Responses To Oxygenation Perfusion and Transport Problems AY 2023 2024

NCM 12 N:
RESPONSES TO OXYGENATION-
PERFUSION AND TRANSPORT
PROBLEMS
CARDIOLOGY NURSING
THE CARDIOVASCULAR SYSTEM
HEART’S NORMAL ANATOMY

 The heart is located in the LEFT side of
the mediastinum
 Consists of Three layers - epicardium,
myocardium and endocardium
 The epicardium covers the outer surface of the heart
 The myocardium is the middle muscular layer of the heart
 The endocardium lines the chambers and the valves
 The layer that covers the heart is the PERICARDIUM
 There are two parts - parietal and visceral pericardium
 The space between the two pericardial layers is the
pericardial space
Structures of the Heart
 The heart also has four chambers

- two atria and two ventricles
 The Left atrium and the right
atrium
 The left ventricle and the right
ventricle
The Cardiovascular System
The heart chambers are guarded by

valves
 The atrio-ventricular valves -
tricuspid and bicuspid
 The semi-lunar valves - pulmonic
and aortic valves
Source: https://www.youtube.com/watch?v=28CYhgjrBLA
Systemic Circulation
The Blood supply of the heart comes from the Coronary

arteries
1. Right coronary artery supplies the RIGHT atrium and
RIGHT ventricle, inferior portion of the LEFT ventricle,
the POSTERIOR septal wall and the two nodes - AV (90%)
and SA node (55%)
2. Left coronary artery- branches into the LAD and
the circumflex branch
 The LAD supplies blood to the anterior wall of
the LEFT ventricle, the anterior septum and the
Apex of the left ventricle
 The CIRCUMFLEX branch supplies the left atrium
and the posterior LEFT ventricle
The CONDUCTING SYSTEM OF THE HEART

Consists of the
 1. SA node- the pacemaker
 2. AV node- slowest conduction
 3. Bundle of His – branches into the Right and the Left
bundle branch
 4. Purkinje fibers- fastest conduction
The Heart sounds

 1. S1- due to closure of the AV valves
 2. S2- due to the closure of the semi-lunar valves
 3. S3- due to increased ventricular filling
 4. S4- due to forceful atrial contraction
Heart rate
 Normal range is 60-100 beats per minute
 Tachycardia is greater than 100 bpm
 Bradycardia is less than 60 bpm
 Sympathetic system INCREASES HR
 Parasympathetic system (Vagus) DECREASES HR
 The stroke volume is affected by preload, contractility and afterload.
 ◦ Frank Starling’s Law states that the more the myocardial fibers are
stretched, the greater the force of contraction.
 ◦ Preload- blood volume in the ventricles at the end of diastole before the
next contraction
 ◦ Afterload -peripheral resistance against which the left ventricle must pump
Blood pressure
 a measure of the pressure exerted by the blood in
the arteries during heart contraction and relaxation.
 Cardiac output X peripheral resistance
 Control is neural (central and peripheral) and
hormonal
 Baroreceptors in the carotid and aorta
 Hormones- ADH, aldosterone, epinephrine can
increase BP; ANF can decrease BP
 The vascular system consists of the arteries,

veins and capillaries
 The arteries are vessels that carry blood away
from the heart to the periphery
 The veins are the vessels that carry blood to the
heart
 The capillaries are lined with squamos cells,
they connect the veins and arteries
 The lymphatic system also is

part of the vascular system and
the function of this system is to
collect the extravasated fluid
from the tissues and returns it to
the blood
Laboratory Test Rationale

 1. To assist in diagnosing MI
 2. To identify abnormalities
 3. To assess inflammation
 4. To determine baseline value
 5. To monitor serum level of medications
 6. To assess the effects of medications
LABORATORY PROCEDURES
CARDIAC Proteins and enzymes
➢ CK- MB ( creatine kinase)
➢Elevates in MI within 4 hours,
peaks in 18 hours and then
declines till 3 days
CARDIAC Proteins and
enzymes
➢CK- MB ( creatine kinase)
➢Normal value is 0-7 U/L
➢ Lactic Dehydrogenase (LDH)
➢ Elevates in MI in 24 hours,
peaks in 48-72 hours
➢ Normally LDH1 is greater
than LDH2

➢Lactic Dehydrogenase (LDH)
➢MI- LDH2 greater than LDH1
(flipped LDH pattern)
➢Normal value is 70-200 IU/L
Myoglobin
➢Rises within 1-3 hours
➢Peaks in 4-12 hours
➢Returns to normal in a day
Myoglobin
➢ Not used alone
➢ Muscular and RENAL disease
can have elevated myoglobin
Troponin I and T
 Troponin I is usually utilized for MI
 Elevates
within 3-4 hours, peaks in 4-24
hours and persists for 7 days to 3 weeks!
 Normal value for Troponin I is less than
0.6 ng/mL
Troponin I and T
REMEMBER to AVOID IM
injections before
obtaining blood sample!
Early and late diagnosis
can be made!
SERUM LIPIDS
 Lipid profile measures the serum
cholesterol, triglycerides and
lipoprotein levels
 Cholesterol= 200 mg/dL
 Triglycerides- 40- 150 mg/dL
SERUM LIPIDS
LDH- 130 mg/dL
HDL- 30-70- mg/dL
NPO post midnight
(usually 12 hours)
ELECTROCARDIOGRAM (ECG)
A non-invasive procedure
that evaluates the electrical
activity of the heart
Electrodes and wires are
attached to the patient
Holter Monitoring
A non-invasive test in which
the client wears a Holter
monitor and an ECG tracing
recorded continuously over
a period of 24 hours
Holter Monitoring
Instruct the client to
resume normal activities
and maintain a diary of
activities and any symptoms
that may develop
ECHOCARDIOGRAM
Non-invasive test that studies
the structural and functional
changes of the heart with the
use of ultrasound
No special preparation is
needed
Stress Test
A non-invasive test that studies
the heart during activity and
detects and evaluates CAD
Exercise test, pharmacologic
test and emotional test
Stress Test
Treadmill testing is the

most commonly used
stress test
Used to determine CAD,
Chest pain causes, drug
effects and dysrhythmias
in exercise
Stress Test
Pre-test: consent may be
required, adequate rest ,
eat a light meal or fast
for 4 hours and avoid
smoking, alcohol and
caffeine
Post-test: instruct client
to notify the physician if
any chest pain, dizziness
or shortness of breath .
Instruct client to avoid
taking a hot shower for
10-12 hours after the test
Pharmacological stress test

 Use of dipyridamole
 Maximally dilates coronary artery
 Side-effect: flushing of face
Pharmacological stress test

Pre-test: 4 hours fasting,
avoid alcohol, caffeine
Post test: report
symptoms of chest pain
 CARDIAC catheterization
 Insertion of a catheter into the heart and
surrounding vessels
 Determines the structure and
performance of the heart valves and
surrounding vessels
 CARDIAC catheterization
 Used to diagnose CAD, assess
coronary artery patency and determine
extent of atherosclerosis
Pretest:
Ensure Consent, assess for
allergy to seafood and iodine,
NPO, document weight and
height, baseline VS, blood
tests and document the
peripheral pulses
Pretest:
Fast for 8-12 hours,
teachings,
medications to allay
anxiety
 Intra-test:
 inform patient of a fluttery
feeling as the catheter
passes through the heart;
inform the patient that a
feeling of warmth and
metallic taste may occur
when dye is administered
 Post-test:
 Monitor VS and cardiac rhythm
 Monitor peripheral pulses, color and
warmth and sensation of the
extremity distal to insertion site
 Maintain sandbag to the insertion site
if required to maintain pressure
 Monitor for bleeding and hematoma
formation
 Maintain strict bed rest for 6-12 hours
 Client may turn from side to side but
bed should not be elevated more than
30 degrees and legs always straight
 Encourage fluid intake to flush out the
dye
 Immobilize the arm if the antecubital
vein is used
 Monitor for dye allergy
CVP
The CVP is the pressure
within the SVC
Reflects the pressure
under which blood is
returned to the SVC and
right atrium
CVP
 Normal CVP is 2 to 8 mmHg/ 6-12 cm
H2O
 Elevated CVP indicates increase in
blood volume, excessive IVF or
heart/renal failure
 Low CVP may indicated hypovolemia,
hemorrhage and severe vasodilatation
Measuring CVP
 1. Position the client supine .(if not
tolerated with bed elevated at 45
degrees)
 2. Position the zero point of the CVP
line at the level of the right atrium.
Usually this is at the MAL, 4th ICS
 3. Instruct the client to be relaxed and
avoid coughing and straining.
CARDIAC ASSESSMENT
ASSESSMENT
1. Health History
Obtain description of present
illness and the chief complaint
SOB, Edema, etc.
Assess risk factors
ASSESSMENT:
Chest Pain
Assess a patient’s chief complaint using the PQRSTU method
 Onset – When did the pain start?

 Location – Where is the pain?
 Duration – When it occurs, how long does the pain last? Is it constant or
intermittent?
 Characteristics – Describe what the pain feels like (e.g., sharp, dull, heavy, etc.).
 Aggravating/Alleviating Factors – What brings on the pain? What relieves the pain?
 Radiation – Does the pain radiate anywhere?
 Treatment – What have you used to treat the pain?
 Effects – What effect has the pain had on you?
 Severity – How severe is the pain from 0-10 when it occurs?
 Associated Symptoms – Have you experienced any nausea or sweating with the
chest pain?
CARDIAC ASSESSMENT
2. Physical examination
Vital signs- BP, PP, MAP
Inspection of the skin
Inspection of the thorax
Palpation of the PMI, pulses
Auscultation of the heart sounds
CARDIAC ASSESSMENT
 3. Laboratory and diagnostic studies
 CBC
 cardiac catheterization
 Lipid profile
 arteriography
 Cardiac enzymes and proteins
 CXR
 CVP
 EEG
 Holter monitoring
 Exercise ECG
CARDIAC IMPLEMENTATION
1. Assess the cardio-pulmonary

status
VS, BP, Cardiac assessment
2. Enhance cardiac output
 Establish IV line to
administer fluids
3. Promote gas exchange

Administer O2
Position client in SEMI-
Fowler’s
Encourage coughing and deep
breathing exercises
4. Increase client activity tolerance
Balance rest and activity periods
Assist in daily activities
5. Promote client comfort
Assess the client’s description of
pain and chest discomfort
Administer medication as
prescribed
6. Promote adequate sleep

