ASSESSMENT OF THE CARDIOVASCULAR SYSTEM Flashcards
Changes lead to a loss of cardiac reserve and are present when there are increased demands on body - more noticeable when increased metabolic needs (exercise/stress)
Cardiac valves
Conduction system
Left ventricle changes
Aorta and other large arteries
Baroreceptors (sensors located in the blood vessels - tell body what going on)
CV changes associated with aging
Calcification (harden) and degeneration (can break down primarily -mitral and aortic valves)
Monitor for murmurs - cannot func as well
Cardiac valves - CV changes associated with aging
Pacemaker cells decrease in number
Fibrous tissue and fat in the sinoatrial node increase - decrease number in muscle fibers
Few muscle fibers in the atrial myocardium and bundle
Conduction time increases - more time for conduction go through muscle
Increased risk for atrial dysrhythmias - due to increased time
Conduction system - CV changes associated with aging
Increases in size, becomes stiff, and less distensible (less able dilated and stretch out - more fibrotic - cannot recoil) - harder fill ventricle
Fibrotic changes decrease speed of early diastolic filling by 50%
Decrease stroke volume (amount blood ejected from LV with each contraction), ejection fraction, and cardiac output - not able oxyengate as well - see symp with increased metabolic needs
Less able to meet oxygen demands
Left ventricle changes - CV changes associated with aging
Thicken, stiffer and less distensible - not stretch as well
Systolic BP increases
Systemic vascular resistance increases - can lead to HTN
Left ventricle pumps against greater resistance - pumping against higher resistance so it can get larger and less effective
Left ventricular hypertrophy
Monitor for hypertension - more at risk for HTN because changes in arteries
Aorta and other large arteries - CV changes associated with aging
Become less sensitive
Monitor for orthostatic hypotension - more likely have this
Baroreceptors (sensors located in the blood vessels - tell body what going on) - CV changes associated with aging
Patient History
Nutrition History - part pat history; very imp; lot things can do effected to health can change
Family and Genetic History - cannot change these and these often affect heart
Current Health Concerns - symp: SOB?
Functional History - know CV probs (HF) - scoring sys dependent on how functional (how do ADLs) - good assessment; severity of CVD
Physical Assessment: imp
Assessment methods
Focus on diff risk factors and symptoms have
Assess nonmodifiable risk factors
Assess modifiable risk factors
Assess for chronic diseases
Patient History
Age, gender, ethnicity, family history
Ex. men and post menopausal women at higher risk for coronary artery disease (CAD); certain things cannot do things amount to affect
Assess nonmodifiable risk factors
Nurses focus on these
Decrease cholesterol
Obesity, smoking (now/in past), inactivity (want moving little bit), psychological stress (how feel when have wait for appt - high stress/anger - contributes to hit)
Assess modifiable risk factors
Ex. Diabetic patients at higher risk for CVD; pulm issues lead to CVD; lots contribute
Assess for chronic diseases
Ex. High sodium, fat and cholesterol can increase risk and big risk factor for CV disease
Eat healthy diet lower risk
Nutrition History
Screen first degree relative (siblings, mothers, fathers) for history of CAD, hypertension, sudden cardiac death
Can have huge impact
Family and Genetic History
Chest pain or discomfort - know at rest/exertion
Dyspnea - SOB; orthopnea
Fatigue - HUGE
Palpitations
Edema - esp peripherally and dependent - heart func not up where need be
Syncope
Extremity pain - vascular probs: PAD and PVD
Ask about these
Current Health Concerns/Symptoms - symp pats having; find out what having
Functional classifications once know have CVD to see how severe it is
Functional History
Look at this: General appearance - distress, holding chest, alert, how communicating, able finish sentence, dyspnea concern
Skin
Extremities
Blood pressure (BP) - huge; way assess CV sys
Venous and arterial pulses
Precordium (area over heart)
Physical Assessment
Assess color and temperature - HUGE; know if decreased circ
Assess nail beds, mucous membranes, and conjunctival mucosa: see changes no matter pigment skin
Decreased perfusion can be manifested as cool, pale, cyanotic, gray and/or moist skin
Skin
Assess for dehydration – skin turgor; huge impact on CV func; not enough fluid volume through not as effective as CO
Assess for edema - big things assess for for CV - know where is: indic what going on
Vascular changes
Extremities
Location and extent (1+, 2+, 3+, 4+): measure, see if pitting: stay/rebound
Assess for edema - big things assess for for CV - know where is: indic what going on
Paresthesia, muscle fatigue, pain, nubmness, coolness, loss of hair, palor
