NCM118

Nursing Care of Clients with Life Threatening Condition, Acutely Ill/Multi-organ Problems,
High Acuity and Emergency Situations; Acute and Chronic

SHOCK, SYSTEMIC INFLAMMATORY

RESPONSE SYNDROME AND MULTIPLE
ORGAN DYSFUNCTION SYNDROME

Guevarra Clan S. Bautista, RN, MN

 SHOCK

• Characterized by decreased tissue perfusion and impaired cellular

metabolism
• Result of imbalance between the supply of oxygen and nutrients
 4 CLASSIFICATIONS OF SHOCK

1. Hypovolemic
2. Cardiogenic
3. Distributive (Neurogenic, Anaphylactic, Septic)
4. Obstructive
 HYPOVOLEMIC SHOCK

 Occurs due to loss of intravascular fluid

 Occurs when there is a reduction in intravascular volume of 15% to 25%.
 This also would represent a loss of 750 – 1,300ml of blood in a 70kg person

A. Absolute Hypovolemia- External loss of whole blood or body fluids

B. Relative Hypovolemia- Pooling of blood or fluids, internal bleeding and massive
vasodilation
 SIGNS AND SYMPTOMS

 Cool, clammy skin

 Hypotension
 Diaphoresis
 History of fluid volume loss
 Thirst
 Increase pulse rate and respiratory rate
 Flat neck vein
 NURSING MANAGEMENT

 Goal: Increase circulating blood volume

 Increase circulating volume to the core body organs by:
 Elevating the legs, elevate at about 20°
 Inflating anti shock suit
 Start second IV line (PLR or NSS) non fast drip to obtain 90mmttg systolic BP.
 Draw blood for cbc, electrolytes, bun, sugar, coagulation, type and cross matched
 Prepare for CVP on central line insertion
 Initiate measure for or to stop bleeding if appropriate (pressure dressing, direct pressure,
iced lavage for G.I bleeding)
 GENERAL INTERVENTION FOR SHOCK
 
 Ensure adequate airway, ventilation and circulation
 Initiate O2 therapy 6-10 L/min, unless history of COPD is present
 Start at least one peripheral IV access, preferably a large bore IV cannula (14, 16 or 18)
 Initiate cardiac monitoring, obtain 12 leads ECG
 Insert foley bladder catheter and monitor urine output for 15-30 minutes
 Initiate continuous v/s monitoring and document on flow sheet
 Provide continuous psychosocial support to person and significant others.
 Monitor level of sensorium
 Applying direct pressure to the site of bleeding
 PHARMACOLOGIC AND MEDICAL MANAGEMENT

 Administration of intravenous fluids

 Blood transfusion
 Treatment of infection if applicable
 Emergency drugs may be administered
 CARDIOGENIC SHOCK

• A condition of diminished cardiac output that severely impairs cardiac perfusion

• Reflects severe left sided cardiac failure
• It is often results from myocardial infarction,
• Characterized by signs and symptoms of hypotension in the presence of
distended neck vein
 PATHOPHYSIOLOGY

• Inability to contract- insufficient contraction of the myocardium

• Pulmonary congestion- blood backs up to weakened left ventricle increasing preload and
pulmonary congestion
• Compensation- Heart rate increases in attempt to maintain the cardiac output
• Diminished stroke volume- Decrease coronary artery perfusion
• Increase workload- All of the above mechanism increases the cardiac workload and enhances the
left sided heart failure
• End result- Myocardial hypoxia, further decrease cardiac output, triggering of compensatory
mechanism to prevent decompensation and necrosis
 DIAGNOSTIC FINDINGS

• Faint heart sounds upon auscultation

• Confirmation of mi during laboratory test
• Abnormal ABG analysis
 CLINICAL MANIFESTATIONS

• Cool, clammy skin

• Decreased blood pressure
• Tachycardia
• Rapid respirations
• Oliguria (urine output less than 20 ml per hour)
• Confusion
• Cyanosis
 MEDICAL/SURGICAL MANAGEMENT

• Intra-aortic Balloon Pump (IABP)- Mechanical assist device that attempts

to improve the coronary artery perfusion and decrease cardiac workload
through an inflatable balloon pump which is percutaneously or surgically
inserted through the femoral artery into the descending thoracic aorta.
INTRA-AORTIC BALLOON PUMP
 MEDICAL/PHARMACOLOGIC MANAGEMENT

ADMINISTRATION OF THE FOLLOWING DRUGS:

 Diuretics- Manage fluid overload
 Anti-arrhythmias/Digitalis- Strengthen cardiac contractility without decreasing the heart rate
 Dobutamine- Increasing the strength of myocardial activity and improving cardiac output
 Dopamine- Prevents ischemia
 Other management depending on etiology
 NURSING MANAGEMENT

• Attach patient to oxygen therapy at 2-6 LPM via nasal cannula

• Initiate an intravenous access using large bore iv cannula
• Assess patient’s general health status including vital signs
• Monitor patient for signs of respiratory symptoms due to fluid accumulation in the lungs
• Monitor hemodynamic status
• Reduce risk
• Monitoring of intake and output
 NURSING MANAGEMENT

