ASSESSMENT OF THE CARDIOVASCULAR SYSTEM pp. 690-699, 702-703 VASCULAR SYSTEM 1.

Provides a route for blood to travel from heart to nourish tissues of the body 2. Carries cellular waste to excretory organs 3. Allows lymphatic flow to drain tissue fluid back into circulation 4. Return blood to heart for recirculation Arterial System Primary function: deliver oxygen and nutrients to various tissues in the body Arteries arterioles smaller terminal arterioles capillaries venules to form capillary network Nutrients are exchanges across capillary membranes by three processes: Osmosis: spontaneous net movement of solvent molecules through a partially permeable membrane into a region of higher solute concentration, in the direction that tends to equalize the solute concentrations on the two sides Filtration: the passage of materials through a membrane by a physical force such as gravity. In the body filtration is also achieved by means of a physical pump, the heart, which effects the rate of filtration by effecting the pressure of the blood through the blood vessels. Diffusion: the movement of molecules from an area of high concentration to an area of low concentration by random molecular motion. At the tissue level, nutrients, chemicals, and body defense systems are exchanged for cellular waste products; the arteries transport these wastes to the excretory organs (kidneys, lungs) to be reprocessed or removed. Also contribute to temperature regulation by movement of blood toward or diverted from skin. Blood pressure (BP): the forces of blood exerted against the vessel walls. Volume, ventricular contraction, and vascular tone are necessary to maintain blood pressure. BP is determined by the quantity of blood flow or cardiac output (CO), as well as by the resistance in the arterioles: BLOOD PRESSURE = CARDIAC OUTPUT X PERIPHERAL VASCULAR RESISTANCE Three mechanisms mediate and regulate BP: The autonomic nervous system (ANS), which excites or inhibits sympathetic nervous system activity in response to impulses from chemoreceptors and baroreceptors The kidneys, which sense a change in blood flow and activate the renin-angiotensin-aldosterone mechanism The endocrine system, which releases various hormones to stimulate the sympathetic nervous system at the tissue level Systolic blood pressure: the amount of pressure/force generated by the left ventricle to distribute blood into the aorta with each contraction of the heart. A measure of how effective the heart pumps and of vascular tone. Diastolic blood pressure: the amount of pressure/force against the arterial walls during the relaxation phase of the heart. BP is regulated by balancing the sympathetic and parasympathetic nervous systems of the ANS. Changes in activity are responses to messages sent by sensory receptors in the tissues of the body. Baroreceptors: in the arch of the aorta and at the origin of the internal carotid arteries are stimulated when arterial walls are stretched by increased BP. Impulses inhibit vasomotor center (in pons, medulla). Inhibition = drop in BP Peripheral chemoreceptors: in the carotid arteries and along the aortic arch. Sensitive to hypoxemia (decrease in partial pressure of arterial oxygen PaO2). When stimulated, send impulses along vagus nerve to activate a vasoconstrictor response and raise BP. Central chemoreceptors in the respiratory center of the brain are stimulated by hypercapnia (increase in partial pressure of arterial oxygen PaO2) and acidosis Stretch receptors in vena cava and right atrium are sensitive to pressure / volume changes. When hypovolemic, stretch receptors in blood vessels sense reduced volume / pressure and send fewer signals to CNS. Stimulates the sympathetic nervous system to increase HR and constrict peripheral blood vessels. Kidneys: renal blood flow or pressure decreases, kidneys retain sodium and water. BP rises due to fluid retention and activation of renin-angiotensin-aldosterone mechanism in vasoconstriction and sodium retention, and thus fluid retention. Vascular volume also regulated

by release of anti-diuretic hormone (vasopressin) from the posterior pituitary gland. Other factors: emotional behavior stimulate sympathetic nervous system increase BP and HR. Increased physical activity increased BP and HR. Body temperature: hypothermic tissues require fewer nutrients BP drops; in hyperthermia, metabolic needs of tissues is greater BP and pulse rate rise.

