Perfusion

Definition of Perfusion refers to the flow of blood through arteries and capillaries delivering nutrients
and oxygen to cells.

Perfusion is a normal physiological process that requires the heart to generate sufficient cardiac output
to transport through patent blood vessels for distribution in the tissues throughout the body.

Ischemia is the term used when blood supply is available but decreased.

Central Perfusion
 Generated by cardiac output
 The amount of blood pumped by the heart each min.
 Where it begins:
o The heart is stimulated by an electrical impulse from the sinoatrial (SA) node and goes to the
atrioventricular (AV) node
o Impulses move through a series of branches (bundle of His) and Purkinje fibers in the
myocardium causing the ventricles to contract. Also, known as Systole.
o This closes the mitral and tricuspid valves and opens the aortic and pulmonic valves to open.
o This results in ejection of blood into the aorta (from left ventricle) and pulmonary arteries
(from the right ventricle)
o Blood ejects, ventricular pressure decreases causing the aortic and pulmonic valves to close.
o Ventricles relax to fill with blood
o Movement of blood from the atria to ventricles is accomplished when pressure of the blood
in the atria is higher than the pressure in the ventricles.
o The higher the atrial pressure open the mitral and tricuspid valves, filling the ventricles with
blood.
 Normal cardiac output
o 4-6 L/min in an adult
 Two variables of cardiac output
o Stroke volume
 Amount of blood ejected with each contraction
o Heart rate

Tissue Perfusion
 Volume of blood that flows through target tissues
 Supplied by blood flowing from arteries to capillaries
 Arteries, capillaries, and veins provide blood flow to and from tissues.
 They maintain blood pressure by constricting or dilating in response to stimuli.

Age-related differences
 Infants
o Heart occupies a larger space in the mediastinum
o Systolic BP is decrease after birth b/c of weaker Lt ventricle
o Lt side of heart gets stronger and systolic BP increases after 1st 6weeks
o After puberty systolic pressure rises to adult levels
 o During growth spurts, heart size increases with increase in BP and decrease in HR
 Older Adults
o Arterial stiffening causes increase BP
o Cardiac output decrease 30-40%
o Orthostatic hypotension

Impaired Central Perfusion

 Problems can result from increase SVR (systemic vascular resistance)
 This is when body tries to compensate by increase HR d/t SVR
o Which can lead to insufficient central perfusion
 Cardiac output affected by a reduction in SVR- d/t vasodilation of arteries
 Clinical manifestations are systemic (affecting the entire body)
 Significant decrease results in shock

Consequences of impaired central perfusion

 Impairment occurs in conditions that decrease cardiac output or cause shock
 Cardiac output decrease with inadequate perfusion to the myocardium, inadequate impulse
conduction through heart, or malfunction of heart valve
 Occlusions or constriction of coronary arteries that reduces blood flow to myocardium can result
in MI & decreases cardiac output
 Shock
o Inability of central perfusion to supply blood to peripheral tissues
o Occurs when
 The heart is unable to act as a pump (cardiogenic shock)
 Fluid is lost (hemorrhagic shock)
 Systemic vasodilation occurs (anaphylactic, neurogenic, or septic shock)

Impaired Tissue Perfusion

 Impair the volume of blood that flows through target tissues in the arteries to capillaries
 Reduces blood flow through capillaries into the interstitial spaces allowing delivery of oxygen,
fluid, and nutrients to cells.
 Different organs and tissues require different volumes of blood to maintain adequate function
 Inadequate tissue perfusion can result from poor central perfusion or from a mechanism within
the organ itself
o Blocked blood vessel leading to or from the tissue
o Excessive edema within the tissue interfering with the cellular oxygen exchange or increased
pressure and associated constriction or collapse of arterioles

Consequences of Impaired Tissue Perfusion

 Impairment is from occlusion, constriction, or dilation of arteries or veins
o Atherosclerosis or thrombi can occlude arteries
o Thrombi occlude veins
 Ischemia is a reversible cellular injury that occurs when the demand for oxygen exceeds the supply
because of a decrease of blood flow
 Decrease oxygen to the mitochondria reduces adenosine triphosphate (ATP) production and
causes 2 problems:
o 1st- Oxygen not available for the cells usual oxidative metabolism. Forced to use anaerobic
metabolism creating ATP from glycogen to maintain cell function
 o 2nd- The inability to maintain the adenosine triphosphatase (ATPase) pumps.
 Na+-K pump normally uses energy provided by ATP to pump Na+ out of the cell and
allow K into the cell.
 If ATP is absent, K deficits develop and causes dysrhythmias in myocardial tissue.
 If ischemia persists, irreversible cell injury or cell death occurs from necrosis.

