NUR 212: Concepts of Nursing Care of the Adult I
Pre-Class Assignment Week 10
Concept: Perfusion
Task
Clustering related information
Explain the pathophysiology and the effects of the pathophysiology of this week's
exemplar, severe heart failure, in terms of the scope of perfusion:
Central Perfusion:
generated by cardiac output and amount of force that the blood is pumped throughout
the body and to peripheral vessels. occurs when the heart is stimulated by electrical
impulses. Typically starts with the SA node, goes to the AV node, to the bundle of
his,then Purkinje fibers in the myocardium which allows the ventricles to contract. This
starts blood flow through the heart and allows certain values to open and close when
needed and ventricles and atrium to contract and
relax__________________________________________________________________
Local/tissue Perfusion:
is the volume of blood that flows through target tissues, from arteries to the capillaries
Task
Identifying signs and symptoms
Gathering complete and accurate data
Relate the assessment information presented in Giddens to the pathophysiology of
heart failure and pericarditis.
What signs and symptoms will you monitor?
Updated 12/17/19 Page 1 of 21
, NUR 212: Concepts of Nursing Care of the Adult I
Pre-Class Assignment Week 10
Manifestations of the Disease Assessment Data to Monitor
Lab- BNP
chest x-ray; echocardiogram
VS, HR, JVD, daily wt for wt gain
Severe heart failure Lung assessment, cough, SOB, shallow
respiration
Edema- pedial and scrotum
I/O (enlarged liver)
fatigue and weakness
chest pain, friction rub, pulsus paradoxus
ECG- monitor for ST changes, echo, CT
Labs- troponin, CRP, ESR, WBC
Pericarditis distended neck veins
VS
Task
Identifying signs and symptoms
Predicting and managing potential complications
Considering the effects of the two exemplars related to perfusion, list the assessment
data and the range of values that would be acceptable related to the assessment data
and at what point the values are not acceptable and the nurse would be concerned.
When a concern arises, what action should the nurse take?
Assessment data Action to take in
Disease ranges that would Values that are not the case of
Updated 12/17/19 Page 2 of 21
, NUR 212: Concepts of Nursing Care of the Adult I
Pre-Class Assignment Week 10
be acceptable acceptable unacceptable
assessment data
Heart Failure
SOB with exerting elevated BNP >100 monitor labs,
self or lying down, pg/ml, elevated decrease salt in
swelling, reduced troponins, elevated diet, limiting fluids,
ability to exercise, BP <130/80, extra diuretics,
weight gain of <3lb elevated BUN/ elevate extremities
creatinine,10-20 or apply ace wraps,
mg/dl weight gain may need US of the
of >3lb heart to monitor
chest pain,abnormal symptoms, obtain
reading on EKG, cxray to look for
increased SOB, fluid build up, obtain
increased daily weights
weakness/fatigue
extreme swelling to
legs/ankles and
feet, irregular
heartbeat,
persistent
cough/wheezing
Pericarditis
SOB, coughing, abnormal CBC- anti-inflammatory
fatigue, chest pain, elevated WBC medications,
heart palpitations >11,000, , elevated antiviral
ESR- men > 3 medications, chest
women >7, x ray, US of heart/
cardiac enzyme echo of heart, EKG
levels, BUN, CRP monitoring anti-
sharp/piercing viral medications,
chest pain over
the center or left
Updated 12/17/19 Page 3 of 21
Pre-Class Assignment Week 10
Concept: Perfusion
Task
Clustering related information
Explain the pathophysiology and the effects of the pathophysiology of this week's
exemplar, severe heart failure, in terms of the scope of perfusion:
Central Perfusion:
generated by cardiac output and amount of force that the blood is pumped throughout
the body and to peripheral vessels. occurs when the heart is stimulated by electrical
impulses. Typically starts with the SA node, goes to the AV node, to the bundle of
his,then Purkinje fibers in the myocardium which allows the ventricles to contract. This
starts blood flow through the heart and allows certain values to open and close when
needed and ventricles and atrium to contract and
relax__________________________________________________________________
Local/tissue Perfusion:
is the volume of blood that flows through target tissues, from arteries to the capillaries
Task
Identifying signs and symptoms
Gathering complete and accurate data
Relate the assessment information presented in Giddens to the pathophysiology of
heart failure and pericarditis.
What signs and symptoms will you monitor?
Updated 12/17/19 Page 1 of 21
, NUR 212: Concepts of Nursing Care of the Adult I
Pre-Class Assignment Week 10
Manifestations of the Disease Assessment Data to Monitor
Lab- BNP
chest x-ray; echocardiogram
VS, HR, JVD, daily wt for wt gain
Severe heart failure Lung assessment, cough, SOB, shallow
respiration
Edema- pedial and scrotum
I/O (enlarged liver)
fatigue and weakness
chest pain, friction rub, pulsus paradoxus
ECG- monitor for ST changes, echo, CT
Labs- troponin, CRP, ESR, WBC
Pericarditis distended neck veins
VS
Task
Identifying signs and symptoms
Predicting and managing potential complications
Considering the effects of the two exemplars related to perfusion, list the assessment
data and the range of values that would be acceptable related to the assessment data
and at what point the values are not acceptable and the nurse would be concerned.
When a concern arises, what action should the nurse take?
Assessment data Action to take in
Disease ranges that would Values that are not the case of
Updated 12/17/19 Page 2 of 21
, NUR 212: Concepts of Nursing Care of the Adult I
Pre-Class Assignment Week 10
be acceptable acceptable unacceptable
assessment data
Heart Failure
SOB with exerting elevated BNP >100 monitor labs,
self or lying down, pg/ml, elevated decrease salt in
swelling, reduced troponins, elevated diet, limiting fluids,
ability to exercise, BP <130/80, extra diuretics,
weight gain of <3lb elevated BUN/ elevate extremities
creatinine,10-20 or apply ace wraps,
mg/dl weight gain may need US of the
of >3lb heart to monitor
chest pain,abnormal symptoms, obtain
reading on EKG, cxray to look for
increased SOB, fluid build up, obtain
increased daily weights
weakness/fatigue
extreme swelling to
legs/ankles and
feet, irregular
heartbeat,
persistent
cough/wheezing
Pericarditis
SOB, coughing, abnormal CBC- anti-inflammatory
fatigue, chest pain, elevated WBC medications,
heart palpitations >11,000, , elevated antiviral
ESR- men > 3 medications, chest
women >7, x ray, US of heart/
cardiac enzyme echo of heart, EKG
levels, BUN, CRP monitoring anti-
sharp/piercing viral medications,
chest pain over
the center or left
Updated 12/17/19 Page 3 of 21
