Perfusion

Assessment
Types of Shock
Hypovolemic Intravascular volume loss - absolute or relative
● Absolute = hemorrhage
● Relative = fluid shift
Examples:

Cardiogenic Shock Pump failure/heart failure

Examples: Heart attack, dysrhythmias, MI

Obstructive Shock Physical obstruction

Example: blood clot, pulmonary embolism

Distributive Shock Systemic vasodilation

● Septic shock: infection
● Neurogenic shock: spinal cord injury
● Anaphylactic shock: widespread hypersensitivity (anaphylaxis)

Classes of Shock
Early ● Sometimes causes a decrease in mean arterial pressure (MAP)
● This states is rarely detected

Compensatory ● Body starts to compensate for a lack of MAP

● Changes: ↑ HR, ↓ BP, ↓ peripheral perfusion (weak pulse), ↓ mental
status (confused)

Decompensated ● Body no longer compensating for lack of perfusion

● Notable changes in assessment indication WORSENING perfusion
● Changes ↑ HR or ↓ HR, ↓↓ BP, ↓↓ peripheral perfusion, ↓↓ mental
status

Refractory Irreversible; result in death of cells, tissues, organs

Lifespan Considerations

Pregnancy/Fetal Perfusion Infants/Children Adults

● ↑ blood volume, w/ ↓ ● Typically, a congenital defect Older adults:

return Infants: ● Myocardium less efficient and
● Changes in hydrostatic ● Poor feeding less contactable
pressure (edema) and blood ● Poor weight gain ● SA node ↓ control
pressure ● Failure to thrive ● Left ventricular slight
● Problems w/ parental ● Dusky color hypertrophy
perfusion can impact Toddlers/children: ● Vessels become stuff
placental perfusion (Ex. ● Squatting and fatigue
placenta previa) ● Developmental delay
● Failure to his milestones

Individual Risk Factors

Age related changes ↓ Myocardial efficiency, SA node ↓ control, ↑ r/o left ventricular heart
failure, blood vessel stiffening (↑ resistance)

Smoking Nicotine's cause vasoconstriction

Obesity Relationship w/ chronic illness: diabetes, hypertension, high cholesterol

Family history High cholesterol atherosclerosis, history of chronic illness, history of hypertension
(genetics)
Diagnosis Diagnostic Tests
Lab Test What are measures? Normal Range
Creatine Kinase - ● Enzyme found in muscle cell Values peak in 10-24 hr, last up to
Myoglobin (CK-MB) ● Elevated → cardiac damage 48 ht

Troponin ● Protein found in muscle cell ● Troponin I (cTnI): < 0.35 mcg/L
● Elevated → cardiac damage ● Troponin T (cTnT): < 0.2 mcg/L
● Values rise in 3-4 hrs, peak in
10-12 hrs

C-Reactive Protein ● Protein released during inflammation

● Elevated → inflammation

Potassium (Serum) ● Measures potassium in blood; the 3.5 - 5.2 mEq/L

primary electorate in heart
● Hyperkalemia or Hypokalemia

Serum Lactate ● Measure lactate in blood; produced 0.5 - 2.2 mEg/L

when body breaks down carbohydrates
for energy when oxygen is too low
● Elevated → ↓ perfusion/shock →
body forced into anaerobic
metabolism

Cholesterol: HDL, ● HDL → GOOD ● HDL: > 60 mg/dL

LDL, Triglycerides ● LDL → BAD ● LDL: < 100 mg/dL
● ↑ LDL, ↑ Triglycerides, ↓ HDL → ● Cholesterol: 140 - 199 mg/dL
plaque in vessel → r/o MI/stroke ● Triglycerides: < 150 mg/dL

Electrocardiogram (ECG/EKG)

EKG section What does it show? Normal Range

P wave Firing of SA node, atrial depolarization → atrial 0.06 - 0.12 sec

contraction

PR interval Time for impulse to spread though atria, AV node, 0.12 - 0.20 sec
bundle of His, bundle branches, to Purkinje fibers

QRS complex Ventricular depolarization → ventricular < 0.12 sec

contraction

ST segment Time b/w ventricular depolarization and repolarization. 0.12 sec

Should be glact/isoelectric (no electric activity)

T wave Ventricular repolarization 0.16 sec

QT interval Total time for depolarization and repolarization of 0.34 - 0.43 sec
ventricles

Sinus Rhythm 60 - 100 bpm

Basic EKG interpretation: 4 basic questions

1. Rate - normal, brady, or tachy?
 2. Rhythm - regular or irregular
3. Is there a P for every QRS?
4. Is the QRS normal or wide?

