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?

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?

Using Clinical Judgement with Perfusion

• The nurse checks the patient’s blood pressure and heart rate after administering the antihypertensive medication. Which of the following steps of the clinical judgement model is used with this action?

Self-Check: Analysis - Matching the System

• Which of the following are cues can suggest reduced perfusion? Select all that apply.

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 laying 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 would treat the patient most effectively:

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 fine crackles in bilateral lower lung lobes.

Nursing actions/interventions:

• The nurse should recognize that which assessment findings show improved perfusion? Select all that apply.

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 discomfort. Which cues are pertinent to developing a hypothesis? Select all that apply.

Prioritizing Hypotheses – Perfusion

• Based on the abnormal findings from Bill’s presentation and assessment, which hypothesis should the nurse select?

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.

Generating a Plan – Perfusion

• The nurse is reviewing provider orders for Bill. Match the rationale with the order.

Basic ECG Interpretation

Prepare: Basic ECG Interpretation

P Waves

• What does the P wave on a rhythm strip represent?

T Waves

• What does the T wave represent on an electrocardiogram or rhythm strip?

QT Interval

• A client with a prolonged QT interval is at risk for which abnormal cardiac rhythm?

Self-Check: Analyzing Cues – Electrical Flow Through the Heart

• Put the following anatomic landmarks in the order in which the electricity normally flows through them:

Self-Check: Recognizing Cues – The Cardiac Cycle

• Identify the correct intervals for this cardiac cycle from the choices given.

Self-Check: Recognizing Cues – ECG Terms

• Select the correct term and drag it next to the definition that best matches.

Self-Check: Recognize Cues – Heart Rhythm Interpretation

• Match the following rhythms with the correct interpretation.

Self-Check: Analyze Cues – Altered Mobility

ST Elevation

• What does ST elevation in 3 or more leads on a 12-lead electrocardiogram (ECG) suggest?

Reflect: Basic ECG Interpretation

Recognizing Cues – Rhythm Strips

• A client in the triage area is having chest discomfort. The unlicensed assistive personnel (UAP) brings a rhythm strip to the nurse to look at. The nurse notices the heart rate is 90 beats per minute, there is a P wave for every QRS, and the PR interval is 0.12ms. What is your analysis of the rhythm strip?

Recognizing Cues – 12 Lead Electrocardiogram

• The client with chest discomfort is brought back to a room for a 12-lead electrocardiogram (ECG). What is the primary reason for using this type of ECG?

Prioritizing Actions- Ventricular Arrhythmias

• While walking to the nurse’s station the nurse sees this rhythm on the telemetry monitor. Place the actions in the order the nurse should complete them, starting with the first.

Analyzing Cues – Rhythm Strips

• The client was defibrillated with a return to normal sinus rhythm on the electrocardiogram (ECG) monitor. After about 1 hour, the alarm on the monitor started chiming. The nurse looking at the monitor noted that the rhythm had no P waves, a narrow QRS, and an irregular heart rate around 90 beats per minute. Which of the following rhythms is most likely?

Analyzing Cues – Atrial Arrhythmias

• When assessing a client admitted with atrial fibrillation for which cues will the nurse assess? Select all that apply.

Prioritizing Care

• Based on the laboratory results, for which electrocardiogram abnormality is this patient most at risk?

Analyzing Cues – Heart Rhythm Measurements

• Complete the following table of information based on your learning by dragging the interval and measurement that matches the muscle action and wave.

Analyzing Cues

• Review the rhythm strip below and match it with the descriptions given.

Electrical Properties

Prepare: Electrical Properties

Electrical Charges

• What pushes an electron charge through an electrical circuit?

Flow of Electricity

• What chemicals regulate the flow of electricity in the human body?

Defibrillators

• What is the primary function of a defibrillator?

Self-Check: Electrical Charge Resistance

• What is the driving force that moves electrical charges through a resistance?

Self-Check: Ohm’s Law

• If the current in the bloodstream is 0.0001 Amps and the heart creates about 0.06 V of voltage, then how much resistance does the bloodstream cause to the flow of electricity?

Self-Check: Electricity in the Body

• A person is not generally worried about using a 5 Amp electric grill, even though 1 Amp of current across the heart is enough to stop it from beating. Why is that?

