ACUTE

BIOLOGIC
CRISIS

Lisette Grace B. Umadhay, RN, MN

OBJECTIVES
At the end of 3H lecture, the students will
be able to:
1. Demonstrate standard assessment
methods & principles & techniques of
physical examination of the critically ill
patients,
2. analyze and interpret the different noninvasive and invasive diagnostic & lab
tests results of clients with multi-organ
problems,

3. Utilize the nursing process in the care of

individuals in ABC/multi-organ system
dysfunction (e.g. cardiac failure, acute
myocardial infarction, stroke, acute
pulmonary failure, acute renal failure,
increased intracranial pressure, diabetic
ketoacidosis)

ACUTE BIOLOGIC
CRISIS
Any conditions that may result
to patient mortality if left
unattended in a brief period of
time.

Standard Assessment
and

Principles & Techniques of

Physical Examination

Nursing Assessment Process In The E.R.

1.
2.

Primary Assessment
Secondary Assessment

Primary Assessment

Immediately identifies any client

problem that poses a threat, immediate
or potential to life, limb or vision.
Information is gathered through
objective data.
Immediate interventions are provided if
any abnormal findings are noted
Uses ABC mnemonics

Primary Assessment

A-airway (patency)
B- breathing (effectiveness)
C- circulation (both peripheral & organ specific)
For trauma patients, the cervical spine area must be
evaluated
If the ABC status is satisfactory, the SECONDARY
ASSESSMENT is performed.

PRIMARY ASSESSMENT PROCESS

Secondary Assessment
Identifies

any other non-life threatening

problems the client may be experiencing.
Both objective & subjective data are obtained
Includes the following assessment:
a. Neurologic assessment
b. History
c. Pain
d. General overview
e. head-to-toe focused assessment

A. NEUROLOGIC ASSESSMENT
Determine clients:
1.
Level of consciousness (LOC)
2.
Orientation to person, place, time & event
3.
Glasgow coma scale (GCS) score
4.
Pupillary size, equality & reaction to light and
accommodation (PERRLA)
5.
Motor movement & strength of hand grips &
pedal pushes
*in children, brief neurologic assessment can be
determined using AVPU mnemonic

CHILD NEUROLOGIC
ASSESSMENT

A- alert (awake & alert, needs no stimulus to respond)

V- verbal (requires a verbal stimulus to elicit response)

P- pain (requires painful stimulus to evoke response)
U- unresponsive

GCS

B. HISTORY
clients chief complaint,
duration of the problem,
mechanism of injury,
past pertinent medical history,
current medications,
use of alcohol,
known allergies and immunizations.
For women, OB history is obtained.

SCENARIO:

A 30 y.o male came in the E.R. with a

chief complaint of multiple stab
wounds. What questions will you ask
the patient to obtain a complete &
accurate history.

D. PAIN

PQRST mnemonic

P provokes
Q- quality (type of pain)
R- Region/Radiation (Location of pain)
S- Severity (pain scale of 1-10, visual analogs)
T- Timing (how long?)
*pain rate of 7 & above is severe and is considered high
risk.

SITUATION:

A 50 y.o female came in the E.R. with

a chief complaint of RLQ pain.
Obtain a detailed pain assessment
applying the PQRST mnemonic.

C. GENERAL OVERVIEW
note clients over-all health condition, skin color,
gait, posture, unusual skin markings or body
odors, mood and affect.
Measurement of vital signs and O2 saturation
are obtained as well.

E. HEAD-TO-TOE FOCUSED
ASSESSMENT
Examine

areas where chief

complaint and other associated
complaints are focused.
Inspection
Auscultation
Percussion
Palpation

Non-invasive and Invasive

diagnostic & lab tests

Superior vana cava

Pulmonary
arteries

Aorta
Pulmonary
arteries

Pulmonary
veins

Pulmonary
veins

Inferior vena cava

CARDIAC CONDUCTION SYSTEM

This pathway is made up of 5 elements:

1. The sino-atrial (SA) node
2. The atrio-ventricular (AV) node
3. The bundle of His
4. The left and right bundle branches
5. The Purkinje fibres

ANATOMY AND PHYSIOLOGY OF

CARDIAC CONDUCTION SYSTEM
AND ITS RELATIONSHIP WITH ECG
WATCH THIS

ELECTROCARDIOGRAM
Essential

tool in evaluating the heart rhythm.

