NR 324 Week 3 EDAPT_Altered Perfusion

Clients with hyperlipidemia, diabetes mellitus, peripheral vascular disease, and arteriosclerosis are at very high risk for both decreased central and peripheral perfusion. ➢ Perfusion is best understood as a continuum of the heart’s ability to adequately supply blood to the body and the patency of arteries to adequately supply blood to peripheral tissues. Normal perfusion is at the healthy end of the continuum while infarction is at the illness end of the continuum. Ischemia occurs before infarction. • Ischemia refers to impaired perfusion, whereas infarction is complete tissue death. Conducting a complete client and family history for risk factors for altered perfusion is essential. Risk factors for altered perfusion can be modifiable or non-modifiable. • Modifiable risk factors include smoking, lack of physical activity, and obesity. • Nonmodifiable risk factors include age, gender, and family history. Conducting a complete client assessment to identify existing problems indicating altered perfusion is essential. The nurse must recognize cues that indicate altered central or peripheral perfusion. • Signs of altered peripheral perfusion include decreased hair distribution on the extremities, nonlocalized and diffuse pain or discomfort, cool skin, and pallor or cyanosis of the extremities. If not treated, skin ulcers may develop or cell death occurs, such as gangrene. • Signs of altered central perfusion include dyspnea, dizziness, syncope, and chest pain. Decreased central perfusion is caused by decreased cardiac output and can be life-threatening. Signs of decreased cardiac output include hypotension, tachycardia, diaphoresis, anxiety, confusion, and dysrhythmias. If not treated, acute myocardial infarction, stroke, and shock may develop. Symptom/Sign Scope of Perfusion Defect Potential Cause organs The nurse is caring for a client with altered central perfusion. The client is at risk for developing myocardial infarction caused by decreased cardiac output. Now that you have recognized and analyzed cues, a plan of care can be created. When prioritizing hypotheses, the nurse should include urgency, risk, difficulty, and time as part of the process. Hypothesis Altered Perfusion Is the client at significant risk of serious injury or death? Cues Immediate that may suggest this include very low blood pressure, serious action (urgency, cardiac dysrhythmias, severe tachycardia or bradycardia, loss of risk) Priority consciousness, and loss of localized perfusion (e.g., reduced, or absent circulation to an extremity). Immediate action must be taken to mitigate injury and prevent death. Is immediate intervention needed when reviewing the cues and data? If yes, then immediate action must be taken to mitigate injury and prevent death. If not, can the client be observed until further changes are noted? Resources Are resources available to carry out the plan of care? Does teaching need to be done sooner rather than later? What is the timing in which these cues occurred? This could Time determine whether immediate action is needed, or observation is appropriate. When prioritizing hypotheses, the nurse must consider that multiple cues can lead to several diagnoses. We must consider all assessment findings and generate several hypotheses. Let’s review Nancy’s symptoms, determine the problem, and prioritize our hypotheses. Bronchodilator medications are