LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN
OUTLINE - RESPONSES TO ALTERED TISSUE
PERFUSION
I. Assessment
a.Subjective Objective Data
b.Diagnostic Assessment
1.Non-invasive (ECG, Echocardiography)
2.Invasive (Cardiac catheterization, CVP,
Pulmonary Artery Pressure Intra-arterial
BP monitoring, Left Arterial Pressure
Monitoring)
II. Nursing Diagnosis
III. Planning
IV. Alterations in Perfusion
a.Acute Ischemic Heart Disease
b.Heart Failure
c. Cardiogenic Shock
d.Coronary Arterial Disease
e.Hypertensive Crisis
f. Cardiomyopathy
g.Arrythmias
h.Venous Thromboembolism
i. Valvular Heart Disease
j. Endocarditis
k.Atherosclerotic Disease of the Aorta
V. Implementation
a.Medical Surgical Management
(Recanalization, Palliative Care for End
Stage Heart Failure, Percutaneous
Transluminal Angioplasty, Pacemakers,
Cardioversion, Ablation, CABG, IABP, Heart
Transplantation, Implantable cardioverters
defibrillator, Atherectomy, Laser
angioplasty, Coronary stents, Balloon
valvotomy, Mechanical Circulatory Assist
Devices, Vascular surgeries, Minimally
Invasive Cardiac Surgery)
b.Pharmacologic Management (Fibrinolytic
therapy)
c. Complimentary Alternative Therapies (Fish
oil/ Omega3, Fatty acids, Hawthorn, Gingko
Biloba, Ginseng, Garlic
VI. Client Education
VII. Evaluation & Outcomes
VIII. Reporting and Documentation of Care
ASSESSMENT OF CLIENTS WITH
CARDIOVASCULAR DISORDERS
1. Nursing History (Non-modifiable risk factors
and Modifiable risk factors)
Non-modifiable factors are unavoidable risk factors
while modifiable risk factors are the avoidable factors.
Non-modifiable Risk Factors
a. Age – a person who is above 40 years old are high
risk to develop cardiovascular diseases, due to the
degenerative changes to the heart and the blood
vessels.
b. Gender – males are prone to cardiovascular
disorders before the age 65 years old. However,
females also have higher propensity to cardiovascular
disorder after the age of 65 years old. Why females?
Because it is due to the decrease of estrogen levels
during the menopausal stage. HDL (good cholesterol)
decreases at this time and also LDL (bad cholesterol)
increases which increases the development of
atherosclerosis- accumulation of cholesterol plaque
into the arteries.
NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION
c. Race – cardiovascular diseases rank among 10
leading causes worldwide. In US, it ranks no. 1 in
mortality while in the Philippines it ranks in 4 or 5 top
10 leading causes of mortality.
d. Heredity- people with history of cardiovascular
disease are at risk to develop this disease.
Modifiable Risk Factors
a. Stress – take away those stress. Stress is a
sympathetic response stimulation that causes the
increase in the secretion of catecholamines which is
norepinephrine which results in vasoconstriction and
tachycardia. It also increases blood pressure and
cardiac workload of the heart.
b. Diet – increase dietary intake of food that is high in
sodium, fats and cholesterol predisposes a person to
cardiovascular disorders. Sodium retains water which
increases blood volume which results in hypertension.
Fats and cholesterol can make you at risk for
development of atherosclerosis.
c. Exercise – improves blood circulation and maintains
vascular tone. It also enhances the release of
chemical activators like tissue plasminogen activators
which prevent platelet aggregation and prevent blood
clotting.
d. Cigarette Smoking- nicotine causes
vasoconstriction and spasm of arteries thus
increasing myocardial oxygen demands. It has been
associated with decrease level of HDL. In smoking,
more carbon dioxide is inhaled more than oxygen.
e. Alcohol – positively correlates with high blood
pressure. Why? Because alcohol causes
vasoconstriction, 30ml of alcohol is stimulant that
causes vasodilation but if you take more than 30ml it
now causes vasoconstriction and elevation if blood
pressure.
f. Hypertension- hypertension develops because of
the increase systemic vascular resistance, endothelial
damage, increase platelet aggregation and increase
permeability of endothelial lining.
g. Hyperlipidemia – because of the increase of LDL
that damages the endothelium of the blood vessel
and causes accumulation of fatty plaques into blood
vessels and proliferation of smooth muscle cells.
h. Diabetes Mellitus – It is associated with
cardiovascular disorders. Why? Glucose is from
carbohydrates that cannot be transported into cells
due to insulin deficiency or increase on resistant to
insulin then the body mobilizes the fats that is also
called lipolysis, to become a source of glucose.
However, not all the fats are converted to glucose,
most of it will remain lipids and hyperlipidemia results
which enhances the risk of atherosclerosis.
i. Obesity – it is the result of increase cardiac
workload. Why? Because the heart has to pump
blood supply to a larger body surface area and can
also be characterized by rise in serum lipid levels.
j. Personality type or Behavioral Factors –
Because the type of behavioral pattern that is
characterized by competitiveness, impatient,
aggressive and time urgency, has been correlated to
coronary artery disease.
k. Contraceptive Pills – it can precipitate
thromboembolism and hypertension because the
estrogen component of oral contraceptive pills
increases blood viscosity, thereby increases the risk
 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN
for thromboembolism. It also stimulates the liver to
synthesize angiotensinogen which triggers the
production of pulmonary converting enzymes.
Angiotensinogen converts to Angiotensin I is further
acted upon your pulmonary converting enzymes and
converted to angiotensin II which is a potent
vasoconstrictor.
2. PHYSICAL EXAMINATION
 Inspection
a. Skin color – take note for pallor, cyanosis or
jaundice. Cyanosis and pallor are due to
inadequate oxygen while jaundice is due to the
hemolysis of the RBC. Bilirubin is released to the
systemic circulation causing a yellowish
discoloration of the skin and sclera.
b. Neck vein distention or jugular vein distention
due to the venous congestion.
c. Respiration – take note signs of dyspnea
d. Point of Maximal Impulse – located in the left
mid clavicular 5th intercostal space
e. Peripheral Edema- due to venous insufficiency
 Palpation
a. Peripheral Pulses – weak or bounding and
irregular pulses. (Very important indicator that a
patient has cardiovascular disorder)
b. Apical Pulse- how to assess? In the point of
Maximal Impulse which is located in the left mid
clavicular 5th intercostal space.
 Percussion
Most probable na makikita dito is yung Pulmonary
Edema because it produces dullness upon
percussion.
 Auscultation
a. S1 – produced by asynchronous closure of mitral
and tricuspid valves. It signals the onset of
ventricular systole (lub).
b. S2 - produced by asynchronous closure of aortic
and pulmonary valves. It signals the onset of
ventricular disorders (dub).
c. S3 – Ventricular diastolic gallop. Characterized
faint low pitch sound produced by rapid
ventricular filling in early diastole. Usually
normal in children and young adults. S3 in older
adults is indicative of congestive heart failure.
d. S4 – Atrial diastolic gallop. Characterized by low
frequency sound which present congestive heart
failure and it is abnormal in all ages.
e. Murmurs – audible vibrations of the heart and
great vessels that are produced by a turbulent
blood flow.
f. Pericardial friction rub – extra heart sound
originating from the pericardial sac. This may be
a sign of inflammation, infection or infiltration.
Characterized by short high pitch scratchy
sound.
COMMON CLINICAL MANIFESTATION OF
CARDIOVASCULAR DISORDERS
 Dyspnea
a. Dyspnea – on exertion. This may indicate decrease
in cardiac heart reserve which means it’s the hearts
ability to adjust and adopt to increase demands.
b. Orthopnea – usually a symptom of an advance
heart failure. Client may experience difficulty of
breathing when lying down and relieve by upright
NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION
position. Client need several pillows to be able to
sleep through the night.
c. Paroxysmal Nocturnal Dyspnea – manifested of
severe shortness of breath that occurs 2-5 hours
after the onset of sleep. During waking hours, the
client assumes upright position which causes
venous pulling. When the client lies, recumbent
during the night the blood from the lower
extremities are distributed to the upper parts of the
body and lung congestion may occur and the client
experience difficulty of breathing.
 Chest Pain – due to the decrease coronary tissue
perfusion and also oxygenation. Anaerobic
metabolism-causes the production of lactic acid-causes
irritation of the nerve ending in the myocardium.
 Edema – increases hydrostatic pressure in the venous
system causing the shifting of plasma therefore
accumulation of fluid in the interstitial compartments
occurs.
 Syncope – generalized muscle weakness with inability
to stand upright followed by a loss of consciousness
this is due to decrease cerebral tissue perfusion.
 Palpitations – describe as pounding or racing or
skipping a beat. Palpitation that occurs during a mild
exertion may indicate the presence of heart failure.
maybe anemia or thyrotoxicosis.
 Fatigue – consequence of inadequate cardia output.
DIAGNOSTIC TESTS
ECG
 Graphical recording of electrical activities of the heart
 First diagnostic test when cardiovascular disease is
suspected.
WAVES, COMPLEXES AND INTERVALS
 P wave – depolarization of atrium. Duration: 0.04 –
0.11 seconds
 PR interval – time of impulse transmission from SA
node to AV node. Duration: 0.12- 0.20 seconds
 QRS complex – depolarization of ventricles. Duration:
0.05-0.10 seconds.
 ST segment – represents the plateau phase of the
action potential.
 T-wave – ventricular repolarization and should not
exceed of 5mm amplitude.
COMMON ECG CHANGES
 U-wave- Depressed ST segment, Short T wave.
Indicative of Hypokalemia
 Prolonged QRS complex, Elevated ST segment, Peaked
T Wave-Hyperkalemia
 Elevated ST segment (first to occur in MI Inverted T-
wave, & Pathologic Q wave) Myocardial Infarction
NURSING REPONSIBILITIES
1. Inform the client that the procedure is painless.
2. He/she will not experience electrocution or a shock.
ECHOCARDIOGRAPHY
 Uses ultrasound to assess cardiac structure and
mobility
 No special preparation is required.
 It is painless and takes approximately 30 to 60
minutes to complete.
 The client has to remain still
 Supine position slightly turned to the left side (with
HOB elevated to 15 to 20 degrees.)
 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