Rhythm Strip Consideration

Normal 60 -100

Bradycardia < 60
Rate too slow

Tachycardia > 100

Rate too fast

Atrial Fibrillation Irregular atrial signing (no

P wave)
3/4th priority
depending on ↓ CO, ↑ r/o clotting,
patient MI, stroke

Premature Occasional irregular beat

Ventricular (d/t ventricular signaling)
Contractions
Monitor! Symptoms?
3/4th priority Frequency?
depending on
frequency

Ventricular Can be sustained (> 60

Tachycardia sec) or nonsustained (<
60 sec)
Emergency if
sustained - 2nd Nonsustaine → notify
priority provider
Sustained = Emergency;
call 911 or Code

Ventricular No identifiable rhythm

Fibrillation
Sustained = Emergency;
call 911 or Code
EMERGENCY - 1st
priority

● Cardiac stress tests: exercise or pharmacological test

● Radiographic studies
○ Chest X-ray
○ Ultrasound
 ○ Arteriogram
○ Echocardiogram

Common Congenital Defects

Atrial Septal Defect Tetralogy of Fallot Transposition of the Great

Arteries

Septal defects allow mixing of Multiple defects Pulmonary artery and aorta are
blood transposed

Detected: Usually not detected Detected: Life-threatening at birth;

Detected: Infants develop
till preschool years noticed right away baby is
hypoxia and cyanosis
blue/cyanotic

Planning/ Clinical Management:

Implementation
Primary Prevention Secondary prevention/ Screening
● Smoking and nicotine cessation ● Blood pressure screening
● Nutrition: ↓ fat, ↓ cholesterol, ↓ ● Lipid screening
sodium
● Exercise: keep heart healthy

Collaborative Interventions:
● Treatment strategies depend on underlying condition
● Most common strategies include:
○ Diet modification and smoking cessation
○ Increase activity (cardiac reconditioning)
■ Impatient
■ Immediately out-patient
■ Long term home management
■ Positioning
■ Actively level
Central Perfusion Tissue (Local Perfusion)
● Pacemaker insertion ● Bypass and/or graft surgery
● Electrical cardioversion ● Stent or angioplasty
● Ablation therapy ● Endarterectomy
● Intra-aortic balloon pump
● Cardiac valve surgery
● Cardiac transplant

Pharmacology

RAAS Suppressants

Angiotensin-Converting Enzyme Inhibitors

(ACEIs): inhibit ACE enzyme from producing
angiotensin II

“-prils”
● Enalapril
● Lisinopril

Angiotensin II Receptor Blockers (ARBs):

block effect of angiotensin II

“- sartans”
● Losartan
● Valsartan

Assessment Is med appropriate?

● Treat high blood pressure → hypotensive → HOLD drug
● Treat heart failure symptoms (excess fluid volume) → edema,
crackles in lungs
● Reduce r/o MI, stroke
● Slow progression of diabetic nephropathy → assess kidney function

Base Line: assess BP/Cardiac assessment

Caution Adverse effects: Dehydration (b/c ↓ thirst, ↓ H2O retention, ↓ volume)

Use/Adverse
Effects Contraindicated: Pregnancy, history of angioedema, renal artery stenosis

Side Effect ACEI ARB Nursing Interventions

1st Dose Yes No Monitor, ensure safety → check BP

HYPOtension after administering med

Cough Yes No Monitor, is it a problem? → notify,

may which to ARB

HYPERkalemia Yes Yes Avoid w/ other meds that raise K+, and
salt substitutes

Angioedema Rare Very Rare Monitor → EMERGENCY!

Implementation/ Monitor for side effects

Patient Teaching
Drug interactions:
● Concurrent use of drugs that lower BP can cause exaggerated hypotension
● Concurrent use of potassium-sparing diuretics and potassium supplements
can cause exaggerate hyperkalemia
● Concurrent use of lithium may result in lithium toxicity
● Concurrent use of NSAIDs may reduce effectiveness of ACE inhibitor

Evaluation Did it work? Why was the patient taking meds?

