Download Assessment of clients with CVS conditions

Assessment of clients with CVS
conditions
Nursing 409
Fall 2016-2017
.
5/4/2017
Group Activiities

What makes people at risk for heart
diseases??

So what do you need to Assess Patients for
possible Cardiac problems ??
5/4/2017
Case Study


At 6:45 a.m., your unit is dispatched for a 50-yearold male with chest pain. You and your partner
proceed to the scene, with a response time of
approximately eight minutes. The closest hospital
from the scene is 40 miles away.
You arrive at the scene, A middle-aged male
answers the door and identifies himself as the
patient. You note that he is diaphoretic and anxious,
and is clenching his fist against the center of his
chest.
5/4/2017
Group Activity

1. What is the significance of the patients
clenched fist in the center of his chest?
5/4/2017
Answer

A clenched fist in the center of the chest (the
precordium) conveys the feeling of pressure or
squeezing and is called Levine's sign . The
presence of Levine's sign is suggestive, but not
conclusive, of cardiac-related chest pain and
should increase your index of suspicion.
5/4/2017
Case Study (cont…)
You sit the patient down and perform an initial
assessment
Blood pressure: 160/92 mmHg.
Pulse: 112 beats/min, strong and regular.
Respirations: 22 breaths/min and unlabored.
Oxygen saturation: 99% (on 100% oxygen).
Signs and symptoms: Chest pressure, restlessness,
diaphoresis, tachycardia, hypertension.
Allergies: None. He is not allergic to aspirin.
Medications: Nitroglycerin (as needed) and Vasotec.
5/4/2017
Think Of

How could this patient's current blood
pressure and heart rate affect his
condition?
5/4/2017
Answer

This patient's vital signs represent a classic
case of "more is not better!" In order for the
heart to beat stronger and faster, it requires
and uses more oxygen. Additionally, an
elevated blood pressure increases afterload
(ventricular resistance), further increasing
myocardial oxygen demand.
5/4/2017
Case Study (cont…)
Pertinent past history: "I have high blood
pressure and the doctor told me I may have a
heart attack if I don't start exercising. He gave
me the nitro to take when I have chest pain."
Last oral intake: "I ate supper last night, but
can't remember the exact time."
Events leading to the present illness: "I was
asleep when the pressure in my chest woke
me up."
5/4/2017
Case Study (cont…)

Level of consciousness: Conscious and alert to
person, place and time; restless and anxious.
Chief complaint: "My chest feels tight and I feel
really weak."
Airway and breathing: Airway is patent;
respirations are slightly increased and unlabored.
Oxygen saturation: 97% (on room air).
Circulation: Radial pulse is rapid, strong and
regular; skin is cool, clammy and pale.
5/4/2017
Focused History and Physical
Examination

Onset: "This began suddenly. It woke me from my sleep."
Provocation/Palliation: "This pressure in my chest is constant.
Nothing that I do makes it better or worse."
Quality: "My chest feels very tight."
Radiation/Referred: "The pressure stays in my chest. I don't hurt
anywhere else."
Severity: Seven on a 0--10 scale.
Time of onset: "This began about an hour ago."
Interventions prior to EMS arrival: None.
Chest exam: No sign of trauma, chest wall is symmetrical and
nontender.
Breath sounds: Clear and equal bilaterally to auscultation.
Jugular veins: Normal, not distended.
5/4/2017
Case Study (cont…)

After confirming no history of bleeding
disorders or allergies, you administer 324 mg
of aspirin to the patient. The patient remains
conscious and alert, but is becoming
increasingly restless. You attach the patient to
a cardiac monitor and interpret his cardiac
rhythm as sinus tachycardia at 110 beats per
minute.
5/4/2017
Case Study (Cont…)

After administering 0.4 mg of nitroglycerin
sublingually to the patient, you and your
partner attach the remaining ECG leads and
obtain a 12-lead tracing of the patient's cardiac
rhythm. As your partner stands up to retrieve
the stretcher from the ambulance, you tell him
that it looks as though the patient may be
having an anterior wall MI.
5/4/2017
Think!!!

What are the physiologic effects of
nitroglycerin?
5/4/2017
Answer

Nitroglycerin (NTG) causes relaxation of
vascular smooth muscle (vasodilation),
promoting systemic pooling of venous blood.
This decreases the volume of blood that is
returned to the heart (preload), as well as the
amount of resistance that the heart must pump
against (afterload). The combined effects of
decreased preload and afterload cause an
overall decrease in myocardial oxygen demand
and consumption.
5/4/2017
Case Study (cont..)

The patient's chest pressure is unrelieved
following two more doses of sublingual
nitroglycerin. You place him on the stretcher
and load him into the ambulance. En route to
the hospital, you continue oxygen therapy and
successfully establish an IV of normal saline
with an 18-gauge catheter. Reassessment of
his blood pressure reveals a reading of 140/88
mmHg.
5/4/2017
Case Study (cont…)

Because three doses of nitroglycerin failed to
relieve his pain, you administer 2 mg of
morphine sulfate via IV push. Within 10
minutes, the patient tells you that the pressure
in his chest has improved and is now a "3" on a
0--10 scale. With an estimated time of arrival at
the ED of 20 minutes, you begin an IV infusion
of nitroglycerin at 10 µg/min and perform an
ongoing assessment .
5/4/2017
Case Study (cont…)

The patient's condition continues to improve en
route to the hospital. You ask him if he has a
history of ulcers, bleeding disorders, recent
surgeries or stroke. He tells you that other than
his high blood pressure and occasional chest
pain, he has no other medical problems. You
call your radio report to the receiving facility
and continue to monitor the patient.
5/4/2017
Think !!!

