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CARDIOVASCULAR SYSTEM
PHYSICAL ASSESSMENT INSPECTION
o o o o o o Arcus Senilus - a light gray ring around the iris caused by cholesterol deposits Xanthelasma yellow raised plaques around the eyelids resulting from lipid deposits Central cyanosis indicates serious heart or lung disease where the hemoglobin is not saturated Peripheral cyanosis suggests peripheral vasoconstriction Peripheral Edema venous pooling of extremities; heart was unable to pump Neck Vein Distention reflects pressure and volume changes in the right atrium; Jugular Vein Distention Capillary Refill check if circulation is adequate* Nail clubbing associated with pulmonary and cardiac disease; Clubbing-thickening and broadening of the tips of the fingers due to bad circulation Syncope or fainting, is a transient loss of consciousness; related to inadequate cerebral perfusion

S2 produced by closure of the aortic and pulmonic valves; onset of ventricular diastole dubb o S3 ventricular diastolic gallop is a faint, low pitched sound produced by rapid ventricular filling in early diastole. S3- normal in children but signifies CHF in adults o S4 atrial diastolic gallop is a low frequency sound which is present in CHF. o Murmurs audible variations in the heart and great vessels produced by turbulent blood flow Side notes: SYSTOLE- contraction phase of the cardiac cycle DIASTOLE- relaxation between contractions o Pericardial friction rub short, high-pitched scratchy extra heart sound originating from the pericardial sac (3 Is; inflammation, infection or infiltration) Bruit a whooshing sound that results from turbulent blood flow from vessel wall irregularities

o o

REVIEW OF SYSTEMS:
Inquire whether the patient has experience the following specific symptoms: Weight gain; Fatigue; Dyspnea; Cough; Orthopnea; Paroxysmal Nocturnal Dyspnea; Palpitations; Chest pain; Syncope and Leg Edema Side notes WHEEZING- breathing with a whistling sound. It results from constriction or obstruction of the throat, pharynx, trachea or bronchi. PAROXYSMAL NOCTURNAL DYSPNEA- Shortness of Breath 2-5 hours after onset of sleep. EDEMA- Increased hydrostatic pressure in the venous system causes shifting of plasma. Therefore, there is accumulation of fluids in the interstitial compartment occurs (within the tissues or between the tissues)

PALPATION
Ascites fluid accumulation in the peritoneal cavity o Homans Sign pain or tenderness when the gastrocnemius muscle of the calf is compressed o Peripheral Pulses* Side notes: PERITONEUM- the serous membrane lining the abdominal cavity and forming a covering for the abdominal organs Homans Sign venous thrombosis o

AUSCULTATION
o S1 produced by closure of the mitral and tricuspid valves; onset of ventricular systole lubb

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DIAGNOSTIC TESTS
LABORATORY TEST
CBC For evaluation of general health status. - Elevated RBCs suggests inadequate tissue oxygenation. Hypoxia - stimulates renal secretion of erythropoietin. NV= 4-6 million /mm3 of blood Elevated WBCs may indicate infectious heart disease and myocardial infarction NV= 4,000 11,000/mm3 of blood Hematocrit - is the percentage of packed RBC in the whole blood. Check for anemia and hemorrhage. NV= 40%-54% Hemoglobin - Main component of RBC. Transport O2 to cells. Elevated in CHF. NV= Males-13.5-17.5 g/dl; Females 1216 g/dl

1. Aspartate Aminotransferase (AST) Elevated level indicates tissue necrosis Normal Range: 7 to 40 mu/ml IE- 4-6 hours; Peaks- 24-36 hrs.; To normal- 4-7 days. 2. Creatine kinase (CK) commonly used to detect myocardial infarction elevates 6-8 hours after an AMI, peaks at 14-36 hours and returns to normal after 48-72 hours CK MB (Creatinine Kinase myocardial muscle) the most cardiac specific enzyme Normal range: o Males- 50-325 mu./ml o Females- 20-250 mu./ml 3. Lactic acid Dehydrogenase (LDH) commonly used to detect myocardial damage Five isoenzymes but only LDH1 and LDH2 are cardiac specific Myocardial damage is suspected if LDH1 is higher than LDH2 Elevates 48 hours after myocardial damage Normal Value = 100 to 225 mu/ml 4. Hydroxybutyrate Dehydrogenase (HBD) Elevation of HBD is always accompanied by elevation of LDH. HBD/LDH ratio may be increased in MI Normal Value= is 140- 350 mu/ml Onset: 10-12 hours, peaks:48-72 hrs. To Normal: 12 to 13 days

