Unit 2: Cardiovascular Assessment Flashcards
Risk Factors for Cardiovascular Disease (CVD)
- family hx
- diabetes mellitus
- chronic renal disease
- hypertension
- dyslipidemia
Non-Modifiable Risk Factors for Cardiovascular Disease
-demographic data (age, sex, ethnic background)
Modifiable Risk Factors for Cardiovascular Disease (CVD)
-Weight
-Dietary habits
-Alcohol consumption
-Smoking
-Sedentary lifestyle; exercise promotes cardiovascular health
>excess consumption of fats and sodium is a dietary habit that puts a patient at risk for heart disease
Common symptomatic complaints r/t cardiovascular disease
- chest pain
- difficulty breathing (dyspnea)
- cough
- palpitations
- edema
- fatigue
- syncope
Chest Pain
- evaluated for location, intensity, radiation, duration, and quality
- want to find information that provides relief of pain
What do Palpitations indicate?
abnormal heart rhythms; dysrhythmias
What does Syncope Indicate?
decreased cardiac output from problems with either the mechanical or electrical properties of the heart
The General Assessment of Cardiovascular System
-assess, inspection, palpation, and auscultation
>Evaluate overall appearance:
-color, diaphoresis, edema, and demeanor and restlessness, agitation or confusion
>Observe:
-weight & build, SOB, and mobility
-patients w/ late-stage HF will present w/ edema and appear frail and fatigued
>Evaluate HR and BP:
-info on the efficiency and strength of the heart
-Normal HR: 60- 100 bpm
-HR heard? palpating the pulse over an artery close to the skin (radial), or auscultating the apical HR (place stethoscope at the junction of the fifth intercostal space and the midclavicular line, the point of maximal impulse (PMI)
What does a low heart rate (HR) indicate?
(bradycardia)
-can indicate good physical conditioning and thus an efficient heart
-can indicate inadequate cardiac output (CO)
>if low HR is associated w/ dizziness, SOB, or chest pain; further evaluation
What does a high heart rate (HR) indicate?
- occurs naturally w/ exercise and exertion
- abnormal when occurring at rest; d/t a weak heart muscle, pain, fever, or inadequate fluid volume; further evaluation
Pulse Deficit
- if performed at the same time, the radial pulse rate is less than the apical HR
- can indicate arrhythmias such as atrial fibrillation or premature ectopic beats
Blood Pressure
info on the force of the hearts contraction and volume of cardiac output, as well as the resistance offered by the arterial vascular system
High Blood Pressure
(Hypertension)
-increases risk of heart failure, MI, and stroke
Low Blood Pressure
(Hypotension)
- should be assessed for clinical significance
- presence of postural hypotension (decrease of 20 mmHg in BP from lying to sitting, to standing position accompanied by a 10% increase in HR could = inadequate cardiac output or blood volume
Normal Blood Pressure Reading
- SBP: < 120 mmHg
- DBP: < 80 mmHg
Elevated Blood Pressure Reading
- SBP: 120-129 mmHg
- DBP: < 80 mmHg
Hypertension
> Stage 1:
- SBP: 130-139 mmHg
- DBP: 80-89 mmHg
> Stage 2:
- SBP: >140 mmHg
- DBP: >90 mmHg
Visual Inspection of Cardiovascular System
- assess color, capillary refill time, edema, presence or absence of jugular vein distention, and clubbing of the fingers and toes
- adequate perfusion = skin color and nail beds are pink
- poor perfusion = appears pale gray or bluish color (cyanosis)
Central Cyanosis
- blue coloring of mucous membranes, lips, and tongue
- caused by impaired heart or lung function
Peripheral Cyanosis
- blue discoloration of the extremities
- caused by heart or lung failure
- can indicate peripheral vasoconstriction or obstruction
Capillary Refill Time
tested by compressing a finger or toe momentarily to stop the blood flow, producing a whitening effect, then releasing pressure and timing the return to normal pink color
-adequate peripheral circulation = a return to color within 3 seconds
Edema
can be a sign of cardiac or liver issues
