Assessment of the Cardiovascular System

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Assessment of the Cardiovascular System

• Wendy Zamora, RN MSN

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The Cardiovascular System

• Anatomy and physiology
• Heartits structure and function
• Valves, arteries
• Cardiac output, cardiac index, heart rate
• Stroke volume
• Preload
• Afterload
• Vascular system
• Contractility

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Blood Pressure

• Blood pressure is the force of blood exerted
  against the vessel walls.

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Blood Pressure Regulation

• Autonomic nervous system
• Baroreceptors
• Chemoreceptors
• Renal system
• Endocrine system
• External factors also affect BP

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Venous System

• Structure a series of veins located adjacent to
  the arterial system
• Function completes the circulation of blood by
  returning blood from the capillaries to the right
  side of the heart
• Cardiovascular changes in the older adult only
  evident when the person is active or under stress

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Assessment Techniques

• History
• Demographic data
• Family history and genetic risk
• Personal history
• Diet history
• Socioeconomic status

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Modifiable Risk Factors

• Cigarette smoking
• Physical inactivity
• Obesity
• Psychological factors
• Chronic disease

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Pain or Discomfort

• Pain or discomfort can result from ischemic heart
  disease, pericarditis, and aortic dissection.
• Chest pain can also result from noncardiac
  conditions such as pleurisy, pulmonary embolus,
  hiatal hernia, and anxiety.
• (Continued)

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Pain or Discomfort (Continued)

• Terms such as discomfort, heaviness, pressure,
  indigestion, aching, choking, strangling,
  tingling, squeezing, constricting, or vise-like
  are all used to describe pain.
• Women often do not experience pain in the chest
  but rather feelings of discomfort or indigestion.

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Pain Assessment

• Onset
• Manner of onset
• Duration
• Frequency
• Precipitating factors
• Location
• Radiation
• (Continued)

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Pain Assessment (Continued)

• Quality
• Intensity, which can be graded from 0 to 10,
  associated symptoms, aggravating factors, and
  relieving factors

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Dyspnea

• Can occur as a result of both cardiac and
  pulmonary disease
• Difficult or labored breathing experienced as
  uncomfortable breathing or shortness of breath
• Dyspnea on exertion (DOE)
• Orthopnea dyspnea when lying flat
• Paroxysmal nocturnal dyspnea after lying down for
  several hours

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Other Manifestations

• Fatigue
• Palpitations
• Weight gain
• Syncope
• Extremity pain

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Physical Assessment

• General appearance
• Integumentary system
• Skin color
• Skin temperature
• Extremities
• Blood pressure
• Venous and arterial pulses central and jugular
  venous pressures, and jugular venous distention

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Precordium

• Assessment of the precordium (area over the
  heart) involves
• Inspection
• Palpation
• Percussion
• Auscultation
• Normal heart sounds
• Paradoxical splitting
• Gallops and murmurs
• Pericardial friction rub

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Serum Markers of Myocardial Damage

• Troponin
• Creatine kinase
• Myoglobin
• Serum lipids
• Homocysteine
• C-reactive protein
• Blood coagulation tests

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Cardiac Catheterization

• Client preparation
• Possible complications myocardial infarction,
  stroke, thromboembolism, arterial bleeding,
  lethal dysrhythmias, and death
• Follow-up care
• Restricted bedrest, insertion site extremity kept
  straight
• Monitor vital signs
• Assess for complications

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Other Diagnostic Tests

• Electrocardiography
• Electrophysiologic study
• Exercise electrocardiography
• Echocardiography
• Pharmacologic stress echocardiogram
• Transesophageal echocardiogram
• Imaging

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Hemodynamic Monitoring

• Invasive system used in critical care areas to
  provide quantitative information about vascular
  capacity, blood volume, pump effectiveness, and
  tissue perfusion
• Pulmonary artery catheter
• Systemic intra-arterial monitoring
• Impedance cardiography

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Interventions for Clients with Dysrhythmias
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Review of Cardiac Electrophysiology

• Automaticity
• Excitability
• Conductivity
• Contractility
• Action potential

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Cardiac Conduction System

• Sinoatrial node
• Electrical impulses at 60 to 100 beats/min
• Atrioventricular junctional area
• Bundle branch system

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Electrocardiography

• Electrocardiogram (ECG)
• Lead systems
• Limb leads
• Chest leads
• Continuous electrocardiographic monitoring
• Telemetry

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Electrocardiographic Complexes, Segments, and
Intervals

• P wave
• PR segment
• PR interval
• QRS complex
• QRS duration
• ST segment
• T wave
• U wave
• QT interval

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Electrocardiographic Rhythm Analysis

• Determine the heart rate.
• Determine the heart rhythm.
• Analyze the P waves.
• Measure the PR interval.
• Measure the QRS duration.

