Transcript CV part 1

Cardiovascular
Lisa Pearson, RN MSN
The Heart
• The heart is divided into 2 sides (right and
left)
• There are 2 major vessels leading blood in
and out of the heart (vena cava and aorta)
• The right side of the heart has
deoxygenated blood as does the vena
cava
• The left side of the heart has oxygenated
blood as does the aorta
Blood Flow of Heart
• Deoxygenated blood is carried to the heart
through the vena cava
• Vena Cava
• Right Atrium
• Tricuspid Valve
• Right Ventricle
• Pulmonary Valve
• Pulmonary Arteries
• Lungs (gas exchange occurs)
Blood Flow of the Heart
• Oxygenated blood is sent from the lungs to the
left side of the heart through the pulmonary
veins
• Pulmonary Veins
• Left Atrium
• Bicuspid (mitral) Valve
• Left Ventricle
• Aortic Valve
• Aorta
Blood Flow
• Once oxygenated blood is pumped into
the aorta, the oxygenated blood reaches
the body through:
• Arteries
• Arterioles
• Capillaries (gas exchange occurs)
Blood Flow
• Once gas exchange occurs in the
capillaries, the deoxygenated blood must
return to the right side of the heart:
• Capillaries (gas exchange)
• Venules
• Veins
• Vena Cava
Blood Flow
The Valves of the Heart
• The tricuspid valve is located in the right
side of the heart separating the right
atrium and right ventricle.
• The tricuspid valve is known as tricuspid,
right, and AV valve.
• The tricuspid valve prevents backflow of
blood from the right ventricle back into the
right atrium.
• Essentially, it is a trapdoor.
The Valves of the Heart
• The pulmonary valve, also called pulmonic
valve, is also located on the right side of
the heart.
• This valve is found in the right ventricle
and leads to the pulmonary arteries.
• The pulmonary valve is a trapdoor that
prevents backflow of blood from entering
back into the right ventricle once it enters
the pulmonary arteries.
The Valves of the Heart
• The bicuspid or mitral valve is located on
the left side of the heart.
• This valve separates the left atrium and
left ventricle.
• This valve prevents any blood from flowing
back into the left atrium from the left
ventricle.
The Valves of the Heart
• The aortic valve is located in the left
ventricle and allows blood to enter into the
aorta.
• This valve prevents blood from backing
back up into the left ventricle.
Sounds of the Heart
• Normal heart sounds heard with a stethoscope
are produced by the closing of the heart valves.
• The first sound is S1 and is heard at the
beginning of systole as “lubb” when the tricuspid
and mitral valves close.
• The second heart sound is S2 and is heard at
the start of diastole as “dupp” when the aortic
and pulmonic semi-lunar valves close.
Sounds of the Heart
• Extra heart sounds usually indicate a
pathological condition.
• Normally, no other sounds are heard between
S1 and S2.
• Placing the stethoscope at the apex of the heart
may help in hearing S3 or S4 (extra heart
sounds).
• Having the patient lean forward or lie on left side
can make the heart sounds easier to hear by
bringing the area of the heart closer to the chest
wall.
Sounds of the Heart
• S3 is normal for children and younger adults (pregnancy last
trimester); however, may be a cardinal sign of heart failure in other
adults.
• S3 may sound like a gallop and is a low-pitched sound heard early
in diastole. Heard after S2 sounds like the “y” in Ken-tuck-y.
• S3 sound may be caused by rapid ventricular filling causing
vibrations.
• S3 may be heard with left-sided heart failure, fluid-volume overload,
and mitral valve regurgitation.
• S4 is a low-pitched sound similar to a gallop but heard late in
diastole right before S1 after the atria contract. Sounds like “ten” in
Ten-nes-see.
• S4 sound may be caused by slow ventricular filling. Atria contract
and eject blood into resistant ventricles, causing vibrations heard as
S4.
• S4 occurs with HTN, CAD, and pulmonary or aortic stenosis, and hx
of MI.
Sounds of the Heart
• Murmurs are caused by turbulent blood
flow through the heart and major blood
vessels.
• A murmur is a prolonged sound caused by
a narrowed valve opening or a valve that
does not close tightly.
• A swishing sound that ranges in intensity
from faint to very loud is produced.
Sounds of the Heart
• The heart has 3 pericardial membranes that make up the
pericardial sac.
• The outermost membrane is the fibrous pericardium
which is a loose-fitting sac around the heart.
• The middle layer is parietal pericardium which is a
serous membrane that lines the fibrous layer.
• The inner most layer is the visceral pericardium or
epicardium which is a serous membrane on the surface
of the heart muscle.
• Between the parietal and visceral layers is serous fluid,
which prevents friction as the heart beats.
Sounds of the Heart
• A pericardial friction rub occurs from
inflammation of the pericardium.
• Can be soft and faint to loud enough to be
audible without a stethoscope.
• A rub has a grating sound like sandpaper being
rubbed together that occurs when the pericardial
surfaces rub together during the cardiac cycle.
• A pericardial friction rub may occur after a
myocardial infraction or chest trauma.
Heart Sounds
Heart Wall Layers
• There are 3 layers of the heart wall.
• The first layer is the epicardium which is the
outer layer.
• The second layer is the middle layer which is the
myocardium. This layer forms most of the heart
wall and is responsible for the contraction of the
heart.
• The third layer is the inner most layer called the
endocardium. It consists of small blood vessels
and bundles of smooth muscle.
Heart Wall Layers
• The thickness of the heart walls or a chamber’s wall
depends on the amount of high-pressure work the
chamber does.
• Because the atria only have to pump blood into the
ventricles, their walls are relatively thin.
• The walls of the right ventricle are thicker because it
pumps blood against the resistance of the pulmonary
circulation.
• The walls of the left ventricle are thickest of all because it
pumps blood against the resistance of the systemic
circulation.
• The more a muscle works, the larger it becomes.
Heart Wall Layers
• Pressure changes within the heart affect the
opening and closing of the valves.
• The amount of blood stretching the chamber and
the degree of contraction of the chamber wall
determine the pressure.
• Example: as blood fills a chamber, the pressure
rises; then, as the chamber wall contracts, the
pressure rises further. This increase in pressure
causes the valve to open and blood to flow out
into an area of lower pressure, leading to an
equal pressure state.
Heart Wall Layers
• The heart of course is a muscle and must have
its own blood supply.
• The coronary vessels include arteries,
capillaries, and veins which bring oxygen rich
blood to the heart muscle and also carry away
de-oxygenated blood from the heart muscle.
• The two main coronary arteries are the first
branches of the ascending aorta which are the
right coronary artery and the left coronary artery.
Heart Wall Layers
• The right coronary artery supplies blood
the right atrium, part of the left atrium, and
most of the right ventricle, and the inferior
part of the left ventricle.
• The left coronary artery, which splits into
the anterior descending and circumflex
arteries, supplies blood the left atrium,
most of the left ventricle, and most of the
interventricular septum.
Heart Wall Layers
• The cardiac veins lie superficial to the
arteries.
• The largest vein, the coronary sinus,
opens into the right atrium.
• Most of the major cardiac veins empty into
the coronary sinus; the anterior cardiac
veins, however, empty into the right
atrium.
Heart Blood Supply
Cardiac Conduction
• How does the heart beat?
• The heart has its own specialized electrical system that sends
impulses throughout the heart to cause the “lub-dub” sound of the
heartbeat.
• This specialized electrical system is called the cardiac conduction or
conduction system which makes the atria and ventricles contract
which is a heartbeat or one cardiac cycle.
• The conduction system of the heart begins with the heart’s
pacemaker: the sinoatrial (SA) node.
• The impulse initiated from the SA node travels down an electrical
pathway that makes both atria contract at the same time and then
the ventricles contract at the same time which makes one heartbeat
or a cardiac cycle.
Cardiac Conduction
• A fraction of a second after the two atria contract simultaneously, the
ventricles contract simultaneously.
• The contraction of the atria and ventricles is known as systole.
• The relaxation of the atria and ventricles is known as diastole.
• So…when the atria contract simultaneously, they are in systole and
the ventricles are in diastole.
• So…when the ventricles contract simultaneously, they are now in
systole while the atria are resting in diastole.
• During systole, the atria and ventricles pump, force, or squeeze
blood out of the chambers into the next area (atria blood goes to
ventricles and ventricle blood goes to pulmonary arteries and aorta).
