Angelito L. Ramos Jr. RN

Clinical Instructor

Acute Biologic CrisisCondition that may result to patient

mortality if left unattended in a brief period of time.

Condition that warrants immediate attention for the reversal of disease process and prevention of further morbidity and mortality.

Conditions that can be considered ABCHeart failure & DysrhythmiasRespiratory Failures & Acute

Respiratory Distress SyndromeRenal Failure & End Stage Renal

DiseaseBurns

Conditions that can be considered ABC Hepatic ComaDKA/HHNKThyroid Crisis & Adrenal CrisisMulti System Organ Failure &

Shock

* ADCPN Resource units in NCM 100-105 with Clinical focus

Coronary Artery Disease & Acute Coronary SyndromesMost Common cause of

cardiovascular disability and death.It refers to a spectrum of illnesses

that range from the least life threatening to the most life threatening acute coronary syndrome(AMI/ Heart attack).

Coronary Artery Disease & Acute Coronary SyndromesIncomplete occlusion of the coronary

arteries lead to Angina (ischemia)Complete occlusion of the coronary

arteries lead to Myocardial InfarctionThe heart will pump harder to meet the

O2 demand leading to Congestive Heart Failure.

Non Modifiable Risk Factors of CAD/ ACSAgeGenderRaceHeredity

Modifiable Risk Factors of CAD/ ACSStressDietExerciseCigarette SmokingAlcoholHypertension

Modifiable Risk Factors of CAD/ ACSHyperlipidimiaDiabetes MellitusObesityPersonality Type or

Behavioral FactorsContraceptive Pills

Cardiovascular AssessmentChest PainMost commonDue to Ischemia or MIPrecipitated by stress or can be relieved by

Nitroglycerin (NTG)In MI, it is more intense, unrelated to

activities and can’t be relieved by NTGIf it occurs during breathing, suspect

respiratory problems

Rough diagram of pain zones in myocardial infarction (dark red = most typical area, light red = other possible areas, view of the chest).

Cardiovascular AssessmentDyspneasubjective feeling (inability to get enough

air).Dyspnea on exertion is due to increased O2

myocardial demand.Orthopnea is related to blood pooling in the

pulmonary bed; suspect Pulmonary EdemaAny sudden or acute dyspnea may be a sign

of Pulmonary Embolism

Tightness of Chest

Cardiovascular AssessmentCough/sputumMucoid and foamy sputum can be a sign of

CHFPink-tinged frothy appearance may signal

Pulmonary Edema.Whitish, viral infectionChange in color other than the above

mentioned may signify bacterial infection.

Cardiovascular AssessmentCyanosisBluish discoloration of the skin and

mucous membraneSat O2 is below 90%

FatigueMay be due to Anemias or related to

decreased Cardiac Output

Cardiovascular AssessmentPalpitationsAwareness of rapid or irregular heart beatAutonomic Nervous System and Adrenal

Glands response (stress)

SyncopeTransient loss of consciousnessDue to decreased cerebral tissue perfusion

Cardiovascular AssessmentEdemaDue to: Increased Hydrostatic Pressure

(HP)Decreased Colloidal Oncotic

Pressure (COP)Obstructed Lymphatic or

Vascular System Related to Inflammatory reaction

Types of EdemaBilateral edema

= CHF or Renal FailureUnilateral edema

= Vascular or Lymphatic obstructionNon-pitting edema

= Inflammatory Pitting edema

= HP and COP derangement

Cardiovascular AssessmentSkinColor, temperature, hair growth,

nails, capillary refillspooning of fingers /clubbing of

fingers

Clubbing of Fingers

Cardiovascular AssessmentHeart rate – 60-100Rhythm – regular or irregularBruits and Thrills – murmurlike; vascular

in origin

- palpate a thrill, auscultate a bruitBlood PressureJugular venous pressure

Cardiovascular AssessmentCardiac rate and rhythmTachycardia = ↑ 100 beats/minuteBradycardia = ↓ 60 beats/minuteArrhythmias = irregular rate and

rhythm

Cardiovascular AssessmentS1 closure of AV valves (lub)S2 closure of SL valves (dub)S3 & S4 diastolic filling soundS3 heard after S2

if present suspect CHF; commonS4 is heard prior to S1; if present suspect

non-compliant ventricles although this is common among the elderly.

Cardiovascular AssessmentMurmurs- turbulence of blood flow; if positive

watch out for FVE; normal until 1 year oldPericardial Friction Rub -“squeaking sound”;

suspect pericardial effusion if this is heardMuffled Heart Sound - if positive rule out

Cardiac Tamponade and other similar problems like Effusion

Laboratory & Diagnostic TestComplete Blood Count- RBC suggest tissue

oxygenation.

