CORONARY ARTERY DISEASE

A Nursing Care Plan Presented to the

Faculty of the Nursing Department

In Partial Fulfillment of
the Requirements in NCM-214 RLE

OXYGENATION & FLUIDS ELECTROLYTES NURSING ROTATION

Submitted to:
MR. RALPH PARUNGAO, RN, MAN
Clinical Instructor

Submitted by:
KRISTILE-ANN L. PACATE, St.N
BSN3C – Group 1

December 03, 2021

Name of Patient: Patient X Age/Sex: 45 - Male Room/Bed #: 101-1

Chief Complaint: Very severe chest pain_________________________ Physician: Dr. Parungao

Diagnosis (if discharged):

DATE CUES NEED NURSING PATIENT INTERVENTION IMPLEMENTATION EVALUATION

& DIAGNOSIS OUTCOME
TIME
D Subjective Cues: C Acute pain related to Within the 1 hour of 1. Perform a 1 After 1 hour of nursing
E - “sakit kaayo O decrease myocardial nursing comprehensive intervention, the patient
C akong G blood flow as intervention, the assessment of was be able to
E dughan” as N evidenced by facial patient will be able pain to include demonstrate a
M verbalized I grimacing with a pain to demonstrate location, decreased of pain as
B by the T scale of 5/5, and decreased of pain characteristics, evidence by:
E patient I increased blood as evidence by: onset, duration, a.) Patient
R V pressure of 180/190 a.) Patient will frequency, verbalized
Objective Cues: E verbalized quality, intensity, “medyo na wala
3 - Pain scale of - Rationale: decreased and precipitating wala na ang
, 5/5 (0 = no P Acute pain is the of pain from factors of pain. sakit saakong
pain, 1 = E unpleasant sensory a pain scale Rationale: To dughan” from a
2 mild pain, 2 R and emotional of 5/5 to 1/5 differentiate angina pain
pain scale of 5/5
0 = moderate C experience (0 = no pain, from pain related to
to 1/5 (0 = no
2 pain, 3 = E associated with actual 1 = mild other causes, and
1 moderate P or potential tissue pain, 2 = evaluate possible pain, 1 = mild
pain, 4 = T damage, or moderate progression to unstable pain, 2 =
severe pain, U described in terms of pain, 3 = angina. moderate pain, 3
5 = worst A such damage. Acute moderate = moderate pain,
pain L pain is caused by the pain, 4 = 2. Administer 2 4 = severe pain,
possible) narrowed arteries severe pain, prescribed 5 = worst pain
- Vital signs H which the oxygen-rich 5 = worst medications then possible)
were taken: E blood that the heart pain assess and document b.) vital signs within
Temp.: 37.6 C A needs can’t get possible) patient response. normal range
PR: 100bpm L through leading to b.) vital signs Rationale: Aspirin is specifically;
HR: 108bpm T heart muscles within used to prevent blood PR: 89 bpm
RR: 29cpm H normal clots and allow blood to
HR: 90bpm

 BP: 180/190mm becoming starved for range flow more freely through RR: 20cpm
Hg P oxygen. specifically; narrowed arteries. BP:120/80mmHg
A Reference: PR: 80- Nitrates are used to c.) Patient
- Heavy T Alaeddini, J. (2018, 90bpm relax blood vessels. manifested an
respirations T July 19). Angina HR: 80- Documentation will absence of facial
noted as E Pectoris: Practice 90bpm provide information grimacing and
evidenced R Essentials, RR: 16- about the progression of moaning
by N Background, 20cpm the disease. Aids in
respiratory Pathophysiology. BP: 110/70- determining the efficacy
rate of MedScape. 120/80mmH of interventions and
29bpm https://emedicine.med c.) Patient will identifies the need for a
- Moaning scape.com/ manifest an change in the Kristile -A
nn L. Pacate, St.N
was article/150215- absence of therapeutic regimen.
observed overview facial
- Patient grimacing 3. Assess and 3
appeared to and monitor vital
be lethargic moaning signs every 5 minutes
- Facial during initial anginal
grimacing attack.
were Rationale: to monitor
observed effectiveness of medical
treatment for the relief of
angina. Blood pressure
may initially rise
because of sympathetic
stimulation, then fall if
cardiac output is
compromised.
Tachycardia also
develops in response to
sympathetic stimulation
and may be sustained
as a compensatory
response if cardiac
output falls.

 4. Provide 4
supplemental
oxygen as
ordered. Rationale:
Increases oxygen
available for myocardial
uptake and
reversal of ischemia.

5. Elevate the 5
head of the bed if the
patient is short of breath.
Rationale: Facilitates
gas exchange to
decrease hypoxia and
resultant shortness of
breath.

6. Place the patient 6

to
complete bed rest.
Rationale: Reduces
myocardial oxygen
demand to minimize risk
of tissue injury.

7. Observe the 7
associated
symptoms.
(dyspnea, nausea,
vomiting, dizziness, and
palpitations)
Rationale: These
presenting symptoms

 might be due to
decreased cardiac
output that stimulates
sympathetic and
parasympathetic
nervous system and the
decrease of cardiac
output will indicate a
warning sign of heart
attack.

8. Monitor serial 8
ECG changes
Rationale:
tracings
ischemic
which may disappear
when the patient is no
longer in pain. They also
serve as a baseline
against which
subsequent pattern
changes can be
compared.

9. Monitor heart 9
rate and rhythm
Rationale:
Patients
may have an increased
risk of acute life-
threatening
dysrhythmias.

 10. Maintain a quiet
and comfortable 10
environment.
Rationale: Mental and
emotional stress
increase myocardial
workload

11. Provide light 11

meals. Have
patient rest for 1
hour after meals
Rationale: This reduces
the myocardial workload
associated with
digestion work.

12. Instruct the 12

patient to notify
the nurse
immediately
when chest pain
occurs.
Rationale: Unbearable
pain triggers a
vasovagal response,
which lowers blood
pressure and heart rate.

Kristile - Ann L. Pacate, St.N

Name and Signature:

REFERENCES:
Alaeddini, J. (2018)). Angina Pectoris: Practice Essentials, Background, Pathophysiology. MedScape.
Retrieved from: https://emedicine.medscape.com/article/150215-overview
Husney, A. (2020). Coronary Artery Disease: Care Instructions. Alberta.
Retrieved from: https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=uf8667
Medtronic (n, d) Treatment options of Coronary Artery Disease (CAD)
Retrieved from: https://www.mayoclinic.org/diseases-conditions/coronary-artery-disease/diagnosis-treatment/drc-20350619
Mayo clinic (n, d) Coronary artery and stents.
Retrieved from: https://www.mayoclinic.org/tests-procedures/coronary-angioplasty/about/pac-20384761
Rai Dilawar Shahjehan, & Bhutta, B. S. (2021). Coronary Artery Disease.
Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK564304/
Thomas, J. (2020)). Heart Disease: Facts, Statistics, and You. Healthline.
Retrieved from: https://www.healthline.com/health/heart-disease/statistics