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Torres, RN Health History : Health History Elicit a description of present illness and chief complaint Include: Onset Course Duration Location precipitating and alleviating factors Common Symptoms Of Cardiovascular Disease : Common Symptoms Of Cardiovascular Disease Chest discomfort or pain Palpitations Syncope Fatigue Dyspnea Cough, hemoptyosis Weight gain Edema Nocturia Chest Discomfort/Pain : Chest Discomfort/Pain One of the most important manifestations of cardiac ischemia Other causes – pulmonary embolus, GERD, esophageal spasm Assume chest discomfort is related to ischemia unless proven otherwise, especially if risk factors or history of CAD Little correlation between severity of pain and gravity of situation Palpitations : Palpitations Dysrhythmias or arrhythmias Causes Stress, caffeine, drugs Myocardial ischemia Mitral valve disease Electrolyte imbalances Ventricular aneurysm Ask about “skipped’ beats, irregular beats, fluttering, racing Inquire about dizziness or fainting Syncope or Changes in Mentation : Syncope or Changes in Mentation Common causes Stroke Hypovolemia Orthostatic hypotension Seizures Dysrhythmias Hypoglycemia Inquire about associated symptoms Fatigue : Fatigue Easy fatigability with mild exertion is common Other causes Anemia Depression Chronic diseases Thyroid dysfunction Dyspnea : Dyspnea Often associated with myocardial ischemia Primary symptom of pulmonary congestion from LV failure Other causes Fever Anemia Pulmonary disorders Obesity Different forms of dyspnea Exertional dyspnea (DOE) Orthopnea Paroxysmal nocturnal dyspnea (PND) Cough and Hemoptysis : Cough and Hemoptysis Cardiovascular causes Heart failure Pulmonary edema ACE inhibitors Ask about the quality Ask about frequency If hemoptysis present, ask if streaks of blood, pink tinged Weight Gain, Dependent Edema and Nocturia : Weight Gain, Dependent Edema and Nocturia As heart fails, fluid accumulates Increase of 3 lbs or more in 24 hr is fluid accumulation Inquire about weight gain, fitting of shoes, or tightening of clothes around waist Nocturia - kidneys inadequately perfused by weak heart and receive increased blood flow during night – output increases Past Medical History : Past Medical History Inquire about previous illnesses Rheumatic fever, autoimmune diseases Diabetes, kidney disease, HPN, dyslipidemia Lung disorders Clotting disorders Explore previous hospitalizations and surgeries Evaluate use of medications, OTC drugs, herbs, recreational drugs Are meds taken as prescribed Financial problems Knowledge about meds Any allergies Family Health History : Family Health History Inquire about diabetes, kidney disease, stroke, heart disease, hypertension (HPN) Inquire about health of parents and siblings Psychosocial History : Psychosocial History Education Occupation Marital status, children and relationships Coping and stress tolerance Health habits – diet, exercise, smoking, alcohol use General Appearance : General Appearance Look at the client and consider Does the client lie quietly or is he restless? Can the client lie flat or must be upright? Do facial expressions reflect pain or distress? Are there signs of cyanosis or pallor? Note level of consciousness (LOC) General Appearance : General Appearance Assess the following areas – general build and appearance of the client, as well as skin color; distress level; LOC; presence of SOB; position and verbal responses. ? Client with chronic heart failure may appear malnourished, thin and cachectic. Latest signs of severe heart failure are ascites, jaundice, and anasarca as a result of prolonged congestion of the liver. Heart failure may cause fluid retention and clients may have engorged neck veins and generalized dependent edema. ? CAD is suspected in client with yellow lipid-filled plaques on the upper eyelids (xanthelasma) or earlobe creases. Clients with poor CO and decreased cerebral perfusion may have mental confusion, memory loss and slowed verbal responses. Inspection Of Skin and Nails : Inspection Of Skin and Nails Assess skin color Pallor Cyanosis Peripheral cyanosis-nose, ears, periphery Central cyanosis-mucous membranes, lips Assess skin temperature and moistness Assess for ecchymosis Assess for wounds, scars, implanted devices PHYSICAL ASSESSMENT : PHYSICAL ASSESSMENT