BLOOD COAGULATION TESTS

1) Prothrombin time (PT)- It measures the time required for clotting to occur after thromboplastin and calcium are added to decalcified plasma. Therapeutic Range = 1.5 to 2 times the normal a. Normal Range is 11 to 16 seconds 2) Partial Thromboplastin Time (PTT)- It measures the time for clotting to occur after a partial thromboplastin reagent is added to blood plasma. Test for heparin.(BEST TO USED BC test). Therapeutic Range= 2 to 2.5 time the normal a. Normal Range is 60 to 70 seconds 3) Activated Partial Thromboplastin Time (APTT)same purpose as PTT. Test for heparin Therapeutic Range= 2 to 2.5 times the normal a. Normal Range is 30-25 secs.

SERUM ELECTROLYTES
o Electrolytes affect cardiac contractility, specifically Na, K, Ca. o Na: 135-145 mEq/l o K: 3.5 to 5 mEq/l o Ca: 4.5 to 5.5 mEq/l

CARDIAC ENZYMES
Cardiac enzymes are released when heart cells die as a result of damage. These enzymes are measured in the serum, and their values rise as indicators of damage to heart cells.

Page 3 of 5 ELECTROCARDIOGRAPHY o Graphical recording of the electrical activities of the heart; indicates alterations in myocardial oxygenation o First diagnostic test to be done when a cardiovascular disorder is suspected o Nsg. Responsibility : Explain to patient that it is painless HOLTER MONITORING It is a continuous 24 hour ECG monitoring The portable monitoring system is called TELEMETRY UNIT Nsg. Responsibility: The nurse should log/ record activities of the client, and any unusual sensations experienced HEMODYNAMIC STUDIES Assessed with 4 parameters: Central Venous Pressure (CVP), Pulmonary Artery Pressure (PAP), Cardiac Output and Intra-arterial pressure Provides for information about blood volume, fluid balance, and how well the heart is pumping Central Venous Pressure Pressure within the superior vena cava and right atrium Monitors BLOOD VOLUME, ADEQUACY OF VENOUS RETURN TO THE HEART and PUMP FUNCTION OF THE RIGHT SIDE OF THE HEART. Needs to be at the level of the right atrium (midaxillary line 4th intercostal space when client is in supine with bed elevated = 45 degrees) Normal Value= RA: 5-12 cm. H2o Pulmonary Artery Pressure Uses the Swan-Ganz catheter via antecubital vein Determines the status of the left-sided heart functions Assists in determining whether the heart is under stretched, overstretched or appropriately stretched Normal Value = 8-13 mmHg Above normal indicates PE

P wave depolarization(cardiac cells lose their negativity) of the atria; 0.04-0.11 secs PR interval time of impulse transmission from the SA node to the AV node; 0.12-0.20 secs QRS complex depolarization of the ventricles; duration is 0.05-0.10 secs ST segment represents the plateau phase of the action potential; T=VD to VR T wave ventricular repolarization; should not exceed 5 mm amplitude

Common ECG changes

Hypokalemia: U- Wave Depressed ST segment Short T-wave Hyperkalemia: Prolonged QRS complex Elevated ST segment Peaked T wave Myocardial Infarction: Elevated ST segment (1st to occur in MI) Inverted T wave Pathologic Q wave

SONIC STUDIES 1. Echocardiography o Uses ultrasound to assess cardiac structure and mobility ; 2D Echocardiogram generates a continuous picture of the beating heart

