Perfusion Student (2) PDF

Perfusion Learning Outcomes  At the end of the lecture the student will:  Identify risk factors for developing selected perfusion disorders.  Articulate the recommended screening practices, laboratory and diagnostic studies for selected perfusion disorders.  Discuss clinical manifes...

Perfusion Learning Outcomes  At the end of the lecture the student will:  Identify risk factors for developing selected perfusion disorders.  Articulate the recommended screening practices, laboratory and diagnostic studies for selected perfusion disorders.  Discuss clinical manifestations of selected disorders of perfusion.  Plan and prioritize nursing interventions for a patient with an alteration in perfusion.  Develop a teaching plan, utilizing current research, for a patient with an alteration in perfusion.  Apply principles of pharmacologic management to the care of patients with an alteration in perfusion.  Discuss management of care for patients receiving transfusion therapy. Exemplars  Peripheral Vascular Disease  Arteriosclerosis & Atherosclerosis  Hypertension  Cardiovascular Disease  Stable Angina  Chronic Heart Failure  Hematologic diseases  Anemia  Leukemia Perfusion  Central Perfusion: a normal physiologic process that requires the heart to generate sufficient cardiac output to transport blood through patent blood vessels for distribution in the tissues throughout the body.  Tissue perfusion refers to the flow of blood through target tissues. The blood flows through arteries and capillaries, delivering nutrients and oxygen to cells, and removing cellular waste products. Normal Physiological Process Central Perfusion Cardiac Output Stroke Volume HR Preload Afterload Contractility Impaired Central Perfusion  Impairment of central perfusion occurs when cardiac output is inadequate.  Conduction or valve problems  Disease of the heart muscle  Increased SVR (afterload)-HTN, Aortic stenosis  Decreased SVR (afterload)-hemorrhage  Reduced cardiac output results in a reduction of oxygenated blood reaching the body tissues (systemic effect).  If untreated, leads to ischemia, cell injury and cell death  If severe, associated with shock Impaired Tissue Perfusion  Impaired tissue perfusion occurs when there is reduced blood flow to the target tissues through the arteries and capillaries.  Poor central perfusion  Blockage of the vessel leading to target organ or tissue  Excessive edema interferes with cellular oxygen exchange  Results of impaired tissue perfusion is impaired blood flow to target tissue  Ischemia, irreversible cell injury and necrosis (cell death) Risk Factors Associated with Impaired Increased age Perfusion  Male  Genetics  Congenital Heart Defects  Cardiovascular Disease  Peripheral Vascular Disease Impaired Perfusion Risk Factors Non-Modifiable Modifiable  Age  Smoking  Sex  Obesity  Genetics  Hyperlipidemia  Ethnicity  HTN  DM  Sedentary lifestyle  Hypertension Copyright © 2020 by Elsevier, Inc. All rights reserved. 11 Hypertension  Modifiable risk factor to prevent CVD  As BP increases, so does the risk of:  MI  Heart failure  Stroke  Renal disease  Retinopathy  Affects ~46% adults in United States  Heart disease associated with HTN leads to 23.7% of deaths in United States Copyright © 2020 by Elsevier, Inc. All rights reserved. 12 Hypertension  Promoting health equity  All ethnicities: Three factors for decreased prevalence  Born outside United States; do not speak English; limited time living in United States  Blacks  Highest prevalence; more resistant HTN; develop at younger age; female greater than male; more nocturnal nondipping BP; more end-organ damage; highest death rate  Less response to renin inhibiting meds; better control with calcium channel blockers and diuretics  Increased risk of angioedema with ACE inhibitors Copyright © 2020 by Elsevier, Inc. All rights reserved. 13 Hypertension  Promoting health equity  Hispanics  Less likely to receive treatment  Lower rate of: awareness, treatment, and control  Gender differences  Men—more common before middle age  Women  increased 2-3x with oral contraceptives  Preeclampsia—possible early sign  More common after menopause; harder to control with older women Copyright © 2020 by Elsevier, Inc. All rights reserved. 