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ASSESSMENT

I. HEALTH HISTORY AND CLINICAL MANIFESTATIONS

CARDIAC SIGNS AND SYMPTOMS


1. Chest pain or discomfort (angina pectoris, Myocardial infarction, Valvular
heart disease)
2. Shortness of breath or dyspnea (Myocardial infarction, Left ventricular
Failure, Heart failure)
3. Palpitations (dysrythmias resulting from myocardial ischemia, valvular heart
disease, ventricular aneurysm, stress, electrolyte imbalance)
4. Fatigue (earliest symptoms associated with several cardiovascular disorders)
5. Dizziness and syncope or loss of consciousness (postural hypotension,
dysrythmias, vasovagal effect, cerebrovascular disorders)
6. Intermittent claudication characterized by extremity pain with exercise (this
indicate peripheral vascular disease)

II. ASSESS FOR CHEST PAIN

a. Angina Pectoris
• Substernal or retrosternal pain spreading across chest; may radiate to
inside of arm, neck or jaw.
• 5-15 minutes in duration
• Usually related to exertion, emotion, eating, cold and smoking
• Rest, nitroglycerine, oxygen are the relieving measures

b. Myocardial Infarction
• Substernal pain or pain over precordium; may spread widely throughout
chest. Pain in shoulders and hands may be present.
• 15 minutes in duration
• Occurs spontaneously but may be squeal to unstable angina.
• Morphine sulfate is the relieving measure

c. Pleuritic pain
• Pain arises from inferior portion of pleura; may be referred to costal
margins or upper abdomen. Patient may be able to localize the pain.
• 30 + minutes in duration
• Often occurs spontaneously. Pain occurs or increases with inspiration
• Rest, time is the relieving measures

d. Pericarditis
• Sharp, severe substernal pain or pain to the left sternum; may be felt in
epigastrium and may be referred to neck, arms and back.
• The duration is intermittent
• Sudden onset. Pain increases with inspiration, swallowing, coughing, and
rotation of trunk.
• Sitting upright, analgesia, anti-inflammatory medications are the relieving
measures

e. Esophageal pain
• Substernal pain; may be projected around chest to shoulders
• 5-60 minutes in duration
• Recumbency, cold liquids and exercise. May occur spontaneously
• Food, antacid, nitroglycerine are the relieving measures
f. Anxiety
• Patient may complain of numbness and tingling of hands and mouth
• 2 –3 minutes in duration
• Stress, emotional tachypnea
• Removal of stimulus and relaxation are the relieving measures

III. PHYSICAL ASSESSMENT

A Physical Examination is performed to confirm the data obtained in the health


history. In addition to observing the patients’ general appearance, a cardiac physical
examination should include the evaluation of the following:
1. Effectiveness of the heart as a pump
2. Filling volumes and pressures
3. Cadiac output
4. Compensatory mechanisms

HEAD TO TOE EXAMINATION


1. General Appearance
2. Cognition
3. Skin
4. Blood pressure
5. Arterial pulses
6. Jugular Venous Pulsation and Pressures
7. Heart
8. Extremities
9. Lungs
10. Abdomen

CORONARY ARTERY DISEASE


• A narrowing or obstruction of one or more coronary arteries as a result of
atherosclerosis
• An accumulation of lipid-containing plaque in the arteries
• Causes decreased perfusion of myocardial tissue and inadequate myocardial
oxygen supply.
• Can cause angina, dysrythmias, myocardial infarction, heart failure and death.
• Collateral circulation, more than one artery supplying a muscle with blood, is
normally present in coronary arteries, especially in older persons.
• Symptoms occur when the coronary artery is occluded to the point that
inadequate blood supply to the muscle occurs, causing ischemia.
• Coronary artery narrowing is significant if the lumen diameter of the left main
artery is reduced at least 50%, or if any major branch is reduced at least 75%.
• The goal of treatment is to alter the atherosclerotic progression.

Non Modifiable Risk Factor Modifiable Risk Factor


 Family History of Coronary  High blood cholesterol
Heart Disease (CHD)  Cigarette smoking, tobacco use
 Increasing age  Hypertension
 Gender (3x in men)  Diabetes Mellitus
 Race (Africans Americans)  Lack of estrogen in women
 Physical inactivity
 Obesity
A. Clinical Manifestation
• Chest Pain
• Palpitations
• Dyspnea
• Syncope
• Cough or hemoptysis
• Excessive fatigue

B. Diagnostic Studies
1. Electrocardiogram (ECG) – recording of the electrical impulses of the
heart
• When blood flow is reduced and ischemia occurs, ST segment
depression or T wave inversion is noted; ST segment returns
• With infarction, cell injury results in ST segment elevation,
followed by T wave inversion

Common ECG Changes

Hypokalemia Hyperkalemia Myocardial Infarction


u-wave Prolonged QRS Elevated ST segment
complex
Depressed ST Elevated ST Inverted T wave
segment segment
Short T wave Peaked T wave Pathologic T wave

