Care of Clients with Life-Threatening Conditions PDF

Care of Clients with Life Threatening Conditions, Acutely Ill/Multi – organ Problems, High Acuity and Emergency Situation (Acute and Chronic) NCM 118 - LECTURE Prof. Paz Dominique C. Dehing HEMODYNAMIC MONITORING Common Hemodynamic Techniques:...

Care of Clients with Life Threatening Conditions, Acutely Ill/Multi – organ Problems, High Acuity and Emergency Situation (Acute and Chronic) NCM 118 - LECTURE Prof. Paz Dominique C. Dehing HEMODYNAMIC MONITORING Common Hemodynamic Techniques: BY: RLE GROUP 3 1. Non-invasive techniques: Blood pressure cuffs, DEFINITION echocardiography 2. Invasive techniques: Pulmonary artery catheterization (Swan- Hemodynamic monitoring refers to the continuous Ganz catheter), assessment and measurement of the blood flow and pressures arterial line monitoring, within the cardiovascular system. It evaluates how well the central venous pressure (CVP) monitoring heart is functioning in terms of pumping blood, the blood volume status, and the resistance of the blood vessels. The goal is to monitor the balance between oxygen delivery and COMPLICATIONS oxygen consumption in the body, which is crucial for maintaining adequate tissue perfusion and organ function. 1. Arterial Line Complications: Infection INDICATION Hemorrhage Thrombosis and Embolism Hemodynamic monitoring is indicated in situations where Ischemia there is a concern about a patient’s cardiovascular status, Nerve Damage particularly when management is necessary. Some common indications include: 2. Central Venous Pressure (CVP) Monitoring Shock states Complications: Acute Heart Failure Infection Severe Trauma Pneumothorax Major Surgery Thrombosis Pulmonary Hypertension Air Embolism Acute Myocardial Infarction Catheter Malposition Critical ill patients Post-cardiac surgery 3. Pulmonary Artery Catheter (Swan-Ganz) Complications: Infection USES Pulmonary Artery Rupture Arrhythmias Thrombosis and Embolism 1. Assess Cardiac Output and Function: Monitoring Pulmonary Infection helps determine how well the heart is pumping blood. 2. Guide Fluid Management: Helps in deciding whether 4. Intra-aortic Balloon Pump (IABP) Complications: a patient needs more fluids, vasopressors, or diuretics. Limb Ischemia 3. Monitor Blood Pressure and Vascular Resistance: Infection Allows real-time measurement of arterial and central Thrombosis and Embolism venous pressures, which are crucial in guiding Aortic Dissection or Rupture treatment decisions. 4. Optimize Oxygen Delivery: By monitoring 5. General Complications: parameters such as cardiac output and oxygen Bleeding saturation, clinicians can ensure that tissues are Sepsis receiving adequate oxygen. Pressure Ulcers 5. Evaluate Response to Treatment: Hemodynamic parameters help assess whether interventions like medications or mechanical support are improving the patient’s status. ASSESSMENT These findings indicated fluid overload and poor cardiac output, leading to low blood pressure and poor tissue NONINVASIVE: perfusion. 1. Electrocardiogram (ECG) 2. Non-invasive Blood Pressure (NiBP) Nursing Interventions 3. Pulse Oximetry (SpO2) 1. Fluid Restriction 4. Echocardiography 2. Monitor Electrolytes and Renal Function 5. Fluid Responsiveness 3. Vital Signs Monitoring 4. Daily Weight and Edema Monitoring INVASIVE: 5. Oxygen Therapy 1. Intra-Arterial Blood Pressure (ABP) 6. Diuretic Administration 2. Central Venous Pressure (CVP) 7. Vasoactive Support 3. Pulmonary Artery Pressure (PAP) 8. Patient education Clinical Assessment Techniques: 1. Physical Examination POP QUIZ! 2. Laboratory test 1. What is the continuous real time blood pressure measurements? A. CVP MANAGEMENT B. PAP C. ABP Important Nursing Management for Hemodynamic Monitoring D. NiBP includes: 2. It is one of the indications of hemodynamic monitoring Continuous Monitoring that monitor blood loss and perfusion? Equipment Maintenance A. PAP Data Interpretation B. Severe Trauma Patient Assessment C. Acute Heart failure Fluid Management D. Pulmonary hypertension Medication Administration Care Plan Development 3. How many non-invasive and invasive procedure are Patient Education there in hemodynamic monitoring? Collaboration A. 3, 5 Emergency Preparedness B. 4, 2 C. 3, 3 D. 5, 5 CASE ANALYSIS 4. What is the primary purpose of hemodynamic Hemodynamic Monitoring in a Patient with Heart Failure monitoring? a) Assess nutritional status Patient Background b) Evaluate cardiac output and fluid status Name: Patient X c) Monitor respiratory function Age: 70 years d) Check electrolyte levels Gender: Male 5. What does a central venous pressure (CVP) reading Medical History: Chronic Heart Failure, indicate? Hypertension, Chronic Kidney Disease (CKD) Stage 3 a) Cardiac output Presenting Condition: Acute Decompensated Heart b) Right atrial pressure Failure (ADHF) c) Left ventricular function d) Pulmonary artery pressure Case Scenario: Patient X was admitted to the hospital with worsening 6. In patients with heart failure, which hemodynamic shortness of breath, fatigue, and peripheral edema. He had a monitoring finding would likely be present? history of heart failure and was experiencing fluid overload, A) Decreased pulmonary artery pressure which led to acute decompensation. Hemodynamic monitoring B) Decreased pulmonary capillary wedge was initiated to guide fluid management and optimize cardiac pressure function. C) Increased central venous pressure D) Increased systemic vascular resist Initial Hemodynamic Findings: ABP: 90/55 mmHg (MAP = 67 mmHg) 7. Which of the following complications is least likely to CVP: 14 mmHg be associated with the insertion of an Arterial Line? Heart