 Provide health education regarding the disease condition

 Control of hypertension
 Diet modification
 Smoking cessation
 Exercise
 ANAPHYLACTIC SHOCK

• Potentially life-threatening condition that occurs within seconds or minutes of

exposure to something a person is allergic to, such as peanuts or bee stings.
•  Immune system to release a flood of chemicals that causes the person to go into
shock 
• Is a severe, life-threatening allergic response to an immunologic reaction (type I
hypersensitivity) between a specific antigen and an immunoglobulin E.
URTICARIA
ANGIOEDEMA
 RISK FACTORS

• Ingestion of food
• Ingestion of chemicals or medication
• Insect venom/insect bites
• Latex allergies
• Previous anaphylaxis
• Allergies or asthma
• Other conditions
 CLINICAL MANIFESTATIONS

• Skin reactions, including hives and itching and flushed or pale skin
• Low blood pressure (hypotension)
• Constriction of the airways and a swollen tongue or throat, which can cause wheezing
and trouble breathing
• A weak and rapid pulse
• Nausea, vomiting or diarrhea
• Dizziness or fainting
• Shortness of breath
 NURSING MANAGEMENT
• Reduce exposure to risk factors

• Provide health education regarding the disease process

• Monitor vital signs and level of consciousness
• Administer oxygen inhalation via face mask
• Maintain a patent airway
• Monitor oxygenation status
• Monitor urine output; foley catheter may be inserted as ordered

• Provide emotional support to both patient and family

• A medical bracelet is encouraged if available
• Instruct patient to be extra cautious with content or chemicals of the food ingested
• Keep and emergency kit and medications available
• Accompany patient to the nearest medical facility
 Medical and Pharmacologic Management
• Removal of the causative agent or antigen
• Administer medication to restore vascular tone
• Cardiopulmonary resuscitation in cases of emergency
• Endotracheal intubation
• Initiation of intravenous therapy
• Administration of epinephrine 0.1 to 0.5 ml repeatedly done every 5 to 20 minutes
• Diphenhydramine is given to reverse the action of histamine
• Albuterol to reverse histamine-induced bronchospasm
• Corticosteroids may be given as ordered (relieves urticarial and angioedema)
 Medical and Pharmacologic Management

• Attach patient to cardiac monitor

• Cimetidine/Ranitidine may be given intravenously
• Gastric lavage may be indicated for secondary ingestion
• Other bronchodilators can be administered
 SEPTIC SHOCK

• Associated with generalized infection which causes an immune response that

activates biochemical mediators associated with an inflammatory response and
produces a variety of effects leading to shock.
• Produces profound vasodilation that results to the leaking of fluid through the walls of
the capillaries into the tissues and hypotension.
• It is characterized by symptoms of systemic infection
plus hypotension and hypoperfusion despite adequate fluid volume replacement.
 RISK FACTORS

• Immunosuppressed patients
• Advanced age
• Malnourishment
• Chronic illness
• Invasive procedures
 PREVENTION

• Strict implementation of sterile technique in procedures

• Prevention of central line infection
• Early debriding of wounds
• Maintain cleanliness of the equipment
 CLINICAL MANIFESTATIONS

• Rapid pulse rate or tachycardia

• Hypotension occurs due to excessive vasodilation
• Rapid breathing or tachypnea
• Decrease urine output
• Changes in the level of sensorium
• Elevation of lactate level
 NURSING MANAGEMENT
• STRICT COMPLIANCE TO PROPER HYGIENE AND HANDWASHING
• STRICT IMPLEMENTATION OF INFECTION CONTROL POLICIES
• TSB AND ADMINISTRATION OF ANTIPYRETICS FOR FEVER
• OBTAIN URINE, BLOOD, SPUTUM AND WOUND DRAINAGE SPECIMENS FOR
IDENTIFICATION AND ELIMINATIONS OF THE CAUSATIVE AGENT OR THE
SOURCE OF INFECTION.
• INITIATION OF IV FLUIDS FOR REPLACEMENT
• AGGRESSIVE NUTRITIONAL MANAGEMENT
• IDENTIFY POSSIBLE RISK FOR INFECTION, ASSESS IV LINES, CENTRAL
VENOUS ACCESS, CATHETERS AND OTHER TUBING FOR POSSIBLE SIGNS
OF INFECTION
 MEDICAL AND PHARMACOLOGIC MANAGEMENT

• Administration of broad spectrum antibiotics after culture and sensitivity

• Naloxone for blood pressure less than 100 mmHg
• Steroids
• CVP may be indicated for elderly patients
• IV fluids
 Neurogenic shock

 Vasodilation occurs as a result of a loss of balance between

parasympathetic and sympathetic stimulation
 A life-threatening medical condition in which there is insufficient blood flow
throughout the body that is caused by the sudden loss of signals from the
sympathetic nervous system that maintain the normal muscle tone in blood
vessel walls
 RISK FACTORS

