Notes For Responses To Altered Tissue Perfusion

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RESPONSES TO ALTERED TISSUE PERFUSION

BASIC FOUNDATIONS

VEINS

- Towards the heart

INFERIOR VENA CAVA (IVC) - blood originates from


the trunk, and visceral organs in the lower body.

SUPERIOR VENA CAVA (SVC) – blood originates from


the head and upper body.

ARTERIES

- Away from the heart

4 MAIN CHAMBERS

2 upper chambers - ATRIA (RIGHT AND LEFT)

2 lower chambers - VENTRICLES (RIGHT AND LEFT)

4 MAIN VALVES (TPMA) (TOILET-PAPER-MY-ASSET)

TRICUSPID - exits from Right Atrium

PULMONIC - exits from Right Ventricle

MITRAL/BICUSPID - exits from Left Atrium

AORTIC - exits from Left Ventricle


DIAGNOSTIC ASSESSMENTS

PROCEDURES NON-INVASIVE INVASIVE


ELECTROCARDIOGRAM (ECG) √
ELECTROCARDIOGRAPHY √
CARDIAC CATHETERIZATION √
CENTRAL VENOUS PRESSURE √
PULMONARY ARTERY PRESSURE √
INTRA-ARTERIAL PRESSURE BP √
MONITORING
RECOGNIZING MYOCARDIAL ISCHEMIA
ISCH-
EMIA-
ISCHEMIA-

SIGNS AND SYMPTOMS

1. Chest pain
2. Discomfort in other areas of the upper body (arms, left shoulder, back, neck, or jaw)
3. SOB
4. Indigestion
5. Rapid irregular heartbeats
6. Nausea and Vomiting
7. Light-headedness, dizziness, extreme weakness or anxiety
8. ST-segment elevation
9. Tall peaked T wave

RELIEVING CHEST PAIN


1. NTG (SL)
2. MORPHINE SO4 (IV)

OTHER MANAGEMENTS
1. Maintain a Calm Environment
2. Balance of Myocardial Oxygen Supply and Demand (e.g. O2 via nasal cannula)
3. Optimize Cardiopulmonary Function (e.g. ECG, Pulse Oximeter, ABG, Cardiac
Biomarkers, Chest Radiograph, Echocardiogram)
4. Promote Comfort and Emotional Support
5. Monitor effects of Pharmacological Therapy
6. Patient Education

CARDIAC BIOMARKERS

CARDIAC ENZYMES ABNORMAL PEAK RETURNS TO


NORMAL
Creatinine Kinase (CK) Within 6-8 hrs 12-28 hrs 24-36 hrs
CK-MB 3-12 hrs 24 hrs 48-72 hrs
MYOGLOBIN (MB) 1-4 hrs 6-7 hrs 24 hrs
TROPONIN - - -
TROPONIN T 3-12 hrs 12 hrs- 2 days Remained ↑ for 5-14
TROPONIN I 3-12 hrs 24 hrs days
Remained ↑ for 5-10
days

CARDIAC ENZYMES
Creatinine Kinase

- Found mainly in heart and skeletal muscles

CK-MB

- More definitive indication of myocardial cell damage than CK alone

Myoglobin

- oxygen-binding protein found in skeletal and cardiac muscle


- occurs earlier than the release of CK.

Troponin

- 3 protein subunits (Troponin C, T and I)

1. Troponin C
- identical in the skeletal and cardiac muscle; not extremely specific for Myocardial Injury

2. Troponin T
- Present chiefly in the bound form to the contractile elements of the myocardial cells;
however, this is also present in the cytoplasm

3. Troponin I
- Extremely specific for the cardiac muscle and has not been isolated from the skeletal
muscle
- ideal marker of Myocardial Injury

ACUTE ISCHEMIC HEART DISEASE/CORONARY ARTERY DISEASE/CORONARY HEART


DISEASE

- develops when the _______ cannot deliver enough oxygen-rich blood to the heart
- caused by _____, a waxy substance, inside the lining of larger coronary arteries.

DIAGNOSTIC ASSESSMENTS

 Electrocardiogram (EKG or ECG)

- determines heart rhythm


 Coronary Calcium Scan 

- measure the amount of calcium in the walls of your coronary arteries.

