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ACUTE BIOLOGIC CRISIS

NINA HAMILI G. PIAO RN


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 could be considered
ABC
Heart failure & Dysrhythmias
Respiratory Failures & Acute Respiratory
Distress Syndrome
Renal Failure & End Stage Renal Disease
Burns
Hepatic Coma
DKA/HHNK
Thyroid Crisis & Adrenal Crisis
Multi System Organ Failure & Shock
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
arterieslead to Angina (ischemia)

Complete occlusion of the coronary


arterieslead to Myocardial Infarction

The heart will pump harder to meet the


O2demand leading to Congestive Heart
Failure.
Non Modifiable Risk Factors
of CAD/ ACS
Age
Gender
Race
Heredity
Modifiable Risk Factors of CAD/ACS

Stress Obesity
Diet Personality Type or
Exercise Behavioral Factors
Cigarette Smoking Contraceptive Pills
Alcohol
Hypertension
Hyperlipidimia
Diabetes Mellitus
Cardiovascular Assessment

Chest Pain In MI, it is more


Most common intense, unrelated to
Due to Ischemia or activities and cant
MI be relieved by NTG
Precipitated by
stress or can be If it occurs during
relieved breathing, suspect
by Nitroglycerin respiratory problems
(NTG)
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
Chest tightness
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
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
Laboratory & Diagnostic Test

Complete Blood Count-


RBC suggest tissue oxygenation.
Elevated WBC may indicate infectious
heart disease and MI.
Erythrocyte Sedimentation Rate (ESR)
It 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.
Laboratory & Diagnostic Test

Blood Coagulation Test:


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:
Serum Cholesterol:
150-200mg/dl
Serum Triglycerides
140-200mg/dl.
Laboratory & Diagnostic Test

Serum Enzymes Studies


Aspatate Aminotransferase(AST)-
Elevated levelindicates tissue necrosis.
Normal Range: 7-40mu/ml
CK-MB-
Elevated 4-6hrs from the onset
of infarction; peaks 24-36 hrs. returns to
normal 4-7days. Normal Range: males:
50-325mu/ml; Females: 50-250mu/ml
Laboratory & Diagnostic Test

Serum Enzymes Studies


Lactic Dehydogenase (LDL)- Onset:
12hrs;Peak: 48hrs; returns to normal: 10-
14 days4. Hydroxybuterate
Dehydroxynase (HBD)- it isvaluable in
detecting silent MI because it iselevated
for a long period of time.Onset: 10-12hrs;
Peaks: 48-72hrs; Returns to Normal 12-13
days
Laboratory & Diagnostic Test

Serum Enzymes Studies


Troponin- Most specific lab test to detect
MI. Troponin has 3 compartments: I,C, &T
. Troponin I persist for 4-7 days.
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
Laboratory & Diagnostic Test

Radiologic Findings (Chest X-Ray)


Normal
Cardiomegaly
Signs of CHF
Laboratory & 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
Laboratory & Diagnostic Test

Coronary Angiogram
allows to visualize narrowings or
obstructions
therapeutic measures can follow
immediately.
Goal of Treatment

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
Intervention

Tranquilizres
To decrease anxiety
Diazepam (5-10 mg per IV/orem)
Laxative
To prevent straining during defecation
Lactulose (HS)
Intervention

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
Intervention

Nursing Consideration:
Assess Pulse Rate before administration;
with hold if bradycardia is present.
Administer with food, may cause GI upset.
Do not administer with asthma it causes
Bronchoconstriction.
Do not give to patient with DM, it causes
hypoglycemia.
Antidote for Beta Blocker poisoning is
Glucagon
Intervention

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
Intervention

Nursing Considerations:
Only a maximum of 3 doses at 5 min. interval.
Offer sips of water before giving it
sublingually.
Store the medication in a cool, dry place; use
dark /amber container.
If side effects is noticed do not discontinue
the drug this is usual in the first few doses
of medication.
Rotate skin sites for nitro patch.
Intervention

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,
Intervention

Aspirin and/or antiplatelet therapy


Continue aspirin indefinitely
Clopidogrel may be used as an alternative
only if resistance or allergy to aspirin.
Intervention

Nursing Considerations:
Assess for signs and symptoms of Bleeding.
Avoid straining at stool to avoid
rectal bleeding.
It should be given with food.
Observe for toxicity- Tinnitus (ringing of ears).
May cause Bronchoconstriction- Observe
for wheezing.
Intervention

Heparin
Assess for S/S of Bleeding.
Keep Protamine Sulfate available.
If used SQ. do not aspirate to prevent
hematoma formation.
Monitor for PTT or APTT
Used for a maximum of 2 weeks.
Intervention

Coumadin (Warfarin Sodium)


Assess for bleeding
Keep Vitamin K available.
Monitor for Prothrombin Time
Do not give together with aspirin to prevent
bleeding.
Minimize green leafy vegetables in the diet.
Intervention

Thombolytic therapy
The effectiveness:
highest in the first 2 hours
After 12 hours, the risk associated with
thrombolytic therapy outweighs any benefit
Intervention

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
Drugs
Intervention

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 under fluoroscopic guidance and
advance to the site of the obstruction.
Intervention

Intravascular Stenting
Biologic Stent is produced through coagulation
of collagen, ellastin andother tissues in the
vessel wall by laser, photocoagulation or radio
frequency.
It is done to prevent restenosis
after Percutaneous Transluminal Coronary
Angioplasty.
Intervention

Surgical Care
Percutaneous Transluminal Coronary
Angioplasty
Intervention

Emergent or urgent
Coronary Artery Graft Bypass Surgery
(CABG) is indicated
angioplasty fails
Severe narrowing of 1or more coronary artery.
Commonly used: Saphenous vein and internal
mamary artery.
Intervention

Coronary Artery Graft Bypass Surgery


Intervention

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

To live as full, vital and productive life


as possible.
Remain within the limits of the hearths ability
to respond to activity and stress.
Cardiac Rehabilitation

Activities:
Exercise may gradually implemented from the
hospital onwards.
Exercise session is terminated if anyone 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.
Cardiac Rehabilitation

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.
Cardiac Rehabilitation

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.
Thank you and Good Day!