Running Head: CASE REVIEW OF A PATIENT WITH CAD 1

Case Review of a Patient with Coronary Artery Disease

Rena Baradi

Old Dominion University

CASE REVIEW OF A PATIENT WITH CAD 2

Case Review of a Patient with Coronary Artery Disease

J.P. is a 65-year-old male whose diagnoses included exertional substernal chest pain with

class 3 angina, coronary artery disease (CAD) with unstable angina pectoris, and essential

hypertension. He is 6’2”, 109 kg, and has no known allergies. Chest pain radiates to the right

side of his neck with sternal pressure when walking less than a block and while doing household

chores (i.e. washing trailer). He developed tightening with pulsation in the right side of his neck

and needed frequent breaks every fifteen minutes. However, upon admission in the emergency

department, the patient denied chest pain radiation, shortness of breath, orthopnea, and dyspnea.

Six days after his initial admission, he undergone a coronary artery bypass grafting (CABG). His

history includes smoking two to three packs of cigarettes a week for over fifty years (and has

secondhand smoke exposure as his wife also smokes) and drinking two to three cases of beer a

week. His chronic tobacco use ceased prior to his surgery. Other problems include joint pain and

arthritis in the knees, hands, and lower back; hypertension; and hypercholesterolemia.

Additionally, he has a history of lung cancer, tuberculosis exposure, and industrial exposures of

silica, radon, coal, and asbestos from the military in the 1960s and 1970s. The purpose of this

case study is to demonstrate the use of knowledge, encompassing nursing research and theory for

planning, providing, and evaluating holistic care provided to a patient.

Medical Diagnosis

Coronary artery disease (CAD) occurs when the coronary arteries of the heart become

occluded from abnormal accumulation of lipid or fatty material (plaque) in the artery vessel

walls. This changes the structure and function of the arteries, resulting in a blockage of the heart

vessels, thus decreased blood flow and oxygenation to the heart. Because of this, the heart

compensates by pumping harder and more efficiently for the lack of oxygen. The patient
CASE REVIEW OF A PATIENT WITH CAD 3

undergone a CABG (coronary artery bypass grafting) procedure due to the CAD. During the

patient’s second day on the cardiac care unit (CCU), his vital signs and labs were within defined

limits, with the exception of the WBC (11.8, high). His previous signs and symptoms prior to the

CABG included chest pain radiation to right side of his neck with sternal pressure, especially

during walks less than a block. He experienced tightening with pulsation in the right side of his

neck and could not tolerate activities without resting every fifteen minutes. The patient had an

18-guage central venous line inserted in his right internal jugular vein; a substernal, pericardial

24-Blake chest tube posterior; a substernal pleural 24-Blake chest tube left; and a urethral Foley

catheter. He had a left leg incision for a saphenous vein harvest during the CABG and a

temporary epicardial pacemaker following surgery.

Nursing Diagnoses

Nursing Diagnosis 1

Prior to the coronary artery bypass grafting (CABG), the patient experienced unstable

angina. A nursing diagnosis to attend to this issue is Acute Pain related to a decrease in

myocardial blood flow and increased workload/oxygen consumption as evidenced by unstable

angina. This greatly affected his activities of daily living, as he was unable to complete tasks or

chores without resting every fifteen minutes. Following a CABG, it is important to keep the

patient comfortable, especially with effective pain control. This aids in maintaining

hemodynamic stability and preventing other complications, including pulmonary issues (Mullen-

Fortino, 2009). Acute pain was still an issue after the CABG, but regarding his median

sternotomy incision from surgery, rather than unstable angina. This Acute Pain related to post-

surgical incision as evidenced by pain scale of 8 of 10 (10 being the worst) and facial grimacing,

affected his ability to effectively move and ambulate on his own. When moving the patient from
CASE REVIEW OF A PATIENT WITH CAD 4

the bed to chair, he required two people. During his attempt at ambulation, he only required one

nurse while using the walker. A nursing theory for J.P.’s care was Kolcaba’s Theory of Comfort.

