NCM118A: Care of Clients with Life- • Courage to work in an unfamiliar setting, caring for

patients who were extremely sick

Threatening Conditions, Acutely Ill / Multi-
• A high demand for education specific to CC practice
Organ Problems, High Acuity, and • Additional knowledge & skills due to the
Emergency Situation development of technology such as:
MIDTERM COVERAGE o Mechanical ventilators
Source: PPT posted by Ma’am Samson and Ma’am Domingo o Cardiac Monitors
o Pacemaker defibrillators
o Dialyzers
INTRODUCTION TO CRITICAL o Intra-aortic balloon pumps
CARE o Cardiac Assist Devices
Nursing expertise, ability to observe patients &
Objectives: appropriate nursing intensity are now considered
1. Define basic terms in Critical Care essential elements of CC.
2. Describe the development of critical care nursing
practice locally and globally Acute and Critical Care Nursing Goal:
3. Determine the competencies of a critical care • To establish a therapeutic relationship with
nurse patients and their relatives and to empower the
4. Explain the Standards of Practice individual’s; physical, psychological, sociological
5. Discuss clinical leadership cultural and spiritual capabilities through
preventive, curative and rehabilitative
DEFINITIONS interventions (World Federation of Critical
Critical Care Unit / Intensive Care Unit Nurses, 2017)
• A hospital unit where 24-hour medical care is Acute – and/or Critical Care Nurse
rendered to patients with life-threatening • A licensed professional nurse who is responsible
injuries and illnesses. for ensuring that all acutely and critically ill
• A team of specially-trained health care providers patients receive optimal care.
are involved in rendering specialized treatments • Basic to the provision of optimal care is
with the use of machines to constantly monitor individual professional accountability through:
vital signs • Adherence to standards of nursing care of
Acutely and Critically Ill Patients acutely ill and critically ill patients
• Patients who are at high risk for mortality due to • Commitment to act in accordance with ethical
present health problems (AACN, 2015). principles
• At high risk of actual or life-threatening health
problems (Aitken, Chaboyer, Elliot, 2019) SCOPE OF PRACTICE
Acute and Critical Care Nursing • Describes the who, what, where, when and how
• The specialty within nursing that specifically the registered nurse functions when caring for
deals with human responses to actual or acutely and critically ill patients (AACN, 2015)
potential life-threatening health symptoms and • Should allow for exchange, expansion, and
diagnosis (AACN, 2015) flexibility of the profession to meet the changing
• Assisting, supporting, and restoring the patient needs of patients, organizations, and society
toward health, or to ease the patient’s pain, or (AACN, 2015).
to prepare them for dignified death (World Boundaries of the practitioner’s license
Federation of Critical Nurses, 2017) • Procedures
• Nursing actions
DEVELOPMENT OF CRITICAL CARE NURSING • Processes
1. Cardiac For which the practitioner has received
2. Cardiothoracic • Education
3. Respiratory • Training
4. Renal • Licensure
5. Metabolic • Certification
6. Neurologic
SCOPE OF CRITICAL CARE PRACTICE
• Partnership between Nursing & Medical Staff
• Steep learning curve for both fields
 • Activities that an individual health care 3. Outcome Identification
practitioner is permitted to perform in a specific 4. Planning
profession. 5. Implementation
• Scope of practice is established by the practice 6. Evaluation
act of the specific practitioner’s board, and the
rules adopted pursuant to that act STANDARDS OF PROFESSIONAL PRACTICE
STANDARD:
CRITICAL CARE BODY OF KNOWLEDGE “authoritative statements that describe the level of care
1. Critical Care Competencies or performance common to the profession of nursing by
2. Professional Organizations which the quality of nursing practice can be judged.”
(AACN, 2015)
PROFESSIONAL ORGANIZATIONS According to AACN (2015), the competent level of
• American Association of Critical Care Nurses behavior in a professional role, including activities
• European Federation of Critical Care Nursing related to:
Association (1997) 1. Quality of practice
• Australasia 2. Professional practice evaluation
➢ Australia 3. Education
➢ New Zealand 4. Communication
• South Africa 5. Ethics
6. Collaboration
CRITICAL CARE NURSES ASSOCIATION OF THE 7. Evidence-based Practice
PHILIPPINES (CCNAPI) 8. Resource utilization
• The national organization of nurses in critical 9. Leadership
care nursing 10. Environmental health
• Formed in 1975, incorporated in 1977
• “Safe, quality patient care is achieved if you are CLINICAL LEADERSHIP:
informed. Primary to how you behave is • It is founded on principles of trust, respect, and
education. We pride ourselves to be considered fairness, it is the fundamental qualities of
as advocates of patients.” healthcare organizations (Bobbio, Belan &
Manganelli, 2012).
DEFINITIONS • It is structuring the knowledge, skills, and
COMPETENCY abilities require for nurses to positioned
• An integration of the knowledge, attitudes, and themselves into roles that are needed for
skills necessary to function in a specific role and effective patient care
work setting (AACN, 2015) • The process of influencing point-of-care
• Involves a range of skills: psychomotor innovation and improvement in both
(technical), cognitive and interpersonal (Aitken, organizational processes and individual care
Chaboyer, Elliot, 2019) practices to achieve quality and safety of care
• “The ability to perform clinical nursing care that outcomes
is based on the nurse’s ethical thinking and
accurate nursing skills and that is provided to WHY CLINICAL LEADERSHIP IS IMPORTANT?
meet the needs of the cared” (Japanese Nurses 1. Complexity
Association, 2017) 2. Chaos
3. High rates of change
COMPETENT NURSE 4. Serious safety and quality issues
• Performing within a clinical environment, 5. Workforce shortages
specific to the context to which it is
demonstrated a combination of: skills, The fundamentals of nursing leadership encourages
behaviors, and knowledge (Aitken, Chaboyer, those who are in the nursing profession: not only to
Elliot, 2019) become more engaged and competent in performing
their basic healthcare functions, but also, to provide
CRITICAL CARE BODY OF KNOWLEDGE (COMPETENCIES) exemplary and quality care while thinking independently
Standards of Care for Acute & Critical Care Nursing and critically within their healthcare setting.
Practice
1. Assessment
2. Diagnosis
 CRITICAL CARE BODY OF KNOWLEDGE (COMPETENCIES)

Standards of Care for Acute & Critical Care Nursing Practice

The Nurse Caring for Acute &
Competencies
Critically Ill Patients
Assessment Collects relevant patient health 1. Collects comprehensive data (patient, family,
data pertinent to the issue, other health care providers, community) to
situation, or trend develop a holistic picture of patient’s needs
2. Prioritizes data collected according to patient
condition r/t the immediate predicted needs
3. Uses valid evidence-based assessment
techniques, instruments, and tools to evaluate
patient condition according to age and health
status.
4. Documents relevant data in patient file in clear
and systemic manner, easily retrievable
5. Maintains documentation within the legal and
ethical framework
6. Organizes, synthesizes, analyses, and interprets
the assessment data of the critically ill patient
from various data sources to derive nursing
diagnoses.
Diagnosis Utilizes the assessed data to 1. Develops nursing diagnoses or related conditions
analyze and formulate the based on nursing assessment
nursing diagnoses and related 2. Uses the collected data in clinical decision-making
condition to improve patient safety
3. Validates diagnoses with patient, family, and
other healthcare providers
4. Documents relevant data in patient file in clear
and systematic manner
5. Formulates nursing diagnoses based on accurate
analysis and interpretation of the assessment data
6. Establishes priorities concerning the critically ill
patients’ problems according to severity
Outcome Identifies expected outcomes for 1. Recognizes the outcomes from assessments and
Identification the patient diagnoses
2. Respects patient and family perspectives and
values in formulating culturally appropriate
outcomes in collaboration with the patient &
family, & with the interprofessional team
3. Considers associated risks, benefits, current
evidence, clinical expertise, & cost when
formulating expected outcomes
4. Modifies expected outcomes based on changes in
patient condition or situation
5. Documents outcomes as measurable goals in
patient file in clear and systematic manner
Planning Develops & facilitates the plan 1. Employs critical thinking and judgment in
that prescribes interventions and developing an individualized plan using best
alternatives to attain outcomes evidence
within the three spheres of 2. Collaborates with the patient, family, and
influence: interprofessional team to develop the plan
• Patient / Family 3. Establishes priorities and continuity of care within
• Nursing / Nursing the plan
Practice
 • Organizations / System 4. Determines the strategies for health promotion
and prevention of further illness or injury within
the plan
5. Considers associated risks, benefits, current
evidence, clinical expertise, resources, and cost
when developing the plan
6. Documents the plan in as clear and systematic
manner
Implementation Implements interventions within 1. Employs strategies to promote and maintain safe
the three spheres of influence: environment
• Patient / Family 2. Coordinates implementation of the plan with the
• Nursing / Nursing patient, family, and interprofessional team
Practice 3. Intervenes to prevent and minimize complications
• Organizations / System and alleviate suffering
4. Facilitates learning for patients, families, and the
community
5. Documents implementation in a clear, systematic
manner
6. Provides age & developmentally appropriate care
in a culturally and ethnically sensitive manner
Evaluation Evaluates processes and 1. Conducts systematic and continuing evaluations
outcomes using E-B techniques, tools, and instruments
2. Collaborates with the patient, family, and
interprofessional team in the evaluation process
3. Revises the assessment, diagnoses, outcomes,
and interventions based on the information
gained during the evaluation process
4. Documents the results of evaluation in a clear and
systematic manner

STANDARDS OF PROFESSIONAL PRACTICE

The Nurse Caring for Acute &

Standard Competencies
Critically Ill Patients
Standard 1: Quality of Contributes to the quality and 1. Participates in clinical inquiry through quality-
Practice effectiveness of nursing practice improvement activities
2. Consults with colleagues, subject matter experts,
and identified stakeholders to initiate changes in
nursing practice and the healthcare delivery
3. Conducts and participates in quality improvement
activities, taking into consideration patient &
family beliefs, values, and preferences
4. Ensures patient confidentiality in reporting any
quality data
5. Evaluates practice in an ongoing process, based
on best evidence
6. Identifies barriers to quality care and patient
outcomes
7. Ensures patient confidentiality in reporting any
quality data
8. Evaluates practice in an ongoing process, based
on best evidence
9. Identifies barriers to quality care and patient
outcomes
Standard 2: Evaluates his/her own nursing 1. Engages in a self-evaluation and reflective
Professional Practice practice in relation to practice on a regular basis, identifying areas of
Evaluation professional practice standards, strength, as well as areas where professional
organizational guidelines, growth would be beneficial
relevant statutes, rules and 2. Takes action to achieve goals identified in the
regulations evaluation process
3. Engages in a self-evaluation and reflective
practice on a regular basis, identifying areas of
strength, as well as areas where professional
growth would be beneficial
4. Takes action to achieve goals identified in the
evaluation process
Standard 3: Education Maintains current knowledge 1. Participates in ongoing learning experiences and
and competence in the care of activities to develop and maintain clinical and
acutely and critically ill patients professional skills and knowledge
2. Seeks learning opportunities that reflect current
and evidence-based practice
3. Participates in ongoing learning experiences and
activities to develop and maintain clinical and
professional skills and knowledge
4. Seeks learning opportunities that reflect current
and evidence-based practice
Standard 4: Utilizes skilled communication 1. Assesses communication format preferences of
Communication in a variety of formats acutely & critically ill patients, families, &
interprofessional team
2. Practices interprofessional communication skills
& reflects upon personal communication style
3. Solicits feedback to continuously improve his or
her own communication and conflict- resolution
skills
4. Conveys accurate information to A & CI-P,
families, & the interprofessional team
5. Questions the rationale supporting care
processes & decisions with all members of the
interprofessional team
6. Discloses observations or concerns related to
safety, hazards, & errors in care or the practice
environment as appropriate
7. Maintains open communication with other
providers to minimize risks associated with
patient handoffs, transfers, & transitions in care
8. Contributes her/his own professional perspective
in discussions with the interprofessional team
9. Maintains open communication with other
providers to minimize risks associated with
patient handoffs, transfers, & transitions in care
10. Contributes her/his own professional perspective
in discussions with the interprofessional team
Standard 5: Ethics The nurse’s decisions and 1. Practices as guided the PNA Code of Ethics, the
actions are carried out in an CCNAPI values and ethical principles
ethical manner in all areas of 2. Promotes ethical accountability & integrity in
practice relationships, organizational decisions, &
stewardship of resources
3. Protects patient confidentiality within legal and
regulatory parameters
 4. Advocates for the concern of patients, their
families, and the community
5. Delivers care in a non-judgmental & non-
discriminatory manner that meets the diverse
needs of the patient, family, & community
6. Maintains patient autonomy, dignity, values,
beliefs, & rights at all times
7. Uses available resources in formulating ethical
decisions
8. Demonstrates a commitment to self-care & self-
advocacy
9. Reports unethical, illegal, incompetent or
impaired practices
10. Assists patient & family in self-determination &
informed decision-making
11. Maintains a therapeutic and professional
nurse/patient relationship within appropriate
role boundaries
12. Contributes to resolving issues involving the
patient, family, & interprofessional team
13. Questions healthcare practice when necessary for
safety and quality improvement
14. Collaborates with the interprofessional team to
promote palliative care ir end-of-life discussions,
decisions, & care
Standard 6: Collaborates with the patient, 1. Partners with others to effect change & produce
Collaboration family, and interprofessional positive outcomes through knowledge-sharing
team 2. Adheres to standards that govern behavior
among the interprofessional team to create a
healthy work environment that promotes
cooperation, respect, & trust
3. Collaborates with the patient’s family to promote
effective & safe transition across care settings
4. Engages in teamwork & conflict resolution
5. Contributes to creating an interprofessional plan
of care
6. Promotes respect & engagement among nursing
colleagues
Standard 7: Evidence- Uses clinical inquiry and 1. Questions clinical practices for the purpose of
Based Practice, integrates best evidence into improving the quality of care
Research and Inquiry practice 2. Describes clinical problems using evidence
generated within a clinical setting such as patient
assessment data, outcomes management, &
quality-improvement data
3. Formulates clinical questions
4. Questions clinical practices for the purpose of
improving the quality of care
5. Describes clinical problems using evidence
generated within a clinical setting such as patient
assessment data, outcomes management, &
quality-improvement data
6. Formulates clinical questions
7. Questions clinical practices for the purpose of
improving the quality of care
 8. Describes clinical problems using evidence
generated within a clinical setting such as patient
assessment data, outcomes management, &
quality-improvement data
9. Formulates clinical questions
Standard 8: Resource Employs appropriate resources 1. Assess the individual patient needs & available
Utilization to plan and provide services resources to achieve desired outcomes
that are safe, effective, and 2. Delegates elements of care (as defined by
financially responsible regulatory agencies) to the appropriate individual
based upon assessed needs & condition of the
patient, potential for harm, patient stability,
predictability of the outcomes, competence of
the individual, and resources available
3. Assess the individual patient needs & available
resources to achieve desired outcomes
4. Delegates elements of care (as defined by
regulatory agencies) to the appropriate individual
based upon assessed needs & condition of the
patient, potential for harm, patient stability,
predictability of the outcomes, competence of
the individual, and resources available
Standard 9: Provides leadership in the 1. Contributes to the creation & maintenance of
Leadership professional practice setting, as healthy work environment
well as in the profession 2. Supports peers & colleagues through mentoring
& other professional development strategies
3. Demonstrates flexibility & the ability to remain
patient-focused in a rapidly changing
environment
4. Contributes to the creation & maintenance of
healthy work environment
5. Supports peers & colleagues through mentoring
& other professional development strategies
6. Demonstrates flexibility & the ability to remain
patient-focused in a rapidly changing
environment
7. Contributes to the creation & maintenance of
healthy work environment
8. Supports peers & colleagues through mentoring
& other professional development strategies
9. Demonstrates flexibility & the ability to remain
patient-focused in a rapidly changing
environment
Standard 10: Maintains a safe and healthy 1. Minimizes environmental risk factors that may
Environmental Health environment cause physical harm or injury to patients,
families, & the interprofessional team
2. Implements strategies to reduce the impact of
environmental factors that jeopardize health,
such as sound, odor, noise, & light
3. Communicates environmental health risks &
exposure-reduction strategies to patients,
families, & colleagues
4. Uses reliable resources to determine if product or
treatment is an environment threat
5. Participates in strategies & activities to promote
healthy communities
 • Helps to form a question and facilitate quick and
CLINICAL GOVERNANCE wider literature search.
• Its framework helps to identify the main
A system through which hospital organizations are
elements of a question and simplify writing a
accountable for continuously improving the quality of
question statement
their services and safeguarding high standards of care by
creating an environment in which excellence in clinical
EBP
area will flourish (Scally & Donaldson, 1998).

Quality of Care Delivery

• Training
• Observance of policies and procedures
• Teamwork • Improves healthcare deliver
• Communication • Strengthen outcomes
• Complaints Management • Diminishes geographical differences in care and
• Leadership cut costs
• Feedback • Increase overall job satisfaction

HISTORY
CLINICAL EFFECTIVENESS
• Florence Nightingale (1800) – improving patient
• EBP
outcomes in the face of unsanitary conditions
• Research & Development
• Archie Cochrane (1970) – originator of the EBM
• Outcome Measures
• Clinical Audit
IMPORTANCE OF EBP TO NURSES
PERSON-CENTEREDNESS
• An empowering approach to care
• Volunteering
• Link between a wealth of medical research and
• Person-centered cultures
practical experience on the ground
• Patient information
• Standardization of care
• Equality & Diversity
• Decrease medical errors
• Shared decision making
• Positive changes to the patients, communities &
• Enhancing care experience
the world
• Public involvement, communication &
engagement
PROCESS
ADVERSE EVENT AND CLINICAL RISK MANAGEMENT
1. Ask
• Adverse event review
2. Search
• Duty of candor
3. Analyze
• Risk management
4. Implement
• Business continuity plan
5. Evaluate
• Patient safety
CONTINOUS IMPROVEMENT
PICO/T
• Applied quality improvement
• An approach for developing a nursing question
• Capacity & capability
in a format allowing users to approach different
• Innovation
nursing research questions with a benefit of EBP
• Quality improvement infrastructure
• It eliminates the potential to assume various
inappropriate and including it in the research as
it is likely to skew the results to the extent of
EVIDENCE-BASED PRACTICE making them dysfunctional
DEFINITION: • Summarizes research questions that explore the
• An approach to healthcare that utilizes the most effect of therapy or prevention, diagnosis,
current research available in order to improve prognosis and etiology
the health and safety of patients while reducing
overall costs and variation in health outcomes PICO/T MEANING
(Journal of Nursing Administration, 2015) Population/Patient
• Age
PICO/T • Gender
• Ethnicity
 • Individuals with certain disorder patients to make decisions about appropriate
health care for specific clinical circumstances
Intervention 2. Produced under the auspices of a medical
• Treatment that will be provided to the subjects specialty association; relevant professional
of the study society; public or private organization;
• Plans to address the health issues of the patient government agency both national and local;
(specific tests, medications, & therapies) health care organization or plan.
3. Based on a systematic review of evidence as
Comparison / Control demonstrated by documentation of each of the
• Compares alternatives to the plan (a different following feature in the clinical practice
type of treatment) guideline or its supporting documents
• Alternative to treating the patient a. An explicit statement that the clinical
Outcome practice guideline was based on a
• Expected results after an intervention systematic review.
✓ Reducing symptoms b. A description of the search strategy that
✓ Eliminating symptoms includes a listing of database(s)
✓ Full recovery searched, a summary of search terms
used, and the specific time period
Time covered by the literature search
• Duration to achieve the desired outcome / including the beginning date
observation of the patient (month/year) and end date
• Period of the data collection (month/year)
• Optional c. A description of study selection that
includes the number of studies
SPIDER identified, the number of studies
S (Sample): The group of participants in qualitative included, and a summary of inclusion
research and exclusion criteria.
Pi (Phenomenon of Interest): The how & why of d. A synthesis of evidence from the
behaviors & experiences selected studies, e.g., a detailed
D (Design) : How the study was devised & conducted description or evidence tables.
E (Evaluation) : The measurement of outcome e. A summary of the evidence synthesis
R (Research Type) : Qualitative, Qualitative, or Mixed (see 3d above) included in the guideline
that relates the evidence to the
recommendations, e.g., a descriptive
summary or summary tables.
CLINICAL PRACTICE GUIDELINES 4. The CPG or its supporting documents contain an
Advances in medical, biomedical, and health services
assessment of the benefits and harms of
research have reduced the level of uncertainty in clinical
recommended and alternative care options
practice.
Clinical Practice Guidelines (CPGs) complement this
Criteria In Developing Clinical Guidelines (National
progress by establishing standards of care backed by
Quality Measures Clearinghouse (NQMC)
strong scientific evidence.
1. Must address some aspect(s) of health care
Criteria In Developing Clinical Guidelines
delivery or population health that can be
(National Guideline Clearinghouse (NGC)
classified into one of the domains
• Clinical Practice Guidelines (CPG) are statements
2. Must be in current use or have been pilot tested
that include recommendations intended to
within the last three years and must be the most
optimize patient care that are informed by a:
recent version if the measure has been revised
o systemic review of evidence and
3. Research papers:
o an assessment of the benefits and harms
• Rationale
of alternative care options (IOM, 2011)
• Description of the denominator
• Data source(s) for the measure
Criteria for Developing the CPG
• Documentation of evidence
1. Contain systematically developed statements
4. At least one of the following criteria must be
including recommendations intended to
satisfied with specific information attached in
optimize patient care and assist physicians
each case (evidence from peer-reviewed
and/or other health care practitioners and
literature is preferred)
 • Cited in one or more reports in a • Basic life support
National Library of Medicine (NLM) • Transfer arrangements to Level 1 is in place for
indexed, peer-reviewed journal, patients with the specific disorders for which the
applying or evaluating the measure’s unit does not provide care
properties
• Documented evidence of reliability and Level 3
validity • Comprehensive care for a wide variety of
• Measure has been developed, adopted, disorders
adapted, or endorsed by an organization • Sophisticated equipment
that promotes rigorous development • Specialized nurses
and use of measurement in health care. • Intensivists
(local, national, international levels) • Comprehensive support service
• (https://www.ahrq.gov/gam/summarie o Pharmacy
s/inclusion-criteria/index.html , October o Nutrition
2018) o Respiratory
o Pastoral
o Social work

RISK MANAGEMENT IN CRITICAL

CARE
DEFINITION
An organized effort to identify, assess, and reduce,
where appropriate, risk to patients, visitors, staff, and
organizational assets.
INTENSIVE CARE Best used in a proactive manner in identifying and
• The practice of administering immediate and managing the risks
continuous care to clients with actual or Examples:
potentially life-threatening health disorder Regular use of hand sanitizers / handwashing
o Brain injuries Methodology:
o Cardiovascular dysfunctions Survey of hospital staff
o Pulmonary dysfunction
o Childbirth WHAT IS NEXT?
o Infection / Sepsis DEVELOPMENT
o Shock and trauma • Healthcare staff can formulate a system
o Endocrine abnormalities addressing and managing the risk
o Multisystem alterations
o Complex surgical procedure THE CAVEAT!
Healthcare risk management acknowledges that the
LEVELS OF ICU dangers of the risk are still there, but with preparation
Level 1 and strong policies, the scope of these threats can be
• Initial stabilization of critically ill patients reduced
provided but limited ability to provide
comprehensive critical care THE PURPOSE
o Provision of Oxygen 1. Preventing the worst-case scenario that can
o Non-invasive monitoring evolve from a certain risk, danger, or threat.
• Patients who require routine care 2. Identify potential hazards or threats and do
• Policies are established to determine which everything possible to mitigate them.
patients require transfer and where they ought
to be transferred HOW TO DEVELOP A HEALTHCARE RISK MANAGEMENT
POLICY (Journal of Epidemiology & Preventive Medicine,
Level 2 2017)
• Comprehensive critical care for most disorders 1. Establish the context
• With invasive monitoring 2. Identify risks
 3. Analyze risks 2. Practice communication skills
4. Evaluate risks 3. Stay informed
5. Treat / manage risks

STRATEGIES:
1. Accurate and complete documentation
PROFESSIONAL DECORUM
PROFESSIONAL NURSE
2. Training new staff in the various risk
Highest standard of professional ethics, behaviors, and
management
work activities while performing one’s profession
3. Involvement of the entire healthcare members
(Maryville University, 2018)
Appropriate treatment or relationships with Patients
• Confidentiality
• Non-Desertion of a patient due to economic
THE CRITICAL NURSE AS A reasons
• Putting the interest of the patient ahead of their
PATIENT’S ADVOCATE own interests
DEFINITION:
Appropriate treatment or relationships with colleagues
• A nurse advocate is one who works on behalf of
• Consideration shown to elderly, junior of
the patients to:
inexperienced colleagues
o Maintain quality of care
• Role Model
o Protect patient’s rights
• An expert, also a master in a specific field
• A nurse advocate intervenes when there is a care
concern
• Following the proper channels, the nurse works
to resolve any patient care issues PATIENT’S BILL OF RIGHTS
Advocacy: Nurses are ideal patient advocates • A guide to ensure every patient gets good,
• An essential part of nursing quality health care
• Interact with patients daily • Contains rules that healthcare providers should
• Awareness of patients’ frustration and confusion observe toward the patient and their families
• Patients rely on nurses not only to provide care during hospitalization
but also to counsel and educate • Not legally binding
• Provide goals and expectations for patient
The Nurse’s Role treatment
• Supports the best interests while respecting the
family’s important role 1. Right to Appropriate Medical Care & Humane
• Attends to health care team meetings with Treatment
patient and family • Human dignity
• Help patient’s make informed decisions • Convictions
regarding their health to include navigating a • Integrity
complex medical system by: • Individual needs
• Translating medical terms • Culture
• Help make ethical decisions • Informed of reason for the delay in treatment
• Immediate care during emergencies shall be
Patient Advocacy Example: extended without any deposit, pledge, mortgage
• Nurses can act as mediators between patients or any form of advance payment for treatment.
and doctors who may have overlooked certain
patient needs or solutions. 2. Right to Informed Consent
If a patient receives an inaccurate • Clear, truthful explanation, except in the
diagnosis, unsafe accommodation, or following cases:
unclear instructions for self-care, the a. Emergency situations
nurse must alert the doctor b. Health of the population
or medical facility and c. Mandated by Law
communicate the issue. d. Minor, legally incompetent
e. Success of the treatment is in jeopardy
Effective Advocacy f. Patient waives right in written form
1. Suspend judgment
Right of Unconscious Patient b. Releases those involved in care from any
• Informed consent must be obtained whenever obligation relative to the consequences
possible, from a legally entitled representative c. Decision will not prejudice public health &
however; safety
• When medical intervention is urgently
needed, Consent of the patient may be 7. Right to Religious Belief
presumed, • Right to refuse medical treatment or
• unless; it is obvious beyond any doubt procedures which may be contrary to religious
(DNR) beliefs, provided;
a. Not imposed by parents of children in a life-
3. Right to Privacy and Confidentiality threatening situation as determined by
• Exceptions: attending physician/medical director
• Patient’s mental or physical condition is
in controversy as directed by the 8. Right to Medical Records
appropriate court • Right to a summary of the medical history &
• Healthcare providers: condition.
a) Benefit the public & safety • View the contents of the medical records,
b) Interest of justice & upon order except:
of a competent court a. Third parties: Psychiatric notes & other
c) Patient waives in writing incriminatory information
d) Needed for continued medical • The health care institution shall safeguard the
treatment or medical confidentiality, ensure the integrity &
advancement authenticity of the medical records; & keep
• Spouse/family upon patient’s decision them as determined by DOH
• Document will be available within 45 days from
4. Right to Information request
• Results of the evaluation
• Additional or further contemplated 9. Right to Leave
medical/surgical treatment • Right to leave the hospital regardless of physical
• Changes in the plan of care prior to its condition provided;
implementation a. Informed of the medical consequences
• Extent of what Philhealth/other payor may b. Releases those involved from any
shoulder the payment obligation relative to the consequences
• Itemized bill of hospitalization c. Will not prejudice public health & safety
• Continuing care requirements following
discharge 10. Right to Refuse Participation in Medical Research
• Brief, written summary of the course of illness • Right to be advised to involve in medical
• Medical certificate free of charge research.
• Written informed consent- human experiment
5. Right to Choose Health Care Provider & Facility • Provisions of the Declaration of Helsinki and its
• Exceptions: guidelines
a. Under the care of service facility
b. Public health & safety 11. Right to Correspondence & to Receive Visitors
c. Patient waives in written form • Subject to reasonable limits prescribed by the
• Right to discuss illness condition with a rules & regulations of the health care
consultant/specialist institution
• Right to seek for a second opinion & 12. Right to Express Grievances
subsequent opinions • Right to express complaints and grievances
about the care and services received without
6. Right to Self-Determination fear of discrimination or reprisal
• Right to avail any recommended diagnostic &
treatment procedures 13. Right to be Informed of Rights & Obligations as a
• Make an advance written directive for Patient
physicians to administer when in the terminal • Such rights and obligations of patients shall be
phase of a terminal illness; provided that: posted in a bulletin board conspicuously placed
a. Knowledgeable of the consequences in a health care institution
 • Workers must recognize healthcare dilemmas
• Make good judgments and decisions based on
their values while keeping within the laws that
ETHICAL AND LEGAL govern them
CONSIDERATIONS • To practice competently with integrity, nurse,
must have regulation and guidance within the
ETHICS VS. LAW profession
Law Ethics
Formal. Written Unwritten principles ETHICAL DILEMMA WITHIN HEALTHCARE
document • Disagreements
• Nurses
Interpreted by courts Interpreted by everyone
• Patient
Established by legislators Presented by
• Healthcare team
philosophers, religious,
• Family al issues involved as well as-
professional groups
making
Applicable to everyone Personal choice
Priority decided by court Priority determined by
ETHICAL DILEMMA
individual
• Conflict between the duties, rights and values of
Court makes final No external decision
the people involved in the situation
decision maker
• A difficult problem or situation in which conflicts
Enforceable by police and Limited enforcement
arise during the process of making morally
courts
justifiable decisions.
• Each patient and family has a set of personal
ETHICS
values that are influenced by their environment
• Comes from the Greek word “ethos” (character)
and culture.
• Each person has their own set of personal ethics
• What are the facts?
and morals
• What is the big picture?
• Moral principles that govern how a person, or a
• Know the legal issues involved as well as how to
group will behave or conduct themselves
engage in ethical discourse and decision-making
• Pertains to the right and wrong of actions,
encompassing the decision-making process of
ETHICAL DECISION MAKING
determining the ultimate consequences of the
• Emerged as a major component of health care
actions
for the critically ill patients
• Ethical values are universal rules of conduct that
• Refers to the process of evaluating and choosing
provide a practical basis for identifying what kind
among alternatives in a manner consistent with
of actions, intentions, and motives are valued
ethical principles

ETHICAL PRINCIPLES
ETHICAL DECISION MAKING PROCESS
• Autonomy: respect for the person and the ability
• Protection
of the persons to make decisions about their
• Implementation
own health and future (informed consent)
• Evaluation
• Beneficence: actions intended to benefit the
• Assessment
patients or others
• Nonmaleficence: actions intended not to harm /
LEGAL AND ETHICAL ISSUES
bring harm to others
• Informed consent
• Justice: being fair. In healthcare, it is the fair
• End-of-life issues
allocation or distribution of healthcare resources
• Organ transplantation (recipients and living
• Veracity: the obligation to tell the truth
donors
• Fidelity: the moral duty to be faithful to the
• Use of restraints
commitments that one makes to others
• Confidentiality: respect for an individual’s
LEGAL ISSUES
autonomy and the right of individuals to control
Tort Law: wrong committed against a person or the
the information relating to their own health
person’s property
1. Negligence (Malpractice)
ETHICS WITHIN HEALTHCARE
2. Assault
• Important
3. Battery
Negligence (Malpractice): Drug allergy test (ANST), drug-drug interaction
• A duty was owed checks, doctor’s conference- suggestions for
• The duty was breached drug doses, routes and frequencies
• The breach of the duty was the proximate cause
of an injury to the patient NOSOCOMIAL INFECTION
• Damages Examples: UTI, surgical site infection, pneumonia,
bloodstream infection.
Prevention: Infection Control Measures

