INTRODUCTION:

Cardiovascular disease are the major cause of morbidity and premature mortality in a man in worldwide. India is one of the developing country contribute a great share to global burden of Cardiovascular disease. Cardiovascular disease claimed 931,108 lives in US during 2001. Almost 2551 people diagnosed as cardiovascular disease per day. Almost 2 people / minute died due to lack of treatment Cardiovascular disease accounts 38.5% of all death, one of every 2.6 death. (Heart disease and stroke statistics, 2008).

According to American heart association, Approximately 7 lack people die each year from sudden cardiac arrest, representing 10% of death in India. Cardiovascular related death occurs once every 37 seconds, also in 2016 more women died from Cardiovascular disease than man. But very few people are aware the first 10 minutes are crucial and can make all the difference in saving a patient during a cardiac arrest. (British heart foundation 2016)

Definition of Cardio vascular Emergencies:

Definition:

An emergency is "an unforeseen occurrence or combination of circumstances which calls for immediate action or remedy."

Cardio vascular Emergencies:

cardiac emergencies are relatively rare, in the aggregate many situations arise in which prompt remedial action is imperative or in which the initiation of appropriate new or special measures should not long be delayed. cardiac emergencies situations urgently calling for correct decision will be discussed briefly

ACUTE CORONARY SYNDROME (ACS):

Acute coronary syndrome (ACS) is a syndrome (set of signs and symptoms) due to decreased blood flow in the coronary arteries such that part of the heart muscle is unable to function properly or dies.

Signs and symptoms:

· Chest pain or discomfort, which may involve pressure, tightness or fullness

· Pain or discomfort in one or both arms, the jaw, neck, back or stomach

· Shortness of breath

· Feeling dizzy or lightheaded

· Nausea

· Sweating

Mnemonics, such as SOCRATES, can be used to assess patients’ chest pain:

S Site of pain;

O Onset of pain;

C Character of the pain;

R Any radiation;

A Associated factors;

T Timing of the pain;

E Exacerbating/alleviating factors; for example, position or inspiration;

S Severity of the pain using a rating scale of 1-10 (10 being the worst pain).

Nursing care:

· Keeping clear and comprehensive notes is crucial to ensure all nurses caring for patients with ACS know the patients’ clinical status, areas of concerns and management plan.

· General priorities for patients with ACS are hemodynamic monitoring and close observation of vital signs.

· A review of fluid status can provide information about renal perfusion, as some patients may present with, or develop, heart failure.

· capillary blood glucose levels should be regularly checked.

CARDIOGENIC SHOCK:

Cardiogenic shock is also sometimes called "pump failure”. It is a condition of diminished cardiac output that severely impairs cardiac perfusion. It reflects severe left-sided heart failure. The causes of cardiogenic shock are known as either coronary or non-coronary.

· Coronary cardiogenic shock is more common than noncoronary cardiogenic shock and is seen most often in patients with acute myocardial infarction.

· Noncoronary cardiogenic shock is related to conditions that stress the myocardium as well as conditions that result in an ineffective myocardial function. Cardiogenic shock occurs as a serious complication in 5% to 10% of patients hospitalized with acute myocardial infarction. Incidence of cardiogenic shock is more common in men than in women because of their higher incidence of coronary artery disease.

Main signs:

· Cardiogenic shock produces symptoms of poor tissue perfusion.

· Patient experiences cool, clammy skin as the blood could not circulate properly to the peripheries.

· Decreased systolic blood pressure.The systolic blood pressure decreases to 30 mmHg below baseline.

· Tachycardia occurs because the heart pumps faster than normal to compensate for the decreased output all over the body.

· The patient experiences rapid, shallow respirations because there is not enough oxygen circulating in the body.

· An output of less than 20ml/hour is indicative of oliguria.

· Mental confusion. Insufficient oxygenated blood in the brain could gradually cause mental confusion and obtundation.

· Cyanosis occurs because there is insufficient oxygenated blood that is being distributed to all body systems.

Medical management:

· The aim of treatment is to enhance cardiovascular status by: Oxygen.

· Oxygen is prescribed to minimize damage to muscles and organs.

· Angioplasty and stenting: A catheter is inserted into the blocked artery to open it up.

· Balloon pump. A balloon pump is inserted into the aorta to help blood flow and reduce workload of the heart.

· Pain control. In a patient that experiences chest pain, IV morphine is administered for pain relief.

· Hemodynamic monitoring. An arterial line is inserted to enable accurate and continuous monitoring of BP and provides a port from which to obtain frequent arterial blood samples.

· Fluid therapy : Administration of fluids must be monitored closely to detect signs of fluid overload

Pharmacologic Therapy:

· IV Dopamine, is a vasopressor, increases cardiac output, blood pressure, and renal blood flow.

