CIRCULATION FLUIDS AND ELECTROLYTES PERFUSION NRSG 311 WEEK
- Slides: 70
CIRCULATION FLUIDS AND ELECTROLYTES PERFUSION NRSG 311 WEEK 8 FALL 2016
OBJECTIVES Circulation: 1) Summarize the physiological processes of the circulatory system. 2) Identify factors affecting circulation and nursing interventions (to include pulse and Blood Pressure). 3) Identify common lab (Hgb, Hct) and diagnostic tests for circulation. 4) Identify commonly used medications for circulation issues: diuretics 5) Use critical reasoning to correlate patient conditions with therapeutic uses, contraindications, and precautions for the following drug classifications: Autonomic Nervous System Agents (anti-hypertensives- beta blockers, alpha blockers) 6) Apply the nursing process to the care of a client with circulation issues. 7) Know terminology. 8) Know NANDA: Ineffective tissue perfusion, excess fluid volume, Decreased cardiac output
VIDEO: https: //www. youtube. com/watch? v=-s 5 i. Co. Caofc 3
BLOOD FLOW THROUGH THE HEART 4
CARDIAC VALVES 1. Tricuspid valve 2. Mitral valve 3. Pulmonic valve 4. Aortic valve 5
PERFUSION: • Definition: Perfusion refers to the flow of blood through arteries and capillaries, delivering nutrients and oxygen to cells and removing cellular waste products.
SCOPE OF CONCEPT
CARDIAC OUTPUT Amount of blood pumped from left ventricle per minute Heart rate × Stroke volume 8
CATEGORIES OF PERFUSION CENTRAL PERFUSION TISSUE OR LOCAL PERFUSION • Force of blood • Volume of blood that movement generated by flows to target tissue cardiac output • Requires patent • Requires adequate vessels, adequate cardiac function, blood hydrostatic pressure, and blood pressure, and volume capillary • Cardiac output (CO) = permeability Stroke volume X Heart rate
BLOOD PRESSURE REGULATION Autonomic nervous system: • Baroreceptors • Chemoreceptors – Hypercapnia Renal system Endocrine system External factors also affect BP 10
POINT TO REMEMBER… Best indicator of fluid balance is weight 2. 2 lb = 1 kg = 1 L of fluid 11
CARDIOVASCULAR SYSTEM ASSESSMENT Patient history Nutritional history Family history and genetic risk Current health problems • Pain, discomfort • Dyspnea, DOE, orthopnea, PND • Fatigue • Palpitations • Edema • Syncope • Extremity pain 12
CARDIOVASCULAR SYSTEM PHYSICAL ASSESSMENT General appearance Skin • Cyanosis, rubor Extremities • Clubbing, edema Blood pressure • Hypotension and hypertension • Postural (orthostatic) hypotension 13
PRECORDIUM Assessment • Inspection • Palpation • Percussion • Auscultation • • Normal heart sounds Paradoxical splitting Gallops and murmurs Pericardial friction rub 14
SERUM MARKERS OF MYOCARDIAL DAMAGE Troponin: Troponin T and troponin I Creatine kinase (CK) Myoglobin Serum lipids • Total cholesterol < 200 mg/d. L • Triglyceride < 150 mg/d. L • HDL > 40 mg/d. L • LDL < 70 mg/d. L for cardiovascular patients Homocysteine Highly sensitive C-reactive protein 15
LABORATORY ASSESSMENT Microalbuminuria Blood coagulation studies • PT/INT • PTT ABG F&E Erythrocyte count H&H Leukocyte count 16
DIAGNOSTIC ASSESSMENT PA and lateral CXR Angiography Arteriography Cardiac catheterization 17
CARDIAC CATHETERIZATION 18
OTHER DIAGNOSTIC ASSESSMENT ECG Electrophysiologic study (EPS) Stress test Echocardiography • Pharmacologic stress echocardiogram • TEE Myocardial nuclear perfusion imaging (MNPI) 19
ANY THOUGHTS?
QUESTION 3 The nurse understands that which assessment finding is the best indicator of fluid retention? A. B. C. D. Tachycardia Weight gain Crackles in the lungs Increased blood pressure 21
GUIDELINES FOR MEASURING VITAL SIGNS Measuring is your responsibility Equipment use; ensure it is working properly Know patient’s usual range and medical Hx Control environmental factors Use systematic approach Collaborate to decide frequency Used for administering medications Analyze results, identify significant findings Instruct patient in vital sign assessment 22 Copyright © 2017, Elsevier Inc. All Rights Reserved.
