Care of the Client with Common Perfusion Problems PDF

Care of the Client with Common Perfusion Problems NUR 170 To understand cardiac The purpose of the heart is to carry necessary supplies out to the tissues. There are components The pump The electrical system The vascular system...

Care of the Client with Common Perfusion Problems NUR 170 To understand cardiac The purpose of the heart is to carry necessary supplies out to the tissues. There are components The pump The electrical system The vascular system The blood volume Pump – heart failure With heart failure the heart does not pump forward as well as it should and therefore there is back up of fluid. This can happen on the left or right side Left sided heart failure Right sided heart failure Left side should pump Right side should pump forward to body….so it forward to lungs… so it backs up to the lungs backs up to the body This back up causes This back up causes edema. In the lungs, edema. In the body, this edema can be assessed edema is noticed when by hearing crackles and assessing the client and seeing the client behave noticing edema in the in a way that shows they dependent areas. are short of air. (alveoli full of fluid)  Heart Failure Inability of the heart to eject enough blood with each heart beat to meet the demands of the heart and Pump the other body tissues. Pump – Heart failure - Left Causes – Identify these as modifiable and non modifiable. Remember to include modifiable in the client teaching in order to assist client to prevent as much as can be prevented. HTN Valvular disease Obesity Cardiomyopathy Previous heart attack Congenital defects (Myocardial infarction)/ Coronary artery disease Angina Rheumatic heart disease Diabetes Family history Substance abuse Pump – heart failure - Right Causes – Identify these as modifiable and non modifiable. Remember to include modifiable in the client teaching in order to assist client to prevent as much as can be prevented. Left ventricular failure Right sided ventricular myocardial infarction Pulmonary hypertension Chronic obstructive pulmonary disease Acute respiratory distress syndrome Pump – heart failure - Compensation Sometimes your body’s compensation mechanisms can make things worse Sympathetic nervous system stimulation (fight/flight) Renin-angiotensin system activation Chemical responses (BNP) Hypertrophy Pump – heart failure – Signs and Symptoms – Left sided heart failure Forward issues (Decreased Backward issues cardiac output) What will the periphery look What will the lungs look like? like? Go through each body system Neuro Cardiac Lungs GI/GU Skin Pump – heart failure – Signs and Symptoms – Right sided heart failure Forward issues (Decreased cardiac output) Backward issues What will the periphery look What will the lungs look like? like? Go through each body system Neuro Cardiac Lungs GI/GU Skin Chronic Heart Failure: Clinical Manifestations F - fatigue A - limitation of activities C - chest congestion & cough E - edema S - shortness of breath Pump – heart failure Additional diagnosis: Electrolytes (always monitor electrolytes with fluid imbalance) Kidney function (always monitor kidneys with fluid imbalance) I’s and O’s (always monitor I’s and O’s with fluid imbalance) BNP (A BNP is always assessed to rule in/rule out and monitor heart failure) Urinalysis EKG ABGs Pump – goals and interventions Improve Perfusion and Cardiac Output Increased gas exchange in lungs and tissues Decrease complications such as pulmonary edema and peripheral edema Assessment Diagnosis Outcomes Interventions Rationale Evaluation (**Recognizing cues) (**Analysis) (**Generating (**Take Actions) (**Evaluation) Solutions) What are You know the What are your What are Why ? How will you potential medical goals? appropriate measure assessments – diagnosis, interventions success? Subjective what are for each goal? /Objective some nursing (be sure to diagnosis? Increase O2 include lab exchange in values) lungs Increase perfusion in the periphery Decrease risk of complications  Pathophysiology for Vascular With vascular diseases, blood flow Vascular is either not getting out to the body as well as it should, or it is not returning to the heart as well as it should. 6 key signs of arterial insufficiency Pain Pallor Pulselessness Paresthesia Paralysis Poikilothermia (coolness)  Peripheral Vascular Vascular Disease Alterations to natural flow of blood through the arteries or veins usually as a result of atherosclerosis Peripheral Artery Peripheral Venous Imagine that blood is not Imagine that blood cannot getting to the foot leave your foot effectively…how does an effectively…how does area look without proper your leg look if blood is blood flow (hint: sit on trapped? (hint: ever tie a your foot) rubber band on your finger too tight? How did your finger look?) Peripheral Artery Peripheral Venous Imagine that blood is not getting to the foot effectively…how does an area look without proper Imagine that blood cannot blood flow (hint: sit on your foot) leave your foot Stage 1: Asymptomatic: Pedal pulses may be effectively…how does decreased your leg look if blood is Stage 2: Intermittent claudication: Occurs with trapped? (hint: ever tie a exercise, Relieved with rest. Due to not getting enough oxygen to LE’s. Described as aching, rubber band on your cramping. Most commonly felt in calf; also feet, thigh, buttocks. finger too tight? How did your finger look?) Stage 3: Ischemic Rest Pain (numbness or burning pain). Pain DOES NOT go away with rest. Exacerbated by elevation of leg. Pain may wake pt from sleep. Stage 4: Necrosis/Gangrene: Ulcers blacken with a gangrenous odor Peripheral Artery Peripheral Venous Assessment Assessment Ankle Brachial Index Measure BP in arm and ankle. ABI= SBP ankle/SBP arm.