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Care of Clients with Problems In Oxygenation,


Fluids and Electrolytes, Metabolism and Endocrine
(NCM103)
Cardiovascular System: Assessment of Cardiovascular System

Anatomy and Physiology of the Heart
3 Layers of the Heart
o Endocardium Consists of endothelial tissues that lines the inside the heart and valves
o Myocardium Middle layer, made up of muscle fibers responsible for pumping action
o Epicardium Exterior layer of the heart
Pericardium
o Visceral Pericardium Adhering to the Epicardium
o Parietal Pericardium Envelops the visceral pericardium
Chambers
o Auricle (Auricle) Receiving chambers
o Ventricle Pumping chambers
Heart Ventricles
o Atrioventricular Valves
Mitral Valve / Bicuspid Valve (Left Atrioventricular Valve)
Tricuspid Valve (Right Atrioventricular Valve)
o Semi-lunar Valves
Pulmonic Valve
Aortic Valve
Coronary Arteries
o Left Coronary Artery
o Right Coronary Artery

Chamber Pressures
RA
(0 8 mm Hg)
RV
(15 25 mm Hg)
LA
(4 12 mm Hg)
LV
(110 130 mm Hg)
Going
To
The
Lungs
8

1
5

m
m

H
g
TV MV
80 mm Hg
PV AV
THICKER
THICKER



Right Side of the Heart
During Ventricular Systole 15 25 mm Hg
Pulmonic Diastolic Pressure 8 15 mm Hg

Left Side of the Heart
Left Ventricle During Systole 110 130
mm Hg
Resting Aortic Pressure 80 mm Hg
Left Ventricular Ejection, Aortic Pressure 110 130 mm Hg
End of Diastole, Atrium and Ventricle 4 12 mm Hg
Physiology of the Heart
+ Cardiac Electrophysiology
1. Automaticity Ability to initiate an electrical impulse
2. Excitability Ability to respond to an electrical impulse
3. Conductivity Ability to transmit an electrical impulse from one cell to another

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+ Conduction System


Pace Maker!
Atria
SA Node
Depolarization
AV Node
Ventricles
Bundle of
His
Purkinje Fibers
Ventricular Contraction
Ventricular Depolarization
Repolarization
(RELAXATION)
Refractory Period
Phases of Refractory Period
1. Effective / Absolute Refractory Period
Rest, unresponsive to any stimuli
2. Relative Refractory Period
Premature Ventricular Contraction (PVC)
Premature contractility

3 Important Factors
1. Preload Refers to the degree of stretch of the ventricular cardiac muscle fibers at the END
of DIASTOLE
2. Afterload Resistance to ejection of blood from the ventricle
3. Contractility Refers to the force generated by the contracting myocardium

Assessment of the Cardiovascular System
o Assess for
o Severity of Condition
o Presence of Risk factors
o Patients Setting
o Purpose for assessment
o Health History
- Demographic Information
- Health status of client
- Clients impression of his health status
o Clinical Manifestations
Stroke Volume = 70 mL/beat
Cardiac Output 4.9 5.6 L/min

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1. Chest Pain
Angina Pectoris
Localized
Short duration
Stimulated by outside factors
Relieved by cardiovascular vasodilators and rest
Myocardial Infarction
Radiates
Long duration
Not associated with outside factors
Rest wont help; narcotic agents are used
Pericarditis
Assess at the Epigastric area
Substernal area can radiate at BACK, ARM, and or NECK
Aggravated by INSPIRATION, SWALLOWING, and COUGHING
Pulmonary Disorders
CANT LOCATE THE PAIN!
2. Shortness of Breath (SOB) Can occur at rest
3. Peripheral Edema
4. Palpitations
Unpleasant sensation of being conscious of ones heart beat
Sinus Tachycardia Disappears without management
5. Fatigue
6. Dizziness, syncope / changes in level of consciousness

Physical Assessment
- Cardiac Assessment Includes Evaluation of:
1. Effectiveness of heart as a PUMP
2. Filling volumes and pressure
- Examination Covers the following areas
1. General appearance and cognition
o Level of distress
o Level of consciousness
o Thought process
2. Inspection
o Pallor
o Peripheral Cyanosis
Impaired circulation
CO
o Central Cyanosis
O
2
Saturation of blood
o Xanthelasma
Yellowish
Raised plaques on nasal portion of one or both eyelids
o Reduced skin turgor
o Temperature of skin
o Ecchymosis / Hematoma
3. Blood Pressure
o Definition: Pressure exerted on the walls of the heart
o Factors that affect BP
CO If less, CO; If more, CO
Vasodilation, Constriction of vessels
Volume, Velocity, Viscosity