Extremities ? Assess the client’s hands, arms, feet and legs for skin changes, clubbing, capillary filling and edema, skin mobility and turgor. ? Vascular changes of an affected extremity may include paresthesia, muscle fatigue and discomfort, pain, coolness, and loss of hair distribution from a reduced blood supply. ? Clubbing of the fingers and toes result from chronic O2 deprivation in the tissue beds. It can be identified by assessing the angle of the nailbed. The angle of the normal nail bed is 160°, with clubbing, the angle of the nailbed increases to > 180° and the base of the nail becomes spongy. Assess Vital Signs : Assess Vital Signs Measure BP in both arms initially Calculate pulse pressure Normal value between 30-40mm Hg A widened pulde pressure may indicate aortic regurgitation A narrowed pulse pressure may be associated with tachycardia, cardiac tamponade, pericardial effusion, or aortic stenosis Perform postural checks Assess pulse Rate Rhythm Quality PHYSICAL ASSESSMENT : PHYSICAL ASSESSMENT Blood Pressure Measurement 1. Postural BP – blood pressure normally drops when a client moves from a flat supine position to a sitting or standing position. Normally the client may report dizziness or lightheadedness, but these symptoms quickly pass and are transient. Postural (orthostatic) hypotension – occurs when the client’s BP is not adequately maintained when moving from a lying to a sitting or standing position. It is defined as a BP fall of more than 10-15mmHg of the diastolic pressure and a 10% - 20% increase in HR. 2. Paradoxical BP – an exaggerated decrease in systolic BP by more than 10 mmHg (normal is 3-10mmHg) during the inspiratory phase of the respiratory cycle. It is sometimes referred to as pulsus paradoxus. Assesses heart rate and rhythm : Assesses heart rate and rhythm Various pulse patterns may be indicative of disease processes Pulsus alterans: a regular rhythm but amplitude varies from beat to beat which may indicate left heart failure Bigeminal pulse: a normal beat alternating with premature contractions, every other beat having a decreased amplitude. This may indicate cardiac dysrhythmia. Pulsus paradoxus: a regular rhythm with decreased amplitude resulting in a drop in systolic BP on inspiration, and increased in expiration. It may be present with constrictive pericarditis, pericarditis, and severe COPD Absent, weak, normal or bounding pulse: a bounding pulse may indicate increased cardiac output while a diminished or absent pulse may indicate a decreased CO or an occlusion. Carotid pulse: should be visualized for pulsations, palpated for thrills, and auscultated for bruits. While inspecting the neck, assess for jugular vein distention. Pulse Quality Scale : Pulse Quality Scale 0 pulse not palpable or absent +1 weak, thready, difficult to palpate +2 diminished +3 easy to palpate, full pulse +4 strong, bounding pulse Assess Neck Vessels : Assess Neck Vessels Determine jugular venous pressure Gives us an estimate of right heart function and CVP Measurements >3 cm are elevated –jugular venous distention (JVD) Assess carotid arteries Assess amplitude of pulse Auscultate for bruits Assess the heart by inspecting the chest for pulsations and palpate for thrills. The area for auscultation include: : Assess the heart by inspecting the chest for pulsations and palpate for thrills. The area for auscultation include: Aortic: located right sternal border, 2nd intercostal space Pulmonary: located at the left sternal border, 2nd intercostal space Mitral: located at the left sternal bordel, 5th intercostal space Erbs Point: located at the left sternal border, 3rd intercostal space Tricuspid: located at 4th intercostal space midclavicular line Apical: located at the 5th intercostal space, midclavicular line Asucultate for presence and type of murmurs : Asucultate for presence and type of murmurs Normal Heart Sounds 1. 1st heart sound (S1) – is created by the closure of the AV valves. It is softer and longer, it is of low-pitch and is best heard at the lower L sternal border or the apex of the heart. 2. 