PATIENT SAFETY GUIDELINES IN EVIDENCE-BASED APPROACH

CRITICAL CARE Practices with the strongest supporting evidence are
”To err is human” generally clinical interventions that decreases the risks
associated with hospitalization, critical care and surgery
Why ICU is particularly prone to medical errors?
1. The care of ICU patients can be complex ICU-PATIENTS SAFETY
2. Patients are very ill and require continuous 1. Standardization of ICU
monitoring 2. Evidence-based approach can help identify
3. Involves multiple consultants practices that are likely to improve patient safety
4. Involves many medications 3. To reduce medication-related errors by using
5. Life and death decisions often need to be made computerized physician order entry with clinical
quickly decision support system
4. Prevention of nosocomial infection
PATIENTS SAFETY PRACTICE
A type of process or structure whose application reduces
the probability of adverse events resulting from exposure NURSING PROCESS
to health care system across a range of diseases and
- Entails gathering and analyzing data
procedures.
o Identify clients’ strengths
• Patient safety is fundamental to delivering
o Potential or actual health problems
quality essential health services
o Developing and continuously reviewing
• Patient safety is a feature of a healthcare system
a plan of nursing interventions to
and a set of tested ways for improving care.
achieve mutually agreed outcomes
- A systematic rationale method of planning and
PURPOSE
providing individualized nursing care
• It aims to prevent and reduce risks, errors and
- Used to identify, diagnose, and treat human
harm that can occur to patients during provision
response to health and illness (ANA)
of health care
• Helps protect patients and creates an
CHARACTERISTICS OF THE NURSING PROCESS
environment where better overall care is
1. System is open & flexible
possible
2. Meet the unique needs of individual, family,
• Helps reduce medical mistakes and prevent
group, or community
adverse patient outcomes
3. Cyclic & dynamic
4. Client centered
MEDICATION ERRORS
5. Planned and goal-directed
• Ordering, transcribing, dispensing, administering
6. Interpersonal & collaborative
(missing dose, dosage, route & frequency) and
7. Permits creativity for the nurse and patient to
monitoring (SE/AE)
solve the stated health problems
8. Emphasizes feedback, which leads either to re-
PREVENTION OF MEDICAL ERROR
assessment of the problem or revision of the
1. Computerized physician order entry -
care of plan
standardized, legible, complete orders by only
9. Universally applicable
accepting typed orders in standard and complete
NURSING PROCESS
format.
ASSESSMENT
2. Clinical decision support system
The systematic & continuous collection of data to
determine a patient’s current & past health status &
functional status.
Assessment Purposes Method of Data Collection
- To establish a data base (all information about - Interview
client) - Observation
o Nursing heath history - Palpation
o Physical assessment - Percussion
o Results of laboratory & diagnostic tests - Auscultation
- Patient’s response to health concerns or illness
- Ability to manage health care needs 2. Organizing Data
Arrange data:
Assessment Types - systematically
1. Initial Comprehensive Assessment - meaningful cluster
- Performed within specified time after admission. Cluster – a set of signs & symptoms that are grouped
Also known as “admission assessment” together in a logical order
E.g., Nursing Admission Assessment E.g.
- Self care need
Purposes:
- Physiological need
- Evaluate health status
- Adaptation need
- Identify functional health patterns
- Coping need
- Provide an in-depth comprehensive databases
2. Problem Focused Assessment
3. Validation of Data
- Collects data about a problem that has been
- Involves comparing the collected data with
identified
another source
- Ongoing process integrated with nursing care
- Act of double checking or verifying data to
- Nurse determines whether problem still exist or
confirm that they are accurate and factual
whether changes in the status of the problem
are observed
Steps in Validation of Data
E.g., hourly assessment of patient’s I & O
- Deciding whether the data require validation
3. Emergency Assessment
- Determining ways to validate the data
- Occurs during any life—threatening condition
- Identifying areas where data are missing
- Physiologic or psychologic crisis
- Failure to validate data may result in premature
E.g., rapid assessment of patient’s vital signs
closure of assessment or collection of inaccurate
during cardiac arrest
data
4. Time Lapsed Assessment
- Several months after initial assessment
DIAGNOSIS
- Evaluate the changes in the patient’s health &
A clinical judgment about the individual, family, or
functional status
community’s responses to actual & potential health
E.g., periodic output of patient’s clinic visits
problems/life processes (NANDA).
o Home health visits
- Analyze the data
o Health & development screening
- Identify the health problems, risks, & strengths
- Formulate diagnostic statements
Components of Assessment
1. Collection of Data
Types of Nursing Diagnosis
- The process of gathering information about a
1. Actual Diagnosis
patient’s health status
- Problem is observed at the time of the nursing
- Includes physical, psychological, emotional,
assessment.
socio-cultural, spiritual factors that may affect
- Based on the presence of associated signs &
the patient’s health status
symptoms.
- Include:
Example:
o Past health history
• Ineffective breathing pattern
o Allergies,
• Anxiety
o Complementary Alternative Medicine
o Present problems
Types of Data 2. Risk Nursing Diagnosis
- Subjective - A clinical judgment that a problem does not
- Objective exist, but the presence of risk factors indicates
that a problem is likely to develop
 Example: Example:
• Risk for infection • Activity intolerance related to generalized
• Risk for complication weakness or obesity
3. Possible Nursing Diagnosis
- Evidence/s about a health problem is incomplete Basic Three-Part Statements (PES Format)
or unclear 1. Problem (P) – statement of the patient’s
Example: response
• “Possible social isolation related to 2. Etiology (E) – factors contributing to/or probable
unknown etiology” causes of the response
• Elderly widow who lives alone has no 3. Signs & Symptoms (S) – defining characteristics
visitors and is happy with the attention evidenced by the client
and conversation from the nursing staff. Example:
4. Syndrome Diagnosis • Activity intolerance related to generalized
- Associated with a cluster of other nursing weakness as evidenced by fatigue
diagnosis
Example: Nursing Diagnosis vs. Medical Diagnosis
• disuse syndrome (long term bed ridden Nursing Diagnosis Medical Diagnosis
patients Made by nurses, Made by physician & a
• Impaired physical mobility. conditions that nurses are condition that only a
5. Wellness Diagnosis licensed to treat physician can treat
- Indicates a healthy response of a patient who Statement of nursing Statement of medical
desire a higher level of wellness judgment judgment
Example:
• Individual coping Describes a patient’s Describes a patient’s
• Family coping physical, sociocultural, specific pathophysiologic
• Potential for enhanced spiritual well psychological, & spiritual responses to an illness
being responses to an illness or
health problem
Three (3) Components of Nursing Diagnosis Responses vary among Responses are uniform
1. The Problem (Diagnostic Label) individuals from one patient to
- Describes the patient’s response to health another
problems Diagnosis changes as the Diagnosis remains the
Example: patient’s response same for as long as the
• Activity intolerance change disease process is present
• Constipation
2. The Etiology (Related Factors and Risk Factors) Relate to the nurse’s Nurses carry out
Example: independent function physician’s prescribed
• Activity intolerance related to generalized treatment (dependent
weakness or obesity or sedentary life function)
• Constipation related to inadequate fluid E.g., tepid sponge bath E.g., Paracetamol 500 mg.
intake or inadequate fiber intake for fever PO for fever
3. The Defining Characteristics
- These are the cluster of signs & symptoms that PLANNING
indicate the presence of diagnostic label A category of nursing behaviors wherein the selection of
Example: the following are done:
• Impaired response to activity, weak, thready - Client centered goals
pulse, tachycardia, irregular pulse & shallow - Expected outcomes
respiration - Nursing interventions

Types of Planning
Formulating Diagnostic Statements
1. Initial
Basic Two-Part Statements (PE Format)
Initiated as soon as possible after the initial
1. Problem (P) – statement of the patient’s
assessment
response
2. Ongoing
2. Etiology (E) – factors contributing to/or probable
causes of the response
 Beginning of the shift as the nurse plans the care - A specific & measurable behavior or response
for that day that reflects a patient’s’ highest possible level of
3. Discharge wellness & independence in function
Begins at first client contact & involves a 3. Select Nursing Interventions and Activities
comprehensive & ongoing assessment to obtain - Performed to achieve the patient’s goals
information about the patient’s on going needs
Types of Nursing Interventions
Developing the Nursing Care Plan (NCP): 1. Independent Interventions
- End-product of the planning - Licensed to initiate based on their
knowledge & skills
Types of NCP - AKA: Nurse Initiated Interventions
1. Informal Care Plan Examples:
- Exist in the nurse’s mind • Physical care
Example: “Ms. Dela Cruz is very tired; I will need • Ongoing assessment
to reinforce her teaching after she is rested” • Emotional support & comfort
2. Formal Care Plan • Teaching
- Written guide that organizes the information • Counselling
about the patient’s care 2. Dependent Interventions
3. Standardized Care Plan - Activities carried out under the physician’s
- Care plan for a group of patients with common orders or supervision
needs - AKA: Physician Initiated Interventions
Example: “all patients with fever” Example:
4. Individualized Care Plan • Medication administration
- Tailored to meet the unique needs of specific 3. Collaborative Interventions
patients - Activities carried out in collaboration with
Example: patient with MI other health team members
5. Kardex Care Plan • Physical therapist
- A system wherein patients’ information & • Social workers
instruction are kept making information • Dietician
accessible • Physician
- Contains information about: 4. Writing Nursing Orders
• Diet - Instructions for the specific activities the
• Activity level nurse performs to help the patient meet
• Self-care, hygienic needs established health care goals
• Treatments
• Procedures Components of Nursing Orders
1. Date
2. Action verb
NCP Categories
3. Content area
1. Student Care plan
- The what and the where of an order
- Learning activity as well as plan of care
4. Time element
- Lengthy & detailed
- Answers when, how long, and how often
2. Computerized Care Plan
the nursing action is to occur
- Generate both standardized & individualized
5. Signature
care plans
- The signature of the nurse prescribing
- Nurse chooses the appropriate diagnosis from a
the order shows the nurse’s
menu suggested by the computer
accountability & has legal significance

Process of Planning
Example of a Nursing Order:
Stages of Planning
1. Setting Priorities
- Process of establishing a preferential order for
nursing diagnoses & interventions
- Maslow’s Hierarchy of Needs
2. Establish Patient Goals and Desired Outcomes
IMPLEMENTATION
1. Nurse puts the nursing care plan into action
 2. Continues with the data collection 3. Implementing the nursing orders
3. Documents the care provided Explain to the patient during implementation:
- What will be done
Implementing Skills - What sensations to expect
Cognitive/ Intellectual Skills - What the patient is expected to do
- Problem solving
- Decision making Nursing Actions
- Critical thinking - Often require teaching, support and comfort
- Curative thinking - Holistic in nature
Interpersonal Skills - Respect the dignity of the patient and enhance
- Verbal & non-verbal activities when the self-esteem
communicating - Patients are encouraged to actively participate
Technical Skills in implementing the nursing actions
- “Hands-on skills”
- Manipulation of equipment When Implementing Nursing Orders
- Nursing procedures - Nursing actions should be based on scientific
knowledge, nursing research & professional
Implementation of Care standards of care
Independent - Clearly understand the orders to be
- Physiologic implemented & question any that are not
- Psychosocial understood
- Spiritual - Adopted to individual patient
Interdependent - Always safe
- Pharmacological
- Complementary & Alternative Therapies 4. Delegating and Supervising
- Nutritional & Diet Therapy Nurse’s Responsibilities
- Surgical Intervention 1. Appropriate delegation of duties
- Immunologic Therapy 2. Adequate supervision of personnel
- Assign some nursing care duties to an
Implementing Skills unlicensed person but cannot assign
responsibility for total care

5. Communicating the nursing actions

Documenting the interventions and client responses
in the nursing progress notes.

PATIENT EDUCATION
Starts from the time patients are admitted to the hospital
and continues until they are discharged

Why?
- Empowers patients to improve their health
1. Reassessing the Client status
Before implementation - More likely to engage in interventions that may
- to ensure that the intervention is needed increase their chances for positive outcomes
- The patient’s condition may have changed - Prevention of medical conditions
2. Determining the nurses need for assistance - Decreases the possibility of complications
The is unable to implement the nursing care safely - Retaining independence by self – sufficiency
- Turning an obese patient in bed
Reduce stress on the client Nurse’s Role
- Turning a patient who experiences acute pain Take advantage of any appropriate opportunity
when moved throughout a patient’s stay to teach about self-care
Lack of knowledge & skills to implement the nursing What?
care - Self-care and its importance
- Unfamiliarity with an equipment - Recognizing the warning signs
- What to do if problem occurs
 - Who to call
Communicate:
How?
- Observations
Assess:
- Decisions Nursing Process
- Physical & psychosocial needs
- Actions
- Determine learning needs, readiness to learn
- Outcomes
Plan:
- Develop care plan based on mutual goal setting
Purposes
to meet individual needs
- Quality improvement
Implementation:
- Research
- Perform teaching using specific instructional
- Basic to the professional and medico legal
methods & tools
requirement of nursing practice
Evaluation:
- Essential for good clinical communication
- Determine physical & psychosocial changes
(KAS)
How?
Fundamental Aspects of Documentation
EVALUATION
The last phase of the nursing process • Contains • Breath
Patients and health care professionals determine: descriptive, sounds
- the patient’s progress toward goal achievement objective • Chest
- effectiveness of the nursing care plan information expansion
F
• Direct • Nail beds
Factual
Types of Evaluation observation
1. Ongoing Evaluation &
- Done while or immediately after measuremen
implementation t
- Enables to make on the spot modification in an • Use of exact • Oral intake
intervention measuremen was 1000 ml
2. Intermittent Evaluation A
ts & over 8 hours
- Performed at specified intervals Accurate
establishes
- Shows the extent of progress toward goal accuracy
achievement
- Enables to correct any deficiencies & modify the • Document:
care plan as needed ✓ Changes in
3. Terminal Evaluation status
• Charting
- Indicates the patient’s condition at the time of ✓ Patient
should
discharge responses
C include
- Includes the status of goals achievement ✓ Communica
Complete appropriate
- Evaluation of the patient’s’ self-care abilities tion with the
& essential
about follow-up care family or
information
other
Reviewing and Modifying the NCP support
after drawing conclusions about the status of the systems
patient’s problems, the nurse modifies the care plan as
• Essential to
indicated.
the patient’s • Resist the
Whether or not goals were met, there are several
ongoing care temptation
decisions to make about continuing, modifying, or
T in order to to leave
terminating nursing care for each problem.
Timely reflect a documentat
clear record ion until the
DOCUMENTATION
of what has end of shift
What?
happened
Any written or electronically generated information
about a patient’s:
- Status
- Care of services DATA PRIVACY ACT OF 2012 (DPA)
Why?
RA 10173
Philippines - Data Protection Overview | Guidance Note - Using the license of other person (command
| Data Guidance. September 2020. responsibility)
- September 8, 2012 – DPA enforced - Giving false documents to obtain license.
- Health information is considered sensitive - Using suspended/revoked/expired license.
personal information that requires a higher level (Renewal of license takes place every 3 years on
of data protection your birth month)
- Personal Data – all types of personal information - Falsely Posing/Advertising a Nurse
- Personal Information – any information; - Appending BSN, RN without having conferred
• recorded in a material form or not, from yet.
which the identity of an individual is - Assisting a person in an unlawful practice.
apparent
• When put together with other information LICENSE
would directly & certainly identify and - This is to show the responsibility of the nurse.
individual PRIMARY PURPOSE: to protect the public.
- Sensitive Data – sensitive personal information - It can also be used for research.
under the act - It is also used for monitoring performances.
- Privileged Information - Any & all forms of data
that constitute privileged communication WHO GIVE THE LICENSE?
• Information between health provider & - PR-BON (Professional Regulatory-Board of
a patient client & lawyer Nursing)/ BON/ PRC- the one making the
- Sanctions – administrative, civil and criminal questions for NLE.
liabilities
REVOCATION & SUSPENSION OF LICENSE
Personal Information - Both of this case, you cannot practice your
- Race - Philosophical beliefs profession.
- Ethnic origin - Health - Revocation- confiscation of license by PR-BON
- Marital status - Education can be temporary or permanent. The common
- Age - Genetic or Sexual life way to get back the license is a proof of changed
- Color - Any alleged/ man.
- Religion committed offense - Suspension- no confiscation of license, usually a
- Political affiliations maximum of 4 years.

LEGAL REMEDY FOR LICENSE

Re-Issuance of License
NCM118A: Care of Clients with Life- - Applicable on the revocation of license.
Threatening Conditions, Acutely Ill / Multi- - No changing of ID number.
Organ Problems, High Acuity, and Replacement of License
- Lost, mutilated license
Emergency Situation - Report it immediately to PRC.
Sources: PPT of the reporters
- Changing of ID Number

RA 9173 (Philippine Nursing Act PR-BON (Professional Regulatory- Board of Nursing)/

BON/ PRC
of 2002) Remember that:
GROUP 1 - Hon. Elsie A. Tee (current BON Chairperson)
- Consist of a chairperson + 6 members
- Scope of Nursing Practice and Standards of Nursing - BON Term = 3 years
Practice. - Maximum of 2 terms (6 years)
- Minimum parameter governing the thing of what - If a member of the BON will be reappointed,
will you does in the practice. how many years will be the BON serve? 3
years.
PROHIBITION OF RA 9173
- Fine/Civil Liability= 50,000-100,000 Qualifications of BON (RN-MAN):
- Imprisonment/Criminal Liability = 1-6years Remember: RNMAN
- Practicing the profession without license. R- Registered Nurse + Master’s Degree (Chairperson:
Masters in Nursing)
N- Natural Born Filipino- citizenship: (Jus Soli- place of Clinical 3 years of 1 year
birth, Jus Sanguinis- parental lineage. Instructor experience experience
- Naturalized FIlipino- refers to foreigner who (specialty area) (specialty
chooses to become a Filipino area)
M- Member of APO (Accredited Professional
Organization) - Philippine Nurse’s Association. PATIENT’S BILL OF RIGHTS
Qualifications of BON (RN-MAN): - A guide to ensure every patient gets good,
- Founded by: Anastacia Giron-Tupaz on quality health care
October 22, 1922. Every 3rd Week of - Contains rules that healthcare providers should
October is Nurse’s Week. observe toward the patient and their families
- First President of PNA: Rosario Delgado during hospitalization
- First Male President: Marco Antonio Sto. - Not legally binding
Tomas (introduces midwifery nursing) - Provide goals and expectations for patient
A- At least 10 years of continuous nursing experience treatment
provided that the last 5 years must be in the Philippines
(for the purpose of familiarity of the set-up) 1. Right to Appropriate Medical Care & Humane
N- Not convicted in any offense in any “moral turpitude” Treatment
or “crime” - Human dignity
- Convictions
Process of Appointment for BON - Integrity
Regular Appointment- includes three (3) phrases - Individual needs
- Nomination- PNA (3 candidates/vacancy) - Culture
Recommendation- PRC (2 candidates/vacancy) - Informed of reason for the delay in treatment
- Appointment- President/Chief Executive - Immediate care during emergencies
o (1 candidate/vacancy)
- Ad Interim- filling-in/ assumption of function in 2. Right to Informed Consent
the absence of an appointed BON. Primary - Clear, truthful explanation, except in the
reason when someone is temporarily cannot following cases: Emergency situations
handle duties. - Health of the population
- Doctrine of Holder- continued assumption of - Mandated by Law Minor, legally incompetent
function despite of expired term or the - Success of the treatment is in jeopardy
extension of duty. - Patient waives right in written form

RA 7164 vs. RA 9173 Rights of Unconscious Patient

RA 7164 RA 9173 Informed consent must be obtained whenever possible,
High School Upper 40% of the Highschool from a legally entitled representative however.
Requirements graduating class graduate, - When medical intervention is urgently needed,
passed the Consent of the patient may be presumed,
entrance and - unless; it is obvious beyond any doubt (DNR)
aptitude exam
NLE Maximum of 3 Unlimited 3. Right to Privacy & Confidentiality
takes, Exceptions:
if still fail, he/she A. Patient’s mental or physical condition is in controversy
should take as directed by the appropriate court
refresher B. Healthcare providers:
course. (4th years - Benefit the public & safety
subjects/ - Interest of justice & upon order of a competent
competency court
appraisal) - Patient waives in writing
License Can get only No age for - Needed for continued medical treatment or
license when license, the medical advancement
reaching 21 years important is C. Spouse/family upon patient’s decision
old you passed
the board 4. Right to Information
exam - Results of the evaluation
 - Additional or further contemplated 9. Right to Leave
medical/surgical treatment Right to leave the hospital regardless of physical
- Changes in the plan of care prior to its condition provided;
implementation A. Informed of the medical consequences
- Extent of what Philhealth/other payor may B. Releases those involved from any obligation
shoulder the payment Itemized bill of relative to the consequences
hospitalization C. Will not prejudice public health & safety
- Continuing care requirements following
discharge 10. Right to Refuse Participation in Medical Research
- Brief, written summary of the course of illness - Right to be advised if the health care provider
- Medical certificate free of charge plans to involve him in medical research,
including but not limited to human
5. Right to Choose Health Care Provider & Facility experimentation which may be performed only
Exceptions: with the written informed consent of the patient
A. Under the care of service facility
B. Public health & safety 11. Right to Correspondence & to Receive Visitors
C. Patient waives in written form - Subject to reasonable limits prescribed by the
- Right to discuss illness condition with a rules & regulations of the health care institution
consultant/specialist
- Right to seek for a second opinion & 12. Right to Express Grievances
subsequent opinions - The patient has the right to express complaints
and grievances about the care and services
6. Right to Self-Determination received without fear of discrimination or
- Right to avail any recommended diagnostic reprisal and to know about the disposition of
& treatment procedures such complaints. Such a system shall afford all
- Make an advance written directive for parties concerned with the opportunity to settle
physicians to administer when in the amicably all grievances.
terminal
- Phase of a terminal illness; provided that: The Critical Nurse as Patients’ Advocate
A. Knowledgeable of the consequences Definition:
B. Releases those involved in care from any - A nurse advocate is one who works on behalf of
obligation relative to the consequences the patients to: Maintain quality of care and
C. Decision will not prejudice public health Protect Patient's Rights.
& safety - A nurse advocate intervenes when there is a
care concern.
7. Right to Religious Belief - Following the proper channels, the nurse works
Right to refuse medical treatment or procedures to resolve any patient care issues.
which may be contrary to religious beliefs, provided;
A. Not imposed by parents of children in a life- Advocacy : Nurses are Ideal Patient Advocates
threatening situation as determined by - An essential part of nursing
attending physician/medical director - Interact with patients daily
- Awareness of patients’ frustration and
8. Right to Medical Records confusion
- Right to a summary of the medical history & - Patients rely on nurses not only to provide care
condition. but also to counsel and educate
- View the contents of the medical records,
except: The Nurse’s Role:
o Third parties: Psychiatric notes & - Supports the best interests while respecting the
other incriminatory information family’s important role
- The health care institution shall safeguard - Attends to health care team meetings with
the confidentiality, ensure the integrity & patient and family
authenticity of the medical records; & keep - Help patient’s make informed decisions
them as determined by DOH regarding their health to include navigating a
- Document will be available within 45 days complex medical system by:
from request • Translating medical terms
• Help make ethical decisions
 - Being in the company of close family and/or
Patient Advocacy friends.’
Example: - In relation to ICUs, the aforementioned ‘good
- Nurses can act as mediators between patients death’ could be defined as when a patient is
and doctors who may have overlooked certain calm, in a private room and in the company of
patient needs or solutions. relatives (Fridh et al, 2009).
- If a patient receives an inaccurate diagnosis,
unsafe accommodation, or unclear instructions Patricia Benner's conceptual model of advocacy
for self-care, the nurse must alert the doctor or behaviors in end-of-life nursing provides the framework
medical facility and communicate the issue. in which nurses can become effective patient
advocates. Developing active listening and effective
Effective Advocacy: communication skills can enhance the nurse-patient
- Suspend Judgment trust relationship and create a healing environment.
- Practice Communication Skills
- Stay Informed The role of advocacy in critical care nursing: A caring
response to another
END OF LIFE CARE The themes uncovered in the analysis describe
ICU Nurse as Patient’s Advocate the nurse's role of advocacy as: to build a caring
- End-of-life nursing encompasses many aspects relationship, to carry out a commitment, to empower,
of care: pain and symptom management, to make room for and interconnect, to be a risk-taker,
culturally sensitive practices, assisting patients to be a moral agent and to create a trusting atmosphere
- and their families through the death and dying conducive to recovery. The meaning of the role of
process, and ethical decisionmaking. advocacy lies in a moral and existential response to
- Regarding end of life care in ICU, nursing another human being, an expression of caring.
advocacy include pain and symptom Advocacy rests on the patient-nurse relationship and
management, ethical decision making, caring occurs as an outspoken demand of another human
based on patients" culture, and assistance being whose autonomy is threatened.
during the death and the dying process (Hebert
et al., 2011). PALLIATIVE CARE
- Is the interdisciplinary specialty focused on
What is patient advocacy? improving quality of life for persons with serious
- Preserving Human Dignity illness and their families.
- Patient Equality - The World Health Organization (WHO) defines
- Freedom from suffering palliative care as ‘an approach that improves the
quality of life of patients and their families facing
How to be an advocate? the problems associated with life-threatening
- Helping patients make informed decisions illness, through the prevention and relief of
- Making Patients a priority suffering by means of early identification and
- Being a resource impeccable assessment and treatment of pain
and other problems, physical, psychosocial, and
Goals of End-of-Life Care spiritual’
- Prevent or relieve suffering
- Provide comfort and support Palliative Cares/Actions
- Maintain human dignity Defined as therapeutic measures, without curative
- Respect patient’s wishes and desires intention aimed to reduce negative impacts of the
- Improve quality of life disease on the patient’s well-being.
- Provide emotional support
Fundamental Principles
End of Life Care Strategy - Accept death as a natural end-of-life process
The DH's (2008) End of Life Care Strategy states that - Always give priority to the patient’s best interest
‘although every individual may have a different idea - Reject futility: diagnostic and therapeutic
about what would, for them, constitute a ‘good death’, - Do not shorten life nor prolong the process of
for many this would involve: dying
- Being treated as an individual, with dignity and - Warrant the quality of life and of death
respect Being without pain and other symptoms - Relieve pain and other associated symptoms
- Being in familiar surroundings
 - Heed the clinical, psychological, social, spiritual administering medications or collecting lab
aspects of patients and relatives specimen.
- Respect the patient’s autonomy and of the legal
representatives Critical Test Results
- Assess the cost-benefit of each medical attitude - Patients in the ICU are not very stable so slight
taken deviation from the normal range could lead to a
- Encourage interdisciplinarity as an assistential potentially life-threatening response from the
practice patient, thus the nurse should report and
abnormal results.
Palliative Actions in The Intensive Care Unit
- Planning and action Clinical Alarms
- Control symptoms and purveyance of the - Clinical alarm systems are intended to alert
patient’s comfort caregivers of potential patient emergencies, but
- Aim the patient’s well-being and not maleficence when improperly configured they can
compromise patient safety. Critical care units
Symptoms Management have numerous clinical alarms, and the resulting
- Opioids are still the main option for pain noise and visual warnings can desensitize staff
management in critically ill patients. and cause them to miss or ignore these alarms.
- Dyspnea is treated by optimizing the treatment The nurse should pay attention to these alarms
of the underlying disease, such as using diuretics intently.
and inotropic agents for heart failure, providing
intravenous hydration suspension, and offering Responding to Adverse Reactions/ Events
non-drug therapy use. - In case of adverse events, the nurse should be
- Opioids are the drugs of choice for dyspnea at prepared to react quickly and accurately because
the end-of- life in an emergency situation time is of the essence.
- Use of anxiolytics can be useful for reducing - In case of adverse events, the nurse should be
dyspnea’s anxiety component prepared to react quickly and accurately because
- Oxygen is considered for patients with in an emergency situation time is of the essence.
hypoxemia
Teamwork
Communication in the Intensive Care Unit - Working in the ICU is a high-risk environment
- In the ICU, communication is a process involving because small errors could cost a patient’s life, in
perception of the environment and of the work such environment it is important for the nurse to
climate, including non–verbal communication by have trust in his/her coworkers, to trust when
the multi-professional team, even the they offer assistance when needed. The
interaction physician/patient and relatives. healthcare team has to be respectful,
- The communication process in the ICU involves trustworthy and feel comfortable speaking up
the patient, relatives or any person with when they notice something’s wrong.
affective nearness, physicians, nurses,
psychologists, clergies and other members of the
multi-professional team.

SAFE PRACTICE IN ICU

Patient Safety Regulations
- The hospital sets guidelines to help ensure
patient safety, included in those guidelines are
proper patient identification, timely response to
critical test, and the appropriate use of clinical
alarms/alerts. In critical care units, patients are
covered with respirators, tubes and cannulas,
which could make patients looks similar.

