Assessment: Perfusion and Oxygenation Flashcards
Discuss specific assessments performed during an examination of a patient’s perfusion status
To assess perfusion, recognize indications of adequate and inadequate perfusion.
Check vitals: HR and BP
Check orientation
Check speech and mental state
Check bilateral movement and sensation
Check pulses (carotid, radial, dorsalis pedis bilaterally)
Listen for abnormal heart sounds
Check skin temperature and color
Check capillary refill time
Central perfusion
noted by HR & BP measurements being within normal limits.
Cerebral tissue perfusion
indicated by the pt’s orientation to time, place, person, situation: expected bilateral movement & sensation, clear speech, presence of carotid pulse, and absence of carotid bruit (blowing/swishing sound).
Peripheral tissue perfusion
present when the pt’s extremities are warm & with appropriate color, and the radial/dorsalis pedis pulse rates are between 60-100 bpm.
Capillary refill time is less than 2 sec
Ankle-brachial index is greater than 0.9 (ankle-brachial index = comparison of BP measured at the ankle with BP measured at the arm)
other factors affecting pt perfusion status
the presence of warm hands/feet & the absence of continuous pain in fingers/toes or leg pain when walking.
Describe normal heart sounds (S1and S2) and the location in which they are heard best
Normal S1 and S2 sounds are lub dub.
S1 is the “lub” sound, caused by the closing of the mitral and tricuspid valves and corresponds to the onset of ventricular contraction. Heard best at the apex of the heart (tricuspid and apical area).
S2 is the “dub” sound, represents closure of aortic and pulmonic valves. it is loudest at the base of heart (Aortic / pulmonic area)
Describe extra heart sound S3
S3, known as the third heart sound, follows S2 and is often represented by a “lub-dub-dee” pattern (“dee” being S3).
this sound is best heard with the stethoscope bell at the mitral area, with the patient lying on the left side.
**S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.
Describe extra heart sound S4
the fourth heart sound, occurring right before S1, and is often represented by a “dee-lub-dub” pattern (“dee” being S4).
**S4 is considered normal in older adults but abnormal in children and adults.
Define murmurs
Heart murmurs are extra heart sounds caused by some disruption of blood flow through the heart. The characteristics of a murmur and grading depend on the adequacy of valve function, rate of blood flow, and size of the valve opening
Specific assessment of a client with a murmur
Timing: Systole or diastole?
Loudness (Grade 1(barely audible) - Grade 6 (Loudest- can hear with stethoscope lifted)
Pitch: High, medium or low
Pattern: Growing louder, tapering off, increasing then decreasing
Quality: Musical, blowing, harsh, rumbling
Location: Where it is best heard (name by valve or intercostal space)
Radiation: Is it heard somewhere else (back, neck, axilla, precordium, etc.)
Posture: Does it disappear with position change?
Discuss specific assessments performed during the examination of the peripheral vascular system
Inspect and palpate the arms
Color of skin and nail beds
Temperature, texture, turgor of skin
Any lesions, edema, clubbing
Check capillary refill time (normal = less than 2 sec for color to return after blanching)
Are the two arms symmetrical?
Any scars on hands and arms?
Palpate radial and brachial pulses bilaterally (grade the force on 3 pt scale: 2+ is normal)
Inspect and palpate the legs
Inspect if legs are symmetrical & inspect them together, noting skin color, hair distribution, venous pattern, size (swelling or atrophy), any skin lesions or ulcers
Palpate for temperature down to the feet comparing symmetrical spots
Palpate inguinal lymph nodes (normal=small <1cm, moveable, nontender)
Palpate peripheral arteries (femoral, popliteal, dorsalis pedis, posterior tibial) and grade the force
the structure of the respiratory system
The upper airway is composed of the nose, pharynx, larynx, and epiglottis.
The lower airway, known as the tracheobronchial tree, includes the trachea, right and left main stem bronchi, segmental bronchi, and terminal bronchioles
The lungs, the main organs of respiration, are located within the thoracic cavity on the right and left sides. The lungs extend from the base at the level of the diaphragm to the apex (top), which is above the first rib.
Right lung has 3 lobes. Left lung has 2 lobes. The main bronchus branches to each lung from the trachea.
It immediately subdivides into secondary bronchi, one to each lobe.
Then the bronchi subdivide again and against becoming smaller and smaller as they branch through each lung.
The smallest are called bronchioles and they end at the terminal bronchioles.
At the end of terminal bronchioles are clusters of alveoli - the site of all gas exchange.
function of the respiratory system
Major function of respiratory system is the exchange of gases - O2 and CO2.
Gas exchange, the intake of oxygen and the release of carbon dioxide, is made possible by pulmonary ventilation, respiration, and perfusion.
Pulmonary ventilation refers to the movement of air into and out of the lungs.
Respiration involves gas exchange between the atmospheric air in the alveoli and blood in the capillaries.
Perfusion is the process by which oxygenated capillary blood passes through body tissues.
Discuss the anatomical landmarks used to assess the respiratory system
On the posterior chest, start at the level of C7, because this is where the apices of the lungs are.
C7 is the protuberance on your back when you bend your head and touch your chin down to your chest.
Go from one side to the other, going down every other intercostal space. Do not forget to assess the lower lateral lobes (#9 and #10). Stop at the level of the 6th rib.
Discuss specific assessments performed during an examination of a patient’s oxygenation status
analyzing the patient’s heart rate, respiratory rate, pulse oximetry reading, and lung sounds, in addition to asking the patient to rate their level of dyspnea.