2. Cardiac Enzymes

ENZYME AST CPK-MB LDH


Normal Value 7 – 40 mu/ml 50 – 325 mu/ml 100 – 225 mu/ml
Onset 4 – 6 hours 3 – 6 hours 12 hours
Peak 24 – 36 hours 12 – 18 hours 18 hours
Return to 4 – 7 days 3 – 4 days 10 – 14 days
Normal
3. Cardiac Catheterization

A. Provides the most definitive source of diagnosis


B. Shows the presence of atheroslerotic lesions
• Assess O2 level, pulmonary blood flow, Cardiac Output, heart
structures
• Coronary artery visualization; use to diagnose CAD; assess
coronary patency and determine extent of atheroslcerosis
• R sided heart catheterization – medial cubital or brachial vein
• L sided heart catheterization – brachial or femoral artery

4. Blood Lipids Levels


• May be elevated
• Cholesterol-lowering medications may be prescribed to reduce
the development of atherosclerostic plaques.

C. Implementation
1. Instruct client regarding the purpose of diagnostic medical surgical
procedures expectations
2. Assist the client to identify risk factors that can be modified
3. Assist the client to set goal to promote lifestyle changes that will reduce
the impact of risk factors
4. Assist the client to identify barriers to compliance with the therapeutic
plan and to identify methods to overcome barriers
5. Instruct the client regarding a low-calorie, low-sodium, low-cholesterol,
and low-fat diet, with an increase in dietary fiber
6. Stress to the client that dietary changes are not temporary and must be
maintained for life; instruct the client regarding prescribed medications.
7. Provide community resources to the client regarding exercise, smoking
reduction, and stress reduction.

D. Surgical Procedure
1. Percutaneous Transluminal Coronary Angioplasty (PTCA) to
compress the plaque against the walls of the artery and dilate the vessel.
2. Laser angioplasty to vaporize the plaque
3. Atherectomy to remove the plaque from artery
4. Vascular stent to prevent the artery from closing to prevent restenosis
5. Coronary Artery Bypass graft improve flow to the myocardial tissue that
is at risk for ischemia or infarction because of the occlude artery

E. Medications
A. Nitrates to dilate coronary arteries to decrease preload and afterload.
B. Calcium channel blockers to dilate coronary arteries and reduced
vasospasms.
C. Cholesterol-lowering medications to reduce the development of
atherosclerotic plaques
D. Beta-blockers to reduce blood pressures in individuals who are
hypertensive

ANGINA PECTORIS
A. Description
a. Chest pain resulting from Myocardial Ischemia caused by inadequate
myocardial blood and oxygen supply
b. Caused by imbalance between oxygen supply and demand
c. Causes include obstruction of coronary blood flow because of
atherosclerosis, coronary artery spasm and conditions increasing
myocardial oxygen consumption
d. The goal of treatment is to provide relief of an acute attack, correct
imbalance between the myocardial oxygen supply and demand, and
prevent progression of the disease and further attack to reduce the
risk of MI

B. Patterns of Angina
a. Stable Angina
• Also called exertional angina
• Occurs with activities that involved exertion or emotional stress,
and is relieved by rest or Nitroglycerine
• It is usually has a stable pattern of onset, duration, severity, and
relieving factors

b. Unstable Angina
• Also called preinfarction angina
• Occurs with unpredictable degree of exertion or emotion and
increase the occurrence, duration, and severity overtime
• Pain may not be relieved with Nitroglycerine

c. Variant Angina
• Also called Prinzmetal’s or Vasospastic Angina
• Result from coronary artery spasm, similar to classic angina but
last longer
• May occur at rest
• Attack may be associated with ST segment division noted on the
ECG

d. Intractable Angina
• A chronic incapacitating angina that is unresponsive to
intervention

e. Preinfarction Angina
• Associated with the acute coronary insufficiency
• Last longer than 15 minutes
• Symptoms of worsening cardiac ischemia

f. Post infarction
• Occurs after MI, when residual ischemia may cause episode of
angina
C. Assessment
1. Pain
2. Dyspnea
3. Pallor
4. Sweating
5. Palpitations and tachycardia
6. Dizziness and faintness
7. Hypertension
8. Digestive disturbance

D. Diagnostic Study
1. ECG: normal during rest, with ST depression or elevation and/or T wave
inversion during an episode of pain
2. Stress Test: Pain or changes in the ECG or vital signs during testing may
indicate ischemia
3. Cardiac Enzymes: Normal findings in Angina
4. Cardiac Catheterization: Provides a definitive diagnosis by providing
information about potency or coronary arteries

E. Implementations
1. Immediate management
• Assess pain
• Provide bed rest
• Administer oxygen at 3 L nasal cannula as prescribe by the
doctor
• Administer Nitroglycerine as prescribe to dilate coronary arteries,
reduced the oxygen requirements of the myocardium, and
relieve the chest pain
• Obtain a 12-lead ECG

