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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