Acute Coronary Syndrome Nursing Diagnosis & Care Plan

Acute Coronary Syndrome (ACS) represents a range of conditions involving sudden, reduced blood flow to the heart. This nursing diagnosis focuses on identifying and managing symptoms, preventing complications, and promoting optimal recovery for patients with ACS.

Causes (Related to)

Acute Coronary Syndrome can develop due to various factors that affect cardiac function and coronary blood flow:

  • Atherosclerotic plaque rupture
  • Coronary artery thrombosis
  • Increased myocardial oxygen demand
  • Decreased myocardial oxygen supply

Risk Factors include:

  • Advanced age
  • Hypertension
  • Diabetes mellitus
  • Hyperlipidemia
  • Smoking
  • Obesity
  • Family history of cardiac disease
  • Physical inactivity
  • Stress

Contributing Conditions include:

Signs and Symptoms (As evidenced by)

Accurate identification of ACS symptoms is crucial for prompt intervention and optimal patient outcomes.

Subjective: (Patient reports)

  • Chest pain or pressure (angina)
  • Radiation of pain to arms, neck, jaw, or back
  • Shortness of breath
  • Anxiety and fear
  • Nausea
  • Dizziness
  • Fatigue
  • Sense of impending doom

Objective: (Nurse assesses)

  • ECG changes
  • Elevated cardiac enzymes
  • Diaphoresis
  • Pale or cyanotic skin
  • Irregular heart rate or rhythm
  • Abnormal vital signs
  • Decreased oxygen saturation
  • Presence of S3 or S4 heart sounds
  • Pulmonary congestion

Expected Outcomes

Successful management of ACS is indicated by:

  • Relief of chest pain and associated symptoms
  • Stabilization of vital signs
  • Improved cardiac function
  • Prevention of complications
  • Enhanced understanding of the condition
  • Successful risk factor modification
  • Improved quality of life
  • Adherence to prescribed treatment plan

Nursing Assessment

Monitor Cardiovascular Status

  • Assess chest pain characteristics
  • Monitor vital signs
  • Evaluate ECG changes
  • Track cardiac enzymes
  • Assess peripheral perfusion

Evaluate Respiratory Function

  • Monitor respiratory rate and pattern
  • Assess oxygen saturation
  • Auscultate lung sounds
  • Note work of breathing
  • Document dyspnea

Assess Pain Status

  • Evaluate pain characteristics
  • Monitor pain intensity
  • Track pain radiation
  • Document pain relief measures
  • Note associated symptoms

Monitor for Complications

  • Assess for arrhythmias
  • Watch for signs of heart failure
  • Monitor for cardiogenic shock
  • Check for bleeding (if on anticoagulation)
  • Evaluate mental status

Review Risk Factors

  • Document modifiable risk factors
  • Assess lifestyle habits
  • Review medication history
  • Check family history
  • Evaluate stress levels

Nursing Care Plans

Nursing Care Plan 1: Acute Pain

Nursing Diagnosis Statement:
Acute Pain related to reduced myocardial blood flow as evidenced by verbal reports of chest pain, radiation to the left arm, and facial grimacing.

Related Factors:

  • Myocardial ischemia
  • Coronary artery spasm
  • Increased cardiac workload
  • Anxiety and stress

Nursing Interventions and Rationales:

  1. Administer prescribed medications promptly
    Rationale: Reduces myocardial oxygen demand and relieves pain
  2. Position patient in semi-Fowler’s position
    Rationale: Reduces cardiac workload and promotes comfort
  3. Monitor pain characteristics and response to interventions
    Rationale: Enables evaluation of treatment effectiveness

Desired Outcomes:

  • Patient reports reduced or resolved chest pain
  • The patient demonstrates reduced anxiety
  • The patient maintains stable vital signs

Nursing Care Plan 2: Decreased Cardiac Output

Nursing Diagnosis Statement:
Decreased Cardiac Output related to altered myocardial contractility as evidenced by ECG changes, decreased peripheral perfusion, and fatigue.

