A Case Study

By
By Sheila
Sheila T.
T. Maniti,
Maniti, SN,
SN, PCHS
PCHS
• Cardiovascular disease is one of the leading causes of death worldwide.
According to the WHO Statistics 2006, CVD ranked fifth among the top ten
causes of death in the Philippines.
• Coronary artery disease (CAD) is the most common type of cardiovascular
disease, and is responsible for most deaths in both men and women, among
developed countries.
• CAD affects people of all races, but the incidence is extremely high among
blacks and Southeast Asians. It occurs in about 5 to 9% of people aged 20
and older. The death rate increases with age and overall is higher for men
than for women, particularly between the ages of 35 and 55.
• Men develop it 10 years earlier than women because, until menopause,
women are protected by high levels of estrogen. After age 55, the death rate
for men declines, and the rate for women continues to climb. After age 70 to
75, the death rate for women exceeds that for men who are the same age.
Patient name : FMT
Hospital no : 906608
Rank : Civilian
Sex : Female
Age : 60 yrs. old
Birthday : September 28, 1949
Marital status : Married
No. of children : Three
Religion : Roman Catholic
Address : Rodriguez Ave, Zone 5, Signal
Village, Taguig City
Date admitted : September 8, 2009/ 1400H
Chief Complaint : Severe chest pain with difficulty of
breathing
Diagnosis : CAD, ACS, Unstable Angina
Braunwald Class II B2, HCVD, FCII
Six hours prior to admission, patient experienced chest pain with
pricking sensation, as well as some shortness of breath. This
prompted her to consult a physician at the Air Force General Hospital,
wherein she was told that she was having a case of MI or myocardial
infarction and she was given some medications (ASA and Isosorbide
Dinitrate).

Later that same day, the doctors at AFGH decided to transfer the
patient to the Armed Forces of the Philippines Medical Center (AFPMC
- V. Luna) Medical Intensive Care Unit for further evaluation and
management.

Upon admission at AFPMC, the patient was conscious and coherent,

afebrile, and still complains of chest pain, dyspnea, and nausea and
vomiting. Her vital signs were taken and results were: BP=130/80,
CR=65, RR=22, T=36.3C.
Previous illness : Diagnosed with hypertension at
the age of 40
Previous hospitalization : During the delivery of her three
children and in 1989 for an
oophorectomy procedure
Allergies : NKA
Medications : Amlodipine (daily maintenance)
Family diseases : Hypertension (mother’s side)

Social history
Patient occupies herself daily as a housewife, taking care of the needs of
her husband and her children. She is well-educated, having attended
college, but was unable to graduate. She is not a member of any
organization in her community. She used to drink alcoholic beverages
occasionally and smoked 3-5 sticks of cigarettes a day prior to her
confinement.
 Pattern of Prior to Admission Current Assessment
Functional
Health
Health She used to have a carefree Being diagnosed with CAD jolted her
Perception & attitude when it comes to her into reevaluating her lifestyle. She is
Management health. Even after being now resolved to take better care of her
diagnosed with hypertension at self and stop her unhealthy habits (i.e.
age 40, aside from taking a smoking & drinking) and is even
prescribed daily maintenance telling her loved ones and friends to do
medication, her unhealthy the same.
lifestyle did not change.
Nutritional – She eats 3 full meals a day, Has nausea & vomiting. Doctor
Metabolic plus 1 to 2 snacks in between. ordered a low-salt, low-cholesterol
She used to be fond of fried, diet. She admits that her appetite is
fatty foods and preferred meat not as satisfied but she knows that she
rather than vegetables and fish. must stick to the right diet in order to
get better.
 Pattern of Prior to Admission Current Assessment
Functional
Health
Elimination She used to void around 4 Her urinary pattern remains the
times a day. She regularly same. At present, she has not yet
moves her bowel once a day. moved her bowels since the day of
She used to complain about her confinement. She is taking
the hardness of her stool. Lactulose to avoid constipation.

