Colegio de San Juan de Letran – Calamba

School of Nursing
Bucal, Calamba City

Prepared by: the remedial group, untouchable!!!!

Coronary Artery Disease

Overview of the disease

What is coronary artery disease?

Coronary artery disease occurs when fatty deposits called plaque (say "plak") build up inside the coronary arteries. The coronary arteries
wrap around the heart and supply it with blood and oxygen. When plaque builds up, it narrows the arteries and reduces the amount of blood
that gets to your heart. This can lead to serious problems, including heart attack.

Coronary artery disease (also called CAD) is the most common type of heart disease. It is also the number one killer of both men and
women.

It can be a shock to find out that you have coronary artery disease. Many people only find out when they have a heart attack. Whether
or not you have had a heart attack, there are many things you can do to slow coronary artery disease and reduce your risk of future problems.

Coronary artery disease is caused by hardening of the arteries, or atherosclerosis. Atherosclerosis occurs when plaque builds up inside the
arteries. (Arteries are the blood vessels that carry oxygen-rich blood throughout your body.) Atherosclerosis can affect any arteries in the body.
When it occurs in the arteries that supply blood to the heart, it is called coronary artery disease.
I. Clinical Summary
a. General Data
i. Name: Mr. LMNOP
ii. Age: 76 y.o.
iii. Birthplace: Los Baños, Laguna
iv. Sex: Male
v. Religion: Dating Daan
vi. Civil Status: Married
vii. Address: Maahas, Los Baños, Laguna
viii. Date Admitted: February 16, 2010
ix. Time Admitted: 12 Noon
x. Attending Physician: Dr. Azarin
b. Clinical impression
Coronary Artery Disease

c. History of Present illness

A week prior to admission the patient experienced fatigue when he was walking to church. He easily gets tired when doing his
daily activities.
2 days prior to admission, He was having chest discomforts and feels weak the whole day.
Few hours before admission, Mr. LMNOP He experience severe crashing pain in his chest and feels heavy like an elephant
stepping on it.
 Past Medical History
 Mr. LMNOP has been Hypertensive for 3 years
 He was diagnosed with Diabetes Mellitus last year 2009-May
 He sober smoking for 10 years
 He is obese and has increased blood lipid levels

d. Physical Assessment

MUSCLES Method Normal Findings Interpretation

Muscle size and Inspection Proportionate the body; even in Disproportionate body; Abnormal
comparison on the other both sides even in both sides
side (+) Edema
Fasciculation and tremors Inspection No fasciculation and tremors Has no fasciculation and Normal
in the muscles tremors
Muscle Strength Has equal muscular strength on Has equal muscle Normal
both sides strength on both sides
JOINTS
Joint Swelling Inspection No swelling, no warmth, no No swelling, no warmth, Normal
redness, no pain, no crepitus no redness, no pain, no
crepitus
EXTREMETIES Inspection, No swelling, no warmth, no No swelling, no warmth, Normal
Palpation redness, no pain no redness, no pain
Muscle Strength

(+5) Active motion against full +4 active motion against Abnormal

Left Arm MNT Grading resistance some resistance
 System

(+5) Active motion against full +4 active motion against

resistance some resistance Abnormal

Right Arm
(+5) Active motion against full +4 active motion against
resistance some resistance

Abnormal

Left Leg (+5) Active motion against full +4 active motion against
resistance some resistance

Abnormal

Right Leg
 e. Anatomy and Physiology

1. Right Coronary
2. Left Anterior Descending
3. Left Circumflex
4. Superior Vena Cava
5. Inferior Vena Cava
6. Aorta
7. Pulmonary Artery
8. Pulmonary Vein
 9. Right Atrium
10. Right Ventricle
11. Left Atrium
12. Left Ventricle
13. Papillary Muscles
14. Chordae Tendineae
15. Tricuspid Valve
16. Mitral Valve
17. Pulmonary Valve
Aortic Valve (Not pictured)

Coronary Arteries

Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have a constant supply
of oxygen and nutrients. The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle
tissue.

The blood leaving the left ventricle exits through the aorta, the bodyÕs main artery. Two coronary arteries, referred to as the "left" and
"right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart.

The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is
less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary
artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery
circles around the left side of the heart and is embedded in the surface of the back of the heart.
Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the
heart; however, the smaller branches penetrate the heart muscle. The smallest branches, called capillaries, are so narrow that the red blood
cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with
carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver.