14 Normal Regulation of Blood Pressure  Blood pressure (BP)—force exerted by blood against walls of blood vessels  Involves both systemic factors and peripheral vascular effects  Important to maintain tissue perfusion during activity and rest.  Function of cardiac output (CO) and systemic vascular resistance (SVR)  CO = SV × HR Copyright © 2020 by Elsevier, Inc. All rights reserved. 15  Gu Copyright © 2020 by Elsevier, Inc. All rights reserved. 16 Etiology of Hypertension  Primary hypertension  Also called essential or idiopathic HTN  Elevated BP of unknown cause  90% to 95% of all cases  Many contributing factors  Altered endothelial function, increased SNS activity, increased Na+ intake, overproduction of Na+ retaining hormones, overweight, diabetes, tobacco, excess alcohol Copyright © 2020 by Elsevier, Inc. All rights reserved. 17 Etiology of Hypertension  Secondary hypertension  Elevated BP with a specific cause; sudden development  5% to 10% of adult cases  Clinical findings relate to underlying cause (See Table 32-3 in the textbook)  Cirrhosis; aortic problems; drug-related; endocrine, neurologic, or renal problems; pregnancy-induced, or sleep apnea  Treatment aimed at removing or treating cause Copyright © 2020 by Elsevier, Inc. All rights reserved. 18 Risk Factors for Primary Hypertension  Age  Family history  Alcohol use  Obesity  Tobacco use  Ethnicity  Diabetes  Sedentary lifestyle  Elevated serum lipids  Socioeconomic status  Excess dietary  Stress sodium  Gender Copyright © 2020 by Elsevier, Inc. All rights reserved. 19 Hypertension Clinical Manifestations  “Silent killer”—asymptomatic until severe and target organ disease occurs  Symptoms of severe hypertension  Fatigue  Dizziness  Palpitations  Angina  Dyspnea Copyright © 2020 by Elsevier, Inc. All rights reserved. 20 Hypertension Complications  Target organ diseases occur most frequently in:  Heart  Coronary artery disease; atherosclerosis  Left ventricular hypertrophy (Fig. 32-4)  Heart failure  Brain—cerebrovascular disease  TIA/Stroke; atherosclerosis  Hypertensive encephalopathy; changes in autoregulation Copyright © 2020 by Elsevier, Inc. All rights reserved. 21 Left ventricular hypertrophy (A) Normal thickness (B) (Fig. 32-4) Copyright © 2020 by Elsevier, Inc. All rights reserved. 22 Hypertension Complications  Peripheral vascular disease  Atherosclerosis leads to PVD, aortic aneurysm, aortic dissection  Intermittent claudication  Kidney  Nephrosclerosis leads to chronic kidney disease (CKD)  Eyes—retinal damage  Blurry or loss of vision; retinal hemorrhage  Damaged retinal vessels indicate concurrent damage to vessels in heart, brain, and kidneys. Copyright © 2020 by Elsevier, Inc. All rights reserved. 23 Hypertension Diagnostic Studies Measurement of BP Labs to: 1) identify or rule out secondary HTN 2) evaluate target organ disease 3) determine CV risk 4) establish baselines before starting therapy (Table 32-5) Renal function, U/A, BMP, CBC, serum lipid profile, uric acid, ECG, ophthalmic exam Other; Echo, LFTs, TSH  Ambulatory blood pressure monitoring (ABPM); avoids “white coat” HTN  Noninvasive, fully automated system that measures BP at preset intervals over 12 to 24-hour period. Teach patient to hold arm still while device reads BP and keep diary of activities Copyright © 2020 by Elsevier, Inc. All rights reserved. 24 Hypertension Interprofessional Care  Overall goals (Table 32-5)  Achieve and maintain goal BP  Reduce CV risk factors and target organ disease  Lifestyle modifications  AHA Life’s Simple 7: (1) Manage BP, (2) Control cholesterol, (3) Reduce blood sugar, (4) Get active, (5) Eat better, (6) Lose weight, (7) Stop smoking Copyright © 2020 by Elsevier, Inc. All rights reserved. 25 Hypertension Lifestyle Modifications  Weight Reduction  Dash Diet  Low Sodium Dietary Intake  Moderation of Alcohol Intake  Physical activity  Avoid tobacco products  Management of risk factors Copyright © 2020 by Elsevier, Inc. All rights reserved. 