NR 324 Week 3 Altered Perfusion

NR 324 Week 3 Altered Perfusion

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Altered Perfusion Nursing Care

Introduction to Nursing Care of Altered Perfusion

When a nurse observes a patient’s blood pressure of 100/50, it triggers the clinical judgment process. The nurse begins by analyzing and recognizing cues, which then leads to prioritizing a hypothesis, generating a solution, and evaluating the outcomes. This cycle is essential in providing effective care for patients with altered perfusion. One critical aspect is understanding which part of the clinical judgment model the nurse is using at various stages of the assessment and treatment process. For instance, the nurse may recognize a cue when identifying the low blood pressure, analyze the data, and prioritize interventions like raising the head of the bed or administering oxygen.

Clinical Judgement in Perfusion

In scenarios of altered perfusion, nurses use clinical judgment to address patient symptoms. For example, when a patient’s blood pressure drops, the nurse might analyze the cue, recognize the urgency, and prioritize interventions like elevating the head of the bed before oxygen administration. Monitoring post-intervention outcomes, such as checking blood pressure and heart rate after antihypertensive medication, is critical to ensuring that perfusion improves. At each step, the nurse must continuously reassess the situation to confirm that interventions are working or to determine if further actions are needed. Evaluating outcomes, such as improved blood pressure and pulse rate, is essential in judging the effectiveness of the interventions.

Self-Check: Identifying and Responding to Cues

Nurses must be adept at recognizing key cues indicative of reduced perfusion. Common signs include confusion, decreased urine output, and elevated B-type natriuretic peptide (BNP) levels. Matching these cues with the correct underlying issues is vital in prioritizing the hypothesis. For instance, if a patient presents with shortness of breath, high blood pressure, and an elevated BNP level, the nurse might hypothesize heart failure and prioritize treatment accordingly. The ability to identify cues that signal an immediate or urgent need for intervention can drastically influence patient outcomes.

Table: Key Elements in Nursing Care for Altered Perfusion

Nurses’ Notes and Vital Signs: Hypertension

Prioritizing Hypotheses – Hypertension

In assessing a patient with hypertension, it is essential to prioritize the potential hypotheses that guide patient care. The following are the key hypotheses based on the clinical information provided:

1. Alteration in Perfusion: This hypothesis is crucial as it pertains to the patient’s cardiovascular system, which is directly affected by hypertension. A failure to address this could lead to significant complications such as heart failure or stroke.

2. Alteration in Cognition and Mood: High blood pressure can contribute to mental status changes, particularly if it leads to cerebral hypoperfusion.

3. Alteration in Gas Exchange: Although not directly linked to hypertension, conditions such as congestive heart failure caused by prolonged high blood pressure could impair gas exchange.

4. Alteration in Hormone Balance: Hypertension can result from an imbalance in certain hormones, like aldosterone or adrenaline.

5. Knowledge Deficit: Patients may not be fully aware of the necessary lifestyle modifications or medical management required to control their hypertension effectively.

Generating a Plan – Hypertension

In creating a nursing care plan for a patient with hypertension, several factors must be taken into account, including the needed level of action, the level of risk, and the priority of each hypothesis or nursing diagnosis.

1. Alteration in Perfusion: Immediate interventions, such as monitoring blood pressure and administering antihypertensive medications, are necessary.

2. Alteration in Cognition and Mood: Patients should be evaluated for any changes in cognition, and appropriate interventions like cognitive assessments should be planned.

3. Knowledge Deficit: The patient should be educated about hypertension, its risks, and strategies for maintaining blood pressure within a normal range through lifestyle changes and medication adherence.

Action/Evaluation – Hypertension

The outcomes that measure nursing diagnoses must match the interventions put in place. For instance, for a nursing diagnosis of “Alteration in Perfusion,” an outcome could be the normalization of blood pressure to within the target range. Similarly, for a “Knowledge Deficit,” an appropriate outcome would be the patient’s ability to verbalize an understanding of their medication regimen and lifestyle changes needed to manage hypertension effectively.

Myocardial Infarction: Prioritizing and Planning Care

Prioritizing Hypotheses – Myocardial Infarction

When managing a patient with an acute myocardial infarction (MI), the nurse must prioritize the most critical hypotheses. It is essential to recognize how long it takes for the heart muscle to become necrotic during an MI, typically within 4-6 hours. Immediate action is required to prevent further damage to the heart muscle.

1. Altered Tissue Perfusion: This is the primary concern for any MI case, as the blood supply to the heart muscle is compromised, leading to ischemia and necrosis.

2. Alteration in Fluid and Electrolyte Balance: Patients experiencing nausea and vomiting may suffer from imbalances that need to be corrected promptly.

3. Altered Gas Exchange: Decreased oxygenation can occur during an MI, necessitating oxygen therapy to improve gas exchange.

Generating a Plan – Myocardial Infarction

The following nursing interventions are anticipated when caring for a patient with unstable angina or an MI:

1. Administering Nitroglycerin 0.4mg Sublingual: This helps alleviate chest pain by dilating coronary vessels.

2. Administering Aspirin 81mg PO: Aspirin prevents further clot formation and is a critical early intervention in managing MI.

3. Drawing Troponin I Lab Test: Troponin levels will confirm myocardial injury and guide further treatment.

Evaluating Outcomes – Myocardial Infarction

When evaluating patient outcomes following interventions for MI, the following indicators suggest improvement:

1. Decreased Chest Discomfort: Reduced pain indicates that ischemia is being relieved.

2. Normalized Blood Pressure: Stabilized blood pressure is a sign of improved cardiovascular function.

3. Improved Oxygen Saturation: Better oxygen levels indicate improved gas exchange and perfusion.

Heart Failure: Recognizing and Managing Cues

Recognizing Cues – Heart Failure

A patient with right-sided heart failure often presents with the following signs and symptoms:

1. Pitting Edema in the lower extremities due to fluid accumulation.
2. Jugular Venous Distention (JVD) as a result of increased pressure in the right atrium.
3. Crackles on Lung Auscultation if fluid retention affects the lungs.

Nursing Actions – Heart Failure

To monitor for exacerbations of chronic heart failure, the following actions should be taken:

1. Daily Weight Monitoring: Notify the healthcare provider if there is a weight gain of more than 3 pounds in 2 days.
2. Daily Blood Pressure and Pulse Checks: Monitor for significant increases, which may indicate worsening heart failure.

Self-Check: Recognizing Cues – Nursing Assessment

For patients admitted with acute heart failure, immediate attention is required if any of the following are present:

1. Chest X-Ray showing Bibasilar Pleural Effusions: Indicative of fluid overload.
2. BNP Levels Elevated: Suggestive of worsening heart failure.

Table: Prioritizing Hypotheses and Nursing Diagnoses

NR 324 Week 3 Altered Perfusion