Nursing Care Plan for Atherosclerosis
Assessment for Atherosclerosis
Assessment is the first step in the nursing process and basic overall, all of the data or client information, which is collected is needed to determine the nursing assessment of the client's problems with atherosclerosis.
1. Activity and rest
3. Elimination
8. Respiration
Nursing Diagnosis for Atherosclerosis
Nursing diagnoses that may arise in patients with atherosclerosis are:
1. Risk for decreased cardiac output related to Strock volume.
2. Ineffective Tissue perfusion related to exchange disorder.
3. Knowledge Deficit related to the lack of information regarding the sources of information.
Assessment is the first step in the nursing process and basic overall, all of the data or client information, which is collected is needed to determine the nursing assessment of the client's problems with atherosclerosis.
1. Activity and rest
- Weakness, fatigue, inability to sleep (possibly obtained tacycardia and dyspnea at rest or during activity).
- History of Acute Myocardial Infarction, coronary heart disease, CHF, Hypertension, diabetes mellitus.
- Blood pressure may be normal or increased, the pulse may be normal or late Capilary refill time, dysrhythmia
- The sound of the heart, extra heart sounds S3 or S4 may reflect the occurrence of heart failure / loss of ventricular contractility.
- Heart rate may be increased or decreased.
- Possible irregular heart rhythm, or also normaI.
- Edema: jugular venous distension, edema anasarca, crackles may also arise with heart failure.
- Skin color may pale, both lips and nails.
3. Elimination
- Bowel sounds may increase, or also normal.
- Nausea, loss of appetite, decreased skin turgor, sweat a lot, vomiting and weight changes.
- Dyspnea or chest pain or pounding in the chest while doing the activity.
- Violent headache, Changes mentation.
- Onset of chest pain that does not suddenly disappear with rest or with the drugs.
- Location of chest pain in the front of substernal, which may spread to the arms, jaw and face.
- Characteristics of pain, may be said to be a pain ever experienced by the patient.
- As a result of the pain as possible in getting the grinning face, changes in posture, crying, decreased eye contact, changes in heart rhythm, ECG, blood pressure, respiration and skin color as well as the level of consciousness.
8. Respiration
- Dyspnea with or without activity, productive cough, smokers with a history of chronic respiratory disease. On examination may get an increase in respiration, pale or cyanosis, crakcles breath sounds or wheezes or too vesukuler. Clear sputum or too pink / pink tinged.
- Stress, difficulty in adapting to stressors, uncontrolled emotions.
- History in the family is suffering from heart disease, diabetes, stroke, hypertension, smokers.
Nursing Diagnosis for Atherosclerosis
Nursing diagnoses that may arise in patients with atherosclerosis are:
1. Risk for decreased cardiac output related to Strock volume.
2. Ineffective Tissue perfusion related to exchange disorder.
3. Knowledge Deficit related to the lack of information regarding the sources of information.
