FAR EASTERN UNIVERSITY

Institute of Nursing
A.Y 2022 – 2023 First Semester

Medical-Surgical Nursing 3
Acute Biologic Crisis (ABC)- Cardio
Altered Tissue Perfusion

MODULE 2 CARDIOVASCULAR DISEASES ISCHEMIC HEART DISEASE

Topic Outline • Also known as coronary artery disease
1. Nature of the Disease (CAD)
2. Diagnosis • Ischemic heart disease (IHD) is a condition
3. Pathophysiology and Plan of Care of in which there is an inadequate supply of
Critical Cardiovascular blood and oxygen to a portion of the
4. Cardiovascular Disease myocardium
a. Acute Ischemic Heart Disease • Imbalance between myocardial oxygen
b. Congestive Heart Failure supply and demand.
c. Hypertension Crisis • Caused mainly by Atherosclerosis of
d. Myocardial Infarction Coronary Artery
5. Pharmacologic Management • It includes – Angina: Stable & Unstable –
6. Nursing Process and Documentation Myocardial infarction – Heart failure &
Arrhythmia
CARDIOVASCULAR DISEASES
The cardiovascular system is sometimes called the Nursing Diagnosis
blood-vascular, or simply the circulatory system. It • Decreased cardiac output related to
consists of the heart (muscular organ that pumps electrical factors (dysrhythmias).
blood) and a closed system of vessels (arteries, • Decreased in myocardial contraction.
veins, and capillaries). • Structural abnormalities (papillary
muscular dysfunction and ventricular septal
Cardiovascular diseases is defined as any serious, rupture)
abnormal condition of the heart or blood vessels
• as Exchange
(arteries or veins). These includes coronary heart
disease (CHD), stroke, peripheral vascular disease,
ANGINA
congenital heart disease, endocarditis, and many
Angina is chest pain or discomfort caused when
other conditions.
your heart muscle doesn't get enough oxygen-rich
blood. It may feel like pressure or squeezing in your
CORONARY ARTERY DISEASE (CAD)
chest. The discomfort also can occur in your
It is the most prevalent type of cardiovascular
shoulders, arms, neck, jaw, or back.
disease in adult. For this reason, it is important for
the nurse to become familiar with various
TYPES OF ANGINAS
manifestation of coronary artery conditions and
• Stable Angina - episodic clinical
methods for assessing, preventing ang treating
syndrome where there is no change in
these disorders. Coronary artery disease Is the term
severity of attacks.
given to heart problems caused by narrow heart
(coronary) arteries that supply blood to the heart • Unstable Angina - Deterioration (24 hrs.)
muscles. in previous stable angina with symptoms
frequently occurring at rest, i.e., acute
Nursing Diagnosis coronary syndrome.
• Activity intolerance, excess fluid volume, • Intractable or Refractory Angina -
and decreased cardiac output. Severe incapacitating chest pain
• Decreased cardiac output. • Silent Ischemia - Objective evidence of
Ischemia (such as electrocardiographic
• Ineffective tissue Perfusion
changes with the stress test), but patient
• Ineffective Airway Clearance
reports no pain
 • Variant Angina (Prinzmetal) - Pain at rest o Nitroglycerin
with reversible ST-Segment elevation; • Lifestyle modification
thought to be caused by coronary artery • Vital signs
vasospasm • Assist w/ ambulation
• Provide emotional support
PATHOPHYSIOLOGY • Health teaching
• Reduced blood flow in a coronary artery • Pain differentiation
(rupture of an atherosclerotic plaque). • Medication
• A clot begins to form on top of the coronary • Diet, exercise, CABG
lesion, but the artery is not completely
occluded EVALUATION
• Flow cannot be increased resulting to Expected patient outcomes may include the
ischemia resulting to chest pain following:
1. Experiences relief of Angina
PRECIPITATING FACTORS 2. Has a stable cardiac and respiratory
• Overexertion status.
• Exposure to cold 3. Maintain adequate tissue perfusion
• Overeating
• Emotional stress MYOCARDIAL INFARCTION
Commonly known as a heart attack, occurs when
RISK FACTORS blood flow decreases or stops to a part of the heart,
• Diabetes Mellitus causing damage to the heart muscle.
• Atherosclerosis (hardening of the blood
vessels due to plaque formation) RISK FACTORS
• Hypertension • Age, Gender
• Hormonal imbalances • Lifestyle: Stress, Habits
• Diet
MEDICATIONS FOR ANGINA • Chronic illness: DM, HPN
Medication Indication
Nitrates Short- and long-term PATHOPHYSIOLOGY
Nitroglycerine (Nitrostat, reduction of myocardial Coronary occlusion due to thrombosis, embolism,
Nitro-Bid) oxygen consumption or hemorrhage adjacent to atherosclerotic plaque.
through selective
Insufficient blood flow from cardiac, hypertrophy,
vasodilation
Beta-adrenergic blocking Reduction of myocardial
hemorrhage, shock, or severe dehydration.
agents (Beta blockers) oxygen consumption by
