Model II-C
Perfusion
The 6 P’s: (1) Pain (2)Pallor (3)Polar (4)Paresthesia (5)Paralysis (6)Pulse
Central Perfusion
Local/Tissue Perfusion
All Pigs Eat Too Much
Heart Sounds: S1 and S2
Wernicke Korsakoff Syndrome:
A+P Review (not on test)
Blood Flow:
Know the route- Blood comes from the body-->superior and inferior vena cana-->right
atrium-->tricuspid-->right ventricle-->pulmonary valve-->pulmonary artery (only artery without
oxygenation)-->
Electric Conductor of Heart: SA node 60-100
AV node 40-60
Bundle of His: (left and right bundle branches into Perkinje
fibers, 20 to 40 bpm, not livable)
Model II-C
Perfusion
On Test:
Central Perfusion
I. Generated by cardiac output: blood pumped out by heart each minute
a) 4 to 6 liters of blood pumped out
II. Cardiac output affects electrical and mechanical systems
a) Peripheral vascular system
III. Central perfusion can be impaired by: occurs with decrease in cardiac output
a) Can lead to a myocardial infarction
b) Can lead to impairment of electrical system like SA or AV node
c) Can lead to malfunctioning of heart valves (tricuspid, mitral valves and shock)
IV. Local tissue perfusion: refers to volume of blood that goes through targeted tissues (targeted
tissues which refers to organs)
a) Can be impaired by injury, HTN/hypotension (constriction and dilation of vein),
thrombosis (!)
b) When adequate oxygen is not available to perfuse to the area, ischemia occurs before it
dies. Ischemia is an injury to the area, and if it goes on too long then the tissue can die
c) Wounds need more blood flow with oxygen and nutrients to heal-->patients need to eat
properly, be repositioned and for blood to get to the area so the wounds can heal
d) When perfusion is impaired, changes in the body can be temporary, long term, or can be
permanent. (temporary can heparain to help to thin out the clot, long term can be
wounds, permanent can be stroke and a deficit from one side to the other)
e) All body systems can be affected by impaired perfusion due to the inability of the blood
to reach those areas
All Pigs Eat Too Much: location of where we listen to the heart sounds
Acronym.
Aortic (2nd intercostal space on the right side)
Pulmonic (2nd intercostal space on the left side)
Erb’s Point (3rd intercostal space underneath the pulmonic on the left side)
Tricuspid (4th intercostal space on the left side)
Mitral (5th intercostal space on left side, midclavicular, apical)
S1 and S2
S1: first heart sound you hear “the lub:
S2: second heart sounds you hear “the dub”
Wernicke Korsakoff Syndrome
Model II-C
Perfusion
Risk factors for impaired perfusion:
Activity level (sedentary lifestyle is bad for perfusion)
Nutrition (poor diet, a diet high in cholesterol (atherosclerosis or plaque buildup))
Hypertension (vessels constrict and put strain on vessels)
Any type of heart disease
Diabetes (puts strain on the vessel)
Smoking (nicotine constricts the vessels)
Alcohol and drug abuse (alcoholics lack folic acid and b vitamins, banana bag because of
malnourishment) and this is Wenicke Korsakoff Syndrome (ataxia)
Immobility (a risk factor, reposition them every two hours extremities and put pillows to
make them comfortable pillow between knees, between feet)
Family genetics
Age (things slow down with age, vessels are like a rubber band but if you get older they get
stiff/more resistance with vessels), thicker/stiffer lumen of vessels, capilary walls start to
thicken so its harder with more toxins inside.
Nursing Assessments for impaired perfusion:
1. Past medical history of the patient
2. Risk factors
3. Get their history
4. Listen to the patient (subjective data)
5. Get information (objective data)
6. Lab findings
7. Listen to the heart rate, rhythm (not lub dub or can be in v tach or a fib, irregular rhythm
and in a fib they can be in a stable a fib)
8. Blood pressure (make sure that patient’s legs are not crossed)
9. Release the valve and completely deflate if you need to
10. Hypotension (decrease the body’s volume, the heart can’t pump enough)-->check if the
hypotension was a change and check in the chart. You can write down a few of the past
vital signs.
