NNN

Cardiovascular Assessment

Oct 03, 20248 min read

History

The focus is in obtaining information about the client’s risk factors and symptoms of cardiovascular disease.

  • Demographic Data:
    • Age: 40+ is at risk
    • Gender: men are at risk due to lifestyle but after menopause, the risk for both genders is more-or-less the same
    • Ethnic Origin: black people have a higher incidence of heart disease. (It may depend on the specific type of heart disease)
  • Family History and Genetic Risk
  • Personal History
  • Dietary History
  • Socioeconomic Status
  • Modifiable Risk Factors:
    • Cigarette Smoking (vasoconstriction, major risk for CAD and PVD)
    • Physical Inactivity (circulatory stasis, a risk for thromboembolism): provide activity/positioning
    • Obesity (lipid/fat deposits): weight-loss promotion, diet therapy
      • Most commonly an issue when abdominal obesity is present: >35” for women, >40” for men.
    • Psychological Variables (stress, release of catecholamines): stress management
    • Chronic Diseases
  • Non-Modifiable Risk Factors: demographic data, family history
    • Important for these factors is the implementation of positive lifestyle changes.

Physical Assessment

A check-up is recommended for individuals with at least one major symptoms.

Major Symptoms

  • Chest Pain or discomfort secondary to an imbalance between oxygen supply and oxygen demand in the heart.
    • Alleviated by nitroglycerin, a vasodilator.
  • Extremity Pain due to ischemia and venous insufficiency.
  • Dyspnea: DOE, Orthopnea, PND

INFO

Orthopnea is best questioned by asking the patient how many pillows they use when they sleep in order to breathe comfortably. It is charted as ” pillow orthopnea”

  • Activity Intolerance/Fatigue

INFO

When a patient is kept on CBR without bathroom privileges, a bedside commode is necessary.

  • Palpitations: heartbeats that can be felt by an individual without the need for auscultation or palpitation.
  • Weight Gain: the most accurate indicator of fluid status/retention.
  • Syncope: sudden fainting due to decreased cerebral perfusion.

Minor Symptoms

  • Skin Color: check the conjunctiva, palm, and lips for changes in skin color (pallor, cyanosis)
    • Submit the patient for a CBC if skin color changes are observed. Anemia may be diagnosed based on HGB count.
  • Skin Temperature: cool, clammy skin is observed for those with decreased blood flow.
  • Clubbing: the rounded appearance of the fingernails as a result of chronic oxygen deficiency.
    • Tested with the Schamroth Window Test which looks for a diamond-shaped window between two opposing fingers when the two nail-beds are lined up against each other.
  • Edema
  • Blood Pressure Changes
    • Hypotension
    • Postural Hypotension
  • Pulse Pressure: normally 30 to 40 mmHg.

Assessment Techniques

Perform a cephalocaudal assessment then focus on the Precordium, the area over the heart.

  1. Inspection: check the apical impulse. A visual apical impulse may be visible for skinnier individuals, but may not be visible. It may or may not be present, both are normal. It may be abnormal for patients with RHD due to valvular defects.
  2. Palpation: feel around the nipple area over the heart, feel for thrills, a vibration over a blood vessel or the precordium. If difficult, you may instruct the patient to assume a left side-lying position.
  3. Percussion: dullness or flatness over the heart or lung fields may reveal accumulations of fluid.
  4. Auscultation: hearing the normal heart sounds (S1, S2) or abnormal heart sounds (Murmurs found in difficult blood flow, Pericardial Friction Rub found in Pericarditis)
    • Aortic Area: 2nd intercostal space on the right sternal border.
    • Pulmonic Area: 2nd intercostal space on the left sternal border.
    • Mitral Area: the best location for hearing heart sounds positioned at the 5th intercostal space, on the midclavicular line. It usually is at or just below the nipple-line.
    • Tricuspid Area: on the 4th or 5th intercostal space, but on the right sternal border.

Laboratory Assessment

Serum Markers

  1. Troponin: takes 3 to 6 hours from the onset of chest pain and remains high for ~2 weeks.
    • Troponin T <0.2 ng/mL
    • Troponin I <0.03 ng/mL
    • The most reliable test for myocardial infarction.
  2. Creatine Kinase (CK-MB): takes 3 to 6 hours from the onset of chest pain and remains for 3 to 4 days.
    • 22 - 198 units/L
    • The most heart-specific serum marker.
  3. Myoglobin: Non-confirmatory test.
    • <90 mcg/L
    • The fastest-manifesting serum marker.

Serum Lipids

  1. Cholesterol: <200 mg/dL (122 to 200 mg/dL)
  2. TGL: <160 mg/dL (40 to 160 mg/dL for men, 35 to 135 mg/dL for women)
  3. HDL: <60 mg/dL (45 to 50 mg/dL for men, 55 to 60 mg/dL for women)
  4. LDL: <180 mg/dL (60 to 180 mg/dL)
  5. HDL-LDL Ratio should be 3-to-1

INFO

The medications used for hyperlipidemia are a classification of drugs called “antihyperlipidemic agents”, often having names that end in “-statin”.