· IV Dobutamine is an inotropic agent that increase myocardial contractility.

· Norepinephrine is a more potent vasoconstrictor that is taken when necessary.

· IV Nitroprusside is a vasodilator that may be used with a vasopressor to further improve cardiac output by decreasing peripheral vascular resistance and reducing preload.

Nursing management:

· Assess the patient’s vital signs, especially the blood pressure.

· Assess for Fluid overload to rule out fluid may accumulate in the lungs.

· Prevent recurrence. Identifying at-risk patients early, promoting adequate oxygenation in order to decrease cardiac workload can prevent cardiogenic shock.

· Hemodynamic status to be monitored such as ABG values, Arterial lines, ECG, cardiac, pulmonary status and laboratory values are documented and reported.

· Adventitious breath sounds, changes in cardiac rhythm, and other abnormal physical assessment findings are reported immediately.

· IV infusions must be observed closely because necrosis and sloughing may occur if vasopressor medications infiltrate the tissues, and it is also necessary to monitor the intake and output.

· Intra-aortic balloon counter pulsation. The nurse makes ongoing timing adjustments of the balloon pump to maximize its effectiveness by synchronizing it with the cardiac cycle.

· Enhance safety and comfort. Administering of medication to relieve chest pain, preventing infection at the multiple arterial and venous line insertion sites, protecting the skin, and monitoring respiratory and renal functions help in safeguarding and enhancing the comfort of the patient.

· Positioning. If the patient is on the IABP, reposition him often and perform passive range of motion exercises to prevent skin breakdown, but don’t flex the patient’s “ballooned” leg at the hip because this may displace or fracture the catheter.

HEART FAILURE:

Heart failure, known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to fill and pump efficiently. Annually 550,000 new cases diagnosed each year as heart failure. Sudden death is common in patients with CHF, occurring at a rate of six to nine times that of the general population. Deaths from heart failure have decreased on average by 12 percent per decade for women and men over the past fifty years.

Categories of heart failure:

· Systolic heart failure (pumping problem)—the inability of the heart to contract enough to provide blood flow forward

· Diastolic heart failure (filling problem)—the inability of the left ventricle to relax normally, resulting in fluid backing up into the lungs

· Left-sided heart failure—the inability of the left ventricle to pump enough blood, causing fluid to back up into the lungs

· Right-sided heart failure—the inefficient pumping of the right side of the heart, causing congestion or fluid buildup in the abdomen, legs, and feet

· Acute heart failure—an emergency situation in which a patient who was completely asymptomatic before the onset of heart failure decompensates when there's an acute injury to the heart, such as a myocardial infarction (MI), impairing its ability to function

· Chronic heart failure—a long-term syndrome in which the patient experiences persistent signs and symptoms over an extended period of time, likely as a result of a preexisting cardiac condition.

Heart failure signs and symptoms may include:

· Shortness of breath (dyspnea) when you exert yourself or when you lie down

· Fatigue and weakness

· Swelling (edema) in your legs, ankles and feet

· Rapid or irregular heartbeat

· Reduced ability to exercise

· Persistent cough or wheezing with white or pink blood-tinged phlegm

· Increased need to urinate at night

· Swelling of your abdomen (ascites)

· Very rapid weight gain from fluid retention

· Lack of appetite and nausea

· Difficulty concentrating or decreased alertness

· Sudden, severe shortness of breath and coughing up pink, foamy mucus

· Chest pain if your heart failure is caused by a heart attack

Medical Management:

Heart Failure Emergencies Call for "Alphabet Therapy"

CAB's

· Circulation Start advanced life support if needed

· Airway Check and secure

· Breathing to be Monitor

LMNOP's:

· Lasix - Reduce fluid congestion

· Morphine - Decrease stress on myocardium

· Nitroglycerin - Insure cardiac circulation

· Oxygen - Oxygen to heart and brain

· Positioning - Sit person up to avoid lungs filling with fluid

Medical Therapies for Heart Failure

· Diuretics help reduce fluid buildup in the lungs and peripheral edema.

· ACE Inhibitors lower blood pressure and reduce the strain on the heart. (These medications also may reduce the risk of a also may reduce the future heart attack)

· Beta-blockers slow heart rate and lower blood pressure to decrease the cardiac workload.

· Digoxin makes the heart beat stronger and pump more blood.