11. Hypertension: increase volume in the body, fluid overload
12. Normal blood pressure: 120/80
Make sure you know if the patient is an athlete because then the BP is lower, check the
patient’s baseline. If its a 45 and an elderly patient, it may be an issue.
140/90 is normal for old-old patient
Temperature sensitivity too
13. Normal pulse oxygen= 95% and over
Disease process with respiratory issues will be between 88 and 90
14. Orientation (AOX3): impaired cerebral perfusion (any changes you will need to call a
rapid
after you
get your vitals), could be stroke, diabetic, bleeding, UTI.
Start assessment first.
Model II-C
Perfusion
15. Activity: how does the patient tolerate activity? (short of breath? Pain in legs when
walking?)
!!Before ambulation make sure that patient can ambulate!! Get the set of vital signs first!!
If patient is weak or orthostatic hypotension, follow with a wheelchair.
16. Palpating pulses: if you can’t hear pulses you get doppler//if still cant hear get another
nurse.
+1 weak
+2 normal
+3 bounding
17. Another nursing assessment: temperature of extremities
18. Capillary refill (does it become normal within 3 seconds? Brisk. Over three seconds is
sluggish)
19. Edema (face, extremities, but you will see it mostly on lower extremities (blood is
pooling because it cant get back to the heart, diabetes, varicose veins, etc). Sometimes
upper extremities.)
A. If unilateral edema, you measure it if it is medication doing this
B. Trace edema or +1 edema
C. +2 edema when you press and has indentation, within 15 seconds its gone
D. +3 deeper indentation, keeps sinking in, 30 second rebound
E. +4 greater than 30 seconds
20. Skin turgor assessment
a) It shows elasticity, hydration
b) Clavicle to check tenting
21. Mobility
a) Rest in between activity, on and off pain during activity
b) Intermittent claudication
c) Pressure, arteriole pressure (less blood flow/nutrients and then when you stop the
blood flow goes through and gets the oxygenation, nutrients and then it feels better.
In a few minutes it will happen again)
22. Immobility
a) Clots and thrombosis
Nursing assessment:
6 p’s for neurovascular assessment
(1) Pain: subjective and objective, rate pain
(2) Pallor: compare affected to unaffected extremity, temperature and looking at color,
arterial issues if white color. If cyanotic, impaired venous perfusion. Capillary refill.
(3) Pulse: peripheral pulses. Compare pulses between affected to unaffected side. Rate the
quality 0 if not able to palpate (get doppler), +1 weak or faint, +2 normal, +3 bounding
(check capillary refill). check pulses distal to injury!
(4) Paralysis: can they wiggle toes/foot?
(5) Parathesia: sensation (pins/needles, numbness, tingling)
(6) Pressure: swelling that occurs for physiological response to injury (usually swelling),
skin is taut, looks shiny and pulled tight (can tear open)
(7) Blood loss and oozing: check casts (too tight can hurt pt), check surgical drain (JP drain,
Model II-C
Perfusion
nephrostomy drain, make sure it doesn’t ooze)
Behavioral Outcome 3: Diagnostic tests
1. A cabbage: Coronary Artery Bypass Graft (not as invasive usually)
2. Peripheral artery revascularization: reroutes blood flow if there is a blockage, in lower
extremity if they can’t get rid of clot fast enough.
3. Stent placement: material put into artery (or vein), stent can have medication and it can open up
the artery/vein for easier blood flow. Can be in heart artery or renal arteries
4. Pharmacological stress test: used if patient cannot use treadmill. Elderly patients or just cant use
treadmill. Involves induced epinephrine.
5. Endartarectomy: removal of part of the inner lining of the carotid because of the plaque buildup.
50% or above of plaque in carotid is bad, it strips the artery of plaque.