Why are you asking the patient these
specific questions?

Are there any special considerations for
this patient?
5/4/2017
History









Chief complains
Chest pain
Dyspnea
Edema of the ankle and feet
Palpitation & syncope
Cough & hemoptysis
Nocturia
Cyanosis
Intermittent claudication
5/4/2017
Chief complains & history of present illnesses







N: normal base line
O: onset
P:precipitating and Palliative factors
Q: Quality & Quantity
R: Region& Radiation
S: Severity
T: Time
5/4/2017
Question

What is the most common symptom of
cardiovascular disease?
–
–
–
–
A. Shortness of breath
B. Chest pain
C. Weight loss
D. High blood pressure
5/4/2017
Answer

B. Chest pain

Rationale: Chest pain is one of the most
common symptoms of patients with
cardiovascular disease (CVD). Therefore, it is
an essential component of the assessment
interview.
5/4/2017
In fact, roughly half of the chest pain cases
seen by doctors are of cardiac origin. The
remaining 50% is referred to as non-cardiac
chest pain (NCCP).
So, where is the pain coming from?!!
How to differentiate between cardiac and non
cardiac chest pain

5/4/2017
Group Activities

After reading the Article discuss in group how
to differentiate cardiac pain from non Cardiac
Pain
(7 minutes discussion)
5/4/2017
Noncardiovascular Causes of
Chest Pain
Source: From Reigle, J. (2005).
5/4/2017
Chest Pain






The most common symptoms of Patients with CVD
A result of an imbalance between oxygen supply and
oxygen demand, it usually develops over time
NOPQRST
Chest pain caused by CAD is often precipitated by
physical or emotional exertion , a meal or being out in
the cold.
Usually located in the substernal region often radiates
to the neck, left arm, the back, or jaw.
The quality of cardiac chest pain is often described as
heaviness, tightness, squeezing, or choking sensation.
5/4/2017
Chest Pain

When asked about time, the patient with cardiac chest
pain reports the pain lasting anywhere from 30
seconds to hours.

if the patient reports the pain is made worse by lying
down, moving, or deep breathing, it may be caused by
pericarditis. If the pain is retrosternal and
accompanied by sudden shortness of breath and
peripheral cyanosis, it may be caused by a pulmonary
embolism.
5/4/2017
History (cont)

Dyspnea: Subjective complains of the difficulty in
breathing not just SOB.
–
In patients with cardiac disease, it is the
result of inefficient pumping of the left
ventricle, which causes a congestion of
blood flow in the lungs.
–
Orthopnea
Paroxysmal nocturnal dyspnea
–
5/4/2017
History (cont)






Edema of the feet and ankles
Palpitation and syncope: awareness of irregular
or rapid heart beat.
Cough & hemoptysis.
Nocturia.
Cyanosis:
– Central vs Peripheral
Intermittent claudication: results when blood
supply to excerciing muscles is inadequate 5/4/2017
Past Health History






Childhood illnesses
Past surgeries
Previous diagnostic tests and interventions
Medications
Allergies
Transfusions
Current health status
Use of medications
 Allergies to food
 Tobacco, alcohol, substances use
 Diet
 Sleep patterns
 Exercise
 Activities

5/4/2017
History (cont.)

Family history
–

Personal and social history
–

Age and cause of death of immediate family
members
Smoking, drinking, occupation
Review of other systems
–
Total health status; impact of CVD on the function of
other body symptoms
Risk Factors



Uncontrollable(e.g age, heredity, gender, race)
Can be modified(smoking, HTN, DM, high
blood cholesterol, physical activities,
obesity…)
Other factors (e.g stress, sex hormones, birth
control bills, alcohol intake)
5/4/2017
Physical Exam


Inspection
– General appearance
– Jugular venous distension
(JVD)
– Skin
– Extremities
Palpation
– Pulses
– Point of maximal impulse
(PMI)


Percussion
Auscultation
– Good stethoscope
– Positioning
– Normal tones – S1/S2
– Extra tones – S3/S4
– Murmurs
– Rubs
5/4/2017
5/4/2017
Physical Examination

Inspection
–
–
–
–
–

Palpation
–
–

General appearance
Jugular venous distention
Chest
Extremities
Skin
Pulses
Precordium
Percussion
Cardiac size
Remember …..Patient may have dextrocardia-heart
–
situated on the right side.
Jugular venous distention


JVP reflects right atrial pressure and provides an
indications of heart hemodynamics.
A level more than 3 cm above the angle of Louis
indicates an abnormally high volume in the venous
system
 Supine 30-45 degrees, remove pillow
 Turn head away from examiner, shine light across
neck to highlight pulsation
 Locate Angle of Louis & position a vertical ruler on
reference point
 2nd ruler horizontal to level of pulsation
5/4/2017
Jugular venous distention


JVP reflects right atrial pressure and provides an
indications of heart hemodynamics.
Normal JVP should not exceed 3 cm above the angle
of louis.




