Nurs 335 Cardiovascular and Peripheral Vascular Lecture Notes PDF

Cardiovascular and Peripheral Vascular Lecture Learning Outcomes By completing this week's class activities, students will be able to conduct and assessment of the cardiovascular and peripheral vascular system (with lymphatics): ◦Apply knowledge of anatomy and physiology as it relates...

Cardiovascular and Peripheral Vascular Lecture Learning Outcomes By completing this week's class activities, students will be able to conduct and assessment of the cardiovascular and peripheral vascular system (with lymphatics): ◦Apply knowledge of anatomy and physiology as it relates to examination heart and peripheral vascular systems. Link this knowledge to the concept of perfusion. ◦Identify important general survey findings and health history questions. ◦Explain correct assessment techniques in examining the heart and peripheral vascular system with rationale. ◦Interpret expected heart sounds (S1, S2, S2 Physiologic Split) by auscultation. ◦Relate how knowledge of these assessment techniques translate to a head to toe approach. ◦Differentiate expected and unexpected findings. ◦Document findings. 2 November 6 2024 Class Agenda Video Heart Anatomy Review Cardiac Physiology Review ○ Electrical Involvement and PQRST ○ Cardiac Cycle ○ Perfusion General Survey Health History Physical Assessment ○ IPPA Peripheral Vascular and Lymphatics Assessment ○ Anatomy and Physiology Review ○ IPPA ○ Pulses and Lymph nodes ○ Expected findings and red flags 3 https://www.youtube.com/watch?v=MmWWoMc Gmo0 4 Anatomy Review  Heart sits mostly left and Note: the Base is measured of the heart is from the 2nd- broad and at 5th intercostal the top. The space. apex is the bottom aspect of the heart at the 5th ICS (apical impulse point). 6  Head and Neck Vasculature https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.ncbi.nlm.nih.gov %2Fbooks%2FNBK499911%2Ffigure%2Farticle- 17736.image.f1%2F&psig=AOvVaw3VVz8w2SjD1ywyCKrzfFr0&ust=1645756238736 000&source=images&cd=vfe&ved=0CAsQjRxqFwoTCJihufSll_YCFQAAAAAdAAAAABA i https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.alamy.com %2Fanatomy-of-the-arteries-veins-and-nerves-of-the-cervical-neck-spine- image7712584.html&psig=AOvVaw0_wtK0OenA55czrfanqEgS&ust=16457561 98507000&source=images&cd=vfe&ved=0CAsQjRxqFwoTCPix3- Kll_YCFQAAAAAdAAAAABAD 7 Physiology Review  To Periphery (rest of body) To Lungs To Lungs From Lungs to LA From Lungs to LA Pulmonic Valve Bicuspid AV Valve Aortic Valve Tricuspid AV Valve To Periphery (rest of body) 9 Perfusion - The process of delivering blood from capillaries to tissues - Cardiac output is the amount of blood ejected from the LV each minute (CO= Stroke Volume x HR) What could be impacting my patient’s ability to perfuse tissue? 10 Electrical Conduction of the Heart Sinoatrial (SA) Node: natural pacemaker. Sends an impulse to atrial muscles to contract and begin the cardiac cycle Atrioventricular Node: transmits the SA impulse to activate Bundle of HIS & Purkinje Fibres AND Synchronize/Mediate impulses Bundle of His & Bundle Branches: conduct impulses through ventricular wall 11  ECG (electrocardiogram) ◦P Wave: atrial depolarization (atrial contraction) ◦PR interval: SA-BB conduction ◦QRS: ventricular systole/contraction (hidden is atrial diastole) ◦T Wave: ventricular diastole (filling) https://www.google.com/url?sa=i&url=https%3A%2F%2Ftenor.com%2Fview%2Fheartbeat- conduction-heart-blood-cardiology-gif- 