Transcript CV Assessment

ASSESSMENT OF
CARDIOVASCULAR
FUNCTION
NUR240
Lecture 1
J. Borrero 9/10
1
LECTURE OBJECTIVES
1. Review anatomy & physiology of the
cardiovascular system.
2. Discuss relevant aspects of the patient
history.
3. Describe physical assessment of
cardiovascular status.
4. Review diagnostic procedures, tests and
medications relative to the cardiovascular
system.
2
Anatomy & Physiology
(What makes it “tick”!)
Functions of the
heart & CV
system
• Pumps blood to
tissues to supply
O2 & nutrients
• Remove CO2 &
metabolic wastes
3
Anatomy & Physiology
CARDIAC CELLS HAVE UNIQUE PROPERTIES
• AUTOMATICITY  CELLS CONTRACT
INDEPENDENTLY (THEY INITIATE THEIR OWN
IMPULSE)
• EXCITABILITY  ION SHIFT
• CONDUCTIVITY  TRANSMIT IMPULSE
TO ANOTHER CARDIAC CELL
• CONTRACTTILITY  HOW WELL THE
CELL CONRACTS
4
Anatomy & Physiology
PERICARDIUM / PERICARDIAL SAC
• Protects heart from trauma
• Serous fluid lubricates and
prevents friction
• Prevents heart from over filling
5
CIRCULATION PATHWAY
HEART IS DIVIDED INTO TWO SIDES
RIGHT & LEFT
ALL BLOOD RETURNS TO THE
HEART THROUGH THE ATRIA
ALL BLOOD LEAVES THE HEART
FROM THE VENTRICLES
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CORONARY ARTERIES
• Supply blood to MYOCARDIUM
• BRANCHES:
LEFT MAIN CORONARY ARTERY
L ANTERIOR DESCENDING (LAD)
L CIRCUMFLEX (LCX)
RIGHT CORONARY ARTERY
POSTERIOR
MARGINAL
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CORONARY ARTERIES
(L)
ARTERY
CIRCUMFLEX
(R)
LAD
ARTERY
8
CONTRACTION OF CARDIAC
MUSCLE
The heart can’t pump unless an electrical
stimulus occurs
Action Potential (AP) – electrical change
(depolarization = contraction)
Brought about by release of calcium
(+ charge) into cells
Intrinsic Pacemakers – depolarize and
generate the AP
9
CONTRACTION OF CARDIAC
MUSCLE
The pacemaker with the fastest rate of
depolarization stimulates the AP
• SA node (60-100 bpm)- Upper R atrium
• AV node (40-60 bpm)- Lower R atrium
• Other pacemakers ( 40)
10
DISRUPTION IN SERUM ELECTROLYES CAN
RESULT IN ALTERATION IN CARDIAC CYCLE
•  K, Ca & Mg lead to
dysrhythmia, weakness
•  Ca leads to  strength of
contraction
•  Na leads to general weakness &
less Na to initiate action potential
•
K leads to dysrhythmias
11
MONITORING MOVEMENT OF THE
CRDIAC ACTION POTENTIAL (AP)
• EKG – monitors the movement of the
AP, the electrical changes NOT the
mechanical changes that follow
• Auscultating heart sounds, palpating
pulses and measuring pressures
monitor the mechanical changes
12
CARDIAC CYCLE
CARDIAC CYCLE –
all the activities
occurring in the
heart during one
contraction, and
subsequent
period of
relaxation.
Graphically
represented on
an EKG (ECG)
13
CARDIAC CYCLE
EKG – A 12
lead EKG is
a graphic
record of
the
electrical
forces
produced
by the heart
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CARDIAC CYCLE
Part of Cycle
Representation
P wave
PR Interval
QRS Complex
ST Segment
T Wave
R-R Interval
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CARDIAC CYCLE
Polarized (resting) cell – represented on
EKG as baseline or isoelectric line
Depolarization – impulse over
specialized cardiac cells (not
neuromuscular impulse)
Repolarized cell – returns to normal. Na
moves out of cell, K moves in –
requires ATP
Note: ischemic tissue may cause
problem
16
ELECTRODE POSITIONS
“LEADS”
• Leads measure electrical activity
between 2 points
• Movement toward  electrode causes
positive deflection
• Movement away from  electrode
causes negative deflection
17
ELECTRODE POSITIONS
A 12 Lead EKG shows electrical activity
from 12 different positions in the heart,
concentrating on (L) ventricle
A 14 Lead EKG includes (R) ventricle
activity
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STROKE VOLUME (SV) &
CARDIAC OUTPUT (CO)
• SV – amount of blood ejected by 1
ventricle in 1 beat
• CO – volume ejected in 1 min
Control of SV and HR = SV&HR are
continually adjusted by the body, and
are affected by the return of blood from
the tissues (think of exercise)
CO = SVxHR
19
STROKE VOLUME (SV) &
CARDIAC OUTPUT (CO)
Extrinsic control of HR is a more
powerful way of controlling CO
than changing SV
1.  CVP causes stretching of (R)
atrial muscle which stimulates
SNS &  HR (to help pump all the
blood returned to it)
2. Remember “Starling’s Law”
20
STROKE VOLUME (SV) &
CARDIAC OUTPUT (CO)
2. Stretch baroreceptors (aorta &
carotid) detect in pressure which
stimulates SNS & HR  (to ensure
adequate blood supply to heart/ brain)
3. If  pressure detected, then PSNS is
stimulated & HR is slowed (vagus
nerve) (prevents excess arterial
pressure which can damage organs)
21
CARDIAC LOAD
Preload = degree of myocardial fiber
stretch at the end of diastole and just
before contraction
Afterload = pressure against which
ventricles must eject blood. This
pressure is affected by systemic
vascular resistance (SVR)
22
23
CARDIAC ASSESSMENT
Cardiac status of all patients should be
routinely assessed. Everyone has a
1. Subjective
CP
Dyspnea
Fatigue
1. Objective
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IMMEDIATE NURSING INTERVENTIONS FOR
ACUTE CARDIAC EVENT
MOVIE Acronym
M- Monitor for pain
O- O2 and pulse ox
V- Vital signs
I- Intravenous fluids
E- EKG monitoring
Anything else??
