NURSING CARE

OF CLIENTS WITH
ALTERED TISSUE
PERFUSION
Continuation - October 7, 2021
C. planning
Recognize myocardial
ischemia
Signs and Symptoms of Myocardial Ischemia:

Cardiovascular:
● Chest pain or discomfort not relieved by rest or nitroglycerin
● Increased jugular venous distention
● Elevated or decreased blood pressure
● Irregular pulse
● Electrocardiogram may show tachycardia, bradycardia, or other
dysrhythmias.
Jugular venous
distention
Recognize myocardial
ischemia
Respiratory:

● Shortness of breath
● Dyspnea
● Tachypnea
● Crackles

Genitourinary:

● Decreased urinary output

Recognize myocardial
ischemia
Skin: Psychological:

● Cool ● Fear with feeling of impending

● Clammy doom, or denial that anything
● Diaphoretic is wrong.
● Pale appearance

Neurologic:

● Anxiety
● Restlessness
● Lightheadedness
Relieve chest pain
● Administration of pain medications, as indicated
● Physical rest in bed with the head of the bed elevated or in a
supportive chair helps decrease chest discomfort and dyspnea.
● Elevate the head and torso of the patient.
● Balancing myocardial oxygen supply and demand
Maintain a calm
environment
● A calm, caring manner during nursing care is essential to lower patient and
stress levels.
● Individual evaluation of the patient and the family is necessary to determine
the most appropriate management of visiting.
● Keep a quiet environment
● Prevent interruptions that disturb sleep
● Providing spiritual support consistent with the patient’s belief
Balance of myocardial oxygen supply
and demand
● Top priority
● Oxygen should be given along with other medication therapy.
● To reduce pain
● A flow rate of 2 to 4 L/min is usually enough to maintain oxygen
saturation levels of at least 95% unless chronic pulmonary disease is
present.
Optimize cardiopulmonary
function

● Assessment of respiratory function

● Monitor fluid volume status to prevent fluid overload
● Encourage patient to breathe deeply and change position
frequently
● Use pulse oximeters to guide the use of oxygen therapy.
Promote comfort and emotional
support
Reducing Anxiety:

● Reduces the sympathetic stress response

● Less sympathetic stimulation decreases the workload of the heart, which
may relieve pain and other signs and symptoms of ischemia.
● Provide information to the patient and family

Providing comfort:

● Reduce pain
● Elevate head and torso
Monitor effects of pharmacological
therapy

● Provision of medications and assessment of the effectiveness of

treatment is a major component of the nurse’s role in caring for the
cardiac patient.
● Many of the medications are accompanied by side effects and
interactions with other drugs, which the nurse must monitor.
Patient education
Lifestyle Modifications:

● Avoid any activity that produces chest pain, extreme dyspnea, or

undue fatigue
● Avoid extremes of heat and cold and walking against the wind.
● Lose weight, as indicated
● Stop smoking and the use of tobacco; avoid secondhand smoke.
● Develop heart-healthy eating patterns, and avoid large meals and
hurrying while eating
Patient education

● Modify meals to align with the Therapeutic Lifestyle Changes (TLC) or

other recommended diets
● Adhere to medical regimen, especially in taking medications.
● Follow recommendations that ensure that blood pressure and blood
glucose are in control.
● Pursue activities that relieve and reduce stress.
Patient education

Managing Symptoms:

● Call 911 if chest pressure or pain is not relieved in 15 minutes by taking 3

nitroglycerin tablets at 5-minute intervals.
● Contact the primary provider if any of the following occur: shortness of
breath, fainting, slow or rapid heartbeat, swelling of feet and ankles.
MEDICAL/SURGICAL
MANAGEMENT
 Medical Interventions
Medical Interventions
Treatment goals for AMI are to establish reperfusion, reduce infarct size, prevent and treat complications, and provide
emotional support and education. Medical treatment of AMI is aimed at relieving pain, providing adequate
oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through
thrombolytic therapy or acute interventional therapy, such as angioplasty.
Pain Relief
The initial pain of AMI is treated with morphine sulfate administered by the IV route. The dose is 2 to 4 mg IV push
over 5 minutes.
Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for
repairing the damaged tissue around the site of the infarct. Treatment with oxygen via nasal cannula at 4 to 6 L/min
assists in maintaining oxygenation. Rest also helps to improve oxygenation. The goal is to maintain oxygen saturation
above 90%.
 Medical Interventions
Prevention of Platelet Aggregation Alterations in platelet function contribute to occlusion of the coronary arteries.
Aspirin (325 mg) is given immediately to all patients with suspected AMI. Aspirin blocks synthesis of thromboxane A2,
thus inhibiting aggregation of platelets.

