Assessment of cardiovascular function

Cardiovascular Medication • Metoprolol • Warfarin - Coumudin • Diltiazem • Furosemide – Lasix Overview of Anatomy and Physiology • Three layers o Endocardium o Myocardium – muscle contraction and pump o Epicardium • Four chambers – know what is happening with s1 and s2 • Heart valves o Know where the valves are and what they do o Atrioventricular valves o Semilunar valves • Vasculature Structure of the Heart: Coronary Circulation Cardiac Conduction System Terms - Cardiac Action Potential • Depolarization: electrical activation of cell caused by influx of sodium into cell while potassium exits cell • Repolarization: return of cell to resting state caused by re-entry of potassium into cell while sodium exits • Refractory periods o Effective refractory period: phase in which cells are incapable of depolarizing o Relative refractory period: phase in which cells require stronger-than-normal stimulus to depolarize Cardiac Action Potential Great Vessel and Heart Chamber Pressures Cardiac Hemodynamics Hemodynamics Terms - Cardiac Output • Stroke volume: amount of blood ejected with each heartbeat • Cardiac output: amount of blood pumped by ventricle in liters per minute • Preload: degree of stretch of cardiac muscle fibers at end of diastole o Affected by volume, diarrhea, dehydration, vomiting • Contractility: ability of cardiac muscle to shorten in response to electrical impulse • Afterload: resistance to ejection of blood from ventricle • Ejection fraction: percent of end diastolic volume ejected with each heart beat o 55-60 normal o 40 lead to HF!! Age-Related Changes of the cardiac System • Atria • Left ventricles • Valves • Conduction system • Sympathetic nervous system • Aorta and arteries • Baroreceptor response Health History • Chief complaint • History of Present Illness • Past medical, surgical history • Past family history • Past social history • Home medications • Nutrition • Allergies Physical Assessment • General appearance o Any altered LOC, check hemoglobin • Skin and extremities o Circulation, color changes, capillary refills, • Blood pressure o Explains CO • Arterial pulses • Jugular venous pulsations o Edema, ascites, postural changes, • Heart inspection and auscultation • General assessment • Any deviations from the normal? o Heart as a pump – pulse pressure (systolic and diastolic), murmurs, gallops o Atrial/ventricular filling volumes o Cardiac output – HTN, tachy, decrease output o Compensatory mechanisms – vasoconstriction, tachy, Most Common Clinical Manifestations • Chest pain o Does it get worse with respiration – noncardiac • Dyspnea – difficulty breathing • Peripheral edema, weight gain, abdominal distention • Palpitations • Fatigue • Dizziness, syncope, changes in level of consciousness Chest Pain • Identify quantity of pain (0-10 SCALE) o PQRST assessment needed • Identify location of pain • Identify quality of pain • Radiation of pain – vascular or neuropathic pain, • Associated signs/symptoms • Duration of pain • Assess for other cardiac conditions • Assess for other significant conditions (see p. 663-664) o Pneumonia, pulmonary embolism o Hiatal hernia, GERD o Costochondritis o Vascular Assessment • Medications • Nutrition • Elimination • Activity, exercise • Sleep, rest • Self-perception, self-concept • Roles, relationships • Sexuality, reproduction • Coping, stress tolerance • Prevention strategies Health Promotion, Perception, and Management Questions • Ask regarding health promotion, preventive practices o What type of health issues do you have? Are you able to identify any family history or behaviors that put you at risk of this health problem? o What are your risk factors for heart disease? What do you do to stay healthy? o How is your health? Have you noticed any changes? o Do you have a cardiologist or primary health care provider? How often do you go for check-ups? o Do you use tobacco or alcohol? o What medications do you take? Cardiac Specific • General appearance – LOC • Assessment of skin/extremities o 6 P’s, are pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), and paralysis. • BP o Pulse pressure o Postural blood pressure changes – orthostatic BP • Arterial pulses o Pulse rate o Pulse rhythm o Pulse amplitude • Jugular venous distention • Heart inspection/palpation • Heart auscultation o Normal heart sounds o Abnormal heart sounds ▪ S3, S4, murmurs, friction rub • Assessment of lungs o Hemoptysis: Pink, frothy sputum is indicative of acute pulmonary edema. o Cough: A dry, hacking cough from irritation of small airways is common in patients with pulmonary congestion from HF. o 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. o 