ACUTE BIOLOGIC CRISIS Clinical Manifestations:

CORONARY ARTERY DISEASE  Chest pain

 Dyspnea / Shortness of breath (SOB)
 Most prevalent type of cardiovascular  Chest tightness
disease in adults.  Epigastric discomfort & pain that
 The most common cause of coronary radiates to the jaw, left arm, and the
artery disease (CAD) is atherosclerosis, back
an abnormal accumulation of lipid, or  Other symptoms:
fatty substances, and fibrous tissue in o Indigestion
the lining of arterial blood vessel walls. o Nausea
 These fatty substances block and o Palpitations
narrow the coronary vessels in a way o Numbness
that reduces blood flow to the heart
Nursing Responsibilities:
Atheroslerosis
1) Controlling Cholesterol Abnormalities
 Most common cause of cardiovascular  Diet & Lifestyle Change
disability that leads to death  Exercise
 Causes narrowing of the artery  Medications – lipid lowering
 Incomplete occlusion of the coronary agents
arteries due to accumulation of fatty 2) Smoking Cessation
deposits 3) Management of HPN
 Complete occlusion of the coronary  Medications – antihypertensive
arteries leads to Myocardial Infarction  Exercise
 The heart will pump harder to meet the 4) Management of DM
O2 demand leading to Heart Failure  Medications – hypoglycemic
agents
Risk Factors:

