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Assessment of Cardiac
Function
Chapter 26
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Assessment of the Cardiovascular
SystemOn Your Own:
Review the anatomy of the heart and
vessels Review normal circulation
Review coronary circulation
Review conduction
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Coronary Circulation
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Mean Arterial Pressure
average pressure at which blood moves
through vasculature (B&S, p. 358
MAP = Systolic BP + 2(diastolic BP)
3
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Mean Arterial Pressure
The Mean Arterial Pressure (MAP) is 80 mm Hg.
What does this mean?
The MAP drops to 60 mm Hg. What are the
implications of this value?
The MAP drops to 55 mm Hg. What are theimplications of this value? What should be
administered to the patient?
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Conduction System of the Heart
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Impulse Conduction
The heart rate is 80 bpm. From where is this impulse
originating? What does this mean?
The heart rate is 50 bpm. From where is this impulseoriginating? Are there any other possibilities? What
does this mean? What could be the cause?
The heart rate is 30 bpm. From where is this impulseoriginating? What does this mean? What could be the
cause?
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Cardiac Hemodynamics
Key principle:
Blood flow, in part, is determined by the flow
of blood from an area of higher pressure to
one of lower pressure
In what chamber would you expect to have the
highest pressure?
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Cardiac Cycle
Diastole
2/3 of the cardiac cycle
Relaxation and filling of the atria and ventricles
Systole
1/3 of the cardiac cycle
Contraction and emptying of the atria and
ventricles
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Mechanical Properties
Cardiac output
What is it?
What is normal?
Why is it important?
Cardiac index
What is it?
What is normal?
Heart rate
What is it?
What is normal?
Stroke volume
What is it?
What is normal?
What factors influence
it?
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Variables that Influence Stroke
Volume
Preload
Degree of myocardial fiber stretch at the
end of diastole and just before contraction Determined by LVED pressure and blood
return from the venous system
Starlings Law: the more the heart fillsduring diastole, the more forcefully it
contracts
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Variables that Influence Stroke
VolumeAfterload
Pressure or resistance that the ventricles mustovercome to eject blood through the semilunarvalves and into the peripheral blood vessels.
Impedance (the peripheral component of afterload)
Pressure heart must overcome to open theaortic valve
Amount of impedance depends upon aorticcompliance and total systemic vascularresistance, a combination of blood viscosity andarteriolar constriction
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Critical Thinking Question
You have a inch and 1 inch diameter
garden hose. You are pumping the same
amount of water through each one.
Which one will have to pump against more
resistance?
Which one will have a lower pressure?
How does this analogy correlate to bloodvessels?
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Preload and Afterload
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Contractility
What is it?
What drug is often given to increase
contractility?
What increases contractility?
What decreases contractility?
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Vascular System
On Your Own
Review Purpose, Structure and Function
Physiology of blood pressure
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Blood Pressure
What is blood pressure?
What two factors are the primary determinants of bloodpressure?
How do increases or decreases in either or both of thesefactors affect blood pressure values?
What body systems are involved in the regulation ofblood pressure?
What external factors can affect blood pressure?
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Assessment: History
Patients will be queried regarding: History of cardiac
symptoms
Dyspnea
Fatigue
Paroxysmal nocturnal
dyspnea
Orthopnea Chest pain
palpatations
Syncope
Cough
Past health history
Medications
Risk factors
Age
Diet Activity
Smoking
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Additional Assessment Areas
Health perception and management
Nutrition and metabolism
Elimination
Activity and exercise
Sleep rest patterns
Cognition and perception
Self-perception and self-concept Roles and relationships
Sexuality and reproduction
Coping and stress tolerance
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Pack-years
Smoking history should be reported in pack
years:
Number of packs per day multiplied by thenumber of years has smoked
(0.5 pack X 10 years = 5 pack years)
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Physical Exam
Cyanosis
Petechiae
Edema
Pulses
Heart sounds
Murmurs
Bruits
Blood pressure
Neck vein distention
Skin color
Hair distribution on
extremities
Lesions
Clubbing
dysrhythmias
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Postural BP Changes
Compare and contrast normal
and abnormal blood pressure
responses to postural position
changes.
What do orthostatic changesindicate?
