The nurse is assessing a male patient diagnosed with chronic heart failure 10 years ago. Which finding would indicate poor perfusion to the tissues?
a. Blood pressure reading of 102/64
b. Absence of hair on the lower legs and feet
c. Pulse rate of 104 beats/min
d. Shortness of breath when supine
B
Absence of hair on the lower extremities is an indicator of poor perfusion because hair growth requires adequate gas exchange. A blood pressure of 102/64 is lower than the average range, but may be normal for this patient. It would not indicate poor perfusion to the tissues. The patient with heart failure is likely to have a slightly elevated heart rate if not taking medications that slow heart rate because the increased rate compensates for reduced cardiac output. Although shortness of breath may occur with heart failure, this is the result of poor pumping action of the heart, allowing fluid to accumulate in the lungs; it is not an indicator of peripheral circulation.
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