Cardiac Assessment Flashcards
The right atrium receives venous blood from the inferior & superior vena cavae and the coronary sinus
Blood then passes through tricuspid valve into right ventricle
W/each contraction, right ventricle pumps blood through the pulmonic valve into the pulmonary artery & to the lungs
Blood flows from the lungs to the left atrium by way of pulmonary veins
Then passes through the mitral valve & into left ventricle
As heart contracts, blood is ejected through the aortic valve into the aorta and thus enters systemic circulation
A visual representation of the cardiac cycle
Cardiac Valves
- Tricuspid valve
- Mitral valve
- Pulmonic valve
- Aortic valve
Cusps of mitral & tricuspid valves are attached to thin strands of fibrous tissue termed chordae tendineae
Chordae are anchored in the papillary muscles of the ventricles
This support system prevents eversion of the leaflets into the atria during ventricular contraction
Pulmonic & aortic valves (also known as semilunar valves) prevent blood from regurgitating into the ventricles @ end of each ventricular contraction
! Perfusion (heart ↔ blood ↔ vessels ↔ lungs)
Patient History - Risk Factors
- Smoking, obesity
> Excess weight (around abdomen?) -
HTN, diabetes
> Kidney failure? - Hyperlipidemia
- Age/gender/EO
> Occupation - Postmenopausal
> Post-meno are 2-3x more likely than pre-meno to have CVD
- Family history
> Domestic partner; other household members; environment; support/support system(s) - Psychosocial
> Psychological stress? - Modifiable vs non-modifiable risk factors
- Specifics of smoking history
> Age at start; duration of habit; # cigs/day - A pos fhx for CAD in a first-deg relative is a major risk factor that’s more significant than other factors like HTN, obesity, DM, or sudden cardiac death
Cardiovascular System Assessment
- Current health problems
- Pain, discomfort
- Dyspnea, DOE, orthopnea, PND
- Fatigue
- Palpitations
- Edema
- Syncope
- Extremity pain
- General appearance
- Skin/temp, color
> Skin color can reflect perfusion and if there’s adequate cardiac output (CO); why assessing radial & pedal pulses matters - Cyanosis, rubor extremities
- Clubbing, edema
- BP
- Hypotension & HTN (if BP too low, CO will be low)
- Postural (orthostatic) hypotension
- Presence or absence of JVD
?
Anatomically, this is the area of the anterior chest wall over the heart
Precordium
Precordium - Assessment
- Inspection (is the chest uneven or misshapen)
- Palpation (to see what you feel; shouldn’t elicit pain)
- Percussion (normally a dull sound)
- Auscultation
> Normal heart sounds vs abnormal
> Gallops & murmurs
> Pericardial friction rub
- Precordial CP can be an indication of a variety of illnesses like costochondritis & viral pericarditis (vs cardiac CP)
Gerontological Consideration
- Age alters the cardiovascular response to physical & emotional stress
- Heart valves become thick & stiff
- Frequent need for pacemakers
- Increase in SBP; decrease or no change in DBP
- With increased age, the amt of collagen in heart increases & elastin decreases
- These changes affect the contractile and distensible properties of the myocardium
- 1 of the major age-associated alterations in cardiovascular response to physical or emotional stress is a decrease in CO & SV caused by decreased contractility & HR response to increased stress
Cardiac valves become thicker & stiffer from lipid accumulation, degeneration of collagen, & fibrosis
__ and __ valves are most frequently affected
Aortic, mitral
- # of pacemaker cells in SA node dec w/age
- # & function of beta-adrenergic receptors in heart dec w/age (therefore, older adult has dec response to physical & emotional stress)
- Arterial & venous blood vessels thicken & become less elastic w/age
> Arteries inc their sensitivity to vasopressin (ADH); both these changes add to a progressive dec or no change in DBP w/age
HTN guidelines:
Ppl >60 systolic over 150 is considered HTN as opposed to under 60 which is >140 systolic
Serum Markers of Myocardial Damage
- Troponin: Troponin T and troponin I
- Creatine kinase (CK)
- Myoglobin
- Serum lipids
- Homocysteine
- Highly sensitive CRP
- Troponin T & I are the most used labs to indicate whether or not someone has had a heart attack; are most heart-specific
Lab Assessment
- Microalbuminuria
- Coagulation studies (PT/INR/PTT)
- ABG
- Fluids & electrolytes (F&E)
- Erythrocyte count
- H&H
- Leukocyte count
Diagnostic Assessment
- PA & lateral CXR
- Angiography
- Arteriography
- Cardiac catheterization
Cardiac Catheterization
- Typical site accessed via femoral artery but could also be done through a radial artery
Other Diagnostic Assessment
- ECG, aka EKG
- Electrophysiologic study (EPS)
- Stress test
- Echocardiography
> Pharmacologic stress echo
> TEE - Myocardial nuclear perfusion imaging (MNPI)
! Best indicator of fluid balance is weight
2.2 lb = 1 kg = 1 L of fluid
If your pt weighs 4 or 5 lbs more than 2 days ago, he/she could have an EXTRA 2 L of fluid retained
?
Is the amount of blood pumped from the left ventricle per minute
In adults, ranges from 4-7L/min
Cardiac output (CO)
B/c CO requirements vary according to body size, the cardiac index is calculated to adjust for differences in body size
The cardiac index can be determined by dividing the __ by the __
CO; body surface area
?
