Cardiovascular Assessment.pdf

Assessment of the Cardiovascular System Benjiber R. Silva LSU-Clinical Instructor NCM18-112c MEDICAL SURGICAL NURSING  Assessment of the Cardiovascular System ❖ The frequency and extent of the nursing assessment of cardiovascular function are based on several fact...

Assessment of the Cardiovascular System Benjiber R. Silva LSU-Clinical Instructor NCM18-112c MEDICAL SURGICAL NURSING  Assessment of the Cardiovascular System ❖ The frequency and extent of the nursing assessment of cardiovascular function are based on several factors: Severity of the patient’s symptoms Presence of risk factors, the practice setting, and the purpose of the assessment. ❖ The assessment priorities vary according to patient needs. Example Acute coronary syndrome (ACS), Signs and symptoms caused by ruptured atheromatous plaque in a diseased coronary artery ❖ Diagnosis and treatment must be started immediately, which includes an electrocardiogram (ECG) within 10 minutes of arrival to the ED ❖ The physical assessment is ongoing and concentrates on evaluating the patient for ACS complications, such as a myocardial infarction (MI), arrhythmias, and HF, and determining the effectiveness of medical treatment. NCM18-112c MEDICAL SURGICAL NURSING  ❖ When assessing cardiovascular health, a comprehensive evaluation is essential to determine the overall condition of the heart and blood vessels. Here’s a general outline of what a cardiovascular health assessment typically includes: 1. Health History Personal History: Document any history of cardiovascular diseases such as hypertension, coronary artery disease, heart attacks, or stroke. Family History: Note any family history of cardiovascular diseases or risk factors like high blood pressure, diabetes, or high cholesterol. Lifestyle Factors: Review lifestyle factors including smoking, alcohol consumption, physical activity, and diet. Symptoms: Ask about symptoms such as chest pain, shortness of breath, palpitations, dizziness, or swelling in the legs. Medical Conditions: Identify any chronic conditions such as diabetes, high cholesterol, or obesity that may impact cardiovascular health. ✓ During the health history, the nurse determines if the patient and involved family members are able to recognize symptoms of an acute cardiac problem, such as ACS or HF, and seek timely treatment of these symptoms. Responses to this level of inquiry will help the nurse individualize the plan for patient and family education. NCM18-112c MEDICAL SURGICAL NURSING  2. Physical Examination Blood Pressure: Measure blood pressure to assess for hypertension. Heart Rate: Check heart rate for rhythm and regularity. Auscultation: Listen to the heart sounds for abnormal murmurs, clicks, or rubs. Peripheral Pulses: Evaluate pulses in the arms and legs to ensure good blood flow. Inspection: Look for signs of fluid retention, such as swelling in the ankles or legs. 3. Diagnostic Tests Electrocardiogram (ECG/EKG): Assess heart rhythm and detect any irregularities Echocardiogram: Use ultrasound to visualize heart chambers, valves, and overall function. NCM18-112c MEDICAL SURGICAL NURSING  Blood Tests: Check levels of cholesterol, triglycerides, and other markers like B-type natriuretic peptide (BNP) for heart failure. Chest X-ray: Look for signs of heart enlargement or fluid buildup in the lungs. NCM18-112c MEDICAL SURGICAL NURSING  4. Risk Assessment Risk Factors: Evaluate risk factors like high blood pressure, smoking, high cholesterol, diabetes, and family history. 5. Patient Education Lifestyle Changes: Discuss the importance of diet, exercise, smoking cessation, and stress management. Medication Adherence: Review any prescribed medications and their role in managing cardiovascular health. NCM18-112c MEDICAL SURGICAL NURSING  6. Follow-Up and Management Plan: Develop a plan for managing any identified issues, which might include medication, lifestyle changes, or further testing. Monitoring: Schedule follow-up appointments to monitor progress and adjust treatment as needed. Common Symptoms The following are the most common signs and symptoms of CVD, with related medical diagnoses in parentheses: Chest pain or discomfort (angina pectoris, ACS, arrhythmias, valvular heart disease) Pain or discomfort in other areas of upper body, including one or both arms, back, neck, jaw, or stomach (ACS) Shortness of breath or dyspnea (ACS, cardiogenic shock, HF, valvular heart disease) Peripheral edema, weight gain, abdominal distention due to enlarged spleen and liver or ascites (HF) Palpitations (tachycardia from a variety of causes, including ACS, caffeine or other stimulants, electrolyte imbalances, stress, valvular heart disease, ventricular aneurysms) NCM18-112c MEDICAL SURGICAL NURSING  Unusual fatigue, sometimes referred to as vital exhaustion (an early warning symptom of ACS, HF, or valvular heart disease, characterized by feeling unusually tired or fatigued, irritable, and dejected) Dizziness, syncope, or changes in level of consciousness (cardiogenic shock, cerebrovascular disorders, arrhythmias, hypotension, orthostatic hypotension, vasovagal episode) Chest Pain ❖ Chest pain and chest discomfort are common symptoms that may be caused by a number of cardiac and noncardiac problems. The nurse keeps the following important points in mind when assessing patients reporting chest pain or discomfort: The location of chest symptoms is not well correlated with the cause of the pain. For example, substernal chest pain can result from a number of causes The severity or duration of chest pain or discomfort does not predict the seriousness of its cause. For example, when asked to rate pain using a 0 to 10 scale, patients experiencing esophageal spasm may rate their chest pain as a 10. In contrast, patients having an acute MI, which is a potentially life-threatening event, may report having moderate pain rated as a 4 to 6 on the pain scale. NCM18-112c MEDICAL SURGICAL NURSING  More than one clinical cardiac condition may occur simultaneously. During an MI, patients may report chest pain from myocardial ischemia, shortness of breath from HF, and palpitations from arrhythmias. Both HF and arrhythmias can be complications of an acute MI. Past Health, Family, and Social History ❖ The health history provides an opportunity for the nurse to assess patients’ understanding of their personal risk factors for peripheral vascular, cerebrovascular, and CAD and any measures that they are taking to modify these risks. Some risk factors, such as: Increasing age Male gender, and Heredity, including race are not modifiable. There are a number of risk factors that can be modified by lifestyle changes or medications, such as: Smoking Hypertension High cholesterol Diabetes Obesity Physical inactivity NCM18-112c MEDICAL SURGICAL NURSING  In an effort to determine how patients perceive their current health status, the nurse asks the following questions: How is your health? Have you noticed any changes from last year? From 5 years ago? Do you have a cardiologist or primary provider? How often do you go for checkups? What health concerns do you have? Do you have a family history of genetic disorders that place you at risk for CVD What are your risk factors for CAD What do you do to stay healthy and take care of your heart? NCM18-112c MEDICAL SURGICAL NURSING  Assessing Chest Pain NCM18-112c MEDICAL SURGICAL NURSING  ▪ Pericarditis is inflammation of the pericardium, a sac-like structure with two thin layers of tissue that surround the heart to hold it in place and help protect it from damage from infection and malignancy. A small amount of fluid keeps the layers separate so there’s less friction between them as the heart beats. NCM18-112c MEDICAL SURGICAL NURSING  Pulmonary diseases may be caused by infection, by smoking tobacco, or by breathing in secondhand tobacco smoke, radon, asbestos, or other forms of air pollution. Pulmonary diseases include asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, pneumonia, and lung cancer. NCM18-112c MEDICAL SURGICAL NURSING NCM18-112c MEDICAL SURGICAL NURSING Costochondritis is inflammation where your ribs join the bone in the middle of your chest (breastbone). It can cause sharp chest pain, especially when moving or breathing. It usually gets better on its own over time. NCM18-112c MEDICAL SURGICAL NURSING  Patients recovering from ACS, including coronary stent placement or coronary artery bypass graft (CABG), are commonly prescribed dual antiplatelet therapy (DAPT). DAPT means that two antiplatelet drugs are prescribed for the patient. Aspirin, an OTC antiplatelet medication, is often prescribed for life. A second antiplatelet P2Y12 inhibitor medication (clopidogrel, prasugrel, or ticagrelor) is prescribed for 1 to 12 months, depending upon a variety of factors, including the patient’s diagnosis and the type of procedure done NCM18-112c MEDICAL SURGICAL NURSING  Nutrition Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: Hyperlipidemia Hypertension Diabetes Diets that are restricted in sodium fat, cholesterol, or calories are commonly prescribed The nurse obtains the following information: The patient’s current height and weight (to determine body mass index [BMI]); waist measurement; BP; and any laboratory test results such as blood glucose, glycosylated hemoglobin (diabetes), total blood cholesterol, HDL and LDL levels, and triglyceride levels (hyperlipidemia) How often the patient self-monitors BP, blood glucose, and weight as appropriate to the medical diagnoses The patient’s level of awareness regarding their target goals for each of the risk factors and any problems achieving or maintaining these goals NCM18-112c MEDICAL SURGICAL NURSING  What the patient normally eats and drinks in a typical day and any food preferences (including cultural or ethnic preferences) Eating habits (canned or commercially prepared foods vs. fresh foods, restaurant meals vs. home cooking, assessing for high-sodium foods, dietary intake of fats) Who shops for groceries and prepares meals Elimination Typical bowel and bladder habits need to be identified: Nocturia (awakening at night to urinate) is common in patients with heart failure (HF). When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow and resulting in syncope in some