A Case Analysis On

CORONARY ARTERY DISEASE

In Partial Fulfillment of the

Requirements of NCM 212-RLE

GERIATRIC NURSING ROTATION

Submitted to:
MRS. MARIA CATHERINE BELARMA, RN, MN
Clinical Instructor

Submitted by:
ELLA LORRAINE OMBOY, St. N
MAREANNE GABRYLLE SALIOT, St. N
NOAH EMMANUEL SOMBILON, St. N

BSN3B-GROUP 3-SUBGROUP 4

November 18, 2020

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 CRITERIA

Introduction/Objectives----------------------------------------------------------------------____/10%
Pathophysiology
Etiology----------------------------------------------------------------------____/10%
Symptomatology----------------------------------------------------------____/10%
Disease Process----------------------------------------------------------____/5%
Management---------------------------------------------------------------____/15%
Prognosis-------------------------------------------------------------------____/10%
Discharge Planning--------------------------------------------------------------------------____/10%
Nursing Theory-------------------------------------------------------------------------------____/10%
Review of Related Literature--------------------------------------------------------------____/10%
References------------------------------------------------------------------------------------____/5%
Promptness-----------------------------------------------------------------------------------____/5%

TOTAL:_____/100%

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Table of Contents
I. INTRODUCTION 4
II. OBJECTIVES 5
III. PATHOPHYSIOLOGY 6
Etiology 6
Symptomatology 9
Disease process/ schematic diagram 11
Narrative 16
Physical Assessment on the Affected System 17
Diagnostic Tools/ Evaluation 18
Nursing Diagnosis 20
Management 21
Medical 21
Surgical 30
Nursing 31
Prognosis 41
IV. DISCHARGE PLANNING 42
V. NURSING THEORIES 45
VI. PREVIEW OF RELATED STUDIES/LITERATURE 46
VII. REFERENCE 51

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INTRODUCTION
The role of nursing in society does not only cater to a specific age group, but it includes
all age groups across the generation. One of its specialized areas is Geriatric Nursing. Geriatric
nursing is a nursing specialty for older adults. Geriatric nurses work with older people, their
families and communities to promote a healthy aging process, full functioning and quality of life.
According to Resnick (2016), it is a comprehensive source of clinical knowledge and
management advice concerning the treatment of older adults. Geriatric nurses not only work
with older adults but also collaborate with their families and their communities to encourage safe
longevity, full productivity and quality of life. According to Williams (2019), Geriatrics is the
medical specialty that deals with the physiology of aging and with the diagnosis and treatment of
diseases affecting older adults. Geriatrics by definition focuses on abnormal conditions and the
medical treatment of these conditions. Geriatric nurses are needed to care for a growing
number of elderly patients.

Heart disease is a catch-all phrase for a variety of conditions that affect the heart’s
structure and function. Coronary Artery Disease (CAD) is a type of heart disease that develops
when the coronary arteries cannot deliver enough oxygen-rich blood to the heart. It is the
leading cause of death in the United States and is often caused by atherosclerosis or the
buildup of plaque, a waxy substance, inside the lining of larger coronary arteries. This buildup
can partially or totally block blood flow in the large arteries of the heart. Some types of this
condition may be caused by disease or injury affecting how the arteries work in the heart.
Symptoms of Coronary Artery Disease may be different from person to person even if they have
the same type of condition, however, because many people show no symptoms, they
themselves do not realize that they have Coronary Artery Disease until they have chest pain, a
heart attack, or sudden cardiac arrest.

Coronary Artery Disease (CAD) is an umbrella term used to cover any group of clinical
symptoms compatible with Acute Myocardial Ischemia, or simply chest pain. It is also called
Coronary Heart Disease (CHD), the single largest killer of American men or women in all
cultural groups (American Heart Association, 2013). According to the AHA, CHD caused more
than 1 out of every 5 deaths in the United States in 2000. From 1990 to 2000, the death rate
from CAD declined to 25%. Multiple factors can be identified as contributing to decline in CAD,
and these factors include more effective medical treatment and an increase awareness an
emphasis on reducing the major modifiable cardiovascular risk factor (e.g, high blood pressure,
smoking, cholesterol, obesity, diabetes) (Principle of medical surgical Nursing Lemone, Burke

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Vol. 2 4th edition 2007 page 974-975) In Acute Coronary Syndrome, it is believed that the
atherosclerotic plaque in the coronary artery can rupture, resulting in platelet aggression
(clumping), thrombus (clot) formation and vasoconstriction. The amount of disruption of
atherosclerotic plaque determines the degree of obstruction infarction (AHA, 2014). In the
Philippines, there are 120, 800 deaths in 2018 or 19.83% of total deaths. The age adjusted
death rate is 197 per 100, 000 persons, ranking the Philippines 32nd in the world in CAD-related
deaths (World Health Rankings, 2018). There are no statistics specified in the number of cases
of CAD in Mindanao, however in 2017, Northern Mindanao Region garnered 5, 854 cases of
heart diseases in general (Statista, 2017).

This case analysis will be beneficial to us as student nurses. Firstly, for nursing practice,
this may act as a reference in learning how to provide appropriate nursing care or, more
precisely, to administer particular strategies when taking care of a client with a similar condition.
Secondly, for nursing education, this analysis will provide nursing knowledge of Coronary Artery
Disease, including its management and treatment. In addition, it will allow us to provide
complete, clear, concise and accurate information concerning the inherent risks of the patient as
we go along with our practice. Finally, this information can be further established in the field of
nursing research, such as serving as a guide to perform further studies and to find articles and
concepts that can be associated with this topic. Moreover, it can be a reference for future
research for elevating the standards of nursing services.

OBJECTIVES

General Objectives

Within the Geriatric Nursing Rotation (November 5-21, 2020), the student nurses of BSN-
3B Group 3 Subgroup 4 will be able to create a case analysis on Coronary Artery Disease
(CAD) informatively that will help to improve the understanding of the disease according to
knowledge, skills and attitude of Geriatric Nursing.

Specific Objectives:

To achieve the general objectives, student nurses specifically aims to;

a. Provide an introduction in relation to geriatric nursing and Coronary Artery Disease;

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 b. Compose objectives that are specific, measurable, attainable, realistic and time-
bounded;
c. Discuss the etiology and symptomatology;
d. Diagram the disease process;
e. Discuss on the physical assessment of a patient with CAD;
f. Identify diagnostic or laboratory tests in detecting CAD;
g. Enumerate medical and surgical management for CAD;
h. Formulate three nursing care plans;
i. Explain the prognosis of patients with CAD in consideration to application of treatment;
j. Make use of nursing theories to correlate with CAD;
k. Compare recent related studies to coronary artery disease, and
l. Cite the references used as sources of information contributing to the case analysis.

ETIOLOGY

Predisposing Factors Present/Absent Rationale

Family History of CAD Present According to Kraus as stated by American

Heart Association (2015), the risk factors and
risk of having heart diseases are strongly
linked to family history. An example of how
family history contributes to increased risk of
heart disease is having a first-degree relative
with comorbidities, specifically familial
hypercholesterolemia. A hereditary condition
defined as an abnormal amount of LDLs in the
blood can result in atheroma thus having a
heart disease (Ninja Nerd Medicine, 2019).

Age Present Increasing age results in decrease of

physiological functions which includes the
arteries. As people get older, the blood
vessels become less flexible, making it more
difficult for the blood to pass through. As years
pass by, plaque is collected into the artery

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 walls and may impede blood flow (Kaiser
Permanente, 2019). Specifically, men over 45
years old and women aged 55 years old are at
risk of having cardiac diseases.

Gender Present Males are said to be more prone in coronary

artery diseases compared to women because
women has an adequate amount of estrogen
in the body in which studies suggest that the
hormone serves as a protection against heart
diseases (Heart Health, 2020). However, post-
menopausal women or when they reach the
age of 55 years old, they have the same risk
with men having CAD because of estrogen
drop (Kaiser Permanente, 2019).

Race Present African-Americans are linked with an

unhealthy diet which made them prone to
cardiac diseases. Non-Hispanic blacks are
said to be also at risk of having CAD because
Non-Hispanic blacks are linked with increased
risk of hypertension (Ninja Nerds Medicine,
2019)

Precipitating Present/Absent Rationale

Factors

Hyperlipidemia Probable indication Having high amounts of bad cholesterol or LDLs in

the blood contributes in accumulation of fats in the
arteries and formation of plaques.