Refers to the # of times the ventricles contract each minute
Normal for an adult is between 60-100 bpm
Heart rate (HR)
- Increases in rate increase myocardial oxygen demand
- The HR is extrinsically controlled by the ___, which adjusts rapidly when necessary to regulate cardiac output
autonomic nervous system (ANS)
The ___ slows the HR, ___ increases the HR
parasympathetic (vagus nerve) system; sympathetic stimulation
?
Is the amount of blood ejected by the left ventricle during each contraction
Stroke volume (SV)
Dub = S2 = ?
Lub = S1 = ?
Diastole
Systole
S1 represents the opening of which valves?
pulmonic, aortic
S1 represents the closing of which valves?
tricuspid, mitral
S2 represents the closing of which valves?
pulmonic, aortic
S2 represents the opening of which valves?
tricuspid, mitral
5 areas for listening to the heart
APE TO MAN
All People Enjoy Time Magazine
?
At the left 2nd ICS
Pulmonic
?
S1,S2; at the left 3rd ICS
Erb’s Point
?
At the lower left sternal border 4th IC
Tricuspid
?
At the right 2nd ICS
Aortic
?
At the left 5th IC, medial to midclavicular line
Mitral
S1
Represents ___
__ and __ closes
__ and __ open
Hear loudest at the apex, mitral, & tricuspid
__ pitch - diaphragm
systole
mitral, tricuspid
aortic, pulmonic
High
S2 (louder than S1)
Represents ___
__ and __ close
__ and __ opens
Hear best at the base - aortic & pulmonic
__ pitch - diaphragm
diastole
aortic, pulmonic
mitral, tricuspid
High
S3
Represents issues with filling into the ventricular __-diastole
___ gallop: lung not compliant; vibrations
Seen in HF as pathologic or mitral valve regurgitation, normal w/young adults
Hear best in L side lying position - mitral
__ pitch - bell
S3 may be the earliest sign of ?
- Shortly after S2
mid
Ventricular
Low
HF, dilated CM, end-stage ischemic heart disease, valvular heart disease (VHD)
S4
Represents issues with filling in __ diastole (before S1)
___ gallop; lung not compliant; vibrations
LV hypertrophy, ischemia
Hear best L lying side decubitus - mitral
__ pitch - bell
- Common cause is HTN, AS, cardiomyopathy, ischemic heart disease
late
Atrial
Low
Murmurs
- Crescendo (increases in intensity) vs decrescendo (decreases in intensity)
- Quality (harsh, blowing, whistling, rumbling, or squeaking)
- Pitch (high or low)
?
Originates from the pericardial sac & occurs w/the movements of the heart during the cardiac cycle
Pericardial friction rub
- Usually transient; sign of inflammation, infection, or infiltration
- May be heard in pts w/pericarditis resulting from MI, cardiac tamponade, or post-thoracotomy
Murmurs
Location - where do you hear it loudest?
Quality - harsh, blowing, whistling, rumbling, or squeaking
Pitch - usually high or low
?
Refers to the average pressure within the arterial system that is felt by organs in the body
Normal 70-110 mmHg
Need at least 60-70 to perfuse major organs
Under 60 - ! bad
Mean Arterial Pressure (MAP)
MAP = [(2 x DBP) + SBP] / 3
Example: BP 130/80; SBP = 130; DBP = 80
[(2 x 80) + 130] / 3 = 96.666 or 97 mmHg
Pulse pressure (PP) is the difference between the SBP & DBP
<40 >60
- This value can be used as an indirect measure of CO
Narrowed PP is rarely normal & results from
- increased peripheral vascular resistance or
- decreased SV in pts w/HF
- hypovolemia
- shock; it can also be seen in those w/mitral stenosis or regurgitation
Increased PP may occur in pts w/
- slow heart rates
- aortic regurgitation
- atherosclerosis
- HTN
- aging
?
Is the difference between apical pulse & peripheral pulse
A normal finding would be that they’re essentially the same
Pulse Deficit
! If they’re different, there’s a problem. The apical is the SOURCE when it gets to the pulses effectively, it should be the same as at the source
Decreased Cardiac Output/Ineffective tissue perfusion
Head
* Impaired orientation, dizziness, syncope, diaphoresis, lightheadedness, cyanosis, pallor
Neck
* Carotid, JVD
Chest
* Pain, dyspnea, PND, orthopnea, palpitations, cough, frothy sputum, blood, murmurs, heart sounds, lung sounds
Abdomen
* N/V, nocturia
Peripheral
* Pain, pulses, hypokinetic?, edema, cyanosis
General
* Fatigue, anxiety, weight
Factors Affecting Cardiac Output
- Preload
> Volume of blood in ventricles at the end of diastole - Contractility
- Afterload
> Peripheral resistance against which the left ventricle must pump
Preload determines the amount of stretch placed on myocardial fibers
Contractility can be increased by epinephrine and norepinephrine released by the SNS. Increasing contractility raises the SV by increasing ventricular emptying
Afterload is affected by size of the ventricle, wall tension, and arterial BP
If arterial BP is elevated, ventricles will meet increased resistance to ejection of blood, increasing the work demand. Eventually, this results in ventricular hypertrophy, an enlargement of cardiac muscle tissue without an increase in CO or the size of the chambers