● HTN → BP lower?
● CHF → fewer symptoms of fluid volume overload
 ● Diabetic Nephropathy → is kidney function better?

Beta Blockers “-olol”

Non-cardioselective: Blocks beta 1 AND 2

(work on heart, vessels, and lunges)
● Propranolol

Cardioselective: Blocks beta 1 ONLY (only

work on the heart)
● Metoprolol

Beta Receptors: Heart, Lungs, Vessels

Assessment Is med appropriate?

● Treat high blood pressure
● Treat heart failure symptoms (excess fluid volume)
● Treat Angina pectoris (chest pain)
● Tachydysrhythmias

Take BP, HR BEFORE and AFTER → BP: <90/60 or HR:<60 → HOLD

Cardio-selective vs. Non Cardioselective → know what to anticipate

Caution Monitor HR/BP → if too low, HOLD med and call provider
Use/Adverse
Effects Caution use: Diabetes (masks hypoglycemia and non-selective BB block
glycogenolysis), certain dysrhythmias (heart block)

Contraindicated: Non-selective BB’s for Asthma

Implementation/ Do NOT stop abruptly, taper recommended

Patient Teaching
Patient monitor at home → teach patient to take HR, BP, check for s/s (dizzy,
syncope)

Drug Interactions:
● Other meds that lower BP → especially calcium channels!
● Blockers
● Insulin

Evaluation Did it work? Why was the patient taking meds?

● HTN → BP lower?
● Tachydysrhythmias → HR lower?
● Angina → pain improved?

Alpha Blockers “-sin”

Prazosin - used in hypertension
● Not a first-line med! Usually used after other antihypertensives have been tied or in addition

Tamsulosin - used for Benign Prostatic Hypertrophy (helps to urinate)

Alpha Receptors: Vessels, Prostate

Assessment Is med appropriate?

● Treat high blood pressure
● Treat Benign Prostatic Hypertrophy

Assess BP and HR

Caution Monitor for Hypotension → BP: < 90/60 → HOLD

Use/Adverse
Effects Side effects: may cause hypotension, sexual dysfunction, vertigo, palpitations

Implementation/ Monitor for side effects

Patient Teaching

Evaluation BP and HR evaluation

Calcium Channel Blockers

Blocks calcium from entering cells → ↓ excitability,

↓ force

Meds w/ action on Heart AND Blood Vessels → ↓ HR,

↓ contractibility, arterial vasodilation
● Verapamil
● Diltiazem
Meds w/ action on Blood Vessels ONLY → arterial
vasodilation
● Nifedipine
● Amlodipine

Assessment Is med appropriate?

● Treat hypertension
● Treat angina pectoris (chest pain)
● Treat Tachyarrhythmias

Assess BP and HR

Caution Caution Use: Heart failure

Use/Adverse
Effects Side effects: Hypotension, bradycardia, constipation, dizziness, headache, peripheral
edema

Implementation/ Administer IV and PO → Give IV slowly!

Patient Teaching
Patent teaching/monitoring: HR, BP at home, notify about s/s

Drug Interactions:
● Avoid grapefruit → uses same CYP3450 metabolism pathway
● Digoxin → causes bradydysrhythmias
● Beta blockers → also ↓ HR, ↓ BP

Evaluation Did it work? Why was the patient taking meds?

● HTN → BP lower?
● Tachydysrhythmias → HR lower?
● Angina → pain improved?

Nitrates “nitro”
Potent vasodilators → primarily veins (↓ preload); some actions on arteries (↓
afterload/residence) → ↓ BP

Many routes available

● PO: pills, sublingual, translingual spray
● Topical: paste, patch
● IV

Assessment Is med appropriate?