Nursing interventions

· Administer medications and assess the patient's response to them

· Assess fluid balance, including intake and output, with a goal of optimizing fluid volume

· Weigh the patient daily at the same time on the same scale, usually in the morning after the patient urinates (a 2- to 3-pound [0.9- to 1.4-kg] gain in a day or a 5-pound [2.3 kg] gain in a week indicates trouble)

· Auscultate lung sounds to detect an increase or decrease in pulmonary crackles

· Determine the degree of jugular vein distension

· Identify and evaluate the severity of edema (pitting edema)

· Monitor the patient's pulse rate and BP and check for postural hypotension due to dehydration

· Examine skin turgor and mucous membranes for signs of dehydration assess for symptoms of fluid overload.

MYOCARDIAL INFARCTION (MI):

Myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle. Acute myocardial infarction is the medical name for a heart attack. A heart attack is a life-threatening condition that occurs when blood flow to the heart muscle is abruptly cut off, causing tissue damage. This is usually the result of a blockage in one or more of the coronary arteries.

Symptoms :

· Pressure or tightness in the chest

· Pain in the chest, back, jaw, and other areas of the upper body that lasts more than a few minutes or that goes away and comes back

· Shortness of breath and cough

· Sweating

· Nausea and vomiting

· Anxiety

· Dizziness

· Fast heart rate

Nursing Management:

One of the most important aspects of care of the patient with MI is the assessment.

· Assess for chest pain not relieved by rest or medications.

· Monitor vital signs, especially the blood pressure and pulse rate.

· Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles.

· Assess for nausea and vomiting.

· Assess for decreased urinary output to rule out blood circulation.

· Assess for the history of illnesses.

· Perform a precise and complete physical assessment to detect complications and changes in the patient’s status.

Nursing Interventions:

· Administer oxygen along with medication therapy to assist with relief of symptoms.

· Encourage bed rest with the back rest elevated to help decrease chest discomfort and dyspnea.

· Encourage changing of positions frequently to help keep fluid from pooling in the bases of the lungs.

· Check skin temperature and peripheral pulses frequently to monitor tissue perfusion.

· Provide information in an honest and supportive manner.

· Monitor the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, changes in skin color, and laboratory values.

PERICARDITIS:

Pericarditis results from fluid accumulation in this space nearly 120 ml of extra fluid is able to accumulate in the pericardium without any adverse increase in pressure. Acute pericarditis can be caused by noninfectious inflammation such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). This is known as serous pericarditis. The fluid found in these instances contains few polymorphonuclear neutrophils, lymphocytes, or histiocytes. The usual volume is 50-200 mL and accumulates slowly. Fibrous adhesions rarely occur with noninfectious serous pericarditis. pericardial effusion causes fluid to build up around the heart and compresses it leads to cardiac tamponade.

Signs and Symptoms of Pericarditis:

Remember “FRICTION”

· Friction rub pericardial (sounds like a grating, scratching sound), Fever

· Radiating substernal pain to left shoulder, neck or back

· Increased pain when in supine position (leaning forward relieves pain)

· Chest pain that is stabbing (will feel like a heart attack)

· Trouble breathing when lying down (supine position)

· Inspiration or coughing makes pain worse

· Overall feels very sick and weak

· Noticeable ST segment elevation

Nursing Interventions for Pericarditis:

· Assess patient’s pain (very painful)

· Keep patient in high Fowler’s position (avoid supine) because this relieves pain

· Monitor for Cardiac Tamponade (fluid compressing the heart):

· Pulsus paradoxus (during the inspiratory phase that is a 10 or greater mmHg drop in the systolic blood pressure)

· Jugular venous distention with clear lungs

· Heart sounds are muffled (fluid buildup on the heart

· Tachycardia

· Hypotension

Administer medications as prescribed by physician:

· NSAIDS (nonsteroidal anti-inflammatory medications) Aspirin OR Ibuprofen…watch for GI bleeding. take with a full glass of water

· Colchicine: decreases the inflammation (used in gout) don’t take with grapefruit juice because this increases toxicity (nausea vomiting, abdominal pain, (can take it with or without food)

· Corticosteriods: used if patient not responding to other treatments…Prednisone..decreases the inflammation

· IV antibiotics for infection

SUDDEN CARDIAC ARREST (SCA):

Sudden cardiac arrest (SCA) is a condition in which the heart suddenly and unexpectedly stops beating. If this happens, blood stops flowing to the brain and other vital organs. SCA usually causes death if it's not treated within minutes. Sudden cardiac arrest is the sudden, unexpected loss of heart function, breathing and consciousness. Sudden cardiac arrest usually results from an electrical disturbance in your heart that disrupts its pumping action, stopping blood flow to the rest of your body. Sudden cardiac arrest is different from a heart attack, which occurs when blood flow to a portion of the heart is blocked. SCD is often the first expression of coronary artery disease and is accountable for approximately 50-percent of the deaths that occur due to this disorder. The incidence of SCD increases with age, is more common in blacks than whites, and is higher (3:1) among men than women. Is more common in those ages 45-75, though not limited to certain age ranges.