Metropolol (Lopressor) blocking beta-adrenergic Comparison of Assessment
Atenolol (Tenormin) stimulation of the heart Angina Pectoris Myocardial
Calcium Ion Antagonists Negative inotropic Infarction
(Calcium Channel effects; indicated in Type squeezing, Sudden, severe,
Blockers) patients not responsive to pressing, crushing, heavy,
Amlodipine (Norvasc) beta-blockers; used as burning tightness
Dilriazem (Cardizem, primary treatment for Location Retrosternal, Substernal,
Tiazac) vasospasm substernal, left radiates to one or
Antiplatelet Medications Prevention of platelet of sternum, both arms, jaw,
Aspirin aggregation radiates to the neck
Clopidogrel (Plavix) left arm
Prasugrel (Effient) Duration Usually, 3-5 >30 mins
Anticoagulants Prevention of thrombus mins
Heparin formation duration<30
Low-molecular weight mins
heparins Relief Rest, Oxygen,
Enoxaparin (Lovenox) nitroglycerin narcotics
Not relieved by
NURSING CARE MANAGEMENT rest and
nitroglycerin
• Provide relief from pain: Subjective Dyspnea, Shortness of
o Rest Data palpitation, breath,
 dizziness, apprehension, 2. Obtain 12-lead electrocardiogram to be
faintness fear of impending read within 10 minutes.
death, nausea 3. Obtain laboratory blood specimens of
Objective Data Tachycardia, Symptoms of
cardiac biomarkers, including troponin.
pallor, shock, cyanosis,
diaphoresis diaphoresis, 4. Begin routine medical interventions
restless • Supplemental oxygen
• Nitroglycerin
DIAGNOSTIC TESTS • Morphine
• ECG • Aspirin
• chest x-ray • Beta-blocker
• chest CT • Angiotensin-converting enzyme
• coronary CT angiography inhibitor within 36 hours
• cardiac MRI, • Anticoagulation with heparin and
• coronary angiography platelet inhibitors Statin
• echocardiogram 5. Evaluate for indications for reperfusion
therapy:
NURSING MANAGEMENT
• Reduce pain & discomfort • Percutaneous coronary intervention
o Narcotics, O2, Semi-fowler’s • Thrombolytic (fibrinolytic) therapy
position to improve ventilation • Continue therapy as indicated:
• Maintain adequate circulation. • IV heparin, low–molecular-weight
• Monitor VS, Urine Output & ECG heparin
• Meds: Anti-arrythmics & anticoagulants • Clopidogrel (Plavix)
• Check for edema, cyanosis, dyspnea, 6. Bed rest for a minimum of 12–24 hours
cough, crackles 7. Statin prescribed at discharge.
• CVP: normal= 5-15cm H20
• ROM, anti-embolic stockings INVASIVE CORONARY ARTERY (1&2)
• Decrease oxygen demand/ Promote AND SURGICAL PROCEDURES (3):
oxygenation 1. Coronary artery bypass graft (CABG)-
o O2, Bedrest (24-48 hrs), rest periods performed with the patient under general
o Semi-fowler’s position anesthesia (saphenous vein, left internal
• Anticipate needs of client: call light, water mammary artery) is grafted distal to the
• Meds: vasodilators, vasopressors, Calcium coronary artery lesion, bypassing the
channel Blockers obstruction
• Maintain fluid & electrolyte balance / 2. Percutaneous Transluminal Coronary
Nutrition Angioplasty (PTCA)- one at cardiac lab.
• Keep IV open; CVP, VS, UO Insertion of catheter at the femoral artery,
• Lab data: Na+135-145; K 3.5-5.0 mEq/L sometimes at the radial vein going to the
• ECG aorta, and into the coronary arteries.
• Diet: low calorie, low sodium, low 3. Coronary Artery Stent- metal mesh that
cholesterol, low fat provides structural support to a vessel at
risk of acute closure (partially/complete)
• Facilitate fecal elimination
after PTCA.
o stool softener, avoid Valsalva,
mouth breathing, bedside commode
Sample PTCA Procedure
• Provide emotional support
A. Balloon-tipped catheter is passed
• Promote sexual functioning into the affected coronary artery and
• discuss concerns include partner placed across the area of the
• resume 5-8 wks. after uncomplicated MI atheroma (plaque).
• Health teaching B. Balloon is then rapidly inflated and
deflated with controlled pressure.
TREATMENT GUIDELINES FOR ACUTE C. A stent is placed to maintain patency
MYOCARDIAL INFARCTION of the artery, and the balloon is
1. Use rapid transit to the hospital. removed
 POSSIBLE COMPLICATIONS AFTER accumulates in the left ventricle, left
PTCA SURGERY atrium.
• Myocardial Ischemia • Pulmonary congestion forcing fluid from
• Bleeding and hematoma formation pulmonary capillaries into pulmonary
• Retroperitoneal hematoma tissue and alveoli causing pulmonary
• Arterial Occlusion interstitial edema and impaired gas
• Pseudoaneurysm exchange.
• Arteriovenous fistulas formation
• Acute kidney injury
Right Heart Failure
• In right sided heart failure right ventricle
cardiac output is less then volume received
from the peripheral venous circulation,
blood accumulates in RA, RV and
peripheral venous system.
• Increased venous pressure led to JVD and
increased capillary hydrostatic pressure
throughout the venous system.