2nd Heart sound (S2) – is caused mainly by the closing of the semilunar valves. It is shorter, high-pitched and is best heard at the base of the heart at the end of ventricular systole. Slide 26: Abnormal Heart Sounds Paradoxical splitting – an abnormal splitting of S2 which is a characteristic of a wider split heard on expiration. It is heard in clients with severe myocardial depression causing early closure of the pulmonic valve or a delay in aortic valve closure. Common in MI, aortic stenosis, aortic regurgitation. 2. Gallops – diastolic filling sounds S3 and S4 are produced when blood enters a noncompliant chamber during rapid ventricular filling . a. S3 (Ventricular gallop) - is produced during the rapid filling phase of ventricular diastole when blood flows from the atrium to a noncompliant ventricle. ? It is probably a normal finding in children or young adults up to 40 years old. Over age 40 is considered pathological and may indicate ventricular overload as in mitral, aortic, or tricuspid regurgitation. It is heard just after S2, early in diastole and may sound similar to “Ken-tuck-y” b. S4 (Atrial gallop) – always abnormal, usually associated with increased resistance to ventricular filling, such as with CHF, CAD, and aortic stenosis. It is heard in late diastole, but just before S1 , and may sound similar to “Ten-ne-see” Slide 27: 3. Murmur – reflects turbulent blood flow through normal or abnormal valves. ? Grading of Murmur Grade I – very difficult to hear, no thrill Grade II – quiet but easily heard, no thrill Grade III – fairly loud, no thrill Grade IV – loud, possible thrill. Grade V – very loud, accompanied by a palpable thrill and audible with the stethoscope partially off the client’s chest. Grade VI – extremely loud, may be heard with the stethoscope slightly above the client’s chest 4. Pericardial Friction Rub – a harsh, scraping sound heard when the layers of the heart rub together due to an inflammatory process. Easily heard throughout the cardiac cycle in the lower sternum and apical areas. 5. Ejection clicks- heard in early systole, may signify aortic valve dysfunction 6. Opening snaps- heard in early diastole, associated with stenosis of mitral valve Assess Respiratory Status : Assess Respiratory Status Respiratory findings frequently exhibited by cardiac clients Tachypnea Dyspnea Crackles Cough Hemoptysis Wheezing Assess O2 saturation Abdominal Assessment : Abdominal Assessment Inspection may reveal ascites Palpation may reveal an enlarged liver Assess for elevated JVD Auscultate for bruit over umbilicus Diagnostic Assessment : Diagnostic Assessment A. Laboratory Tests – this is done to establish a diagnosis, to detect concurrent disease, to assess risk factors and to monitor response to treatment. 1. Serum Cardiac Enzymes – events leading to cellular injury cause a release of enzymes from intracellular storage. a. Creatine Kinase (CK) – an enzyme specific to cells of the brain, the myocardium, and the skeletal muscles. The presence of CK in the blood indicates tissue necrosis or injury and CK levels follow a predictable rise and fall during a specified period of time. CK-MB – most specific enzyme analyzed in acute MI. the first enzyme levels to increase. 2. Lactate Dehydrogenase (LDH) – is widely distributed in the body and is found in the heart, liver, kidneys, brain and erythrocytes. LDH1 and LDH2 are found in the heart. If the serum level of LDH1 is higher than the concentration of LDH2, the pattern is said to have flipped, signifying myocardial damage. 3. Aspartate Aminotransferase (AST) – previously known as serum glutamic-oxaloacetic transaminase (SGOT). Like LDH, it is not specific to cardiac muscle tissue. V. Diagnostic Assessment : V. Diagnostic Assessment 2. Serum Lipids ? Elevated lipid levels are considered a CAD risk factor. Cholesterol, triglycerides and the CHON components of HDL and LDL are evaluated to assess the client’s degree of risk for CAD. A serum cholesterol greater than 260mg/dl gives a client three times greater risk of CAD than a serum level of 200mg/dl. ? A nonfasting blood sample for the measurement of serum cholesterol level is acceptable. However, if triglycerides are to be evaluated, the physician obtains the specimen after a 12-hour fast. 3. Blood Coagulation Tests – evaluate the ability of the blood to clot and are important in clients with a greater tendency to form thrombi. They are also important for clients receiving anticoagulant therapy. a. Prothrombin Time (PT) – is used when initiating and maintaining therapy with oral anticoagulants such as Na Warfarin (Coumadin, Warfilone). It measures the activity of the prothrombin, fibrinogen and other clotting factors. ?11-16 secs b. Partial Thromboplastin Time (PTT) – is assessed in clients receiving Heparin (Hepalcan). It measures deficiency in all coagulation factors, except factors VII and XIII. ?60-70 secs c. activated Partial Thromboplastin Time (aPTT) - most specific for heparin treatment ? 