• Spinal cord injury

• Induction of spinal anesthesia
• Depressant action of medication
• TRAUMA/FRACTURE
 PATHOPHYSIOLOGY
• Stimulation- sympathetic stimulation causes vascular smooth muscle to constrict;
parasympathetic stimulation causes vascular smooth muscle to relax or dilate.
• Vasodilation- parasympathetic stimulation causes vasodilation for an extended period of
time causing hypovolemic state
• Hypotension- inadequate blood supply due to vascular dilation
• Cardiovascular changes- Parasympathetic stimulation with neurogenic shock causes a
drastic decrease in the patient’s systemic vascular resistance and bradycardia
• Insufficient perfusion- Inadequate BP results in the insufficient perfusion of tissues and
cells common to all shock states
 Clinical Manifestations

• Dry, warm skin- inadequate perfusion

• Hypotension due to massive dilation
• Bradycardia
• Diaphragmatic breathing- if injury is below the 5th cervical vertebra, the patient will exhibit
diaphragmatic breathing due to loss of nervous control of the intercostal muscles (which are
required for thoracic breathing)
• Respiratory arrest- if injury is above the 3rd cervical vertebra, the patient will go into respiratory
arrest immediately following the injury, due to loss of nervous control of the diaphragm
 NURSING MANAGEMENT
• Elevate head of bed- helps prevent the spread of anesthesia (Patient receiving spinal or epidural anesthesia)
• If spinal injury is present, immobilize the affected area
• Application of anti-embolic stockings to prevent pooling of blood in the legs
• Assess for presence of Homan’s sign for possible DVT
• Elevation of the head of bed
• Passive range of motion exercises
• Maintain airway patency
• Administer oxygen therapy
• Provide pattern of activities to maintain rest periods
• Monitoring of blood pressure and other vital signs
 MEDICAL AND PHARMACOLOGIC MANAGEMENT

• Inotropic agents such as dopamine may be infused for fluid resuscitation.

• Atropine is given intravenously to manage severe bradycardia.
• Steroids- Patient with obvious neurological deficit can be given I.V.
Steroids, such as methylprednisolone in high dose, within 8 hours of
commencement of neurogenic shock.
• Heparin- Administration of heparin as prescribed may
prevent thrombus formation
 AIRWAY OBSTRUCTION

• A life threatening medical emergency in which there is a barrier or

obstruction that impairs the oxygen delivery in the body
• May be due to tongue or spinal cord injury, foreign body lodged in the
airway, swelling due to allergic reaction, infection or trauma,
peritoncillar abscess, a medication or a certain disease condition
 PATHOPHYSIOLOGY

• Obstruction may lead to progressive hypoxia, hypercarbia and

respiratory or cardiac arrest
• Permanent brain damage may occur within 3-5 minutes secondary
to hypoxia
CLINICAL MANIFESTATIONS OF AIRWAY OBSTRUCTION
• Inability to breath, speak or cough
• Clutching of neck between thumb and fingers
• Choking
• Apprehensive appearance
• Refusing to lie flat
• Stridor
• Labored breathing
• Flaring of nostrils
• Anxiety
• Restlessness and confusion
• Cyanosis
• Loss of consciousness
 ASSESSMENT AND DIAGNOSTIC FINDINGS

• History taking about the present condition (the patient may be requiring help)
• Inspection of the oropharyngeal area may reveal the offending object
• X-rays, laryngoscopy, bronchoscopy
 NURSING MANAGEMENT

• Assess the patient’s condition

• Remove the obstructing object
• Encourage victim to cough forcefully and to persist with spontaneous coughing and
breathing (for partial airway obstruction and a good oxygen exchange exist)
• Wheezing may be present between coughs, if the patient demonstrates a weak,
ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or
cyanosis, the patient should be considered to have serious obstruction
• Initiate rescue breath after obstruction is removed
 ESTABLISHING AN AIRWAY

• Head-tilt, chin lift maneuver

• Jaw thrust maneuver
• Removal of the offending object
• Insertion of nasopharyngeal/oropharyngeal airway
• Endotracheal intubation
• Cricothyroidotomy (Cricothyroid Membrane Puncture)
• Intubation with the king tube or laryngeal mask airway- inserted in the trachea and
functions like ET tube, for patients who are not hospitalized
 Oropharyngeal Airway

King Tube/Laryngeal Mask Airway

Endotracheal Intubation
 KING TUBE/LARYNGEAL MASK AIRWAY

 Done if patient is not hospitalized and intubation cannot be done in the field
 Inserted in the trachea
 One balloon is large and occludes the oropharynx. This permits ventilation by forcing air through the larynx
 Smaller balloon is inflated with air and occludes the esophagus at a site distal to the glottis
 Auscultation is done after the tube is inserted to ensure that glottis is not obstructed
 CRICOTHYROIDOTOMY/CRICOTHYROID MEMBRANE
PUNCTURE