Patient Identification
- To prevent errors, nurses should use at least 2
patient identifiers to prevent mishaps when
Nursing Care of the Clients with Altered - Note for the quality of the respirations
- Observe for Central Cyanosis, Peripheral Edema
Ventilatory Function
and neck vein engorgement
GROUP 2
- Observe for the Hallmark signs and symptoms

ACUTE AND CHRONIC Diagnostic Tests:

- Spirometry
PULMONARY - ABG Analysis
DISEASE - CT Scan

Nursing Diagnoses
- Impaired gas exchange and ineffective airway
clearance due to chronic inhalation of toxins.
- Impaired gas exchange related to ventilation-
perfusion inequity
- Ineffective breathing pattern related to
shortness of breath, mucus,
bronchoconstriction, and airway irritants

PLANNING for Health Restoration and Maintenance

Promote Proper Airway Clearance
- Initiate O2 Therapy
- Proper Position to aid lung expansion
- Strict Pharmacotherapy
- Limit exposure to triggers and causes Prevent
Exacerbation
- Strictly follow treatment regimen
ASSESSMENT - Limit exposures to triggers
SUBJECTIVE AND OBJECTIVE DATA Risk Reduction
Causes: - Environmental Exposure is a major risk factor
- Obstructions in the Parenchyma associated with COPD.
- Infections - Totally modifiable

Risk Factors: IMPLEMENTATION

- Allergens (Dust, Pollens, Pesticides) Management:
- Airway Irritants (Smocking, Fumes) O2 Therapy
- Infections - To prevent acute dyspnea during exacerbations.
- Weather Changes - To increase the baseline resting partial pressure
- Genetic Susceptibility (Alpha-1 Antitrypsin of arterial oxygen (PaO2) to at least 60 mm hg at
Deficiency) sea level and arterial oxygen saturation (SaO2) to
at least 90%.
Signs and Symptoms: - Long term oxygen therapy (More than 15 hours
- Cough (At least 3 months in each of 2 per day) is usually introduced in very severe
consecutive years) COPD.
- Sputum Production (At least 3 months in each of
2 Pharmacologic Treatment:
- consecutive years) Medications to manage COPD are based on the
- Dyspnea disease severity.
- Wheezing • Grade 1 – Short Acting Bronchodilators
- Decrease or loss of Breath Sounds • Grade 2 and 3 – Short Acting Bronchodilators
- Hypoxia and one or more Long -acting Bronchodilators.
• Grade 3 or 4 – Regular treatment of
Physical Examination:
Bronchodilators and Inhaled Corticosteroids
- Observe for patient’s assumed position
Other medications
- Take the Pulse and Respiratory Rate
- Alpha1 -Antitrypsin Augmentation Therapy
- Take the Patients History
 - Antibiotic Agents - Chest pain
- Mucolytic Agents - Cough
- Vaccines (Influenza and pneumococcal) - Rapid or irregular heartbeat
- Dizziness
Surgical Management: - Excessive sweating
- Bullectomy - Fever
- Lung Volume Reduction Surgery - Leg pain or swelling, or both, usually in the calf
- Lung Transplantation - caused by a deep vein thrombosis
- Clammy or discolored skin (cyanosis)
Other Treatments:
- Fluids Physical examination
- Pulmonary Rehabilitation - Vital signs
- Positioning - Neck- Jugular venous distension may be seen in
- cases of massive pulmonary embolism.
CLIENT EDUCATION / HEALTH TEACHING - Auscultation
- Breathing Exercises - Extremities- signs of deep vein thrombosis may
- Activity Pacing be
- Self-care Activities - present among patients with PE
- Physical Conditioning
Diagnostic Findings
- Chest x-ray
PULMONARY EMBOLISM - ECG
- ABG
- Pulmonary angiogram
- V/Q scan

Nursing Diagnoses
- Impaired gas exchange may be related to
decreased lung perfusion caused by the
obstruction of pulmonary arterial blood flow by
the embolus as evidenced by desaturation
(oxygen saturation below 90%)
- Ineffective breathing pattern may be related to
chest pain as evidenced by abnormal arterial
blood gasses
- Acute pain: Chest may be related to lung
infarction

PLANNING for Health Restoration and Maintenance

ASSESSMENT - Reduce the symptoms
SUBJECTIVE AND OBJECTIVE DATA - Prevent death
Causes of Pulmonary embolism - Reduce the risk of developing chronic
- Family history - pulmonary hypertension
- Heart disease - Prevent recurrence
- Cancer
- Surgery IMPLEMENTATION
- Covid-19 Medical Management
- Nasal oxygen is administered immediately to
Risk factors relieve hypoxemia, respiratory distress, and
- Smoking central cyanosis.
- Being overweight - IV infusion lines are inserted to establish routes
- Supplemental estrogen for medications or fluids that will be needed.
- Pregnancy Anticoagulation Therapy
- Anticoagulant therapy (heparin, warfarin sodium
Signs and Symptoms [Coumadin]) has traditionally been the primary
- Shortness of breath method for managing acute DVT and PE
 (numerous specific options for treatment are - Severe infection
available). - Massive blood transfusion
Thrombolytic Therapy - Pneumonia
- Thrombolytic therapy may include urokinase, - Severe inflammation of the pancreas
streptokinase, and alteplase. It is reserved for PE (pancreatitis)
affecting a significant area and causing - Overdoses of alcohol or certain drugs (e.g.,
hemodynamic instability. aspirin, cocaine, opioids, phenothiazines, and
Surgical Management tricyclic antidepressants)
- A surgical embolectomy is rarely performed but - Lung and bone marrow transplantation–within
may be indicated if the patient has a massive PE few days of a lung transplant, the recipient is
or hemodynamic instability or if there are prone to development of ARDS
contraindications to thrombolytic therapy.
Initial signs and symptoms:
CLIENT EDUCATION / HEALTH TEACHING - Rapid, shallow breathing
- Advise patient to continue wearing - Dyspnea
antiembolism stockings as long as directed.
- Instruct patient to avoid laxatives, which affect Progressive signs and symptoms:
vitamin K absorption (vitamin K promotes - Hypoxemia
coagulation). - Crackles
- Recommend that patient change position - Rhonchi
regularly when traveling, walk occasionally, and - Restlessness
do active exercises of legs and ankles. - Mental sluggishness
- Advise patient to drink plenty of liquids. - Motor dysfunction
- Teach patient to report dark, tarry stools
immediately. Diagnostic Tests
- Recommend that patient wear identification - Chest x-ray
stating that he or she is taking anticoagulants. - Blood tests
- Laboratory exam
- Echocardiogram
- Bronchoscopy
ACUTE RESPIRATORY DISTRESS - Open lung biopsy
SYNDROME (ARDS)
Nursing Diagnoses
- Impaired Gas Exchange
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Anxiety

PLANNING FOR HEALTH RESTORATION AND

MAINTENANCE

ASSESSMENT
SUBJECTIVE AND OBJECTIVE DATA
Causes:
Direct injury to the lungs:
- Chest trauma, such as a heavy blow
- Breathing vomit
- Breathing smoke, chemicals, or salt water
- Burns

Injury to the lungs:

 ASSESSMENT
SUBJECTIVE AND OBJECTIVE DATA
Causes/Nursing History
- Asthma
- COPD
IMPLEMENTATION
- Atelectasis
Medical Management:
- Fluid in lungs
- Ventilatory Support.
- Breathing muscle problems
- Prone Positioning.
- Sedation and medications to prevent
Risk Factors
movement.
- Age
- Fluid management.
- Lifestyle habits
- Environment
CLIENT EDUCATION / HEALTH TEACHING
- Occupation
Teaching Patient Self-Care:
- Avoid germs.
Signs and Symptoms
- Ask about vaccines.
- DOB
- Eat healthy foods.
- Coughing of mucus
- Do not smoke.
- Wheezing
- Eat healthy foods.
- Fatigue
- Limit or do not drink alcohol as directed.
- Daily headache
- Talk to your health care provider about
- Anxiety
depression and follow up visitation.
- Confusion
- Improve breathing by
• Pulmonary rehabilition, if directed
Physical Examination
• Breathing exercises
- Check for bluish color
• Elevate upper body
- Listen to heart and lung sounds
• Exercise as directed - Get vital signs
- Take medication on time - Measure blood

DIAGNOSTIC TESTS
RESPIRATORY FAILURE - ABG (Arterial Blood Gas)
- Blood tests
- Bacterial cultures
- Bronchoscopy
- CT scan
- EKG/ECG
- Echocardiography
- Lung biopsy
- Pulmonary function test

Nursing Diagnoses
- Ineffective airway clearance may be related to:
Increased production or retained pulmonary
secretion possibly evidenced by: wheezing,
DOB, changes in depth of respiration
 - Impaired gas exchange may be related to: Nursing Care of the Clients with Altered
altered delivery of O2, air trapping possibly
Ventilatory Function
evidenced by: dyspnea, restlessness, reduced
GROUP 3
tolerance for activities, cyanosis, changes in
ABGs and VS
- Anxiety may be related to: perceived threat of PNEUMONIA
death possibly evidenced by: apprehension, Pneumonia is an acute inflammation of the lung
fearful expression, extraneous movement parenchyma that is caused by an infectious agent that
can lead to alveolar consolidation.
PLANNING for Health Restoration and Maintenance
- Client positioning COMMUNITY-ACQUIRED PNEUMONIA
- Preventing desaturation Pathogens that can cause CAP includes:
- Promoting secretion clearance - Streptococcus pneumoniae
- Health teaching - Legionella species
- Optimizing oxygenation and ventilation - Pseudomonas aeruginosa
- preventing atelectasis - Mycoplasma pneumoniae
- Chlamydia pneumoniae
IMPLEMENTATION - Haemophilus influenzae
Management
1. Oxygen therapy Other Risk Factors:
2. Pharmacologic treatment - Alcoholism
- Antibiotics - Chronic Obstructive Pulmonary Disease
- Bronchodilators - Diabetes
- Corticosteroids - Coronary Artery Disease
3. Other treatments - Impaired Swallowing
- Fluids - Altered Mental Status
- Nutritional support
- Physical therapy VENTILATORY-ACQUIRED PNEUMONIA
- Positioning - The presence of tracheostomy tubes,
endotracheal tubes, nasogastric tubes, poor GI
CLIENT EDUCATION / HEALTH TEACHING motility, gastric distention, and immobility.
- Deep coughing - Treatments that neutralize the normally acidic
- Huff coughing gastric contents, such as antacids, H2 blockers,
- Self-drainage or autogenic drainage proton-pump inhibitors, or tube feeding
- Active cycle of breathing therapy (ACBT)
- Physical exercise PATHOGENESIS
- Dietary intake Aspiration Devices
- Positioning - Invasive Devices
- Oropharyngeal Colds
- Position (supine); immobilized
- Decreased LOC
Inhalation
- Respiratory treatment equipment
- Anesthesia
- Contaminated water or medications
Hematogenous Spread
Host Factors
- Extreme ages
- Chronic Diseases (CP, AIDS)
- Immunocompromised State (Steroid,
AIDS, transplantation)

ASSESSMENT
Signs and Symptoms
- Fever
 - Cough, typically productive - Activity intolerance related to impaired
- Purulent sputum or hemoptysis respiratory function as evidenced by weakness,
- Dyspnea fatigue and tachycardia in response to activity
- Pleuritic chest pain
- Tachypnea PLANNING
- Abnormal breath sounds (crackles, bronchial - Improve airway patency.
breath sounds) - Rest to conserve energy.
- Maintenance of proper fluid volume.
• Assess respiratory symptoms. Symptoms of - Maintenance of adequate nutrition.
fever, chills, or night sweats in a patient should - Understanding of treatment protocol and
be reported immediately to the nurse as these preventive measures.
can be signs of bacterial pneumonia. - Absence of complications.
• Assess clinical manifestations. Respiratory
assessment should further identify clinical IMPLEMENTATION
manifestations such as pleuritic pain, Intervention Rationale
bradycardia, tachypnea, and fatigue, use of Elevate HOB, change Doing so would lower the
accessory muscles for breathing, coughing, and position frequently. diaphragm
purulent sputum. and promote chest
• Physical assessment. Assess the changes in expansion, aeration
temperature and pulse; amount, odor, and color of lung segments,
of secretions; frequency and severity of cough; mobilization, and
degree of tachypnea or shortness of breath; and expectoration of
changes in the chest x-ray findings. secretions.
• Assessment in elderly patients. Assess elderly Suction as indicated: Stimulates cough or
patients for altered mental status, dehydration, frequent coughing, mechanically clears
unusual behavior, excessive fatigue, and adventitious breath airway in a patient who
concomitant heart failure. sounds, desaturation cannot do so because of
related to airway ineffective cough or
DIAGNOSTIC EXAM secretions. decreased level of
Gram Stain and Culture of Sputum consciousness.
- Gram stain and culture of sputum for causative Note: Suctioning can
organisms. May require fiberoptic bronchoscopy cause increased
with brush specimen or bronchoalveolar lavage hypoxemia; hyper
specimen retrieval in situations where oxygenate before, during,
pneumonia responds poorly to empiric and after suctioning.
treatment. This may also be necessary early in Teach and assist the 3.1. Deep breathing
admission in patients who are patient with proper deep- exercises facilitates
immunocompromised, and susceptible to breathing exercises. maximum expansion of
opportunistic organisms that require very Demonstrate proper the lungs and smaller
specific antibiotic coverage. splinting of the chest and airways, and improves
Chest X-Ray effective coughing while the productivity of cough.
- New or progressive in an upright position. 3.2. Coughing is a reflex
- infiltrates on chest x-ray. Encourage patient to do and a natural self-
- Infiltrates may be either localized or diffuse in so often. cleaning mechanism that
nature. assists the cilia to
Others maintain patent airways.
- Elevated WBC – indicates infection It is the most helpful way
- Abnormal arterial blood gases (hypoxemia, to remove most
hypocapnia). secretions.
3.3. Splinting reduces
NURSING DIAGNOSES chest discomfort and an
- Ineffective airway clearance related to copious upright position favors
tracheobronchial secretions as evidenced by deeper and more forceful
abnormal breath sounds, dyspnea cough with or cough effort making it
without sputum production or hypoxemia more effective.
 Maintain adequate Fluids, especially warm - Hydration. Hydration is an important part of the
hydration by forcing liquids, aid in the regimen because fever and tachypnea may
fluids to at least 3000 mobilization and result in insensible fluid losses.
mL/day unlessexpectoration of - Administration of antipyretics. Antipyretics are
contraindicated (e.g.,
secretions. Fluids help used to treat fever and headache (Ibuprofen)
heart failure). Offer maintain hydration and (Ibuprofen)
warm, rather than cold, increases ciliary action to - Administration of antitussives. Antitussives are
fluids. remove secretions, and used for treatment of the associated cough
reduces the viscosity of (bromhexine, ambroxol, neltenexine)
secretions. Thinner - Bed rest. Complete rest is prescribed until signs
secretions are easier to of infection are diminished.
cough out. - Oxygen administration. Oxygen can be given if
Encourage ambulation. Helps mobilize secretions hypoxemia develops.
and reduces atelectasis. - Pulse oximetry. Pulse oximetry is used to
Assist and monitor effects 6.4. Chest percussion determine the need for oxygen and to evaluate
of nebulizer treatment helps loosen and mobilize the effectiveness of the therapy.
and another respiratory secretions in smaller - Aggressive respiratory measures. Other
physiotherapy: incentive airways that cannot be measures include administration of high
spirometer, IPPB, removed by coughing or concentrations of oxygen, endotracheal
percussion, postural suctioning. intubation, and mechanical ventilation.
drainage. Perform 6.5. Coordination of
treatments between treatments and oral EVALUATION
meals and limit fluids intake reduces likelihood Expected patient outcomes include the following:
when appropriate. of vomiting with - Demonstrates improved airway patency.
coughing, expectorations. - Rests and conserves energy by limiting activities
Administer medications, Mucolytics increase or and remaining in bed while symptomatic and
as indicated: liquefy respiratory then slowly increasing activities.
secretions. - Maintains adequate hydration.
Expectorants increase - Consumes adequate dietary intake.
productive cough to clear - States explanation for management strategies.
the airways. They liquefy - Complies with management strategies.
lower respiratory tract - Exhibits no complications.
secretions by reducing its - Complies with treatment protocol and
viscosity. prevention strategies.
Bronchodilators are CLIENT EDUCATION
medications used to - Oral antibiotics. Teach the patient about the
facilitate respiration by proper administration, potential side effects,
dilating the airways. and symptoms to report.
Analgesics are given to - Breathing exercises. Teach the patient breathing
improve cough effort by exercises to promote secretion clearance and
reducing discomfort, but volume expansion.
should be used cautiously - Follow-up check-up. Strict compliance to follow-
because they can up checkups is important to check the latest
decrease cough effort chest x-ray result or physical examination
and depress respirations. findings.
- Smoking cessation. Smoking should be stopped
Other Managements: because it inhibits tracheobronchial ciliary action
- Blood culture. Blood culture is performed for and irritates the mucous cells of the bronchi.
identification of the causal pathogen and prompt
administration of antibiotics in patients in whom RESPIRATORY PANDEMIC
CAP is strongly suspected .
PANDEMIC
- Administration of macrolides. Macrolides are
A disease outbreak that spans to several countries and
recommended for people with drug drug-
affects large number of people. Most often caused by
resistant resistant S. pneumoniae (Azithromycin,
viruses which easily spreads from person to person.
erythromycin)
INFECTIOUS RESPIRATORY DISORDERS
disease conditions that associates with alteration of
normal function of the lungs caused by infectious
microorganism such as viruses, bacteria, or fungi.

RESPIRATORY PANDEMIC
An outbreak of respiratory disease condition usually of
viral origin that results to a mass infection, infection,
spread a large of people globally affecting several
countries.
- Influenza A (H1N1)
- Severe acute respiratory syndrome (SARS)
- Middle east respiratory syndrome (MERS)
- COVID-19 (Corona virus disease 2019)

CHAIN OF INFECTION SEVERE ACUTE RESPIRATORY

A. Susceptible Host
B. Infectious Agent SYNDROME (SARS)
C. Reservoir SARS a viral respiratory illness caused by a SARS-
D. Portal of Exit associated coronavirus. It is an airborne virus and can
E. Mode of Transmission spread through small droplets of saliva in a similar way
F. Portal of Entry to the cold and influenza.

INFLUENZA SARS COV2 (COVID 19 DISEASE)

Influenza is an acute contagious respiratory disease in A new strain of corona virus that causes a disease in the
viral origin. Influenza viruses are recognized into three respiratory tract that ranges from mild common cold to
types: A, Band C. more severe disease. The mechanism of transmission is
similar to SARS, via airborne to respiratory droplets.
TYPES OF INFLUENZA
A. can be further classified into serotypes which PATHOPHYSIOLOGY
numbered N0N1, H1N1, H2N2, H3N2 Process
B. no strain specific variations, has a lot of cross- 1. Animal Reservoir
relationship between the strains but are not 2. Animal to human transmission
numbered 3. Human to human transmission
C. not prevalent and serotypes are not defined. a. Droplet transmission
b. Respiratory tract mucosa
PATHOPHYSIOLOGY c. Binding
d. Proliferation of the virus in the epithelial
cells
e. Incubation of 2-10 days

Phases
1. Viral replication
2. Inflammatory pneumonitis
3. Pulmonary fibrosis

MIDDLE EAST RESPIRATORY

SYNDROME (MERS)
Viral respiratory disease caused by a recognized
coronavirus that first recognized in Saudi Arabia (2012).
The virus is strongly linked to camels as its reservoir. The
disease results to an upper to lower respiratory infection.
It can be of mild cases to severe as ARDS (acute
respiratory distress syndrome)
 - Cough
- Tiredness
Early symptoms of SARS-COV-2:
- Loss of taste
Other symptoms can include:
- Shortness of breath or difficulty of breathing
- Muscles aches
- Sore throat
- Runny nose
- Headache
- Chest pain
- Conjunctivitis
- Nausea
- Vomiting
ASSESSMENT - Diarrhea
INFLUENZA - Rash
Patients manifest the following signs and symptoms:
- Fever and chills MIDDLE EAST RESPIRATORY SYNDROME (MERS)
- Cough Common signs and symptoms include:
- Sore throat - Fever
- Congested eyes - Chills/rigor
- Myalgia - Headache
- Shortness of breath - Non-productive cough
- Weight loss - Dyspnea
- Sneezing - Myalgia
- Headache Other Signs and Symptoms:
- Rhinorrhea - Sore throat
- Coughing - Coryza
- Abdominal pain - Nausea
- Decreased appetite - Vomiting
- Fatigue - Dizziness
Emergency signs and symptoms in children - Progressive sputum
- Difficulty breathing - Diarrhea
- Cyanotic lips - Abdominal pain
- Chest pain
- Dehydration DIAGNOSTIC EXAM
- Severe muscle pain Pulse Oximeter
- Seizures - Oxygen saturation reveals significant decrease
- Worsening of existing medical conditions due to decreased inspired oxygen caused by
progressive pulmonary secretions.
SEVERE ACUTE RESPIRATORY SYNDROME (SARS) Arterial Blood Gas
SARS usually beings with Flu-like signs and symptoms: - Respiratory Alkalosis: elevated blood pH and
- Fever decreased partial pressure of oxygen.
- Chills Molecular RT PCR
- Muscle Aches Collected via nasopharyngeal, oropharyngeal swabs. For
- Headache patients under mechanical ventilation, collection is from
- Diarrhea (occasional) the lower respiratory tract via expectorated sputum and
After a week: bronchoalveolar lavage
- Fever of 38°C or higher - Result: presence of specific genetic material of
- Dry cough the pathogen that caused the disease.
- Shortness of breath Chest X-ray
- Bilateral multifocal alveolar opacities
SARS COV2 (COVID 19 DISEASE)
Signs and symptoms may appear 14 days after exposure. NURSING DIAGNOSES
Common signs and symptoms include: - Ineffective Airway Clearance related to Excessive
- Fever and Tenacious Secretions
 - Impaired Gas Exchange related to Ventilator expectorant, bronchospasm and
Perfusion Imbalance as manifested by low bronchodilators, and mobilization of
oxygen saturation and hypoxia. analgesics as ordered. secretions. Analgesics are
given to improve cough
PLANNING effort by reducing
For health restoration and maintenance discomfort.
- Client Positioning
- Preventing Desaturation Manage Oxygenation to Prevent Desaturation
- Promoting Secretin Clearance Oxygen is started with the arrival of the patient in the ER
- Patient Education and is administered according to the severity of the
- Optimizing Oxygenation and Ventilation presentation.
- Preventing Atelectasis
Type SpO2
IMPLEMENTATION Simple face mask or nasal 94 to 97%
Intervention Rationale cannula
Independent Venturi mask <94%; RR of >30/min
Assess rate and depth of Tachypnea, shallow Endotracheal and Mechanical Ventilator
respirations and chest respirations, and Indicated with lower tidal volumes (4 -8 mL/kg) and
movement. Monitor for asymmetric chest lower inspiratory pressures (plateau pressure <30 cm H
signs of respiratory failuremovement are present 20).
such as cyanosis and because of discomfort of
severe tachypnea. moving chest wall or fluid ECMO (Extracorporeal Membrane Oxygenation)
in the lungs. Patients with refractory hypoxemia despite ET and
Auscultate the lung fields, Decreased airflow Mechanical ventilation. Efficient support for refractory
note areas of decreased happens in consolidated hypoxemia, cardiogenic/septic shock unresponsive to
or absent airflow and regions with fluid. maximal therapy.
adventitious breath Crackles, rhonchi, and
sounds, such as crackles wheezes are heard on Adjunct Therapies
and wheezes. inspiration and expiration Antibiotics
in response to - Helps in preventing and management of
accumulation of secondary bacterial infections and sepsis
secretion. (azithromycin, doxycycline, clarithromycin,
Elevate HOB Keeping the head ceftriaxone, erythromycin, amoxicillin)
elevated lowers the Corticosteroids
diaphragm, it maximizes - Used for short period of time, usually 3-5 days
lung expansion, aeration for progressive deterioration of oxygen
of lung segments, and saturation, increased activation of the pro-
mobilization and inflammatory response and rapid worsening of
expectoration of features on chest imaging. (prednisone,
secretions for airway prednisolone)
clearance. Antiviral Drugs
If patient is conscious, Warm fluids aid in - Effective management to inhibit the
force warm fluids at least mobilization and proliferation of the viral causative agent that
2.5 L per day, unless expectoration of results to the disease. (remdesivir, lopinavir,
contraindicated secretions. oseltamivair)
Suction secretions as Stimulates cough or
indicated by oxygen mechanically clears CLIENT EDUCATION
desaturation related to airway in clients who is - Hand hygiene
airway secretions. unable to do so because - Cough and sneeze etiquette
of ineffective cough or - Maintain appropriate precautionary standards
decreased level of or measures
consciousness. - Sanitation and Disinfection
Dependent
Administer medicated Facilitates in the
such as mucolytics, reduction of
 Pulmonary function studies
PULMONARY HYPERTENSION - PaO2 is decreased, a normal or decreased vital
- A condition characterized by an increased
capacity and lung compliance
pressure in the pulmonary circulation – when
Ventilation–perfusion scan or pulmonary angiography
systolic pulmonary artery pressure exceeds 30
- Defects in pulmonary vasculature, such as
mmHg or the mean pulmonary artery pressure
pulmonary emboli.
exceeds 25 mmHg.
- Pulmonary hypertension can be caused by an
NURSING DIAGNOSES
elevation in the left atrial pressure, increased
- Decreased Cardiac Output related to Increased
pulmonary blood flow, or increased pulmonary
Pulmonary Venous Pressure and Increased
vascular resistance.
Pulmonary Vascular Resistance as Evidenced by
dyspnea, increased PVR substernal chest pain
ASSESSMENT
and right ventricular hypertrophy
Signs and Symptoms
- Impaired Gas Exchange related to pulmonary
- Dyspnea is the main symptom of pulmonary
edema as evidenced by dyspnea, hypoxia,
hypertension, occurring at first with exertion and
substernal chest pain and fatigue
eventually at rest
- Substernal chest pain
PLANNING
- Weakness
For health restoration and maintenance
- Fatigue
- Maintaining Cardiac Output
- Syncope
- Fluid Management
- Dizziness
- Optimizing Oxygenation
- Heart palpitations
- Client Positioning
- Occasional hemoptysis
- Patient Education
- Signs of right-sided heart failure (peripheral
edema, ascites, distended neck veins, liver
IMPLEMENTATION
engorgement, crackles, heart murmur)
Intervention Rationale
Assess the patient’s vital To assist in creating an
Risk Factors
signs (heart rate, blood accurate diagnosis and
- Certain drugs and toxins
pressure, body monitor effectiveness of
- Liver diseases, rheumatic disorders, lung
temperature and O2 medical treatment. The
conditions
saturation), urine combination of a low
- Certain heart diseases
production, central venous central venous O2
- Thromboembolic disease
pressure, central venous saturation (<60%) with
- Low-oxygen conditions
O2 saturation and blood rising lactate levels and
- Genetics
lactate levels. low or absent urine
production signals
Routine Blood Test
imminent right heart
- B -type Natriuretic Peptide
failure.
- Basic Metabolic Panel
Assess heart sounds via Heart murmur or gallop
- Complete Metabolic
auscultation. Observe for upon auscultation could
- Liver Function Tests
any signs of decreasing indicate pulmonary
- Complete Blood Count
peripheral tissue perfusion hypertension. The
such as slow capillary refill, presence of signs of
DIAGNOSTIC EXAMS
facial pallor, cyanosis, and decreasing peripheral
Right cardiac catheterization
cool, clammy skin. tissue perfusion indicate
- Confirmation of the diagnosis and gauging
deterioration of the
severity – elevated pulmonary arterial pressure
patient’s status which
Chest X-Ray
require immediate
- Enlargement of right ventricle and enlarged
referral to the physician
pulmonary arteries.
Administer supplemental To increase the oxygen
Electrocardiogram
oxygen, as prescribed. level or maintain
- Right ventricular hypertrophy, right axis
Discontinue if SPO2 level is saturation above 90%.
deviation, and tall peaked P waves in inferior
within the target range, and achieve an SpO2
leads, tall anterior R waves, and ST-segment
value within the target
depression and/or T-wave inversion anteriorly
or as ordered by the range. To minimize the Prostanoids and nitric
physician. Elevate the head RV’s afterload, hypoxia oxide - Intravenous
of the bed if the patient is and hypercarbia must prostanoids
short of breath. be avoided, and high (epoprostenol,
flow oxygen, if available, iloprost, treprostinil)
is an excellent therapy should be considered in
to that end. the critically ill patient.
Administer diuretics for More commonly, Prostanoids are
fluid management, as deterioration in RV powerful vasodilators.
ordered function is associated Inhaled nitric oxide (NO)
with the development can be an effective way
of of reducing RV
peripheral oedema. afterload.
Excess volume loading Inotropes - Inotropic
of therapy to improve TV
the right ventricle can contractility.
reduce RV contractility, (a) Dobutamine -
and posterior bowing of increase cardiac output
the interventricular (b) Milrinone - a
septum can lead to phosphodiesterase
underfilling of the left inhibitor
ventricle and further (c) Epinephrine -
reduction in cardiac increase cardiac output
output. and will not cause
Administer medications, as systemic vasodilation
ordered. Vasopressors
- Vasodilators Vasodilator - Lowers (a) Norepinephrine -
- Guancylate cyclase pulmonary blood universal first line agent
(GSC) stimulators pressure and may for shock in the
- Endothelin improve the pumping emergency department
receptor ability of the right side (b) Vasopressin - first
antagonist of the heart. line pressor in right
- Calcium channel GSC - Increases the level heart failure patients
blockers of nitric oxide which can (c) Phenylephrine –
- Anticoagulants relax the pulmonary essentially
(usually warfarin) arteries, thereby contraindicated due its
- Oral decreasing the pressure potent pulmonary
Phosphodiesterase Endothelin receptor vasoconstriction effects.
5 inhibitors (PDE5i) antagonist - Stops the
- Prostanoids and endothelin from Other Management
nitric oxide narrowing the arterial Pulmonary Artery Catheter
- Inotropes walls A pulmonary artery catheter is indicated for assessment
- Vasopressors Calcium channel of:
blockers - Relaxes the 1. Shock
muscles in the arterial 2. Cardiovascular function
walls 3. Pulmonary function
Anticoagulants (usually 4. Hemodynamic function peri, intra, post cardiac
warfarin) - Reduces the surgery
formation of blood clots 5. Fluid requirements and the effectiveness of
in the pulmonary therapy
arteries Pulmonary artery catheter insertion provides accurate
Oral Phosphodiesterase measurements of pulmonary pressures, pressures,
5 inhibitors (PDE5i) - cardiac output, and LA filling pressures.
Relaxes pulmonary Extracorporeal membrane oxygenation (ECMO)
smooth muscle cells - As a bridge to lung transplantation
Surgical interventions:
 - Atrial septostomy b. Iatrogenic
- Lung/Heart and Lung Organ Transplant - Accidental
- Intubation must be seen as an absolute last - Artificial
resort .
Causes
CLIENT EDUCATION The cause leads to the identification type of
I. Avoidance of activities that may exacerbate the pneumothorax.
condition 1. Rupture of a bleb. Spontaneous pneumothorax
- Restrict lifting, pushing, or shoving to less than may occur in an apparently healthy person in the
20 pounds absence of trauma due to the rupture of an air-
- Stop Cigarette Smoking filled bleb.
- Avoid or reduce alcohol intake 2. Blunt trauma. Blunt traumas like rib fractures
- High Altitude could cause traumatic pneumothorax.
II. Physical Activity 3. Invasive procedures. Traumatic pneumothorax
- Walking may occur during invasive thoracic procedures in
- More strenuous forms of aerobic exercise should which the pleura is inadvertently punctured .
not be done regularly. 4. Penetrating chest or abdominal trauma.
III. Infection prevention Traumas such as stab wounds or gunshot
- Influenza and pneumococcal vaccine wounds could cause traumatic pneumothorax.
IV. Genetic counselling
V. Lifestyle changes PATHOPHYSIOLOGY
a. Dietary changes Refer to the slides
o Eat foods that are high in Nutrients
(Potassium, CLINICAL MANIFESTATIONS
o Magnesium and Vitamins) - Pain
o Limit foods that contain refined sugar, - Minimal respiratory distress
saturated - Dyspnea
o fats, and cholesterol - Central cyanosis
o Eat foods that are high in fiber. - Chest expansion
o Limit sodium intake. - Breath sounds
o Monitor fluid intake. - Tracheal alignment
o Monitor weight.
b. Restrict lifting and pushing. ASSESSMENT
c. Stop smoking. - Tracheal alignment
d. Limit alcohol intake. - Expansion of the chest.
Special Situations - Breath sounds.
VI. Pregnancy - Percussion of the chest.
- High risk of mortality - Absent breath sounds on affected side
- Combined use of two (2) contraceptive methods - Cyanosis
VII. Elective Surgery - Decreased chest expansion unilaterally
- Dyspnea
- Hypotension
- Sharp chest pain
PNEUMOTHORAX - Subcutaneous emphysema as evidenced by
Pneumothorax occurs when air leaks into the space
crepitus on palpation
between your lung and chest wall. This air pushes on the
- Sucking sound with open chest wound
outside of your lung and makes it collapse. A
- Tachycardia
pneumothorax can be a complete lung collapse or a
- Tachypnea
collapse of only a portion of the lung.
- Tracheal deviation to the unaffected side with
tension pneumothorax
CLASSIFICATION OF PNEUMOTHORAX
Spontaneous
DIAGNOSTIC EXAMS
a. Primary Spontaneous
- Thoracic CT
b. Secondary Spontaneous
- Chest X-ray
Traumatic
- ABGs
a. Non-iatrogenic
- Thoracentesis
 - Hemoglobin development of
complications
MEDICAL MANAGEMENT (spontaneous rupture of
- Chest tube a bleb creating
- Maintain a closed chest drainage system a new pneumothorax).
- Monitor a chest tube for any kinks or bubbling Auscultate breath Breath sounds may be
- Autotransfusion sounds. diminished or absent in a
- Antibiotics lobe, lung segment, or
- Oxygen Therapy entire lung field
(unilateral).
SURGICAL MANAGEMENT Note chest excursion and Chest excursion is
If more than 1500 ml of blood is aspirated initially by position of the trachea unequal until lung re-
thoracentesis, the rule is to open the chest wall expands. Trachea
surgically. deviates away from the
- Thoracotomy. The chest wall is opened affected side with tension
surgically to remove the blood or air trapped in pneumothorax.
the pleural space. Assist patient with Supporting chest and
splinting painful area abdominal muscles
NURSING DIAGNOSIS when coughing, deep make coughing more
- Impaired gas exchange related to respiratory breathing. effective and less
distress as evidenced by labored respirations traumatic
Maintain a position of Promotes maximal
PLANNING comfort, usually with the inspiration; enhances
The goals for the patient include: head of bed elevated. lung expansion and
- Relief of pain. Turn to the affected side. ventilation in unaffected
- Adherence to the prescribed pharmacological Encourage patient to sit side
regimen. up as much as possible
- Establishment of a normal, effective respiratory Maintain a calm attitude, Maintain a calm attitude,
pattern as evidenced by the absence of cyanosis. assisting the patient to assisting the patient to
- Demonstration of increase in perfusion. “take control” by using “take control” by using
- Be relaxed and report anxiety is reduced to a slower and deeper slower and deeper
manageable level. respirations. respirations

IMPLEMENTATION EVALUATION
Intervention Rationale Expected patient outcomes include the following:
Determine etiology and Understanding the cause - Pain is relieved.
precipitating factors of lung collapse is - Adhered to prescribed pharmacological
(spontaneous collapse, necessary for proper regimen.
trauma, malignancy, chest tube placement and - Established a normal, effective respiratory
infection, a complication choice of other pattern as evidenced by absence of cyanosis.
of mechanical therapeutic measures. - Demonstrated increase in perfusion.
ventilation). - Patient is relaxed and reported anxiety is
Check out respiratory Respiratory distress and reduced to a manageable level
function, noting rapid orchanges in vital signs may
shallow respirations,
occur as a result of CLIENT EDUCATION
dyspnea, reports of “air physiological stress and Care of the patient at home should include:
hunger,” development of pain or may indicate the - Asepsis. The site of incision should be handled
cyanosis, changes in vital
development of shock aseptically to avoid occurrence of infection.
signs due to hypoxia or - Medications. Medications prescribed such as
hemorrhage. analgesics and antibiotics should be taken
Observe for synchronous Difficulty breathing religiously.
respiratory pattern when “with” ventilator and - Follow up. Follow up appointments should be
using a mechanical increasing airway attended to allow the physician to assess the
ventilator. Note changes pressures suggests surgical site and the state of your respiratory
in airway pressures. worsening of condition or system.
- Activity. Alternate rest and activities to avoid Nursing Care of the Clients with Altered
over exhaustion and difficulty in breathing
Tissue Perfusion
GROUP 4

ACUTE CORONARY SYNDROME

Acute Coronary Syndrome (ACS) formerly called
Ischemic heart disease.
- Acute coronary syndrome (ACS) is an umbrella
term for a situation where the blood supply to
the heart muscle is reduced or suddenly blocked,
producing a variety of clinical symptoms
compatible with myocardial ischemia, and
precipitating a medical emergency.
- The disorder is characterized by a narrowing of
coronary arteries due to atherosclerotic plaque,
damaging the internal linings of coronary
arteries.
- Hard plaque causes hardened arteries, whereas
soft plaque can cause formation of blood clots,
either of which can restrict blood flow.

