Altered Perfusion
Nursing Care: Altered Perfusion
Prepare: Nursing Care of Altered Perfusion
Using Clinical Judgement with Perfusion
The nurse notices that the patient’s blood pressure is 100/50. Which part of the clinical judgement model is the nurse
performing?
Analyzing a cue
Prioritizing a hypothesis
Recognizing a cue
Generating a solution
Using Clinical Judgement with Perfusion
The nurse decides to raise the head of the bed before administering oxygen. Which part of the clinical judgement model is
the nurse using?
Analyzing a cue
Recognizing a cue
Generating a solution
Prioritizing a hypothesis
Using Clinical Judgement with Perfusion
The nurse checks the patient’s blood pressure and heart rate after administering the antihypertensive medication. Which o
the following steps of the clinical judgement model is used with this action?
Prioritizing a hypothesis
Analyzing a cue
Evaluating outcomes
Generating a solution
Self-Check: Analysis - Matching the System
Which of the following are cues can suggest reduced perfusion? Select all that apply.
Confusion
Reduced capillary refill
Increased capillary refill
Increased B-type natriuretic peptide
Decreased urine output
Decreased B-type natriuretic peptide
Self-Check: Recognizing Cues - Perfusion
,Self-Check: Generating Hypothesis - Matching Cue to Problem
Review the potential problems listed below. Match the sign or symptom the nurse should expect to find as a possible cue,
and identify the scope of the perfusion defect.
Self-Check: Prioritizing hypotheses - Perfusion
Review the following examples and select the answers to the questions about each hypothesis of altered perfusion.
,Reflect: Perfusion
Recognizing Cues – Perfusion
Select the cues that are an immediate or urgent priority.
Prioritizing Hypotheses – Perfusion
You are caring for Julie who is experiencing shortness of breath. Her oxygen saturation is 87%. In addition, her blood
pressure is 160/90 with a pulse 102. The lower lungs have coarse crackles, and the shortness of breath worsens when lay
flat. She has 3+ pitting edema in the lower extremities. Labs show an elevated B-type natriuretic peptide (BNP) level, a
potassium level of 3.5 (normal 3.5 to 4.5 meq/dl).
Select from the following nursing diagnoses/hypothesis and drag the top three to the correct prioritized order.
Prioritizing Hypotheses – Perfusion
Julie is diagnosed with heart failure. You receive the following orders from the provider, prioritize them in the order that wou
treat the patient most effectively:
1. Oxygen at 12 L per simple facemask
2. Given furosemide 40mg intravenously now
3. Give potassium 20mEq by mouth now
4. Continuous oximetry
5. Monitor vital signs q4hours
Evaluating Outcomes – Perfusion
,Julie has the following Nursing Diagnoses:
Alteration in perfusion as evidenced by elevated B-Type Natriuretic Peptide Levels, blood pressure 160/96, pulse 105
Alteration in gas exchange as evidenced by oxygen saturation below 90%, complaints of shortness of breath, and basilar fi
crackles in bilateral lower lung lobes.
Nursing actions/interventions:
● Furosemide 40mg IV
● Elevated head of bed to 45 degrees
● Administer oxygen at 2 L/min by nasal cannula
The nurse should recognize that which assessment findings show improved perfusion? Select all that apply.
Blood pressure increased
Intake greater than output
Intake less than output
Pulse rate decreased
Pulse rate elevated
Blood pressure decreased
Weight loss
Weight gain
Recognizing Cues – Perfusion
You are caring for Bill who is complaining of palpitations and fatigue. His oxygen saturation is 93%. His blood pressure is
115/65 with a pulse 144. His heart rate is irregularly irregular. He is short of breath with activity. He denies chest discomfo
Which cues are pertinent to developing a hypothesis? Select all that apply.
Blood pressure of 115/65
Pulse of 144
Shortness of breath with activity
Symptoms of palpitations and fatigue
Irregularly irregular heart rate
Oxygen saturation of 93%
Prioritizing Hypotheses – Perfusion
Based on the abnormal findings from Bill’s presentation and assessment, which hypothesis should the nurse select?
Altered fluid volume excess
Altered gas exchange
Altered fluid volume deficit
Altered tissue perfusion
Knowledge deficit
Analyzing Cues – Perfusion
Bill’s electrocardiogram shows atrial fibrillation. His heart rate is rapid and irregularly irregular. Which factors related to his
heart rate and rhythm contribute to altered tissue perfusion? Select all that apply.
Low blood flow in ventricle causing potential clot formation
Decreased cardiac output
Low blood flow in atrium causing potential clot formation
Reduced filling time during the cardiac cycle
Increased filling time during the cardiac cycle
Increased cardiac output
Generating a Plan – Perfusion
The nurse is reviewing provider orders for Bill. Match the rationale with the order.