Rate: 105 bpm A) Infection Urine Output: 20 mL/hr. B) Nerve Damage SpO2: 92% on nasal cannula (2 L/min) C) Pneumothorax  D) Thrombosis and Embolism CLIENTS WITH ALTERED VENTILATORY FUNCTIONS 8. Which of the following complications can result from BY: RLE GROUP 2 improper aseptic technique during Central Venous Pressure (CVP) monitoring? Introduction A) Pneumothorax B) Thrombosis C) Catheter Malposition Mechanical Ventilation D) Infection - Mechanical ventilation is a life-support technique used to assist or replace spontaneous breathing. It 9. What is the primary goal of hemodynamic monitoring operates by applying positive pressure to drive air into in critically ill patients? the lungs, supporting patients who cannot breathe A) To monitor the patient’s fluid intake and adequately on their own due to various conditions. It output is typically indicated when a patient’s lungs fail to B) To assess and maintain adequate tissue maintain safe oxygen and carbon dioxide levels. perfusion and organ function C) To track the patient’s physical activity levels D) To determine the patient’s nutritional status Types of Mechanical Ventilation Positive Pressure Ventilators: 10. Which of these is one of the non-invasive assessment - Increases airway pressure through an artificial techniques used in hemodynamic monitoring? airway (e.g., endotracheal tube) to push air into A. Electrocardiogram the lungs. B. Central Venous Pressure C. Pulmonary Artery Pressure Negative Pressure Ventilators: D. Intra Arterial Blood Pressure - Applies negative pressure around the chest, allowing air to flow into the lungs through natural 11. All of these is a technique used to assess the physical airways. status of the patient during hemodynamic monitoring, EXCEPT. A. SpO2 Modes of Ventilation B. Jugular Venous Distension Assist Control (A/C) C. Skin Turgor - Allows patients to initiate breaths, with the D. Capillary Refill ventilator delivering a pre-set tidal volume. 12. All of these are the indications for hemodynamic Synchronized Intermittent Ventilation (SIMV) monitoring, EXCEPT. - Combines patient-initiated breaths with A. Edema mechanical assistance. B. Acute Myocardial Infarction C. Pulmonary Hypertension Continuous Positive Airway Pressure (CPAP) D. Severe Trauma - Keeps the airways open during spontaneous breathing. Controlled Ventilation - Vent initiates all breaths at a pre-set rate and tidal volume Pressure Support Ventilation (PSV) - Pt initiates breath & vent delivers a pre-set inspiratory pressure to help overcome airway resistance and keeps airways open Airway Pressure Release Ventilation (APRV) - Elevation of airway pressures with brief intermittent releases of airway pressure Why are Ventilators used? 1. To assist or take over the work of breathing. 2. To deliver high concentrations of oxygen into the lungs. 3. To help get rid of carbon dioxide. 4. To reduce the energy a patient uses on breathing so their body can focus on recovery.  - Measures exhaled CO2 (EtCO2), with normal levels Altered Ventilatory Functions between 35-45 mmHg. Airway Compromise: - Useful for monitoring patients under sedation or at - Due to disease or trauma, patients may need risk of respiratory depression. airway protection or mechanical assistance. Physical Examination Hypoventilation: Inspection: Observe chest expansion symmetry, use - Results from impaired drive, pump failure, or gas of accessory muscles, and respiratory rate. exchange issues, leading to hypercapnic Auscultation: Listen for abnormal lung sounds respiratory failure. (wheezing, crackles, diminished breath sounds). Palpation: Check for abnormalities such as fremitus Hypoxemic Respiratory Failure: (vibrations) or tenderness. - Inability to maintain adequate oxygenation in the Percussion: Identify areas of dullness (fluid) or blood despite high oxygen therapy, often seen in hyperresonance (air trapping). conditions like ARDS. Increased Ventilatory Demand: Invasive Techniques - Occurs when the body's need for oxygen or Arterial Blood Gas (ABG) Analysis carbon dioxide removal exceeds the lungs' ability - Assesses oxygenation, ventilation, and acid-base to meet that demand, common in severe sepsis balance. or metabolic acidosis. Endotracheal Intubation - Secures airway for mechanical ventilation in patients Common Conditions unable to breathe adequately. COPD - Chronic airflow limitation due to inflammation and Tracheostomy destruction of airways and alveoli. - Creates a direct airway through the neck for long-term ventilation support. Asthma - Hyperresponsiveness of the airways causing Thoracentesis bronchoconstriction. - Removes fluid from the pleural space to relieve respiratory distress. Pneumonia - Infection causing alveoli to fill with fluid, leading to Chest Tube Insertion impaired oxygen absorption. - Drains air or fluid from the pleural cavity, improving lung expansion. ARDS - Damage to the alveolar-capillary membrane, causing Bronchoscopy fluid leakage into the alveoli. - Visualizes the airways, suctions secretions, or removes foreign bodies. Pulmonary Fibrosis - Scarring of lung tissue causing difficulty in breathing. Mechanical Ventilation - Assists or controls ventilation for patients with respiratory failure. Key Symptoms of Altered Ventilatory Function Dyspnea Tachypnea Management Hypoxemia Hypercapnia Pharmacological Interventions Wheezing Bronchodilators Cough - Function: Relaxes muscles around the airways, Chest tightness improving airflow. - Used for conditions like asthma, COPD. Assessment Corticosteroids - Function: Reduces inflammation in the airways, Non-Invasive Techniques preventing further narrowing. Pulse Oximetry - Used in asthma and COPD