Cigarette smoking, Probable indication According to American Heart Association (2015),

tobacco use cigarettes have thousands of chemicals that can
damage health. Specifically, carbon monoxide

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 decreases the supply of oxygen carried by the red
blood cells and contributes in the hardening of
arteries. Nicotine, which has a direct effect on the
arteries, has the capacity to injure arterial walls.

Hypertension Probable indication High blood pressure results in narrowing of

arteries because of forcing the blood to flow thus it
contributes to the damage of blood vessels. As
arteries become less elastic, damaged and
constricted, resulting in impeding circulation, high
blood pressure contributes on the presence of
patient’s chest pain, arrhythmias or worse, heart
attack (Mayo Clinic, 2019).

Diabetes Mellitus Probable indication An increase of blood sugar can lead to serious
heart complications because the body cannot use
all of the sugar, thus it sticks to the red blood cells.
Resulting in viscous blood, the build-up can block
and damage the blood vessels carrying blood to
and from the heart, which impedes the
transportation of oxygen and nutrients to the heart
(Diabetes UK, n. d.).

Obesity Probable indication When a person is obese, the subcutaneous,

visceral fats are squeezing the vital organs which
impedes blood flow and increases blood pressure
(Penn Medicine, 2019). Aside from that, having
excess fat on the tissues represents large
amounts of bad cholesterol which can lead to
CAD.

Physical Inactivity Probable indication Physical inactivity such as sitting for long periods
of time or having a sedentary lifestyle precipitates
the occurrence of CAD because as a person does
not have regular physical activity, blood flow slows
down allowing the build-up of fats to the blood

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 vessels. Aside from that, lipoprotein lipase, a
catalyst for breaking down of fats, is decreased for
about 90% if one has sedentary lifestyle
(Beaumont, 2018).

SYMPTOMATOLOGY

Signs and Present/Absent Rationale

Symptoms

Chest Pain Probable indication Angina or discomfort is the most common

symptom of CAD. When plaque builds up in the
arterial wall, there is narrowing of arteries and they
can block the blood flow to heart muscle and the
rest of the body resulting in chest pain (Centers for
Disease Control and Prevention, 2019).

Shortness of Probable indication This usually occurs during activity. As there is

Breath impeded blood flow to the heart, there is
inadequate nutrition of the heart and it cannot
pump enough blood to meet the body’s needs
(Mayo Clinic, 2019).

Fatigue Probable indication Blood cannot move as freely as it normally would.

As the arteries are hardened and narrowed, the
heart adds an extra effort to move blood and as
the heart works overtime, tiredness occurs
(Cardiovascular Solutions Institute, 2019).

Gastrointestinal Present Gastrointestinal symptoms occur when a person

symptoms overeats, having a high-fat diet and too much
(Indigestion, intake of caffeine, alcohol and smoking (Mayo
heartburn, nausea, Clinic, 2019). This lifestyle precipitates the
epigastric distress) formation of plaque in the arteries.

Numbness Probable indication Since there is obstructed blood flow, as there is

added pressure in an atheromatous blood vessel,

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 the nerves are not given enough nutrition which
reduces sensation.

Palpitations Probable indication The usual cause of palpitations are not found.
However, stress (response from angina), anxiety,
and stimulants contribute to the occurrence of
palpitations and it may lead to arrhythmias then
into tachycardia (Mayo Clinic, 2020).

Tachycardia Probable indication Heart rate is controlled by the sympathetic nervous

system as it releases catecholamines to
accelerate the heart rate. Known as the “flight
response”, faster-than-normal heartbeat occurs
when there is an unexpected stressful event such
as unexpected chest pain. Tachycardia is also
worsened when a person has hypertension, drinks
too much caffeine and alcohol, and smoking
(Mayo Clinic, 2020).

Diaphoresis Probable indication Sweating is regulated by the sympathetic nervous

system and excessive sweating occurs as a
response to stressful situations or emergencies.
As in the case of coronary artery disease which
has a clinical manifestation of chest pain which
can occur anytime, diaphoresis can be also
observed. A person being anxious about the
disease process may also contribute to the
occurrence of diaphoresis.

SCHEMATIC DIAGRAM

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NARRATIVE

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 All the predisposing factors and precipitating factors contribute to the endothelial
damage of the coronary artery. The physiological function of the endothelium is to produce nitric
oxide, prostaglandin I2 which are antithrombotic agents, inactivating the platelets. The
endothelium also produces heparin sulfate and thrombomodulin which act in activating
antithrombotic agents to prevent clotting. When the coronary artery endothelium is damaged,
these agents will not be produced and platelets are activated.Low-density lipoproteins (LDL)
circulating at the blood vessels will leak into the damaged area. Thus, there will be
inflammation. As inflammation occurs, the body’s response will be sending macrophages to the
damaged area. The function of the macrophages are to phagocytose foreign materials. As
macrophages phagocytose the LDLs, macrophages become super active that they will secrete
massive amounts of cytokines: growth factors, chemokines, and even some free radicals.
Growth factors aid in proliferation of the smooth muscle cells such as the tunica media. Instead
of isolating the smooth muscles in the endothelium, they proliferate to the site where the LDLs
are accumulated. Chemokines are responsible for attracting more macrophages in the site
increasing the phagocytosis process where the LDLs are. The free radicals oxidizes the LDLs
converting them to be LDL- C, which enhances the inflammatory response. As there is further
macrophage attraction, smooth muscle cell proliferation and synthesis of LDL-Cs, the
accumulated macrophages which ingested LDLs are now called foam cells or lipid laden
macrophages. Over time, the foam cells necrotize and undergo apoptosis leading to the leakage
of LDL-C which can circulate in the sub-intimal space, thus leading into formation of fatty
streaks. The body’s response to counteract the disease process is that the tunica media
secretes collagen on the surface to prevent the inflamed part from fissures thus forming a
fibrous cap. The fibrous cap can be stable and unstable. Unstable fibrous cap means it is not
intact and can be prone to fissures. As the unstable fibrous cap ruptures, there will be leakage
of the cholesterol in the blood flow. The LDL-Cs are thrombogenic which attracts the platelets in
the area creating a thrombus. Stable and unstable fibrous cap can cause the impediment of
blood flow, this will lead to atherosclerosis or hardening of the arteries due to the build-up of
plaque. Atherosclerosis’ clinical manifestations are angina, shortness of breath, fatigue,
diaphoresis, gastrointestinal symptoms such as heartburn and indigestion, tachycardia,
palpitations and numbness. These can be treated with medications such as statins, anti-
hypertensives, anticoagulants and surgical interventions such as PTCA and CABG. Nursing
interventions alleviate the symptoms. When treated, the heart may have improved functioning
and the symptoms are reduced, giving the patient good recovery. If not treated, there will be
further plaque rupture and subsequent thrombus formation which will eventually lead to the

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occlusion of the artery. As the artery cannot give nutrients to an organ which supplies, there will
be ischemia, then necrosis, leading to myocardial infarction. Myocardial infarction can still be
treated with aforementioned surgical treatments with possible good recovery saving the person
from death, but without early recognition and treatment, myocardial infarction can be the cause
of death of the patients with coronary artery disease.

PHYSICAL ASSESSMENT ON THE AFFECTED SYSTEM

Physical Assessment in CAD cases must include the observation of the cardiovascular
and respiratory status of the person. Tachycardia is a common manifestation in patients with
Acute Coronary Syndrome (ASC) and Myocardial Infarction (MI), and irregular heart rate may
signal the presence of atrial fibrillation. The blood pressure should also be noted, as
hypotension usually reflects compromised flow of blood within organs and tissues of the
body. Patients with CAD usually have rapid breathing and are tachypneic. During
auscultation of the heart, S4 gallop is a common early finding, and the presence of S3 is an
indication of a reduced left ventricular function (Shah, 2019).

In our patient, F.C, he had noticed the changes of his body including heartburn and
indigestion, which he might have mistaken for chest pain. He experienced shortness of
breath and had an increased respiratory rate and blood pressure as well as excessive
generalized sweating and presence of pain radiating towards the neck and jaw. He had a
strong family history of heart attacks, had obvious symptoms of exertion and had 70%
blockage in the left main artery.

Functional Assessment

Katz Index of Activities of Daily Living (ADLs) is a widely used graded instrument for
older adults that assesses the six functions, namely the bathing, dressing, going to the toilet,
transferring, feeding and continence (Fuentes-Garcia, 2020). The point system is only
composed of 1 point that indicates independence, and 0 point that indicates dependence of
the older adult. In this tool, the higher the score is, the more independent the client is.