High and Low Output Heart Failure

• High output failure occurs in response to
condition that causes the heart to work
harder to supply blood; the increase oxygen
demand can only meet only with an
POTENTIAL COMPLICATIONS OF increase in cardiac output.
CARDIAC SURGERY • Low output failure occurs in response to
• Hypovolemia (Most common cause of high BP of hypovolemia which results in
decreased cardiac output after cardiac impaired peripheral circulation and
surgery) vasoconstrictions.
• Persistent Bleeding
• Cardiac tamponade ETIOLOGY
• The incidence of heart failure increases
HEART FAILURE with advancing age and coronary artery
• Heart failure is often referred as congestive disease
Heart failure is often referred as congestive • Diabetes
heart failure (CHF). Occurs when heart is • Cigarette Smoking
unable to pump sufficiently to maintained • Obesity
blood flow to meets the body needs • Elevated Total Cholesterol
• This condition results of SYSTOLIC • Abnormally High or Low Hematocrit Level
DYSFUNCTIONS or DIASTOLIC • Proteinuria
DYSFUNCTIONS.
COMMON PRECIPITATING CAUSES OF
NURSING DIAGNOSIS HEART FAILURE
1. Decreased cardiac output • Anemia
2. Activity intolerance • Infection
3. Excess fluid volume • Thyrotoxicosis
4. Risk for impaired gas exchange • Hypothyroidisms
5. Risk for impaired skin integrity • Arrhythmias
• Bacterial Endocarditis
CLASSIFICATIONS OF HEART FAILURE • Valvular Dysfunction
Left Heart Failure • Pulmonary Embolism
• In left sided heart failure, left ventricle • Pulmonary Disease
cardiac output is less then volume received • Pagats Disease
from pulmonary circulation; blood • Nutritional Deficiencies
• Hypovolemia
 MEDICAL MANAGEMENT Nursing Intervention
• Eliminate or reduce any etiologic • Promoting activity tolerance
contributory factors, such as uncontrolled • Managing fluid volume
hypertension or atrial fibrillation with a • Controlling Anxiety
rapid ventricular response • Monitoring and managing potential
• Optimize Pharmacologic and other Complication
therapeutic regimens
• Reduce the workload on the heart by NURSING MANAGEMENT
reducing preload and afterload • administer medications and assess the
• Promote a lifestyle conducive to cardiac patient's response.
health • assess fluid balance, including intake and
• Prevent episodes of acute decompensated output, with a goal of optimizing fluid
HF volume.