Activity & Her daily physical activity Due to her illness, the doctor
Exercise would be doing household ordered her to have complete bedrest
chores in the morning. She with bathroom privileges. However,
did not have any regular she plans to a regular exercise
exercise. schedule once her health is better.
 Pattern of Prior to Admission Current Assessment
Functional
Health
Cognitive- She does not have any mental or Her illness did not seem to have
Perceptual sensory function deficiency. She altered her cognitive and
can use her five senses well and perceptual functions. She
can express her self clearly and remains able to use the full
logically. function of her senses and is still
able to communicate really well.

Sleep & Rest She used to sleep around 7 hours Upon confinement, she feels that
at night, by usually going to bed all she does now sleep. She
at 11pm and waking up at 6am. wants to rest really well so that
During the day, she would her body could recover quickly.
sometimes take a 1-hour nap in
the afternoon.
 Pattern of Prior to Admission Current Assessment
Functional
Health
Self She used to be a “happy-go- Her illness made her reexamine her
Perception lucky” person prior to her views about her self and her life and she
and Self confinement. feels that she should value her self better
Concept from now on.
Sexuality & She disclosed that she is not Her illness has not altered her sexuality
Reproductive really sexually active and reproductive pattern.
anymore.
Role- She had a good relationship She has gotten closer to her family, who
Relationship with her husband and has now become her caregivers while in
children. However, she does the hospital. She also got to spend more
not have any other role except time with her siblings who often visit
that of being a housewife and her, along with her nieces and nephews.
mother.
 Pattern of Prior to Admission Current Assessment
Functional
Health

Coping & She used to become She feels that she should learn how to
Stress easily irritated by small relax and not be easily affected by minor
Tolerance things and would often issues. She wants to start enjoying life
nag her husband and more with her loved ones.
children when she feels
stressed out.

Values & She did not pray nor Her illness made her closer to God, who
Belief attend the Catholic she believes is the only one who is in
church regularly. control of her life. She plans to attend
mass regularly after being discharged
from the hospital.
Body Part/ Assessment Significant findings
System Techniques
Skin/ Face Inspection Skin is slightly pale, smooth texture, and cool temperature
Palpation (36 C). Skin turgor is normal. Pallor is also evident in the
face. No involuntary movements nor signs of fac paralysis.
Auscultation
Nails Inspection Nails are kept short and clean. No signs of clubbing.
Head/ Hair Inspection Size is proportional to the body, with no areas of tenderness.
Palpation Hair is black and evenly distributed, fine and thin, free
from split ends. The scalp is white, clean, free from lumps,
scars and dandruff. Has moderate headache with pain scale
level of 3/10 accompanied by nausea.
Eyes Inspection No secretion, no erythema. Conjunctiva are pink, shiny,
and moist. The sclera are white and clear. Irises are pro-
portional to the size of the eye, round, black & symmetrical.
Pupils equal in size and shape, and reactive to light.
Reports slight decrease in visual acuity upon confinement.
Body Part/ Assessment Significant findings
System Techniques

Ears Inspection Both are parallel, proportional to the size of the head, bean-
shaped. The helix is in line with the outer cantus of the eyes.
Ear canals are pinkish, clean, with scant amount of
cerumen and few cilia. Sense of hearing is normal.

