Perfusion Concept Map Nursing Fundamentals

ASSESSMENT Focused assessments - cardiac, respiratory, skin Health HX - pain, syncope, dizziness, dyspnea, edema, bleeding/bruising, fatigue, palpitations, chest pain, exercise tolerance? BP (Sitting & Orthostatic) Pulse strength, rate, & rhythm Capillary refill Skin color, temp & turgor Edema - grade pitting, measure leg circumerences DIAGNOSTIC TESTS Labs: BUN & creatinine, CRP eGFR, O2, coagulation panel, serum lipids, cardiac enzymes Radiology: EKG, ultrasound, ECHO, CXR Cardiac stress test (Cardiologist) COLLABORATIVE INTERVENTIONS Dietician - nutrition counseling Addictions counseler (smoking cessation) Physical therapist Cardiologist Respiratory therapist Cardiothoracic surgeon (valve replacement/bypass) PHARMACOTHERAPY Anti-hypertensives Anti-coagulants Statins Diuretics Oxygen therapy RISK FACTORS FOR IMPAIRED PERFUSION Smoking Poor diet Dehydration Health conditions - diabetes, heart defect, sickle cell disease Immobility (sedentary lifestyle, injury, obesity) Hypertension & hyperlipidemia Older adults (decreased stroke volume & cardiac output) Genetic conditions (von Willebrand disease, Hemophelia) PERFUSION NURSING INTERVENTIONS Encourage daily ambulation or perform ROM exercises for pts with impaired mobility Apply sequential compression devices/stockings per HCP orders Monitor & document patient's I&O and daily weight Reposition patient every 2 hours Position patient appropriately (lower or elevate extremities/HOB) Administer medication & oxygen per provider orders. Provide blankets & maintain a room temperature comfortable for the patient Monitor for any signs of DVT or development of pressure ulcers CONSEQUENCES (Scope of Impaired Perfusion) Orthostatic hypotension & hypertension Atherosclerosis DVT, PE, MI Ischemia, hypoxia, anoxia Pulmonary embolism Cardiac arrest & cardiogenic shock (permanent damage) Myocardial infarction (worst case scenario) GOALS & OUTCOMES Patient's capillary refill is < 2 seconds & skin turgor shows no signs of tenting Patient exhibits improved tolerance to physical activity Patient states he/she will ambulate for at least 30 minutes every day PATIENT EDUCATION Provide information & resources on smoking cessation. Demonstrate simple exercises that can be done at home without the need for a gym or equipment. Inform patient of affordable, healthy meal ideas Educate pt/caregiver on proper use of compression stockings Educate patient on appropriate positioning for their condition