Venous System

Primary function: complete the circulation of the blood by returning blood from the capillaries to the right side of the heart Veins located next to arterial system; a second superficial venous circulation runs parallel to the subcutaneous tissue of the extremity; two systems connected by veins that move blood from superficial to deep veins Able to accommodate large shifts in volume with minimal changes in venous pressure; allows for administration of IV fluids and blood transfusions, maintains pressure during blood loss and dehydration Valves that direct blood flow to heart, prevent back-flow; skeletal muscles provides force to push venous blood forward; superior and inferior vena cava valveless and large enough to allow blood flow back to the heart Gravity exerts an increase in hydrostatic pressure in capillaries when upright, delaying venous return; decreases in dependent areas (legs) when lying down less difficulty returning blood to heart.

CARDIOVASCULAR CHANGES ASSOCIATED WITH AGING Many changes result in loss of cardiac reserve and are therefore not evident when resting, only when physically or emotionally stresses does the heart become unable to meet increased metabolic demands of the body CHANGE Cardiac Valves: calcification and mucoid degeneration occur, esp in mitral and aortic valves Conduction System: Pacemaker cells decrease in number, fibrous tissue and fat in the sinoatrial node increase; few muscle fibers remain in the atrial myocaridum and bundle of His; conduction time increases Left Ventricle: Size of left ventricle increases; becomes stiff and less distensible; fibrotic changes decrease speed of early diastolic filling by about 50% NURSING INTERVENTIONS RATIONALES

Assess heart rate and rhythm and heart Murmurs may be detected before other sounds for murmurs. Question pt about symptoms. Valvular abnormalities may dyspnea. result in rhythm changes. Assess the ECG and heart rhythm for dysrhythmias or a heart rate less than 60 beats/min. The sinoatrial (SA) node may lose inherent rhythm. Atrial dysrythmias occur in older adults, 80% of older adults experience premature ventricular contractions (PVCs). Ventricular changes result in decreased stroke volume, ejection fraction, & cardiac output during exercise; heart less able to meet increased oxygen needs. Max heart rate with exercise is decreased. Heart less able to meet increased oxygen demands. Hypertension may occur and must be treated to avoid target organ damage.

Assess the ECG for a widening QRS complex and a longer QT interval. Assess the heart rate at rest and with activity. Assess for activity intolerance.

Aorta and Other Large Arteries: Thicker and become stiffer and less distensible; systolic BP increases to compensate for stiff arteries; systemic vascular resistance increases as a result of less distensible arteries, therefore the left ventricle pumps against greater resistance, contributing to left ventricular hypertrophy

Assess BP. Note increase in systolic, diastolic, and pulse pressures. Assess for activity intolerance and SOB. Assess the peripheral pulses.

Baroreceptors: Become less sensitive

Assess BP with pt lying, then standing or sitting. Assess for dizziness when pt changes position. Teach pt to change position slowly.

Orthostatic & postprandial changes occur due to ineffective baroreceptors. Changes: BP decrease of 10mmHg or more, dizziness, and fainting.