 Stress Tests

- checks how the heart works during physical stress

 Cardiac MRI

- detect tissue damage or problems with blood flow in the heart or coronary arteries

 Cardiac Positron Emission Tomography (PET) Scan

- assesses the blood flow through the small coronary blood vessels and into the heart tissues

 Coronary Angiography

- show the insides of the coronary arteries

 Coronary Computed Tomographic Angiography

- shows the insides of the coronary arteries rather than an invasive cardiac catheterization

PROCEDURES

 Percutaneous coronary intervention (PCI) 

-used to open coronary arteries that are


narrowed or blocked by the buildup of
atherosclerotic plaque. A small mesh tube
called a STENT is usually implanted after
PCI to prevent the artery from narrowing
again.

 Coronary artery bypass grafting


(CABG) 

-used to improve blood flow to the heart by


using normal arteries from the chest wall
and veins from the legs to bypass the
blocked arteries. Surgeons typically use
CABG to treat people who have severe
obstructive coronary artery disease in
multiple coronary arteries.
 Transmyocardial laser revascularization or coronary endarterectomy 

-used to treat severe angina associated with coronary heart disease when other treatments are
too risky or did not work.

PATIENT EDUCATION

 Aiming for a healthy weight


 Being physically active
 Heart-healthy eating (DASH- Dietary Approaches to Stop hypertension) 
 Managing stress
 Quitting smoking
 Get enough good-quality sleep

HEART FAILURE

- chronic, progressive condition in which the _______ enough blood to meet the body’s
needs for blood and oxygen

TYPES OF HEART FAILURE


LEFT- SIDED HEART FAILURE failure of the left ventricle to fill or empty
properly
RIGHT- SIDED HEART FAILURE failure of the right ventricle to pump
adequately

CLASSIFICATION

1. SYSTOLIC FAILURE 
- the left ventricle loses its ability to contract normally.

2. DIASTOLIC FAILURE
- the left ventricle loses its ability to relax normally because the muscle has become stiff.

DIAGNOSTIC ASSESSMENTS
1. CHEST X-RAY
2. ECG
3. ECHOCARDIOGRAPHY
4. EXERCISE STRESS TEST
5. RADIONUCLIDE VENTRICULOGRAPHY/ MULTIPLE-GATED ACQUISITION
SCANNING (MUGA)

- checks how well the heart muscle is supplied with blood


- checks how well the heart's chambers are working
- checks whether part of the heart has been damaged by a heart attack

6. CARDIAC CATHETERIZATION
7. MRI
8. EJECTION FRACTION MEASUREMENT
- measurement is expressed as a percentage
- checks how much blood the left ventricle pumps out with each contraction

SURGICAL PROCEDURES
1. Heart transplantation

- the damaged heart is replaced with a healthy one from a donor who has been declared
brain dead.
- donor heart should match the tissue of the patient receiving the heart

NURSING RESPONSIBILITES

- • Provide emotional support to the patient and his family. Begin to address their fears by
discussing the procedure, possible complications, and the impact of transplantation and
a prolonged recovery period on the patient’s life.
- • After surgery maintain reverse isolation.
- • Administer immunosuppressants, and monitor the patient closely for signs of infection.
Transplant recipients may exhibit subtle signs because immunosuppressants mask
obvious signs.
- • Monitor vital signs every 15 minutes until stabilized, and assess the patient for signs of
hemodynamic compromise, such as hypotension, decreased cardiac output, and shock.
- • If necessary, administer nitroprusside during the first 24 to 48 hours to control blood
pressure. An infusion of dopamine can improve contractility and renal perfusion.
- • Volume replacement with normal saline, plasma expanders, or blood products may be
necessary to maintain CVP.
- • A patient with elevated PAP may receive prostaglandin E to produce pulmonary
vasodilation and reduced right ventricular afterload.
- • Monitor ECG for rhythm disturbances.
- • Maintain the chest tube drainage system at the prescribed negative pressure.
Regularly assess for hemorrhage or sudden cessation of drainage.
- • Continually assess the patient for signs of tissue rejection (decreased electrical activity
on the ECG, right axis shift, atrial arrhythmias, conduction defects, weight gain, lethargy,
ventricular failure, jugular vein distention, and increased T-cell count).
- • Keep in mind that the effects of denervated heart muscle or denervation (in which the
vagus nerve is cut during heart transplant surgery) makes such drugs as edrophonium
(Tensilon) and anticholinergics (such as atropine) ineffective.