Other Tests

  1. CRP: <1.0 mg/dL; signifies inflammation or infection, and is released by the liver.
  2. Blood Coagulation Test: evaluating the ability of the blood to clot/form thrombi.
    • Prothrombin Time (PT): normally 11 to 16 seconds; used for evaluating coumadin effect.
    • Partial Thromboplastin Time (PTT): normally 60 to 70 seconds; used for evaluating heparin effect.
    • Goal in Testing: x1.5 to x2.0 of normal value.
    • Antidotes:
      • Heparin Toxicity: Protamine Sulfate
      • Coumadin Toxicity: Vitamin K
    • When on anticoagulants, always monitor the patient for bleeding (epistaxis, gums, bruising)
  3. ABG: determine respiratory or metabolic acidosis or alkalosis.
  4. Serum Electrolytes: analysis of K+, Ca++, Na+, or Mg that directly affect muscle and nerve function.
  5. CBC: determination of anemia, leukocytosis/leukopenia, blood sugar (glycosylated hemoglobin), etc.

Radiographic Examinations

  1. Chest X-Ray: an x-ray of the thorax to determine the size, silhouette, and position of the heart.
  2. Angiography: visualization of blood vessels by using contrast media (potentially an allergen; consult with the patient for their allergies) and fluoroscopy.

INFO

When performing a CXR, the patient should only wear a gown (remove even brassieres) and for them to take in a full, deep breath and hold it during the X-Ray.

Cardiac Catheterization

A small catheter is inserted into the heart from large blood vessels used for diagnostic procedures. It is the most definitive yet most invasive method for heart disease.

  1. Right-Sided Heart Catheterization: routes from the brachial vein into the superior vena cava or from the femoral vein into the inferior vena cava into the heart. The catheter goes with the flow of the deoxygenated blood.
  2. Left-Sided Heart Catheterization: routes from an artery and into the heart against the flow of blood.

Purposes of Cardiac Catheterization

  1. Measure oxygen concentration
  2. Measure chamber pressures
  3. Check patency of the coronary arteries (Coronary Arteriography)
  4. Evaluate valve function

Nursing Responsibilities

Before

  • Obtain consent
  • Assess for allergies
  • NPO 6-8 hours
  • Educate:
    • A warm or flushing sensation will be felt as the dye is administered.
    • Flow and purpose of the procedure
  • Cleaning:
    • (Depends on the institution) Phisohex Baths are used to clean the patient’s body for prophylaxis.
    • Shave the groin area
  • Take baseline vital signs

After

  • Bed rest with pressure dressing (prepare rolled gauze and 4”x4” gauze)
  • Keep arms/legs straight. If the catheterization was done through the femoral artery/vein, keep the bed at most 30° in angle as to not stress the femoral artery/vein.
  • Monitor VS, especially the peripheral pulse distal to extremity used.
  • Promote Circulation: Check pulse, color, temperature, and tingling.

Complications

  • MI, Stroke, Arterial Bleeding, Thromboembolism, Lethal Dysrhythmias, maybe even death.

Electrocardiography (ECG)

The graphical measurement of the electrical currents flowing through the heart. It is measured via electrodes placed on the skin and connected to an amplifier and strip chart recorder.

  • The strip chart has 1mm by 1mm cells, which represent 0.04s of 0.1mV (25mm per second, 10mm per 1mV)

12-Lead ECG

Determination of 12 leads/electrical currents in the body, which requires five electrodes attached to the arms, legs, and chest.

The Skills in Conducting ECG...

…will be a focus for fourth year students! For now, we focus on interpretation.

PQRST Waves

  1. P Wave (0.08 - 0.10s): atrial depolarization
  2. PR Interval (0.12 - 0.20s): measured from the start of P to the start of the QRS complex.
  3. PR Segment (0.12 - 0.20s): measures from the end of P to the start of the QRS complex.
  4. QRS Complex (0.04 - 0.10s): ventricular depolarization
  5. QT Interval (≤0.44s):
  6. ST Segment: early ventricular repolarization (isoelectric)
  7. T Wave: ventricular repolarization
    • Elevated T Wave: Hyperkalemia
  8. U Wave: (may or may not be present) late ventricular repolarization
    • Elevated U Wave: Hypokalemia

Forms of ECG

  1. Resting ECG: the patient is lying down
  2. Holter Monitoring/Ambulatory ECG: the patient performs activities of daily living with a wireless ECG monitor.
  3. Stress Test ECG/Exercise ECG: the patient performs strenuous activities while connected to an ECG monitor usually only for a few minutes.
    • Used for confirming CAD or to evaluate treatment effectiveness
    • Basis for cardiac rehabilitation program
    • Eat a light meal for breakfast prior to the stress test.
    • Wear jogging shoes and pants as proper attire.

Echocardiography (ECHO)

Ultrasound waves are used to assess cardiac structure and mobility, particularly at the valves, ventricular enlargement, cardiac dilation, etc. It takes 30 to 60 minutes to perform.

Hemodynamic Monitoring

Evaluation of the volume and pressure of blood in the heart and vascular system by means of a surgically inserted catheter.

  1. Direct Blood Pressure Monitoring: via the radial, brachial, or femoral arteries. The barometer is placed on the tip of the catheter inserted into the heart.
  2. Central Venous Pressure Monitoring: pressure exerted by the blood in the right atrium.
    • Normal Value: 2 to 7 mmHg or 4 to 10 cmH2O
  3. Pulmonary Artery Pressure Monitoring: a catheter is inserted through the RA, RV, and into the primary pulmonary artery.
    • If placed before the pulmonary artery bifurcates and expanded, the catheter measures pulmonary artery pressure.
    • If placed further into the left pulmonary artery and expanded, the catheter measures pulmonary artery/capillary wedge pressure.
    • Normally 4 to 12 mmHg, higher than 25 mmHg will start resulting in pulmonary edema.

Backlinks

  • No backlinks found

Graph View