 Opening of the cricothyroid membrane to establish an airway

 This procedure is used in emergency situations in which endotracheal intubation is
either not possible or contraindicated (airway obstruction from extensive
maxillofacial trauma, cervical spine injuries, laryngospasm, laryngeal edema (after
an allergic reaction or extubation, hemorrhage into neck tissue, or obstruction of the
larynx)
CRICOTHYROIDOTOMY/CRICOTHYROID MEMBRANE
PUNCTURE
 MAINTAINING VENTILATION

• Assessment of the lungs for bilateral breath sounds

• Monitor placement and patency of artificial airways
• Perform suctioning and continuous monitoring of vital signs
• Monitor oxygen saturation and arterial blood gas
• Monitor for signs of impending infection
• Monitor patient for bleeding
• Maintain oxygenation therapy
 HEMORRHAGE

• Excessive blood loss or decrease in the circulating blood volume may be

due to trauma or injury or even due to medication or certain disease
condition
• Internal hemorrhage happens inside the body or organ and not usually
visible to the eyes
 RISK FACTORS

• Trauma
• Injury
• Internal bleeding
• Medication
• Disease condition
 MANAGEMENT

FLUID REPLACEMENT
 Insertion of intravenous access using large bore iv cannula on the uninjured area or
extremity
 Obtain blood samples for analysis, typing and cross-matching
 Administration of fluids, blood and blood products including colloids
 Monitoring of patient’s urine output, insertion of foley catheter is often a choice
 MANAGEMENT

CONTROL OF EXTERNAL BLEEDING

 Assessment of the cause of bleeding and the site of bleeding
 Application of direct, firm pressure over the bleeding site
 Application of firm pressure dressing
 Elevation of the affected area
 Application of tourniquet proximal to the bleeding area (note the location, time
of placement and time of removal of the tourniquet)
 MANIFESTATION OF INTERNAL BLEEDING

• Absence of external bleeding

• Tachycardia
• Hypotension
• Thirst
• Cool, moist skin
• Apprehension
• Delayed capillary refill
 MANAGEMENT

CONTROL OF INTERNAL BLEEDING

 Packed RBC, plasma and platelets are given at rapid rate
 Obtain ABG specimen to evaluate pulmonary function and perfusion status
 Pharmacology and surgical approach
 Monitor patient closely until intervention is administered
 Elevate the feet in cases of hypotension
CARDIOVASCULAR EMERGENCIES
ASSESMENT OF THE CLIENTS WITH CARDIOVASCULAR
DISORDERS
Nursing History:
Risk factors may be classified as follow:
Non – modifiable risk factor
Modifiable risk factors
• Physical examination
• Common clinical manifestations
• Diagnostic tests
 NON-MODIFIABLE RISK FACTORS

• Age above 40 years old

• Gender
• Race
• Genetics
 MODIFIABLE FACTORS
• Lifestyle (stress, diet, exercise, smoking, drinking)
• Cigarette smoking
• Hypertension
• Hyperlipidemia
• Diabetes mellitus
• Obesity
• Personality and behavioral factors
• The use of contraceptive pills
 PHYSICAL EXAMINATION-INSPECTION

• Skin color
• Neck vein distention (jugular vein distention)
• Respiration
• Point of maximal impulse (PMI)
• Peripheral edema
 PHYSICAL EXAMINATION-PALPATION

• Peripheral pulses
• Apical pulse
• Breath sounds
 PHYSICAL ASSESSMENT-HEART SOUND

HEART SOUNDS
 S1 is produced by asynchronous closure of the mitral and tricuspid valves. It signals the onset of
ventricular systole “lubb”
 S2 is produced by asynchronous closure of the aortic and pulmonic valves. It signals the onset of
ventricular diastole “dub”
 S3 or ventricular diagnostic gallop is a faint, low pitched sound produced by rapid ventricular filling
in early diastole. It is normal in children and in young adults. It indicates congestive heart failure
(CHF) in older adults
 S4 or atrial diastolic gallop is a low frequency sound which is present congestive heart failure
 HEART SOUNDS

MURMUR- AUDIBLE VIBRATIONS OF THE HEART AND GREAT

VESSELS THAT ARE PRODUCED BY TURBULENT BLOOD FLOW
PERICARDIAL FRICTION RUB- AN EXTRA HEART SOUND
ORIGINATING FROM THE PERICARDIAL SAC. THIS MAY BE SIGN
OF INFLAMMATION, INFECTION OR INFILTRATION (SHORT, HIGH-
PITCHED, SCRATCHY SOUND)
COMMON CLINICAL MANIFESTATIONS OF CARDIOVASCULAR
DISORDERS