7. Prevent infection
 Monitor skin integrity of lower
extremities
 Assess skin site for edema,
redness and warmth
 Monitor for fever
 Change position frequently
8. Minimize patient anxiety

Encourage verbalization of
feelings, fears and concerns
Answer client questions.
Provide information about
procedures and medications
Care of Clients with Oxygenation-
Perfusion Problems
Coronary Artery
Disease(CAD)
Acute Coronary
Syndrome(ACS)
Hypertension
Vascular Disorders
Coronary Artery Disease (CAD)
 CAD results from the focal

narrowing of the large and
medium-sized coronary
arteries due to deposition of
atheromatous plaque in the
vessel wall
Coronary Artery Disease (CAD)
 It is sometimes called
coronary heart disease or
ischemic heart disease.
For some people, the first

sign of CAD is a heart
attack.
Forms of coronary artery disease
 There are two main forms of coronary artery disease:

 Stable ischemic heart disease: This is the chronic
form. Coronary arteries gradually narrow over many
years. Over time, the heart receives less oxygen-rich
blood. Client may feel some symptoms, but able to live
with the condition day to day.
 Acute coronary syndrome: This is the sudden form
that’s a medical emergency. The plaque in the coronary
artery suddenly ruptures and forms a blood clot that
blocks blood flow to your heart. This abrupt blockage
causes a heart attack.
CAD
RISK FACTORS
 1. Age above 45/55 and Sex- Males and post-menopausal
females
 2. Family History
 3. Hypertension
 4. DM
 5. Smoking
 6. Obesity
 7. Lifestyle factors that raise risk
 Diet high in saturated fat or refined carbohydrates.
 Lack of physical activity.
 Sleep deprivation.
 Smoking, vaping or other tobacco use.
 8. Hyperlipidemia
CAD
RISK FACTORS
Most important MODIFIABLE
factors:
Smoking
Hypertension
Diabetes
Cholesterol abnormalities
CAD
Pathophysiology
Fatty streak formation in the
vascular intima → T-cells and
monocytes ingest lipids in the
area of deposition→
atheroma→ narrowing of the
arterial lumen → reduced
coronary blood flow →
myocardial ischemia
CAD
Pathophysiology
 There is decreased perfusion of
myocardial tissue and inadequate
myocardial oxygen supply
 If 50% of the left coronary arterial
lumen is reduced or 75% of the other
coronary artery, this becomes
significant
 Potential for Thrombosis and embolism
CAD
Symptoms of chronic CAD include:
• Stable angina: This is the most common symptom.

Stable angina is temporary chest pain or discomfort
that comes and goes in a predictable pattern.
Patient notice it during physical activity or
emotional distress. It goes away when client rest or
take nitroglycerin
• Shortness of breath (dyspnea): Some people feel

short of breath during light physical activity.
CAD
First symptom of CAD is a heart attack. Symptoms of a heart
attack include:
o Chest pain or discomfort (angina). Angina can range from mild

discomfort to severe pain. It may feel like heaviness, tightness,
pressure, aching, burning, numbness, fullness, squeezing or a dull
ache. The discomfort may spread to your shoulder, arm, neck, back
or jaw.
o Shortness of breath or trouble breathing.
o Feeling dizzy or lightheaded.
o Heart palpitations.
o Feeling tired.
o Nausea, stomach discomfort or vomiting. This may feel like
indigestion.
o Weakness.
CAD
Management:
1. Cardiac rehabilitation (rehab) is an important program for anyone

recovering from a heart attack, heart failure, or other heart problem that
required surgery or medical care. In these people, cardiac rehab can help
improve quality of life and can help prevent another cardiac event. Cardiac
rehab is a supervised program that includes
o Physical activity
o Education about healthy living, including healthy eating, taking medicine as
prescribed, and ways to help you quit smoking
o Counseling to find ways to relieve stress and improve mental health
2. Lifestyle changes, such as eating a healthier (lower sodium, lower fat) diet,
increasing physical activity (aim for 30 minutes of walking five days a week,
or find activities client enjoy), reaching a healthy weight, and quitting
smoking, limit alcohol intake.
3. Medicines to treat risk factors for CAD, such as high cholesterol, high blood
pressure, or an irregular heartbeat.
CAD
Management:
4. Surgical procedures to help restore blood flow to the heart
o Percutaneous coronary intervention (PCI): Another

name for this procedure is coronary angioplasty. It’s
minimally invasive. The surgeon uses a small balloon to
reopen blocked artery and help blood flow through it
better. The surgeon may also insert a stent to help artery
stay open.
o Coronary artery bypass grafting (CABG): This surgery
creates a new path for the blood to flow around
blockages. This “detour” restores blood flow to the heart.
CABG helps people who have severe blockages in
several coronary arteries.
Acute Coronary
Syndrome (ACS)
 An umbrella term for situations where the
blood supplied to the heart muscle is
suddenly blocked.
 Heart attack, or unstable angina -well-

known conditions which are both acute
coronary syndromes
 Top cause of death in people over 35 years

of age
Common signs of an acute coronary
syndrome:
 Chest pain or discomfort, which may involve
pressure, tightness or fullness
 Pain or discomfort in one or both arms, the jaw,
neck, back or stomach
 Shortness of breath
 Feeling dizzy or lightheaded
 Nausea
 Sweating
Risk factors:
 Smoking
 High blood pressure
 High blood cholesterol
 Diabetes
 Physical inactivity
 Being overweight or obese
 A family history of chest pain, heart disease or
stroke
Management:
 Medications:
 The initial treatment for all ACS includes aspirin (300
mg) and heparin bolus and intravenous (IV) heparin
infusion if there are no contraindications
 Antiplatelet therapy with ticagrelor or clopidogrel.
Ticagrelor is not given to the patients receiving
thrombolysis.
 Beta-blockers, statin, and ACE inhibitors should be
initiated in all ACS cases as quickly as possible unless
contraindications exist.
Management:
 Supportive measures like pain control with morphine/
fentanyl and oxygen in case of hypoxia.
 Nitroglycerin sublingual or infusion can be used for pain

relief as well. In cases of inferior wall ischemia,
nitroglycerine can cause severe hypotension and should be
used with extreme caution
Management:
 Continuous cardiac monitoring for arrhythmia
 The American Heart Association (AHA) recommends an
emergent catheterization and percutaneous intervention (PCI)
for STEMI with door to procedure start time of fewer than 90
minutes.
 A thrombolytic (tenecteplase or other thrombolytic) is
recommended if there is no PCI available and the patient
cannot be transferred to the catheterization lab in less than
120 minutes. AHA guideline dictates the door to needle
(TNK/other thrombolytics) time to be less than 30 minutes.
Management:
 Cases not amenable to PCI are taken for CABG (coronary
artery bypass graft) or managed medically depending upon
comorbidities and patient choice.
 Public education about lifestyle modification and making
people aware of healthier life choices.
 The patient should be urged to stop smoking, maintain a
healthy body weight, exercise regularly and remain
compliant with the medications.
Angina Pectoris
Chest pain resulting

from coronary
atherosclerosis or
myocardial ischemia
Angina Pectoris: Clinical Syndromes
Three Common Types of

ANGINA
1. STABLE ANGINA
The typical angina that
occurs during exertion,
relieved by rest and drugs
and the severity does not
change
Three Common Types of ANGINA

2. Unstable angina
Occurs unpredictably
during exertion and
emotion, severity
increases with time and
pain may not be relieved
by rest and drug
Three Common Types of ANGINA

3. Variant angina
Prinzmetal angina,
results from coronary
artery VASOSPASMS, may
occur at rest
Angina Pectoris
ASSESSMENT FINDINGS
1. Chest pain- ANGINA
 The most characteristic symptom
 PAIN is described as mild to severe
retrosternal pain, squeezing,
tightness or burning sensation
 Radiates to the jaw and left arm
Angina Pectoris
ASSESSMENT FINDINGS
1. Chest pain- ANGINA
 Precipitated by Exercise, Eating
heavy meals, Emotions like
excitement and anxiety and
Extremes of temperature
 Relieved by REST and
Nitroglycerin
Angina Pectoris
ASSESSMENT FINDINGS
 2. Diaphoresis
 3. Nausea and vomiting
 4. Cold clammy skin
 5. Sense of apprehension and
doom
 6. Dizziness and syncope
Angina Pectoris
LABORATORY FINDINGS
1. ECG may show normal tracing if
patient is pain-free. Ischemic changes
may show ST depression and T wave
inversion
2. Cardiac catheterization
 Provides the MOST DEFINITIVE
source of diagnosis by showing the
presence of the atherosclerotic
lesions
Angina Pectoris
NURSING MANAGEMENT
1. Administer prescribed medications
 Nitrates- to dilate the coronary
arteries
 Aspirin- to prevent thrombus
formation
 Beta-blockers- to reduce BP and HR
 Calcium-channel blockers- to dilate
coronary artery and reduce vasospasm
2. Teach the patient management of anginal attacks
 Advise patient to stop all activities
 Put one nitroglycerin tablet under the tongue
 Wait for 5 minutes
 If not relieved, take another tablet and wait for 5
minutes
 Another tablet can be taken (third tablet)
 If unrelieved after THREE tablets→ seek medical
attention
Nitroglycerin Dose
 Angina Pectoris (Acute Relief)
 0.3-0.6 mg SL q5min up to 3 times; use at first sign of angina
 Prompt medical attention needed if no relief
 Dissolve under tongue or in buccal pouch; do not rinse mouth

or spit for 5 minutes after administration
 Angina Pectoris (Prophylaxis)

 1 tablet SL 5-10 minutes before activities likely to provoke
angina attacks
Angina Pectoris
3. Obtain a 12-lead ECG

4. Promote myocardial perfusion
 Instruct patient to maintain bed rest
 Administer O2 @ 3 lpm
 Advise to avoid valsalva maneuvers
 Provide laxatives or high fiber diet
to lessen constipation
 Encourage to avoid increased
physical activities
Angina Pectoris
5. Assist in possible treatment modalities