- bilateral lower extremity edema
- unilateral extremity edema
- pitting edema
Bilateral lower extremity edema
if not associated w/ local injury, indicates venous insufficiency or heart failure
-leg swelling in both lower legs
Unilateral extremity edema
if not associated w/ local injury, can indicate a venous or lymphatic obstruction
-one extremity
Pitting Edema
indenting of the skin that remains after pressure has been applied then released
Distention of Jugular Veins
- seen in a constrictive disease such as pericarditis or cardiac tamponade
- seen in right ventricular failure, valvular disease, or hypervolemia
- associated w/ poor contractile function of the heart that is present in heart failure
Clubbing of fingers/toes
Long-term perfusion problem produced by a decrease in oxygenated blood flow to the affected extremities
Palpation: Temperature
assessment of skin temperature
- Adequate CO = warm skin temperatures
- Cool or cold temperatures = vasoconstriction, heart failure, or shock
- Variations in temp = vasoconstriction or vascular disease in the affected extremities
Palpation: Pulses
radial and dorsalis pedis pulses
- others: femoral, popliteal, and posterior tibial pulses
- strong, palpable pulses = adequate CO and good flow through the peripheral vessels
Auscultation
assessment of heart and lung sounds
Heart Sounds
“Lub” and “Dub” are produced by the closure of the valves during the cardiac cycle
- Heart sounds: S1, S2, S3, S4, Systolic murmur, click, friction rub
- fever, inflammation, excess fluid, and narrowed or incompetent valves are clinical situations that produce extra sounds such as clicks, rubs, or murmurs
- any condition that creates a noncompliant LV will produce a S4
- any condition that creates an overly compliant LV will produce a S3 heart sound
Heart Sounds: S1
“Lub”
- closure of AV valves
- signifies beginning of ventricular systole
- sounds longer + louder compared to S2
Heart Sounds: S2
“Dubb”
- closure of semilunar valves
- signifies beginning of diastole
- short + soft
Heart Sounds: S3
“ventricular gallop”
- can be heard in children and young adults
- heard best in lateral decubitus position, and at apex
- caused by vibration in the ventricular walls during filling or early diastole
- occurs just after S2 when the mitral valve opens, allowing passive filling of the left ventricle
- if heard in an adult, may = decreased ventricular compliance; ventricular dysfunction
- combined S1, S2, and S3 resemble a gallop
- any condition that creates an overly compliant LV will produce a S3 heart sound
- heard best w/ bell on stethoscope
- timing: early diastole
- description: gallop-like sounds
Heart Sounds: S4
“atrial gallop”
- timing: heard in late diastole and occurs after atrial contraction
- occurs just before S1 when the atria contract to force blood into the left ventricle
- occurs during active LV filling when atrial contraction forces blood into a noncompliant LV
- indicates decreased ventricular compliance
- gallop-like sounds
- heard best with bell on stethoscope
Click
- high-pitched sound
- heard early in diastole
- caused by mitral valves stenosis
Murmurs
- caused by turbulent flow through the valves
- turbulence caused by regurgitation of blood through an incompetent valve, flow through a narrowed valve, or an increase in flow in hypermetabolic states (hyperthyroidism or fever)
Systolic Murmur
- caused by valvular disease such as aortic stenosis
- turbulent blood flow heard
- timing: systole between S1 and S2
Diastolic Murmur
- caused by valvular disease such as aortic or pulmonic regurgitation
- turbulent blood flow heard
- timing: diastole after S2
Friction Rub
- scratching or grating sound heard during both systole and diastole
- sound produced by inflammation of the pericardium (pericarditis)
- timing: anywhere during cardiac cycle
How to Describe Heart Sounds
- Pitch: high, medium, or low
- Quality: blowing or harsh
