Transform Perfusion: Cardiac/ Peripheral to Make It ... · •Tetralogy of Fallot •Arrhythmias...

© 2014 I CAN Publishing, Inc. 1

Transform Perfusion: Cardiac/Peripheral to Make It !

INSANELY EASY!

1 Copyright ICAN Publishing Inc. 2015

Copyright ICAN Publishing Inc. 2014

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Constriction / Obstruction

Structural, Functional (Mechanical & Electrical Conduction)

Alteration in Cardiac Output

Infections/ Inflammation

Vascular Heart Structural & Functional

Congenital Defects

Electrical Conduction

Infections/Inflammation

• Hypertension • Atherosclerosis • Peripheral Vascular Disease •  Deep Vein Thrombosis

• Acute Coronary Syndrome • Angina • Myocardia Infarction

• Heart Failure • Cardio- myopathy • Valvular Heart Disease • Cardiogenic Shock

• Atrial Septal Defect (ASD) • Ventricular Septal Defect (VSD) • Coarctation of the Aorta • Tetralogy of Fallot

• Arrhythmias Dysrhythmias

• Rheumatic heart disease •  Endocarditis • Myocarditis • Pericarditis

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SAFETY System Specific Assessments Cardiac/Peripheral Perfusion

“PUMPS” Pulses: assess bilaterally and compare, peripheral and jugular vein distention (JVD), capillary refill > 3 seconds, auscultate heart sounds (presence of S3 or S4), heart rate, rhythm, (pulse ↓ or ↑ with arrhythmias), and BP. Assess for ↓ level of consciousness (LOC), syncope. U Urine output (> 30 mL/hour), I & O, and daily weights. Compare, contrast, and trend all. M Moist lung sounds (adventitious), ↑ respirations, check O2 sat, assess for peripheral edema (compare R & L extremities). P Pain characteristics will vary; assess to see if pain increases with activity. S Skin color pale, cool extremities, ↑ temperature (i.e., infections of the heart or heart valves disorders).


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SAFETY: Reflecting on a Teaching Moment

During a cardiac assessment, where should the nurse place the stethoscope to accurately evaluate the aortic heart sound?

a. the second intercostal space right of the sternum b. the second intercostal space left of the sternum c. the fifth intercostal space at the left midclavicular line d. the third intercostal space right of the sternum •  Answer a

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SAFETY - First Do Priority Interventions Cardiac/Peripheral Perfusion

“PERFUSE” Position HOB ↑. NOTE: if BP decreases, lower HOB to semi-Fowler’s or supine position. Give supplement O2 as needed. Avoid restrictive clothes, cold, and nicotine. Evaluate VS, pulses, edema (compare R & L extremities), lung sounds, ECG, CVP and hemodynamic monitoring. Evaluate surgical incision site: bleeding, skin temp, circulation, color, and healing. Report urine output < 30 mL/hour or trending ↓. Fluids: Isotonic fluid, monitor amount; maintains patent IV line. Note: ↓ fluids if heart failure or cardiogenic shock. Use “CLUSTER” to manage energy conservation Support stockings or intermittent-compression devices (except for DVT on affected leg). Encourage ambulation/ROM to increase perfusion and circulation (except if there is chest pain, an infection of the heart, severe heart failure or cardiomyopathy that requires rest)


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SAFETY System Specific Assessments Concept Cardiac/Peripheral Perfusion


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System Specific Assessments “PUMPS”

First Do Priority Interventions “PERFUSE”

Evaluation of Expected Outcomes“PUMPS”

Pulses (peripheral & JVD)assess bilaterally & compare, capillary refill > 3 seconds, auscultate heart sounds (note presence of S3 or S4), heart rate, rhythm (pulse ↓ or ↑ with arrhythmias), & BP. Assess for ↓ level of consciousness (LOC), syncope. Urine output, ( > 30mL/hour), evaluate daily wt & compare. Moist lung sounds (adventitious) ↑ RR, edema (compare R & L extremities). Pain will vary. Assess if pain ↑ with activity. Skin color pale, cool extremities, ↑ temp (for infections of the heart or heart valves disorders).