Supine 30-45 degrees, remove pillow
Turn head away from examiner, shine light across neck to
highlight pulsation
Locate Angle of Louis & position a vertical ruler on reference
point
2nd ruler horizontal to level of pulsation
5/4/2017
Jugular venous pressure




Hypovolemic patients may need to lie flat
before you see the veins
When JVP increases, the patient may need to
be elevated 60-90 degrees.
Increased JVP may suggest Rt side HF,
tricuspid stenosis or superior vena cava
obstruction, pericaridal effusion,
In patients with COPD, veins collapsed with
inspiration and pressure elevated during
expiration.
5/4/2017
Jugular venous pressure



Unilateral distension of jugular vein may be
due to local obstruction or kinking.
jugular venous pressure of more than 1 cm
while pressure is applied to the abdomen for
60 seconds (hepatojugular or abdominojugular
test) indicates the inability of the heart to
accommodate the increased venous return.
Factors influencing the JVP includes total body
volume, right atrial contraction, and the
distribution of blood volume through the
pulmonic artery
5/4/2017
Inspection (Cont)

Inspect chest:
– Apical pulse: At left
4th or 5th ICS at MCL
5/4/2017
Palpation

Palpate pulses bilaterally
– Temporal
– Carotid * important to only palpate one side at a time
– Brachial
– Radial
– Ulnar
– Femoral
– Popliteal
– Dorsalis pedis
– Posterior tibial
5/4/2017
Palpation
–
–
Pulsus alternans is a pulse that alternates in
strength with every other beat; it is often found
in patients with left ventricular failure.
Pulsus paradoxus is a pulse that disappears
during inspiration but returns during expiration.
 Pulsus
paradoxus is a sign that is indicative of
several conditions, including cardiac
tamponade, pericarditis, chronic sleep apnea,
andobstructive lung disease (e.g. asthma, COPD)
5/4/2017
Palpation

Precordium: with the palmer aspect of the four
fingers palpate:
– The Apex, base, and left sternal border for any
additional pulsation.
– During palpation of these areas, the nurse feels
for a thrill, which is a palpable vibration. A thrill
usually represents a disruption in blood flow
related to a defect in one of the semilunar
valves.
5/4/2017
Palpation

Apical Impulse: Point of maximum Impulse
(PMI)
– Location: At left 4th or 5th ICS at MCL
– Size: 1 x 2 cm
– Amplitude: short, gentle tap
– Duration: short
5/4/2017
Palpation
Right
2nd
ICSaortic
area
Left 2nd
ICSpulmonic
area
Epigastric
(subxiphoi
d)
Left
sternal
border
right
ventricular
area
Apex
Left
Ventricul
ar Area
5/4/2017
palpation
Palpation of Carotid pulse
 Carotid pulse should not be
assessed simultenous because
This can obstruct flow to the
Brain

5/4/2017
Percussion





Percuss for Cardiac Enlargement
Lt. Anterior axillary line 5th intercostal space &
toward the sternal border
Resonance over lung – dull over heart
Normal – lt. Border of cardiac dullness 5th
interspace MCL: @ 2nd interspace dullnes
coincides with the lt. Sternal border
2nd interspace to 5th MCL
5/4/2017
Auscultation
–
1.
2.
3.
Supine position with bed elevated
Listen with the diaphragm at the right 2nd interspace
near the sternum (aortic area).
Listen with the diaphragm at the left 2nd interspace
near the sternum (pulmonic area).
Listen with the diaphragm at the left 3rd, 4th, and 5th
interspaces near the sternum (tricuspid area).
5/4/2017
Auscultation
1.
2.
3.
Listen with the diaphragm at the apex (PMI) (mitral
area).
Listen with the bell at the apex.
Listen with the bell at the left 4th and 5th interspace
near the sternum
5/4/2017
Auscultation
5/4/2017
Auscultation
Aortic – 2nd rt. Interspace
 Pulmonary – 2nd lt. Interspace
 Erb’s Point – 3rd lt. Interspace
 Tricuspid – 5th interspace
lt. Lower sternal border
 Apical – 5th interspace
lt. MCL

5/4/2017
Heart sounds
5/4/2017
Heart sounds

S1:
–
–

S2:
–
–

loud sounds
produced by AV valves
loud sounds
produced by semilunar valves
S3, S4:
–
–
soft sounds
blood flow into ventricles and atrial contraction
5/4/2017
First & Second Heart Sound
5/4/2017
First heart sound

First Heart sound S1 (Lub):
– Is timed with the closure of (AV valves ; mitral &
tricuspid) at the beginning of ventricular systole.
– Louder than S2 at the apex (mitral valve closure is
responsible for most of the sound produced).
– Loud S1: The intensity of the 1st heart sound may
be increased when PR interval is shortened, as in
tachycardia or in mitral stenosis due to valve leaflets
thickened.
– Splitting of S1 sound may be casued by delay in the
conduction of impulses through the right bundle
branch
5/4/2017
First Heart Sound
–
–
–
–
–
Soft S1: is heard when the PR interval is prolonged.
Split S1: is heard when right ventricular emptying is
delayed. The mitral valve closes before the tricuspid
valve and splits the sound into its two components.
Splitting S1 is best heard over the tricuspid area.
Coincide (correlate) with (upstroke) of carotid artery
pulse.
Coincide with the R wave of the QRS complex of the
ECG
58
5/4/2017
Second heart sound