ASSESSMENT OF THE CARDIOVASCULAR SYSTEM pp. 690-699, 702-703 Patient History Nonmodifiable (uncontrollable) Age: incidence of coronary artery disease (CAD) and valvular disease increases with age Gender: men have a higher risk of CAD than women, except in the over 80 age group. Postmenopausal women are 2-3 times more likely than premenopausal women to have CAD; after an acute MI, women have a higher mortality rate and suffer more complications than men. Women with abdominal obesity (greater waist-hip ratio) are more likely to have CVD than women with excess weight in their buttocks, hips, and thighs. Ethnic origin: the number of premature deaths (younger than 65) is greatest among American Indians and lowest among Asians. Family history of cardiovascular disease (CVD): Chronic diseases/illnesses: heart disease is the leading cause of diabetic related deaths; death rate is 2-4 times higher. Storke risk is 2-4 times higher among diabetics. Note: diabetes mellitus, renal disease, aenmia, high BP, stroke, bleeding disorder, connective tissue diseases, chronic pulmonary diseases, heart disease, thrombophlebitis Modifiable (controllable): personal lifestyle habits Cigarette smoking: major risk factor for CVD, esp CAD and peripheral vascular disease (PVD). Tar, nicotine, carbon monoxide implicated. Number of cigarettes smoked daily, duration of smoking habit, age of pt when smoking started Pack years = number of packs per day x number of years smoked Ask about the patient's desire to quit, past attempts to quit, and the methods used. Determine nicotine dependence by asking questions such as: How soon after you wake up in the morning do you smoke? Do you wake up in the middle of your sleep time to smoke? Do you find it difficult not to smoke in places where smoking is prohibited? Do you smoke when you are ill? 3-4 years after stopping smoking, CVD risk is similar to a nonsmoker. Ask those who do not currently smoke whether they have ever smoked and when they quit. Passive smoke reduces blood flow in coronary arteries, risk for dying increases among those who are exposed to secondhand smoke. Sedentary lifestyle: Recommended 30 minutes daily light of moderate exercise. Overweight: BMI 25-30 Obesity: BMI over 30, particular problem for African American women, Mexican Americans, and native Hawaiians. Associated with hypertension, hyerlipidemia, diabetes; all known contributors to CVD. Psychological factors: more at risk are those who are highly competitive, overly concerned with meeting deadlines, often hostile or angry; psychological stress depression, hostility. How do you respond when you have to wait for an appointment? Observe. Previous treatment for CVD: previous diagnostic procedures (e.g., electrocardiography [ECG], cardiac catheterization), and invasive treatment of CVD. Ask specifically about recurrent tonsillitis, streptococcal infections, and rheumatic fever; these conditions may lead to valvular abnormalities of the heart. Ask about any known congenital heart defects. Drug history: any current or recent use of prescription or OTC medications or herbal/natural products. Inquire about known sensitivities to any drug and the nature of the reaction (e.g., nausea, rash). Ask if they have recently used cocaine or any IV street drugs; often associated with heart disease. Women: oral contraceptives or an estrogen replacement. Incidence of MI and stroke in women older than 35 years taking oral contraceptives is increased if they smoke, have diabetes, or hypertension. Social history: information about the patient's living situation, including having a domestic partner, other

household members, environment, and occupation. Annual household income less than $30,000 have a greater risk for CVD than people who have an income over $50,000. Occupation: type of work performed and the requirements of the specific job. For instance, does the job involve physical exertion such as lifting heavy objects? Is the job emotionally stressful? What does a day's work entail? Does job require him or her to be outside in extreme weather conditions? Nutrition History

ASSESSMENT OF THE CARDIOVASCULAR SYSTEM pp. 690-699, 702-703 Health Perception What advice has your health care provider offered you about exercise, diet, or smoking? Health Management Can you follow that advice? Pattern What medications (both over-the-counter and prescription) are you supposed to be taking? Are you taking them as suggested or prescribed? What problems have you had with the medications? Nutrition-Metabolic Pattern What is your usual daily diet? (Analyze diet for saturated fat, cholesterol, total calorie, and sodium content.) How much fluid do you drink daily? Are you thirsty? What do you weigh? When did you last weigh yourself? How often do you weigh yourself? What is your height? Do you know your cholesterol level? What is it? How often do you feel nauseated or not interested in eating? Do your feet/ankles swell during the day? At night, too? How often do you urinate in the daytime? How often do you wake up at night to urinate? What is the most strenuous exercise you did last week? How active are you compared with 6 months ago? 1 year ago? How often do you feel fatigued or tired? Can you climb a flight of stairs and walk a block without feeling short of breath or experiencing chest pain? Do you experience leg cramps when you walk or climb stairs? Where do you sleep? (In bed? In a lounge chair?) How many pillows do you sleep on? Do you ever wake up at night short of breath? What happens when you wake up short of breath? Do you ever wake up at night with pain or cramps in your legs? How do you relieve that sensation? How is your memory? What does your family say about your memory? How often do you feel dizzy, disoriented, or faint? Do you ever have chest discomfort? How often? What precipitates it? What is it like? How do you relieve it? What is its level on a scale of 0 to 10? Do you ever have leg or buttock pain? What are its characteristics? How do you learn best? What is your job? What does a day's work entail? What are your family responsibilities? With whom do you live? Who is available to help you? Has your ability to engage in sexual activity changed in the past year? If so, how? Do you take any medications that affect your sexual response? If so, what? What do you think has been happening to you? How do you respond to being caught in a traffic jam or meeting a deadline? What do you do to relax? What do you do when you feel stressed?