Nose Inspection Both nostrils are patent, there is presence of cilia and some
mucous in the internal sare. Nasal flaring is evident, esp.
during episodes of dyspnea. Nasal cannula is inserted for
oxygenation at 3L/min. Sense of smell is highly functional.
Mouth Inspection Lips are pale, symmetrical. Mucous membranes are pink
and moist. No swelling of gums, and tonsils are not
inflamed. Teeth are yellowish and properly aligned.
Tongue is medium sized and freely movable. Sense of taste
is highly functional.
 Body Part/ Assessment Significant findings
System Techniques
Neck/ Throat Inspection Neck is proportional in size, no palpable mass nor area of
Palpation tenderness. Has no difficulty in swallowing, nor
Auscultation hoarseness of voice. Performs range of motion without
difficulty. There is slight jugular vein distention, and
presence of carotid bruit upon auscultation.
Breasts and Inspection No abnormal masses or lumps. Left breast slightly larger
axillae Palpation than the right. No enlarged axillary lymph nodes.
Chest/ Lungs Inspection Chest pain characterized as frequent, oppressive, crushing
(Respiratory) Palpation pain (pain scale level of 6/10) in the center of the chest,
Percussion that radiates to the left shoulder and arm that is felt even
when at rest. There is shortness of breath and slight
Auscultation tachypnea (RR=23). Chest wall is symmetrical. No other
abnormalities like chest retractions nor abnormal breath
and lung sounds were observed.
 Body Part/ Assessment Significant findings
System Techniques
Heart/ Vessels Inspection Normal heart rate (HR=78), elevated BP (160/100),
(Cardiovascular) Palpation diffused apical impulse, distant heart sounds with 3rd
Auscultation and 4th heart sounds detected during auscultation.

Abdomen Inspection Skin is flabby, soft, globular. No tenderness or

(Gastrointestinal) Palpation abnormal mass. Complains of nausea and vomiting,
Percussion esp. during onset of chest pain.

Upper extremities Inspection Tingling pain in left shoulder and arms. Pale, moist,
Palpation cool skin especially in the left upper extremity.
Weakness of extremities. Able to do full range of
motion. Radial pulse is weak in strength, but with
normal, regular rhythm.
 Body Part/ Assessment Significant findings
System Techniques

Lower extremities Inspection Normal skin color and temperature of both lower
Palpation extremities. No edema present. Weakness of
extremities. Able to do full range of motion.
Dorsalis pedis pulse was hard to palpate.

Genitalia Inspection No abnormal discharges, lesions. Scars from

(Genitourinary) previous child births present. Urinary output is
normal.

Anus Inspection Patent anus, no abnormal lesions. No hemorrhoids.

No bowel movement since hospital admission.
Diagnostic Result Significance
Test

12-lead •ECG during chest pain A resting 12-lead electrocardiogram should

ECG showed sinus rhythm, normal be obtained on all patients with suspected
(Electrocar- axis, biphasic T-wave in V4- CAD. ECG results are normal in
diogram) V5, and minimal ST approximately 50% of patients with chronic
depression in V6. stable angina, and can remain normal
•A repeat ECG taken 30 during an episode of chest discomfort.
minutes after pain relief Importantly, a normal electrocardiogram
showed 1mm ST elevation does not exclude coronary artery disease.
with biphasic T-wave in V1 depression of the ST segment or T wave
– V3 and 1 mm ST inversion signifies ischemia. Dysrhythmias
depression with T-inversion and heart block may also be present.
in V4 – V6. Significant Q waves are consistent with a
prior MI.
 Diagnostic Test Result Significance

Chest X-Ray AP Normal Chest x-ray results for CAD patients are sually
(Sitting Position) normal; however, infiltrates may be present,
reflecting cardiac decompensation or
pulmonary complications.

2D Result not yet This is invaluable for assessing the patient

Echocardiogram available during with suspected hypertrophic cardiomyopathy
time of data and is also recommended for the assessment of
left ventricular systolic function in patients
gathering. who have congestive heart failure, complex
ventricular arrhythmias, or a history of a past
myocardial infarction.
 Cardiac Computed Tomography Angiography. A noninvasive imaging
assessment of coronary atherosclerosis is now possible. When negative, this
test possesses a high negative predictive value. The positive predictive value is
also high but exact stenosis quantification can be complicated. Associated
calcification can cause a blooming artifact, resulting in an overestimation of
stenosis severity.

 Stress Testing Exercise or pharmacological stress electrocardiography.

This provides more diagnostic information, such as duration and level of activity
attained before onset of angina. A markedly positive test is indicative of severe
CAD. Studies have shown stress echo studies to be more accurate in some
groups than exercise stress testing alone. Nuclear imaging studies (rest or
stress scan) done with Thallium-201 may also be considered. Ischemic regions
appear as areas of decreased thallium uptake.