TYPES OF ACS
Unstable Angina
- May be new onset of pain with exertion or at
rest, or acceleration in frequency, duration, or
intensity of chest pain.
- Occurs in no regular pattern, usually lasts longer
(15 minutes).
- ECG: ST-Segment depression and inverted T
waves. (not always detected)
- Cardiac biomarkers are not elevated

NSTEMI
- Pain and angina equivalents may be much the
same as in UA or may be of longer duration and
more intense.
- ECG: ST-Segment depression and inverted T
waves (which may persist after resolution of
ischemia and pain.)
- Cardiac biomarkers are elevated
- Involves less than full- thickness damage of heart
muscle.

STEMI
- Pain and angina longer duration and more
intense.
- ECG: ST- segment elevation in two adjoining
leads and abnormal Q waves that appear
because of alterations in electrical conductivity
of the infarcted myocardial cells.
- Cardiac biomarkers are elevated
- Produces an entire thickness damage of heart
muscle (transmural)
ASSESSMENT - Encourage immediate reporting of pain for
Subjective: prompt administration of medications, as
Client verbalized “I’m experiencing chest pain that indicated
radiates to my jaw, shoulder and left arm” - Maintain bedrest or chair rest in position of
comfort during acute episode.
Risk Factors - Stay with client who is experiencing pain or
- Hypertension appears anxious
- Sedentary Lifestyle - Prepare for interventions such as angioplasty
- Smoking - Have emergency equipment and medications
- Alcohol available
- Diet (high fat) - Monitor laboratory data, such as cardiac
- Drug Abuse enzymes, arterial blood gases (ABGs), and
- Obesity electrolytes.
- Age (Elderly) - Maintain IV or saline-lock access, as indicated.

Physical Assessment Medical Management

- Shortness of breath Percutaneous Transluminal Angioplasty
- Diaphoresis - A procedure that can open a blocked blood
- Palpitations vessel using a small, flexible plastic tube, or
- unusual fatigue catheter, with a "balloon" at the end of it. When
- Hypoxemia the tube is in place, it inflates to open the blood
- placing fist over mid-sternum vessel, or artery, so that normal blood flow is
- rubbing left arm restored.
- muscle tension Coronary Artery bypass surgery
- Redirects blood around a section of a blocked or
Diagnostic Assessment partially blocked artery in your heart. - The
- ECG: ST segment elevation, wide QRS procedure involves taking a healthy blood vessel
complexes, T wave inversion from your leg, arm or chest and connecting it
- CKMB – elevated after 6-12h MI below and above the blocked arteries in your
- Troponin I – elevated after 4-6h MI heart. With a new pathway, blood flow to the
- Angiography (Cardiac Catheterization) - Locate heart muscle improves.
clots and narrowing of blood vessel
Pharmacological Management
NURSING DIAGNOSES Aspirin (Anacin, Bayer aspirin)
- Acute pain related to myocardial ischemia - Aspirin remains a first-line therapy for
- Decreased cardiac output related to decreased UA/NSTEMI and is often given in prehospital
myocardial blood flow transport or emergency room.
- Deficient Knowledge regarding condition and Sublingual and/or IV nitroglycerin
potential complications - Provide symptomatic relief by means of several
mechanisms, including coronary vasodilation,
PLANNING improved collateral myocardial blood flow, and
- Relieve or control pain. reduction of cardiac workload.
- Prevent or minimize development of myocardial Morphine sulfate (MS)
complications. - Provides sedation, which produces relaxation;
- Provide information about disease process, and interrupted flow of vasoconstricting
prognosis, and treatment. catecholamines, thereby effectively relieving
- Support client or significant other (SO) in severe chest pain
initiating necessary lifestyle or behavioral Beta blockers; metoprolol, nadolol
changes. - Beta blockers have antiarrhythmic and
antihypertensive properties, as well as the ability
IMPLEMENTATION to reduce ischemia. They minimize the
Nursing Management imbalance between myocardial supply and
- Monitor heart rate and rhythm demand by reducing afterload and wall stress
- Monitor serial ECG, noting ST- segment changes ACEIs Inhibitors; enalapril, lisinopril
associated with ischemia.
 - Given to expand blood vessels, allowing heart to
work more easily and efficiently, and improving
cardiac output/ systemic perfusion
Calcium channel blockers; amlodipine, nicardipine
- Produce relaxation of coronary vascular smooth
muscle, dilate coronary arteries.

Complementary
- Loves Garlic
- Hawthorn
- Bromelain

CLIENT EDUCATION
- Begin with information client already knows and
move to what client does not know, progressing
from simple to complex. Use short simple
sentences and concepts initially. Repeat and
summarize as needed. Avoid giving too much
information in one setting.
- Teach the patient about the risk factors and
encourage to reduce individual risk factors such
as smoking, alcohol consumption and obesity.
- Provide medication list in writing. Discuss
expected drug effects, as well as potential side
effects and interactions. Review potential
problems that need reporting.
- Emphasize importance of checking with
physician before taking OTC drugs or Herbals

EVALUATION
- Desired activity level achieved, with return to
ASSESSMENT
activity baseline, and self- care needs met with
- Coronary artery disease
minimal or no pain.
- Heart attack
- Remains free of complications.
- Heart valve disease
- Disease process, prognosis, and therapeutic
- High blood pressure
regimen understood.
- Irregular heartbeats
- Participates in treatment program and
- Congenital heart disease
behavioral changes.
- Diabetes
- Some diabetes Medication
HEART FAILURE - Certain other medications
- Alcohol use
- Sleep apnea
- Smoking or tobacco use
- Obesity
- Viruses

Objective:
Physical Assessment
- Decreased or elevated blood pressure (BP),
dysrhythmias, tachycardia, tachypnea, increased
venous pulsations, pulsus alternans (alternating
strong and weak heartbeats), increased central
venous pressure (CVP), jugular venous
distention, crackles (rales), wheezes, decreased
breath sounds, cardiac gallop and/or murmur,
 hepatomegaly, ascites, and pitting edema in hepatojugular reflex, weight gain, hypertension,
dependent areas (lower extremities, sacrum) oliguria, generalized edema
- Activity Intolerance may be related to imbalance
Signs and Symptoms between oxygen supply and demand, physical
- Shortness of breath with activity or when lying deconditioning, sedentary lifestyle, possibly
down evidenced by reported or observed weakness,
- Fatigue and weakness fatigue; changes in vital signs in response to
- Swelling in the legs, ankles and feet activity (dysrhythmias; exertional dyspnea,
- Rapid or irregular heartbeat pallor, diaphoresis)
- Reduced ability to exercise - Risk for impaired Gas Exchange possibly
- Persistent cough or wheezing with white or pink evidenced by associated condition of alveolar-
blood-tinged mucus capillary membrane changes (fluid collection or
- Swelling of the belly area (abdomen) shifts into interstitial space or alveoli)
- Very rapid weight gain from fluid buildup - Risk for impaired Skin Integrity possibly
- Nausea and lack of appetite evidenced by risk factors of alteration in fluid
- Difficulty concentrating or decreased alertness volume, inadequate nutrition, pressure over
- Chest pain if heart failure is caused by a heart bony prominences, [prolonged chair or bedrest]
attack. and associated conditions of impaired circulation
- Deficient Knowledge regarding cardiac
Diagnostic Assessment function/disease process, therapy and self-care
- Chest x-ray examination needs may be related to lack of information or
- Electrocardiogram misinterpretation, possibly evidenced by
- Left ventricular ejection fraction questions, statements of concern,
- Echocardiography misconceptions, development of preventable
- Cardiac Catheterization complications, or exacerbations of condition
- Left ventriculography
- Endomyocardial biopsy PLANNING
- Pulmonary function tests - Improve myocardial contractility and systemic
- Oximetry/arterial blood gas (ABG) values perfusion
- Serum blood urea nitrogen (BUN), creatinine - Reduce fluid volume overload
- Serum electrolytes - Prevent complications
- Cardiac enzymes - Provide information about disease and
- Liver function tests, including serum aspartate prognosis, therapy needs, and prevention of
amino-transferase and serum bilirubin recurrences
- Brain natriuretic peptide (BNP) - Promoting physical activities
- Digoxin level - Reducing fatigue
- CBC - Relieving fluid overload symptoms
- Thyroid-stimulating hormone level - Decreasing anxiety
- Increasing the patient’s ability to manage
NURSING DIAGNOSES anxiety
- Decreased Cardiac Output may be related to - Encouraging the patient to verbalize his or her
altered myocardial contractility, inotropic ability to make decisions and influence outcome
changes; alterations in rate, rhythm, and - Teaching the patient about self-care program
electrical conduction; and structural changes Discharge goals:
(valvular defects, ventricular aneurysm), possibly - Cardiac output adequate for individual needs
evidenced by tachycardia, dysrhythmias, - Complications prevented or resolved
changes in BP, extra heart sounds, decreased - Optimum level of activity and functioning
urine output, diminished peripheral pulses, cool, attained
ashen skin; orthopnea, crackles; dependent or - Disease process, prognosis, and therapeutic
generalized edema, and chest pain regimen understood
- Excess Fluid Volume may be related to reduced - Plan in place to meet needs after discharge
glomerular filtration rate (GFR), increased
antidiuretic hormone production, and sodium IMPLEMENTATION
and water retention, possibly evidenced by Nursing Management
orthopnea and abnormal breath sounds, S 3 - Promoting activity tolerance
heart sound, jugular vein distention, positive - Managing fluid volume
 - Controlling anxiety - Aldosterone antagonists. These are potassium-
- Minimizing powerlessness sparing diuretics that have additional properties
that may help people with severe systolic heart
Medical/Surgical Management failure live longer. Unlike some other diuretics,
- Coronary bypass surgery. The procedure spironolactone and eplerenone can raise the
involves taking a healthy blood vessel from your level of potassium in your blood to dangerous
leg, arm or chest and connecting it below and levels.
above the blocked arteries in your heart. The - Inotropes. These medications are given by IV to
new pathway improves blood flow to your heart people with severe heart failure who are in the
muscle. hospital. Inotropes help the heart pump blood
- Heart valve repair or replacement. Heart valve more effectively and maintain blood pressure.
repair or replacement may be done as open- - Digoxin (Lanoxin). This drug, also called digitalis,
heart surgery, a minimally invasive surgery or a increases the strength of your heart muscle
heart procedure using flexible tubes called contractions. It also tends to slow the heartbeat.
catheters (cardiac catheterization). Digoxin reduces heart failure symptoms in
- Implantable cardioverter-defibrillators (ICDs). systolic heart failure. It may be more likely to be
An ICD is used to prevent complications of heart given to someone with a heart rhythm problem,
failure. An ICD is a device similar to pacemaker. such as atrial fibrillation.
It's implanted under the skin in your chest with - Hydralazine and isosorbide dinitrate (BiDil).
wires leading through your veins and into your This drug combination helps relax blood vessels.
heart. It may be added to your treatment plan if you
- Ventricular assist devices (VADs). A VAD — also have severe heart failure symptoms and ACE
known as a mechanical circulatory support inhibitors or beta blockers haven't helped.
device — is a device that helps pump blood from - Vericiguat (Verquvo). This newer medicine for
the lower chambers of your heart (ventricles) to chronic heart failure is taken once a day by
the rest of your body. mouth. It's a type of drug called an oral soluble
- Heart transplant. Some people have such severe guanylate cyclase (sGC) stimulator. In studies,
heart failure that surgery or medications don't people with high-risk heart failure who took
help. These people may need to have their vericiguat had fewer hospital stays for heart
hearts replaced with a healthy donor heart. failure and heart disease-related deaths
- Cardiac resynchronization therapy (CRT). Also compared with those who received an inactive
called biventricular pacing, CRT is a treatment for pill (placebo).
heart failure in people whose lower heart - Other medications. Your doctor may prescribe
chambers (ventricles) aren't pumping in sync other medications to treat specific symptoms.
with each other. For example, some people may receive nitrates
for chest pain, statins to lower cholesterol or
Pharmacological Management blood-thinning medications to help prevent
- Angiotensin-converting enzyme (ACE) blood clots
inhibitors. These drugs relax blood vessels to
lower blood pressure, improve blood flow and Complementary/Alternative Therapies
decrease the strain on the heart. Examples - Hawthorn is from the rose family and has been
include enalapril (Vasotec, Epaned), lisinopril used since the early 1800s to treat circulation
(Zestril, Qbrelis, Prinivil) and captopril. and respiration (breathing) problems. There is
- Angiotensin II receptor blockers. These drugs, not enough research to suggest its successful use
which include losartan (Cozaar), valsartan to treat irregular heartbeat, high blood pressure,
(Diovan) and candesartan (Atacand), have many chest pain, atherosclerosis (hardening of the
of the same benefits as ACE inhibitors. They may arteries), and heart failure.
be an option for people who can't tolerate ACE - Berberine is an active ingredient in goldenseal
inhibitors. and is a vasodilator. It may improve heart
- Beta blockers. These drugs slow your heart rate function and quality of life but can potentially
and reduce blood pressure. Beta blockers may interact with a number of medications.
reduce signs and symptoms of heart failure,
improve heart function, and help you live longer. Nutrition and Dietary Supplements
- Diuretics. Often called water pills, diuretics - Magnesium is a key element in heart health. It
make you urinate more frequently and keep fluid has a role in maintaining normal heart rhythm
from collecting in your body. and is often used to treat irregular heartbeat
 (arrhythmia). Magnesium can interact negatively - Reduce stress
with some heart medications. - Sleep easy
- Carnitine is a nutrient that helps the body
convert fatty acids into energy, which is used in EVALUATION
muscular activities of the body. It may affect - Cardiac output adequate for individual needs.
thyroid medication or interact with blood- - Complications prevented or resolved.
thinning medications, such as coumadin, aspirin, - Optimum level of activity and functioning
and others. attained.
- Coenzyme Q10 (CoQ10) supplements can help - Disease process, prognosis, and therapeutic
reduce swelling in the legs, enhance breathing by regimen understood.
reducing fluid in the lungs, and improve exercise - Plan in place to meet needs after discharge.
capacity in some people with heart failure. It
may negatively interact with blood-thinning CARDIOGENIC SHOCK
medications, blood pressure medications, and Risk factors:
chemotherapy agents. - Acute Myocardial Infarction
Amino Acids - Previous Cardiac Disease
- Arginine can lower blood pressure so it may be - Use of Cocaine
unsafe when taking blood pressure medications. - Coronary Artery Disease
It can have negative interactions with other - Smoking
drugs that increase blood flow, such as nitrates, - Hypertension
and those used to treat erectile dysfunction.
- Taurine helps the heart muscle contract but can Objective:
interact with lithium, causing it to be unsafe in Physical Assessment
some people, including those with bipolar - Cardiogenic shock is diagnosed after
disorder. documentation of myocardial dysfunction and
exclusion of alternative causes of hypotension,
CLIENT EDUCATION such as hypovolemia, hemorrhage, sepsis,
- Medications, including drug name, purpose, pulmonary embolism, pericardial tamponade,
dosage, schedule, precautions, and potential aortic dissection, or preexisting valvular disease.
side effects. Also discuss drug-drug, food-drug, - Patients in shock may appear ashen or cyanotic
and herb-drug interactions. and have cool and mottled skin.
- Signs and symptoms that necessitate immediate - Rapid and faint peripheral pulses and may be
medical attention: dyspnea, decreased exercise irregular if arrhythmias are present.
tolerance, alterations in pulse rate/rhythm, - Jugular venous distension and crackles in the
alterations in or loss of consciousness (caused by lungs.
dysrhythmias or decreased cardiac output), - Heart sounds are usually distant.
oliguria, and weight gain of greater than 2-3 lb in - Pulse pressure may be low and patients are
24 hr or 3-5 lb in 48 hr. usually tachycardic.
- Reinforcement that heart Signs and Symptoms:
failure/cardiomyopathy is a chronic disease - Rapid breathing
requiring lifetime treatment. - Severe shortness of breath
- Importance of abstaining from alcohol, which - Sudden, rapid heartbeat (tachycardia)
increases cardiac muscle deterioration. - Loss of consciousness
- Importance of a low-sodium diet (less than 1000 - Weak pulse
mg/day) to prevent fluid retention - Low blood pressure (hypotension)
- Sweating
Lifestyle and Home Remedies - Pale skin
- Stop smoking - Cold hands or feet
- Check your legs , ankle and feet for swelling daily - Urinating less than normal or not at all
- Discuss weight monitoring with your doctor
- Maintain a healthy weight Diagnostic Assessment
- Eat a healthy diet - Chest X-ray
- Limit saturated or trans fats in your diet - Blood Tests
- Get vaccination - Electrocardiogram (ECG or EKG)
- Limit fluids - Echocardiogram
- Be active - Swan-Ganz Catheter
 CLIENT EDUCATION
NURSING DIAGNOSES - Provide supplemental oxygen as ordered. If the
- Ineffective Tissue Perfusion may be related to patient develops respiratory distress, be
changes in circulating volume and/or vascular prepared for intubation and mechanical
tone, possibly evidenced by changes in skin color ventilation.
and temperature and pulse pressure, reduced - Administer low-dose morphine sulfate as
BP, changes in mentation, and decreased urinary ordered to reduce preload in an attempt to
output. decrease pulmonary congestion.
- Decreased Cardiac Output may be related to - Minimize oxygen demand by maintaining bed
structural damage, decreased myocardial rest and decreasing anxiety, fever, and pain.
contractility, and presence of dysrhythmias, - Position the patient for maximum chest
possibly evidenced by ECG changes, variations in excursion and comfort.
hemodynamic readings, jugular vein distention, - Administer diuretics and /or vasodilators as
cold or clammy skin, diminished peripheral ordered to reduce circulating volume and
pulses, and decreased urinary output. decrease preload.
- Impaired Gas Exchange possibly evidenced by
risk factors of ventilation perfusion imbalance, Discharge and Home Care Guidelines:
alveolar-capillary membrane changes. - Control hypertension
- Deficient Fluid Volume may be related to - Avoid smoking
excessive vascular loss, inadequate intake or - Maintain a healthy weight
replacement, possibly evidenced by - Diet
hypotension, tachycardia, decreased pulse - Exercise
volume and pressure, change in mentation, and
decreased, concentrated urine. EVALUATION
- Anxiety may be related to change in health - Prevented recurrence of cardiogenic shock.
status and threat of death, possibly evidenced by - Monitored hemodynamic status.
increased tension, apprehension, sympathetic - Administered medications and intravenous
stimulation, restlessness, and expressions of fluids.
concern. - Maintained intra-aortic balloon counter
pulsation.
PLANNING
Nursing Priorities
- Improve myocardial contractility
- Prevent risk factors of ventilation perfusion
CORONARY ARTERY DISEASE
ASSESSMENT
imbalance
Subjective Data:
- Improve circulation volume
- Chest pain or pressure, or other symptoms of
- Provide adequate fluid volume
heart disease. Your doctor will ask you to
- Reduce anxiety
describe your symptoms. Also, he or she will
want to know where any pain or pressure starts
IMPLEMENTATION
and if it spreads to other parts of your body. Your
Medical Management
doctor will also ask when it happens. Tell your
- Angioplasty and Stenting
doctor about other symptoms, such as nausea,
- Balloon Pump
vomiting, shortness of breath, dizziness, fainting,
- Extracorporeal Membrane Oxygenation (ECMO)
rapid heartbeat, irregular heartbeat, or
- Coronary Artery Bypass Surgery
“skipped” heartbeat, along with your chest
- Surgery to repair and injury to your heart
symptoms.
- Ventricular Assist Device (VAD)
- Other symptoms of coronary artery disease,
- Heart Transplant
such as fatigue, irregular or rapid heartbeats,
swelling, shortness of breath, coughing, or
Pharmacological Management
difficulty breathing when lying down.
- Vasopressors
- Personal health history. Your doctor will ask
- Inotropic Agents
questions about your health and lifestyle. He or
- Aspirin
she will ask about your cholesterol levels, blood
- Antiplatelet Medication
pressure, exercise habits, stress level, and other
- Other blood-thinning medications
areas of your life. Tell your doctor if you smoke
 or if you have diabetes or any other health heart rate and mimic exercise. This test can
problems. detect angina and coronary blockages.
- Family medical history . Your doctor will want to - Coronary calcium scan: This test measures the
know if one or more of your close relatives have amount of calcium in the walls of your coronary
or had early coronary artery disease. Tell your arteries, which can be a sign of atherosclerosis.
doctor if you have a family history of heart - Echocardiogram: This test uses sound waves to
attack, heart failure, abnormal heart rhythms, see how well structures of your heart are
sudden death, diabetes, high cholesterol, and working and overall function of your heart
high blood pressure. - Blood tests: Many blood tests are ordered for
factors that affect arteries, such as triglycerides,
Objective Data: cholesterol, lipoprotein, C-reactive protein,
Physical Assessment glucose, HbA1c (a measure of diabetic control)
- History of angina symptoms that occur and other tests.
predictably with activity and are relieved by rest - Cardiac catheterization: This test involves
- Abnormal heart rate or rhythm inserting small tubes into the blood vessels of
- Abnormally high or low blood pressure the heart to evaluate heart function including
- Signs of atherosclerosis (diminished or unequal the presence of coronary artery disease.
pulses in the arms or legs, abnormal sounds - Nuclear imaging: This test produces images of
heard when listening to blood flow through the heart after administering a radioactive
blood vessels) tracer.
- New or changed heart murmur - Computed tomography angiogram: Uses CT and
- Enlarged heart contrast dye to view 3D pictures of the moving
- Signs of heart failure (bulging neck veins, extra heart and detect blockages in the coronary
heart sounds, fluid in the lungs, fluid buildup in arteries
the abdomen, enlarged liver, or swelling in the
legs and feet) NURSING DIAGNOSES
- Medical history that reveals two or more risk - Altered tissue perfusion (myocardial) related to
factors for heart disease narrowing of the coronary artery(ies) associated
with atherosclerosis, spasm, and/or thrombosis
Signs and Symptoms - Acute pain
- Chest discomfort (angina) described as - Risk for decreased cardiac output
heaviness, tightness, pressure, aching, burning, - Anxiety
numbness, fullness, squeezing or a dull ache. The - Deficient knowledge (Learning Need) regarding
discomfort can also spread to or only be felt in condition, treatment plan, self-care, and
your left shoulder, arms, neck, back or jaw. discharge needs
- Feeling tired.
- Dizziness, lightheadedness. PLANNING
- Nausea. Nursing Priorities:
- Weakness. - Increase cardiac output to improve myocardial
- Discomfort or pain in the shoulders, neck, contractility
abdomen (belly) and/or back. - Improve oxygen saturation
- Feeling of indigestion or heartburn. - Reduce pain
- Unexplained anxiety.
- Cold sweat. IMPLEMENTATION
Medical Management
Diagnostic Assessment - Percutaneous transluminal coronary angioplasty
- Electrocardiograph tests (EKG): This test records or intracoronary atherectomy, or placement of
the electrical activity of the heart. Can detect intracoronarystent.
heart attack, ischemia and heart rhythm issues. - Coronary artery bypass grafting.
- Exercise stress tests: This is a treadmill test to - Transmyocardial revascularization.
determine how well your heart functions when
it’s working the hardest. Can detect angina and Pharmacological Management
coronary blockages. - Antianginal medications (nitrates, beta-adrenergic
- Pharmacologic stress test: Instead of using blockers, calcium channel blockers, and angiotensin
exercise to test your heart when it is working its converting enzyme inhibitors) to promote a
hardest, medication is given to increase your favorable balance of oxygen supply and demand.
 - Antilipid medications to decrease blood cholesterol - Care of Incision - Often the incision heals with no
and tricglyceride levels in patients with elevated home healthcare, but the patient needs to know
levels. the signs of infection.
- Antiplatelet agents to inhibit thrombus formation. - Activity Restrictions - The activity
- Folic acid and B complex vitamins to reduce recommendations will depend on the type and
homocysteine levels. extent of the patient’s underlying condition.

CLIENT EDUCATION EVALUATION

- Do not smoke. Avoid second-hand smoke too. - Prevented recurrence of Coronary Artery
Smoking can increase your risk of a heart attack Disease.
or stroke. If you need help quitting, talk to your - Monitored patient status.
doctor about stop-smoking programs and - Administered medications and intravenous fluid
medicines. These can increase your chances of
quitting for good.
- Eat heart-healthy foods. These include Nursing Care of the Clients with Altered
vegetables, fruits, nuts, beans, lean meat, fish,
Tissue Perfusion
and whole grains. Limit saturated fat, sodium,
GROUP 5
and alcohol. Limit drinks and foods with added
sugar.
- If your doctor recommends it, get more exercise. HYPERTENSIVE CRISIS
Ask your doctor what level of exercise is safe for PATHOPHYSIOLOGY
you. Walking is a good choice. Bit by bit, increase - First is a failure of the vascular bed's
the amount you walk every day. Try for at least autoregulatory system, which maintains a
2½ hours a week. You also may want to swim, constant flow of blood between organs. When
bike, or do other activities. the perfusion pressure lowers, the
- Stay at a healthy weight. Lose weight if you need accompanying blood flow reduces for a short
to. time before returning to normal within a few
- Manage other health problems. These include minutes.
diabetes, high blood pressure, and high - The second mechanism is the activation of
cholesterol. If you think you may have a problem renin–angiotensin system, leading to further
with alcohol or drug use, talk to your doctor. vasoconstriction and thus generating a vicious
- If you have angina symptoms, pay attention to cycle of continuous injury and subsequent
your symptoms. This can help you see what ischemia.
causes them and what is typical for you. - Besides these mechanisms, a prothrombotic
- Avoid colds and influenza (flu). Get a state may play a key role in hypertensive crisis.
pneumococcal vaccine shot. If you have had one Platelet activation may be an early finding in the
before, ask your doctor whether you need pathophysiologic sequelae of hypertensive
another dose. Get a flu vaccine every year. If you crises.
must be around people with colds or flu, wash
your hands often.
- If you think you have symptoms of depression, TYPES OF HYPERTENSIVE CRISIS
talk to your doctor. Symptoms include feeling 1. Hypertensive Urgency
sad or hopeless most of the time, or losing Hypertensive urgency occurs when blood pressure
interest in activities that used to make you spikes -- blood pressure readings are 180/110 or
happy. higher -- but there is no damage to the body's
organs. Blood pressure can be brought down safely
Discharge and Home Care Guidelines: within a few hours with blood pressure medication.
- Prevention- Review the risk factor and lifestyle 2. Hypertensive Emergency
modifications that are acceptable to the patient Hypertensive emergency means blood pressure is so
and her or his family members. high that organ damage can occur. Blood pressure
- Medications - Be certain that the patient and must be reduced immediately to prevent imminent
appropriate family members understand all organ damage.
medications, including the correct dosage, route,
action, and adverse effects. Organ damage associated with hypertensive
emergency may include:
PERIOPERATIVE
 - Changes in mental status, such as confusion - Reduce mean arterial BP by no more than 25%
- Bleeding into the brain (stroke) - Monitor arterial BP continuously and note
- Heart failure sudden increases or decrease in readings.
- Chest pain (unstable angina) - A precipitous drop in BP can cause reflex
- Fluid in the lungs (pulmonary edema) ischemia to the heart, brain, kidneys, and/or GI
- Heart attack tract. Note trends in mean arterial pressure and
- Aneurysm (aortic dissection) the patient’s response to
- Eclampsia (occurs during pregnancy) - therapy.
- Monitor hourly urine output and note any
presence of blood in the urine.
ASSESSMENT - Continuously monitor the ECG fir dysrhythmias
- To diagnose a hypertensive emergency, your or ST segment and T-wave changes associated
health care providers will ask you several with ischemia or injury.
questions to get a better understanding of your
medical history. They will also need to know all IMPLEMENTATION
medications you are taking, including The objective of nursing care for hypertensive patients
nonprescription and recreational drugs. Also, be focuses on lowering and controlling the blood pressure
sure to tell them if you are taking any herbal or without adverse effects and without undue cost.
dietary supplements.
In patients who present with markedly elevated blood Increasing Knowledge
pressure, a careful history and exam are necessary to - Emphasize the concept of controlling
determine which of these patients is having a true hypertension rather than curing it.
hypertensive emergency. - Encourage the patient to consult a dietitian to
Subjective Data: help develop a plan for weight loss.
- Headache - Support groups for weight control, smoking
- Nausea cessation, and stress reduction may be beneficial
- Dizziness for some patients; others can benefit from the
- Visual disturbances support of family and friends.
- Altered level of consciousness - Assists the patient to develop and adhere to an
Objective Data appropriate exercise regimen, because regular
Physical examination, the nurse must also pay specific activity is a significant factor in weight reduction
attention to the rate, rhythm, and character of the apical and a blood pressure–reducing intervention in
and peripheral pulses to detect effects of hypertension the absence of any loss in weight
on the heart and blood vessels. A thorough assessment
can yield valuable information about the extent to which Teaching Patients Self-Care
the hypertension has affected the body and about any - The therapeutic regimen is the responsibility of
other personal, social, or financial factors related to the the patient in collaboration with the health care
condition. provider.
- Education about high blood pressure and how to
NURSING DIAGNOSIS manage it, including medications, lifestyle
Based on the assessment data, nursing diagnoses for the changes of diet, weight control, and exercise,
patient may include the following: setting goal blood pressures, and assistance with
- Ineffective tissue perfusion related to social support, can help the patient achieve
compromised blood flow secondary to severe blood pressure control.
hypertension resulting in end-organ damage. - Involving family members in education programs
- Deficient knowledge regarding the relation enables them to support the patient’s efforts to
between the treatment regimen and control of control hypertension.
the disease process - Written information about the expected effects
- Noncompliance with therapeutic regimen and side effects of medications is important.
related to side effects of prescribed therapy When side effects occur, patients need to
understand the importance of reporting them
PLANNING and to whom they should be reported.
The major goals for the patient include understanding of
the disease process and its treatment, participation in a Pharmacological Management
self-care program, and absence of complications. - Clevidipine (Intravenous)
- Esmolol (Intravenous)
 - Nitroglycerin (Intravenous) 3. Has no complications
- Nicardipine (Intravenous) a. Reports no changes in vision
- Postoperative surgical HTN b. Exhibits no retinal damage on vision testing
c. Maintains pulse rate and rhythm and respiratory
Hypertensive crisis, Eclampsia, Pre-Eclampsia rate within normal ranges
- Hydralazine d. Reports no dyspnea or edema
- Labetalol e. Maintains urine output consistent with intake
- Nicardipine f. Has renal function test results within normal
range
Hypertensive Emergency with acute pulmonary g. Demonstrates no motor, speech, or sensory
edema deficits
- Nitroglycerin (Intravenous) h. Reports no headaches, dizziness, weakness,
- Clevidipine (Intravenous) changes in gait, or falls.
- Nitroprusside (Intravenous)

Hypertensive Emergency with acute renal failure

CARDIOMYOPATHY
PATHOPHYSIOLOGY
- Fenoldopam
- Cardiomyopathy is the disease of the
- Nicardipine
myocardium which inhibits effective pumping.
- Clevidipine
- 3 Types of Cardiomyopathy: Dilated,
Hypertrophic and Restrictive
PATIENT EDUCATION
- All types lead to a weaker pump which then
- Prevent another Hypertensive Crisis
causes Decrease O2 to the body & Decrease
- Check your blood pressure at home.
Cardiac Output
- Manage any other health conditions you have.
- As cardiomyopathy worsens, the heart becomes
- Ask about all medicines.
weaker. The heart becomes less able to pump
- Limit sodium (salt) as directed.
blood throughout the body and incapable of
- Follow the meal plan recommended by your
maintaining a normal electrical rhythm.
- healthcare provider.
Ultimately leads to heart failure.
- Exercise to maintain a healthy weight.
- Decrease stress.
- Limit alcohol as directed.
- Do not smoke.

