KEY ISSUE
Risk for ineffective tissue
perfusion
Objective Data:
 Irregular heart rhythm
noted upon auscultation
 Bruits present upon
auscultation of apical
pulse
 Cardiac and Vascular
Markers = 6.0mg/dL
 Activated Partial
Thromboplastin Time =
37.1 sec
 Prothrombin Time = 12.0
sec, 87.9
 Eryhtrocyte
Sedimentation Rate =
107nm/hr
Scientific Basis:
Arteriosclerosis is hardening and
thickening of the walls of the
arteries. This condition can occur
because of fatty deposits on the
inner lining of arteries
(atherosclerosis), calcification of
the wall of the arteries, or
thickening of the muscular wall of
the arteries from chronically
elevated blood pressure. When
arteriosclerosis affects the
coronary arteries that supply
DESIRED OUTCOME INTERVENTIONS ACTUAL OUTCOMES
After 8 hours of nursing interventions, patient will Independent: February 13, 2020
be able to: 1. Assess and monitor After 8 hours of
vital signs. nursing interventions:
- Manifest a blood pressure level within R: To look for significant - Patient
then normal range changes in vital signs. manifested a
- Verbalize understanding of risk factors of 2. Measure capillary refill blood pressure
condition, therapy regimen, side effects of R: To determine level of 120/80
medications, and when to inform adequacy of systemic - Patient
healthcare provider circulation expressed
- Demonstrate behavior and lifestyle 3. Consistently monitor understanding
changes to improve circulation laboratory studies such on the
- Exhibit understanding of home care as cardiac markers and abnormal signs
measures related to possible coagulation teste of tissue
complications such as delayed wound R: To determine perfusion such
healing probability, location and as chest pain
degree of impairment. and nonhealing
4. Educate client and SO wounds.
in reportable symptoms
including any changes in
blood pressure level from
the normal range, chest
pain, and nonhealing
wounds.
R: To provide opportunity
for timely evaluation and
intervention
5. Discuss relevant risk
factors of the present
disease such as necessary
diet changes
R: Information necessary
for client to make
informed choices about
blood to the heart muscle, a remediating risk factors
shortage of oxygen delivered to and committing to
the heart itself may lead to a heart lifestyle changes.
attack.

Source: Stöppler, M. C. (2017, July

20). What Is Arteriosclerotic
Cardiovascular Disease? Retrieved
February 16, 2020, from
https://www.medicinenet.com/ar
teriosclerotic_cardiovascular_dise
ase/ask.htm

A bruit is an audible vascular

sound associated with turbulent
blood flow. Although usually
heard with the stethoscope, such
sounds may occasionally also be
palpated as a thrill.

As stenosis increases, pressure

caused by the constriction
changes to increasing velocity
within the artery. With increasing
flow velocity, luminar flow
through a stenosis eventually
changes to turbulent flow,
producing vibrations and a bruit.

Source: Kurtz, K. J. (1990, January

1). Bruits and Hums of the Head
and Neck. Retrieved from
https://www.ncbi.nlm.nih.gov/bo
oks/NBK289/

Coagulation factors are proteins

circulating in the blood that are
essential for proper blood clot
formation. Coagulation factor
tests measure the function of or
sometimes the amount of these
proteins in the blood.

Normal coagulation factor activity

usually means normal clotting
function. Low activity of one or
more coagulation factors usually
means impaired clotting ability.

Elevated levels of several factors

are seen in situations of acute
illness, stress, or inflammation.
Some people have persistent
elevations of factor VIII that may
be associated with an increased
risk of venous thrombosis.

Source: Coagulation Factors.

(2019, May 3). Retrieved from
https://labtestsonline.org/tests/c
oagulation-factors