patients. Straining during urination can produce the same response. NCM18-112c MEDICAL SURGICAL NURSING  Many cardiac medications can cause gastrointestinal side Platelet aggregation inhibitors: effects or bleeding, the nurse Abciximab, asks about: Eptifibatide, Tirofiban Bloating Diarrhea Constipation, Anticoagulants (low-molecular- Stomach upset weight heparins such as: Heartburn Dalteparin or Enoxaparin; Loss of appetite Nausea, and vomiting Heparin; or oral anticoagulants such as Warfarin, Rivaroxaban, or Apixaban). Screening for bloody urine or stools should be done for patients taking antiplatelet medications : aspirin, clopidogrel, prasugrel, ticagrelor), NCM18-112c MEDICAL SURGICAL NURSING  Activity and Exercise Changes in the patient’s activity tolerance are often gradual and may go unnoticed. The nurse determines if there are recent changes by comparing the patient’s current activity level with that performed in the past 6 to 12 months. New symptoms or a change in the usual symptoms during activity is a significant finding. Activity-induced angina or shortness of breath may indicate CAD. Symptoms occur when myocardial ischemia is present, due to an inadequate arterial blood supply to the myocardium, in the setting of increased demand (e.g., exercise, stress, or anemia). Certain medications that can result in activity intolerance such as beta- adrenergic blocking agents ( medicines that lower blood pressure). Examples of beta blockers taken by mouth include: Acebutolol. Atenolol (Tenormin). Bisoprolol. Prescribed for Metoprolol (Lopressor, Toprol XL). Nadolol (Corgard). Nebivolol (Bystolic). Propranolol (Inderal LA, InnoPran XL). NCM18-112c MEDICAL SURGICAL NURSING  Additional areas to explore include the presence of architectural barriers in the home: Stairs, multilevel home The patient’s participation in cardiac rehabilitation His or her current exercise pattern including intensity, duration, and frequency. Sleep and Rest Clues to worsening cardiac disease, especially HF, can be revealed by sleep related events. Patients with worsening HF often experience orthopnea (shortness of breath when lying down that's relieved by standing or sitting up) Patients experiencing orthopnea will report that they need to sleep upright in a chair or add extra pillows to their bed. Sudden awakening with shortness of breath, called paroxysmal nocturnal dyspnea ( sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position ) Sudden pulmonary congestion. Sleep-disordered breathing (SDB) is an abnormal respiratory pattern due to intermittent episodes of upper airway obstruction causing apnea and hypopnea (shallow respirations) during sleep. NCM18-112c MEDICAL SURGICAL NURSING  During the health history, the nurse assesses for Sleep-disordered breathing (SDB) by asking patients at risk if they: Snore loudly Have frequent bouts of awaking from sleep Awaken with a headache Experience hypersomnolence (severe daytime sleepiness) https://www.youtube.com/watch?v=-gie2dhqP2c Self-Perception and Self-Concept The health history is used to discover how patients perceive their health by asking questions that may include the following: What is your cardiac condition? How has this illness changed your feelings about your health? What do you think caused this illness? What consequences do you think this illness will have on your physical activity, work, social relationships, and role in your family? How much of an influence do you think you have on controlling this illness? NCM18-112c MEDICAL SURGICAL NURSING  Roles and Relationships To assess patients’ roles in their families and their relationships, both components of social support, the nurse asks each patient: Who do you live with? Who is your primary caregiver at home? Who helps you manage your health? Are there adequate finances and health insurance? The answers to these questions help the nurse determine if consultation with social services or others is necessary to tailor the plan of care to meet the patient’s self-care needs. Sexuality and Reproduction Sexual dysfunction affects twice as many people with CVD compared with the general population. Depression, anxiety, erectile dysfunction, and major cardiac events such as an MI are common reasons that patients report decreased sexual activity. Patients and their partners are concerned about the effects of physical exertion on the heart and if the activity may cause another heart attack, sudden death, or untoward symptoms such as angina, dyspnea, or palpitations. The nurse can help patients by initiating discussions about sexuality and encouraging them to discuss problems with their primary provider or cardiologist. The exercise and counseling provided in cardiac rehabilitation programs may also improve sexual activity NCM18-112c MEDICAL SURGICAL NURSING  Reproductive history is necessary for women of childbearing age, particularly those with seriously compromised cardiac function. Reproductive history includes information about: previous pregnancies, plans for future pregnancies, oral contraceptive use (especially in women older than 35 years who smoke), menopausal status, and the use of hormone