1.

Discuss different Acute Biologic Crisis conditions together with the roles and
responsibilities of the nurse in the care of the following.
•Cardiac anatomy
•Cardiac failure - Acute Myocardial infarction
2. Use critical thinking in the management of these cases
3. Familiarize with the different treatment modalities and equipments used
Acute Biologic Crisis
●Condition that may result to patient
mortality if left unattended in a brief period
of time.

●Condition that warrants immediate

attention for the reversal of disease process
and prevention of further morbidity and
mortality.
Coronary
artery
disease
Assessment
Patient Assessment
1. Coronary Artery Disease & Acute
Coronary Syndromes
●Most Common cause of cardiovascular
disability and death.

●It refers to a spectrum of illnesses that

range from the least life threatening to
the most life threatening acute coronary
syndrome(AMI/ Heart attack).
 Coronary Artery Disease & Acute
Coronary Syndromes
●Incomplete occlusion of the coronary
arteries lead to Angina (ischemia)
●Complete occlusion of the coronary
arteries lead to Myocardial Infarction
●The heart will pump harder to meet
the O2 demand leading to Congestive
Heart Failure.
Non Modifiable Risk Factors of
CAD/ ACS
●Age
●Gender
●Race
●Heredity
 Modifiable Risk Factors of CAD/
●Stress
ACS tachycardia

norepinephrine
●Diet vasoconstriction

Na, cholesterol & fat CVD

Circulation, maintains vascular tone&
●Exercise enhances release of chemical activators
that prevent blood clotting
●Cigarette Smoking
Vasoconstriction & Myocardial
●Alcohol spasm of arteries. demand

20 ml = vasodilation 30 ml = vasoconstriction
●Hypertension
As a result of Systemic vascular
resistance
Modifiable Risk Factors of CAD/ ACS
Accumulation of fatty
●Hyperlipidimia plaques

●Diabetes Mellitus due to insulin insufficiency or Increases

Glucose cannot be transported into the cells

resistance to insulin
●Obesity Increase cardiac workload

●Personality Type or Behavioral

Factors Type A – competitive, impatient, aggressive has
been correlated to CAD

●Contraceptive Pills
Cardiovascular Assessment
Chest Pain
● Most common
● Due to Ischemia or MI
● Precipitated by stress or can be relieved by
Nitroglycerin (NTG)
● In MI, it is more intense, unrelated to
activities and can’t be relieved by NTG
● If it occurs during breathing, suspect
respiratory problems
Rough diagram of pain zones in myocardial infarction
(dark red = most typical area, light red = other possible
areas, view of the chest).
Cardiovascular Assessment
Dyspnea
● subjective feeling (inability to get enough
air).
● Dyspnea on exertion is due to increased O2
myocardial demand.
● Orthopnea is related to blood pooling in the
pulmonary bed; suspect Pulmonary Edema
● Any sudden or acute dyspnea may be a sign
of Pulmonary Embolism
Tightness of Chest
Cardiovascular Assessment
Cough/sputum
● Mucoid and foamy sputum can be a sign of
CHF
● Pink-tinged frothy appearance may signal
Pulmonary Edema.
● Whitish, viral infection
● Change in color other than the above mentioned
may signify bacterial infection.
Cardiovascular Assessment
Cyanosis
● Bluish discoloration of the skin and
mucous membrane
● Sat O2 is below 90%

Fatigue
● May be due to Anemias or related to
decreased Cardiac Output
Cardiovascular Assessment
Palpitations
● Awareness of rapid or irregular heart beat
● Autonomic Nervous System and Adrenal
Glands response (stress)

Syncope
● Transient loss of consciousness
● Due to decreased cerebral tissue perfusion
Cardiovascular Assessment
Edema
● Due to: Increased Hydrostatic Pressure (HP)
● Decreased Colloidal Oncotic
Pressure (COP)
● Obstructed Lymphatic or
Vascular System
● Related to Inflammatory reaction
Types of Edema
● Bilateral edema
= CHF or Renal Failure
● Unilateral edema
= Vascular or Lymphatic
obstruction
● Non-pitting edema
= Inflammatory