 PTCA- percutaneous transluminal
coronary angioplasty
 To compress the plaque against the
vessel wall, increasing the arterial
lumen
 CABG- coronary artery bypass graft
 To improve the blood flow to the
myocardial tissue
Angina Pectoris
6. Provide information to family

members to minimize anxiety
and promote family
cooperation
7. Assist client to identify risk
factors that can be modified
8. Refer patient to proper
agencies
HYPERTENSIVE CRISIS
 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.
 https://www.ncbi.nlm.nih.gov/books/NBK470371/
HYPERTENSION
Types of Hypertension
1. Primary or ESSENTIAL
Most common type
2. Secondary
Due to other conditions like
Pheochromocytoma,
renovascular hypertension,
Cushing’s, Conn’s , SIADH
HYPERTENSION
PATHOPHYSIOLOGY
 Multi-factorial etiology
 BP= CO (SV X HR) x TPR (total peripheral resistance)
 Any increase in the above parameters will increase BP
 1. Increased sympathetic activity
 2. Increased absorption of Sodium, and water in the kidney
 3. Increased activity of the RAAS
 4. Increased vasoconstriction of the peripheral vessels
 5. insulin resistance
HYPERTENSION
ASSESSMENT FINDINGS
1. Headache
2. Visual changes
3. chest pain
4. dizziness
5. N/V
HYPERTENSION
 Risk factors for Cardiovascular Problems in Hypertensive patients
Major Risk factors
 1. Smoking
 2. Hyperlipidemia
 3. DM
 4. Age older than 60
 5. Gender- Male and post menopausal W
 6. Family History
HYPERTENSION
 DIAGNOSTIC STUDIES
 1. Health history and PE
 2. Routine laboratory- urinalysis, ECG,
lipid profile, BUN, serum creatinine ,
FBS
 3. Other lab- CXR, creatinine
clearance, 24-huour urine protein
HYPERTENSION
MEDICAL MANAGEMENT
1. Lifestyle
modification
2. Drug therapy
3. Diet therapy
HYPERTENSION
MEDICAL MANAGEMENT
Drug therapy
 Diuretics
 Beta blockers
 Calcium channel blockers
 ACE inhibitors
 A2 Receptor blockers
 Vasodilators
HYPERTENSION
NURSING INTERVENTIONS
1. Provide health teaching to
patient
Teach about the disease process
Elaborate on lifestyle changes
Assist in meal planning to lose
weight
HYPERTENSION
 NURSING INTERVENTIONS
 1. Provide health teaching to the
patient
 Provide list of LOW fat , LOW
sodium diet of less than 2-3 grams
of Na/day
 Limit alcohol intake to 30 ml/day
 Regular aerobic exercise
 Advise to completely Stop smoking
HYPERTENSION
 Nursing Interventions
 2. Provide information about anti-
hypertensive drugs
 Instruct proper compliance and not
abrupt cessation of drugs even if pt
becomes asymptomatic/ improved
condition
 Instruct to avoid over-the-counter drugs
that may interfere with the current
medication
HYPERTENSION
 Nursing Intervention
 3. Promote Home care management
 Instruct regular monitoring of BP
 Involve family members in care
 Instruct regular follow-up
 4. Manage hypertensive emergency
and urgency properly
Vascular Diseases
ANEURYSM
Dilation involving an
artery formed at a
weak point in the
vessel wall
ANEURYSM
 Saccular=when one side of

the vessel is affected
 Fusiform=
when the entire
segment becomes dilated
ANEURYSM
 RISK FACTORS
1. Atherosclerosis
2. Infection= syphilis
3. Connective tissue disorder
4. Genetic disorder= Marfan’s
Syndrome
ANEURYSM
 PATHOPHYSIOLOGY
Damage to the intima and media→
weakness→ outpouching
Dissecting aneurysm→ tear in the

intima and media with
dissection of blood through the
layers
ANEURYSM
 ASSESSMENT
1. Asymptomatic
2. Pulsatile sensation on the abdomen
3. Palpable bruit
ANEURYSM
LABORATORY:
• CT scan
• Ultrasound
• X-ray
• Aortography
ANEURYSM
Collaborative Management:
• Anti-hypertensives
• Synthetic graft
ANEURYSM
Nursing Management:
• Administer medications
• Emphasize the need to avoid
increased abdominal pressure
• No deep abdominal palpation
• Remind patient the need for serial
ultrasound to detect diameter
changes
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
 Refers to arterial insufficiency
of the extremities usually
secondary to peripheral
atherosclerosis.
 Usually found in males age 50
and above
 The legs are most often
affected
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
Risk factors for Peripheral
Arterial occlusive disease
Non-Modifiable
1. Age
2. gender
3. family predisposition
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
 Risk factors for Peripheral Arterial
occlusive disease
Modifiable
 1. Smoking
 2. HPN
 3. Obesity
 4. Sedentary lifestyle
 5. DM
 6. Stress
PERIPHERAL ARTERIAL OCCLUSIVE
DISEASE
ASSESSMENT FINDINGS
 1. INTERMITTENT CLAUDICATION-
the hallmark of PAOD
 This is PAIN described as aching,
cramping or fatiguing discomfort
consistently reproduced with the
same degree of exercise or
activity
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
 ASSESSMENT FINDINGS
 1. INTERMITTENT CLAUDICATION-
the hallmark of PAOD
 This pain is RELIEVED by REST
 This commonly affects the
muscle group below the arterial
occlusion
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
Assessment Findings
2. Progressive pain on the
extremity as the disease
advances
3. Sensation of cold and
numbness of the
extremities
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
 Assessment Findings
 4. Skin is pale when
elevated and
cyanotic/ruddy when placed
on a dependent position
 5. Muscle atrophy, leg
ulceration and gangrene
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
Diagnostic Findings
1. Unequal pulses
between the extremities
2. Duplex
ultrasonography
3. Doppler flow studies
PAOD
 Medical Management
1. Drug therapy
 Pentoxyfylline (Trental) reduces blood
viscosity and improves supply of O2 blood
to muscles
 Cilostazol (Pletaal) inhibits platelet
aggregation and increases vasodilatation
 2. Surgery- Bypass graft and anastomoses
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
1. Maintain Circulation to the
extremity
 Evaluate regularly peripheral
pulses, temperature, sensation,
motor function and capillary
refill time
 Administer post-operative care to
patient who underwent surgery
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
2. Monitor and manage complications
 Note for bleeding, hematoma,
decreased urine output
 Elevate the legs to diminish edema
 Encourage exercise of the extremity
while on bed
 Teach patient to avoid leg-crossing
PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
3. Promote Home
management
 Encourage lifestyle changes
 Instruct to AVOID smoking
 Instruct to avoid leg
crossing
Care of Clients with
Oxygenation-Transport
Problems
Source:https://www.youtube.com/watch?v=5aOgQD1DjAI
Care of Clients with Oxygenation-
Transport Problems
Anemia
Nutritional anemia
Hemolytic anemia
Aplastic anemia
Sickle cell anemia
ANEMIA
A condition in which
the hemoglobin
concentration is lower
than normal
ANEMIA
Three broad categories