to prevent exacerbations. - Assesses oxygen saturation (SpO2) levels. Antibiotics Capnography - Function: Treats bacterial infections contributing to ventilatory issues. - Critical in conditions like pneumonia. Mucolytics Diaphragmatic and pursed-lip breathing help - Function: Helps thin mucus in the airways, aiding control breathlessness. expectoration. - Used in chronic bronchitis or cystic fibrosis. Mechanical Ventilation Volume-controlled or pressure-controlled Diuretics strategies depending on the patient’s needs. - Function: Reduces fluid overload in the lungs. - Used in conditions like pulmonary edema or heart failure. Complications of Ventilatory Support Ventilator-Associated Pneumonia (VAP) - Bacteria enter the ventilator circuit, leading to Non-Pharmacological Techniques infection. Oxygen Therapy - Risk factors: Prolonged ventilation, poor oral Nasal Cannula: Provides low-flow oxygen (1-6 hygiene. L/min). Non-Rebreather Mask: High-flow oxygen for patients Oxygen Toxicity in severe respiratory distress. Venturi Mask: Precise oxygen delivery, especially useful in COPD patients. Positive Airway Pressure Devices CPAP: Keeps alveoli open, improving gas exchange. o CPAP = continuous positive airway pressure BiPAP: Provides alternating levels of pressure to assist with inhalation and exhalation. o BiPAP = bilevel positive airway pressure Chest Physiotherapy Percussion, vibration, and postural drainage help clear secretions. - Prolonged exposure to high FiO2 causes lung tissue inflammation. Barotrauma Incentive spirometry encourages deep breathing to prevent atelectasis. - Over-distension of alveoli from excessive airway pressures leads to pneumothorax or subcutaneous emphysema. Endotracheal Tube Complications - Dislodgement or obstruction by mucus can occur. - Prolonged use can lead to tracheal stenosis. Respiratory Muscle Weakness - Prolonged mechanical ventilation leads to difficulty in weaning due to muscle atrophy. Positioning and Breathing Exercises Semi-Fowler’s position aids lung expansion.  Nursing Interventions Nursing Management Plan Airway Management Resource Management - Assess for airway obstruction. - Ensure availability of oxygen tanks, ventilators, and - Perform suctioning to clear secretions. other respiratory supplies. Positioning Collaboration - Use High-Fowler’s position to facilitate lung - Work with respiratory therapists, physicians, and expansion. pharmacists to coordinate patient care. Monitoring Staff Training - Vital signs, oxygen saturation, and ABG analysis are - Ongoing education on respiratory care and early crucial in monitoring respiratory status. recognition of ventilatory dysfunction. Ventilator Care Daily Monitoring - Regularly check ventilator settings, respond to - Perform regular assessments and documentation of alarms, and prevent complications like VAP. respiratory patterns, vital signs, and oxygen levels. Patient Education and Emotional Support Patient Education and Collaboration - Teach patients and families about ventilatory care and Condition address anxiety or fears. - Explain the respiratory condition (e.g., COPD, asthma) in simple terms. Case Study Medication Management - Ensure understanding of inhalers, bronchodilators, Status of the Patient and corticosteroids. Demographic Data: John D., 58 years old, male. Recognizing Symptoms Medical History: Hypertension, Type 2 Diabetes Mellitus, 30 - Teach how to recognize signs of respiratory distress. pack-year smoking history. Environmental Management Current Diagnosis and Treatment: Diagnosed with Acute - Minimize triggers like allergens, smoke, and dust. Respiratory Distress Syndrome (ARDS) due to pneumonia. Receiving mechanical ventilation, antibiotics, and supportive Breathing Exercises care. - Teach techniques like pursed-lip and diaphragmatic breathing. Nursing Assessment of the Patient Collaboration Vital Signs: - Engage with healthcare team members (PCP, o Respiratory rate: 32 bpm respiratory therapists, nurses, pharmacists). o Heart rate: 120 bpm o O2 saturation: 80% on a non-rebreather mask Conclusion Test Results: Proper Ventilatory Management: o Chest X-ray: Bilateral infiltrates o Ensures oxygenation and prevents o ABG: pH 7.28, PaCO2 60 mmHg, PaO2 55 complications like VAP and barotrauma. mmHg (on 100% oxygen). Nurse's Role: o Critical in monitoring, airway management, Nursing Observations: and patient education to improve outcomes. o Diffuse crackles, labored breathing, and confusion. Outcome: o Effective management leads to quicker Current Care Plan and Recommendations recovery and better quality of life for patients. Nursing Care Plan: o Mechanical ventilation (low tidal volume, high PEEP), prone positioning, sedation, Quiz fluid management, broad-spectrum 1. What is the primary purpose of mechanical antibiotics. ventilation? Evaluation: a) To monitor vital signs o Gradual improvement in respiratory function b) To assist or replace spontaneous breathing over two weeks. c) To increase heart rate Recommendations: d) To manage pain o Continue monitoring respiratory status and weaning from ventilatory support as 2. Which of the following is a common condition that condition stabilizes. may lead to the need for mechanical ventilation? a) Hypertension b) Asthma  c) Diabetes 11. Which condition is a common cause of hypercapnic d) Kidney failure respiratory failure in patients with altered ventilatory function? 