Notes For Responses To Altered Tissue Perfusion
Notes For Responses To Altered Tissue Perfusion
Notes For Responses To Altered Tissue Perfusion
BASIC FOUNDATIONS
VEINS
ARTERIES
4 MAIN CHAMBERS
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
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
Creatinine Kinase
CK-MB
Myoglobin
Troponin
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
- 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
Stress Tests
Cardiac MRI
- detect tissue damage or problems with blood flow in the heart or coronary arteries
- assesses the blood flow through the small coronary blood vessels and into the heart tissues
Coronary Angiography
- shows the insides of the coronary arteries rather than an invasive cardiac catheterization
PROCEDURES
-used to treat severe angina associated with coronary heart disease when other treatments are
too risky or did not work.
PATIENT EDUCATION
HEART FAILURE
- chronic, progressive condition in which the _______ enough blood to meet the body’s
needs for blood and oxygen
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)
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.
- the balloon is then inflated to _____ and is removed once the artery is _____
NURSING RESPONSIBILITIES
BEFORE
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:
BENEFITS:
- 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
- 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
- the part of the plant most frequently used for health purposes is the ____
BENEFITS:
- 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.
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