NR 324 Week 3 Altered Perfusion

NR 324 Week 3 Altered Perfusion

Student Name

Chamberlain University

NR-324 Adult Health I

Prof. Name:

Date

Altered Perfusion Nursing Care

Introduction to Nursing Care of Altered Perfusion

When caring for a patient exhibiting signs of altered perfusion, such as a blood pressure reading of 100/50 mmHg, nurses engage in the clinical judgment process. This involves identifying cues, analyzing data, formulating hypotheses, implementing interventions, and evaluating outcomes. For example, the low blood pressure value signals the need to assess the patient for symptoms of hypoperfusion. The nurse might decide to elevate the head of the bed and administer oxygen based on prioritized hypotheses and clinical indicators. Understanding which phase of the clinical judgment model is being used allows nurses to deliver precise and timely care.

Clinical Judgment in Perfusion

In the context of altered perfusion, clinical judgment plays a central role. A drop in blood pressure, for instance, prompts the nurse to evaluate the situation by collecting and analyzing cues. If an intervention is initiated, such as administering an antihypertensive medication or repositioning the patient, the nurse must reassess the patient’s response. Monitoring changes in vital signs like heart rate and blood pressure helps determine whether perfusion is improving. This continuous cycle ensures that interventions are adjusted as necessary to support optimal outcomes.

Self-Check: Identifying and Responding to Cues

Nurses must remain vigilant in identifying early signs of compromised perfusion. Symptoms such as mental confusion, decreased urine output, and elevated B-type natriuretic peptide (BNP) levels should prompt further assessment. For example, a patient with shortness of breath, peripheral edema, and elevated BNP may be experiencing heart failure. In such cases, prioritizing interventions—like initiating diuretics or oxygen therapy—can significantly impact recovery. Recognizing cues that require immediate action is critical in averting complications.

Table 1: Key Elements in Nursing Care for Altered Perfusion

Nurses’ Notes and Vital Signs: Hypertension

Prioritizing Hypotheses – Hypertension

In patients with hypertension, nurses must consider several hypotheses to guide care:

• Altered Perfusion: High priority, as unmanaged hypertension may progress to conditions like stroke or heart failure.
• Cognitive and Mood Changes: Cerebral hypoperfusion linked to hypertension can cause confusion or mood shifts.
• Impaired Gas Exchange: Secondary to heart failure caused by sustained hypertension.
• Hormonal Imbalance: Conditions such as hyperaldosteronism may contribute to elevated blood pressure.
• Knowledge Deficit: A lack of understanding regarding hypertension management can impede adherence to treatment plans.

Generating a Plan – Hypertension

A comprehensive care plan for hypertension includes the following:

• Altered Perfusion: Regular monitoring of blood pressure, administration of antihypertensives, and lifestyle interventions.
• Cognitive and Mood Changes: Ongoing cognitive evaluations to identify neurological symptoms.
• Knowledge Deficit: Patient education on lifestyle changes, medication compliance, and potential complications of hypertension.

Action/Evaluation – Hypertension

Outcomes must reflect the effectiveness of nursing interventions. For instance, with altered perfusion, the goal is to stabilize blood pressure. In cases of knowledge deficit, success is measured by the patient’s ability to articulate key concepts regarding self-care, including medication use and lifestyle modifications.

Myocardial Infarction: Prioritizing and Planning Care

Prioritizing Hypotheses – Myocardial Infarction

Immediate prioritization is crucial in managing an acute myocardial infarction (MI). The key hypotheses include:

• Altered Tissue Perfusion: A critical focus due to ischemia caused by blockage in coronary circulation.
• Fluid and Electrolyte Imbalance: Commonly due to vomiting and poor oral intake.
• Impaired Gas Exchange: Occurs when oxygenation is compromised during cardiac events.

Generating a Plan – Myocardial Infarction

Effective interventions in MI management include:

• Administering Nitroglycerin (0.4 mg SL): Alleviates chest pain by enhancing coronary perfusion.
• Aspirin (81 mg PO): Reduces clot formation and limits infarct size.
• Drawing Troponin I Levels: Helps confirm cardiac injury and inform next steps in treatment.

Evaluating Outcomes – Myocardial Infarction

Indicators of successful MI management include:

• Decrease in chest pain intensity
• Return of blood pressure to baseline
• Improved oxygen saturation indicating better perfusion

Heart Failure: Recognizing and Managing Cues

Recognizing Cues – Heart Failure

Right-sided heart failure manifests through several observable signs:

• Peripheral Edema: Indicates fluid retention.
• Jugular Venous Distention (JVD): Reflects elevated central venous pressure.
• Pulmonary Crackles: Suggest fluid accumulation affecting gas exchange.

Nursing Actions – Heart Failure

To monitor chronic heart failure progression, nurses should:

• Conduct daily weight assessments; notify the provider for >3 lbs gain in 48 hours.
• Monitor daily vitals, particularly blood pressure and pulse, for trends suggesting worsening heart function.

Self-Check: Recognizing Cues – Nursing Assessment

Urgent indicators in acute heart failure include:

• Bibasilar Pleural Effusions on X-ray: Suggestive of fluid overload.
• Elevated BNP Levels: Confirm fluid retention and worsening cardiac function.

Table 2: Prioritizing Hypotheses and Nursing Diagnoses

References

American Heart Association. (2023). Heart failure management and guidelines. https://www.heart.org

Giddens, J. F. (2021). Concepts for nursing practice (3rd ed.). Elsevier.

Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care (10th ed.). Elsevier.

National Institute for Health and Care Excellence. (2022). Hypertension in adults: Diagnosis and management. https://www.nice.org.uk/guidance/ng136

NR 324 Week 3 Altered Perfusion

Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier.