Tissue Perfusion PDF

Tissue Perfusion CRITICAL CARE NURSING WHAT IS TISSUE PERFUSION? Tissue perfusion is the circulation of blood through the vascular bed tissue. It is crucial for organ functions such as formation of urine, muscle contraction and exchange of oxygen and carbon dioxide. It is dependent to blood flow...

Tissue Perfusion CRITICAL CARE NURSING WHAT IS TISSUE PERFUSION? Tissue perfusion is the circulation of blood through the vascular bed tissue. It is crucial for organ functions such as formation of urine, muscle contraction and exchange of oxygen and carbon dioxide. It is dependent to blood flow which are affected by circulating volume, cardiac pump function and peripheral vascular resistance.  TISSUE PERFUSION The blood in the body has a liquid portion called blood plasma. Blood plasma transports nutrients, oxygen, and removes waste from the cells in the body, known as tissue perfusion. Blood flow must move through the capillaries uninterrupted to maintain proper tissue perfusion. All the organs in the body require constant blood pressure with adequate oxygen saturation and nutrients. Perfusion specifies the amount of blood reaching the tissue of interest and is measured in units of ml/100g-min.  ANATOMY AND PHYSIOLOGY OF THE HEART Veins - carries blood towards the heart Arteries - carries blood away from the heart Artria - 2 upper chambers of the heart Ventricles - 2 lower chambers of the heart 4 Main valves - act as a one-way valve to prevent backflow of blood Tricuspid Valve – exits from R atrium Pulmonic valve – exits from R ventricle Mitral (bicuspid) valve – exits from L atrium Aortic Valve – exits from L ventricle  ANATOMY AND PHYSIOLOGY OF THE HEART SVC (superior vena cava) – blood coming from the upper body; head, neck, upper limbs, and chest IVC (inferior vena cava) – blood coming from the lower body; trunk, viscera, and lower limbs Blue – deoxygenated blood; SVC & IVC, pulmonary artery Red – oxygenated blood  BLOOD FLOW OF THE HEART Superior Vena Cava/Inferior Vena Cava → Right Atrium → Tricuspid Valve → Right Ventricle → Pulmonary Valve → Pulmonary Artery → R & L Pulmonary Arteries *branched out from Pulmonary Arteries* → LUNGS = GAS EXCHANGE → Pulmonary Veins → Left Atrium → Mitral Valve → Left Ventricle → Aortic Semilunar Valve → Ascending Aorta → Aortic Arch *3 major branches* → Descending Aorta *chest to the abdomen then splits to provide blood to the pelvis and lower limbs*  TISSUE PERFUSION actual gas exchange of oxygen and cells stop getting adequate o2 carbon dioxide that takes place in supply capillaries (small bvs) ALTERED TISSUE PERFUSION  ALTERED TISSUE PERFUSION Insufficient perfusion (ischemia) - when demand exceeds supply-induces an oxygen debt and causes a buildup of toxic cellular waste, stressing the vitality of the tissue. Untreated ischemia leads to cellular dysfunction, loss of organ function, and even cellular death i.e., tissue infarction. Excessive perfusion (hyperemia) - when supply exceeds demand-is frequently associated with formation of edema in the associated tissue.  ALTERED TISSUE PERFUSION When the arteries do not have the proper nutrients or oxygen to provide the cells, this causes decreased tissue perfusion. Long-term (chronic) insufficient perfusion can cause tissue damage, organ damage, or even death. Ineffective tissue perfusion occurs with insufficient blood flow, decreased oxygen, or nutrients on a cellular level. There are four early warning signs of ineffective tissue perfusion: renal, gastrointestinal, peripheral, and cerebral. Renal perfusion regulates urine output. Gastrointestinal perfusion is the change in bowel sounds while using a stethoscope. One may be nausea. Peripheral perfusion is the flow of blood to the arms and legs. Cerebral perfusion is blood flow to the brain, resulting in dizziness.  ALTERED TISSUE PERFUSION 4 early warning signs of ineffective tissue perfusion: Renal perfusion regulates urine output. Gastrointestinal perfusion is the change in bowel sounds while using a stethoscope. One may be nausea. Peripheral perfusion is the flow of blood to the arms and legs. Cerebral perfusion is blood flow to the brain, resulting in dizziness. Can lead to: 1. Temporary – minimal to no consequences 2. Acute – destructive effect on patient 3. Chronic – tissue organ damage or 4. Death WHAT HAPPENS WHEN TISSUE PERFUSION IS DECREASED? Tissue perfusion depends on blood flow. The change in blood flow causes decreased tissue perfusion. Evidence of reduced tissue perfusion is blood pressure changes, low pulse, swelling, labored breathing, abnormal heartbeat, mood swings, reduced urination, open blood vessels, central nervous system functioning, and decreased oxygenation concentration in the blood. The decreased tissue perfusion causes a problem with oxygen-transporting into the cells. The decreased oxygen decreases the ability of the cells to create ATP (adenosine triphosphate). ATP is energy that the cells use to perform normal processes.  CAUSES OF INADEQUATE TISSUE PERFUSION Any condition that limits blood flow can cause reduced perfusion to vital organs and distal extremities. This reduced blood flow can result in tissue death, leading to organ damage, loss of limb, or even patient death. Impaired tissue perfusion may be caused by hypovolemia, caused by internal or external bleeding. Conditions that lead to decreased cardiac output such as cardiac shock, cardiac arrest, and myocardial infarction (MI), also cause decreased perfusion. Impaired blood flow because of a physical blockage, either internal (such as thrombus) or external (too tight of a cast) can cause impaired tissue perfusion. Medications used in critical care, vasopressors or “pressers,” can decrease distal perfusion to the point of tissue death, a known risk.  THE RISK FOR INEFFECTIVE TISSUE PERFUSION Ineffective tissue perfusion may be related to diabetes, anemia, smoking, sedentary lifestyle, obesity, and high blood pressure. A few things that can inhibit the perfusion of oxygen into the blood are smoking, vascular disease, other diseases, and anemia. Those who are at a higher risk of ineffective tissue perfusion are the elderly, African Americans, and Hispanics.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Shock Post Traumatic Hemorrhagic Shock Hemorrhagic shock is a condition of reduced tissue perfusion and is defined as a form of hypovolemic shock in which severe traumatic blood loss leads to inadequate oxygen and nutrients delivery to tissues. Hypovolemic shock occurs when the body begins to shut down due to the loss of large amounts of blood or fluid. Whenever cellular oxygen demand outweighs supply, both the cell and the organism are in a state of shock.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION How hemorrhagic shock is diagnosed There are often no advance warnings of shock. Instead, symptoms tend to arise only when you’re already experiencing shock. A physical examination can reveal signs of shock, such as low blood pressure and a rapid heart rate. Someone in shock may also be less responsive when asked questions by an emergency room doctor. X-rays, CBC, blood tests, ultrasound, CT scan, MRI  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION MEDICAL MANAGEMENT Volume expansion. Saline solution or lactated Ringer’s solution, then possibly plasma proteins or other plasma expanders, may produce adequate volume expansion until whole blood can be matched. Pneumatic antishock garment. A pneumatic antishock garment counteracts bleeding and hypovolemia by slowing or stopping arterial bleeding; by forcing any available blood from the lower body to the brain, heart, and other vital organs; and by preventing return of the available circulating blood volume to the legs.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION MEDICAL MANAGEMENT Treat underlying cause. If the patient is hemorrhaging, efforts are made to stop the bleeding or if the cause isdiarrheaor vomiting, medications to treat diarrhea and vomiting are administered. Redistribution of fluid. Positioning the patient properly assists fluid redistribution, wherein a modified Trendelenburg position is recommended in hypovolemic shock.