Risk Factors for impaired perfusion

Populations at Risk
 Middle-aged and older adults
 Males
 African Americans
 Infants with congenital heart defects

Individual Risk Factors

 Atherosclerosis
 Myocardial disease
 Modifiable risk factors:
o Smoking
o Elevated lipids
o Sedentary lifestyle
o Obesity
o Diabetes mellitus
o Hypertension
 Unmodifiable Risk factors
o Age: increases with age
o Gender: men>women
o Genetics: fam. Hx

Assessment
 Central perfusion is present if HR and BP are WNL
 Tissue perfusion is present if extremities are warm with color appropriate for race and the radial
and dorsalis pedis pulse rates are 60-100 bpm with reg. rhythm, palpable. Capillary refill is less
than 3 seconds
 Baseline History
o Ask about:
 Diet
 Exercise
 Smoking
 Alcohol consumption
o Problem-based history
 Pt may describe:
 Pain
 SOB
 Edema
 Fainting
 Use F/U questions to obtain additional data.
 Onset
  Location
 Duration
 Severity
 What helps or makes worse
 What has been done to help relieve it
o Pain
 From impaired tissue perfusion
 Inadequate perfusion to carry oxygen to meet tissue needs causes ischemic pain
 Myocardial ischemia
 Also called stable angina
 Caused when there is an increased demand for oxygen on the heart.
 Often r/t:
 Physical exertion
 Exposure to cold temps
 Emotional stress
 Angina pectoris
 Chest pain as a constricting or squeezing sensation
 Relieved by:
 Rest
 Taking Nitroglycerin tablets
 Acute coronary syndrome
 Unstable angina advancing to MI
 Report:
 Severe chest pain that is NOT relieved by nitroglycerin
 SOB
 Radiating pain to the jaw or arms
 Nausea
 Vomiting
 Diaphoresis
 Some women may report:
 Atypical chest pain
 SOB
 Fatigue
 Pain in legs could be caused by
 Peripheral arterial disease (PAD)
 Deep vein thrombus (DVT)
 Pt with PAD
 Pain when walking that is relieved with rest (intermittent claudication)
 Pt with DVT
 "rest pain"
 Leg pain while walking that is not relieved with rest
o Dyspnea
 Inadequate circulation of blood interferes with oxygen transport to tissue
 May be reported by pt with:
 Primary perfusion problems
 CHF
 Primary gas exchange problems
 COPD
 o Edema
 Excessive fluid in the interstitial spaces
 Indicates a fluid overload or an accumulation of fluids
 May be caused from renal disease when blood cannot be filtered by kidneys
 Right-sided heart failure is another cause if the right ventricle is unable to eject
its usual volume of blood
 Blood backs up into Rt atrium
 Then to right ventricle
 Into inferior and superior venae cavae
 Because veins are unable to transport blood to heart, fluid is pushed into
interstitial spaces
o Dizziness or fainting
 If occurs while pt sits up suddenly, this is known as orthostatic hypotension
 Dizziness unrelated to position change could be caused by inadequate blood flow to
brain
 Carotid arteries could be occluded

Examination Findings

Central Perfusion
 Vital sign changes
o Hypotension
o Tachycardia
 Auscultation of heart reveal S1 and S2 heart sounds as well as S3 and S4 abnormal heart sounds
(murmurs)
 Mental status could be affected d/t insufficient oxygenation to brain
 Edema can develop from fluid retention or inadequate cardiac output

Tissue Perfusion
 Less hair on LE
 Pale skin
 Cool skin
 Diminished to absent dorsalis pedal or posterior tibial pulses
 Slow cap refill
 Decrease in urine output
 Lack of perfusion stimulates the renin-angiotensin-aldosterone system, causing increase in BP
because of both angiotensin II (vasoconstricts blood vessels) and increase in aldosterone secretion
(retains Na+ and then water, causing peripheral edema)
 When mild atherosclerosis occludes the Rt carotid artery, causes transient ischemic attack (TIA)
o Left-sided weakness and difficulty speaking

Diagnostic Tests
 Blood tests
o Enzymes and markers
 Creatine kinase (CK)
 An enzyme present in myocardium (CK-MB), muscle (CK-MM) and brain (CK-BB)
 CK-MB elevated post MI
 Lactate dehydrogenase (LDH)
  Enzyme in heart, liver, muscles, erythrocytes
 Elevated after damage to the myocardium and erythrocytes
 Natriuretic peptides
 Atrial natriuretic peptide (ANP)- secreted from right atrial cells when right atrial
pressure increases
 Brain-type natriuretic peptide (BNP)- secreted from cardiac cells in increased
amounts when pressure is high
 Both are used to detect heart failure
 Troponin
 Myocardial muscle protein released after myocardial injury
 Increased post MI
 Used to predict likelihood of future cardiac events
 Homocysteine (Hcy)
 Amino acid produced during protein metabolism
 Can be hereditary or acquired from diet deficiencies
 Predictor of
 CAD
 CVA
 PAD
 Venous thrombosis
 C-reactive protein (CRP)
 Produced by liver during acute inflammation
 Predict risk of future cardiac events
o Serum lipids
 Detect hyperlipidemia
 ECG
o 12 lead can detect myocardial ischemia or infarction
 Cardiac stress tests
o Exercise cardiac stress test
 Most common d/t simple and noninvasive
 Exercises on treadmill with increase in speed and elevation
 ECG recorded during test
 Monitoring HR, BP and RR
 Pharmacologic stress test
o Performed when pt cannot perform exercise stress test
o Agents administered include dobutamine and adenosine
o ECG monitoring performed
 Radiographic studies
o Chest X-ray
 Gives visualization of the lungs, ribs, clavicles, vertebrae, heart, and major thoracic
vessels
o Ultrasound
 Uses high-frequency sound waves to indicate blood flow in the artery
 Duplex imaging uses a color Doppler system to map blood flow
o Arteriogram
 Visualization of arteries by injecting contrast into them to see location and extent of
occlusion
 Cardiac cath
Clinical management