In CAD cases, the functionality, which is the central focus of health in older adults, may
slowly decreased due to the pain and fatigue experienced by the patient. Fatigue occurs
when the heart is unable to pump enough blood to meet the body’s demand, and that is

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 because of the build-up plaque that blocks or narrow the coronary artery. If fatigue and pain
is present, there is a possibility that the patient might need assistance in performing activities,
or become totally dependent on others to perform the actions. As such, it is important to use
the Katz Index in assessing which of the six functions the patient needs assistance, and
which can he still perform on his own even with the presence of the disease.

Diagnostic Tools/Evaluation

a. Electrocardiogram (ECG)

An Electrocardiogram test is a simple and painless procedure done in order to measure

the electrical signals in the heart. It is often use to find or monitor various heart disorders like
arrhythmias, blocked arteries, heart damage, heart failure and heart attack. During the test, a
technician will attach 10 electrodes with adhesive pads on the skin of the chest, arms and
legs, and the patients may perform preparations beforehand such as avoiding oily or greasy
skin creams and lotions and wearing loose clothes. (Steinbaum, 2019). In cases of CAD, a
12- lead electrocardiogram may show change that indicates ischemia, including T-wave
inversion, ST-segment elevation, or development of abnormal Q wave (Hinkle & Cheever,
2018).

b. Echocardiogram

Echocardiogram uses sound waves to produce images of the heart. Its purpose is to
identify heart disease, specifically to check for problems with the valves or chambers and
detect congenital heart defects before birth. During an echocardiogram, the doctor will be
able to determine whether the parts of the heart wall are contributing to the heart’s pumping
activity, and if the parts are moving weakly, it may indicate damage during a heart attack or
could be receiving less oxygen, which is a sign of coronary artery disease (Mankad, 2020).

c. Exercise Stress Test

The purpose of exercise stress test is to determine how well the heart responds on
times when it is working on its hardest, and if the heart has received enough blood and

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proper blood flow on activities such as exercising. During the test, the patient will be asked to
exercise, usually with the use of treadmill while being hooked on an electrocardiogram
machine as the doctor monitors the heart rate. It is important to remember that patients must
inform the physician about conditions and symptoms that may hinder exercising, such as stiff
joints from arthritis (Whitworth, 2018).

d. Nuclear Stress Test

Nuclear stress test is similar to exercise stress test but with the addition of images to
the electrocardiogram recordings. The test uses a radioactive dye and the imaging machine
to show the blood flow to the heart. It helps in diagnosing CAD, and may also be used to
guide the treatment appropriate for a heart disorder (Mankad, 2017). Before the test, the
patient will be asked questions regarding the medical history and how often and strenuous
he/she exercises, so as to determine the amount of exercise for the test. It is generally safe,
but it is important to watch out for allergic reaction, dizziness or chest pain and low blood
pressure.

e. Cardiac Angiogram

Cardiac Angiogram, or more commonly known as Cardiac Catheterization, is a

procedure that allows the physician to see how well the functioning of the blood vessels
supplying the heart. Its purpose is to check for heart disease such as the CAD, a heart valve
disease or disease of the aorta, as well as to check how the heart muscle is working
(Steinbaum, 2019). The procedure is done by placing a catheter into a blood vessel of the
arm or leg and guides it to the heart with the use of a special x-ray machine. The physician
will also use a contrast dye that is injected into the blood vessel through the catheter to
create x-ray videos of the valves, coronary arteries and heart chambers.

f. Cardiac Biomarkers

Cardiac biomarkers, or also known as cardiac enzymes, are used to diagnose CAD
cases with acute MI. These include the troponin, creatine kinase and myoglobin, which are
released into the circulation when myocardial necrosis occur, as seen in MI (Hinkle &
Cheever, 2018).

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 CARDIAC DEFINITION AND NORMAL VALUES
BIOMARKERS

Troponin It is a protein found in the myocardial cells that regulates the

myocardial contractile process. An increased level of troponin in the
serum can be detected within a few hours during acute MI and
remains elevated for as long as 2 weeks. Therefore, it can be used
to detect recent myocardial damage. Cardiac troponin levels may
also rise during inflammation and other forms of stress on the
myocardium (Hinkle & Cheever, 2018).

Creatine Kinase CK-MB is the cardiac specific isoenzyme, and thus found in many
cardiac cells, therefore increasing when there is a damage to these
cells. An elevated CK-MB is an indicator of acute MI (Hinkle &
Cheever, 2018).
N: <5.0 ng/mL
Myoglobin It is a heme protein that helps transport oxygen and similar with the
CK-MB, is also found in the cardiac and skeletal muscle. An
increase in the levels of myoglobin does not necessarily indicate an
acute cardiac event, but the negative results can be used to rule out
MI. (Hinkle & Cheever, 2018).
N:<82 ng/mL

Nursing Diagnosis

1. Activity Intolerance

Activity Intolerance is defined as the insufficient physiological or psychological energy

to endure or complete required or desired daily activities (Hermann & Kamitsuru, 2018). The
common cause of this problem is related to generalized weakness, sedentary lifestyle,
imbalance between the oxygen supply and demand and bed rest or immobility. It can also be
defined as the inability to perform daily activities because of decreased energy for any
reason.

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 There is an activity intolerance with the patient, as there are symptoms of exertion. He
may be unable to perform normal activities due to his condition, since the coronary arteries
are blocked or narrowed, depriving the heart of oxygen needed for survival. As a result, there
is also a lack of oxygen throughout the body, preventing the patient from performing
strenuous activities.

2. Acute Pain

Acute pain is defined as the unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of such damage. It could also
be the sudden or slow onset of any intensity from mild to severe with an anticipated
predictable end, and with a duration of less than 3 months (Hermann & Kamitsuru, 2018).
The cause is any of the three, namely a biological injury agent, chemical injury agent or a
physical injury agent.

Because there is a blockage or narrowing of the coronary artery in CAD cases, the
heart does not receive enough blood and is deprived of oxygen. If this scenario has extended
over a long period of time, tissue damage may occur, thus resulting to an acute pain.

3. Ineffective Breathing Pattern

Ineffective breathing pattern is when the inspiration and/or expiration of a person do not
provide adequate ventilation. This is a result of fatigue, pain, hyperventilation and even
obesity. When the patient experiences an ineffective breathing pattern, he/she may suffer
from tachypnea or dyspnea, and may have nasal flaring.

The patient shows increased respiratory rate and shortness of breath, and with his
condition wherein the heart does not receive enough blood and oxygen due to the presence
of plaque in the artery, the whole body is also compromised and cannot meet its own
demand, including the oxygenation to other parts of the body.

Medical Management

1. Cardiac Rehabilitation

Cardiac Rehabilitation is done to CAD patients who have an MI but is already in a

stable condition. It is an active rehabilitation program, and it is an important continuous care

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 program for patients that targets risk reduction though providing patient and family education,
offering individual and group support and encouraging physical activity as well as physical
conditioning (Hinkle & Cheever, 2018). Its goal is to extend and improve the quality of life of
the patient, while the immediate objectives is to limit the effects and progression of
atherosclerosis, returning the patient to work and to his/her pre-illness lifestyle, enhancing
the patient’s psychosocial and vocational status and preventing another cardiac event.

2. Thrombolytic therapy

The purpose of thrombolytics is to dissolve the thrombus in the coronary artery,

allowing reperfusion in which the blood flows through the coronary artery again, thus
minimizing the size of infarction and preserving ventricular function. Although the
thrombolytics can dissolve the thrombus, it does not affect the underlying atherosclerotic
lesion, and the patient may still be referred for a cardiac catheterization and other invasive
procedures. It is important to watch out if the patient is bleeding or has bleeding disorder, and
should be given within 30 minutes of arrival in the hospital (Hinkle & Cheever, 2018).