Occlusion in periphery area imp assess extremities
Vascular changes
Hypertension - diagnose with:
BP < 90/60 may not be adequate for providing enough oxygen and sufficient nutrition to body cells - worried about enough O2 and blood supply to rest body; monitor MAP invasively or vaguely calc; want not between 60-70 to adequately perfuse organs; want greater than 70
Postural (orthostatic) hypotension
Pulse pressure
Blood pressure (BP) - huge; way assess CV sys
Systolic blood pressure (SBP) >140 mm Hg
Diastolic blood pressure (DBP) > 90 mm Hg
Taking drugs to control BP
Any things diagnosed with it
Hypertension - diagnose with:
Decrease of more than 20 mm Hg of the SBP or more than 10 mm Hg of the DBP and 10-20% increase in HR with changes in position
More common in older because baroreceptors not working as well
Postural (orthostatic) hypotension
Difference between systolic and diastolic values, used an indirect measure of cardiac output
Narrowed pulse pressure: concerning; indicates that some cardiac dysfunc going on; more vascular resistance going on
Pulse pressure
Venous pulsations in neck assess for jugular venous distention (JVD) - check neck area; HF, backup, constriction filling JV visibility see distended
Assess all major peripheral pulses: distal ones first then move up; doc how strong pulses area
Hypokinetic pulse – weak pulse
Hyperkinetic pulse – bounding pulse
Can use doppler if necessary
Auscultate carotid for bruits – normally there are no sounds if the artery has uninterrupted blood flow; hold breath not hear swishing; if do is occlusion/narrowing
Venous and arterial pulses
Inspection - no masses/sunken in areas
Auscultation - listen for S1 and S2
Precordium (area over heart)
S1-Mitral and tricuspid valve closing; lower sternal border; longer than S2
S2-Pulmonic and aortic valve closing; shorter; base of heart so higher
Abnormal heart sounds (splitting of S2; S3, S4, murmurs - issues with valves, pericardial friction rub - infection/inflammation - something going on that rubbing pericardium against heart wall)
Auscultation - listen for S1 and S2
Cellular injury/death causes a release of enzymes and those enzyme levels are used to diagnose Acute Coronary Syndrome (ACS) - commonly enzymes drawn when come in with chest complaint/cardiac issues
Troponin
Creatine kinase (CK)
CK-MB
Myoglobin
Lab assessments: cardiac markers/enzymes
Myocardial muscle protein released when there is injury to myocardial muscle
Large increases with serial need do interventions: likely having cardiac injury
Very specific for myocardial injury
Do upon initial and q3h; also do with ECG at same time; diagnostic for MI - protein released with myocardial injury
Normal=T <0.10 ng/mL and I < 0.03 ng/mL
Troponin
Enzyme specific to cells of the brain, myocardium, and skeletal muscle
CK indicates tissue necrosis or injury - not as specific as troponin
Normal=females 30-135 units/L and males 55-170 units/L
Creatine kinase (CK)
Specially found in myocardial muscle
Normal =0% of total CK
Indication injury
CK-MB
Protein found in cardiac and skeletal muscle
Elevated indication injury
Normal= < 90 mcg/L
Myoglobin
Elevated levels increase risk for CAD - higher good HDL
Cholesterol
Triglycerides
HDL
LDL
HDL:LDL ratio
Lab assessments: serum lipids
<200 mg/dL
Higher risk for CAD: builds up plaque in vessels and causes probs
Cholesterol
Between 40 and 160 mg/dL for men and between 35 and 135 mg/dL for women
Higher risk for CAD: builds up plaque in vessels and causes probs
Triglycerides
> 45 mg/dL for men and > 55 mg/dL for women
Considered “good cholesterol”
Want higher
HDL
<130 mg/dL
Higher risk for CAD: builds up plaque in vessels and causes probs
LDL
3:1 ratio
If ratio good say lower risk for CAD
HDL:LDL ratio
BNP (B-type natriuretic peptide)
Coagulation Studies
Homocysteine
C-reactive protein (CRP)
Microalbuminuria
Lab assessments: miscellaneous
Sensitive tool to diagnose and eval HF
Will be elevated and used for diagnosing heart failure
>100 is diagnostic and the higher the worse the heart failure; often used post-HF because higher levels because have chronic HF BNP is often high; used lot to see effectiveness of heart
BNP is produced and released by the ventricles when they are stretched and fluid overload
Natriuretic peptides are neurohormones that promote vasoldilation and diuresis through sodium loss in the renal tubules
BNP (B-type natriuretic peptide)
Imp esp if have vascular issues or on anticoags or post-MI
Evaluates the ability of blood to clot
Monitor when patients on anticoagulants
Coagulation Studies
Amino acid produced when proteins break down - put at higher risk for CVD
Elevated levels indicates increase the risk for cardiac disease
Normal: < 14 mmol/dL
Homocysteine
Any inflammatory process can produce CRP in the blood - gen inflammatory marker; seen with HTN when any inflammation going on
Normal: < 1.0 mg/dL
