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CHAPTER 26 ASSESMENT OF CARDIOVASCULAR FUNCTION Health History o Chief Complaint o History of present illness o Past Medical History o Family

y Medical History o Obstetric and Reproductive History o Personal And Social History o Review of Systems o Others: Activity & exercise( Flight of stairs) Sleep & Rest (orthopnea) Self-perception & Self-concept Roles and Relationships Sexuality and Reproduction Risk Factors for Heart Diseases o Non-modifiable risk factors: Family history of premature coronary artery disease Increasing age Gender (men and postmenopausal women) Race (higher incidence in African Americans than in Caucasians) o Modifiable risk factors Hyperlipidemia Hypertension Cigarette Smoking Elevated Blood glucose (e.g DM) Obesity Physical Inactivity Type A personality characteristic Use of oral Contraceptives Common Cardiac signs and symptoms o Chest pain and discomfort (Angina Pectoris, ACS, dysrhythmias, valvular diseases) o Shortness of breath and dyspnea (MI, Left Heart Failure) o Edema & Weight gain (Right Heart failure) o Palpitations o Fatigue Chest pain o In assessing pain scale is used and : P-rovoke (what provoked the pain; e.g anxiety) Q-uality R-egion/radiation S-everity T-iming o The nurse should keep the following important points in mind when assessing patients reporting chest pain or discomfort: The location of chest symptoms in not well correlated with the cause of pain. The severity or duration of chest pain or discomfort does not predict the seriousness of its cause o Types: Angina-uncomfortable pressure, squeezing, or fullness in substernal chest area; Substernal or retrosternal pain spreading across chest

Radiate: o Can radiate across chest to the medial aspect of one or both arms and hands, jaw, shoulders, upper back or epigastrum. o Arms and hands as paresthesia Time :5-10 min Precipitating Events & Aggravating Factors o Physical exertion, emotional upset, eating a large meal, or exposure to extreme temperature Alleviating Factor: o Rest, Nitroglycerin and Oxygen

ACS- same as angina pectoris; pain or discomfort ranges from mild to severe; associated with Shortness of breath, diaphoresis, palpitations, fatigue, and nausea or vomiting Substernal or retrosternal pain spreading across chest Radiate: o Arms and hands as paresthesia Time : >15 min Precipitating Events & Aggravating Factors o Physical exertion, emotional upset, within 24 hours of symptom onset o Can occur at rest or while asleep Alleviating Factor: o Morphine Pericarditis Sharp, severe substernal or epigastric pain Radiate: o Neck, arms and back Time: Intermittent Precipitating Events & Aggravating Factors o Sudden onset o Pain increases in swallowing, inspiration , coughing and rotation of trunk Alleviating Factor: o Sitting upright, Analgesia, anti-inflammatory medications. Associated symptoms: o Fever, malaise, dyspnea, cough, nausea, dizziness and palpitations. Pulmonary Disorders (pneumonia, pulmonary embolism) Sharp, severe substernal or epigastric pain arising from inferior portion of pleura (pleuritic pain); patient may be able to localize the pain; when coughing or inspiring Time: >30 min Precipitating Events & Aggravating Factors o Follows an infectious and noninfectious process( MI, cardiac surgery, cancer, immune disorders, uremia) o Pleuritic pain increases with inspiration, coughing, movement, and supine positioning Alleviating Factor: o Treatment of underlying cause. Esophageal disorders( hiatal hernia, reflux esophagitis or spasm) Substernal pain described as sharp, burning or heavy Often mimics angina

Radiate: o Neck, arms and shoulders. Time: 5-60 min Precipitating Events & Aggravating Factors o Cold liquids o Exercise Alleviating Factor: o Food, Antacid or Nitroglycerin Anxiety and panic disorders Pain is described as stabbing to a dull ache. Time: Peaks in 10 min Precipitating Events & Aggravating Factors o Sudden onset o Associated with a specific trigger Alleviating Factor: o Removal of stimulus, relaxation, medication to treat anxiety or underlying disorder. Musculoskeletal disorders (costochondritis) Sharp or stabbing pain localized in anterior chest; unilateral Radiate: o Chest & Epigastrum or back Time: Hours to days Precipitating Events & Aggravating Factors o Reinfections, idiopathic o Exacerbated by deep inspiration, coughing, sneezing and movement of upper torso Alleviating Factor: o Rest, ice or heat o Analgesic/ Anti-inflammatory medications. Physical Assessment o General Appearance Level of consciousness (alert, lethargic, stuporous, comatose) Mental status( Oriented to person, place, time; coherence) Changes in Level of consciousness and mental status perfusion to the brain Patients are observed for signs of distress( Pain, Shortness of Breath, or anxiety) Nurse notes: Size of patient(normal, overweight or underweight) Patients Height and Weight BMI o Inspection of the skin Pallorlack of oxyhemoglobin. It is a result of anemia or decreased arterial perfusion. Pallor is best observed around the fingernails, lips, and oral mucosa. In patients with dark skin, the nurse observes the palms of the hands and soles of the feet. Peripheral cyanosissuggests decreased flow rate of blood to a particular area, which allows more time for the hemoglobin molecule to become desaturated. This may occur normally in peripheral vasoconstriction associated with a cold environment, in patients with anxiety, or in disease states such as HF.