3. Antihyperlipidemics
Generic Name: Atorvastatin
Brand Name: Lipitor
Action Classification: Antihyperlipidemic; Hydroxymethylglutaryl
CoA (HMG-CoA) reductase inhibitor (Pregnancy Category: X)
Mode of Action: It inhibits the enzyme HMG-CoA reductase which
hastens the early step in cholesterol which decreases low-density
lipoprotein (LDL) and very low-density lipoprotein (VLDL). It also increases the number of LDL
receptors on liver cells to enhance LDL uptake and breakdown.
Dose and Route:
For controlling lipid levels as adjunct to diet in primary and mixed dyslipidemia
● Initial: 10 or 20 mg 1 tablet PO once daily; then increased according to lipid level.
Maintenance: 10 to 80 mg once daily

For reducing debilitating cardiovascular events such as stroke and Myocardial infarction in
patients with multiple risk factors of Coronary Artery Disease (CAD), but without known CAD.
● Adults: 10 mg 1 tablet PO once daily

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Indications: Primary prevention of cardiovascular disease in high-risk patients, reduces risk of
stroke and heart attack in pts with type 2 diabetes with or without evidence of heart disease,
reduces risk of stroke, Adjunct to diet therapy in management of hyperlipidemia.
Contraindications: Active hepatic disease, pregnancy and lactation, hypersensitivity to
atorvastatin or its components, unexplained persistent rise in serum transaminase level
Side Effects: The drug is generally well tolerated and side effects are usually mild and lasts for
just a short period of time. Frequent: Headache. Occasional: Myalgia, rash, pruritus, allergy,
nausea. Rare: Flatulence, dyspepsia, depression
Adverse Effects: Potential for cataracts, photosensitivity, rhabdomyolysis, orthostatic
hypotension, hyperglycemia, arrhythmias
Drug Interactions:
+ Amlodipine, cimetidine, clarithromycin, diltiazem, erythromycin, itraconazole, ritonavir = ↑
atorvastatin level
+ Antacid, colestipol, efavirenz, rifampin = ↓ blood atorvastatin level
+ Protease inhibitor = ↑ atorvastatin level; ↑ risk of myopathy and rhabdomyolysis
+ Digoxin = ↑ blood digoxin level, causing toxicity
+ Cyclosporine = ↑ atorvastatin bioavailability and risk of adverse reactions
Nursing Responsibilities:

1. Monitor vital signs.

R: Monitoring vital signs aid in detecting underlying physiological conditions, and since
the drug may have adverse effects like hypotension and arrhythmias, detection of these
findings may indicate dose adjustment.
2. Ask the patient for any hypersensitivity to statin drugs.
R: This is to prevent further complications due to the incorrect drug and administration.
3. Assess the patient’s present medication intake.
R: Checking the medication history is done to determine whether it can provide optimal
therapeutic effect and prevent toxicity due to unfavorable drug interactions.
4. Obtain CBC, lipid levels and liver function tests.
R: Glucose levels are checked to detect severity of the adverse effects (hyperglycemia).
Lipid levels are measured to determine the effectiveness of the drug and liver function
tests determine drug dose adjustment.
5. Monitor signs of muscle pain or weakness.

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 R: It can be a sign of rhabdomyolysis, thus immediate intervention by the physician is
needed to prevent further complications..
6. Assess the patient for rashes, pruritus, malaise.
R: Though side effects are usually mild and transient, these signs and symptoms must
be reported to the physician and dose adjustment is needed to prevent further allergic
reactions and alleviate discomfort..
7. Encourage the patient to have a low-fat, low-cholesterol diet.
R: This is formulated by the dietitian to control lipid levels, reducing cardiovascular
attacks.
8. Report any sign of troubled breathing related to allergic reaction.
R: Troubled breathing related to allergic reaction is a sign of drug overdose. Immediate
notification of the prescriber is needed.
9. Encourage the patient in small frequent meals.
R: Nausea can be a side effect of the drug. To prevent further problems, comfort must
be taken into consideration.
10. Instruct the patient not to drink grapefruit juice.
R: It increases blood atorvastatin level, thus it increases risks of adverse effects.

4. Nitrates
Generic Name: Nitrogylcerin
Brand Name: Minitran, Nitro-Bid, Nitro-Dur, Nitrolingual, NitroMist,
Nitrostat, Nitro-Time, Rectiv, Trinipatch
Drug Classification:

● Pharmacotherapeutic: Nitrate
● Clinical: Antianginal, antihypertensive, coronary vasodilator

Mode of action:

● Dilates coronary arteries and improve collateral blood flow to ischemic areas within
myocardium.
● The IV form produces peripheral vasodilation.
● Therapeutic effect: Decreases myocardial oxygen demand; reduces left ventricular
preload, afterload.

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Suggested Dose:

● Angina, Coronary Artery Disease

● Translingual Spray (ADULT, EDLERLY): 1 to 2 sprays onto or under tongue of
every 3-5 mins until relief is noted (no more than 3 sprays in 15 minute period).
● Suglingual (ADULT, ELDERLY): One tablet (0.3-0.4 mg) under tongue. If chest
pain fails to improve or worsens in 3-5 mins, call 911. After the call, it may take
additional tablet. A third tablet may be taken 5 mins after second dose (maximum
of 3 tablets.)
● PO (extended-release) (ADULT, ELDERLY): 2.5-6.5mg 3-4 times per day.
Maximum is 26mg 4 times per day.
● Topical (ADULTS, ELDERLY): Initially ½ inch upon waking and ½ inch 6hrs later.
May double dose to 1 inch and double again to 2 inches. Maximum is 2 doses
per day including nitrate-free interval of 10-12hrs.
● Transdermal patch (ADULTS, ELDERLY): Initially is 0.2-0.4 mg/hr. Maintenance
is 0.4-0.8 mg/hr., patch on for 12-14 hrs., patch off for 10-12hrs. (Prevent
tolerance).
● Heart Failure, Acute Myocardial Infarction
● IV (ADULT, ELDERLY): Initially is 5mcg/min via infusion pump. Increase in 5-
mcg/min increments at 3 to 5 mins interval until BP response is noted or until
dosage reaches 20 mcg/min q3-5 mins. Dosage may be further titrated according
to clinical, therapeutic response up to 400mcg/min.
● Anal Fissure
● Rectal (ADULT, ELDERLY): One inch (1.5mg) q12hrs. for up to 3 weeks.
● Renal/Hepatic Impairment
● No dose adjustment.

Indications:

● Angina, Coronary Artery Disease

● Heart Failure, Acute Myocardial Infarction
● Anal Fissure
● Renal/Hepatic Impairment

Contraindications:

25
 ● Hypersensitivity to nitroglycerin
● Allergy to adhesives (transdermal)
● If there is increased ICP
● with severe anemia
● Concurrent use of sildenafil, tadalafil, vardenafil (PDE5 inhibitors).
● IV form: Restrictive cardiomyopathy, pericardial tamponade, constrictive pericarditis.
● Sublingual and rectal form: Increased intracranial pressure, severe anemia.
● Cautions: Blood volume depletion, severe hypotension (systolic BP is ess that
90mmHg), bradycardia (less than 50 beats per min), inferiror wall MI and suspected right
ventricular involvement.

Side Effects:

● Frequent:
● Headache (possible severe; occurs mostly in early therapy, diminishes rapidly in
intensity, usually disappears during continued treatment), transient flushing of
face/neck, dizziness (especially if patient is standing immobile or is in a warm
environment), weakness, orthostatic hypotension.
● Sublingual: Burning, tingling sensation at oral point of dissolution.
● Ointment: Erythema, pruritus.
● Occasional:
● GI upset.
● Transdermal: Contact dermatitis

Adverse Effects:

● Discontinue drug if blurred vision and dry mouth occurs.

● Severe orthostatic hypotension may occur, manifested by syncope, pulselessness,
cold/clammy skin and diaphoresis.
● Tolerance may occur with repeated, prolonged therapy; minor tolerance may occur with
intermittent use of sublingual tablets.
● High dose tends to produce severe headache.

Drug Interactions:

● DRUG:

26
 ● Alcohol, other antihypersensitive (eg. amLODIPine, lisinospril, valsartan),
vasodilators may increase risk of orthostatic hypotension.
● Concurrent use of sildenafil, tadalafil, vardenafil (PDE5 inhibitors) produces
significant hypotension.
● HERBAL:
● Ephedra, ginger, ginseng, and licorice may increase hypertension.
● Black cohosh, goldenseal and hawthorne may cause hypotension.
● FOOD:
● None known
● LAB VALUES:
● May increase serum methemogloblin, urine catecholamine concentrations.

Nursing Responsibilities:

1. Check the blood pressure and pulse before administration of drug as blood pressure can
drop precipitously after a single dose.
2. Nitroglycerin is highly unstable and should be stored in light resistant container in cool
environment.
3. Tolerance may occur during continuous administration, thus patches or topical ointments
are to be removed for 12 hrs. every day to reduce tolerance.
4. Assess the patient for facial or neck flushing.
5. Inform patient to take oral form on an empty stomach, however, if headache occur
during therapy, take medication with meals.
6. Inform patient to dissolve sublingual tablet under the tongue; do not swallow.
7. Warn the patient not to chew the tablets or capsules; do not crush these preparations.
8. Encourage patient to report blurred vision, persistent or severe headache, rash, more
frequent or more severe angina attacks and fainting.
9. Encourage patient to avoid alcohol as it intensifies hypotensive effect.
10. Do not use within 48 hrs. of sildenafil, tadalafil, vardenafil (PDE5 inhibitors) at is may
cause acute hypotensive episode.