3. Which mode of mechanical ventilation allows patients a) Hypertension to initiate breaths while the ventilator delivers a pre- b) Hypoglycemia set tidal volume? c) Chronic Obstructive Pulmonary Disease a) Continuous Positive Airway Pressure (CPAP) (COPD) b) Synchronized Intermittent Ventilation (SIMV) d) Renal failure c) Assist Control (A/C) d) Positive Pressure Ventilation (PPV) 12. What is the primary nursing intervention for patients experiencing dyspnea due to altered ventilatory 4. Which non-invasive technique is commonly used to function? monitor a patient's oxygen saturation? a) Administer pain medication a) Tracheostomy b) Ensure airway patency and provide oxygen b) Capnography support c) Arterial blood gas analysis c) Encourage fluid intake d) Pulse oximetry d) Perform daily weight monitoring 5. Ventilator-associated pneumonia (VAP) is a complication of ventilatory support that can be prevented by: a) Providing regular patient education b) Monitoring oxygen levels frequently c) Ensuring proper airway management d) Administering bronchodilators 6. Which of the following medications is often used to manage conditions with altered ventilatory functions like asthma and COPD? a) Diuretics b) Bronchodilators c) Antihistamines d) Beta-blockers 7. Which assessment technique is considered invasive when evaluating ventilatory function? a) Capnography b) Pulse oximetry c) Arterial blood gas (ABG) analysis d) Physical examination of respiratory patterns 8. Hypoxemic respiratory failure is characterized by: a) High levels of carbon dioxide in the blood b) Inability to maintain adequate oxygen levels c) Excessive breathing effort d) Difficulty exhaling carbon dioxide 9. Which non-pharmacologic intervention is typically used to increase oxygenation in patients with altered ventilatory functions? a) Antibiotics b) Chest physiotherapy c) Bronchodilators d) Corticosteroids 10. What is the nurse's key role in managing patients on mechanical ventilation? a) Administering medications b) Adjusting ventilator settings c) Monitoring airway and ventilation d) Diagnosing lung diseases  ALTERED TISSUE PERFUSION 3 TYPES OF ACUTE ISCHEMIC HEART DISEASE BY: RLE GROUP 1 1. Unstable Angina 2. Non-ST Elevation Myocardial Infarction DEFINITION 3. ST Elevation Myocardial Infarction Altered Tissue Perfusion is a condition where there is a disruption in the normal blood flow to tissues, resulting in EFFECTS ON TISSUE PERFUSION inadequate oxygen and nutrient delivery to cells, leading to In acute ischemic heart disease, the coronary arteries tissue damage or dysfunction. It can affect various organ become narrowed or blocked, leading to a reduction in blood systems, depending on the severity and location of the flow (perfusion) to the heart muscle. This decreased perfusion perfusion problem. means that the heart muscle receives less oxygen and nutrients, which are essential for its function. As a result, affected tissues can suffer: Altered Tissue Perfusion is a general term that 1. Oxygen Deprivation: Myocardial cells begin to means any change in normal blood flow to tissues. become ischemic (starved for oxygen), leading to This could be increased, decreased, or no blood flow, metabolic disturbances. but it doesn't explain the specific problem or cause. 2. Cell Injury: Prolonged ischemia can cause irreversible cell damage or necrosis, leading to Ineffective Tissue Perfusion (a NANDA nursing conditions like myocardial infarction (heart attack). diagnosis) refers specifically to inadequate blood 3. Functional Impairment: The heart’s ability to flow to tissues, leading to a lack of oxygen and contract effectively is compromised, which can lead to nutrients, which can cause tissue damage. decreased cardiac output and potentially heart failure. "Ineffective" means the blood flow is not enough to keep the ASSESSMENT tissues healthy, making it a clearer term for poor perfusion. 1. History: Look for risk factors (e.g., hypertension, diabetes, smoking), and assess symptoms such as: Chest pain Types of Altered Tissue Perfusion Radiating pain Peripheral: Affects blood flow to the extremities. Shortness of breath Cerebral: Affects blood flow to the brain. Nausea or sweating Cardiopulmonary: Affects blood flow to the heart and 2. Physical Examination: Monitor vital signs for lungs. abnormalities such as elevated heart rate Renal: Affects blood flow to the kidneys. (tachycardia), blood pressure changes, and signs of Gastrointestinal: Affects blood flow to the digestive heart failure (e.g., edema). organs. 3. Diagnostic Tests: Electrocardiogram (ECG) Causes Cardiac biomarkers Atherosclerosis: Plaque buildup narrowing arteries. Imaging Embolism/Thrombosis: Blood clot blocking circulation. NURSING MANAGEMENT Hypovolemia: Low blood volume reducing flow. 1. Immediate Care: Heart Failure: Heart can't pump enough blood. Medications: Administer nitrates (e.g., Hypertension/Hypotension: High or low blood nitroglycerin) to relieve chest pain, antiplatelet pressure affecting flow. agents (e.g., aspirin) to prevent further clot formation, and possibly anticoagulants. Signs and Symptoms Oxygen Therapy Pain, cyanosis, numbness (Peripheral) Monitoring Dizziness, confusion, loss of consciousness 2. Patient Education (Cerebral) Lifestyle Modifications Shortness of breath, chest pain (Cardiopulmonary) Medication Adherence Reduced urine output (Renal) Recognizing Symptoms 3. Promote Rest and Reduce Myocardial Workload Bed rest COMPLICATIONS/CONDITIONS RELATED TO ALTERED Limit physical activity TISSUE PERFUSION Encourage rest periods 4. Emotional Support: ACUTE ISCHEMIC HEART DISEASE Address the psychological impact of the Acute ischemic heart disease (AIHD) refers to a diagnosis and provide reassurance. Offer condition where blood flow to the heart muscle is suddenly resources for counseling if needed. reduced or blocked, often due to a blood clot in a coronary artery. This leads to insufficient oxygen supply to the heart, causing symptoms like chest pain, shortness of breath, and potentially leading to serious complications like a heart attack (myocardial infarction).  