- Intensity: faint, quiet, or loud
- Timing: during diastole (rest) or systole (contraction)
- Location: heard best on chest wall
Lung Sounds
gives indication of both lung + cardiac health
- Normal: clear
- Abnormal: rales, rhonchi, or rubs in the lung fields indicate presence of fluid; may be a result of pulmonary disease or congestive heart failure and decreased cardiac function
Laboratory Markers as Predictors of Heart Disease
> Lipid panel: requires fasting
- Cholesterol: < 200 mg/dL
- LDLs: < 100 mg/dL
- HDLs: 40-60 mg/dL
- Triglycerides: < 150 mg/dL
>Non-specific markers: -Glucose: 65-99 mg/dL -Homocysteine: 4.4-10.8 mm/L -C-reactive protein: 0 (only present w/ inflammation) -Coagulation Studies: Platelets: 150,000-400,000 mc/L Fibrinogen levels: 200-400 mg/dL Prothrombin Time (PT): 10-13 sec PTT: 25-35 seconds INR: < 2.0
Cholesterol
less than 200 mg/dL (< 200 mg/dL)
- lipid necessary for synthesis of hormones and cell walls
- available through ingestion of animal products (meat) and thorough synthesis in the liver
- not soluble in blood; combines w/ proteins to form lipoproteins (LDLs, HDLs) to facilitate transport through vascular system
Low-Density Lipoproteins (LDLs)
- transports cholesterol into the cell
- can deposit cholesterol on the walls of arterial vessels
- Normal: < 100 mg/dL
- elevated levels ( > 100 mg/dL) = increased risk of heart disease
High-Density Lipoproteins (HDLs)
- protective lipoproteins
- transports cholesterol away from the cells to the liver for excretion
- Normal: > 40-60 mg/dL
- decreased levels ( < 40 to 60 mg/dL) = risk for heart disease
Total Cholesterol Level
- includes LDLs and HDLs
- Normal: 200 mg/dL or less
- Increased = risk factor for atherosclerotic vessel disease
Triglycerides
- store unused ingested calories in fat cells, which may be later released as an energy source between meals
- Normal: < 150 mg/dL
- increased levels ( > 150 mg/dL) = risk factor for heart disease
Glucose
65-99 mg/dL
-diabetes + hyperglycemia are risk factors for CVD
Homocysteine
- 4-10.8 mm/L
- amino acid
- increased = risk for heart disease
- can damage the lining of arterial walls, causing clot formation
- decreased dietary intake of folic acid and B vitamins is associated w/ increased levels of homocysteine
C-reactive Protein
- not specific for cardiac disease
- elevated levels = increased production of C-reactive protein in the liver secondary to systemic inflammation
- Normal: 0
- only present when inflammation is present
Coagulation studies
- Platelets
- Fibrinogen levels
- Prothrombin Time
- Partial thromboplastin time
- International normalized ratio (INR)
Platelets
- 150,000-400,000
- used for screening purposes
- increased = increased risk of atherosclerotic heart disease
Fibrinogen Levels
200-400 mg/dL
- used for screening purposes
- increased = risk of atherosclerotic heart disease
Prothrombin Time (PT)
- 10-13 seconds
- measured in patients w/ increased risk of clot formation (a-fib)
- used to monitor anticoagulation therapy
Partial Thromboplastin Time (PTT)
- 25-35 seconds
- measured in patients w/ increased risk of clot formation
- used to monitor anticoagulation therapy
Internalized normalized ration (INR)
- < 2.0
- measured in patients w/ increased risk of clot formation
- used to monitor anticoagulation therapy
Laboratory Markers of Acute Cardiac Damage or Injury
- Creatinine kinase myocardial bands (CK-MB): 0-3 mg/ml
- Creatinine kinase
- Troponin: < 0.4 mg/ml
- Myoglobin: 0-85 mg/ml
- Brain natriuretic peptide (BNP): < 100 pg/ml
Creatinine Kinase (CK)
- general marker for cellular injury
- released from cells in the brain, skeletal muscle, and cardiac tissue after muscle damage has occurred
Creatinine Kinase myocardial bands (CK-MB)
- 0-3 mg/ml
- specific to cardiac tissue
- CK-MB releases from the cells when myocardial damage occurs
- increased levels can be seen at 3 hours after myocardial damage
- can remain elevated for up tp 36 hours before going back to normal