5. Anticoagulant
Generic name: Heparin
Brand name: Hep-Pak, Heparin Lock Flush, Hep-Lock, Uniparin,
Liquaemin Sodium

27
Drug classification: (Pharmacological and Therapeutic class) : Anticoagulant
Mode of action: Under normal circumstances, antithrombin III (ATIII) inactivates thrombin
(factor IIa) and factor Xa. This process occurs at a slow rate. Administered heparin binds
reversibly to ATIII and leads to almost instantaneous inactivation of factors IIa and Xa The
heparin-ATIII complex can also inactivate factors IX, XI, XII and plasmin. The mechanism of
action of heparin is ATIII-dependent. It acts mainly by accelerating the rate of the neutralization
of certain activated coagulation factors by antithrombin, but other mechanisms may also be
involved. The antithrombotic effect of heparin is well correlated to the inhibition of factor Xa.
Heparin is not a thrombolytic or fibrinolytic. It prevents progression of existing clots by inhibiting
further clotting. The lysis of existing clots relies on endogenous thrombolytics.

Suggested dose: Continuous IV infusion:

- Initial dose: 5000 units by IV injection

- Maintenance dose: 20,000 to 40,000 units per 24 hours by continuous IV infusion

Intermittent IV injection:

- Initial dose: 10,000 units IV

- Maintenance dose: 5000 to 10,000 units IV every 4 to 6 hours

Deep subcutaneous (intrafat) injection:

- 333 units/kg subcutaneously followed by 250 units/kg subcutaneously every 12 hours; the
following dosage regimen has also been recommended: 5000 units by IV injection followed by
10,000 to 20,000 units subcutaneously, and then 8000 to 10,000 units subcutaneously every 8
hours or 15,000 to 20,000 units subcutaneously every 12 hours.

Indication: Deep Vein Thrombosis; pulmonary Embolism; embolism Prevention; open-heart

surgery; disseminated Intravascular coagulation; maintaining patency of intravenous indwelling
catheters; unstable Angina; post myocardial Infection.

Contraindication: Patients hypersensitive to drug; conditionally contraindicated to patient with

active bleeding; blood dyscrasia; bleeding tendencies; suspected intracranial hemorrhage;
suppurative thrombophlebitis; inaccessible ulcerative lesions.

Side effects: Easy bleeding and bruising; pain; redness; warmth; irritation, or skin changes
where the medicine was injected; itching of your feet; bluish-colored skin.

Adverse effects: CNS: Fever;

EENT: rhinitis, conjuctivitis, lacrimation;

28
 HEMATOLOGIC: hemorrhage, overly prolonged clotting time, thrombocytopenia;

SKIN: Irritation, mild pain, hematoma, ulceration, pruritus, urticaria, cutaneous or

subcutaneous necrosis.

OTHER: white clot syndrome, hypersensitivity reactions, chills, burning of feet,

anaphylaxis.

Drug interactions: Drug-drug:

Aspirin: may increase the risk of bleeding.

Oral anticoagulants: may cause additive anticoagulation.

Other antiplatelet drugs: may increase anticoagulant effect. Use together

cautiously.

Thrombolytics: may increase risk of hemorrhage.

Drug-herb:

dong quai, feverfew, garlic, ginger, horse chestnut, motherwort, red clover: may
increase risk of bleeding.

Nursing responsibilities:

1. Draw blood to establish baseline coagulation values before therapy.

2. Be alert for adverse reactions and drug interactions.

3. Monitor platelet counts regularly. Thrombocytopenia caused by heparin may be linked to a

type of arterial thrombosis known as white clot syndrome.

4. do not administer solutions more concentrated than 100 units/ml because it can irritate
blood vessels.

5. evaluate patient’s and family’s knowledge of drug therapy.

6. Place notice above patient’s bed to inform I.V. team or laboratory staff to apply pressure
dressings after taking blood.

7. take bleeding precautions.

8. to minimize the risk of hematoma, avoid excessive I.M. injection of other drugs. If possible,
don’t give I.M. injections at all.

9. Instruct patient and family to watch for signs of bleeding and to notify prescriber
immediately if they occur.

29
10. Tell patient to avoid over-the-counter medications containing aspirin, other salicylates, some
herbal remedies, and other drugs that may interact with heparin.

Surgical Management

1. Percutaneous Transluminal Coronary Angioplasty

Percutaneous Transluminal Coronary Angioplasty (PTCA), or also called as

Percutaneous Coronary Intervention (PCI) and is formerly known as Angioplasty with Stent,
is a procedure that relieves the narrowing and obstruction of the coronary arteries. It allows
blood and oxygen to be delivered to the heart muscle through the use of a small balloon
catheter inserted to the artery of the groin or wrist (Kulick, 2020). The balloon will advance to
the narrowing of the coronary artery, and is then inflated to enlarge the opening. In addition
to the simple balloon angioplasty, a stent in a mesh wire design will also be used to remain in
the artery and act as a scaffold to keep the blood flowing.

1. Coronary Artery Bypass Graft

The Coronary Artery Bypass Graft, or also known as bypass surgery, is when a
surgeon takes blood vessels from another part of the body to go around, or bypass the
blocked artery. As a result, more blood and oxygen are able to flow into the heart, treating
the signs and symptoms of CAD (Beckerman, 2020). In this procedure, a vein from the leg or
an artery in the chest or wrist can be used, and the surgeon will attach one end of the graft to
the other end of below the blockage. It is important to take note of the risk, such as bleeding
tendencies during surgery, infection at the incision site, pneumonia, breathing problems and
even failure of the graft.

30
Nursing Management
1. Activity Intolerance

Name of Patient: MGC Age/Sex: 60/Female Rm./Bed #: ___

Chief Complaint: Physician: _______________________________
Diagnosis: ___Coronary Artery Disease_____
DATE CUES NEE NURSING GOAL OF CARE NURSING IMPELE EVALUATION
AND D DIAGGNOSIS INTERVENTIONS MTATIO
TIME NS
Subjective: A Activity Intolerance After 8 hours of  Determines factors 1 After 8 hours of
“Mabilis C related to nursing contributing to nursing
akong T imbalance in intervention, the fatique. intervention, the
hingalin kahit I oxygen supply and client will R: The clients client participated
sa pag gawa V demand as participate marks to have willingly in
ng mga I evidenced by willingly in pulmonary necessary and
simpleng T verbal reports of necessary and congestion and desired activities
baga” as Y weakness. desired under observation to
verbalized by activities. have acute coronary a) The client
the patient. - syndrome. verbalized of
incorporating
R a) The client  Evaluate client’s such exercise
Objective: E verbalized of perceived limitations 2 and exposure
S incorporating by asking past to sunlight in
a.) With T such activities and her daily living.
verbal exercise and present activities. c) The patient will
reports of P exposure to R: Comparative be able to
weakness A sunlight in baseline data and to increase and
b.) With T her daily provide information achieve
excertiona T living. about needed desired activity
l dypnea E b) The patient intervention. level,
Facial R will be able progressively,
grimace N to increase  Assess with no
and achieve cardiopulmonary 3 intolerance

31
desired response to physical symptoms
activity level, activity, including noted such as
progressively vital signs before, respiratory
, with no during and after compromise.
intolerance activity.
symptoms R: Manifestation
noted such results intolerance
as of activity
respiratory
compromise.  Provide and monitor 4
response to
supplemental
oxygen
R: To provide an
increase in oxygen
supply.

 Assist client with

activities when 5
walking to the wash
room, getting up in
bed and lying back
to bed.
R: To protect the
client from injury

 Provide intervals of
rest between 6
activities.
R: To minimize
occurrences of
fatique

 Encourage and
acknowledge the 7
difficulty of the

32
 situation of the
client.
R: Helps to
minimize frustration
and rechannel
energy.