Position HOB ↑ . NOTE: if BP↓, lower HOB to semi-Fowler’s or supine position. Give O2 as needed. Avoid restrictive clothes, cold & nicotine. Evaluate VS and pulses (compare R & L), edema (compare R & L), lung sounds, ECG, CVP & hemodynamic monitoring. Evaluate surgical incision site for bleeding, circulation, skin temp, color, signs of infection, and healing. Report urine output < 30 mL/hour or trending ↓ , daily weights & compare. Fluids: monitor amt, maintain patent IV line. Note: ↓ fluids if heart failure or cardio shock. Use “CLUSTER” to manage energy conservation. (See activity tolerance) Support stockings or intermittent compression devices (except for DVT on affected leg). Encourage ambulation/ROM to ↑ perfusion (except: chest pain, an infection of heart, severe heart failure, or cardiomyopathy that requires rest).

Pulses & BP WDL for client Urine > 30mL/hour Moist lung sounds resolved, no edema; respiratory rate WDL Pain, none or managed Skin warm and dry, color WDL for client

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Insanely Easy Tip to Remember Arterial & Venous Vascular Assessments:

The “Ps”


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Peripheral Artery Disease Peripheral Venous Disease Pain–Sharp, sudden (Intermittent Claudication) Pallor–Pale and shiny, loss of hair growth Peripheral Temp–Cool Peripheral Circulation–No edema, capillary refill > 3 seconds Pulses–Weak to no pulse

Pain–Dull, heavy, and achy Pallor–Brown, brawny, edema Peripheral Temp–Warm Peripheral Circulation–Lower leg edema Pulses–Pulses present (may be difficult to palpate due to edema)

Insanely Easy Tip! Arterial has an A - Get blood AWAY from heart! Venous blood is Blue - Get blood BACK to heart!

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I Can Publishing Inc. 2011 8


Which nursing plan of action indicates the UAP understands how to appropriately care for a client with Peripheral Artery Disease?

a.  Measure the diameter of the calf of the leg and compare

to unaffected leg. b.  Position the affected leg above the level of the heart. c.  Apply compression stockings after client gets out of bed. d.  Assist client to dangle legs off the side of the bed.

Answer d


SAFETY - Trend Potential Complication DVT

Copyright ICAN Publishing Inc. 2014 9

System Specific Assessment “DVT”

First Do Priority Interventions “REST”

Diameter of calf and thighs; compare bilaterally for swelling Vein tenderness and redness, note Temperature ↑ (also at site of clot, warm to touch)

Rest (bed rest: can use bedside commode as prescribed). Elevate legs 6–8 inches at night, avoid constriction at the knee. Support stockings and/or intermittent compression devices on unaffected leg ONLY. Warm compresses to affected leg. Treat with anticoagulant therapy. May need to prepare for inferior vena cava interruption surgery (filter trap for emboli) or removal of clot by thrombolysis, etc.

Insanely Easy Tip! Prevent DVTs

Clients need to MOVE &

drink FLUIDS to Keep Blood Moving!!!

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SAFETY System Specific Assessments Acute Myocardial Infarction

INSANELY EASY TIP! •  If Angina is relieved with REST or

NITRO, the client needs to be referred for follow-up care.

•  The goal is to intervene before there is cardiac-tissue death.

•  If the angina is NOT relieved, the client/family/nurse should call 911 or HCP !!!!

Diagnostics to Confirm MI •  Troponin levels are the gold

standard lab test for an MI (because they only go up with cardiac-tissue injury or death).

•  Client history, troponin levels, ECG, and cardiac catheterization help confirm if the client has had an MI.


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POST-CARDIAC CATHETERIZATION PRIORITY CARE: “PEE” Push fluids to FLUSH DYE FROM KIDNEYS!! Evaluate renal function. Evaluate for bleeding and circulation & intervene as needed!

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I Can Publishing Inc. 2011 11


Which action by the LPN / LVN indicates the need for the nurse to intervene immediately?

a.  The LPN /LVN brings breakfast to a client who is scheduled for an echocardiogram later in the morning.

b.  The LPN /LVN assesses a client’s blood pressure prior to administering nitroglycerin (Nitro-Stat) 0.4 mg SL.

c.  The LPN /LVN assists a client to the bathroom 20 minutes after the client has returned from a cardiac catheterization.

d.  The LPN /LVN returns a client to bed after the heart rate increases from 72 to 100bpm while ambulating in the hall.

