FIN Exam 1: Perfusion

Atherosclerosis

the buildup of plaque (fats, cholesterol, etc.) on the artery walls

Edema

swelling caused by excess fluid trapped in your body's tissues

What are some common causes of edema?

• venous insufficiency

• heart failure

• kidney problems

• liver disease

• certain medications

Peripheral artery disease (PAD)

A type of atherosclerosis characterized by a narrowing of the arteries, preventing adequate flow to the limbs (most commonly legs and feet)

Cardiac blood flow steps

1. Body

2. SVC/IVC

3. Right atrium

4. Tricuspid valve

5. Right ventricle

6. Pulmonary valve

7. Pulmonary arteries

8. Lungs

9. Pulmonary veins

10. Left atrium

11. Mitral valve

12. Left ventricle

13. Aortic valve

14. Aorta

15. Body

Systole

Simultaneous contraction of ventricles

Diastole

Ventricular relaxation

• When ventricles passively fill from atria

Bradycardia

<60 BPM in adults

Tachycardia

>100 BPM in adults

Stoke volume

The amount of blood ejected from the left ventricle with each heartbeat

Cardiac output

Total volume of blood the heart ejects

Stroke volume tells you…

Cardiac output provides…

SV tells you how much blood in the heart pushes out with each beat

CO provides a measure of the heart’s overall pumping efficiency per minute

Perfusion

Process of delivering blood to tissues and organs in the body

• tells you how well blood is delivering O2 and nutrients to a specific area

Flow and perfusion are best approximated by…

Mean arterial pressure

MAP = ? x ?

MAP = CO x SVR

CO = ? x ?

CO = HR x SV

SV = ? - ?

SV = EDV - ESV

SVR = (? - ?)/CO

SVR = (MAP - CVP)/CO

• CVP: estimated right heart/venous pressure

Afterload

Amount of pressure (work) in systemic circulation which the left ventricle must work against during diastole

Preload

Volume and stretch of ventricular muscle at the end of diastole

Systemic vascular resistance

Refers to the resistance to blood flow offered by the systemic circulation

Intropy

To increase the force or strength of the heart’s contractions

Chontropy

• the speed of the heart

• Adjust heart rate to meet the body’s needs

  • Example: increasing HR during exercise or decreasing during rest

Perfusion

The process of blood flowing through the body’s vessels to deliver O2 and nutrients to the tissues and organs

Poor perfusion

Blood isn’t getting to the areas it needs to

Affects of poor perfusion on the brain (2)

• Dizziness

• Confusion (AMS)

Affects of poor perfusion on the heart (2)

• Angina (chest pain)

• Arrhythmias

Affects of poor perfusion on lungs

Respiratory distress

Affects of poor perfusion on GI tract (3)

• Nausea/vomiting

• Abdominal pain

• Constipation/diarrhea

Affects of poor perfusion on genitourinary/kidneys (2)

• Decreased urine output

• Kidney injuries

Affects of poor perfusion on extremities (3)

• Pain

• Numbness

• Tingling

Affects of poor perfusion on skin (3)

• Poor wound healing

• Change of color

• Temperature

Affects of poor perfection on musculoskeletal system (3)

• Muscle cramps

• Decreased muscle strength/tone

• Weakness

What cardiovascular complications can occur because of poor perfusion? (6)

• Hypertension/hypotension

• Heart attack

• Heart failure

• Stroke

• Cardiogenic shock

• Hypoxemia

What cerebral complications can occur because of poor perfusion? (2)

• Stroke and TIA (transient ischemic shock)

• Cognitive decline/impaired executive function

What peripheral complications can occur because of poor perfusion? (2)

• Peripheral artery disease (PAD)

• Peripheral venous disease (PVD)

What other complications can occur because of poor perfusion? (6)

• Renal insufficiency

• Mesenteric ischemia

• DVT/pulmonary embolism

• Wound healing

• Infection

• Death

Steps of RAAS system

1. BP or BV decrease, causing the kidneys to release renin

2. Renin acts on angiotensinogen, converting it to angiotensin 1

3. Angiotensin 1 is then converted to angiotensin 2 via angiotensin converting enzyme (ACE)

4. Angiotensin 2 causes vasoconstriction, causing BP to increase

5. Angiotensin 2 acts on adrenal glands to release aldosterone

6. Aldosterone promotes kidneys to retain Na+ and H2O, resulting in BP increase

Since CO = HR x SV, and MAP = CO x SVR, hypertension is the result of… (2)

• Increased CO — usually due to increased vascular volume

• Increased SVR — vasoconstriction

What are the 4 targets of organ damage due to HTN? (4)

• Heart

• Brain

• Kidneys

• Eyes

Hypertension

• Elevated BP

• Force of blood pushing against artery walls is consistently too high

• Heart works harder to pump blood around body

How is hypertension diagnosed?