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 (Inderal), may cause airway narrowing, especially in patients with underlying pulmonary disease. • Assessment of abdomen o Abdominal distension: 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. As a result, the liver and spleen become engorged with excessive venous blood (hepatosplenomegaly). As pressure in the portal system rises, fluid shifts from the vascular bed into the abdominal cavity. Ascitic fluid, found in the dependent or lowest points in the abdomen, will shift with position changes. o Hepatojugular reflux: This test is performed when right ventricular or biventricular HF is suspected. The patient is positioned so that the jugular venous pulse is visible in the lower part of the neck. While observing the jugular venous pulse, firm pressure is applied over the right upper quadrant of the abdomen for 30 to 60 seconds. An increase of 1 cm or more in jugular venous pressure is indicative of a positive hepatojugular reflux. This positive test aids in confirming the diagnosis of HF. o 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. When urine output is decreased, the patient must be assessed for a distended bladder or difficulty voiding. The bladder may be assessed with an ultrasound scanner (see Fig. 53-8 in Chapter 53) or the suprapubic area palpated for an oval mass and percussed for dullness, indicative of a full bladder. Diagnostic Interpretation: Laboratory Evaluation • Assists in making a diagnosis • Screens for risk factors associated with CAD • Establishes baseline values • Monitor responses to therapy • Assess for abnormalities that affect prognosis Laboratory Tests: Cardiac Biomarkers (know values and why) • Creatinine Kinase (CK) • Creatinine Kinase Isoenzymes (CK-MB) • Proteins • Myoglobin • Troponin T and Troponin I Laboratory Tests: Hematology, Chemistry, Coagulation Studies (know values and why) • Lipid profile • Brain (b-type) natriuretic peptide (BNP) – 100suggests HF • C-reactive protein - • Homocysteine - • Blood chemistries - • Coagulation studies • PTT, PT, INR – clotting factor • Hematologic studies • CBC (WBC, Hgb, hematocrit) Diagnostic Evaluation • Imaging o Chest-x-ray ▪ Size, position, contour of heart, any fluid present, catheter placement, pacemaker placement ▪ Reveals cardiac and pericardial calcifications ▪ Assists in diagnosing other conditions • Electrocardiography o Electrical activity of the heart (12 leads, looks at 12 different views) ▪ Halter monitor for continuous readings o 12 leads – camera that takes multiple pictures o Diagnoses ▪ Dysrhythmias ▪ Conduction abnormalities – does the beat start lover in the system and why? ▪ Chamber enlargement ▪ Myocardial ischemia, infarction, injury ▪ Electrolyte disturbances • Ca, K, NA, cholesterol: what to expect with elevation and drops Example of 12-lead EKG - You do not need to memorize this! Electrocardiography: Continuous • Standard of care, formally done for outpatients to see what their rhythm is over time – halter monitor o The difference is the period of time needed o The regular ECG is a quick moment to see where the heart is at whereas continuous comes after in order to monitor longer • Monitors more than one lead at a time • Monitors for ST segment changes • Provides visual and audible alarms (Continuous monitoring overall) o Interprets and stores alarms o Trends data over time o Prints copy of rhythms Cardiac Stress Testing • Normally: cardiac arteries dilate to four times their usual diameter in response to increased metabolic demands for oxygen and nutrients o Atherosclerotic vessels dilate less= ischemia o Abnormalities are likely to be detected during times of increased demand (stress) • Cardiac stress test procedures are noninvasive ways to evaluate response to stress (increased metabolic demand) 1. Exercise stress testing ▪ Walking on a treadmill until the target HR is reached or pt experiences signs of MI 2. Pharmacological stress testing – know the type of medications • Stress test determines the following 1. Presence of CAD 2. Cause of chest pain – presence of ischemia 3. Functional capacity of the heart after an MI or surgery 4. Effectiveness of antianginal or antiarrhythmic medications 5. Occurrence of dysrhythmias 6. Specific goals for physical fitness program • Contraindications o Severe aortic stenosis o Acute myocarditis or pericarditis o Severe HTN o Suspected left main disease (widow maker) – they will need heart surgery o Heart failure o Unstable angina (review) • Complications o AMI o Cardiac arrest o Heart failure o Unstable angina • ACLS training required – rapid response is aware of the stress test • Exercise Stress Testing