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Diploma in Nursing

Integrated Nursing Sciences 2.1

SBL for Coronary Artery Disease

Learning Objectives

1. Remember and recollect important principles in Coronary Artery Disease

2. Identify patient’s issue (or problems) from the case study, integrating evidences gathered from
patient’s history and investigative results to the patient’s diagnosis of stable angina and acute
coronary syndrome.
3. Identify the possible risk factors that could have predispose the patient to developing the disease.
4. Link the pathophysiological changes of the disease to the management of the patient in the
scenario.
5. Develop and prioritize an individualized plan of care for the patient in the case scenario. Include at
least 2 important nursing diagnoses and describe 5 nursing interventions with rationale for each
nursing diagnosis
6. Identify and role-play the discharge planning for the patient in the scenario. To include necessary
props to aid the understanding of the patient and /or caregivers.

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Watch Overview of CAD: https://youtu.be/NZ14XjOQoFY

Trop T/I Trop T/I Trop T/I Trop T/I Trop T/I
Negative Positive Negative Positive Positive

Unstable Unstable
NSTEMI NSTEMI STEMI
Angina Angina

NEJM. (2017). Acute Myocardial Infarction. Retrieved from https://resident360.nejm.org/clinical-

pearls/acute-myocardial-infarction (Modifications made)

# Note
ST Segment
The ST segment normally remains isoelectric (see the light tracing on the ECG)
ST segment depression and T inversion indicates myocardial ischemia (UA or NSTEMI)
ST segment elevation indicates myocardial Injury (STEMI)
Trop I /T positive
Indicates proteins released during myocardial infarction and are sensitive indicators of myocardial damage.
Important principles of CAD

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Important Principles of CAD

1) Fill in the blanks with the following options: STEMI, NSTEMI, Unstable Angina, ST-Elevation, No
ST-Elevation, Positive, Negative, 12-Lead ECG, Cardiac Biomarkers

Acute Coronary Syndrome

2) Using the diagram below, explain the differences between the investigative findings of Stable
Angina vs Acute Coronary Syndrome (ACS)

ACS
Diagnosis Stable Angina
Unstable Angina NSTEMI STEMI

ECG
Trop T/I

In the immediate management of ACS (UA-NSTEMI-STEMI)

3) Describe the key management of ACS using the acronym MONAP:

M
O
N
A
P

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Read through the following case study and identify the relevant factors related to CAD risk factors or
clinical manifestations by highlighting.

SBL Coronary Artery Disease

Day 1, 12 noon

Mr. Lee Ho Yin, 50-year-old, presents to the emergency department with new presentation of left sided
chest discomfort upon exertion. He had alighted from his usual bus stop and was attempting to walk
home when he felt “a dull and heavy chest pressure”. The discomfort went away after he stopped at a
nearby bus stop to rest. He was admitted for clinical observation.

Past Medical Hx: He has been treated for hyperlipidemia x 2 years

Family Hx: Father died of ischemic heart disease at 60 years old; his brother has hypertension.

Physical Examination
Neurological: conscious, alert, pupils equally round and reactive to light
Respiratory: RR 21 breaths per minute, SaO2 94 % on room air
Cardiovascular: Pulse rate 120 bpm, BP 158/85 mmHg, temperature 37o C.
Chest tightness upon exertion, relieved with rest.
Gastrointestinal: abdomen soft, non-tender, bowel sounds present
Others: Weight 85 kg, Height 170cm. Serum cholesterol 245mg/dL (normal range < 200mg/dL). He leads
a stressful live as a banker. Has no time to exercise, “eats everything nice” and smokes 1 packet of
cigarettes daily for 20 years.

Doctor’s Orders:
O2 at 3LPM nasal cannula if SpO2 ≤ 90%
Serial 12 Lead ECG and Troponin I 8 hourly X 3

Medications
PO aspirin 100 mg OM
PO carvedilol 25 mg BD
PO hydrochlorothiazide 25 mg OM
SL nitroglycerin 0.5 mg/PRN
PO atorvastatin 80 mg ON

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1) Identify Mr. Lee’s risk factors that predisposed him to the development of CAD.

