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CCBC Nursing 160: Exam Three Prep | Questions and Answers Latest {} A+ Graded | 100% Verified
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CCBC Nursing 160: Exam Three Prep | Questions and Answers Latest {} A+ Graded | 100% Verified
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CCBC Nursing 160: Exam Three Prep | Questions and Answers Latest {2024- 2025} A+Graded | 100% Verified
What is the term used to describe the exchange of blood, gases, and fluids between the vessels, tissues,
and organ systems? - Perfusion.
What is the primary purpose of the cardiovascular system? - Primary purpose is to pump blood and
distribute it to all areas of the body.
*When problems exist with the cardiovascular system it can lead to death.*
How does the cardiovascular system function? - It promotes the perfusion of blood through the body,
carries cellular wastes to excretory organs, and promotes the return of blood to the heart for
oxygenation.
What is the first thing the nurse should do when a patient comes in with possible perfusion issues? - An
ASSESSMENT!
What kind of questions should the nurse make sure to ask the patient in regards to possible perfusion
problems? - 1. *Health History:*
- History of present illness: What is their chief complaint and is it urgent or not? For example, chest pain
is ALWAYS urgent.
- Past medical history: Any comorbidities, such as diabetes or PVD? Have they had any childhood
infections that could have damaged the heart?
- Family history of perfusion problems?
- Functional health patterns: how is their nutrition? How well do they sleep? How active are they? Any
problems with sexuality or stress? What are their personal habits?
- ADL's: Any DOE? Are they sedentary or active? Do they have any edema or fatigue? When did it start?
How long has it been going on? What brings it on and what relieves it?
- Height and weight: Elevated BMI can be an indicator or precursor to CVD.
- Medications
,In regards to functional health patterns, what are some signs and symptoms that could be indicative of
possible CVD? - 1. *Nutrition*
- weight loss or gain: more than 2 pounds in a day or 5 pounds in a week? (Even a measly 5 pounds can
increase the demands on cardiac function).
- special diets: for example, if they do have perfusion issues they should be restricting sodium and eating
low fat.
2. *Sleep*
- sleep apnea: causes snoring and fatigue and is often associated with cardiovascular problems due to a
perfusion source. Ex, they may be snoring because of an airway obstruction that is decreasing their
perfusion.
- dyspnea
- fatigue
- orthopnea
3. *Sexual Acitivity*
- difficulty or frequency: if it's not being perfused then it won't work.
- fertility issues
4. *Activity*
- sedentary or active?
- *activity intolerance is a BIG indicator of perfusion issues!* Are they SOB or experiencing DOE?
5. *Personal Habits*
- caffeine use
- alcohol use
- tobacco use
- illicit drug use: patient may not tell you but if they are their vessels are usually already sclerotic and
they may have cellulitis.
6. *Stress*
,- increased coping response -->increases HR and BP
What are some non-modifiable (cannot be changed) risk factors related to perfusion issues? - 1. Age
2. Family history (genetics)
3. Gender
4. Race
What are some modifiable risk factors related to perfusion issues? - 1. Smoking
2. Obesity
3. Dyslipidemia
4. Stress
5. Sedentary lifestyle
6. Modifiable medications: DM, HTN, Metabolic Syndrome (improvement of the control of the diseases
can help decrease the possibility of damage to the vessels)
What kind of medications is it important to ask the patient about when assessing whether or not a
perfusion issue is present? - ALL OF THEM!
1. Current list of medications.
2. Any OTC medications such as: decongestants (these are stimulants and can affect BP, ex: Claritin),
cold meds, nasal sprays, vitamins, and laxatives.
3. Any CAM such as: garlic, fish oil (oils change the metabolic rate of other pills), omega fatty acids, and
even curcumin/curry (these have a strong systemic anti-inflammatory effect).
What are some notable signs and symptoms related to perfusion issues? - 1. *CHEST PAIN/DISCOMFORT
IS ALWAYS AN EMERGENCY AND REQUIRES IMMEDIATE ASSESSMENT!* This occurs because there is
decreased blood flow occurring from the coronary arteries to the heart tissues which causes pain.
2. Vital Signs.
3. SOB/Dyspnea/DOE.
, 4. Edema or weight gain.
5. Palpitations (the sensation of rapid HR to the point where the patient is aware of it = not normal).
6. Fatigue or weakness.
7. Dizziness or syncope/fainting.
8. Auscultate heart sounds: S1 and S2 (*S1 is best heard at the fifth intercostal space to the left of the
sternum at the apex and S2 is heard best at the base of the heart, the area between the apex and the
sternum*). Remember: S1 at apex, S2 at the base.
What should the nurse ask the patient about any pain they may be experiencing related to a possible
perfusion issue? - Pain Assessment = PQRST.
*P = Provocation/Palliation:*
What where you doing when the pain started? What caused it? What makes it better? Worse? What
seems to trigger it? Stress? Position? Certain activities?
What relieves it? Medications, massage, heat/cold, changing position, being active, resting?
What aggravates it? Movement, bending, lying down, walking, standing?
*Q = Quality/Quantity:*
What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing,
throbbing, nauseating, shooting, twisting or stretching.
*R = Region/Radiation:*
Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around? Did
it start elsewhere and is now localized to one spot?
*S = Severity Scale:*
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