Thrombolytic Therapy One common treatment for STEMI is thrombolytic therapy. Research has shown that
occlusion of the coronary vessel does not cause immediate myocardial cell death. Ischemia begins within minutes of
the vessel occlusion, and prolonged injury results in AMI. The goals are to dissolve the lesion that is occluding the
coronary artery and to increase blood flow to the myocardium.

Percutaneous coronary intervention (PCI) is performed in the management of AMI with improved outcomes over
thrombolytic therapy. PCI should be performed within 90 minutes of arrival to the emergency department, with a
target of less than 60 minutes (termed door to balloon time).
 recanalization
Recanalization formation of new canals or paths, especially blood vessels, through an obstruction such as a clot;
called also canalization.

Vascular recanalization- Recanalization of vessels in any location in the body is performed using a laser endoscope.
A laser endoscope uses optic fibers to allow the radiologist to see and remove plaques (blockages) from arteries.

Deep venous recanalization- If you have chronic deep venous thrombosis, or blood clots in the legs, venous
recanalization is a minimally invasive procedure that breaks down clots to prevent them from traveling to the heart or
lungs.
 Percutaneous Transluminal
Angioplasty
Percutaneous transluminal angioplasty (PTA) is a procedure that can open up a blocked blood vessel using a
small, flexible plastic tube, or catheter, with a "balloon" at the end of it. When the tube is in place, it inflates to open
the blood vessel, or artery, so that normal blood flow is restored.

Why is it necessary?
Fatty deposits can build up in your blood vessels, reducing blood flow and in some cases, blocking it completely. The
biggest danger from fat build up is that pieces may break off, form clots, and cause a heart attack or stroke. The PTA
can open blocked arteries and reduce these risks.
Percutaneous Transluminal
Angioplasty
 CABG
BYPASS SURGERY
Coronary artery bypass grafting, or "CABG" (pronounced "cabbage"), is a common heart procedure. A surgeon
takes a section of a healthy blood vessel from your leg, chest, or arm. The vessel is then connected (grafted) to your
coronary artery slightly past the site of the blockage. This creates a new path for blood to flow around (bypass) the
blockage in the artery so it can get to your heart. Patients undergoing bypass are put under general anesthetic and
are not awake during surgery. Two bypass surgical procedures for coronary artery disease are: (1) beating heart
surgery and (2) arrested heart surgery.

● Beating heart surgery – Also known as off-pump surgery, beating heart surgery is done while the heart is beating.
This often requires special equipment that allows the surgeon to operate on the heart while it is moving. Beating heart
surgery is appropriate for certain patients.

● Arrested heart surgery – Most CABG surgeries are done through an incision in the chest while the heart is stopped
and a heart-lung machine takes over the job of circulating the blood. This is called arrested heart surgery or
conventional bypass surgery
CABG
 Pacemakers
What is a pacemaker?
A pacemaker is a device that sends small electrical impulses to the heart muscle to maintain a suitable heart rate or
to stimulate the lower chambers of the heart (ventricles). A pacemaker may also be used to treat fainting spells
(syncope), congestive heart failure and hypertrophic cardiomyopathy.

Electrical System of the Heart

The atria and ventricles work together, alternately contracting and relaxing to pump blood through the heart. The
electrical system of the heart is the power source that makes this possible.

Normally, the electrical impulse begins at the sinoatrial (SA) node, located in the right atrium. The electrical activity
spreads through the walls of the atria, causing them to contract.