 MUGA (Multi-Gated Acquisition Scan). Evaluates specific and general

ventricle performance, regional wall motion, and ejection fraction.
• Ergonovine (Ergotrate) Injection.
On occasion, this may be used for
patients who have angina at rest to
demonstrate hyperspastic coronary
vessels.
• Coronary Arteriography. Cardiac
catheterization with angiography is
the definitive test for CAD in
patients with known ischemic
disease with angina or
incapacitating chest pain, in patients
with cholesterolemia and familial
heart disease who are experiencing
chest pain, and in patients with
abnormal resting ECGs.
The major vessels of the coronary circulation
are the left main coronary that divides into
left anterior descending and circumflex
branches, and the right main coronary artery.
The left and right coronary arteries originate
at the base of the aorta from openings called
the coronary ostia located behind the aortic
valve leaflets. The left and right coronary
arteries and their branches lie on the surface
of the heart, and therefore are sometimes
referred to as the epicardial coronary
vessels. These vessels distribute blood flow
to different regions of the heart muscle. It is
the small arteries and arterioles in the
microcirculation that are the primary site for
regulation of blood flow.
• Flow is tightly coupled to oxygen demand.  This is necessary because the heart
has a very high basal O2 consumption. In non-diseased coronary vessels,
whenever cardiac activity and O2 consumption increases, the increase in
coronary blood flow is nearly proportionate to the increase in O2 consumption.
• Good autoregulation bet. 60-200 mmHg perfusion pressure helps to maintain
normal coronary blood flow whenever coronary perfusion pressure changes due to
changes in aortic pressure.
• Sympathetic activation to the heart results in coronary vasodilation and increased
coronary flow due to increased metabolic activity (increased HR, contractility)
despite direct vasoconstrictor effects of sympathetic activation on the coronaries.
This is termed "functional sympatholysis."
• Parasympathetic stimulation of the heart elicits modest coronary vasodilation (due
to the direct effects of released acetylcholine on the coronaries).
• A coronary artery must be narrowed to <30% of its original size before there is a
serious reduction in the blood flow to the heart muscle served by that vessel.
Generally, about 5% of the total cardiac output of blood goes through the coronary
arteries; thus there is adequate coronary blood flow to meet normal demands at
rest even if the vessels are 70 to 90% occluded.
Laboratory Result Normal values Significance
tests Increase Decrease
Hematology
Hemoglobin 138 140-170 g/L M) Polycythemia, COPD, failure Various anemias,
120-170 g/L (F) of oxygenation because of pregnancy, severe or
congestive heart failure and prolonged hemorrhage
normally in people living at and with excessive fluid
high altitudes intake
Hematocrit 0.41 0.40-0.50 (M) Erythrocytosis of any cause, Severe anemias, anemia
0.38-0.48 (F) and in dehydration or of pregnancy, acute
hemoconcentration associated massive blood loss
with shock
RBC 4.87 4.6-6.2 x Severe diarrhea and Anemia, leukemia, and
1012/L (M) dehydration, polycythemia, after hemorrhage when
4.2-5.4 x acute poisoning, pulmonary blood volume has been
1012/L (F) fibrosis restored
WBC 11.60 4.5-11 x 109/L Infectious mononucleosis, Aplastic anemia,
viral and some bacterial immunodeficiency
infections, hepatitis including AIDS
 Lab Result Normal Significance
tests values Increase Decrease
Hematology
Platelet 343 200-400 x Malignancy, myeloproliferative Thrombocytopenic purpura,
count 109/L disease, rheumatoid arthritis acute leukemia, aplastic anemia
and postoperatively & during cancer chemotherapy
PT 10.7 10-14 sec. Prolonged by deficiency of factors I, II, V, VII & X, fat mal-
INR 0.97 1.0 absorption, severe liver disease, coumarin anticoagulation therapy