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Shock Syndrome Related to Sepsis Sepsis is broadly defined as a bacterial infection of the bloodstream. This infection typically spreads rapidly through the body and affects multiple systems in the body. Septic shock is a significant drop in blood pressure that can lead to respiratory or heart failure, stroke, dysfunction of other organs, and possibly death. Ineffective tissue perfusion is defined as decreased oxygen levels in the blood. This causes the tissue to be unable to receive the needed nourishments. Sepsis can constrict blood flow due to the inflammatory reaction of the body to the infection. This constriction would then deprive parts of the body of oxygen, resulting in ineffective tissue perfusion.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Fibromyalgia Syndrome (FMS) is a chronic condition causing pain, stiffness, and tenderness of the muscles, tendons, and joints. It is also characterized by restless sleep, tiredness, fatigue, anxiety, depression, and disturbances in bowel functions. Fibromyalgia appears to be linked to changes in how the brain and spinal cord process pain signals. As a result, the medical practitioner will usually rely on the group of symptoms to make a diagnosis.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Which tests are used to diagnose fibromyalgia syndrome? Complete blood count Erythrocyte sedimentation rate Cyclic citrullinated peptide test Rheumatoid factor Thyroid function tests Anti-nuclear antibody Celiac serology Vitamin D  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION High blood pressure, also called hypertension, is blood pressure that is higher than normal. In hypertension, capillary rarefaction induces an increase in blood pressure, a relative decrease in tissue perfusion and an increased cardiovascular risk. An abrupt increase in pressure brings about a rapid and reversible vasoconstriction of small resistance vessels due to their inherent myogenic tone. Prolonged elevations of pressure can cause a range of more lasting changes in the microcirculation.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Medical Management Diuretics. Diuretics, sometimes called water pills, are medications that help your kidneys eliminate sodium and water from the body. These drugs are often the first medications tried to treat high blood pressure. Angiotensin-converting enzyme (ACE) inhibitors. These medications — such as lisinopril (Prinivil, Zestril), benazepril (Lotensin), captopril and others — help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Medical Management Angiotensin II receptor blockers (ARBs). These medications relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. ARBs include candesartan (Atacand), losartan (Cozaar) and others. Calcium channel blockers. These medications — including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and others — help relax the muscles of your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for older people and people of African heritage than do ACE inhibitors alone.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Obesity is a complex disease involving an excessive amount of body fat. Obesity isn't just a cosmetic concern. It's a medical problem that increases the risk of other diseases and health problems, such as heart disease, diabetes, high blood pressure and certain cancers. Specific to cardiovascular health, a significant effect of obesity is the increase in the development of peripheral vascular disease, a condition identified by decreased perfusion to peripheral limbs and tissues, causing edema, and leading to a decrease in function and progressive loss of tissue viability.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Which tests are used to diagnose obesity? Childhood weight history Prior weight loss efforts and results Complete nutrition history Sleep patterns Physical activity Associated past medical histories like cardiovascular, diabetes, thyroid, and depression Surgical history Medications which can promote weight gain Social histories of tobacco and alcohol use Family history  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Medical Management: Appetite suppressants are believed to work by appetite such as: >INCREASING THE AVAILABILITY OF NEUROTRANSMITTERS which suppress. 1. NOREPINEPHRINE 2. SEROTONIN 3. DOPAMINE 4. SIBUTRAMINE works by inhibiting the uptake of these neurotransmitters 5. ORLISTAT reduces nutrient absorption by binding to gastrointestinal lipase and prevents the hydrolysis of dietary fat  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Medical Management: Patients who are treated with ORLISTAT excrete about a third of the dietary fat that they consume in their stools and can be expected to lose about 9% of their baseline weight on average. The currently accepted approach is to combine caloric restriction with exercise and behavioral modification as the initial treatment recommendation for most overweight or obese patients. Diet modification, exercise, and behavioral modifications should be the cornerstones of every treatment plan.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION DIABETES MELLITUS It refers to a group of diseases that affect how the body uses blood sugar (glucose). Glucose is an important source of energy for the cells that make up the muscles and tissues. It's also the brain's main source of fuel. The main cause of diabetes varies by type. The decreased myocardial perfusion in diabetes is due primarily to reduced maximal myocardial blood flow. Diabetes is diagnosed and managed by checking your glucose level in a blood test. There are three tests that can measure your blood glucose level: fasting glucose test, random glucose test and A1c test.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Which tests are used to diagnose diabetes mellitus? A fasting plasma glucose test measures your blood glucose after you have gone at least 8 hours without eating. This test is used to detect diabetes or prediabetes. An oral glucose tolerance test measures your blood sugar after you have gone at least eight hours without eating and two hours after you drink a glucose-containing beverage. This test can be used to diagnose diabetes or prediabetes.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION Which tests are used to diagnose diabetes mellitus? In a random plasma glucose test, your doctor checks your blood sugar without regard to when you ate your last meal. This test, along with an assessment of symptoms, is used to diagnose diabetes, but not prediabetes. A hemoglobin A1c (HbA1c) test can be done without fasting, and can be used to diagnose or confirm either prediabetes or diabetes.  DIFFERENT CASES OF ALTERATIONS IN TISSUE PERFUSION MEDICAL MANAGEMENT No cure Goal: Euglycemia and prevention of complications Regular monitoring for complications Laboratory assessment Oral meds/insulin >Surgical management of DM pancreas transplant Islet cell transplants  NURSING MANAGEMENT Nursing care planning and management for ineffective tissue perfusion is directed at: removing vasoconstricting factors; improving peripheral blood flow reducing metabolic demands on the body patient’s participation understanding the disease process and its treatment and preventing complications CARDIOVASCULAR PHYSICAL ASSESSMENT SUBJECTIVE DATA -Nursing Hx (medical hx, allergies, family hx) Assess (ask for): chest pain, palpitations, SOB or dyspnea, presence of edema OBJECTIVE DATA -Vital signs, height and weight -Inspection: thin, obese, level of alertness, skin color, turgor, texture, temperature, and diaphoresis; check if mucous membranes are pallor; clubbing, cyanosis. Assess arterial or venous disorders and symmetry, noting skin color, hemosiderin staining, edema, weeping, lesions, scars, or clubbing, and pattern and distribution of body hair CARDIOVASCULAR PHYSICAL ASSESSMENT -Palpation: Palpate over the precordium to find the apical impulse. Also note any thrills, heaves, or