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o Normal Value: 120/80 mm Hg (Systole/Diastole)
o Pulse Pressure = 30 or 40 mm Hg; <30 mm Hg CO
o Postural blood pressure changes
Sudden change of position = BP
Changes in Position
o HR by 4 25 bpm
o BP by 5 10 mm Hg
4. Arterial Pulse
o Factors to Evaluate
a. Pulse Rate = Beats per minute
b. Pulse Rhythm
Inhalation = PR
Exhalation = PR Sinus arrhythmias
c. Pulse Configuration / Contour
Assess jugular vein
Feeble pulse: Aortic stenosis
Falling Off: Collapsing / Water-hammer Pulse
- Aortic Insufficiency
d. Pulse Quality / Amplitude Scale
1. 0 Not Palpable
2. +1 Weak
3. +2 Diminished
4. +3 Easy to palpate
5. +4 STRONG!
5. Jugular Venous Pulsation
] Observe Jugular veins
_ Above the clavicle
_ Client is supine then elevate the head
] CVP Reading
_ Measures the pressure within the SVC
_ Normal Value: 5 10 cm H
2
O According to MAM!
_ 0 Level of manometer, should be on the level of the heart of the client
_ Evaluation based on initial CVP reading of the client
6. Heart Inspection and Palpation
o Examine the following areas
1. Aortic Area 2
nd
ICS right of Sternum
2. Pulmonic area 2
nd
ICS left of Sternum
3. Erbs Point 3
rd
ICS left of Sternum
4. Tricuspid Area 4
th
and 5
th
ICS left of Sternum
5. Epigastric Area Below Xiphoid Process
6. Point of Maximal Impulse (PMI) Left midclavicular line, 5
th
ICS
7. Chest Percussion
o Left Border of the heart
3
rd
5
th
ICS
o Bell
LOW frequency sounds
Placed on Skin LIGHTLY
o Diaphragm
HIGH Frequency sounds
Placed on skin FIRMLY





If there is increased pressure in
the RA, there is a STRONG pulse
in the Jugular Veins
Thrill = NOISY /
OBSTRUCTION of
FLOW within Blood
Vessel

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8. Cardiac Auscultation
+ Normal Heart Sounds
- S1 1
st
Heart Sound (Atrioventricular Valves)
- S2 2
nd
Heart Sound (Semi-lunar Valves)







+ Gallop Sound
- S3 3
rd
Heart Sound
- S4 4
th
Heart Sound
+ Snaps and Clicks
_ Pitch Difference
o Snaps
High pitched sounds
Brought about by mitral stenosis
o Clicks
Low pitched sounds
Pressure of ventricles is HIGH!
+ Murmur
~ Location (Base / Apex) of heart
~ Timing (Systole / Diastole)
~ Intensity
1. Grade I Very faint, unexperienced
2. Grade II Quiet, experienced
3. Grade III and IV Associated with Thrill, LOUD!!
4. Grade V and VI Very loud, heard without stethoscope
~ Pitch - High / Low Pitch
~ Quality Blowing, whistling, rustling, rumbling, harsh
~ Radiation Can be found on different areas

9. Inspection of Extremities
Decrease capillary refill / Blanching Sign
Should have NO NAIL POLISH
Normal Within 3 seconds
Vascular changes
Decreased arterial circulation
Varicosities, Bourgeois Disease
Intermittent claudication
Hematoma Associated with anticoagulants
Peripheral Edema / Dependent Edema
At the lower extremities
Assess for pitting edema
Graded by +1 up to +4
o +1 (0 2 mm)
o +4 (6 8 mm)
Clubbing of the Fingers and Toes
Assess efficiency of blood flow on extremities (O
2
Saturation)
Lower Extremity Ulcer
Needs adequate blood supply

10. Other Systems
Gallop Sounds
Caused by the vibration of myocardium
Softer
Due to rapid ventricular filling
Normal in certain groups of clients
o Children
o Young Adults
o People who have Heart Failure