PHARMACOLOGICAL MANAGEMENT SURGICAL MANAGEMENT

• Digoxin (Digitalis) • Heart Transplantation: When the heart is
• Beta blocker (-olol) irreversibly managed and no longer
• Inotropes functions adequately and when the client is
• Angiotensin II receptor blockers (ARBs) (- at risk of dying, cardiac transplantation and
sartan_ use of an artificial heart to assist or replace
• Ace inhibitors- can raise potassium levels the failing heart are measures.
o Accupril (quinapril), 20-40 mg; one • A heart transplant, or a cardiac transplant,
10 or 20 mg tablet 2x/day on an is a surgical transplant procedure performed
empty stomach, 1 hour before or 2 on patients with end-stage heart failure or
hours after a meal or with a light, severe coronary artery disease when other
low-fat meal. medical or surgical treatments have failed
• Water Pills - There are many brands of of last resort.
diuretics. Some are taken once a day.
Others are taken 2 times a day. The most PRE-OPERATIVE
common types are: • A typical heart transplantation begins when
o Chlorothiazide (Diuril), a suitable donor heart is identified. The
chlorthalidone (Hygroton) heart comes from a recently deceased or
brain-dead donor, also called a beating
NURSING PROCESS heart cadaver.
ASSESSMENT • The patient is also given
Observe for effectiveness of therapy and for the immunosuppressant medication so that the
patient’s ability to understand and implement self- patient's immune system does not reject the
management strategies. Sign and symptoms of new heart.
pulmonary and systemic fluid overload.
PROCEDURES
Nursing Diagnosis • Orthotopic heart transplantation (OHT)
• Activity intolerance and fatigue related to is a well-established and commonly utilized
decreased cardiac output. procedure for end-stage heart failure
• Excess fluid volume related to the Heart patients. Heterotopic heart transplantation
Failure syndrome. (HHT) is a surgical procedure that allows
• Anxiety related to breathlessness from the graft to be connected to the native heart
inadequate oxygenation. in a parallel fashion.

Planning • Heterotopic heart transplantation (HHT)

• Promote activity and reduce fatigue is a surgical procedure that allows the graft
• Relieve fluid overload syndrome to be connected to the native heart in a
• Decreasing anxiety and encourage patient parallel fashion. The main advantage of
to verbalize HHT is to assist the patient's native heart
• Teach the patient about self-care program
 and to maintain circulation in the cases of
severe acute rejection. HYPERTENSIVE URGENCY
• defined as an elevation of SBP
• Total Artificial Heart (TAH) (>220mmHg) and/or DBP (>125mmHg)
Much research has been conducted trying to without evidence of acute end-organ
develop a mechanical device that can damage.
permanently replace the heart and has no • defined as a sudden increase in systolic
external tubes or cables. Several successful and/or diastolic BP associated with end-
cases have been reported. However, organ damage of the CNS, the heart, or the
research is continuing. kidneys.
• Not necessitate admission to ICU
• Ventricular Assist Device (VAD) • BP is lowered gradually over a period of 24
It is an Electromechanical device for to 48 h
assisting cardiac circulation, which is used • Usually treated with rapid-acting oral
either to partially or to completely replace antihypertensive agents
the function of a failing heart.
ORAL DRUGS
The function of VADs is different from that • ACE Inhibitors : ex. Captopril, Capo tent.
of artificial cardiac pacemakers; some are • B- blockers: labetalol
for short-term use, typically for patients • Clonidine guanabenz, prazosin, and
recovering from myocardial infarction minoxidil
(heart attack) and for patients recovering • Loop diuretic: is generally prescribed in
from cardiac surgery. addition to be antihypertensive agents.

