Acute Biological Crisis

Angelito L. Ramos Jr. RN Clinical Instructor

Acute Biologic Crisis Condition 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 ABC Heart failure & Dysrhythmias Respiratory Failures & Acute

Respiratory Distress Syndrome Renal Failure & End Stage Renal Disease Burns

Conditions that can be considered ABC Hepatic Coma DKA/HHNK Thyroid Crisis & Adrenal Crisis Multi System Organ Failure & Shock * ADCPN Resource units in NCM 100-105 with Clinical focus

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/ ACS Age Gender Race Heredity

Modifiable Risk Factors of CAD/ ACS Stress Diet Exercise Cigarette Smoking Alcohol Hypertension

Modifiable Risk Factors of CAD/ ACS Hyperlipidimia Diabetes Mellitus Obesity Personality Type or Behavioral

Factors Contraceptive Pills

Cardiovascular Assessment Chest Pain Most common Due to Ischemia or MI Precipitated by stress or can be relieved by Nitroglycerin (NTG) In MI, it is more intense, unrelated to activities and can’t be relieved by NTG If 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 Assessment Dyspnea subjective 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 Edema Any sudden or acute dyspnea may be a sign of Pulmonary Embolism

Tightness of Chest

Cardiovascular Assessment Cough/sputum Mucoid and foamy sputum can be a sign of CHF Pink-tinged frothy appearance may signal Pulmonary Edema. Whitish, viral infection Change in color other than the above mentioned may signify bacterial infection.

Cardiovascular Assessment Cyanosis Bluish discoloration of the skin and mucous membrane Sat O2 is below 90% Fatigue May be due to Anemias or related to decreased Cardiac Output

Cardiovascular Assessment Palpitations Awareness of rapid or irregular heart beat Autonomic Nervous System and Adrenal Glands response (stress) Syncope Transient loss of consciousness Due to decreased cerebral tissue perfusion

Cardiovascular Assessment Edema Due to: Increased Hydrostatic Pressure (HP) Decreased Colloidal Oncotic Pressure (COP) Obstructed Lymphatic or Vascular System Related to Inflammatory reaction

Types of Edema Bilateral edema

= CHF or Renal Failure Unilateral edema = Vascular or Lymphatic obstruction Non-pitting edema = Inflammatory Pitting edema = HP and COP derangement

Cardiovascular Assessment Skin Color, temperature, hair growth, nails, capillary refill spooning of fingers /clubbing of fingers

Clubbing of Fingers

Cardiovascular Assessment Heart rate – 60-100 Rhythm – regular or irregular Bruits and Thrills – murmurlike; vascular in

origin - palpate a thrill, auscultate a bruit Blood Pressure Jugular venous pressure

Cardiovascular Assessment Cardiac rate and rhythm Tachycardia = ↑ 100 beats/minute Bradycardia = ↓ 60 beats/minute Arrhythmias = irregular rate and rhythm

Cardiovascular Assessment S1

closure of AV valves (lub) S2 closure of SL valves (dub) S3 & S4 diastolic filling sound S3 heard after S2 if present suspect CHF; common S4 is heard prior to S1; if present suspect noncompliant ventricles although this is common among the elderly.

Cardiovascular Assessment Murmurs

- turbulence of blood flow; if positive watch out for FVE; normal until 1 year old Pericardial Friction Rub -“squeaking sound”; suspect pericardial effusion if this is heard Muffled Heart Sound - if positive rule out Cardiac Tamponade and other similar problems like Effusion

Laboratory & Diagnostic Test Complete 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 Test Blood 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 Test Blood 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 Test Serum 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: 50250mu/ml

Laboratory & Diagnostic Test Serum 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 Test Serum 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 & Severe crushing, heaviness stabbing chest pain Relieved quickly:315min 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 Test Serum Electrolytes/ Blood Chemistry: 1.Sodium (Na) 2.Potassium (K) 3.Calcium (Ca) 4.Magnessium (Mg) 5.Glucose 6.Glycosylated Hemoglobin (Hemoglobin A1c)

Laboratory & Diagnostic Test ECG/ EKG- ST segment elevation and T

wave inversion

Diagnostic Test Radiologic Findings

Chest X-Ray Normal Cardiomegaly Signs of CHF

Diagnostic Test Hemodynamic Monitoring Swan-Ganz Catheterization Right

side of the heart

Pulmonary

artery pressure

Pulmonary

artery occlusive pressure Right atrial pressure Cardiac output

Swan-Ganz Catheterization

Diagnostic Test Coronary Angiogram  allows to visualize

narrowings or obstructions therapeutic measures can follow immediately.

Goal: Pain relief Reduction of myocardial oxygen

consumption Prevention and treatment of complications

Intervention Admit to the CCU/ ICU Activity Day 1: bed rest, if stable Day 2-3: bed rest, but patient may

be allowed to sit on a chair for 1520 minutes Early mobilization is recommended for uncomplicated AMI

Intervention Monitoring Vital Signs First 6 hours- q30-60 minutes Next 24 hours- q 2 hours Thereafter q 4 hours Diet NPO: 1st 24 hours If stable low salt, low cholesterol diet

Intervention IV Fluids D5W to KVO If unable to take food/

fluid per orem 1000ml/8 hours K supplement

Intervention Pain Medication Morphine SO4 (2-5mg/IV dose) Potent

analgesic Peripheral venous vasodilation Pulmonary venous distention Inferior wall MI: may increase vagal discharge

Tranquilizres To decrease anxiety Diazepam (5-10 mg per IV/orem)

Laxative To prevent straining during defecation Lactulose (HS)

Drugs to Limit Infarct Size Beta 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

Nitrates Act by augmenting perfusion at the border of

ischemic zone. Generalized vasodilation Reducing myocardial O2 demand Lowering preload Lowering 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 indefinitely Clopidogrel 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 therapy The effectiveness: highest in the first 2 hours After 12 hours, the risk associated with thrombolytic

therapy outweighs any benefit contraindicated unstable angina and NSTEMI and for the treatment of individuals with evidence of cardiogenic shock streptokinase, 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 bleeding and 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 Stenting Biologic 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 indicated angioplasty fails Severe narrowing of 1 or more coronary artery. Commonly used: Saphenous vein and internal mamary artery.

Complications Inflammation Mechanical Electrical abnormalities

Cardiac Rehabilitation A 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 Counseling Self management education guide. Control hypertension with continued medical supervision. Diet Weight reduction program Progressive exercise Stress management techniques Resumption 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 role Take nitroglycerine before sexual activity If dyspnea, chest pain or palpitations occur, moderation should be observed; if symptom persist stop sexual activity. Develop other means of sexual expression.

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