1. Reference: Lewis, S.M. & Dirksen, S.R. (2014). Medical surgical nursing: Assessment and management of clinical problems (9th Ed.). St. Louis, MO: Elsevier Inc.
2. Reference: Nurse Labs. (2012). 5 Coronary Artery Disease Nursing Care Plans . Retrieved from http://nurseslabs.com/5-coronary-artery-disease-nursing-care-plans/
3. Patient Information
   1. Patient is a 45 year old male who is active 3-5 days a week and enjoys hiking the Sandias and walking his 2 dogs. Patient I.M. has NKDA and is not currently taking any prescription medications. He is here for his annual "check-up" but expresses increasing concern for monitoring his cholesterol and blood pressure because he lost his father to complications of coronary artery disease at age 55. I.M. knows that his father's weight and lack of physical activity contributed to his poor prognosis but he is also seeking reassurance that his efforts to be health and active have decreased his risk for having an MI.
4. Health/Medical/Social Hx
   1. I.M.'s blood pressure is slightly elevated at 148/90, Height is 6'2" and at a weight of 210lbs his BMI is 27. Patient notes a stressful job as a financial advisor but also that he "relaxes" by walking his dogs and hiking. Patient's father died at 55 due to complications of coronary artery disease and his mother currently lives at home with her own dog and she suffers from type II diabetes and is limited physically due to rhuematoid arthritis. I.M. denies smoking and admits to drinking "socially" on the weekends but "never more than a few beers." His current diet is mostly comprised of "tv foods" that can be microwaved and ready quickly because of his "fast-paced" schedule.
5. Nursing Diagnosis
   1. Risk for decreased cardiac output related to increased vascular resistance
   2. Risk for poor tissue perfusion related to decreased cardiac output
   3. Risk for acute pain related to ischemic event of the heart
   4. Risk for decreased activity tolerance related to fatigue and imbalance for oxygen demands
6. Collaborative Problems
   1. Lack of knowledge
   2. Denial
   3. Continuation of identified unhealthy behavior
   4. Increased anxiety/worry
   5. Depression
7. Expected S/S
   1. Decreased cardiac output manifestations
      1. Restlessness
      2. Increased blood pressure
      3. Weak and thready peripheral pulses
      4. Cold extremities
   2. Poor tissue perfusion manifestations
      1. Shortness of breath
      2. Pallor
      3. Prolonged capillary refill time
      4. Easy fatigue
      5. Decreased urine output
   3. Acute Pain manifestations
      1. Irritability
      2. Trouble sleeping
      3. Subjective pain
      4. Objective pain (pain scale)
      5. Facial expressions (grimace, crying, frown)
      6. Vital sign changes (increased respirations, increased heart rate, elevated blood pressure)
      7. Diaphoresis
   4. Decreased activity tolerance manifestations
      1. Weakness
      2. Lethargy
      3. Verbalization of fatigue with previously achievable activities
      4. Disinterest in activities
8. Nursing Interventions/orders/actions
   1. Decreased cardiac output
      1. Assess patients status
      2. Monitor and record vital signs
      3. Encourage position change Q2Hours
      4. Encourage patient to verbalize subjective changes in status (pain, irritability)
      5. Provide patient with techniques for relaxation (breathing, music)
      6. Educate patient on low salt and low fat diet
   2. Poor tissue perfusion
      1. Continue to assess the patient and monitor and record vital signs
      2. Record temperature and appearance (color) of skin
      3. Assess peripheral pulses and capillary refill
      4. Encourage a warm environment and provide one while the patient is in your care
      5. Monitor and record urine output
      6. Educate and encourage patient to perform range of motion activities
   3. Acute pain
      1. Continue to assess the patient and monitor and record vital signs
      2. Assess and record the pain (location, quality, duration, time of onset, alleviating factors, provoking factors)
      3. Provide comfort (pillows, bed position)
      4. Consult physician on analgesic use or other medication options for pain relief
         1. Administer medications as ordered
      5. Promote diversional activities (converse with the patient)
      6. Stress adequate rest
   4. Decreased activity tolerance
      1. Continue to assess the patient and monitor and record vital signs
      2. Determine current activity tolerance and establish realistic goals
         1. Can patient continue current activities?
      3. Plan care to provide rest periods
      4. Educate on performing the more strenuous activities while energy levels are higher
      5. Educate on importance of assistance
      6. Assess future implications for increased activity (the care of the dogs)
9. Desired outcomes
   1. Decreased cardiac output
      1. The patient can verbalize the disease process and provide examples of activities that decrease cardiac workload
      2. The patient will take opportunities to inform health care professional of changes in status
      3. The patient will verbalize a diet low in sodium and fat
   2. Poor tissue perfusion
      1. The patient can verbalize the disease process
      2. The patient will demonstrate breathing techniques to promote oxygenation
      3. The patient will be free of shortness of breath
   3. Acute pain
      1. The patient can verbalize the disease process
      2. Patient will verbalize understanding and purpose of medications provided for pain relief
      3. Patient will provide examples of comfort measures he can take in his home in case of pain
      4. Patient will verbalize a decrease in pain according to the pain scale
      5. Patient will verbalize his tolerable level of pain (according to the pain scale)
   4. Decreased activity tolerance
      1. The patient can verbalize the disease process
      2. The patient will explain his techniques to preserve activity tolerance (continue to hike, continue to walk dogs but will rest if necessary)
10. Client optimum functioning goals
    1. This patient, currently a young and healthy male, has two main risk factors for an ischemic heart event or coronary artery disease. Both are non-modifiable risk factors one being his father's history and the second be his age. This client should have the goal of maintaining activity levels but changing his diet to include a low salt and low fat regimen. His current diet is a risk factor but as mentioned, it is modifiable.
    2. Additionally, the client desires to be free of pain and to not have his activities limited.
11. Nursing optimum functioning goals
    1. Prevention of complications
    2. Maintenance of current cardiac functioning and activity tolerance
    3. Patient is free of pain
    4. Maintain a safe environment