CARDIAC CATHETERIZATIONS
Purposes:
 Assess oxygen levels, pulmonary blood flow cardiac
output, heart structures.
 Coronary artery visualization.

NURSING INTERVENTION
 Before the procedure provide psychosocial support –
to alleviate anxiety
 Assess for allergy to iodine/seafoods. It uses contrast COMPLICATIONS:
medium  Carotid Artery Puncture
 Obtain baseline VS.  Pneumothorax
 Withhold meals before the procedure- to prevent  Air Embolism
nausea and vomiting and also aspiration  Arrhythmia
 Have client void. To promote comfort  Perforation of SVC or R. Atrium/Ventricle
 Administer sedative as ordered.  Infection
 Mark distal pulses.  Pleural Effusion
 Do cardiac monitoring. To assess for dysrhythmias  Extravasion of Infusate
 Done under local anesthesia  Allergic reaction to catheter material
 May experience warm or flushing sensation
 Fluttering sensation as the catheter enters the heart.
After the procedure
 Bed rest – for atleast 6-8 hrs that is to prevent
bleeding tendencies.
 Monitor VS- especially peripheral pulses. Diminished or
absent pulses indicates circulatory impairment and this
may due to vasospasm or obstruction caused by
thromboembolism.
 Monitor ECG – Takes note the dysrhythmias
 Apply pressure dressing
 Immobilize affected extremity in extension – to
promote circulation
 Do not elevate HOB more than 30 degrees femoral
site was used. Acute hip flexion causes circulatory
impairment.
 Monitor extremities for color, temperature, pulse and
sensation.

