NURS 287 Lecture Notes - Central Venous Pressure, Capillary Refill, Pulse Oximetry
28 Apr 2013
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Document Summary
The initial assessment is geared toward the abcs: airway, breathing, and circulation. Further assessment focuses on the assessment of tissue perfusion and includes evaluation of vital signs, peripheral pulses, level of consciousness, capillary refill, skin (e. g. , temperature, color, moisture), and urine output. The overall goals for a patient in shock include (1) assurance of adequate tissue perfusion, (2) restoration of normal bp, (3) return/recovery of organ function, and (4) avoidance of complications from prolonged states of hypoperfusion. Trends in these parameters yield more important information than individual numbers. Trendelenburg (head down) position during hypotensive crisis is not supported by research and may compromise pulmonary function and increase intracranial pressure. The patient"s ecg should be continuously monitored to detect dysrhythmias that may result from the cardiovascular and metabolic derangements associated with shock. Heart sounds should be assessed for the presence of an. The presence of an s3 sound in an adult usually indicates heart failure.