1. Nonmodifiable Angina Pectoris

o Age
o Gender  Angina Pectoris is a clinical syndrome
o Race usually characterized by episodes or
o Hereditary paroxysms of pain or pressure in the
anterior chest.
2. Modifiable  The cause is insufficient coronary blood
o Obesity flow, resulting in a decreased oxygen
o Stress supply when there is increased
o Physical Inactivity/Exercise myocardial demand for oxygen in
o Cigarette Smoking response to physical exertion or
o Diabetes Mellitus emotional stress.
o Hypertension  In other words, the demand for oxygen
o Metabolic Syndrome exceeds the supply.
o Hyperlipidemia
o Behavioral Factors of a Person
o Contraceptive Pills
Types of Angina: a. Instruct patient to stop all
activities, lie down in bed, and
1. Stable place in semi Fowler’s position
 Predictable & consistent pain b. Note location and severity of
that occurs on exertion and is chest pain
relieved by rest and/or c. Perform ECG as ordered
Nitroglycerin d. Oxygen administration
2. Unstable (also known as Preinfarction
angina or Cresendo angina) 2) Pharmacologic Therapy
 Symptoms increase in e. Nitroglycerin
frequency & severity; may not f. Beta-Adrenergic Blocking
be relieved by rest and/or Agents (Metoprolol)
Nitroglycerin g. Calcium-Channel Blocking
3. Intractable or refractory Agents (Amlodipine, Diltiazem)
 Severe incapacitating recurring h. Antiplatelet and Anticoagulant
chest pain despite following the Medications (Aspirin, Heparin)
right treatment plan.
4. Variant (also known as Prinzmetal
angina) ACUTE CORONARY SYNDROME
 Chest pain at rest with
reversible ST-segment  An emergent situation
elevation; thought to be caused characterized by an acute onset
by coronary artery vasospasm of myocardial ischemia that
5. Silent Ischemia results in myocardial death if
 Objective evidence of ischemia definitive measures do not
(such as ECG changes with a occur promptly.
stress test), but patient reports  The spectrum of ACS includes
no pain. unstable angina, Non ST
Elevation Myocardial Infarction
Clinical Manifestations: (NSTEMI), and ST-segment
Elevation Myocardial Infarction
a) Chest pain radiating to the neck, jaw, (STEMI)
shoulders, and upper arms (usually the
left) Unstable Angina
b) Mild indigestion
c) Choking or heavy sensation in the upper  It is a type of angina that causes
chest unexpected chest pain, and usually
d) Shortness of breath occurs while resting.
e) Weakness or numbness in the upper  The most common cause is reduced
extremities blood flow to the heart muscle because
f) Other symptoms: pallor, diaphoresis, the coronary arteries are narrowed by
dizziness, and N/V fatty buildups (atherosclerosis) which
can rupture causing injury to the
Nursing Responsibilities: coronary blood vessel resulting in blood
clotting which blocks the flow of blood
1) Treating the Angina to the heart muscle.
Clinical Manifestations: heart attack. The more damage
there is to the heart, the
1) Sudden chest pain not relieved by rest greater the amount of troponin
2) Shortness of breath (SOB) T and I there will be in the
3) Indigestion blood. A blood sample is
4) Nausea needed.
5) Anxiety
6) Cool, pale, moist skin
7) Tachycardia ACUTE MYOCARDIAL INFARCTION
8) Tachypnea
 Occurs when one of the heart's
Pathophysiology f Unstable Angina: coronary arteries is blocked suddenly or
has extremely slow blood flow.
a) Formation of plaque/fatty deposits  A heart attack, or myocardial infarction
(Atherosclerosis) (MI), is permanent damage to the heart
b) Rupture of atherosclerotic plaque muscle. "Myo" means muscle, "cardial"
a. Reduced blood flow in the refers to the heart, and "infarction"
coronary artery means death of tissue due to lack of
c) Clot aggregation that forms into a blood supply.
thrombus on top of the coronary lesion
(partial artery occlusion) Basic Pathophysiology:
d) Chest pain --- Unstable Angina
a) Blocked coronary artery
b) Impeded blood flow to the heart
Diagnostics: c) Damaged heart tissue that can lead to
ischemia (w/o tissue death) or
a) 12-lead ECG infarction (w/ tissue death)
 Should be obtained 10 minutes
from the time a patient reports Clinical Manifestations:
chest pain
 Expected ECG changes are T- a) Most common: CHEST PAIN and
wave inversion, ST-segment shortness of breath.
elevation, and development of b) Other S/Sx:
an abnormal Q wave o Pressure or tightness in the
b) Echocardiogram (2D-Echo) chest
c) Cardiac biomarkers o Pain in the chest that radiates
a. Troponin I & Troponin T, in the back, jaw, and other
Creatine Kinase MB (CKMB), areas of the upper body.
Myoglobin o Tachycardia
o Sweating
Troponin I / Troponin T o Nausea and vomiting
o Cough
o A troponin test measures the o Dizziness
levels of troponin T or troponin
I proteins in the blood. These Classification of Severity: KILLIPS
proteins are released when the
heart muscle has been 1) Class I
damaged, such as occurs with a  No evidence of Heart Failure
 2) Class II o Assess and Refer ASAP
 Findings of mild to moderate o Do ECG
heart failure
- S3 gallop b. POST MI:
- rales < half-way up lung fields o Monitor the patient closely and
- elevated jugular venous assist on their ADL.
pressure  Patient usually on bed
3) Class III rest without bathroom
 Pulmonary Edema privileges
4) Class IV o Medication administration
 Cardiogenic Shock (Systolic BP <  TIP : watch-out for
90 and signs of hypoperfusion possible side effects of
such as oliguria, cyanosis, and your drugs
excessive sweating)