Elimination Pattern Activity/Exercise Pattern

Sleep/Rest Pattern

Cognitive/Perceptual Pattern

Role/Relationship Pattern

Sexuality/Reproductive Pattern Coping/Stress Tolerance Pattern

Recall of food and fluid intake during a 24-hour period, self-imposed or medically prescribed dietary restrictions or supplementations, and the amount and type of alcohol consumption. Others who are responsible for shopping and cooking should be included in this screening. Family History and Genetic Risk Ask about the age, health status, and cause of death of immediate family members. A positive family history for CAD in a first-degree relative (parent, sibling, or child) is a major risk factor. It is more important than other factors such as hypertension, obesity, diabetes, or sudden cardiac death. Current Health Problems Ask the pt to describe his or her health concerns. Onset, duration, sequence, frequency, location, quality, intensity, associated symptoms, and precipitating, aggravating, and relieving factors. Major symptoms with CVD: chest pain or discomfort, dyspnea, fatigue, palpitations, weight gain, syncope, extremity pain. Pain or discomfort can result from ischemic heart disease, pericarditis, and aortic dissection. Can also be due to noncardiac conditions: pleurisy, pulmonary embolus, hiatal hernia, gastroesophageal reflux disease, neuromuscular abnormalities, and anxiety. Evaluate the nature and characteristics of chest pain. Because pain resulting from myocardial ischemia is life threatening, its cause should be considered ischemic (reduced or obstructed blood flow to the myocardium) until proven otherwise. When assessing for symptoms, ask pt about discomfort, heaviness, pressure, and indigestion. Women: Some patients do not experience pain in the chest but instead feel discomfort or indigestion. Triad of symptoms: indigestion or feeling of abdominal fullness, chronic fatigue despite adequate rest and feelings of an inability to catch my breath. The pt may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or viselike. Others with severe neuropathy may experience few or no traditional symptoms except SOB, despite major ischemia. Did the symptoms begin suddenly or develop gradually (manner of onset)? How long did the symptoms last (duration)? Repeated painful episodes: assess how often the symptoms occur (frequency). If pain is present, ask whether it is different from any other episodes of pain. Ask the patient to describe what activities he or she was doing when it first occurred, such as sleeping, arguing, or running (precipitating factors). If possible, the patient should point to the area where the chest pain occurred (location) and describe if and how the pain radiated (spread). Ask how the pain feels and whether it is sharp, dull, or crushing (quality of pain). Ask the patient to grade it from 1 to 10 (intensity). Other signs and symptoms that occur at the same time (associated symptoms), such as dyspnea, diaphoresis (excessive sweating), nausea, and vomiting. Factors that made the chest pain worse (aggravating factors) or less intense (relieving factors). Dyspnea (difficult or labored breathing) can occur as a result of both cardiac and pulmonary disease; ask what factors precipitate and relieve dyspnea, what level of activity produces dyspnea, and what the patient's body position was when dyspnea occurred. If associated with activity, such as climbing stairs --> dyspnea on exertion (DOE). This is usually an early symptom of heart failure and may be the only symptom experienced by women. Orthopnea (dyspnea that appears when he or she lies flat): pt with advanced heart disease may need several pillows to elevate the head and chest, or a recliner to prevent breathlessness. Severity is measured by the number of pillows or the amount of head elevation needed to provide restful sleep. Usually relieved by sitting up or standing. Paroxysmal nocturnal dyspnea (PND) develops after the patient has been lying down for several hours. Blood from the lower extremities is redistributed to the venous system, which increases venous return to the heart. A diseased heart cannot compensate for the increased volume and is ineffective in pumping the additional fluid into the circulatory system. Pulmonary congestion results. The patient awakens abruptly, often with a feeling of suffocation and panic. Sits upright and dangles the legs over the side of the bed to relieve the dyspnea, may last for 20 minutes. Fatigue may be described as a feeling of tiredness or weariness resulting from activity. Fatigue is not diagnostic, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs

after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle. Can also accompany other symptoms or may be an early indication of heart disease in women. Time of day the pt experiences fatigue and activities they can perform. Fatigue resulting from decreased cardiac output often worse in the evening. Ask whether the pt can perform same activities they could perform a year ago or same activities as others of the same age. Often limited activities in response to

Current Health Problems continued... fatigue and unaware how much less active he or she has become. Palpitations: a feeling of fluttering or unpleasant feeling in the chest caused by an irregular heartbeat. May result from a change in heart rate or rhythm or an increase in the force of heart contractions. Rhythm disturbances that may cause palpitations: paroxysmal supraventricular tachycardia, premature contractions, and sinus tachycardia. Occur during / after strenuous physical activity may indicate overexertion or heart disease. Noncardiac factors that may precipitate palpitations include anxiety, stress, fatigue, insomnia, hyperthyroidism, and the ingestion of caffeine, nicotine, or alcohol. Ask the patient about specific factors causing palpitations. Sudden weight increase: of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. Ask whether the patient has noticed a tightness of shoes, indentations from socks, or tightness of rings. Syncope: a brief loss of consciousness. Most common cause is decreased perfusion to the brain. Any condition that suddenly reduces cardiac output, resulting in decreased cerebral blood flow, such as cardiac rhythm disturbances, especially ventricular dysrhythmias, and valvular disorders, such as aortic stenosis, may trigger this symptom. Near-syncope refers to dizziness with an inability to remain in an upright position. Explore the circumstances that lead to dizziness or syncope. Older Adults: Syncope in the aging person may result from hypersensitivity of the carotid sinus bodies in the carotid arteries. Pressure applied to these arteries while turning the head, shrugging the shoulders, or performing a Valsalva maneuver (bearing down during defecation) may stimulate a vagal response. A decrease in BP and heart rate can result, which can produce syncope. May also result from postural (orthostatic) or postprandial (after eating) hypotension. Extremity pain: may be caused by ischemia from atherosclerosis and venous insufficiency of the peripheral blood vessels. Patients who report a moderate to severe cramping sensation in their legs or buttocks associated with an activity such as walking have intermittent claudication related to decreased arterial tissue perfusion. Claudication pain is usually relieved by resting or lowering the affected extremity to decrease tissue demands or to enhance arterial blood flow. Leg pain that results from prolonged standing or sitting is related to venous insufficiency from either incompetent valves or venous obstruction. This pain may be relieved by elevating the extremity. Palpitations: a feeling of fluttering or unpleasant feeling in the chest caused by an irregular heartbeat. May result from a change in heart rate or rhythm or an increase in the force of heart contractions. Rhythm disturbances that may cause palpitations: paroxysmal supraventricular tachycardia, premature contractions, and sinus tachycardia. Occur during / after strenuous physical activity may indicate overexertion or heart disease. Noncardiac factors that may precipitate palpitations include anxiety, stress, fatigue, insomnia, hyperthyroidism, and the ingestion of caffeine, nicotine, or alcohol. Ask the patient about specific factors causing palpitations. Sudden weight increase: of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. Ask whether the patient has noticed a tightness of shoes, indentations from socks, or tightness of rings. Syncope: a brief loss of consciousness. Most common cause is decreased perfusion to the brain. Any condition that suddenly reduces cardiac output, resulting in decreased cerebral blood flow, such as cardiac rhythm disturbances, especially ventricular dysrhythmias, and valvular disorders, such as aortic stenosis, may trigger this symptom. Near-syncope refers to dizziness with an inability to remain in an upright position. Explore the circumstances that lead to dizziness or syncope. Older Adults: Syncope in the aging person may result from hypersensitivity of the carotid sinus bodies in the carotid arteries. Pressure applied to these arteries while turning the head, shrugging the shoulders, or performing a Valsalva maneuver (bearing down during defecation) may stimulate a vagal response. A decrease in BP and heart rate can result, which can produce syncope. May also result from postural (orthostatic) or postprandial (after eating) hypotension. Extremity pain: may be caused by ischemia from atherosclerosis and venous insufficiency of the

peripheral blood vessels. Moderate to severe cramping sensation in their legs or buttocks with an activity such as walking have intermittent claudication related to decreased arterial tissue perfusion. Usually relieved by resting or lowering the affected extremity to decrease tissue demands or to enhance arterial blood flow. Leg pain that results from prolonged standing or sitting is related to venous insufficiency from either incompetent valves or venous obstruction. May be relieved by elevating the extremity.