Self-Check: Electrolytes

• Electrolytes are:

Self-Check: Electrical Current

• It is safe to use electricity to send a current through muscle or brain tissue.

Reflect: Electrical Properties

Electrical Flow

• What is the property of a material which delays electrical flow?

Charge in the Body

• Molecules which carry charge throughout the body are called:

Defibrillators

• A defibrillator is a device which:

Electrical Current

• Electrical current through muscles can cause them to:

Defibrillator Current

• A defibrillator generates a voltage of about 500 V. If the resistance of skin is about 1 million ohms, how much current does the defibrillator generate in the body?

Electrical Properties of Skin

• Name one electrical property of human skin.

Electrical Current

• Electrical current is:

Electroencephalograms

• What does an electroencephalogram (EEG) measure?

Hypertension

Prepare: Hypertension

Prioritizing Hypothesis – Hypertension

• In seeing a client with hypertension, which of the following indicates the urgent need for treatment?

Generating a Plan – Hypertension

• Which of the following actions will the nurse plan when treating a client with acute hypertension? Select all that apply.

Evaluating Outcomes – Hypertension

• After the nurse acts to treat acute hypertension, which of the following outcomes should the nurse use to determine the need for additional action?

Self-Check: Assessing Blood Pressure

• Review the picture below and identify any cues that may concern you about the accuracy of the blood pressure this unlicensed assistive person (UAP) is collecting:

Self-Check: Analyzing Cute – Hypertension

• A client is being treated in the emergency department for a blood pressure of 167/94. In reviewing their history, select the cues associated with chronic hypertension, and the ones associated with an acute elevation in blood pressure

Self-Check: Prioritizing the Hypothesis

• Review the following examples and select the answers to the questions about each hypothesis of Altered Perfusion.

Self-Check: Generating a Solution – Chronic Hypertension

• The nurse is seeing a client with chronic uncontrolled hypertension. What are some actions the nurse can take to improve control of their condition? Select all that apply.

Self-Check: Prioritizing Actions – Hypertension

• The nurse was notified by unlicensed assistive personnel that the client has a blood pressure of 153/65. The client has no history of hypertension, and previous blood pressure measurement was 116/54. The nurse notes recently overhearing a verbal argument between the client and a family member. Which of the following actions should the nurse consider taking next?

Reflect: Hypertension

Recognize and Analyze Cues – Hypertension

CHECK BOTH NURSES' NOTES & VITAL SIGNS

• The nurse just started a shift. Review the available documentation and select significant cues needed to formulate a hypothesis and generate a plan. Be sure to review all tabs of the client’s health record. Select all significant cues on all tabs that apply.

Prioritizing Hypothesis – Hypertension

• Which are the priority hypotheses based on the given information? Select all that apply.

Generating a Plan – Hypertension

• Considering the needed level of action, the level of risk, and the level of priority, select each for the hypotheses/nursing diagnoses below:

Action/Evaluation – Hypertension

• Match the outcome to measure the nursing diagnosis.

Recognize and Analyze Cues – Hypertension

CHECK BOTH NURSES' NOTES & VITAL SIGNS

• The nurse just started a shift. Review the available documentation and select significant cues needed to formulate a hypothesis and generate a plan. Select all significant cues on all tabs that apply.

Prioritizing Hypothesis – Hypertension

• Which are the following priority hypotheses based on the information below? Select all that apply.

Generating a Plan – Hypertension

• Considering the needed level of action, the level of risk, and the level of priority, select each for the hypotheses/nursing diagnoses below.

Action/Evaluation – Hypertension

• Match the outcome to measure the nursing diagnosis.

Myocardial Infarction

Prepare: Myocardial Infection

Prioritizing Hypothesis – Myocardial Infarction

• When a patient has an acute myocardial infarction, how much time does it take for the entire thickness of the heart muscle to become necrotic?

Generating a Plan – Myocardial Infarction

• Which prescribed actions will the nurse anticipate when treating a client with unstable angina? Select all that apply.

Evaluating Outcomes - Myocardial Infarction

• When a client is experiencing alteration in perfusion due to stable angina, which outcome measurement would suggest improvement after nursing actions?

