Student Handout - Perfusion Assessmen

istory of Present Illness ecause of the possible urgency in care required, the nurse then establishes the patient’s reason for seeking care. The patient is asked if any of the following signs and/or symptoms are present: hest pain or discomfort OB or dyspnea

Chest

Pain reported

Pain assessment – location, any

radiation, onset, duration, rating, and descriptors can be remembered by using the mnemonic PQRSTU. Acute

Coronary Syndrome Inflammatory Heart Disorders Chest pain - non-cardiac causes. Leg Pain

current, accurate list is essential. ver-the-counter (OTC) medications such as laxatives, vitamins, herbals, antacids, pain killers, and supplements. Examples of OTC items that can influence perfusion include:

 decongestants—cold medicines, nasal sprays –may increase BP.  garlic - can reduce the ability of blood to clot  fish oil, omega fatty acids prevention of atherosclerotic vascular diseases

uestions should include: Any recent weight loss or gain? If yes, how much, over what time period. Any changes in appetite recently? Any special diet? (calorie counted, Na restriction, fluid restriction) Usual amount of caffeine and alcohol consumed?

ssess for nocturia. ssess for constipation

ny orthopnea and/or paroxysmal nocturnal

leep apnea

dyspnea.

Assessing

the patient’s frequency, intensity, and duration of activity Patient’s without adequate perfusion may complain of symptoms such as shortness of breath, chest pain or discomfort, increased fatigue, and/or muscle cramping.

Assess

the patient’s use of:

› alcohol › tobacco (pack years = packs per

day x # of years) › street drugs Stressors

and how the patient copes with stress.

past

childhood illnesses

 rheumatic and scarlet fevers

Ask

for information about any accidents, injuries, hospitalizations, or surgeries in the past? Has the patient had or currently have diabetes, hypertension, heart disease, sickle-cell crisis, anemia, or cancer?

What

is the family history (blood relatives) of perfusion disorders?

excessive bleeding or excessive clot

formation cardiac surgery, cardiac disease (including myocardial infarction & sudden cardiac death) hypercholesterolemia hypertension.

ital Signs lood Pressure mean arterial pressure pulsus paradoxus pulse pressure orthostatic measurement

S1 S2 S3

- An S3 is a ventricular gallop sound that occurs when blood enters the non-compliant ventricles during early diastole. A suddenly occurring S3 is said to be an early sign of heart failure. S4 – An S4 is an atrial gallop sound occurring when blood enters from the atrium with atrial contraction into non-compliant ventricular chambers at the end of ventricular diastole. S4 occurring with S3 is called a summation gallop and is said to be a sign of severe heart failure.



Murmurs - gentle blowing, swooshing sounds  reflect turbulent blood flow through the valves



Conditions that can result in murmurs include:  velocity of blood increases  viscosity of blood decreases  structural defects in the valves  unusual openings occur in the chambers



Murmurs are described by their  Location  Timing  Grading  Pitch  Quality  Radiation

licks –An ejection click can occur with septal defects, abrupt dilation of the aorta, forceful opening of the aortic valve, opening or closing of prosthetic valve. naps - An abnormal motion of a stenotic mitral valve can cause an opening snap that is often heard at the beginning of a mitral murmur. ericardial Friction Rub - A friction sound

Assess

presence or absence quality symmetry of bilateral pulses in

the arms and legs Pulse

Alternans (or pulsus alternans) Pulse deficit Assessment of the carotid pulse

olor emperature ruising, petechiae, or wounds should be noted dema

ndication of fluid status (overload or dehydration) edications are dosed depending on the patient’s weight. Remember some of the dosage labels: mcg/kg/min, mg/kg/min, etc. alculate Body Mass Index (BMI) bese

30 or higher

verweight 25 to 29.9

O = Stroke Volume (SV) x Heart Rate (HR)  *Normal for CO : 4 to 8 L/minute  *Normal for SV : 60 to 120 ml/beat  Example:  Stroke Volume = 80mL/beat  Heart Rate= 72/min  CO = 80 x 72 = 5760 mL/min or 5.8 L/min

O can be directly measured by advanced invasive monitoring devices such as a

Stroke

Volume is changed by an alteration in any of the following: preload, afterload, and/or contractility. Preload Afterload Contractility Ejection Fraction

 Modifiable lifestyle factors  dyslipidemia  obesity  sedentary lifestyle  smoking  stress  Conditions that can be controlled and are

considered modifiable are Diabetes Mellitus, Hypertension, and Metabolic Syndrome.

 Non-modifiable  age, family history, gender, and race.

Changes

as a person ages include

stiffening and loss of elasticity of

vessels thickening of valves and muscles decreased sensitivity of receptors decrease of numbers of cells conducting electrical impulses.

 areas

that are influenced by one’s culture and spiritual beliefs

 dietary choices  acceptance of blood or blood products  health practices (i.e. use of herbals)  description of pain  biological reactions to medications

B-type Natriuretic Peptide (BNP) Coagulation Studies Complete Blood Count (CBC) Electrolytes Iron & Laboratory Indicators of Iron

Deficiency

Anemia Lipid Profile C-Reactive Protein Homocysteine Type & Cross Match *Source for lab values: Van Leeuwan, A.M., etal (2006). Davis’s comprehensive handbook of laboratory and diagnostic tests with nursing implications (2nd ed), Phila: F.A. Davis

With

any blood draw

any needed restrictions in food/fluid intake any restriction in medication

administration specimens are obtained on time when being done serially or when based on administration of medications. After

blood is drawn monitor venipuncture site for bleeding, hematoma, phlebitis, and/or infection. Watch for lab results and report any significant abnormalities to the ordering Provider.