35-45 secs Diagnostic Assessment : Diagnostic Assessment 4. Arterial Blood Gases (ABG) – determination of tissue oxygen, CO2 removal and acid-base status is essential to appropriate intervention and treatment 5. Serum Electrolytes ? Cardiac effects of hypokalemia include increased electrical instability, ventricular dysrythmias, the appearance of U wave on the ECG and an increased risk of digitalis toxicity. The effects of hyperkalemia in the myocardium include slowed ventricular conduction and contraction, followed by asystole (cardiac standstill). ? Cardiac manifestations of hypocalcemia are ventricular dysrythmias, prolonged QT interval and cardiac arrest. Hypercalcemia shortens the QT interval and causes AV block, digitalis hypersensitivity and cardiac arrest. ? Serum sodium values reflect fluid balance and may be decreased, indicating a fluid excess in clients with heart failure. 6. Complete Blood Count (CBC) ? The erythrocyte count is usually decreased in rheumatic fever and subacute infective endocarditis. It is increased in heart disease characterized by inadequate tissue perfusion. ? Decreased Hgb and Hct levels indicate anemia and can manifest as angina or aggravate heart failure. ? The leukocyte count is typically elevated after MI and in various infections and inflammatory disease of the heart (e.g., pericarditis, infective endocarditis) Diagnostic Assessment : Diagnostic Assessment B. Radiographic Examinations 1. Chest Radiography (Chest X-Ray) – assesses cardiac enlargement, pulmonary congestion, cardiac and placement of central venous catheters, ET tubes and hemodynamic monitoring devices. Slide 34: 2. Cardiac Fluoroscopy – a simple x-ray examination that reveals the action of the heart. It is used to place and position intracardiac catheters and IV pacemaker wires and can also be helpful in identifying abnormal structures, calcifications and tumors of the heart. Slide 35: 3. Angiography or arteriograph is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins and the heart chambers. This is traditionally done by injecting a radio-opaque contrast agent into the blood vessel and imaging using X-ray based techniques such as fluoroscopy. The word itself comes from the Greek words angeion, "vessel", and graphein, "to write or record". The film or image of the blood vessels is called an angiograph, or more commonly, an angiogram. Preparation: a. The radiologist will explain the procedure and the risks to the client before signing the consent. b. Assess for allergy reaction to iodine-containing substances such as sea foods . c. Shave and scrub the area that will be catheterized. d. Most often, the femoral artery is used. The nurse must document VS and mark and describe pedal pulses in the client’s medical record. Diagnostic Assessment : Diagnostic Assessment Follow – up Care: 1. Bed rest in supine position for 8-12 hours. Make sure that the extremity that was catheterized is not flexed during this time. 2. A pressure dressing or bandage is kept in place over the injection site, a sand bag over the dressing may be used. 3. Assess the insertion site for bloody drainage or hematoma formation. 4. Assess the distal pulses and compare skin temperature in the affected extremity with that of opposite extremity. 5. The radiologist must be informed immediately if bleeding, loss of pulses, or changes in the VS occur. 6. Administer the prescribed IVF or oral fluids to facilitate elimination of contrast medium. Diagnostic Assessment : Diagnostic Assessment 4. Cardiac Catheterization – the most definitive but most invasive test in the diagnosis of heart disease. It includes the study of right and/or left side of the heart and the coronary arteries. Indications: a. To confirm suspected heart disease, including CAD, myocardial disease, valvular disease and valvular dysfunction. b. To determine the location and extent of the disease process c. To determine whether cardiac surgery is necessary. d. To evaluate effects of medical treatment or cardiovascular function and CABG patency. 