7044974&psig=AOvVaw3rAeXvIaK4oicDhzAy_Du5&ust=1645747753418000&source=images &cd=vfe&ved=0CAwQjhxqFwoTCLiZyqmGl_YCFQAAAAAdAAAAABBd 12 https://www.google.com/url?sa=i&url=https%3A%2F%2Fgfycat.com%2Fgifs%2Fsearch%2Fcardiac%2Bconduction %2Bsystem&psig=AOvVaw3rAeXvIaK4oicDhzAy_Du5&ust=1645747753418000&source=images&cd=vfe&ved=0C AsQjRxqFwoTCLiZyqmGl_YCFQAAAAAdAAAAABBY  General Survey and Vitals Recall how to take accurate vitals and ensure you have a baseline to inform your assessment. - Temp - BP and MAP! - Pulse and presence of deficits - Daily weights- first thing in the AM, post void is ideal 13 What are some expected and unexpected cardiac assessment findings in a general survey or overall inspection of the patient? Pair Share! Turn to your partner and share your ideas! 14 15  Health History PP. 537- 540 Determine Risk Factors - History of Smoking? - How do they maintain a healthy diet? Do they work to be active? How do they manage stress? - Is there any family history of heart disease? Past history of a congenital heart defect? - Is their blood pressure or cholesterol levels managed or a risk factor? - Are they on any cardiac medications? Why? Assessment of Signs and symptoms - Chest pain/discomfort/pressure/tightness - Radiating pain: neck/jaw/shoulder arm pain/back pain - Dyspnea/ Orthopnea/Paroxysmal Nocturnal Dyspnea - Cough - Palpitations (feeling like your heart is fluttering or that you skipped a beat) - Diaphoresis - Fatigue/Sleep changes/Exercise or activity intolerance - Edema - Nocturia 16 Inspect the Neck and Jugular Vein Inspect if you are able to see pulsations and/or distension of the Internal Jugular vein along the SCM Have the patient HOB at a 30-45 degree angle and their head turned slightly left Use tangential lighting to visualize the vessels under the skin If visible distension is present, you can measure the Jugular Venous Pressure Distension is NOT an expected https://www.google.com/imgres?imgurl=https%3A%2F%2Fpost.medicalnewstoday.com%2Fwp-content%2Fuploads%2Fsites finding. %2F3%2F2020%2F02%2F320320_1100-732x549.jpg&imgrefurl=https%3A%2F%2Fwww.medicalnewstoday.com%2Farticles %2F320320&tbnid=wwtY4L4wtTGR6M&vet=10CBMQxiAoAmoXChMI0OSG7bCX9gIVAAAAAB0AAAAAEAc..i&docid=mhRzzFvZwgBxAM&w =732&h=549&itg=1&q=heart%20failure%20adult%20example %20&hl=en&ved=0CBMQxiAoAmoXChMI0OSG7bCX9gIVAAAAAB0AAAAAEAc 17 Measuring Jugular Venous Pressure (JVP) Note: Less than 3cm above the sternal angle with no visible distension is our EXPECTED finding How to estimate: 1. Locate Sternal Angle (Sternal angle is about 5 cm above right atrium) 2. Landmark Right Internal JV location (head turned slightly to left) or EJV if that is more visible 3. Observe for highest point of distention and measure distance from from the sternal angle 18 Carotid Artery Assessment (IAP) Inspect - Visualize Auscultate - Listen with the bell of your stethoscope for Bruits - Have patient hold breath to ensure breath sounds don’t impede assessment Palpate ◦One side at a time to avoid obstructing cerebral blood flow ◦Compare bilaterally Expected Findings include: Normal rate, rhythm, quality with no adventitious sounds 19 Carotid or Jugular? How to tell the Jugular Venous Pulse from the Carotid Pulse? (Call the POLICE) P- Palpation: JV pulse is non palpable O- Occlusion: JV pulse readily occludes L- Location: Sits between the SCM heads- lateral to carotid I- Inspiration: drops with inspiration C- Contour: Biphasic waveform E- Erection/Position: Drops when sitting upright 20 