Exam 1 (UB Nursing)

Perfusion

•The flow of blood through arteries and capillaries delivering nutrients and oxygen to cells (Giddens, 2017)

•Normal physiologic process requires the heart to generate sufficient cardiac output to transport blood through patent (open) blood vessels for distribution throughout the body

- Maintaining cardiovascular health is essential

Cardiac Output

- the amount of blood pumped by the heart each minute

- heart rate x stroke volume

- blood is moved through the heart into the peripheral vessels

Scope of Perfusion

optimal perfusion -> impaired perfusion -> no perfusion (tissue death)

Antecedents - What does the body need to have for adequate perfusion?

- functioning cardiopulmonary system

- adequate fluid volume --> not too much, not too little

- blood vessels free from clots and atherosclerotic blocks

Attributes - What are we looking for to be sure the concept of perfusion is present?

•Blood pressure within normal limits (WNL)

•Capillary refill is

How do you know the person next to you is perfusing?

•Patient is alert and oriented x 4

•Skin is warm to touch

•There is a pulse

•Organs are functioning as expected

• ex. Normal urine output, heart is beating

Consequences of impaired perfusion

•Patient has altered LOC (level of consciousness), confused, fainting

•Loss of fine tactile sensation (tissue perfusion is impaired)

•Compartment syndrome (perfusion is interrupted and the blood is back up, cool to touch)

•Ischemic pain – lack of oxygen, reversible, mI

•Tissue necrosis

•Decreased organ function (renal perfusion)

•death

Compartment Syndrome

- build up of pressure from internal bleeding or swelling of the tissues

- this pressure decreases blood flow and deprives muscles and nerves of oxygen and nutrients

- cool to touch

Ischemic pain

- Results from a profound, sudden loss of blood flow to an organ or tissue

- reversible

- Ex: MI

5 P's

- pain

- pallor

- pulselessness

- paresthesia

- paralysis

Subjective Assessment Findings for Perfusion

- Acute or chronic pain

- paresthesia

- dyspnea

- edema (could be objective)

- CNS symptoms --> dizziness, fainting, visual changes, changes in ability to speak

Paresthesia

- Abnormal sensation such as burning, prickling, or tingling or numbness.

- numbness to limb

Dyspnea

Shortness of breath or difficulty breathing.

- Heart failure

- Coronary Artery Disease (CAD)

- Myocardial ischemia or Myocardial Infarction

- Pulmonary disorders

Edema

- fluid buildup in external tissue

Objective Assessment Findings for Perfusion

•Hypoxia

•Hypotension or hypertension

•LOC changes

•Edema

•Capillary refill (needs to be less than 2)

•Temperature

•5 P's - pain, pallor (paleness), paresthesia (numbness), paralysis (cannot move at all), pulselessness

•Organ dysfunction (look at lab results)

•Syncope (patient passes out)

Impaired Central Perfusion

•This occurs because CO is reduced

*** Heart is no longer efficiently pumping

•Hypovolemia or hypervolemia

•Contractility - loss of muscle contracting force

•This results in a reduction of oxygenated blood reaching the organs (systemic effect)

•If severe → shock

•If untreated →ischemia, cell injury, cell death

Impaired Tissue (Local) Perfusion

•Loss of vessel patency or permeability or inadequate central perfusion

•Chronically high blood pressure makes the heart work harder

•Blood clots, plaques build up, thrombosis (clot is adhered to the artery), loss of elasticity of blood vessels (become stiff

•Impaired blood flow to tissues (localized effect)

•Conditions that interfere with cellular gas and nutrient exchange - ex. Edema

Central Perfusion

-created by cardiac output

•Heart rate that is too fast does not give the heart time to fill up again so cardiac output is decreased

•Slower pulse decreases cardiac output too - heart muscle is less efficient

•Athlete with slow heart rate has strong heart muscle so CO not decreased

Tissue or Local Perfusion

•Amount of blood that is able to reach a specific part of tissue - leg, kidneys

•Requires patent vessels, adequate hydrostatic pressure in capillary beds and capillary permeability of oxygen and nutrients exchange