CENTRAL VENOUS PRESSURE

 Blood from the systemic veins flows into the right
atrium.
 The pressure in the right atrium is the CVP
 A catheter is passed via; the subclavian vein or jugular
vein into the superior vena cava to determine the
venous return and intravascular volume of the right
atrium.
 The normal value is 5-10cm H20
PURPOSE:
1. To serve as a guide of fluid balance in critically ill
patients
2. To estimate the circulating blood volume
3. To determine the function of the right side of the
heart
4. To assist in monitoring circulatory failure
5. None of these variables are measured directly; they
must be interpreted.

NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION

 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

 Pulmonary Artery Occlusion Pressure (PAOP)

 Cardiac output
 Mixed Venous Oxygen Saturation (SvO2)
 Indirect measurements that are possible:
 Systemic Vascular Resistance
 Pulmonary Vascular Resistance
 Cardiac Index
 Stroke volume index
 Oxygen Delivery
 Oxygen uptake
INDICATIONS
 Diagnostic
 Differentiation among causes of shock
 Differentiation between mechanisms of pulmonary
edema
 Evaluation of pulmonary hypertension
 Diagnosis of pericardial tamponade
 Diagnosis of right to left intracardiac shunts
 Unexplained dyspnea
 Therapeutic
 Management of perioperative patients with
unstable cardiac status
 Management of complicated myocardial infarction
 Management of patients following cardiac surgery/
high risk surgery
 Management of severe preeclampsia
 Guide to pharmacologic therapy
 Burnes/ renal failure/ heart failure/ sepsis/
decompensated cirrhosis
 Assess response to pulmonary hypertension specific
therapy

CONTRAINDICATIONS
ABSOLUTE RELATIVE
Infection at Coagulopathy
insertion site
Presence of RV Thrombocytopenia
assist device
Insertion during
CPB
Insertion during Electrolyte
CPB disturbances
(K/Mg/Na/Ca)
Lack of consent Severe pulmonary
HTN
MAKING DECISION TO PLACE PULMONARY
ARTERY CATHETER
 In critically ill or perioperative patients, decision to
place a pulmonary artery catheter should be based on
patient’s hemodynamic status or diagnosis that cannot
be answered satisfactory by clinical or non-invasive
assessment.
PULMONARY ARTERY PRESSURE PREPARATION
 Pulmonary artery catheters (also called as Swan-Ganz  Patient has to be monitored with continuous ECG
Catheter) are used for evaluation of a range of throughout the procedure, in supine position
condition. regardless of the approach
 Although their routine use has fallen out of favor, they  Aseptic precaution must be employed
are still occasionally placed for management of  Cautions should be taken while cannulating via UV/
critically ill patients Subclavian vein
PHYSIOLOGIC MEASUREMENTS EQUIPMENTS
 Direct measurements of the following can be obtained  2% Chlorhexidine skin preparation solution
from an accurately placed pulmonary artery catheter  Sterile gown, gloves, face shield and cap
(PAC)  Sterile gauze pads
 Central Venous Pressure (CVP)  1% lidocaine -5cc
 Right sided intracardiac pressure (RA/V)  Seeker needle -23G
 Pulmonary Artery Pressure (Pap)  Introducer needle -18G

NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION

 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

 J-tip guidewire
 Transduction tubing
 Sterile catheter flush solution
 Sheath
 Pulmonary catheter
 Sterile sleeve for catheter
 2.0 silk suture
 Sterile dressing

IMPORTANT TIP
 When advancing catheter -always inflate tip
 When withdrawing catheter- always deflate
 Once in pulmonary artery -NEVER INFLATE AGAINST
RESISTANCE -RISK OF PULMONARY ARTERY
RUPTURE

INTERPRETATION OF HEMODYNAMIC VALUES

AND WAVEFOMS
 Ensuring accurate measurements:
 Zeroing and Referencing
PAC must be appropriately zeroed and referenced
to obtain accurate reading -> in supine position/ 30
degrees’ semi-recumbent position
 Correct placement
By either pressure waveform/ fluoroscopic guidance
 Fast flush test

TECHNIQUE
1. Aseptic precautions undertaken
2. Local infiltration done
3. Check balloon integrity by inflating 1.5 ml of air
4. Check lumens patency by flushing with saline 0.9%
5. Cover catheter with sterile sleeve provided
6. Cannulate vein with Seldinger technique
7. Place sheath
8. Pass catheter through sheath with tip curved towards CATHETER WAVEFORMS AND PRESSURES
the heart  Pressure waveforms can be obtained from:
9. Once the tip of catheter passed through introducer  RIGHT ATRIUM
sheath -> inflate balloon at level of right ventricle  RIGHT VENTRICLE
10. The progress of the catheter through right atrium and  PULMONARY ARTERY
ventricle into pulmonary artery and wedge position RIGHT ATRIUM
can be monitored by changes in pressure trace  In presence of a competent tricuspid valve, RA
11. After acquiring wedge pressure -> deflate balloon. pressure waveform reflect both:
 Venous return to RA during ventricular systole
 RV End Diastolic pressure
 Normal RA pressure: 0-7 mmHg

NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION

 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

PULMONARY ARTERY
 Elevated RA pressure:  The risk of arrhythmias is greatest while catheter tips
 Diseases of RV (infarction/ cardiomyopathy) is in RV
 Pulmonary hypertension  Thus, catheter should be advanced from RV to PA
 Pulmonic stenosis without delay
 Left to right shunts  When catheter tip passes pulmonary valve -> diastolic
 Pericardial diseases pressure increases and characteristic dichrotic notch
 LV systolic failure appears in waveform
 Hypervolemia  Normal pulmonary artery pressure
 Differentiating among etiologies depends on  Systolic: 15-25 mmHg
 clinical  Diastolic: 8-15 mmHg
 radiographical  Mean: 16 (10-22 mmHg)
 Echocardiographic features + PAC findings  Main components of PA tracing:
E.g.: Increased RA pressure and Mean pulmonary  Systolic and diastolic pressure
pressure -> PAH  Dichrotic notch (due to closure of pulmonic valve)
E.g.: Increases RAP and Normal PA pressures -> RV
disease/ Pulmonary stenosis
 Abnormal RA waveforms:
- Tall v waves: Tricuspid Regurgitation
- Giant/ Cannon A waves:
 Ventricular tachycardia
 Ventricular pacing
 Complete heart block
 Tricuspid stenosis