therapy (HT) Women have a higher risk for developing CVD are: Women who have a history of preeclampsia during pregnancy Preterm labor Giving birth to an infant that was small for gestational age Coping and Stress Tolerance Anxiety, depression, and stress are known to influence both the development of and recovery from CAD and HF Depression is twice as prevalent in women compared to men and has a negative impact on quality of life and overall prognosis. The risk of depression is lower if the patient has relationship and work stability, a higher educational level, a healthy lifestyle, and the absence of comorbidities such as diabetes. NCM18-112c MEDICAL SURGICAL NURSING  The Patient Health Questionnaire (PHQ-2) is a two-question self-reported patient assessment tool recommended by the AHA. The nurse asks the patient: Do you have little interest or pleasure in doing things over the last 2 weeks? Are you feeling down, depressed or hopeless over the last 2 weeks? The nurse scores the patient’s responses to each question by assigning 0 - for “not at all,” 1 - for “several days,” 2 - for “more than half the days,” 3 - for “nearly every day.” PHQ-2 score ranges from 0 to 6 ❖ Patients with a positive score greater than or equal to 3 complete a focused screening called the PHQ-9 and are referred to their primary providers for further evaluation A widely used tool used to measure life stress is the Social Readjustment Rating Scale (SRRS) NCM18-112c MEDICAL SURGICAL NURSING  Who is the PHQ-9 Assessment for? Review the list below to determine if this assessment should be used with your client. If you answer NO to all four questions, the PHQ-9 is a good fit to use with your client. 1. Is your client experiencing normal bereavement? 2. Does your client have a history of Manic Episodes (Bipolar Disorder)? 3. Does your client have a physical disorder or are they taking medication, or other drugs that may be the biological cause of the depressive symptoms? 4. Is your client under 18? If they are, please refer to the Child Depression & Anxiety (RCADS 25) measure or the Child Depression (CES-DC) measure. Note: The PHQ-9 can also be used for patients with stroke, and is suitable for geriatric patients, patients with traumatic brain injury, in primary care and obstetrics-gynaecology settings, and with members of the general population. The Scale The scale is made up of 9 items that target symptoms of major depressive disorder. Since this assessment relies on clients to self-report, it’s important that you verify the answers with them in session to ensure they understood each question, and to gather any other relevant information and context they provide about their symptoms and experience. NCM18-112c MEDICAL SURGICAL NURSING  The PHQ-9 requires the client to provide answers based on how often they experienced the below challenges, over the course of the last 2 weeks. NCM18-112c MEDICAL SURGICAL NURSING  Scoring the PHQ-9 A diagnosis of Major Depressive Disorder should be considered if there are 5 or more items that score in the shaded section, with one of these items being #1 or #2. Other depressive disorders should be considered if the client presents 2-4 items in the shaded section, with one corresponding to #1 or #2. Nurse can then determine the severity by adding up the overall score: Depression severity is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of “not at all”, “several days”, “more than half the days”, and “nearly every day”, respectively. The PHQ-9 total score for the nine items ranges from 0 to 27. NCM18-112c MEDICAL SURGICAL NURSING  Physical Assessment ❖ Physical assessment is conducted to confirm information obtained from the health history, to establish the patient’s current or baseline condition, and, in subsequent assessments, to evaluate the patient’s response to treatment. ❖ During the physical assessment, the nurse evaluates the cardiovascular system for any deviations from normal with regard to the following: The heart as a pump (reduced pulse pressure, displaced PMI from fifth intercostal space midclavicular line, gallop sounds, murmurs) Atrial and ventricular filling volumes and pressures (elevated jugular venous distention, peripheral edema, ascites, crackles, postural changes in BP) Cardiac output (reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation) Compensatory mechanisms (peripheral vasoconstriction, tachycardia) NCM18-112c MEDICAL SURGICAL NURSING General Appearance This part of the assessment evaluates the patient’s level of consciousness (alert, lethargic, stuporous, comatose) and mental status (oriented to person, place, time; coherence). ❖ Changes in level of consciousness and mental status may be attributed to inadequate perfusion of the brain from a compromised cardiac output or thromboembolic event (stroke). ❖ Patients are observed for signs of distress, which include pain or discomfort, shortness of breath, or anxiety. Nurse notes the size of the patient (normal, overweight, underweight, or cachectic). The patient’s height and weight are measured to calculate BMI, as well as the waist circumference. Used to determine if obesity (BMI greater