HEART FAILURE o Blood Tests: Check for markers of heart Heart failure (HF) is a chronic condition in which the damage (like troponins), electrolyte heart is unable to pump sufficient blood to meet the body’s imbalances, and renal function. metabolic needs, leading to inadequate tissue perfusion and o Imaging: Echocardiogram or chest X-ray to fluid buildup in organs like the lungs and extremities. evaluate heart structure and function, and to look for fluid in the lungs. IMPACTS ON TISSUE PERFUSION Heart failure reduces blood flow to organs, leading to poor NURSING MANAGEMENT oxygen delivery and organ dysfunction, resulting in fatigue, 1. Monitoring: dyspnea, and fluid retention. Vital Signs: Continuously assess blood pressure, heart rate, respiratory rate, and oxygen ASSESSMENT saturation. 1. History: Look for symptoms like shortness of breath, Cardiac Monitoring: Use telemetry to detect fatigue, and swelling. Risk factors include arrhythmias and changes in heart rhythm. hypertension, heart disease, or recent heart attack. Fluid Status: Monitor input and output to assess 2. Physical Examination: Check for crackles in the kidney function and fluid balance. lungs, leg swelling, jugular vein distension, and signs 2. Administering Medications: of poor circulation like cold, pale skin. Inotropes: Medications like dobutamine may be 3. Diagnostic Tests: given to improve heart contractility. Echocardiogram: Measures heart function. Diuretics: To manage fluid overload, if Chest X-ray: Checks for fluid in lungs and applicable. enlarged heart. Vasopressors: If blood pressure is critically low, BNP Test: Elevated levels suggest heart failure. medications may be needed to improve vascular ECG: Identifies heart rhythm problems. tone. 3. Oxygen Therapy: NURSING MANAGEMENT Administer supplemental oxygen to ensure 1. Medications: Give diuretics, ACE inhibitors, and adequate oxygenation of tissues. beta-blockers to manage fluid and improve heart 4. Positioning: function. Elevate the head of the bed to help improve 2. Fluid Restriction: Limit fluids to prevent overload. breathing and reduce the workload on the heart. 3. Oxygen Therapy: Provide oxygen to improve 5. Emotional Support: breathing and reduce the heart’s workload. Provide reassurance and support to the patient 4. Daily Weights: Monitor for fluid retention. and their family, as cardiogenic shock can be a 5. Patient Education: Teach about medications, low- frightening experience. sodium diet, and recognizing worsening symptoms. 6. Collaboration: Work closely with the healthcare team, including physicians and specialists, to develop and CARDIOGENIC SHOCK implement a comprehensive care plan. Cardiogenic shock is a serious medical condition 7. Education: that occurs when the heart is unable to pump enough blood to Inform the patient and family about the condition, meet the body's needs. This can lead to dangerously low blood treatment plan, and what to expect during pressure and inadequate blood flow to vital organs. recovery. Cardiogenic shock occurs when the heart can't pump enough blood to meet the body's needs, leading to poor CORONARY ARTERY DISEASE tissue perfusion. Narrow and blockage of blood flow - atherosclerotic plaque ASSESSMENT common - cardiovascular diseases Vital Signs: Monitor heart rate, blood pressure, "Silent killer" respiratory rate, and oxygen saturation. Hypotension and tachycardia are common indicators. Roles affecting tissue perfusion Physical Examination: Look for signs of poor Reduced Oxygen Supply perfusion, such as cold, clammy skin, altered mental Tissue Hypoxia status, and decreased urine output. Impaired Cardiac Function Patient History: Gather information on symptoms, Potential for MI recent heart issues (like a heart attack), and any existing heart conditions. Assessment Diagnostic Tests: 1. PATIENT HISTORY o Electrocardiogram (ECG): To assess heart rhythm and identify any abnormalities, such Risk Factors as ischemia or arrhythmias. - Smoking history - Hypertension - Hyperlipidemia - Diabetes  - Family history of heart disease - Smoking cessation - Physical inactivity Symptom History HYPERTENSIVE CRISIS - Chest pain A hypertensive crisis is a sudden, severe increase - Dyspnea in blood pressure. The blood pressure reading is 180/120 - Palpitations mmHg or greater. - Syncope - Fatigue TWO TYPES OF HYPERTENSIVE CRISIS: - Dizziness Urgent Hypertensive Crisis - Nausea or vomiting - very high blood pressure, but no signs of organ 2. PHYSICAL EXAMINATION damage. Vital signs - BP Emergency Hypertensive Crisis - PR - very high blood pressure and have a life- - RR threatening damage to the body’s organ. - SpO2 - Temperature Effects on Tissue Perfusion Cardiovascular System 1. Vascular Damage - Inspection 2. Ischemia - Palpation 3. Fluid Leakage - Auscultation 4. Organ Problems Respiratory System - Assess for signs of respiratory distress or ASSESSMENT abnormal lung sounds 1. Vital Signs Peripheral Vascular System 2. Neurological Assessment - check for edema, capillary refill, pulse 3. Cardiovascular Assessment - assess skin changes 4. Renal Functions 3. DIAGNOSTIC ASSESSMENT 5. Pulmonary Assessment ECG 6. Skin Assessment Lab tests - Cardiac biomarkers DIAGNOSTIC TEST - Lipid profile 1. ECG - Blood glucose 2. Urinalysis - Electrolytes and renal function 3. Chest X-ray Echocardiography 4. CT scan Chest X-ray 5. Serum Electrolytes & Creatinine Stress Testing Coronary Angiography NURSING MANAGEMENT 1. Monitor blood pressure frequently. Know the target set Nursing Management