6. Chest xray: diagnostic tool to see if there is enlargement of the heart.
7. Ultrasound
8. Labs:
a) CBC (red blood cells, plateltet count, white blood cells).
b) Panel for electrolytes (sodium potassium, magnesium, calcium--> too much of any
affects heart).
c) BNP: btype natriuretic peptide, hormone within heart in response to pressure changes
d) CRP: C reactive protein. Inflammation marker. Somewhere there is inflammation
e) CK and Troponin: cardiac markers, for severe chest pain for damage of heart muscle
f) Homosysteine levels: amino acids playing role in perfusion and blood formation
g) Serum lipids: HDL, LDL.
Nursing Interventions
1) Listen to heart sounds
a) Apical heart rate: mid clavicular 5th intercostal
i. Lub: S1
ii. Dub: S2
2) Preventions
a) Primary prevention
i. Promotes or includes health promotion and prevention of the development of
disease
1. Healthy life, nutrition, exercise, avoid smoking, keep healthy weight and BP,
cholesterol check.
b) Secondary prevention:
i. Screening, early diagnosis and prompt treatment
3) Other Nursing interventions:
a) monitor vital signs (high hr and low bp: infection/ dehydration) tachycardia (low
pressure and low volume to compensate, need to give fluids). check patient’s baseline
and history. (always check patient’s vitals in chart before report)
b) Review patient medical history (are there trends or is what they came up for something
new)
c) LOC (non verbal, forgetful confused, Aox3 or obtundant)-->always know mentation
Model II-C
Perfusion
when you go in for physical assessment
d) Examine the skin color and temperature (general look and feel extremities)
e) Check for wounds (turn and reposition patients every two hours especially immobile),
use Braden scale (sensory perception moisture activity friction and know the numbers
for each)
f) Assess peripheral pulses
g) Monitor for fluid balance and weight gain (see if gaining or losing weight to assess
edema loss)
h) Lab values tell a lot (vital signs & lab values: H+H (low H+H means anemia, low red
blood cell count)
i. Polycythemia: too many RBCs (can form clots bc blood is too thick)
ii. Dehydration: vomiting and diahrrea causes dehydration. Elderly and infants get
dehydrated sooner within 24 hours.
i) Apply compression stockings and SCD’s: SCDs are mechanical (fill with air).
compression stockings.
Potential complications from impairments of Central Perfusion
-Malfunctioned heart valve
-Decrease in cardiac output (heart has ejection fraction)
-Impaired local tissue perfusion
-Occlusions
-Constrictions of artery
-Dilation of artery (too much fluid all at once causes imbalance and puts heart under stress<
bring very high blood pressure down very slowly)
-Can interfere with blood flow
-Blood flow can result in ischemia which can lead to death of the area
Medications: not on test
-vasodilators (dilate arteries)
-vasopressors (constrict arteries)
-Diuretics (take extra fluid off the patient, too much urine can deplete potassium. On lasix
(which pulls potassium) they use potassium supplement).
-anti dysrthymics: supraventricular tachycardia.
-anticoagulants: prevent blood clots
-antiplatelets: platelet aggregators stop them from sticking
-thrombocytics: are clot busters, they dont use this for clot in calf area. TPA for stroke but
CAT scan first to ensure that there is no head bleed.
-Lipid lowering agents: statins (to decrease cholesterol) --> can cause muscle pain
Patient Teaching:
.
ensure that they visit pcp
.
Ask them questions to make sure they understand
.
Adhere to medication regimens (explain reasoning behind taking medication)
.
Discuss related risk factors for impaired perfusion (sedentary, drugs, alcohol, bad diet)
.
Teach patients to report signs and symptoms of shortness of breath, weight gain (fluid
Model II-C
Perfusion
.
.
.
.
overload) and chest pain.and importance of calling for help. 2 lb in 24 hours.
Benefits of heart healthy diet and exercise
Position patient according to condition which means that there are different positioningfor
arterial perfusion or venous perfusion.
. If arterial: dangle feet to get blood to feet. The letter A, dangle feet
. If arterial, feet up
Alternative options for smoking cessation: community group, patches to stop.
Always take medication as prescribed. Need to call physican before stopping medication.
Or else it will rebound.