Hypoperfusion

- reduced amount of blood flow

Infarction

tissue death from lack of oxygen

What is a myocardial infarction

- begins when there is an inadequate amount of blood flow to the heart (hypoperfusion)

- next there is ischemia of heart muscle and a transition from reversible to irreversible damage

- which culminates into an infarction replacing the now dead myocardium with fibrous scar tissue

- takes 6 hours of ischemia to result in an infarction

Normal diastolic pressure

60-80 mmHG

Normal systolic pressure

90-120 mmHG

Atherosclerosis

condition in which fatty deposits called plaque build up on the inner walls of the arteries

Consequences of Ischemia - Coronary

•Pain

•Dyspnea

•Decreased oxygen saturation

•Crackles in lungs

•Heart rate changes (usually tachycardiac)

•Hypotension

•Slow capillary refill (greater than 2 seconds)

•Pale clammy skin

Consequences of Ischemia -- Brain

•confusion

•Change in LOC

•Syncope

•Paresis

•paralysis

Consequences of Ischemia -- Lungs

•Impaired gas exchange - transport of oxygen and removal of CO2 not working probably

•Decreased pulse oximetry

Consequences of Ischemia -- Renal

•Decreased urine output

•Increased BUN- normal 7-20 mg/dl

•Increased Creatinine - 0.7-1.3 mg/dl

•Toxicity because waste is building up and not being excreted from body

Normal BUN levels

7-20 mg/dL

Normal Creatine Levels

0.7 - 1.3 mg/dL

High Risk Factors for Impaired Perfusion

•Middle aged and older adults - natural progression of aging - diet, sedentary lifestyle, hypertension

•Pregnancy

•Middle and elder aged adults due to atherosclerosis

•African Americans males

Modifiable Risk Factors for Impaired Perfusion

•Smoking

•Obesity

•Diabetes

•Alcoholism

•Sedentary lifestyle

•Hyperlipidemia

•Hypertension

* Coagulopathy (clots

Primary Prevention of Impaired Perfusion

•Smoking cessation – causes vasoconstriction

•Diet – low saturated fat/DASH – dietary approaches to stop hypertension

•Exercise

•Weight control – extra amount of tissue and miles the blood has to travel to transport oxygen and perfuse adequately affects cardiovascular health

Primary Prevention

Efforts to prevent an injury or illness from ever occurring.

Secondary Prevention

-focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent worsening health status

- screening

Tertiary Prevention

actions taken to contain damage once a disease or disability has progressed beyond its early stages

Secondary Prevention (Screening) for Impaired Perfusion

•Annual physicals

•Blood pressure

•Glucose and hemoglobin A1C (blood test)

•Lipid screening (HDL is good, LDL is bad)

•Improved access to health care

Tertiary Prevention for Impaired Perfusion

•Treatment strategies depend on underlying condition

•Diet modifications (low salt/fat diet)

•Increased activity

•Medications - pharmacotherapy

Types of medications for Impaired Central Perfusion

•Antihypertensives (blood pressure)

•Antiarrhythmics

•Inotropics – stimulate contraction of the heart - increase CO

•Antianginal agents – chest pain due to lack of O2 to the heart muscle

•Vasopressors – cause vasoconstriction – dire situations – closes down peripheral vessels and squeeze the blood towards the central vital organs

•Vasodilators – decrease vasoconstriction

Types of Medications for Impaired Local Perfusion

•Anticoagulants - prevent clot formation and altered perfusion

•Thrombolytics – clot busters, narrow window

•Lipid-lowering agents – decrease cholesterol and triglycerides

•Vasodilators

•Antiplatelet agents and platelet inhibitors – make platelets slippery

Antihypertensives

drugs used to lower blood pressure

Antiarrhythmics

drug used to treat rhythm abnormalities

Inotropics

Medications that effect the contractility of the heart or the force of cardiac contractions

- stimulate contraction of the heart

- increase CO

Antianginal Agents

- promote vasodilation

- chest pain due to lack of O2 to the heart muscle

Vasopressors

- cause vasoconstriction

- dire situations

- closes down peripheral vessels and squeeze the blood towards the central vital organs