2. Percutaneous coronary intervention (PCI) also referred to as Angioplasty


- a procedure to reopen blocked blood vessels
- a catheter with a tiny deflated is inserted through an incision in the femoral artery

- the balloon is then inflated to _____ and is removed once the artery is _____

3. Coronary artery bypass graft (CABG)

- reroutes the blood supply around a blocked section of the artery


- healthy blood vessels are removed from another part of the body (e.g. leg or the chest
wall) then _______

NURSING RESPONSIBILITIES
BEFORE

• Reinforce the doctor’s explanation of the surgery.


• Explain the complex equipment and procedures used in the critical care unit (CCU) or
postanesthesia care unit (PACU).
• Explain that the patient awakens from surgery with an endotracheal (ET) tube in place and
connected to a mechanical ventilator. He’ll also be connected to a cardiac monitor and may
have in place a nasogastric (NG) tube, a chest tube, an indwelling urinary catheter, arterial
lines, epicardial pacing wires, and a PA catheter. Tell him that discomfort is minimal and that the
equipment is removed as soon as possible.
• Review incentive spirometry techniques and range-of-motion (ROM) exercises with the patient.
• Make sure that the patient or a responsible family member has signed a consent form.
• Before surgery, prepare the patient’s skin as ordered.
• Immediately before surgery, begin cardiac monitoring, and then assist with PA catheterization
and insertion of arterial lines. Some facilities insert PA catheters and arterial lines in the
operating room, before surgery

AFTER

• After CABG, look for signs of hemodynamic compromise, such as severe hypotension,
decreased cardiac output, and shock.
• Begin warming procedures according to your facility’s policy.
• Check and record vital signs and hemodynamic parameters every 5 to 15 minutes until the
patient’s condition stabilizes. Administer medications and titrate according to the patient’s
response, as ordered.
• Monitor ECGs continuously for disturbances in heart rate and rhythm. If you detect serious
abnormalities, notify the practitioner, and be prepared to assist with epicardial pacing or, if
necessary, cardioversion or defibrillation.
• To ensure adequate myocardial perfusion, keep arterial pressure within the limits set by the
doctor. Usually, mean arterial
pressure (MAP) less than 70 mm Hg results in inadequate tissue perfusion; pressure greater
than 110 mm Hg can cause hemorrhage and graft rupture. Monitor PAP, CVP, left atrial
pressure, and cardiac output as ordered.
• Frequently evaluate the patient’s peripheral pulses, capillary refill time, and skin temperature
and color, and auscultate for heart sounds; report abnormalities.
• Evaluate tissue oxygenation by assessing breath sounds, chest excursion, and symmetry of
chest expansion. Check ABG results every 2 to 4 hours, and adjust ventilator settings to keep
ABG values within ordered limits
• Maintain chest tube drainage at the ordered negative pressure (usually –10 to –40 cm H2O),
and assess regularly for hemorrhage, excessive drainage (greater than 200 mL per hour), and
sudden decrease or cessation of drainage.
• Monitor the patient’s intake and output. Assess urine output at least hourly during the
immediate postoperative period and then less frequently as the patient’s condition stabilizes.
• Assess for electrolyte imbalances, especially hypokalemia and hypomagnesmia, and replace
electrolytes as ordered.
• As the patient’s incisional pain increases, give an analgesic as ordered. Give other drugs as
ordered.
• Throughout the recovery period, assess for symptoms of stroke, pulmonary embolism, and
impaired renal perfusion.
• After weaning the patient from the ventilator and removing the ET tube, provide chest
physiotherapy. Start with incentive spirometry, and encourage the patient to cough, turn
frequently, and deep breathe. Assist with ROM exercises, as ordered, to enhance peripheral
circulation and prevent thrombus formation.
• Explain that postpericardiotomy syndrome commonly develops after open-heart surgery.
Instruct the patient about signs and symptoms, such as fever, muscle and joint pain, weakness,
and chest discomfort.
• Prepare the patient for the possibility of postoperative depression, which may not develop until
weeks after discharge. Reassure him that this depression is normal and should pass quickly.
• Maintain nothing-by-mouth status until bowel sounds return. Then begin clear liquids and
advance diet as tolerated and as ordered. Expect sodium and cholesterol restrictions. Explain
that this diet can help reduce the risk of recurrent arterial occlusion.