Related Factors:

  • Reduced coronary blood flow
  • Myocardial dysfunction
  • Altered contractility
  • Dysrhythmias

Nursing Interventions and Rationales:

  1. Monitor hemodynamic parameters
    Rationale: Enables early detection of deterioration
  2. Maintain bed rest during the acute phase
    Rationale: Reduces cardiac workload
  3. Administer prescribed cardiac medications
    Rationale: Improves cardiac function and tissue perfusion

Desired Outcomes:

  • The patient maintains adequate cardiac output
  • The patient demonstrates improved tissue perfusion
  • The patient reports decreased fatigue

Nursing Care Plan 3: Anxiety

Nursing Diagnosis Statement:
Anxiety related to acute health crisis as evidenced by expressed feelings of fear, restlessness, and increased vital signs.

Related Factors:

  • Threat to health status
  • Fear of death
  • Uncertainty about prognosis
  • Change in health status

Nursing Interventions and Rationales:

  1. Provide clear, concise information
    Rationale: Reduces fear of the unknown and promotes understanding
  2. Maintain a calm, reassuring presence
    Rationale: Helps reduce anxiety and promotes trust
  3. Teach relaxation techniques
    Rationale: Provides coping mechanisms and reduces stress

Desired Outcomes:

  • The patient demonstrates reduced anxiety levels
  • The patient uses effective coping strategies
  • The patient verbalizes understanding of the condition

Nursing Care Plan 4: Risk for Decreased Tissue Perfusion

Nursing Diagnosis Statement:
Risk for Decreased Tissue Perfusion related to reduced coronary blood flow as evidenced by ECG changes and elevated cardiac enzymes.

Related Factors:

  • Atherosclerotic changes
  • Coronary artery spasm
  • Thrombus formation
  • Altered blood flow

Nursing Interventions and Rationales:

  1. Monitor vital signs and hemodynamic status
    Rationale: Enables early detection of perfusion changes
  2. Assess peripheral circulation
    Rationale: Indicates adequacy of tissue perfusion
  3. Position to optimize blood flow
    Rationale: Promotes optimal tissue perfusion

Desired Outcomes:

  • The patient maintains adequate tissue perfusion
  • The patient demonstrates stable vital signs
  • The patient shows no signs of complications

Nursing Care Plan 5: Knowledge Deficit

Nursing Diagnosis Statement:
Knowledge Deficit related to lack of exposure to information about ACS as evidenced by questions about the condition and expressed uncertainty about self-care measures.

Related Factors:

  • Lack of exposure to information
  • Misinterpretation of information
  • Unfamiliarity with resources
  • Anxiety affecting learning

Nursing Interventions and Rationales:

  1. Provide education about condition and management
    Rationale: Promotes understanding and compliance
  2. Teach about risk factor modification
    Rationale: Empowers patient to make lifestyle changes
  3. Instruct about medication regime
    Rationale: Ensures proper medication adherence

Desired Outcomes:

  • Patient verbalizes understanding of the condition
  • The patient demonstrates proper medication administration
  • The patient identifies lifestyle modifications needed

References

  1. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. 
  2. Eng-Frost J, Chew D. Diagnosis and management of acute coronary syndromes. Aust Prescr. 2021 Dec;44(6):180-184. doi: 10.18773/austprescr.2021.049. Epub 2021 Dec 1. PMID: 35002027; PMCID: PMC8671020.
  3. Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
  4. Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
  5. Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
  6. Licordari R, Costa F, Garcia-Ruiz V, Mamas MA, Marquis-Gravel G, de la Torre Hernandez JM, Gomez Doblas JJ, Jimenez-Navarro M, Rodriguez-Capitan J, Urbano-Carrillo C, Ortega-Paz L, Piccolo R, Versace AG, Di Bella G, Andò G, Angiolillo DJ, Valgimigli M, Micari A. The Evolving Field of Acute Coronary Syndrome Management: A Critical Appraisal of the 2023 European Society of Cardiology Guidelines for the Management of Acute Coronary Syndrome. J Clin Med. 2024 Mar 25;13(7):1885. doi: 10.3390/jcm13071885. PMID: 38610650; PMCID: PMC11012418.
  7. Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. 
  8. Wang R, Neuenschwander FC, Lima Filho A, Moreira CM, Santos ES, Reis HJ, Romano ER, Mattos LA, Berwanger O, Andrade JP. Use of evidence-based interventions in acute coronary syndrome – Subanalysis of the ACCEPT registry. Arq Bras Cardiol. 2014 Apr;102(4):319-26. doi: 10.5935/abc.20140033. Epub 2014 Feb 17. PMID: 24652052; PMCID: PMC4028936.
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Anna Curran. RN, BSN, PHN

Anna Curran. RN, BSN, PHN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.

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