SOLUTIONS SCORED A+
✔✔what are the components of a focused perfusion assessment? - ✔✔1. client or
health history data : history of heart disease, hypertension, medications, lifestyle (diet,
active, smoker, alcohol)
2. physical examination: objective data (BP, HR, blood sugar, for cause of problem)
3. diagnostic tests: multiple BP tests, ECG, blood work (cholesterol), CT scan, MRI,
urine output
✔✔what are the methods of a focused perfusion assessment? - ✔✔1. inspection: sense
of sight, what did you see and observe? Personal grooming, color of your patient (pale
or bluish?), is there another condition affecting appearance?
2. palpitation: we use our hands/sense of touch, we want to check temperature with the
back of hand (are they warm or cold? Check legs and arms, pulses), consistencies and
comparison in size
3. percussion: sound -- tapping fingers on clients body to check for consistency
4. auscultation: stethoscope to check heart/chest, abdomen, bowels
5. communication: cognitive (changes of condition), what we are going to be
doing/going to do, ask questions to get consent, asking family about changes, health
care providers
✔✔define peripheral perfusion - ✔✔flow of blood through arteries and capillaries to
target tissues
✔✔what are signs of optimal perfusion? - ✔✔proper colour of skin (pinkish), less than 3
seconds for capillary refill, not fatigued, normal baseline for BP, good bowel movements
✔✔what are signs of impaired perfusion? - ✔✔pale/cyanotic skin colour, threading
pulse, bounding pulse, low or high BP compared to baseline, cold/numb skin, dizziness,
SOB, fatigued
✔✔what is the normal BP range for an older adult? - ✔✔130-139/80-89
✔✔what are examples of target organs that can be damaged due to uncontrolled
hypertension? - ✔✔kidney (nephropathy, kidney failure)
eyes (vision loss)
brain (stroke)
heart (heart failure, myocardial infarction)
✔✔what are examples of primary management of hypertension? - ✔✔lifestyle changes
,- healthy diet
- exercise
- not smoking
✔✔what are examples of secondary management of hypertension? -
✔✔increased/routine screening
- blood screening
- lipid screening
early diagnosis
prompt treatment
✔✔what are examples of tertiary management of hypertension? - ✔✔medication
surgical intervention
✔✔what are the factors that can influence cardiac output and peripheral vascular
resistance? - ✔✔- force of contraction
- heart rate
- heavy exercise
- blood viscosity
- sympathetic and parasympathetic nervous system
--> SNS: speeds up rate, increases contractibility, speeds conduction through the AV
node
- end diastolic volume
- venous return (blood back to the right atrium)
✔✔what factors can affect a BP reading? - ✔✔- caffeine
- exercise
- pain
- faulty equipment
- full bowel
- medications
- poor assessment techniques by staff
✔✔What is the renin-angiotensin-aldosterone system? (RAAS) - ✔✔- renin released
due to low blood pressure
- angiotensin II is a vasoconstrictor
- aldosterone promotes Na+ and water retention (increase in blood load --> increase
BP)
✔✔vasopressin (antidiuretic hormone, ADH) - ✔✔- responds to decreased blood
pressure
- vasoconstrictor
- increases BP
, ✔✔epinephrine and norepinephrine - ✔✔- constricts most blood vessels but dilates
blood vessels in skeletal and cardiac muscles --> increased BP
✔✔define gas exchange - ✔✔the process by which oxygen is transported to cells and
carbon dioxide is transported from cells
✔✔what are the consequences of impaired gas exchange? - ✔✔compensation ->
hyperventilation
hypoxemia
hypercapnia
dyspnea
cyanosis
hypoxic injury
anoxia
✔✔Define Hyoxemia - ✔✔low oxygen in the blood
--> can cause hypoxia
✔✔Define hypoxia - ✔✔An insufficiency of oxygen in the body's tissues
--> can cause cell damage
✔✔Define ischemia - ✔✔insufficient flow of oxygenated blood to the tissue
✔✔define anoxia - ✔✔complete lack of oxygen in the tissue
--> cell death
✔✔Define dyspnea - ✔✔shortness of breath
✔✔Define cyanosis - ✔✔a bluish discolouration of the skin or muscous membranes
resulting from poor circulation or inadequate oxygenation of the blood.
✔✔what are the signs and symptoms of optimal gas exchange? - ✔✔ventilation
diffusion
perfusion
gas transport
✔✔what are the signs and symptoms of impaired gas exchange? - ✔✔- hypoxemia
- abnormal breathing patterns
- abnormal arterial blood gasses
- restlessness
- cyanosis
- dyspnea
- coughing and nasal flaring
hypoxia