4. Valve replacement
- the patient is connected to a heart-lung machine that supplies ______ then the bad
valve is removed and replaced.

CARDIOGENIC SHOCK
- a serious condition that occurs when the heart cannot pump enough blood and oxygen
to the brain, kidneys, and other vital organs
- considered as a medical emergency

ALTERNATIVE THERAPIES
FISH OIL/OMEGA- 3 FATTY ACIDS
- found in foods and in the human body. 

BENEFITS:

 reduce levels of _____


 help relieve symptoms of ______
 slows the progression of the eye disease age-related macular degeneration

HAWTHORN (Crataegus oxyacantha)

- is a fruit-bearing shrub with a long history as a medicinal substance

BENEFITS:

- relieve digestive ailments


- dyspnea
- kidney stones
- cardiovascular disorders (improve coronary blood flow, and positive effects on oxygen
utilization)

RECOMMENDED DAILY DOSE

- 160-900 mg of a native water-ethanol extract of the leaves or flowers (equivalent to 30-169 mg


of epicatechin or 3.5-19.8 mg of flavonoids) administered in two or three doses

- At ________ dosage, this may cause a mild rash, headache, sweating, dizziness, palpitations,
sleepiness, agitation, and gastrointestinal symptoms

GINKGO BILOBA
Common Names: ginkgo, Ginkgo biloba, fossil tree, maidenhair tree, Japanese silver
apricot, baiguo, yinhsing

Latin Names: Ginkgo biloba

- the extract from ginkgo leaves is promoted as a dietary supplement for many conditions
(anxiety, allergies, dementia, eye problems, peripheral artery disease)
- appears to be safe when taken by mouth in moderate amounts.

SIDE EFFECTS

- headache
- stomach upset
- dizziness
- palpitations
- constipation
- allergic skin reactions

CONTRAINDICATION
- bleeding disorder due to ↑ risk of bleeding
- pregnancy

GINSENG
Common Names: Asian ginseng, Chinese ginseng, Korean ginseng, red ginseng, white
ginseng

Latin Names: Panax ginseng

- the part of the plant most frequently used for health purposes is the ____

BENEFITS:

- resistance to environmental stress and as a general tonic to _____

- improve physical stamina

- concentration and memory

- stimulate immune function

- slow the aging process

- relieve respiratory and cardiovascular disorders

- depression

- anxiety

- menopausal hot flashes

GARLIC

BENEFITS:

 Boosts immunity
 Works as an anti-inflammatory
 Improves cardiovascular health
 Gives better hair and skin complexion
 Treats athlete’s foot
REFERENCES

BOOKS:

Morton, P., & Fontaine, D. (2009). Critical Care Nursing: A Holistic Approach. 9th
Edition. Lippincott-Raven Publishers.

Burns, S., & Delgado, S. (2018). AACN Essentials of Critical Care Nursing. 4th Edition.
New York: McGraw-Hill Education.

Sheehy, S. (2010). Emergency Nursing: Principles and


Practice. 6th Edition. Elsevier., Inc.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4660641/
https://www.ncbi.nlm.nih.gov/books/NBK209964/
https://www.nhlbi.nih.gov/health-topics/coronary-heart-disease
https://www.cdc.gov/heartdisease/coronary_ad.htm
https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure
https://www.nhlbi.nih.gov/health-topics/coronary-heart-disease
https://www.nhlbi.nih.gov/health-topics/cardiogenic-shock
https://www.nccih.nih.gov/health/omega3-supplements-in-depth
https://www.nccih.nih.gov/health/ginkgo
https://www.nccih.nih.gov/health/asian-ginseng
https://health.clevelandclinic.org/6-surprising-ways-garlic-boosts-your-health/
https://pubmed.ncbi.nlm.nih.gov/11887407/
https://www.nhlbi.nih.gov/health/cardiomyopathy

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