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Transcript
Ignatavicius: Medical-Surgical Nursing, 7th Edition
Chapter 35: Assessment of the Cardiovascular System
Key Points - Print


In almost every year since 1900, cardiovascular disease has been the number-one cause of
death in the United States. Of particular concern is that CVD is the leading cause of death for
women.
When diseases or other problems of the CV systems occur, oxygenation and perfusion
decrease which may result in life-threatening events.
ANATOMY AND PHYSIOLOGY REVIEW
 The electrical and mechanical properties of cardiac muscle determine the function of the
cardiovascular system.
 The healthy heart is able to adapt to various pathophysiologic conditions, such as stress, infections,
and hemorrhage, to maintain adequate blood flow to the body tissues.
 Blood flow from the heart into the systemic arterial circulation is measured clinically as cardiac
output (CO), the amount of blood pumped from the left ventricle each minute.
 The vascular system provides a route for blood to travel from the heart to various tissues of
the body, carries cellular wastes to the excretory organs, allows lymphatic flow to drain tissue
fluid back into the circulation, and returns blood to the heart for recirculation.
 Blood pressure is regulated by balancing the sympathetic and parasympathetic nervous
systems of the autonomic nervous system.
 The three mechanisms that mediate and regulate blood pressure include the autonomic
nervous system, which excites or inhibits sympathetic activity in response to impulses from
chemoreceptors and baroreceptors, the kidneys, which sense a change in blood flow and
activate the renin-angiotensin-aldosterone mechanism, and the endocrine system, which
releases various hormones to stimulate the sympathetic nervous system at the tissue level.
CARDIOVASCULAR CHANGES ASSOCIATED WITH AGING


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A number of physiologic changes in the cardiovascular system occur with advancing age.
Many of these changes result in a loss of cardiac reserve.
Assess the older adult for cardiovascular changes associated with aging.
Recall that syncope is a transient loss of consciousness and is common in older adults.
ASSESSMENT METHODS
 The focus of the patient history is on obtaining information about risk factors and symptoms of
cardiovascular disease.
 Identify patients at risk for cardiovascular disease, especially those with hyperlipidemia,
hypertension, excess weight, physical inactivity, smoking, psychological stress, a positive family
history, and diabetes.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points - Print
35-2
 Assess the patient’s age, gender, ethnic origin, and chronic disease or illnesses.
 Postmenopausal women are two to three times more likely than premenopausal women to
have cardiac disease.
 Age, gender, ethnic background, and family history of CVD are nonmodifiable or
uncontrollable risk factors for CVD.
 Modifiable or controllable risk factors are personal habits, including cigarette use, physical
inactivity, obesity, and psychological variables.
 The smoking history should include the number of cigarettes smoked daily, the duration of the
smoking habit, and the age of the patient when smoking started.
 The social history includes information about the patient’s living situation, including having a
domestic partner, other household members, environment, and occupation.
 Review the family history, and obtain information about the age, health status, and cause of death
of immediate family members.
 A positive family history for CAD in a first-degree relative is a major risk factor that is more
significant than other factors such as hypertension, obesity, diabetes, or sudden cardiac death.
 Assess the patient’s report of pain to differentiate the pain of angina and myocardial infarction
(MI) from other noncardiac causes; discomfort, indigestion, squeezing, heaviness, and
viselike are common terms used to describe chest pain of cardiac origin.
 Expand on the description of symptoms by obtaining information about their onset, duration,
sequence, frequency, location, quality, intensity, associated symptoms, and precipitating,
aggravating, and relieving factors.
 Major symptoms usually identified by patients with CVD include chest pain or discomfort,
dyspnea, fatigue, palpitations, weight gain, syncope, and extremity pain.
 Women often present with a “triad” of symptoms, including indigestion or abdominal
fullness, chronic fatigue despite adequate rest, and inability to catch one’s breath.
 Dyspnea that is associated with activity is referred to as dyspnea on exertion. It is usually an
early symptom of heart failure and may be the only symptom in women.
 Extremity pain may be caused by ischemia from atherosclerosis and/or venous insufficiency
of the peripheral blood vessels.
 Patients may be classified according to the New York Heart Association’s Functional
Classification or other system to indicate the degree to which ordinary physical activities are
affected by heart disease.
 Physical assessment begins with an assessment of appearance, including general build, skin
color, distress level, level of consciousness, shortness of breath, position, and verbal
responses.
 Higher blood pressure increases the workload of the left ventricle and oxygen consumption of
the myocardium.
 Use jugular venous pressure to assess the filling volume and pressure on the right side of the
heart.
 Assess for bruits in the carotid arteries, which are swishing sounds that develop due to
atherosclerotic plaque build-up in narrowed vessels.
