ASSESSMENT OF THE CARDIOVASCULAR SYSTEM

Question 1

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)

Answer 1

CV changes associated with aging

Question 2

Calcification (harden) and degeneration (can break down primarily -mitral and aortic valves)
Monitor for murmurs - cannot func as well

Answer 2

Cardiac valves - CV changes associated with aging

Question 3

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

Answer 3

Conduction system - CV changes associated with aging

Question 4

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

Answer 4

Left ventricle changes - CV changes associated with aging

Question 5

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

Answer 5

Aorta and other large arteries - CV changes associated with aging

Question 6

Become less sensitive
Monitor for orthostatic hypotension - more likely have this

Answer 6

Baroreceptors (sensors located in the blood vessels - tell body what going on) - CV changes associated with aging

Question 7

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

Answer 7

Assessment methods

Question 8

Focus on diff risk factors and symptoms have
Assess nonmodifiable risk factors
Assess modifiable risk factors
Assess for chronic diseases

Answer 8

Patient History

Question 9

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

Answer 9

Assess nonmodifiable risk factors

Question 10

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)

Answer 10

Assess modifiable risk factors

Question 11

Ex. Diabetic patients at higher risk for CVD; pulm issues lead to CVD; lots contribute

Answer 11

Assess for chronic diseases

Question 12

Ex. High sodium, fat and cholesterol can increase risk and big risk factor for CV disease
Eat healthy diet lower risk

Answer 12

Nutrition History

Question 13

Screen first degree relative (siblings, mothers, fathers) for history of CAD, hypertension, sudden cardiac death
Can have huge impact

Answer 13

Family and Genetic History

Question 14

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

Answer 14

Current Health Concerns/Symptoms - symp pats having; find out what having

Question 15

Functional classifications once know have CVD to see how severe it is

Answer 15

Functional History

Question 16

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)

Answer 16

Physical Assessment

Question 17

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

Answer 17

Skin

Question 18

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

Answer 18

Extremities

Question 19

Location and extent (1+, 2+, 3+, 4+): measure, see if pitting: stay/rebound

Answer 19

Assess for edema - big things assess for for CV - know where is: indic what going on

Question 20

Paresthesia, muscle fatigue, pain, nubmness, coolness, loss of hair, palor
Occlusion in periphery area imp assess extremities

Answer 20

Vascular changes

Question 21

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

Answer 21

Blood pressure (BP) - huge; way assess CV sys

Question 22

Systolic blood pressure (SBP) >140 mm Hg
Diastolic blood pressure (DBP) > 90 mm Hg
Taking drugs to control BP
Any things diagnosed with it

Answer 22

Hypertension - diagnose with:

Question 23

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

Answer 23

Postural (orthostatic) hypotension

Question 24

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

Answer 24

Pulse pressure

Question 25

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

Answer 25

Venous and arterial pulses

Question 26

Inspection - no masses/sunken in areas Auscultation - listen for S1 and S2

Answer 26

Precordium (area over heart)

Question 27

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)

Answer 27

Auscultation - listen for S1 and S2

Question 28

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

Answer 28

Lab assessments: cardiac markers/enzymes

Question 29

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

Answer 29

Troponin

Question 30

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

Answer 30

Creatine kinase (CK)

Question 31

Specially found in myocardial muscle Normal =0% of total CK Indication injury

Answer 31

CK-MB

Question 32

Protein found in cardiac and skeletal muscle Elevated indication injury Normal= < 90 mcg/L

Answer 32

Myoglobin

Question 33

Elevated levels increase risk for CAD - higher good HDL Cholesterol Triglycerides HDL LDL HDL:LDL ratio

Answer 33

Lab assessments: serum lipids

Question 34

<200 mg/dL Higher risk for CAD: builds up plaque in vessels and causes probs

Answer 34

Cholesterol

Question 35

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

Answer 35

Triglycerides

Question 36

> 45 mg/dL for men and > 55 mg/dL for women Considered “good cholesterol” Want higher

Answer 36

HDL

Question 37

<130 mg/dL Higher risk for CAD: builds up plaque in vessels and causes probs

Answer 37

LDL

Question 38

3:1 ratio If ratio good say lower risk for CAD

Answer 38

HDL:LDL ratio

Question 39

BNP (B-type natriuretic peptide) Coagulation Studies Homocysteine C-reactive protein (CRP) Microalbuminuria

Answer 39

Lab assessments: miscellaneous

Question 40

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

Answer 40

BNP (B-type natriuretic peptide)

Question 41

Imp esp if have vascular issues or on anticoags or post-MI Evaluates the ability of blood to clot Monitor when patients on anticoagulants

Answer 41

Coagulation Studies

Question 42

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

Answer 42

Homocysteine

Question 43

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

Answer 43

C-reactive protein (CRP)

Question 44

Small amounts of protein in the urine Indicates cardiac/endothelial dysfunction

Answer 44

Microalbuminuria

Question 45

huge in role of cardiac func aggressive about treating abnormalities

Answer 45

Lab assessments: electrolytes:

Question 46

CXR Angiography or arteriography Electrocardiogram (ECG) Echocardiography (Echo) Exercise electrocardiography (EPS) Transesophageal echocardiography (TEE) Myocardial nuclear perfusion imaging Magnetic resonance imaging (MRI) Cardiac catheterization

Answer 46

Diagnostic testing

Question 47

Examine size (hypertrophy will tell this), silhouette and position of heart - not specifics

Answer 47

CXR

Question 48

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

Answer 48

Angiography or arteriography

Question 49

Very common and valuable diagnostic Common if come in with chest pain Examines electrical activity of heart Preparation: None required; common and valuable

Answer 49

Electrocardiogram (ECG)

Question 50

Uses ultrasound to assess cardiac structure and mobility Specifically looks at valves; where get EF Preparation: None required Done as outpat; bedside; great test

Answer 50

Echocardiography (Echo)

Question 51

“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

Answer 51

Exercise electrocardiography (EPS)

Question 52

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

Answer 52

Patient Preparation - Exercise electrocardiography (EPS)

Question 53

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

Answer 53

Transesophageal echocardiography (TEE)

Question 54

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

Answer 54

Myocardial nuclear perfusion imaging

Question 55

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

Answer 55

Magnetic resonance imaging (MRI)

Question 56

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

Answer 56

Cardiac catheterization

Question 57

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

Answer 57

Preparation: - Cardiac catheterization

Question 58

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

Answer 58

Post procedure care - Cardiac catheterization