Inspection- Cardiac - Inspect the thorax and precordium for scars, pulsations, deformities, lesions, masses, heaves - HOB at 30 21 Percussion Replaced by chest X-ray or Echocardiogram to assess fluid in the thoracic cavity or cardiomegaly. Side note: fluid can be assessed through auscultation of precordium 22 Palpation - Palpate the apical impulse at the 5th ICS at the MCL - Use your palm to gently palpate the http://pressbooks.library.ryerson.ca/vitalsign/wp-content/uploads/sites/26/2018/01/ ApicalPulseFinal-1024x1003.jpg area surrounding the heart for tenderness or masses 23 Auscultation Diaphragm of the stethoscope is used to auscultate the heart sounds made from the AV and semilunar valves closing. S1 S2 Note: Auscultate on the SKIN SURFACE. Not over clothes or gown for best assessment 24 https://geekymedics.com/wp-content/uploads/2020/04/Heart-murmur-locations-1- 700x300.jpg 25 26 Other findings in Auscultation - S2 Physiologic Split - when valves close at slightly different times due to changes in intrathoracic pressure (especially during inspiration) Muffled heart sounds - S3 and S4 sounds (extra heart sounds) - S3 : “Lub REDduFLAG bub” (may be expected for Cardiac in people less than 40 or in Tamponade CHF) - S4: “Be Lub Dub” (Pathological origin) - Murmurs (whooshing) - Caused by disrupted blood flow due to septal defects, valve abnormalities, Patent ductus arteriosus, or stenotic vessels - Systolic murmurs: Aortic or pulmonic stenosis, AV valve regurgitation, VSD - Diastolic Murmurs: AV valve stenosis, Aortic or 27 pulmonic regurgitation 28 Red Flags LOC Changes Chest Pain Shortness of breath (!!!) Lightheadedness Fluid Volume Overload ECG changes See Table 19-1 p. 533 29  Peripheral Vascular System and Lymphatics Assessing the Periphery Peripheral Lymphatics Combine Previous Vascular Ax ➔ Lymphedema Learning (including Fascial Compartments) ➔ Lymph nodes ➔ Skin Hair and Nails ➔ Chylothorax ➔ CNS/PNS ➔ Pulses ➔ CVS/Respiratory ➔ Edema Plus MSK ➔ Compartment Assessment! syndrome? ➔ Deep venous thrombosis? 31 Anatomy & Physiology Review PVS and Lymphatics A+P Peripheral Vascular Arteries - Thick walled, elastic, high pressure - Largest is the Aorta Veins - Thinner and less elastic, low pressure - Valves to prevent back-flow - Superior vena cava Capillaries - Location of exchange of gases, nutrients, metabolites 33 A+P Lymphatics Lymphatic system - Lymph nodes & vessels - Valves for flow - Maintains fluid balance & immune function - Run parallel to arteries & veins - Lymph drains into Thoracic duct & Right Lymphatic duct subclavian veins superior vena cava right atrium 34 Fascial Compartments - Fascia are sheets of connective tissue that enclose the blood vessels, nerves and muscles which make up compartments. - Limited stretch in the fascia can cause problems when there is inflammation to any of the enclosed components. 35  Why might someone have this General Survey condition? What are the risk factors? Pair share!! https://www.thrombosisadviser.com/image-library/ 36 RED FLAG: Deep Vein Thrombosis Deep Vein Thrombosis (DVT) - Pain/edema/warmth - Weak pulses - Delayed Cap Refill *Risk of Pulmonary Embolism (PE) - Acute respiratory distress, chest pain, high HR, sweating, anxiety 37 Health History Analysis of S/S for - Personal History Periphery: - Medications - Pain - Family History (Hx of - Numbness/tingling stroke, clots etc.) (sensation) *Keeping in mind CVS - Cramping questions! - Changes in Skin Colour - Edema - Function 38  PVS and Lymphatics - Inspection Inspect Raynaud's Phenomenon - All extremities, comparing colour, size, and quality. - Hint: bring back Skin/Hair/Nails Mottlin g Cyanos is https://content.ca.healthwise.net/resources/12.9/en-ca/media/medical/hw/aci4607_460x300.jpg Any guesses? 