His chief complaint was the median sternotomy incisional pain from the CABG, which directly

affected his activity performance. The patient received Percocet PRN and stated it was working

wonders for his pain and would like to maintain the pain level as it was controlled and tolerable.

Nursing Diagnosis 2

Following the CABG, a priority is keeping the patient hemodynamically stable to ensure

his organs are adequately perfused. A second nursing diagnosis would include Risk for

Decreased Cardiac Output as evidenced by essential hypertension. Monitoring for signs of

decreased cardiac output include tachycardia, cool extremities, diminished peripheral pulses, and

decreased urine output (Mullen-Fortino, 2009). Dysrhythmias (specifically tachydysrhythmias)

are common during the postoperative days after a CABG. Hypothermia, acidosis, and electrolyte

disturbances are also important to monitor. Fortunately, the patient’s labs were within defined

limits, with the exception of pO2 at 109 (high) and bicarbonate at 21.5 (low). Beta blockers and

antiarrhythmic medications are often prescribed to prevent heart dysfunction after the CABG; the

patient was prescribed metoprolol (Lopressor) and amiodarone (Cordarone).

Nursing Diagnosis 3

A third nursing diagnosis would be Risk for Fluid Overload as evidenced by history of

smoking, age 65 or greater, and endotracheal intubation (during CABG procedure) (Mullen-

Fortino, 2009), which are all characteristics of the patient. His O2 saturation, however, was

greater than 96%, showed no signs of shortness of breath, and no use of accessory muscles

(especially during his attempt at ambulation). Breath sounds were monitored frequently and
CASE REVIEW OF A PATIENT WITH CAD 5

pillow splinting the incision occurred when coughing or moving. Guaifenesin (Mucinex) was

prescribed to thin the mucus, as he was immobile hours postoperatively. Optimal pain control

was provided so he could move freely in the days following the CABG, as well as assisting the

patient with early ambulation. Furosemide (Lasix), a diuretic, was prescribed with the critical

care K+ (potassium) replacement protocol.

Nursing Diagnosis 4

Following the open chest surgery, a sternal infection may develop, which can progress

into deeper chest membranes, such as the mediastinum (Mullen-Fortino, 2009). The addition of

multiple lines and tubes increased the risk of infection. A fourth nursing diagnosis is Risk for

Infection as evidenced by older age, chest tubes, central line (right internal jugular), and Foley

(urethral) catheter. Research shows that catheter-related bloodstream infections are higher at the

internal jugular and femoral sites than subclavian sites (Schulz, 2014). Fortunately, the dressings

covering the A-line and chest tubes were dry and intact. Later on in the patient’s care,

unnecessary tubes were removed, including the Foley catheter (as patient was able to ambulate to

the bathroom) and chest tubes (that no longer had drainage). Protocols for the Foley catheter use

and urinary tract infection prevention, included cranberry extract (PO, by mouth) and the

antifungal topical powder nystatin (mycostatin) on the genitals. Another protocol to prevent a

MRSA (Methicillin-resistant Staphylococcus aureus) infection was the nasal application of

mupirocin (Bactroban). Hyperglycemia promotes pathogen proliferation and can impair

neutrophil function (Bryan, 2013). To reduce the risk of deep sternal wound infections,

continuous IV regular insulin (Humulin) was infused to prevent postoperative hyperglycemia.

Nursing Diagnosis 5
CASE REVIEW OF A PATIENT WITH CAD 6

A psychosocial nursing diagnosis for this patient is Readiness for Enhanced Therapeutic

Regimen Management related to smoking cessation as evidenced by ceasing of smoking prior to

heart surgery and verbalization of quitting smoking for good, after fifty years. Throughout the

patient’s hospitalization, he was prescribed a nicotine patch, which helps deter cigarette cravings.