25
Pain Assessment
SLIDA or
Precipitating/alleviating factors
Quality
Radiation
Severity
Timing
26
OTHER ELEMENTS OF
CARDIAC ASSESSMENT
• Previous cardiac hx
• Other medical conditions that may affect heart
function
• Chest injury
• Previous heart surgery
• Past medical hx
• Medications: prescribed, OTC, herbals
• Activity tolerance
• Health habits
• Family hx
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EXAMINATION
•
•
•
•
Inspection
Palpation
Percussion-?
Auscultation = S1, S2 at PMI
Aortic
Pulmonic
Tricuspid
Mitral
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Heart Rhythm
Regular, Irregular, Regular Irregular
Abnormal Sounds: Gallops
Murmurs
Bruits
S3 ventricular gallop – heard in early
diastole
S4 atrial gallop – generally abnormal
29
Assessment of Murmurs
Turbulent blood flow in valvular
disorders and septal defects
Timing of murmurs is a must!
Systolic murmurs occur between S1 &
S2
Diastolic murmurs occur between
S2 & S1
Grade 1 – 6 identifies intensity of murmur
30
31
Other assessments
• Jugular vein pressure – assess JVD which
reflects increased filling volume and
pressure on (R) side of heart
 JVD associated with (R) HF, SVC
obstruction (Normal is 3-10cm H20)
• Pulse deficit – the difference between apical
HR and peripheral pulse-associated with
Afib, and heart blocks
• Pulse pressure – the difference between
systolic & diastolic pressure
32
Other assessments
• Respiratory: Lung sounds = rate,
rhythm, quality, sputum
• GI-Abdomen
• Peripheral Vascular:Lower extremities
33
Diagnostic Procedures
1. EKG 12 Lead
continuous cardiac monitoring
holter monitor
2. Chest x-ray – detects
enlargement of heart &
pulmonary congestion
34
Diagnostic procedures
3. Echocardiography – ultrasound that
reveals size, shape and motion of
cardiac structures
Evaluates heart wall thickness, valve
structure, differentiates murmurs
4. TEE – transesophageal
echocardiography provides a clearer
image because less tissue for sound
waves to pass through
35
Diagnostic procedures
5. Angiography / cardiac catherization
determines coronary lesion size,
location, evaluate (L) ventricular
function, measures heart pressures
6. Exercise tolerance test
7. Radionuclide Imaging
36
Lab Studies
Cardiac enzymes = enzymes are released when
cells are damaged (MI). Enzymes are found in
many tissues/muscles, and some are specific
to cardiac tissue.
Serial measurement can aid in dx, and monitor
course of MI
Cardiac enzymes =
CPK – MB (CK-MB),myoglobin, Troponin
In general, the greater the rise in the serum
level of an enzyme, the greater the degree or
extent of damage to the muscle.
LDH
37
Blood studies
2.
3.
4.
5.
6.
Electrolytes
Lipid panel
CBC
C – Reactive Protein
BNP- Human B-Natriuretic
Peptide
7. Blood coags-PT/PTT/INR
38
Lipid Panel
Desirable
Total
Under 200
Cholesterol
LDL
Under 130
HDL
30-80
Triglycerides
40-150
Borderline
High
200-239
High
130-159
160 or >
240 or >
Elevated levels neg
correlated with CAD
and may be
protective
39
C Reactive Protein
Hs-CRP Level
Risk
< 1.0mg/L
Low risk of CVD
1.0-3.0 mg/L
Average risk of CVD
>3.0 mg/L
High Risk of CVD
40
NCLEX TIME
Mary is attending a sophomore level nursing class
on anatomy and physiology. Which statement, if
made by Mary, demonstrates a good
understanding of the anatomy and physiology of
the heart?
A."The heart is encapsulated by a protective coating
called the endocardium.“
B."The SA node is considered the main regulator of
heart rate.“
C."The left atrium receives deoxygenated venous
blood from all peripheral tissues.“
D."Stroke volume is the amount of blood ejected by
the right ventricle during each diastole
41
NCLEX TIME
Kirsten is completing her graduate clinical rotation in
a large urban teaching hospital in a medical
coronary care unit (CCU). Which observation
demonstrates a good understanding of completing
a thorough cardiac examination?
• A. In an obese client, an adult cuff size of 12 to 14
cm is preferable.
• B.The carotid artery on the neck is auscultated to
assess for the presence of a bruit.
• C.The apical impulse is auscultated over the fifth
intercostal space in the midclavicular line.
• D.Palpation is used to determine cardiac size. 42
NCLEX TIME
Edward is a 40-year-old white male. He is an accountant who
works on average 11 hours per day. He reports feeling
stressed each day, even with mundane things such as a
traffic jam. His father had a massive myocardial infarction
at the age of 48. His mother has a history of congestive
heart failure. He seldom has time to exercise, but does eat
balanced meals when possible, although he does not get
to eat three meals a day. Select all factors that place
Edward at risk for heart disease.
• A.Family history
• B.Age
• C.Coping-stress tolerance
• D.Race
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• E.Occupation