 Encourage patient
to expose himself in 8
sun light around 7 –
8am
R: Sunlight is rich
in Vitamin D and will
help the client to
increase vitality

 Assist and provide

passive and active
ROM 9
R: To maintain and
enhance muscle
tone of client

33
2. Acute Pain

Name of Patient: F. C. Age/Gender: 57/M Ward: San Lorenzo Room no:307-3

Chief Complaint: Indigestion and Heartburn Physician: Dr. Jear Yap .
Diagnosis: Coronary Artery Disease

Date/ Cues Need Nursing Patient Nursing Interventions Implemen Evaluation

Time Diagnosis Outcome/Objec tation
tives of Care

N Subjective: C Acute pain Within 1 hour of 1. Monitor vital signs 1 @November 16, 2020
O - - Pain scale of O related to nursing care, R: Detect any 9am
V 2 out of 3 G decreased my patient will physiological conditions.
E when chest N oxygen supply be able to: Changes in HR and “Goal Completely Met”
M pain occurs I to the changes in systolic blood
B (0-no pain; 1- T myocardium as a. verbalize pressure greater than At the end of 1 hour of
E mild pain; 2- I evidenced by relief from 20mmHg from baseline nursing care, my
R moderate; 3- V grimacing, pain with a indicates myocardial O2 patient was able to:
intense) E diaphoresis and pain scale demands and
- verbalization of lesser than 2 necessitates immediate
1 - “Pain is P intense pain. out of 3, intervention. a. verbalize relief
6 radiating at E b. Display a from pain with a
, the neck, arm R R: relaxed face 2. Provide patient an 2 pain scale of 1 out
and jaw with a C Acute pain is and non- environment of 3 with the
2 crushing E referred to diaphoretic conducive for him to verbalization of “I
0 sensation” as P unpleasant appearance, rest (no noise, air thank the Lord for
2 verbalized by T sensory and and conditioner giving me the
0 the patient U emotional c. Have a temperature well- hope, the pain I
A experience with baseline vital regulated, organized have right now is
@ Objective: L actual tissue sign values bed side) mild. I’ll rate it as
8 Temp: 36.7 damage which as in BP, RR R: Providing rest to the one out of three”

34
A degrees P occurs less and PR. patient eases angina.
M Celsius A than three b. Display a relaxed
PR: 101 bpm T months 3. Stay with the patient 3 face and skin is
RR: 23 cpm T (Herdman & and provide not moist to touch,
CR: 104 bpm E Kamitsuru, reassurance during and
BP: 130/90 R 2018). periods of chest pain. c. Have baseline
mmHg N Coronary artery R: These measures vital signs
disease occurs reduce anxiety, which (BP=120/80mmHg
Baseline VS usually in might otherwise worsen ; RR= 18; PR= 84)
BP=100/70 males, old age angina.
mmHg and with other
PR= 80-90 comorbidities 4. Reassess location, 4 Noah Emmanuel G.
bpm and these risk character and Sombilon, St. N
RR= 16-20 factors severity of the pain
cpm contribute to the R: This assessment
damage of monitors for degree,
vascular character and trend of
- - Restless endothelium, a pain for continuous
- - Grimace face primary step to check and comparisons.
while progress in
massaging CAD. As the 5. Teach the patient on 6
the left part of endothelial pursed-lip
chest, function of the breathing/relaxation
shoulder and arteries are also exercises.
holds the disrupted, lipids R: These relieve anxiety
neck specifically and are measures to
- -Excessive LDLs are decrease BP, PR and
sweating leaked causing RR.
- - Nuclear inflammation
stress test: which attracts 6. Administer O2 as 10
70% the prescribed
blockage; macrophages R: Hypoxia is common
impeded which would because of the
blood flow via turn them to decreased perfusion and
coronary foam cells, then adds stress to the
artery into myocardium.

35
- -Nitroglycerin atheroma/plaqu
administered e. Since there is 7. Maintain the patient 5
PO narrowing and in a recumbent
(extended- obstruction of position with elevated
release) the blood flow, head of the bed of 30
(ADULT, angina, a chest degrees during
ELDERLY): pain, occurs as angina or
5mg 4 times oxygen delivery nitroglycerin
a day to the heart is administration.
- - Amlodipine decreased R: This position lessens
administered (Hinkle and occurrence of
PO 10mg OD Cheever, 2018). headache/hypotension
- Through the by enabling better blood
disease flow to heart and head.
process,
grimacing may 8. Administer 7
be present to nitroglycerin as
the patient as a prescribed
response to R: This medication
pain, relieves angina and
diaphoresis reduces the myocardial
occurs from a oxygen demand.
nervous
response, and 9. Notify the health care 8
verbalization of provider for
crushing and unrelieved pain.
pressurized R: If pain is unrelieved or
pain radiating at returns very quickly,
the neck, arm emergency medical
and even jaw is treatment is advised.
also expected.
10. Administer 9
amlodipine as
prescribed.
R: Calcium-channel
References: blockers are intended for

36
 angina pectoris and they
Herdman, T. H. reduce blood pressure.
& Kamitsuru, S.
(2018). Nursing
diagnoses References:
definitions and
classification Swearingen, P. (2016).
2018-2020 All-in-one nursing care
(11th ed.). New planning resource. St.
York: Thieme Louis, Missouri:
Publishers ELSEVIER

Hinkle, J., &

Cheever, K.
(2018). Brunner
& Suddarth’s
textbook of
medical-
surgical
nursing. (14th
ed.). Wolters
Kluwer:
Philadelphia

37
3. Ineffective Breathing Pattern

Name of Patient: F.C. Sex: Male Age: 76 y.o Room and Bed no:
Chief Complaint: Indigestion and heartburn Diagnosis: Coronary Artery Disease
Attending Physician:
DATE CUES NEED NURSING OBJECTIVES NURSING IMPLE EVALUATIONS
AND DIAGNOSIS OF CARE INTERVENTIONS MENTA
TIME TION
OBJECTIVE: Ineffective Within 3 days 1. Assess the patient’s
Nov. - “I start A breathing pattern of nursing overall condition. 1 November 19, 2020
16, having some C related to fatigue interventions, R: Assessment provides a @ 8:00am
2020 indigestion T secondary to the patient will baseline on the patient’s
@ and I CAD as be able to current condition. “Goal partially met”
7:30a heartburn”, V manifested by show effective
m as I increased breathing 2. Continue monitoring After 3 days of
verbalised T respiratory rate, pattern as the patient’s vital 2 nursing
by the Y shortness of manifested by: signs. intervention, a
patient - breath and chest a. normal R: Vital signs help alert normal RR is
E pain. respiratory the healthcare provider for achieved, and
SUBJECTIVE: X rate any unusualities. patient is able to
- VS: E RATIONALE: b. loss of perform deep
Temp: 36.7C R CAD occurs shortness 3. Position the patient in breathing
CR: 93bppm C when the of breath a high or semi- 3 techniques. There
(N: 70- I coronary arteries when doing fowler’s position. is less chest pain,
80bpm) S that supply activities R: Semi fowler’s position as verbalized by
RR: 23cpm E blood, oxygen c. diminished promotes lung expansion the patient,
(N16-20cpm) and nutrients to fatigue and increased ventilation, however, the
BP: the heart are when doing overall improving the shortness of breath
130/90mmH damaged due to activities oxygenation of the and feeling of
g the presence of d. diminished patient. fatigue are still
(N: build-up chest pain present.
>120/80mm plagues. This 4. Administer oxygen
Hg) causes therapy if needed as 5
- Weight: 77kg narrowing of the per doctor’s order.

38
- Height: vessels, and will R: Oxygen therapy
160cm eventually enhances myocardial
BMI: 30.1 reduce the blood oxygen supply.
kg /m2 flow to the heart,
(Overweight) resulting to 5. Perform deep
(N: 23-30 unmet needs of breathing techniques 4
kg /m 2) the body and the together with the
- chest pain development of patient.
- shortness of fatigue and R: Deep breathing
breath chest pain when techniques or exercise
- showed engaging in can help the patient relax
symptoms activities as well and manage stress, which
related to as shortness of is another risk factor of
exertion breath. All of CAD.
- patient has which are
feeling of indicators of 6. Provide the medicine
fatigue when ineffective with the right dosage
doing breathing at the right time. 6
activities. pattern, along R: Nitroglycerin treats
- sedentary with the patient’s episode of chest pain in
lifestyle increase of RR. patients with CAD.
- physical
inactivity of Source: 7. Encourage patient to
the patient Coronary Artery report immediately 9
- Has family Disease. when pain persisted
history of (2020, June or worsened.
heart attacks 5). R: To allow immediate
- Has history Retrieved intervention when pain is
of type 2 November experienced.
diabetes 15, 2020,
- No history of from 8. Encourage patient to
vices MayoClinic: have frequent rest 7
- Medication https://www periods and to pace
include .mayoclinic. the activities or
Nitrogycerin org/disease exercises. Aerobic
- Initial s- exercise such as

39
 nuclear conditions/ walking, cycling and
stress test coronary- jogging are allowed
revealed artery- but should be done in
normal blood disease/sy moderation.
flow during mptoms- R: Exercise can help
rest, but not causes/syc lower the chance of a
during -20350613 heart attack as well as to
exercise. combat fatigue, making
- Second the patient feel less tired
nuclear in the long run.
stress test
revealed 9. Encourage patient to
resolved take small frequent
problem meals of the allowed 8
- has food such as fruits
underwent and vegetables high in
bypass fiber that helps lower
(CABG) cholesterol levels.
- R: Eating frequently with
small amount of food
results in less laboured
breathing during meals,
while the smaller amount
reduces pressure in the
stomach after eating,
making it easier to
breathe.