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Normal Rhythms

• Normal sinus rhythm
• Sinus arrhythmia

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Dysrhythmias

• Tachydysrhythmias
• Bradydysrhythmias
• Premature complexes
• Repetitive rhythms
• Escape complexes and rhythms

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Dysrhythmias

• Classification
• Sinus dysrhythmias
• Sinus tachycardia
• When the rate of SA node discharge exceeds 100
  beats/min
• Clinical manifestations
• Interventions

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Sinus Bradycardia

• Rate of sinus node discharge lt 60 beats/min
• Clinical manifestations
• Interventions

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Premature Atrial Complexes

• Ectopic focus of atrial tissue fires an impulse
  before the next sinus impulse is due.
• Clinical manifestations
• Interventions

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Supraventricular Tachycardia

• Rapid stimulation of atrial tissue occurs at a
  rate of 100 to 280 beat/min with a mean of 170
  beats/min in adults.
• Paroxysmal supraventricular tachycardia rhythm
  is intermittent and terminated suddenly with or
  without intervention.
• Clinical manifestations
• Interventions

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Atrial Flutter

• Rapid atrial depolarization occurring at a rate
  of 250 to 350 times per minute
• Clinical manifestations
• Interventions

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Atrial Fibrillation

• Multiple, rapid impulses from many atrial foci at
  a rate of 350 to 600 times per minute
• Clinical manifestations
• Interventions

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Junctional Dysrhythmias

• Atrioventricular cells generating electrical
  impulses at a rate of 40 to 60 beats/min
• These rhythms are most commonly transient, and
  clients usually remain hemodynamically stable.

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Idioventricular Rhythm

• Also called ventricular escape rhythm
  ventricular nodal cells pace the ventricles. P
  waves are independent of the QRS complex (AV
  dissociation).
• Clinical manifestations
• Interventions

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Premature Ventricular Complexes

• A result of increased irritability of ventricular
  cells early ventricular complexes followed by a
  pause
• Clinical manifestations
• Interventions

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Ventricular Tachycardia

• Also called V tach repetitive firing of an
  irritable ventricular ectopic focus, usually at a
  rate of 140 to 180 beats/min
• Clinical manifestations
• Interventions

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Ventricular Fibrillation

• Also called V fib a result of electrical chaos
  in the ventricles
• Clinical manifestations
• Interventions

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Ventricular Asystole

• Also called ventricular standstill complete
  absence of any ventricular rhythm
• Clinical manifestations
• Interventions

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Atrioventricular Blocks

• Atrioventricular blocks are differentiated by
  their PR interval.
• First-degree atrioventricular block
• Second-degree atrioventricular block
• Third-degree atrioventricular block

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First-Degree Atrioventricular Block

• PR interval greater than 0.20 second
• Clinical manifestations
• Interventions

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Second-Degree Atrioventricular Block

• Progressive prolongation of the PR interval,
  followed by a dropped beat and a pause each
  group has one more P wave than QRS complexes
• Clinical manifestations
• Interventions

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Second-Degree Heart Block Type II

• Mobitz type II block is an infranodal block
  occurring below the bundle of His.
• Constant block in one of the bundle branches
  results in a wide QRS complex and dropped beats.
• Clinical manifestations
• Interventions

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Third-Degree Heart Block

• Heart block is complete.
• None of the sinus impulses conducts to the
  ventricles.
• Clinical manifestations
• Interventions

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Bundle Branch Blocks

• Conduction delay or block within one of the two
  main bundle branches below the bifurcation of the
  bundle of His
• Clinical manifestations
• Interventions

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Decreased Cardiac Output Ineffective Tissue
Perfusion

• Interventions include
• Cardiac care
• Nonsurgical management
• Drug therapy
• Vaughn-Williams classification
• Other antidysrhythmic drugs
• Emergency cardiac drugs