Vasodilators

medications that cause dilation of blood vessels

- decrease vasoconstriction

anticoagulant

drug that prevents clot formation and altered perfusion

thrombolytics

clot busters - break down clots that are already formed

- narrow window

lipid-lowering agents

- decrease cholesterol and triglycerides

antiplatelet agents and platelet inhibitors

Drugs that prevent platelets from clumping together and forming blood clots

- makes platelets slippery

CVA or stroke

•Insufficient perfusion to specific regions of the brain leading to neuronal dysfunction and brain cell death

•Cerebral hypoperfusion – brain experiences a decrease in blood supply

•Ischemic stroke – blood clot that plugs the blood vessel going to the brain

•Hemorrhagic stroke – a blood vessel that breaks and bleeds into the brain

•Transient Ischemic Attack (TIA) – Mini stroke – damage is not permanent, could go into a CVA

Cerebral Hypoperfusion

- brain experiences a decrease in blood supply

Ischemic stroke

•Blockage and/or stenosis (narrowing) of cerebral artery due to:

•Blood clot

•Stenosis caused by plaque buildup

•Large vessel disease caused by a thrombi

•Small vessel disease or lacunar infarcts (small infarcts)

Hemorrhagic strokes -- Intracranial Hemorrhage

•Ruptured cerebral blood vessel

•Occurs suddenly, often when the person is active

•Hypertension most common cause

•Poor outcomes

•Rapid onset - depends on location of hemorrhage

•Pressure on brain tissue may cause coma and death

transient ischemic attack (TIA)

- mini stroke

- damage is not permanent

- could go into a CVA

Pathophysiology of CVA or Stroke

•Blood flow and oxygenation to cerebral neurons decrease

•Pathophysiologic changes can happen in 5 minutes

•Ischemic core (already infarcted, not able to be re-perfused) is surrounded by penumbra (functionally impaired brain tissue but viable)

Survival of Penumbra Cells during a stroke depends on

•Timely return of adequate circulation

•Volume of toxic products released by adjacent dying cells

•Degree of cerebral edema (swelling)

•Alteration in local perfusion

•This is why getting help ASAP is so important in stroke victims

Ischemic Stroke -- Thrombotic

•Occlusion of large vessel by thrombus

•Most common in resting or sleeping older adults

•Lower BP in sleep → less pressure to push blood through narrowed artery

•Occurs rapidly but progresses slowly over 1-3 days

Ischemic Stroke -- Embolic Stroke

•Blood clot or clump of matter travels through the cerebral vessels becomes lodged in a vessel too narrow for further movement and area of brain becomes ischemic

•Seen in younger patients and occurs when patient awake and active

•d/t atrial fibrillation, bacterial endocarditis, recent mi, rheumatic heart disease

•Sudden onset, immediate deficits

•Manifestation last hours to days or persists

Who is at risk for a CVA or Stroke?

•Hypertension - primary risk factor - heart is pumping harder than it should

•Diabetes that is not well controlled

•Heart disease

•Smoking

•Personal or family history or TIA

•Age

•Race

•Alcohol or illicit drug use

•Sedentary lifestyle

•High cholesterol

•Unhealthy diet - high in saturated fat

•Obesity

•Sickle cell disease

Risk Factors specific to Women

- oral contraceptive use

- pregnancy and childbirth

- menopause

- migraines with aura (see lights before event)

- autoimmune disorders

- clotting disorders

Effects of CVA/Stroke on Right side of the brain

•Left side of body affected

•Vision problems

•Memory loss

Effects of CVA/Stroke on left side of the brain

•Right side of body affected

•Speech, language problems

•Slow, cautious behavioral style

•Memory loss

Effects of CVA/Stroke on Brainstem

- breathing, body temperature, digestion, alertness/sleep, swallowing, "locked in state"

Effects of CVA/Stroke on Frontal Lobe

- •reasoning, judgment, speaking, voluntary motor activity

Effects of CVA/Stroke on Cerrebellum

- balance, coordination and control of voluntary movement, fine muscle control

Aspiration

Breathing fluid, food, vomitus, or an object into the lungs

What does FAST mean? (used for determining a stroke)

F - Face drooping : Does one side of the face drool or is it numb?

A - Arm weakness : Is one arm weak or numb?

S - Speech difficultly : Is speech slurred?

