1. Discuss different Acute Biologic Crisis conditions together with the roles and responsibilities of the nurse in the care of the following.

•Cardiac failure - Acute Myocardial infarction• Acute pulmonary failure • Acute renal failure • Stroke • Increased Intracranial pressure• Metabolic emergencies – e.g. DKA/HHNK• Massive Bleeding • Extensive surgeries• Extensive Burns • Emerging illnesses (SARS, Avian Flu)• Multiple injuries

2. Use critical thinking in the management of these cases3. Familiarize with the different treatment modalities and equipments used

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.

1. Coronary Artery Disease & Acute Coronary Syndromes

Most 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 Syndromes

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

Complete occlusion of the coronary arteries lead to Myocardial Infarction

The 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/ ACSStress

Diet

ExerciseCigarette SmokingAlcohol

Hypertension

norepinephrine

tachycardia

vasoconstriction

Na, cholesterol & fat CVD

Circulation, maintains vascular tone& enhances release of chemical activators that prevent blood clotting

Vasoconstriction & spasm of arteries.

Myocardial demand

20 ml = vasodilation 30 ml = vasoconstriction

As a result of Systemic vascular resistance

Modifiable Risk Factors of CAD/ ACS

HyperlipidimiaDiabetes MellitusObesityPersonality Type or

Behavioral FactorsContraceptive Pills

Accumulation of fatty plaques

Glucose cannot be transported into the cells due to insulin insufficiency or Increases resistance to insulin

Increase cardiac workload

Type A – competitive, impatient, aggressive has been correlated to CAD

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 obstruction

Non-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 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 Care

Percutaneous 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 heart’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.

ACUTE RENAL FAILURE Rapid onset of oliguria (<400 ml /day) , with severe rise in BUN & creatinine (Azotemia – accumulation of nitrogen in blood )

Acute renal failure is classified as pre renal, intra renal or post renal. All conditions that lead to pre renal failure impair blood flow to the kidneys (renal perfusion), resulting in a decreased glomerular filtration rate and increased tubular resorption of sodium and water. Intra renal failure results from damage to the

Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP

Oliguric – UOP < 400/d, ^BUN,Crest, Phos, K, may last up to 14 d

Diuretic – UOP ^ to as much as 4000 mL/d but no waste products, at end of this stage may begin to see improvement

Recovery – things go back to normal or may remain insufficient and become chronic

Complications ARF

Hyperkalemia – most dangerous complication, may lead to cardiac arrest if rise in K+ is too fast

Nursing Care ARF

Daily WeightCVP monitoringDiuretic as prescribedLow protein, K,Na &

high carbohydrate diet

Nursing Care ARFEmergency

management of Hyperkalemia : insulin & dextrose Kayexalate enema

Chronic Renal failure

Chronic irreversible progressive reduction of functioning renal tissue

Common causes CRFDiabetic nephropathyHypertensive nephropathyGlomerulonephritisChronic pyelonephritis

Stages CRF1. Reduced Renal Reserve high

BUN no clinical symptoms yet

2. Renal insufficiency- mild Azotemia – impaired urine concentration , nocturia

Stages CRF3. Renal failure – Severe

azotemia, acidosis,concentrated urine, severe anemia & electrolyte imbalances

CRF systemic SSHyper K, Hypernatremia, Hypocalcemia

AnemiaAnorexia, nausea & vomiting

CRF systemic SSAmmoniacal breathImmunosuppressionHTN, CHFPulmonary edemaSevere pruritusPeripheral neuropathyUremic amaurosis

Nursing Care ESRDLow Protein, Low Na dietPrepare client for peritoneal / hemodialysis

Monitor Anemia

Nursing Care ESRDAdminister epoietin alpha (Epogen), diuretics, antihypertensives as prescribed

Kidney transplant

Peritoneal DialysisPeritoneal Dialysis

Peritoneal DialysisPeritoneal Dialysis

HemodialysisHemodialysis

HEMODIALYSIS: Is the diffusion of dissolved particles from the blood into the dialysate bath of the hemodialysis machine across the semipermeable membrane of the dialyzer.