• During diastole, the atria and ventricles fill with blood again (atria will
receive blood from vena cava and pulmonary veins and ventricles
receive blood from atria).
Cardiac Conduction
• So…back to the electrical conduction of the heart.
• The SA node is known as the pacemaker of the heart and is located
in the wall of the right atrium.
• The SA node initiates or generates the first impulse to get the
heartbeat going by sending an electrical impulse throughout an
electrical connecting system of the heart.
• When the SA node fires, an electrical signal or impulse shoots down
an electrical pathway to the atrioventricular (AV) node which is
located in the lower interatrial septum.
• Once the impulse is received by the AV node, the signal travels to
the Bundle of His which is located in the upper interventricular
septum.
• Now the impulse is in the ventricles!
Cardiac Conduction
• So…the impulse leaves the AV node and travels down the Bundle of
His which branches off into the right and left bundle branches.
• The right bundle branch is the electrical pathway that runs down the
right side of the ventricle septum.
• The left bundle branch is the electrical pathway that runs down the
left side of the ventricle septum.
• Once the impulse races down the right and left bundle branches, the
impulse continues to travel around each ventricle through the
Purkinje fibers.
• The Purkinje fibers wrap around each ventricular myocardium.
• The impulse ends in the Purkinje fibers.
Cardiac Conduction
Cardiac Conduction
• Let’s review this once again…a complete cardiac cycle or one
heartbeat.
• The SA node in the upper right atrium wall fires an impulse which
travels to the AV node (this initial impulse is also sent across the left
atrium).
• When the impulse is traveling throughout the atria, the atria is
stimulated to contract.
• Once the impulse is received by the AV node, the AV node acts as a
relay station and sends the impulse down the Bundle of His which
divides into two branches down the ventricular septum called the
right and left bundle branches and the impulse continues down
through the Purkinje fibers which wrap around each ventricle.
• Once the impulse is sent from the AV node the impulse speeds
through the Bundle of His, right and left bundle branches, and
Purkinje fibers which now stimulate the ventricles to contract.
Cardiac Conduction
• Let’s look at the “pacemakers” of the heart.
• The SA node is the heart’s primary pacemaker which initiates the
start of a heartbeat.
• Sometimes, for some reason, the SA node may not work right. It
may fire occasionally, too often, or not at all.
• If the SA node decides it does not want to function correctly, the
heart has a backup plan!
• Pacemaker cells are located in lower areas of the heart and can
initiate an impulse only when they don’t receive an impulse from
another area.
• The backup pacemakers are the AV node and Bundle of
His/Purkinje fibers.
Cardiac Conduction
• The SA node has a firing rate of 60 to 100 beats/minute. This means
each time there is an impulse initiated in the SA node, the heart is
going to beat 60-100 beats/minute which is a normal heart rate.
• If for some reason the SA node is not working right, then the AV
node will fire 40-60 beats/minute. This means if no signal is received
from the SA node, then the AV node will initiate the heartbeat but
will be at a slower rate.
• If the SA node and the AV node decide not to work right, then the
last resort for a the heart to continue to have heartbeats is found in
the Bundle of His/Purkinje fibers.
• The Bundle of His/Purkinje fibers will initiate the heartbeat of a
cardiac cycle at a firing rate of 20 to 40 beats/minute.
• The person with a defective SA node will need medical assistance
for a permanent pacemaker because the heart will not continue to
beat with just the AV or Bundle of His/Purkinje fibers firing.
Cardiac Conduction
• Regulation of heart rate is generated by the SA node; however, the
nervous system can change the heart rate in response to
environmental circumstances.
• The sympathetic and parasympathetic nervous systems are
responsible for the changes of heart rate in response to
environmental circumstances.
• The sympathetic nervous system increases heart rate, BP, Cardiac
Output and force of contraction thanks to the hormone epinephrine.
Example: Fight or Flight Syndrome, fear, low oxygen, low BP, etc.
• The parasympathetic nervous system decreases heart rate.
Example: vagal nerve stimulation such as bearing down with BM.
Cardiac Conduction
• The heart has what is called a depolarization- repolarization cycle.
• When the atria and ventricles contract, this is known as
depolarization.
• When the atria and ventricles complete a cardiac cycle (one
heartbeat), repolarization occurs.