Heard over pulmonic area (2nd left ICS)
Loud S2: The intensity of S2 may be increased in the
presence of aortic or pulmonic valvular stenosis or with
an increase in the diastolic pressure forcing the
semilunar valves to close, as occurs in pulmonary or
systemic hypertension
– Is produced by vibrations initiated by the closure of
semilunar valves (Aortic & Pulmonic).
– Loudest at the base.
5/4/2017
Second Heart Sound
Physiological Normal splitting of S2 may
occur with Inspiration (aortic & pulmonic
valves closes separately).
During inspiration, there is an increase in
venous return to the RT side of the heart,
which causes a delay in the emptying of the
RV and the closure of the Pulmonic valve
which cause splitting.
–

S1
A2
P2
S2
5/4/2017
Inspiration
Third heart sound (Cont)

S3 (Ventricular gallop):
An S is a low-frequency sound that occurs during
the early, rapid-filling phase of ventricular
diastole. A noncompliant or failing ventricle
cannot distend to accept this rapid inflow of
 blood. This causes turbulent flow, resulting in the
vibration of the AV valvular structures or
ventricles them selves, producing a low-pitch
sound.
– S3 may be physiological or pathological.
5/4/2017
3
Third heart sound (Cont)

S3 often indicates volume overload
secondary to congestive heart failure
or valvular regurgication.
5/4/2017
4th Heart Sound

S4 (Atrial Gallop)
– Is a late diastolic sound that occurs just
prior to S1.
– It is a low-frequency sound heard best
heard at the apex in left lateral position
with the bell.
– The presence of S4 usually indicates
cardiac disease secondary to a decrease
in ventricular compliance caused by either
ventricular hypertrophy or myocardial
ischemia.
5/4/2017
4th Heart Sound

S4 (Atrial Gallop)
– when contraction of the atrium forces
the final amount of blood into the
ventricles. The vibration occurs
because the ventricle is too full to
contain the additional blood. This can
occur in pathologic states such as
ventricular hypertrophy.
5/4/2017
4th Heart Sound (cont)
Could be normal in adults > 40 with NO
evidence of cardiac disease
– Pathologic S4 occur with patients who
have CAD, HTN, and aortic stenosis.
– S4 is heard best at the lower left
sternal border & becoming louder
during inspiration.
–
5/4/2017
Additional Heart Sounds
 Summation
Gallop: S3 & S4 present when
there is a rapid heart rates as ventricular
diastole shortens, S3 & S4 fuse together and
become audible as a single sound. Heard on
apex.

Friction Rubs: A pericardial friction rub is a
high pitched, scratchy sound produced by
inflamed pericardial surface layers which
rubbing together.
5/4/2017
Murmurs

a.
b.
Sounds are produced either by:
the forward flow of blood through a narrowed
or constricted valve into a dilated vessels
chamber.
the backward flow of blood through an
incompetent valve or septal defect.
5/4/2017
Murmurs

Describe the following attributes of Murmurs:
1.
Timing:
1.
Systolic murmur (occurs between S1 & S2)
–
2.
Diastolic murmur (occurs between S2 and S1).
–
2.
3.
4.
Midsystolic, pansysolic, late systolic
Early diastolic, middiastolic, or late diastolic
Location of Maximal Intensity: The site where murmur
originates (heard best).
Radiation: from point of maximum intensity still the sound
heard.
Pitch: high, medium, or low.
5/4/2017
Murmurs
5.
Intensity: the grade on 6-point scale to describe the intensity of murmur
6.
Quality: blowing, harsh, rumbling, or musical.
5/4/2017
Murmurs


The murmurs associated with aortic stenosis
and pulmonic stenosis are described as
crsescendo–decrescendo or diamond shaped
Mitral or tricuspid valvular insufficiency or a
defect in the ventricular septum produces
systolic regurgitant murmur
5/4/2017
Laboratory & Diagnostic
Procedures
5/4/2017
Cardiac laboratory studies



Hematological studies
Coagulation studies
Blood chemistry
–
–


Common electrolyte
Other blood chemistry
Serum lipid studies
Cardiac enzymes
5/4/2017


Why hematological studies????
What coagulation studies ?????
5/4/2017
Cardiac Laboratory Studies

Hematolgical studies:
Complete Blood count
Blood is the transport medium for nutrients such as
oxygen and glucose, as well as electrolyte. Plasma,
protein, and hormones.
Changes in blood cell integrity and total cell count may
reflect specific disorders of the cardiac system and
should be considered an integral part of the
laboratory assessment
–
5/4/2017
Cardiac laboratory studies

Coagulation Studies
–
–
–
Provides information about the patient`s ability to
form, maintain, and dissolve blood clots.
Platelets count, prothrombin time (PT), Partial
thromboplastin(PTT), Fibrinogen level and,
activated clotting time.
Clients with AF, Endocarditis, after MI, or prosthetic
valves tends to form thrombi
5/4/2017
Cardiac Laboratory Studies

Electrolytes
–
–
–
–
K…important in the regulating of cardiac rate.
Na…maintain acid base balance and regulate fluid
balance
CL…maintain acid base balance
Ca …Ionized calcium (free calcium) is responsible
for cardiac and neuromuscular excitability and blood
coagulability.
5/4/2017
Cardiac Laboratory Studies