According to one study, patients who undergone a CABG experienced passion for life after their

surgery, revealing that patients tend to find a new perspective on life and their health

postoperatively (Mohammadi, 2015). Familial support (specifically from the spouse) is

especially important in recovering faster than those who do not have support (Roohafza, 2015).

The patient’s wife is also a smoker. If she decides to quit smoking too, this can further increase

the patient’s smoking cessation success rate.

Prioritization and Interrelatedness

The patient experienced unstable angina related to the CAD. He experienced acute pain,

leading to the CABG. Although acute chest pain was evident prior to his surgery, it is also an

issue post-operatively due to incisional pain. Acute Pain was prioritized as it was an issue

directly experienced. The next three nursing diagnoses are risks as the patient did not have

evidence of experiencing these problems, but are nonetheless valuable issues to monitor,

especially following a CABG. In Decreased Cardiac Output, the volume of blood the heart

pumps out for the rest of the body is decreased. This results in diminished blood flow to the

kidneys. The kidneys sense the reduction of blood volume in the body and counteracts by

retaining salt and water. The kidneys have the false sense of the body needing more fluid when

the body has enough. This results in Fluid Overload. Risk for Infection is another issue to

monitor. However, the patient shows no signs of infection systemically (i.e. no increased or

decreased temperature, increased heart rate or respiratory rate, or decreased urination) or locally
CASE REVIEW OF A PATIENT WITH CAD 7

at the incision site or tube insertion sites (i.e. no redness, swelling, foul discharge, or warmth).

The patient shows positive progress towards smoking cessation and the issue of smoking itself

poses no threat for his plan of care, thus prioritized last.

Outcomes for Top Two Nursing Diagnoses

Outcomes for Nursing Diagnosis 1

The priority nursing diagnosis for the patient is Acute Pain related to post-surgical chest

incision. The patient came to the cardiac care unit on his second day postoperative. An outcome

would include the patient will verbalize controlled or disappeared pain fifteen to thirty minutes

after the pain medication (Percocet) is administered. The patient will have a decreased pain level

as evidenced by a pain grade of two or less on a 0 to 10 scale (10 being the worst) by the fifth

day postoperative. The patient will have controlled pain as evidenced by ambulating twenty feet

in the hallway without showing any nonverbal signs (i.e. facial grimacing or moaning) by the

fifth day postoperative.

Outcomes for Nursing Diagnosis 2

The outcomes for the nursing diagnosis Risk for Decreased Cardiac Output are measured

based on the patient’s vital signs and ability to tolerate activities. The patient will demonstrate

adequate cardiac output as evidenced by blood pressure and pulse rate within defined limits for

the patient and strong peripheral pulses every two hours (i.e. SBP 140-159, DBP 90-99 (patient

has essential hypertension), pulse rate normally in the 80s for the patient). The patient will

exhibit warm dry skin, absence of dyspnea, angina, dysrhythmias, and pulmonary crackles every

two hours. The patient will demonstrate increased activity tolerance by postoperative day four as

evidenced by ambulating in the hallway twenty or more feet.

CASE REVIEW OF A PATIENT WITH CAD 8

Interventions for Top Two Nursing Diagnoses

Interventions for Nursing Diagnosis 1

Acute Pain following a CABG is experienced due to the median sternotomy chest

incision, removal of the saphenous vein from the leg, sternal or rib retraction, musculoskeletal

trauma, or fractured ribs (Guden, 2012). Chest tubes are also uncomfortable and are one of the

causes of pain after cardiac surgery (Guden, 2012). According to Guden, pain associated with

chest tubes and sternotomy can diminish pulmonary functions because of hypoventilation,

leading to mucus retention. The patient was prescribed Mucinex to thin mucus secretions. It is

important to explain and utilize the pain scale with the patient, 0 being no pain and 10 being the

worst, as well as establishing what is a tolerable pain level for the patient (which was a 3 grade).