• Repolarization is the resting part of the heart’s cardiac conduction
prior to the next firing of the SA node which begins another
heartbeat.
• We will talk more about this when we learn to read an ECG strip.
Cardiac Output
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Cardiac Output refers to the amount of blood the heart pumps in 1 minute
from the left ventricle.
To determine the cardiac output, multiply the heart rate by the stroke
volume (the amount of blood ejected with each heartbeat).
The average resting heart rate of 75 beats/minute with an average resting
cardiac output of 5 to 6 L per minute.
Starling’s Law states that with exercise, the heart rate and stroke volume
increases as does the cardiac output as much as 4 times the resting level.
Ejection Fraction is a measure of ventricular efficiency and is usually about
60%.
Ejection Fraction is refers to the percentage of blood that’s pumped out of a
filled ventricle with each heart beat. The usual normal amount of blood left
over is approximately 120 to 130 ml.
Percentages less than 60% means more blood is being left in the ventricle
due to the ventricle not pumping as forcefully.
Hormones and the Heart
• We learned that the hormone epinephrine is released
from the adrenal medulla under stressful situations and
will increase the heart rate, BP, cardiac output, and
contractions of the heart.
• Aldosterone is released from the adrenal cortex which is
important for cardiac function to help regulate blood
levels of sodium and potassium which are needed for the
electrical activity of the myocardium. (even a small
deficiency or excess of K+ can impair the heart beat and
rhythm).
Hormones and the Heart
• The heart actually produces and stores two neurohormones A-type
natriuretic peptide (ANP) and B-type natriuretic peptide (BNP). Both
help ensure cardiac equilibrium.
• Disruptions in fluid balance within the circulatory system trigger
release of these hormones, which act as natural diuretics and
antihypertensives.
• ANP is found in atrial tissue and is released by the atria in response
to acute increased fluid volume and blood pressure.
• BNP is found in ventricular tissue and helps accurately diagnose
and grade heart failure severity. It is released by the ventricles in
response to prolonged fluid volume overload or elevated pressure.
• The atria and ventricles become enlarged in response to increased
fluid volume.
Hormones and the Heart
• As nurses, you would most likely see physicians
writing orders for a BNP level.
• The higher the BNP level, the greater the degree
of heart failure.
• Also, the higher the BNP, the patient’s level of
difficulty in completing ADLs increases.
• As the nurse, you would need to be aware of the
BNP level and plan your nursing care of the
patient accordingly.
Blood Vessels
• Blood flows through the body in five types of vessels:
arteries, arterioles, capillaries, venules, and veins.
• When blood leaves the left side of the heart, it leaves via
the aorta which is the largest artery of the body. The
aorta then branches off throughout the body into arteries
which in turn become smaller vessels which are the
arterioles. The arterioles become very small vessels
called capillaries. The capillaries send blood back to the
heart by venules, veins, and then the vena cava (largest
vein of body).
Blood Vessels
• The capillaries are microscopic and only allow
blood cells to pass in single-file.
• The capillaries are where nutrients and gas
exchange occur. They also have filtration of fluid
in the capillaries.
• The filtration of some of the plasma of the blood
in the capillaries forms tissue fluid.
• Some of this tissue fluid is returned to the
capillaries and some is collected in lymph
capillaries.
Blood Vessels
• Once in the lymph capillaries, it is know called
lymph. It will be returned to the blood through
the lymph vessels.
• If the pressure in blood capillaries increase,
more tissue fluid than usual is formed, which is
too much for the lymph vessels to collect which
in turn becomes EDEMA.
• This process of forming edema is important to
remember when learning and understanding
heart failure.
Blood Vessels
• Arteries have thick, muscular walls to accommodate high speed and
pressure of blood flow.
• Arterioles have thinner walls than arteries and control blood flow to
capillaries.
• Capillaries have microscopic walls and have a capillary sphincter
that makes blood cells enter in single-file.
• Venules gather blood from the capillaries and have thinner walls
than arterioles.
• Veins have thinner walls but larger diameters than arteries.
• Valves in the veins (especially lower extremities) prevent blood
backflow. Pressure from the moving volume of blood from below
pushes pooled blood in each valved segment toward the heart.
Blood Pressure
• When you take a patient’s BP, you’re measuring the lateral force
that blood exerts on the arterial walls as the heart contracts (systolic
pressure) and relaxes (diastolic pressure).