TABLE 35-1 Assessment of Chest Discomfort: How Various Types of Chest Pain Differ ONSET ANGINA Sudden, usually in response to exertion, emotion, or extremes in temperature QUALITY / SEVERITY Squeezing, viselike pain LOCATION / RADIATION Substernal; may spread across the chest and the back and/or down the arms DURATION / RELIEVING FCTRS Usually the left side of chest without radiation; Usually lasts less than 15 min; relieved with rest, nitrate administration, or oxygen therapy Continuous or no chest discomfort; relieved with morphine, cardiac drugs, and oxygen therapy Intermittent; relieved with sitting upright, analgesia, or administration of antiinflammatory agents Continuous until the underlying condition is treated or the patient has rested

MYOCARDIAL INFARCTION

Sudden, without precipitating factors, often in early morning

Intense stabbing, viselike pain or pressure, severe

Substernal; may spread throughout the anterior chest and to the arms, jaw, back, or neck Substernal; usually spreads to the left side or the back

PERICARDITIS

Sudden

Sharp, stabbing, moderate to severe

PLEUROPULMONARY

Variable

Moderate ache, worse on inspiration

Lung fields

ESOPHAGEALGASTRIC

Variable

Squeezing, heartburn, variable severity

Substernal; may spread Variable; may be to the shoulders or the relieved with antacid abdomen administration, food intake, or taking a sitting position Not well located and Usually lasts a few usually does not minutes radiate to other parts of the body as pain

ANXIETY

Variable, may be in response to stress or fatigue

Dull ache to sharp stabbing; may be associated with numbness in fingers

Functional History Table 35-2 New York Heart Association Functional Classification of Cardiovascular Disability Class I Class II Patients with cardiac disease but without resulting limitations of physical activity Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain Patients with cardiac disease resulting in slight limitation of physical activity They are comfortable at rest Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain Patients with cardiac disease resulting in marked limitation of physical activity They are comfortable at rest

Class III

Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain Class IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort Symptoms of cardiac insufficiency or of the anginal syndrome may be present, even at rest If any physical activity is undertaken, discomfort is increased

Physical Assessment Any changes noted during the course of illness can be compared with this initial database. Evaluate the patient's vital signs on admission to the hospital or during the initial visit to the clinic or health care provider's office. General Appearance Assess general build and appearance, skin color, distress level, level of consciousness, shortness of breath, position, and verbal responses. Poor cardiac output and decreased cerebral perfusion may cause confusion, memory loss, and slowed verbal responses, esp in older adults. Patients with chronic heart failure may appear malnourished, thin, and cachectic. Late signs of severe right-sided heart failure are ascites, jaundice, and anasarca (generalized edema) as a result of prolonged congestion of the liver. Heart failure may cause fluid retention and may be manifested by obvious generalized dependent edema. Skin Includes color and temperature. The best areas in which to assess circulation include the nail beds, mucous membranes, and conjunctival mucosa, because small blood vessels are located near the surface of the skin in those areas. If there is normal blood flow or adequate perfusion to a given area in light-colored skin, it appears pink, perhaps rosy, and is warm. Decreased perfusion is manifested as cool, pale, and moist skin. Pallor is characteristic of anemia and can be seen in areas such as the nail beds, palms, and conjunctival mucous membranes in any patient. Cyanosis: A bluish or darkened discoloration of the skin and mucous membranes in light-skinned people, results from an increased amount of deoxygenated hemoglobin; occurs later as a sign of decreased perfusion with other symptoms. Dark-skinned patients may experience cyanosis as a graying of the same tissues. Central cyanosis involves decreased oxygenation of the arterial blood in the lungs and appears as a bluish tinge of the conjunctivae and the mucous membranes of the mouth and tongue, may indicate impaired lung function or a right-to-left shunt found in congenital heart conditions. Because of impaired circulation, there is marked desaturation of hemoglobin in the peripheral tissues, which produces a bluish or darkened discoloration of the nail beds, earlobes, lips, and toes. Peripheral cyanosis occurs when blood flow to the peripheral vessels is decreased by peripheral vasoconstriction. Constriction results from a low cardiac output or an increased extraction of oxygen from the peripheral tissues. Peripheral cyanosis localized in an extremity is usually a result of arterial or venous insufficiency. Rubor (dusky redness) that replaces pallor in a dependent foot suggests arterial insufficiency. Skin temperature can be assessed for symmetry by touching different areas of the body with the dorsal (back) surface of the hand or fingers. Decreased blood flow results in decreased skin temperature. It is lowered in several clinical conditions, including heart failure, peripheral vascular disease, and shock. Extremities Assess the patient's hands, arms, feet, and legs for skin changes, vascular changes, clubbing, and edema. Skin mobility and turgor are affected by fluid status. Dehydration and aging reduce skin turgor, and edema decreases skin elasticity. Vascular changes in an affected extremity may include paresthesia, muscle fatigue and discomfort, numbness, pain, coolness, and loss of hair distribution from a reduced blood supply. Clubbing of the fingers and toes is caused by chronic oxygen deprivation in body tissues. It is common in patients with advanced chronic pulmonary disease, congenital heart defects, and cor pulmonale (rightsided heart failure). The angle of the normal nail bed is 160 degrees. Withclubbing, the nail straightens out to an angle of 180 degrees and the base of the nail becomes spongy.

