Chapter 25

Assessment of
Cardiovascula
r Function
Learning outcomes #1
• 1.Describe the relationship between the anatomic
structures and the physiologic function of the
cardiovascular system.
• 2. Incorporate assessment of cardiac risk factors into the
health history and physical assessment of the patient
with cardiovascular disease.
• 3. Explain the proper techniques to perform a
comprehensive cardiovascular assessment.
• 4. Discriminate between normal and abnormal
assessment findings identified by inspection, palpation,
percussion, and auscultation of the cardiovascular
system.

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Learning outcomes #2
• 5. Recognize and evaluate the major manifestations of
cardiovascular dysfunction by applying concepts from the
patient’s health history and physical assessment findings.
• 6. Discuss the clinical indications, patient preparation,
and other related nursing implications for common tests
and procedures used to assess cardiovascular function
and diagnose cardiovascular diseases.
• 7. Compare the various methods of hemodynamic
monitoring (e.g., central venous pressure, pulmonary
artery pressure, and arterial pressure monitoring) with
regard to indications for use, potential complications, and
nursing responsibilities

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 Three layers: • Semilunar valves: aortic
and pulmonic
endocardium,
myocardium, epicardium • Coronary arteries
• Cardiac conduction system
The myocardium is the (electrophysiology)
layer of the heart • The normal electrophysiological
responsible for the conduction route is SA node to
pumping action. AV node to bundle of HIS to
Purkinje fibers.
 Four chambers: Right • Cardiac hemodynamics
atrium and ventricle, left
atrium and ventricle
 Atrioventricular valves:
 tricuspid and mitral

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Anatomy of the Heart

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Cardiac Conduction System:
Electrophysiology

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Question #1
Which of the following is the primary pacemaker for the
myocardium?
A. Atrioventricular junction
B. Bundle of His
C. Purkinje fibers
D. Sinoatrial node

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 Answer

D. Sinoatrial node
Rationale: The sinoatrial node is the primary pacemaker
for the myocardium.

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Cardiac Action Potential #1
• Depolarization: electrical activation of cell caused by
influx of sodium into cell while potassium exits cell
• Repolarization: return of cell to resting state caused by
reentry of potassium into cell while sodium exits
• Systole is the action of the chambers of the heart
becoming smaller and ejecting blood.
• Diastole (relaxations)

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Cardiac Action Potential #2

• Refractory periods
– Effective refractory period: phase in which cells are
incapable of depolarizing
– Relative refractory period: phase in which cells
require stronger-than-normal stimulus to depolarize

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Greater Vessels, Heart Chambers and
Pressures

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Cardiac Hemodynamics #1
• Stroke volume(SV): amount of blood ejected with each
heartbeat
– Preload: degree of stretch of cardiac muscle fibers at
end of diastole
– Afterload: resistance to ejection of blood from
ventricle
– Arterial vasoconstriction increases the systemic
vascular resistance, which increases the afterload.
– Contractility: ability of cardiac muscle to shorten
in
response to electrical impulse

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Cardiac Hemodynamics #2

• Ejection fraction: percent of end diastolic volume ejected

with each heart beat (left ventricle)
• Cardiac utput (CO): amount of blood pumped by
ventricle in liters per minute.
• CO = SV × HR

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• Control of heart rate
– Autonomic nervous system, baroreceptors
• Control of stroke volume
– Preload: Frank-Starling Law
– Afterload: affected by systemic vascular resistance,
pulmonary vascular resistance

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Contractility

– Contractility increased by catecholamines, SNS,

some medications
– Decreased by hypoxemia, acidosis, some
medications

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Question #2
Which of the following best defines stroke volume?
A. The amount of blood ejected with each heartbeat
B. Amount of blood pumped by the ventricle in liters per
minute
C. Degree of stretch of the cardiac muscle fibers at the
end of diastole
D. Ability of the cardiac muscle to shorten in response
to
an electrical impulse

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Answer

A. The amount of blood ejected with each heartbeat

Rationale: Stroke volume is the amount of blood ejected
with each heartbeat. Cardiac output is the amount of
blood pumped by the ventricle in liters per minute.
Preload is the degree of stretch of the cardiac muscle
fibers at the end of diastole. Contractility is the ability of
the cardiac muscle to shorten in response to an electrical
impulse.

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• Demographic information
• Family/genetic history
• Risk factors
– Modifiable

– Nonmodifiable

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Most Common Clinical Manifestations
• Chest pain
Chest pain associated with angina is often precipitated by
physical exertion.
• Dyspnea
• Peripheral edema, weight gain
• Fatigue
• Dizziness, syncope, changes in level of consciousness

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Question #3

Where does the nurse auscultate the apex of the heart?