EVALUATION
1. Maintains adequate tissue perfusion
a. Maintains blood pressure at less than 140/90
mm Hg (or less than 130/85 mm Hg for persons
with diabetes mellitus or proteinuria greater
than 1 g per 24 hours) with lifestyle
modifications, medications, or both
b. Demonstrates no symptoms of angina,
palpitations, or vision changes
c. Has stable BUN and serum creatinine levels TYPES OF CARDIOMYOPATHY
b. Has palpable peripheral pulses Dilated Cardiomyopathy
2. Complies with the self-care program - Most common form Cardiomyopathy
a. Adheres to the dietary regimen as prescribed: - Thinning of the heart muscle and enlargement of
reduces calorie, sodium, and fat intake; the heart chamber, commonly on the left
increases fruit and vegetable intake ventricle
b. Exercises regularly - Heart stretches as it tries to compensate for
c. Takes medications as prescribed and reports any weakened pumping action
side effects - Often produces signs of congestive heart failure,
d. Measures blood pressure routinely such as breathlessness and fluid retention
e. Abstains from tobacco and excessive alcohol - Rarely, can occur after pregnancy, this is known
intake as peripartum cardiomyopathy
f. Keeps follow-up appointments
 - family history of coronary artery disease
- a previous heart attack, excessive alcohol
consumption
- drug abuse
- obesity

Certain conditions can also increase risk, including:

- high blood pressure, diabetes thyroid disorders
- a buildup of iron in the heart muscle sarcoidosis,
which causes inflammation in the body’s organs.
- Cancer treatments, including radiation and
Hypertrophic Cardiomyopathy (HCM) certain types of chemotherapy, may also
- Second most common form; most often increase a person’s risk.
inherited
- Causes heart wall to thicken, leaving less space ASSESSMENT
for blood in the chambers and making the heart Objective Cues:
work harder to pump blood out Signs and Symptoms
- Most common in the interventricular septum - Shortness of breath or trouble breathing,
facing the left ventricle, obstructing blood flow especially with physical exertion
to the aorta (see picture) - Fatigue
- Can affect people of all ages - Swelling in the ankles, feet, legs, abdomen and
veins in the neck
- Dizziness
- Lightheadedness
- Fainting during physical activity
- Arrhythmias (irregular heartbeats)
- Chest pain, especially after physical exertion or
heavy meals
- Heart murmurs (unusual sounds associated with
heartbeats)

DIAGNOSTIC ASSESSMENT
Non-Invasive Procedures
Chest X-Ray
Restrictive Cardiomyopathy
- It can help your doctor detect signs of heart
- Causes portions of the heart wall to become rigid
failure, such as changes in the shape or size of
and lose elasticity
the heart
- Heart chambers are unable to fill and pump out
Echocardiogram
blood properly because of stiffness in the heart
- This test checks your heart valves and helps your
- Usually caused by buildup of scar tissue and
doctor determine the cause of your symptoms.
protein build up
Electrocardiogram
- This test can provide clues as to whether the
heart is thickened, its chambers are enlarged, or
if it’s receiving enough blood and oxygen.
Treadmill Stress Test
- Test to evaluate symptoms, determine your
exercise capacity and determine if exercise
triggers abnormal heart rhythms.
Cardiac MRI
- Your doctor might order a cardiac MRI if the
images from your echocardiogram aren't helpful
in making a diagnosis.
Cardiac CT Scan
RISK FACTORS AND SYMPTOMS - An X-ray tube inside the machine rotates around
Risk factors for cardiomyopathy and heart failure your body and collects images of your heart and
include:
 chest to assess heart size and function and the - The alcohol causes these cells to die. The
heart valves. thickened tissue shrinks to a more normal size.

Invasive Procedures PHARMACOLOGICAL MANAGEMENT

Cardiac catheterization First Line Medication
- A cardiac catheterization can reveal blockages in - Angiotensin-converting enzyme (ACE) inhibitors.
your blood vessels. - Angiotensin II receptor blockers (ARBs).
Endomyocardial Biopsy - Sacubitril/valsartan (Entresto).
- A small piece of the inner heart wall is removed - Beta blockers.
Second Linde Medication
using a tiny metal device at the tip of the
- Diuretics.
catheter. The sample of heart tissue is then
- Digoxin (Lanoxin).
examined under the microscope.
- Ivabradine (Corlanor).
- Blood-thinning medications (anticoagulants).
NURSING DIAGNOSES
1. Altered Tissue Perfusion related to PLANNING & INTERVENTIONS
2. Altered myocardial contractility COMPLEMENTARY/ALTERNATIVE
Lifestyle Changes
Objectives These lifestyle changes can help you manage
1. Relieve client’s chest discomfort cardiomyopathy:
2. Promote comfort and emotional support - Quit smoking.
3. Monitor effects of Pharmacological therapies - Lose weight if you're overweight.
1. 4. Provide Patient Education - Get regular exercise, but talk to your doctor first
about the safest type and amount for you.
- Eat a healthy diet.
PLANNING & INTERVENTIONS - Use less salt (sodium). Aim for less than 1,500
milligrams of sodium a day.
Medical/Surgical Management
- Avoid or drink less alcohol.
Septal Myectomy
- Try to manage your stress.
- Is an open-heart surgery.
- Get enough sleep.
- Removes part of the thickened septum that’s - Take all your medications as directed by your
bulging into the left ventricle. doctor.
Pacemaker - Go to your doctor for regular follow-up
- Small device uses electrical pulses to prompt the appointments.
heart to beat at a normal rate.
Cardiac resynchronization therapy (CRT) device Herbals
- Device coordinates contractions between the • Hawthorn- Effective for the signs and symptoms
heart’s left and right ventricles. of early stage congestive heart failure, the main
Left ventricular assist device (LVAD) complication of cardiomyopathy.
- Implantable device helps the heart pump blood • Arjun- Seen to preserve myocardium and
to the body demonstrated marked improvement in various
Implantable cardioverter defibrillator (ICD) myocardial injuries.
- helps to maintain a normal heartbeat by sending • Coenzyme Q10- Is a non-prescription nutritional
an electric shock to the heart if an arrhythmia, or supplement. It is a fat-soluble molecule that has
a role in energy production within the cells of the
irregular heartbeat, is detected.
body. Because of its antioxidant activity,
Heart Transplant
coenzyme Q10 may help to reduce these toxic
- A heart transplant is a last resort for people who
effects, which damage the components of the
have end-stage heart failure. “End-stage” means cardiac cells, and disrupt cellular signaling.
that all other treatment options have been Coenzyme Q10 plays an important role in
explored, without success. conducting signals within the heart muscle and
Ventricular assist device (VAD) in generating energy.
- This helps blood flow through your procedure)
heart. PATIENT EDUCATION
- It can be used as a long-term treatment or as a Work hard to remove the salt from your diet. Here are
short-term treatment while waiting for a heart tips:
transplant. - Limit canned, dried, packaged, and fast foods.
Alcohol septal ablation (nonsurgical procedure) - Don’t add salt to your food at the table.
 - Season foods with herbs instead of salt when you - Knows the importance of monthly follow-ups
cook. and knows when to seek help from the
- When you eat out, ask that the chef not add any healthcare provider.
salt to your dish.
- Don't eat fried or greasy foods.
- Be careful of bottled beverages. They can
ARRYTHMIAS
contain a lot of salt.

Also check the labels of over-the-counter medicines and

supplements. They may be high in sodium. Ask your
pharmacist or provider if you need help finding a low-salt
product. Be as active as you can. Ask your healthcare
provider how to get started:
- Simple activities such as walking or gardening
can help.
- Find activities you enjoy and make them a
priority. Normal Sinus Rhythm
- Cardiac rehabilitation programs can help you
reach your
- activity goals. You exercise while staff closely
watches the stress on your heart.

Other tips for home care:

- Limit how much fluid you have each day. PATHOPHYSIOLOGY
- Break the smoking habit. Dysrhythmia (also referred to as arrhythmia): disorder
- Take your medicines exactly as directed. of the formation or conduction (or both) of the electrical
- Check with your pharmacist to see if products impulse within the heart, altering the heart rate, heart
are heart safe and won't interact with other rhythm, or both and potentially causing altered blood
medicines you take. flow. With common signs and symptoms, such as:
- Visit your healthcare provider regularly. - Palpitations
- Weigh yourself at the same time each day. - Pounding in the chest
- Limit how much alcohol you drink. - Dizziness or feeling lightheaded
- Shortness of breath
Call your healthcare provider right away if you have any - Chest discomfort
of the following: - Weakness or fatigue (feeling very tired)
- You gain more than 2 pounds in 1 day, more than It includes 4 types which are the:
5 pounds in 1 week. SINUS NODE
- New or increased chest pain that doesn't get 1. Sinus Bradycardia
better with medicine Occurs when the sinus node creates an impulse at a
- New or increased shortness of breath or slower-than-normal rate.
coughing Usually Caused by:
- Weakness in the muscles of your face, arms, or - Lower metabolic needs
legs - Vagal Stimulation
- Trouble speaking - Medications
- Rapid pulse or pounding heartbeat - Increased ICP
- Fainting, or feeling dizzy or lightheaded - Myocardial Infarction
- New or increased swelling in your hands, feet, or Treatment is directed toward increasing the heart
ankles rate.
All characteristics of sinus bradycardia are the same
EVALUATION as those of normal sinus rhythm, except for the rate.
- Patient’s chest discomfort has subdued and
anxiety levels reduced. 2. Sinus Tachycardia
- Patient is aware and understood his condition. - Occurs when the sinus node creates an impulse
- Understood the purpose of medical/surgical at a faster-than-normal rate.
managements in regards to cardiomyopathy. - Usually Caused by: acute blood loss, anemia,
- Expresses the importance of following treatment shock, hypervolemia, hypovolemia, congestive
and applying them to his daily regime. heart failure, pain, hypermetabolic states, fever,
• Lifestyle changes exercise, anxiety, or sympathomimetic
• Pharmacologic treatment medications.
 - As the heart rate increases, the diastolic filling seek medical attention. It may start and stop
time decreases, possibly resulting in reduced suddenly. Atrial fibrillation may occur for a very
cardiac output and subsequent symptoms of short time (paroxysmal), or it may be chronic.
syncope and low blood pressure. If the rapid rate - A rapid ventricular response reduces the time for
persists and the heart cannot compensate for ventricular filling, resulting in a smaller stroke
the decreased ventricular filling, the patient may volume. Because this rhythm causes the atria
develop acute pulmonary edema. and ventricles to contract at different times, the
atrial kick (the last part of diastole and
3. Sinus Arrythmia ventricular filling, which accounts for 25% to 30%
Occurs when the sinus node creates an impulse at an of the cardiac output) is also lost.
irregular rhythm; the rate usually increases with - This leads to symptoms of irregular palpitations,
inspiration and decreases with expiration. fatigue, and malaise.
Usually caused by: - There is usually a pulse deficit, a numerical
- Respiratory Diseases difference between apical and radial pulse rates.
- Some Non-respiratory Diseases such as The shorter time in diastole reduces the time
heart disease and valvular disease (rare). available for coronary artery perfusion, thereby
Sinus arrhythmia does not cause any significant increasing the risk for myocardial ischemia. The
hemodynamic effect and usually is not treated. erratic atrial contraction promotes the
formation of a thrombus within the atria,
ATRIAL increasing the risk for an embolic event. There is
1. Premature Atrial Complex a two- to five-fold increase in the risk of stroke
- A single ECG complex that occurs when an (brain attack).
electrical impulse starts in the atrium before the
next normal impulse of the sinus node. JUNCTIONAL
- Usually Caused by: caffeine, alcohol, nicotine, 1. Premature Junctional Complex
stretched atrial myocardium (as in - A premature junctional complex is an impulse
hypervolemia), anxiety, hypokalemia (low that starts in the AV nodal area before the next
potassium level), hypermetabolic states, or atrial normal sinus impulse reaches the AV node.
ischemia, injury, or infarction Premature junctional complexes are less
- PACs are often seen with sinus tachycardia and common than PACs.
PACs are common in normal hearts. If PACs are - Usually Caused by:
infrequent, no treatment is necessary. If they are • digitalis toxicity,
frequent (more than 6 per minute), this may • congestive heart failure,
herald a worsening disease state or the onset of • coronary artery disease.
more serious dysrhythmias, such as atrial - The ECG criteria for premature junctional
fibrillation. complex are the same as for PACs, except for the
P wave and the PR interval. The P wave may be
2. Atrial Flutter absent, may follow the QRS, or may occur before
- Occurs in the atrium and creates impulses at an the QRS but with a PR interval of less than 0.12
atrial rate between 250 and 400 times per seconds. Premature junctional complexes rarely
minute. Because the atrial rate is faster than the produce significant symptoms. Treatment for
AV node can conduct, not all atrial impulses are frequent premature junctional complexes is the
conducted into the ventricle, causing a same as for frequent PACs.
therapeutic block at the AV node.
- Usually caused or high risk among patients with 2. Junctional Rhythm
advanced age, valvular heart disease, coronary - Junctional or idionodal rhythm occurs when the
artery disease, hypertension, cardiomyopathy, AV node, instead of the sinus node, becomes the
hyperthyroidism, pulmonary disease, acute pacemaker of the heart. When the sinus node
moderate to heavy ingestion of alcohol (“holiday slows or when the impulse cannot be conducted
heart” syndrome), or the aftermath of open through the AV node, the AV node automatically
heart surgery. discharges an impulse.
- Atrial flutter can cause serious signs and - Junctional rhythm may produce signs and
symptoms, such as chest pain, shortness of symptoms of reduced cardiac output.
breath, and low blood pressure.
3. Atrioventricular Nodal Reentry Tachycardia
3. Atrial Fibrillation - AV nodal reentry tachycardia occurs when an
- Causes a rapid, disorganized, and uncoordinated impulse is conducted to an area in the AV node
twitching of atrial musculature. It is the most that causes the impulse to be rerouted back into
common dysrhythmia that causes patients to the same area over and over again at a very fast
 rate. Each time the impulse is conducted through obtaining a 12-lead ECG, may be the only action
this area, it is also conducted down into the necessary.
ventricles, causing a fast ventricular rate. AV
nodal reentry tachycardia that has an abrupt 3. Ventricular Fibrillation
onset and an abrupt cessation with a QRS of - A rapid but disorganized ventricular rhythm that
normal duration had been called paroxysmal causes ineffective quivering of the ventricles.
atrial tachycardia (PAT). There is no atrial activity seen on the ECG.
- Usually Caused by: - Usually Caused by:
• caffeine, • Result from untreated or unsuccessfully
• nicotine, treated VT.
• hypoxemia, and stress. • electrical shock and Brugada syndrome
• Underlying pathologies include: • Few or no risk factors for coronary artery
coronary artery disease and disease, and a family history of sudden
cardiomyopathy. cardiac death.
- The tachycardia usually is of short duration, - This dysrhythmia is always characterized by the
resulting only in palpitations. A fast rate may also absence of an audible heartbeat, a palpable
reduce cardiac output, resulting in significant pulse, and respirations. Because there is no
signs and symptoms such as restlessness, chest coordinated cardiac activity, cardiac arrest and
pain, shortness of breath, pallor, hypotension, death are imminent if ventricular fibrillation is
and loss of consciousness. not corrected.

VENTRICULAR 4. Idioventricular Rhythm

1. Premature Ventricular Complex - Also called ventricular escape rhythm, occurs
- It is an impulse that starts in a ventricle and is when the impulse starts in the conduction
conducted through the ventricles before the system below the AV node. When the sinus node
next normal sinus impulse. PVCs can occur in fails to create an impulse (e.g., from increased
healthy people. vagal tone), or when the impulse is created but
- Usually caused by: cannot be conducted through the AV node (e.g.,
• caffeine, due to complete AV block), the Purkinje fibers
• nicotine, automatically discharge an impulse.
• or alcohol - Commonly causes the patient to lose
• cardiac consciousness and experience other signs and
• ischemia or infarction, symptoms of reduced cardiac output.
• increased workload on the heart
• digitalis toxicity, 5. Ventricular Asystole
• hypoxia, - Commonly called flatline, ventricular asystole is
characterized by absent QRS complexes,
• acidosis, or electrolyte imbalances,
although P waves may be apparent for a short
especially hypokalemia.
duration in two different leads.
- In the absence of disease, PVCs are not serious.
- There is no heartbeat, no palpable pulse, and no
In the patient with an acute MI, PVCs may
respiration. Without immediate treatment,
indicate the need for more aggressive therapy.
ventricular asystole is fatal. Cardiopulmonary
- The effect of a PVC depends on its timing in the
resuscitation and emergency services are
cardiac cycle and how much blood was in the
necessary to keep the patient alive.
ventricles when they contracted.

ASSESSMENT
2. Ventricular Tachycardia
Subjective Cues
- It is defined as three or more PVCs in a row,
A health history is obtained to identify any previous
occurring at a rate exceeding 100 beats per
occurrences of decreased cardiac output, such as
minute. The causes are similar to those for PVC.
syncope (fainting), lightheadedness, dizziness, fatigue,
VT is usually associated with coronary artery
chest discomfort, and palpitations.
disease and may precede ventricular fibrillation.
- Coexisting conditions
VT is an emergency because the patient is usually
- All medications
(although not always) unresponsive and
- A thorough psychosocial assessment
pulseless.
- The patient’s tolerance or lack of tolerance for
Objective Cues
this rapid rhythm depends on the ventricular
Physical assessment
rate and underlying disease. If the patient is
- Assess the skin of the patient, which may be pale
stable, continuing the assessment, especially
and cool.
 - Assess for signs of fluid retention, such as: Neck - Minimizing care-related interventions during
vein distention and crackles and wheezes normal sleeping hours, and interventions
auscultated in the promoting patient comfort and relaxation
- l lungs, may be detected.
- the rate and rhythm of apical and peripheral Promote Comfort & Emotional Support
pulses are also assessed, and any pulse deficit is - High-quality supportive care
noted. - Communicate with patients
- Vital Signs and auscultates for extra heart sounds - Comfort the patient
(especially S3 and S4) and for heart murmurs.
Monitor Effects of Pharmacological Therapy
DIAGNOSTIC PROCEDURES - Vital signs
- Electrocardiography (ECG) - Quantification of all fluid intake and output
- Stress Test - Often daily weight
- Echocardiogram
- Cardiac Catheterization IMPLEMENTATIONS
- Tilt Table Test MEDICAL AND SURGICAL MANAGEMENT
Invasive
NURSING DIAGNOSES • Electrical cardioversion - It delivers an electrical
- Decreased cardiac output shock to the chest wall, which synchronizes the
- Anxiety related to fear of the unknown heart and allows the normal rhythm to restart.
- Deficient knowledge about the dysrhythmia and • Catheter ablation - During ablation, energy is
its treatment delivered through a catheter to tiny areas of the
heart muscle.
PLANNING • Pulmonary vein isolation – It is a procedure that
Recognize Myocardial Ischemia uses special catheters to render bands of vein
- Chest pressure or pain, typically on the left side tissue, thought to cause atrial fibrillation,
of the body (angina pectoris) dysfunctional.
- Commonly by women, older people and people
with diabetes Electrical Devices (Implantable)
Symptoms: • Permanent Pacemaker - A device that sends
• Neck or jaw pain small electrical impulses to the heart muscle to
• Shoulder or arm pain maintain a normal heart rate. This is mostly used
• A fast heartbeat to prevent the heart from beating too slowly.
• Shortness of breath when you are physically • Implantable cardioverter-defibrillator (ICD) – A
active sophisticated electronic device used primarily to
• Nausea and vomiting treat ventricular tachycardia and ventricular
• Sweating fibrillation
• Fatigue There are several ways an ICD can restore a
normal heart rhythm:
Relieve Chest Pain - Antitachycardia pacing (ATP)
Home remedies - Cardioversion
• Perform relaxation techniques - Defibrillation
• Reduce or eliminate stimulant intake - Antibrachycardia pacing
• Stimulate the vagus nerve
• Keep electrolytes balanced Heart Surgery
• Keep hydrated • Maze procedure – surgeon makes a series of
• Avoid excessive alcohol use surgical incisions in the heart tissue in the upper
• Exercise regularly half of your heart (atria) to create a pattern or
Pain Medications maze of scar tissue.
• Calcium Channel Blockers - These drugs • Coronary bypass surgery – To improve the blood
dilate your blood vessels. This allows more flow to the heart.
blood to flow to the heart, which helps ease
chest pain and decrease blood pressure. IMPLEMENTATION
Pharmacological Management
Maintain a Calm Environment Beta-blockers
Noise-reduction strategies - Acebutolol (Sectral)
- Dimming lights in the evening - Atenolol (Tenormin)
- Bisoprolol (Zebeta)
- Metoprolol (Lopressor, Toprol-XL)
 - Nadolol (Corgard)
- Propranolol (Inderal LA, innopran XL) PATIENT EDUCATION
- Taking Medications
Calcium Channel Blockers - Monitor Pulse
- Amlodipine (Norvasc) - Manage risk factors
- Diltiazem (Cardizem, Tiazac) - Take it one day at a time
- Felodipine - Activity
- Isradipine
- Nicardipine (Cardene SR) EVALUATION
- Nifedipine (Procardia) - Make sure the arrhythmia is controlled
- Nisoldipine (Sular) - Experiences reduced anxiety
- Verapamil (Calan, Verelan, Covera-HS) - Properly adjust your medications
- Expresses an understanding of the arrhythmia
Antiarrhythmic drugs and its treatment
- Amiodarone(Cordarone, Pacerone) - Describes a plan to eradicate or limit factors that
- Flecainide (Tambocor) contribute to the occurrence of the arrhythmia
- Ibutilide (Corvert), which can only be given - Evaluate the function of any implanted devices
through IV
- Lidocaine (Xylocaine), which can only be given
through IV
- Procainamide (Procan, Procanbid)
- Propafenone (Rythmol)
- Quinidine (many brand names)
- Tocainide (Tonocarid)

Anticoagulants
- Warfarin
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
- Edoxaban (Savaysa)

IMPLEMENTATION
Alternative Therapies
- Yoga
• Yoga comprises of three key elements:
• Asanas (body postures)
• Pranayama (breathing exercises)
• Dhyana (meditation)
- Acupuncture – The art of acupuncture involves
the belief that all humans have a form of vital
energy called as Qi, which flows through
channels called meridians linking all parts of the
body.
- Biofeedback
• Deep breathing
• Progressive muscle relaxation
• Guided imagery(concentrating on color
or image)
• Meditation.

Complementary Therapies
- Fish oil / Omega 3 Fatty Acids
- Vitamins and Antioxidants
- Herbal Medicines
- Barberry
- Shensongyangxin
- Cinchona
- Hawthorn (Crataegus oxycantha)
Nursing Care of Clients with Life Threatening Conditions, Acutely
Ill/ Multi-Organ Problems, High Acuity, And Emergency Situation
ACUTELY AND - Patients who are at high risk for
TOPIC OUTLINE CRITICALLY ILL mortality due to present health
1 Scope of Critical Care PATIENTS problems. (AACN, 2015)
2 Leadership in Critical Care - At high risk of actual or life-
3 threatening health problems.
4 (Aitken, Chaboyer, Elliot, 2019)
5 ACUTE AND - The specialty within nursing that
6 CRITICLA CARE specifically deals with human
NURSING responses to actual or potential
INTRODUCTION life-threatening health symptoms
and diagnosis. (AACN, 2015)
DEVELOPMENT OF CRITICAL CARE NURSING - Assisting, supporting, and restoring
the patient toward health, or to
1. CARDIAC 1. RENAL ease the patient’s pain, or to
2. CARDIOTHORACIC + 2. METABOLIC prepare them for dignified death.
(WFCN, 2017)
3. RESPIRATORY 3. NEUROLOGIC
ACUTE AND - To establish a therapeutic
1. Partnership between Nursing & Medical Staff. CRITICAL CARE relationship with patient’s and
2. Steep learning curve for both fields NURSING GOAL their relatives and to empower the
3. Courage to work in an unfamilliar setting, caring for individual’s physical, psychological,
patient who were extremely sick. sociological, cultural and spiritual
4. A high demand for education specific for CC practice. capabilities through preventive,
5. Additional knowledge & skills due to the development curative and rehabilitative
of technology suchs as: interventions. (WFCN, 2017)
• Mechinical ventillators ACUTE/CRITICAL - A licensed professional nurse who
• Pacemakers defibrillators CARE NURSE is responsible for ensuring that all
• Intra-aortic balloon pumps acutely and critically ill patients
• Cardiac monitors receive optimal care.
• Dialyzers - Basic to the provisions of optimal
care is individual professional
• Cardiac Assist Devices
accountability through:
Nursing Expertise, abilitity to obseve patients and o Adherence to standards of
appropriate nursing intensity are now considered essential nursing care of acutely and
elements of CC. critically ill patients.
o Commitment to act in
® Critical Care nursing – Highest level of care accordance with ethical
® Nurses must gave highest level of knowledge, principles.
education, training to give the highest level of care.
SCOPE OF PRACTICE
• Boundaries of the practitioner’s license
DEFINITIONS o Procedures
CRITICAL CARE - A hospital unit where 24-hour o Nursing actions
UNIT/ INTENSIVE medical care is rendered to o Processes
CARE UNIT patients with life-threatening
injuries and llnesses. For which the practitioner has received:
- A team of specially-trained health o Education
care providers are involved in o Training
rendering specialized treatments o Licensure
with the use of machines to o Certification
constantly monitor vital signs. • Describes the WHO, WHAT, WHERE, WHEN, WHY &
HOW the registered nurse functions when caring for
accurately and critically ill patients. (AACN, 2015)
• Should allow for exchange, expansion, and flexibility of knowledge. (Aitken, Chaboyer, Elliot,
the profession to meet the changing needs of patients, 2019)
organizations and society. (AACN, 2015) ® or Knowledge, Skills, Attitude (KSA)
® Being a critical care nurse, you must be flexible to meet
the needs of diverse patients. STANDARDS OF PROFESSIONAL PRACTICE (COMPETENCIES)
• Activities that an individual health care practitioner is
permitted to perform in a specific profession. COMPETENCIES
• Scope of practice is established by the practice act of STANDARDS OF CARE FOR ACUTE AND CRITICAL CARE
the specific practitioner’s board, and the rules adopted NURSING PRACTICE
pursuant to that act.
1. Assessment
2. Diagnosis
3. Outcome Identification
CRITICAL CARE BODY OF KNOWLEDGE
4. Planning
5. Implementation
PROFESSIONAL ORGANIZATIONS 6. Evaluation
• American Association of Critical Care Nurses
• European Federation of Critical Care Nursing ® The team work as one in the assessment phase.
Association (1997) ® Outcome identification – separates the ordinary nursing
o British Association of Critical Care Nurses practice from nursing practice in the ICU/Critical care
o 22 members unit.
• Australasia
o Australia ASSESSMENT PHASE
o New Zealand Standards of Practice/Care
• South Africa
• Critical Care Nurses Association of the Philippines THE NURSE CARING FOR ACUTE AND CRITICALLY ILL
PATIENTS
(CCNAPI)
o The national organizations of the nurses in 1. Collects relevant patient health data pertinent to the
critical nursing issue, situation, or trend.
o Formed 1975, incorporated in 1977
o “Safe, quality patient care is achieved if you COMPETENCIES
are informed. Primary to how you behave is
education. We pride ourselves to be 1. Collects comprehensive data of:
considered as advocates of patients.” • patient, family, other health care provider and
community.
• To develop a holistic picture of patient’s needs.
DEFINITIONS
COMPETENCY - An integration of the knowledge,
2. Prioritize data collected according to patient
attitudes, and skills necessary to
conditions r/t the immediate predicted needs.
function in a specific rule and work
3. Uses valid evidence-based assessment techniques,
settings. (AACN, 2015)
instruments, and tools to evaluate patient condition
- Involves a range of skills:
according to ae and health status.
o Psychomotor (technical)
4. Document relevant data in patient file in clear and
o Cognitive
systemic manner, easily retrievable.
o Interpersonal
5. Maintains documentation within the legal and
(Aitken, Chaboyer, Elliot, 2019)
ethical framework.
- the ability to perform clinical nursing
care that is based in the nurse’s
® Ex: A patient comes to the ER which shows
ethical thinking and accurate nursing
symptoms of respiratory problem; dyspnea, fever,
skills and that is provided to meet the
etc etc.
needs of the cared” (Japanese Nurses
® Competencies:
Association, 2017)
o Assess the patient to collect pertinent dta
COMPETENT - Performing within a clinical o Patient is dyspneic (priority)
NURSE environment specific to the context to
o Instrument: Oxygen Sat, Laboratory
which it is demonstrated a examinations (ABG)
combination of skills, behaviors and

2
 o Document the results, data in a systemic PLANNING
manner. Standards of Practice/Care
o Adhere to the ethico-standard.
THE NURSE CARING FOR ACUTE AND CRITICALLY ILL
o Read from other sources to know why the PATIENTS
patient has this manifestation and to be
ready for the diagnosis. 3. Identifies expected outcomes for the patient.

Organizes, synthesizes, analyses, and interprets the

assessment data of the critically ill patient from various COMPETENCIES:
data sources to derive nursing diagnoses.
1. Recognizes the outcomes from assessments and
diagnoses.
2. Respects patient and family perspectives and values
in formulating culturally appropriate outcomes in
collaboration with the patient and family, & with
the interprofessional team.
3. Considers associated risks, benefits, current
evidence, clinical expertise, & cost when
DIAGNOSIS
formulating expected outcomes.
Standards of Practice/Care 4. Modifies expected outcomes based on change sin
THE NURSE CARING FOR ACUTE AND CRITICALLY ILL patient conditioned or situation.
PATIENTS 5. Documents outcome as measurable goals in patient
file in clear and systemic manner.
2. Utilizes the assessed data to analyze and formulate the
Ex:
nursing diagnoses and related condition.
® Nursing Diagnosis: Ineffective Airway Clearance
® Based on the laboratory exams, the ABGs revealed
respiratory alkalosis 78% pulse oximeter.
COMPETENCIES:
® Expected Outcome: Respiratory Arrest (if no plan of
care)
1. Develops nursing diagnoses or related conditions
based on nursing assessment.
2. Uses the collected data in clinical decision-making
to improve patient safety.
3. Validates diagnosis with patient, family, and other EXPECTED OUTCOMES
healthcare providers. Standards of Practice/Care
4. Documents relevant dta in patient file in clear and THE NURSE CARING FOR ACUTE AND CRITICALLY ILL
systemic manner. PATIENTS
5. Formulates nursing diagnoses based on accurate
analysis and interpretation of the assessment data. 4. Develops and facilitates the plan that prescribes
6. Establishes priorities concerning the critically ill interventions and alternatives to attain outcomes
patients problems according to severity. within the three spheres of influences:
• Patient / Family
• Nursing / Nursing Practice
• Organizations / System

3
 COMPETENCIES: COMPETENCIES:

1. Employs critical thinking and judgement in 1. Employs strategies to promote and maintain safe
developing an individualized plan using best environment
evidence. 2. Coordinates implementation of the plan with the
2. Collaborates with the patient, family, and patient, family, and interprofessional team.
interprofessional team to develop the plan. 3. Intervenes to prevent and minimize complications
and alleviate suffering.
MEASUREMENT CRITERIA 4. Facilitates learning for patients, families, and the
community.
3. Establishes priorities and continuity of care within 5. Documents implementation in a clear systematic
the plan. manner.
4. Determines the strategies for health promotion and 6. Provides age & developmentally appropriate care in
prevention of further illness or injury within the a culturally. And ethically sensitive manner.
plan.
5. Considers associated risk, benefits, current ® Note the religion/culture of the patient when giving
evidence, clinical expertise, resources and cost interventions
when developing a plan. ® Implement now the plan of care:
6. Documents the plan in as clear and systemic o Position the patient in high fowlers
manner. o Raise the oxygen concentration (face
mask/venturi mask)
® Plan of Care Example: o Give mechanical ventilation
® Independent Nsg Intervention: o Refer to respiratory therapist to promote
o High fowlers position better lung expansion (collaborative)
o Raise oxygen concentration (face
mask/venture mask)
® Dependent NSG Intervention:
o Mechanical Ventilation
EVALUATION
® Collaborative NSG Intervention:
Standards of Practice/Care
o Refer to Respiratory Therapist
THE NURSE CARING FOR ACUTE AND CRITICALLY ILL
PATIENTS
6. Evaluates processes and outcomes.

