NCM112j - Disturbances in Oxygenation Cardio System, Peripheral Vascular, Fluid and Electrolytes

Module 1: Assessment of the Clients with Cardiovascular Disorders

CARDIAC ASSESSMENT:
Assessment of the Clients with
Cardiovascular Disorders
1. Health History
 Obtain description of present illness
 Chief complaint
o Chest pain, SOB, Edema etc.
 Assess risk factors
Risk Factors:
 Non-modifiable Risk factors
 Modifiable Risk Factors

Risk factors
Non – Modifiable Risk Factors
 Age: Above 40 years old
 Gender: Males
 Race: Americans
 Heredity: Family Hx of CVD
Modifiable Risk Factors
 Stress
 Diet
 Exercise
 Cigarette smoking
 Alcohol
 Hypertension
 Hyperlipidemia
 DM
 Obesity
 Personality type
 Contraceptive pill

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 NCM112j - Disturbances in Oxygenation Cardio System, Peripheral Vascular, Fluid and Electrolytes
Module 1: Assessment of the Clients with Cardiovascular Disorders
Thorax

Additional Assessment Areas

Gordon’s 11 functional patterns
1. Health perception and management Peripheral Pulses
2. Nutrition and metabolism
3. Elimination
4. Activity and exercise
5. Sleep rest patterns
6. Cognition and perception
7. Self-perception and self-concept
8. Roles and relationships
9. Sexuality and reproduction
10. Coping and stress tolerance
11. Value – Belief Pattern
CARDIAC ASSESSMENT
1. Physical examination
 Vital signs- BP
- Inspection: skin color, Neck vein
(jugular vein distention)
- Respiration: (dyspnea), PMI,
peripheral edema
- Palpation: peripheral pulses, apical
pulse Percussion: pulmonary edema
(dullness on percussion of the chest)  Bilaterally
- Auscultation  simultaneously
 Heart sounds o Rate, rhythm, quality
 Murmurs
 Light touch
 Pericardial friction rub (grating sound
• Peripheral pulses
produced by friction of the heart
 0 (absent),
against the pericardium)
 1 (palpable),
 described as a short, high pitched,
 2 (normal)
scratchy sound.
 3 (full),
 4 (full and bounding

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NCM112j - Disturbances in Oxygenation Cardio System, Peripheral Vascular, Fluid and Electrolytes
Module 1: Assessment of the Clients with Cardiovascular Disorders
Common Clinical Manifestations of  Elevates within 3-4 hours, peaks in 4-
Cardiovascular Disorders 24 hours
• Dyspnea  persists for 7 days to 3 weeks!
- Dyspnea on exertion (DOE)  NV: less than 0.6 ng/mL
- Orthopnea (DOB in lying position) Lactic Dehydrogenase (LDH)
- Paroxysmal nocturnal dyspnea (SOB  Elevates 24 hrs, peaks in 48-72 hrs
2-5 hrs after onset of sleep)
 Chest pain (decreased Coronary Serum Lipids
perfusion)  Serum Cholesterol ( fat or lipid) = 200
 Edema (increased hydrostatic mg/dl
pressure in venous system, shifting of  Serum Triglycerides- 40- 150 mg/dl
plasma) • LDL- 130 mg/dL
 Syncope (generalized muscle • HDL- 30-70- mg/dL
weakness, decrease Cerebral  NPO for 10 – 12 hours
perfusion)
 Palpitations: unpleasant awareness
of heartbeat Serum lipids
 Fatigue: inadequate CO  lipid profile measures serum
cholesterol, tri-glyceride, and
Laboratory and diagnostic tests lipoprotein levels.
related to cardiac function  lipid profile is used to assess the risk
1. Complete blood count of developing coronary artery disease.
 Elevated RBC’s: suggests  desirable range for:
inadequate tissue perfusion  serum cholesterol is lower than 200
 Elevated WBC’s: infectious heart mg/dL
disease, MI  low-density lipoprotein cholesterol
 Erythrocyte Sedimentation rate lower than 130 mg/dL
(ESR)  high-density lipoprotein cholesterol at
- Normal range: 30 to 70 mg/dL.
- Males : 15-20 mm/hr  Lipoprotein -a or Lp(a), a modified
- Females : 20- 30 mm/hr form of LDL, increases atherosclerotic
plaques and increases clots; value
2. Blood coagulation tests should be less than 30 mg/dL.
- Prothrombin time (PT) ( 10-13
seconds) Cardiac Serum Enzymes
- Partial Thromboplastin Time ( PTT) 1. CK–MB
( 25-35 seconds)  CK- MB ( myocardial muscle) : an
elevation in value indicates myocardial
Laboratory Cardiac enzymes damage. Normal value : 0% - 5% of
CK- MB (creatine kinase) total. Total CK is 26 to 174 units/ L.
 Elevates within 4 hours, peaks in 18 2. Troponin
hours  Most specific test to detect MI
 declines till 3 days  3 components: I, C, T
 Normal value is 0-7 U/L 1. Troponin I: modulate the contractile
Troponin I and T state
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NCM112j - Disturbances in Oxygenation Cardio System, Peripheral Vascular, Fluid and Electrolytes
Module 1: Assessment of the Clients with Cardiovascular Disorders
2. Troponin C: binds calcium - U -wave
3. Troponin I binds I and C - depressed ST segment
 Elevated Troponin T is as sensitive as - Short T wave
CK- MB in detecting myocardial injury • Hyperkalemia
 Troponin I persists for 4 – 7 days - Prolonged QRS complex
3. Lactic Dehydrogenase (LDH) - Elevated ST segment
 Most sensitive indicator of myocardial - Peaked T wave
damge • MI
 In MI< LDH1 is elevated and its levels - Elevated ST segment (1st ECG
exceeds LDH2 - change that occurs in MI)
 Normal range: 100-225 mU/ml - Inverted T wave
 Range with Myocardia Infarction - Pathologic Q wave (permanent in
 Onset 12 hrs ECG of post MI client)
 Peaks 48 hrs
 Returns to normal : 10 to 14 days