T - Time to phone 9-1-1 : If someone shows any of these symptoms , phone 9-1-1 immediately.

Signs to call 9-1-1 for a possible stroke

- sudden weakness, numbness in face, arm, leg

- sudden confusion, difficulty speaking or comprehending

- sudden difficulty with vision

- sudden severe headaches with no cause

Clinical Manifestations of Stroke/CVA

•Vary according to which cerebral artery is involved

•Women tend to have non-traditional signs and symptoms

*** Disorientation, confusion, loss of consciousness

•Most common is weakness of face and arm, sometimes leg

•Numbness in one side of the body, loss of vision, speech difficulties, sudden severe headache, difficulties with balance

Complications of Cognitive, Behavioral Changes for CVA/Stroke Victim

•Changes in consciousness

•Emotional lability

•Loss of self-control

•Decreased tolerance of stress

•Intellectual changes - memory loss, decreased attention span, poor judgment, inability to think abstractly

Communication Disorders (CVA/Stroke)

•Most impairments are partial

•Affect speech and language

•Aphasia

***Expressive

***Receptive

***Mixed or global

•Dysarthria --> problem with saying different words

Motor Deficits of Stroke

•Mild weakness to severe limitation

•Weakness, paralysis, and/or spasticity

***Hemiplegia

***Hemiparesis

***Flaccidity

*** spasticity

•Altered mobility

•Elimination disorders - incontinence

Treatment for Stroke

•Stroke prevention

•Acute care immediately after stroke is recognized

***Rapid recognition and reaction to warning signs

***Rapid diagnosis and treatment in hospital

•Rehabilitation

- if within 3 hours, thrombolytic can be given

Blood Pressure is determined by

- amount of blood the heart pumps

- condition of heart valves

- pulse rate

- pumping power of the heart

- size and condition of the arteries

The pressure in the CV system is determined by 3 elements

•Heart rate

•Stroke volume

•Total peripheral vascular resistance * A.K.A systemic vascular resistance

Total Peripheral Resistance (TPR)

force that resists the flow of blood through the vessels, mostly determined by the arterioles, which contract to increase resistance; important in determining overall blood pressure

Hypertension

•Excessive Pressure or force of blood flowing through arteries

•Causes the heart to pump with much more force in order to overcome the higher pressures

•*Primary Hypertension – no known cause – persistent elevated systolic pressure

•Secondary Hypertension – due to another disease process ex. Kidney disease, pregnancy

•Often asymptomatic until the degree of HTN becomes severe or critical – the silent killer

•May present with headaches (often in the am) dizziness, nausea, nosebleeds (epistaxis), fatigue and difficulty sleeping

- Major risk factors for chronic heart disease, heart failure, stroke, renal failure

Primary or Essential Hypertension

•90% of people with HTN

•No known cause – environmental? Genetic?

•Usually have elevated total peripheral resistance

•Organs are being perfused effectively, usually have no symptoms

•Underlying danger if HTN is the prolonged force on the vessels of the vascular system (for both Primary and secondary HTN)

Secondary Hypertension

•Elevated blood pressure from identified underlying cause

•Kidney disease

•Coarctation of aorta

•Endocrine disorders

•Neurologic disorders

•Drug use

•Pregnancy

•Hypothyroidism

•Obstructive sleep apnea

Hypertension Pathophysiology

•The sustained increase in blood pressure results in permanent thickening and remodeling of the blood vessels

•This causes increased peripheral vascular resistance and a back up of pressure to certain organs - brain, heart and kidneys

•When resistance to blood flow increases, blood pressure must increase for the flow to remain constant (the heart is trying to compensate)

•Disorders include thickening of the myocardium, enlargement of ventricles, heart failure, MI, CVA and kidney damage

•Constant, excessive high blood pressure damages the inner lining of blood vessels and cause a disruption or interruption of blood flow to the tissues

•Htn leads to blood vessel damage, atherosclerosis and damage to small vessels in end organs

•Puts a tremendous strain on the heart muscle and increases myocardial oxygen consumption

Systemic Arterial Pressure

•Contraction of the left ventricle sends blood surging to the aorta creating pressure that forces blood into all branches of the aorta

•This pressure is greatest during systole (cardiac contraction) and falls to its lower level during diastole

•Measuring the systolic and diastolic pressures indicates the pumping pressure of the ventricle and the generalized pressure in the system, or :

***The pressure the ventricle has to overcome to pump blood out of the heart

Hypotension

•For blood to be delivered to every cell in the body the pressure of the blood in the arteries needs to remain relatively high.