Central cyanosisa bluish tinge observed in the tongue and buccal mucosadenotes serious cardiac disorders (pulmonary edema and congenital heart disease). Venous blood passes through the pulmonary circulation without being oxygenated. Xanthelasmayellowish, slightly raised plaques in the skin May be observed along the nasal portion of one or both eyelids. May indicate elevated cholesterol levels (hypercholesterolemia). Blood Pressure Systemic arterial BP is the pressure exerted on the walls of the arteries during ventricular systole and diastole. Factors affecting Blood Pressure: Cardiac output Distention of the arteries, and the volume, velocity, and viscosity of the blood. Category of Hypertensive: Normal: <120/<80 Pre-hypertension: 120-139/80-89 Hypertension I:140-159/90-99 Hypertension II:>=160/>=100 Pulse Pressure The difference between the systolic and the diastolic pressure is called the pulse pressure Indicates how well the patient maintains cardiac output. Pulse pressure increases in the conditions that: stroke volume ( anxiety, exercise, bradycardia) systemic vascular resistance(fever) distensibility of the arteries(atherosclerosis, aging, hypertension) pulse pressure reflecting reduced stroke volume and ejection velocity(shock, HF, hypovolemia, mitral regurgitation) Obstruction to blood flow during systole (mitral or aortic stenosis). Postural Blood Pressure changes Occurs when the BP drops significantly after the patient assumes an upright posture. It is usually accompanied by dizziness, lightheadedness, or syncope. Three most common causes in patients with cardiac problems are Reduced volume of fluid or blood in the circulatory system (intravascular volume depletion, dehydration inadequate vasoconstrictor mechanisms Insufficient autonomic effect on vascular constriction. Arterial Pulses Factors to be evaluated in examining the pulse are rate, rhythm, quality, configuration of the pulse wave and quality of the arterial vessel Pulse Rate Anxiety can rate. Pulse Rhythm In young people it increases during inhalation and slows during exhalation.(sinus arrhythmia) Disturbance in rhythm(dysrhythmia)Pulse deficit Pulse deficit is the difference between the apical rate and the peripheral rate. Pulse Quality Can be described as absent, diminished, normal or bounding. Heart Inspection and Palpation

The heart is examined indirectly by inspection, palpation, percussion and auscultation of the chest wall. Six Areas: Aortic Area o 2nd Intercostal Space Right Parasternal Border Pulmonic Area o 2nd Intercostal Space Left Parasternal Border Erbs point o 3rd Intercostal Space Left Parasternal Border Tricuspid o 4th Intercostal Space Left Parasternal Border Mitral o 5th Intercostal Space Left Midclavicular Line Heart Sounds The normal heart sounds, S1 and S2, are produced primarily by the closing of the heart valves. The time between S1 and S2 corresponds to systole S1First Heart Sound. Closure of the mitral and tricuspid valves Heard best at the apex of the heart (apical area). Its intensity increases when the valve leaflets are made rigid by calcium in rheumatic heart disease and in any circumstance in which ventricular contraction occurs at a time when the valve is caught wide open. S2Second Heart Sound. Closing of the aortic and pulmonic valves Gallop Sounds If the blood filling the ventricle is impeded during diastole, as occurs in certain disease states, then a temporary vibration may occur in diastole that is similar to, although usually softer than, S1 and S2. A gallop sound occurring during rapid ventricular filling is called a third heart sound (S3); it represents a normal finding in children and young adults Gallop sounds heard during atrial contraction are called fourth heart sounds (S4) o An S4 is often heard when the ventricle is enlarged or hypertrophied and therefore resistant to filling. Such a circumstance may be associated with CAD, hypertension, or stenosis of the aortic valve. Opening Snap Are abnormal diastolic sounds heard during opening of an AV valve. For example: Mitral Stenosis-unusually high pitched sound very early in diastole. Murmurs Murmurs are created by the turbulent flow of blood. Murmurs are characterized and consequently described by several characteristics, including timing in the cardiac cycle, location on the chest wall, intensity, pitch, quality, and pattern of radiation The causes of the turbulence may be: o a critically narrowed valve o a malfunctioning valve that allows regurgitant blood flow

o o

a congenital defect of the ventricular wall a defect between the aorta and the pulmonary artery, or an increased flow of blood through a normal structure (eg, with fever, pregnancy, hyperthyroidism).

