CCBC perfusion.2023 student copy.pdf

NURN 155 ASSESSMENT PERFUSION MARY CHRISTINE COX, MS, RN, NPD-BC, CLC, CHC OBJECTIVES By the end of this presentation the student will be able to: 1. Define perfusion. 2. Identify at least 3 modi...

NURN 155 ASSESSMENT PERFUSION MARY CHRISTINE COX, MS, RN, NPD-BC, CLC, CHC OBJECTIVES By the end of this presentation the student will be able to: 1. Define perfusion. 2. Identify at least 3 modifiable risk factors. 3. Discuss normal and abnormal findings in the physical assessment. 4. Verbalize considerations for patients with perfusion disturbances. DEFINITION Perfusion: the flow of blood through arteries and capillaries delivering nutrients and oxygen to the cells and removing cellular waste  https://www.youtube.com/watch?v=WeRo-ScRG8E PERFUSION ASSESSMENT Cognition Vital Signs Heart Sounds/apical Pulse Pulses Health interview/subjective data  Elevated Serum lipids Hypertension Tobacco use MODIFIABLE Physical inactivity RISK Obesity Diabetes FACTORS Metabolic syndrome Psychological states High stress Personally – hypertension, elevated cholesterol or triglycerides, heart murmur, PERSONAL congenital heart disease, rheumatic fever, anemia AND FAMILY CARDIAC Family – hypertension, obesity, HISTORY diabetes, coronary artery disease, sudden death at a young age Dyspnea, cough Fatigue Cyanosis/Pallor HISTORY Edema Medication – prescription, OTC HISTORY SLEEP PATTERNS – ELIMINATION – ORTHOPNEA, NOCTURIA, PAROXYSMAL CONSTIPATION NOCTURNAL DYSPNEA, SLEEP APNEA LEG PAIN OR CRAMPS SKIN CHANGES AUSCULTATI ON Bell – low pitched sounds Diaphragm – high pitched sounds AUSCULTATI ON Normal heart sounds (S1 & S2) Extra heart sounds (S3, S4) Dysrhythmias Murmurs  AUSCULTATION POINTS OF THE HEART HEART SOUNDS: S1, S2, S3, S4 https://www.youtube.com/shorts/XqPm3Sx0HY4 HEART SOUNDS HEART MURMURS INSPECTION & PALPATION - APICAL Palpate the apical impulse or PMI: point of maximal impulse Located 4th-5th intercostal space, midclavicular line Apex of heart Pulsation coincides with carotid pulse HTTPS://WWW.GOOGLE.COM/SEARCH? SCA_ESV=558777580&RLZ=1C1CHBD_ENUS889US889&SXSRF=AB5STBI_PEOLPKQ18O15TTA4EXIFXHBNXQ:1692628 702718&Q APICAL+PULSE+ASSESSMENT&TBM=ISCH&SOURCE=LNMS&SA=X&VED=2AHUKEWJFIB- K_E2AAXXBFLKFHR33CLSQ0PQJEGQIDBAB&BIW=1280&BIH=875&DPR=1#IMGRC=5SKJJODYUEE7OM INSPECT, PALPATE AND PERCUSS JUGULAR VENOUS DISTENSION -JVD Marker of fluid volume Inspect the client’s neck while patient is at a 30-45 degree angle while turning head slightly PERICARDIAL FRICTION RUB An inflammation in pericardium “scratchy” sound best heard in the 3rd ICS left side (called Erb’s Point), have patient sit up and lean forward, use diaphragm of stethoscope PERIPHERAL VASCULAR SYSTEM Blood flow Pulses & Condition of skin Sufficiency of and nails arterial circulation Integrity of venous system Reflects heart function better than peripheral arteries Commonly auscultated Carotid bruit Narrowed blood vessel creates turbulence, causes blowing/swishing sound CAROTID PULSE PULSES Rate & regular or irregular Presence or absence - unable to palpate use Doppler Symmetry Quality 0: absent, not palpable 1+: pulse diminished, barely palpable 2+: expected/normal 3+: full pulse, increased 4+: bounding pulse CAPILLARY REFILL Depress and blanch nail beds – release and note time for color return Normal if color returns in 1-2 seconds INSPECTION & PALPATION Color  pale, cyanotic, or mottled  buccal membranes pink Moisture  moist vs. dry Temperature  cool or warm EDEMA Accumulation of fluid in the Pitting: leaves an indentation interstitial space in the tissue with pressure Brawny: chronic edema, with discoloration of the extremity, Non-pitting: swelling is occurs with long standing evident, but no pit is formed swelling. This rarely abates with pressure; swelling will and does not pit with pressure abate with treatment PITTING EDEMA BRAWNY EDEMA DOPPLER Doppler Ultrasonic stethoscope Detect a weak peripheral pulse Measure a low blood pressure Magnifies pulsatile sounds TEDS Thromboembolic device Elastic stockings Aid in maintaining external pressure on the muscles of lower extremities to promote venous return Measure calf for correct size SCD’S Sequential compression stockings Alternately inflates (10-15 sec)and deflates (45-60 sec) Decreases venous stasis by increasing venous return LABORATORY STUDIES Neurohormone secreted in response to elevated ventricular pressure. Normal < 100 pg/mL Elevated is a marker for heart failure LAB VALUES B-TYPE NATRIURETIC PEPTIDE  PT - Prothrombin time - 11.0-13.0 sec INR – International Normalized LAB Ratio –