Next, the electrical impulse travels through the AV node, located between the atria and ventricles. The AV node acts
like a gate that slows the electrical signal before it enters the ventricles.
 Pacemakers
This delay gives the atria time to contract before the ventricles do. From the AV node, the electrical impulse travels
through the His-Purkinje network, a pathway of specialized electricity-conducting fibers. Then the impulse travels into
the muscular walls of the ventricles, causing them to contract. This sequence occurs with every heartbeat (usually
60-100 times per minute).

Why do I need a pacemaker?

If the electrical pathway described above is interrupted for any reason, changes in the heart rate and rhythm occur
that make a pacemaker necessary.
 Cardioversion
What is electrical cardioversion?
Cardioversion is a procedure used to return an abnormal heartbeat to a normal rhythm. This procedure is used when the heart is beating
very fast or irregularly. This is called an arrhythmia. Arrhythmias can cause problems such as fainting, stroke, heart attack, and even
sudden cardiac death. With electrical cardioversion, a high-energy shock is sent to the heart to reset a normal rhythm. It is different from
chemical cardioversion, in which medicines are used to try to restore a normal rhythm.
 Ablation
Radiofrequency catheter ablation is a method used to treat dysrhythmias when medications, cardioversion, or both,
are not effective or not indicated. The objective of catheter ablation is to permanently interrupt electrical conduction or
activity in a region of dysrhythmogenic cardiac tissue

What is ablation for atrial fibrillation?

Ablation is a procedure to treat atrial fibrillation. It uses small burns or freezes to cause some scarring on the inside of
the heart to help break up the electrical signals that cause irregular heartbeats. This can help the heart maintain a
normal heart rhythm.
Ablation
 IABP
What is intra-aortic balloon pump therapy?
An intra-aortic balloon pump (IABP) is a type of therapeutic device. It helps your heart pump more blood. You may
need it if your heart is unable to pump enough blood for your body.

The IABP consists of a thin, flexible tube called a catheter. Attached to the tip of the catheter is a long balloon. This is
called an intra-aortic balloon, or IAB. The other end of the catheter attaches to a computer console. This console has
a mechanism for inflating and deflating the balloon at the proper time when your heartbeats.

When the heart contracts, it sends blood out to the body. As it relaxes, blood flows into the coronary arteries to bring
oxygen to the heart. An IABP allows blood to flow more easily into your coronary arteries. It also helps your heart
pump more blood with each contraction.
IABP
 Heart Transplantation
What is a heart transplant?
A heart transplant is a surgery to remove the diseased heart from a person and replace it with a healthy one from an
organ donor. To remove the heart from the donor, two or more healthcare providers must declare the donor
brain-dead.

Why might I need a heart transplant?

You may need a heart transplant if your heart is failing and other treatments are not effective.
End-stage heart failure is a disease in which the heart muscle is failing severely in its attempt to pump blood through
the body. It means other treatments are no longer working. End-stage heart failure is the final stage of heart failure.
Despite its name, a diagnosis of heart failure does not mean the heart is about to stop beating. The term failure
means the heart muscle is failing to pump blood normally because it is damaged or very weak, or both.
 Palliative Care for End -Stage Heart
Failure
1. Palliative Care AHA/ASA Policy Statement: Palliative care is an essential health benefit that is central to
high-quality overall care. Integrating palliative care in the management of patients with advanced CVD and stroke
may provide the following benefits:
• Improved patient and caregiver understanding of the disease, treatment, and prognosis.
• Improved treatment of symptoms and relief of suffering.
• Shared decision-making based on patient values, preferences, and goals.
• Enhanced patient-clinician communication.
• Individual advance care planning based on benefits, risks, and burdens of care.
• Improved patient and caregiver outcomes.
• Improved preparation for end-of-life and associated care.
• Bereavement support Palliative Care Symptom Management of Life-Limiting Illness End-of-Life Care / Hospice
Symptom Management and Comfort Care Circulation.
 Pharmacological Management
DIURETICS- first-line drugs for all patients with signs of volume overload. Diuretics work by reducing blood volume,
therefore, decreasing venous pressure, arterial pressure, pulmonary edema, peripheral edema, and cardiac dilation.