• Use a cuff that’s 20-25% wider than the patient’s arm circumference
and make sure you place it centered on the upper arm. (if cuff is too
high or too low or too small or too big, then the BP reading will not
be accurate).
• Support the patient’s arm at heart level. Check BP in both arms
unless contraindicated.
• Use the bell of the stethoscope and deflate the cuff at 2 to 3 mm Hg
per second.
• Normal BP range is systolic 90-140 and diastolic 60-90. (90/60140/90).
Blood Pressure
• If heart rate and force increase, then BP will
increase to a limit.
• If the heart is beating very fast, the ventricles are
not filled completely before they contract,
cardiac output decreases, and BP drops.
• Vasoconstriction causes BP to increase.
• We will discuss HTN later.
Nursing Assessment of CV System
• Nursing assessment of the CV system includes a patient health
history and physical examination.
• If the patient is experiencing an acute problem (chest pain, SOB,
etc.), focus on the most serious signs and symptoms and physical
assessment data until the patient is stabilized. An in-depth nursing
assessment can be completed when the patient is stable.
• Subjective Data you would include in your assessment is past and
current symptoms, any medications currently taking, recreational
drugs, surgeries and dates, current treatments, diet, activity, tobacco
use, and recent stressors.
• Subjective Data: health history, medical history, medications, family
history, and health promotion.
Nursing Assessment of CV System
• Objective Data: physical assessment, BP, pulses, respirations,
inspection, clubbing, palpation, percussion, auscultation.
• When checking BP on admission or first assessment, check BP in
each arm lying, sitting, and standing unless contraindicated. * The
older adult is at an increased risk for developing orthostatic
hypotension, which could precipitate a fall due to a combination of
age related changes, immobility, chronic illnesses, and medications.
• Clubbing of the nail beds occurs from oxygen deficiency over time.
Often caused by congenital heart defects or the long-term use of
tobacco.
• Clubbing is characterized by the distal ends of the fingers and toes
appear swollen and appear club-like.
Nursing Assessment of CV System
Diagnostic Studies for CV System
• There are two types of diagnostic studies: non-invasive and
invasive.
• Non-invasive studies include CXR (chest x-ray), CT (cardiac calcium
scan),cardiac calcium scan, magnetic resonance imaging (MRI),
electrocardiogram (ECG/EKG), holter monitor, exercise tolerance
testing, tilt table test, cardiac stress test, peripheral vascular stress
test, echocardiogram (echo), transesophageal echocardiogram
(TEE), radioisotope imaging, thallium imaging, positron emission
tomography (PET), doppler ultrasound, and blood work.
• Invasive studies include angiography, cardiac catheterization,
hemodynamic monitoring, and electrophysiologic study.
Diagnostic Studies for CV System
• CXR: no discomfort, can reveal enlarged heart, calcifications, and
fluid around heart. Will confirm correct placement of pacemaker
leads and other IV lines. Assess for possible pregnancy. No signed
consent required.
• Cardiac Calcium Scan: shows plaque or calcifications in the
coronary arteries. Patient told to avoid caffeine and smoking 4 hours
before test. May need written consent signed.
• MRI: may or may not be used for cardiac diagnostic testing. Patients
with pacemakers, metal implants, metal shavings, or shrapnel are
not candidates for this test. May or may not have signed consent.
• ECG/EKG: assesses the electrical activity of the heart from different
views. Assesses for abnormalities such as MI, ischemia, electrolyte
imbalances, etc. No consent form. May need to shave hair to place
electrodes.
Diagnostic Studies for CV System
• Holter Monitor: may be used for 48 hours to capture any
abnormalities. Teach to push event button and document what
activity was during event. May or may not have consent form.
• Tilt Table Test: helps with diagnosis of syncope (fainting spells) by
assessing heart rate and BP during a change in position from lying
down to standing up. May or may not have consent signed.
• Exercise Tolerance/Stress Test: measures cardiac function or
peripheral vascular disease during a defined exercise protocol
(treadmill/bike). Patient teaching: no smoking, eating, or drinking 2-4
hours prior to test. Wear comfortable shoes, bra, clothing. Rest after
test before eating. Avoid eating or drinking stimulants for a few
hours after test. May or may not have signed consent.
