Acute Biologic Crisis

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<p>UNIVERSITY OF THE ASSUMPTION City of San Fernando, Pampanga College of Nursing NCM 106</p> <p>CARE OF THE CLIENTS WITH PROBLEMS IN ACUTE BIOLOGIC CRISIS</p> <p>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.</p> <p>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</p> <p>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.</p> <p>Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN</p> <p>Page 1</p> <p>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.</p> <p>Pathophysiology:</p> <p>Left-Sided Cardiac Failure</p> <p>-</p> <p>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.</p> <p>Clinical Manifestations</p> <p>Right-Sided Cardiac Failure</p> <p>-</p> <p>Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN</p> <p>Page 2</p> <p>Clinical Manifestations</p> <p>Diagnostics</p> <p>-</p> <p>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)</p> <p>*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</p> <p>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</p> <p>-</p> <p>-</p> <p>-</p> <p>-</p> <p>-</p> <p>-</p> <p>Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN</p> <p>-</p> <p>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</p> <p>-</p> <p>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</p> <p>-</p> <p>Pharmacologic Therapy</p> <p>-</p> <p>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</p> <p>-</p> <p>-</p> <p>-</p> <p>-</p> <p>Client Education -</p> <p>-</p> <p>-</p> <p>Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN</p> <p>-</p> <p>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</p> <p>-</p> <p>Acute Myocardial Infarction Description - Occurs when the heart muscle is deprived of oxygen and nutrientrich blood. However, in the case of MI, this deprivation occurs over a sustained period to the point at which irreversible cell death and necrosis take place. Infarction results from sustained ischemia and is irreversible causing cellular death and necrosis.</p> <p>Etiologic factors</p> <p>-</p> <p>Physical exertion Emotional stress Weather extremes Digestion after a heavy meal Valsalva maneuver Hot baths or showers Sexual excitation Pathophysiologic characteristic (Coronary artery disease) Coronary artery blood flow is blocked by atherosclerotic narrowing, thrombus formation or persistent vasospasm; myocardium supplied by the arteries is deprived of oxygen; persistent ischemia may rapidly lead to tissue death Chest pain or discomfort ( described as aching or squeezing pain, most common location is substernal, radiating to neck, jaw, back, shoulders, left arm or occasionally the right arm) complain of heartburn or indigestion pallor, diaphoresis, cold skin, shortness of breath, weakness, dizziness, anxiety, and feelings of impending doom Electrocardiogram (12-lead) capable of diagnosing MI in 80% of patients, making it an indispensable, noninvasive, and costeffective tool. Reading shows ST elevation, accompanied by Twave inversion; and later new pathologic Q wave Cardiac Enzymes elevated CK with MB isoenzymes &gt;5percent (early diagnosis); elevated Troponin (early to late diagnosis); or elevated LDH with flipped isoenzymes (late diagnosis) WBC count leukocytosis (10,000/mm3 to 20,000/mm3) appears on thesecond day after AMI and dis appears after 1 week Positron Emission Tomography (PET) is used to evaluate cardiacPage 5</p> <p>Pathophysiology</p> <p>-</p> <p>Clinical Manifestations</p> <p>-</p> <p>Diagnostics -</p> <p>Laboratory Tests</p> <p>-</p> <p>-</p> <p>Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN</p> <p>Imaging Studies -</p> <p>metabolism and to assess tissue perfusion Magnetic Resonance Imaging helps identify the site and extent of an MI Tranesophageal Echocrdiography (TEE) is an imaging technique in which transducer is placed against the wall of the esophagus; the image of the myocardium is clearer when the esophageal site is used. Acute Pain related to myocardial ischemia resulting from coronary artery occlusion Ineffective Tissue Perfusion related to thrombus in coronary artery Decreased Cardiac Output related to negative inotropic changes in the heart secondary to myocardial ischemia Impaired Gas Exchange related to decreased cardiac output Anxiety and Fear related to hospital admission and fear of death Assess pain status frequently with pain scale Assess hemodynamic status including BP, HR, LOC, skin color, and temperature (every 5 minutes during with pain;every 15 minutes) Monitor continuous ECG to detect dysrhytmias Perform 12-lead ECG immediately with new pain or changes in level of pain Monitor respirations, breath sounds, and input and output to dtect early signs of heart failure Monitor O2 saturation and administer O2 as prescribed Provide for physiological rest to decrease oxygen demands on heart Keep client NPO or progress to liquid diet as ordered; maintain IV access for medication as needed Provide a calm environment and reassure client and family to decrease stress, fear and anxiety Report significant changes immediately to physician to ensure rapid treatment of complications Maintain bed rest for 24 to 36 hours and gradually increase activity as ordered while closely monitoring CO,ECG and pain status</p> <p>Nursing Diagnoses</p> <p>-</p> <p>Nursing Management</p> <p>-</p> <p>-</p> <p>Pharmacologic Therapy</p> <p>-</p> <p>Nitroglycerine (to dilate coronary vessels and increase blood flow) Morphine Sulfate (to relieve chest pain) Anticoagulant (heparin) and Antiplatelet (aspirin) - to prevent additional clot formation Streptokinase (to dissolve clot) Beta blockers (to decrease cardiac work) Anti-dysrhytmic drugs</p> <p>Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN</p> <p>Page 6</p> <p>Surgical Interventions</p> <p>-</p> <p>Percutaneous transluminal coronary angioplasty (PTCA) involves the passage of an inflatable balloon catheter into the stenonic coronary vessel, which is then dilated, resulting in compression of the atherosclerotic plaque and widening of the vessel Coronary artery bypass grafting (CABG) done by harvesting either a saphenous vein from the leg or the left internal mammaryartery and then used to bypass areas of obstruction in the heart Include appropriate family members whenever possible Explain cardiac rehabilitation program if ordered Explain modifiable risk factors and develop a plan with client including supportive resources to change lifestyle to decrease these factors Explain medication regime as prescribed; identify side effects to report (provide written instructions for later reference) Stress the importance of immediate reporting of chest pain or signs of decreased CO2 Instruct about bleeding precautions if client is on anticoagulant therapy: use soft toothbrush, electric razor, avoid trauma or injury; wear or carry medical alert identification</p> <p>-</p> <p>Client Education</p> <p>-</p> <p>-</p> <p>Acute Pulmonary failure Description Defined as a fall in arterial oxygen tension and a rise in arterial carbon dioxide tension.</p> <p>- The ventilation and/or perfusion mechanisms in the lun...</p>

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