Electrolytes
Na 141 135-145 Excessive levels of sodium ions result in depression of cardiac
mmol/L function, which is thought to stem from their competition with
calcium ions at some critical site during the contractile process.
At the other extreme, a deficiency of sodium ions in the
extracellular environment leads to the development of a
potentially lethal condition called cardiac fibrillation. In this
situation, the cardiac muscle contracts at an extremely high rate
and in an uncoordinated fashion such that little or no blood is
actually pumped by the heart.
 Lab Result Normal Significance
tests values Increase Decrease
Electrolytes
K 3.0 3.5-5 An excess of potassium ions in the extracellular environment
mmol/L markedly reduces the heart rate as well as the strength of
contraction
Ca 2.11 2.2- Spastic contraction of the heart results from the presence of
2.6 mmol/ excess calcium ions. This typically results from the direct effects
L of calcium ions upon the contractile process of cardiac muscle. A
marked reduction in the calcium ion concentration has effects
similar to those observed with high potassium levels.
CK Isoenzyme & Hepatic Enzyme
Serum 49 62-124 People with high levels of the substance creatinine in their blood
Creatini umol/L were five times more likely to die of heart attack or stroke than
ne those with low levels
SGPT 19.3 10-44 U/L An increase in SGPT signifies myocardial Infarction, skeletal
(ALT) muscle disease, liver disease
 Laboratory studies recommended as a part of the initial
evaluation of patients with coronary artery disease should include
determination of fasting glucose and fasting lipid levels (total
cholesterol, high-density lipoprotein [HDL] cholesterol, triglycerides,
and calculated low-density lipoprotein [LDL] levels).

Other markers such as lipoprotein (a) (Lp[a]) and high-

sensitivity C-reactive protein, may be useful in assessing cardiac risk.
High-sensitivity C-reactive protein is gaining greater prominence in
assessing the inflammatory level of vascular disease and predicting
future risk of vascular events, such as myocardial infarctions and
cerebrovascular accidents.
 RISK FACTORS
(family history of hypertension, sedentary lifestyle, cigarette smoking)

GRADUAL BUILDUP OF ARTHEROSCLEROTIC PLAQUE

(process of artherosclerosis)

CORONARY ARTERY BECOMES BLOCKED

INADEQUATE BLOOD SUPPLY TO HEART MUSCLE

(myocardial ischemia)

PLAQUE RUPTURE
(may be triggered by physical exertion, mechanical stress due to an increase in
cardiac contractility, pulse rate, blood pressure, and possibly, vasoconstriction)

THROMBUS OR BLOOD CLOT FORMATION

ACUTE CORONARY SYNDROMES

(due to further blocking of coronary artery)

