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 non-
compliant 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: 50-
250mu/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:3- Not relieve by rest and
15min by rest or medication
sublingual nitrogen.
Initiated by physical Pain last longer >20min
exertion or stress
Radiation may or may May or may not have
not be present 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 15-
20 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.
"You can not do all the good
the world needs, but the
world needs all the good you
can do."

Thank You!