Answer c

SAFETY Comparison of R & L Heart Failure System Specific Assessments


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Left-Sided Heart Failure “DYSPNEA”

Right-Sided Heart Failure “EDEMA” Everything is ↑

Dyspnea, orthopnea, and nocturnal. Yes, vital signs. Early signs: ↑ RR, ↑ HR, ↑ BP, restless, skin and mucous membranes pale. (Geri clients: acute confusion is early sign). Late signs: VS ↓ , cyanosis, ↓ level of consciousness, lethargy. Secretions altered, productive cough (i.e., color, consistency, tenacity and odor); pink tinged, frothy sputum = pulmonary edema. Signs of infection (i.e., ↑ temp, ↑ WBC,). Precipitating factors: infection, immobility, allergens, stress, trauma, post-op complications, and pleurisy. Note characteristics of the cough (dry, moist); discomfort with breathing. Evaluate SaO2 < 95% with arterial blood gases (ABGs), pulse oximetry < 92%. Adventitious breath sounds (wheezes, crackles),atelectasis after post-op, immobility), arrhythmias (late), use of accessory muscles asymmetrical chest expansion, activity intolerance

Enlarged liver Distended neck veins, JVD (jugular vein distention) Enlarged spleen Most edema in lower extremities Ascites, ↑ weight > 2 lbs./24 hr. EDEMA will result in the following: ↑ HR, peripheral pulses (may be bounding) ↑ Blood pressure ↑ RR (due to the ascites increasing pressure on the diaphragm) ↑ Confusion

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A client with heart failure suddenly exhibits shortness of breath, RR é from 15 - 27, coughing frothy pink sputum & crackles are heard bilaterally. Which order could the nurse delegate to the LPN?

a. Monitor vital signs every 15 minutes b. Give morphine sulfate 2mg IV push STAT

c. Insert a urinary catheter d. Start an IV and cap it with a saline lock.

Answer c


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Which systems-specific assessment would be the priority for the LPN / LVN to report to the charge nurse for a client with heart failure? a.  R-18 increased to R- 22 with exertion. b.  HR- 72 decreased from 88 after taking digoxin

(Lanoxin). c.  Weight increase from 142 lbs. to 146 lbs. in 48 hours. d.  Oxygen saturation decreased from 98% to 95% with

exertion. Answer 3


FLIP PILLS” 55


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What teaching plan would be most important for a client who is taking diltiazem (Cardizem)?

a.  Discuss with the client the importance of reporting muscle cramps.

b.  Explain the importance of increasing fiber in diet when taking medication.

c.  Review the importance of holding medication if HR – 72 bpm.

d.  Review the need to decrease fluid intake.

Answer 2



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The client with hypertension is being treated with metoprolol (Lopressor), hydrochlorothiazide (HydroDiuril), and captopril (Capoten). The client B/P is 120/80 and pulse is 48. Which of the following is the best action by the nurse?

a. Administer metoprolol (Lopressor) & hydrochlorothiazide (Hydrodiuril), & hold the captopril (Capoten).

b. Administer the captopril (Capoten) & hydrochlorothiazide (Hydrodiuril) and hold the metoprolol (Lopressor).

c. Administer all of the medications and notify the physician. d. Withhold all the medications and notify the physician.

Answer B


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SAFETY Equipment Use Perfusion: Cardiac/Peripheral


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Elect to Cardiovert: Get in Sync!!! “CARDIOVERT”

Defibrillate: Do or DIE !!! “DEFIBRILLATE”

Conscious client, sedate and medicate for pain Anticoagulation prior to cardioversion Requires shock to be synchronized, use low joules Done only by HCP IV will be needed Oxygen before and after, NOT during Vital signs and rhythm evaluate throughout Elective procedure, need consent Rhythms for cardioversion: atrial fibrillation Tell everyone to clear prior to shock; use conduction medium to prevent burns

Defibrillate only on an unconscious client Emergency–Call a Code Fibrillation ventricular or pulseless V tachycardia IV needed for drugs according to ACLS protocol Begin CPR and continue in between defibrillations Respiratory, support with oxygen Increase joules/needed; defib x 3 only at max joules Locate crash cart Learn to correctly place paddles/electrode pads Always use conduction medium to prevent burns Tell everyone to clear prior to shock Evaluate vital signs, rhythm, and response to meds

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Which of these nursing actions indicates an understanding of how to safety use the defibrillator? The nurse: a. Sets the defibrillator in a synchronous mode to cardiovert. b. Maintains fingers on the discharge buttons prior to discharging voltage to assure accuracy. c. Begins defibrillation at maximum joules d. Uses conduction medium to prevent burns Answer d


NCLEX® SUCCESS =

Clinical Decision Making Strategies Connecting to

2013 NCLEX® Standards and Nursing Concepts

Questions # 1-10


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Recipe for Student Success

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R – Review, Reflect and Reward YOUR Success

Transform Perfusion: Cardiac/ Peripheral to Make It ... · •Tetralogy of Fallot •Arrhythmias...

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