FAJARDO, DENNISON C.

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 clients 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)

stimulates the development of collateral circulation. Collateral circulation arises from preexisting essels that enlarge to reroute blood flow around a hemodynamically significant stenosis or occlusion. Collateral flow allows continued perfusion to the tissues, but it is often inadequate to meet increased metabolic demand, and ischemia results. -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. The client will be able to be monitored and receive proper nursing care: Monitor Vital Signs

Good nutrition promotes healing. 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.

Monitor peripheral pulses. If there is new onset of loss of pulses with bluish, purple or black areas and extreme pain, notify the physician immediately. Do not elevate the legs above the level of the heart.

Ensure proper circulation

With arterial insufficiency, leg elevation decreases arterial blood supply to the legs. Keep extremities warm to maintain vasodilation and blood supply. Heat application can easily damage ischemic tissue.

Keep the client warm and have the client wear socks and shoes or slippers while mobile. Do not apply heat.

Pay meticulous attention to foot care. Refer to a podiatrist if the client has a foot or nail abnormality. Monitor physiological changes Note skin color and feel the temperature of the skin.

Ischemic feet are very vulnerable to injury; meticulous foot care prevents further injury.

Skin pallor or mottling, cool or cold skin temperature, or an absent pulse can signal arterial obstruction, which is an emergency that requires immediate intervention. Rubor indicates dilated or damaged vessels. Brownish discoloration of the skin indicates chronic venous insufficiency.

Check capillary refill. Nailbeds usually return to a pinkish color within 2-3 seconds after nailbed compression. Note skin texture and the presence of hair, ulcers, or gangrenous areas on the legs or feet. Thin, shiny, dry skin with hair loss; brittle nails, and gangrene or ulcerations on toes and anterior surfaces of the feet are seen the clients with arterial

insufficiency. Assess for pain in the extremities, noting severity, quality, timing and exacerbating and alleviating factors. Differentiate venous from arterial disease. In clients with venous insufficiency. The pain lesions with elevation and exercise. In clients with arterial insufficiency. The pain increases with elevation of the legs and exercise. Some clients have both arterial and venous insufficiency. Arterial is associated with pain when walking that is relieved by rest. Clients with severe arterial disease have foot pain while at rest. Thrombosis with clot formation usually first detected as swelling of the involved leg and then as pain. Leg measurement discrepancies of more than 2 cm warrant further investigation. Malnutrition contributes to anemia, which further compounds the lack

Observe for signs of DVT, including pain, tenderness, or swelling in the calf and thigh, and redness in the involved extremity.

Maintain appropriate diet

Assess clients nutritional status, paying close attention to obesity,

hyperlipidimia, and malnutrition. Refer to a dietician if appropriate. Measure urine output hourly.

of oxygenation to tissues.

An output below 30ml/hr may indicate deficient fluid vol., which can result decreased oxygen delivery and organ system failure. Exercise helps to increase venous return, build up collateral circulation, and strengthen the calf muscle pumps.

Perform toe-up and point flex exercises.