COMPETENCIES:
IMPLEMENTATION
Standards of Practice/Care 1. Conducts systematic and continuing evaluations
THE NURSE CARING FOR ACUTE AND CRITICALLY ILL using E – B technique, tools and instruments
PATIENTS 2. Conducts systematic and continuing evaluations
using E-B techniques, tools, and instruments
5. Implements interventions within the three spheres of 3. Collaborates with the patient, family and
influence: interprofessional team in the evaluation process
• Patient / Family 4. Revise the assessment, diagnoses, outcomes, and
• Nursing / Nursing Practice interventions based on the information gained
• Organizations / System during the evaluation process
5. Document the results of evaluation in a clear and
systematic manner

® EVALUATION: Document the effectiveness of the

interventions
® (ex: patient was given venturi mask 10 liters, pulse
ox. Remained at 85-86% from 78%)

4
 STANDARD OF PROFESSIONAL PRACTICE STANDARD 2: PROFESSIONAL PRACTICE EVALUATION
The competent level of behaviour in a professional role,
® The nurse caring for the acutely and critically ill
including activities related to:
patient: Evaluates his/her own nursing practice in
1. Quality of practice relation to professional practice standards,
2. Professional practice evaluation organizational guidelines, relevant statutes, rules and
3. Education regulations.
4. Communication
5. Ethics COMPETENCIES:
6. Collaboration
7. Evidence-based Practice 1. Engages in as self-evaluation and reflective practice
8. Resource utilization on a regular basis, identifying areas of strength, as
9. Leadership well as areas where professional growth would be
10. Environmental Health beneficial.
2. Takes action to achieve goals identified in the
evaluation process.
® Best feedback: PATIENT. Ask if the patient’s
condition improved after intervention.
STANDARD 1: QUALITY OF PRACTICE

® The nurse caring for the acutely and critically ill

patient: Contributes to the quality and effectiveness
of nursing practice. STANDARD 3: EDUCATION

COMPETENCIES: ® The nurse caring for the acutely and critically ill
patient: Maintains current knowledge and
1. Participates in clinical inquiry through quality competence in the care of acutely and critically ill
improvement activities. patients.
2. Consults with colleagues, subject matter experts,
and identified stakeholders to initiate changes in ® As an ICU nurse, we should continue to upgrade
nursing practice and the healthcare delivery. with the latest. Ex: through webinars, seminars,
3. Conducts and participates in quality improvement lectures, our knowledge is being upgraded.
activities, taking into consideration patient and ® Ex: before the normal bp is 120/80 mmHg, not it is
family beliefs, values, and preferences. 90-108/70-80 mmHg. If 120 ang systolic, pre-
® Taking care of a patient, we should take into hypertensive na (WHO)
account the totality/holistic of an individual.
4. Ensures patient confidentiality in reporting and COMPETENCIES:
quality data.
5. Evaluates practice in an ongoing process, based on 1. Participates in ongoing learning experiences and
best evidence. activities to develop and maintain clinical and
6. Identifies barriers to quality care and patient professional skills and knowledge.
outcomes. 2. Seeks learning opportunities that reflect current
7. Participates in the development, implementation, and evidence-based practice.
evaluation, & revisions of policies, procedures, 3. Shares educational findings, experiences, and ideas
and/or guidelines. with peers.
8. Uses creativity & innovation to enhance quality 4. Contributes to a work environment conductive to
nursing care. the education of healthcare professionals.
9. Demonstrates quality by documenting the 5. Maintains professional records or a portfolio that
application of the nursing process in responsible, provides evidence of competence and lifelong
accountable, & ethical manner and ion a clear and learning.
retrievable format.

5
 3. Protects patient confidentiality within legal and
STANDARD 4: COMMUNICATION regulatory parameters.
4. Advocates for the concern of patients, their
® The nurse caring for the acutely and critically ill families, and the community.
patient: Utilizes skilled communication in a variety of 5. Delivers care in a non-judgmental &
formats. nondiscriminatory manner that meets the diverse
needs of the patient, family, and community.
® We should adjust to level of 6. Maintains patient autonomy, dignity, values,
understanding/communication of the patient. beliefs, and rights at all times.
® Regardless of race/sex/condition, we should
COMPETENCIES: give equal care to patients.
® Even if the patient is dying, there should be
1. Assesses communication format preferences of dignity/dignified death.
acutely & critically ill patients, families, and 7. Uses available resources in formulating ethical
interprofessional team. decisions
2. Practices interprofessional communication skills and 8. Demonstrates a commitment to self-care and self-
reflects upon personal communicating style. advocacy.
3. Solicits feedback to continuously improves his or 9. Reports unethical, illegal, incompetent ot impaired
her own communication and conflict-resolution practices.
skills. 10. Assists patient and family in self0determination and
4. Conveys accurate information to A & CI=P families informed decision-making.
and the interprofessional team. 11. Maintains a therapeutic and professional
5. Questions the rationale supporting care processes nurse/patient relationship within appropriate role
and decisions with all members of the boundaries.
interprofessional team. 12. Contributes to resolving issues involving the
6. Disclose observations or concerns related to safety, patient, family, and interprofessional team.
hazards, and errors in care or the practice 13. Questions healthcare practice when necessary for
environment as appropriate. safety and quality improvement.
7. Maintains open communication with other 14. Collaborates with interprofessional team to
providers to minimize risks associated with patient promotes palliative care or end-of-life discussions,
handoffs, transfers, and transitions in care. decisions and care.
8. Contributes her/his own professional perspective in
discussion with the interprofessional team.
® Endorsing is an effective way of communicating
with colleagues to minimize risks/negligence.
9. Exhibits respect for other’s perspectives in STANDARD 6: COLLABORATION
discussion with patients, family, & the
interprofessional team. ® The nurse caring for the acutely and critically ill
10. Advocates for escalation of care delivery when the patient: Collaborates with patient, family, and
needs of the patients are not adequately met. interprofessional team.

COMPETENCIES:

STANDARD 5: ETHICS 1. Partners with others to effects change and produce

positive outcomes through knowledge-sharing.
® The nurse caring for the acutely and critically ill 2. Adheres to standards that govern behavior among
patient: The nurse’s decision and actions are carried interprofessional team to create a healthy work
out in an ethical manner in all areas of practice. environment that promotes cooperation, respect
and trust.
COMPETENCIES: 3. Collaborates with the patient’s family to promote
effective and safe transition across care settings.
1. Practices as guided the PNA code of ethics, the 4. Engages in teamwork and conflict resolution.
CCNAPI values and ethical principles. 5. Contributes to creating an interprofessional plan of
2. Promotes ethical accountability & integrity in care.
relationships, organizational decisions, and 6. Promotes respect and engagement among nursing
stewardships of resources. collegues.

6
 5. Advocates for additional resources that enhance
STANDARD 7: EVIDENCE-BASED PRACTICE / RESEARCH / nursing practice and quality care.
INQUIRY

® The nurse caring for the acutely and critically ill

patient: Uses clinical Inquiry and integrates best
evidence into practice.
STANDARD 9: LEADERSHIP
COMPETENCIES:
® The nurse caring for the acutely and critically ill
1. Questions clinical practices for the purpose of patient: Provides leadership in the professional
improving the quality of care. practice setting, as well as in the profession.
2. Describes clinical problems using evidence
generated within a clinical setting such as patient COMPETENCIES:
assessment data, outcomes management, and
quality improvement data. 1. Contributes to the creation and maintenance of
3. Formulates clinical questions. healthy work environment.
® The doctors will meet to talk about the 2. Supports peers and colleagues through mentoring
interventions/outcome management in order and other professional development strategies.
to improve the care given to the patient. 3. Demonstrates flexibility and the ability to remain
4. Participates in evaluating evidence to determine the patient0focused in a rapidly changing environment.
applicability of the practice. 4. Directs the coordination of care among caregivers,
5. Assists with integrating evidence into policy, including oversight of licensed and unlicensed
procedure, and practice. personnel in any assigned or delegated tasks.
6. Implements practice changes based on evidence, 5. Participates on committees, councils and
clinical expertise and patient preferences to professional teams.
improve care processes and patient outcomes. 6. Promotes advancement of the profession through
participation in professional organization.
7. Develops a culture of safety for patient, families,
and the interprofessional team.
8. Promotes communication of information and
STANDARD 8: RESOURCE UTULIZATION advancement of the profession through writing,
publishing, & presentations for professional or lay
® The nurse caring for the acutely and critically ill audiences.
patient: Employs appropriate resources to plan and 9. Promotes development and implementation of
provide services that are safe, effective, and financially innovative solutions.
responsible.

COMPETENCIES:

1. Assess the individual patient needs and the STANDARD 10: ENVIRONMENTAL HEALTH
available resources to achieve desired outcomes.
2. Delegates elements of care (as defined by ® The nurse caring for the acutely and critically ill
regulatory agencies) to the appropriate individual patient: Maintains a safe and healthy environment.
based upon assessed needs and condition of the
patient stability, predictability of the outcomes, COMPETENCIES:
competence of the individual and resources
available. 1. Minimizes environmental risk factors that may
3. Assists the patient and family in identifying and cause physical harm or injury to patients, families
securing appropriate services to address health0- and the interprofessional team.
related needs according to resources availability. 2. Implements strategies to reduce the impact of
4. Informs the patient and family regarding the environmental factors that jeopardizes health such
options, alternatives, risks, and benefits if nursing as sound, odor, noise, & light.
interventions.

7
 3. Communicates environmental health risks &
exposure-reduction strategies to patients, families,
& colleagues.
4. Uses reliable resources to determine if product or
treatment is an environmental threat.
5. Participates in strategies & activities to promote
healthy communities.

CLINICAL GOVERNANCE

• A system through which hospital organizations are

accountable for continuously improving the quality of
their services and safeguarding high standards of care
by creating an environment in which excellence in ICU PHYSICAL DESIGN
clinical area will flourish. (Scally & Donaldson, 1998)

QUALITY of care delivery

§ Training
§ Observance of policies and procedures
§ Teamwork
§ Communication
§ Complaints Management
§ Leadership
§ Feedback

8
 INTENSIVE CARE ® 50/50 patients
® More comprehensive and
• The practice of administering immediate and sophisticated care is required.
continuous care to client with actual or potentially life-
threatening health disorder. RISK MANAGEMENT IN CRITICAL CARE
o Brain injuries
o Cardiovascular dysfunctions DEFINITION - An organized effort to identify,
o Pulmonary dysfunction assess, and reduce, where
o Childbirth appropriate, risk to patients,
o Infection / sepsis visitors, staff, and organizational
o Shock and trauma assets.
o Endocrine abnormalities - Comprises the system and
o Multisystem alterations processes employed to uncover,
o Complex surgical procedure. mitigate, and prevent risks in
healthcare institutions.
LEVELS OF ICU Examples - Regular use of hand
LEVEL 1 • Initial stabilization of critically ill sanitizers/handwashing
patients provided but limited - Color-coded signs and walkways
ability to provide comprehensive - Harassment-related training and
critical care. policies of staff
• Provision of oxygen - Robust cyber security.
• Non-invasive monitoring - Legal teams identification of
• Patients who require routine care potential risk of malpractice
• Policies are established to lawsuits.
determine which patients require
transfer and where they ought to
be transferred. RISK MANAGEMENT PROCESS
® Level 1 – close monitoring only. IDENTIFICATION - write all down the threats and risks
No invasive procedure has been you can think of and ask for ones
done. from other stakeholders.
LEVEL 2 • Comprehensive critical for most ASSESSMENT - evaluate each risk by determining
disorders. the like hood of it happening and
• With invasive monitoring the level of impact it’d have.
• Basic life support MITIGATING - implement process changes to
• Transfer arrangements to level 1 reduce the impact of each risk and a
is place for patients with the response plan for if it happens.
specific disorder for which the
unit does not provide care. MONITORING - review the progress of the plan and
® Level 2 – Close monitoring + check if a risk has occurred but was
more intensive care is required. missed on a continuous basis.
® Ventilated patients. REPORTING - communicate the effectiveness of
® Ex: Head Injury Patient. the risk plan to stakeholders to keep
LEVEL 3 • Comprehensive care for a wide engagement up.
variety of disorders. Ex: Risk Problem: A patient who is semi-conscious, restless,
• Sophisticated equipment and irritable. Risk MGT: Side rails up.
• Specialized nurses
• Intensivists ® NOTES.
• Comprehensive support service 1. IDENTIFICATION – all the threats & risks
o Pharmacy 2. ASSESSMENT – evaluating each specific risk.
o Nutrition 3. MITIGATION – decrease in impact of each risk. A
o Respiratory response for it if tit happens. (e.g impact to restless,
o Pastoral irritable pt [ could harm him/her], corresponding
o Social work solution [raise side rails]
® Level 3 – ex: semi-conscious 4. MONITORING – “review progress”, “checking for new
patient with atelectasis. risk, “how effective”, constant.

9
5. REPORTING – Communication between HC providers QUALITY AND SAFE MONITORING

What is quality monitoring healthcare?

- Quality measures are “tools that help us measure or
quantify health care processes, outcomes, patient
perceptions, and organizational structure and/or
systems. “1 they may also be called performance
measures”

What is safety monitoring?

METHODOLOGY
- Safety monitoring is the regular checking or corporate
Survey of hospital staff. safety standards and procedures. The monitor must be
Monitoring patients to observe any challenges the face a competent person who is appointed by the company
during their time in a hospital and does not have responsibilities that would distract
Analyzing past record for patterns or trends him or her from their monitoring duties.
Feedbacks from patients
Incident reports. What is the difference between safety and quality?
- Quality has been defined by the federal agency for
WHAT IS NEXT? healthcare research and quality (AHRQ) as “doing the
right thing at the right time for the right person and
• DEVELOPMENT – health care staff can formulate a having the best possible result” Patient safety is simply
system addressing and managing the risk. defined by the World health Organization as “the
• PREVENTION – prevent the risk from spreading. prevention of errors and adverse effects to patient.”
• AVOIDANCE – avert the possibility of disrupting
healthcare activities. What are the components of quality in healthcare?
- Quality health care is care that is safe, effective,
patient-centered, timely, efficient and.. cut sa ppt
THE CAVEAT
• Healthcare risk management acknowledges that the What is continuing professional development important in
dangers of the risk are still there, but with preparation nursing?
and strong policies, the scope of these threats can be - CPD is an important foundation of lifelong learning and
reduced. helps nurses and midwives maintain their competence
THE PURPOSE to practice. Research on CPD shows that by engaging
others in CPD planning, this results in positive learning
1. Preventing the worst case-scenario that can evolve outcomes and evidence-based changes to practice.
from a certain risk, danger, or threat.
2. Identify potential hazards or threats and do everything For Employers, investing in a programme of CPD can deliver
possible to mitigate them. a range of benefits:
- Ensures standards across the company are high and
consistent.
- Promotes greater workforce engagement
- Enhances staff commitment to job roles.
- Allows the sharing of best practice.
HOW TO DEVELOP A HEALTH CARE RISK MANAGEMENT - Maximizes staff potential
POLICY - Improves staff morale.

1. Establish the context

2. Identify risks
3. Analyze risks
4. Evaluate risks
5. Treat / Manage risks

10
 EVIDENCED BASES PRACTICE IN NURSING PICO/T SPIDER ® 5 A’s – Ask, Acquire, Appraise, Apply, & Audit.

PICOT
P – POPULATION / - Age
PATIENT - Gender
- Ethnicity
- Ondividuals with cerain diseases.
I – INTERVENTIONS - Treatment that will be provided to
the subjects of study
- Plans to address the health issues of
the patient (specific tests,
medications, & therapies)
C- COMPARISON / - Compares alternatives to the plan (a
CONTROL different type of treatment)
O – OUTCOME - Expected results after an
intervention
• Improves healthcare deliver
o Reducing symptoms
• Strengthen outcomes o Eliminating symptoms
• Diminishes geographical differences in care and cut o Full recovery
costs. T – TIME - Duration to achieve the desired
• Increase overall job satisfaction. outcome / observation of the patient
- Period of the data collection
- Optional
HISTORY
SPIDER CHARTING
• FLORENCE NIGHTINGALE (1800) – improving patient
S (SAMPLE) • The group of participants in qualitatibe
outcomes in the face of unsanitary conditions. research
• ARCHIE COCHRANE (1970) – originators of the EBM. PI • The how & why of behaviors &
(PHENOMENON experiences.
OF INTEREST)
D (DESIGN) • How the study was devised & conducted.
IMPORTANCE OF EBP TO NURSES E • The measurement of outcome.
(EVALUATION)
1. An empowering approach to care R (RESEARCH • Qualitative, Quantitative or Mixed.
2. Link between a wealth of medical research and TYPE)
practical experience on the ground.
3. Standardization of care
4. Decrease medical errors
5. Positive charges to the patients, communities and the
world.

PROCESS

11
 PICO EXAMPLES • Ventilator assisted pneumonia care bundle
• Palliative care bundle
1. HEALTH EXAMPLES
• Pressure area care bundle
Here is a health example of clinical problem formulated using PICO
“I work in an aged care facility where uriniary tract infections are a • Sepsis care bundle
common problem. I’ve heard that cranberry juice can help prevent • PVC care bundle
UTIs. I wonder if there’s any evidence for that and whether it might
help our patients?” ® Clostridium – for gram stain microorganism
P – Patients in aged care homes
I – Cranberry juice
C – No interventions (status quo)
O – Prevention of UTIs

2. NON-HEALTH EXAMPLE
“I conduct Library induction classes for new students in an academic
library. I wonder if playing mysic during the class would improve
their retention of information and their experience of using the
library”
P – First year students at an academic library attending face-to-face
induction classes
I – Playing background music in the classroom
C – No intervention (staus quo)
O – Increase retention of information and improve student comfort
with the library.

SPIDER EXAMPLES

What are the experiences of the first year univertisty students in

using library

S – First year university students

PI – Library use
D – Survey
E – Experiences (of using the library)
R – Qualitative

CARE BUNDLES CHECKLIST

• A care bundle is a collection of interventions (usually 3 –

5) that are evidenced based.
• All clinical staff know that these interventions are best
practice but frequently their application in routine care
is inconsistent.
• A care bundles is a means to ensure that the application
of all the interventions is consistent for all patients at all
times thereby improving outcomes.

TYPES OF CARE BUNDLES

• WHO Surgery Safety Checklist
• Urinary catheter care bundle
o Insertion and Management
• Clostridium difficile

12
 CONTINOUS QUALITY IMPROVEMENT PDCA NURSES ROLE AS MEMBER OF THE RESEARCH TEAM

5 Major uses of Plan-Do-Check-Act (PDCA) Ethical principles for nursing research are in many ways the
• Process improvement natural extensio0n of ethical principles for professional
• Change management nursing practice. Whether planning research or reading,
• Maintaining control over a project understanding and applying ethical principles is an
• Performance management important element of ensuring the highest quality evidence
• Organizational competitiveness for practices.

® PLAN – DO – CHECK – ACT = continuous loop, used for PRINCIPLES OF RESEARCH ETHICS
TESTING IMPROVEMENT MEASURES on SMALL,
innotive. • Respect for persons-autonomy and protecting those
® Plan – establish obj & process with diminished autonomy.
® Do – Implementing • Beneficence and non-maleficence.
® Check – monitoring & measuring processes against • Justice
health and safety policy, objs, legal & other • Informed consent
requirements reporting results. • Confidentiality and data protection.
® Act – taking actions = to continually improve. • Integrity
® E.g epistaxis: hyperextending the neck = blood backflow • Conflict of interest
to lungs = blood clots = pulmonary edema.
The following are examples of a few of the most common
personal ethics shared by many professionals:
• Honesty. Many people view honesty as an important
ethic.
• Loyalty. Loyalty is another common personal ethic that
many professional shares.
• Integrity.
• Respect
• Selflessness
• Responsibility.

What are the qualities and roles of a nurse researcher?

- Nurse researchers identify research questions, design
and conduct scientific studies, collect, and analyze
data and report their finding. They often rely on grants
WHAT CAN PDCA BE USED FOR? to fund their work, which requires writing grant
- The PDCA/PDSA cycle is a continuous loop of planning, proposals and meeting certain reporting requirements.
doing, checking (or studying), and acting. It provides a
simple and effective approach for solving problems and What are the roles of nurses?
managing changes. The model is useful for testing - Nurses have many duties, including caring for patients,
improvement measures on a small scale before communicating with doctors, administering medicine
updating procedures and working practices. and checking vital signs. Making up for the biggest
healthcare job in the U.S nurses plays a vital role in
WHAT IS THE MOST IMPORTANT PART OF PDCA? medical facilities and … (cut sa ppt)
- The argument for “do” being the most important step is
that if it is skipped, nothing happens, and there is no
process to begin with. Check. Checking confirms that ROLE OF THE RESEARCH NURSE
you’re on target to do what you said you would do.
Regular check-ins confirm that everyone is sync and Identifying and screening potential patients. Making sure
progressing towards the end goal. that patient shave all the necessary information to allow
them to make a study. Ensuring that patients give fully
informed consent before they are enrolled in a study.

Currently research is not a part of the nursing curriculum

but is being introduced in the form of assignments in varies
subjects. Nurses therefore has a very basic idea of what

13
research entails, but there is still a huge gap as to research etiquette, waste management and decontamination,
training in the nursing curriculum. For this reason, and appropriate use of personal protective equipment.
appropriate training in roles and responsibilities that enters
the area of research. The reasons for nurses making the
switch from clinical service to research are varied. It may
range from desire to work better hours, earn a better salary
or seek new opportunities and challenges. Many nurses,
however, choose research out of curiosity to explore a new
aspect of…. CUT NANAMAN HAYS SHARIF ANO BA

INFORMATION AND COMMUNICATION TECHNOLOGIES IN

CCU

- The CCIS provides near-real time data on very patient

admitted to level 3 and level 2 critical care units in
Ontario’s acute care hospitals. The system also
provides information on bed availability, critical care
service utilization and patient outcomes through the
“Report Functionality”

- CCIS is a the most comprehensive source of province-

wide information on access to critical care, quality of NOTES
care and outcomes for critically ill patients. The data
captured in CCIS is also used to develop quarterly 1. Identify pt. correctly ▪ e.g. wrist tag
reports to inform health care system improvements. 2. Improve staff communication ▪ e.g laboratory
staff & ward staff should have a good relationship
What is an example of clinical information system? in order to secure lab results on time.
- Inpatient clinical information systems including The 3. Use of medicine safety ▪ e.g. syringe with
Inpatient Electronic Medical Record (EMR) And cefuroxime must be labeled with plaster that's
Computerized Provider Order Entry (CPOE) Systems. taped to it
Specialty systems like the Emergency Department, 4. Use of alarm system
Information System, ICU Information System,
5. Prevention of infection ▪ e.g. SOP - handwashing
Cardiology Information System, and Oncology
(to prevent cross contamination)
Information System.
- There are various types of information system for
6. Identify pt. safety risks ▪ e.g. those with suicidal
example: transaction processing system, decisions tendencies
support systems, knowledge management systems, 7. Prevent mistakes in surgery ▪ e.g. right location
learning management systems, database management for surgery
systems, and office information systems.

What are 3 of the universal guidelines for patient safety? THIS IS DONE TO MAKE SURE THAT EACH PATIENT GETS THE
• The easy to remember mnemonic is based on a CORRECT MEDICINE AND TREATMENT
universal protocol from the Joint Commission and
stand for: Universal Precautions (achieved by using • Identify patients correctly
sterile cap, mask, gown and gloves); wider skin prep; • Prevent infection
extensive draping; and tray positioning. • Improve staff communication
• Identify patient safety risks
What safety precautions can used in the ICU to reduce the • Prevent mistakes in surgery
risk and hazards?
• There are standard and transmission-based regulations
in healthcare facilities to prevent infections occurring
is the ICU workforce. Standard precaution include
hand washing, respiratory hygiene and cough

14
 ETHICS vs LAW ETHICAL DILLEMA WITHIN HEALTHCARE
LAW ETHICS
Formal. Written document Unwritten principles • DISAGREEMENTS
Interpreted by courts Interpreted by everyone o Nurses
Established by legislators Presented by philosophers, o Patient
religious, professional o Healthcare team
groups. o Family issues involved as well as making
Applicable to everyone Personal choice decisions.
Priority decided by court Priority determined by
individual • Conflict between the Duties, Rights, Values of the
Court makes final decisions No external decision maker. people involved in the situation.

ETHICAL & LEGAL CONSIDERATIONS

ETHICAL DILEMMA

• What are the facts?

• What is the big picture?
• Know the legal issues involved as well as how to
engage in ethical discourse and decision making.

LEGAL & ETHICAL ISSUE

• Informed consent
• End-of-life issues
• Organ transplantation (recipients and living donors)
• Use of restraints

LEGAL ISSUES

TORT LAW: wrong committed against a person or the

person’s property.
ETHICS 1. Negligence
2. Assault
3. Battery
• Comes from the Greek word “ethos” (character)
• Each person has their own set of personal ethics and
morals. CRITICAL CARE ETHICAL AND LEGAL RESPONSIBILITIES
• Moral principles that govern how a person, or a group WITHHOLDING - Never initiating a treatment
will behave or conduct themselves.
WITHDRAWING - To stop a treatment once
ETHICAL DESION MAKING started. Best made after
• Merged as a major component of healthcare for the careful discussion (healthcare
critically ill. professional, patient, and
• Refers to the process of evaluating and choosing family)
among alternatives in a manner consistent with ethical
principles. INFORMED CONSENT - In order to be considered
legally effective, consent to
ETHICS WITHIN HEALTHCARE medical treatment must
• Important meet 3 tests:
• Workers must recognize healthcare dilemmas 1. Voluntary
• Make good judgements and decisions based on their 2. Adequately informed or
values while keeping within the laws that govern them. knowing
• To practice competently with integrity, nurse, must 3. Given by an individual
have regulation and guidance within the profession. with adequate mental
capacity and legal
authority.

15
 ® Minors cannot sign. - Nurses may serve a witness
for people consenting to
ADVANCE DIRECTIVES donate organs.
- Is a documented by which a
person makes provisions for - Organ Transplant Act, 2072
health care decisions in the has also been passed in
event that, in the future, Nepal.
he/she becomes unable to - First brain death donor
make those decisions. kidney transplant was
- These directives may also performed on may 2017.
designate a specific surrogate AUTOPSY - An autopsy or postmortem
decision maker who then has examination is an
ethical and possibly legal examination of the body
standing to make medical after death.
decisions for the patient. - The law describes under
® “interventions” what circumstances an
® Made while pt is mentally autopsy must be performed,
capacitated. for example, all medico-Legal
INCIDENT REPORTS cases should undergo
- Document the occurrence of
autopsy.
anything out of the ordinary
that results in, or has the
potential result in harm to a
patient, employee or visitor.
- The nurse responsible for a
potentially or actually
harmful incident or who
witnesses an injury is the one
who fills out the incident
form.
® Who will fill it up?
® (1) One who is responsible
for the incident.
® (2) one who is a witness.
PASSIVE EUTHANASIA - Passive euthanasia is legal in
India. On 7 march 2011 the
supreme court of India
legalized passive euthanasia
by means of the withdrawal
of life support by patients in
WHAT IS THE IMPORTANCE OF RA 913 TO THE NURSING
a permanent vegetative
PROFESSION?
state.
- In Nepal?
• This bill seeks to institute reforms to further protect
® Withdrawal of life support.
and develop nursing profession, amending for the
DECLARING BRAIN - Require a physician not purpose Republic Act (RA) No. 9173, otherwise known
DEATH involved in the patient as the “Philippines Nursing Act of 2002” RA 9173 was
treatment to document brain enacted in 2002 to provide a comprehensive definition
death and another physician and understanding of the nursing profession.
to confirm the findings.
- 3 essential findings in brain
death are coma, absence of
brainstem reflexes and
apnea.

ORGAN DONATION - The donation can be made by

DECISION a provision in a will or by
signing a card-like form.

16
 PATIENT BILL OF RIGHTS - Extent of what Philhealth/
other payor may shoulder the
• A guide to ensure every patient gets good, quality payment.
healthcare. - Itemized bill of
• Contains rules that healthcare providers should hospitalization.
observe toward the patient and their families during - Continuing care requirements
hospitalization. following discharge.
• Not legally binding. - Brief, written summary of the
course of illness.
- Medical certificate free of
1. RIGHT TO - Human dignity charge.
APPROPRIATE - Convictions 5. RIGHT TO - Exceptions:
MEDICAL CARE - Integrity CHOOSE HEALTH a) Under the care of service
AND HUMANE - Individual needs CARE PROVIDER facility.
TREATMENT. - Culture & FACILITY b) Public health & safety.
- Informed of reason for the c) Patient waives in written
delay in treatment. form.
- Immediate care during - Right to discuss illness
emergencies. condition with a consultant/
2. RIGHT TO - Clear, truthful explanation, specialist.
INFORMED except in the following - Right to seek for a second
CONSENT situations: opinion & subsequent
o Emergency situations opinions.
o Health of the population
o Mandated by the law
o Minor, legally PATIENT BILL OF RIGHTS AND OBLIGATIONS:
incompetent. UNCONSCIOUS CLIENT
o Success of the
treatment is in jeopardy.
• A patient has the responsibility to provide, to the best
o Patient waives right in
of their knowledge, accurate and complete information
written form.
about present complaints, past illness, hospitalizations,
3. RIGHT TO EXCEPTIONS: medications, and other matters relating to his/her
PRIVACY & a) Patient’s mental or physical health.
CONFIDENTIALITY condition is in controversy as
directed by the appropriate RIGHT OF UNCONSCIOUS PATIENT
court
• Informed consent must be obtained whenever
b) Health care providers: possible, from a legally entitled representative
o Benefit the public & however;
safety. o When medical intervention is urgently
o Interest of justice & needed, consent of the patient may be
upon order of a
presumed.
competent court.
o Unless it is obvious beyond any doubt (DNR)
o Patient waives in
writing.
o Needed for continued
medical treatment or
medical advancement.
c) Spouse/family upon patient’s
decision.
4. RIGHT TO - Results of the evaluation
INFORMATION - Additional or further
contemplated medical/
surgical treatment.
- Changes in plan of care prior
to its implementation.

17
 ICU NURSE AS A PATIENT’S ADVOCATE those who are vulnerable or are unable to speak up for
themselves.
They can help patients make informed decisions regarding
their health, including them navigate a complex medical WHAT ARE THE 3 TYPES OF ADVOCACY
system, translating medical terms and helping patients
make ethical decisions. Because they have the most direct 1. Self-advocacy
interaction with patients, nurses are idally positioned to be 2. Individual Advocacy
advocate. 3. Systems advocacy

HOW IS A NURSE A PATIENT ADVOCATE? WHAT ARE THE 7 PRINCIPLES OF SOCIAL WORK?

Advocacy is an essential part of nursing. Nurses are ideal • Purposeful Expression of Feelings
patient advocates because they interact with patients daily. • Controlled Emotional Involvement
They know when patients are frustrated and confused • Acceptance
about their care plan. Patients rely on nurses to not only • Individualization
provide care but to counsel and educate them about their • Non-Judgmental Attitude
healthcare choices. • Client Self-Determination
• Confidentiality
WHAT IS THE NURSE’S ROLE PATIENT ADVOCACY?
WHAT ARE THE 6 CORE VALUES OF SOCIAL WORK?
Nurse advocates support the patient’s best interest while
respecting the family’s important role. They attend The following broad ethical principles are based on social
healthcare team meetings with the patient and family to work’s core values of service, social justice, dignity and
clarify any communication problems and ensure worth of the person, importance of human relationships,
information from the healthcare team is complete and integrity, and competence. These principles set forth ideals
correct. to which all social workers should aspire.

WHAT DOES IT MEAN TO BE NURSE ADVOCATE DOES NURSING ADVOCACY INCLUDE END OF LIFE CARE

A nurse advocate is a nurse who works on behalf of Regarding end-of-life care in ICU, nursing advocacy include
patients to maintain quality of care and protect patient’s pain and symptom management, ethical decision making,
rights. They intervene when there is a care concern, and caring based on patients’ culture, and assistance during the
following the proper channels, work to resolve any patient death and the dying process.
care issues.
WHAT IS AN EXAMPLE OF PATIENT ADOVCACY?
PROFESSIONAL NURSNIG ETIQUETTE

Nurses as mediators between patients and doctors who

1. Introduce yourself. Put out your hand for a handshake
may have overlooked certain patient needs or solutions. and say your name in a confident voice. Be ready to
For example, if a patient receives an inaccurate diagnosis, introduce colleagues to others as well.
unsafe accommodation, or unclear instructions for self- 2. Have a confident handshake. Many people judge
care, the nurse must alert the doctor or medical facility and others by the quality of their handshake, so make sure
communicate the issues. it’s confident and firm (but not too firm-don’t overdo
3 TIPS FOR EFFECTIVE NURSE ADVOCACY it.)
3. Keep your conversations on track. To avoid
inadvertently offending someone, stay away from
1. Suspend Judgement. Shafer explains that the first step
controversial topics such as religion and politics.
to better patient advocacy is to suspend judgement.
4. Watch your body language. When making
2. Practice communication skills
conversation, don’t forget that the care you invest is in
3. Stay informed.
your words can be undone by nonverbal
WHAT IS THE ROLE OF ADVOCACY IN SOCIAL WORK communication.
5. Cultivate a positive work environment. Be polite and
Advocate. In this role, social workers fight for the rights of courteous to your colleagues, no matter how stressful
others and work to obtain needed resources by convincing the situation.
others of the legitimate needs and rights of members of 6. Dress for success. If you dress to casually, patients may
society. Society workers are particularly concerned for question your professionalism and attention to detail.
7. Present a positive, professional Image. --- na cut na.