Troponin
- less than 0.4 mg/ml
- specific marker of cardiac muscle damage
- preferred method for diagnosing cardiac injury
- protein released from damaged tissue
- can elevate within 4 hours of injury
- stay elevated for up to 10 days (reason why it is a valuable marker for diagnosing injury in recent past)
Myoglobin
- 0-85 mg/ml
- protein released and elevated in muscle damage
- not specific for cardiac tissue
- can be used in conjunction w/ other values
Brain Natriuretic Peptide (BNP)
- less than 100 pg/ml (< 100 pg/ml)
- is released from overstretched ventricular tissue; venous dilation which decreases preload, arterial dilation which decreases afterload, and diuresis
- elevations are indicators of HF
Nursing Implications r/t obtaining CK, CK-MB, and Troponin
- timing of blood draws
- for acute injury, lab tests obtained at baseline and then at regular intervals (3 to 4 hours) for 12 hours
Diagnostic Imaging Studies
- Electrocardiography (ECG)
- Radiology (CXR)
- Echocardiography
- Cardiac Stress Testing
- Catheterization and Angiography
Electrocardiography (ECG)
-routinely completed to assess electrical conduction system of the heart
-identifies dysrhythmias, new or old heart muscle damage, electrolyte abnormalities, and/or cardiac hypertrophy
-10 electrodes are placed on specific parts of the body
>V1: 4th ICS, just to the right of the sternum
>V2: 4th ICS, just to the left of the sternum
>V4: On midclavicular line and 5th ICS
>V6: on midaxillary line, horizontal w/ V4
>V5: between V6 and V4 on anterior axillary line
>V3: between V4 and V2
Nursing Implications for electrocardiogram (ECG)
-can be resting or ambulatory >Resting: -supine position, quiet -completed in several minutes -skin clean, dry, and as free from hair as possible to ensure good electrode contact w/ skin
> Ambulatory: (halter monitoring)
- can be done continuously over several days while maintaining normal activity
- pt instructed to keep log of activities
- symptoms such as chest pain, SOB, or syncope may be correlated w/ rhythm changes
Radiology: Chest x-ray (CXR)
- provides info about size, shape, and position of heart
- cannot diagnose heart disease, but can highlight complications (cardiac enlargement or pulmonary congestion)
- can diagnose pneumonia, pneumothorax, and other primary lung disorders
- used to confirm placement of central venous catheters, endotracheal tubes, and chest tubes
Nursing Implications for Chest x-ray
- hospital gown replaces any clothing worn on upper body, especially a bra
- pt instructed to hold breath for several seconds while film is obtained, minimizing movement and improving quality of x-ray
Echocardiography
- uses ultrasound to provide info on the size and pumping function of the heart, blood volume states, and valve function and integrity
- 2 types: Transthoracic echocardiogram (TTE), Transesophageal echocardiogram (TEE)
> TEE: obtained by placing a ultrasound transducer in the pts esophagus; provides info from the posterior of the heart
-used when complications such as obesity or lung disease may obscure the TEE by interfering w/ the transmission
> TTE: placing a transducer on the patients chest
Nursing Implications for a TEE
- no eating or drinking for at least 8 hours prior to procedure (NPO)
- small sips of water w/ medication is an exception
- given sedation for the test; have someone drive them home
Cardiac Stress Test
-done to evaluate heart functioning during times of increased work load
-way to evaluate functional ability of the heart
-screening tool for symptoms of cardiovascular disease that may become apparent only when the heart is stressed
-done on treadmill or stationary bike
-attached to a monitoring system
-HR, rhythm, and BP are monitored at regular intervals
>Chemical stress testing
>Isotope/ Nuclear stress testing
Chemical Stress Testing
is done if the patient is unable to exercise b/c of physical limitations