5 Diagnostic Assessment : Diagnostic Assessment 6.Electrocardiography (ECG) Forms: Resting ECG (12 Leads ECG) – An electrocardiogram (ECG or EKG) is a recording of the electrical activity of the heart over time produced by an electrocardiograph, usually in a noninvasive recording via skin electrodes. Its name is made of different parts: electro, because it is related to electrical activity, cardio, Greek for heart, gram, a Greek root meaning "to write". provides information about cardiac dysrythmias, myocardial ischemia, the site and extent of MI, cardiac hypertrophy, electrolyte imbalance and effectiveness of cardiac drugs. The 12-Lead view : The 12-Lead view Each limb lead I, II, III, AVR, AVL, AVF records from a different angle All six limb leads intersect and visualize a frontal plane The six chest leads (precordial) V1, V2, V3, V4, V5, V6 view the body in the horizontal plane to the AV node The 12 lead ECG forms a camera view from 12 angles Views from Augmented and Limb Leads- Frontal : ?2004 Anna Story 43 Views from Augmented and Limb Leads- Frontal Precordial lead snapshots : Precordial lead snapshots Think of each precordial lead as a horizontal view of the heart at the AV node With the limb leads and the precordial leads you have a snapshot of heart portions Unipolar and Bipolar : Unipolar and Bipolar Limb leads I, II, III are bipolar and have a negative and positive pole Electrical potential differences are measured between the poles AVR, AVL and AVF are unipolar No negative lead The heart is the negative pole Electrical potential difference is measured betweeen the lead and the heart Chest leads are unipolar The heart also is the negative pole Lead Placement is Important : Lead Placement is Important Each positive electrode acts as a camera looking at the heart Ten leads attached for twelve lead diagnostics. The monitor combines 2 leads. Mnemonic for limb leads White on right Smoke(black) over fire(red) Snow(white) on grass(green) Precordial Leads : ?2004 Anna Story 47 Precordial Leads Precordial Leads : Precordial Leads Placement of the precordial leads are very important. In order to remember where the leads are placed you can remember the Rule of Four V1 is at the 4th intercostal space just right of the sternum V2 is at the 4th intercostal space just left of the sternum V3 is halfway between V3 and V4 V4 is at the palpable apex or at the 5th intercostal space in the midclavicular line V5 is in the same horizontal plane a V4 in theanterior axillary line V6 is in the same horizontal plane as V4 in the mid axillary line Slide 49: Where the positive electrode is positioned, determines what part of the heart is seen! Limb Leads : Limb Leads ECG tracing : ECG tracing The ECG Tracing: Waves : The ECG Tracing: Waves P- wave Marks the beginning of the cardiac cycle and measures the electrical impulse that causes atrial depolarization and mechanical contraction Duration: 0.06-0.11 sec QRS- Complex Measures the impulse that causes ventricular depolarization Duration: 0.06-0.10sec Important indicator of ventricular myocardial cell activity Q-wave- may or may not be evident on the ECG, represents septal depolarization R-wave- first upward deflection following P wave S-wave- the first downward deflection following the R-wave T- wave Marks ventricular repolarization that ends the cardiac cycle Intervals and Segments : Intervals and Segments P-R interval Time interval for impulse to go from the SA to the AV node normal 0.12-0.20 secs QRS Interval Time interval for impulse to go from AV node to stimulate Purkinjie fibers Less than 0.12 secs QT Interval Time interval from beginning of depolarization to the end of repolarization Duration: <0.44 sec ST segment end of the S to the beginning of the T Represents the beginning of ventricular repolarization B. Ambulatory ECG (Holter Monitoring) – allows continuous recording of cardiac activity during an extended period (usually 24 hours) while the client is performing the usual ADL. : B. Ambulatory ECG (Holter Monitoring) – allows continuous recording of cardiac activity during an extended period (usually 24 hours) while the client is performing the usual ADL. Preparation: b.1. Encourage the client to maintain a normal day’s schedule. b.2. Instruct to