perfusion
how to assess for perfusion
- Heart rate - Blood pressure - Patients orientation to time, place, person, situation (central perfusion) - Extremities warm with color appropriate for race (tissue perfusion) - Capillary refill time less than 2 seconds - Subjective data: Presence of warmth in extremities and absence of pain in extremities
circulatory system
1. Transports oxygen, waste, nutrients, hormones, heat, etc... around the body 2. two major divisions - pulmonary and systemic
A client is being treated for chronic kidney disease (CKD). One of the nurse's responsibilities is to explain to the client the need to keep her blood pressure under control. Why is blood pressure control so important in CKD clients? 1. Elevated blood pressure will exacerbate nephron loss and accelerate renal failure. 2. Elevated blood pressure will slow the excretion of protein (proteinuria) and lead to a hypertrophic kidney. 3. Elevated blood pressure will decrease pressure on the nephron with a corresponding decrease in GFR, leading to renal failure. 4. Elevated blood pressure will result in greater amounts of urine formation and will over-tax renal function.
Elevated blood pressure (hypertension) will damage the kidney further and accelerate the progress toward renal failure. There are increases in glomerular pressure and increases in proteinuria that further damage the glomerulus and the nephron, thereby accelerating nephron loss.
A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? 1. left lateral 2. right lateral
left. The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava.
systole vs diastole
systole (contraction) and diastole (relaxation)
Approximately what percentage of the stroke volume is ejected during the first quarter of systole
60
The nurse is assessing a client who had an abdominal aortic aneurysm repair 2 hours ago. Which finding warrants further evaluation? 1. creat 1.2 and BUN 26 2. BP 80/50 3. pedal pulses 1+ 4. absent bowel sounds and mild abdominal distention
A blood pressure of 80/50 mm Hg in a client who has just had surgical repair of an abdominal aortic aneurysm warrants further evaluation as this indicates decreased perfusion to the brain, heart, and kidneys. A BUN of 26 and a creatinine of 1.2 are normal findings. While +1 pedal pulses may be an abnormal finding, it is not uncommon, and it is important to compare this finding to previous assessments and note if this is a change of the strength of the pedal pulses. Absent bowel sound and mild abdominal distension is expected for a client immediately following surgery. However this finding should be monitored as it could indicate a paralytic ileus.
S3
An S3 ("DUB") is heard early in diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle. It is heard immediately after S2. "Lub-dub-DUB" is used to imitate the abnormal sound of a beating heart when an S3 is present.
A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? 1. dependent edema 2. bibasilar crackles 3. JVD
Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
When caring for a patient receiving estrogen replacement therapy for postmenopausal symptoms, the nurse documents a diagnosis related to impaired tissue perfusion. Which condition is the nurse referring to in the diagnosis?
DVT
The nurse is counseling a client regarding a high cholesterol level. The nurse teaches the client that which lipoprotein is the main carrier of cholesterol?
LDL. HDL is 50 percent protein; VLDL carries a large amount of triglycerides. IDLs are fragments of VLDLs
A client with a diagnosis of chronic renal failure secondary to diabetes has seen a gradual increase in her blood pressure over the past several months, culminating in a diagnosis of secondary hypertension. Which factor has most likely resulted in the client's increased blood pressure? 1. Coarctation of the aorta 2. Increased levels of adrenocortical hormones 3. Activation of the renin-angiotensin-aldosterone mechanism 4. Increased sympathetic stimulation by the autonomic nervous system
The largest single cause of secondary hypertension is renal disease. The reduced renal blood flow that occurs with renovascular disease causes the affected kidney to release excessive amounts of renin, increasing circulating levels of angiotensin II and raising blood pressure.
When it is determined that a client's red blood cells (RBCs) have a biconcave shape, what will be the nurse's reaction? 1. The nurse will be pleased, as that shape allows for increased oxygen diffusion. 2. The nurse will be concerned, as this is an indication of sickle cell anemia. 3. The nurse will immediately notify the client's health care provider of this serious finding. 4. The nurse will arrange for bedside oxygen for the client to use as needed.
The nurse will be pleased, as that shape allows for increased oxygen diffusion.
The ejection fraction is
The percentage of end diastolic volume pumped per beat. the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole.
dependent edema
a fluid accumulation in the tissues influenced by gravity; usually greater in the lower extremities than in tissue levels above the level of the heart
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:
acutely decreased (hemorrhage)
What is the primary underlying disorder of pulmonary edema? 1. Decreased left ventricular pumping 2. Decreased right ventricular elasticity 3. Increased left atrial contractility 4. Increased right atrial resistance
decreased LV pumping
signs of bleeding include
include tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria.
A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? 1. peripheral pulses q.15 min 2. BP q. 2 hours
initially q.15 but then can change so go with the pulses
Which of the following blood flow patterns reduces friction, allowing the blood layers to slide smoothly over one another? 1. Laminar 2. Turbulent 3. Crosswise 4. Axially
laminar. Axially, crosswise, and turbulent blood flow would result in increased friction. In turbulent flow, the laminar stream is disrupted and the flow becomes mixed, moving radially (crosswise) and axially (lengthwise)
The nurse is performing a skin assessment on a bedbound client who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than
one hour
Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole? 1. preload 2. ejection fraction
preload
vagal response
stimulation of the vagus nerve causing a parasympathetic response. *involuntary
Afterload is
the amount of resistance to ejection of blood from a ventricle.
Preload is
the the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole.
Stroke volume is
the volume of blood pumped with each ventricular contraction. the amount of blood pumped out of the ventricle with each contraction. CO=SV x HR
A client has experienced the α1-receptor stimulation. The nurse would assess the client for:
vasoconstriction
