Atherosclerosis is a specific form of arteriosclerosis in which an artery wall thickens as a result of invasion and accumulation of white blood cells (WBCs) (foam cell) and proliferation of intimal smooth muscle cell creating a fibrofatty plaque.
The spectrum of presentation includes symptoms and signs consistent with the following conditions:
- Asymptomatic state (subclinical phase)
- Stable angina pectoris
- Unstable angina (ie, ACS)
- AMI
- Chronic ischemic cardiomyopathy
- Congestive heart failure
- Sudden cardiac arrest
- Chest pain
- Shortness of breath
- Weakness, tiredness, reduced exertional capacity
- Dizziness, palpitations
- Leg swelling
- Weight gain
- Symptoms related to risk factors
Nursing Interventions for Atherosclerosis
1. Acute Pain related to an impaired ability of blood vessels to supply oxygen to the tissues.
Goal: reduced pain
Expected outcomes: patient states chest pain disappear, or can be controlled, the patient did not seem grimace, demonstrate relaxation techniques.
Intervention and Rational:
1. Monitor characteristics of pain through verbal and hemodynamic responses (crying, pain, grimacing, can not rest, respiratory rhythm, blood pressure and changes in heat rate).
Rationale: Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.
2. Provide a comfortable environment, reduce the activity, limit visitors.
Rationale: Helps reduce external stimuli that can add to the tranquility so patients can rest in peace and the power of the heart is not too hard.
3. Assess the description of pain experienced by patients include: place, intensity, duration, quality, and distribution.
Rationale: Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other symptoms to obtain accurate data.
4. Observation of vital signs before and after drug administration.
Rationale: Knowing the patient's progress, after being given the drug.
5. Teach relaxation techniques with a sigh
Rationale: Helps relieve pain experienced by patients psychologically which can distract the patient that is not focused on the pain experienced.
2. Ineffective Tissue Perfusion: Peripheral related to impaired circulation
Goal: clients show improvement perfusion with
Expected outcomes: a peripheral pulse / same, normal skin color and temperature, an increase in behaviors that increase tissue perfusion.
Intervention and Rational:
1. Observation of skin color on the sick.
Rationale: The skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.
2. View and examine the skin for ulceration, lesions, gangrene area.
Rationale: Lesions may occur from the size of a pin needle to involve all the fingertips and can lead to infection or damage / loss of tissue seriously.
3. Note the decrease in pulse; traffic change skin (no color, glossy / tense).
Rationale: This change indicates progress or chronic process.
4. Advise for the proper nutrients and vitamins.
Rationale: The balance of a good diet includes protein and adequate hydration, necessary for healing of the sick.
5. Encourage patients perform the exercises or exercises gradually extremities.
Rationale: For circulation.
65. Monitor signs of tissue perfusion adequacy.
Rationale: To identify the early signs of impaired perfusion.
Source :
http://list-nanda-nursing-diagnosis.blogspot.co.id/2013/01/ineffective-tissue-perfusion-peripheral.html
http://list-nanda-nursing-diagnosis.blogspot.co.id/2013/01/acute-pain-ncp-atherosclerosis.html