Diagnostics: HEART FAILURE /

CONGESTIVE HEART FAILURE (CHF)
a) Positive of 2 out of 3
 Physical symptoms  It’s when your heart muscle doesn't
 Blood Test (Cardiac Biomarkers) pump blood as well as it should.
 Electrocardiogram (ECG)  In heart failure, the main pumping
b) To know the specific location of the chambers of your heart may become
damaged area of the heart: stiff and not fill properly between beats.
 Coronary Angiogram In some cases of heart failure, your
heart muscle may become damaged
Medical Management: and weakened, and the ventricles dilate
to the point that the heart can't pump
a. Severe Cases blood efficiently throughout your body.
 Angioplasty
 Coronary Artery Bypass Graft Classification of Heart Failure:
(CABG)
b. Medications 1. Based on stages/ severity
 Thrombolytics (tPA) o Compensated or
 Blood Thinners Decompensated
(Aspirin/Clopidogrel) 2. Based on which side of the heart is involved
or affected
 Pain Reliever (Morphine)
o Left-sided Heart Failure
 Nitrates
o Right-sided Heart Failure
 ACE inhibitors (for hypertensive
3. Based on Cardiac Output
patients)
o Low-output Cardiac Failure
 Beta Blockers (to reduce cardiac
o High-output Cardiac Failure
workload)
4. Based on duration
 Oxygen support o Acute Heart Failure
o Chronic Heart Failure
Nursing Responsibilities: 5. Based on Functions Affected
o Systolic
a. CONCURRENT MI o Diastolic
o Early recognition
Types of Heart Failure: 1) Heart failure can be ongoing (chronic),
or your condition may start suddenly
1. Left-sided heart failure: fluid may back (acute).
up in your lungs, causing shortness of 2) Heart failure signs and symptoms may
breath. include:
2. Right-sided heart failure: fluid may back  Congestion
up into your abdomen, legs and feet,  Sudden, severe SOB and coughing up
causing swelling. pink, foamy mucus
3. Systolic heart failure: the left ventricle  Dyspnea when you exert yourself or
can't contract vigorously, indicating a when you lie down
pumping problem.  Edema in legs, ankles and feet
4. Diastolic heart failure: The left ventricle  Hypertension
can't relax or fill fully, indicating a filling  Persistent cough or wheezing with
problem. white or pink blood-tinged phlegm
 Swelling of your abdomen (ascites)
Other Classifications:
3) Other signs and symptoms may include:
A. New York Heart Association
classification (symptom-based scale)  Fatigue and weakness
 Rapid or irregular heartbeat
a. Class I - no symptoms of HF.
 Very rapid weight gain from fluid
b. Class II - can perform everyday
retention
activities w/o difficulty but
 Difficulty concentrating or decreased
become winded or fatigued
alertness
during exertion.
 Chest pain if your heart failure is caused
c. Class III - have trouble
by a heart attack
completing everyday activities.
d. Class IV - with short of breath
Diagnostics:
even at rest.
 MOST COMMON
B. American College of Cardiology/AHA
a. Blood Test (Pro-BNP)
guidelines (category for people who are
b. ECG
at risk of developing heart failure.)
c. 2D echo (measure your EF)
d. Chest Xray (detect Pulmonary
a. Stage A – patient with several
Congestion)
risk factors for HF but S/Sx is
absent
b. Stage B – patient with heart  OTHERS
disease still no S/Sx of HF a. Stress Test
c. Stage C – patient with heart b. CT Scan
disease and is experiencing or c. MRI
has experienced S/Sx of HF d. Angiogram
d. Stage D – patient with
advanced heart failure requiring Medical Management
specialized treatments.
 Surgical
Clinical Manifestations: a. CABG
b. Heart Valve repair/replacement
 c. Ventricular Assist Device C. Type 3 (Perioperative Respiratory
d. Heart Transplant Failure)
a. Subtype of type 1 that results
 Medications from lung or alveolar atelectasis.
a. ACE inhibitors (for hypertensive General anesthesia can cause
patients) collapse of dependent lung
b. Beta Blockers (to reduce cardiac alveoli.
workload)
c. Diuretics Causes:
d. Inotropes
e. Digoxin  Airway Obstruction
f. Oxygen support  Head Injury
 Pneumonia
Nursing Responsibilities:  Asthma
 Chronic Obstructive Pulmonary Disease
1. Monitor patient closely (specially I&O) (COPD)
2. Limit OFI  Severe Obesity
3. Medication administration  Stroke
4. Assist on patient’s ADL  Pulmonary Embolism
5. Facilitate procedures
Clinical Manifestations:

ACUTE RESPIRATORY FAILURE  Early Signs

1) Dyspnea
 Sudden and life-threatening 2) Air Hunger
deterioration of the gas exchange 3) Restlessness
function of the lung and indicates 4) Fatigue
failure of the lungs to provide adequate 5) Headache
oxygenation or ventilation for the 6) Tachycardia
blood. 7) Increased Blood Pressure
 A decrease in arterial oxygen tension
(PaO2) to less than 50 mmHg (hypoxia)  As Hypoxemia progresses:
and an increase in arterial carbon 1) Confusion
dioxide tension (PaCO2) to greater than 2) Lethargy
50 mmHg (hypercapnia), with an 3) Tachypnea
arterial pH of less than 7.35. 4) Central Cyanosis
5) Diaphoresis
Types: 6) Respiratory Arrest