18
 cancer these “late effects” if they happen or
PATIENT CARE FOR CRITICALLY ILL
treatment last for months or years after
treatment.
Palliative care in the ICU is a widely discussed topic and its 7. For • As for child prepare to start cancer
increasingly applied in clinics. It encompasses symptoms children treatment, you might worry about
control and end-of-life management, communication with the treatment-related side effects.
relatives and setting goals of care ensuring dignity in death But palliative care is also available for
and decision-making power. children. It is an important part of
your child’s treatment plan,
regardless of his or her age or the
WHAT IS THE PURPOSE OF PROVIDING PALLIATIVE CARE TO stage of disease.
SERIOUSLY ILL PATIENTS
8. For • Palliative care is not only for the
caregivers person with cancer. It can also
Palliative care specialized medical care that focuses on and include support for caregivers and
providing patients relief from pain and other symptoms of a
children children of people with cancer.
serious illness, no matter the diagnosis or stage of disease.
Palliative care teams aim to improve the quality of life for 9. For older • Palliative care can be especially
adults important if you are 65 or older.
both patients and their families.
Older adult can have more physical
side effects, especially from
AREAS WHERE PALLIATIVE CARE chemotherapy.
1. Emotional • Having cancer can make you feel
many different emotions, such as FIVE PHYSICAL SIGNS THAT DEATH IS NEARING
sadness, anxiety, or anger. It can also 1. LOSS OF • As the body shuts down, energy
make you very stressed. A support APPETITE needs decline. Your loved one may
group, counselor, psychologist or start to refuse foods that are hard
other specialist can help you to chew or digest like meat.
understand and cope with these
2. INCREASED • Decreased food intake leads to less
emotions.
PHYSICAL energy and simple activities like
2. Spiritual • Having cancer can bring up many WEAKNESS sitting on the edge of the bed, lifting
spiritual questions. you might one’s arm to change clothes and
struggle to understand why you got having a short conversation become
cancer., or you might want a greater difficult.
purpose after surviving cancer.
3. LABORED • Towards end of life most people
3. Mental • Cancer symptoms, treatments, and BREATHING begin to experience changes in
medications can all affect how your breathing. Shortness of breath is
mind works. For example, if you are often described as air hunger.
not sleeping enough, you might feel 4. CHANGES • Dehydration from decreased oral
stressed and have a hard time IN intake will lower blood pressure,
thinking clearly. Or you might be very
URINATION leading to decreased renal function
anxious about whether your
(decreased urine output) and
treatment is working.
eventually renal failure.
4. Financial • Cancer treatment can be expensive. 5. SWELLING • Various chronic illnesses contribute
This might be a cause of stress and OF FEET, to edema and swelling of the feet
anxiety for you and your family. In ANKLES, & and hands as the disease becomes
addition to treatment cost, you might HANDS unmanageable.
find that you have other extra
expenses, such as the cost of
travelling to a cancer center for care.
5. Physical • Physical side effects of care and its
treatment depend on several factors.
These include your type of cancer, its
stage, the treatment, and your
general health. Physical side effects
can include:
6. Palliative • Sometimes, physical side effects can
care after last after treatment ends. Doctor call

19
 NURSING PROCESS ASSESSMENT Collection of information about
patients health condition
INTRODUCTION DIAGNOSIS Identify the patients problems from
collected data
The nursing process entails gathering and analysing data in PLANNING Set the goal of care and started and
order to identify clients strengths and potential or actual identify appropriate nursing
health problems and developing and continually reviewing actions
a plan of nursing interventions to achieve mutually agreed IMPLEMENTATION Putting the plan
outcomes into action
• Critical thinking is used throughout nursing the process EVALUATION Evaluate if goals are
• Critical thinking and the creativity it requires and achieved or not
inspires are key elements in quality nursing care
ASSESSMENT

DEFINITION – CRITICAL THINKING

• Critical thinking as “ the act of thinking about thinking PURPOSE OF ASSESSMENT
– PAUL (1988)
• Critical thinking is reasonable, rationale, reflective, 1. To establish a data base ( all information about client)
autonomous, creative, fair and inspires an attitude of o Nursing health history
inquiry that focuses on deciding what to believe or do o Physical Assessment
o Results of laboratory & diagnostic tests
2. Patient’s response to health concerns or illness
HISTORY OF CRITICAL ANALYSIS
3. Ability to manage health care needs
Socrates (born about 470 BC) was a greek philosopher who
developed the Socratic method of question and answer.

Example: TYPES OF ASSESSMENT

• Is this question important? INITIAL • Performed with in specified time
• What could you assume instead? Why? COMPREHENSIVE after admission to a health care
• How do you know? ASSESSMENT agency
• What effect would that have? • Also called an admission
• What are the alternatives? assessment
• What are the implications of that? • Example: Nursing Admission
Assessment
• PURPOSES
o To evaluate health status
o To identify functional health
OVERLAPING PHASES OF THE NURSING PROCESS
patterns
Indicates the five overlapping phases of the nursing o To provide an in depth
process. Each phase depends upon the accuracy of the comprehensive databases
proceeding phases. Each phase involves critical thinking
PROBLEM • Collects data about a problem that
FOCUSED has already been identified
ASSESSMENT • Ongoing process integrated with
nursing care
• Nurse determines whether
problem still exist and whether the
status of the problem has changes
• Example: Hourly assessment of
patient’s fluid intake and urine
output
TIME LAPSED • Several months after initial
ASSESSMENT OR assessment.
ONGOING • Evaluate the changes in the clients
ASSESSMENT health & functional status

20
 • Example: • Use and accept silence to help the patient search for
o Periodic output patient clinic more thoughts or to organize them
visits • Use eye contact and be calm, unhurried and
sympathetic
o Home health visits
o Health & development
screening. SOURCE OF DATA
EMERGENCY • Occurs during any life threatening
ASSESSMENT condition PRIMARY SOURCE • Data directly gathered from
• Any physiologic or psychologic the patient using interview
crisis of the client and physical examination.
• Example: Rapid assessment of SECONDARY SOURCE • Data gathered from family
patient’s vital signs during cardiac members, significant others,
arrest medical records/ charts, health
team members and journals/
literature.
COLLECTING OF DATA
• It is the process of gathering information about a
patient’s health status
• Includes physical, psychological, emotion, socio
cultural, spiritual factors that may affect clients health
status
• Includes past health history of client ( allergies, past
surgeries, chronic diseases, use of folk healing
methods), present problems of client (pain, nausea,
vomiting etc)

METHOD OF DATA COLLECTION

GUIDELINES FOR INTERVIEW

• Listen attentively, using all your senses
• Speak slowly and clearly
• Use language that client understand
• Clarify points that are not understood
• Plan questions to follow a logical sequence
• Ask only one question at a time
• Allow the patient to clarify the asked question, if need
• Do not impose your own values on the patient
• Avoid using personal examples
• Non verbally convey respect, concern, interest and
acceptance

21
 DIAGNOSIS PLANNING

• Diagnosing is the second phase of the nursing process, • Planning is the third phase of the nursing process, in
in which the nurse interprets assessment data, which the nurse and client develop client goals/
identifies client strengths and health problems and desired outcomes and nursing strategies to prevent,
formulate diagnostic statements reduce or alleviate the client’s health problem
• It is a clinical judgment about individual, family or
community responses to actual and potential health ONGOING PLANNING ® It occurs at the beginning
problems / life processes – NANDA - 2003 of a shift as the nurse plans
• NANDA – North American Nursing Diagnosis the care to be given that
Association day

DISCHARGE PLANNING ® It begins at first client

TYPES OF NURSING DIAGNOSIS contact and involves
ACTUAL • It is a client problem that is present comprehensive and
DIAGNOSIS at the time of the nursing ongoing assessment to
assessment. obtain information about
• It is based on the presence of the patients ongoing needs
associated signs and symptoms
• Example: AN INFORMAL CARE ® It is a plan of action that
o Ineffective Breathing Pattern PLAN exists in the nurses mind
o Anxiety ® Eg: Nurse may think “ Mrs.
RISK NURSING • It is a clinical judgment that a Shanthi is very tired, I will
DIAGNOSIS problem does not exist, but the need to reinforce her
presence of risk factors indicates teaching after she is
that a problem is likely to develop rested”
unless nurses intervention
• Example: Risk for infection, Risk for SHORT TERM GOAL ® It is an objective that is
complication expected to achieved /
SYNDROME • It is a diagnosis that is associated within a short time, usually
DIAGNOSIS with a cluster of other nursing less than a week
diagnosis ® Example:
• Eg: o Client will achieve
o Disuse syndrome (long term comfort with in 24
bed ridden patients) hours post operatively
o Impaired physical mobility o Client will raise right
arm to shoulder height
WELNESS • It is one indicating a healthy
by Friday
DIAGNOSIS response of a patient who desire a
higher level of wellness
LONG TERM GOAL ® It is an objective that is
• Eg:
expected to believe over a
o Individual coping
longer time frame, usually
o Family coping
over weeks or months
o Potential for enhanced
® Example:
spiritual well being
o Client will adhere to
post-operative activity
DIFFERENCE BETWEEN NGS DX AND MED DX restrictions for one
month.
NURSING DX MEDICAL DX o Client will regain full
• It is a statement of • It is made by a physician use of right arm in 6
nursing judgment and and refers to a condition weeks
refers to a condition that only a physician can
that nurses are treat
licensed to treat

22
 TYPES OF NURSING INTERVENTION

REASSESSING THE CLIENT

® Just before implementing an order, the nurse must
INDEPENDENT • Nurses are licensed to initiate
reassess the client to make sure the intervention is still
INTERVENTIONS on the basis of their
needed. Even though an order is written on the care
knowledge and skills
plan, the clients condition may have changed
• They include physical care, on
going assessment, emotional DETERMINING THE NURSES NEED FOR ASSISTANCE
support, teaching, counselling
® When implementing some nursing care, the nurse may
• It is also known as nurse-
require assistance for one of the following reasons:
initiated interventions
® The nurse is unable to implement the nursing care
DEPENDENT • These are activities carried out safely alone. Eg: Turning an obese patient in bed
INTERVENTION under the physicians orders or
supervision IMPLEMENTING NURSING ORDERS
• It is also known as physician ® It is important to explain to the client what will be
initiated interventions done, what sensations to expect and what the client is
• Example: Administer Inj. expected to do
Paracetamol for a patients
with fever more than 101° F

COLLABORATIVE • Are the actions of nurse

INTERVENTION carries out in collaboration
with other health team
members, such as physical
therapists, social workers,
dietician & physician

COGNITIVE SKILLS
® It include problem solving, decision making, critical
thinking and curative thinking
® It is also known as intellectual skills

TECHNICAL SKILLS
® These are “hands on” skills such as manipulating
equipment, giving injecting and bandaging, moving,
lifting and repositioning clients

23
 EVALUATION

• It is the fifth and last phase of the nursing process, in

which clients and health care professionals determine
the client’s progress toward goal achievement and the
effectiveness of the nursing care plan

ONGOING • It is done while or immediately after

implementing a nursing order. It
enables the nurse to make on the
spot modification in an intervention.
INTERMITTENT • It is performed at specified intervals (
Eg. Once a week), shows the extent
of progress toward goal achievement
& enables the nurse to correct any
deficiencies and modify the care plan
as needed.
TERMINAL • It indicates the clients condition at
the time of discharge. It includes the
status of goals achievement and
evaluation of the clients self-care
abilities with regard to follow up
care.

IDENTIFYING DESIRED OUTCOMES

• It is used to evaluate the client’s response to nursing

care
• Desired outcome serve two purposes. They are:
• Establish the kind of evaluative data that need to
collected
• Provide a standard against which the data are judged

24
Nursing Care of Clients with Life Threatening Conditions, Acutely Ill/ Multi-
Organ Problems, High Acuity, And Emergency Situation

TOPIC 15 CLINICAL PATHWAY & LIFE-

1 CORONARY HEART DISEASE THREATENING PATHWAY
2 CONGESTIVE HEART FAILURE
3 CARDIOGENIC SHOCK CORONARY
ARTERY DISEASE
4 HYPERTENSIVE CRISIS
5 CARDIOMYOPATHY MODIFIABLE RISK
FACTORS
NON-
MODIFIABLE

6 ARRYTHMIA
§ Smoking § Gender
§ Alcohol/Drug Use § Age
§ Hypertension § Sedentary Lifestyle § Family History
§ Diet § Metabolic Syndrome/Diabetes § Genetics (Such As Familial
§ Psychological Stress/Anxiety § Hypocholesteremia)
NURSING CARE OF CLIENTS WITH Dyslipidemia

ALTERED TISSUE PERFUSION

ANGINA
STABLE UNSTABLE

CORONARY HEART DISEASE

Angina is chest pain may be intermittent and may be Chest pain may indicate more serious unstable angina

• It is the narrowing or obstruction of one or accompanied by shortness of breath. It often has a

squeezing or pressure-like quality. It may radiate into the
or a heart attack if it includes the following: §
Unrelieved by rest or nitroglycerin § Severe angina §
shoulder(s), arm(s), or jaw. This type of angina usually Begins at rest § Lasts more than 15 minutes §
more coronary arteries as a result of lasts for about 5 minutes or less. It is often relieved with
rest. Angina can be triggered by: § exercise or exertion §
Accompanying symptoms may include: Shortness of
breath, Sweating, Nausea, Weakness, Dizziness,
emotional stress § cold weather § a large meal Palpitations/irregular heartbeat, and/or Chest pain
atherosclerosis, which is an accumulation of
CLINICAL INTERVENTONS
lipid-containing plaque in the arteries. q Lifestyle Changes: Healthy eating, Quit Smoking, Exercise regularly to maintain healthy weight, and manage stress.
Drugs: Cholesterol-modifying medications, Aspirin, Anti-platelets, Beta blockers, Calcium Channel Blockers, Nitrates, and
Angiotensin-converting enzyme (ACE) inhibitors and Angiotensin II receptor blockers (ARBs).
Angioplasty and CABG
q Discuss warning signs with member such as uncomfortable pressure, squeezing, fullness or pain in chest, jaw, back, one or both

PATHOPHYSIOLOGY q
arms, and stomach.
Advise members with stable angina on how to o administer the short-acting nitrate
- to use it immediately before any planned exercise or exertion
- that side effects such as flushing, headache and light
- headedness may occur
- to sit down or find something to hold on to if feeling light-headed.
- to repeat the dose after 5 minutes if the pain has not been alleviated
- to call an emergency ambulance if the pain has not gone 5 minutes after taking a second dose

Life Threatening Pathway

Coronary Artery Disease

Plaque buildup

Stable Atheromatous plaque Rupture of plaque Unstable Atheromatous plaque

Thrombosis at site of Rupture Embolism of thrombus

Obstruction to blood flow

Low blood supply

Increase myocardial
oxygen demand Low oxygen supply

Decrease perfusion
of myocardium

Transient Ischemia
cardiomyocytes
Death of
cardiomyocytes

Transient Ischemia Death of

cardiomyocytes cardiomyocytes

Myocardial
Stable Angina Unstable Angina Infarction

Acute Coronary Death

Syndrome
 ASSESSMENT Associated • Diaphoresis, nausea,
Character • Substernal chest pain, manifestation indigestion, dyspnea,
pressure, heaviness, or tachycardia, and
discomfort. Other increase in blood
sensations include a pressure.
squeezing, aching,
burning, choking, Signs of • A change in frequency,
strangling, or cramping unstable duration, and intensity
pain angina of stable angina
Severity • Pain maybe mild or symptoms.
severe and typically • Angina pain last longer
present with a gradual than 10 minutes, is
buildup of discomfort unrelieved by rest or
and subsequent gradual sublingual nitroglycerin,
fading away. and mimics signs and
Location • Behind middle or upper symptoms of impending
third of sternum, the myocardial infarction.
patient will generally
make a fist over the site
of pain (positive Levine
DIAGNOSTIC PROCEDURES
sign; indicates diffuse
deep visceral pain), The physician may tell the patient if CAD is
rather than point to it present after:
with fingers. - Learning patient’s signs/symptoms
Radiation • Usually radiates to neck, - Medical History
jaw, shoulders, arms, - Risk factors
hands, and posterior - After doing a physical exam
intrascapular area. Pain Doctors also get diagnostic tests to find
occurs more commonly extent of CAD and its effect on patient’s
on the left side than the heart. This helps them choose the best
right; may produce treatment for the patient.
numbness or weakness 1. Electrocardio ECG or EKG test
gram monitors and records
in arms, wrist, or hands.
the electrical activity or
Duration. • Usually, last 2 to 10 signals that travel
minutes after stopping through the heart. It
activity; nitroglycerin may help determine or
relieves pain within 1 detect whether a patient
minute. has heart attack,
ischemia and heart
rhythm issues.
Precipitating • Physical activity,
2. Echocardiogr This imaging test uses
factors exposure to hot or cold ultrasound waves to
am
weather, eating a heavy create a picture of the
meal, and sexual heart. It reveals whether
intercourse increase the certain things in the
workload of the heart heart and on how well
the structures are
and, therefore, increase
oxygen demand.

2
 working and the overall Ø Coronary artery
function of the heart. bypass graft
3. Cardiac This procedure is used to (CABG) surgery
Catheterizati treat a range of problems Ø Hybrid coronary
with your heart’s revascularizatio
on
chambers, valves, and n
vessels, and to diagnose 7. Stress Tests Your doctor may order a
heart diseases and stress test to check the
conditions. The dye function of your heart
helps enhance the and arteries.
radiographic image of An abnormal result can
coronary arteries to indicate a reduction in
identify any blockages. blood flow to the heart
during exertion—called
4. CT Coronary It is an innovative ischemia—that’s
Angiogram approach that uses typically caused by a
computer tomography blockage in the heart
and contrast dye to view arteries.
3D pictures of the
moving heart,
investigating chest pain, Types of Stress Tests
and detect blockages in
the coronary arteries.
5. Blood tests A lot of blood tests are Exercise stress Pharmacologic Nuclear stress Echo stress Test
Test stress Test Test
ordered for factors that For people who are In this test, In this test, a small Also known as
affect arteries such as able to exercise, an
exercise stress test
medication
injected into an arm.
is amount of
radioactive tracer is
Echocardiogram. It
can reveal how well

triglycerides, helps your doctor

determine whether
It causes the heart’s
blood vessels to
injected into a vein
in the arm. Small
the heart is pumping
blood. Your doctor

cholesterol, lipoprotein, your heart receives

enough blood and
dilate, or widen,
depending on the
electrodes
placed on
are
your
can identify any
areas where blood
oxygen during medication your chest, wrists, and isn’t flowing
C-reactive protein, activity. It also doctor chooses. ankles to measure properly.
reveals how the your heart rate.
glucose, HbA1c (a heart responds to
exercise.
measure of diabetic
control) and other tests.
NURSING DIAGNOSES
6. Myocardial It helps cardiologists:
Perfusion - Identify suspected • Altered tissue perfusion (myocardial)
areas of restricted blood related to narrowing of the coronary
Imaging
flow, before artery/ies
(Nuclear) recommending a cardiac • Acute pain associated with
Scan catheterization atherosclerosis, spasm, and/or
- Determine if they thrombosis
should look for non-
• Decreased cardiac output related to
heart related causes of
inotropic changes
chest pain
- Assess damage after
a heart NURSING INTERVENTION
attack (myocardial
infarction) MEDICAL SURGICAL INTERVENTION
- Evaluate the Bypass • Invasive surgery
effectiveness of earlier Surgery • Coronary artery bypass
treatments, including: grafting, or "CABG"
Ø Angioplasty and (pronounced "cabbage"), is
stenting
a common heart
procedure. A surgeon

3
 takes a section of a • The plastic sheath which
healthy blood vessel from was inserted in the
your leg, chest, or arm. patient’s groin, neck, or
The vessel is then arm will be removed soon
after unless the patient
connected (grafted) to requires specialized blood
your coronary artery thinning medication.
slightly past the site of the
blockage. MICS CABG • Minimally Invasive
• 2 TYPES Procedure
o Beating Heart • can be performed through
Surgery - off-pump a small rib incision rather
surgery, beating heart than through a median
surgery is done while sternotomy
the heart is beating
o Arrested Heart NSG CONSIDERATION
Surgery - heart is • Candidates for minimally
stopped and a heart- invasive coronary surgery
include patients who have:
lung machine takes
Blocked or diseased
over the job of vessels on the left side of
circulating the blood. the heart only. Not had
Coronary • tiny balloon to widen the previous bypass surgery.
balloon inside channel of the No pre-existing scar tissue
angioplasty artery and enable blood to on the heart or chest.
flow at a normal or near-
normal rate
PHARMACOLOGIC INTERVENTION
Antianginal • to promote a
NSG CONSIDERATIONS medications favorable balance of
• Patients should be kept
oxygen supply and
lying flat for several hours
demand.
after the procedure.
• Diagnostic catheterization NSG CONSIDERATION
patients are kept on bed • Instruct patients to
rest for four hours avoid eating or
• Interventional smoking during
catheterization patients administration as
stay on bed rest for six this may alter
hours. absorption.
Stenting • uses a device called a stent • Patients should sit
to restore blood flow in the during
coronary artery administration to
decrease the risk for
NSG CONSIDERATION injury due to the
• The patient should be possibility of
taken to a recovery room
hypotension,
to wait for the anesthesia
to wear off; typically, this dizziness, and
will take up to one hour. weakness

4
Anti-lipid • to decrease blood reactions, especially
medications cholesterols and if drug previously
triglyceride levels in taken. Keep
patients with supportive
elevated levels. equipment and
emergency drugs
readily available in
case of serious
allergic response.
NSG CONSIDERATION
• Do not use with
patients who have ALTERNATIVE TREATMENT
hepatic disease. Omega-3 fatty • Reduce inflammation in
acids the body. Omega-3 fatty
• Use caution with
geriatric patients acids may also decrease
due to increased risk triglycerides, mildly
for myopathy. lower the blood pressure,
and help immune system
Anti-platelet • to inhibit thrombus
Agents function.
formation.
Phytosterols • Reduce the levels of low-
NSG CONSIDERATION density lipoprotein
• Administer drug (LDL), also known as bad
with meals to relieve cholesterol. Lowering the
GI upset. LDL cholesterol to an
• Educate patient on acceptable level helps to
ways to promote reduce risk of CAD.
safety like using Vitamin D • Reduce risk of heart
electric razor, soft- disease. But you need to
bristled toothbrush, consult first your doctor
and cautious before taking in order to
movement because know how much vitamin
any injury at this D you need to take.
point can precipitate
bleeding.
Folic acid and B CLIENT EDUCATION
• to reduce
complex vitamins Disease - Discuss pathophysiology
homocysteine levels
Condition of condition.
- Discuss impact of illness
NSG CONSIDERATION on desired lifestyle and
• Administer orally if activities, including
at all possible. With work, driving, sexual
severe GI activity, and hobbies.
malabsorption or Lifestyle - Assist patient and
very severe disease, Modifications significant other to
give IM, IV, or and identify sources of
Prevention of physical and emotional
subcutaneously.
Attacks stress and discuss ways
• Monitor patient for that they can be avoided,
hypersensitivity

5
 as avoiding these may Coronary Artery Disease (CAD) is treatable,
prevent attacks but there is no cure. This means that once
Self- - Demonstrate how to diagnosed with CAD, you have to learn to live
management monitor own pulse and with it for the rest of your life. By lowering
and follow up BP during and after your risk factors and losing your fears, you
check ups activities, and to can live a full life despite CAD.
schedule activities, avoid
strain and take rest At age 50 women can expect to live 7.9 years
periods. and men 6.7 years with heart disease. The
- Demonstrate steps to average woman experiences heart disease
take when anginal onset three years older and heart attacks 4.4
attacks occur, (cessation years older than men.
of activity, keeping
“rescue” NTG on hand,
administration of prn CONGESTIVE HEART FAILURE
medication, use of
relaxation techniques). ® Patient with heart failure, 90% die within a
- Discuss importance of year, others less than 5 years
follow-up appointments.
- LEFT-SIDED HEART FAILURE
Medications - Inform the patient of the ® “FIRST”
importance of consulting ® The one responsible for damaging the right
the physician before portion of the heart
taking any OTC drugs. ® A.K.A Congestive Heart Failure
- Review symptoms to be
reported to physician: RIGHT-SIDED HEART FAILURE
increase in frequency of ® “LAST”
attacks, changes in ® The one that gets damage in the long run
response to medications.
® A.K.A Pulmonary Heart Failure
Diet - Educate client about
Modification incorporating Omega- 3
Fatty Acids into their THE 4 STAGES OF HEART FAILURE
diet.
- Food containing Vitamin
D may also be
incorporated into the
client’s diet, provided
that a physician has been
consulted first.
- Food that contain
vitamin D include
shrimp, Chinook salmon,
fortified soy milk, milk,
eggs, fortified orange
juice, canned tuna,
fortified breakfast
cereals and fortified
margarine

6
SIGNS AND ® Chest discomfort CARDIOGENIC SHOCK
SYMPTOMS (early sign)
® Fatigue, restlessness
® Tiredness in doing
activities
® Stomach pain
® Heart burn
® Acid reflux
® Nausea
® Asthmatic attacks
(VC)
® Frequent diaphoresis
® Snoring
MANAGEMENT ® Exercise (e.g brisk
walking) • Cardiogenic Shock is a life-threatening
® Decrease/discontinue condition in which your heart suddenly
smoking can’t pump enough blood to meet your
® Healthy diet (low body’s needs. The condition is most often
sodium, low-fat, and caused by a severe heart attack, but not
low cholesterol) everyone who has a heart attack has
® Chocolate (dark) cardiogenic shock.
® Do not overeat • Cardiogenic shock occurs when cardiac
® Position: Right Lateral output is insufficient to meet the
(to prevent BV metabolic demands of the body, resulting
compression = ⬆ in inadequate perfusion.
pressure)
® Volume Overload (Sympathetic Reaction)
® Ischemia & Inflammation (hypoxemia,
TREATMENT AND MANAGEMENT systemic inflammatory response
• Treatment of heart failure depends on syndrome)
the underlying cause and this will direct
the main treatment to prevent further
deterioration. Heart failure can be cured 4 STAGES OF CARDIOGENIC SHOCK
if it has a treatable cause. INITIAL STAGE • There is
• If the cause is due to coronary heart diminished cardiac
disease, then then patient may require output without any
coronary stents or bypass surgery. If clinical symptoms.
there is a heart valve cause, then the COMPENSATORY • The baroreceptors
defective valve will need surgery to STAGE respond to the
repair or replace the value. decreased cardiac
output by
stimulating the
sympathetic
nervous system to
release
catecholamines to
improve
myocardial
contractility and
vasoconstriction,
leading to
increased venous

7
 return and arterial 3 PHASES OF SHOCK
blood pressure. COMPENSATED ® is the phase of
• Impaired renal shock in which
perfusion activates the body is still
the renin- able to
angiotensin compensate for
system, whose end absolute or
product, relative fluid loss.
angiotensin II, ® S/S:
cause sodium and ® Restlessness,
water retention as agitation and
well as anxiety – the
vasoconstriction. earliest signs of
PROGRESSIVE • Follow the hypoxia
STAGE compensatory ® Pallor and
stage if there is no clammy skin –
intervention or if this occurs
the intervention because of
fails to reverse the microcirculation
inadequate tissue ® Nausea and
perfusion. vomiting –
refractory. • In this stage the decrease in blood
vital organs have flow to the GI
failed and shock system
can no longer be ® Thirst
reversed. ® Delayed capillary
• Brain damage and refill
cell death are ® Narrowing pulse
occurring, and pressure.
death is imminent.
DECOMPENSATEED ® the late phase of
CAUSE shock in which
• Usually caused by poor pumping function the body’s
of the heart. compensatory
• Bleeding, which can cause shock by mechanisms
reducing the amount of blood circulation, (such as
depriving the vital orgnas of the body. increased heart
rate,
vasoconstriction,
increased
respiratory rate)
are unable to
maintain
adequate
perfusion to the
brain and vital
organs.”
® It occurs when
the blood volume
decreases by
more than 30%.
® S/S :

8
 ® Alterations in GLASSCOW SCALE (for cardiogenic shock)
mental status
® Tachycardia ® PERRLA – neurological vital sign (?)
® Tachypnea ® Motor
® Labored and ® Eye opening
irregular
breathing Decortication
® Weak to absent ® abnormal flexion
peripheral pulses ® pain can still be felt
® A decrease in ® (+) rigid guarding
body temperature
® Cyanosis Decebration
® Abnormal extension
® Pain can still be felt
® (-) rigid guarding.
IRREVERSIBLE ® the terminal
SHOCK phase of shock
and once the COMPLICATIONS
patient
• Cardiopulmonary Arrest
progresses into
• Dysrhythmia
this phase it is
the point of no • Renal Failure
return because • Multisystem Organ Failure
there is a rapid • Ventricular Aneurysm
deterioration of • Thromboembolic Sequelae
the • Stroke
cardiovascular • Death
system and the
patient’s
compensatory
mechanisms have SIGNS AND SYMPTOMS
failed. • Cool, clammy skin
® Patient will • Pale or ashen skin
present severe
• Bluish tinge to lips or fingernails (or gray
decreases in in the case of dark complexions)
cardiac output,
• Rapid pulse
blood pressure
• Rapid Breathing
and tissue
• Nausea or vomiting
perfusion. In a
• Enlarged pupils
last-ditch effort to
save the core of • Weakness or fatigue
the body blood is
shunted away
from the kidneys,
liver and lungs to
maintain
perfusion of the
brain and heart.

9
 HYPERTENSIVE CRISIS TYPES OF CARDIOMYOPATHY
Dilated • The pumping ability of
• A hypertensive crisis is a severe increase your heart’s main
in blood pressure that can lead to stroke. pumping chamber –
• Extremely high blood pressure the left ventricle
o Systolic: 180 or higher becomes enlarge
o Diastolic: 120 or higher. (dilated) and can’t
® Normal BP (WHO) effectively pump blood
o Systolic: 90 – 104 put of the heart.
o Diastolic: 70 – 80 • Affect all ages, most
o If systolic is 120 mmHg = common in MIDDLE
prehypertensive. AGE people and
mostly likely affect
MEN.
CAUSE • Most common cause:
• The most common cause: Chronic Coronary Artery
Hypertension with acute exacerbation Disease or Heart
resulting from medication Attack. Can also be
noncompliance. due to genetic defects.