In order to meet the criteria for this diagnosis, the critical circulatory collapse must be; 1) unexpected, 2) it must relate in some manner to heart problems, and 3) it should occur with minimal warning or a complete absence of prelude symptoms. This means the event occurs proximal to any warnings, typically within one hour of the start of any type of cardiac related symptoms.

Symptoms:

· Sudden collapse

· Absence of pulse

· Absence of breathing

· Loss of consciousness

· Sometimes other signs and symptoms precede sudden cardiac arrest. These may include fatigue, fainting, blackouts, dizziness, chest pain, shortness of breath, weakness, palpitations or vomiting. But sudden cardiac arrest often occurs with no warning.

Management:

The management of these patients presents a tremendous challenge for both physicians and nurses: physicians are responsible primarily for the definition of type, location, and severity of the arrhythmia;

Medications Used to Manage sudden Cardiac deaths

· Antiarrhythmic drugs (Digoxin )

· Sodium channel blockers (Quinidine, Procainamide , Lidocaine, , Phenytoin)

· Beta blockers (Metoprolol, Propranolol, Esmolol, Atenolol)

· Potassium channel blockers(Amiodarone, Azimilide, Tedisamil)

· Calcium channel blockers (Verapamil, Diltiazem, Adenosine )

AHA Chain of Survival:

· Recognize an Emergency

· Early Access to Medical Care (calling 9-1-1 immediately)

· Early CPR

· Early Defibrillation

· Early Advanced Care

· New tools in the battle against sudden cardiac death are becoming available. One example is, ELS = Extracorporeal Life Support + CPR

Nurses Role:

Nurses focus primarily on the patient's response to illness and treatment in terms of its potential impact on their lifestyle. The clear focus for each discipline is necessary for development of a more purposeful and comprehensive treatment plan for the patient.

GOOD Heart Health Reduces Sudden Cardiac Death

· Good diet, exercise, and reduction of stress and nutrition play becomes more evident for reducing cardiac death.

· A recent study which showed that 1,000 milligrams of fish-oil capsules per day lowers the risk of sudden cardiac death by nearly half (Kirchheimer, 2006; Ho. Connie K 2013).

NURSING DIAGNOSIS:

· Decreased Cardiac Output

· Ineffective Breathing Pattern

· Ineffective Airway Clearance

· Acute Pain

· Impaired Gas Exchange

· Risk for Impaired Gas Exchange

· Activity Intolerance

· Excess Fluid Volume

· Risk for Impaired Skin Integrity

· Deficient Knowledge

· Excess Fluid Volume

· Ineffective Tissue Perfusion

· Hyperthermia

· Fatigue

CONCLUSION:

· Nurses represent a large proportion of health care community. They play a vital role in treatment as they are close to the patients and their families during all the process of disease.

· The great importance for nurses to meet the rehabilitative care needs of patients through education, support, supervision and reinforcement.

· Nursing education in cardiac rehabilitation can improve health outcomes and reduce the risk of a new cardiac event.

· The educational activities of nurses play a big role because nursing is traditionally associated with the care of the healthy and the ill. The development of nurses’ educational skills provides them with quality professional foundations that they can fully utilize to support their clients’ health.

REFERENCE:

1. Jaya kuruvilla (2018),Essentials of critical care nursing(1^sted.), New Delhi: Jaypee Publishers; 4-72

2. Shuva Das Gupta (2016), Nursing interventions for the Critically ill(2^nded.), New Delhi: Jaypee Publishers; 33-56

3. Sharon L. Lewis (2015), Medical Surgical Nursing(10^thed.), New York: Elsevier Publishers; 113-172

4. Kahutheriamma Thomas(2018), Medical Surgical Nursing(1^sted.), New Delhi: Jaypee Publishers; 376-382

5. Joyce M. Black (2018), Medical Surgical Nursing(8^thed.), New York: Elsevier Publishers;4-72

6. Brunner and Siddharts (2009), Medical Surgical Nursing(12^thed.), North America: lippincott Publishers;1132-1164

7. Linda S.Williams (2015), Understanding Medical Surgical Nursing(4^thed.), New Delhi: Jaypee Publishers;1173 - 1182

8. http://www.ncbi.nm.nih.gov

9. http://www.nrzp.cz/doc/NRPM.doc

10. http://en.wikipedia.org/wiki/critically ill

Received on 19.08.2018 Modified on 06.09.2018

Asian J. Nursing Education and Research. 2019; 9(1):121-126.

DOI: 10.5958/2349-2996.2019.00024.7