Nursing Care: Altered Perfusion
Prepare: Nursing Care of Altered Perfusion
Using Clinical Judgement with Perfusion
The nurse notices that the patient’s blood pressure is 100/50. Which part of the clinical judgement model is the nurse
performing?
Analyzing a cue
Prioritizing a hypothesis
Recognizing a cue
Generating a solution
Using Clinical Judgement with Perfusion
The nurse decides to raise the head of the bed before administering oxygen. Which part of the clinical judgement model is
the nurse using?
Analyzing a cue
Recognizing a cue
Generating a solution
Prioritizing a hypothesis
Using Clinical Judgement with Perfusion
The nurse checks the patient’s blood pressure and heart rate after administering the antihypertensive medication. Which o
the following steps of the clinical judgement model is used with this action?
Prioritizing a hypothesis
Analyzing a cue
Evaluating outcomes
Generating a solution
Self-Check: Analysis - Matching the System
Which of the following are cues can suggest reduced perfusion? Select all that apply.
Confusion
Reduced capillary refill
Increased capillary refill
Increased B-type natriuretic peptide
Decreased urine output
Decreased B-type natriuretic peptide
Self-Check: Recognizing Cues - Perfusion
,Self-Check: Generating Hypothesis - Matching Cue to Problem
Review the potential problems listed below. Match the sign or symptom the nurse should expect to find as a possible cue,
and identify the scope of the perfusion defect.
Self-Check: Prioritizing hypotheses - Perfusion
Review the following examples and select the answers to the questions about each hypothesis of altered perfusion.
,Reflect: Perfusion
Recognizing Cues – Perfusion
Select the cues that are an immediate or urgent priority.
Prioritizing Hypotheses – Perfusion
You are caring for Julie who is experiencing shortness of breath. Her oxygen saturation is 87%. In addition, her blood
pressure is 160/90 with a pulse 102. The lower lungs have coarse crackles, and the shortness of breath worsens when lay
flat. She has 3+ pitting edema in the lower extremities. Labs show an elevated B-type natriuretic peptide (BNP) level, a
potassium level of 3.5 (normal 3.5 to 4.5 meq/dl).
Select from the following nursing diagnoses/hypothesis and drag the top three to the correct prioritized order.
Prioritizing Hypotheses – Perfusion
Julie is diagnosed with heart failure. You receive the following orders from the provider, prioritize them in the order that wou
treat the patient most effectively:
1. Oxygen at 12 L per simple facemask
2. Given furosemide 40mg intravenously now
3. Give potassium 20mEq by mouth now
4. Continuous oximetry
5. Monitor vital signs q4hours
Evaluating Outcomes – Perfusion
,Julie has the following Nursing Diagnoses:
Alteration in perfusion as evidenced by elevated B-Type Natriuretic Peptide Levels, blood pressure 160/96, pulse 105
Alteration in gas exchange as evidenced by oxygen saturation below 90%, complaints of shortness of breath, and basilar fi
crackles in bilateral lower lung lobes.
Nursing actions/interventions:
● Furosemide 40mg IV
● Elevated head of bed to 45 degrees
● Administer oxygen at 2 L/min by nasal cannula
The nurse should recognize that which assessment findings show improved perfusion? Select all that apply.
Blood pressure increased
Intake greater than output
Intake less than output
Pulse rate decreased
Pulse rate elevated
Blood pressure decreased
Weight loss
Weight gain
Recognizing Cues – Perfusion
You are caring for Bill who is complaining of palpitations and fatigue. His oxygen saturation is 93%. His blood pressure is
115/65 with a pulse 144. His heart rate is irregularly irregular. He is short of breath with activity. He denies chest discomfo
Which cues are pertinent to developing a hypothesis? Select all that apply.
Blood pressure of 115/65
Pulse of 144
Shortness of breath with activity
Symptoms of palpitations and fatigue
Irregularly irregular heart rate
Oxygen saturation of 93%
Prioritizing Hypotheses – Perfusion
Based on the abnormal findings from Bill’s presentation and assessment, which hypothesis should the nurse select?
Altered fluid volume excess
Altered gas exchange
Altered fluid volume deficit
Altered tissue perfusion
Knowledge deficit
Analyzing Cues – Perfusion
Bill’s electrocardiogram shows atrial fibrillation. His heart rate is rapid and irregularly irregular. Which factors related to his
heart rate and rhythm contribute to altered tissue perfusion? Select all that apply.
Low blood flow in ventricle causing potential clot formation
Decreased cardiac output
Low blood flow in atrium causing potential clot formation
Reduced filling time during the cardiac cycle
Increased filling time during the cardiac cycle
Increased cardiac output
Generating a Plan – Perfusion
The nurse is reviewing provider orders for Bill. Match the rationale with the order.
