Transcript Nursing 201 Advanced Cardiac 2.0 Nursing assessment and

Nursing 201
Advanced Cardiac
2.0 Nursing assessment and management of
patients with dysfunctions of circulation, and
undergoing related diagnostic tests.
Laurie Brown RN, MSN, MPA-HA, CCRN Fall 2005
This is important!
There are three systems that must work
together for the heart to beat efficiently:
1.
2.
3.
Circulatory
Conduction
Coronary
Review of the Cardiovascular
System
Route of blood from the heart:
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Arteries, arterioles, capillaries, venules, veins
Distribution of the Total Blood Volume
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Heart - Approx 9 % of blood volume at any given time.
Arteries and veins act simply as conduits for blood!
Only capillaries directly serve cells by exchanging
materials with them.
Cardiac Tissues
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Connective tissues – form the fibrous
skeleton and valves.
Cardiac muscle – produces the contractile
force of the heart.
Epithelial tissue – lines the cardiac
chambers and covers the outer surfaces of
the heart.
Arterial System
General Features
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Elastic Arteries
Muscular Arteries
Arterioles
Exterior Anatomy of the Heart
Anatomy of the Heart
Valves of the Heart
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Tricuspid – Directs the flow of blood from
the right atrium to the left ventricle.
Mitral Valve – Directs the flow of blood
from the left atrium to the left ventricle.
Pulmonic (semilunar) – Lies between the
right ventricle and the pulmonary artery.
Aortic Valve (semilunar) – Lies between
the left ventricle and the aortic artery.
Circulation in the Heart
1. Oxygen-poor blood
(shown in blue) flows from
the body into the right
atrium.
2..Blood flows through the
right atrium into the right
ventricle.
3. The right ventricle pumps
the blood to the lungs,
where the blood releases
waste gases and picks up
oxygen.
3. The newly oxygen-rich
blood (shown in red)
returns to the heart and
enters the left atrium.
4. Blood flows through
the left atrium into the
left ventricle.
5. The left ventricle
pumps the oxygen-rich
blood to all parts of the
body.
The
Circulatory
System
Coronary Circulation
Coronary Blood Flow
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Coronary Blood Flow is directly linked to
oxygen demand.
Autoregulation helps to maintain normal
coronary blood flow whenever coronary
perfusion pressure changes due to
changes in aortic pressure.
Autoregulation
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Autoregulation is defined as…
The intrinsic ability of an organ to maintain a
constant blood flow despite changes in
perfusion pressure.
Control of an event such as blood flow
through a tissue (e.g., cardiac muscle) by
alteration of the tissue.
Coronary Blood Flow
Heart Sounds
Heart sounds… are caused by the closure
of heart valves.
The first sound (lub), or S1, is caused by
closure of the atrioventricular (AV) valves.
The second sound (dup), or S2, is caused
by the closure of the semilunar valves.
Murmurs and Stenosis…
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A valve that does not
close efficiently, results in
the backflow of blood
(i.e., insufficiency or
regurgitation).
A valve that does not
open wide enough may
cause turbulent backflow
secondary to obstruction
or narrowing (i.e.,
stenosis).
Landmarks
Pericardial Friction Rub
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Non-infective
Infective
Autoimmune
Scratching, grating, squeaking, high
pitched sound
Definitions…
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Cardiac output
Pre-load
After-load
Cardiac reserve
Starling’s law of the heart
Pulse deficit
Pulse pressure
Physiology of Circulation (cont.)
Peripheral Resistance
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Opposition to flow
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A measure of the amount of friction blood encounters
as it passes through the vessels.
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Most friction is encountered in the peripheral
circulation (peripheral resistance (PR)).
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Sources of resistance…
Physiology of Circulation (cont.)
Blood Pressure
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Force per unit area exerted on the wall of a vessel by
its contained blood expressed in mm Hg.
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Usually means systemic arterial blood pressure in the
largest arteries near the heart.
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The differences in blood pressure within the vascular
system provided the driving force that keeps blood
moving through the body.
Physiology of Circulation
Blood Flow
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Actual volume of blood flowing through the entire
circulation or any part of it (a vessel, an organ, etc.)
in a given period of time (ml/min).
Equals cardiac output (CO) when applied to the
entire circulation.
Varies widely among individual body organs as
determined by their immediate needs.
The Cardiac Cycle
1. Isovolumetric ventricular
contraction
2. Ventricular ejection
3. Isovolumetric relaxation
4. Ventricular filling
5. Atrial systole
Ejection fraction (EF)
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The ejection fraction (EF) represents the
amount of blood pumped out of the heart
(left ventricle) with each beat. In the
healthy heart, it is around 70%.
An EF below 55% is considered abnormal.
What is congestive heart failure?
Taber’s defines heart failure as…
“The inability of the
heart to circulate blood
effectively enough to
meet the body's
metabolic needs”.