When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the
coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function
properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial
infarction or heart attack.
Superior Vena Cava

The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the head and upper
body feed into the superior vena cava, which empties into the right atrium of the heart.
Inferior Vena Cava

The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower
torso feed into the inferior vena cava, which empties into the right atrium of the heart.
Aorta

The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood
from the left ventricle to the various parts of the body.
Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all
arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart.
Pulmonary Vein
The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry
de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart.
Right Atrium

The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs
and lower torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-
like manner. The tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated blood collected in
the right atrium to flow into the right ventricle.
Right Ventricle

The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve leading into the pulmonary artery is closed,
allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the tricuspid valve closes and
the pulmonary valve opens. The closure of the tricuspid valve prevents blood from backing into the right atrium and the opening of the
pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs.
Left Atrium

The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node
progresses through the atria, the blood passes through the mitral valve into the left ventricle.
Left Ventricle

The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The
aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left
ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left
atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body.
Papillary Muscles
The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to
the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles opens these valves.
When the papillary muscles relax, the valves close.
Chordae Tendineae

The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left
ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the
respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart
strings."
Tricuspid Valve

The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to
flow into the right ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to
exit through the pulmonary valve into the pulmonary artery.
Mitral Value

The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into
the left ventricle. It closes as the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through
the aortic valve into the aorta.
Pulmonary Valve

The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated
blood collected in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart.
Aortic Valve
The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left
ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart.

f. Pathophysiology
Drug Classification Action Indication Contraindication Side effects Nursing
Consideration
Isosorbide Anti-Anginal Isosorbide Long-term Acute MI w/ low- Headaches, Development of
mononitrate Drugs  mononitrate has a treatment filling pressures, nausea, tolerance may
direct relaxant of ischaemic left heart failure vomiting, occur with all forms
effect on vascular heart disease. w/ low-filling transient skin of nitrate therapy
smooth muscle and Prevention pressures, shock, disorders particularly with
leads to of angina attac very low BP, (flushing) and the long-acting
vasodilation. ISMN ks. Follow-up hypertrophic allergic skin preparations that
causes dilatation treatment of obstructive reactions may maintain
particularly of heart attacks cardiomyopathy, sometimes continuously high
venous vessels. The when constrictive occur, plasma nitrate
blood supply to the symptoms of pericarditis, rise in the pulse concentration.
heart is reduced angina pericardial rate and with
and the preload persist. Pulmo tamponade, dizziness and Isosorbide
causes a fall in the nary aortic stenosis, weakness mononitrate 60 mg
raised filling hypertension. mitral stenosis, falls in bp. SR capsule is not
pressures of both Treatment of marked anemias, suitable for the
ventricles with a chronic cardia head trauma, treatment of
consequent c failure, in cerebral sudden cardiac
 reduction in combination hemorrhage, pain (eg, acute
ventricular size and w/ cardiac closed-angle anginal attack or
wall tension.  glycosides glaucoma, acute myocardial
&/or diuretics. hyperthyroidism, infarction).
concomitant
therapy w/
sildenafil,
tadalafil &
vardenafil.
Ciprofloxaci Anti- infective Treatment of Hypersensitivity Nausea, Patients w/
n Quinolones  Upper resp tract to nalidixic acid, convulsive
infections vomiting,
infections, skin & pipemidic disorders, history
including anth diarrhea,
soft tissue acid, norfloxacin,  abdominal of CNS damage,
rax, biliary
infections & ciprofloxacin & impaired renal or
tract discomfort,
uncomplicated UTI other hepatic functions.
infections, anorexia, dry
bone & joint quinolones. mouth & Psychotic reactions
infections, gas Childn <18 yr. stomatitis, can occur w/ 1st
troenteritis, go Pregnancy & insomnia, treatment
norrhea,legion lactation. dizziness, (terminate
naire's headache, treatment
disease, hematologic immediately).
meningitis, per reactions eg
itonitis, lower transient
resp tract disease in
 infections, skin leukocytes,
infections, erythrocytes,
surgical Hb, hematocrit,
infection, platelets &
prophylaxis, ty increase in
phoid & eosinophils.
paratyphoid fe
ver, typhus
& UTI
Losartan Angiotensin II  Losartan and its Treatment of Anuria or Dizziness, Should be given
Antagonists, D active metabolite HTN in hypersensitivity abdominal with caution in
iuretics  are highly bound to patients who to the other pain, edema, patients who are
plasma proteins, do not sulfonamide- palpitations, volume-depleted
primarily albumin, respond to derived drugs. back pain, and in patients
with plasma free monotherapy For pregnant cough, sinusitis, with bilateral
fractions of 1.3% alone woman: upper artery stenosis or
and 0.2%, contraindicated respiratory renal artery
respectively. The to pregnant and infection and stenosis in a
terminal t½ lactating mothers skin rash. solitary functioning
of losartanis about because of the kidney because of
2 hrs and of the unestablished the fear of
metabolite is about safety of the precipitating renal
6-9 hrs.  combination in failure in such
such population. patients. Patients
 with impaired
hepatic function
should receive the
combination with
caution for the fear
of precipitating
hepatic coma in
such patients.
Clopivaz Anticoagulants Platelet aggregation Prevention of Hematopoietic GI disturbances Monitor blood
, Antiplatelets inhibitor. Recovery atheroscleroti disorder eg & skin rashes. counts within 2 wk
& Fibrinolytics of normal platelet c events in neutropenia or Blood dyscrasia of stopping
(Thrombolytics function occurs peripheral thrombocytopeni including treatment.
)  after about 7 days. arterial a, hemorrhagic neutropenia & Discontinue
Potential disease, or diathesis or other thrombotic therapy 10-14 days
interactions may within 35 days hemorrhagic thrombocytope pre-op
occur with drugs of MI, or disorders nic purpura, &
metabolised within 6 mths associated w/ hemorrhagic
ofischemic prolonged disorders.
stroke, or bleeding time. Hepatitis &
(given w/ Increased risk of cholestatic
aspirin) in bleeding eg GI jaundice.
acute ulcer, acute Increased
coronary cerebral blood-lipid
syndrome hemorrhage or conc may occur
 w/out S-T- severe liver on long-term
segment dysfunction. therapy.
elevation.