than 30 kg/m2) and abdominal fat (males: waist greater than 40 inches; females: waist greater than 35 inches) are placing the patient at risk for CAD. NCM18-112c MEDICAL SURGICAL NURSING Assessment of the Skin and Extremities Examination of the skin includes: all body surfaces, starting with the head and finishing with the lower extremities. Skin color, temperature, and texture are assessed for acute and chronic problems with arterial or venous circulation. Signs and symptoms of acute obstruction of arterial blood flow in the extremities, referred to as the six Ps, are pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), and paralysis. During the first few hours after invasive cardiac procedures (e.g., cardiac catheterization, percutaneous coronary intervention [PCI], or cardiac electrophysiology testing), affected extremities should be assessed frequently for these acute vascular changes. Major blood vessels of the arms and legs may be used for catheter insertion. During these procedures, systemic anticoagulation with heparin is necessary, and bruising or small hematomas may occur at the catheter access site. However, large hematomas are a serious complication that can compromise circulating blood volume and cardiac output. Patients who have undergone these procedures must have catheter access sites frequently observed until hemostasis is adequately achieved. NCM18-112c MEDICAL SURGICAL NURSING  Edema of the feet, ankles, or legs is called peripheral edema. Edema can be observed in the sacral area of patients on bed rest. It is important that clinicians use a consistent scale in order to ensure reliable clinical measurements and management. Peripheral edema is a common finding in patients with HF and peripheral vascular diseases, such as deep vein thrombosis or chronic venous insufficiency. Prolonged capillary refill time indicates inadequate arterial perfusion to the extremities. To test capillary refill time, the nurse compresses the nail bed briefly to occlude perfusion and the nail bed blanches. Then, the nurse releases pressure and determines the time it takes to restore perfusion. Normally, reperfusion occurs within 2 seconds, as evidenced by the return of color to the nail bed. Prolonged capillary refill time indicates compromised arterial perfusion, a problem associated with cardiogenic shock and HF. NCM18-112c MEDICAL SURGICAL NURSING  Clubbing of the fingers and toes indicates chronic hemoglobin desaturation and is associated with congenital heart disease. Clubbing of fingers Clubbing of toes Hair loss, brittle nails, dry or scaling skin, atrophy of the skin, skin color changes, and ulcerations are indicative of chronically reduced oxygen and nutrient supply to the skin observed in patients with arterial or venous insufficiency. Scaling skin Atrophy of the skin NCM18-112c MEDICAL SURGICAL NURSING  Common Assessment Findings Associated with Cardiovascular Disease NCM18-112c MEDICAL SURGICAL NURSING NCM18-112c MEDICAL SURGICAL NURSING  ❖ Peripheral arterial disease (PAD) NCM18-112c MEDICAL SURGICAL NURSING  Blood Pressure Systemic arterial BP is the pressure exerted on the walls of the arteries during ventricular systole and diastole. A normal adult BP is considered : A systolic BP less than 120 mm Hg over a diastolic BP less than 80 mm Hg High BP IS called hypertension ▪ Stage 1 hypertension - is a systolic BP between 130 and 139 mm Hg or a diastolic BP between 80 and 89 mm Hg. ▪ Stage 2 hypertension - is a systolic BP over 140 mm Hg or a diastolic over 90 mm Hg Hypotension refers to an abnormally low systolic and diastolic BP that can result in lightheadedness or fainting. NCM18-112c MEDICAL SURGICAL NURSING  Pulse Pressure The difference between the systolic and the diastolic pressures is called the pulse pressure A normal pulse pressure is 40 mm Hg (BP 120/80 mm Hg) A narrow pulse pressure occurs when there is vasoconstriction that is compensating for a low stroke volume and ejection velocity Shock, HF, hypovolemia, mitral regurgitation) or obstruction to blood flow during systole (mitral or aortic stenosis). (Example BP of 92/74 mm Hg and pulse pressure of 18 mm Hg) A wide pulse pressure is associated with conditions that elevate the stroke volume (anxiety, exercise, bradycardia), or cause vasodilation (fever, septic shock). (Example BP of 88/38 mm Hg and pulse pressure of 50 mm Hg) NCM18-112c MEDICAL SURGICAL NURSING Orthostatic (Postural) Blood Pressure Changes There is a gravitational redistribution of approximately 500 mL of blood into the lower extremities immediately upon standing. This venous pooling reduces blood return to the heart, compromising preload that ultimately reduces stroke volume and cardiac output. Normal postural responses that occur when a person moves from a lying to a standing position include: a heart rate increase of 5 to 20 bpm above the resting rate an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg a slight increase of 5 mm Hg in diastolic pressure Orthostatic (postural) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting to a standing position. ▪ It is usually accompanied by dizziness, lightheadedness, or syncope. ▪ The risk of orthostatic hypotension increases with age and is associated with fall risk NCM18-112c MEDICAL SURGICAL NURSING Example of BP and heart rate measurements in a patient with orthostatic hypotension: Supine: BP 120/70 mm Hg, heart rate 70 bpm Sitting: BP 100/55 mm Hg, heart rate 90 bpm Standing: BP 98/52 mm Hg, heart rate 94 bpm NCM18-112c MEDICAL SURGICAL NURSING Arterial Pulses Areas the pulse rate can be found The arteries are palpated to evaluate the pulse rate, rhythm, amplitude, contour, and obstruction to blood flow. NCM18-112c MEDICAL SURGICAL NURSING  Pulse Rhythm Rhythm of the pulse is normally regular Minor variations in regularity of the pulse may occur with respirations ▪ Pulse rate may increase during inhalation and slow during exhalation due to changes in blood flow to the heart during the respiratory cycle. This phenomenon, called sinus arrhythmia, occurs most commonly in children and young adults. Normal Sinus Rhythm Sinus Arrythmia NCM18-112c MEDICAL SURGICAL NURSING  Disturbances of rhythm (arrhythmias) often result in a Pulse Deficit Pulse Deficit is a difference between the apical and radial pulse rates. Example : Radial Pulse=70 beats per minute Apical Pulse=76 beats per minute What does this value for pulse deficit indicate? Pulse deficits commonly occur with atrial fibrillation, atrial flutter, and premature ventricular contractions. NCM18-112c MEDICAL SURGICAL NURSING  These arrhythmias stimulate the ventricles to contact prematurely, before diastole is finished. As a result, these early ventricular contractions produce a smaller stroke volume, which can be heard during auscultation but do not produce a palpable pulse NCM18-112c MEDICAL SURGICAL NURSING Pulse Amplitude Used to assess peripheral arterial circulation The following is an example of a 0 to 4 scale: 0: Not palpable or absent +1: Diminished—weak, thready pulse; difficult to palpate; obliterated with pressure +2: Normal—cannot be obliterated +3: Moderately increased—easy to palpate, full pulse; cannot be obliterated +4: Markedly increased—strong, bounding pulse; may be abnormal Note : If the pulse is absent or difficult to palpate, the nurse can use a continuous wave Doppler. NCM18-112c MEDICAL SURGICAL NURSING  Jugular Venous Pulsations Right-sided heart function can be estimated by observing the pulsations of the jugular veins of the neck, which reflects central venous pressure (CVP) Patients with euvolemia (normal blood volume), the jugular veins are normally visible in the supine position with the head of the bed elevated to 30 degrees Obvious distention of the veins with the patient’s head elevated 45 to 90 degrees indicates an abnormal increase in CVP. This abnormality is observed in patients with right-sided HF, due to hypervolemia, pulmonary hypertension, and pulmonary stenosis NCM18-112c MEDICAL SURGICAL NURSING Heart Inspection and Palpation The heart is examined by inspection, palpation, and auscultation of the precordium or anterior chest wall that covers the heart and lower thorax. A systematic approach is used to examine the precordium in the following six areas. Aortic Pulmonic Erb’s Point Tricuspid Mitral NCM18-112c MEDICAL SURGICAL NURSING  Aortic area—second intercostal space to the right of the sternum. Pulmonic area—second intercostal space to the left of the sternum Erb point—third intercostal space to the left of the sternum Tricuspid area—fourth and fifth intercostal spaces to the left of the sternum Mitral (apical) area—left fifth intercostal space at the midclavicular line Epigastric area—below the xiphoid process Areas of the precordium to be assessed when evaluating heart function NCM18-112c MEDICAL SURGICAL NURSING  Palpating the apical impulse Remain on the patient’s right side, and ask the patient to remain supine. Use the finger pads to palpate the apical impulse in the mitral area (fifth intercostal space at the midclavicular line). You may ask the patient to roll to the left side to better feel the impulse using the palmar surfaces of your hand. NCM18-112c MEDICAL SURGICAL NURSING  Several abnormalities that the nurse may find during palpation of the precordium. Normal Palpation Findings : The apical impulse is palpable in only one intercostal space Abnormal Palpation Findings : Palpability in two or more adjacent intercostal spaces indicates left ventricular enlargement apical impulse below the fifth intercostal space or lateral to the midclavicular line usually denotes left ventricular enlargement from left ventricular HF If the apical impulse can be palpated in two distinctly separate areas and the pulsation movements are paradoxical (not simultaneous), a ventricular aneurysm may be suspected NCM18-112c MEDICAL SURGICAL NURSING  Heart Auscultation Stethoscope is used to auscultate each of the locations identified in Figure below, with the exception of the epigastric area. Purpose of cardiac auscultation is to determine heart rate and rhythm and evaluate heart sounds. Normal heart sounds, referred to as S1 and S2 , are produced by closure of the AV valves and the semilunar valves, respectively. The period between S1 and S2 corresponds with ventricular