Hemodialysis requires vascular access:

Subclavian vein/ Femoral vein (temporary)

Arteriovenous fistula, arteriovenous shunt,/ arteriovenous graft

( Permanent)

HemodialysisHemodialysis

Hemodialysis

Nursing Management: Assess the integrity of the hemodialysis access site

Monitor VSAssess client for fluid overload

Nursing Management:

Weigh the client before and after the dialysis treatment ( to determine fluid loss)

Hold meds that can be dialyzed off

Monitor for SS of Shock & Disequilibrium syndrome

Complication: Disequilibrium Syndrome – is the rapid change in composition of extracellular fluid where the solutes of the blood are removed from the blood faster than that of the CSF, causing osmotic movement of fluid into the CSF causing cerebral edema.

Nursing Management: Disequilibrium syndrome:

Assess for Nausea & vomitingAssess for headacheRestlessness, agitation & or confusion

Watch out for seizures

Nursing Management: Disequilibrium syndrome:

Notify physician if SS of disequlibrium syndrome occurs

Reduce environmental stimuliDialyze the patient at a shorter period

and at a slower rate

Kidney Transplant

Cell destruction of the layers of the skin and resultant depletion of fluid and electrolytes

Types of BurnsThermal : exposure to flameChemical: exposure to strong acids or alkali

Electrical: Caused by electrical strong electrical current results in internal tissue injury

Burn Depth:

Superficial thickness burn (1st degree)- mild to severe erythema of skin, blanches with pressure – heals in 3-7 days

Partial thickness burn(2nd degree) – large blisters; painful heals 2-3 weeks

Burn Depth:

Full thickness burns (3rd degree) – white yellow deep red to black (eschar) disruption of blood flow, no pain; scarring and wound contractures will develop. Grafting is required; healing takes weeks to months

Burn Depth:

Deep full thickness burn (4th degree) – Involves injury to muscle and bone= appears black(eschars) – hard and inelastic healing takes weeks to months; grafts are required

Nursing Diagnosis

Decreased Cardiac output Related to Fluid shifts

Rule Of 9

Head and neck 9%Anterior trunk 18% ( chest-9 abdomen-9)

Posterior trunk-18%

Rule Of 9Arms 9% each (forearms only or upper arms only 4.5%)

Legs – 18% each Perineum-1%

Rule of 9

PARKLAND (BAXTER) FORMULA FOR FLUID REPLACEMENT

4ml Lactated Ringer’s sol x Kg body mass x total percentage of body surface burned

PARKLAND (BAXTER)

•1st 8 hours = ½ of total 24 hour fluid replacement

•next 8 hours = ¼ of total

•last 8 hours= ¼ of total

A man Suffered from a 3rd degree burn involving the head and neck, front of the torso (chest & abdomen), and whole left arm. Weight is 50 kg

Calculate the: TBSA burned

24 hour fluid replacement in ml1st 8 hours fluid replacement

2nd 8 hour remaining 8 hour

TBSA:

Head & neck= 9%

front of torso = 18% Whole left arm = 9%

TBSA burned 36%

24 hour replacement: Parkland Baxter formula

4mlX 50 kgs x (TBSA)36%

= 7200 ml

1st 8 hours :7200 ml

2

= 3600 ml = 1st 8 hours

2nd 8 hours & remaining 8 hours respectively :

3600 ml 2

= 1800 ml = 2nd 8 hours= 1800 ml = last 8 hours

MANAGEMENT OF BURNS:Administer fluids as prescribedMaintain a high calorie, high

protein dietMonitor intake and outputMonitor for infections of burn site

Burn Medications:Nitrofurazone ( Furacin) – broad spectrum antibiotic ointment or cream – used when bacterial resistance to other drugs is a problem : apply 1/16 inch thick film directly to burn

Burn Medications:Mafenide ( Sulfamylon) – water

soluble cream bacteriostatic gr + - bacteria- apply 1/16 inch directly to burn – notify physician if hyperventilation occurs as this drug may ppt. metabolic acidosis.

Burn Medications:Silver Sulfadiazene

( Silvadene) – cream Broad spectrum to gr+ - ; does not cause metabolic acidosis – keep burn covered at all times with Sulfadiazine – (1/16 inch thick);

Monitor CBC – causes leukopenia

Burn Medications:Silver Nitrate – Antiseptic solution against gr-, dressings are applied to the burn and then kept moist with Silver nitrate ; used on extensive burns that may precipitate fluid and electrolyte imbalance.