by the physician Assess and monitor 2. Administer antihypertensive medications as - Vital signs (BP, HR, RR, SpO2, Temp.) prescribed - Chest pain 3. Limit fluid intake if the patient is in heart failure - ECG 4. Assess ECG to ensure the patient is not having a - Lung sounds heart attack 5. Check report of the chest x-ray to ensure the patient Administer medications as prescribed is not in heart failure - Antiplatelet agents 6. Listen to the heart for murmurs and lungs for rales - Nitroglycerin and crackles - Beta-blockers 7. Check if the patient has edema - Statins 8. Check renal function and electrolyte levels - ACE inhibitors/ARBs 9. Encourage rest and provide a quiet room Promote Rest and Activity Balance 10. Educate patient on a low salt diet, exercise, and - Encourage rest healthy eating - Gradually increase physical activity but educate 11. Educate the patient on the importance of taking px pacing themselves antihypertensive medications Oxygen Therapy - Administer oxygen if pt’s Spo2 is low (as prescribed) CARDIOMYOPATHY Provide patient education a disease of the heart muscle that affects its ability to - Diet pump blood efficiently. It can lead to impaired tissue perfusion, - Weight Management which is the process by which blood delivers oxygen and - Medication adherence nutrients to tissues throughout the body.  EFFECTS ON TISSUE PERFUSION REDUCED CARDIAC OUTPUT: Hypoxia Decreased Perfusion to Vital Organs: Compensatory Mechanisms ASSESSMENT Vital Signs Irregular rhythms Physical Assessment - fluctuating cardiac output, Peripheral Perfusion - uneven blood distribution, Electrocardiogram (ECG) - and poor perfusion of vital organs. Echocardiogram Laboratory Tests Patient Symptoms NURSING MANAGEMENT Monitoring Positioning Administer Medications Oxygen Therapy Assessment Patient Education 1. Vital signs: HR, Rhythm, BP, and RR Preventing Complications 2. Assess for symptoms: Emotional Support a. Palpitations b. Chest pain c. SOB d. Dizziness, syncope or fatigue ARRHYTHMIA 3. Assess for signs of poor perfusion: An arrhythmia (also called dysrhythmia) is an a. Cyanosis abnormal heartbeat. Arrhythmias can start in different parts of b. Pallor your heart and they can be too fast, too slow or just irregular. c. Cold extremities d. Delayed capillary refill Overview of Heart Conduction System e. Changes in LOC The electrical impulse travels from the 4. Evaluate patient’s history: Sinoatrial Node (SA node) a. CVD Atrioventricular Node (AV node) b. Hypertension Bundle of His c. Electrolyte imbalances 5. Electrocardiogram (ECG) Effects on Tissue Perfusion When an arrhythmia occurs, it can reduce cardiac Management output, meaning less oxygenated blood reaches the body. 1. Monitoring and documentation 2. Medication administration Tachyarrhythmias a. beta-blockers - hypoxia, b. calcium channel blockers - ischemia, 3. Cardioversion or defibrillation - and potential organ dysfunction 4. Educate patient about: a. medication adherence b. dietary changes c. smoke cessation d. exercise 5. Monitor fluid and electrolyte balance 6. Collaborating with cardiologist for further diagnostic evaluation Bradyarrhythmias - fatigue, - dizziness, - or syncope  NON-INVASIVE MONITORING ECHOCARDIOGRAPHY ELECTROCARDIOGRAM (ECG) Uses sound waves to create images of the heart and An electrocardiogram tracks and documents your blood flow, providing a non-invasive assessment. heart’s electrical activity for diagnostic purposes. Visualizes heart chambers, valves, and walls to detect Changes seen on an ECG, such as ischemic changes abnormalities affecting blood flow. or arrhythmias, can suggest that the heart's ability to Measures how well blood moves through the heart pump effectively has been compromised, which could and major vessels, indicating perfusion status. lead to reduced tissue perfusion. Calculates the percentage of blood pumped out of the heart with each beat, helping assess cardiac function. Assesses how well heart valves open and close, which is crucial for proper blood flow. Helps detect conditions such as heart failure, cardiomyopathy, or congenital heart defects that can impact perfusion. INVASIVE MONITORING Intra-arterial Blood Pressure Used to measure real-time, continuous blood pressure inside an artery. Provides highly accurate blood pressure readings and is commonly used in critical care settings. Central Venous Pressure Measures the pressure in the central veins, specifically in the right atrium or superior vena cava. Reflects right ventricular preload, or the amount of blood returning to the heart, and is used to assess fluid status and cardiac function. PUMONARY ARTERY PRESSURE PAP measures the blood pressure in the pulmonary artery, which carries blood from the heart to the lungs. Provides information on right heart function and can indicate how well the heart is pumping blood to the lungs. NON-INVASIVE BLOOD PRESSURE High PAP levels may indicate pulmonary Refers to the process of measuring blood pressure hypertension, which can lead to decreased blood flow without penetrating the skin or inserting instruments and oxygen delivery to tissues. into the body. Elevated pressure can impair gas exchange in the Commonly used in both clinical and home settings lungs, affecting oxygen levels in the blood and, subsequently, tissue perfusion. PULSE OXIMETRY Monitoring PAP can help assess the effectiveness of Pulse oximetry is a non-invasive method that provides treatments for conditions affecting lung or heart real-time data on oxygen saturation (SpO2) levels, function. reflecting peripheral perfusion. Measures the percentage of hemoglobin saturated MIXED VENOUS OXYGEN SATURATION with oxygen, which