 Increase in mean pulmonary pressure:

Acute
 Venous thromboembolism
 Hypoxemia induced pulmonary vasoconstriction
Acute on Chronic
 Hypoxemia induced pulmonary VC in patient with
chronic cardiopulmonary disease
- Loss of a waves: Chronic
 Atrial fibrillation/ atrial flutter  Pulmonary hypertension.
RIGHT VENTRICLE
 Transitioning from SVC or RA to RV: TYPES OF PHT
 Once balloon is inflated in the SVC/RA -> the  Primary
catheter is slowly advanced  Due to heart disease
 When the catheter tip is across tricuspid valve ->  Due to lung disease
pressure waveforms changes and systolic pressure  Due to chronic venous thromboembolism
increases.  Miscellaneous (sickle cell anemia)
 2 pressures are typically measured in right ventricular
pressure waveform COMPLICATIONS
 Peak RV systolic pressure -> 15-25 mmHg General
 Peak RV diastolic pressure -> 3-12 mmHg  Immediate
 Bleeding
 Arterial puncture
 Air embolism
 Thoracic duct injury (L side)
 Pneumothorax/ hemothorax

NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION

 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

 Delayed  When flowing blood suddenly stopped by tip of

 Infections
 Thrombosis
Related to insertion of PAC:
 Arrhythmias (most common -ventricular RBBB)
 Misplacement
 Knotting
 Myocardial valve/ vessel rupture
Related to maintenance and use of PAC:
 Pulmonary artery perforation
 Thromboembolism
 Infection
INTRA-ARTERIAL BLOOD PRESSURE
MONITORING
Pressure required to obliterate blood flow.
INDICATIONS
 Low flow conditions
 Shock or high vasopressor doses
 Can attenuate or obliterate generation of sound
 Underestimation of BP
 Non compressible arteries
 Overestimation of BP
AUTOMATED NIBP
 Based on oscillometry (described by Marey 1876)
variation in cuff pressure resulting from arterial
pulsations during cuff deflation sensed by monitor
 Pressure at which peak amplitude of arterial pulsations
occur, corresponds closely by directly measured MAP
 Systolic and diastolic BP are derived from proprietary
formulas systolic and diastolic BP are less reliable than
MAP
INVASIVE BLOOD PRESSURE MONITORING
 The technique involves the insertion of a catheter into
a suitable artery and then displaying the measured
pressure wave on a monitor
ADVANTAGE OF IABP
 Continuous beat-to-beat pressure measurement, close
monitoring of critically-ill patients on vasoconstrictive
drugs
 Pulse waveform analysis provide other important
hemodynamic parameters
 Reduces the risk of tissue injury and neuropraxias in
patients who will require prolonged blood pressure
measurement
 Allows frequent arterial blood sampling
 More accurate than NIBP, especially in the extremely
hypotensive on the patients with arrythmias
COMPONENTS OF AN IABP MEASURING SYSTEM
catheter, kinetic energy is partially converted into
pressure. This may add 2-10 mmHg SBP
 This is referred to as end hole artifact or end pressure
product.
 Cannulation sites: Radial, ulnar, Dorsalis pedis,
posterior tibial, femoral arteries.
Fluid-filled tubing
 Provides a column of non-compressible, bubble free
fluid between the arterial blood and the pressure
transducer for hydraulic coupling.
 Ideally, the tubing should be short, wide and non-
compliant (stiff) to reduce damping.
 Extra 3-way taps and unnecessary lengths of tubing
should be avoided where possible.
Transducer
 Converts mechanical impulse of a pressure wave into
an electrical signal through movement of a
displaceable sensing diaphragm.
 It functions on principle of strain gauze and
wheatstone bridge circuit.
Strain Gauze
 are based on the principle that the electrical resistance
of wire or silicone increases with increasing stretch
 The flexible diagram is attached to wire or silicone
strain gauges in such a way that with movement of
the diaphragm the gauges are stretched or
compressed, altering their resistance
Wheatstone bridge
 Circuit designed to measure unknown electrical
resistance
Signal Processor, amplifier and display
 The pressure transducer relays its electrical signal via
a cable to a microprocessor where it is filtered,
amplified, analyzed and displayed on a screen as a
waveform of pressure vs. time
 Beat to beat blood pressure can be seen and further
analysis of the pressure waveform can be made, either
clinically, looking at the characteristic shape of the
waveform, or with more complex systems, using the
shape of the waveform to calculate cardiac output and
other cardiovascular parameters
Infusion/flushing system
 fills the pressure tubing with fluid and helps prevent
blood from clotting in catheter, by continuously
flushing fluid through the system at a rate of 1-3ml/hr,
by keeping a flush bag at pressure of 300 mmHg.
 Heparinizing the flush system is not necessary

Intra-arterial Cannula
 Should be wide and short INVASIVE HEMODYNAMIC MONITORING: INTRA-
 Forward flowing of blood contains kinetic energy ARTERIAL MONITORING

NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION

 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

 This provides continuous detection of arterial BP via  Pallor

an indwelling intra-arterial catheter.  Diaphoresis
 Valuable in monitoring the BP of the clients with low  Dyspnea
cardiac output  Faintness
Cardiac output= stroke volume x heart rate  Palpitations
 Intra-arterial readings are at least 10 mmHg higher  Dizziness
than cuff BP readings  Digestive disturbances.
 The intra-arterial BP line can be used for obtaining ANGINA: PQRST PAIN ASSESSMENT
blood samples for ABG and blood studies.  Method of assessment of chest pain
 Heparinize the catheter to maintain patency.  P- provocative
 Check catheter insertion site for hemorrhage,  Q- quality
hematoma, redness or signs of infarction  R- region
 Do neurovascular check distal to catheter insertion  S- severity
site- color, temperature, capillary filling and sensation.  T- timing/ treatment
 In the provocative assessment, we need to ask the
ANGINA PECTORIS (MYOCARDIAL ISCHEMIA) patients on the activities which brings on the pain.
This is a transient chest pain.  In the quality, what does the pain feel like?
 Caused by insufficient blood flow to the myocardium  In the region or radiation, where is the pain? Does
resulting in myocardial ischemia it radiate elsewhere?
 Results when myocardial oxygen demand exceeds  In the severity, how does the pain rate in the scale of
myocardial oxygen supply. 1-10?
PATHOPHYSIOLOGY  For the timing and treatment, when did the pain
CAUSES begin? How long does it last? How do you do to
Atherosclerosis relieve the pain? Are these measures effective?
Hypertension TYPES OF ANGINA
Diabetes Mellitus  Stable angina
Thromboangitis Obliterans  Chest pain lasts for more than 15 minutes and
recurrence is less frequent
Polycythemia Vera
 Unstable angina
Aortic Regurgitation
 Also known as pre-infarction angina,
crescendo angina, intermittent coronary
syndrome.
Reduced Coronary Tissue Perfusion  Chest pain last for more than 15 minutes but less
than 30 minutes.
 Recurrence is more frequent
Diminished Myocardial Oxygenation  May occur at night
 Intensity of pain increases upon the recurrence.
 Variant angina
Anaerobic Metabolism
 Also known as Prinzmetal’s angina
 Of longer duration and may occur at rest
Increased Lactic Acid Production (Lactic Acidosis)  Attacks tends to occur in the early hours of the day
and may result from a coronary artery spasm.
 Nocturnal angina
 Occurs only in the night and possibly associated
Chest Pain with Rapid Eye movement (REM) sleep
 Angina decubitus
 Paroxysmal chest pain that occurs when the client
sits or stands up
CLINICAL MANIFESTATION  Intractable angina
 Pain  Chronic incapacitating angina unresponsive to
 Transient, paroxysmal subternal or interventions
precordial pain  Postinfarction angina
 Describes as heaviness or tightness of  Occurs after a myocardial infarction and residual
the chest, “indigestion”, crushing ischemia may cause episodes of angina
 Radiates down one or both arms, left PRECIPITATING EVENTS
shoulder, jaw, neck and back.  EXERTION- vigorous exertion done very sporadically
 Precipitate by activity or exertion  EMOTIONS- excitement and sexual activity.
 Relieved by rest and nitroglycerine.  EATING HEAVY MEAL
 S- Substernal  ENVIRONMENT- exposure to cold weather.
 A- Anterior chest MEDICAL MANAGEMENT AND NURSING
 V- Vague (radiates) INTERVENTIONS
 E- exertion-related  Vasodilators: Nitroglycerine, Amyl Nitrate,
 R- Relieved by rest and nitroglycerine Isosorbide
 S- Short duration (less than 30 minutes)

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 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN
 Has a direct relaxing effects on the vascular smooth
muscles resulting in a generalized vasodilation, also
decreases the peripheral resistance, decreases the
systolic pressure, produces venous pulling and
decreases the preload.
 We also have coronary valued vasodilation,
redistribution of myocardial blood flow more
efficiently.
 For the Nursing responsibility in nitroglycerin
therapy, you need to assume sitting or supine
position when taking the drug to prevent hypostatic
hypotension.
 Take maximum of 3 doses at 5 minutes interval
 Practice gradual change of position to prevent
orthostatic hypertension.
 If taken sublingually, the medication causes
burning or stinging sensation under the tongue,
this indicates that the medication is potent.
 For a sublingual route, produces onset of actions in
1 to 2 minutes, duration of action is 30 minutes.
 Offer sips of water before giving sublingual nitrates
because dryness of mouth may inhibit drug
absorption
 Instruct client to avoid drinking alcohol too avoid
hypotension, weakness and faintness.
 Advise client to always carry 3 tablets in his/her
pocket and store the nitroglycerine in a cool, dry
place. Use dark and amber colored tight container.
Do not store it in the refrigerator. It may be
destroyed by heat, light or moisture.
 Change stock of nitroglycerine every 3 months
 Observe for the side effects of nitroglycerin therapy
like headache, flush face, dizziness, faintness, and
tachycardia which are common during the first few
doses of the medication.
 For the transdermal nitro-patch, it is applied once a
day. Usually in the morning. Rotation of the skin
site is necessary usually at the chest wall. Remove
the patch during night to prevent tolerance.
 Evaluate effectiveness if the chest pain is relieved.
 Beta blockers
 Examples are those with “-olol” such as
Propranolol, ismolol.
 It decreases myocardial oxygen demand by
decreasing heart rate, BP, myocardial contractility
and calcium output.
 For nursing responsibilities, assess pulse rate
before administration of drug. Withhold if
bradycardia is present.
 Administer with food to prevent GI upset and do
not administer propranolol to patients with asthma
because it causes bronchoconstriction
 Do not administer propranolol to patients with
diabetes mellitus because is causes hypoglycemia.
 Give with extreme caution in clients with heart
failure
 Observe for the side effects such as nausea,
vomiting, mental depression, mild diarrhea, fatigue,
and impotence.
 Antidote for beta blocker poisoning is Glucagon
 Calcium channel blockers
 Ex. Amlodipine
 Inhibits calcium ions transportation into the
myocardial cells to depress the inotropic and
chronotropic activity thus decreasing the workload
NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION
and it also has a vasodilation effect and it reduces
the coronary vasospasm
 For the Nursing responsibility, assess heart rate
and BP. Monitor for the hepatic and renal
functioning.
 Administer 1 hour before or 2 hours after meals.
Food delays absorption and decreases the plasma
levels of the drug.
 Antidote for Calcium channel poisoning is also
GLUCAGON.
 Platelet Aggregation Inhibitors
 Examples are aspirin, clopidogrel, dipyridamole.
 Inhibits platelet aggregation or blood clotting.
 For the Nursing responsibility, assess for the signs
and symptoms of bleeding.
 Avoid straining at stool to prevent rectal bleeding.
 Aspirin may be given with food to prevent GI upset.
 For aspirin toxicity (like tinnitus or ringing of ears),
it may also cause bronchoconstriction observe for
wheezing sound, auscultate the lungs.
 Anticoagulants
 Example is heparin sodium and warfarin
 Inactivates the thrombin and other clotting factors
inhibiting conversion of fibrinogen to fibrin
 Fibrin clot formation is prevented here as part of
mechanism of action of heparin sodium,
 For the warfarin sodium such as Coumadin, inhibits
the hepatic synthesis of Vit. K
 For the Nursing responsibility of heparin sodium
therapy, assess for the signs and symptoms of
bleeding and keep protamine sulfate available. If
administered subcutaneously, do not aspirate. Do
not massage the site of heparin injection to prevent
hematoma formation.
 Monitor the APTT or PTT levels. Remember that the
therapeutic effects of APTT and PTT is 2 to 2.5
 Use heparin sodium for an maximum of 2 weeks.
 For the warfarin sodium or Coumadin, assess for
the signs and symptoms of bleeding
 Keep Vit K or phytomenadione readily available.
Administered as an antidote if bleeding occurs with
Coumadin or warfarin therapy
 The need to monitor for the prothrombin time. The
therapeutic effect of prothrombin time is 1.5 to 2
with an INR of 2 to 3
 Minimize green leafy vegetables in the diet because
it contains Vit. K and antagonizes the effect of
Coumadin.
 Do not give aspirin and Coumadin together to
prevent bleeding.
TREATMENT AND SURGICAL INTERVENTIONS
 Percutaneous Transluminal Coronary
Angioplasty (PTCA)
 this is a mechanical ventilation of the coronary
vessel wall be compressing the atheromatous
plaque
 specialized balloon tipped catheter inserted under a
fluoroscopic guidance advanced to the site of the
coronary obstruction
 recommended for clients with single vessel
coronary artery disease or atherosclerosis.
 Intravascular stenting
 a biologic stent through coagulation of collagen,
elastin and other tissues in the vessel wall by laser.
 Photocoagulation or radio frequency induced heat
 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