eurohormone primarily secreted from the ventricles in response to increased preload with resulting elevated ventricular pressure. ormal level should be < 100 pg/mL -type Natriuretic Peptide is a serum marker for heart failure ynthetic BNP is now available in an IV nesiritide (Natrecor) sed to treat acute exacerbations of heart failure.

form

ctivated partial thromboplastin time (aPTT)

› Normals › APTT 21-35 sec › Therapeutic APTT (patient on heparin) is 1.5 to 2.5

baseline

T

› Normals - Prothrombin time (PT) 11.0-13.0 sec

NR

› Normals - INR <2.0 (not on anticoagulant) › INR 2.0 to 3.0 - treatment for venous thrombosis,

Fibrinogen



Normal – Fibrinogen 200-400 mg/dL

(adult)

Fibrin

Degradation Products (FDP)

Normal - Fibrin Degradation Products

< 10 mg/dL

D-Dimer Normal - D-Dimer <250ng/mL

Refer

back to the NURN 152 Lab/Diagnostics module for specifics about the CBC. specific to perfusion Hemoglobin WBC counts platelets

he electrolytes that are most influential in perfusion are sodium, potassium, calcium, and magnesium.

ormals  Sodium 135 – 145 mEq/L  Potassium 3.5 – 5.0 mEq/L  Calcium (ionized) 4.5 – 5.5 mg/dL  Magnesium 1.6 – 2.6 mg/dL

ormals  Iron  50 to 170 ug/dL in females  65 to 175 ug/dL in males

 Ferritin  20-250 ng/mL in men  10 – 120 ng/mL in women <40 yr old  12 – 263 ng/mL in women >40 yr old

 Transferrin 200-380 mg/dL  TIBC 250 – 350 ug/dL

ormals (Desirable Optimal Levels) holesterol (total)

<200 mg/dL

igh Density Lipoprotein (HDL) > 60 mg/dL ow Density Lipoprotein (LDL) < 100 mg/dL riglycerides

<150 mg/dL

ormal C-Reactive Protein

1.0-3.0 mg/L

Normal

Homocysteine

8-20 umol/L



Blood Group

Can give blood to

Can receive blood from

AB

AB

AB, A, B, 0

A

A and AB

A and 0

B

B and AB

B and 0

0

AB, A, B, 0

0

Patients with Rh negative blood can only receive Rh negative blood. Rh positive patients can accept Rh positive or negative.

Prior

to the test focused assessment pre-test checklist Invasive or Semi-invasive testing requires a signed consent Patient teaching ascertain any allergies consider the appropriateness of transporting patient off the unit During the testing Post test  reassess  continue patient teaching

ontrast material is injected into the vascular system to allow for visualization, via fluoroscopy, of the structure and patency of blood vessels ontraindications -allergies to shellfish or iodinated dye or renal failure. re-Procedure NPO up to 12 hrs consent is needed checklist completed IV access site is to be the groin or antecubital space that area will prepped eaching regarding the procedure lie prone on a table area where the catheter is to be inserted is numbed  After the catheter is inserted and dye injected, pictures will be taken

Post-procedure - monitor for  reaction to the contrast agent  embolus (stroke)  hematoma or hemorrhage at insertion site  infection  renal dysfunction  conscious sedation -vital signs, respiratory status, and safety are monitored closely 

Computed

tomography or Computerized Axial Tomographic scan (CAT) uses xrays to provide cross-sectional images of chest including heart and great vessels. Contraindications to the procedure include iodine or shellfish Pre-Procedure screened for renal dysfunction and may be medicated to

prevent renal damage from the contrast material may be NPO depending upon the area to be scanned

Teaching

regarding the procedure

positioned on table while the scanner revolves around the pt the test is noninvasive and painless needs to lie perfectly still

will an IV line if contrast to be used machine is very noisy

Post-procedure monitor for  allergic reaction to contrast agent  contrast-induced renal dysfunction. 

A continuous wave Doppler ultrasound device is used as a non-invasive way to hear and evaluate blood flow. A conducting gel is applied to the skin and the transducer is slowly moved over the area where the vessel is located. Duplex Ultrasound Imaging Studies use a pulsing Doppler to send information to a computer which then produces images on the screen.

Echocardiography

is a noninvasive ultrasound involving transmission of high-frequency sound waves to produce images on a computer screen Transthoracic Echocardiography is done simultaneously with an ECG. It is used to assess heart valves, direction of blood flow, size and motion of myocardium and heart chambers. Conducting gel is applied to the chest wall

and the transducer is applied “hold his breath” for short periods of time may be asked to turn on his left side

Transesophageal

Echocardiography (TEE) may be used to visualize the back side of the heart. Pre-Procedure -fasts for 6 hours, signs a consent. Teaching regarding the procedure an IV line for sedation and meds throat will be sprayed numbing agent VS will be monitored Conscious sedation

Post-procedure monitor  the return of the gag reflex adverse reactions to sedation any potential injury

for

adioactive isotopes are given to enhance the intended viewing area. ulti-gated acquisition scan (MUGA scan) quilibrium radionuclide (ERNA)

angiocardiography

re-Procedure  IV to inject the contrast

n 12-lead EKG represents the electrical activity of the heart at one point in time. re Procedure

Explain the procedure Position supine as flat as

possible Uncover chest & limbs Identify landmarks Prepare skin for electrode adherence. Place electrodes at landmarks Attach corresponding

ost-procedure: etermine if the EKG appears normal. f a repeat EKG is not needed • remove electrodes from skin • assist patient with re-positioning • leave patient safe & comfortable

eave equipment ready for emergency use.

atient learning individualized. eed information about:

diagnostic testing (pre, during,

post) disease process (pathophysiology, cause, treatment options) disease and symptom management (medications, alternative and complimentary therapies, lifestyle changes) support available (groups, home