-IV administration of medication (dobutamine) stimulates the heart similar to exercise
Isotope/Nuclear stress testing
is a combination of a regular stress test and a chemical stress test
- IV injection is a nuclear isotope tracer (Thallium)
- purpose: visualize areas of poor perfusion in the heart d/t blocked arteries
- the isotope is more readily supplied to and picked up by tissues that have adequate perfusion, creating “hot spots” when imaged
- areas of poor perfusion get a lesser supply of the isotope creating “cold spots”
> another form is done w/ isotope technetium which becomes bonded to damaged tissue
-imaging is done hours after injection, allowing renal clearance of the medication not accumulated in the damaged cardiac tissue
Nursing Implications for Cardiac Stress Testing
- not to eat or drink for 4 hours prior to the procedure to avoid any nausea that might be associated w/ heavy exercise
- avoid smoking prior to test
- avoid caffeine prior to test
Cardiac Catheterization
- invasive x-ray procedure
- radiopaque catheter is advanced through an artery or vein to the heart under fluoroscopy in order to evaluate cardiac filling pressures, CO, and valvular function
- both right ad left heart studies can be conducted
> Right heart catheterization:
- done through suitable vein (femoral, brachial, or subclavian)
- catheter is advanced to the right heart via the inferior or superior vena cava
> Left heart catheterization:
- done through a suitable artery (femoral, brachial, radial)
- catheter advanced through aorta ad into left heart
Coronary Angiography
- primary reason cardiac cath is performed
- left-sided cardiac catheterization w/ purpose of inspecting the coronary arteries for blockage and determining the necessity of revascularization procedures (PCI or coronary bypass surgery)
- done by cineangiography
- once catheter in place, contrast dye is injected that allows visualization of the vessels
- multiple consecutive images are obtained, allowing visualization of the dye, noting areas of stenosis or blockage
Risk Associated with Catheterization
- threat of dysrhythmia
- touching myocardium w/ tip if catheter causes an extrasystole or irregular beat
- bleeding
- infection
- MI
- perforation of he heart or great vessels
- stroke
Nursing Implications/Patient Teachings for a Catheterization
- fasting 6 to 8 hours prior
- expected duration and activities to expect (IV insertion, sedation)
- Info regarding potential sensations experienced during procedure; “hot flash” as dye is injected or palpitations if dysrhythmias occur
- maintain adequate fluid intake after procedure
- avoid strenuous activity until provider gives the OK
- monitor cannula insertion site for bleeding
- assess peripheral pulses
Pre Procedure Care for Catheterization
- baseline vitals
- review blood work focusing on renal studies (d/t dye)
- pre-procedure check list that includes obtaining height and weight and ensure patient has been NPO
- administer pre-procedure hydration
- check glucose while NPO
- anticipate holding diabetic medications
Intraprocedural Care for Catheterization
- psychological support to ease fear
- cardiac monitoring to observe for dysrhythmias
- readiness and ability to respond w/ advanced cardiac life-support interventions
Safety Alert: Cardiac Cath Post Procedure Interventions
- flat bedrest for 2 to 6 hours to prevent stress on the insertion site
- observe the catheter insertion site for bleeding or hematoma formation
- cardiac monitoring
- frequent vital signs
- monitor for chest pain
- assess for signs of stroke (confusion, weakness, slurred speech)
- monitor peripheral pulses, color, and temperature in affected extremity
- monitor urine output secondary to osmotic diuresis caused by contrast dye
- maintain oral and/or IV fluid intake to ensure renal clearance of the dye and to maintain adequate hydration status
- obtain bloodwork to assess renal function, hemoglobin/hematocrit, and coagulation studies