> 3mg/dL indicates high risk for heart disease
Elevations are also seen with hypertension, infection, and smoking
C-reactive protein (CRP)
Small amounts of protein in the urine
Indicates cardiac/endothelial dysfunction
Microalbuminuria
huge in role of cardiac func
aggressive about treating abnormalities
Lab assessments: electrolytes:
CXR
Angiography or arteriography
Electrocardiogram (ECG)
Echocardiography (Echo)
Exercise electrocardiography (EPS)
Transesophageal echocardiography (TEE)
Myocardial nuclear perfusion imaging
Magnetic resonance imaging (MRI)
Cardiac catheterization
Diagnostic testing
Examine size (hypertrophy will tell this), silhouette and position of heart - not specifics
CXR
Gen term
Uses contrast dye and fluroscopy to examine any arterial vessels
Preparation: Screen for allergy to dye; Sedation required; usually NPO because usually done under sedation
Angiography or arteriography
Very common and valuable diagnostic
Common if come in with chest pain
Examines electrical activity of heart
Preparation: None required; common and valuable
Electrocardiogram (ECG)
Uses ultrasound to assess cardiac structure and mobility
Specifically looks at valves; where get EF
Preparation: None required
Done as outpat; bedside; great test
Echocardiography (Echo)
“Stress test”
Assesses cardiovascular/heart in response to an increased workload: exercise (typ - walk/run on treadmill) or drug induced stress on heart if cannot tolerate exercise - look at heart and see how responds; diagnostic test see how doing
Patient Preparation
Exercise electrocardiography (EPS)
Encourage rest the night before the procedure
Light meal 2 hours before the test (depends on physician order) - toast; drink water up to test
Avoid smoking, alcohol, and caffeine-containing beverages on the day of the test - take caffeine cannot have test done
Beta blockers and calcium channel blockers usually held - not give meds that lower HR because want see what heart does with stress: To allow heart rate to increase with stress
Wear comfortable clothing and rubber-soled supportive shoes that move around in on treadmill
Patient Preparation - Exercise electrocardiography (EPS)
Look at heart by putting US/transducer down into esophagus
Examines cardiac structure and function using ultrasound that is placed behind the heart in the esophagus or stomach
Sim to EGD but looking at heart - good picks at back heart
Sedation is required - back esophagus
Preparation and post-op: similar to upper GI endoscopic exam; make sure gag reflex back; NPO
Good diagnostic test; look at for infected heart valves
Transesophageal echocardiography (TEE)
Use Radioactive tracer substances used to view cardiovascular abnormalities - put in and see what blood flow and ventricular func is for
Can view myocardial blood flow and left ventricular function
Preparation: NPO, no caffeine or cigarettes 4 hours prior
Myocardial nuclear perfusion imaging
Magnetic and radio waves used to view cardiac wall thickness, heart chambers, valve and ventricular function, and blood movement
Preparation: screen for metallic objects implanted or wearing
Magnetic resonance imaging (MRI)
Studies of the right or left side of the heart and the coronary arteries and heart using fluroscopy and inject contrast dye - look at all vessels of heart; invasive but definitely diagnostic when need get something definitive
Preparation:
Post procedure care
Cardiac catheterization
Renal protection from contrast dye - contrast dye is toxic; eval of kidneys; creatinine drawn and if any dysfunc renally going to want ensure lot fluids ahead of time
fluids may be given 12-24 hours before the procedure for renal protection
Administer acetylcysteine - protects kidneys from contrast dye - before and after
CXR, CBC, Coagulation screen (imp because accessing through bartering), and ECG done - pre-op
NPO after midnight or liquid breakfast if procedure scheduled in the afternoon - emergency: not NPO
Assess patient for contrast dye allergy (antihistamine or steroid may be given): HUGE; can do if still have allergy - lot premed before have procedure (antihistamine or steroid)
Sedative may be given prior but also asleep during procedure
Hold digitalis or diuretic prior to procedure
Preparation: - Cardiac catheterization
Keep on Bed rest and keep insertion site extremity straight - may access through femoral artery and need keep extremity straight
Not HOB above certain height
Monitor vital signs - check for bleeding
Assess insertion site for drainage or hematoma - bulging present
Assess peripheral pulses, temperature, and color in affected extremity - extremity accessed; checked q15 then q30 then q1h - check frequently so nothing occluded/bleeding
Monitor I & O/ Maintain hydration - imp esp if hydration if had underlying renal issues
Observe for complications
Extensive monitoring post cardiac cath
Post procedure care - Cardiac catheterization