Interventions for acute pain require frequently assessing for pain and documenting the location,

intensity, and quality. Pain should be assessed utilizing verbal and nonverbal (i.e. grimacing,

crying, sweating, increased respiratory rate) cues. Increased respiratory rate may result from pain

and is associated with anxiety and stress causing a temporary loss of catecholamines, which

increase heart rate and blood pressure. Reviewing and discussing the patient’s history of previous

angina and pain resembling angina is essential to compare the pain he had previously, prior to

the CABG, as well as identifying complications such as infarction, pulmonary embolism, or

pericarditis. According to a quantitative study, the main focus for post-CABG care involved pain

control (Karlsson, 2013). Five weeks post-surgery, sternal pain was still a priority, but there was

more focus on lifestyle (Karlsson, 2013). Pain control management must be taught prior to

discharge. As for another study, postoperative participants received standard care, including

sitting out of bed on postoperative day one, ambulation of at least sixty feet on postoperative day

two, and mobility progression on subsequent days (Sturgess, 2014). Furthermore, thoracic
CASE REVIEW OF A PATIENT WITH CAD 9

exercises may reduce postoperative pain by improving muscle control of the thoracic cage and

abdominal muscles, inhibiting the presence of pain following surgery (Sturgess, 2014).

With a third study, focusing on follow-up care with a nurse practitioner (NP) rather than a

primary care provider, NP assessment interviews were taken at two to three days after discharge

(Sawatzky, 2013). Pain was the most frequent symptom reported during this interview, with

almost 80% of the participants (Sawatzky, 2013). The care provided by the nurse practitioner

resulted in reduction of patient symptoms, enhanced patient satisfaction, and decreased health-

related costs in the early post-discharge period. Evidence from the study showed NP follow-up

care for CABG surgery patients effectively bridged the gap between institutional and primary

care, contributing to research goals of improving health services and optimizing cardiac surgery

population outcomes (Sawatzky, 2013).

Analgesics, or pain medications, are vital in adequate pain management. Research shows

pain management in the immediate postoperative period reduces complications from sympathetic

stimulation and allows for faster recovery (Mullen-Fortino, 2009). Pain causes muscle tension

and vasoconstriction, impairing circulation and tissue perfusion, slowing wound healing, and

increasing cardiac work. Premedication and the subsequent reduction of pain improves client

participation and cooperation with care. Percocet (PO) was provided to the patient every four

hours. Percocet begins taking effect fifteen to thirty minutes after it is consumed and peaks at

one hour. Vital signs are checked before and after pain medication administration as dizziness,

lightheadedness, and blurred vision may occur. The patient was instructed to report pain

immediately, as a delay would cause distribution of pain, inhibiting the pain medication

effectiveness. Additionally, severe pain can cause shock, which can stimulate the sympathetic

nervous system, resulting in further damage and interference with pain relief. NSAIDs are
CASE REVIEW OF A PATIENT WITH CAD 10

administered postoperatively as analgesic agents (Guden, 2012). The patient was prescribed

aspirin tablet (PO) once a day. The patient was taught to splint over the chest incision during

coughing with a pillow, as accessory respiratory muscles may have been cut during surgery.

Splinting supports the incision, reducing pain during coughing. It is important to provide a quiet

environment as much as possible for the patient and letting him perform activities at his pace to

keep him as comfortable as possible. Lowering external stimuli reduces anxiety and heart strain.

Interventions for Nursing Diagnosis 2

Cardiac output may be compromised postoperatively due to fluid loss (drainage),

depression of myocardial function by drugs, and dysrhythmias (Sabzi, 2012). To monitor for

decreased cardiac output, the heart and breath sounds are auscultated at least every four hours.

