Chapter 35

Assessment of the Cardiovascular System

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Cardiovascular System: Assessment

Patient history Nutritional history Family history and genetic risk Current health problems:

Pain or discomfort Dyspnea, DOE, orthopnea, PND Fatigue Palpitations Edema Syncope Extremity pain

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Cardiovascular System: Physical Assessment

General appearance Skin Extremities Blood pressure

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Coronary Artery Disease

Includes stable angina and acute coronary syndromes

Ischemia—insufficient oxygen supply to meet the requirements of the myocardium

Infarction—necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue

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Nonmodifiable Risk Factors

Age Gender Family history Ethnic background

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Modifiable Risk Factors

Elevated serum cholesterol Cigarette smoking Hypertension Impaired glucose tolerance Obesity Physical inactivity Stress

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Cardiac Catheterization

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Percutaneous Transluminal Coronary Angioplasty (PTCA)

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Percutaneous Transluminal Coronary Angioplasty

Clopidogrel before the procedure IV heparin after the procedure IV or intracoronary nitroglycerine or

diltiazem Long-term therapy, antiplatelet therapy,

beta blocker, ACE inhibitor or ARB

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Other Procedures

Arthrectomy Stents Rheolytic thrombectomy

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Coronary Stents

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CABG

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CABG (Cont’d)

Preoperative care Operative procedures Postoperative care:

Management of F&E balance Management of other complications—

hypotension, hypothermia, hypertension, bleeding, cardiac tamponade, change in level of consciousness

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Coronary Artery Bypass Graft Surgery

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Community-Based Care

Home care management Health teaching Health care resources

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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

May become suddenly ill or slowly develop symptoms over many years.

Question patient about attacks of rheumatic fever and infective endocarditis and about 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

Nonsurgical management focuses on drug therapy and rest

Drug therapy, including diuretics, beta blockers, digoxin, oxygen, and sometimes nitrates

Prophylactic antibiotic Management of atrial fibrillation 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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Heart Valves

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Community-Based Care

Home care management Health teaching Health care resources

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Infective Endocarditis

Microbial infection involving the endocardium

Occurs primarily in patients who abuse IV drugs, have had valve replacements, have experienced systemic infections, or have structural cardiac defects

Possible ports of entry—oral cavity, 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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Diagnostic Assessment

Blood culture Echocardiography The most reliable criteria for diagnosing

endocarditis include positive blood cultures, a new regurgitant murmur, and evidence of endocardial involvement by echocardiography

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Interventions

Antimicrobials. Anticoagulants are of no value in

preventing embolization from vegetations. Patient’s activities are balanced with

adequate rest.

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Surgical Management

Removing the infected valve Repairing or removing congenital shunts Repairing injured valves and chordae

tendineae Draining abscesses in the heart or

elsewhere

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Peripheral Arterial Disease

Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation

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Lower Extremity Arterial Disease

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Physical Assessment

Intermittent claudication Pain that occurs even while at rest;

numbness and burning

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Physical Assessment (Cont’d)

Hair loss and dry, scaly, pale or mottled skin and thickened toenails

Severe arterial disease—extremity is cold and gray-blue or darkened; pallor may occur with extremity elevation; dependent rubor; and/or muscle atrophy

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Diagnostic Assessments

Imaging assessment

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Nonsurgical Management

Exercise Positioning Promoting vasodilation Drug therapy Percutaneous transluminal angioplasty Laser-assisted angioplasty Atherectomy

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Surgical Management

Aortoiliac and aortofemoral bypass surgery

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Axillofemoral Bypass Graft

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Surgical Management

Preoperative Intraoperative

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Surgical Management (Cont’d)

Postoperative care: Assessment for graft occlusion Promotion of graft patency Treatment of graft occlusion Monitoring for compartment syndrome Assessment for infection

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Acute Peripheral Arterial Occlusion

Embolus—the most common cause of occlusions, although local thrombus may be the cause

Assessment—pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia

Drug therapy Surgical therapy Nursing care

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Aneurysms of Central Arteries

Aneurysm—a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter

Fusiform aneurysm Saccular aneurysm Dissecting aneurysm (aortic dissection) Abdominal aortic aneurysm Thoracic aortic aneurysm

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Arterial Aneurysms

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Assessment of Abdominal Aortic Aneurysm (AAA)

Pain related to AAA is usually steady with a gnawing quality, is unaffected by movement, and may last for hours or days.

