Acute Biologic Crisis

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UNIVERSITY OF THE ASSUMPTION City of San Fernando, Pampanga College of Nursing NCM 106

CARE OF THE CLIENTS WITH PROBLEMS IN ACUTE BIOLOGIC CRISIS

Course Description:It deals with the principles and techniques of nursing care management of sick clients across the lifespan with the emphasis on the adult and older person with alteration/problems in acute biologic crisis.

Objectives:At the end of the course, and given actual clients with problems in acute biologic crisis, the student should be able: 1. Scientia (Academic Excellence) a. Utilize the nursing process in the care of individuals, families, in community and hospital settings. i. Assess with the client his/her condition/health status through interview, physical examination, interpretation of laboratory findings ii. Identify actual and potential diagnosis iii. Plan appropriate nursing interventions with client and family for identified nursing diagnosis iv. Implement plan of care with client and family v. Evaluate the progress of the clients condition and outcomes of care b. Ensure a well-organized and accurate documentation system

2. Virtus (Christian Formation) a. Observe bioethical principles and the core values (love of God, caring, love security and of people) b. Utilize the bioethical principle and core values and nursing standards in the care of clients. c. Integrate the various principles, concept and application of bioethics in the care of the client. 3. Communitas (Community Service) a. Determine the different principles and techniques of nursing care management in promoting the health of the community. b. Take part in the community projects that would require the utilization of appropriate health promotion and disease prevention. c. Relate with client and their family and the health team appropriately. d. Promote personal and professional growth of self and others.

Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN

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Cardiac Failure Description Etiologic Factors : Is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygenation and nutrients CHF is most commonly used when referring to left-sided and rightsided failure Formerly called Congestive Heart Failure Increased metabolic rate (eg. fever, thyrotoxicosis) Hypoxia Anemia Cardiac failure most commonly occurs with disorders of cardiac muscles that result in decreased contractile properties of the heart. Common underlying conditions that lead to decreased myocardial contractility include myocardial dysfunction, arterial hypertension, and valvular dysfunction. Myocardial dysfunction may be due to coronary artery disease, dilated cardiomyopathy, or inflammatory and degenerative diseases of the myocardium. Atherosclerosis of the coronary arteries is the primary cause of heart failure. Ischemia causes myocardial dysfunction because of resulting hypoxia and acidosis (from accumulation of lactic acid). Myocardial infarction causes focal myocellular necrosis, the death of myocardial cells, and a loss of contractility; the extent of the infarction is prognostic of the severity of CHF. Dilated cardiomyopathy causes diffuse cellular necrosis, leading to decreased contractility. Inflammatory and degenerative diseases of the myocardium, such as myocarditis, may also damage myocardial fibers, with a resultant decrease in contractility. Systemic or pulmonary HPN increases afterload which increases the workload of the heart and in turn leads to hypertrophy of myocardial muscle fibers; this can be considered a compensatory mechanism because it increases contractility. Valvular heart disease is also a cause of cardiac failure. The valves ensure that blood flows in one direction. With valvular dysfunction, valve has increasing difficulty moving forward. This decreases the amount of blood being ejected, increases pressure within the heart, and eventually leads to pulmonary and venous congestion.

Pathophysiology:

Left-Sided Cardiac Failure

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Pulmonary congestion occurs when the left ventricle cannot pump the blood out of the chamber. This increases pressure in the left ventricle and decreases the blood flow from the left atrium. The pressure in the left atrium increases, which decreases the blood flow coming from the pulmonary vessels. The resultant increase in pressure in the pulmonary circulation forces fluid into the pulmonary tissues and alveoli; which impairs gas exchange. Dyspnea on exertion Cough Adventitious breath sounds Restless and anxious Skin appears pale and ashen and feels cool and clammy Tachycardia and palpitations Weak, thready pulse Easy fatigability and decreased activity tolerance When the right ventricle fails, congestion of the viscera and the peripheral tissues predominates. This occurs because the right side of the heart cannot eject blood and thus cannot accommodate all the blood that normally returns to it from the venous circulation.