10. Reassess the

patient’s general 10
condition.
R: Reassessment Mareanne Gabrylle
provides information if the V. Saliot, St. N
interventions are
successful or not.

40
PROGNOSIS
In general, the prognosis of Coronary Artery Disease (CAD) will vary depending on the
number of affected vessels and the degree of dysfunction of the left ventricle. The left ventricle
is the heart’s main pumping chamber and a Left Ventricular Ejection Fraction (LVEF) of 55% or
higher is considered as normal (Mankad, 2019). In CAD cases, however, the LVEF is reduced.
With this is mind, a patient that still has a somewhat good left ventricular function and only a
single affected vessel has a good prognosis, about 90% survival rate. Early detection and
diagnosis of CAD, just as with any disease or chronic condition, can also lead to a good
prognosis with a successful treatment plan, usually including lifestyle changes, medicine
administration, medical procedures and even surgical interventions (Baldridge, 2019). Patients
with three involved vessels and a severe left ventricular dysfunction may have unfavourable
outcomes, resulting to a poor prognosis. Nevertheless, according to Dumitru and Baker (2018),
the Coronary Artery Bypass Graft (CABG) helps increase the survival rate of CAD patients with
reduced LVEF. It was reported that patients with an ejection fraction of 30% but has underwent
CABG has 80% survival rate, and 83% for those patient who underwent the bypass with an
ejection fraction below 20%.

CAD is usually cause by atherosclerosis, or the build-up of plaque inside the artery walls.
This build-up causes blockage and narrowing of the coronary artery vessels in a way that it
reduces the blood flow to the myocardium of the heart (Hinkle & Cheever, 2018). There is no
cure to atherosclerosis, but early treatment and management, specifically the lifestyle changes,
can slow down or halt the progress of the disease. It can lead to a good prognosis, and patients
with atherosclerosis are able to live longer with better quality of life than before.

In cases where the disease progresses, ischemia and angina pectoris may occur.
Ischemia is the condition wherein there is an inadequate blood supply, depriving the cardiac
muscle cells of oxygen needed for survival due to the blockage or narrowing of vessels, which
then causes angina pectoris, or the chest pain brought about by the myocardial ischemia
(Hinkle & Cheever, 2018). The prognosis of angina pectoris worsens with increasing age and
poor left ventricular function. The left ventricular function is a strong predictor of long-term
survival, and therefore, an LVEF of less than 40% is a poor prognostic sign, along with unstable
angina and recent Myocardial Infarction (Alaeddini & Shirani, 2018). Patients with stable angina,
however, surprisingly have good prognosis, even with three affected vessels, as long as the
ventricular function is normal (Sweis, 2020.)

41
 With the onset of myocardial ischemia that results to myocardial death, Acute Coronary
Syndrome (ACS) will follow. One condition is the Myocardial Infarction (MI), wherein a portion of
the heart muscle no longer receives blood flow and becomes necrotic due to complete occlusion
of the artery (Hinkle & Cheever, 2018). MI or heart attack, is a serious event with approximately
30% mortality rate and about 50% of the deaths occurring before arrival to hospital. 5-10% of
the survivors died within a year of their first MI. Zafari (2017) state that a better prognosis is
associated with successful early reperfusion, preserved left ventricular function, and short-term
and long-term treatment of beta-blockers, aspirin and ACE inhibitors while a poorer prognosis is
associated with advanced age, delayed or unsuccessful reperfusion and poorly preserved left
ventricular function.

In our patient, the progress of CAD was prevented because of his early observation of the
signs and symptoms and has underwent bypass, thus resulting to a good prognosis of his case.
Prevention of CAD is possible with lifestyle change and better selection of food, especially for
older adults.

DISCHARGE PLANNING

METHOD HEALTH TEACHINGS RATIONALE

Medication
● Instruct patients to take ● To adhere in prescribed therapeutic
the prescribed regimen for health maintenance and
medications as ordered by resistance.
the physician.

● Instruct patient to avoid

taking OTC drugs unless
given with medical advice

Exercise
● Encourage patient to ● It promote a healthy lifestyle,
include at least 30 maximizing the level of health and
minutes of walking or

42
 jogging or perform increase the body’s immunity
tolerated and preferred
activities as a means of
exercise.

Treatment
● Instruct the patient about ● Lowering the blood pressure
home-made interventions reduces the risk of MI by 20-25%,
in reducing blood pressure risk of stroke by 35-40%, and risk of
such as: heart failure by 50%.

a.) Pineapple or Calamnsi

juice to reduce blood
pressure.

b.) Chewing of raw or

fried garlic after meals.

c.) Refrain from

consumption of
caffeinated beverages

Hygiene
● Encourage daily oral care. ● Medication such as calcium channel
blockers can cause gum tissue to
swell and overgrow, resulting to
difficulties in chewing.

● Handwashing prevent the spread of

● Encourage performance microorganism, thus preventing
additional disease or infection.

43
 of proper handwashing.

Outpatient
● Emphasize the
importance of adhering to
medications and attending
follow – up check up.
● Adherence to maintenance
therapy, appropriate diet and having
exercise will reduce the likelihood of
occurrences and aggravation of
disease.

● Encourage patients to
adhere to weekly blood
pressure monitoring

● Encourage client to attend

follow up check up

● Advise patient to refer to

health care professional
for sudden onset of blurry
vision, intense head ache,
chest pain unrelieved with
rest and medications.

Diet
● Instruct patient to avoid ● To maintain and ensure adequate
consumption of salty and intake for nourishment.
fatty foods.

● Instructed patient to limit

consumption of high

44
 caloric foods such as rice
to reduce occurrences of
high blood pressure and
increase in blood sugar.

NURSING THEORIES
Virginia Avenel Henderson’s Nursing Need theory

Virginia Avenel Henderson (November 30, 1897 – March 19, 1996) was a nurse,
theorist, and author known for her Need Theory and defining nursing as: “The unique function of
the nurse is to assist the individual, sick or well, in the performance of those activities
contributing to health or its recovery (or to peaceful death) that he/she would perform unaided if
he had the necessary strength, will or knowledge.” Henderson is also known as “The First Lady
of Nursing,” “The Nightingale of Modern Nursing,” “Modern-Day Mother of Nursing,” and “The
20th Century Florence Nightingale.” She develops The Need Theory emphasizes on the
importance of increasing the patient’s independence and focus on the basic human needs so
that progress after hospitalization would not be delayed. Encouraging activity is fostering
independence but it should always be under conditions of safety. Additionally, we should involve
them in decision-making and conduct activities specific to what they enjoy. Furthermore, as
nurses, we should have good and proper communication skills so as not to add to their mental
struggle of understanding their surroundings, given that any time they might lose the sense of
time and awareness.

Jean Watson’s Theory of Human Caring

Dr. Jean Watson is a distinguished professor, nurse theorist, and founder and director of
the nonprofit Watson Caring Science Institute. She is best known for her Theory of Human
Caring. Watson created the theory between 1975 and 1979 from her personal views of nursing.
Her hope at the time was that her theory would help distinguish nursing science as a separate
and important entity from medical science. Nursing has changed dramatically as science and
medicine have adapted to meet the growing needs of our population. It's increasingly a skilled-

45
based profession. However, it’s important to remember the root of nursing, which are based on
caring and healing principles.

In relation to this case, geriatric residents are in need of special care since they are
dependent and weak. Caring is a mutually beneficial experience for both the resident and the
nurse, as well as between all health team members. In addition, it is important to remember that
Watson emphasizes that we must care for ourselves to be able to care for others. Caring
improves patient outcomes and customer satisfaction. It is the wonder of enduring relationships
and human connection.

