NANDA - Nursing Diagnosis

Nursing Care Plan

Ineffective Tissue perfusion : peripheral related to Atherosclerosis

Atheroscleros is when the inside of the arteries are thickened, hardened and stiffened, causing the space for blood flow to be narrowed or closed. This will decrease the oxygen supply to local or distant tissues.

Atherosclerosis is a disease of the arterial blood vessels (arteries), in which the walls of the blood vessels become thickened and hardened by "plaques." The plaques are composed of cholesterol and other lipids, inflammatory cells, and calcium deposits.

Cause:

  • Coronary Artery Disease -loss of blood to areas of the heart
  • Stroke -loss of blood to areas of the brain
  • Peripheral Vascular Disease -characterized by leg pain with walking
Symptoms depend on which arteries are affected. For example:
  • Coronary (heart) arteries-may cause symptoms of heart disease, such as chest pain
  • Arteries in the brain-may cause symptoms of a stroke such as weakness or dizziness
  • Arteries in the lower extremities-may cause pain in the legs or feet and trouble walking


Ineffective Tissue perfusion : peripheral

Decrease in oxygen resulting in failure to nourish tissues at the capillary level

Defining Characteristics:
  • Edema;
  • positive Hoeman's sign;
  • altered skin characteristics (hair, nails, moisture);
  • weak or absent pulses;
  • skin discolorations;
  • skin temperature changes;
  • altered sensations;
  • diminished arterial pulsations;
  • skin color pale on elevation, color does not return on lowering the leg;
  • slow healing of lesions; cold extremities;
  • dependent, blue, or purple skin color


Nursing Diagnosis for Atherosclerosis : Ineffective Tissue perfusion : peripheral related to circulation disorders.

Goal: demonstrate improved perfusion

Outcomes: a peripheral pulse, skin color and temperature is normal, the increase behaviors that increase tissue perfusion.

Nursing Interventions and Rational:

1. Observation of the affected part of skin color.
R /: Skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.

2. Note the decrease in pulse; skin changes (colorless, shiny / tense).
R /: These changes indicate progress or chronic process.

3. View and examine the skin for ulceration, lesions, areas of gangrene.
R /: Lesions can occur from the size of a pin needle to involve all the fingertips and can lead to infection or damage / loss of tissue.

4. Push the right nutrients and vitamins.
R /: The balance of a good diet includes protein and adequate hydration, necessary for healing.

5. Monitior signs of tissue perfusion adequacy.
R /: To know the early signs of impaired perfusion.

6. Encourage the patient performs the exercises, or exercises gradually extremities.
R /: For circulation.

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