4. ELECTROCARDIOGRAM (ECG)
 graphical recording of the electrical
activity of the heart
 A non-invasive procedure
 Painless
 Electrodes and wires attached
 There is no risk of electrocution
 Avoid muscular contraction/movement
5. Electrocardiography

Common ECG Changes

• Hypokalemia

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NCM112j - Disturbances in Oxygenation Cardio System, Peripheral Vascular, Fluid and Electrolytes
Module 1: Assessment of the Clients with Cardiovascular Disorders
6. Holter Monitoring
 Continuous ( 24 hour) ECG monitoring Nursing Interventions before TEE
 Portable monitoring system called 1. Ascertain Hx of esophageal surgery,
telemetry unit malignancy or allergy to anesthetics
 Attempts to assess the activities which or sedatives.
precipitate dysrhythmias, time of the 2. NPO 4-6 hours before the procedure
day the client experiences (prevents aspiration)
dysrhythmias 3. Void before procedure
 Client/ nurse Record activities and 4. Remove dentures, oral prosthetics
unusual sensations experience. (prevent airway obstruction.
Stress Test: Treadmill testing: 5. Administer sedatives as ordered
ECG is monitored during exercise on a 6. Keep suction, resuscitation
treadmill or a bicycle – like device. equipment readily available.
 consent 7. Cardiac monitoring done during
 light meal or fast for 4 hours procedure.
 NO: smoking, alcohol and caffeine 8. Topical spray to depress gag reflex.
 Walking shoes, comfy clothes ( facilitates insertion of transducer
 Notify MD: chest pain, dizziness, SOB into the esophagus.
 Avoid hot shower for 10-12 hrs 9. Place patient in chin – to – chest
Sonic Studies position to facilitate passage of
 Echocardiography endoscope.
 Transesophageal Echocardiography Nursing Interventions after TEE
1. Echocardiography 1. NPO until gag reflex returns. To
 uses ultrasound imaging of the prevent aspiration.
 cardiac structures and mobility. 2. Place patient in lateral or semi-
 No special preparation required, fowlers position.
painless and takes approx. 30 to 60 3. To promote drainage of secretions
mins to compete. from the mouth.
 Client has to: 4. Encourage to cough.
- remain still, 5. Throat lozenges, relieves throat
- in supine position slightly turned to soreness.
the left side, 6. Observe S/s of complications:
- with HOB elevated 15 to 20 degrees. - pharyngeal bleeding
2. Transesophageal - Cardiac dysrhythmias
Echocardiogram - Vasovagal reaction
- Transient hypoxemia