39 Lymphedema 40 Edema Check your reference card 📌 https://www.osmosis.org/answers/pitting-edema More | Osmosis 41 Palpation for Lymphatics 42 Palpation for PVS ➔ Move distal to proximal (out to in) ➔ Note: ◆ TEXTURE/MOISTURE ◆ TEMPERATURE Warm and Dry or Trunk Warm-Extremities Cool ◆ TURGOR ◆ CAPILLARY REFILL Less than or equal to 2sec/Between 2-3sec/Greater than or equal to 4sec ◆ EDEMA Determine if pitting or non pitting If pitting: grade it ◆ PULSES Documenting strength grade and comparing for symmetry 43  Pulse s *Infants and small children: brachial is the preferred pulse to assess in the upper extremities Red Boxes indicate “central pulses” https://www.registerednursern.com/wp- content/uploads/2019/05/pulse-points- 44 nursing.png Assessment of Pulses: Know Your Scale! For Textbook: Box 20-3 Tests Grading of Pulses Connect Care Pulse AHS Extremity Grading Neurovascular Pulse Pulse Grading Strength/Amplitude Measured from Non- palpable – Bounding - Absent 0 - Weak +1 - Strong+2 - Full (increased) +3 - Bounding +4 45 Doppler Used when: - Pulses are difficult to palpate due to injury, edema, surgery, https://cdn.exmed.net/public/ 0012438_proadvantage- **Pulses once palpable and that lubricating-jelly.jpeg begin to require a doppler must be reported. - If pulse is then unable to be heard https://abc-medical.com/wp- on the doppler, that is an content/uploads/2020/10/ NATEN80_500-x-500.jpg emergent situation 46  Compartment Syndrome https://www.thelancet.com/journals/ RED lancet/article/PIIS0140- 6736%2813%2961954-6/fulltext FLAG Usually caused by bleeding or swelling after Fasciotomy injury into closed compartment or an untreated DVT. - Pain and paresthesia. - >6 hours = permanent damage! - Think: surgery on a limb, fractures, traumas 47  Limb Ischemia RED FLAG: 6 Ps of Limb Ischemia Pain quality & quantity ◦Rest pain usually worse distally (may be relieved by dependency) 📌 Pallor (pale, mottled skin) - Compare to opposite limb (white rather than blue) - Chronic may appear pink due to compensatory vasodilation - Buerger’s test: Pallor on elevation and erythema on dependency Pulselessness - Use a Doppler Polar sensation/Poikilothermia - Cold to palpation compared to other limb Paresthesia (burning, tingling, numbness) - Earlier sign as small sensory nerves fibres are sensitive to ischemia Paralysis - Late sign 48  Extravasatio Infiltrati n on https://allnurses.com/iv-infiltration-problems-t4 696rses (vesicant leaking (IV fluid into https://www.e-cep.org/ leaking into upload//thumbnails/ compartments) kjped-58-454-g005.jpg surrounding compartment s) Another form of Compartment Syndrome IV Infiltration and Extravasation 49  Perfu sion Recall Red Flag Assessment Findings and connect your interdisciplinary team as needed 50 Practice, practice, practice! 51 References and Resources Moran, G.(2006) Practice learning resources: Cardiology teaching package. School of Health Sciences, University of Nottingham. https://www.nottingham.ac.uk/nursing/practice/resources/rsing - The University of Nottingham Stephen, T.C., & Skillen, D. L., (2021). Canadian nursing health assessment: A best practice approach – enhanced reprint. Philadelphia: Lippincott, Williams, & Wilkins. 52