Hypertrophic • Involves abnormal

thickening of the
heart muscles, which
makes it harder for
the heart to work.
• Mostly affects the
muscles heart’s main
pumping chamber
(left ventricle)

• Can develop at any

age, but most severe if
it occurs in childhood.
• Most people with this
type have family
history of the disease.
Unclassified • Other types of
CARDIOMYOPATHY cardiomyopathy fall
into this category.
• A disease of the heart muscles that makes Restrictive • The heart muscles
it header for your heart to pump blood to become stiff and less
the rest of your body. flexible, it can’t
• Cardiomyopathy can lead to heart failure. expand and fill with
• MAIN CAUSE: Viral Infections in the blood between
heart. heartbeats.
• In other cases: another disease or its • This least common
treatment causes cardiomyopathy. This type of
includes complex congenital heart cardiomyopathy can
disease, nutritional deficiencies, occur at any age, but
uncontrollable, fast heart rhythms, or it most affect older
certain types of chemotherapy for cancer. people.
® Cause: septal defect and genetic defects. • Can occur for no
known reason

10
 (idiopathic), or it can
be caused by a disease
elsewhere in the body
that affects the heart,
such as amyloidosis.
Arrhythmogenic • Rare type of
right cardiomyopathy.
ventricular • The muscle in the
dysplasia lower right chamber
(right ventricle) is
replaced by scar
tissue, which can lead
to heart rhythm
problems.
• Often caused by TYPES OF ARRYTHMIA
genetic mutations.
Supraventricular • tachycardias that
Arrhythmia occur
ARRYTHMIA in the atria or the
atrioventricular
• An arrhythmia is a problem with the rate or (AV) node
rhythm of your heartbeat. It means that • Atrial fibrillation -
your heart beats too quickly, too slowly, or irregular, rapid
with an irregular pattern. heartbeat that can
• Arrhythmia is caused by changes in heart be intermittent,
tissue and activity or in the electrical long lasting, or
signals that control your heartbeat. These permanent
changes can be caused by damage from • Atrial flutter -
disease, injury, or genetics. regular, rapid
heartbeat
Ventricular • Tachycardias that
Arrythmias begin in the lower
chambers of the
heart.
• Ventricular
tachycardia (VT) -
rapid, regular
heartbeat
that can last for
just a few seconds
or much longer.
• Ventricular
fibrillation (VFib)
- rapid, irregular
heartbeat that
causes the
ventricles to quiver
ineffectively
instead of pumping
blood

11
 PATHOPHYSIOLOGY determining if
there is underlying
heart disease or
coronary artery
disease
associated with an
arrhythmia.
•
Echocardiogram • A type of
ultrasound used to
provide a view of
the heart to
determine if there
is heart muscle
or valve disease
that may be causing
an
arrhythmia. This
test may be
performed at rest
or with activity
Cardiac • This test helps your
Catherization doctor determine if
the cause
of an arrhythmia is
coronary artery
disease. This
test also provides
information about
how well your
heart muscle and
valves are working.
Electrophysiology • A special heart
TYPES OF ARRYTHMIA Study catheterization that
Electrocardiogram • evaluates
Holter Monitor • The test measures your heart’s
the movement of electrical system.
electrical Catheters are
signals or waves inserted into your
through your heart. heart to record the
These signals electrical
tell your heart to activity. The EPS is
contract (squeeze) used to find the
and pump cause of the
blood abnormal rhythm
Stress Test • Also called exercise and determine the
stress test best
• A test used to treatment for you.
record arrhythmias During the test, the
that start or arrhythmia can be
are worsened with safely reproduced
exercise. This test and
also may terminated
be helpful in

12
Tilt Table Test • Also called a stimulants that may trigger a rapid
passive head-up tilt heartbeat
test or head Living with Arrhythmias
upright tilt test.
• Records your blood Taking medications
pressure and heart • Take all medications exactly as
rate on prescribed.
a minute-by-minute • Never stop taking any prescription
basis while the medication without first consulting your
table is healthcare provider.
tilted in a head-up • If you have any side effects, tell your
position at different healthcare provider about them.
levels. • Tell your healthcare provider about all
The test results your other drugs and supplements,
may be used to including over-the-counter medications
evaluate heart and vitamins.
rhythm, blood
pressure and Monitor your pulse
sometimes other • Put the second and third fingers of one
measurements as hand on the inside of the wrist of the
you change other hand, just below the thumb OR on
position. the side of your neck, just below the
Cardiac event • it records and Corner of your jaw.
Monitor stores • Feel for the pulse.
your heart's • Count the number of beats in one full
electrical activity minute.
for a few
• Keep a record of your pulse along with the
minutes. Try to get
day and time taken and notes about how
a reading when you
you felt at
notice
the time
symptoms. Your
doctor will
Certain substances can contribute to an
interpret the
abnormal/irregular heartbeat, including:
results
• Caffeine
• Tobacco
CLIENT EDUCATION
• Alcohol
Prevention
• Cold and cough medications
• To prevent heart arrhythmia, it's
• Appetite suppressants
important to live a heart-healthy lifestyle
to reduce your risk of • Psychotropic drugs (used to treat certain
mental illnesses)
heart disease. A heart-healthy lifestyle
may include: • Antiarrhythmics (paradoxically, the same
o Eating a heart-healthy diet drugs used to treat arrhythmia can also
cause arrhythmia. Your healthcare team
o Staying physically active and
will monitor you carefully if you're taking
keeping a healthy weight
antiarrhythmic medication.)
o Avoiding smoking
o Limiting or avoiding caffeine and • Beta-blockers for high blood pressure.
alcohol • Street drugs such as cocaine, marijuana and
“speed” or methamphetamines
o Reducing stress, as intense stress
and anger can cause heart rhythm
problems Manage your risk factors
o Using over-the-counter medications Just having certain arrhythmias increases
with caution, as some cold and cough your risk of heart attack, cardiac arrest and
medications contain stroke. Work

13
with your healthcare team and follow their heartbeats and
instructions to control other risk factors. related symptoms.
Wolff- • With an
ParkinsonWhite appropriate
PROGNOSIS referral, treatment,
Syndrome (tachys
Tachycardia in atria) and patient
• The long-term outlook is usually good education, patients
when tachycardia is caused by fever, with WPW
blood loss, hyperthyroidism, medication syndrome can
or diet. Many tachycardias related to expect to have a
heart or lung problems can normal life
be controlled with medication, surgery, or expectancy and
other procedures. good quality of life
Atrial Fibrillation • Atrial Fibrillation Ventricular • The prognosis of VT
(tachys in atria) does raise the risk Tachycardia depends on the
of dying early. (tachys in cause and cardiac
Heart failure and ventricles) status. Patients
stroke are two of who develop VT
the main causes of can suffer from
death in people hemodynamic
with AFib. But with failure and the
improved mortality can
treatments, overall exceed 30% if no
deaths from AFib treatment is
have dropped. Most provided.
atrial arrhythmias Ventricular • The prognosis for
have an excellent Fibrillation ventricular
prognosis. (tachys in fibrillation is grave,
ventricles) and death follows
Atrial flutter • The prognosis for quickly without
(tachys in atria) atrial flutter emergency
depends on the treatment. Without
patient’s immediate
underlying medical treatment,
condition. Any ventricular
prolonged atrial fibrillation can
arrhythmia can cause death within
cause tachycardia- minutes. Most
induced people who
cardiomyopathy. experience
Supraventricular • Most people with ventricular
tachycardia supraventricular fibrillation have
(tachys in atria) tachycardia live underlying
healthy lives heart disease or
without restrictions have experienced
or treatment. For serious trauma
others, lifestyle
changes, Ventricular • The prognosis of VT
medication, and Tachycardia depends on the
heart procedures (tachys in cause and cardiac
may be needed to ventricles) status. Patients
control or eliminate who develop VT can
the rapid suffer
from hemodynamic

14
 failure and the pacemakers are not a
mortality can cure, but they are a
exceed 30% if no very effective
treatment is treatment. Most
provided. patients treated with
pacemakers have a
positive prognosis.
Ventricular • The prognosis for
fibrillation ventricular Conduction Look Once appropriately
(tachys in fibrillation is grave, paced, the prognosis
ventricles) and death follows for patients with
quickly without symptomatic complete
emergency heart block depends
treatment. Without on their underlying
immediate disease process.
treatment, Patients with acquired
ventricular AV block secondary to
fibrillation can idiopathic fibrosis
cause death within have a prognosis
minutes. similar to those of the
Most people who same age without heart
experience block. By contrast,
ventricular patients with
fibrillation have complete heart block
underlying heart due to an extensive
disease or have myocardial infarction
experienced serious will have a poor
trauma. prognosis despite
pacing. Congenital
Long QT syndrome • The prognosis is complete heart block
(tachys in good overall for without additional
ventricles) patients with long structural heart
QT syndrome disease carries a good
(LQTS) treated with prognosis. In patients
beta-blockers with bifascicular or
(and other trifascicular block,
therapeutic their prognosis
measures, if depends on the extent
needed). of t heir underlying
Bradycardia heart disease
• Prognosis varies depending on what’s
causing bradycardia. Some conditions can
be reversed
or managed through medication, lifestyle
changes and regular monitoring. Others
may
require a pacemaker or implantable
cardioverter-defibrillator.
Sick sinus Many people with sick
syndrome sinus syndrome don’t
have symptoms for
years. If it’s causing a
slow heart rate,

15
Nursing Care of Clients with Life Threatening Conditions, Acutely Ill/ Multi-
Organ Problems, High Acuity, And Emergency Situation

TOPIC 17 PATHOPHYSIOLOGY
1 GI BLEEDING
• GI bleeding is not a disease, but a
2 LIVER FAILURE
symptom of a disease. There are many
3 PANCREATITIS
possible causes of GI bleeding, including
4 HYPERTENSIVE CRISIS hemorrhoids, peptic ulcers, tears or
5 INTRA-ABDOMINAL HYPERTENSION inflammation in the esophagus,
6 DIABETIC KETOACIDOSIS diverticulosis and diverticulitis,
ulcerative colitis and Crohn's disease,
colonic polyps, or cancer in the colon,
NURSING CARE OF CLIENTS WITH stomach or esophagus.
ALTERED METABOLIC – • GIBs are categorized into two types:
GASTROINTESTINAL AND LIVER Upper GI bleeds and Lower GI bleeds.
FUNTION Each type can present with different
hallmark presentations and require
different management. Historically,
ACUTE GI BLEEDING distinction of upper GIB (UGIB)and lower
GIB (LGIB) was based on the location of
• Gastrointestinal bleeding is a symptom of bleeding in relation to the ligament of
many upper or lower gastrointestinal (GI) Treitz. With this definition, bleeding
proximal to the ligament of Treitz is
disorders. It may be obvious (in emesis or
categorized as an UGIB, while bleeding
stool) or occult (hidden). It refers to any distal to the ligament of Treitz is
bleeding that starts in the gastrointestinal categorized as a LGIB.
tract. The level of bleeding can range from • Gastrointestinal (GI) bleeding can
mild to severe and can be life-threatening. originate anywhere from the mouth to the
Gastrointestinal (GI) bleeding is a anus and can be overt or occult. The
potentially life-threatening abdominal manifestations depend on the location
and rate of bleeding.
emergency that remains a common cause of
• Hematemesis is vomiting of red blood and
hospitalization.
indicates upper GI bleeding, usually from
• Gastrointestinal bleeding can fall into two a peptic ulcer, vascular lesion, or varix.
broad categories: upper and lower sources Coffee-ground emesis is vomiting of dark
of bleeding. brown, granular material that resembles
• LIGAMENT OF TREITZ – also known as the coffee grounds. It results from upper GI
suspensory ligament of duodenum. The bleeding that has slowed or stopped, with
conversion of red hemoglobin to brown
anatomic landmark that separates upper hematin by gastric acid.
and lower bleeds. This peritoneal structure • Hematochezia is the passage of gross
suspends the duodenojejunal flexure from blood from the rectum and usually
the retroperitoneum. indicates lower GI bleeding but may result
• HEMATEMESIS - Bleeding that originates from vigorous upper GI bleeding with
above the ligament of Treitz. rapid transit of blood through the
intestines.
• HEMATOCHEZIA - bleeding that originates
• Melena is black, tarry stool and typically
below Treitz. indicates upper GI bleeding, but bleeding
from a source in the small bowel or right
colon may also be the cause. About 100 to
200 mL of blood in the upper GI tract is
required to cause melena, which may
 persist for several days after bleeding has
ceased. Black stool that does not contain SIGNS AND SYMPTOMS (CLINICAL
occult blood may result from ingestion of PATHYWAY)
iron, bismuth, or various foods and should
not be mistaken for melena. A. UPPER
• Chronic occult bleeding can occur from
anywhere in the GI tract and is detectable
by chemical testing of a stool specimen.
• Acute, severe bleeding also can occur
from anywhere in the GI tract. Patients
may present with signs of shock. Patients
with underlying ischemic heart disease
may develop angina or myocardial
infarction because of coronary
hypoperfusion.
• GI bleeding in patients with underlying
liver disease may precipitate
portosystemic encephalopathy or
hepatorenal syndrome (kidney failure
secondary to liver failure).
• Upper GIB is dependent on endoscopic
therapy and may benefit from various
pharmacologic treatments in specific
scenarios, such as proton pump inhibitors
and macrolides. Management of lower GIB
is focused on colonoscopy and
mechanically treating bleeds, with little
pharmacological intervention.

B. LOWER

2
 TYPES OF BLEEDING CAUSES
ARTERIAL BLEEDING
• Most severe and urgent type of bleeding.
• Result from a penetrating injury, blunt
trauma, or damage to organs or blood
vessels.
• Distinction: blood is bright red, comes out in
spurts & pulses.
• Type of bleeding is hard to control. Bcs it’s a
pulse from the beating heart = will not clot
or stop easily.

TREATMENT UPPER GI
• Initial step: put pressure on the wound with Peptic Ulcer • Most common cause
latex gloved hand and sterile gauze. of upper GI bleeding.
• If bleeding stops: cover with sterile gauze • Sores on the lining of
and bandage to maintain pressure on the stomach and upper
wound. portion of the small
• If bleeding is in arm or leg: elevate the part intestine.
above the level of the heart. • Bcs of stomach acid
• Last resort: apply tourniquet above the (bacteria or use of
bleeding wound. inflammatory drugs)
à damage of lining =
CAPILLARY BLEEDING formation of sores.
Tears in the • Mallory-Weiss tears.
• Typically happens due to injury in the skin. lining of • Cause a lot of
• Much more common than other types. esophagus bleeding
• Venous bleeding: blood oozes from the • Most common with
damaged body part. alcoholics.
• Least severe type.
• Easiest to control à bcs it comes from blood
vessels on the surface. Abnormal, • Occurs most often to
enlarged veins in people with serious
TREATMENT the esophagus liver disease.
• Initial step: cleanse wound with soap and (eso. Varices)
water.
• Wound may need irrigation under pressure Esophagitis • Most commonly
to remove contaminants, this will prevent caused by GERD.
infections.
• Final step: apply pressure with latex gloves LOWER GI
and sterile dressing. Diverticular • Small bulging pouch
Disease in digestive
VENOUS BLEEDING (diverticulosis) à
inflamed =
• Less severe than arterial bleeding but can diverticulitis
still be life threatening. Inflammatory • Ulcerative colitis,
• Immediate medical attention required. Bowel Disease crohns’s disease,
inflammation of the
• Distinction: dark red color.
lining in digestive
tract.
TREATMENT
• Same with arterial bleeding.

3
 Tumors • Benign/Malignant in of a long tube, which is
esophagus, stomach, passed through the
colon or rectum à rectum to enable the
weaken digestive doctor to examine the
tract = bleeding.
large intestine and
Colon polyps • Small clumps in the
rectum.
lining of colon à
bleeding. Capsule • In this procedure, the
Hemorrhoids • Swollen veins in anus Endoscopy patient will be asked to
or lower rectum. swallow a vitamin-size
capsule with a tiny
Anal fissures • Small tears in the camera inside. The
lining of the anus.
capsule travels through
Proctitis the digestive tract
• Inflammation of the
lining of the rectum. taking thousands of
pictures that are sent to
a recorder he/she
TREATMENT wears on a belt around
• ACID SUPPRESION - patient with GI the waist. This enables
bleeding is treated with Proton Pump the doctor to see inside
Inhibitor (PPI). the small intestine.

DIAGNOSTIC EXAM Flexible • A tube with a light and

The doctor will take a medical history, sigmoidoscopy. camera is placed in the
including a history of previous bleeding, rectum to look at it and
conduct a physical exam and possibly order the last part of the large
tests. Tests might include: intestine that leads to
• Blood tests. There may be a need for the rectum (sigmoid
complete blood count, a test to see how colon).
fast the blood clots, a platelet count and Balloon- • A specialized scope
liver function test. assisted inspects parts of the
• Stool tests. Analyzing the stool can help enteroscopy. small intestine that
determine the cause of occult bleeding. other tests using an
• Nasogastric lavage. A tube is passed endoscope can't reach.
through the nose into the stomach to Sometimes, the source
remove the stomach contents. This might of bleeding can be
help determine the source of bleed. controlled or treated
during this test.
Upper • This procedure uses a Angiography • A contrast dye is
endoscopy tiny camera on the end injected into an artery,
of a long tube, which is and a series of X-rays
passed through the are taken to look for
mouth to enable the and treat bleeding
doctor to examine the vessels or other
upper gastrointestinal abnormalities.
tract. Imaging test • A variety of other
Colonoscopy • This procedure uses a imaging tests, such as
tiny camera on the end an abdominal CT scan,

4
 might be used to find • The patient was taught with a list of
the source of the irritating foods and drugs to avoid like
bleeding. coffee, tea, caffeine, spicy foods, rough
• If the GI bleeding is
foods, citric acid juices, hot foods as they
severe, and
noninvasive tests can't can increase acid in the stomach.
find the source, there • The patient was instructed to eat small,
might be a need for frequent meals, to chew food well, and to
surgery so that doctors eat slowly to avoid distress on the GI
can view the entire tract. The patient was instructed to drink
small intestine.
water with meals to aid in digestion.
• The patient was advised to evade use of
NURSING DIAGNOSIS aspirin having medications like ibuprofen
and other nonsteroidal anti-inflammatory
1. Fluid Volume Deficit related to blood volume
medicines as this interferes with your
loss secondary to GI bleeding as evidenced
by hematemesis, hematochezia, and blood's clotting action.
lightheadedness. • The patient was advised to evade
2. Acute Pain related to abdominal muscle coughing, sneezing, lifting, straining
spasms secondary to bleeding peptic ulcers. during defecation, or vomiting to rest the
3. Ineffective Tissue Perfusion GI and avoid recurrent bleeding.
(Gastrointestinal Peripheral)

INTRA-ABDOMINCAL HYPERTENSION/
CLIENT EDUCATION
ABDOMINAL COMPARTMENT
• The disorder, its course, treatment, and SYNDROME.
medications ordered, including intended
effects, dosage, and adverse effects to • Abdominal compartment syndrome refers
report. to organ dysfunction caused by intra-
• The signs and symptoms of actual or abdominal hypertension.
impending GI bleeding, such as blood in • under recognized because it primarily
affects patients who are already quite ill and
vomitus or stools, pallor, cool skin, and whose organ dysfunction maybe incorrectly
lightheadedness; include instructions to ascribed to progression of the primary
notify the physician should any such illness.
signs occur.
• Encourage compliance with abstinence if
alcohol use causes bleeding and refer to
support groups such as Alcoholic
Anonymous.
• Preoperative teaching, as indicated.
• Educate the patient (or guardian) on how
to fill out a fluid balance.
• The patient was advised to evade milk
because it occasionally increases gastric
acid secretion.
• The patient was taught to design a diet
high in vitamin K to promote proper blood
clotting.

5
Normal intra abdominal pressure = 5 -7 mmHg

o >12 in adults & > 10 in children = Intra-

abdominal hypertension.
o >20 in adults & >10 in children + organ
dysfunction or organ failure = Abdominal CAUSES OF ACUTE LIVER FAILURE
Compartment Syndrome. Acetaminophen • Large doses can
overdose damage your liver
4 TYPES or lead to failure.
- Grade 1, IAP 12 – 15mmHg
Viruses (hep A, • Lead to liver
- Grade II, IAP 16 – 20 mmHg
B, & E, the damage or
- Grade III, IAP 21 – 25 mmHg cirrhosis.
Epstein-Barr
- Grade IV, IAP >25 mmHg Virus,
Cytomegalovirus,
HOW TO MEASURE
herpes simplex
- Urinary catheter, bcs bladder is inside
the abdominal cavity. virus
- Bladder pressure = Intraabdominal Reactions to • Some kill cells in
Pressure certain your liver. Other
prescription and damage the duct
- herbal system that moves
LIVER FAILURE medications bile thought it.
Eating poisonous • A kind called
• A life-threatening condition that demands wild mushrooms Amanita
urgent medical care. Most often, liver Phalloides, also
failure happens gradually, over many known as death
years. It’s the final stage of many liver cap, contains
disease. But a rare condition known as toxins that damage
acute liver happens rapidly (in as little as liver cells and lead
48 hours) and can be difficult to detect at to liver failure
first. within a couple of
• Liver failure happens when large parts of days.
the liver become damaged beyond repair Autoimmune • As with the viral
and the liver cant work anymore. hepatitis hepatitis, this
disease, in which
® Volume Overload (Sympathetic Reaction) your body attacks
® Ischemia & Inflammation (hypoxemia, your liver, can lead
systemic inflammatory response to acute liver
syndrome) failure.
Wilson’s Disease • This genetic
disease prevents
TYPES OF LIVER FAILURE your body from
removing copper.
• ACUTE à this is when your liver stops It builds up in and
working within a matter of days or damages your
weeks. Most people who get this don’t liver.
have any type of liver disease or Acute fatty liver • In this rare
problem before this event. of pregnancy condition, excess
fat gathers on your
• CHRONIC à damage to your liver builds liver and damages
up over time and causes it to stop it.
working.

6
 Septic shock • This overwhelming o protease: breaks down proteins to
infection in your amino acids
body can damage o lipase: breaks down fats
your liver or cause ® PANCREATIC ENZYMES DON’T ACTIVATE
it to stop working. UNLESS THEY ARE IN THE DUODENUM.
(stomache acid activates it)
Budd chair • This rare disease
syndrome narrows and blocks
® Inflammation in pancreas = cant deliver
the blood vessels in
your liver. enzymes and hormones à pancreas
swells and leaks it.
Industrial toxins • Many chemicals
® Patient can experience the following:
including. Carbon
tetrachloride, a o Blood sugar issues (insulin di ma
cleaner and deliver)
degreaser, can o Ascites
damage your liver. o Malabsorption (weight loss
problems) (bcs no enzymes
delivered)
SYMPTOMS o GI issues (diarrhea, pain, oily stools)
o Shock…multi-organ failure
• The early symptoms of liver failure, same respiratory distress (leaks can go to
with liver disease condition. the lungs and cause ARDS)
o Internal Bleeding…hemorrhage
• Early symptoms:
o Structure changes of the pancreas:
o Nausea
fibrosis, cysts (filled with infection,
o Loss of appetite
rupture, hemorrhage), abscesses,
o Fatigue
duct changes
o Diarrhea
• Progresses à symptoms more serious.
Like:

Acute Pancreatitis
PANCREATITIS
• Acute pancreatitis – inflammation of the
pancreas that develops quickly.
® Inside the pancreas are special cells that • Main symptom: abdominal pain. Settles in
secrete enzymes (acinar) and hormones few days then becomes severe & very
(islets of Langerhans). These cells serious
perform exocrine and endocrine functions. • Most common cause: Alcoholic.
® ENDOCRINE FUNCTION: The endocrine cells ® Sudden inflammation of the pancreas
called Islet of Langerhans cells produce due to something that has triggered the
insulin, glucagon, somatostatin, and digestive enzymes to become activated
pancreatic polypeptide (all play a role in inside the organ (there will be a high
metabolism of nutrients and balancing blood amylase and lipase level in the blood).
sugar). These substances enter the blood ® It can be reversed if treated quickly and
stream via a network of blood vessels promptly.
surrounding the pancreas. ® Can be fatal (lead to chronic)
® Most common cause: Gallstones and high
® EXOCRINE FUNCTION: Acinar cells which
amount of alcohol consumption.
secrete digestive enzymes into the
pancreatic ducts MAIN CAUSE OF ACUTE PANCREATITIS
o amylase: breaks down carbs to glucose
A. GALLSTONES

7
® Gallstones are hardened deposits of of digestive enzymes into the surrounding
undissolved cholesterol, salts, or bilirubin tissues which is causing bleeding and it is
leaking down into the flanks and
that can block the bile duct which will
umbilicus.
cause pancreatic juices to build up in the
pancreas ( ang gall bladder and pancreas
share the ampulla of vater, so ang bile
from gallbladder and enzymes sabay sila
naga flow sa ampulla vater papunta sa
duodenum) CHRONIC PANCREATITIS
® Blockage à increase pressure in
pancreatic ducts à activate the enzymes • Chronic pancreatitis/Pancreatic Cancer, a
in the pancreas à pancreastitis. blockage in the pancreatic duct, or cystic
fibrosis.
B. HIGH ALCOHOL CONSUMPTION • Yellow stool = pancreatitis prevents
® Alcohol damages the cells of the pancreas pancreas from providing enough of the
enzymes that the intestines need to digest
specifically the acinar cells along with
food
duct cells (remember they produce ® Chronic inflammation of the pancreas
bicarbonate and fluids), and that can lead
(can be from repeated episodes of acute
to pancreatic duct occlusion due to the
pancreatitis but most commonly due to
thickening of the fluid that lines the
years of alcohol abuse)
pancreatic ducts and this can lead to the
® Irreversible.
activation of the enzyme cells inside the
® In chronic Pancreatitis patient can
pancreas. experience:
® other causes infection, tumor, o loss of the function of the
medications, trauma endocrine and exocrine cells
(digestion and blood glucose
problems)
SIGNS AND SYMPTOMS o damaged ducts
® Abdominal Pain: Sudden, very painful o fibrosis
mid-epigastric pain or left upper quadrant o pancreas may become enlarged or
which can be felt in the back as well due shrunk
to the location of the pancreas o cysts and calcification….patient
® Pain worst when lying flat… the doesn’t get better and damage is
pancreas is swollen/ inflamed and the irreversible.
person lies flat, this pulls the peritoneum
tighter over the pancreas and causes
increased pain. MAIN CAUSE OF CHORNIC
® May report the pain started after PANCREATITIS
consuming greasy/high fat meal or
alcohol. A. HEAVY LONG TERM ALOCHOL CONSUMP
® Fever, increased HR, decreased BP ® Recurrent pancreatitis due to alcohol à
® Nausea and vomiting damage to pancreatic ducts/acinar cells
® Hyperglycemia à scar tissue formation à inflammation
® Increased amylase and lipase slowly destroys the pancreas overtime.
® Cullen Signs – bluish discoloration
around the belly button. B. CYSTIC FIBROSIS
® Grey-Turner Sign – bluish discoloration ® Patients with this condition are lacking
on the flanks (side ng tyan) the protein CFTR. This plays a role in the
® Cullen and Grey-Turner - They represent movement of chloride ions to help balance
retroperitoneal bleeding from the leakage

8
 salt and water in the epithelial cells that ® CT or ultrasound: imaging of the pancreas
line the ducts of the pancreas ® ERCP (Endoscopic Retrograde
® < protein CFTR à dec. production of Cholangio-Pancreatography): use to
bicarbonate secretion of epithelial cells à diagnose and sometimes treat the cause of
pancreatitis. It assesses the pancreas, bile
causes thick mucus in pancreatic ducts à
ducts, and gallbladder with a small scope.
causes blockage à increase pressure à In addition, it can be used to help remove
activate the enzymes in the pancreas à gallstones, dilate the blocked ducts with a
damage of pancreas. stent or balloon, drain cysts etc.
® the pancreas experiences fibrosis of the
pancreas’ tissue and no longer produces
digestive enzyme to help with food NURSING INTERVENTION
digestion. The patient will need ® Maintain NPO status (to let pancreas
supplements of pancreatic digestive rest…once symptoms subside reintroduce
solids food very carefully..start with
enzymes.
liquids..no fat per MD order)
® other causes: hypercalcemia, ® Maintain IV hydration….TPN may be
hyperlipidemia etc. ordered (if taking a while to heal) for
nutrition per MD order
SIGNS AND SYMPTOMS ® Insert NG tube and maintain per MD
® Abdominal pain: Chronic epigastric pain order (used to remove stomach contents
that is persistent (can have no pain and gas)
because the pancreas is not producing ® Monitor blood sugars: hyperglycemia
enzymes because of the extent of the ® Monitor stools: oily/greasy? And their
damage) frequency…if they are taking pancreatic
® Pain becomes worst after drinking alcohol enzymes, the number of oily/greasy stools
or eating a greasy/fatty meal should decrease
® May have a mass and swelling in ® Monitor nutrition: daily weights, intake
abdomen due to pseudocyst formation on and output (urine color…can turn dark
the pancreas brown)
® Diarrhea with stool that is called ® Administering pain medication per MD
Steatorrhea: oily/fatty stools due to the order for pain (usually IV route due to
lack of pancreatic enzymes to help digest severity) …Typically, NO Morphine
fats because it can cause spasm of sphincter
® Weight loss: because no enzymes to help of Oddi
digest the food ® Nonpharmacological methods for pain:
® Signs and symptoms of Jaundice: leaning forward or sitting up (no supine
yellowing of skin and eyes…damage to the positioning)
common bile duct which helps remove bile ® Administering drugs to decrease acid
from the liver, so the bile builds up secretion to help prevent the activation of
® Dark urine: due to the excessive bile in digestive enzymes (similar to the drugs
the body (kidneys cant filter well) used in Peptic Ulcer Disease and GERD):
® Signs and symptoms of Diabetes PPIs, H2 blockers, antacids per MD order
Mellitus: the pancreas’ islet of ® Administering Pancreatic enzymes
Langerhans that secrete insulin are NOT “Creon/Pancreatin”.
working. o Mix with acidic food (e.g apple
sauce) acid activates enzymes.
o Don’t mix with Alkaline food (e.g
milk, ice cream, pudding)
DIAGNOSIS ® Education on Diet
® Blood tests: amylase, lipase, electrolytes o AVOID alcohol or greasy/fatty food
(abnormal)

9
 o Low fat, bland small meals rather • Length of stay:
than large, high protein, stay around 25 days.
hydrated • Recovery time:
o Limit sugar and avoid refined within 18 days.
carbs (high fructose corn syrups, • Nutrient
breads) but concentrate on absorption: some
complex carbs like fruits, cannot be absorbed.
vegetables, grain….body will • Risk of compli:
release less insulin, especially if moderate.
patient develops diabetes…need Sleeve • Weight loss: rapid
complex carbs, high protein
Gastrectomy • Length of stay: 4
days
• Recovery time: not
BARIATRICS
definite
• Field that focuses on and treats those who • Reversibility: No.
have obesity to promote weight loss and • Nutrient
increase overall health with diet, exercise absorption: not
and behavior therapy. affected.
• Bariatric surgery à metabolic or weight • Risk: 17%
loss surgery. experience some
• Bariatric Patient à BMI = ³ 30. compli. (case to
• Morbid Obesity à BMI = > 40. case basis)
• Qualify for Bariatric à BMI = 35 – 39 or • Compli: severe
>40, with significant health problems (e.g emesis, abdominal
diabetes typ 2, sleep apnea, high bp. distention, stomach
ache,
malabsorption.

TYPES OF BARIATRICS
Adjustabkle • Can ¯ 55% of body
Gastric Band weight
Application • Length of stay: 7
days
• Recovery time: 5
das
• Reversibility: Yes.
• Risk of compli:
LOW.
• Uses silicon band à
applied on upper
part of the stomach.
Gastric Bypass • Formation of new
route

10
 DIABETIC KETOACIDOSIS C. LIVER & GLUCAGON
® Liver release stored glucagon (bcs it
thinks theres no glucose in the body) à
makes the patient more hyperglycemic.

D. KETONES
® Fats break down = ketones (byproduct)
® In DKA: cannot use glucose à uses fats to
fuel the body à fats breakdown à
ketones(acidic) in the blood à ketones
causes the blood to become acidic (in
Diabetic patient) à blood becomes acidic
à Metabollic Acidosis.

E. KIDNEYS
® Reabsorbs glucose in renal tubules.
® In DKA: too much glucose in the blood, it
cant be reabsorbed à leaks into urine à
OSMOTIC DIURESIS à polyuria and
excretion of electrolytes.
CLINICAL MANIFESTATIONS
® DIABETIC KETOACIDOSIS HAPPENS
MAINLY IN DIABETIC TYPE 1.

CAUSES
® UNDETECTED DIABETES – patient
doesn’t know he/she is diabetic. First sign.
® MORE INSULIN NEEDED IN THE
BODY THAN NORMAL. - the body needs
more units of insulin than it is actually
receiving from injections.
® NOT EATIING (SKIPPING MEALS) -
body starts to go into “starvation” mode
and begins to burn ketones (normally in
nondiabetics when the body goes into
starvation mode it can cope when ketones
4533 are released by regulating insulin and
glucagon to maintain sugar levels…but in
KEY PLAYERS OF DKA the diabetic they don’t have that ability
and ketones production is dangerous).
A. GLUCOSE ® NOT TAKING INSULIN AS
® Fuels cells so it can function SCHEDULED: therefore, the blood
® In DKA: no insulin present à glucose levels are not controlled…ketones
hyperglycemia >300 mg/dL. are produced, and the cycle of acidosis
starts to take place in the body.
B. INSULIN
® Helps takes glucose into the body for fuel.
® In DKA: not enough insulin à glucose
cannot enter cell à glucose remain in
blood à body thinks its starving à look
other source of energy.

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 SIGNS AND SYMPTOMS 250 to 300 mg/dL. This will help
gradually bring the blood sugar
® Hyperglycemia down and help the insulin do its job
® Ketones in the blood by removing the ketones.
® Metabolic Acidosis ® Administered insulin: REGULAR (only
® Polyuria type given IV) and make sure K+ is
normal >3.3
® Polydipsia
o NOTE: if you rapidly bring a
® Dehydration
patient’s blood glucose down (or
® Nausea and Vomiting up) the brain can’t cope and water
® Abdominal Pain (pediatrics) will be moved from the blood to the
® Kussmaul Breathing CSF and you will get cerebral
® Acetone Breathe Smell edema and increased intracranial
® Tachycardia pressure
® Hypotension ® Tip for insulin administration: when
® Confusion priming tubing for insulin infusion waste
® Fatigue 50cc to 100cc (per institution protocol)
because insulin absorbs into the plastic
NURSING INTERVENTIONS lining of the tubing.
® o Watch potassium levels very
closely because insulin causes K+
® Teach patient early signs and when to
to move back into the cell
seek treatment:
o Administer Potassium solution IV
® Monitor glucose and ketones during to combat this…. note renal
illness every 4 hours, especially if dealing function before administering.
with illness/infection
® If vomiting and cannot eat food or drink
liquids notify doctor (if can tolerate drink
liquids every hour)
® Notify medical doctor if blood sugars are
higher than normal or greater than 300
mg/dL consistently
® Ketones present in the urine
® Excessive thirst, frequent urination,
abdominal pain, nausea and vomiting,
acetone breath

TREATMENT

® Goal: Hydrate, decrease blood glucose,

monitor Potassium level and cerebral
edema (esp. in children), correct acid-
base imbalance

® Administering IV fluids: (depending on

MD order) such as 0.9% normal saline
(start out with a bolus of this) and
progress with 0.45% NS to hydrate the
cells (depends on how dehydrated the
patient is)
o 5% dextrose may be added to the
0.45% NS when glucose is around

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