 DYSPNEA- SHORTNESS OF BREATH

 DYSPNEA ON EXERTION- THIS MAY INDICATE DECREASED CARDIAC RESERVE (HEART’S
ABILITY TO ADJUST AND ADAPT TO INCREASED DEMANDS).
 ORTHOPNEA- IS USUALLY A SYMPTOM OF MORE ADVANCED HEART FAILURE.
 PAROXYSMAL NOCTURNAL DYSPNEA- IS MANIFESTED BY SEVERE SHORTNESS OF
BREATH THAT USUALLY OCCURS 2 TO 5 HOURS AFTER THE ONSET OF SLEEP.
 CHEST PAIN- THIS MAY BE DUE TO DECREASED CORONARY TISSUE PERFUSION OR
COMPRESSION AND IRRITATION OF NERVE ENDINGS
 COMMON CLINICAL MANIFESTATIONS OF
CARDIOVASCULAR DISORDERS
• EDEMA- INCREASED HYDROSTATIC PRESSURE IN THE VENOUS SYSTEM CAUSES
SHIFTING OF PLASMA, ACCUMULATION OF FLUIDS IN THE INTERSTITIAL COMPARTMENT
OCCURS.
• SYNCOPE- THE CLIENT EXPERIENCES GENERALIZED MUSCLE WEAKNESS WITH AN
INABILITY TO STAND UPRIGHT, FOLLOWED BY LOSS OF CONSCIOUSNESS.
• PALPITATIONS- THE CLIENT EXPERIENCES UNPLEASANT AWARENESS OF THE
HEARTBEAT. THIS IS DESCRIBED BY THE CLIENT AS “POUNDING,” “RACING,” OR
“SKIPPING”. PALPITATIONS THAT OCCUR DURING MILD EXERTION MAY INDICATE THE
PRESENCE OF HEART FAILURE ANEMIA OR THYROTOXICOSIS.
• FATIGUE- THIS MAY BE A CONSEQUENCE OF INADEQUATE CARDIAC OUTPUT.
 DIAGNOSTIC TESTS RELATED TO CARDIOVASCULAR FUNCTION
 

COMPLETE BLOOD COUNT

 EVALUATION OF THE GENERAL HEALTH STATUS OF THE PATIENT
 ELEVATED RBC’S SUGGESTS INADEQUATE TISSUE OXYGENATION,
HYPOXIA STIMULATE RENAL SECRETION OF ERYTHROPOIETIN
 ELEVATED WBC’S MAY INDICATE POSSIBLE INFECTIOUS
 ERYTHROCYTE SEDIMENTATION RATE (ESR)
 MEASURES HOW QUICKLY RED BLOOD CELLS SETTLE IN A TEST TUBE
 ELEVATED DURING INFECTIONS AND MYOCARDIAL INFARCTION
 FASTER THAN NORMAL INDICATES INFLAMMATION
 SLOWER THAN NORMAL INDICATES BLOOD ABNORMALITIES

NORMAL VALUES
 MALES: 0-22 MM/HOUR
 FEMALE: 0-29 MM/HOUR
 BLOOD COAGULATION TEST

PROTHROMBIN TIME (PRO-TIME)

 IT MEASURES THE TIME REQUIRED FOR CLOTTING TO OCCUR AFTER
THROMBOPLASTIN AND CALCIUM ARE ADDED TO DECALCIFIED
PLASMA
 IT IS VALUABLE IN EVALUATING THE EFFECTIVENESS OF COUMADIN
(THERAPEUTIC RANGE IS 1.5 TO 2 TIMES THE NORMAL OR
CONTROL.19 – 24 SEC)
 NORMAL VALUE: 10-13 SECONDS
 PARTIAL THROMBOPLASTIN TIME (PTT)

• IT MEASURES THE TIME REQUIRED FOR CLOTTING TO OCCUR AFTER

A PARTIAL THROMBOPLASTIN REAGENT IS ADDED TO BLOOD PLASMA.
• IT IS THE BEST SINGLE SCREENING TEST FOR DISORDERS OF
COAGULATION.
• IT IS DETERMINED TO EVALUATE THE EFFECTIVENESS OF HEPARIN.
(THERAPEUTIC RANGE IS 2 TO 2 ½ TIMES THE NORMAL OR CONTROL)
• NORMAL RANGE IS 60 TO 70 SECS.
 BLOOD UREA NITROGEN (BUN)

• ONE OF INDICATOR OF RENAL FUNCTION

• DECREASED CARDIAC OUTPUT LEADS TO LOW RENAL
TISSUE PERFUSION AND REDUCTION IN GLOMERULAR
FILTRATION RATE. THE BUN LEVEL BECOMES ELEVATED
• NORMAL RANGE IS 10 TO 20 MG/DL 
 BLOOD LIPIDS

CHOLESTEROL
THE CLIENT SHOULD BE ON NPO FOR 10 TO 12 HRS.
NORMAL RANGE IS 150 TO 250 MG/DL.
TRIGLYCERIDES
THE CLIENT SHOULD OBSERVE FASTING FOR 10 – 12 HOURS.
NORMAL RANGE IS 140 TO 200 MG/DL
 BLOOD CULTURES