 Prosthetic intravascular cylindric stents maintain  State of circulatory congestion produced by myocardial
good luminal geometry after a balloon deflation and dysfunction
withdrawal.  Inability of the heart to pump the amount of
 Done to prevent re-stenosis or narrowing of blood oxygenated blood necessary to effect venous return
vessel after PTCA and to meet the metabolic requirements of the body
 Laser therapy  Myocardial infarction comprises myocardial function by
 Produces necrosis, hemostasis, coagulation and reducing the contractility and producing abnormal wall
evaporation of tissue. motion. The ability of the ventricles to empty lessens,
 Coronary Artery Bypass Graft (CABG) the stroke volume falls, and residual volume increases
 Reduces the angina and improves the activity CAUSES OF CHF
tolerance of the patient.  Direct damage to the heart (mitral myocarditis,
 Recommended if severe narrowing of one or more ventricular aneurysm)
branches the coronary arteries exists.  Ventricular overload. Increased preload and increased
 The main purpose is myocardial revascularization. afterload. In the increased preload (mitral or aortic
 The common used routes are the saphenous veins regurgitation, atrial or ventricular septal defects, or
in the internal mammary rapid infusion of IV fluids.) Increased afterload (aortic
NURSING INTERVENTIONS IN CLIENTS WITH or pulmonary valve stenosis, systemic hypertension,
ANGINA PECTORIS and pulmonary hypertension)
 Constrictions of the ventricles (cardiac tamponade,
pericarditis, restrictive cardiomyopathies).
CLASSIFICATION OF HEART FAILURE
 Backward heart failure
 Results from damming up of blood in the vessels
proximal to the heart
 Forward heart failure
1. PROMOTING COMFORT  Inability of the heart to maintain cardiac output.
 Relieving pain is the first thing. Nitroglycerin is PATHOPHYSIOLOGY of LSCHF
the drug of choice for relief of pain during acute
ischemic attacks
2. Promoting tissue perfusion
 Instruct the client to avoid over fatigue and stop
activity immediately in the presence of chest pain,
dyspnea, lightheadedness, faintness which
indicates low tissue perfusion.
3. Promoting activity and rest
 Encourage to lower activity or shorter periods of
activity with more rest periods. Avoid over
exertion.
 Plan for regular activity program
 Take nitroglycerin before exercise
 Increase the extent of exercise gradually.
4. Facilitating learning
 Promote positive attitude and active participation
of the client and the family to encourage
compliance of the medication
5. Promoting relief of anxiety and feeding of well-
being
 Promoting relief of anxiety and feeling of well-
being. Participate in the reduction of client’s level
of anxiety to minimize the client’s outburst, worry
and tension  In the left side, it is more on pulmonary while on the
 Encourage to maintain an optimistic outlook to right side is more on the cardio.
health, relieve the work of the heart.
6. Diet activity RIGHT SIDED CONGESTIVE HEART FAILURE
 Low salt low fat diet, low cholesterol and high PATHOPHYSIOLOGY
fiber diet.  Causes:
 Avoid saturated fats like animal fats. white meat, 1. LSCHF
chicken w/o skin, turkey and fish are low in 2. Pulmonary embolism
cholesterol 3. Right ventricular Infarction
7. Activity 4. Congenital septal defect
 Encouraged with the patient’s limitations or  This results to the following
tolerance