2. Following Acute Episodes


• Instruct the client regarding the purpose of diagnostic medical
and surgical procedure and the pre procedure and post
procedure expectation
• Assist the client to identify angina-precipitating event
• Instruct the client to stop activity and rest if the chest pain occurs
and to take nitroglycerine as prescribe
• Instruct the client regarding the prescribe medication
• Instruct client to seek medical attention if pain persist
• Provide diet instruction to the client, stressing the dietary
changes are not temporary and must be maintain for life
• Assist the client to identify risk factor that can be modified
• Assist the client to set goals that will promote changes in lifestyle
to reduce impact of risk factor
• Assist the client identify barriers to compliance with therapeutic
plan to identify methods to become barriers
• Provide community resources to the client regarding exercise
and stress reduction

F. Medications
1. Refer medication to treat Coronary Artery Disease
2. Antiplatelet therapy to inhibit platelets aggregation and reduce
the risk of developing an Acute MI
MYOCARDIAL INFARCTION
A. Description
• Occurs when Myocardial Tissues is abruptly and severely deprived of
oxygen.
• Ischemia can lead to necrosis of myocardial tissue if blood flow is not
restored.
• Infarction does not occur instant but evolves over several hours
• Obvious physical changes do not occur in the heart until 6 hours after
the infarction, when the infarction area appears blue and swollen
• After 48 hours, the infarction turns to gray with yellow steaks as
neutrophils invade the tissue
• By 6 – 10 days after infarction, granulation to tissue forms
• Over 2 –3 months, the necrotic area develops into scar, scar tissue
permanently changes the size and shape of the entire ventricle

B. Location Of Myocardial Infarction


• Obstruction of the left anterior descending (LAD) artery results in the
anterior septal MI or both
• Obstruction of the circumflex results in the posterior wall MI or lateral
wall MI
• Obstruction of the right coronary artery results in the inferior wall MI

C. Risk Factors
• Atherosclerosis
• Coronary Artery Disease
• Elevated Cholesterol Levels
• Smoking
• Hypertension
• Obesity
• Physical Inactivity
• Impaired Glucose Tolerance
• Stress

D. Diagnostics Study
A. Total Creatinine Kinase
a. Rise within 3 hours after the onset of chest pain
b. Peak within 24 hours after the damage and death of the tissue

B. Creatinine Phosphokinase-MB isoenzymes


a. Peak elevation occur 12 –24 hours after the onset of the chest
pain
b. Levels returns to normal 48 – 72 hours later

C. Troponin Level
a. Rise within 3 hours
b. Remain elevated for up to 7 days

D. Myoglobin
a. Rises within 1 hour after cell death, peaks in 4 – 6 hours and
returns to normal within 24- 36 hours or less
E. Lactate Dehydrogenase (LDH) Levels
a. Rises within 12 –24 hours after MI
b. Peak between 40 – 72 hours and fall to normal in 7 days
c. Serum levels of LDH isoenzymes rise higher than serum level of
LDH2

F. White Blood Cells (WBC) counts


a. An elevated white blood cell counts of 10,000-20,000 cells/mm3
appears on the second day following after the MI and last up to
the week

G. Electrocardiogram (ECG)
a. ST segment elevation, T wave inversion, abnormal Q wave
b. Hours to days after MI; ST and T wave changes will return to
normal but the Q wave usually remain permanently

H. Diagnostic Test for The Acute Stage


a. Exercise tolerance test or stress test may be prescribed to
assess for ECG changes and ischemia to evaluate for medical
therapy or identify clients who may need invasive therapy
b. Thallium Scan may be prescribed to assess for ischemia or
necrotic muscle tissue
c. Cardiac catheterization: performed to determine the extent and
location of the obstruction of the coronary artery

E. Assessment
1. Pain
2. Nausea and vomiting
3. Diaphoresis
4. Dyspnea
5. Dysrhytmia
6. Feeling of fear and anxiety
7. Pallor, cyanosis, coolness of the extremities
8. Feeling of doom, restlessness

F. Complications of Myocardial infarctions


1. Dysrythmias
2. Heart failure
3. Pulmonary Edema
4. Cardiogenic Shock
5. Thrombophlebitis
6. Pericarditis
7. Mitral valve insufficiency
8. Post Infarction Angina
9. Ventricular Rupture
10. Dressler’s Syndrome (a combination of pericarditis, pericardial effusion,
which can occur several weeks to months following an MI)

G. Implementations of Myocardial Infarctions


1. Obtain description of chest discomfort
2. Assess vital signs
3. Assess cardiovascular status and maintain cardiac monitoring
4. Obtain 12 lead ECG
5. Administer nitroglycerine as prescribed
6. Administer morphine sulfate as prescribe to release chest discomfort that
is unresponsive to nitroglycerine
7. Administer oxygen at 2 – 4 L by nasal cannula as prescribe
8. Place the client in semi-fowlers position to enhance comfort and tissue
oxygenation.