can indicate the effectiveness of SvO2 measures the percentage of oxygen bound to oxygen delivery to tissues. hemoglobin in blood returning to the heart from the Can detect low oxygen levels (hypoxemia) before body. clinical symptoms arise, allowing for early intervention Reflects how well tissues are using oxygen; low levels to improve tissue perfusion. may indicate inadequate perfusion or oxygen delivery. Changes in SpO2 levels can indicate how well a Provides insight into the balance between oxygen patient responds to treatments aimed at improving supply (from the lungs and heart) and oxygen perfusion, such as fluid resuscitation or oxygen demand (from tissues). therapy. Changes in SvO2 can signal issues like sepsis, While useful, it’s important to consider factors like shock, or heart failure before clinical symptoms poor peripheral circulation, nail polish, or skin appear. pigmentation, which can affect accuracy. When combined with other hemodynamic measurements, SvO2 provides a comprehensive view of cardiovascular and respiratory function.  CASE STUDY 3. Monitor renal function with serum creatinine, BUN, Demographic Profile: Michael Rodriguez, 58 years old, male, and urine output hourly. 90 kg (Obese) 4. Maintain strict intake and output measurements to monitor fluid balance. Medical History: 5. Ensure the patient remains on bed rest to reduce Hypertension (poorly controlled) oxygen demand. Type 2 Diabetes Mellitus 6. Educate the patient about the importance of Dyslipidemia medication adherence. Family history of hypertension Noncompliant with medication Evaluation: Chronic Kidney Disease (Stage 2) BP was reduced from 240/130 mmHg to 150/90 mmHg without complications, and the patient’s Current Diagnosis: Hypertensive Crisis (Hypertensive condition stabilized. Emergency) Headache improved with BP control, and the patient Admitting Diagnosis: Severe hypertension with signs of experienced less dizziness. target organ damage (Acute Renal Failure). Receiving Renal function monitored closely with signs of Nicardipine and Furosemide. Maintenance Meds: Amlodipine, improvement, as indicated by a gradual increase in Atorvastatin, and Metformin. The patient was also put in urine output. continuous bp monitoring with arterial line and hourly urine Patient education provided, and the patient expressed output was monitored to assess renal function. understanding and commitment to better medication and lifestyle compliance. VITAL SIGNS: Temperature: 37.4°C, Heart Rate: 98 beats per minute, Blood Recommendation Pressure: 230/130 mmHg (on admission), Respiratory Rate: Continue IV antihypertensives until BP stabilizes 20 breaths per minute, Oxygen Saturation: 96% on room air below 140/90 mmHg, then transition to oral medications. Test Results: Continue to monitor renal function closely, with repeat Serum Creatinine: 3.2 mg/dL (acute renal failure) creatinine and urine output assessments to ensure no Blood Urea Nitrogen (BUN): 50 mg/dL (elevated, further deterioration. indicating renal dysfunction) Initiate outpatient follow-up with cardiology and Electrolytes: Potassium 4.5 mEq/L, Sodium 152 nephrology for long-term BP management and renal mEq/L care. Urinalysis: Proteinuria, hematuria (signs of renal Encourage lifestyle modifications, including weight damage) loss, low-sodium diet, and regular exercise, to ECG: Left ventricular hypertrophy, no ischemic manage hypertension and prevent future crises. changes Referral to a dietitian for individualized meal planning. Nursing Observations: Alert, but complains headache, dizziness, and light- QUIZ TIME!! headedness. Urine output is decreased to 20 mL/hr. 1. WHAT DOES ALTERED TISSUE PERFUSION Nursing Diagnosis: REFER TO? Impaired Tissue Perfusion related to severe hypertension with a) Increased blood flow to organs signs of acute renal failure as evidenced by light-headedness, b) Disruption of normal blood flow to tissues dizziness, headache, high blood pressure, and decreased c) Complete oxygen delivery to cells urine output. d) Atherosclerosis Goal: 2. WHICH TYPE OF ALTERED TISSUE PERFUSION The patient will demonstrate improved tissue perfusion and AFFECTS THE BRAIN? stable renal function, as evidenced by: a) Peripheral Blood pressure within the normal range. b) Cerebral Absence of light-headedness, dizziness, and c) Cardiopulmonary headache. d) Renal Improved renal function markers, such as stabilized creatinine and urine output within 48-72 hours. 3. ATHEROSCLEROSIS CAN CAUSE ALTERED TISSUE PERFUSION BY: Nursing Interventions a) Narrowing of arteries 1. Monitor BP continuously via arterial line and b) Increasing blood flow administer IV antihypertensive medications as c) Reducing oxygen demand ordered. d) Improving cardiac output 2. Assess neurological status every 1-2 hours for signs of worsening (example: confusion) 4. A COMMON SYMPTOM OF PERIPHERAL TISSUE PERFUSION PROBLEMS IS:  a) Cyanosis CLIENTS WITH ALTERED PERCEPTION b) Dizziness BY: RLE GROUP 4 c) Shortness of breath d) Reduced urine output 5. WHICH OF THE FOLLOWING IS A TYPE OF ACUTE ISCHEMIC HEART DISEASE? a) ST Elevation Myocardial Infarction b) Cardiac Tamponade c) Ventricular Fibrillation d) Hypertensive Crisis 6. THE TERM ‘INEFFECTIVE TISSUE PERFUSION’ MEANS: a) Inadequate blood flow causing tissue damage b) Excessive blood flow leading to tissue DEFINITION damage An altered level of consciousness is characterized c) Complete shutdown of tissue perfusion as a decreased wakefulness, awareness, or alertness, and d) Optimal perfusion to all organs includes a range of categories like Lethargic – Patient is drowsy but awakens – 7. CARDIOGENIC SHOCK OCCURS WHEN: although not fully – to