Displays the electrical action of the heart.
Several types:
1. Continuous monitoring
2. 12-lead
3. Signal averaged
4. Holter monitoring
. Allows identification of disorders of cardiac
rate, rhythm and contraction.

ROLE OF THE ECG MACHINE

The ECG machine is designed to recognize and

record any electrical activity within the heart. It
prints out this information on ECG paper made
up of small squares 1mm squared.

PRE-PROCEDURE CARE
1. Explain that the test helps evaluate the hearts
function by recording its electrical activity.
2. Remove all metal objects in the body, prevent body
from touching any metal.
3. Steps for ECG monitoring:
A. attach the electrodes to the clients skin
B. connect the electrodes to the monitor by a cable
C. Adjust the monitor/leads to obtain a readable ECG
3. During the procedure, advise the client to stand still,
breath normally, and refrain from talking.
4. Record the clients age, height, weight and note any
cardiac medications being taken.

12 LEAD ELECTROCARDIOGRAM

There are 10 wires on an ECG machine that are

connected to specific parts of the body. These
wires break down into 2 groups:

1.
2.

6 Chest Leads
4 limb or peripheral
leads (one of these
is "neutral")

UNIPOLAR LEADS
The "AV" stands for "Augmented Vector".
The last letter refers to position, which are as
follows:

Label

Meaning of label

Position of lead
on body

AVr

Augmented vector right

Right wrist

AVL

Augmented vector left

Left wrist

AVf

Augmented vector foot

Left foot

BIPOLAR LEADS
Lead

l- information between AVr and AVl

Lead ll- information between AVr and AVf
Lead lll- information between AVl and AVf

aV
r

L
V
a

aVf

POST-PROCEDURE CARE
1. After the procedure, disconnect the
equipment.
2. If using a conductive gel, wipe the gel
from the clients skin.
3. If using conductive stickers, remove
unless serial ECG readings are to be
done.

SINUS RYTHM

Normal rhythm of the heart where electrical stimuli are

initiated in the SA node, and are then conducted through
the AV node and bundle of His, bundle branches and
Purkinje fibres.

p wave- represents atrial depolarization

QRS Complex- at this point the electrical

stimulus passes from the bundle of His into the
bundle branches and Purkinje fibres. The amount
of electrical energy generated is recorded as a
complex of 3 waves known collectively as the QRS
complex.

Q wave and represents depolarization in the septum

R wave represents the electrical stimulus as it passes

through the main portion of the ventricular walls.

S wave represents depolarization in the Purkinje

fibres

T wave - Both ventricles repolarise before the

cycle repeats itself and therefore a 3rd wave (t
wave) is visible representing ventricular
repolarisation.

ST segment - There is a brief period between the

end of the QRS complex and the beginning of the
T wave where there is no conduction and the line
is flat. This is known as the ST segment and it is
a key indicator for both myocardial ischaemia and
necrosis if it goes up or down.

SUMMARY

P - atrial depolarization

PR interval- time it takes for the impulses to

spread from the atria to the ventricles

QRS- ventricular depolarization

QT interval- electrical systole

T - ventricular repolarization
U - follows T-wave (hypokalemia)

CONTINUOUS ECG MONITORING

PROCEDURE
Adjust the monitor by setting the alarms for
desired high and low rates.
Reassure the client that the equipment does not
cause electrical shock or hurt.
Clients receiving telemetry can get up and move
about their room or walk while their heart
rhythm is monitored.
3 electrodes are used: 2 detects hearts activity
and the third is an electrical ground.

HOLTER MONITORING
Ambulatory electrocardiography
A continuous ECG tracing is recorded
continuously for a day or longer on an outpatient
basis.
Detects dysrhythmias that may not appear on a
routine ECG but occur when the client is
ambulating at home or work.
Useful in evaluating effectiveness of
antidysrhythmic or pacemaker therapy.

PRE-PROCEDURE CARE
1.

Place 2-3 electrodes on the chest, attach them

to the telemetry unit.

2.

Encourage client to go about usual activities

and keep written account of these activities
along with manifestations that develop.