Diagnosed based on average BP readings over multiple measures on different occasions (at least 1-4 weeks apart)

Primary (essential) hypertension

High BP with no identifiable underlying medical cause

• Often are due to modifiable/non-modifiable risk factors

Secondary hypertension

Identifiable medical condition/medication

What are the associated risk factors for hypertension? (5)

• Dyslipidemia

• Obesity

• Metabolic syndrome

• Kidney disease

• Autoimmune disease

What conditions increase the prevalence of hypertension? (4)

• Heart failure

• CAD

• History of stroke

• Kidney disease

What are some modifiable risk factors for hypertension? (6)

• Diet

• Exercise

• Tobacco use

• Alcohol consumption

• Stress

• Medications: antidepressants, decongestants, and NSAIDS

What are some non-modifiable risk factors for hypertension?

• Age

• Family history

• Race

• Chronic kidney disease (RASS issues)

• Diabetes

Hyperlipidemia

High cholesterol

• Abnormally high levels of fatty substances/lipids in the blood

Hyperlipidemia development is a significant risk factor of ____, which can lead to…(3)

• Atherosclerosis (plaque build up)

• Can lead to hypertension, heart disease, and stroke

What drug is used to control lipids in the blood stream, which decreases risk of atherosclerosis?

Statin

How is hyperlipidemia diagnosed? What does it measure? (4)

• Fasting blood draw

• Measures:

  • Total cholesterol

  • LDL (bad)

  • HDL (good)

  • Triglycerides

How is hyperlipidemia treated? What does it do?

• Lifestyle modifications

• Statins

• Helps lower LDLs

Primary hypertension

High BP with no identifiable underlying medical cause

Secondary hypertension

HTN caused by an identifiable medical condition or medication

What are some possible causes for secondary hypertension? (7)

• Renal disease

• Adrenal gland abnormalities (i.e. RAAS)

• Pheochromohytoma

• Infections

• Obstructive sleep apnea

• Congenital heart defects

• Medications: antidepressants, decongestants, and NSAIDS

What are some lifestyle modifications that can be done to decrease BP? (5)

• Reduce weight

• DASH diet

• Sodium restriction

• Physical activity

• Moderation of alcohol consumption

DASH diet

• Rich in fruits and veggies

• Low-fat dairy products

• Reduced content of saturated total fat

Sodium restriction mg

<2000 mg

Classes of medications for chronic hypertension (4)

• Calcium channel blockers

• Thiazide diuretics

• Angiotensinogen Converting Enzyme (ACE) inhibitors

• Angiotensin receptor blockers (ARBs)

Concerns and side effects of hypertension pharmacological management (3)

• Dizziness, orthostatic hypotension

• Fall precautions with starting or dose increase

• Caution with position changes

Calcium channel blockers (CCBs) mechanism of action

• Blocks the release of intercellular calcium

• Vasodilator

“Nursing education” to give to patients taking CCBs — must report

• Irregular heartbeat

• Constipation

• Shortness of breath (SOB)

Thiazide diuretics mechanism of action

Blocks the Na+/Cl- transporter and the distal convoluted tubule in the kidney

“Nursing education” to give to patients taking thiazide diuretics (5)

• Contradicted with known sensitivity to sulfa drugs

• Side effects

• Can trigger gout flares

• Caution with alcohol, barbiturates, opioids, and hot water

• Monitor for signs of electrolyte imbalance

Side effects of thiazide diuretics (8)

• dry mouth

• thirst

• weakness

• drowsiness

• lethargy

• muscle aches

• tachycardia

• GI disturbances

ACE inhibitors mechanism of action

Block the conversion of angiotensin 1 into angiotensin 2

“Nursing education” to give to patients taking ACE inhibitors

• Potential side effects: dry cough, hyperkalemia, dizziness, headache, rash

• Angioedema (rare, but life-threatening)

• Monitor renal function

ARBs mechanism of action

Block the release of angiotensin 2 (vasoconstrictor)

“Nursing education” to give to patients taking ARBs (angiotensin receptor blockers)

• Monitor K+ — Hyperkalemia

• Monitor renal function

Goals for managing hypertension

• Maintain BP <130/80

• Adhere to self-management program

• Minimize complications

Nursing interventions to improve hypertension (3)

• Patient education

• Promote adherence to therapeutic regimen

• Monitoring and managing potential complications

What is the primary cause of peripheral arterial disease?

Athleroscleosis

What is the result of PAD with regards to blood distribution?