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Nonsurgical Management

• Vagal maneuvers
• Carotid sinus massage
• Valsalva maneuvers

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Temporary Pacing

• Modes of pacing
• Synchronous pacing
• Asynchronous pacing
• Noninvasive temporary pacing
• Procedure
• Complications

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Invasive Temporary Pacing

• Procedure
• Complications
• Prevention of microshock

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Treatments

• Cardiopulmonary resuscitation
• Advanced cardiac life support
• Cardioversion synchronized countershock that may
  be used for emergent hemodynamically unstable
  ventricular or supraventricular tachydysrhythmias
  or electively for stable tachydysrhythmias
  resistant to medical therapies

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Defibrillation

• Asynchronous countershock depolarizes a critical
  mass of myocardium simultaneously to stop the
  re-entry circuit and allow the sinus node to
  regain control of the heart.
• Maintain a patent airway.
• Administer oxygen.
• (Continued)

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Defibrillation (Continued)

• Assess vital signs and level of consciousness.
• Administer antidysrhythmic drugs.
• Monitor for dysrhythmias .
• Assess for burns, emotional support,
  documentation.

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Other Therapies

• Automatic external defibrillation
• Radiofrequency catheter ablation
• Surgical procedures
• Permanent pacemaker
• Coronary artery bypass grafting
• Aneurysmectomy
• Insertion of implantable cardioverter/defribillato
  r
• Open-chest cardiac massage

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Interventions for Clients with Cardiac Problems
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Heart Failure

• Also called pump failure, general term for the
  inadequacy of the heart to pump blood throughout
  the body causes insufficient perfusion of body
  tissue with vital nutrients and oxygen
• Left-sided heart failure
• Right-sided heart failure
• High-output failure

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Compensatory Mechanisms

• Sympathetic nervous system stimulation
• Renin-angiotensin system activation
• Other neurohumoral responses
• Myocardial hypertrophy

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Etiology

• Heart failure is caused by systemic hypertension
  in 75 of cases.
• About one third of clients experiencing
  myocardial infarction also develop heart failure.
• Structural heart changes, such as valvular
  dysfunction, cause pressure or volume overload on
  the heart.

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Left-Sided Heart Failure

• Manifestations include
• Weakness
• Fatigue
• Dizziness
• Confusion
• Pulmonary congestion
• Shortness of breath
• Oliguria
• Organ failure, especially renal failure
• Death
• Assess blood pressure, mental status, breath
  sounds

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Right-Sided Heart Failure

• Manifestations include
• Distended neck veins, increased abdominal girth
• Hepatomegaly (liver engorgement)
• Hepatojugular reflux
• Ascites
• Dependent edema
• Weight the most reliable indicator of fluid gain
  or loss

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Assessments

• Laboratory assessment
• Radiographic assessment
• Electrocardiography
• Echocardiography
• Pulmonary artery catheters

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Impaired Gas Exchange

• Interventions include
• Ventilation assistance
• Hemodynamic regulation
• Energy management, diet therapy, drug therapy

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Decreased Cardiac Output

• Interventions include
• Optimization of cardiac output stroke volume
  (determined by preload, afterload, and
  contractility) and heart rate
• (Continued)

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Decreased Cardiac Output (Continued)

• Drug therapy including
• Angiotensin-converting enzyme
• ACE inhibitors
• Diuretics
• Human B-type natriuretic peptides
• Nitrates
• Inotropics
• Beta-adrenergic blockers

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Hemodynamic Regulation

• Interventions include
• Reduce afterload.
• Reduce preload.
• Improve cardiac muscle contractility.
• Administer drugs as prescribed.
• Monitor for therapeutic and adverse effects.
• Teach client and family drug therapy.

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Drugs That Reduce Afterload

• Angiotensin-converting enzyme (ACE) inhibitors
• Human B-type natriuretic peptides

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Interventions That Reduce Preload

• Diet therapy
• Drug therapy
• Diuretics
• Venous vasodilators

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Drugs That Enhance Contractility

• Digitalis
• Digitalis toxicity includes anorexia, fatigue,
  changes in mental status.
• Monitor heart rate and electrolytes.
• Other inotropic drugs including dobutamine,
  milrinone, and levosimendan
• Beta-adrenergic blockers

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Other Nonsurgical Options

• Continuous positive airway pressure
• Cardiac resynchronization therapy
• Investigative gene therapy