Electrolytes
–
–
–
Mg…Alterations in normal magnesium levels are reflected
in disruptions in neuromuscular activity, such as in the
patient with arrhythmia
Glucose …reflect nutritive status of the cell.
Phosphorus…Abnormalities can be seen with alterations
in heart rate, alterations in neuromuscular function, and
reciprocal changes in serum calcium.
5/4/2017
Cardiac Laboratory Studies

Serum Lipid Profile:
–
–
–
Cholesterol: Can accumulate in arterial walls.
(recommended <200mg/dl; <160 if CAD exists)
HDL: . Higher levels of HDL are associated with
decreased risk of coronary heart disease.
HDL >60mg/dl
5/4/2017
Cardiac Laboratory Studies

Serum Lipid Profile:
–
–
–
LDL: Higher levels of LDL are associated with a
higher risk for the development of cardiovascular
disease.
LDL (60-70% of total cholesterol); <130 mg/dl
Triglycerides: Levels greater than 200 mg/dL can
contribute to the development of atherosclerosis and
coronary artery disease.
5/4/2017
Why Cardiac enzyme
To determine whether you are having a heart
attack or a threatened heart attack( unstable
angina )if you have chest pain, shortness of
breath, nausea, sweating, and abnormal
electrocardiography
5/4/2017
Cardiac Enzymes




present in low amounts in the serum of healthy
individuals.
when cells are injured, enzymes leak from
damaged cells.
No single enzyme is specific to the cells of a
single organ.
Cardiac enzymes are enzymes found in cardiac
tissue.
5/4/2017
Cardiac Enzymes



Three of the many enzymes present in cardiac tissue
have widespread use in the diagnosis of acute MI:
creatine kinase (CK), lactate dehydrogenase (LDH),
and aspartate aminotransferase (AST; previously
termed serum glutamic oxaloacetic transaminase
[SGOT]).
CK can be divided further into components called
isoenzymes ( more specific for cardiac disease).
The routine sampling of serum for AST and LDH for
the diagnosis of acute MI is no longer
recommended.
5/4/2017
Creatine Kinase (Creatine phosphokinase):
 This enzyme is found in heart muscle (CK-MB),
skeletal muscle (CK-MM), and brain (CK-BB).




Total CPK (creatine phosphokinase)
Normal:
Men:55–170 international units per liter
(IU/L) Women:30–135 IU/L.
Creatine kinase is increased in over 90% of
myocardial infarctions. However, it can be increased
in muscle trauma, physical exertion, postoperatively,
convulsions.
5/4/2017
Cardiac enzymes
Creatine Phosphokinase Isoenzymes
 Rises and returns to normal sooner than total CK
Rises in 4-6 hours
Returns to normal in 2 days
peaks in 24-28 hours
Serial analysis of Ck Isoenzymes is the most specific,
sensitive, and cost effective In diagnosing MI.
Elevated in percarditis, myocarditis, trauma, and
cardiac surgery.

5/4/2017
Cardiac enzymes


Creatine Phosphokinase Isoforms
This test is becoming more popular. MB2 (tissue
CK-MB) is released from heart muscle and
converted in blood to MB1(plasma CK-MB). A level
of MB2 equal or greater than 1.0 U/L and an
MB2/MB1 ratio equal or greater than (1)1.5
indicates myocardial infarction.
5/4/2017
Lactic Dehydrogenase
No longer used for IHD
5/4/2017
comments

Cardiac enzyme levels must always be compared with
symptoms, medical history, physical examination, and
electrocardiography (EKG, ECG) results.

Troponin is an accurate method for quickly diagnosing heart
attack, but because it takes up to 6 hours to rise, it can be low
or negative at first.

Troponin is more specific to heart muscle and remains in the
bloodstream longer than CPK.
5/4/2017

CPK-MB, which is found only in heart muscle, is a
more specific way to estimate the amount of heart
muscle damage than total CPK.

The total CPK enzyme level can be elevated from
vigorous exercise, intramuscular injections, crush
injuries to muscles, muscular dystrophy, or muscle
inflammation.

Another enzyme, myoglobin, may be tested along
with cardiac enzymes to diagnose a heart attack.
5/4/2017
What Affects the Test








Other diseases, such as muscular dystrophy and
certain autoimmune diseases.
Other heart conditions, such as myocarditis and
some forms of cardiomyopathy.
Medicines, especially injections into muscles (IM
injections).
Cholesterol-lowering medicines (statins).
Heavy alcohol use.
Recent strenuous exercise.
Kidney failure.
Recent surgery or serious injury.
5/4/2017
Brain natriuretic peptide (BNP)
& N-terminal prohormone of brain natriuretic
peptide (NT-proBNP)




secreted by the ventricles of the heart in response to
excessive stretching of heart muscle cells
a normal level rules out acute heart failure in the
emergency setting
typically increased in patients with left ventricular
dysfunction, with or without symptoms
Normal: BNP <100 ng /ml
5/4/2017

Biochemical Markers: myocardial protiens
–
–
–
Myocardial proteins specific for detecting
myocardial damage.
Myoglobin
Troponin
5/4/2017
Myoglobin:
– Is the O2 transporting pigment of skeletal
and cardiac muscle.
– Found in striated muscle. Damage to
skeletal or cardiac muscle releases
myoglobin into circulation.
–

Time sequence after myocardial infarction
–
–
–

Rises fast (1-2 hours) after myocardial infarction
Peaks at 2-4 (6 – 8) hours
Returns to normal in 20 - 36 hours.
Very sensitive to reperfusion after thromobolytic
therapy.
5/4/2017
Troponin

These are contractile proteins of the myofibril. The cardiac isoforms
are very specific for cardiac injury and are not present in serum
from healthy people.