Diagnostic Studies for CV System
• Cardiac Stress Test: simulates sympathetic nervous system (fight
or flight) stimulation. Shows heart response to increased oxygen
needs. Used to evaluate coronary artery disease, ischemic heart
disease, cause of chest pain, and dysrhythmias. Baseline VS prior
to test. Patient will use treadmill, bike, or stair climber. VS and ECG
continue to be monitored after test until return to baseline. May or
may not have consent signed.
• Peripheral Vascular Stress Test: patient walks for 5 minutes at 1.5
miles per hour on treadmill. Pulse measurements are checked at
certain intervals including baseline, during test, and after test. Test is
stopped if claudication occurs. May or may not have signed consent.
Diagnostic Studies for CV System
• Echocardiogram (echo): ultrasound of heart which can detect
abnormalities of septum, valves, and other structures of the heart.
No prep required. No consent form to be signed.
• Transesophageal Echocardiogram (TEE): able to visualize the
heart with a clearer picture by placing transducer in the esophagus.
The picture is clearer because the lungs and ribs are not obstructing
the view as with echo. Patients are prepped as NPO for about 6
hours prior to test, will receive sedative, and have throat
anesthetized. Suction continuously during procedure. Nurse should
check for gag reflex return as routine post-op care. Consent form
should be signed.
Diagnostic Studies for CV System
• Radioisotopes: shows cardiac contractility, injury, and perfusion.
Patient should lie supine with arms over head for about 30 minutes
to help medication circulate to heart. Radioactivity is small and gone
within a few hours. May or may not have consent form signed.
• Thallium Imaging: Thallium 201 given IV to evaluate cardiac blood
flow and perfusion. With exercise, thallium given 1 minute before
end of test to circulate thallium. Scan done within 10 minutes and
repeated in 2 to 4 hours for comparison. Cold spots on initial images
indicate ischemia. If cold spots are gone in later images, it indicates
exercise-induced ischemia. If the cold spots are still present in later
images, they show scarred areas. If unable to do exercise with test,
then Persantine or adenosine (coronary vasodilators) can be given.
May have consent form signed.
Diagnostic Studies for CV System
• Positron Emission Tomography (PET): Special medication is
given IV and scans are performed to evaluate cardiac perfusion and
cardiac metabolic function. Exercise may also be used. Patient’s
blood sugar must be 60 to 140 for accuracy. Consent may be
signed.
• Doppler Ultrasound: evaluates PVD. Painless, takes about 20
minutes to complete. No consent form signed.
Lab Work Common for CV
• Cardiac Enzymes: when heart cells are damaged or die, they
rupture and release enzymes into the bloodstream. Levels of these
enzymes rise in the serum as a result. You will see orders from
physicians that state: VP Cardiac Enzymes now and q8h x3.
• Cardiac Enzymes lab work includes: creatine kinase (CK) which is
also called creatine phosphokinase (CPK). Troponin I, CK-MB, and
myoglobin.
• Troponin I: are highly sensitive indicators of myocardial damage,
which is helpful in diagnosing MI. Elevated levels within 4-6 hours of
damage may be seen. These levels peak in 10-24 hours and remain
elevated for up to 7 days after injury.
Lab Work Common for CV
• CK: is found in three types of tissue (brain, skeletal muscle, and
heart muscle). CK-BB is brain; CK-MM is skeletal muscle; and CKMB is cardiac muscle.
• CK-MB levels rise within 4-6 hours after cardiac cells are damaged,
peak in 12-24 hours, and return to normal in 49-72 hours. These
levels are drawn in serial intervals (q8h). It is important to avoid IV
and IM injections before drawing the first CK to prevent elevation in
the CK levels from cell trauma caused by the procedure. Afterwards,
IV meds are preferred to IM medications to prevent contributing to
this elevation.
Lab Work Common for CV
• Myoglobin: is a protein found in skeletal and cardiac muscles and is
released into the bloodstream when cell damage occurs. It can only
provide an estimate of damage and is used with other more specific
tests such as Troponin to diagnosis MI. Levels elevate within 1 hour
of an acute MI. Peak levels are reached 4-12 hours after an MI, and
levels return to normal within 18 hours after the onset of chest pain,
so it is a test that must be done early when MI is suspected.
