Acute Pain related to Atherosclerosis

Nursing Care Plan for Atherosclerosis - Nursing Diagnosis : Acute Pain

Atherosclerosis is an inflammation in human blood vessels, which caused accumulation of atheromatous plaque.

Atherosclerosis (also known as arteriosclerotic vascular disease or ASVD) is a specific form of arteriosclerosis in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol and triglyceride.

Atherosclerosis is a chronic disease that remains asymptomatic for decades. Atherosclerotic lesions, or atherosclerotic plaques are separated into two broad categories: Stable and unstable (also called vulnerable).

Clinically, atherosclerosis is typically associated with men over the age of 45. Sub-clinically, the disease begins to appear at early childhood, and perhaps even at birth. Noticeable signs can begin developing at puberty. Though symptoms are rarely exhibited in children, early screening of children for cardiovascular diseases could be beneficial to both the child and his/her relatives.


Acute Pain

Definition : Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months (NANDA)

Defining Characteristics:

Subjective

Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).

Objective

Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.


Nursing Diagnosis for Atherosclerosis : Acute Pain related to impaired ability of blood vessels to supply oxygen to the tissues.

Having given nursing care, is expected to decrease pain, with outcomes: patient states; chest pain disappear or be in control, the patient does not seem grimace, demonstrate relaxation techniques.

Nursing Intervention

1. Monitor the characteristics of pain through verbal response, and hemodynamics (crying, pain, grimacing, can not rest, respiratory rhythm, blood pressure and changes in heat rate).
R /: Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.

2. Assess the picture of pain experienced by patients include: place, intensity, duration, quality, and distribution.
R /: Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other diseases, so we get accurate data.

3. Provide a comfortable environment, reduce the activity, limit visitors.
R /: Helps reduce external stimuli that can add to the tranquility so that the patient can rest and the heart does not work too hard.

4. Teach relaxation techniques with a deep breath
R /: Helps relieve pain experienced by the patient psychologically which can distract the patient that is not focused on the pain experienced.

5. Observation of vital signs before and after drug administration.
R /: They can cause respiratory depression and hypotension.