fine vibrations, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis pulses using the pads of the index and middle fingers. All pulses should be regular in rhythm and equal in strength. Palpate the patient's legs and arms to assess skin temperature, texture, turgor, and edema. CARDIOVASCULAR PHYSICAL ASSESSMENT -Auscultation: S1 and S2 are normal heart sound. A third heart sound, S3, is commonly heard in patients with a high cardiac output and in children. It is called a ventricular gallop when it occurs in adults. S3 may be a cardinal sign of heart failure. S3 is best heard at the apex when the patient is lying on his left side. S4 is considered an adventitious sound and is called an atrial gallop (or presystolic gallop). It is heard best over the tricuspid or mitral areas with the patient on his left side. Listen for MURMURS that occur when there is turbulent blood flow caused by structural defects in the heart’s chambers or valves. NON-INVASIVE CARDIOVASCULAR DIAGNOSTIC ASSESSMENT The electrocardiogram (ECG) is a graphical record of the heart’s electrical activity. Electrodes are applied to the body surface to obtain a graphical representation of cardiac electrical activity. To assess the cardiac rhythm accurately, a prolonged recording from one lead is used to provide a rhythm strip. Lead II, which usually gives a good view of the P wave, is most commonly used to record the rhythm strip. ECG INTERPRETATION 1. Calculate the heart rate 2. Determine if the ECG rhythm is regular or irregular. Assess: P-wave P to QRS relationship measurement of PR interval measurement of QRS segment measurement of QT interval T-wave ectopic beats RELATED NURSING CARE Make sure that all electrical equipment and outlets are grounded to avoid electric shock Clean patient skin and clip hair where electrodes will be place. Instruct client to relax and breathe normally Tell patient to avoid tightening of muscles, grasping bedrails and talking during ECG tracing Tell the client that ECG will not cause any pain or discomfort NON-INVASIVE CARDIOVASCULAR DIAGNOSTIC ASSESSMENT ECHOCARDIOGRAPHY is an ultrasound test use to identify abnormal heart structure, size, function, and valvular disease. The techniques most commonly used are M- mode (motion mode), for recording the motion and dimensions of intracardiac structures, and two-dimensional (cross-sectional), for recording lateral motion and providing the correct spatial relationship between structures. Transducer directs ultrahigh-frequency sound waves toward cardiac structure, which reflect these waves. RELATED NURSING CARE Explanation of the procedure to the patient No food and fluid restrictions Position client to his left or right or supine position Offer wipes to clean the water- soluble gel  INVASIVE CARDIOVASCULAR DIAGNOSTIC ASSESSMENT Cardiac catheterization may be performed to identify CAD or cardiac valvular disease, to determine pulmonary artery or heart chamber pressures, to obtain a myocardial biopsy, to evaluate artificial valves, or to perform angioplasty or stent an area of CA D. The test is performed by inserting a long catheter into a vein or artery (depending on whether the right side or the left side of the heart is being examined) in the arm or leg using fluoroscopy, the catheter is then threaded to the heart chambers or coronary arteries, or both. Contrast dye is injected, and heart structures are visualized, and heart activity is filmed.  INVASIVE CARDIOVASCULAR DIAGNOSTIC ASSESSMENT CVP is the venous pressure in right auricle of the heart. The determination of the central venous pressure (CVP) provides a direct measurement of the changes in the pressure of blood returning to the heart. CVP is useful hemodynamic parameter to observe when managing an unstable patient’s fluid volume status. It is acquired by threading a central venous catheter (subclavian double lumen central line shown) into any of several large veins. It is threaded so that the tip of the catheter rests in the lower third of the superior vena cava. The pressure monitoring assembly is attached to the distal port of a multilumen central vein catheter.  CONDITIONS WITH ALTERED TISSUE PERFUSION Normal CVP ranges from 5 to 10 cm H2O or 2 to 6 mmHg. Changes in preload status are reflected in CVP readings. Any condition that alters venous return, circulating blood volume, or cardiac performance may affect CVP. If circulating volume increases (such as with enhanced venous return to the heart from fluid overload, heart failure, and positive- pressure breathing), CVP rises. If circulating volume decreases (such as with reduced venous return from hypovolemia secondary to dehydration, interstitial fluid shift or hemorrhage, and negative pressure breathing), CVP drops.  MEASURING CVP WITH A WATER MANOMETER 1. Prime the IV tubing and manometer setup. Attach the water manometer to an IV pole or place it next to the patient’s chest. 2. Connect the IV tubing to the CV catheter. Trace the tubing from the patient to its point of origin to make sure that it’s attached to the proper port. 3. Align the base of the manometer with the zero- reference point by using a leveling device and secure the manometer in place. Because CVP reflects right atrial pressure, you must align the right atrium (the zero- reference point) with the zero mark on the manometer. 4. Turn the stopcock off to the patient and slowly fill the manometer with IV solution until the fluid level is 10 to 20 cm H2O higher than the patient’s expected CVP value. Don’t overfill the tube because fluid that spills over the top can become a source of  MEASURING CVP WITH A WATER MANOMETER 5. Turn the stopcock off to the IV solution and open to the patient. The fluid level in the manometer will drop. When the fluid level comes to rest, it will fluctuate slightly with respirations. Expect it to drop during inspiration and to rise during expiration. Record CVP at the end of expiration, when intrathoracic pressure has a negligible effect, and the fluctuation is at its highest point. Note the value either at the bottom of the meniscus or at the midline of the small floating ball. 6. After obtaining CVP value, turn the stopcock to resume the IV infusion. Adjust the IV drip rate, as required. 7. Place the patient in a comfortable position. INVASIVE CARDIOVASCULAR DIAGNOSTIC ASSESSMENT Pulmonary artery pressure monitoring is used in critical care for assessing left ventricular function, diagnosing the etiology of shock, and evaluating the patient’s response to medical interventions (e.g., fluid administration, vasoactive medications). A pulmonary artery catheter and a pressure monitoring system are used. Once the catheter is in position, the following are measured: right atrial, pulmonary artery systolic, pulmonary artery diastolic, mean pulmonary artery, and pulmonary artery wedge pressures.  INVASIVE CARDIOVASCULAR DIAGNOSTIC ASSESSMENT Left atrial pressure indicates the left ventricular filling pressure in patients who have systolic or diastolic left ventricular dysfunction or valvular heart disease. A special catheter designed for this purpose, called a pulmonary artery balloon occlusion catheter or Swan-Ganz catheter, is clinically used for indirect pressure measurements.  INVASIVE CARDIOVASCULAR DIAGNOSTIC ASSESSMENT This catheter is inserted into a large vein (usually the internal jugular vein in the neck or the femoral vein in the groin) and passed through the right heart into a pulmonary artery. The catheter tip is equipped with a small soft balloon that, when inflated, lodges in a segmental pulmonary artery and temporarily blocks flow to the segment. After a short period of equilibration, because there is no blood flow passing the catheter tip, the pressure measured at the tip of the catheter reflects the pressure “downstream”in the pulmonary veins and left atrium.  