BODY TEMPERATURE: PHYSIOLOGY • Heat produced - heat lost = body temperature Copyright © 2017, Elsevier Inc. All Rights Reserved. Temperature sites: • Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery 23 Body temperature:
BODY TEMPERATURE REGULATION Neural and vascular control Heat loss (radiation, conduction, convection, evaporation) Heat production Skin temperature regulation Behavioral control Copyright © 2017, Elsevier Inc. All Rights Reserved. 24
FACTORS AFFECTING BODY TEMPERATURE Age Exercise Hormone level Circadian rhythm Stress Environment Copyright © 2017, Elsevier Inc. All Rights Reserved. 25 Temperature alterations
TEMPERATURE ALTERATIONS Fever (pyrexia) • Heat-loss mechanisms are unable to keep pace with excessive heat production • Febrile • Afebrile 26 Copyright © 2017, Elsevier Inc. All Rights Reserved.
HYPOTHALAMIC TEMPERATURE CONTROL 27 Copyright © 2017, Elsevier Inc. All Rights Reserved.
TEMPERATURE ALTERATIONS (CONT. ) Hyperthermia Heatstroke Heat exhaustion Hypothermia 28 Copyright © 2017, Elsevier Inc. All Rights Reserved.
NURSING PROCESS Assessment Copyright © 2017, Elsevier Inc. All Rights Reserved. 29 • Through the patient’s eyes • Sites • Thermometers • Fahrenheit or Celsius scale
NURSING PROCESS (CONT. ) Nursing diagnosis • Cluster defining characteristics to form a nursing diagnosis Examples of nursing diagnoses for patients with body temperature alterations • • Risk for Imbalanced Body Temperature Hyperthermia Hypothermia Ineffective Thermoregulation 30 Copyright © 2017, Elsevier Inc. All Rights Reserved.
NURSING PROCESS (CONT. ) Planning • Goals and outcomes • Setting priorities • Teamwork and collaboration Implementation • Health promotion 31 Copyright © 2017, Elsevier Inc. All Rights Reserved.
PULSE … AND MORE https: //www. youtube. com/watch? v=JIHl. Fn. Tqu. Oo
PULSE Pulse • Palpable bounding of blood flow noted at various points on the body • The indicator of circulatory status Pulse rate • Number of pulsing sensations in 1 minute Electrical impulses originate from the sinoatrial (SA) node Regulation of ventricular contraction and stroke volume 33 Copyright © 2017, Elsevier Inc. All Rights Reserved.
ASSESSMENT OF PULSE (CONT. ) Character of the Pulse Copyright © 2017, Elsevier Inc. All Rights Reserved. 35 • Rate • Rhythm • Strength • Quality
PULSE DEFICIT
NURSING PROCESS AND PULSE DETERMINATION Activity intolerance Anxiety Acute Pain Decreased cardiac output Deficient/excess fluid volume Impaired gas exchange Ineffective peripheral tissue perfusion 37 Copyright © 2017, Elsevier Inc. All Rights Reserved.
QUICK QUIZ! 2. You notice that a teenager has an irregular pulse. The best action you should take includes: A. reading the history and physical. B. assessing the apical pulse rate for 1 full minute. C. auscultating for strength and depth of pulse. D. asking whether the patient feels any palpitations or faintness of breath. 38 Copyright © 2017, Elsevier Inc. All Rights Reserved.
RESPIRATIONS Reviewed last week Easy to assess • Respiratory rate: breaths/minute • Ventilatory depth: deep, normal, shallow • Ventilatory rhythm: regular/irregular
ASSESSMENT OF DIFFUSION AND PERFUSION Measure oxygen saturation of the blood Copyright © 2017, Elsevier Inc. All Rights Reserved. 40 Measurement of arterial oxygen saturation
BLOOD PRESSURE Force exerted on the walls of an artery by pulsing blood under pressure from the heart • Systolic = Maximum peak pressure during ventricular contraction • Diastolic = Minimal pressure during ventricular relaxation Pulse pressure = Difference between systolic and diastolic pressures 41 Copyright © 2017, Elsevier Inc. All Rights Reserved.
PHYSIOLOGY OF ARTERIAL BLOOD PRESSURE Factors Affecting Arterial Blood Pressure Cardiac output Peripheral resistance Blood volume Viscosity Elasticity 42 Copyright © 2017, Elsevier Inc. All Rights Reserved.