• Blood Lipids include triglycerides, cholesterol, and phospholipids.
A lipid profile may be ordered which can screen for increased risk for
coronary artery disease (CAD).
Diagnostic Studies for CV System
• Angiography: two types; arteriography and venography.
Arteriography examines arteries. Venography studies veins. Dye is
injected into the vascular system to visualize the vessels on
radiographs. This test is used to assess blood clot formation,
peripheral vascular disease (PVD), and to test vessels for potential
grafting use. Assess for allergies, NPO for about 4 hours before test,
teach that the dye produces a hot, burning feeling when injected.
Consent should be signed. Post-op care includes VS, allergic
reaction signs, hemorrhage at the injection site, and pulses are
monitored.
Diagnostic Studies for CV System
• Cardiac Catheterization: assesses heart’s anatomy and
physiology. Measures pressures in heart chambers, great blood
vessels, and coronary arteries and provides information on cardiac
output and oxygen saturation. Fluoroscopy is used, and dye can be
injected once the catheter is in place to visualize the heart chambers
and vessels. This is often done before cardiac surgery. Consent
must be signed. Assess patient for allergies to iodine and procedure
dyes. Patient is NPO after midnight prior to test. May be awake or
slightly sedated during procedure. May feel a warm, flushing
sensation when the dye is injected. Procedure may take 2-3 hours.
May use right or left groin. Groin to be used is prepped prior with
soap and water, shaved, and cleansed with special antimicrobial
solution. During a catheterization, the physician may insert stents or
perform angioplasty (ballooning to open vessels). Other tests may
be done during this test.
Diagnostic Studies for CV System
• Cardiac Catheterization continued: complications can be allergic
reaction, breaking of the catheter, hemorrhage, thrombus formation,
emboli of air or blood, dysrhythmias, MI, CVA, and puncture of the
heart chambers or lungs. Patient remains supine with affected leg
straight for several hours after procedure. May have sandbag,
pressure dressing, or seal dressing to groin site. May be done as
outpatient.
• Hemodynamic Monitoring: is bedside monitoring to monitor the
pressures of the blood vessels or heart. A catheter is attached to a
transducer and monitor, called an arterial line (A-line), which is in the
radial or femoral artery to measure arterial BP. Cardiac pressures,
cardiac output, central venous pressure, wedge pressure, etc. is
used. May be through Swan-Ganz line. RN or MD will perform
hemodynamic monitoring.
Diagnostic Studies for CV System
• Electrophysiologic Study: to study the heart’s electrical system.
Catheter with electrodes are inserted via the femoral vein into the
right side of heart. The heart’s electrical impulses are then recorded
and pacing can also be done. Dysrhythmias can be triggered and
ablation can be done. Patient is NPO 6-8 hours prior to test.
Consent form must be signed.
Therapeutic Interventions for CV System
• Exercise may be ordered 2-3 times a week such as with cardiac
rehab.
• Smoking Cessation
• Diet: low fat, low cholesterol, low sodium diet may be ordered. To
reduce fat, red meats, fried foods, whole milk, and cheese should be
limited or avoided. Cholesterol can be reduced by avoiding egg
yolks, organ meats, animal fats, and shellfish. Five to six servings of
fresh fruit and vegetables should be eaten daily. Increasing fish
intake and eating poultry without skin are parts of healthy diet.
• Oxygen may be used at home. Teach no open flames or smoking
with oxygen use. If concentrator is used, backup tanks should be
kept in home.
• Medications may be prescribed.
Therapeutic Interventions for CV System
• Antiembolism devices such as elastic stockings (TED) and
intermittent pneumatic compression devices (SCD) may be used
even in the home to prevent blood clots and help with circulation.
TED hose must be applied correctly to avoid tourniquet effect. May
be removed for a short time daily to inspect skin or irritation.
• Lifestyle changes may need to be changed such as stress reduction,
meditation, and relaxation.
Therapeutic Interventions for CV System
• Cardiac Surgery may be needed for valve replacement and/or
bypass of coronary vessels.
• Patients should be taught to hold any blood thinners 5-7 days prior
to surgery to prevent excessive bleeding.
• Patients and family members should be taught prior to surgery what
to expect prior to surgery, during surgery, and after surgery.