Modifiable Risk Factor Evidence

Non-modifiable Risk Factor Evidence

2) Identify patient’s issue (or problems) from the case study integrating evidences gathered from
patient’s history and investigative results to the patient’s diagnosis.

Issue Nursing Diagnosis Evidence

Chest tightness upon exertion, relieved with rest.

BP 158/85 mm Hg

BMI: 29.4 Weight 85 kg, Height 170cm

Has no time to exercise, “eats everything nice” and

smokes 1 packet of cigarettes daily for 20 years

Hyperlipidemia X 2 years

Serum cholesterol 245mg/dL (normal range <

200mg/dL) on atorvastatin.

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3. State four (4) characteristics of Mr. Lee’s ECG rhythm and interpret the ECG taken on arrival (only lead
II is presented).

Rate is
Rhythm is
The P Wave is
ORS Complex is
Interpretation

The Troponin I result was negative. Together with the ECG reading and clinical presentation, the
probable diagnosis is ________.

The next day, Mr. Lee was scheduled for a treadmill cardiac stress test. The test result was abnormal.
The stress test result is strongly suggestive of coronary artery disease (CAD).

Day 2, 10 am

Mr. Lee complained of feeling “very tired” after his treadmill cardiac stress test. The nurse asked him to
rest in bed (RIB). Half an hour later, the nurse checked on Mr. Lee. Mr. Lee complained of a sharp chest
pain that has been ongoing for the last 10 minutes. He is feeling a “little breathless” as well.

Physical Examination
Respiratory: RR 24 breaths per minute, SaO2 89 % on room air
Cardiovascular: Pulse rate 140 bpm, BP 168/95 mmHg, temperature 37o C.
Chest tightness increasing. Pain score is 6/10 after S/L GTN 0.5 mg X 3 tablets given

The doctor ordered a 12-lead ECG and blood for Troponin I stat. The ST changes was confirmed in at
least 2 of the leads.

Heart Squad (2015). ST

changes. Retrieved from

https://heartsquad.com/overview/st-changes/

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4. State four (4) characteristics of Mr. Lee’s ECG rhythm and interpret the ECG taken

Rate is
Rhythm is
The P Wave is
ORS Complex is
Interpretation

The cardiac enzymes as presented below

Parameters Result Normal Value

CK 150 30-170 IU/L
CKMB 4 0-4.9 ng/ml
Troponin I 0.01 <0.03 ng/L

5.Identify Mr. Lee’s probable diagnosis from the symptoms manifested and the investigative results. Provide
a rationale for your answer (Refer to Page 2).

Mr Lee is diagnosed with _____________________________________

Doctor’s Orders:
O2 at 3LPM nasal cannula if SpO2 ≤ 90%
Serial 12 Lead ECG and Cardiac Enzymes and Trop I X 2
Continuous cardiac monitoring and RIB

Medications
PO soluble aspirin 325 mg stat
PO ticagrelor 180 mg stat
PO carvedilol 25 mg BD
IV nitroglycerin 10-40 mcg/min
IV morphine 4 mg stat, if pain persist
PO atorvastatin 80 mg ON

6. a) Identify five (5) immediate nursing interventions the nurse should provide to manage Mr. Lee’s
condition.

Nursing Interventions Rationale

To establish baseline data and monitor for disease

progress.

Tachycardia and hypotension may indicate the

development of cardiogenic shock.

Supplemental oxygen increases oxygen supply to

myocardium, decrease ischemia and pain.

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Note: No mortality benefit. Associated with a

higher risk of recurrent MI and major cardiac
arrhythmias in NSTEMI/UA [AHA/ACC 2015
(Class 1) when oxygen ≤ 90%,AHA, 2015]
Administer medications as ordered:
To bind to the opioid receptor sites (mu and kappa)
and alters the release of neurotransmitter. This
alters the perception and tolerance of pain. 
 
To dilate main coronary arteries, which increases
oxygen delivery to the heart. It also dilates
peripheral veins and arteries to reduce preload and
afterload, reducing cardiac oxygen demand. 
 