CONDITIONS WITH ALTERED TISSUE PERFUSION ACUTE ISCHEMIC HEART DISEASE ACS refers to an imbalance between myocardial oxygen supply and demand secondary to an acute plaque disruption or erosion; a dynamic state in which coronary blood flow is acutely reduced, but not fully occluded. The spectrum of ACS includes unstable angina ST-segment elevation myocardial infarction (STEMI) and Non-ST-segment elevation myocardial infarction or heart attack (NSTEMI) Most people affected by ACS have significant stenosis of one or more coronary arteries.  CONDITIONS WITH ALTERED TISSUE PERFUSION ETIOLOGY ACS is primarily cause by atherosclerosis. Risk factors for ACS are, older age – men of 45 years or older, women aged 55 years or older, high blood pressure or cholesterol, Smoking, Lack of physical activity, unhealthy diet, obesity, or overweight diabetes and family history. MANIFESTATIONS Chest pain, usually substernal or epigastric. The pain often radiates to the neck, left shoulder and/or left arm. The pain may occur at rest and typically lasts longer than 10 to 20 minutes. Dyspnea, diaphoresis, pallor and cool skin may be present. Tachycardia and hypotension may occur. The person may be nauseated or will feel light headedness.  CONDITIONS WITH ALTERED TISSUE PERFUSION SYMPTOMS ANGINA Feel like pressure squeezing, burning, or tightness Start behind the breastbone but can also occur in arms, shoulders, jaw, throat or back Cold sweats, dizziness, light headedness, nausea or a feeling of indigestion, neck pain, SOB especially with activity, sleep disturbances, weakness  CONDITIONS WITH ALTERED TISSUE PERFUSION DIAGNOSTIC ASSESSMENTS ECG Stress test Cardiac MRI Coronary angiography Coronary calcium scan -Measure the amount of calcium present in walls of the coronary artery -Build up of calcium can be a sign of atherosclerosis, coronary artery disease or coronary microvascular disease  CONDITIONS WITH ALTERED TISSUE PERFUSION DIAGNOSTIC ASSESSMENTS Cardiac Positron Emission Tomography (PET) Scanning -Used to assess the blood flow through the small coronary blood vessel into the heart tissues Nuclear heart scan -A type of PET scan that can diagnose coronary microvascular disease Coronary Computed Tomographic Angiography -Allows to show the insides of the coronary arteries rather than an invasive cardiac catherization  CONDITIONS WITH ALTERED TISSUE PERFUSION MEDICATIONS ACE inhibitors and beta blockers: Helps lower BP and decrease workload in the heart Calcium Channel blockers: Helps lower BP by allowing blood vessels to relax Metformin: Helps control plaque build up if ever the patient has diabetes Nitroglycerin: Helps in dilating coronary arteries and relive or prevent from chest pain from angina Ranolazine: Used to treat coronary microvascular disease and chest pain  CONDITIONS WITH ALTERED TISSUE PERFUSION MEDICATIONS Statins/Non-statins therapy: helps in controlling high blood cholesterol 1. Statin therapy is usually recommended by the physician if there is high risk in developing coronary artery disease or if the patient has stroke or diabetes; also if the age is between 40-75 2. Non-statin therapy may be used to reduce cholesterol or omega 3 fatty acids if statin therapy did not work (Ezetimibe, Evolocumab, Bile acid sequestrants)  CONDITIONS WITH ALTERED TISSUE PERFUSION PHARMACOLOGIC MANAGEMENT.Thrombolytic drugs - break down the fibrin in blood clots restoring blood flow to ischemic cardiac muscle and can prevent permanent damage. Nitrates and beta-blockers - used to restore blood flow to the ischemic myocardium reducing the workload of the heart. Aspirin, clopidogrel and other antiplatelet drugs and heparin are given to clients who do not have an excessive bleeding risk. These drugs inhibit blood clotting and reduce the risk of thrombus formation, suppress platelet aggregation, interrupting the process of forming a stable blood clot.  CONDITIONS WITH ALTERED TISSUE PERFUSION Non -Surgical Revascularization Procedures Percutaneous transluminal coronary revascularization (PTCA). PTCA procedures are similar to the procedure used for coronary angiography. A catheter is introduced into the arterial circulation and is guided into the opening of the narrowed coronary artery using local anesthesia.  CONDITIONS WITH ALTERED TISSUE PERFUSION Intracoronary stents are metallic scaffolds used to maintain an open arterial lumen. The stent is placed over a balloon catheter, guided into position and expanded as the balloon is inflated. It then remains in the artery as after the balloon is removed. Endothelial cells will completely line the inner wall of the stent to produce a smooth inner lining. Antiplatelet medications are given following stent insertion to reduce the risk of thrombus formation at the site.  CONDITIONS WITH ALTERED TISSUE PERFUSION Atherectomy procedures is different form stenting. In contrast to stent procedures, which enlarge the artery by displacing plaque, atherectomy remove plaque from the identified lesion. The directional atherectomy catheter shaves the plaque off vessel walls using a rotary cutting head, retaining the fragments in its housing and removing them from the vessel. Rotational atherectomy catheters pulverize plaque into particles small enough to pass through the coronary microcirculation. Laser atherectomy devices use laser energy to remove plaque.  CONDITIONS WITH ALTERED TISSUE PERFUSION Surgical Revascularization Procedures Coronary Artery Bypass Grafting (CABG) surgery involves a section of a vein or artery to create a connection for bypass between the aorta and the coronary artery beyond the obstruction This allows blood to perfuse the ischemic portion of the heart. The vessels most commonly blood vessels used for CABG are the internal mammary artery in the chest and the saphenous vein from the leg.  CONDITIONS WITH ALTERED TISSUE PERFUSION Surgical Revascularization Procedures Aortic Valve Replacement Surgery Indication - If aortic valve is not functioning properly >Aortic regurgitation: aortic valve doesn't close properly, causing blood to leak backward from the - aorta into the left ventricle >Aortic stenosis - a narrowing of the aortic valve opening; restricts the blood flow from the left ventricle to the aorta and may also - affect the pressure in the left atrium  CONDITIONS WITH ALTERED TISSUE PERFUSION Disease which causes include: Rheumatic fever - complication of untreated strep throat Endocarditis - bacterial infection of valve Sclerosis - hardening of the aortic leaflets Faulty aortic valve can cause the heart muscle to become enlarged and weakened.  CONDITIONS WITH ALTERED TISSUE PERFUSION Nursing Management for ACS Acute intervention -Pain (nitroglycerin, morphine, oxygen) Continuous monitoring -ECG, vs, pulse oximetry, -Heart and lung sounds Rest and comfort -Balance rest and activity -Begin cardiac rehabilitation  CONDITIONS WITH ALTERED TISSUE PERFUSION HEART FAILURE Heart failure is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or inadequate tissue perfusion caused by conditions that impair the ejection of oxygen- and nutrient-rich blood from the ventricles. It is a clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood It is often a long-term effect of coronary heart disease (CHD) and myocardial infarction (MI) when left ventricular damage is extensive enough to impair cardiac output.  CONDITIONS WITH ALTERED TISSUE PERFUSION Etiology Atherosclerosis of the coronary arteries is a primary cause of HF Several conditions causing heart failure are coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Manifestations In chronic HF, patients may have signs and symptoms of both left and right ventricular failure. The clinical manifestation of left sided heart failure is pulmonary congestion such as dyspnea, cough, pulmonary crackles, and low oxygen saturation levels.  CONDITIONS WITH ALTERED TISSUE PERFUSION An extra heart sound, the S3, or “ventricular gallop,” maybe detected on auscultation.It is caused by abnormal ventricular filling. However right sided heart failure has systemic clinical manifestations including edema of the lower extremities, hepatomegaly ascites and weight gain due to retention of fluid.  