systole When the heart rate is within the normal range, systole is much shorter than the period between S2 and S1 (diastole) S1 and S2 are the only sounds heard during the cardiac cycle NCM18-112c MEDICAL SURGICAL NURSING  S1—First Heart Sound (“lub”) Tricuspid and mitral valve closure creates the first heart sound (S1 ) S1 is usually heard the loudest at the apical area. S2—Second Heart Sound (“dub”) Closure of the pulmonic and aortic valves produces the second heart sound (S2 ), commonly referred to as the “dub” sound. Normal heart sounds. The first heart sound (S1 ) is produced by closure of the mitral and tricuspid valves (“lub”). The second heart sound (S2 ) is produced by closure of the aortic and pulmonic valves (“dub”) NCM18-112c MEDICAL SURGICAL NURSING  Abnormal Heart Sounds Abnormal sounds develop during systole or diastole when structural or functional heart problems are present. S3 and S4 gallop sounds are heard during diastole These sounds are also called opening snaps, systolic clicks, and murmurs These sounds are created by the vibration of the ventricle and surrounding structures as blood meets resistance during ventricular filling. The term gallop evolved from the cadence that is produced by the addition of a third or fourth heart sound, similar to the sound of a galloping horse. Gallop sounds are very low-frequency sounds and are heard with the bell of the stethoscope placed very lightly against the chest. NCM18-112c MEDICAL SURGICAL NURSING  S3—Third Heart Sound Heart Murmurs An S3 (“DUB”) is heard early in diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle. It is heard immediately after S2. “Lub-dub- DUB” is used to imitate the abnormal sound of a beating heart when an S3 is present. In older adults, an S3 is a significant finding, suggesting HF. NCM18-112c MEDICAL SURGICAL NURSING  It is best heard with the bell of the stethoscope If the right ventricle is involved, a right-sided S3 is heard over the tricuspid area with the patient in a supine position. A left-sided S3 is best heard over the apical area with the patient in the left lateral position. Gallop sounds. An S3 (“DUB”) is an abnormal sound heard immediately following S2 (closure of semilunar valves). This sound is generated very early in diastole as blood flowing into the right or left ventricle is met with resistance. S4 (“LUB”) is an abnormal sound created during atrial systole as blood flowing into the right or left ventricle is met with resistance. Arrows represent the direction of blood flow. NCM18-112c MEDICAL SURGICAL NURSING  S4—Fourth Heart Sound S4 (“LUB”) occurs late in diastole S4 heard just before S1 is generated during atrial contraction as blood forcefully enters a noncompliant ventricle. This resistance to blood flow is due to ventricular hypertrophy caused by hypertension, CAD, cardiomyopathies, aortic stenosis, and numerous other conditions. “LUB lub-dub” is the mnemonic used to imitate this gallop sound. S4 , produced in the left ventricle, is auscultated using the bell of the stethoscope over the apical area with the patient in the left lateral position A right-sided S4 , although less common, is heard best over the tricuspid area with the patient in supine position. Summation gallop - during tachycardia, all four sounds combine into a loud sound (“LUB lub-dub DUB.”) NCM18-112c MEDICAL SURGICAL NURSING  Opening snaps are abnormal diastolic sounds heard during opening of an AV valve. Example, mitral stenosis can cause an opening snap, which is an unusually high-pitched sound very early in diastole This sound is caused by high pressure in the left atrium that abruptly displaces or “snaps” open a rigid valve leaflet In a similar manner, stenosis of one of the semilunar valves creates a short, high-pitched sound in early systole, immediately after S1. This sound, called a systolic click, is the result of the opening of a rigid and calcified aortic or pulmonic valve during ventricular contraction. Murmurs are created by turbulent flow of blood in the heart. Causes of the turbulence may be: Critically narrowed valve Malfunctioning valve that allows regurgitant blood flow Congenital defect of the ventricular wall Defect between the aorta and the pulmonary artery, or an increased flow of blood through a normal structure (e.g., with fever, pregnancy, hyperthyroidism). NCM18-112c MEDICAL SURGICAL NURSING  Friction Rub A harsh, grating sound that can be heard in both systole and diastole is called a friction rub. Caused by abrasion of the inflamed pericardial surfaces from pericarditis. A pericardial friction rub can be heard best using the diaphragm of the stethoscope, with the patient sitting up and leaning forward. ABNORMAL HEART SOUNDS CLICK THE LINK https://www.osmosis.org/learn/Abnormal_heart_sounds NCM18-112c MEDICAL SURGICAL NURSING Assessment of Other Systems Lungs Findings frequently exhibited by patients with cardiac disorders include the following: Hemoptysis: Pink, frothy sputum is indicative of acute pulmonary edema. Cough: A dry, hacking cough from irritation of small airways is common in patients with pulmonary congestion from HF. NCM18-112c MEDICAL SURGICAL