Friction Rub. In pericarditis, a harsh, grating sound that can be heard in both systole and diastole. It is caused by abrasion of the pericardial surfaces during the cardiac cycle. Because a friction rub may be confused with a murmur, care should be taken to identify the sound and to distinguish it from murmurs that may be heard in both systole and diastole. A pericardial friction rub can be heard best using the diaphragm of the stethoscope, with the patient sitting up and leaning forward. Inspection of the Extremities Decreased capillary refill time Indicates a slower peripheral flow rate from sluggish reperfusion and is often observed in patients with hypotension or HF. Capillary refill time provides the basis for estimating the rate of peripheral blood flow. To test capillary refill, briefly compress the nail bed so that it blanches, and then release the pressure. Normally, reperfusion occurs within 3 seconds, as evidenced by the return of color. Vascular changes from decreased arterial circulation include decrease in quality or loss of pulse, discomfort or pain, paresthesia, numbness, decrease in temperature, pallor, and loss of movement. During the first few hours after invasive cardiac procedures (eg, cardiac catheterization), affected extremities should be assessed for vascular changes frequently. Hematoma, or a localized collection of clotted blood in the tissue May be observed in patients who have undergone invasive cardiac procedures such as cardiac catheterization, PTCA, or cardiac electrophysiology testing. Peripheral edema is fluid accumulation in dependent areas of the body (feet and legs, sacrum in the bedridden patient). Assess for pitting edema (a depression over an area of pressure) by pressing firmly for 5 seconds with the thumb over the dorsum of each foot, behind each medial malleolus, and over the shins. Pitting edema is graded as absent or as present on a scale from slight (1+ = 0 to 2 mm) to very marked (4+ = more than 8 mm). Peripheral edema is observed in patients with HF and in those with peripheral vascular diseases such as deep vein thrombosis or chronic venous insufficiency. Clubbing of the fingers and toes Implies chronic hemoglobin desaturation, as in congenital heart disease. Lower extremity ulcers Observed in patients with arterial or venous insufficiency. Other Systems: Lungs o Tachypnea Rapid, shallow breathing May be noted in patients who have HF or pain, and in those who are extremely anxious.

Cheyne-Stokes respirations: A pattern of rapid respirations alternating with apnea. Patients with severe left ventricular failure may exhibit Cheyne-Stokes breathing. o Hemoptysis: Pink, frothy sputum is indicative of acute pulmonary edema. o Cough A dry, hacking cough from irritation of small airways is common in patients with pulmonary congestion from HF. o Crackles: Typically, crackles are first noted at the bases (because of gravitys effect on fluid accumulation and decreased ventilation of basilar tissue), but they may progress to all portions of the lung fields. o Wheezes Compression of the small airways by interstitial pulmonary edema may cause wheezing. Beta-adrenergic blocking agents (beta-blockers), such as propranolol (Inderal), may precipitate airway narrowing, especially in patients with underlying pulmonary disease. Abdomen o Hepatojugular reflux Liver engorgement occurs because of venous return secondary to right ventricular failure. The liver is enlarged, firm, nontender, and smooth. The hepatojugular reflux may be demonstrated by pressing firmly over the right upper quadrant of the abdomen for 30 to 60 seconds and noting a rise of 1 cm or more in jugular venous pressure. This rise indicates an inability of the right side of the heart to accommodate increased volume. o Bladder distention Urine output is an important indicator of cardiac function, especially when urine output is reduced. This may indicate inadequate renal perfusion or a less serious problem such as one caused by urinary retention. When the urine output is decreased, the patient needs to be assessed for a distended bladder or difficulty voiding. Diagnostic Evaluation o Cardiac Enzyme Analysis(biomarkers) Most Specific enzymes analyzed in acute MI. CK(Creatinine Kinase) CK-MB Myoglobin [Myo-muscle]- least used to diagnose MI; not specific. o Serum Enzyme Studies Aspartate Aminotransferase (AST) Formerly: Serum Glutamic Oxaloacetic Transaminase(SGOT) Level indicates tissue necrosis Normal range is 7 to 40 mu/ml