•The pressure can fall dramatically (hypoperfusion) from loss of blood volume, excessive vasodilation, or from failure of the heart to pump effectively

• Can be dangerous when it causes poor oxygen perfusions to the brain and other vital organs

•Severe hypotension can progress to shock and even death as the cells are not able to get the oxygen and nutrients they need

•Shock – circulatory failure causing inadequate O2 delivery, producing cellular and tissue hypoxia – can result in Multiorgan failure (MOF) and death

Shock

circulatory failure causing inadequate O2 delivery, producing cellular and tissue hypoxia - can result in Multiorgan failure (MOF) and death

Hypertension defined as

•Systolic BP ≥ 140 mmHg or

•Diastolic BP ≥ 90 mmHg

Prehypertension BP for Adults

- Systolic 120-139 mmHg

- Diastolic 80 - 90 mmHg

Hypertension Stage 1 BP for Adults

- Systolic 140-159 mmHg

- Diastolic 90-99 mmHg

Hypertension Stage 2 BP for Adults

- Systolic ≥ 160 mmHg

- Diastolic ≥ 100 mmHg

Hypertensive Emergency

•BP > 180 mmHg systolic, 120 mmHg diastolic

•Also called malignant hypertension, hypertensive crisis

•Treatment within 1 hour is vital to prevent cardiac, renal, vascular damage

•Cerebral edema may result from cerebral artery spasms

Populations at Risk for Hypertension

•Primarily in middle-age, older adults

•Higher prevalence in Black patients than White, Hispanic patients

•More White men than women

•More Black and Hispanic women than men

•Native Americans, Alaska Natives at high risk

•All income groups

Risk Factors for Hypertension

•Family history

•Age

•Race

•Mineral intake - electrolytes

•Obesity

•Insulin resistance

•Excess alcohol consumption

•Stress

•Physical inactivity

•Vitamin D deficiency

•Depression

Prevention for Hypertension

•Healthy lifestyle choices, habits can prevent high BP, reverse prehypertension, help control existing hypertension, prevent complications and long-term problems of hypertension

*** Maintain healthy weight

*** diet - DASH - dietary approaches to stop hypertension eating plan

*** Regular physical activity

*** Stress management

*** Follow medication regimens

*** Quit smoking

•Patients with prehypertension should take steps to avoid progressing to high BP

•Patients with high BP

*** Regular medical care

*** Follow prescribed treatment plan

Clinical Manifestations of Early Stages of Primary Hypertension

- typically asymptomatic (no symptoms)

- marked only by elevated BP

- initially transient, eventually become permanent

Clinical Manifestations of Hypertension -- Vague Symptoms

•Headache on awakening

•Nocturia (going to bathroom at night)

•Confusion

•Nausea, vomiting

•Visual disturbances, retinal changes

Sustained Hypertension increases the risk for...

- coronary heart disease

- stroke

- heart failure

- renal failure

Hypertension Cardiovascular System Effects

- heart muscle weakens and becomes less efficient

- Rate of atherosclerosis accelerates - damage to the arteries

- Workload of left ventricle increases, leading to hypertrophy - enlarged left side of the heart

- increased Diastolic BP significant cardiovascular risk factor until age 50

- increased Systolic BP becomes more important risk factor after age 50

Hypertension Neurologic System Effects

- the brain needs a nourishing blood supply to work properly

- •TIA - transient ischemic attack - disruption of blood flow to the brain

•CVA - cerebrovascular accident- brain does not get enough oxygen or nutrients; clots

- alterations in speech or vision may be first sign

Hypertension - Retinopathy Effects

•Hemorrhages, exudates, arteriolar narrowing, cotton wool spots

•Papilledema if severe - swelling of optic disc

Hypertension - Chronic Kidney Disease (CKD) or Chronic Renal Failure (CRF)

increased levels of BUN and creatine; Nocturia