An S3 ventricular gallop is an early sign of heart failure, while an S4 is indicative of decreased

ventricular compliance. Adventitious breath sounds (wheezes, crackles, or rales) may be signs of

heart failure or respiratory compromise. According to Sabzi’s study, more research must be

completed to effectively create a clinical diagnostic for the Risk of Decreased Cardiac Output

nursing diagnosis that could be utilized across all healthcare settings. Assessing and recording

skin color, temperature, and the presence and quality of peripheral pulses are imperative, as pale

or cyanotic coloring, cool and clammy skin, and diminished pulses indicate decreased peripheral

circulation and decreased cardiac output. Vital signs, including heart rate and blood pressure, are

monitored because tachycardia can occur because of pain, anxiety, hypoxemia, and

decreased cardiac output. Blood pressure changes (hypertension or hypotension) may occur due

to cardiovascular response. Monitoring and documentation of cardiac rhythm (with the use of an

electrocardiogram (EKG)) are to check for dysrhythmias, as they are common and can interfere

with cardiac filling and contractility, thus decreasing the cardiac output.
CASE REVIEW OF A PATIENT WITH CAD 11

Intake and output are measured hourly to help evaluate fluid volume status. The patient’s

urethral catheter was removed when he could ambulate. It was vital to teach the importance of

measuring his output, as a severe decrease in urine output may be an early indicator of decreased

cardiac output. Chest tube output was also recorded hourly, prior to their removal. Chest tube

drainages that are greater than 70 mL/hour or are warm, red, and free flowing indicate

hemorrhaging. Hemoglobin, hematocrit, and serum electrolytes were monitored for any

abnormal values. Low hemoglobin and hematocrit values can indicate hemorrhaging. Electrolyte

imbalances (specifically potassium, calcium, and magnesium) impact cardiac rhythm and

contractility (Pereira de Melo, 2011). Medications ordered in the early postoperative period are

administered to maintain cardiac output, including antiarrhythmic medications to correct

arrhythmias affecting cardiac output. Amiodarone (Cordarone) 200 mg PO was given three times

a day with meals. The patient had a temporary epicardial pacemaker. Temporary pacing may be

needed to maintain the cardiac output with bradydysrhythmias. If the patient experienced an

acute episode, he should maintain bed rest in a comfortable position. Resting will lower oxygen

consumption and demand, decreasing the risk of myocardial decompensation.

Cultural Considerations

The patient’s family was at bedside throughout his hospitalization and were very pleasant

people. They were very respectful and understanding of the staff and asked questions kindly if

they had any. Talking through procedures as they are occurring is beneficial, especially when the

patient may feel dependent and vulnerable, such as during the Foley catheter removal and

bathing.

Evaluation
CASE REVIEW OF A PATIENT WITH CAD 12

The priority nursing diagnosis was Acute Pain related to the post-surgical chest incision.

The outcome “the patient will verbalize controlled or disappeared pain fifteen to thirty minutes

after the pain medication (Percocet) is administered” was met as evidenced by the patient’s

verbal response, “The Percocet works wonders for the pain.” Later in the day, the patient asked

when he could receive his next dose of Percocet, further stating, “I like where the pain level is. I

would rather have the pain medication now before they start wearing off.” The nurse established

that the pain medication is given every four hours, and the patient understood, stating he was

able to wait another forty minutes for the next dose. The outcome “the patient will have a

decreased pain level as evidenced by a pain of two or less on a 0 to 10 scale (10 being the worst)

by the fifth day postoperative” cannot be fully evaluated as it has not reached the adequate time

frame. The patient was on his second day postoperative. However, the patient states that the pain

is controlled effectively with the Percocet. The third outcome “the patient will have controlled

pain as evidenced by ambulating twenty feet in the hallway without showing any non-verbal

signs (i.e. facial grimacing or moaning) by the fifth day postoperative” cannot be fully evaluated

due to the current time frame; however, the patient attempted ambulating outside his door with

the use of a walker and one nurse, walking about twenty feet before returning to his room. The

patient is making great progress and knows his limitations.

