Post on 26-Mar-2015
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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