NUR 212: Concepts of Nursing Care of the Adult I
Pre-Class Assignment Week 10
Concept: Perfusion
Task
Clustering related information
Explain the
... [Show More] pathophysiology and the effects of the pathophysiology of this week's
exemplar, severe heart failure, in terms of the scope of perfusion:
Central Perfusion:
generated by cardiac output and amount of force that the blood is pumped throughout
the body and to peripheral vessels. occurs when the heart is stimulated by electrical
impulses. Typically starts with the SA node, goes to the AV node, to the bundle of
his,then Purkinje fibers in the myocardium which allows the ventricles to contract. This
starts blood flow through the heart and allows certain values to open and close when
needed and ventricles and atrium to contract and
relax__________________________________________________________________
Local/tissue Perfusion:
is the volume of blood that flows through target tissues, from arteries to the capillaries
Task
Identifying signs and symptoms
Gathering complete and accurate data
Relate the assessment information presented in Giddens to the pathophysiology of
heart failure and pericarditis.
What signs and symptoms will you monitor?
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NUR 212: Concepts of Nursing Care of the Adult I
Pre-Class Assignment Week 10
Manifestations of the Disease Assessment Data to Monitor
Severe heart failure
Lab- BNP
chest x-ray; echocardiogram
VS, HR, JVD, daily wt for wt gain
Lung assessment, cough, SOB, shallow
respiration
Edema- pedial and scrotum
I/O (enlarged liver)
fatigue and weakness
Pericarditis
chest pain, friction rub, pulsus paradoxus
ECG- monitor for ST changes, echo, CT
Labs- troponin, CRP, ESR, WBC
distended neck veins
VS
Task
Identifying signs and symptoms
Predicting and managing potential complications
Considering the effects of the two exemplars related to perfusion, list the assessment
data and the range of values that would be acceptable related to the assessment data
and at what point the values are not acceptable and the nurse would be concerned.
When a concern arises, what action should the nurse take?
Disease
Assessment data
ranges that would Values that are not
Action to take in
the case of
Updated 12/17/19 Page 2 of 21
NUR 212: Concepts of Nursing Care of the Adult I
Pre-Class Assignment Week 10
be acceptable acceptable unacceptable
assessment data
Heart Failure
SOB with exerting
self or lying down,
swelling, reduced
ability to exercise,
weight gain of <3lb
elevated BNP >100
pg/ml, elevated
troponins, elevated
BP <130/80,
elevated BUN/
creatinine,10-20
mg/dl weight gain
of >3lb
chest pain,abnormal
reading on EKG,
increased SOB,
increased
weakness/fatigue
extreme swelling to
legs/ankles and
feet, irregular
heartbeat,
persistent
cough/wheezing
monitor labs,
decrease salt in
diet, limiting fluids,
extra diuretics,
elevate extremities
or apply ace wraps,
may need US of the
heart to monitor
symptoms, obtain
cxray to look for
fluid build up, obtain
daily weights
Pericarditis
SOB, coughing,
fatigue, chest pain,
heart palpitations
abnormal CBCelevated WBC
>11,000, , elevated
ESR- men > 3
women >7,
cardiac enzyme
levels, BUN, CRP
sharp/piercing
chest pain over
the center or left
anti-inflammatory
medications,
antiviral
medications, chest
x ray, US of heart/
echo of heart, EKG
monitoring antiviral medications, [Show Less]