternatives for financial and clinical assistance through social services

4) Advocating for the clients participation using a community-based case management program has demonstrated improved clinical and financial outcomes for clients with complex chronic conditions.

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

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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?