• ASSIST IN THE DIAGNOSIS OF INFECTIOUS DISEASES OF THE HEART

E.G. PERICARDITIS
• CAUTION IS TAKEN TO PREVENT CONTAMINATION OF THE SPECIMEN
• HELPS IDENTIFY APPROPRIATE ANTIBIOTICS FOR SPECIFIC BACTERIA
 ENZYME STUDIES
• ASPARTATE AMINOTRANSFERASE (AST)
• FORMERLY, SGOT
• ELEVATED LEVEL INDICATES TISSUE NECROSIS
• NORMAL RANGE IS 7 TO 40 MU/ ML.
• RANGE WITH MYOCARDIAL INFARCTION
• INITIAL ELEVATION : 4 TO 6 HRS.
• PEAKS : 24 TO 36 HRS.
• RETURNS TO NORMAL : 4 TO 7 DAYS
 LACTIC DEHYDROGENASE (LDH)
• AMONG THE FIVE LDH ISOENZYMES, LDH L IS THE MOST SENSITIVE INDICATOR OF
MYOCARDIAL DAMAGE.
• IN MI, LDH L IS ELEVATED AND ITS LEVEL EXCEEDS LDH2. THIS MAKES LDH1/LDH2 RATIO
“FLIPPED”
• NORMAL RANGE IS 100 TO 225 MU/ML.
• RANGE WITH MYOCARDIAL INFARCTION
• ONSET : 12 HRS.
• PEAKS : 48 HRS.
• RETURNS TO NORMAL : 10 TO 14 DAYS
 CREATININE PHOSPHOKINASE (CK- MB)
• IT IS THE MOST CARDIAC SPECIFIC ENZYME
• IT IS AN ACCURATE INDICATOR OF MYOCARDIAL DAMAGE
• NORMAL RANGE IS :
• MALES : 50-325 MU./ML
• FEMALES : 50-250 MU / ML.
• RANGE WITH MYOCARDIAL INFARCTION
• ONSET : 3 TO 6 HRS.
• PEAKS : 12 TO 18 HRS.
• RETURNS TO NORMAL : 3 TO 4 DAYS
 URINALYSIS

• THIS TEST IS PERFORMED TO ASSESS THE EFFECTS OF CARDIOVASCULAR

DISEASE ON RENAL FUNCTION AND THE EXISTENCE OF CONCURRENT RENAL
OR SYSTEMIC DISEASES, E.G. GLOMERULONEPHIRITIS, HYPERTENSION OR
DIABETES.
• ALBUMINURIA IS DETECTED IN CLIENTS WITH MALIGNANT HYPERTENSION AND
CHF.
• MYOGLOBINURIA SUPPORTS DIAGNOSIS OF M.I
SERUM ELECTROLYTES
• ELECTROLYTES AFFECT CARDIAC CONTRACTILITY,
SPECIFICALLY NA, K, CA
• NORMAL RANGE IS AS FOLLOWS :
• NA: 135 TO 145 MEQ. / L
• K: 3.5 TO 5 MEQ. / L
• ELECTROCARDIOGRAPHY (ECG, EKG)
• IT IS THE GRAPHICAL RECORDING OF THE ELECTRICAL ACTIVITIES OF THE HEART. IT
INDICATES ALTERATIONS IN MYOCARDIAL OXYGENATION.
• IT IS THE FIRST DIAGNOSTIC TEST DONE WHEN CARDIOVASCULAR DISORDER IS
SUSPECTED.
• INFORM THE CLIENT THAT THE PROCEDURE IS PAINLESS. HE WILL NOT EXPERIENCE
ELECTROCUTION OR SHOCK.
• WAVES, COMPLEXES AND INTERVALS.
• P WAVE. DEPOLARIZATION OF ATRIA. DURATION IS 0.04 TO 0.11 SECS.
• PR INTERVAL. TIME OF IMPULSE TRANSMISSION FROM THE SA NODE TO THE AV NODE.
DURATION IS 0.12 TO 0.20 SECS.
• QRS COMPLEX. DEPOLARIZATION OF THE VENTRICLES. DURATION IS 0.05 TO 0.10 SECS.
• MAGNETIC RESONANCE IMAGING (MRI)
 
• STRONG MAGNETIC FIELD AND RADIOWAVES ARE USED TO DETECT AND
DEFINE DIFFERENCES BETWEEN HEALTHY AND DISEASED TISSUES.
• MRI CAN ACTUALLY SHOW THE HEART BEATING AND THE BLOOD FLOWING IN
ANY DIRECTION. IT CAN IMAGE OVER THREE SPATIAL DIMENSIONS AND OVER
TIME.
• IT IS USED FOR EXAMINATION OF THE AORTA, DETECTION OF TUMORS,
CARDIOMYOPATHIES AND PERICARDIAC DISEASE.
NURSING INTERVENTIONS: MRI
• SECURE WRITTEN CONSENT.
• INFORM THE CLIENT THAT THE PROCEDURE LASTS 45 TO 60 MINUTES.
• ASSESS FOR CLAUSTROPHOBIA. THE CLIENT WILL BE PLACED IN A TUNNEL – LIKE
DEVICE.
• REMOVE ALL MENTAL ITEMS, E.G. WATCH, EYEGLASSES AND JEWELRY.
• INSTRUCT THE CLIENT TO REMAIN STILL DURING THE PROCEDURE.
• INFORM THE CLIENT THAT MRI UNIT MAKES LOUD, KNOCKING NOISE.
• CAUTION: CLIENTS WITH PACEMAKERS, PROSTHETIC VALVES OR RECENTLY
IMPLANTED CLIPS OR WIRES ARE NOT ELIGIBLE FOR MRI SCANS.
 CARDIAC FAILURE