g. Nursing Care Plan

Assessment Diagnosis Planning Interventions Evaluations

Subjective cues: Activity Intolerance After 8 hours of -Instruct and help patient -Patient’s blood
"Hindi ko kayang umihi related to imbalance implementing the to alternate periods of pressure, pulse and
sa cr, mabilis akong between oxygen supply nursing interventions, rest and activity respiratory rates remain
mapagod" as verbalized and oxygen demand as the patient will be able: R: to reduce body's normal parameter.
by the patient. evidenced by ongoing -to state sense of oxygen demand and -Patient is proficient in
O2 inhalation via nasal satisfaction with each prevent fatigue. conserving energy while
Objective cues: cannula. new level of activity - Maintain oxygen performing ADLs.
 Facial grimace attained. inhalation -Patients demonstrate
 with ongoing O2 -to demonstrate skill in -Teach patient exercises and understanding of
inhalation: 2L/min. conserving energy while for increasing strength relationship between
 with indwelling carrying intolerance with and endurance, signs and symptoms of
foley catheter deficit in oxygen supply Body Mechanics activity intolerance and

 afebrile: 36.0'C or use. Promotion: Energy deficit in oxygen supply

 BP: 100/50 -to increased level of: Management: or use.

 R: 20 breaths per Activity tolerance;
minute Endurance; Energy
conservation; Self care
Environmental  Goal met.
Management; Exercise
Therapy; Muscle
control; Oxygen
Therapy (breathing
exercise); Progressive
Muscle Relaxation,
R: which will improve
breathing and gradually
increase activity level.

Assessment Diagnosis Planning Interventions Evaluations

Subjective cues: Nutrition: Less than After implementing the -Obtained and recorded -Patient remains at or
"Masasabi kong body requirements nursing interventions,: patient's weight at the above specified weight.
masmataba ako noon related to inability to -Patient will gain at least same time everyday to -Patient and family
nakaraang 3 buwan digest or absorb 5% of his present weight obtain accurate readings. communicate
kumpara nagyon" as nutrients because change weekly. -Monitored fluid intake understanding of special
verbalized by the in normal eating pattern -Patient and family and output because body dietary needs, either
patient. as evidenced by members will weight may decrease a verbally or through
decreased in body communicate result of fluid loss. behavior.
Objective cues: weight. understanding of special -Maintained parenteral  Goal met.
 Dietary pattern:Low dietary needs. fluids,as ordered, to
sugar, Low- provide patient with
salt,Low- cholesterol needed fluids and
 Weight fluctuations electrolytes.
over 10 years. -Provide a diet prescribe
 Diarrhea for patient's specific

 Poor muscle tone condition.

(unable to ambulate) R: to improve patient's

nutritional status and
increase weight.
-Determined food
preference and provide
them within the
limitations of patient's
prescribed diet.
R: This enhances
compliance with diet
regime.
-If patient vomits,
records the amount,
color, and consistency.
Keep a record of all
stools. Vomitus and
stool characteristics
indicates status of
nutrition absorption.
-Monitored bowel
sounds once per shift.
R: Normal active sounds
may indicate readiness
for enteral feedings;
hyperactive sounds may
indicate poor absorption
and may accompanied b
diarrhea.
-Taught the principles of
good nutrition for
patient's specific
condition.
R: This encourages
patient and family
members to participate
in patient's care.
-Involved family
members in meal
planning
 R:to encourage them to
help patient comply with
diet regimen after
discharge.

Assessment Diagnosis Planning Interventions Evaluations

No verbal cues Decreased cardiac After 8 hours of - Assessed the apical and Evaluation
output related to present implementing the radial pulse.
Objective cues: illness (CAD) sa nursing interventions, - Monitored closely vital Patient did not respond
 Afebrile, T: 36.0'C evidenced by cardiac the patient's cardiac signs( Q1) paying on the expected
 + bradycardia, P: 46 rate (PR) of 43 bpm. status will stabilize. particular to pulse rate outcome.
beats per minute - there are no evidenced and cardiac rhythm. There are still evidenced
 + dysrhythmia of bradycardia and - Maintained on high of bradycardia and

 R: 20 breaths per dysrhythmia. back rest position. dysrhythmia.

minute - Maintained oxygen

 with ongoing O2 inhalation (2L/min). Goal not/ partially met.

inhalation via nasal - Instructed the patient to

cannula reduced or avoid

stressful elements such
 with indwelling
as excessive noise and
foley catheter,
light environment.
intact.
- Instructed the patient to
increased fluid intake
and dietary fiber and
advised to take natural
stool softeners such as
papaya.
- Administered
medications, as ordered
and observed for the
adversed reaction.