keep a diary, or log, in which to note the time of activities, such as eating, sleeping, walking, and working and to record any symptoms such as chest pain, lightheadedness, fainting and palpitations b.3. Instruct the client to avoid operating heavy machinery, using electric shavers and hair dryers and bathing or showering. These activities may interfere with the ECG recorder Diagnostic Assessment : Diagnostic Assessment c. Exercise ECG (Stress Test/Exercise Tolerance Test)- assesses the CV response to an increases workload. The stress test helps to determine the heart’s functional capacity and screens for asymptomatic CAD. Dysrythmias that develop during exercise may be identified and the effectiveness of antidysrythmic drugs can be evaluated. Slide 57: Preparation: c.1. The client must be adequately informed about the purpose and the risks involved. A written consent must be obtained. c.2. Assure the client that the procedure is performed in a controlled environment with prompt nursing and medical attention available. c.3. Instruct the client to get plenty of rest the night before the procedure. The client should not eat anything after going to bed or at least within 2 hours before the test. The client should not smoke or drink alcohol or caffeine-containing beverages on the day of the test. c.4. Advise client to wear comfortable, loose clothing and rubber-soled, supportive shoes. c.5. instruct the client to tell the physician if any symptoms, such as chest pain, dizziness, SOB and an irregular HR are experienced during the test. c.6. Emergency supplies such as cardiac drugs, defibrillator and other equipment necessary for resuscitation are available in the room in which the stress test is performed. Slide 58: 7. Echocardiography – is a non-invasive, risk-free test and is easily performed at a client’s bed side or an outpatient basis. often referred to in the medical community as a cardiac ECHO or simply an ECHO, is a sonogram of the heart. Also known as a cardiac ultrasound, it uses standard ultrasound techniques to image two-dimensional slices of the heart. Diagnostic Assessment : Diagnostic Assessment 8. Hemodynamic Monitoring – provides quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusion. ? It is often referred to as direct monitoring because it involves procedures that directly measure pressures in the heart and great vessels Slide 60: Right Atrial, Pulmonary Artery, and Pulmonary Wedge Pressures - a pulmonary artery catheter is a triple-lumen or quadruple-lumen catheter with the capacity to measure right atrial and indirect left atrial pressures or pulmonary artery wedge pressure (PAWP). The CO may also be obtained from the catheter. ? RA pressure is measured by a pressure sensor on the catheter inside the RA. Normal RA pressure ranges from 1-8 mmHg. Increased RA pressures may occur with right ventricular failure, whereas low right atrial pressure is usually indicative of hypovolemia ? Normal pulmonary artery pressure (PAP) is 20-30mmHg systolic and 8-12mmHg diastolic, with a mean of 10-20mmHg and may be constantly visible on the monitor Pulmonary capillary wedge pressure (PCWP) provides an indirect estimate of left atrial pressure (LAP).Normal PCWP is 8-12mmHgElevated PCWP are usually indicative of pulmonary congestion. : Pulmonary capillary wedge pressure (PCWP) provides an indirect estimate of left atrial pressure (LAP).Normal PCWP is 8-12mmHgElevated PCWP are usually indicative of pulmonary congestion. Slide 62: b. CVP Monitoring – CVP is similar to RA pressure, but CVPs are measured in cm H2O rather than mmHg. A normal CVP is 3-8 cm H2O. Central venous pressure (CVP) describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. ? Elevated CVPs may indicate hypervolemia, low CVP may indicate hypovolemia. How to Obtain a CVP Reading? b.1. position the H2O manometer so that the zero mark on the air-fluid interface is at the same height as the phlebostatic axis. b.2. Turn the stopcock to fill the manometer with IVF. b.3. Turn the stopcock to record the CVP. With each respiration, the fluid level in the manometer should fluctuate. When the level has stabilized, read the highest level of the fluid columns. b.4. Return the stopcock to resume the flow of IVF to the client. Slide 66: End of discussion You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.