(this document transient dysrhythmias and

correlate client manifestations with the
underlying rhythm)

CARDIAC RHYTHMS

CARDIAC RHYTHMS
Sinus

Bradycardia
Sinus Tachycardia

Cardiac Dysrhythmias
U-wave
Atrial fibrillation
Atrial tachycardia
Ventricular tachycardia
Ventricular fibrillation

THE U WAVE
Another wave after the PQRST complex.It is not very
common and is easy to overlook.
Found in severe hypokalemia

ATRIAL FIBRILLATION
an irregular and often rapid heart rate that
commonly causes poor blood flow to the body
the heart's two upper chambers (the atria) beat
chaotically and irregularly out of coordination
with the two lower chambers (the ventricles) of
the heart
symptoms include heart palpitations, shortness
of breath and weakness
usually isn't life-threatening, it is a serious
medical condition that sometimes requires
emergency treatment
absence of P-wave

ATRIAL FLUTTER
Your heart's upper chambers (atria) beat too
quickly.
caused by problems in your heart's electrical
system.
200-350 beats per minute
a saw-toothed waveform

VENTRICULAR TACHYCARDIA
A rapid heartbeat that starts in the ventricles.
Pulse rate of more than 100 beats per minute,
with at least three irregular heartbeats in a row.
The condition can develop as an early or late
complication of aheart attack. It may also occur
in patients with:

Cardiomyopathy
Heart

failure
Heart surgery
Myocarditis
Valvular

heart disease

VENTRICULAR FIBRILLATION
A severely abnormal heart rhythm that can be
life-threatening.
Interruption of the heartbeat for only a few
seconds can lead to fainting (syncope) or cardiac
arrest.
Fibrillation is an uncontrolled twitching or
quivering of muscle fibers (fibrils).
Blood is notpumped from the heart. Sudden
cardiac death results.

VENTRICULAR TACHYCARDIA

VENTRICULAR FIBRILLATION

EXERCISE:

Identify the cardiac dysrhythmia

WHAT IS THE HEART RATE?

HEART RATE CAN BE EASILY

CALCULATED FROM THE EKG STRIP:

The rule of 300: when the rhythm is regular, the

heart rate is 300 divided by the number of large
squares between the QRS complexes.
For

example, if there are 4 large squares between

regular QRS complexes, the heart rate is 75
(300/6=50).

The 6 Second Rule: This method can be used with

an irregular rhythm to estimate the rate. Count
the number of R waves in a 6 second strip and
multiply by 10.
For

example, if there are 7 R waves in a 6 second

strip, the heart rate is 70 (7x10=70).

ACTIVITY
Draw the ECG tracing of the following and write a
short description about it
1.
2.
3.
4.

First degree AV Block

Second degree AV block Mobitz I
Second degree AV block Mobitz II
Third degree / complete heart block

15 minutes break time

HEMODYNAMIC STATUS
Assessed
1.
2.
3.
4.

in four parameters:

Central venous pressure

Pulmonary artery pressure
Cardiac output
Intra-arterial pressure

Each is obtained through invasive

procedures
o Provides information about blood volume ,
fluid balance, and how well the heart is
pumping
o

PULMONARY ARTERY CATHETER

Used

to monitor hemodynamic status

Most commonly used catheter is a quadruplelumen thermodilution catheter.
4 lumina
1.
2.
3.
4.
5.

Proximal
Distal lumen
Small third lumen
Fourth lumen
Fifth port

Lumen

Location

Uses

Proximal lumen

Right
atrium

CVP, IVF, Blood samples

Distal lumen

Pulmonary PA systolic pressure, diastolic

artery
pressure, mean pressure, PCWP

Small third lumen

Fourth lumen
Fifth port

inflation/deflation of balloon
computer

thermistor port, CO
infusion of fluids, O2 sat

PULMONARY ARTERY CATHETER

PRE-PROCEDURE CARE
1.
2.
3.
4.

Obtain informed consent

Assess adequacy of circulation in selected extremity.
Accurately monitor and record arterial pressure.
Prevent complications of arterial cannulation:
a. check all connections frequently to ensure that they
remain tight and secure
b. evaluate cannulated extremity for neurovascular
function every 2 hours
c. assess color, temp., capillary refill and sensation
distal site of cannulation
d. check insertion site for signs of infection
e. change dressing per institution policy

PULMONARY ARTERY CATHETER

POST-PROCEDURE CARE
1.