1. Loss of RBC- occurs with
bleeding
2. Decreased RBC production
3. Increased RBC destruction
Hypoproliferative Anemia
Iron Deficiency Anemia

Results when the dietary
intake of iron is
inadequate to produce
hemoglobin

Etiologic Factors
1. Bleeding- the most common
cause
2. Mal-absorption
3. Malnutrition
4. Alcoholism

Pathophysiology
The body stores of iron
decrease, leading to
depletion of hemoglobin
synthesis
IronDeficiency Anemia
Pathophysiology
The oxygen carrying
capacity of hemoglobin is
reduced→ tissue hypoxia

Assessment Findings
1. Pallor of the skin and mucous
membrane
2. Weakness and fatigue
3. General malaise
4. Pica

5. Brittle nails
6. Smooth and sore tongue
7. Angular cheilosis

Laboratory findings
1. CBC- Low levels of Hct, Hgb
and RBC count
2. low serum iron, low ferritin
3. Bone marrow aspiration-
MOST definitive

Medical management
1. Hematinics
2. Blood transfusion
Iron Deficiency Anemia

Nursing Management
1. Provide iron rich-foods
Organ meats (liver)
Beans
Leafy green vegetables
Raisins and molasses
Nursing Management
2. Administer iron
 Oral preparations tablets- Fe
fumarate, sulfate and gluconate
 Advise to take iron ONE hour before
meals
 Take it with vitamin C
 Continue taking it for several months
Nursing Management
2. Administer iron
 Oral preparations- liquid
 It stains teeth
 Drink it with a straw
 Stool may turn blackish- dark in
color
 Advise to eat high-fiber diet to
counteract constipation
Nursing Management
2. Administer iron
 IM preparation
 Administer DEEP IM using the Z-track
method
 Avoid vigorous rubbing
 Can cause local pain and staining
APLASTIC ANEMIA
A condition
characterized by
decreased number of
RBC as well as WBC and
platelets
APLASTIC ANEMIA
CAUSATIVE FACTORS
1. Environmental toxins-
pesticides, benzene
2. Certain drugs-
Chemotherapeutic agents,
chloramphenicol, phenothiazines,
Sulfonamides
3. Heavy metals
4. Radiation
APLASTIC ANEMIA
Pathophysiology
Toxins cause a direct bone marrow
depression→ acellular bone
marrow→ decreased production of
blood elements
APLASTIC ANEMIA
ASSESSMENT FINDINGS
1. fatigue
2. pallor
3. dyspnea
4. bruising
5. splenomegaly
6. retinal hemorrhages
APLASTIC ANEMIA
LABORATORY FINDINGS
1. CBC- decreased blood cell
numbers
2. Bone marrow aspiration
confirms the anemia-
hypoplastic or acellular
marrow replaced by fats
APLASTIC ANEMIA
Medical Management
1. Bone marrow
transplantation
2. Immunosupressant
drugs
3. Rarely, steroids
4. Blood transfusion
APLASTIC ANEMIA
Nursing management
1. Assess for signs of
bleeding and infection
2. Instruct to avoid
exposure to offending
agents
Megaloblastic Anemias
Anemias characterized by
abnormally large RBC
secondary to impaired DNA
synthesis due to deficiency of
Folic acid and/or vitamin B12
Folic Acid deficiency

Causative factors
1. Alcoholism
2. Mal-absorption
3. Diet deficient in uncooked
vegetables
Pathophysiology of Folic acid
deficiency
Decreased folic acid→ impaired
DNA synthesis in the bone
marrow→ impaired RBC
development, impaired nuclear
maturation but CYTOplasmic
maturation continues→ large size
 Vitamin B12 deficiency