Pain is in the abdomen, flank, or back. Abdominal mass is pulsatile. Rupture is the most frequent complication

and is life threatening.

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Assessment of Thoracic Aortic Aneurysm

Assess for back pain and manifestation of compression of the aneurysm on adjacent structures.

Assess for shortness of breath, hoarseness, and difficulty swallowing.

Occasionally a mass may be visible above the suprasternal notch.

Sudden excruciating back or chest pain is symptomatic of thoracic rupture.

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Diagnostic Assessment

X-ray “eggshell” appearance CT Aortic arteriography Ultrasonography

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Nonsurgical Management

Monitor the growth of the aneurysm. Maintain BP at a normal level to decrease

the risk of rupture.

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Abdominal Aortic Aneurysm Resection

Preoperative care Operative procedure Postoperative care:

Monitor vital signs Assess for complications Assess for signs of graft occlusion or rupture

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Thoracic Aortic Aneurysm Repair

Preoperative care Operative procedure Postoperative care assessments:

Vital signs Complications Sensation and motion in extremities Respiratory distress Cardiac dysrhythmias

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Endovascular Repair of Abdominal Aortic Aneurysm

Patients selected for endovascular repair are generally at high risk for major abdominal surgery

Various designs Benefits of endovascular repair Complications of endovascular repair

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Aneurysms of the Peripheral Arteries

Femoral and popliteal aneurysms Symptoms—limb ischemia, diminished or

absent pulses, cool to cold skin, and pain Treatment—surgery Postoperative care—monitor for pain

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Aortic Dissection

May be caused by a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall

Pain described as tearing, ripping, and stabbing

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Aortic Dissection (Cont’d)

Emergency care goals include: Elimination of pain Reduction of blood pressure Decrease in the velocity of left ventricular

ejection Nonsurgical treatment Surgical treatment

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Venous Thromboembolism

Thrombus—a blood clot Thrombophlebitis Deep vein thrombosis (DVT) Pulmonary embolism Virchow’s triad Phlebitis

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Assessment

Calf or groin tenderness or pain Sudden onset of unilateral swelling of the

leg Checking Homans’ sign—not advised Localized edema Venous flow studies—venous duplex

ultrasonography MRI D-dimer

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Nonsurgical Management

Rest, drug therapy, preventive measures Drug therapy includes:

Unfractionated heparin therapy Low–molecular weight heparin Warfarin therapy Thrombolytic therapy

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Surgical Management

Thrombectomy Inferior vena caval interruption Ligation or external clips

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Shock

Widespread abnormal cellular metabolism that occurs when the human need for oxygenation and tissue perfusion is not met to the level needed to maintain cell function.

“Whole-body” response. Shock is a “syndrome.” Any problem that impairs oxygen delivery to

tissues and organs can start the syndrome of shock and lead to a life-threatening emergency.

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Classification of Shock by Origin of the Problem

Hypovolemic Cardiogenic Vasogenic Septic

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Hypovolemic Shock

Occurs when low circulating blood volume causes a mean arterial pressure decrease; the body’s oxygen need is not met

Commonly caused by hemorrhage (external or internal) and dehydration

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Health Promotion and Maintenance

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Physical Assessment/Clinical Manifestations

Cardiovascular changes Pulse Blood pressure Oxygen saturation Skin changes Respiratory changes Renal and urinary changes Central nervous system changes Musculoskeletal changes

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Assessment

Psychosocial assessment Laboratory tests

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Nonsurgical Management

Goals of shock management are to maintain tissue oxygenation, increase vascular volume to normal range, and support compensatory mechanisms

Oxygen therapy IV therapy Drug therapy