A. Erb’s point
B. Fifth intercostal space
C. Pulmonic area
D. Tricuspid area

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Answer

B. Fifth intercostal space

Rationale: The nurse auscultates the apex of
the heart at the left fifth intercostal space at
the midclavicular line.

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Assessment #1
• Physical examination
• Palpation, percussion, auscultation
• Medications
• Nutrition
• Elimination
• Activity, exercise
• Sleep, rest

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Assessment #2
• Vital signs
• Pulse pressure is the difference between the systolic and
diastolic pressure.
• Self-perception, self-concept
• Roles, relationships
• Coping, stress tolerance
• Prevention strategies
• Family history

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Health Promotion, Perception, and
Management Questions
• Ask regarding health promotion, preventive practices
– What type of health issues do you have? Are you able
to identify any family history or behaviors that put you
at risk of this health problem?
– What are your risk factors for heart disease? What do you
do to stay healthy?
– How is your health? Have you noticed any changes?

• Ask regarding health promotion, preventive practices

– Do you have a cardiologist or primary health care
provider? How often do you go for checkups?
– Do you use tobacco or alcohol?
– What medications do you take?
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Laboratory Tests #1
• Cardiac biomarkers
• CK
• CK-MB
• Troponin T and I
This is an accurate indicator of
myocardial injury.
• Myoglobin
• Lipid profile
• Increased LDL and decreased HDL increase my risk of
coronary artery disease.”
• the blood specimen for the lipid profile should be obtained after
a 12- hour fast.

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Laboratory Tests #2
• Brain (B-type) natriuretic peptide
• This test will allow the care team to investigate the possibility of
heart failure
• C-reactive protein
High-sensitivity CRP is a protein produced by the liver in response
to systemic inflammation. Inflammation is thought to play a role in
the development and progression of atherosclerosis
• Homocysteine
• Genetic factors and a diet low in folic acid, vitamin B6, and
vitamin B12 are associated with elevated homocysteine levels.
• A 12-hour fast is necessary
• Refer to Table 25-4

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Electrocardiography #1

• 12-lead ECG
• Continuous monitoring: hardwire, telemetry
• Continuous ambulatory monitoring
• Transtelephonic monitoring
• Wireless mobile monitoring

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Electrocardiography #2

• Cardiac stress testing

– Exercise stress testing
– Pharmacologic stress testing
• Echocardiography
– Transthoracic
– Transesophageal
– the patient will remain on bed rest following the
procedure.
During the recovery period, the patient must maintain bed rest
with the head of the bed elevated to 45 degrees. The patient
must be NPO 6 hours preprocedure. The patient is sedated to
make him or her comfortable, but will not be heavily sedated,
and opioids are not necessary. Also, the patient will have a
peripheral IV line initiated pre
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Diagnostic Tests
• Radionuclide imaging
– Myocardial perfusion imaging
– Test of ventricular function, wall motion
– Computed tomography
– Magnetic resonance angiography

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Cardiac Catherization
• Invasive procedure study used to measure cardiac
chamber pressures, assess patency of coronary arteries
• is usually done to assess how blocked or open a patients
coronary arteries are.”
• Requires ECG, hemodynamic monitoring; emergency
equipment must be available
• Assessment prior to test; allergies, blood work

• Assessment of patient postprocedure; circulation,

potential for bleeding, potential for dysrhythmias
• Activity restrictions
• Patient education pre- and postprocedure

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Hemodynamic Monitoring #1
• CVP
•To assess Right ventricular function
Hypovolemia may cause a decreased CVP.
-An increasing pressure may be caused by hypervolemia or by a
condition, such as heart failure, that results in decreased
myocardial contractility Increase CVP
Gauze dressings should be changed every 2 days or transparent
dressings at least every 7 days and whenever dressings
become damp, loosened, or visibly soiled
• Pulmonary artery pressure
To assess left ventricular function
C o pyr igh t © 201 4 W ol ters K luw er Hea lt h | L ip p inc o tt W illia ms &
To assess the pat i e n t ' s r e s p o n s e to f lu id a n d
W ilk in s
d r u g administration

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Hemodynamic Monitoring #2
• Intra-arterial BP monitoring
• Arterial catheters are useful when arterial blood gas
measurements and blood samples need to be obtained
frequently.
• The radial artery is the usual site selected. However,
placement of a catheter into the radial artery can further
impede perfusion to an area that has poor circulation. As
a result, the tissue distal to the cannulated artery can
become ischemic or necrotic. Vigilant assessment is thus
necessary.

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Phlebostatic Level

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Pulmonary Artery Catheter and Pressure
Monitoring System

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Hemodynamic Monitoring
• Complications from use of hemodynamic monitoring
systems are uncommon, but can include pneumothorax,
infection, and air embolism.

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