FACTORS INFLUENCING BLOOD PRESSURE Age Stress Ethnicity Gender 43 Copyright © 2017, Elsevier Inc. All Rights Reserved.
FACTORS INFLUENCING BLOOD PRESSURE (CONT. ) Daily variation Medications Activity, weight Smoking 44 Copyright © 2017, Elsevier Inc. All Rights Reserved.
HYPERTENSION More common than hypotension Thickening of walls Loss of elasticity Family history Risk factors 45 Copyright © 2017, Elsevier Inc. All Rights Reserved.
HYPOTENSION Systolic <90 mm Hg Dilation of arteries Loss of blood volume Decrease of blood flow to vital organs Orthostatic/postural 46 Copyright © 2017, Elsevier Inc. All Rights Reserved.
NURSING PROCESS AND BLOOD PRESSURE DETERMINATION Hypotension, hypertension, orthostatic hypotension, and narrow or wide pulse pressures are defining characteristics of certain nursing diagnoses, including the following: • • Activity Intolerance Anxiety Decreased Cardiac Output Deficient/Excess Fluid Volume Risk for Injury Acute Pain Ineffective Peripheral Tissue Perfusion 47 Copyright © 2017, Elsevier Inc. All Rights Reserved.
QUICK QUIZ! 4. When assessing the blood pressure of a school-age child, using an adult cuff of normal size will affect the reading and produce a value that is: A. accurate. B. indistinct. C. falsely low. D. falsely high. 48 Copyright © 2017, Elsevier Inc. All Rights Reserved.
HEALTH PROMOTION AND VITAL SIGNS Monitor vital signs. Include age-related factors. Include environmental and activity factors. 49 Copyright © 2017, Elsevier Inc. All Rights Reserved.
SAFETY GUIDELINES FOR NURSING SKILLS Cleaning devices between patients decreases the risk for infection. Rotating sites during repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown. Analyze trends for vital signs, and report abnormal findings. Determine the appropriate frequency of measuring vital signs based on the patient’s condition. 50 Copyright © 2017, Elsevier Inc. All Rights Reserved.
FLUID AND ELECTROLYTE OBJECTIVES: 1. HOW TO DEFINE AND DESCRIBE THE CONCEPTS OF FLUID AND ELECTROLYTE BALANCE. 2. THE RISK FACTORS FOR IMPAIRED FLUID AND ELECTROLYTE BALANCE. 3. HOW TO RECOGNIZE THE CAUSES OF FLUID AND ELECTROLYTE IMBALANCE. 4. THE APPROPRIATE NURSING AND COLLABORATIVE INTERVENTIONS TO PROMOTE FLUID AND ELECTROLYTE BALANCE. 6. THE COMPLICATIONS OF FLUID VOLUME DEFICIT.
FLUID BALANCE 52 Copyright © 2017, Elsevier Inc. All Rights Reserved.
FLUID BALANCE (CONT. ) Fluid balance consists of • Fluid intake • Fluid distribution • Fluid output Copyright © 2017, Elsevier Inc. All Rights Reserved. 53 • Antidiuretic hormone • Renin-angiotensinaldosterone system • Atrial natriuretic peptide
FLUID BALANCE (CONT. ) Thirst Copyright © 2017, Elsevier Inc. All Rights Reserved. 54 • An important regulator of fluid intake when plasma osmolality increases • Thirst-control mechanism is located within the hypothalamus in the brain
FLUID BALANCE (CONT. ) Fluid output • Normally via skin, lungs, GI tract, kidneys • Influenced by Copyright © 2017, Elsevier Inc. All Rights Reserved. 55 • Antidiuretic hormone (ADH) • Renin-angiotensinaldosterone system (RAAS) • Atrial natriuretic peptides (ANPs)
FLUID BALANCE (CONT. ) Fluid intake Thirst regulates fluid intake ~2300 m. L/day Fluid distribution Extracellular and intracellular Vascular and interstitial Hormonal Influences Antidiuretic hormone Renin-angiotensin-aldosterone mechanism Atrial natriuretic peptides Fluid output Through kidneys, skin, lungs, and GI tract Insensible loss Sensible loss Copyright © 2017, Elsevier Inc. All Rights Reserved. 56
QUICK QUIZ! 1. A patient is diaphoretic and has an oral temperature of 104° F. These are classic signs of: A. ADH deficit. B. extracellular fluid loss. C. insensible water loss. D. sensible water loss. 57 Copyright © 2017, Elsevier Inc. All Rights Reserved.