UNSTABLE ANGINA ACUTE MYOCARDIAL INFARCTION

(with incomplete coronary occlusion) (with complete coronary occlusion)
• Coronary artery disease is a chronic process that begins during adolescence and
slowly progresses throughout life. Independent risk factors include a family history of
premature coronary artery disease, cigarette smoking, diabetes mellitus, hypertension,
hyperlipidemia, sedentary lifestyle, and obesity. These risk factors accelerate or
modify a complex and chronic inflammatory process that ultimately manifests as
fibrous atherosclerotic plaque, which is the gradual buildup of cholesterol and other
fatty materials in the wall of a coronary artery.
• As an atheroma grows, it may bulge into the artery, narrowing the interior (lumen) of
the artery and partially blocking blood flow. As an atheroma blocks more and more of
a coronary artery, the supply of oxygen-rich blood to the heart muscle (myocardium)
can become inadequate. The blood supply is more likely to be inadequate during
exertion, when the heart muscle requires more blood. An inadequate blood supply to
the heart muscle (from any cause) is called myocardial ischemia.
• The rupture of an atheroma often triggers the formation of a blood clot (thrombus).
The clot further narrows or completely blocks the artery, causing acute myocardial
ischemia. The consequences of this acute ischemia are referred to as acute coronary
syndromes. These syndromes include unstable angina and several types of heart attack,
depending on the location and degree of the blockage. In a heart attack, the area of the
heart muscle supplied by the blocked artery dies.
Angina is not a disease itself. It is the primary symptom of coronary artery
disease.  Angina can also be a warning sign of heart attack. 
The most common symptoms of angina are:
• Increased heart rate.
• Increased blood pressure.
• Chest pain described as a feeling of tightness, pressure, heaviness,
squeezing, or burning. This pain is usually on the left side and radiates
to the lower jaw, neck, shoulder, back, arm, or hand.
Other symptoms of angina include burning in throat, feelings of
indigestion
and shortness of breath.
Unstable angina is "unstable" not only because a plaque has ruptured (a
situation which always threatens to progress to a myocardial infarction),
but also because the symptoms it produces - the angina – generally
occurs much more frequently, often at rest, lasts much longer, and begins
responding poorly to nitroglycerin.
In planning the appropriate nursing care for this particular case study,
specific goals were formulated, which include the relief of pain and
ischemic signs and symptoms, prevention of further myocardial damage,
maintenance of or attainment of adequate cardiac output and tissue
perfusion, reduced anxiety, absence of complications, and adherence to
self-care program. The problems listed below are prioritized according
to Maslow’s Hierarchy of Needs.

Actual Nursing Problems 1. Acute pain

2. Decreased cardiac output
3. Impaired gas exchange
Potential Nursing Problems 4. Anxiety
5. Constipation
6. Ineffective therapeutic regimen
management
M = medication
• Explain the rationale for, side effects of, & importance of taking prescribed medications.
• Inform client of pertinent food and drug interactions.
• Instruct client to take lipid-lowering agents (e.g., HMG-CoA reductase inhibitors
["statins"], gemfibrozil, ezetimibe, niacin) and antiplatelet agents (e.g., aspirin,
clopidogrel) as prescribed.
• Instruct client to consult physician before taking other prescription and nonprescription
medications
• Instruct client to inform all health care providers of meds being taken
E = exercise & daily activities
• Gradually increase activity by engaging in a regular aerobic exercise program
• Avoid strenuous exercise and activities that involve pushing or lifting heavy objects
• Avoid exercising for at least an hour after eating and exercise with caution at higher
altitude and when the environmental temperature is extremely hot or cold
• Avoid tobacco use before exercise
• Rest between activities
• Stop any activity that causes shortness of breath, palpitations, dizziness, or extreme
fatigue or weakness
• Begin a cardiovascular fitness program if recommended by physician
T = Treatment
The non-surgical treatments for CAD include changes in lifestyle and use of medications.
At times, coronary angiography, an invasive diagnostic procedure, is the only invasive
procedure done to a CAD patient. But when medications and lifestyle changes are not able
to control symptoms or the narrowing progresses to a point that the heart muscle is at risk
for invasive procedures (surgery) called percutaneous coronary interventions or PCI’s.

Care of the client after coronary angiography

1. Assess vital signs, catheterization site for bleeding or hematoma, peripheral pulses, and
neurovascular status q15 min. for first hour, q30 min. for the next hour, then q1H x 4 hrs.
2. Maintain bed rest usually for 6 hrs. If the femoral artery is used, or 2-3 hrs. if the brachial
site is used. The head of the bed may be raised to 30 degrees.
3. Keep a pressure dressing, sandbag, or ice pack in place over the arterial access site. Check
frequently for bleeding
4. Instruct to avoid flexing or hyperextending the affected extremity for 12 to 24 hours.
5. Unless contraindicated, encourage liberal fluid intake. This promotes excretion of the
contrast medium,reducing the risk of toxicity (particularly to the kidneys).
6. Promptly report diminished peripheral pulses, formation of or enlargement of hematoma,
severe pain at the insertion site or in the affected extremity, chest pain, or dyspnea.
7. Provide instructions about dressing changes, follow-up appointments, and potential
complications prior to discharge.
T = Treatment

Care after percutaneous coronary intervention (PCI)