● Treat angina pectoris (chest pain) → pain b/c heart muscle has ↓ O2

Assess BP, HR, and chest pain

Caution Monitor for hypotension if already on a BP lowering med

Use/Adverse
Effects Side effects: Headache, hypotension
Adverse effect: Reflex tachycardia (↑ HR to compensate for ↓ BP)

Tolerance: use lowest dose, long-acting forms when possible, provide medication-free
 period daily (~8hr off)

Implementation/ Patient teaching/monitoring: Protocol, usage (topical/SL)

Patient Teaching ● X3 dose at home for chest pain
1. Dose 1, wait 5 minutes
2. Call 911 if pain is not relieved, take Dose 2, wait 5 min
3. Take Dose 3 pain is not relieved
● Temperature, light, oxygen sensitive → dont put in pocket
● Expiration dates/multiple bottle

Drug Interaction:
● Sildenafil (causes vasodilation → ↓ BP)
● Other BP lowering drugs
● Alcohol

Evaluation Did it work? Why was the patient taking meds?

● Angina → pain improved?

Call 911 if pain is not relieved in 5 minutes after 1st Dose

Digoxin
Increases force of contraction of heart and ↓ HR → ↑ cardiac
output and work of heart

Antidote: Digi-bing (for toxicity)

Considerations:
● K+ and Dioxin compete for Na/K ATPase → K+
needs to be at normal levels!
● Hyperkalemia → ↓ Digoxin effectiveness
● Hypokalemia → ↑ r/o Digoxin toxicity

(electrolyte shifts → changes hearts pumping force)

Assessment Is med appropriate?

● Treat heart failure
● Treat some dysrhythmias

Assess Apical pulse → HOLD if HR < 60 and call provider

Monitor Serum Potassium
Routs: PO, IV (requires continuous cardiac monitoring)

Caution Contraindications: Digoxin toxicity, hypokalemia (↑ r/o toxicity)

Use/Adverse Monitor renal impairment
Effects
Adverse effects: dysrhythmias, bradycardia, [toxicity → CNS effects:
weakness, vision disturbances (white-yellow halos, blurred vision), GI
(Anorexia, N/V, abdominal pain]

Implementation/ Patient teaching/monitoring: take as prescribed, monitor HR, s/s of toxicity

Patient Teaching
Serum levels monitored for therapeutic range

Interactions:
● Diuretics → affect fluid/electrolyte balance
● ACE inhibitors/ARBs
● Other anti-dysrhythmias

Evaluation Did it work? Why was the patient taking meds?

● HF → reduced symptoms?
● Dysrhythmias → slower HR?

Lipid Lowering Medications “-statins”

Atorvastatin, Simvastatin, Lovastatin
↓ cholesterol synthesis in the liver

Assessment Is med appropriate?

● Reduce r/o cardiovascular disease
 Monitor cholesterol levels (serum lipid panel)

Caution Contraindicated: viral or alcoholic hepatitis, pregnancy (category X)

Use/Adverse Precaution: liver disease, alcohol use
Effects Monitor: Hepatotoxicity, Myopathy (muscle pain/weakness), Rhabdomyolysis
(flank pain, ↓ urine output)

Implementation/ Patient teaching/monitoring:

Patient Teaching ● PO during evening
● Take lovastatin w/ evening meal

Evaluation Did med lower cholesterol levels?

Evaluation Did it work? Why was the patient taking meds?

● HF → reduced symptoms?
● HTN → BP lower?
● Tachydysrhythmias → HR lower?
● Angina → pain improved?
● CHF → fewer symptoms of fluid volume overload
● Diabetic Nephropathy → is kidney function better?
● Lower cholesterol?

Key Terms:
Perfusion: blood flow through the circulatory system for optimal cellular activity
Central perfusion: blood flow through the heart
Tissue perfusion: peripheral perfusion to organs and tissues
Ischemia: a condition in which the blood flow (and thus oxygen) is restricted or reduced in a part of the body
Infraction: A blockage of blood flow to the heart muscle
Anoxia: an absence of oxygen
Hypoxia: low levels of oxygen in your body tissues.
Hypoxemia: A low level of oxygen in the blood
Hydrostatic pressure: the pressure that any fluid in a confined space exerts
Oncotic pressure: osmotic pressure induced by the proteins, notably albumin, in a blood vessel's plasma that
causes a pull on fluid back into the capillary
Normal Central Perfusion: force of blood movement generated by cardiac output which requires adequate:
● cardiac function
● blood pressure
● Blood volume
Normal Tissue or Local Perfusion: volume of blood that flows to target tissue which requires adequate:
● Patent vessels
● Adequate hydrostatic pressure
● Capillary permeability
● Oncotic/colloid pressure
Central Perfusion and Tissue Perfusion

Anatomy Review