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Assessment of Clubbing
Schamroth Method
Place fingernails of the ring fingers
together and hold up to light If a diamond shape can be seen between
the nails findings are normal
Absence of the diamond shape indicatesclubbing
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Assessing for Clubbing
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Diagnostic Tests
Cardiac Biomarkers
Chemistries
CXR & Fluroscopy
ECG
Continuous Cardiac
Monitoring
Cardiac StressTesting
Echocardiography
Radionuclide imaging
Cardiac
catheterization
Angiography
Hemodynamic
monitoring
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Important Markers ofMyocardial
Damage
Creatine Kinase
specific to brain, myocardial, and skeletalmuscle cells
Presense in blood indicates tissuenecrosis or injury
Isoenzymes identify specific source
CK-MB activity is most specific forMI withpredictable rise over 3 days (peak at 24 hoursafter onset of chest pain)
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Early Markers
CK-MB antibody assay can detectmyocardial necrosis within 3 hours ofEDadmission
CK-MB subforms 1 and 2 (early andspecific indicators)
Myoglobin (early, sensitive, but non-
specific) Troponin T and I (early with wide
diagnostic time frame)
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Additional Labs
Blood Chemistries
Coagulation studies
Hematologic studies Lipid Profile
Cholesterol and Triglycerides
BNP CRP
Homocysteine
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Other Diagnostic Tests
ECG
Continuous electrocardiographic monitoring Hardwire vs. Telemetry
Signal averaged
Continuous Ambulatory ECG (HolterMonitor)
Echocardiography Traditional vs. Transesophageal
Cardiac Stress Testing Exercis, Pharmacologic, Mental
Radionuclide Imaging Myocardial Nuclear Perfusion Imaging
ERNA (aka MUGA) Computed Tomography (CT)
Positron Emission Tomography (PET)
Heart Catheterization /Angiography
Electrophysiologic Studies
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Cardiac Catheterization
Provides:
Visualization of coronary blood flow
Measurement of pressures in heart chambers
Determination of O2 saturation of the blood Visualization of the valves
Procedure:
One or more catheters inserted (femoral;brachial)
Dye injected
Takes about 1 hour
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Cardiac Catheterization
Before the test:
ECG
Chest x-ray
Urine Blood
BUN/Creatinine
Fast 8-12 hours
IV started
Patient Education Length of procedure
May feel palpitationsand flushing
Basic Pre-oppreparation
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Cardiac Catheterization
Indications:
Confirm suspected
disease
Determine locationand extent of disease
To assess stable
angina, uncontrolled
HF
To determine best
therapeutic options
To evaluate effects of
treatment
Complications
Rt: thrombophlebitis, PE,vagal response
Lt: MI, Stroke, arterialbleeding or thrombo-
embolism, dysrhythmias
Rt. or Lt.: cardiac
tamponade, hypovolemia,pulmonary edema,
hematoma, contrast
media reaction
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Cardiac Catheterization
During the test:
May be asked to cough or deep breathe
After the test:
Firm pressure over site observe for bleeding,hematoma
Circulatory checks every 15 minutes for 1-2hours then every 1-2 hours after stable
Observe for dysrhythmias
Keep leg or arm straight for several hours
Increase fluids to flush out dye
Watch for orthostatic hypotension when first up
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Hemodynamic Monitoring
Invasive system used in critical care toprovide quantitative information aboutvascular capacity, blood volume, pump
effectiveness, and tissue perfusion. Directly measures pressures in heart and
great vessels
CV
P, PA,I
ntraarterial BP Provides more accurate measurements ofblood pressure, heart function and volumestatus
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Hemodynamic Monitoring
Involves significant risks, informed consent
is required
Components Catheter with infusion system
Transducer
Monitor
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Hemodynamic Monitoring
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Central Venous Pressure (CVP)
Pressure in vena cave or right atrium Indirect measurement of right ventricular pressure
Normal 0-8 mm Hg
Elevated: hypervolemia, Heart failure
Low:
decreased preload related to hypovolemia
Complications Infection, Pneumothorax, Air embolism
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Pulmonary Artery Pressure
Normal: 25/9; mean 15 mm Hg
Measurement helpful: Assesses LV function
Assists in determining etiology of shock
Evaluates response to medical interventions
Capable of measuring: RA pressure
PA systolic pressure
PA diastolic pressure Mean pulmonary artery pressure (4.513 mm Hg)
Pulmonary artery wedge pressure
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Pulmonary Artery Pressure
Elevated PA wedge pressure:
LV failure; hypervolemia; regurgitation;
intracardiac shunt
Low PA wedge pressure:
Hypovolemia; afterload reduction
Complications:
Infection, PA rupture, Pulmonary thrombo-
embolism, Pulmonary infarction, Catheter
kink, Dyrhythmias, Air embolism
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Intrarterial BP Monitoring
Direct and continuous BP measurement
Provides access for ABG or blood
samples Must have collateral circulation
Allen test
Ultrasound Doppler study
Complications: Local obstruction, air embolism, pain and arterial
spasm, infection
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