Self-Check: Recognizing Cues – Nursing Assessment

Review the information below and identify cues you feel pertinent to the client’s care needs. Deborah is 68-years-old and visited the emergency department experiencing substernal chest discomfort with pain radiating to the jaw. She is diaphoretic. She is nauseous and vomiting.

• Past Medical History
• Medication
• Family History
• Social History
• Pain Scale

Self-Check: Analyzing Cute – Angina

• Review the assessments below and indicate the most likely type of discomfort:

Self-Check: Prioritizing the Hypothesis

• Review the following examples and select the level of action, risk, and priority with each client of altered perfusion due to partial or complete coronary artery occlusion.

Self-Check: Generating a Solution – Myocardial Infarction

• A client is experiencing an acute myocardial infarction. Which of the following nursing actions do you anticipate would be ordered? Select all that apply.

Self-Check: Prioritizing Actions – Myocardial Infarction

• Your client is a 72-year-old male who was admitted with an ST elevation myocardial infarction (STEMI). Nitroglycerin was started intravenously (IV). The client was given one dose of Metoprolol 100mg IV along with Aspirin 81mg daily. Troponin I was positive, and electrocardiogram shows ST elevation in lead II, III, and AVF suggesting an inferior wall myocardial infarction. The nurse reviewing the orders notes the following. Which action is priority?

Reflect: Myocardial Infection

Analyzing Cues – Myocardial Infarction

• Review the examples below and indicate if the altered perfusion is partial (stable angina), complete (unstable angina), or not related to altered perfusion at all (non-cardiac pain) based on the cues.

Recognizing Cues – Myocardial Infarction

• In the note below, which four findings would require follow-up?

Analyzing Cues – Myocardial Infarction

• Review the client findings below. For each finding, indicate if you expect this finding with each of the listed disease processes (more than one answer may apply):

Prioritizing Hypothesis – Myocardial Infarction

• Which of the following is the priority nursing diagnosis based on the information?

Prioritizing Hypothesis – Myocardial Infarction

• After determining Audrey is experiencing a myocardial infarction, the following orders are received from the health care provider.
• What are the top four actions to take immediately from the following orders?

Prioritizing Hypothesis – Myocardial Infarction

• The nurse is reviewing her chart. Select the items that need further follow-up:

Prioritizing Hypothesis – Myocardial Infarction

• Complete the following with the most accurate information:

Prioritizing Hypothesis – Myocardial Infarction

• As part of discharge planning, which of the following diagnoses/hypotheses are the most accurate. Select all that apply.

Heart Failure

Prepare: Heart Failure

Recognizing Cues – Heart Failure

• The nurse is caring for someone with right-sided heart failure. Which of the following symptoms can they expect to find? Select all that apply.

Nursing Actions – Heart Failure

• In preparing for discharge teaching, which of the following actions can the client take to most accurately monitor for an exacerbation of chronic heart failure?

Nursing Actions – Heart Failure

• When a client is admitted for symptomatic heart failure, what is the priority medication the nurse can anticipate administering?

Self-Check: Recognizing Cues – Heart Failure

• The home health nurse is visiting the following clients. Review the assessments below and indicate the most likely type of heart failure:

Self-Check: Recognizing Cues – Nursing Assessment

• The nurse reviews the chart of a client admitted with acute heart failure. Which of the following indicates acute heart failure?

Self-Check: Generating a Solution – Heart Failure

• A client is experiencing acute left sided heart failure. Which of the following prescribed actions would the nurse expect? (Select all that apply.)

Self-Check: Prioritizing the Actions – Heart Failure

• The nurse is reviewing admission orders for a new client admitted with acute heart failure. Which of the following items or conditions would require immediate action? Select all that apply.

Self-Check: Nursing Actions – Heart Failure

• Your client is a 72-year-old male discharged from the hospital after experiencing an acute exacerbation of heart failure. In reviewing the discharge plan, which of the following actions will directly reduce rehospitalization for exacerbation of heart failure? Select all that apply.

Reflect: Heart Failure

Recognize Cues – Heart Failure

• Which of the following need to be addressed urgently?