stimulation. Will answer a) The heart pumps excessive blood questions and follow commands, but slowly and b) The heart fails to pump enough blood inattentively. c) There is excessive blood loss Obtunded – Patient is difficult to arouse and needs d) Hypertension causes heart failure constant stimulation in order to follow a simple command. May respond verbally with 1 or 2 words, 8. A patient with heart failure might show WHICH OF but will drift back to sleep between stimulation. THE FOLLOWING SYMPTOMS? Stuporous – Patient arouses to vigorous and a) Tachycardia and fluid retention continuous stimulation; typically, a painful stimulus is b) Hypotension and dry skin required. May moan briefly but does not follow c) Bradycardia and increased urine output commands. Only response may be an attempt to d) Rapid weight loss withdraw from or remove the painful stimulus. Comatose – Patient does not respond to continuous 9. WHICH OF THE FOLLOWING DIAGNOSTIC TESTS or painful stimulation. Does not move – except, IS USED TO ASSESS heart rhythm problems? possibly, reflexively – and does not make any verbal a) Electrocardiogram (ECG) sounds. b) Echocardiogram c) Chest X-ray d) Blood Urea Nitrogen (BUN) THE PATHOLOGY DEPENDS ON THE CAUSES 10. A HYPERTENSIVE CRISIS IS characterized by a blood pressure reading of: a) 140/90 mmHg b) 160/100 mmHg c) 180/120 mmHg or greater d) 100/60 mmHg 11. Pulse oximetry is used to measure: a) Blood pressure b) Cardiac output c) Oxygen saturation in the blood d) Heart rate CONDITIONS THAT MAY ALTER PERCEPTION 12. WHICH OF THE FOLLOWING NURSING Neurologic INTERVENTIONS IS APPROPRIATE FOR A patient in cardiogenic shock? Traumatic Brain Injury – may affect cognitive functions, a) Fluid restriction causing altered perception of time, space, and self b) Administer oxygen therapy c) Reduce heart rate with beta-blockers Common Types of Brain Injury d) Increase blood pressure using diuretics contusion concussion Traumatic Brain Injury PERSISTENT VEGETATIVE STATE, wakefulness but - A violent or sudden blow to the head that causes devoid of conscious content, (+) cognitive/affective structural injury or physiological disruption of the brain mental process intact Mechanism of Injury Causes of ↓ Levels of Consciousness - Penetrating trauma- penetration of a foreign object Primary brain injury or disease e.g. bullet Blunt trauma- deceleration, acceleration, or Trauma; Vascular disease; Infections; Neoplasms; rotational forces. Seizures Systemic conditions Classification of Brain Injuries Metabolic encephalopathies; Hypoxic 1. SKULL FRACTURE encephalopathies; Toxicity; Physical causes; ➔ open (dura is torn) Deficiency states ➔ closed (dura is not torn) ➔ vault (parietal or temporal) NURSING MANAGEMENT ➔ Basilar: CSF loss- rhinorrhea or otorrhea Maintain a patent airway Battle Sign Provide frequent suctioning and oral hygiene Raccoon eyes Postural drainage as prescribed Palsy of the 7th cranial nerve Regular turning schedule and repositioning Complications: Induce and maintain hypothermia Cranial nerve injury and leakage of CSF Provide sensory stimulation; promote bowel function and prevent urinary retention 2. Concussions Encourage family participation - Temporary loss of neurological function without Frequently monitor signs of complications apparent structural change. (RESPIRATORY FAILURE, PNEUMONIA, PRESSURE ULCERS, ASPIRATIONS) 3. Contusion (bruising) - More severe head injury with bruising of the brain; possible surface hemorrhage. CARE FOR CLIENTS WITH INCREASED INTRACRANIAL PRESSURE 4. Diffuse axonal injury - Widespread derangement of axons of the brain parenchyma volume cerebral hemispheres, corpus callosum and o 1400 ml (80%) brainstem cerebrospinal fluid o 150 ml (10%) Medical Management blood Non - surgical o 150 ml (10%) management of ICP maintenance of adequate cerebral perfusion pressure Monro’s Theory - The sum of volumes of brain, CSF, and (CPP) and oxygenation intracranial blood is constant treatment of any complications (e.g., pneumonia, - An increase in one should cause a decrease in one or infection). both of the remaining two Surgical Etiology of Increased ICP craniotomy too much CSF decompressive craniotomy specifically for elevated tumor (benign or malignant ICP bleeding in the brain (hemorrhagic stroke or aneurysm) encephalitis UNCONSCIOUSNESS high blood pressure Consciousness Arousal (wakefulness) Awareness (content) ❖ Unresponsiveness and unawareness of environmental stimuli Forms COMA, unconsciousness AKINETIC MUTISM, unresponsiveness; (+) eyes open at times.  PATHOPHYSIOLOGY + Doll’s Eyes = brain stem is intact THE BABINSKI REFLEX signs and symptoms early altered LOC- irritability & restlessness decreased mental status normal plantar response: toes down (flexion) sleepiness Note: this reflex is only normal for infants 1 year old and flat affect and drowsiness below moderate seizures constant headache coma sudden abnormal posture vomiting/emesis without nausea diplopia late and deadly signs Lungs: Cheyne-Stokes respirations Neck: Nuchal Rigidity (stiff neck) Eyes: pupils fixed and dilated (8 mm) sometimes unequal Normal Pupils: 2-6 mm OCULOCEPHALIC REFLEX (DOLL’S EYES) CUSHING’S TRIAD opposite of shock ↑ hypertension ↓ bradycardia ↓ bradypnea ASSESSMENT AND DIAGNOSTICS CT scan NO Lumbar Puncture ICP Monitoring w/ Subarachnoid Screw Normal ICP: 5-15 mmHg NURSING INTERVENTIONS I – mmobilize the head/ c-spine - immobilization; head in neutral position, log roll as “one unit” C - O2 needs to be low (normal level: 35-45 mmHg Brief period of localized cerebral ischemia that causes P – ositioning; Semi-Fowler’s, 30-35 degrees or higher. NO neurologic deficits lasting for