The second nursing diagnosis involved Risk for Decreased Cardiac Output. An outcome

included the patient will demonstrate adequate cardiac output as evidenced by blood pressure

and pulse rate within defined limits for the patient and strong peripheral pulses every two hours

(i.e. SBP 140-159, DBP 90-99 (patient has essential hypertension), pulse rate normally in the 80s

for the patient). The patient’s blood pressure remained within these defined limits for his

baseline values every two hours, with no signs of abnormalities. Another outcome is the patient
CASE REVIEW OF A PATIENT WITH CAD 13

will exhibit warm dry skin, absence of dyspnea, angina, dysrhythmias, and pulmonary crackles

every two hours. During each assessment, the patient remained sign-free of labored breathing,

denied any chest pain, no auscultation of crackles or signs of fluid in the lungs, and had warm,

dry skin. The third outcome was the patient will demonstrate increased activity tolerance by

postoperative day four as evidenced by ambulating in the hallway twenty or more feet. Although

the time frame is not completed, the patient is making progress towards reaching this outcome,

as evidenced by his ability to ambulate ten feet outside his room, and walking the ten feet back,

before having to sit down from the exertion. No additional or alternative plans are needed for the

patient’s care. The patient shows progresses towards expected outcomes. He understands his

limitations and independently alters his activities of daily living to complete an activity, until he

is able to efficiently perform them.

Conclusion

The 65-year-old male patient had medical issues, including coronary artery disease,

unstable angina, and essential hypertension. He undergone a coronary artery bypass grafting and

came to the cardiac care unit on his first day postoperative. A priority nursing diagnosis for his

care was Acute Pain as he was directly experiencing this issue, which affected his activity

tolerance. His secondary diagnosis was Risk for Decreased Cardiac Output. Although he showed

no signs of decreased cardiac output, it is vital to monitor as it can quickly lead to other organ

issues, including poor perfusion and/or the kidneys’ perceived low volume, leading to fluid

overload. Knowledge obtained from this study include understanding the pathophysiology of

coronary artery disease (CAD) and its manifestation of signs and symptoms in the patient,

prioritizing problems based on what the patient is experiencing and the interrelatedness of these

issues, and reviewing current research to validate the effectiveness of nursing interventions.
CASE REVIEW OF A PATIENT WITH CAD 14

References

Bryan, C. S., & Yarbrough, W. M. (2013). Preventing Deep Wound Infection after Coronary

Artery Bypass Grafting. Texas Heart Institute Journal, 40(2), 125-139.

Guden, M., Korkmaz, A. A., Onan, B., Onan, I. S., Tarakci, S. I., & Fidan, F. (2012). Subxiphoid

versus Intercostal Chest Tubes Comparison of Postoperative Pain and Pulmonary

Morbidities after Coronary Artery Bypass Grafting. Texas Heart Institute Journal, 39(4),

507-512.

Karlsson, A., Lidell, E., & Johansson, M. (2013). Health-care professionals' documentation of

wellbeing in patients following open heart surgery: a content analysis of medical records.

Journal Of Nursing Management, 21(1), 112-120. doi: 10.1111/j.1365-

2834.2012.01458.x

Mohammadi, N., Abbasi, M., Nasrabadi, A., Salehiomran,, A., Davaran, S., & Norouzadeh, R.

(2015, April 20). Passion for Life: Lived Experiences of Patients after Coronary Artery

Bypass Graft. The Journal of Tehran University Heart Center, 10(3), 129-133.

Mullen-Fortino, M., & Oʼbrien, N. (2009, January). Caring for a patient after coronary artery

bypass graft surgery. Nursing Critical Care, 4(1), 22-27.

doi: 10.1097/01.ccn.0000343231.17320.e5

Pereira de Melo, R., Venícios de Oliveira Lopes, M., Leite de Araujo, T., de Fatima da Silva, L.,

Aline Arrais Sampaio Santos, F., & Moorhead, S. (2011). Risk for decreased cardiac

output: validation of a proposal for nursing diagnosis. Nursing In Critical Care, 16(6),
CASE REVIEW OF A PATIENT WITH CAD 15

287-294. doi: 10.1111/j.1478-5153.2011.00453.x

Roohafza, H., Sadeghi, M., Khani, A., Andalib, E., Alikhasi, H., & Rafiei, M. (2015).