Troponin complex is a heteromeric protein playing an important
role in the regulation of skeletal and cardiac muscle contraction.
It consists of three subunits, troponin I (TnI), troponin T (TnT)
and troponin C (TnC); (TnC is available in smooth muscles)
TnT and TnI are presented in cardiac muscles in different forms
than in skeletal muscles.
Only one tissue-specific isoform of TnI is described for cardiac
muscle tissue (cTnI).
cTnI is expressed only in myocardium.




5/4/2017




Troponin I (cTnI) or T (cTnT) are the forms
frequently assessed .
*Rises 2 - 6 hours after injury
Peaks in 12 - 16 hours
cTnI stays elevated for 5-10 days,
cTnT for 5-14 days
5/4/2017
Useful resources


http://www.cardiosource.org/Science-AndQuality/Practice-Guidelines-and-QualityStandards.aspx American College of
Cardiology.
http://www.nhlbi.nih.gov/about/ncep/ National
Cholesterol Education Program
5/4/2017
r Diagnostic
Markers
C –Reactive Protein



C-reactive protein are newer marker of systemic
inflammation, has been shown to be elevated in patients with
acute coronary syndromes.
Normal values are 0 to 2 mg/dL.
Serum values greater than 3 mg/dL in patients with acute
coronary syndrome (ACS) or greater than 5 mg/dL in
patients who are post–coronary interventional procedure may
indicate a higher risk!!!
5/4/2017
D dimer



D dimer represents the end product of thrombus formation
and dissolution that occurs at the site of active plaques in
acute coronary syndromes; this process precedes myocardial
cell damage and release of protein contents.
D dimer, which is detected early and remains elevated for
days, can identify unstable plaque in high-risk patients when
troponin and CK-MB have not yet been released.
Universal normal serum values for D dimer 500 μg/L indicates
increased sensitivity for acute MI.
(D-dimer values < or = 500 ug/L are normal)
5/4/2017
Cardiac Diagnostic Studies
5/4/2017
 New
and advanced diagnostic
tests and tools are constantly
being introduced to further
understand the complexity of
disease, injury, and congenital
or acquired abnormalities.
5/4/2017
Non Invasive Procedure:
 ECG.
 Electrophysiological
studies
 Holter
Monitor.
 Signal averaged
 Stress


Test.
Echocardiography.
Chest X-ray Studies.
5/4/2017
Electrocardiogram (ECG or EKG)



Electrocardiogram:
A test that records the electrical activity of the
heart, shows abnormal rhythms (arrhythmias or
dysrhythmias), and detects heart muscle damage.
provide information about the Mechanical function
and conduction of the heart – can not tell about
structural or perfusion disorders.
5/4/2017
Types

Continuous Monitoring ECG.

Standard/12-lead.

15 leads ECG

18 leads ECG

Signal-Averaged (SAE)
5/4/2017
Continuous Monitoring
provide continuous monitoring
of cardiac activity in the
cardiac unit.
5/4/2017
5/4/2017
Continuous Monitoring
5/4/2017
Five Electrode system


The five-electrode system that increases the
monitor’s capability beyond the three-electrode
system
A five-electrode monitor offers the additional
advantage of allowing the nurse to view two or
more different leads simultaneously on the
monitor screen.
5/4/2017
Five leads ECG
5/4/2017
Standard/12-lead
Record electrical impulses as
they travel through the heart.
5/4/2017
5/4/2017
Standard-12-lead
5/4/2017
Electrocardiogram
5/4/2017
18 leads ECG






V1: Fourth intercostal space at the right border of the
sternum
V2: Fourth intercostal space at the left border of the
sternum
V3: Halfway between V2 and V4
V4: Fifth intercostal space at the midclavicular line
V5: Fifth intercostal space at the anterior axillary line
(halfway between V4 and V6)
V6: Fifth intercostal space at the midaxillary line, level
with V4
5/4/2017
18 leads ECG






V4R: Fifth intercostal space at the right midclavicular line
V5R: Right anterior axillary line, in a straight line from
V4R
V6R: Right midaxillary line, in a straight line from V5R
V7: Left posterior axillary line, level with V6
V8: Left midscapular line (halfway between V7 and V9)
V9: Immediately left of the vertebral column
5/4/2017
Signal-Averaged (SAE)
Signal-Averaged (SAE):

A test that is much like an ECG, but takes longer
because it records more information.