Analyzing Cues – Heart Failure

• The utilization review nurse is auditing charts of several clients currently on the medical/surgical unit. She is looking for similarities and differences between the charts. Review the following assessment findings. Select which findings as consistent with the admission diagnoses.

Nursing Intervention – Heart Failure

• The nurse is completing a care plan on this client. Match the nursing diagnoses with the most appropriate actions and assessment findings.

Analyzing Cues – Heart failure

• Which of the following assessment findings would most accurately indicate an improved outcome for this client’s heart failure?

Analyzing Cues – Heart Failure

• Deborah is at the office for follow-up of her right sided heart failure. She is frustrated with the amount of medication she takes. In reviewing her medication, the nurse explains which medications she is taking for heart failure. Select the medications she is taking for heart failure below:

Deborah Follow-Up

• Deborah is at the office for follow-up of her right sided heart failure. Review the visit information below and identify any items that require further follow-up concerning her heart failure.

Generating Hypothesis – Heart Failure

• You are seeing Deborah in the office 2 days after being seen by the provider for follow-up of her right heart failure.
• You are reviewing today’s chart information. Which of the following items is pertinent to your follow-up evaluation or her right heart failure?

Evaluating Outcomes – Chronic Heart Failure

• Deborah is accompanied by her husband for today’s visit. While discussing prevention of heart failure symptoms and promotion of wellness, he makes the following statements. Which one of these statements indicates more teaching is needed?

DVT

Prepare: Deep Vein Thrombosis

Recognizing Cues - Deep Vein Thrombosis (DVT)

• Which options are risk factors for developing a deep vein thrombosis (DVT)? Select all that apply.

Assessment Findings – Deep Vein Thrombosis (DVT)

• Which of the following assessment findings are expected in a client with a deep vein thrombosis? Select all that apply.

Measuring Outcomes - Deep Vein Thrombosis (DVT)

• What is a possible complication of a deep vein thrombosis?

Self-Check: Recognizing Cues – Thrombus

• Review the two altered perfusion problems. Drag the expected symptoms and history findings that match each one.

Self-Check: Generating a Plan – DVT

• Review the following nursing diagnoses. Drag and drop the actions you would select for each one to complete your care plan.

Self-Check: Generating a Plan – DVT

• Review the medications below. Each is used in the treatment of deep vein thrombosis. They are often selected for different reasons. See if you can match the route, frequency, and considerations with the correct medication.

Self-Check: Prioritizing Nursing Actions – DVT

• Review the following assessment items or prescribed orders and determine whether they require immediate action, urgent action, or routine action.

Self-Check: Evaluation of Outcomes – DVT

• In evaluating the outcomes of the nurse's interventions in caring for a patient with a DVT, which of the following assessment items would indicate the interventions were effective? (Select all that apply.

Reflect: DVT

Recognize Cues – Deep Vein Thrombosis (DVT)

• Which of the following need to be addressed urgently?

Recognizing Cues - Deep Vein Thrombosis (DVT)

• The utilization review nurse is auditing charts of several patients currently on the medical/surgical unit. She is looking for similarities and differences between the charts. Review the following assessment findings. Select which findings are consistent with the admission diagnoses.

Analyzing Cues - Deep Vein Thrombosis (DVT)

• Ilse will be started on enoxaparin 60mg subcutaneous every 12 hours. She will also be started on dabigatran 150mg PO twice daily. In preparing to administer and offer client teaching for these two medications, what does the nurse need to consider?

Recognizing Cues - Deep Vein Thrombosis (DVT)

Ilse is in the office today for follow-up. The nurse is developing a teaching plan for her. Review her chart information and identify areas that will need immediate and follow up teaching.

Recognizing Cues - Deep Vein Thrombosis (DVT)

• Jorge was admitted for a right total knee replacement. He came back from surgery a couple of hours ago. There is an order for a sequential compression device to the non-surgical leg, but he is refusing this. In reviewing his chart below, identify the items that put him at higher risk for a deep vein thrombosis.

Analyzing Cues and Intervening - Deep Vein Thrombosis (DVT)

• After reviewing the nursing progress note, select any urgent findings in the note and select the priority nursing action from the choices below.

Prioritize Actions - Deep Vein Thrombosis (DVT)