Med Surg Exam 4(Unit 9: Caring for the patient common perfusion problems)

Unit 9: Caring for the patient common perfusion problems CARDIOVASCULAR ASSESSMENT:  Perform a complete cardiovascular assessment. As HTN is a risk factor for CAD, assess BP in both arms. Check for all major pulses as well as capillary refill and temperature of lower extremities. Prolonged capillary filling (>3 seconds in young to middle-aged adults; >5 seconds in older adults) indicates poor circulation.  Listen with a stethoscope or use a Doppler to assess for the presence of a bruit, which is heard as a swishing sound as blood attempts to push through a narrowed artery. Bruits often occur in the carotid, aortic, femoral, and popliteal arteries.  Obtain information about family history and modifiable risk factors, including eating habits, lifestyle, and physical activity levels. Ask about a history of smoking and how much alcohol is consumed each day. Assess body mass index (BMI) and weight. DYSRHYTHMIAS  Dysrhythmias are disorders of the electrical conduction of the heart that result in disturbances in the heart rate and/or heart rhythm. Dysrhythmias may alter blood flow and lead to hemodynamic changes.  Sinus bradycardia has a heart rate less than 60 BPM. Rates < 45 BPM cause syncope, dizziness, weakness, confusion, diaphoresis, SOB, and angina. The treatment of choice is atropine but an external pacemaker may be needed. Patient must avoid strenuous physical activity following placement of pacemaker to allow time to settle. Nurse should withhold beta blockers.  Ventricular fibrillation (VF), a life-threatening dysrhythmia, is the leading cause of sudden cardiac death. A patient in VF has no cardiac output and must receive intervention promptly. This rhythm is fatal if not successfully treated within 3 to 5 minutes. Begin CPR, defibrillate as soon as possible, and administer antidysrhythmics.  Ventricular tachycardia (VT) is a life-threatening dysrhythmia that occurs when an irritable ectopic focus in the ventricles takes over as the pacemaker. If a pulse is present and no change in LOC, synchronized cardioversion may be needed to restore NSR. If the patient in VT does not have a pulse, treat as v-fib and defibrillate. HEART FAILURE  Heart failure usually begins with failure of the left ventricle and progresses to failure of both ventricles. Causes of left-sided heart failure (LHF) include hypertension, coronary artery disease, and mitral or aortic valve disorders. Patients experience tachypnea, muscle weakness, and fatigue. A cough is usually noted due to fluid being trapped in the lungs. Bibasilar crackles may be noted when auscultating the lungs.  Right-sided heart failure may be caused by left ventricular failure, right ventricular MI, or pulmonary hypertension. RHF usually results due to COPD, pulmonary hypertension, or ARDS. Fluid is retained, resulting in edema of the extremities. Jugular vein distention may also be present.  The diagnosis of heart failure is based on the health history data and presenting manifestations as well as diagnostic test results. A B-type natriuretic peptide (BNP) level will be ordered. The BNP is a protein produced and released by the ventricles when the patient has fluid overload because of HF.  Instruct the patient to weigh daily and that 1 kg of weight gain or loss equals 1 liter of retained or lost fluid. The same scale should be used every morning before breakfast for the most accurate assessment of weight. Instruct patients to call their primary care provider if they gain 2 to 3 pounds in 1 day or 5 to 7 pounds in one week.  Teach the patient energy conservation techniques, such as eating small meals and resting afterward, as well as spacing out ADLs and activities to conserve oxygen and avoid excessive fatigue. CORONARY ARTERY DISEASE  The primary cause of CAD is inflammation and lipid deposition in the wall of the artery. Arteriosclerosis is a thickening, or hardening, of the arterial wall that is often associated with aging. Non-modifiable risk factors for CAD include age, gender, family history, and ethnic background. The more risk factors a person has, the greater the risk of CAD.  Laboratory tests to diagnosis CAD include a lipid panel where total cholesterol, HDL, LDL, and triglycerides are measured. Elevated cholesterol levels are confirmed by HDL and LDL measurements. Cholesterol management focuses on an LDL < 100 mg/dL and an HDL > 40.  Procedures to open occluded vessels are performed in the cardiac catheterization laboratory which includes high-resolution fluoroscopy (patients may experience feeling of heat when dye is injected) and x-ray. These procedures include angioplasty, atherectomy, stents, and revascularization.  Coronary artery bypass graft (CABG) surgery involves the bypass of a blockage in one or more of the coronary arteries using the saphenous veins, mammary artery, or radial artery as conduits or replacement vessels. ARTERIOSCLEROSIS