Range with Myocardial Infarction o Peak at 24-36 hours o Returns to normal at 4-7 days Creatinine Phosphokinase (CK-MB) Most specific cardiac enzyme Accurate indicator of myocardial damage Normal range: is o Male: 50-325 mu/mL o Females: 50-250 mu/mL Range with Myocardial Infarction o Onset: 3-6 hours o Peaks: 12-18 hours o Returns to normal: 3-4 days Lactic Dehydrogenase (LDH) Among the fiver LDH isoenzyme, LDH 1 is the most sensitive indicator of myocardial damage In MI LDH1 is elevated and its level exceeds LDH 2. o Flipped LDH1/LDH2 Normal Range: 100-225 mU/mL Range with myocardial Infarction o Onset: 12 hours o Peaks: 48 hours o Returns to normal: 10-14 days Hydroxybutyrate Dehydrogenase (HBD) of HBD accompanied by LDH levels. It is valuable in detecting silent MI HBD/LDH ratio may be increased in MI Normal range is: 140-350 u Range with Myocardial Infarction o Onset: 10-12 hours o Peaks: 48-72 hours o Returns to normal: 12-13 days Troponin Most specific laboratory test to detect MI Troponin has three components: I , C and T o Troponin I modulates the contractile state. o Troponin C- binds calcium o Troponin T- Binds Troponin I and C o Elevated Troponin T is as sensitive as CK-MB for the detection of Myocardial Injury o Troponin I persist for 4-7 days Lipid Profile Measured to evaluate persons risk for developing atherosclerotic disease, especially if there is family history of premature heart disease or to diagnose a specific lipoprotein abnormality. It Measures: Total Cholesterol Level ( Normal: <200mg/dL) o A lipid require for hormone synthesis and cell membrane formation. Low-denstiy lipoprotein (Normal: <160mg/DL) o Primary transporter of cholesterol and triglycerides into the cell. o Bad cholesterol

High-density lipoprotein (Normal: Men: 35-70mg/DL Women; 3585 mg/dL) o Transport cholesterol away from the tissue cells of the arterial wall to the liver for excretion. Triglycerides ( Normal: 100-200 mg/dL o Composed of free fatty acids and glycerol, are stored in the adipose tissue and are source of energy. Serum Laboratory tests Sodium(Na+) Normal: 135-145 mEq/L Hyponatremia (low sodium level) indicates fluid excess and can be caused by HF or administration of thiazide diuretics. Hypernatremia (high sodium level) indicates fluid deficit and can result from decreased water intake or loss of water through excessive sweating or diarrhea. Calcium( Ca+) Normal: 8.6-10.2 mg/DL Calcium is necessary for blood coagulability and neuromuscular activity. Hypocalcaemia and Hypercalcemia can cause dysrhythmias. Blood Urea Nitrogen (BUN) Normal: 10-20mg/dL BUN are end products of protein metabolism excreted by the kidneys. Creatinine: Normal: 0.7-1.4 mg/dL Normal Creatine and Elevated BUN reflects fluid Volume Deficit Elevated BUN and Elevated Creatinine reflects Renal Impairment. Coagulation Studies Intrinsic pathway Partial thromboplastin time (PTT) and Activated Partial Thromboplastin Time (aPTT) measure the activity of the intrinsic pathway. o 60-70 seconds o The values of PTT and aPTT are used to assess the effects of heparin therapy. Patients receiving heparin have their PTT or aPTT levels maintained at 1.5 to 2.5 times their baseline values (reference range, 25 to 38 seconds). Extrinsic pathway Prothrombin time (PT) measures the extrinsic pathway activity o 11-16 seconds o Used to monitor the effects of therapeutic anticoagulation with warfarin (Coumadin). Hematologic Studies Complete Blood Count Total number of WBC, RBC, platelet count, hemoglobin and hematocrit. Chest X-ray & Fluoroscopy Chest X-ray can be obtained to determine the size, contour, and position of the heart. Fluoroscopy allows visualization of the heart on an x-ray screen. Electrocardiography The ECG is a diagnostic tool used in assessing the cardiovascular system. It is a graphic recording of the electrical activity of the heart; an