● Pitting edema
= HP and
COP derangement
Cardiovascular Assessment
Skin
●Color, temperature, hair growth, nails,
capillary refill
●spooning of fingers /clubbing of
fingers
Clubbing of Fingers
Cardiovascular Assessment
●Heart rate – 60-100
●Rhythm – regular or irregular
●Bruits and Thrills – murmurlike; vascular
in origin
- palpate a thrill, auscultate a bruit
●Blood Pressure
●Jugular venous pressure
Cardiovascular Assessment
Cardiac rate and rhythm
●Tachycardia = ↑ 100 beats/minute
●Bradycardia = ↓ 60 beats/minute
●Arrhythmias = irregular rate and
rhythm
Cardiovascular Assessment
● Murmurs - turbulence of blood flow; if
positive watch out for FVE; normal until 1 year
old
● Pericardial Friction Rub -“squeaking sound”;
suspect pericardial effusion if this is heard
● Muffled Heart Sound - if positive rule out
Cardiac Tamponade and other similar problems
like Effusion
Laboratory & Diagnostic Test
● Complete Blood Count- RBC suggest tissue
oxygenation.
Elevated WBC may indicate infectious heart
disease and MI.
● Erythrocyte Sedimentation Rate (ESR)- Its is
elevated in infectious heart disorder or MI.
Normal range: Males: 15-20mm/hr
Females: 20-30 mm/hr
Laboratory & Diagnostic Test
● Blood Coagulation Test:
1.Prothrombin Time (PT, Pro Time)- It
measures time required for clotting to occur.
Used to evaluate effectiveness of COUMADIN.
Normal range 11-16 secs.
2.Partial Thromboplastin Time (PTT)- Best
screening test for disorders of coagulation. Used
to determine the effectiveness of HEPARIN.
Normal Range: 60-70 secs.
Laboratory & Diagnostic Test
● Blood Urea Nitrogen (BUN)- Indicator of
renal function
Normal Range: 10-20mg/dl (5-25mg/dl is also
accepted).
● Blood Lipids:
1.Serum Cholesterol: 150-200mg/dl
2.Serum Triglycerides: 140-200mg/dl.
Laboratory & Diagnostic Test
● Serum Enzymes Studies
1.Aspatate Aminotransferase(AST)- Elevated level
indicates tissue necrosis. Normal Range: 7-40mu/
ml
2.CK-MB- Elevated 4-6hrs from the onset of
infarction; peaks 24-36 hrs. returns to normal 4-7
days.
Normal Range: males: 50-325mu/ml; Females:
50-250mu/ml
Laboratory & Diagnostic Test
● Serum Enzymes Studies
3. Lactic Dehydogenase (LDL)- Onset: 12hrs;
Peak: 48hrs; returns to normal: 10-14 days
4. Hydroxybuterate Dehydroxynase (HBD)- it is
valuable in detecting silent MI because it is
elevated for a long period of time.
Onset: 10-12hrs; Peaks: 48-72hrs; Returns to
Normal 12-13 days
Laboratory & Diagnostic Test
●Serum Enzymes Studies
5. Troponin- Most specific lab test to
detect MI. Troponin has 3
compartments: I,C, &T .
Troponin I persist for 4-7 days.
Angina Myocardial Infarction
Chest Pain- tightness & Severe crushing,
heaviness stabbing chest pain
Relieved Not relieve by rest and
quickly:3-15min by rest medication
or sublingual nitrogen.
Initiated by physical Pain last longer >20min
exertion or stress
Radiation may or may May or may not have
not be present radiation of pain
Frequently associated
with shortness of breath
Laboratory & Diagnostic Test
● Serum Electrolytes/ Blood Chemistry:
1.Sodium (Na)
2.Potassium (K)
3.Calcium (Ca)
4.Magnessium (Mg)
5.Glucose
6.Glycosylated Hemoglobin (Hemoglobin A1c)
 Laboratory & Diagnostic Test
●ECG/ EKG- ST segment elevation and T
wave inversion
Diagnostic Test
● Radiologic Findings
Chest X-Ray
● Normal
● Cardiomegaly
● Signs of CHF
Diagnostic Test
● Hemodynamic Monitoring
● Swan-Ganz Catheterization
● Right side of the heart
● Pulmonary artery pressure
● Pulmonary artery occlusive pressure
● Right atrial pressure
● Cardiac output
Swan-Ganz Catheterization
Diagnostic Test
● Coronary Angiogram
● allows to visualize
narrowings or
obstructions
● therapeutic
measures can
follow immediately.
●Goal:
●Pain relief
●Reduction of myocardial oxygen
consumption
●Prevention and treatment of
complications
Intervention
●Admit to the CCU/ ICU
●Activity
●Day 1: bed rest, if stable
●Day 2-3: bed rest, but patient may
be allowed to sit on a chair for
15-20 minutes
● Early mobilization is
recommended for uncomplicated
AMI
Intervention
●Monitoring Vital Signs
●First 6 hours- q30-60 minutes
●Next 24 hours- q 2 hours
●Thereafter q 4 hours
●Diet
●NPO: 1st 24 hours
●If stable low salt, low cholesterol diet
Intervention
●IV Fluids
●D5W to KVO
●If unable to take food/
fluid per orem
● 1000ml/8 hours
●K supplement
Intervention
● Pain Medication
● Morphine SO4 (2-5mg/IV dose)
● Potent analgesic
● Peripheral venous vasodilation
● Pulmonary venous distention
● Inferior wall MI: may increase vagal
discharge
●Tranquilizres
●To decrease anxiety
●Diazepam (5-10 mg per IV/orem)
●Laxative
●To prevent straining during
defecation
●Lactulose (HS)
Drugs to Limit Infarct Size
●Beta Blockers
●Hyperdynamic states, HPN w/o
evidence of heart failure
●Reduce myocardial oxygen consumption
by decreasing: BP. Heart Rate,
Myocardial Contractility and calcium
output.