26  Causes of Secondary HTN  Neurological Disorders  Increased ICP  Sleep apnea  Vascular:  Coarctation of aorta  Pregnancy  Medications  Renal Disease Hypertension: Drug Therapy  High Blood Pressure Clinical Practice Guidelines—antihypertensive recommendations  Age > 65, SBP > 130 mmHg, ambulatory in community setting: Goal SBP < 130 mmHg  Age > 65, SBP >130 mmHg, care facility or multiple comorbidities or limited life expectancy: Goal—patient/team decision  Age> 18 with HTN, known CVD or other risk factors: Goal—130/80  All others without CVD or other risk factors: Goal BP 40” men; 35” women  Increased LDLs, triglycerides; HTN; insulin resistance  Apple figure > CAD than pear figure Copyright © 2020 by Elsevier, Inc. All rights reserved. 80 Risk Factors  Contributing modifiable risk factors  Diabetes—2-4 × CAD  Increased endothelial dysfunction  Altered lipid metabolism, increased cholesterol and triglycerides  Metabolic syndrome  Multiple risk factors related to insulin resistance including central obesity, HTN, abnormal serum lipids, and high fasting blood glucose Copyright © 2020 by Elsevier, Inc. All rights reserved. 81 Risk Factors  Contributing modifiable risk factors  Psychologic states  Type A personality  Acute and chronic stress, depression, anxiety, hostility and anger, lack of social support results in increased SNS stimulation results in increased catecholamines results in endothelial injury, increased HR, increased force of myocardial contraction results in increased O2 demand  Altered coagulation Copyright © 2020 by Elsevier, Inc. All rights reserved. 82 Risk Factors  Contributing modifiable risk factors  Increased homocysteine level  Breakdown of essential amino acid methionine (protein)  Damage endothelium, promote plaque buildup, enhance clotting  Substance use  Cocaine and methamphetamine results in coronary artery spasm resulting in chest pain and MI Copyright © 2020 by Elsevier, Inc. All rights reserved. 83 Interprofessional and Nursing Care Health promotion  Identifying high-risk persons  Health history, including family history  Presence of cardiovascular symptoms  Lifestyle patterns  Psychosocial history  Employment history  Values and beliefs about health and illness; education and literacy Copyright © 2020 by Elsevier, Inc. All rights reserved. 84 Interprofessional and Nursing Care  Managing high-risk persons  Prevention: control modifiable risk factors  Encourage lifestyle changes  Education  Clarify personal values  Set realistic goals Copyright © 2020 by Elsevier, Inc. All rights reserved. 85 Interprofessional and Nursing Care  Physical activity  FITT formula:  Frequency, Intensity, Type and Time  30 minutes most days plus weight training 2 days/wk  Regular physical activity helps with:  Weight reduction  Reduction of systolic BP  Increase in HDL cholesterol Copyright © 2020 by Elsevier, Inc. All rights reserved. 86 Interprofessional and Nursing Care  Nutritional Therapy  Reduced Saturated fats and cholesterol  Increased Complex carbohydrates and fiber  Reduced Red meat, egg yolks, and whole milk  Increased Omega-3 fatty acids Copyright © 2020 by Elsevier, Inc. All rights reserved. 87 Interprofessional and Nursing Care  Lipid-lowering drug therapy  Lipid profile screening  Statin therapy recommended:  Patients with known CVD  LDL cholesterol > 190 mg/dL  Age 40 to 75 with diabetes and LDL 70 to 189 mg/dL  Age 40 to 75 with LDL 70 to 189 mg/dL and 10-year risk for CVD at least 7.5% Copyright © 2020 by Elsevier, Inc. All rights reserved. 88  Interprofessional and Nursing Care HMG-CoA Reductase Inhibitors (Statins) atorvastatin (Lipitor) fluvastatin (Lescol XL) lovastatinpitavastatin (Livalo) pravastatin (Pravachol) rosuvastatin (Crestor) simvastatin (Zocor) Copyright © 2020 by Elsevier, Inc. All rights reserved. 89 Gerontologic Considerations: CAD  Increased incidence and mortality associated with CAD in older adults  Strategies to reduce risk and treat CAD are effective  Treat: hypertension and increased lipids  Smoking cessation, increased physical activity  Most likely to change when hospitalized or have chest pain Copyright © 2020 by Elsevier, Inc. All rights reserved. 