Primary Prevention
 Healthy diet
 Exercise most days of the week
 No smoking

Secondary Prevention (screening)

 Routine monitoring
o BP
o Lipid screening
 Men 35 and older
 20-35 yrs if increased risk
 Women 45 and older
 20-45 yrs if increased risk for coronary heart disease

Collaborative Interventions

Nutrition Therapy
 Heart-healthy diet
o Tertiary prevention
 Lower lipid levels
 Lose weight
 Maintain optimal weight
o Considered an intervention for both primary prevention and disease management
Activity, exercise, and positioning
 These are part of any treatment regimen
o For purpose of weight loss and weight maintenance
o Cardiac rehabilitation post acute coronary syndrome
o Progressive activity for patients with PAD
Smoking Cessation
 Primary prevention
 Collaborative intervention
Pharmacotherapy
 Vasodilators- increase the diameter of blood vessels
o Treat HTN and angina
o Angiotensin-converting enzyme (ACE) inhibitors
 Captopril
 Lisinopril
 Losartan
o Nitrates
 Nitroglycerine
o Potassium channel activators
 Diazoxide
 Minoxidil
o Smooth muscle relaxants
 Hydralazine
 Vasopressors- decrease the diameter of blood vessels by stimulating the a-adrenergic or
dopamine receptors to effect the normal mechanism of vasoconstriction
o Epinephrine
o Norepinephrine
o Dobutamine
 Diuretics- reduce blood volume by preventing the reabsorption of sodium in the kidneys, which
increases urine output
o Furosemide
o HCTZ
o Triamterene
o Spironolactone
 Antidysrhythmics- correct erratic electrical impulses to create regular cardiac rhythms by:
o blocking electrolytes that affect electrical conduction in the heart. Na+, K, Ca
 Verapamil
 Diltiazem
 Nifedpine
o Blocking B-adrenergic receptors
 Lopressor
 Metoprolol
 Toprol
 Cardioglycosides- have positive inotropic effect with a lowering of HR to increase cardiac output
and treatment for heart failure
o Digoxin
 Anticoagulants- prevent blood clotting at several locations in the clotting cascade to suppress the
production of fibrin
o Heparin
o Exoprin
o Warfarin sodium
o Ardeparin
 Antiplatelet- prevent platelets from aggregating to form clots
o Two classes:
 Glycoprotein platelet inhibitors
 Tirofiban
 Eptifibatide
 Abciximab
 Platelet aggregation inhibitors
 Aspirin
 Ticagrelor
 Thrombolytics- disrupt blood clots that are impairing perfusion by lysing fibrin
o Tissue plasminogen activator
o Alteplase
o Urokinase
o Streptokinase
 Lipid-lowering agents- decrease the levels of lipids that contribute to atherosclerosis and result in
blood vessel occlusion by reducing the synthesis of cholesterol
o Atorvastatin
o Fluvastatin
o Lovastatin
 o Pravastatin

Procedures and Surgical Interventions

 Pacemaker insertion
o Electronic device used to increase HR in severe bradycardia
 Electrical cardioversion
o Cardiac defibrillation- used for emergency treatment during cardiac arrest with v-fib and
ventricular tachycardia
o Synchronized cardioversion- procedure used to convert an abnormal rhythm to normal sinus
rhythm
 Intra-aortic balloon pump
o Temporary circulatory assistance
o Reduce afterload to decrease workload of the ventricles
o Improves coronary blood flow
 Heart valve surgery
o Procedure to replace or repair one or more heart valves with a prosthetic valve
 Cardiac transplant
 Coronary artery bypass graft (CABG)
o Procedure surgically implants patent blood vessels to transport blood between aorta and
the myocardium distal to the obstructed coronary artery
 Peripheral artery revascularization
o Procedure using an autogenous vein or synthetic graft to bypass the lesion in the artery that
is impairing perfusion
 Stent placement and angioplasty
o Stent is a mesh-like structure designed to expand the artery to maintain patency
 Endarterectomy
o A surgical procedure in which the artery is opened to remove obstructing plaque that is
impairing perfusion
 Carotid artery is a common site

Clinical Nursing Skills for Perfusion

 Assessment
 Cardiac monitoring
 Hemodynamic monitoring
o Continuous arterial BP monitoring
o Pulmonary artery pressure monitoring
 Circulatory assist devices
o Intra-aortic balloon pump
o Ventricular assist device
 Medication administration
 Patient teaching