A. Type 1 (Hypoxemic Respiratory Failure) Diagnostics:

a. Failure to exchange oxygen in
the lungs a) Chest X-ray (CXR)
b) Chest CT Scan
B. Type 2 (Hypercapnic Respiratory c) Arterial Blood Gas (ABG)
Failure)
a. Failure to exchange or remove
carbon dioxide in the lungs
Medical Management: Clinical Manifestations:

a) Bronchodilators (Salbutamol inhalation) 1) Severe shortness of breath

b) Steroids (Hydrocortisone) 2) (SOB)
c) Antibiotics (Treat underlying infection) 3) Labored and unusually rapid breathing
d) Non-invasive Positive Pressure 4) Low blood pressure
Ventilation (CPAP or BiPAP) 5) (HYPOTENSION)
e) Oxygen Therapy 6) Confusion and extreme tiredness
f) Intubation and mechanical ventilation
Causes:
Nursing Interventions:
1) Sepsis
a) Monitor patient’s respiratory status 2) Inhalation of harmful substances. Thick
include the vital signs smoke or chemical fumes, inhaling
b) Monitor level of response and oxygen (aspirating) vomit or near-drowning
saturation episodes.
c) Arterial blood gas (ABG) 3) Severe pneumonia. Pneumonia
affecting all five lobes of the lungs.
4) Chest other major injury. Traumas that
ACUTE RESPIRATORY DISTRESS SYNDROME directly damage the lungs.
(ARDS) 5) Others. Pancreatitis (inflammation of
the pancreas), massive blood
 Occurs when fluid builds up in the tiny, transfusions and burns.
elastic air sacs (alveoli) in your lungs.
The fluid keeps your lungs from filling Pathophysiology:
with enough air, which means less
oxygen reaches your bloodstream. This 1) Injury to alveolar-capillary membrane
deprives your organs of the oxygen they 2) Damaged type II alveolar cell
need to function. 3) Decreased surfactant production
 Characterized by a sudden and 4) Decreased alveolar compliance and
progressive pulmonary edema, recoil
increasing bilateral infiltrates on chest 5) Decreased lung compliance (Atelectasis,
X-ray, hypoxemia refractory to oxygen Bronchoconstriction, Vascular
supplementation, and reduced lung narrowing & obstruction, Pulmonary
compliance. edema)
 Formerly called, Adult Respiratory 6) Impaired gas exchange
Distress Syndrome; Having a mortality 7) ARDS
rate of 50-60%
 Patients with ARDS usually require Complications:
mechanical ventilator with a higher-
than-normal airway pressure 1) Blood clots. Lying still in the hospital
 2 major factors associated with the while you're on a ventilator can increase
development of ARDS: direct and your risk of developing blood clots,
indirect injury to the lungs. particularly in the deep veins in your
 *Direct injury: cigarette smoking. legs. If a clot forms in your leg, a portion
 *Indirect insult: shock, trauma. of it can break off and travel to one or
 Major cause of death in ARDS: SEPSIS. both of your lungs (Pulmonary
 Embolism) — where it blocks the blood 8) Tiredness and muscle weakness. Being
flow. in the hospital and on a ventilator can
cause your muscles to weaken. You also
2) Collapsed lung (Pneumothorax). In most may feel very tired following treatment.
ARDS cases, a breathing machine called
a ventilator is used to increase oxygen in Diagnostics:
the body and force fluid out of the lungs.
However, the pressure and air volume of a) There's no specific test to identify ARDS.
the ventilator can force gas to go The diagnosis is based on the physical
through a small hole in the very outside exam, chest X-ray and oxygen levels. It's
of a lung and cause that lung to collapse. also important to rule out other diseases
and conditions — for example, certain
3) Infections. Because the ventilator is heart problems — that can produce
attached directly to a tube inserted in similar symptoms.
your windpipe, this makes it much easier
for germs to infect and further injure b) IMAGING
your lungs. a. Chest X-ray. A chest X-ray can
reveal which parts of your lungs
4) Scarring (Pulmonary Fibrosis). Scarring and how much of the lungs have
and thickening of the tissue between the fluid in them and whether your
air sacs can occur within a few weeks of heart is enlarged.
the onset of ARDS. This stiffens your b. Computerized tomography
lungs, making it even more difficult for (CT). A CT scan combines X-ray
oxygen to flow from the air sacs into images taken from many
