Nursing Assessment of the Cardiovascular System

1. Nursing Assessment of the Cardiovascular System Keith Rischer RN, MA, CEN

2. Today’s Objectives… • Review the anatomy and physiology of the cardiovascular system. • Describe cardiovascular changes associated with aging. • Identify factors that place patients at risk for cardiovascular problems. • Explain and describe pre- and post-care associated with diagnostic cardiovascular testing. • Explain the purpose of hemodynamic monitoring.

3. Aortic-Pulmonic Mitral-Tricuspid

4. Right Coronary Left Anterior Descending Circumflex Coronary Arteries

5. Cardiac Conduction SA node  Both Atria  AV Node Both Ventricles  Bundle of His Bundle Branches- Perkinje Fibers

6. Diastole Diastole Lower # in BP (120/80) Ventricles are relaxed Passively fill from atria

7. Systole Higher # in BP (120/80) Ventricles are contracting and emptying SBP accurately reflects afterload

8. Cardiac Output • CO = Stroke volume x heart rate • SV (80cc) x HR (80)= 6400cc (6.4 lpm) • Daily pumps 1800 gallons • 657,000 gallons every year • Over 80 year lifetime: • 52,560,000 gallons

9. Preload: Right side of heart Preload=primarily venous blood return to RA Right and left side of heart filling pressure (atria>ventricles) Pressure/Stretch in ventricles end diastole

10. Maximum efficency of CO achieved when myocardium stretched appx 2 ½ times length Think rubber band CO decreased with lower preload/filling pressures or too high Starling’s Law of the Heart

11. “AFTER” load: Left side of heart Force of resistance that the LV must generate to open aortic valve Correlates w/SBP

12. Contractility Ability of heart to change force of contraction without changing resting length Influenced by Ca++ Inotropic-Influencing contractility independent of Starling mechanism Positive inotropic Negative inotropic

13. Assessment Techniques • History • Demographic data • Age • Gender • Pre vs. post menopause • Family history and genetic risk • Personal medical history • DM, HTN • BCP use for women • Diet

14. Modifiable Risk Factors • Cigarette smoking • Physical inactivity • Obesity • Psychological factors • Chronic disease

15. Changes with Aging • Calcification in valves • Pacemaker cells decrease in number • Conduction time increases • Left ventricle increases • Aorta and large vessels thicken and become stiffer • Baroreceptors less sensitive

16. Women & CAD Vague-atypical chief c/o Only 53% have CP as chief c/o Fatigue chief c/o Typically develop CAD 10+ years later then men Mortality twice as high Less likely to have definitive 12 lead EKG Smaller coronary arteries Higher prevalence of silent ischemia CABG higher mortality rate/complications After first MI-more likely to suffer fatal event Women > 50 pay must address HTN, high cholesterol, family history, diabetes

17. Men Women Develop 10-15 years earlier Initial event AMI Classic CP sx Develop greater collateral circulation compared to women Influence of menopause…4x risk Causes more deaths in women than men Initial event angina Atypical CP sx…fatigue

18. Elderly & CAD More likely to have vague, atypical c/o SOB, fatigue, syncope or falls Any fall must be investigated for mitigating circumstances Less likely to have radiation

19. Clinical Manifestations: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 (PND) • after lying down for several hours

20. Other Clinical Manifestations • Fatigue • Palpitations • Weight gain • Syncope • Extremity pain • Ischemia • Venous insufficiency

21. CV Physical Assessment • General appearance • Integumentary system • Skin color • Skin temperature • Extremities • Blood pressure • Orthostatic • Arterial pulses • Jugular venous distention

22. Precordium • Auscultation • Normal heart sounds…S1S2 • Paradoxical splitting • Gallops • S3 • S4 • Murmurs • Systolic most common • Pericardial friction rub

23. Serum Markers of Myocardial Damage • Troponin • B-Natruetic Peptide • Serum lipids • C-reactive protein • Lytes • K+ • Mg++ • Blood coagulation • PT & INR

24. Brain Natriuetic Peptide:BNP 95 % of BNP resides in ventricles As pressure inc in ventricles in HF-BNP is released Bodies own ACE/B-blocker Only lab test that measures HF Normal is less than 100 Elevated 100-500 + for CHF >500 Uses: dx- assess response to tx

25. Cardiac Catheterization • Client preparation • Possible complications: myocardial infarction, stroke, thromboembolism, arterial bleeding, lethal dysrhythmias, and death • Pre-procedure: • Review procedure (video) • Consent • NPO or light breakfast • Cath site shaved • Premeds - sedative

26. Cardiac Catheterization • Procedure • Pt awake – report any chest pain or symptoms • May proceed to Stent Placement • Follow-up care: • Restricted bedrest, insertion site extremity kept straight • Assess groin site and distal pulses closely • Monitor vital signs • Force fluids • Assess for complications

27. Cardiac Catheterization Report

28. Other Diagnostic Tests • 12 lead EKG • Holter monitor (ambulatory) • Electrophysiologic (EP) study • Exercise Stress test • Echocardiography • Pharmacologic stress echocardiogram • Transesophageal echocardiogram • Thallium imaging

29. Hemodynamic Monitoring:Arterial Line

30. Hemodynamic Monitoring: Pulmonary Artery catheter

31. Hemodynamic Monitoring Strips