  INABILITY OF THE
HEART TO PUMP SUFFICIENT BLOOD TO MEET THE
NEEDS OF THE TISSUES FOR OXYGEN AND NUTRIENTS
 HEART FAILURE INDICATES MYOCARDIAL DISEASE IN WHICH THERE IS A
PROBLEM WITH CONTRACTION OF THE HEART (SYSTOLIC
DYSFUNCTION) OR FILLING OF THE HEART (DIASTOLIC DYSFUNCTION) THAT
MAY OR MAY NOT CAUSE PULMONARY OR SYSTEMIC CONGESTION.
 HEART FAILURE IS MOST OFTEN A PROGRESSIVE, LIFE-LONG CONDITION
THAT IS MANAGED WITH LIFESTYLE CHANGES AND MEDICATIONS
 LEFT-SIDED HEART FAILURE

• PULMONARY CONGESTION OCCURS WHEN THE LEFT

VENTRICLE CANNOT EFFECTIVELY PUMP BLOOD OUT OF THE
VENTRICLE INTO THE AORTA AND THE SYSTEMIC CIRCULATION
• VENOUS BLOOD VOLUME AND PRESSURE INCREASES,
FORCING FLUID FROM THE PULMONARY CAPILLARIES INTO THE
PULMONARY TISSUES AND ALVEOLI, CAUSING PULMONARY
INTERSTITIAL EDEMA AND IMPAIRED GAS EXCHANGE.
 RIGHT-SIDED HEART FAILURE

• FAILURE OF THE RIGHT VENTRICLE CAUSES CONGESTION IN THE

PERIPHERAL TISSUES AND THE VISCERA.
• THE RIGHT SIDE OF THE HEART CANNOT EJECT BLOOD AND CANNOT
ACCOMMODATE ALL THE BLOOD THAT NORMALLY RETURNS TO IT FROM
THE VENOUS CIRCULATION.
• INCREASED VENOUS PRESSURE LEADS TO JUGULAR VEIN DISTENTION 
 STAGES/CLASSIFICATION OF CARDIAC FAILURE
 STAGE A. PATIENTS AT HIGH RISK FOR DEVELOPING LEFT VENTRICULAR
DYSFUNCTION BUT WITHOUT STRUCTURAL HEART DISEASE OR SYMPTOMS OF
HEART FAILURE
 STAGE B. PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION OR STRUCTURAL
HEART DISEASE THAT HAS NOT DEVELOPED SYMPTOMS OF HEART FAILURE
 STAGE C. PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION OR STRUCTURAL
HEART DISEASE WITH CURRENT OR PRIOR SYMPTOMS OF HEART FAILURE
 STAGE D. PATIENTS WITH REFRACTORY END-STAGE HEART FAILURE REQUIRING
SPECIALIZED INTERVENTIONS
 PATHOPHYSIOLOGY

 SYSTOLIC HF RESULTS IN DECREASED BLOOD VOLUME BEING EJECTED FROM THE VENTRICLE
 THE SYMPATHETIC NERVOUS SYSTEM IS THEN STIMULATED TO
RELEASE EPINEPHRINE AND NOREPINEPHRINE
 DECREASE IN RENAL PERFUSION CAUSES RENIN RELEASE RESULTING TO THE FORMATION
OF ANGIOTENSIN I
 ANGIOTENSIN I IS CONVERTED TO ANGIOTENSIN II BY ACE, VASOCONSTRICTION OCCURS AND
STIMULATES ALDOSTERONE RELEASE, CAUSES SODIUM AND FLUID RETENTION
 REDUCTION IN THE CONTRACTILITY OF THE MUSCLE FIBERS OF THE HEART AS THE WORKLOAD
INCREASES
 COMPENSATION- THE HEART COMPENSATES FOR THE INCREASED WORKLOAD BY INCREASING THE
THICKNESS OF THE HEART MUSCLE (HYPERTROPHY)
 RISK FACTORS

 CORONARY ARTERY DISEASE

 ISCHEMIA
 HYPERTENSION
 VALVULAR DISEASE
 CLINICAL MANIFESTATION- LEFT SIDED HEART
FAILURE

• DYSPNEA PRECIPITATED BY MODERATE ACTIVITY

• COUGH ASSOCIATED WITH LEFT VENTRICULAR FAILURE IS
INITIALLY DRY AND NONPRODUCTIVE
• CRACKLES
• LOW OXYGEN SATURATION
• WEIGHT GAIN
 CLINICAL MANIFESTATION- RIGHT-SIDED HF