90  Peripheral Artery Disease Copyright © 2020 by Elsevier, Inc. All rights reserved. 91 Peripheral Artery Disease (PAD)  Involves thickening of the artery walls and progressive narrowing of arteries of upper and lower extremities  Symptomatic age 60 to 80; earlier with diabetes  In United States, 8.5 million have PAD   prevalence with blacks  Strongly related to other cardiovascular disease (CVD) and risk factors  Higher risk of mortality, CVD mortality, major coronary events and stroke Copyright © 2020 by Elsevier, Inc. All rights reserved. 92 Etiology and Pathophysiology  Atherosclerosis is leading cause in majority of cases  Gradual thickening of the intima and media due to cholesterol and lipid deposits  Exact cause unknown; inflammation and endothelial injury play a major role Copyright © 2020 by Elsevier, Inc. All rights reserved. 93 Pathogenesis of Atherosclerosis Copyright © 2020 by Elsevier, Inc. All rights reserved. 94 Etiology and Pathophysiology  Risk factors:  Tobacco use  Atherosclerosis  Diabetes  HTN  High cholesterol  Age greater than 60  See Gender Differences Box  Multiple risk factors increase the risk of PAD  Atherosclerosis often affects coronary, carotid, and lower extremity arteries  Symptoms occur when arteries are 60% to 75% blocked Copyright © 2020 by Elsevier, Inc. All rights reserved. 95 PAD of Lower Extremities Common Sites of Atherosclerotic Lesions Copyright © 2020 by Elsevier, Inc. All rights reserved. 96 Clinical Manifestations  Classic symptom of PAD— intermittent claudication  Ischemic muscle pain that is caused by a constant level of exercise  Build up of lactic acid from anaerobic metabolism  Resolves within 10 minutes or less with rest  Reproducible Copyright © 2020 by Elsevier, Inc. All rights reserved. 97 Clinical Manifestations  Paresthesia  Numbness or tingling in the toes or feet from nerve tissue ischemia  Neuropathy causes severe shooting or burning pain  Produces loss of pressure and deep pain sensations from reduced blood flow  Injuries often go unnoticed by patient Copyright © 2020 by Elsevier, Inc. All rights reserved. 98 Clinical Manifestations  Reduced blood flow to limb:  Thin, shiny, and taut skin  Loss of hair on the lower legs  Diminished or absent pedal, popliteal, or femoral pulses  Pallor of foot with leg elevation  Reactive hyperemia of foot with dependent position Copyright © 2020 by Elsevier, Inc. All rights reserved. 99 Clinical Manifestations  Pain at rest  Progressive disease  Occurs in feet or toes  Aggravated by limb elevation  Occurs from insufficient blood flow to distal tissues  Occurs more often at night  Pain relief by gravity Copyright © 2020 by Elsevier, Inc. All rights reserved. 100 Complications Prolonged ischemia leads to:  Atrophy of skin and underlying muscles  Delayed healing  Wound infection  Tissue necrosis  Arterial ulcers over bony prominences Copyright © 2020 by Elsevier, Inc. All rights reserved. 101 Complications  Most serious: Nonhealing arterial ulcers and gangrene  Collateral circulation may prevent gangrene  May result in amputation  If adequate blood flow is not restored and if severe infection occurs  Indicated with uncontrolled pain and spreading infection Copyright © 2020 by Elsevier, Inc. All rights reserved. 102 Diagnostic Studies  Doppler ultrasound  Segmental blood pressure  Duplex imaging  Bidirectional, color Doppler  Ankle-brachial index (ABI) Done using a hand-held Doppler  Angiography and magnetic resonance angiography Copyright © 2020 by Elsevier, Inc. All rights reserved. 