Peripheral edema is a common finding in patients with cardiovascular problems; the location helps determine potential cause. Bilateral edema of the legs may be seen in those with heart failure or chronic venous insufficiency. Abdominal and leg edema can be seen in patients with heart disease and cirrhosis of the liver. Localized edema in one extremity may be the result of venous obstruction (thrombosis) or lymphatic blockage of the extremity (lymphedema). Edema in dependent areas, such as the sacrum, when a patient is confined to bed. May also result from third spacing when plasma proteins decrease. Dependent foot and ankle edema is a common side effect of certain antihypertensive drugs, like amlodipine. Document the location of edema as precisely as possible (e.g., midtibial or sacral) and the number of centimeters from an anatomic landmark. The extent of edema can be assessed as mild, moderate, or severe (or 1+, 2+, 3+, or 4+). Determine whether the edema is pitting (the skin can be indented) or nonpitting.

Blood Pressure Arterial blood pressure is measured indirectly by sphygmomanometry. Hypertension: systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher, or taking drugs to control blood pressure.BP exceeding 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. About one of every five Americans has hypertension. Hypotension: less than 90/60 mm Hg may not be adequate for providing enough oxygen and sufficient nutrition to body cells. In certain circumstances, such as shock, the Korotkoff sounds are less audible or are absent. In these cases, palpate the BP, use an ultrasonic device (Doppler device), or obtain a direct measurement by arterial catheter in the critical care setting. When BP is palpated, only the systolic pressure can be determined. Postural (orthostatic) hypotension: dizziness or light-headedness when pts move from a flat, supine position to a sitting or a standing position at the edge of the bed. A decrease of more than 20 mm Hg of the systolic pressure or more than 10 mm Hg of the diastolic pressure, as well as a 10% to 20% increase in heart rate. The causes of postural hypotension include cardiovascular drugs, blood volume decrease, prolonged bedrest, age-related changes, or disorders of the ANS. Measure the BP when the patient is supine. After remaining supine for at least 3 minutes, the patient changes position to sitting or standing. Normally systolic pressure drops slightly or remains unchanged as the patient rises, whereas diastolic pressure rises slightly. After the position change, wait for at least 1 minute before auscultating BP and counting the radial pulse. The cuff should remain in the proper position on the patient's arm. Observe and record any signs or symptoms of dizziness. Paradoxical blood pressure is an exaggerated decrease in systolic pressure by more than 10 mm Hg during the inspiratory phase of the respiratory cycle (normal is 3 to 10 mm Hg). Certain clinical conditions (pericardial tamponade, constrictive pericarditis, and pulmonary hypertension) that potentially alter the filling pressures in the right and left ventricles may produce a paradoxical BP. During inspiration, the filling pressures normally decrease slightly. However, decreased fluid volume in the ventricles resulting from these pathologic conditions produces a marked reduction in cardiac output. Pulse pressure: The difference between the systolic and diastolic values; can be used as an indirect measure of cardiac output. Narrowed pulse pressure is rarely normal and results from increased peripheral vascular resistance or decreased stroke volume in patients with heart failure, hypovolemia, or shock. It can also be seen in those with mitral stenosis or regurgitation. An increased pulse pressure may occur in patients with slow heart rates, aortic regurgitation, atherosclerosis, hypertension, and aging. The ankle-brachial index (ABI) can be used to assess the vascular status of the lower extremities. A BP cuff is applied to the lower extremity just above the malleolus. The systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. The higher of these two pressures is then divided by the higher of the two brachial pulses to obtain the ABI. Normal values for the ABI are 1.00 or higher because BP in the legs is usually higher than BP in the arms. ABI values less than 0.80 usually indicate moderate vascular disease, whereas values less than 0.50 indicate severe vascular compromise. Although used primarily to help identify peripheral