2.
3.

After removal of catheter, maintain firm

constant pressure for 5-15 minutes over the site
of the artery to prevent hematoma formation.
Secure a pressure dressing over the site for 12
hours.
Monitor for infection (increased redness,
warmth, tenderness, elevated temp.) and report
to physician.

Watch this
SWAN GANZ CATHETER INSERTION

CENTRAL VENOUS PRESSURE

The pressure in the right atrium
Measured with a central venous line.
Normal CVP 5-10cm H2O

Decrease in CVP

Increase in CVP

1. decrease in circulating
volume which may result
from fluid imbalance,
2. hemorrhage or severe
vasodilation and
3. pooling of blood in the
extremities with limited
venous return

1. increased blood volume

because of sudden shift in
fluid balance,
2. excessive IV infusion,
3. renal failure, or
4. sodium and water
retention.

MEASURING CVP

CVP READING

CVP is usually recorded at the mid-axillary line

where the manometer arm or transducer is level
with the phlebostatic axis.
(Phlebostatic axis- where the fourth intercostal space and midaxillary line cross each other)

NURSING RESPONSIBILITIES WHEN

READING CVP
1. Explain the procedure to the patient to gain
informed consent.
2. If IV fluid is not running, ensure that the CVC is
patent by flushing the catheter.
3. Place the patient flat in a supine position if
possible. Alternatively, measurements can be
taken with the patient in a semi-recumbent
position. The position should remain the same for
each measurement taken to ensure an accurate
comparable result.

The normal range for CVP is 5-10cm H2O

POTENTIAL CVP COMPLICATIONS

Hemorrhage

from the catheter site

Catheter occlusion
Infection
Air embolus
Catheter displacement

PULMONARY CAPILLARY WEDGE

PRESSURE (PCWP)
An indirect indicator of left ventricular pressure
Normal value is 8-13 mmHg

Conditions that cause a change in PCWP

Decreased PCWP

Increased PCWP

insufficient volume

left ventricular failure

Insufficient pressure in
the left ventricle

pulmonary congestion

hypovolemic shock

Cardiac output= stroke volume x heart rate (5-6 L/min)

Stroke volume= amount of blood ejected from the
ventricles with each contraction

Conditions that cause a change in cardiac output

Decreased CO

Increased CO

Acute heart failure

Hypoxia

Shock

Exercise

Heat stroke

IVF intake

Dysrhythmias

Septic shock

Arterial hemorrhage
Myocardial ischemia

ABG

ARTERIAL BLOOD GAS

Monitors

the status of the acid-base homeostasis

in the body
Parameters include:
pH
7.35- 7.45
PaCO2 35- 45 mmHg
HCO3 22- 26 meq/L
Determines presence of acid-base imbalance
Evaluate level of compensation

Acidosis- any pathologic process that

causes a relative excess of acid in the body
Acidemia- excess acid in the blood.
Alkalosis- primary condition resulting in
excess base in the body.
Alkalemia- elevation of serum pH.
*Note: the terms are lab findings and not a
diagnosis.

ABG specimen collection

WATCH THIS

ANALYSIS OF ABG

1. Classify the pH
(Normal 7.34-7.45)
Acidemia: 7.35
Alkalemia: 7.45
2. Assess PaCO2
(Normal 35-45mmHg)
Respiratory acidosis: 45 mmHg
Respiratory Alkalosis: 35 mmHg
3. Assess HCO3
(Normal 22-26 meq/L)
Metabolic acidosis: 22 meq/L
Metabolic alkalosis: 26 meq/L
4. Determine presence of compensation
Compensation present: paCO2 & HCO3 are abnormal
Compensation absent: only one component is abnormal
5. Identify primary disorder- where the pH is leaning
towards is probably the primary cause

ANALYSIS OF ABG MNEMONICS

R
O

espiratory
opposite

M etabolic
E equal

ABG EXERCISE

1.

pH
7.20
PaCO2 50 mmHg
HCO3 18 meq/L

3.

pH
7.6
PaCO2 45 mmHg
HCO3 30 meq/L

2.

pH
7.13
PaCO2 49 mmHg
HCO3 24 meq/L

4.

pH
7.49
PaCO2 32 mmHg
HCO3 30 meq/L

End of Part 1
Interlude