 Causative factors
 1. Strict vegetarian diet
 2. Gastrointestinal malabsorption
 3. Crohn's disease
 4. gastrectomy
 Vitamin B12 deficiency
Pernicious Anemia
 Due to the absence of intrinsic factor
secreted by the parietal cells
 Intrinsic factor binds with Vit. B12 to
promote absorption
 Assessment findings
 1. weakness
 2. fatigue
 3. listless
 4. neurologic manifestations are
present only in Vit. B12 deficiency
 Assessment findings
 Pernicious Anemia
Beefy, red, swollen tongue
Mild diarrhea
Extreme pallor
Paresthesias in the extremities
 Laboratory findings
 1. Peripheral blood smear- shows giant
RBCs, WBCs with giant hypersegmented
nuclei
 2. Very high MCV
 3. Schilling’s test
 4. Intrinsic factor antibody test
 Medical Management
 1. Vitamin supplementation
 Folic acid 1 mg daily
 2. Diet supplementation
 Vegetarians should have vitamin intake
 3.
Lifetime monthly injection of IM Vit
B12
 Nursing Management
 1. Monitor patient
 2. Provide assistance in ambulation
 3. Oral care for tongue sore
 4. Explain the need for lifetime IM
injection of vit B12
Hemolytic Anemia: Sickle Cell
A severe chronic incurable

hemolytic anemia that
results from heritance of
the sickle hemoglobin
gene.
Causative factor
Genetic inheritance of the
sickle gene- HbS gene
Pathophysiology
Decreased O2, Cold,
Vasoconstriction can
precipitate sickling
process
Pathophysiology
Factors→ cause defective
hemoglobin to acquire a
rigid, crystal-like C-shaped
configuration→ Sickled
RBCs will adhere to
endothelium→ pile up and
plug the vessels→ ischemia
results→ pain, swelling and
fever
1. jaundice
2. enlarged skull and
facial bones
3. tachycardia, murmurs
and cardiomegaly
Primary sites of
thrombotic occlusion:
spleen, lungs and CNS
Chest pain, dyspnea
1. Sickle cell crises
Results from tissue hypoxia and
necrosis
2. Acute chest syndrome
Manifested by a rapidly falling
hemoglobin level, tachycardia,
fever and chest infiltrates in the
CXR
Medical Management
1. Bone marrow
transplant
2. Hydroxyurea
Increases the HbF
3. Long term RBC
transfusion
Nursing Management
1. manage the pain
Support and elevate
acutely inflamed joint
Relaxation techniques
analgesics
Nursing Management
2. Prevent and manage
infection
Monitor status of patient
Initiate prompt antibiotic
therapy
Nursing Management
3. Promote coping skills
Provide accurate information
Allow patient to verbalize her
concerns about medication,
prognosis and future
pregnancy
Nursing Management
4. Monitor and prevent
potential complications
Provide always adequate
hydration
Avoid cold, temperature that
may cause vasoconstriction
Nursing Management
Leg ulcer
Aseptic technique
Nursing Management
Priapism
Sudden painful erection
Instruct patient to empty
bladder, then take a warm bath
Polycythemia
Refers to an INCREASE volume

of RBCs
The hematocrit is ELEVATED to
more than 55%
Clasified as Primary or
Secondary
Polycythemia
POLYCYTHEMIA VERA
Primary Polycythemia
A proliferative disorder in
which the myeloid stem cells
become uncontrolled
Polycythemia
Causative factor
unknown
Polycythemia
Pathophysiology
The stem cells grow
uncontrollably
The bone marrow becomes
HYPERcellular and all the blood
cells are increased in number
Polycythemia
Pathophysiology
The spleen resumes its function
of hematopoiesis and enlarges
Blood becomes thick and viscous
causing sluggish circulation
Polycythemia
Pathophysiology
Overtime, the bone marrow
becomes fibrotic
Polycythemia
Assessment findings
1. Skin is ruddy
2. Splenomegaly
3. headache
4. dizziness, blurred vision
5. Angina, dyspnea and
thrombophlebitis
Polycythemia
Laboratory findings
1. CBC- shows elevated RBC
mass
2. Normal oxygen saturation
3 Elevated WBC and Platelets
Polycythemia
Complications
1. Increased risk for
thrombophlebitis, CVA and MI
2. Bleeding due to
dysfunctional blood cells
Polycythemia
Medical Management
1. To reduce the high blood cell
mass- PHLEBOTOMY
2. Allopurinol
3. Dipyridamole
4. Chemotherapy to suppress bone
marrow
Polycythemia
 NursingManagement
1. Primary role of the nurse is
EDUCATOR
2. Regularly asses for the development
of complications
3. Assist in weekly phlebotomy
4. Advise to avoid alcohol and aspirin
5. Advise tepid sponge bath or cool
water to manage pruritus
Leukemia
 Malignant disorders of blood

forming cells characterized by
UNCONTROLLED proliferation
of WHITE BLOOD CELLS in the
bone marrow- replacing
marrow elements . The WBC
can also proliferate in the
liver, spleen and lymph nodes.
Leukemia
The leukemias are named after

the specific lines of blood cells
afffected primarily
Myeloid
Lymphoid
Monocytic
Leukemia
 The leukemias are named also

according to the maturation of cells
 ACUTE
The cells are primarily immature
 CHRONIC
The cells are primarily mature or
differentiated
Leukemia
ACUTE myelocytic leukemia