vascular disease, the ABI may be effective as a risk factor in predicting other CV disease in women, especially coronary artery disease (Pearson, 2010). A toe brachial pressure index (TBPI) may be performed instead of or in addition to the ABI to determine arterial perfusion in the feet and toes. TBPI is the toe systolic pressure divided by the brachial (arm) systolic pressure. Venous and Arterial Pulses Observe the venous pulsations in the neck to assess the adequacy of blood volume and central venous pressure (CVP). Specially educated or critical care nurses can assess jugular venous pressure (JVP) to estimate the filling volume and pressure on the right side of the heart. An increase in JVP causes jugular venous distention (JVD). Normally the JVP is 3 to 10 cm H2O. Increases usually caused by right ventricular failure. Other causes: tricuspid regurgitation or stenosis, pulmonary hypertension, cardiac tamponade, constrictive pericarditis, hypervolemia, and superior vena cava obstruction. Assessment of arterial pulses provides information about vascular integrity and circulation. For patients with suspected or actual vascular disease, all major peripheral pulses should be assessed for presence or absence, amplitude, contour, rhythm, rate, and equality. Palpate the peripheral arteries in a head-to-toe approach with a sideto-side comparison. A hypokinetic pulse is a weak pulse indicative of a narrow pulse pressure. Seen with hypovolemia, aortic stenosis, and decreased cardiac output. A hyperkinetic pulse is a large, bounding pulse caused by an increased ejection of blood; occurs in patients with a high cardiac output (with exercise, sepsis, or thyrotoxicosis) and in those with increased sympathetic system activity (with pain, fever, or anxiety). Auscultation of the major arteries (e.g., carotid and aorta) is necessary to assess for bruits. Bruits are swishing sounds that may occur from turbulent blood flow in narrowed or atherosclerotic arteries. Assess for the absence or presence of bruits by placing the bell of the stethoscope on the neck over the carotid artery while the patient holds his or her breath. Normally there are no sounds if the artery has uninterrupted blood flow. A bruit may develop when the internal diameter of the vessel is narrowed by 50% or more, but this does not indicate the severity of disease in the arteries. Once the vessel is blocked 90% or greater, the bruit often cannot be heard. Diagnostic Assessment: Laboratory Assessment: Chart 35-3 Laboratory Profile Normal Range Serum Cardiac Enzymes Creatine kinase (CK) Females: 30-135 units/L Males: 55-170 units/L Values higher after exercise CK-MB (CK2) 0% of total CK Significance of Abnormal Findings Elevations indicate possible brain, myocardial, and skeletal muscle necrosis or injury. Elevations occur with myocardial injury or after percutaneous transluminal angioplasty and intracoronary streptokinase infusion. Elevation indicates increased risk for coronary artery disease (CAD). Elevation indicates increased risk for CAD. Elevation indicates increased risk for CAD.

Serum Lipids

Total lipids: 400-1000 mg/dL Cholesterol: 122-200 mg/dL, or 3.16-6.5 mmol/L Older adult (>70 yr): 144-280 mg/dL Triglycerides Females: 35-135 mg/dL Males: 40-160 mg/dL Older adult (>65 yr): 55-260 mg/dL Plasma high-density lipoproteins (HDLs) Females: >55 mg/dL Males: >45 mg/dL Older adult: range increases with age Plasma low-density lipoproteins (LDLs) 60-180 mg/dL Older adult (>65 yr): 92-221 mg/dL HDL:LDL ratio 3:1

Elevations protect against CAD.

Elevation indicates increased risk for CAD. Elevated may protect against CAD.

VLDL 25%-50% C-reactive protein (CRP): <1.0 mg/dL Serum Markers Troponins Cardiac troponin: T <0.20 ng/mL Cardiac troponin: I <0.03 ng/mL Myoglobin: <90 mcg/L

Elevated indicates risk for CAD. Elevation may indicate tissue infarction or damage. Elevations indicate myocardial injury or infarction. Elevation indicates MI.