Clinical Manifestations

Right-Sided Cardiac Failure

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Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN

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Clinical Manifestations

Diagnostics

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Edema of the lower extremities (dependent edema) Weight gain Hepatomegaly (enlargement of the liver) Distended neck veins Ascites (accumulation of fluid in the peritoneal cavity) Anorexia and nausea Nocturia (need to urinate at night) Weakness Chest Xray (may show cardiomegaly or vascular congestion) Echocardiogram (shows decreased ventricular function and decreased ejection fraction) CVP (elevated in right-sided failure)

*pulmonary artery pressure monitoring may be used as guide treatment in serious case of pulmonary edema Nursing Diagnoses Nursing Management Activity intolerance r/t imbalance between oxygen supply and demand secondary to decreased CO Excess fluid volume r/t excess fluid/sodium intake or retention secondary to CHF and its medical therapy Anxiety r/t breathlessness and restlessness secondary to inadequate oxygenation Non-compliance r/t to lack of knowledge Powerlessness r/t inability to perform role responsibilities secondary to chronic illness and hospitalization

a. Acute phase monitor and record BP, pulse, respirations, ECG and CVP to detect changes in cardiac output maintain client in sitting position to decrease pulmonary congestion and facilitate improved gas exchange auscultate heart and lung sounds frequently: increasing crackles, increasing dyspnea, decreasing lung sounds indicate worsening failure administer O2 as ordered to improve gas exchange and increase oxygenation of blood; monitor arterial blood gases (ABG) as ordered to assess oxygenation administer prescribed medications on accurate schedule Monitor serum electrolytes to detect hypokalemia secondary to diuretic therapy monitor accurate input and output ( may require Foley cathether to allow accurate measurement of urine output) to evaluate fluid status if fluid restriction is prescribed, spread the fluid throughout the day to reduce thirstPage 3

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Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN

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encourage physical rest and organized activities with frequent rest periods to reduce the work of the heart provide a calm reassuring environment to decrease anxiety; this decreases oxygen consumption and demands on the heart

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b. Chronic heart failure educate client and family about the rationale for the regimen establish baseline assessment for fluid status and functional abilities monitor daily weights to evaluate changes in fluid status assess at regular intervals for changes in fluid status or functional activity level

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Pharmacologic Therapy

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ACE Inhibitors (promotes vasodilation and diuresis by decreasing afterload and preload eventually decreasing the workload of the heart.) Diuretic Therapy. A diuretic is one of the first medications prescribed to a patient with CHF. Diuretics promote the excretion of sodium and water through the kidneys Digitalis (increases the force of myocardial contraction and slows conduction through the AV node. It improves contractility thus, increasing left ventricular output.) Dobutamine.(Dobutrex) is an intravenous medication given to patients with significant left ventricular dysfunction. A catecholamine, it stimulates the beta1-adrenergic receptors. Its major action is to increase cardiac contractility. Milrinone (Primacor). A phosphodiesterase inhibitor that prolongs the release and prevents the uptake of calcium. This in turn, promotes vasodilation, causing a decrease in preload and afterload and decreasing the workload of the heart. Nitroglycerine ( a vasodilator reduces preload) Morphine to sedate and vasodilate,decreasing the work of the heart Anticoagulants may be prescribed. Beta-adrenergic blockers maybe indicated in patients with mild or moderate failure Include family member or others in teaching as appropriate Weight monitoring: teach client the importance of measuring and recording daily weights and report unexplained increase of 3-5 pounds Diet: sodium restriction to decrease fluid overload and potassium rich foods to replenish loss from medications; do not restrict water intake unless directed Medication regime: explain the importance of following all medication instructionsPage 4

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Client Education -

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Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN

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Activity: help client plan paced activity to maximize available cardiac output Symptoms: report to MD promptly any of the following: chest pain, new onset of dyspnea on exertion, paroxysmal and nocturnal dyspnea Report even minor changes to MD as they may be an early sign of decompensation

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Acute Myocardial Infarction Description - Occurs when the heart muscle is depriv