Mechanism of action: inhibit reabsorption of sodium and chloride in the ascending loop of Henle and distal renal
tubule, interfering with the chloride-binding cotransport system, causing increased excretion of water, sodium,
chloride, magnesium, and calcium.

Commonly used diuretics include:

Thiazide diuretics [hydrochlorothiazide (Microside)]- are oral agents that produce moderate diuresis and
are used for long-term therapy of heart failure when edema is moderate.
Loop diuretics [furosemide (Lasix), ethacrynic acid (Edecrin)]- drug of choice for patients with severe
heart failure. Loop diuretics can also cause severe hypotension.
Potassium-sparing diuretics [spironolactone (Aldactone)]- are used to counteract potassium loss caused
by thiazide and loop diuretics, thereby reducing the risk of digoxin-induced dysrhythmias
 Pharmacological Management
Vasodilators, arterial dilators, and combination drugs
Commonly used vasodilators include:

Isosorbide dinitrate (ISDN) [Nitro Dur, Isordil]- causes selective dilation of veins. For
patients with severe refractory HF, ISDN can reduce congestive symptoms and improve
exercise capacity.

Hydralazine [Apresoline] causes selective dilation of arterioles therefore can help improve
cardiac output and renal blood flow.
Pharmacological Management
Vasodilators, arterial dilators, and combination drugs
Commonly used vasodilators include:

Nitroglycerin when given intravenously is a powerful venodilator that produces a dramatic reduction
in venous pressure.

Sodium nitroprusside [Nitropress] rapidly dilates arterioles and veins.

Nesiritide administration leads to a rapid and balanced vasodilatory effect
Pharmacological Management
Angiotensin-converting enzyme (ACE) inhibitors- blocks the
renin-angiotensin-aldosterone-system (RAAS) by inhibiting the conversion
of angiotensin I to angiotensin II. These drugs also decrease the release
of aldosterone and suppressing the degradation of kinins.

Angiotensin II receptor blockers (ARBs)- They prevent the

vasoconstrictor and aldosterone-secreting effects of angiotensin II by
binding to the angiotensin II receptor sites.
PHARMACOLOGICAL MANAGEMENT
Digitalis (Lanoxin)- second-line agent for heart failure. Digoxin is a
cardiac glycoside that increases the myocardial contractile force (positive
inotropic action). Monitor the renal function and serum potassium levels of
patients taking digitalis.

Inotropic agents- these medications are useful for short-term or acute

treatment of HF unresponsive to cardiac glycosides, vasodilators, and
diuretics to increase myocardial contractility and produce vasodilation.
PHARMACOLOGICAL MANAGEMENT
Beta-adrenergic receptor antagonists- Beta-blockers directly block the negative
effects of the SNS on heart failure. Caution must be taken for patient’s volume overload
as they can reduce myocardial contractility.

Morphine sulfate- Decreases vascular resistance and venous return, reducing

myocardial workload, especially when pulmonary congestion is present.

Antianxiety agents and sedatives- Promote rest, reducing oxygen demand and
myocardial workload.

Anticoagulants: low-dose heparin, warfarin (Coumadin)- Anticoagulants are used

prophylactically to prevent thrombus and embolus formation in the presence of risk
factors such as venous stasis, enforced bed rest, cardiac dysrhythmias, and history of
previous thrombotic episodes.
COMPLIMENTARY/
ALTERNATIVE
THERAPIES
 ALTERNATIVE THERAPIES
Fish Oil/ Omega 3 Fatty Acids
Omega-3 fatty acids are essential nutrients that are important in preventing

and managing heart disease.

Findings show omega-3 fatty acids may help to:

● Lower blood pressure

● Reduce triglycerides
● Slow the development of plaque in the arteries
● Reduce the chance of abnormal heart rhythm
● Reduce the likelihood of heart attack and stroke
● Lessen the chance of sudden cardiac death in people with heart disease
 ALTERNATIVE THERAPIES

HAWTHORN- Control high blood pressure and high

cholesterol. It has also been used on the skin to treat boils
and skin sores.
 ALTERNATIVE THERAPIES
Ginko Biloba
May improve memory function, relieve stress,
treat dizziness, improves blood circulation and antioxidant.