O2 rich blood cannot reach your peripheral limbs

Symptoms of PAD (7)

• Pain at rest

• Pain/cramps With exertion

• Numbness/tingling

• Hair loss

• Erectile dysfunction

• Temperature changes (cool to touch)

• Skin changes (feet can have a red, ruddy appearance)

Risk factors for PAD (4)

• Smoking

• Hypertension

• Diabetes

• Hyperlipidemia

Signs of PAD via a physical assessment (10)

• Temperature changes

• Buerger signs

• Pale/blue-ish skin

• Smooth, shiny skin with no hair

• Increased capillary refill time (>3 seconds)

• Swelling

• Absent or weak pulses. May have audible bruit over affected vessel

• Unhealed sores/ulcers

• Numb toes

• Pain — worse at night

Buerger sign test

patient lies flat, when lifting legs to 45 degrees, they develop pallor (look pale), when sitting the patient up and hanging legs off the bed, will become very red.

Temperature changes with PAD

• Cold and pale when elevated

• Ruddy and cyanotic when (dependent rubor) when hanging down (dependent position)

Location and appearance of unhealed sores or ulcers in PAD

• Ends of tips of toes, tops of feet, or around outer ankle (lateral malleolus)

• “Punched out” appearance

  • Deep, sharply defined, round/oval edges

  • Pale, non-granulating, or necrotic base

With PAD, _______ the extremity or placing it in ______ position increases the pain, whereas putting the extremity in a _____ position reduces the pain

• Elevating

• Horizontal

• Dependent

Intermittent Claudication

term that describes muscle pain, typically in the legs that occurs during physical activity and alleviated by rest. This is caused by tissue ischemia

Gangrene

The death of body tissue due to a lack of blood supply or infection

Dry vs wet gangrene

• Dry: when no blood has reached toes; more likely to amputate

• Wet gangrene: more likely to cause rapid spread of infection due to an infection developing in ischemic tissue

Ankle-brachial Index (ABI)

Diagnostic tool for PAD that measures the ratio of ankle systolic BP/highest brachial systolic BP

Normal, mild/moderate, ischemic, and severe ABD levels

• Normal: 0.9 to 1.3

• Mild to moderate disease: 0.5-0.9 (claudication)

• Ischemic rest pain: <0.5

• Severe disease: <0.4

CT angiography

3D image that uses contrast to help visualize blood vessels/artieries in detail — evaluate blockages

What is a serious complication of PAD?

Critical limb ischemia

Ischemia

Restricted blood supply to the body, resulting in insufficient O2 and nutrient delivery to the tissues (death)

Signs and symptoms of ischemia (7)

• Persistent pain even at rest

• open sores that do not heal,

• tissue death (gangrene)

• pulselessness

• thickened toenails

• leg heaviness/tiredness

• discoloration

PAD common nursing diagnoses (6)

• Altered peripheral tissue perfusion related to compromised circulation

• Chronic pain related to impaired tissue oxygenation

• Activity intolerance related to pain

• Risk for impaired skin integrity

• Risk for infection

• Knowledge deficit regarding self-care

PAD treatments

• Medications

• Surgery

What types of medications can be used to treat PAD? (5)

• BP meds

• Statins to lower cholesterol

• Antiplatelet to prevent blood clots

• Cilostatzol

• Pentoxifyllin

Side effects of antiplatelet meds

Increased risk of bleeding

PAD surgical interventions (4)

• Balloon angioplasty with stent placement

• Aorto-femoral bypass surgery

• Femoral-popliteal bypass surgery

• Amputation

Purpose of balloon angioplasty with stent for PAD

Widening of a blocked or narrowed blood vessel by a balloon catheter

Purpose of Aorto-femoral bypass surgery with PAD

Reroutes blood flow around a blocked or narrowed artery in the abdomen and grow, specifically the aorta and femoral arteries

• Grafting a healthy blood vessel or a synthetic graft

Purpose of Femoral-popliteal bypass surgery

Restore blood flow to the leg/limb/space by creating a new pathway around a blocked artery

• Grafting a healthy blood vessel or a synthetic graft from the femoral artery to the popliteal artery

Arterial bypass surgery post-op nursing care (5)

• Monitor surgical site for bleeding

• Monitor peripheral neurovascular status (6 Ps)

• Pain management

• Promote mobility

• Discharge teaching

6 P’s of arterial bypass surgery post-op nursing care

• Pain: any pain? (when, where?)

• Pallor: pale skin in the affected limb

• Pulselessness: absence of a pulse in the affected limb (medical emergency)

• Paresthesia: Numbness, tingling or burning feeling

• Paralysis: Weakness/loss of movement in affected limb

• Poikilothermia: coolness of the affected limb compared to the other side