ECG can be recorded with 12, 15, or 18 leads, showing the activity from those different reference points. Cardiac Stress Test Determine: CAD, cause of Chest pain after an MI or Heart Surgery, Effectiveness of anti-anginal or antiarrhythmic medications, dysrhythmias that occur during physical exercise. Exercise Stress Test Done on Treadmill Nursing Consideration: o Patient should have an adequate sleep the night before the test. o Avoid caffeine before the test. o Avoid smoking and taking nitroglycerine, 2 hours before the test o Closely Monitor Vital Signs after the test. o Instruct the patient to Fast for 4 hours prior the test. Pharmacologic Stress Test Through administration of medications that mimic the effect of Exercise o Adenosine o Dipyridamole o Dobutamine Nursing Intervention: o Instruct the patient to Fast for 4 hours prior the test. Echocardiography A noninvasive ultrasound test that is used to examine the size, shape, and motion of cardiac structures. It is a particularly useful tool for diagnosing pericardial effusions, determining the etiology of heart murmurs, evaluating the function of prosthetic heart valves, determining chamber size, and evaluating ventricular wall motion. Radionuclide Imaging Radionuclide imaging studies involve the use of radioisotopes (Thallium & Technetium) to evaluate coronary artery perfusion noninvasively, to detect myocardial ischemia and infarction, and to assess left ventricular function. Nursing Intervention Reassure Patient that radiation is minimal and has a little risk. Hemodynamic Monitoring Central venous Pressure Monitoring Normal Reading- 2-6 mm Hg The CVP, the pressure in the vena cava or right atrium, is used to assess right ventricular function and venous blood return to the right side of the heart. o Problem that can elevate CVP such as: Hypervolemia Right-Sided Heart Failure o Problems that can decrease CVP such as: Reduced right ventricular preload Hypovolemia Dehydration Vomiting or Diarrhea Overdiuresis

The CVP can be continuously measured by connecting either a catheter positioned in the vena cava or the proximal port of a pulmonary artery catheter to a pressure monitoring system. Catheter placement is confirmed by a chest x-ray The Dressing must be kept dry and air occlusive. o Dressing must be done using sterile technique The Catheter can also be used for infusing the IV fluids, administering IV medications and drawing blood specimen Pulmonary Artery Pressure Monitoring Pulmonary artery pressure monitoring is an important tool used in critical care for assessing left ventricular function, diagnosing the etiology of shock, and evaluating the patients response to medical interventions (eg, fluid administration, vasoactive medications). Pulmonary artery pressure monitoring is achieved by using a pulmonary artery catheter and pressure monitoring system. Cardiac Catheterization & Angiography Is an invasive diagnostic procedure in which radiopaque arterial and venous catheters are introduced into selected blood vessels of the right and left sides of the heart. Catheter advancement is guided by fluoroscopy. Nursing Intervention: Instruct the patient to fast, usually for 8 to 12 hours, before the procedure. Prepare the patient for the expected duration of the procedure; indicate that it will involve lying on a hard table for less than 2 hours. Reassure the patient that mild sedatives or moderate sedation will be given intravenously. Prepare the patient to experience certain sensations during the catheterization. Knowing what to expect can help the patient cope with the experience. o Explain that an occasional pounding sensation (palpitation) may be felt in the chest because of extrasystoles that almost always occur, particularly when the catheter tip touches the myocardium. o The patient may be asked to cough and to breathe deeply, especially after the injection of contrast agent. Coughing may help to disrupt a dysrhythmia and to clear the contrast agent from the arteries. o Breathing deeply and holding the breath helps to lower the diaphragm for better visualization of heart structures. o The injection of a contrast agent into either side of the heart may produce a flushed feeling throughout the body and a sensation similar to the need to void, which subsides in 1 minute or less. Nursing Responsibility after procedure o Observe the catheter access site for bleeding or hematoma formation, and assess the peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, and then every 1 to 2 hours until the pulses are stable. o Evaluate temperature and color of the affected extremity and any patient complaints of pain, numbness, or tingling

sensations to determine signs of arterial insufficiency. Monitor for dysrhythmias by observing the cardiac monitor Inform the patient that if the procedure is performed percutaneously through the femoral artery (and without the use of devices such as VasoSeal, Perclose, or AngioSeal), the patient will remain on bed rest for 2 to 6 hours with the affected leg straight and the head elevated to 30 degrees o Instruct the patient to report chest pain and bleeding or sudden discomfort from the catheter insertion sites immediately. o Encourage fluids to increase urinary output and flush out the dye. o Ensure safety by instructing the patient to ask for help when getting out of bed the first time after the procedure, because orthostatic hypotension may occur and the patient may feel dizzy and lightheaded. Complication: o Pneumothorax During catheter insertion, the needle may puncture the apical lung as it passes through the subclavian vein. o Constant wedging of the Pulmonary Artery Catheter The catheter may migrate into smaller pulmonary vessels resulting in pulmonary ischemia. A medical emergency Balloon must deflated and pulled back slightly. o Ventricular Irritation Occurs when the catheter floats back into the right ventricle or is lodged through the ventricle. May cause ventricular dysrhythmias. o Air embolism Occurs when the balloon ruptures. o o