Lub Dub~
S1 LUB LONGER and LOUDER
S2 DUB SHORTER and SOFTER
> Best heard at the base of the heart
Difference of MURMUR to THRILL
Murmur If AUSCULTATED
Thrill If PALPATED

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o Lungs
Tachypnea
Cheyne-Stokes Respiration
o Hyperxemia Apnea (Alternative)
Hemoptysis Coughing of blood / sputum with blood
Cough
Crackles / Rales Associated with lungs with fluid
Wheezes Narrowed airway
o Abdomen
Hepatojugular Reflex Right Sided Heart Failure

Bladder Distention
o Urine Output

Diagnostic Evaluation
A. Cardiac Biomarker Analysis (Plasma Analysis of Cardiac Enzymes)
1. Creatinine Kinase (CK-MB)
+ Fastest to increase in number
+ Diagnosed for MI
2. Lactic Dehydrogenase
+ Reaches its peak in 2 3 days
3. Myoglobin
+ Specially a cardiac muscle enzyme
+ Reaches its peak fast but disappears rapidly
- 4 12 Hours Disappears!!
4. Troponin T and I
+ Appears early, but remains in the circulation in 3 weeks

B. Blood Chemicals
1. Serum Sodium (Normal: 135 145 mEq/L)
` Hyponatremia Fluid Excess
` Hypernatremia Fluid Deficit
2. Serum Potassium (Normal: 3.5 5.0 mEq/L)
` Plays a great role in contractility of the HEART
- Hypokalemia Cardiac Arrhythmias
- Hyperkalemia Cardiac Arrhythmias
3. Serum Calcium (8.5 10.5 mg/dL)
` Plays a great role in the coagulability of the HEART for NODAL CELLS
- Nodal cells
4. Serum Magnesium (1.8 2.7 mg/dL)
` Responsible for Reabsorption of Ca
` Maintenance and Storage of Ca and K




Cardiac Biomarkers
Cardiac muscles produce
enzymes that will not be
released unless the
myocardium is impaired

CK
Lactic Dehydrogenase
Myoglobin
Troponin T and I


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Lipid Measurements
Lipid Profile
o LDL (< 160 mg/dL)
o HDL ( 35 70 mg/dL)
Cholesterol Level (Normal: Less than 200 mg/dL)
Triglycerides (Normal: 100 200 mg/dL)

C. Brain (B-Type) Natriuretic Peptide (BNP)
@ Neurohormone Regulates BP and Fluid Volume
@ Value 51.2 pg/ml Correlated with mild heart failure
@ > 1000 pg/ml SEVERE HEART FAILURE!! :o

D. C Reactive Protein (CRP)
O Produced by the LIVER
O Factor in the development of Atherosclerosis!
O IN RESPONSE to INFLAMMATION
O Values:
Low Less than 1.0 mg/dL
Moderate 1.0 3.0 mg/dL
Severe 3.0 mg/dL or HIGHER

E. Homocysteine
: Amino Acid linked in the development of Atherosclerosis
: Values:
Normal: 5 15 umol/L
Moderate: 16 30 umol/L
Severe: More than 100 umol/L

Chest X-Rays and Fluoroscopy
1. Chest X-Ray
2. Fluoroscopy
3. Electrocardiography
Continuous Electrocardiographic Monitoring
a. Hardwire Cardiac Monitoring Inside the room with the patient
b. Telemetry Monitor is AWAY from the patient
c. Continuous Ambulatory Monitoring (Holter) Done at HOME

Cardiac Stress Test
No coffee and alcohol before the procedure
Exercise Stress Test

Radionuclide Imaging
Myocardial perfusion imaging uses:
o Thallium 201
o Technetium 99m
CT Scan
PET Scan
MRI

Echocardiography
Receive heart sounds produced by the heart
] Traditional Echocardiography (TE)
o Lubricant on chest with
Transducer
] Transesophageal Echocardiography
o Inserted through the mouth and
into the esophagus
] Cardiac Catheterization
o Femoral Artery
Done for children with
cardiac abnormalities
(Stenosis, Regurgitation)
IVC RA RV
PA
o Through Fluoroscopy
] Angiography
o Visualization of BLOOD
VESSELS
o Use of RADIO OPAQUE DYE
o Followed by X-Rays
o To know the adequacy /
inadequacy of blood flow