Detect low-amplitude signals and detect electrical
impulse (late potential) occurs during diastole late into
QRS complex and ST-segment that can’t be detected
by normal ECG. Done at bed side to determine if pt is
susceptible for vent dysrhythmias.
5/4/2017
Signal-Averaged (SAE)
Signal-Averaged (SAE):

Detect ustained ventricular tachycardia in patients with
malignant ventricular tachycardia, a history of MI,
unexplained syncope, nonischemic congestive
cardiomyopathy, or nonsustained ventricular
tachycardia..
5/4/2017
Single Average
5/4/2017
5/4/2017
Holter Monitoring


A small, portable, battery-powered ECG machine worn by a
patient to record heartbeats on tape over a period of 24 to 48
hours - during normal activities. At the end of the time period, the
monitor is returned to the physician's office so the tape can be
read and evaluated.
ECG tracing recorded continuously for a day or longer to detect
arrhythmias that may not appear in a routine ECG but when the
pt. At work or moving.
5/4/2017
Holter Monitoring


a small portable ECG size of a transistor radio.
The monitor is carried with shoulder strap
(battery pack).
The purpose is to obtain continuous or
intermittent graphic tracing of the patient's
pulse & ECG while performing daily activities.
It is maintained for at least 24 hours. The
patient keeps a log (diary) of activities R/T time
of day
5/4/2017


There are 2 types of Holter monitoring:
A. continuous recording - the ECG is recorded
continuously during the entire testing period.
B. event monitor, or loop recording - the ECG is
recorded only when the patient starts the
recording, when symptoms are felt.
Holter monitoring may be done when arrhythmia
is suspected but not seen on a resting or signalaverage ECG, since arrhythmias may be transient
in nature and not seen during the shorter recording
times of the resting or signal-average ECG.
5/4/2017
5/4/2017
5/4/2017
Diagnostic Studies

Exercise Electrocardiogram (Stress Testing):

–
–
measure body reaction to increased exercise level. (changes in
HR, RR, BP, perception is recorded)
Identify client at risk and diagnosis Angina.
It is indicated for:





symptoms of coronary artery disease
determining functional capacity post MI
evaluate exercise induced arrhythmias
evaluate at risk individuals for coronary artery disease
evaluate pharmacological effect on angina
5/4/2017
–
–
–
Advise the patient to avoid stimulants the day of the
test (caffeine), to wear comfortable walking shoes.
Some medications may be withheld prior to the test
(Digoxin)
Test terminated when the heart rate (HR) reach the
maximum or when ST depression greater than 3mm,
fatigue, or chest pain.
Positive if the pt has chest pain, or hypotension,
dysrhythmias before the predicted HR is achieved..
5/4/2017
Exercise Electrocardiogram (Stress
Testing):
5/4/2017
5/4/2017
Stress Testing


Terminate test if chest pain or fatigue, greatly
increased HR, S/S MI or ischemia, drop in BP,
sudden bradycardia, sever dyspnea, STsegment depression >2-4 mm, loss of
coordination, hypertension.
A positive exercise test is that test that has to
be terminated before reaching the predicted
maximum or submaximal limits.
5/4/2017
Diagnostic Studies

Radionuclide testing/ Pharmacologic stress
testing:
–
–
–
Used in clients who are physically unable to exercise
(such as patients with Orthopedic problem, neuro
problem).
Noninvasive injection of small amount of radioisotope
(e.g. thallium ).
Evaluate myocardial perfusion and LV fnx.
5/4/2017



May be combined with pharmacologic stress testing for
clients unable to exercise
Ischemic or injured cardiac muscles will not be able to
take up the radioactive substance normally; the result
will appear as a cold/dark spot indicating the area of
injury that did not take up the radio active substance
that was injected.
Vasodilators (Persantine & adenoside) drugs may be
used to induce the same ischemic changes in the
diseased heart, as in exercise-induced ischemia
5/4/2017
Diagnostic Studies
Echocardiography (ultrasound):
–
–
A noninvasive test that uses sound waves to produce a
study of the motion of the heart's chambers and valves.
The echo sound waves create an image on the monitor
as an ultrasound transducer is passed over the heart.
Noninvasive evaluation of cardiac structure. No
preparation necessary, painless. Patient Need to lie
quietly 30 min to 1 hr.
5/4/2017
5/4/2017
5/4/2017
5/4/2017
–
–
–
Diagnosis of cardiac tamponade at the bedside.
Provide information about cardiac structure,
cardiac wall motion, ejection fraction (EF), ventricle
volumes, and valves.
An echocardiogram can utilize one or more of four
special types of echocardiography
5/4/2017
5/4/2017



M-Mode echocardiography :
This is the simplest type of echocardiography.
M-mode echo is useful for measuring heart
structures, such as the heart's pumping
chambers, the size of the heart itself, and the
thickness of the heart walls.
5/4/2017

Doppler echocardiography :

This Doppler technique is used to measure and
assess the flow of blood through the heart's
chambers and valves.
Also, Doppler can detect abnormal blood flow
within the heart, which can indicate a problem
with one or more of the heart's four valves or
with the heart's walls.

5/4/2017

Color Doppler:
 Color
Doppler is an enhanced form of
Doppler echocardiography. With
color Doppler, different colors are
used to designate the direction of
blood flow.
 This simplifies the interpretation of
the Doppler technique.
5/4/2017

2-D (2-dimensional)echocardiography
This technique is used to "see" the actual
structures and motion of the heart structures.
 A 2-D echo view appears cone-shaped on the
monitor, and the real-time motion of the heart's
structures can be observed.
 This enables the physician to see the various heart
structures at work and evaluate them.

5/4/2017

Transesophageal Echocardiography (TEE):

Is done by inserting a probe down your throat (esophagus)
to the level of the heart.
The TEE transducer works the same as the transducer used
for the other procedures.
However, a clearer image can be obtained with a better
quality than echo.
Useful in clients with thick lung tissues.