your bloodstream. different directions into cross-
sectional views of internal
5) Breathing problems. Many people with organs. CT scans can provide
ARDS recover most of their lung function detailed information about the
within several months to two years, but structures within the heart and
others may have breathing problems for lungs.
the rest of their lives. Even people who
do well usually have shortness of breath c) Arterial Blood Gas (ABG)
and fatigue and may need supplemental
oxygen at home for a few months. d) Complete Blood Count (CBC) to check for
anemia
6) Depression. Most ARDS survivors also
report going through a period of e) HEART TEST
depression, which is treatable. a. Because the signs and
symptoms of ARDS are similar to
7) Problems with memory and thinking those of certain heart problems,
clearly. Sedatives and low levels of your doctor may recommend
oxygen in the blood can lead to memory heart tests such as:
loss and cognitive problems after ARDS.
In some cases, the effects may lessen f) Electrocardiogram. This painless test
over time, but in others, the damage tracks the electrical activity in your
may be permanent. heart. It involves attaching several wired
sensors to your body.
 g) Echocardiogram. A sonogram of the Nursing Responsibilities:
heart, this test can reveal problems with
the structures and the function of your 1) Perfusion
heart. 2) Positioning
3) Protective Lung Ventilation
Treatment: 4) Protocol Weaning
5) Preventing Complications
a) The first goal in treating ARDS is to
improve the levels of oxygen in your A. Perfusion:
blood. Without oxygen, your organs
can't function properly.  GOAL OF CARE for ARDS patients is to
maximize perfusion in the pulmonary
b) Oxygen capillary system by increasing oxygen
a. To get more oxygen into your transport between the alveoli and
bloodstream, your doctor will pulmonary capillaries.
likely use:
c) Supplemental oxygen. For milder 1) Increase fluid volume without
symptoms or as a temporary measure, overloading the patient
oxygen may be delivered through a mask 2) Oxygen therapy
that fits tightly over your nose and 3) Administer Inotropes/Vasodilators as
mouth. ordered
4) Strict monitoring of vital signs including
d) Mechanical ventilation. Most people central venous pressure (CVP)
with ARDS will need the help of a
machine to breathe. A mechanical B. Positioning
ventilator pushes air into your lungs and
forces some of the fluid out of the air 1) Proper positioning of the patient aids in
sacs. drainage of lung secretions
e) Fluids. Carefully managing the amount 2) Promotes mobility to improve blood
of intravenous fluids is crucial. Too much perfusion
fluid can increase fluid build-up in the 3) Turning to sides every 1-2 hours
lungs. Too little fluid can put a strain on
your heart and other organs and lead to C. Protective Lung Ventilation:
shock.
f) Medication  Is to support organ function by providing
a. People with ARDS usually are adequate ventilation and oxygenation
given medication to: while decreasing the patient’s work of
i. Prevent and treat breathing
infections
ii. Relieve pain and 1) Assist in intubation and mechanical
discomfort ventilation
iii. Prevent blood clots in 2) Suction secretions per ET and per mouth
the legs and lungs 3) Monitor tidal volume (VT) and positive
iv. Minimize gastric reflux end expiratory pressure (PEEP) of the
v. Sedate ventilator
4) Prevention of Ventilator-Induced Lung
Injury (VILI)
5) BiPAP / CPAP
D. Protocol Weaning

1) Carry out weaning orders as ordered by

the Pulmonologist
2) Monitor and assess patient’s response
to weaning
3) Weaning precautions (WOF: respiratory
distress, untoward vitals signs)

E. Preventing Complications

1) Deep Vein Thrombosis (DVT): Passive

ROM exercises, Frequent position
changes, Anticoagulant prophylaxis,
Anti-embolic stockings
2) Pressure Ulcers: Frequent position
changes, Promoting adequate nutrition,
Frequent skin assessment and proper
skin care, Implementing pressure-
relieving devices (air mattress)
3) Poor Nutrition: Monitor nutritional
status, Administer parenteral nutrition
as ordered
4) Ventilator Acquired Pneumonia (VAP):
Compliance to Infection Control
Protocols, Oral/Mouth care