DKA( Diabetic Ketoacidosis) / HHNS

( Hyperglycemic

Hyperosmolar Nonketotic Syndrome)

DKA- Is a life threatening complication of DM type 1 = develops because of severe insulin deficiency

MANIFESTATATIONS

1. Hyperglycemia

2. Dehydration

3. Electrolyte loss and acidosis

CAUSE; Missed insulin dose, or infection

HHNS- SIMILAR TO dka WITH EXTTREME hyperglycemia except that in HHNS there is no acidosis. This is for DM type 2

ASSESSMENT: Blood glucose – 300 – 800 mg/dl

Low bicarbonate & low pH

Dehydration

ASSESSMENT: Mental status changesNeurological deficitsSeizures

NURSING INTERVENTION:Administer Insulin IV push 5-10 units

1st then IV infusion

NURSING INTERVENTION:Restore Fluids ( administer fluids as

prescribed)Treat dehydration w/ rapid infusion of NSS or .45% saline

when blood glucose reaches 250-300 mg/dl D5NS, or D5 .45%Saline is used

NURSING INTERVENTION:Always use infusion pump for IV

insulinMonitor serum potassium ( initially

as a result of acidosis Hyperkalemia is present upon admin of insulin K+ level drops)

NURSING INTERVENTION:Monitor LOC= too rapid decrease in

blood glucose may cause cerebral edema

THYROID CRISIS – (THROID STORM/ Thyrotoxicosis)- Acute life threatening condition that occurs in a client with uncontrollable hyperthyroidism – maybe a result of manipulation of thyroid gland during surgery(release of thyroid hormones to bloodstream)

THYROID CRISIS – (THROID STORM/ Thyrotoxicosis)-

Causes: Undiagnosed , untreated hyperthyroidism, infection, trauma

Medical management:Antithyroid medications; beta blockers; glucocorticoids & iodides are given before surgery to prevent thyroid crisis

Medical management:Antithyroid meds: Iodide, Propylthiouracil, Methimazole

Iodides/ Iodine = Reduce the vascularity of the thyroid gland before thyroidectomy,

Medical management:Iodides= used in the treatment of

thyroid storm because it enables the storage of TH in the thyroid gland.

However it is given only for 10-14 days Because eventually it looses its effect on the thyroid gland.

NURSING INTERVENTION:ASSESSMENT : elevated Temp

( high fever); tachycardia; agitation; tremors

Maintain a patent airway

Administer antithyroid meds as prescribed ( sodium iodide solution)

Monitor VS

MULTI ORGAN DYSFUNCTION SYNDROME

(MODS)

SEPSIS, DEAD TISSUE, PNEUMONITIS, PANCREATITIS

RESPIRATORY FAILURE

INTUBATION (maybe stable for 7-14 days)

MALFUNCTION of GI

SEEDING OF BACTERIA FR. GI TO OTHER ORGANS

HYPERMETABOLIC STATE

HYPERMETABOLIC STATE (hyperglycemia, hyperlactacidemia, ulceration in GI- seeding of bacteria from GI to other organs)(skin breakdown, loss of muscle mass, delayed healing of surgical wounds)(mortality rate 60%)

LIVER FAILURE (jaundice)

RENAL FAILURE(mortality rate 90-100%)

Criteria for Diagnosis of MODS

Cardiovascular Failure presence of 1 or more of the ff:

<54 bpmSystolic < 60 mm HgVtach/ V fibpH < 7.24

Respiratory FailureRR < 5/min RR> 49/min

Renal Failure presence of 1 or more of the ff:Output < 479 ml/24 hr or < 159 ml/ 8 hrBUN > 100mg/dlCrea > 3.5mg/dl

Hematologic Failure presence of 1 or more of the ff:

WBC < 1000 uLPlatelets < 20,000HCT < 20%

Hepatic failure presence of both of the FF:

Bilirubin > 6 mg %PT > 4 sec over control in absence

of anticoagulation (normal PT – 11-12sec)

Neurologic Failure

GCS < 6 in absence of sedation

Medical Management: Control of infection w/ antibiotics

( common MRSA & Vancomycin resistant

Aggressive pulmonary care mech vent & O2 (intubation)

Enteral (NGT) feeding

Nursing Management

Limited : effective client & family coping

The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not.

Mark Twain