Symptoms of Heart Failure
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Shortness of breath
(dyspnea)
Fatigue
Edema – associated
with fluid overload
Lightheadedness
Hypoxia
Orthopnea
Cognitive changes
Other…
Auto-regulatory Mechanisms
of
The Heart
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The heart is supplied by the two branches
of the autonomic nervous system.
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The sympathetic (adrenergic)
The parasympathetic, or (cholinergic)
Changes Associated With Aging…
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Decreased vessel elasticity
Increased calcification of
vessels
Impaired valve function
Decreased muscle tone
(including the heart
Decreased baroreceptor
response to blood pressure
changes
Decreased conduction ability
of the heart
Other stuff…
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Contractility:
The ability of muscle cells to contract after
depolarization. This ability depends on how
much the muscle fibers are stretched at the
end of diastole.
The inherent ability of cardiac muscle fibers
to shorten or contract.
Cardiac Risk Factors
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Non-modifiable
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Modifiable
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Other
Cardiac Testing
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Blood Tests
Electrical
Structure
Pressure
Blood Flow
Ischemic Tissue
Laboratory Tests
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CK or CK-MB
LDH (LDH1, LDH2)
AST (SGOT)
Lipids
PT/PTT
ABGs
Electrolytes
CBC
Troponin & Myoglobin
C-reactive protein (CRP)
Homocysteine
B Type Natriuretic Peptid
Tests
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EKG
Stress Test
Transesophageal Echocardiography
Echocardiography
Phonocardiography
Radiographic
X-ray
 Fluoroscopy
 Angiography
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Cardiac Cath
 DSA (Digital
Subtraction
Angiography)
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Cardiac Testing
Angiography
 Angioplasty
 Biopsy
 VO2 max
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Tests
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Nuclear Cardiography
 Technetium Pyrophosphate Scanning
 Thallium Imaging
 MUGA Scan
Tests
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Positron Emission Tomography (PET)
MRI
CAT Scan
Small Pericardial Effusion
Hemodynamic Monitoring
Physical Assessment
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General appearance
Mental Status
Vital signs
Pulses
Heart rate and rhythm
Perfusion
Edema
Lung sounds
Other…
Case Study… FRED
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82 y/o male w/30 + year
history of COPD presents
to the ER with C/O SOB
and chest pain and now is
to be admitted to your
unit. He has a IV at TKO
and O2 per NP at 2L. He
was given a Nitro and an
aspirin in the ER.
Fred
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Admitting Dx: CHF, R/O MI
Past Medical Hx: Mild CHF, COPD x 30 years,
CAD, HTN
PE: Skin pink and dry, brisk capillary refill,
oriented x 4, S3 heart sounds, SOB with any
exertion, audible expiatory and inspiratory
wheezes, crackles at bases bilaterally, 1+ pitting
edema to mid calf
FRED
1.
2.
3.
4.
5.
6.
7.
Chief Complaint
Cardiac (Medical) History
Tests (Labs & others)
Medications
Physical exam
Vital signs
Nursing Diagnosis
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Admitting Dx: CHF, R/O MI
Past Medical Hx: Mild CHF, COPD x 30 years, CAD,
HTN
Vital signs: 184/94, 122, 30, T 99.1
ABGs on RA - 7.55, CO2 26, O2 54
PE: Skin pink and dry, brisk capillary refill, oriented x
4, S3 heart sounds, SOB with any exertion, audible
expiatory and inspiratory wheezes, crackles at bases
bilaterally, 1+ pitting edema to mid calf
Q-R-S-T-A-A-A
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Quality - dull/squeezing
Region – radiation
 changing
 right arm/left arm
Severity/Setting
 rest vs exertion
 after meals
 scale of pain
Q-R-S-T-A-A-A
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Time
 sudden/gradual onset
Alleviators
 Position
Aggravators
 food/position/exertion/people
 constant/episodic
Associated Symptoms
 SOB, cough, temp, nausea, diarrhea
Application - Chief Complaints…
What are Fred’s
chief complaints?
Cardiac History
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Ask about his
personal history,
family history and
social history.
Fred - Medications
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What medications is he
currently taking?
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Diuretic, ACE inhibitor, ß-blocker,
K+, Bronchodilators and
Glucocorticoids
Physical Exam
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What we know…
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SOB (subjective and objective)
Vital signs
ABG’s
Skin…Perfusion
Mental status
Heart sounds
Lung sounds
Edema
Nursing Diagnosis
What nursing
diagnosis would be
appropriate for Fred
at this time?
Remember, ND’s
serve to guide and
direct nursing care!
Which question should you ask a client
experiencing palpitations?
A. Family history of high blood pressure or heart
problems
B. Activity when symptoms begins
C. Anything that makes symptoms more or less severe
D. Amount of coffee or tea consumed each day