CONDITIONS WITH ALTERED TISSUE PERFUSION Surgical Intervention Heart transplant is the transfer of a heart from one person to another. This is the treatment of choice for patients with refractory end stage heart failure, cardiomyopathy and inoperable CAD. Donor and recipient matching is base on body heart size and ABO compatibility. The recipient is prepared for surgery and cardiopulmonary bypass is used. The usual procedure involves the removal of the patient’s heart except the posterior right and left atrial walls and their venous connections and the donor heart will be transplanted.  CONDITIONS WITH ALTERED TISSUE PERFUSION Post-Transplant Issues Bleeding Cardiac tamponade Atrial arrhythmias Hypothermia Rejection Early postoperative infections.  CONDITIONS WITH ALTERED TISSUE PERFUSION Palliative Care for End-Stage Heart Failure Done when symptoms are still present even while px is in rest and w/ optimal medical mgt. As heart failure enter advance stage, physical and spiritual suffering increase. Patients face a growing risk for death Associated with advanced age, high burden of comorbidity creating a complex setting in wc care of this px must occur. To complement traditional therapies as well as address entire process of care of the complex px.  CONDITIONS WITH ALTERED TISSUE PERFUSION Palliative Care for End-Stage Heart Failure Improve symptom amelioration Patient-caregiver communication Provide emotional support Medical decision making  CONDITIONS WITH ALTERED TISSUE PERFUSION MYOCARDIAL ISCHEMIA Isch: restraint or suppression Emia: blood Ischemia: reduction or suppression of blood to either organ or tissue Blood carries oxygen – if there is reduction of blood flow in the cells there will also be a reduction of oxygen supply to those cells  CONDITIONS WITH ALTERED TISSUE PERFUSION Due to decreased Blood Flow to the Blood vessels (Coronary artery) CORONARY ARTERY A network of blood vessels that surround the heart muscle Supply oxygen and nutrients to the heart muscle They need continuous supply to function effectively No O2 sypply = cell death  CONDITIONS WITH ALTERED TISSUE PERFUSION Myocardial infarction aka Heart attack is irreversible because of cell damage. Problems occur when there is blockage on the inside or something that compressing the blood vessel on the outside Atherosclerosis: Buildup of plaque in the inner wall, when it ruptures clot formation occurs thus restricting BF.  CONDITIONS WITH ALTERED TISSUE PERFUSION SIGNS AND SYMPTOMS Chest pain/Angina Discomfort in other areas of the upper body (arms, left shoulder, back, neck, or jaw) Shortness of breath (SOB) Indigestion Rapid irregular heartbeats Nausea and Vomiting  CONDITIONS WITH ALTERED TISSUE PERFUSION SIGNS AND SYMPTOMS Light-headedness, dizziness, extreme weakness or - anxiety ST-segment elevation Tall peaked T wave MANAGEMENT Nitroglycerin (vasodilator) - if pain persist after administration, give morphine sulfate via IV 2-4mg MORPHINE SULFATE - for px wt myocardial infarction; respiratory depressant (can cause hypotension); monitor BP and RR  CONDITIONS WITH ALTERED TISSUE PERFUSION CARDIAC BIOMAKERS Creatinine Kinase (CK) Mainly found in heart and skeletal muscles; has an isoenzyme CK-MB: Indication of myocardial cell damage Myoglobin (MB) Oxygen binding protein which is also found in skeletal and cardiac muscle Released earlier compared to Creatinine Kinase (CK)  CONDITIONS WITH ALTERED TISSUE PERFUSION CARDIAC BIOMAKERS Troponin - has 3 protein subunits Troponin C: calcium binding components; identical to skeletal and cardiac muscle; not specific for myocardial injury Troponin T: (TROPOMYOSIN) binding component; contains contractile element to myocardial cells; exhibit dual release of cytoplasmic Troponin I: binds to actin in thin myofilaments to hold the actin- tropomyosin; ideal marker for myocardial injury  CONDITIONS WITH ALTERED TISSUE PERFUSION CARDIOGENIC SHOCK a MEDICAL EMERGENCY in which heart cannot pump enough blood to brain, kidney, and other vital organs Causes: Heart attack, cardiac tamponade, chest trauma, bleeding, infection Signs&Symptoms: low BP, weak irregular pluse, SOB, jugular vein distention, cold and clammy skin, LOC  CONDITIONS WITH ALTERED TISSUE PERFUSION DIAGNOSTICS ABG Cardiac CT Scan CXR Coronary Angiography Echocardiography ECG  CONDITIONS WITH ALTERED TISSUE PERFUSION CORONARY ARTERIAL DISEASE (CAD) Coronary heart disease or coronary artery disease (CAD) is narrowing, or blockage of the coronary arteries usually caused by the accumulation of atherosclerotic plaque in the coronary arteries. Coronary heart disease may be asymptomatic or may lead to angina pectoris, acute coronary syndrome, myocardial infarction (MI), arrhythmias, heart failure and even sudden death.  CONDITIONS WITH ALTERED TISSUE PERFUSION Etiology Coronary atherosclerosis is the most common cause of reduced coronary blood flow. The two main coronary arteries, the left and the right, supply blood, oxygen and nutrients to the myocardium. They originate in the root of the aorta, just outside the aortic valve. Risk factors are family history, overweight, physical inactivity, unhealthy eating, and smoking tobacco. Manifestation The signs and symptoms of coronary arterial disease include the following: chest pain or pressure, jaw pain, shortness of breath, fatigue, dizziness, palpitation, irregular heart rhythm heart murmurs.  CONDITIONS WITH ALTERED TISSUE PERFUSION MEDICAL AND SURGICAL MANAGEMENT Lifestyle changes Quit smoking tobacco, reduce or stop your consumption of alcohol, regular exercise, lose weight to a healthy level eat low in trans-fat, low in sodium and low sugar diet , and stress management. Medications Antiplatelet medications, statins, fibric acid derivatives, beta blockers, calcium channel blockers, non-nitrate anti-anginal, nitrates, ACE inhibitors, repatha, anticoagulants  CONDITIONS WITH ALTERED TISSUE PERFUSION SURGICAL INTERVENTIONS Coronary artery bypass graft surgery: to restore blood flow to the heart in open chest surgery Balloon angioplasty: to widen blocked arteries and smoosh down the plaque buildup, usually performed with insertion of a stent to help keep the lumen open after the procedure coronary artery bypass graft surgery. Enhanced external counterpulsation: to stimulate the formation of new small blood vessels to naturally bypass clogged arteries in a noninvasive procedure  CONDITIONS WITH ALTERED TISSUE PERFUSION Other treatment modalities Angiogenesis. Stem cells and other genetic material are introduced through the vein or directly into the damaged heart tissue. It helps new blood vessels grow. Other approach which is an outpatient procedure is the enhanced external counterpulsation (EECP) Cuffs are applied on the legs, inflating and deflating the cuffs to boost blood supply to the coronary arteries.  CONDITIONS WITH ALTERED TISSUE PERFUSION HYPERTENSIVE CRISIS Hypertensive crisis is a severe increase in blood pressure that can lead to a stroke. Extremely high blood pressure having systolic pressure of 180 mm Hg or higher and a diastolic pressure of 120 mm Hg or higher which can damage blood vessels. Hypertensive crisis is present if the elevated blood pressure (BP) is complicated by progressive target organ dysfunction.  CONDITIONS WITH ALTERED TISSUE PERFUSION Acute end-organ damage in the setting of a hypertensive emergency may include the following: Neurologic: hypertensive encephalopathy, cerebral vascular accident/cerebral infarction, subarachnoid hemorrhage, intracranial hemorrhage. Cardiovascular: myocardial ischemia/infarction, acute left ventricular dysfunction, acute pulmonary edema, aortic dissection, unstable angina pectoris.  CONDITIONS WITH ALTERED TISSUE PERFUSION ETIOLOGY The most common cause for a hypertensive crisis is chronic hypertension with an acute exacerbation. A variety of secondary causes of HTN can lead to a hypertensive crisis including, renal parenchymal disease, renovascular disease, renal infarction, pregnancy (preeclampsia and eclampsia), central nervous system disorders. Poorly controlled hypertension in a patient requiring emergency surgery is also a hypertensive crisis because of the increased cardiovascular risk that accompanies inadequate pre-operative BP control and the accompanying perioperative increase in catecholamine levels and increased vascular resistance.  