NURSING  Abdomen For the patient with CVD Abdominal distention: A protuberant abdomen with bulging flanks indicates ascites. Ascites develops in patients with right ventricular or biventricular HF (both right- and left-sided HF). In the failing right heart, abnormally high chamber pressures impede the return of venous blood Liver and spleen become engorged with excessive venous blood (hepatosplenomegaly). Fluid shifts from the vascular bed into the abdominal cavity which causes ascites NCM18-112c MEDICAL SURGICAL NURSING  Hepatojugular reflux: This test is performed when right ventricular or biventricular HF is suspected. While observing the jugular venous pulse, firm pressure is applied over the right upper quadrant of the abdomen for 30 to 60 seconds. Bladder distention: Urine output is an important indicator of cardiac function. Reduced urine output may indicate inadequate renal perfusion or a less serious problem such as one caused by urinary retention. NCM18-112c MEDICAL SURGICAL NURSING  Crackles: HF or atelectasis associated with bed rest, splinting from ischemic pain, or the effects of analgesic, sedative, or anesthetic agents often results in the development of crackles. Typically, crackles are first noted at the bases (because of gravity’s effect on fluid accumulation and decreased ventilation of basilar tissue), but they may progress to all portions of the lung fields. Wheezes: Compression of the small airways by interstitial pulmonary edema may cause wheezing. Beta-adrenergic–blocking agents (beta-blockers), particularly noncardioselective beta-adrenergic–blocking agents such as propranolol, may cause airway narrowing, especially in patients with underlying pulmonary disease. NCM18-112c MEDICAL SURGICAL NURSING Diagnostic Evaluation Laboratory Tests Samples of the patient’s blood are sent to the laboratory for the following reasons: To screen for risk factors associated with CAD To establish baseline values before initiating other diagnostic tests, procedures, or therapeutic interventions To monitor response to therapeutic intervention To assess for abnormalities in the blood that affect prognosis ❖ Normal values for laboratory tests may vary depending on the laboratory and the health care institution. This variation is due to the differences in equipment and methods of measurement across organizations. NCM18-112c MEDICAL SURGICAL NURSING  Cardiac Biomarker Analysis Diagnosis of MI is made by evaluating the history and physical examination the 12-lead ECG, the results of laboratory tests that measure serum cardiac biomarkers. Myocardial cells that become necrotic from prolonged ischemia or trauma release specific enzymes (creatine kinase [CK]), CK isoenzymes (CK-MB), proteins (myoglobin, troponin T, and troponin I) ▪ Abnormally high levels of these substances can be detected in serum blood samples Lipid Profile Cholesterol, triglycerides, and lipoproteins are measured to evaluate a person’s risk of developing CAD, especially if there is a family history of premature heart disease, or to diagnose a specific lipoprotein abnormality. NCM18-112c MEDICAL SURGICAL NURSING  Cholesterol Levels Cholesterol is a lipid required for hormone synthesis and cell membrane formation. It is found in large quantities in brain and nerve tissue. Two major sources of cholesterol are diet (animal products) and the liver, where cholesterol is synthesized. High cholesterol levels increase the risk of CVD regardless of the patient’s age Factors that contribute to variations in cholesterol levels include age, gender, diet, exercise patterns, genetics, menopause, tobacco use, and stress levels. Lifestyle changes are recommended to lower cholesterol levels NCM18-112c MEDICAL SURGICAL NURSING  Common Serum Laboratory Tests and Implications for Patients with Cardiovascular Disease NCM18-112c MEDICAL SURGICAL NURSING NCM18-112c MEDICAL SURGICAL NURSING NCM18-112c MEDICAL SURGICAL NURSING NCM18-112c MEDICAL SURGICAL NURSING NCM18-112c MEDICAL SURGICAL NURSING  Triglycerides Triglycerides, composed of free fatty acids and glycerol, are stored in the adipose tissue and are a source of energy. Triglyceride levels increase after meals and are affected by stress. Diabetes, alcohol use, and obesity can elevate triglyceride levels. These levels have a direct correlation with LDL and an inverse one with HDL. Brain (B-Type) Natriuretic Peptide BNP is a neurohormone that helps regulate BP and fluid volume. BNP levels are useful for prompt diagnosis of HF in settings such as the ED Elevations in BNP can occur from a number of other conditions such as pulmonary embolus, MI, and ventricular hypertrophy. NCM18-112c MEDICAL SURGICAL NURSING  A BNP level greater than 100 pg/mL is suggestive of HF. C-Reactive Protein CRP is a protein produced by the liver in response to systemic inflammation. Inflammation is thought to play a role in the development and progression of atherosclerosis. Homocysteine An amino acid, is linked to the development of atherosclerosis because it can damage the endothelial lining of arteries and promote thrombus formation. (See Diagnostic in the module) NCM18-112c MEDICAL SURGICAL NURSING