HYPERTENSION ETIOLOGY OF HYPERTENSIVE CRISIS

Hypertension is another name for high blood • may occur in patients with no history of the
pressure. It can lead to severe health complications condition or can be precipitated by
and increase the risk of heart disease, stroke, and noncompliance with medical therapy or
sometimes death. Blood pressure is the force that a diet, or both; or by inadequate treatment.
person's blood exerts against the walls of their • Common causes include
blood vessels. 1. ARF
2. Acute CNS events
CLASSIFICATIONS OF HYPERTENSION 3. Drug-induced hypertension
Stage Systolic Pressure Diastolic 4. Ingestion of tyramine-containing foods
(mmHg) Pressure or beverages during treatment with a
(mmHg) monoamine oxidase inhibitor (MAOI)
1 140-159 90-99 5. Pregnancy-induced epilepsies
2 160-179 100-109 6. Pheochromocytoma
3 ³180 110
MANIFESTATION
HYPERTENSIVE CRISES Hypertensive crisis can be manifested by any of the
A hypertensive crisis is a severe increase in blood following symptoms, depending on the end-organ
pressure that can lead to a stroke. Extremely high involved
blood pressure — a top number (systolic pressure) 1. ARF, identified by a sudden absence of
of 180 millimeters of mercury (mm Hg) or higher urine output Catecholamine excess.
or a bottom number (diastolic pressure) of 120 mm 2. Cardiovascular compromise, identified by
Hg or higher — can damage blood vessels. the chest pain of an acute coronary
syndrome or aortic dissection.
Nursing Diagnosis
• Risk for decreased cardiac output PHARMACOLOGIC MANAGEMENT
• Activity intolerance Drugs commonly used to treat:
• Acute Pain 1. Angiotensin-converting enzyme (ACE)
• Ineffective Coping inhibitors
• Imbalanced Nutrition: More than body 2. Angiotensin receptor blockers (ARBs)
requirements. 3. Diuretics
 4. Beta-blockers
5. Calcium channel blockers

NURSING MANAGEMENT
• Monitor blood pressure frequently
• Administer antihypertensive medications
as prescribed.
• Have two large-bore IVs.
• Provide oxygen f the saturations are low
(less than 94%)
• Limit fluid intake if the patient is in heart
failure.
• Assess ECG to ensure the patient is not
having a heart attack.

HYPERTENSIVE EMERGENCY
• A hypertensive emergency is an acute,
marked elevation in blood pressure that is
associated with signs of target-organ
damage. These can include pulmonary
edema, cardiac ischemia, neurologic
deficits, acute renal failure, aortic
dissection, and eclampsia.

References
Doenges, Marilynn E. , Mary Frances Moorhouse
& Alice C. Murr. “Nurse’s Pocket Guide:
Diagnoses, Prioritized Interventions and
Rationales”. 14th Edition.
Kozier, Barbara, Glenora Erb & Co.
“Fundamentals of Nursing Concepts, Process
and Practice”. 10th Edition. 2016.
Suzanne C. Smeltzer & Brenda G. Bare. “Brunner
& Suddarth’s Textbook of Medical – Surgical
Nursing.” 14 Edition. 2018