ACUTE lymphocytic leukemia
CHRONIC myelocytic leukemia

CHRONIC lymphocytic leukemia
Leukemia
ETIOLOGIC FACTORS
UNKNOWN
Probably exposure to radiation
Chemical agents
Infectious agents
Genetic
Leukemia
PATHOPHYSIOLOGY of ACUTE
Leukemia
Uncontrolled proliferation of
immature cells→ suppresses bone
marrow function→ severe anemia,
thrombocytopenia and
granulocytopenia
Leukemia
PATHOPHYSIOLOGY of CHRONIC
Leukemia
Uncontrolled proliferation of
DIFFERENTIATED cells→ slow
suppression of bone marrow
function→ milder symptoms
Leukemia
 ASSESSMENT FINDINGS
 ACUTE LEUKEMIA
 Pallor
 Fatigue
 Dyspnea
 Hemorrhages
 Organomegaly
 Headache
 vomiting
Leukemia
 ASSESSMENT FINDINGS
 CHRONIC LEUKEMIA
Less severe symptoms
organomegaly
Leukemia
LABORATORY FINDINGS
 Peripheral WBC count varies widely
 Bone marrow aspiration biopsy reveals
a large percentage of immature cells-
BLASTS
 Erythrocytes and platelets are
decreased
Leukemia
Collaborative Management
1. Chemotherapy
2. Bone marrow transplantation
Leukemia
Nursing Management
 1. Manage AND prevent infection
 Monitor temperature
 Assess for signs of infection
 Be alert if the neutrophil count drops
below 1,000 cells/mm3
Leukemia
Nursing Management
 2. Maintain skin integrity
 3. Provide pain relief
 4. Provide information as to therapy-

chemo and bone marrow transplantation
References:
 1. Hinkle,J.L.& Cheever,K.H.(2018).Brunner & Suddarth’s Textbook of Medical Surgical Nursing,14th
 Ed.Wolters Kluwer .LWW.com
 2. Borromeo,A.R.et.al (2014).Lewi’s Medical-Surgical Nursing .Assessment and Management of Clinical
Problems.Philippine Ed.8th Ed. Mosby Elsevier (Singapore)Pte Ltd
 3. https://www.heart.org/en/health-topics/heart-attack/about-heart-attacks/acute-coronary-
syndrome
 4. https://healthinfo.uclahealth.org/Library/DiseasesConditions/Pediatric/Blood/160,34
 5. https://my.clevelandclinic.org/health/diseases/22769-aneurysm
 6. https://www.cdc.gov/heartdisease/coronary_ad.htm
 7. https://my.clevelandclinic.org/health/diseases/16898-coronary-artery-disease
 8.
https://www.ncbi.nlm.nih.gov/books/NBK459157/#:~:text=Treatment%20%2F%20Management,depends%20o
n%20local%20cardiologist%20preference.
 9. Google search engine for image
 10.Youtube.com
Lorena Abiera, RN, MAN

Responses To Oxygenation Perfusion and Transport Problems AY 2023 2024

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NCM 12 N:

HEART’S NORMAL ANATOMY

 The heart also has four chambers

The heart chambers are guarded by

The Blood supply of the heart comes from the Coronary

The CONDUCTING SYSTEM OF THE HEART

The Heart sounds

 The vascular system consists of the arteries,

 The lymphatic system also is

Laboratory Test Rationale

CARDIAC Proteins and enzymes

Treadmill testing is the

Pharmacological stress test

Pharmacological stress test

Assess a patient’s chief complaint using the PQRSTU method

 Onset – When did the pain start?

1. Assess the cardio-pulmonary

3. Promote gas exchange

6. Promote adequate sleep

8. Minimize patient anxiety

 CAD results from the focal

For some people, the first

 There are two main forms of coronary artery disease:

• Stable angina: This is the most common symptom.

• Shortness of breath (dyspnea): Some people feel

o Chest pain or discomfort (angina). Angina can range from mild

1. Cardiac rehabilitation (rehab) is an important program for anyone

4. Surgical procedures to help restore blood flow to the heart

o Percutaneous coronary intervention (PCI): Another

 Heart attack, or unstable angina -well-

 Top cause of death in people over 35 years

 Nitroglycerin sublingual or infusion can be used for pain

Chest pain resulting

Three Common Types of

Three Common Types of ANGINA

Three Common Types of ANGINA

 Prompt medical attention needed if no relief

 Dissolve under tongue or in buccal pouch; do not rinse mouth

 Angina Pectoris (Prophylaxis)

3. Obtain a 12-lead ECG

5. Assist in possible treatment modalities

6. Provide information to family

 A hypertensive emergency is an acute, marked elevation

 Saccular=when one side of

Dissecting aneurysm→ tear in the

Three broad categories

Iron Deficiency Anemia

Iron Deficiency Anemia

Iron Deficiency Anemia

Iron Deficiency Anemia

Iron Deficiency Anemia

Iron Deficiency Anemia

Iron Deficiency Anemia

Iron Deficiency Anemia

Folic Acid deficiency

 Vitamin B12 deficiency

 Vitamin B12 deficiency

A severe chronic incurable

Refers to an INCREASE volume

 Malignant disorders of blood

The leukemias are named after

 The leukemias are named also