Medicinal Uses and Indications

Based on studies conducted in laboratories, animals, and people,
ginkgo is used for the following:
● Dementia and Alzheimer disease
● Intermittent claudication
● Anxiety
● Glaucoma
● Memory and thinking
● Macular degeneration
● Premenstrual syndrome (PMS)
● Raynaud's phenomenon
 ALTERNATIVE THERAPIES
Ginseng- Stimulates mental activity; enhances immune system, appetite.

● Reduce the risk of cancer

● Help boost the immune system
● Improve mental performance and well being

Available forms include:

● Standardized extract
● Fresh root
● Dried root
● Tincture (1:5)
● Fluid extract (1:1)
 ALTERNATIVE THERAPIES
GARLIC- Used to help prevent heart disease, including atherosclerosis
or hardening of the arteries (plaque buildup in the arteries that can
block the flow of blood and may lead to heart attack or stroke), high
cholesterol, high blood pressure, and to boost the immune system.
Eating garlic regularly may also help protect against cancer.
PATIENT EDUCATION
 PATIENT EDUCATION
Eat Right
Healthy food habits can help you reduce three of the major risk factors for heart attack: high
cholesterol, high blood pressure and excess body weight. The best way to help lower your
blood cholesterol level is to eat less saturated fat, avoid cholesterol and control your weight.
● Eat a variety of fruits, vegetables and grain products, especially whole grains.
● Consume fat-free and low-fat dairy products, fish, beans, skinless poultry and lean
meats.
● Limit foods high in saturated fat, trans fat and cholesterol.
 PATIENT EDUCATION
Be Active
Physical activity is good for your entire body, especially your heart. While getting into a
regular exercise routine is great, there are a number of quick ways to easily add more
physical activity into your days:
● Take the stairs Get in the habit of taking the stairs instead of the elevator. If you are
going to a high floor, take the elevator part of the way – either walk up a few flights
and then catch the elevator, or get off early and walk the rest of the way.

● Go for a walk Even a short walk around the block or through your office can help get
your heart rate up and invigorate your body.
 PATIENT EDUCATION
● Stop smoking and the use of tobacco; avoid secondhand smoke.

● Follow-up care.

● Adhere to medical regimen, especially in taking medications.

Evaluation
Activity intolerance

● Identified factors affecting activity tolerance and eliminate or reduce their

effects when possible.
● Used identified techniques to enhance activity tolerance.
● Participated willingly in necessary / desired activities.
● Reported measurable increase in activity tolerance.
● Demonstrated a decrease in physiological signs of intolerance (pulse,
respirations, and blood pressure remain within client’s normal range).
Anxiety

● Appeared relaxed and report that anxiety is reduced to a manageable level.

● Identified healthy ways to deal with and express anxiety.
● Used resources / support systems effectively.
Imbalanced nutrition: less than body
requirements
● Demonstrated progressive weight gain towards goal.
● Displayed normalization of of laboratory values and be free of signs of
malnutrition
● Verbalized understanding of causative factors when know and necessary
interventions.
● Demonstrated behaviors and lifestyle changes to regain and/or maintain
appropriate weight.
Impaired peripheral tissue perfusion

● Demonstrated increased perfusion as individually appropriate (skin warm and

dry, peripheral pulses present and strong, absence of edema, free of pain and
discomfort).
● Verbalized understanding of of risk factors or condition, therapy regimen, side
effects of medications, and when to contact healthcare provider.
● Demonstrated behavior and lifestyle changes to improve circulation (regular
exercise, cessation of smoking, weight reduction, disease management).
Disturbed sleep pattern

● Identified individually appropriate interventions to promote sleep.

● Reported improved sleep.
● Reported increased sense of well-being and feeling rested.
powerlessness

● Expressed sense of control over the present situation and future outcome.
● Made choices related to and be involved with care.
● Identified areas over which individual has control.
● Acknowledged reality that some areas are beyond individual’s control.
High Risk for ineffective therapeutic regimen

● Verbalized understanding of condition, disease process, and treatment.

● Performed necessary procedures correctly and explain reasons for the actions.
● Initiated necessary lifestyle changes and participate in treatment regimen.