1. Nursing care includes assessment, recognition, and effective
management ofcomplications; patient comfort and safety
2. All episodes of chest pain should be reported to a physician.
3. Bed rest guidelines vary from 3-6 hours depending on the procedure.
4. Immobilization of the affected extremity is indicated during the period of bed rest.
5. Assessment of the PCI access sites includes monitoring the arterial and venous puncture sites
for bleeding, hematoma, ecchymosis, localized tenderness, a pulsating mass, and new bruits.
Assessment of peripheral circulation includes evaluation of bilateral pulses for comparison,
warmth and color of the affected extremity, and capillary refill.
6. Patients should be advised to avoid strenuous activity the week after the PCI procedure, but
they may resume walking and driving in 48 hours.
7. Patients should seek medical assistance if they have expansion of and/or pulsation in the
groin swelling, new or significantly worsening discoloration, leg weakness, numbness, or
pallor, redness, warmth at the access site, or puslike drainage from the site.
H = Health Teaching on Necessary Lifestyle Changes
• Assist client to identify changes in lifestyle that can help him/her to eliminate or reduce
the modifiable risk factors for CAD (e.g., dietary modification, physical exercise on a
regular basis, moderation of alcohol intake, smoking cessation).
• Inform the client of factors that may precipitate angina pectoris (e.g., strenuous or
isometric exercises, consumption of a large meal, exposure to extreme cold, strong
emotions, smoking).
• Encourage to achieve and maintain ideal body weight.
• Inform that uncontrolled stress or anger is linked to increased coronary artery disease
risk. It is good to learn skills such as time management, relaxation, or yoga.
• Blood pressure control is an important goal, systolic and diastolic blood pressures
should be in the normal range (systolic less than 135 mm Hg, diastolic less than 85 mm
Hg).
• Encourage client to limit daily alcohol consumption (daily alcohol intake exceeding 1 oz
of ethanol may contribute to the development of hypertension and heart disease).
• Teach client how to count his/her pulse, being alert to the regularity of the rhythm.
• Stress the importance of reporting the following signs and symptoms:
irregular, abnormally fast or slow pulse shortness of breath
diminished activity tolerance swelling of feet or ankles
increase in severity or frequency of angina attacks
O = Outpatient Instructions and Follow-ups
• Reinforce the importance of keeping follow-up appointments.
• Implement measures to improve client compliance
• Include significant others in teaching sessions if possible
• Encourage questions & allow time for reinforcement and clarification of information.
• Provide written instructions regarding future appointments, dietary modifications, activity
level, medications prescribed, & signs and symptoms to report.

D = Diet
• Provide instructions on how the client can reduce intake of saturated fat & cholesterol:
1.reduce intake of meat fat (e.g., trim visible fat off meat; replace fatty meats such as fatty cuts of
steak, hamburger, and processed meats with leaner products)
2. reduce intake of milk fat (avoid dairy products containing more than 1% fat)
3. reduce intake of trans fats (e.g., avoid stick margarine and shortening)
4. use vegetable oil rather than coconut or palm oil in cooking and food preparation
5. use cooking methods such as steaming, baking, broiling, poaching, microwaving, and grilling
6. restrict intake of eggs
• Encourage client to increase intake of omega-3 fatty acids (e.g., flaxseed, cold water
ocean fish such as salmon and halibut) to help lower triglycerides and increase HDLs.
D = Diet S = Spiritual/ Sexual Acitivities
• Encourage patient, as well as patient’s
relatives to seek spiritual support.
• Encourage patient’s husband on
alternative ways on showing affections
such as hugs and kisses.
• Avoid intercourse for at least 1-2
hours after a heavy meal or alcohol
consumption and when fatigued or
stressed
• Engage in sexual activity in a familiar
environment and in a position that
minimizes exertion (e.g., side-lying,
partner on top)
• Recognize that a new sexual
relationship can be started but may result
in greater energy expenditure initially
•Avoid hot or cold showers just before
and after intercourse.