Introduction to Perfusion Activity PDF

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Introduction to Perfusion Activity Med-Surg 2 Sydney Wiles 1. What evidence (assessment findings) do you have that a client has optimal central perfusion? Make a list of findings that support your assessment. - Heart Rate: 60-100 bpm - BP: 120/80 (normal) or within normal limits for age range - O2 Saturation: 90% or greater - Level of Consciousness 2. How would you determine if the client has optimal tissue perfusion to the lower extremities? Make a list of the examination techniques you would use to validate optimal perfusion. - Skin color: appropriate for ethnicity o Use observation to determine color of skin - Temperature of skin: warm to the touch o Use palpation with the back of your hand to determine temperature of the patient’s lower extremities - Capillary refill: less than 3 seconds o Perform a capillary refill squeeze on the toes, normal if less than 2 seconds - Condition of skin: intact, dry, no redness, no edema o Use observation/palpation to determine the integrity of the patient’s skin - Peripheral pulses: 2+ o Use palpation to feel for the dorsalis pedis pulses and document the findings 3. Create a list of common symptoms and clinical findings associated with impaired central and peripheral perfusion. - Smoking: vasoconstriction - Hypertension/Hypotension - Diabetes Mellitus: atherosclerosis - Physical inactivity: obesity - High blood cholesterol: atherosclerosis - Age: increases risk - Gender: men > women - Genetic Factors: family history - Race and ethnicity - Angina - Edema (swelling) - Tachycardia/Bradycardia - Syncope (dizziness) - Dyspnea 4. Discuss why each symptom or clinical finding occurs from a physiologic perspective for central perfusion: hypotension, tachycardia, presence of S3/S4, change in mentation, shortness of breath, changes in heart rhythm, peripheral edema, diaphoresis/anxiety, squatting. a. Hypotension: Blood pressure is the function of cardiac output and systemic vascular resistance working together. The mechanisms of BP can affect both cardiac output and/or

systemic vascular resistance. In the case of hypotension, the sympathetic nervous system is dilating the blood vessels, making it easier for the blood to pump to the heart, but it is not being pumped forcefully enough, making it harder for the blood to circulate throughout the body causing a drop in BP (hypotension). b. Tachycardia: In the case of tachycardia, the conduction pathway remains static while the discharge rate coming from the sinus node increases due to some form of vagal inhibition and/or sympathetic stimulation such as physical activity. Tachycardia is often associated with physiological and/or psychological stressors but could also be a side effect from drugs such as epinephrine or atropine. c. Presence of S3/S4: These heart sounds are typically heard when there is blood in an incorrect area of the heart. S3 usually occurs when compliance of the ventricles becomes decreased during filling, and S4 is caused by atrial contraction of the heart. d. Change in mentation: When blood flow is decreased, less blood is flowing to the lungs, resulting in less oxygenated blood being carried to areas such as the brain. Neurons require a constant and consistent supply of oxygen to maintain functionality, and when they do not have it, changes in a patient’s mental state may occur. e. Shortness of breath: In the case of decreased blood flow throughout the body, the tissues within the body do not receive an adequate amount of oxygen to function properly, causing the patient to become short of breath. f. Changes in heart rhythm: When cardiac electrical function is altered, the heart rhythm will experience changes in rhythm. g. Peripheral Edema: This type of edema occurs when there is a build up of unwanted fluid within the interstitial spaces. When the right ventricle is unable to eject at its usual volume due to a build-up of blood within the venous system, extra fluid is forced within the interstitial spaces. h. Diaphoresis/Anxiety: In certain situations, the sympathetic nervous system may react, causing one’s heart to race and kick on the fight or flight response. i. Squatting: This causes an increase in cardiac output and arterial BP, which as a result decreases heart rate and forearm vascular resistance. 5. Discuss the clinical findings and symptoms associated with peripheral/tissue perfusion: cool, pale skin, absent peripheral pulses, capillary refill greater than 2 seconds, low ABI, pain in legs with walking, Decreased urine production. a. Cool, pale skin: Decreased blood flow to the tissues of the body can cause a decreased temperature in the extremities as well as a change of color in the skin. b. Absent peripheral pulses: A decreased amount of blood flow to the peripheral can cause a decrease in pressure, diminishing peripheral pulses causing them to be absent when palpating. c. Capillary refill greater than 2 seconds: If a patient has decreased perfusion, when pressing on their capillary bed and halting the blood flow to the digit, it will take longer for the color and blood flow to return to the digit. d. Low ABI: This is a measure of how much blood is able to reach the lower extremities through the blood vessels. When there is a decreased amount of perfusion, your legs and feet may not be getting the correct amount of blood flow which may cause pain. e. Pain in legs with walking: When there is inadequate perfusion, oxygen needs for the tissues are not being met, causing the patient to experience ischemic pain due to the build-up of lactic acid. The demands of the leg muscles are too much for the

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inadequate supply of oxygen to handle. The pain may stop when the patient stops walking due to less oxygen being needed when the patient is at rest. Decreased urine production: This is an indirect indicator of cardiac output. Blood flows from the heart into the aorta, and then into the renal arteries, and lastly through nephrons that produce urine.

References Giddens, J.F. Concepts for Nursing Practice, 2nd Edition [Pageburstls]. Retrieved from https://pageburstls.elsevier.com/#/books/9780323374736/ Jeff, S.L.&.S.R.D.&.M.H.&.L.B.&M.M.H.&. Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. [Pageburstls]. Retrieved from https://pageburstls.elsevier.com/#/books/9780323328524/...