103 Interprofessional Care Risk Factor Modification  Goal: reduce CVD risk factors  BP control (reduce sodium; DASH diet)  Tobacco cessation  Hemoglobin A1C 60 y.o. Children: peak 4 y.o., rare after 15 y.o. Prognosis highly variable -- the younger the patient, the better the Prognosis: 5 year survival 80% for children but 40% for adults prognosis Bone/abdominal, CNS pain “Undifferentiated” form: worse prognosis Chemo: corticosteroids and vinca alkaloids Neutropenia: fever, weakness, bleeding Bone marrow transplant Chemo: aggressive induction therapy Bone marrow transplant CHRONIC MYELOGENOUS LEUKEMIA CHRONIC LYMPHOCYTIC LEUKEMIA Rare: < 20 y.o.; median age 55-60 y.o. Most common form; 2/3 > 60 y.o. Prognosis: 3-5 years while chronic, only months once it becomes acute Prognosis: 2 (late) – 14 (early) years Three stages: chronic, transformation, accelerated (blast) crisis Painful enlarged lymph nodes Malaise, anorexia, weight loss possible “B” symptoms: night sweats, weight loss, fever Gleevec, Interferon, hydroxyurea Chemo: monoclonal antibodies Bone marrow transplant Infections: antibiotics, immunoglobulin  Leukemia from a conceptual Leukemia view:  Manifestations You will have problems with  Bruises, both PERFUSION and petechiae, pallor  PROTECTION. The patient Open lesions, bleeding gums suffers from symptoms of  Anorexia, wt. pancytopenia. The loss overproduction non-working  Enlarged liver WBCs will take over, meaning and spleen the patient has no ability to  Tachycardia, palpitations PROTECT themselves (either  Orthostatic from infection or bleeding) and hypotension reduced RBCs which means  D.O.E., fatigue, decreased PERFUSION. Hence, headache, fever, the manifestations on the left.  Bone or joint pain and swelling, hematuria Leukemia Clinical Manifestations  Inadequate marrow elements predispose patient to  Anemia  Thrombocytopenia  Decreased number and function of WBCs Copyright © 2020 by Elsevier, Inc. All rights reserved. 209 209 Leukemia Collaborative Care  Initial goal is to attain remission  Complete, partial, or molecular  Prognosis is directly related to ability to maintain a remission  Prognosis becomes more unfavorable with each relapse  Chemotherapy is the mainstay of treatment Copyright © 2020 by Elsevier, Inc. All rights reserved. 210 210 Leukemia Chemotherapy Regimens  Combination chemotherapy  Mainstay of treatment  Three purposes  Decrease drug resistance  Decrease drug toxicity by using multiple drugs  Interrupt cell growth at multiple points in cell cycle Copyright © 2020 by Elsevier, Inc. All rights reserved. 211 211 Leukemia Other Treatments  Corticosteroids  Radiation therapy  Total body radiation in preparation for bone marrow transplantation  Organ- or field-specific such as liver or spleen  Immunotherapy and targeted therapy Copyright © 2020 by Elsevier, Inc. All rights reserved. 212 212 Leukemia Hematopoietic Stem Cell Transplant  Goal of HSCT  Eliminate all leukemic cells using combinations of chemotherapy with or without total body irradiation  Eradicates patient’s hematopoietic stem cells  Replaced with those of an HLA-matched  Sibling  HLA-half-matched relative  Volunteer donor (allogenic)  Identical twin (syngeneic) Copyright © 2020 by Elsevier, Inc. All rights reserved. 213 213 Nursing Management Planning  Overall goals  Understand and adhere to treatment plan  Have minimal side effects and complications of disease and treatment  Establish realistic hope and goals, feeling supported during periods of treatment, relapse, and remission Copyright © 2020 by Elsevier, Inc. All rights reserved. 214 214 Nursing Management Acute Care  Many physical and psychologic needs  Diagnosis evokes great fear  Equated with death  Family needs help adjusting to stress of sick role  May be viewed as hopeless, horrible Copyright © 2020 by Elsevier, Inc. All rights reserved. 215 215 Nursing Management Acute Care  Important nursing interventions  Maximizing patient’s physical functioning  Teaching patients that acute side effects of treatment are usually temporary  Encouraging patients to discuss quality of life issues Copyright © 2020 by Elsevier, Inc. All rights reserved. 216 216 Leukemia – Case Study What should be included in this teaching?  Your patient has been diagnosed with leukemia after presenting to the office with frequent bruising, bleeding gums, fatigue and fevers. You are to teach the patient about bleeding precautions, managing fatigue and protecting himself from infections Copyright © 2020 by Elsevier, Inc. All rights reserved. 217