o Walks on a treadmill, bike, arm crank o Exercise intensity increases o Patient monitoring (EKG, VS) o Target HR achieved= ? ischemia • Pharmacologic Stress Testing o Physical disability/deconditioned o Persantine and Adenocard IV ▪ Mimic effects of stress ▪ Dobutamine if no tolerance to exercise o Vasodilating medication used in conjunction with radionuclide imaging techniques Nursing Interventions • NPO x 3 hours before the test • Avoid stimulants (caffeine, tobacco, chocolate, carbonated beverage, tea, caffeine-free) • Meds with sips of water • May instruct to hold beta blocking agents, theophylline, aminophylline 24-48hr before test (metropolol) • Appropriate attire • Sensations with medications – flushing, nausea, headache, ST segment changes Cardiac Evaluations • Transesophageal echocardiography (TEE) o Goes internally through the esophagus and needs sedation • Transthoracic echocardiography – across the chest, external imaging o Noninvasive o Ejection fraction – is seen in both, percentage o Size, shape and motion of cardiac structures o Pericardial effusions o Determines chamber size o Etiology of heart murmurs o Function of heart valves o Ventricular wall motion • Myocardial perfusion imaging – determine if arterial perfusion to the heart is compromised during activity and to evaluate the extent of myocardial damage • Computerized tomography • MRI • MRA – diagnosing diseases of the aorta, heart muscle, and pericardium, as well as congenital heart lesions. • PET scan Cardiac Catheterization • Invasive diagnostic procedure • Radiopaque arterial and venous catheters advanced into right and left heart • Guided by fluoroscopy – contrast is used, ask for allergies and check kidney functions through BUN and creatinine before the test o After procedure check for any elevation in creatinine mainly and urine output is in normal ranges (30mL/hr) o If so you must increase fluids, best way to do that is through PO but IV can be used • Gold standard for diagnosis: what we are looking for o CAD o Coronary artery patency o Determines extent of atherosclerosis o Determines whether revascularization may be necessary o Pulmonary artery HTN o Valvular hear disease • Lecture notes o Femoral and brachial access o Post procedure bed rest 2-6 hours before ambulating o Need a lab baseline value Cardiac Catheterization: Complications • Anaphylaxis (iodine) – due to the use of furosemide, look for signs of itching, flushing, breathing difficulties • Contrast induced nephropathy[CIN] o increase of baseline creatinine by 25% within 2 days of procedure = acute kidney disease • Bleeding – from the access point o Manual pressure o FemoSTop o QuickSeal/AngioSeal – applied on top of insertion sight to help close it o Sutures – less likely used for closing o Neurovascular assessment – pulse check, temperature, capillary refill Nursing Interventions • Fast 8-12 hours prior • Transportation home • Explanation of procedure • Observe catheter access site for bleeding/hematoma • Neurovascular assessment of extremity • Screening for dysrhythmias • Bedrest for 2-6 hours, positioning • Monitor cardiovascular status/chest pain/VS • Monitor for CIN • Bed rest time depends on how much anticoagulation medication they are given Hemodynamic Monitoring = Pressure • Central Venous Pressure (CVP) – central line is used for hemodynamic monitoring mostly in the ICU o Measure right ventricular pressure o Measures filling pressure in right atrium/ventricle at end of diastole (PRELOAD) ▪ Hypervolemia – high volume ▪ Hypovolemia – low volume o CVP = 2-6 mm Hg • Pulmonary Artery Pressure Monitoring – measure left ventricular pressure o Assess left ventricular function o Diagnose ethology of shock o Evaluate response to therapy o Administer medications o Place pacemaker o Measures cardiac chamber pressures Phlebostatic Level - Pulmonary Artery Catheter and Pressure Monitoring System Intra-arterial Blood Pressure Monitoring • Obtains direct and continuous BP measurement in critically ill patients with severe hypertension or hypotension • Obtain arterial blood gas specimen • Radial artery Heart Failure Chronic Heart Failure • 6 million people diagnosed with heart failure 75 years of age • Most common reason for hospitalization for those over 65 • 25% of patients discharged with CHF are readmitted within 30 days • Economic burden: $30 billion annually Types of Heart Failure • Diagnosed by echocardiogram o Normal Ejection fraction (EF 55-65%) • Systolic heart failure o Alteration in ventricular function o Weakened heart muscle o Severely reduced EF • Diastolic Heart failure o Less common o Stiff and noncompliant heart muscle= difficult for ventricle to fill o Normal EF