Elevated WBC may indicate infectious heart disease and MI.

Erythrocyte Sedimentation Rate (ESR)- Its is elevated in infectious heart disorder or MI.

Normal range: Males: 15-20mm/hr

Females: 20-30 mm/hr

Laboratory & Diagnostic TestBlood Coagulation Test:

1.Prothrombin Time (PT, Pro Time)- It measures time required for clotting to occur. Used to evaluate effectiveness of COUMADIN. Normal range 11-16 secs.

2.Partial Thromboplastin Time (PTT)- Best screening test for disorders of coagulation. Used to determine the effectiveness of HEPARIN. Normal Range: 60-70 secs.

Laboratory & Diagnostic TestBlood Urea Nitrogen (BUN)- Indicator of

renal function

Normal Range: 10-20mg/dl (5-25mg/dl is also accepted).

Blood Lipids:

1.Serum Cholesterol: 150-200mg/dl

2.Serum Triglycerides: 140-200mg/dl.

Laboratory & Diagnostic TestSerum Enzymes Studies

1.Aspatate Aminotransferase(AST)- Elevated level indicates tissue necrosis. Normal Range: 7-40mu/ml

2.CK-MB- Elevated 4-6hrs from the onset of infarction; peaks 24-36 hrs. returns to normal 4-7 days.

Normal Range: males: 50-325mu/ml; Females: 50-250mu/ml

Laboratory & Diagnostic TestSerum Enzymes Studies

3. Lactic Dehydogenase (LDL)- Onset: 12hrs; Peak: 48hrs; returns to normal: 10-14 days

4. Hydroxybuterate Dehydroxynase (HBD)- it is valuable in detecting silent MI because it is elevated for a long period of time.

Onset: 10-12hrs; Peaks: 48-72hrs; Returns to Normal 12-13 days

Laboratory & Diagnostic TestSerum Enzymes Studies

5. Troponin- Most specific lab test to detect MI. Troponin has 3 compartments: I,C, &T .

Troponin I persist for 4-7 days.

Angina Myocardial Infarction

Chest Pain- tightness & heaviness

Severe crushing, stabbing chest pain

Relieved quickly:3-15min by rest or sublingual nitrogen.

Not relieve by rest and medication

Initiated by physical exertion or stress

Pain last longer >20min

Radiation may or may not be present

May or may not have radiation of pain

Frequently associated with shortness of breath

Laboratory & Diagnostic TestSerum Electrolytes/ Blood Chemistry:

1.Sodium (Na)

2.Potassium (K)

3.Calcium (Ca)

4.Magnessium (Mg)

5.Glucose

6.Glycosylated Hemoglobin (Hemoglobin A1c)

Laboratory & Diagnostic TestECG/ EKG- ST segment elevation and T

wave inversion

Diagnostic TestRadiologic Findings

Chest X-RayNormalCardiomegalySigns of CHF

Diagnostic TestHemodynamic Monitoring

Swan-Ganz CatheterizationRight side of the heartPulmonary artery pressurePulmonary artery occlusive pressureRight atrial pressureCardiac output

Swan-Ganz Catheterization

Diagnostic TestCoronary Angiogram

allows to visualize narrowings or obstructions

therapeutic measures can follow immediately.

Goal:Pain reliefReduction of myocardial oxygen consumption

Prevention and treatment of complications

InterventionAdmit to the CCU/ ICUActivity

Day 1: bed rest, if stableDay 2-3: bed rest, but patient

may be allowed to sit on a chair for 15-20 minutesEarly mobilization is

recommended for uncomplicated AMI

InterventionMonitoring Vital Signs

First 6 hours- q30-60 minutesNext 24 hours- q 2 hoursThereafter q 4 hours

DietNPO: 1st 24 hoursIf stable low salt, low cholesterol

diet

InterventionIV Fluids

D5W to KVOIf unable to take food/fluid per orem1000ml/8 hours

K supplement

InterventionPain Medication

Morphine SO4 (2-5mg/IV dose)Potent analgesicPeripheral venous vasodilationPulmonary venous distentionInferior wall MI: may increase vagal

discharge

TranquilizresTo decrease anxietyDiazepam (5-10 mg per IV/orem)

LaxativeTo prevent straining during defecation

Lactulose (HS)

Drugs to Limit Infarct SizeBeta Blockers

Hyperdynamic states, HPN w/o evidence of heart failure

Reduce myocardial oxygen consumption by decreasing: BP. Heart Rate, Myocardial Contractility and calcium output.

Ex: Propranolol, Metoprolol, Atenolol

Nursing Consideration:

1.Assess Pulse Rate before administration; withhold if bradycardia is present.

