1. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board CONCEPT Nursing: A Concept-Based Approach to Learning Volume One Perfusion 22

2. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board About Perfusion

3. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Normal Presentation Heart Pericardium Layers of the heart wall –Epicardium –Myocardium –Endocardium

4. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Figure 22-3 The internal anatomy of the heart, frontal section.

5. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Chambers and Valves of the Heart 4 hollow chambers –Right atrium –Left atruim –Right ventricle –Left ventricle Heart chambers separated by valves –Atria separated by atrioventricular valves –Pulmonic valve –Aortic valve

6. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Normal Heart Sounds Closure of valves creates heart sounds –AV valve produces S 1 –Semilunar produces S 2 Contraction and relaxation of the heart Splitting of S 2 normal in some S 3 ventricular gallop S 4 atrial gallop Characteristics of heart sounds

7. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Figure 22-5 Heart sounds in systole and diastole.

8. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Normal Heart Sounds, continued Additional Heart Sounds –Damaged tissue –Mitral stenosis –Ejection clicks –Nonejection clicks –Friction rubs –Heart murmurs

9. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Systemic, Pulmonary, Coronary Circulation Pulmonary circulation –Right side of heart Systemic circulation –Left side of heart Coronary circulation –Vessels that supply the heart muscle itself

10. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Transition from Fetal to Pulmonary Circulation Flow of blood Foramen ovale Blood pumped into aorta, systemic circulation System vascular resistance

11. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board The Cardiac Cycle and Cardiac Output One heartbeat of contraction and relaxation Stroke volume Cardiac output Ejection fraction

12. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board The Cardiac Cycle and Cardiac Output, continued Cardiac output determined by –Autonomic stimulation –Preload –Afterload –Contractility Clinical indicators of cardiac output –Cardiac index

13. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Conduction System of the Heart Sinoatrial node (SA node) –Creates impulse –Depolarization causes myocardial contraction Action potential is basis for EKG Depolarization Repolarization Anatomic landmarks for cardiovascular assessment

14. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Pulse Wave of blood created by LV contraction Peripheral pulse Apical pulse Factors affecting pulse

15. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Blood Pressure Measure of pressure of blood flow through arteries –Systolic –Diastolic Pulse pressure Measured in millimeters of mercury Determinant of blood pressure Factors affecting blood pressure

16. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Developmental Aspects Pediatric differences –Cardiac functioning –Oxygenation Cardiovascular changes in pregnancy –Cardiac output increases early in pregnancy –Enlarging uterus places pressure on veins  Interferes with returning blood flow –When supine, pressure on vena cava

17. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Figure 22-13 Vena caval syndrome. The gravid uterus compresses the vena cava when the woman is supine. This reduces the blood flow returning to the heart and may cause maternal hypotension.

18. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Developmental Aspects Cardiovascular changes in pregnancy, continued –Blood volume increases –Leukocyte production increases –Fibrin and plasma fibrinogen increase

19. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Developmental Aspects, continued Normal changes of aging –Determined by genetics  Physical, social environment –Cardiovascular system –Vascular system –Pulmonary system –Renal system

20. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Figure 22-14 Normal changes of aging in the cardiovascular system.

21. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Alterations Alterations in pediatric cardiology –Congenital heart defects –Congenital anomalies Common cardiovascular illnesses of aging –CAD – Cardiomyopathy –Dysrhythmia – Valve disease –Shock – Hypertension –Stroke – PIH

22. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Assessment Physical assessment –Inspection –Palpation –Percussion –Auscultation Perfusion assessments –Apical impulse – Heart sounds –Cardiac rate and rhythm – Murmurs

23. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Assessing the Pulse Techniques Assess for –Rate– Rhythm –Volume– Arterial wall elasticity Developmental considerations Pulse sites Apical pulse assessment Apical-radial pulse assessment

24. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Assessing Blood Pressure Measured with sphygmomanometer Blood pressure sites Methods –Direct –Indirect  Auscultate, palpate  Korotkoff’s sounds  5 phases of blood pressure

25. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Assessing Blood Pressure, continued –Developmental considerations –Care settings –Common errors in assessing blood pressure  Haste  Unconscious bias –Hypotension  Orthostatic hypotension

26. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Health Assessment Interview Explore chief complaint Assessing chest pain Genetic considerations

27. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Diagnostic Tests Determining cardiac function –Serum cholesterol, triglycerides, lipids –Stress/exercise tests –X-ray, MRI, CT, PET –Echocardiogram –Transesophageal echocardiogram –Cardiac catheterization, angiography –Pericardiocentesis

28. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Diagnostic Tests, continued –Electrocardiography  Interpreting an ECG –Troponin, MB isoenzyme of creatine kinase Nursing responsibilities –Explain the procedure and preparation –Assess for medication use –Support client during test if necessary –Document procedure, monitor results

29. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Caring Interventions Support, improve, promote perfusion Interventions to –Reduce stress on the heart –Decrease cardiac workload –Increase efficacy of cardiac contractions –Meet fluid needs –Primary prevention  Diet  Exercise

30. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Caring Interventions, continued Interventions – 3 categories –Inputs –Outputs –Pressure supports Specific skills –Assessing pulses –Recording and interpreting an ECG –Administering CPR

31. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Caring Interventions Specific skills, continued –Achieving defibrillation –Measuring for, application of elastic compression stockings –Fetal monitoring –Applying SCD –Applying continuous cardio-respiratory monitoring –Obtaining capillary wedge pressures

32. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Caring Interventions Specific skills, continued –Measuring cardiac output –Reading central and peripheral blood pressures –Caring for arterial pressure monitoring

33. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nursing: A Concept-Based Approach to Learning, Volume One North Carolina Concept-Based Learning Editorial Board Pharmacologic Therapies Classifications –Statins –Antihypertensives –Adrenergic agonists –Calcium channel blockers –Cardiac glycosides –Phosphodiesterase inhibitors –Nitrates –Thrombolytics