Psychological state in patients undergoing coronary artery bypass grafting surgery or

percutaneous coronary intervention and their spouses. International Journal of Nursing

Practice, 21, 214-220. Retrieved from doi: 10.1111/ijn.12234.

Sabzi, F., Kazerani, H., Jalali, A., Samadi, M., & Ghasemi, F. (2012, August 7). Coronary

Arteries Bypass Grafting Surgery in Elderly Patients. The Journal of Tehran University

Heart Center, 8(2), 76-88.

Sawatzky, J. V., Christie, S., & Singal, R. K. (2013). Exploring outcomes of a nurse practitioner-

managed cardiac surgery follow-up intervention: a randomized trial. Journal Of

Advanced Nursing, 69(9), 2076-2087. doi: 10.1111/jan.12075

Schulz, C. F., Lopes, C. T., Herdman, T. H., Lopes, J. L., & Barros, A. L. (2014). Construction

and Validation of an Instrument for Assessment of the Nursing Diagnosis, Risk for

Infection, in Patients Following Cardiac Surgery. International Journal Of Nursing

Knowledge, 25(2), 94-101. doi: 10.1111/2047-3095.12018

Sturgess, T., Denehy, L., Tully, E., & El-Ansary, D. (2014). A pilot thoracic exercise programme

reduces early (0-6 weeks) sternal pain following open heart surgery. International

Journal Of Therapy & Rehabilitation, 21(3), 110-117.

CASE REVIEW OF A PATIENT WITH CAD 16

Honor Code

“I pledge to support the Honor System of Old Dominion University. I will refrain from any form

of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a

member of the academic community it is responsibility to turn in all suspected violators of the

Honor Code. I will report to a hearing if summoned.”

Name: __Rena Baradi__________________________________

Signature: __Rena Baradi (electronically signed)____________

Date: ____12/3/16_____________________________________
CASE REVIEW OF A PATIENT WITH CAD 17

NURS 451 Client Case Study

Grading Criteria
Student: _Rena Baradi________________ Score: __________
Grading Criteria Points Faculty Comments Points
Awarded
Introduction
Pt. Overview 2
Scope of paper 1

Medical Diagnosis
Dx for ICU adm. 2
Patho 4
Related S/S 4

Nursing Diagnosis
5 NANDA (1+ psych/soc) 5
Priority with theorist support 10

Outcomes for top 2 NDX #1 #2

Appropriate for NDX 2.5 2.5
Attainable within timeframe 2.5 2.5

Interventions for top 2 NDX #1 #2

Interventions with rationale 6 6
SOP /Clinical Path 2 2
Patient/family teaching 2 2
Critical Thinking 2 2
Cultural Considerations 3

Evaluation #1 #2
Progress toward outcomes 5 5
Additional/alternative plan 1 1

Conclusion
Review of learning 3
CASE REVIEW OF A PATIENT WITH CAD 18

Grading Criteria Points Faculty Comments Points

Awarded
Sources
5+ sources 1
3+ primary nursing research
Study results reviewed/applied 3 3 3
Study poorly reviewed/applied 1 1 1
Research omitted 0 0 0

APA Format (Cover page,

headings, margins, type size)

Format conforms to APA Format 3

Format includes 1-3 APA errors 2
Format includes 4-6 APA errors 1
Format includes >6 errors 0

APA- References/Reference Page

Conform to APA Format 4

Include 1-3 APA errors 3
Include 4-6 APA errors 2
Include >6 APA errors 1
Do not conform to APA format 0

Writing Style (Grammar, spelling,

punctuation, language)

Logical, organized, without errors 3

Logical, organized minor errors 2

(<5)

Lacks logic/organization OR major 1

spelling/grammar/errors (>5)

Lacks logic / organization AND 0

major spelling / grammar / errors
(>5)

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