2.Administer with food, may cause GI upset.

3.Do not administer with asthma it causes Bronchoconstriction.

4.Do not give to patient with DM, it causes hypoglycemia.

5.Antidote for Beta Blocker poisoning is Glucagon

NitratesAct by augmenting perfusion at the border

of ischemic zone.Generalized vasodilationReducing myocardial O2 demand

Lowering preloadLowering afterload

Ex: IV Nitroglycerine, Sublingual Niotroglycerine, Oral/Transdermal Nitroglycerine

Nursing Considerations:

1.Only a maximum of 3 doses at 5 min. interval.

2.Offer sips of water before giving it sublingually.

3.Store the medication in a cool, dry place; use dark /amber container.

4.If side effects is noticed do not discontinue the drug this is usual in the first few doses of medication.

5.Rotate skin sites for nitro patch.

ACE inhibitors reduce mortality rates after MI. Administer ACE inhibitors as soon as

possible ACE inhibitors have the greatest benefit in

patients with ventricular dysfunction. Continue ACE inhibitors indefinitely after

MI. Angiotensin-receptor blockers may be used

as an alternative adverse effects, such as a persistent cough,

Aspirin and/or antiplatelet therapy

Continue aspirin indefinitelyClopidogrel may be used as an alternative only if resistance or allergy to aspirin.

Nursing Considerations:

1.Assess for signs and symptoms of Bleeding.

2.Avoid straining at stool to avoid rectal bleeding.

3.It should be given with food.

4.Observe for toxicity- Tinnitus (ringing of ears).

5.May cause Bronchoconstriction- Observe for wheezing.

Heparin

1.Assess for S/S of Bleeding.

2.Keep Protamine Sulfate available.

3.If used SQ. do not aspirate to prevent hematoma formation.

4.Monitor for PTT or APTT

5.Used for a maximum of 2 weeks.

Coumadin (Warfarin Sodium)

1.Assess for bleeding

2.Keep Vitamin K available.

3.Monitor for Prothrombin Time

4.Do not give together with aspirin to prevent bleeding.

5.Minimize green leafy vegetables in the diet.

thombolytic therapyThe effectiveness:

highest in the first 2 hoursAfter 12 hours, the risk associated with thrombolytic

therapy outweighs any benefitcontraindicated

unstable angina and NSTEMIand for the treatment of individuals with evidence of

cardiogenic shockstreptokinase, urokinase, and alteplase (recombinant

tissue plasminogen activator, rtPA), reteplase, tenecteplase

Surgical CarePercutaneous Transluminal Coronary Angioplasty

-treatment of choice PCI provides greater coronary patency lower risk of bleedingand instant knowledge about the extent of the

underlying disease.A specially designed balloon – tipped catheter is

inserted uder flouroscopic guidance and advance to the site of the obstruction.

Intravascular StentingBiologic Stent is produced through

coagulation of collagen, ellastin and other tissues in the vessel wall by laser, photocoagulation or radio frequency.

It is done to prevent restenosis after Percutaneous Transluminal Coronary Angioplasty.

Emergent or urgent coronary artery graft bypass surgery (CABG) is indicatedangioplasty fails Severe narrowing of 1

or more coronary artery.

Commonly used: Saphenous vein and internal mamary artery.

ComplicationsInflammationMechanicalElectrical abnormalities

Cardiac RehabilitationA process which a person restored to

health and maintains optimal physiologic, psychosocial and recreational functions.

Begins with the moment a client is admitted to the hospital for emergency care, it continues for months and even years after the client is discharged from the health care facility.

Goals of Rehabilitation:

1.To live as full, vital and productive life as possible.

2.Remain within the limits of the hearth’s ability to respond to activity and stress.

Activities: Exercise may gradually implemented

from the hospital onwards. Exercise session is terminated if any

one of the following occurs: cyanosis, cold sweats, faintness, extreme fatigue, severe dyspnea, pallor, chest pain, PR more than 100/ min., dysrhythmias greater than 160/95mmHg.

Teaching and CounselingSelf management education guide.

Control hypertension with continued medical supervision.

DietWeight reduction programProgressive exerciseStress management techniquesResumption of sexual activity after 4-6 weeks

from discharge, if appropriate.

Teaching guide on resumption of sexual activities:

Assume less fatiguing position.The non- MI partner take the active roleTake nitroglycerine before sexual activityIf dyspnea, chest pain or palpitations

occur, moderation should be observed; if symptom persist stop sexual activity.

Develop other means of sexual expression.

"You can not do all the good the world needs, but the world needs all the good you can do."

Thank You!