●Ex: Propranolol, Metoprolol, Atenolol
● Nursing Consideration:
1.Assess Pulse Rate before administration;
withhold if bradycardia is present.
2.Administer with food, may cause GI upset.
3.Do not administer with asthma it causes
Bronchoconstriction.
4.Do not give to patient with DM, it causes
hypoglycemia.
5.Antidote for Beta Blocker poisoning is
Glucagon
●Nitrates
● Act by augmenting perfusion at the border of
ischemic zone.
● Generalized vasodilation
● Reducing myocardial O2 demand
● Lowering preload
● Lowering afterload
● Ex: IV Nitroglycerine, Sublingual
Niotroglycerine, Oral/Transdermal
Nitroglycerine
● Nursing Considerations:
1.Only a maximum of 3 doses at 5 min. interval.
2.Offer sips of water before giving it sublingually.
3.Store the medication in a cool, dry place; use
dark /amber container.
4.If side effects is noticed do not discontinue the
drug this is usual in the first few doses of
medication.
5.Rotate skin sites for nitro patch.
● ACE inhibitors
● reduce mortality rates after MI.
● Administer ACE inhibitors as soon as
possible
● ACE inhibitors have the greatest benefit in
patients with ventricular dysfunction.
● Continue ACE inhibitors indefinitely after
MI.
● Angiotensin-receptor blockers may be used
as an alternative
● adverse effects, such as a persistent cough,
●Aspirin and/or antiplatelet
therapy
●Continue aspirin indefinitely
●Clopidogrel may be used as
an alternative only if
resistance or allergy to aspirin.
● Nursing Considerations:
1.Assess for signs and symptoms of
Bleeding.
2.Avoid straining at stool to avoid rectal
bleeding.
3.It should be given with food.
4.Observe for toxicity- Tinnitus (ringing
of ears).
5.May cause Bronchoconstriction-
Observe for wheezing.
Heparin
1.Assess for S/S of Bleeding.
2.Keep Protamine Sulfate available.
3.If used SQ. do not aspirate to
prevent hematoma formation.
4.Monitor for PTT or APTT
5.Used for a maximum of 2 weeks.
●Coumadin (Warfarin Sodium)
1.Assess for bleeding
2.Keep Vitamin K available.
3.Monitor for Prothrombin Time
4.Do not give together with aspirin to
prevent bleeding.
5.Minimize green leafy vegetables in
the diet.
thombolytic therapy
● The effectiveness:
● highest in the first 2 hours
● After 12 hours, the risk associated with
thrombolytic therapy outweighs any benefit
● contraindicated
● unstable angina and NSTEMI
● and for the treatment of individuals with evidence
of cardiogenic shock
● streptokinase, urokinase, and alteplase (recombinant
tissue plasminogen activator, rtPA), reteplase,
tenecteplase
Surgical Care
● Percutaneous Transluminal Coronary
Angioplasty
-treatment of choice
● PCI provides greater coronary patency
● lower risk of bleeding
● and instant knowledge about the extent
of the underlying disease.
● A specially designed balloon – tipped
catheter is inserted uder flouroscopic
guidance and advance to the site of the
obstruction.
 Intravascular Stenting
●Biologic Stent is produced through
coagulation of collagen, ellastin and
other tissues in the vessel wall by
laser, photocoagulation or radio
frequency.
●It is done to prevent restenosis after
Percutaneous Transluminal Coronary
Angioplasty.
● Emergent or urgent
coronary artery graft
bypass surgery (CABG)
is indicated
● angioplasty fails
● Severe narrowing of 1
or more coronary artery.
● Commonly used:
Saphenous vein and
internal mamary artery.
Complications
●Inflammation
●Mechanical
●Electrical abnormalities
Cardiac Rehabilitation
●A process which a person restored to health
and maintains optimal physiologic,
psychosocial and recreational functions.
●Begins with the moment a client is
admitted to the hospital for emergency
care, it continues for months and even
years after the client is discharged from the
health care facility.
●Goals of Rehabilitation:
1.To live as full, vital and productive life as possible.

2.Remain within the limits of the heart’s ability to

respond to activity and stress.
Activities:
● Exercise may gradually
implemented from the hospital
onwards.
● Exercise session is terminated if
any one of the following occurs:
cyanosis, cold sweats, faintness,
extreme fatigue, severe dyspnea,
pallor, chest pain, PR more than
100/ min., dysrhythmias greater
than 160/95mmHg.
Teaching and Counseling
● Self management education guide.
● Control hypertension with
continued medical supervision.
● Diet
● Weight reduction program
● Progressive exercise
● Stress management techniques
● Resumption of sexual activity
after 4-6 weeks from discharge, if
appropriate.
Teaching guide on resumption of sexual
activities:
● Assume less fatiguing position.
● The non- MI partner take the active role
● Take nitroglycerine before sexual activity
● If dyspnea, chest pain or palpitations
occur, moderation should be observed; if
symptom persist stop sexual activity.
● Develop other means of sexual
expression.