CONDITIONS WITH ALTERED TISSUE PERFUSION RISK FACTORS Risk factors leading to hypertensive crisis are systemic illnesses with renal involvement, such as: systemic lupus erythematosus, scleroderma, microangiopathic hemolytic anemia. Endocrine disorders such as: Cushing disease, primary aldosteronism, or a pheochromocytoma, and autonomic hyperactivity in spinal cord/head injuries, or cerebrovascular accident infarction/ hemorrhage  CONDITIONS WITH ALTERED TISSUE PERFUSION MANIFESTATIONS The most common non-specific symptoms are chest pain, headache, blurred vision, weight loss and less common presenting symptoms include dizziness, nausea, dyspnea, fatigue, malaise, epigastric pain, polyuria, gross hematuria. The specific symptos related to end organ damage include chest pain (myocardial ischemia or MI), back pain (aortic dissection), dyspnea (pulmonary edema or congestive heart failure) neurologic symptoms seizures altered consciousness (hypertensive encephalopathy).  CONDITIONS WITH ALTERED TISSUE PERFUSION MEDICAL MANAGEMENT Typical management with ICU level-care Arterial line for close bp management At about 24 hours, switch to oral bp medications as wean IV meds. Oral doses: Sodium nitroprusside, Fenoldopam, Labetalol, Esmolol, Nicardipine, Clevidipine, Nitroglycerine, Phentolamine, Enalaprilat, Nifedipine, Clonidine  CONDITIONS WITH ALTERED TISSUE PERFUSION CARDIOMYOPATHY Cardiomyopathies are disorders that affect the heart muscle affecting both systolic and diastolic functions. Cardiomyopathies may be either primary or secondary in origin. Primary cardiomyopathies are idiopathic; their cause is unknown. Secondary cardiomyopathies occur as a result of other processes, such as ischemia, infectious disease, exposure to toxins, connective tissue disorders, metabolic disorders or nutritional deficiencies.  CONDITIONS WITH ALTERED TISSUE PERFUSION PHARMACOLOGICAL TREATMENT Dilated cardiomyopathy Treatment for dilated cardiomyopathy is essentially the same with the treatment of chronic heart failure. Drug classes include angiotensin – converting enzymes inhibitors, Angiotensin II receptor blockers, ,beta blockers, cardiac glycosides, diuretics, vasodilators, anti- arrhythmics, inotropic agents and anti coagulants for some patients.  CONDITIONS WITH ALTERED TISSUE PERFUSION PHARMACOLOGICAL TREATMENT Hypertrophic Cardiomyopathy The purpose is to reduce the pressure gradient across the left ventricle outflow, reducing the inotropic state thus improving its compliance and reduce diastolic dysfunction. Amiodarone (Cordarone) has shown to reduce the incidence of arryhtmogenic sudden cardiac death. Drug classes include beta- adrenergic blockers, anti- arrhythmics, calcium channel blockers, anti- coagulants.  CONDITIONS WITH ALTERED TISSUE PERFUSION NON-PHARMACOLOGIC INTERVENTIONS Sodium diet restriction to 2 gms/day, Fluid restriction, cardiac rehabilitation program and aerobic exercises. SURGICAL MANAGEMENT Cardiac transplant is the definitive treatment for dilated cardiomyopathy. Ventricular assist devices may be used to support cardiac output until a donor heart is available. An implantable cardioverter- defibrillator (ICD) often is inserted to treat potentially lethal arrhythmias. A dual-chamber pacemaker also may be used to treat hypertrophic cardiomyopathy.  CONDITIONS WITH ALTERED TISSUE PERFUSION ARRYTHMIA An arrhythmia, or irregular heartbeat, is a problem with the rate or rhythm of your heartbeat. Your heart may beat too quickly, too slowly, or with an irregular rhythm. It is normal for your heart rate to speed up during physical activity and to slow down while resting or sleeping.  CONDITIONS WITH ALTERED TISSUE PERFUSION Normal Electrical Conduction The electrical impulse that stimulates and paces the cardiac muscle normally originates in the SA node, an area located near the superior vena cava in the right atrium. In the adult, the electrical impulse usually occurs at a rate of 60-100x a minute. The electrical impulse quickly travels from the SA node through the atria passing through the internodal tracts to the AV node. The electrical stimulation of the muscle cells of the atria causes them to contract. The structure of the AV node slows the electrical impulse, giving the atria time to contract and fill the ventricles with blood. This part of atrial contraction is frequently referred to as the atrial kick and accounts for nearly one third of the volume ejected during ventricular contraction.  CONDITIONS WITH ALTERED TISSUE PERFUSION Normal Electrical Conduction The electrical impulse then travels very quickly through the bundle of His to the right and left bundle branches and the Purkinje fibers, located in the ventricular muscle. The electrical stimulation is called depolarization, and the mechanical contraction is called systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole. The process from sinus node electrical impulse generation through ventricular repolarization completes the electromechanical circuit, and the cycle begins again.  CONDITIONS WITH ALTERED TISSUE PERFUSION ETIOLOGY Many conditions and diseases may cause dysrhythmias; the most common are coronary artery disease (CAD) and myocardial infarction (MI). Other causes include fluid and electrolyte imbalance, hormonal imbalance, changes in oxygenation, medications, and drug toxicity MANIFESTATIONS General indicators include alterations in level of consciousness (LOC), vertigo, syncope, seizures, weakness, fatigue, activity intolerance, shortness of breath, dyspnea on exertion, chest pain, palpitations, sensation of “skipped beats,” anxiety, and restlessness.  CONDITIONS WITH ALTERED TISSUE PERFUSION PHYSICAL ASSESSMENT Increases or decreases in heart rate, blood pressure, and respiration rate; changes in heart rhythm; dusky color or pallor; crackles (rales); cool skin; decreased urine output; weakened and paradoxical pulse; and abnormal heart sounds. DIAGNOSTIC TESTS 12-lead ECG: To detect dysrhythmias and identify possible origin. Serum electrolyte levels: To identify electrolyte abnormalities that can precipitate dysrhythmias. The most common are potassium and magnesium abnormalities.  CONDITIONS WITH ALTERED TISSUE PERFUSION DIAGNOSTIC TESTS Drug levels: To identify toxicities (e.g., of digoxin, quinidine, procainamide, aminophylline) that can precipitate dysrhythmias, or to determine substance abuse that can affect heart rate and rhythm, such as cocaine. Ambulatory monitoring: To identify subtle dysrhythmias, associate abnormal rhythms by means of patient’s symptoms, and assess response to exercise. Electrophysiology study: Two to three catheters are placed into the heart, giving it a pacing stimulus at varying sites and of varying voltages. The test determines origin of dysrhythmia, inducibility, and effectiveness of drug therapy in dysrhythmia suppression.  CONDITIONS WITH ALTERED TISSUE PERFUSION DIAGNOSTIC TESTS Exercise stress testing: Used in conjunction with Holter monitoring to detect advanced grades of PVCs (those caused by ischemia) and to guide therapy. SINUS NODE ARRYTHMIAS Sinus node arrhythmias may occur as a normal compensatory response (e.g. to exercise) or because of altered automaticity. In these rhythms, as in NSR, the initiating impulse is from the sinus node. They differ from NSR in the rate or regularity of the rhythm. Sinus arrhythmias include sinus arrhythmia, sinus tachycardia and sinus bradycardia  CONDITIONS WITH ALTERED TISSUE PERFUSION Sinus arrhythmia is a sinus rhythm in which the rate varies with respirations, causing an irregular rhythm. The rate increases during inspiration and decreases with expiration. Sinus arrhythmia is common in the very young and the very old. It can be caused by an increase in vagal tone, by digoxin toxicity or by morphine administration.  