Page 4 of 5 o o o No Special Preparation Required It is painless and takes 30 to 60 mins to complete HOB is elevated* Nursing Interventions:
Get adequate sleep the night before Avoid tea, coffee and alcohol on the day of the test Avoid smoking and taking nitroglycerine , 2 hours before the test Wear comfortable, loose-fitting clothes Eat a light breakfast/ lunch 2 hours before the test Inform the physician for unusualities developed during the test Rest after the test

2. Doppler Ultrasonography o Assesses arterial disease through evaluation of audible arterial signals or measurement of limb blood pressures o Lesser accurate than Duplex scanning 3. Phonography o Recordings of audible vibrations from the heart and great vessels o Used to assist in determining the timing of cardiac sounds and murmurs o Microphones are placed under elastic straps, usually at the base and apex of the heart o No preparation is required 4. Ultrasonic Duplex Scanning Uses: To localize vascular obstruction To evaluate the degree of stenosis To determine the presence and absence of vascular reflux Most sensitive and specific test in detecting DVTs

COMPUTED TOMOGRAPHY Allows visualization of the arterial wall and its structures May detect Abdominal Aortic Aneuryms Nursing Interventions: Explain the procedure NPO, if with contrast medium Ascertain history to allergy to iodine and seafoods Assess for claustrophobia Advise to remain still during the entire procedure Sedation if unable to remain still PREOP CARE Obtain informed consent Fasting is not required but preferred Contrast agent is commonly given Remove any foreign objects from the body Assess for claustrophobia Sedation may be required MAGNETIC RESONANCE IMAGING Expensive, non-invasive procedure Provides the best information on heart chamber size, wall motion, valvular function, vessel tissue changes and great vessel blood flow without radiation Commonly used for examination of the aorta and detection of tumors, aneurysms, masses, cardiomyopathies and pericardial disease

SERUM LIPIDS
o o Shows serum cholesterol, triglyceride and lipoprotein levels Elevated blood cholesterol esp LowDensity Lipoprotein (LDL) is associated with the development of atherosclerosis Inverse relationship with LDL and HDL

EXERCISE TESTING
o Commonly uses the Treadmill stress test or a bicycle-like device with ECG

Purpose: 1. Identify ischemic heart disease 2. Evaluate patients with chest pain 3. Evaluate effectiveness of a therapy 4. Develop individual fitness program

Page 5 of 5 Uses magnetic fields to obtain crosssectional images of the body Used to detect aneuryms and DVT from pelvic iliac veins ad leg veins TECHNITIUM 99m SCINTIGRAPHY o Used to study the motion of the left ventricular wall and measure the ability of the ventricle to expel blood o Narrowed coronary arteries exhibits diminished wall motion or contractility THALLIUM 201 SCINTIGRAPHY o MOST WIDELY USED ISOTOPE FOR MYOCARDIAL PERFUSION o Areas of myocardium that receive less blood flow also receive less thallium o Infracted or scarred myocardium does not extract thallium and shows up as COLD SPOTS

Nursing Interventions Assess for implanted metal devices in the body Assess for claustrophobia Instruct to remain still during the procedure Sedation may be done PREOP CARE Obtain consent Remove metals from the body Fasting is not required Instruct to remain still during the procedure Assess for claustrophobia ANGIOGRAPHY/VENOGRAPHY POSTPROCEDURE CARE o Frequent assessment of VS, neurologic status and distal pulse checks o Assess for hematoma at injection site o Transfemoral approach: Bed rest 6-8 hours and punctured extremity is kept in straight alignment; Transaxillary approach: no bed rest needed o Encourage fluid intake and IVF hydration MYOCARDIAL SCINTIGRAPHY Studies myocardial function, motion and perfusion by IV injection of radioactive isotope Isotope is absorbed by the blood cells of the heart muscle and photons are emitted, which are detected by an external gamma camera

Nursing Responsibilities: Assess for pregnancy Instruct the client to take a light meal, to prevent nausea, and stomach cramping and for better uptake of the radioisotope Omit the usual dose of prescribe Beta-Blockers, Calcium Channel Blockers Report any chest pain experienced in the procedure