REVIEW OF RELATED STUDIES

Topic: The Role of Gender in the Importance of Risk Factors for Coronary Artery Disease
Bibliography: Gheisari, F., Emami, M., Shahraki, H., Samipour, S., & Nematollahi, P. (2020).
The role of gender in the importance of risk factors for coronary artery disease. Retrieved on
November 6, 2020 from doi: 10.1155/2020/6527820

Summary:
Coronary Artery Disease (CAD), also known as Ischemic Heart Disease (IHD), is the
reduction of blood supply due to the plaque build-up or atherosclerosis. CAD is often
underdiagnosed and is considered as a leading cause of mortality in female gender but a
European study showed contrasting results. Modifiable factors include abnormal lipid levels,
smoking, unhealthy diet, mental stress and nonmodifiable factors include male gender, age and
genetics. Despite the fact that the risk factors are expressed equally to male and female, the
severity of each risk factor must be taken into consideration according to this article. As
symptoms usually show late in age especially in women because of biological defense against
CAD before menopause, women diagnosed with CAD are manifested with cardiovascular risk
factors and a higher prevalence. In a reliable report, women are more vulnerable to
hypertension, diabetes and alcohol resulting in CAD than men considering the women’s
hormonal level changes after menopause, while men are more prone to hypercholesterolemia
resulting in CAD. Upon testing 1012 respondents, the age requirement is greater than 30 years
old and the mean age range is 56.4-57.4 years old. The results show that the association
between previous myocardial infarction and CAD is significantly higher in females and no
association to males, whereas association of diabetes or hypertension with CAD is equal in both
males and females. In addition, there is no association between smoking, opium addiction and

46
obesity with CAD in both genders. The results also show that an increase of 8 years in a
woman’s age and 20 years of a man’s age increases the risk of CAD for 1.5-fold. Upon
comparing related literature, it is discussed that CAD is more common in men and there are still
inconsistencies and lack of trend on association wherein some studies would conclude that
hypertension in women is significantly associated with CAD, and other risk factor associations
toward the disease is contrasting to the study. Therefore, in older age, hypertension, diabetes,
and history of myocardial infarction have significant correlation to CAD for women, while the
aforementioned comorbidities are significant risk factors for men to cardiovascular diseases.

Reaction:
Upon reading the article, despite the inconsistencies with other literature, I still agree
with this because it may be a head start for future studies that would dig deeper on the risk
factors associated with gender considering the study’s specificity. The risk factors seem to be
almost equal to both genders and the biological processes in the body are taken into account
which would suffice the support of the statements. I have realized that coronary artery disease
and other cardiovascular diseases are considered high-mortality and immediate application of
knowledge, skills and attitude on oxygenation and geriatric concepts must be applied. In my
perception, it is not necessary to be relaxed that women are more prone of having these risks or
men are vulnerable to CAD but instead in our early years, we must not abuse our organs
through unhealthy lifestyle and misconception of the disease because even having a heartache
in relationships hurts, heart diseases does not just hurt a person but it can disrupt the activities
of daily living which may lead to despair as a regret of one’s past according to Erikson’s theory. I
do not have any personal related experiences with a person having CAD or any patient that I
have encountered having cardiovascular disease, but I can say that what they have been
through is unimaginable because we cannot exactly see the pain, the attack the patient may
experience and other thoughts that could haunt them in relation to acquiring the disease. After
reading the article, the positive impact is that it gives additional knowledge to the people about
CAD specifically the significance and correlation of the risk factors towards the disease.
However, the negative impact of the article is that it can give the opportunity for other people to
be less compliant of a healthy lifestyle because they may think that since one is a male/female
with no comorbidities, he/she can remain careless in terms of lifestyle. This article benefits the
education, practice and research in the nursing field. In education, the knowledge on
cardiovascular diseases, specifically coronary artery disease is widened as it emphasizes the
risk factors. As new data are collected and new conclusions are established, nursing

47
management is also expanded and applied through practice. In nursing practice, the nurses will
be able to enhance their adeptness due to adequate knowledge provided by the article, nursing
interventions are expounded, and individualized care to the patients can be achieved. Lastly, in
the nursing research, it gives the future researchers a head start in focusing the risk factors of
CAD and enhances the field in general. As researchers are producing more and more output,
blueprints on the success and hard work of nursing is documented as manifested by established
new facts.

Title: The Incidence and Characteristic Features of Anemia in Older Patients with Coronary
Artery Disease
Bibliography: James, A., Pavliukovych, N., & Pavliukovych, O. (2018). The Incidence And
Characteristic Features Of Anemia In Older Patients With Coronary Artery Disease. Prague:
Central Bohemia University. doi:http://dx.doi.org/10.12955/cbup.v6.1270

Summary:
In the study of Kovalenko et.al, cardiovascular diseases are said to be the among the
leading cause of mortality in the country of Ukraine for many years, and many previous studies
show that the presence of anemia is associated with the increase short-term and long-term
outcomes in patients with cardiovascular diseases, especially to those with coronary artery
disease. Thus, this study aims to determine the incidence and characteristic features of anemia
in elderly and senile patients with chronic forms of coronary artery disease. The method to
gather the data uses the 1993 case reports of patients with coronary artery disease and
comorbid anemia, and among all of the examined patients, 70% were found out to have the said
comorbid.
The result of the study revealed that anemic syndrome is present in 69.89% of the
population, that is, around 1393 cases. Among these cases, men have a higher number than in
females, especially in the ages 60 years and above. Mild anemia is the most frequently found in
CAD patients with a total number of 1317 cases, followed by moderate degree of anemia and
severe anemia in 11 patients. With this information, a comparison was made on the incidence of
comorbid anemia depending on the form of chronic CAD. It was then found out that anemia
complicated the course of stable angina pectoris and post-infarction or diffuse cardiosclerosis.
In conclusion, coronary artery disease are complicated by the comorbid anemia and has
affected the patient’s stay in the hospital. CAD accompanied with mild anemia has an average

48
of 18 days in-hospital treatment duration, while moderate anemia is about 20 days and severe
anemia for 21 days.

Reaction:
Based on the results, I was once again reminded of the importance of holistic care that
should be given to any patient. A nurse must not only focus on treating the diagnosis or disease
of the client, but should also observe for an underlying illness. The severity of anemia affected
the number of hospital days of the patient, and in order to help them improve faster, a nurse
should also address the other problem.
For the nursing implication, more similar studies should be created under nursing
research, specifically on other comorbid that may further complicate coronary artery disease.
The information from these researches can be used to strengthen the nursing education,
emphasizing holistic care to the patient. For the nursing practice, student nurses should bear in
mind that anemia can contribute to the progress of CAD if ever they are assign to such case.

Title: Heart Diseases and Conditions; Findings from Mayo Clinic Reveals New Findings on
Coronary Artery Disease (Noninvasive Stress Testing for Coronary Artery Disease)
(Noninvasive Stress Testing for Coronary Artery Disease)

Bibliography: Heart Diseases and Conditions; Findings from Mayo Clinic Reveals New
Findings on Coronary Artery Disease (Noninvasive Stress Testing for Coronary Artery Disease)
(Noninvasive Stress Testing for Coronary Artery Disease)
https://search.proquest.com/docview/1562475411/E819D541CD3740D3PQ/1?
accountid=171161

Summary:

Coronary artery disease develops when the major blood vessels that supply your heart
become damaged or diseased. Cholesterol-containing deposits (plaques) in your coronary
arteries and inflammation are usually to blame for coronary artery disease. The coronary
arteries supply blood, oxygen and nutrients to your heart. A buildup of plaque can narrow these
arteries, decreasing blood flow to your heart. Eventually, the reduced blood flow may cause
chest pain (angina), shortness of breath, or other coronary artery disease signs and symptoms.
A complete blockage can cause a heart attack.

49
Because coronary artery disease often develops over decades, you might not notice a problem
until you have a significant blockage or a heart attack. But you can take steps to prevent and
treat coronary artery disease. A healthy lifestyle can make a big impact.

Reaction:

Coronary artery disease is thought to begin with damage or injury to the inner layer of a
coronary artery, sometimes as early as childhood. The damage may be caused by various
factors, including: smoking, high blood pressure, High cholesterol, diabetes or insulin resistance

As student nurse, it’s a big help to learn and to be educated about this kind of case in order for
us to properly give the right interventions and care that can help lessen and decreases various
complications that would arise due to Coronary Artery disease. We can also apply appropriate
nursing theories in order to develop the appropriate nursing care plan. This article can help us
enhance our skills and ability for our future career.

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