BSN304 GROUP 14 DIAGNOSIS: Stroke in evolution, hypertensive atherosclerotic cardiovascular disease GOALS AND OBJECTIVES GOAL: Within 8 hours of nursing intervention, the client will achieve optimum tissue perfusion as evidenced by an improvement in vital signs and laboratory values OBJECTIVES: 1. The client will be able to promote wellness The client¶s and the family will be able to know the different risk factor associated with disease INTERVENTIONS RATIONALE EVALUATION The client was able to maintain acceptable-optimum tissue perfusion as evidenced by the absence of untoward signs and symptoms. The client can do ADL well without the limitation of the disease

NURSING CARE PLAN - NAME: Felipe, Moreno CUES SUBJECTIVE: OBJECTIVE: Vital Signs: T: 36.4OC PR: 70 bpm RR: 20 cpm BP: 150/70 Lipid Profile results: Cholesterol: 8.12 mmol (normal: 3.90 ± 6.50 mmol)) LDL: 6.55 mmol (normal: 1.27 ± 4.47 mmol) HDL: 1.04 mmol (normal: >1.45mmol) Radiologic Exam results: (+) Atheromatous Aorta NURSING DIAGNOSIS Risk for ineffective tissue perfusion (arterial, venous, and peripheral) related to interruption of blood flow secondary to atheromatous aorta

ANALYSIS Atherosclerosis affects the intima of the large and medium-sized arteries. These changes consist of the accumulation of lipids calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery. These accumulations are referred to as atheromas/plaques. The most commong direct result is the narrowing of the lumen of the arteries and obstruction by thrombosis. According to the reaction-to-injury theory, vascular endothelial cell injury may result from chronic hyperlipidemia. Gradual narrowing of the arterial lumen

Discuss the different factors associated with the diagnosis Assist client in incorporating managements in ADL and identify necessary lifestyle changes

Information necessary for client to make informed choices about remedial risk factors and commitment to lifestyle changes, as appropriate, to prevent onset of complications/manage symptoms when condition is present. (NANDA by Doenges, et. al 11th edition p.712)

. Do not apply heat. Monitor peripheral pulses. Ensure proper circulation With arterial insufficiency. Do not elevate the legs above the level of the heart. The client will be able to be monitored and receive proper nursing care: Monitor Vital Signs Good nutrition promotes healing. Keep the client warm and have the client wear socks and shoes or slippers while mobile. A low salt low fat diet will prevent exacerbation of the condition (Textbook of MedicalSurgical Nursing 12th edition by Brunner and Suddarth Volume 1 page 861) These are symptoms of arterial obstruction that can result in loss of a limb if not immediately reversed. purple or black areas and extreme pain. but it is often inadequate to meet increased metabolic demand. Collateral flow allows continued perfusion to the tissues. notify the physician immediately. and ischemia results. Heat application can easily damage ischemic tissue. Collateral circulation arises from preexisting essels that enlarge to reroute blood flow around a hemodynamically significant stenosis or occlusion. Keep extremities warm to maintain vasodilation and blood supply. leg elevation decreases arterial blood supply to the legs. If there is new onset of loss of pulses with bluish.stimulates the development of collateral circulation. -Textbook of Medical-Surgical Nursing 12th edition by Brunner and Suddarth Volume 1 page 856 Emphasize the importance of a low salt low fat diet 2.

Ischemic feet are very vulnerable to injury. Monitor physiological changes Note skin color and feel the temperature of the skin. and gangrene or ulcerations on toes and anterior surfaces of the feet are seen the clients with arterial . Brownish discoloration of the skin indicates chronic venous insufficiency. which is an emergency that requires immediate intervention. Refer to a podiatrist if the client has a foot or nail abnormality. dry skin with hair loss. Skin pallor or mottling. or gangrenous areas on the legs or feet. brittle nails. Nailbeds usually return to a pinkish color within 2-3 seconds after nailbed compression. meticulous foot care prevents further injury. Rubor indicates dilated or damaged vessels. Check capillary refill. cool or cold skin temperature. shiny.Pay meticulous attention to foot care. Note skin texture and the presence of hair. or an absent pulse can signal arterial obstruction. Thin. ulcers.

Some clients have both arterial and venous insufficiency. . In clients with venous insufficiency. Arterial is associated with pain when walking that is relieved by rest. timing and exacerbating and alleviating factors. Thrombosis with clot formation usually first detected as swelling of the involved leg and then as pain. Assess for pain in the extremities. or swelling in the calf and thigh. paying close attention to obesity. Malnutrition contributes to anemia.insufficiency. Differentiate venous from arterial disease. including pain. tenderness. In clients with arterial insufficiency. The pain increases with elevation of the legs and exercise. which further compounds the lack Observe for signs of DVT. The pain lesions with elevation and exercise. and redness in the involved extremity. Clients with severe arterial disease have foot pain while at rest. noting severity. Leg measurement discrepancies of more than 2 cm warrant further investigation. quality. Maintain appropriate diet Assess client¶s nutritional status.

hyperlipidimia. An output below 30ml/hr may indicate deficient fluid vol. which can result decreased oxygen delivery and organ system failure. and malnutrition.. Refer to a dietician if appropriate. and strengthen the calf muscle pumps. Exercise helps to increase venous return. . build up collateral circulation. Measure urine output hourly. of oxygenation to tissues. Perform toe-up and point flex exercises.