CONDITIONS WITH ALTERED TISSUE PERFUSION Sinus tachycardia has all of the characteristics of NSR, except that the rate is greater than 100 bpm. Tachycardia arises from enhanced automaticity in response to changes in the internal environment. may be an early sign of cardiac dysfunction, such as heart failure. Tachycardia is detrimental in the person with cardiac disease because it increases oxygen demand and decreases oxygen supply (because of decreased diastole reducing coronary artery filling time).  CONDITIONS WITH ALTERED TISSUE PERFUSION Sinus bradycardia has all of the characteristics of NSR, but the rate is less than 60 bpm. Sinus bradycardia may result from increased vagal (parasympathetic) activity or from depressed automaticity due to injury or ischemia to the sinus node. Sinus bradycardia may be asymptomatic; it is important to assess the person before treating the rhythm. Manifestations of decreased cardiac output, such as decreased level of consciousness, syncope (faintness) or hypotension, indicate a need for intervention  CONDITIONS WITH ALTERED TISSUE PERFUSION SUPRAVENTRICULAR ARRYTHMIAS These are arrythmias when an action potential originates in atrial tissue outside the sinus node. In these arrhythmias, an ectopic pacemaker takes over or overrides the SA node. They may also occur when the SA node fails; an escape rhythm develops as a fail- safe mechanism to maintain the heart rate.  CONDITIONS WITH ALTERED TISSUE PERFUSION A premature atrial contraction (PAC) is an ectopic atrial beat that occurs earlier than the next expected sinus beat. PACs can arise anywhere in the atria. They are usually asymptomatic and benign, but they may initiate paroxysmal supraventricular tachycardia in susceptible individuals.  CONDITIONS WITH ALTERED TISSUE PERFUSION PACs are common in older adults, often occurring without an obvious cause. Strong emotions, excessive alcohol intake, tobacco and stimulants such as caffeine can precipitate PACs. They also may be associated with myocardial infarction, heart failure and other cardiac disorders, hypoxemia, pulmonary embolism, digoxin toxicity and electrolyte or acid– base imbalances. In people with underlying heart disease, PACs may precede a more serious arrhythmia. The ectopic impulse of the PAC is usually conducted normally, leading to depolarisation of cardiac muscle and a normal QRS complex.  CONDITIONS WITH ALTERED TISSUE PERFUSION Paroxysmal supraventricular tachycardia (PSVT) is tachycardia of sudden onset and termination. PSVT is usually initiated by a re-entry loop in or around the AV node; that is, an impulse re-enter the same section of tissue over and over, causing repeated depolarizations and occurs more frequently in women.  CONDITIONS WITH ALTERED TISSUE PERFUSION PSVT affects ventricular filling and cardiac output and decreases coronary artery perfusion. Its manifestations include complaints of palpitations and a ‘racing’ heart, anxiety, dizziness, dyspnea, anginal pain, diaphoresis, extreme fatigue and polyuria.  CONDITIONS WITH ALTERED TISSUE PERFUSION Atrial flutter is a rapid and regular atrial rhythm thought to result from an intra- atrial re-entry mechanism. Causes include sympathetic nervous system stimulation due to anxiety or caffeine and alcohol intake; thyrotoxicosis; coronary heart disease or myocardial infarction; pulmonary embolism; and abnormal conduction syndromes, such as WPW syndrome.  CONDITIONS WITH ALTERED TISSUE PERFUSION People with atrial flutter may complain of palpitations or a fluttering sensation in the chest or throat. If the ventricular rate is rapid, manifestations of decreased cardiac output, such as decreased level of consciousness, hypotension, decreased urinary output and cool, clammy skin, may be noted.  CONDITIONS WITH ALTERED TISSUE PERFUSION Atrial fibrillation is a common arrhythmia characterized by disorganized atrial activity without discrete atrial contractions. Multiple small re-entry circuits develop in the atria. Atrial cells cannot repolarize in time to respond to the next stimulus. It may occur suddenly and recur or it may persist as a chronic arrhythmia.  CONDITIONS WITH ALTERED TISSUE PERFUSION Manifestations of atrial fibrillation are dependent on the ventricular rate. With rapid ventricular response rates, manifestations of decreased cardiac output such as hypotension, dyspnea, fatigue and angina may develop. People with extensive heart disease may develop syncope or heart failure. Atrial fibrillation increases the risk of formation of thromboemboli. Organ infarction may occur as a result; the incidence of stroke is high.  CONDITIONS WITH ALTERED TISSUE PERFUSION VENTRICULAR ARRYTHMIAS These originate in the ventricles. Because the ventricles pump blood into the pulmonary and systemic vasculature, any disruption of their rhythm can affect cardiac output and tissue perfusion. A wide and bizarre QRS complex (greater than 0.12 sec) is a characteristic feature of ventricular arrhythmias. This occurs because ventricular ectopic impulses begin and travel outside normal conduction pathways.  CONDITIONS WITH ALTERED TISSUE PERFUSION Premature ventricular contractions (PVCs) are ectopic ventricular beats that occur before the next expected beat of the underlying rhythm. They usually do not reset the atrial rhythm and are followed by a full compensatory pause. These may be associated with an increased risk of lethal arrhythmias and result from either enhanced automaticity or a re-entry phenomenon.  CONDITIONS WITH ALTERED TISSUE PERFUSION PVCs may be isolated or occur in a specific pattern. Two PVCs in a row are called a couplet or paired PVCs. Three consecutive PVCs (a triplet or salvo) is a short run of ventricular tachycardia. Ventricular bigeminy is characterized by a PVC following each normal beat; a PVC noted every third beat is called ventricular trigeminy.  CONDITIONS WITH ALTERED TISSUE PERFUSION Ventricular tachycardia is a rapid ventricular rhythm defined as three or more consecutive PVCs. Ventricular tachycardia may occur in short bursts or ‘runs’, or may persist for more than 30 seconds (sustained ventricular tachycardia). The rate is greater than 100 bpm and the rhythm is usually regular. Re- entry is the usual electrophysiological mechanism responsible for VT.  CONDITIONS WITH ALTERED TISSUE PERFUSION People in sustained VT generally develop signs and symptoms of decreased cardiac output and hemodynamic instability, including severe hypotension, a weak or non- palpable pulse, and loss of consciousness. Allowed to continue, VT can deteriorate into ventricular fibrillation. Sustained ventricular tachycardia is a medical emergency that requires immediate intervention, particularly in people with cardiac disease.  CONDITIONS WITH ALTERED TISSUE PERFUSION Ventricular fibrillation is extremely rapid, chaotic ventricular depolarization causing the ventricles to quiver and cease contracting; the heart does not pump. This is known as cardiac arrest; it is a medical emergency requiring immediate intervention with cardiopulmonary resuscitation (CPR). VF is the most common initial rhythm and is found in 60–80% of all cardiac arrests.  CONDITIONS WITH ALTERED TISSUE PERFUSION ATRIOVENTRICULAR CONDUCTION blocks are conditions where there is conduction defects that delay or block transmission of the sinus impulse through the AV node. Impaired conduction may result from tissue injury or disease, increased vagal (parasympathetic) tone, drug effects or a congenital defect. AV conduction blocks vary in severity from benign to severe.  CONDITIONS WITH ALTERED TISSUE PERFUSION First-degree AV block is a benign conduction delay that generally poses no threat, has no symptoms and requires no treatment. Impulse conduction through the AV node is slowed, but all atrial impulses are conducted to the ventricles. It may result from injury or infarct of the AV node, other cardiac diseases or drug effects.  CONDITIONS WITH ALTERED TISSUE PERFUSION Second-degree AV block is characterized by failure to conduct one or more impulses from the atria to the ventricles. Type 1 - repeating pattern of increasing AV conduction delays until an impulse fails to conduct to the ventricles. Type 2 - intermittent failure of the AV node to conduct an impulse to the ventricles without preceding delays in conduction.  