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Surgical Management

• Newer surgical therapies include the following
• Partial left ventriculectomy
• Endoventricular circular patch
• Acorn cardiac support device
• Myosplint

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Activity Intolerance

• Interventions include
• Ventilation assistance
• Hemodynamic regulation
• Energy management
• Interdisciplinary interventions, which regulate
  energy to prevent fatigue and optimize function

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Potential for Pulmonary Edema

• Interventions include
• Assess for early signs, such as crackles in the
  lung bases, dyspnea at rest, disorientation, and
  confusion.
• Rapid-acting diuretics are prescribed, such as
  Lasix or Bumex.
• Oxygen is always used.
• Strictly monitor fluid intake and output.

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Valvular Heart Disease

• Mitral stenosis
• Mitral regurgitation (insufficiency)
• Mitral valve prolapse
• Aortic stenosis
• Aortic regurgitation (insufficiency)

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Assessment

• Client may become suddenly ill or slowly develop
  symptoms over many years.
• Question client about attacks of rheumatic fever,
  infective endocarditis, and possibility of IV
  drug abuse.
• Obtain chest x-ray, echocardiogram, and exercise
  tolerance test.

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Common Nursing Diagnoses

• Decreased Cardiac Output related to altered
  stroke volume
• Impaired Gas Exchange related to ventilation
  perfusion imbalance
• Activity Intolerance related to inability of the
  heart to meet metabolic demands during activity
• Acute Pain related to physiologic injury agent
  (hypoxia)

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Nonsurgical Management

• Drug therapy, including diuretics, beta blockers,
  digoxin, oxygen, and sometimes nitrates
• Prophylactic antibiotic
• Management of atrial fibrillation, cardioversion
• Anticoagulant
• Rest with limited activity

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Surgical Management

• Reparative procedures
• Balloon valvuloplasty
• Direct, or open, commissurotomy
• Mitral valve annuloplasty
• Replacement procedures

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Infective Endocarditis

• Microbial infection involving the endocardium
• Occurs primarily with IV drug abuse, valvular
  replacements, systemic infections, or structural
  cardiac defects
• Possible ports of entry mouth, skin rash,
  lesion, abscess, infections, surgery, or invasive
  procedures including IV line placement

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Manifestations

• Murmur
• Heart failure
• Arterial embolization
• Splenic infarction
• Neurologic changes
• Petechiae (pinpoint red spots)
• Splinter hemorrhages

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Interventions

• Antimicrobials
• Rest, balanced with activity
• Supportive therapy for heart failure
• Anticoagulants
• Surgical management

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Pericarditis

• Inflammation or alteration of the pericardium,
  the membranous sac that encloses the heart
• Dresslers syndrome
• Postpericardiotomy syndrome
• Chronic constrictive pericarditis

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Assessment

• Substernal precordial pain radiating to left side
  of the neck, shoulder, or back
• Grating, oppressive pain, aggravated by
  breathing, coughing, swallowing
• Pain worsened by the supine position relieved
  when the client sits up and leans forward
• Pericardial friction rub

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Interventions

• Hospitalization for diagnostic evaluation,
  observation for complications, symptom relief
• Nonsteroidal anti-inflammatory drugs
• Corticosteroid therapy
• Comfortable position, usually sitting
• Pericardial drainage
• Chronic pericarditis radiation or chemotherapy
• Uremic pericarditis dialysis
• Pericardiectomy

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Emergency Care of Cardiac Tamponade

• Cardiac tamponadean extreme emergency
• Increased fluid volume
• Hemodynamic monitoring
• Pericardiocentesis
• Pericardial window
• Pericardiectomy

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Rheumatic Carditis

• Sensitivity response that develops following an
  upper respiratory tract infection with group A
  beta-hemolytic streptococci
• Inflammation in all layers of the heart
• Impaired contractile function of the myocardium,
  thickening of the pericardium, and valvular damage

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Clinical Manifestations

• Tachycardia
• Cardiomegaly
• New or changed murmur
• Pericardial friction rub
• Precordial pain
• Changes in electrocardiogram
• Indications of heart failure
• Existing streptococcal infection

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Cardiomyopathy

• Subacute or chronic disease of cardiac muscle
• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathy

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Interventions

• Nonsurgical management
• Surgical management
• Cardiomyoplasty
• Heart transplantation