• LIVER ENLARGEMENT
• ABDOMINAL DISTENTION
• LOSS OF APPETITE
• FAINTING
• CHEST DISCOMFORT
• CYANOSIS
• EDEMA OF THE LOWER EXTREMITIES
ASSESSMENT AND DIAGNOSTIC FINDING
• ECG
• CHEST X-RAY
• SONOGRAMS (ECHOCARDIOGRAPHY)
• HEART SCAN
• CARDIAC CATHETERIZATION
• BLEEDING/CLOTTING TIME AND ELECTROLYTES
• ABG
• PULSE OXIMETRY
• ALBUMIN
• BUN
 PHARMACOLOGIC MANAGEMENT

• ACE INHIBITORS- PROMOTES VASODILATION

• ANGIOTENSIN II BLOCKERS- HELP DECREASE BLOOD PRESSURE
• BETA BLOCKERS- STOPS STIMULATION OF THE SYMPATHETIC
NERVOUS SYSTEM
• DIURETICS- REMOVES EXTRA FLUIDS
• CALCIUM CHANNEL BLOCKERS- PROMOTES VASODILATION RESULTING
TO DECREASE VASCULAR RESISTANCE
 NURSING MANAGEMENT
• ASSESS FOR SYMPTOMS OF DYSPNEA, FATIGUE AND EDEMA
• PROVIDE EDUCATION REGARDING THE DISEASE CONDITION
• ASSESS JUGULAR VEIN FOR POSSIBLE DISTENTION
• WEIGH PATIENT DAILY
• AUSCULTATE LUNGS FOR PRESENCE OF ADVENTITIOUS BREATH SOUNDS
• MONITOR LEVEL OF CONSCIOUSNESS
• ADMINISTER OXYGEN THERAPY
• ADMINISTER MEDICATIONS AS PRESCRIBED
• REPOSITION PATIENT ACCORDINGLY
 MYOCARDIAL INFARCTION

• DESTRUCTION OF THE MYOCARDIUM DUE TO THROMBUS

FORMATION THAT RESULTS TO OCCLUSION OF THE CORONARY
ARTERY
 RISK FACTORS

• Vasospasm or sudden constriction of the coronary artery

• Decrease oxygen supply
• Unmanaged hypertension
• Elevated cholesterol level
• Smoking
• Family history of cardiac problems
• Obesity
• Diabetes
• Stress
 PREVENTION

• Lifestyle and diet modification

• Smoking cessation
• Exercise
• Adequate rest and sleep
• Weight loss
 CLINICAL MANIFESTATIONS
• Chest pain
• Shortness of breath
• Tachycardia
• Tachypnea
• Cool clammy skin
• Dizziness
• Nausea and vomiting
• Fatigue
• Shortness of breath
 ASSESSMENT AND DIAGNOSTIC FINDING

• ECG
• Troponin I elevates at 4-6 hours; peak: 14-18 hours
• Electrolytes
• Lipid profile
• Other cardiac biomarkers
CARDIAC BIOMARKERS
 NURSING MANAGEMENT
• Rest
• Administration of oxygen
• Assessment of pain and vital signs
• Continuous monitoring
• Health education
• Emotional support
• Place patient in ICU attached to cardiac monitor
• Implement CBR without BRP
• Resume sexual activity within 6 weeks
 MEDICAL/PHARMACOLOGIC MANAGEMENT

1. Morphine
2. Oxygen
3. Nitroglycerin (maximum of 3 doses in 5 minutes interval)
4. Aspirin (80mg tabs)
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
PENROSE DRAIN
JACKSON PRATT DRAIN
HEMOVAC DRAIN
 ACUTE PULMONARY FAILURE

 A sudden life-threatening deterioration of the gas exchange

function of the lungs
 Failure of the lungs to provide adequate ventilation and
oxygenation for the blood
 PATHOPHYSIOLOGY

• Impaired ventilation and perfusion mechanism in the lungs

• Respiratory failure leads to impaired functioning of the nervous system
• Decrease oxygen supply to the tissues
• Possible tissue damage
 RISK FACTORS
• Trauma
• Injury
• Cardiac problems
• COPD
• Lung infections
• Asthma
• Smoking
• Genetics
 CLINICAL MANIFESTATION

• Restlessness • Tachypnea
• Fatigue • Cyanosis
• Headache • Diaphoresis
• Dyspnea • Respiratory arrest
• Increase air hunger
• Tachycardia
• Confusion
• Lethargy
 NURSING MANAGEMENT
• Assessment of the overall health status of the patient (history, vital signs)
• Administration of oxygenation therapy
• Repositioning and assisting in intubation procedure
• Continuous monitoring of the patient’s ventilator status and oxygenation level
• Arterial blood gas analysis
• Maintaining mechanical ventilation
• Intensive and critical monitoring of the patient’s condition
• Positioning and turning
• Oral care
• Promote range of motion exercises
• Administration of drugs as ordered
 MEDICAL MANAGEMENT

• Correction of the underlying cause

• Endotracheal intubation and maintaining mechanical ventilation
• Antibiotics for infection
• Bronchodilators
• Corticosteroids