 
To inhibit the synthesis of prostaglandin and its
derivatives tromboxaneA2, to  
reduce platelet aggregation. 
 
 
To prevent in-stent thrombosis/ 
To block the adenosine diphosphate receptors on
plasma membrane of platelets, causing the
membrane not to be able to receive signals for
aggregation thus the prevention of platelet
aggregation. 
 

Note: Morphine has no mortality benefit.

Higher risk of death in patients presenting with
NSTEMI/UA (AHA/ACC Recommendation Class
IIb)

To open up the artery that is blocked and allow

perfusion to the affected heart muscles

Or

6 b. Formulate a nursing care plan for Mr Lee with five (5) nursing interventions and rationales for the
nursing diagnosis of ineffective tissue perfusion related to decrease blood flow in the coronary arteries as
evidenced by increasing chest pain unrelieved by S/L GTN; feeling of “breathlessness”; RR 24 breaths per
minute and SaO2 89 % on room air

Resource: Adapt from Answers in Q6a.

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Nursing Intervention Rationale

Assessment

Monitor vital signs including heart rate,

respiratory rate, blood pressure, SpO2 and
pain score

Administer oxygen at 3 L/min per nasal

cannula as SpO2 is 89%

Administer medications as ordered:

 IV Nitroglycerin (NTG) 10-40

mcg/min
 PO soluble Aspirin 325 mg stat  

 PO Ticagrelor 180mg stat

Prepare Mr. Lee for Percutaneous Coronary

Intervention

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Refer to the TIMI Risk Score for UA/NSTEMI which is used to estimate the mortality for patients with
UA/NSTEMI and provides guidance on the urgency of PCI

Go to this link: https://www.mdcalc.com/timi-risk-score-ua-nstemi#evidence and input the criteria. Copy

the results here and briefly explain the findings.

3 points
13% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring
urgent revascularization.

View Percutaneous Coronary Intervention: https://youtu.be/I45kJJoCa6s

Mr. Lee was scheduled for PCI in the late afternoon. The AM nurse is preparing Mr. Lee for PCI.

7a. Identify four (4) nursing intervention taken, to minimize adverse outcomes from the procedure.

Nursing Intervention Rationale

This is to prevent aspiration as sedation is given
during the procedure.
As PCI is an invasive procedure, precautions are
needed to prevent excessive bleeding if PT/PTT is
prolong.

A contrast agent is injected through the catheter

thus the kidneys will need to be prepared for the
procedure if there’re signs of kidney
impairment/an increase in the urea and
creatinine levels.
To prevent in-stent thrombosis and
thromboembolic event.
To verify that Mr. Lee is agreeable to the
treatment.

Adapt from resource: https://nurseslabs.com/cardiac-catheterization-nursing-care-plans/4/

Mr. Lee has just been transferred back to the ward from the cardiac catheterization laboratory.

7b. Formulate a nursing care plan with four (4) nursing interventions and rationale for the nursing diagnosis:
“Risk for bleeding related to cardiac catheterization procedure.”

Nursing intervention Rationale

To establish baseline data and monitor for

tachycardia and hypotension which may indicate
bleeding.

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To assess for bleeding from puncture site

To assess for complications of cardiac tamponade.

To prevent bleeding from the puncture site.

8. Identify and role-play the discharge planning for the patient in the scenario. To include necessary
props to aid the understanding of the patient.

Health Education Rationale

Teach Mr. Lee to identify signs and symptoms of

severe chest pain, unrelieved by rest and sublingual
GTN

Refer Mr. Lee to a smoking cessation programme

Refer Mr. Lee to a dietician and advise him to

adhere to a diet:

 Low in fat and cholesterol diet

 Low in salt and high in calcium

Recommend participating in an approved weight

loss program.

To attend a Cardiac Rehabilitation program

To take medications as prescribed by doctor.

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INDIVIDUAL
Case Study Summary for INS2.1

Patient’s Name

Diagnosis

Issues

Immediate Management M O ( +/-) N A P

NCP Post PCI

Health Education

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