 Assessment of the precordium involves inspection, palpation, percussion, and auscultation.
 Auscultate the heart for heart rate and rhythm, normal first and second sounds, as well as for
abnormalities such as an S3, S4, murmur, or gallop.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points - Print
35-3
 Blood tests are used to help establish a diagnosis, detect concurrent disease, assess risk
factors, and monitor response to treatment.
 Arterial blood gas evaluation is used to determine tissue oxygenation, carbon dioxide
removal, and acid-base status.
 Posteroanterior and left lateral x-ray views of the chest are routinely obtained to determine the
size, silhouette, and position of the heart.
 Angiography of the arterial vessels, or arteriography, is an invasive diagnostic procedure used
when an arterial obstruction, narrowing, or aneurysm is suspected.
 Assess patients for allergy to iodine-based contrast media before having diagnostic tests
requiring a contrast agent.
 The most definitive test in the diagnosis of heart disease is cardiac catheterization.
 Prepare patients having a cardiac catheterization for expectations of the procedure and postprocedure care.
 Assess patients having cardiac catheterizations for potential complications.
 The electrocardiogram provides information about cardiac dysrhythmias, myocardial
ischemia, the site and extent of MI, cardiac hypertrophy, electrolyte imbalances, and the
effectiveness of cardiac drugs.
 An electrophysiologic study is an invasive procedure during which programmed electrical
stimulation of the heart is used to induce and evaluate lethal dysrhythmias and conduction
abnormalities.
 The exercise electrocardiography test or stress test assesses cardiovascular response to an
increased workload to determine the functional capacity of the heart and screen for
asymptomatic coronary artery disease.
 If a patient cannot exercise on a bike or treadmill, Dipyridamole (Persantine, ApoDipyridamole) or dobutamine hydrochloride (Dobutrex) is administered to simulate the
effects of exercise. Tell the patient that these vasodilators may cause flushing, headache,
dyspnea, and chest tightness for a few moments after injection.
 Echocardiography uses ultrasound waves to assess cardiac structure and mobility, particularly
of the valves.
 Transesophageal echocardiography examines cardiac structure and function with an
ultrasound transducer placed in the esophagus immediately behind the heart to provide
detailed views of posterior cardiac structures.
 Myocardial nuclear perfusion imaging can view, record, and evaluate cardiovascular
abnormalities using radioactive tracer substances.
 MRI permits determination of cardiac wall thickness, chamber dilation, valve and ventricular
function, and blood movement in the great vessels.
 Electronic-beam computed tomography helps to determine whether calcifications are present
in the arteries.
 Hemodynamic monitoring is an invasive system used in critical care areas to provide
quantitative information about vascular capacity, blood volume, pump effectiveness, and
tissue perfusion.
 Following invasive cardiovascular diagnostic testing, such as angiography and cardiac
catheterization, monitor the insertion site for bleeding and hematoma formation and assess
vital signs, especially reporting new dysrhythmias. Note any change in circulation distal to the
insertion site.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points - Print
35-4
 Recent guidelines suggest that C-reactive protein (CRP) is very helpful in determining
treatment outcomes in patients at risk for coronary disease, and for managing statin therapy
after an acute myocardial infarction.
 A patient with cardiac illness usually perceives it as a major life crisis.
 Assess the meaning of the illness to the patient and family.
 Discuss with the patient any feelings or concerns he or she might have about the stress of
cardiac illness, diagnostic testing, or other issues, and use therapeutic measures to decrease
anxiety.
 Recognize that denial is a common and normal response to help patients cope with
threatening circumstances.
 Be aware that coping behaviors of those who have cardiovascular problems vary from patient
to patient.
 Allow the patient to express feelings about an actual or perceived loss of health or social
status related to cardiovascular disease.
 Assess vital signs carefully in patients having invasive cardiovascular testing; report new
dysrhythmias after testing.
 After invasive cardiovascular diagnostic testing, such as angiography and cardiac
catheterization, monitor the insertion site for bleeding and hematoma formation.
 Identify patients at risk for cardiovascular disease, especially those with hyperlipidemia,
hypertension, excess weight, physical inactivity, smoking, psychological stress, a positive
family history, and diabetes.
 Teach patients how to reduce the risk of heart disease through exercise, diet modification,
smoking cessation, and medications, as needed.
 The American Heart Association provides guidelines to combat obesity and improve cardiac
health include ingesting more nutrient-rich foods which have vitamins, minerals, fiber, and
other nutrients, but are low in calories. To get the necessary nutrients, teach patients to
choose foods like vegetables, fruits, whole-grain products, and fat-free dairy products most
often.
 Inform patients that genetics and other nonmodifiable risk factors, such as family history and
gender, contribute to the development of CVD.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.