CONDITIONS WITH ALTERED TISSUE PERFUSION Third-degree AV block occurs when atrial impulses are completely blocked at the AV node and fail to reach the ventricles. As a result, the atria and ventricles are controlled by different and independent pacemakers, with separate rates and rhythms. The ventricular impulse arises from either junctional fibres (rate: 40-60bpm) or a ventricular pacemaker at a rate of less than 40 bpm.  CONDITIONS WITH ALTERED TISSUE PERFUSION MEDICAL AND SURGICAL MANAGEMENT 1. Medications Antiarrhythmic drugs are primarily used for acute treatment of arrhythmias, although they may also be used to manage chronic conditions. The overall goal of therapy is to maintain an effective cardiac output by stabilizing cardiac rhythm.  CONDITIONS WITH ALTERED TISSUE PERFUSION Class I drugs (Sodium Channel Blockers) Class IA: decrease the flow of sodium into the cell and prolong the action potential. Class IB: decrease the refractory period but have little effect on automaticity. Class IC: drugs slow impulse conduction velocity but have little effect on refractoriness.  CONDITIONS WITH ALTERED TISSUE PERFUSION Class II drugs (Beta blockers) Decrease automaticity and conduction through the AV node. They also reduce the heart rate and myocardial contractility. Used to treat supraventricular tachycardia and to slow the ventricular response rate to atrial fibrillation. These drugs may cause bronchospasm and are contraindicated for people with asthma, chronic obstructive pulmonary disease (COPD) or other restrictive or obstructive lung diseases.  CONDITIONS WITH ALTERED TISSUE PERFUSION Class III drugs (Calcium Channel blockers) These drugs block potassium channels, prolonging repolarization and the refractory period. Drugs in this class are used primarily to treat ventricular tachycardia and ventricular fibrillation. Class IV drugs (Potassium Channel blockers) These drugs ecrease automaticity and AV nodal conduction. Used to manage supraventricular tachycardias. Like the beta-blockers, calcium channel blockers reduce myocardial contractility.  CONDITIONS WITH ALTERED TISSUE PERFUSION MEDICAL AND SURGICAL MANAGEMENT 2. Countershock It is used to interrupt cardiac rhythms that compromise cardiac output and the person’s welfare. Delivery of a direct current charge depolarizes all cardiac cells at the same time. This simultaneous depolarization may stop a tachyarrhythmia and allow the sinus node to recover control of impulse formation. There are two types of countershock: synchronized cardioversion and defibrillation.  CONDITIONS WITH ALTERED TISSUE PERFUSION Synchronized cardioversion delivers direct electrical current synchronized with the person’s heart rhythm, delivering of the shock with the QRS complex. This will prevent ventricular fibrillation by avoiding current delivery during the vulnerable period of repolarization. Cardioversion is usually done as an elective procedure to treat supraventricular tachycardia, atrial fibrillation, atrial flutter or hemodynamically stable ventricular tachycardia.  CONDITIONS WITH ALTERED TISSUE PERFUSION Defibrillation is an emergency procedure that delivers direct current without regard to the cardiac cycle. It can be delivered by external or internal paddles or pads. Conductive gel pads or paste is applied and external paddles or pads are placed on the chest wall at the apex and base of the heart. Internal paddles are applied directly on the heart and may be used in surgery, the emergency department or critical care.  CONDITIONS WITH ALTERED TISSUE PERFUSION MEDICAL AND SURGICAL MANAGEMENT 3. Pacemaker Therapy A pulse generator used to provide an electrical stimulus to the heart when the heart fails to generate or conduct its own at a rate that maintains the cardiac output. The pulse generator is connected to leads (insulated wires) passed intravenously into the heart or sutured directly to the epicardium. The leads sense intrinsic electrical activity of the heart and provide an electrical stimulus to the heart when necessary.  CONDITIONS WITH ALTERED TISSUE PERFUSION Temporary pacemakers use an external pulse generator attached to a lead threaded intravenously into the right ventricle, to temporary pacing wires implanted during cardiac surgery or to external conductive pads placed on the chest wall for emergency pacing. Permanent pacemakers use an internal pulse generator placed in a subcutaneous pocket in the subclavian space or abdominal wall. The generator connects to leads sewn directly onto the heart (epicardial) or passed transvenously into the heart (endocardial).  CONDITIONS WITH ALTERED TISSUE PERFUSION MEDICAL AND SURGICAL MANAGEMENT 4. Cardioverter Defrillator The implantable cardioverter defibrillator (ICD) detects life- threatening changes in the cardiac rhythm and automatically delivers an electric shock to convert the arrhythmia back into a normal rhythm. ICDs are used for sudden death survivors, people with recurrent ventricular tachycardia and individuals with demonstrated risk factors for sudden death. ICDs can deliver a shock as needed, provide pacing on demand and can store ECG records of tachycardic episodes.  CONDITIONS WITH ALTERED TISSUE PERFUSION MEDICAL AND SURGICAL MANAGEMENT 4. Cardiac Mapping and Catheter Ablation Used to locate and destroy an ectopic focus. These diagnostic and therapeutic measures use electrophysiology techniques and can be performed in the cardiac catheterization laboratory. Cardiac mapping is used to identify the site of earliest impulse formation in the atria or the ventricles. Catheter electrodes and computer technology are used to pinpoint the ectopic site on a map of the heart. These same catheters can be used to deliver the ablative intervention.  CONDITIONS WITH ALTERED TISSUE PERFUSION Catheter Ablation is used to treat supraventricular tachycardias, atrial fibrillation and flutter, and, in some cases, paroxysmal ventricular tachycardia. Anticoagulant therapy may be started after catheter ablation to reduce the risk of clot formation at the ablation site  CONDITIONS WITH ALTERED TISSUE PERFUSION COMPLIMENTARY AND ALTERNATIVE MEDICINES Fish oil / Omega Fatty 3 Acids -Found in food and in the body -Federal Gov of US Recommendation: 8 or more ounces of a variety of seafoods per week Benefits: lowers levels of triglyceride, relieve symptoms of rheumatoid arthritis, slows down progression of eye disease  CONDITIONS WITH ALTERED TISSUE PERFUSION COMPLIMENTARY AND ALTERNATIVE MEDICINES Hawthorn Latin Name: Crataegus oxyacantha Fruit bearing shrub with long history as a medicinal substance Benefits: relieve digestive ailments, dyspnea, kidney stones, cardiovascular d/o (improve coronary blood flow, and positive effects on oxygen utilization), positive effect on bld lipids  CONDITIONS WITH ALTERED TISSUE PERFUSION Side Effects Mild rash Sweating Dizziness Palpitations Agitations Sleepiness GI symptoms  CONDITIONS WITH ALTERED TISSUE PERFUSION COMPLIMENTARY AND ALTERNATIVE MEDICINES Ginkgo Biloba Common Names: ginkgo, Ginkgo biloba, fossil tree, maidenhair tree, Japanese silver apricot, baiguo, yinhsing Benefits: promoted as a dietary supplement for many conditions, dementia, eye problems, anxiety, peripheral artery disease, tinnitus, and other health problems  CONDITIONS WITH ALTERED TISSUE PERFUSION Side Effects Contraindications headache bleeding disorder due to stomach upset ↑ risk of bleeding dizziness pregnancy palpitations constipation allergic skin reactions  CONDITIONS WITH ALTERED TISSUE PERFUSION COMPLIMENTARY AND ALTERNATIVE MEDICINES Ginseng Common names: Asian ginseng, Chinese ginseng, Korean ginseng, red ginseng, white ginseng Latin Name: Panax ginseng Benefits: promote resistance to environmental stress, improve well being, improve stamina, concentration and memory, stimulate immune function, slow aging process  CONDITIONS WITH ALTERED TISSUE PERFUSION Side Effects Cardiovascular and Improve cardiovascular health Respiratory Disorder Better hair and skin complexion Depression Help treat athlete’s foot Anxiety Anti-inflammatory Menopausal Boosts immunity END OF DISCUSSION