CONGESTIVE HEART FAILURE

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 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN
 Reduced myocardial Contractility
 Increased Cardiac Workload
 Decreased diastolic filling
 Obstruction of right atrial emptying
Increased right arterial pressure
Right- sided heart failure
Blood dame back from RV to RA
Pressure of blood into the pulmonary capillary
bed increases
Increased pressure in the venous circuit
(venous backup)
Sign and Symptoms
 Neck vein engorgement (jugular vein
distention)
 Hepatomegaly
 Portal hypertension -------- cardiac cirrhosis
 Ascites
 Peripheral edema (pitting/dependent)
 Splenomegaly
 Jaundice
 Hemolytic anemia
 Internal hemorrhoids
 Leg varicosities
 Weight gain
 S3S4 heart sounds
 Elevated CVP reading
 Right sided congestive heart failure results from
pulmonary disorders, that is called COR-PULMONALE.
The sign and symptoms of left sided heart failure are
due to pulmonary edema, cellular hypoxia and
activation of renin-angiotensin aldosterone system.
 The sign and symptoms of right sided congestive heart
failure is due to venous backing
MEDICAL MANAGEMENT OF CONGESTIVE
HEART FAILURE
1. Digitalis therapy
 is the major therapy for CHF
 has a positive inotropic effect, which means it
strengthen the force of cardiac contractility, if we
say negative inotropic effect it decreases the heart
rate. Negative dromotropic effect decreases
conduction of heart cells
 Nursing responsibility:
a. Assess the heart rate before administering the
digitalis. If the heart rate is 60 bpm or 120bpm
and above withhold the drug. Bradycardia or
rebound tachycardia may occur
b. Monitor the serum potassium level because
hyperkalemia enhances digitalis toxicity
because it potentiates the effect of the drug.
c. Evaluate the effectiveness of digitalis. There
should be increase cardiac output, increase
urinary output, strong pulse, lowering of BP,
absence of rales and crackles
NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION
d. Assess for signs and symptoms of digitalis
toxicity such as bradycardia, anorexia, nausea
and vomiting, diarrhea, dysrhythmias is the
most dangerous, altered visual perception
(green and yellow vision), blurred vision and
presence of halo around light in elderly.
e. For males, antiadrenogenic effect like
gynecomastia, decrease libido, impotence.
 Commonly used Digitalis or cardiac glycosides:
a. Digoxin (Lanoxin)
b. Lanatocide
c. Crystodigin
 ANTIDOTE: digoxin immune Fab (Digibind)
2. Diuretic therapy
 Its purpose is to decrease cardiac workload by
reducing the circulating volume and thereby
reducing the preload.
 Assess for sign and symptoms of hypokalemia
when administering thiazide and loop diuretics.
 Give potassium supplements and potassium rich
foods
 Diuretics are best administered early morning and
early afternoon to prevent sleep pattern
disturbance related to nocturia.
 If Thiazide are ineffective and oral aldosterone
antagonist and potassium spare diuretics may be
given with thiazide
 The diuretics used to treat CHF includes
thiazides, chlorothiazide, hydrochlorothiazide.
 For loop diuretics we have furosemide and
Bumetanide 
 For potassium sparing, we have spironolactone
and Triamterene 
3. Vasodilators
 Action is to decrease afterload by decreasing
resistance to vascular emptying
 Most commonly used drugs Nitroprusside,
hydralazine, nifedipine and captopril
 Nifedipine is a calcium channel blocker with
vasodilator effect, also captopril
4. Sympathomimetic
 Dobutamine and dopamine
OTHER MEDICAL MANAGEMENT/ TREATMENT
1. Diet
 Sodium restriction to prevent fluid excess
2. Activity
 Balanced program of activity and rest should be
carried out
3. Oxygen Therapy
 To increase oxygen supply
NURSING INTERVENTION
1. Promoting oxygenation
 Administer O2 inhalation vis nasal cannula at 2-6
Lpm as ordered
 Evaluate ABG result
 Maintain semi-fowler or high fowler position to
maximize oxygenation by promoting greater lung
expansion
2. Promoting rest and activity
 Bed rest or limited activity may be necessary
during the acute phase; you need to provide an
over bed table close to the patient to allow resting
the head and arms. The arms should be supported
by the pillow to reduce the pull on the shoulder
 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

muscle when in high fowler position which is most 9. If acute pulmonary edema occurs in the client
comfortable for the patient with CHF:
 Administer diazepam or valium at least 2-10 mg;  Place in high fowler’s position with legs slightly
3-4 times a day as ordered to allay apprehension lowered to facilitate breathing and to reduce the
 Gradual ambulation is encouraged to prevent risk preloads.
of venous thrombosis and embolism due to  Morphine sulfate – 10-15 mg via IV as ordered to
prolonged immobility primarily reduced the preload and afterload and to
 Mobility should be progress through daggling, address the anxiety of the patient.
sitting on the chair and walking in increase  Oxygen therapy - atleast 40 -70% via nasal
distance under close supervision cannula or facemask.
 Assess signs of activity intolerance such as  Aminophylline IV – as ordered to relieve
dyspnea, fatigue and increase pulse rate and do bronchospasm and increases urinary output and
not stabilize readily increases cardiac output.
3. Decreasing anxiety  Diuretic therapy
 Identify feelings and concerns related to his  Vasodilators – dopamine, dobutamine, and
feelings monitor serum potassium because diuretics may
 Identify strengths that can be used for coping result to hypokalemia.
 Learn what can be done to decrease anxiety  Sympathomimetics
 TAKE NOTE: anxiety causes increase  Monitor serum potassium
breathlessness which can be perceived by the
client as an increase in the severity of heart failure CARDIOGENIC SHOCK
and this in turn increases the anxiety  Shock state which results from profound left
4. Facilitating fluid balance ventricular failure usually from massive MI.
 Controlling sodium intake is important  Results to low cardiac output thereby systemic
 Administer diuretics and digitalis as prescribed hypoperfusion.
 Monitor intake and output, weight and vital signs  It has a high mortality rate.
5. Providing skin care PATHOPHYSIOLOGY
 Provide skin care, edematous skin is fully nourish Massive MI
and susceptible to pressure sores.
 Change position at frequent intervals
Decreased Myocardial Contractilityv
 Assess circuit area regularly
 Use protective devices to prevent pressure ulcers
Decreased Cardiac Output
or pressure sores
6. Promoting nutrition
 Provide bland, no calorie, no residue with vitamin Hypoperfusion (heart, brain, kidneys)
supplementation during the acute phase
Clinical Manifestations: Tissue Hypoxia
 Frequent small feeding minimize exertion and
 Decreased Systolic BP
reduce gastrointestinal blood requirement  Oliguria
 There may be no need to severely restrict the  Cold, clammy skin, weak Organ Damage
sodium intake of the client who receive diuretic pulse, cyanosis
however no added salts, diet is prescribed. Salty (circulatory insufficiency)
foods must be omitted.  Mental lethargy, Death
7. Promoting elimination confusion (poor cerebral
 Advise to avoid straining during defecation such as perfusion)
Valsalva maneuver because it increases cardiac
workload
 What happens for patients having Cardiogenic shock?
 Administer laxatives as ordered like docusate
The main cause of this cardiogenic shock or power
sodium (Colace)
pump failure is MASSIVE MYOCARDIAL
 Encourage use of bedside commode
INFARCTION.
8. Facilitating learning
 So, if there is Massive myocardial infarction the
 Teach client and family about the disorder and
myocardial contractility decreases and by the time that
self-care
there is a decrease in the myocardial contractility the
 Monitor the signs and symptoms of the CHF like
cardiac output also decreases and if there is a
weight gain, loss of appetite, dyspnea, orthopnea,
decrease cardiac output then it will result to decrease
edema of the legs, persistent cough then reports
perfusion and blood flow into the heart, brain and
those signs and symptoms to the physician.
kidneys.
 You also need to avoid fatigue, balance rest with
 So what happens if there is a hypoperfusion to the
activity.
heart, brain and kidneys? There could be tissue
 Observe prescribe sodium restrictions and the
hypoxia, organ damage and may lead to death.
patients need to eat small frequent meals rather
 What are the clinical manifestations? Drop systolic BP,
than three large meals a day.
oliguria, cold clammy skin, weak pulse, cyanosis,
 Take the prescribed medications at regular basis
mental lethargy, confusion or poor cerebral perfusion.
example we have your digitalis, diuretics and
MEDICAL MANAGEMENT
vasodilators.
Pharmacotherapy
 Observe a regular follow-up care as directed.

NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION

 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

 Vasodilators
 Nitroprusside
 Phentolamine
 Nitroglycerin
 Inotropic agent
 Digitalis
 Dopamine
 dobutamine  Coronary Artery Disease or CAD – there is an
 Diuretics accumulation of plaque in the blood vessels, most
 Furosemide specifically in the artery. There is an accumulation of
cholesterol plaque.
 Na bicarbonate
 to relieve lactic acidosis
as part of your NURSING INTERVENTION:
 Monitor hourly urine output, level of
consciousness and arrhythmias.
 Provide psychosocial support
 Decrease pulmonary edema – auscultate for fields of
crackles and wheezes. Take note for dyspnea, cough,
hemoptysis and orthopnea. You need to monitor ABG
for hypoxia and metabolic acidosis. Place the client in
a fowlers position to reduced venous return.
 Administer during therapy as ordered:
 Morphine sulfate – to reduced venous return,
 Aminophylline – to reduced bronchospasm that
is caused by severe congestion,
 Vasodilators - to reduce venous return like your
Nitroglycerin and nitroprusside
 Diuretic – to decrease circulating volume

Utilize counterpulsation device – to decrease

ventricular workload for the client with severe shock like
your:
 Intra-aortic balloon pump (IABP) – this will be
performed in an augmentation during diastole
resulting in an increased perfusion of the coronary
arteries and the myocardium and the decreased in left
ventricular workload. The balloon will be inflated
during diastole. Deflated during systole.
 Indications:
 cardiogenic shock
 acute myocardial infarction
 unstable angina pectoris  Risk factors:
 open heart surgery  Modifiable:
- Stress
- Diet
- Sedentary living
- Smoking
- Alcohol
- Hypertension
- Diabetes mellitus
- Obesity
Nursing Interventions: (for patient having
- Hyperlipidemia/hypercholesterolemia
Cardiogenic Shock)
- Behavioral factors
 Perform hemodynamic monitoring
- Contraceptive pills
 Collect your PAC, PCW measurement, intra-arterial
 Nonmodifiable
blood pressure
- Age
 Administer oxygen therapy
- Gender – usually male
 Correct hypovolemia via administering specific IV
- Race - americans and asians
fluids as ordered
- Heredity – or familial
 Those risk factors will create a Nonspecific injury to
CORONARY HEART DISEASE (CHD)
arterial wall (endothelial injury), by that time that
endothelial injury happens, there could be a
Desquamation of endothelial lining thus resulting

NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION

 LECTURE 5: RESPONSES TO ALTERED TISSUE PERFUSION PART 1 & 2
MARK ANGELO CRISTION, MAN, RN

in an increased permeability or adhesion

molecules.
 Lipids and platelets assimilate into the area and
oxidized LDL attracts monocytes and
macrophages to the site and plaques begin to
form from cells which imbed into the
endothelium and lipids are engulfed by the cells
and smooth muscle cells develop and that’s why
there is Coronary Atherosclerotic Heart Disease
which is the formation of plaque in the blood vessels.
Result to a decreased coronary tissue perfusion
and decreased blood flow resulting to a coronary
ischemia leading to a decreased myocardial
oxygenation angina pectoris and myocardial
infarction.

MANAGEMENT GUIDE
 Daily management of hypertension – take medication
as regular basis, do not stop.
 Stop smoking as soon as possible. – smoking reduces
available oxygen in the heart and can precipitate
angina. Smoking can increase heart rate and blood
pressure.
 Avoid passive smoke – 2 hours of passive smoke
decreases oxygen to the heart and increases heart
rate and blood pressure.
 Lose weight – you need to plan a regular exercise
under medical supervision. If the patient is
overweight, he/she may need to lose weight. Seek
help from professionals.
 Follow a healthy heart diet
 Reduce stress
 Allow time to rest
 Lifelong Lifestyle Modification

NCA 118 ┃NURSING CARE OF CLIENT WITH LIFE THREATENING CONDITION