5/4/2017
5/4/2017
5/4/2017
5/4/2017
Nursing Considerations for TEE procedure:





•
Pt should be NPO at least 6 hours before procedure
You will undress pts from the waist up, and EKG pads attached
to pts chest & then givehim/her a gown to wear.
Tell your patient that he/she will lie on a table or bed for the
procedure.
An intravenous (IV) line is placed in pts hand or arm, so that
sedative medication can be given. Sedatives are given to help in
relaxation, but your patient will remain awake enough to assist in
the procedure by swallowing as the TEE probe is passed down
throat.
A numbing medication will be sprayed in the back of pt throat to
make passage of the TEE probe more comfortable.
After procedure pt should be NPO until gag reflex has return
5/4/2017
Diagnostic Studies

Chest X-ray Studies:
–
Show the size and position of the heart, position of
intracardial lines, …
5/4/2017
5/4/2017
Magnetic Resonance Imaging
(MRI):
–
most expensive, provides best information on
chamber size, wall motion, valve function, and large
vessel blood flow quantification, wall thickness, and
tissue characteristics
5/4/2017
5/4/2017
5/4/2017
Magnetic Resonance Imaging (MRI) cont’:

The patient is placed in a tube for 60-90 minutes
(explain this to the patient so he/she will not be
fearful), patient may be premedicated.

NPO for at least 4 hours before the procedure.

Contraindicated in patients who have implanted
metal parts (pacemakers, wires, metal valves,
pumps, …)
5/4/2017
5/4/2017
Diagnostic Studies

Electrophysiological Studies
Invasive method to record cardiac
electrical activity
– A catheter inserted through the femoral,
basilic, or subclavian vein
– The procedure is to reproduce any
dysrhythmia so that its origin may be
isolated
–
5/4/2017
Nursing Consideration:
 NPO 6-8hrs.
 Applied pressure over the site puncture & then
applied pressure dressing .
 Placed pt on bed rest 6hrs.
 Check V/S & inserted site frequently.
 Instruct pt about bleeding signs, swelling,
hematoma formation & arrythmia.
5/4/2017
5/4/2017
5/4/2017
Diagnostic procedures
Cardiac Catheterization
 Cardiac catheterization with
coronary angiography is a
diagnostic procedure done to
evaluate certain types of heart
disease.
5/4/2017
Diagnostic Studies
Cardiac Catheterization: A catheter is inserted into a
large vein or artery in either the leg (groin) or the
arm (anticubital) areas to evaluate the right and left
sides of the heart. Blood samples are obtained to
determine O2 content in the various heart
chambers.
–
–
Insertion of a catheter into the heart and surrounding
tissue
Diagnostic information on the structure, performance,
valves, and circulatory system
5/4/2017
Cardiac Catheterization
Cardiac Catheterization performs to
provide information about:
a.
b.
c.
d.
Blockages of the arteries.
Function of the valves.
Pressures.
Pumping ability
5/4/2017
Cardiac Catheterization


Fractional flow reserve (FFR) is a
measurement that is obtained to help
determine the ischemic potential of coronary
stenoses.
FFR is performed in the cardiac catheterization
laboratory in conjunction with angiography and
is defined as the ratio of maximal blood flow in
a stenotic blood vessel compared with normal
maximal blood flow.
5/4/2017
Cardiac Catheterization
(Pre-Procedure care):




Explain procedure to patient and family.
Verify that the patient has taken nothing by mouth
for at least 6
hours before the procedure except prescribed
medications as advised by the physician.
Ensure that ordered preoperative laboratory
studies have been completed and results are
available.
5/4/2017
Cardiac Catheterization
(Pre-Procedure care):



Ensure that informed consent has been
obtained.
Establish intravenous (IV) access per
institutional protocol or physician order.
Place patient on cardiac monitoring system with
blood pressure and pulse oximetry monitoring.
5/4/2017
Cardiac Catheterization
(Pre-Procedure care):



Provide supplemental oxygen as
ordered/indicated.
Premedicate patient per physician order.
Obtain vital signs before transfer to
catheterization laboratory
5/4/2017
Cardiac Catheterization
5/4/2017
Cardiac Catheterization
•Catheterization Procedure:
•Local anesthesia.
• Inserting an introducer-sheath.
• Inserting a catheter.
• Advancing the catheter.
5/4/2017
Cardiac Catheterization
–
Right-Sided catheterization:

–
Femoral or brachial vein (Rt-sided) to Rt atrium, ventricle
then wedged in small PA (pulmonary artery)
Left-Sided Catheterization:

Femoral or brachial artery, to the aorta then Lt. ventricle
5/4/2017
Diagnostic Procedures
Angiography:
–
–
IV injection of contrast material into the heart
during catheterization. Immediately, then xrays taken to visualize any abnormalities in the
cardiac circulation.
Coronary angiography shows the following:
 How many coronary arteries are
blocked

Where are they blocked

The degree of each blockage
5/4/2017
Cardiac Catheterization
–
post coronary care:
assess pulses & B/P.
assess amplitude of pulses on
extremities used
force fluids - unless worried about fluid
volume overload to facilitate elimination
of contrast media
5/4/2017
Cardiac Catheterization
–
post coronary care:
 Pressure
dressing over arterial site (usually
groin) & complete bed rest for up to 12 hrs &
check site for bleeding.
 Possible complications; Ventricular fibrillation,
tachycardia, CVA, hypotension from contrast
media that has diuretic effect
 Instruct client to avoid bending the hips during
the first 12-24 hours.
5/4/2017