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

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Keith Rischer RN, MA, CEN

Nursing Assessment of the Cardiovascular System

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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.

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Aortic-Pulmonic Mitral-Tricuspid

Coronary ArteriesCoronary Arteries

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Right Coronary Left Anterior

Descending Circumflex

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Cardiac ConductionCardiac Conduction

SA node

Both Atria

AV Node

Both Ventricles

Bundle of His

Bundle Branches-

Perkinje Fibers

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DiastoleDiastole

DiastoleDiastole

Lower # in BP Lower # in BP (120/80)(120/80)

Ventricles are relaxed Ventricles are relaxed Passively fill from Passively fill from

atriaatria

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SystoleSystole

Higher # in BP Higher # in BP (120/80)(120/80)

Ventricles are Ventricles are contracting and contracting and emptyingemptying

SBP accurately SBP accurately reflects afterloadreflects afterload

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Cardiac OutputCardiac Output

CO = Stroke volume x heart rateSV (80cc) x HR (80)= 6400cc (6.4

lpm)

• Daily pumps 1800 gallonsDaily pumps 1800 gallons• 657,000 gallons every year657,000 gallons every year• Over 80 year lifetime:Over 80 year lifetime:

• 52,560,000 gallons52,560,000 gallons

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Preload: Right side of heartPreload: 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

Starling’s Law of the HeartStarling’s Law of the Heart

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Maximum efficency of CO achieved when Maximum efficency of CO achieved when myocardium stretched appx 2 ½ times lengthmyocardium stretched appx 2 ½ times length

Think rubber bandThink rubber band CO decreased with lower preload/filling pressures CO decreased with lower preload/filling pressures

or too highor too high

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““AFTER” load: Left side of heartAFTER” load: Left side of heart

Force of resistance Force of resistance that the LV must that the LV must generate to open generate to open aortic valveaortic valve

Correlates w/SBPCorrelates w/SBP

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ContractilityContractility

Ability of heart to change force of Ability of heart to change force of contraction without changing resting lengthcontraction without changing resting length

Influenced by Ca++Influenced by Ca++ Inotropic-Influencing contractility Inotropic-Influencing contractility

independent of Starling mechanismindependent of Starling mechanism Positive inotropicPositive inotropic Negative inotropicNegative inotropic

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Assessment Techniques

HistoryDemographic data

AgeGenderPre vs. post menopause

Family history and genetic riskPersonal medical history

DM, HTNBCP use for women

Diet

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Modifiable Risk Factors

Cigarette smoking Physical inactivity Obesity Psychological factors Chronic disease

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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

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Women & CADWomen & CAD

Vague-atypical chief c/oVague-atypical chief c/o Only 53% have CP as chief c/oOnly 53% have CP as chief c/o Fatigue chief c/oFatigue chief c/o

Typically develop CAD 10+ years later then menTypically develop CAD 10+ years later then men Mortality twice as highMortality twice as high

Less likely to have definitive 12 lead EKGLess likely to have definitive 12 lead EKG Smaller coronary arteriesSmaller coronary arteries Higher prevalence of silent ischemiaHigher prevalence of silent ischemia CABG higher mortality rate/complicationsCABG higher mortality rate/complications After first MI-more likely to suffer fatal eventAfter first MI-more likely to suffer fatal event

Women > 50 pay must address HTN, high cholesterol, family Women > 50 pay must address HTN, high cholesterol, family history, diabeteshistory, diabetes

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MenMen WomenWomen

Develop 10-15 years Develop 10-15 years earlierearlier

Initial event AMIInitial event AMI Classic CP sxClassic CP sx Develop greater Develop greater

collateral circulation collateral circulation compared to womencompared to women

Influence of Influence of menopause…4x riskmenopause…4x risk

Causes more deaths Causes more deaths in women than menin women than men

Initial event anginaInitial event angina Atypical CP sx…Atypical CP sx…

fatiguefatigue

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Elderly & CADElderly & CAD

More likely to have vague, atypical c/oMore likely to have vague, atypical c/o SOB, fatigue, syncope or fallsSOB, fatigue, syncope or falls Any fall must be investigated for mitigating Any fall must be investigated for mitigating

circumstancescircumstances Less likely to have radiationLess likely to have radiation

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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

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Other Clinical Manifestations

Fatigue Palpitations Weight gain Syncope Extremity pain

Ischemia Venous insufficiency

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CV Physical Assessment

General appearance Integumentary system Skin color Skin temperature Extremities Blood pressure

Orthostatic Arterial pulses

Jugular venous distention

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Precordium

AuscultationNormal heart

sounds…S1S2Paradoxical splittingGallops

– S3– S4

Murmurs – Systolic most

commonPericardial friction

rub

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Serum Markers of Myocardial Damage

Troponin B-Natruetic Peptide Serum lipids C-reactive protein Lytes

K+ Mg++

Blood coagulation PT & INR

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Brain Natriuetic Peptide:BNPBrain Natriuetic Peptide:BNP

95 % of BNP resides in ventricles95 % of BNP resides in ventricles As pressure inc in ventricles in HF-BNP is released As pressure inc in ventricles in HF-BNP is released Bodies own ACE/B-blockerBodies own ACE/B-blocker Only lab test that measures HFOnly lab test that measures HF Normal is less than 100Normal is less than 100

Elevated 100-500Elevated 100-500 + for CHF >500+ for CHF >500

Uses: dx- assess response to txUses: dx- assess response to tx

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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

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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

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Cardiac Catheterization Report

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Other Diagnostic Tests

12 lead EKG Holter monitor (ambulatory) Electrophysiologic (EP) study Exercise Stress test Echocardiography

Pharmacologic stress echocardiogramTransesophageal echocardiogram

Thallium imaging

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Hemodynamic Monitoring:Arterial Line

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Hemodynamic Monitoring: Pulmonary Artery catheter

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Hemodynamic Monitoring Strips