Radiologic Tests
 Chest X ray
 Cardiac catheterization
 Angiography
 MRI

1. CARDIAC catheterization

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NCM112j - Disturbances in Oxygenation Cardio System, Peripheral Vascular, Fluid and Electrolytes
Module 1: Assessment of the Clients with Cardiovascular Disorders
 Insertion of a catheter into the heart  Dye allergy
and surrounding vessels
Purposes: 2. Chest Roentgenograms (X- rays )
 Assess O2 levels, pulmonary blood  Determines overall size and
flow, CO, Heart structures, and configuration of the heart and size of
performance of the heart valves and the cardiac chambers
surrounding vessels (coronary  Helps detect problems with your heart
visualization) and lungs.

Invasive Hemodynamic Monitoring

 Central venous pressure
 Pulmonary artery pressure (PAP)
Pulmonary Artery Pressure
Measurement
During procedure, cardiologist:
 place a thin flexible catheter into a
blood vessel( neck)
 Catheter is guided into the lower right
heart chamber and pulmonary artery
 To measure blood pressure in the
main pulmonary arteries and the right
ventricle.

 Intra-test:
 Fluttery feeling
 warmth and metallic taste

Cardiac Cath
 Strict bedrest: 6-12 hours
 May turn side to side but bed should
not be elevated more than 30 degrees
and legs always straight
 Encourage fluid intake to flush
 Immobilize arm
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NCM112j - Disturbances in Oxygenation Cardio System, Peripheral Vascular, Fluid and Electrolytes
Module 1: Assessment of the Clients with Cardiovascular Disorders
 Complications:
 Infection, Pneumothorax, Air
embolism

Pulmonary Artery Pressure

 Normal: mean 15 mm Hg
 Measurement helpful: CVP
- Assesses LV function  Pressure within the SVC
- Assists in determining etiology of  Normal: 0 - 8 mmHg
shock
- Evaluates response to medical
interventions
 Capable of measuring:
- RA pressure
- PA systolic pressure
- PA diastolic pressure
- Mean pulmonary artery pressure
(4.5–13 mm Hg)
- Pulmonary artery wedge pressure

Central Venous Pressure (CVP)

 Measures pressure in vena cave or
right atrium Angiography / arteriography
o Indirect measurement of right  Introduction of contrast medium into
ventricular pressure the vascular system to outline the
 Normal: 0-8 mm Hg: 4-10 cm H2O heart and blood vessels
 Elevated: hypervolemia, Heart failure  Done during cardiac catheterization
 Low: decreased preload related to
hypovolemia
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NCM112j - Disturbances in Oxygenation Cardio System, Peripheral Vascular, Fluid and Electrolytes
Module 1: Assessment of the Clients with Cardiovascular Disorders
- Encourage coughing and deep
breathing exercises

4. Increase client activity tolerance

 Nursing interventions:
 Same as in
catheterization
 Observe for. Hypotension
(contrast medium used may
cause diuretic effect)
Cardiac implementation
1. Assess the cardio-pulmonary status
- VS, BP, Cardiac assessment
2. Enhance cardiac output
- Establish IV line
- Balance rest and activity periods
- Assist in daily activities
- Provide strict bed rest if indicated
- Soft foods
- Assistance in self-care
Cardiac 6. Promote adequate sleep
7. Prevent infection
- Monitor skin integrity of lower
extremities
- Assess skin site for edema, redness
and warmth
- Monitor for fever
- Change position frequently
5. Promote client comfort
- Assess the client’s description of pain
and chest discomfort
- Administer meds as prescribed:
- Morphine for MI
- Nitroglycerine: Angina
- Diuretics: to relieve congestion in CHF
6. Minimize patient anxiety
- Encourage verbalization of feelings,
fears
- Answer client questions.
- Provide information about procedures
and medications and concerns

3. Promote gas exchange

- Administer O2
- Position client in SEMI-Fowler’s
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NCM112j - Disturbances in Oxygenation Cardio System, Peripheral Vascular, Fluid and Electrolytes
Module 1: Assessment of the Clients with Cardiovascular Disorders