FLUID IMBALANCES ECF imbalances • Volume • Osmolality imbalances • Hypernatremia, “water deficit”; hypertonic • Hyponatremia, “water excess”; hypotonic Clinical dehydration Copyright © 2017, Elsevier Inc. All Rights Reserved. 58 • ECV deficit and hypernatremia combined
ELECTROLYTE BALANCE Intake and absorption Distribution • Plasma concentrations of K+, Ca 2+, Mg+, and phosphate (Pi) are very low compared with their concentrations in cells and bone. • Concentration differences are necessary for normal muscle and nerve function. Output • Urine, feces, and sweat • Vomiting, drainage, and fistulas 59 Copyright © 2017, Elsevier Inc. All Rights Reserved.
ELECTROLYTE IMBALANCES Potassium (K+) • Hypokalemia • Hyperkalemia Calcium (Ca 2+) • Hypocalcemia • Hypercalcemia Magnesium (Mg 2+) • Hypomagnesemia • Hypermagnesemia 60 Copyright © 2017, Elsevier Inc. All Rights Reserved.
QUICK QUIZ! 2. The body’s fluid and electrolyte balance is maintained partially by hormonal regulation. Which of the following statements shows an understanding of this mechanism? A. “The pituitary secretes aldosterone. ” B. “The kidneys secrete antidiuretic hormone. ” C. “The adrenal cortex secretes antidiuretic hormone. ” D. “The pituitary gland secretes antidiuretic hormone. ” 61 Copyright © 2017, Elsevier Inc. All Rights Reserved.
NURSING PROCESS: ASSESSMENT Through the patient’s eyes Nursing history • Age: very young and old at risk • Environment: excessively hot? • Dietary intake: fluids, salt, foods rich in potassium, calcium, and magnesium • Lifestyle: alcohol intake history • Medications: include over-the-counter (OTC) and herbal, in addition to prescription medications 62 Copyright © 2017, Elsevier Inc. All Rights Reserved.
NURSING PROCESS: ASSESSMENT (CONT. ) Medical history • Recent surgery (physiological stress) • Gastrointestinal output • Acute illness or trauma • Respiratory disorders • Burns • Trauma • Chronic illness • Cancer • Heart failure • Oliguric renal disease 63 Copyright © 2017, Elsevier Inc. All Rights Reserved.
PHYSICAL ASSESSMENT Daily weights • Indicator of fluid status • Use same conditions Fluid intake and output (I&O) • 24 -hour I&O: compare intake versus output • Intake includes all liquids eaten, drunk, or received through IV • Output = Urine, diarrhea, vomitus, gastric suction, wound drainage Laboratory studies 64 Copyright © 2017, Elsevier Inc. All Rights Reserved.
NURSING DIAGNOSIS • Decreased cardiac output • Acute confusion • Excess fluid volume • Risk for injury 65 Copyright © 2017, Elsevier Inc. All Rights Reserved. • Risk for electrolyte imbalance • Impaired gas exchange • Deficient knowledge regarding disease management • Deficient fluid volume
PLANNING Goals and outcomes • Establish an individual patient plan of care for each nursing diagnosis Setting priorities • The patient’s clinical condition determines which of the nursing diagnoses takes the greatest priority Teamwork and collaboration 66 Copyright © 2017, Elsevier Inc. All Rights Reserved.
IMPLEMENTATION Health promotion • Fluid replacement education • Teach patients with chronic conditions about risk factors and signs and symptoms of imbalances. 67 Copyright © 2017, Elsevier Inc. All Rights Reserved.
INTERVENTIONS Interventions for electrolyte imbalances • Support prescribed medical therapies • Provide for patient safety 68 Copyright © 2017, Elsevier Inc. All Rights Reserved.
IMPLEMENTATION Restorative care • Home intravenous therapy • Nutrition support • Medication safety • Medications • OTC drugs • Herbal preparations 69 Copyright © 2017, Elsevier Inc. All Rights Reserved.
EVALUATION Through the patient’s eyes • Review with patients how well their major concerns regarding fluid and electrolyte were alleviated or addressed. Patient outcomes • Evaluate the effectiveness of interventions using the goals and outcomes established for the patient’s nursing diagnoses. 70 Copyright © 2017, Elsevier Inc. All Rights Reserved.
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