Chapter 28: Cardiovascular Diagnostic and Therapeutic Procedures

Chapter 28: Cardiovascular Diagnostic and Therapeutic Procedures

Evaluate heart function by:

• Measuring cardiac enzymes in blood

• Using ultrasound to visualize heart structure and motion

• Assessing cardiac response to exercise

• Using catheters to assess blood volume, perfusion, fluid status, pumping ability, and degree of arterial blockage

Common procedures nurses should know:

• Cardiac enzymes and lipid profile

• Echocardiography

• Stress testing

• Hemodynamic monitoring

• Angiography

Therapeutic procedures:

• Central vascular access placement

• Percutaneous coronary interventions

Cardiac Enzymes and Lipid Profile

Cardiac enzymes are released into the bloodstream when myocardial injury occurs

Lipid profile evaluates cholesterol levels and risk for heart disease

Cardiac enzymes are specific markers for diagnosing myocardial infarction (MI)

Indications

• Angina

• Myocardial infarction

• Heart disease

• Hyperlipidemia

Cardiac Enzymes and Lipid Profile Considerations

Preprocedure Considerations

• Fast for 12 to 14 hours before lipid profile sampling

Interpretation of Findings: Cardiac Enzymes

• Creatine kinase MB isoenzyme

  • Reference range: 0 percent of total CK (20 to 200 units/L)

  • Detectable after MI: 3 to 6 hours

  • Duration of elevation: 2 to 3 days

  • More sensitive to myocardium

• Troponin T

  • Reference range: less than 0.1 ng/mL

  • Detectable after MI: 2 to 3 hours

  • Duration of elevation: 10 to 14 days

• Troponin I

  • Reference range: less than 0.03 ng/mL

  • Detectable after MI: 2 to 3 hours

  • Duration of elevation: 7 to 10 days

• Myoglobin

  • Reference range: less than 90 mcg/L

  • Detectable after MI: 2 to 3 hours

  • Duration of elevation: 24 hours

Interpretation of Findings: Lipid Profile

• Total cholesterol

  • Less than 200 mg/dL

  • Screens for heart disease

• LDL

  • Less than 130 mg/dL

  • “Bad” cholesterol

  • Transports cholesterol from liver to body cells

• Triglycerides

  • Males: 40 to 160 mg/dL

  • Females: 35 to 135 mg/dL

  • Evaluates risk for heart disease

• HDL

  • Females: greater than 55 mg/dL

  • Males: greater than 45 mg/dL

  • “Good” cholesterol

  • Protects coronary arteries by transporting cholesterol back to the liver

The nurse at the provider’s office is reviewing the laboratory test results for the client. The nurse should identify that which of the following results indicates the client is at risk for heart disease?

Select all that apply.

a

Cholesterol (total) 245 mg/dL

b

HDL 90 mg/dL

c

LDL 140 mg/dL

d

Triglycerides 125 mg/dL

e

Troponin I 0.02 ng/mL

a

Cholesterol (total) 245 mg/dL

c

LDL 140 mg/dL

Transthoracic Echocardiography (TTE)

Noninvasive ultrasound test

Diagnoses valve disorders and cardiomyopathy

Evaluates heart size, shape, motion, and ejection fraction

Indications

• Cardiomyopathy

• Heart failure

• Angina

• Myocardial infarction

Transthoracic Echocardiography (TTE) Considerations

Preprocedure

• Explain test is noninvasive and lasts up to 1 hour

Intraprocedure

• Client lies on left side and remains still

Postprocedure

• Review results and discuss follow up plan

Transesophageal Echocardiography (TEE)

Provides clearer images than TTE due to less tissue interference

Transducer passed through mouth into esophagus

Indications

• Heart failure

• Valvular heart disease

• Atrial or ventricular thrombi

• Monitoring during valve replacement or CABG surgery

Transesophageal Echocardiography (TEE) Considerations

Preprocedure

• Obtain informed consent

• NPO for 4 to 6 hours

• Establish IV access

Intraprocedure

• Monitor level of consciousness, ECG, blood pressure, heart rate, respiratory rate, and oxygenation

• Moderate sedation required

Postprocedure

• Monitor vital signs, oxygenation, and return of gag reflex

• Maintain head of bed at 45 degrees

Stress Testing

Exercise stress test involves walking on a treadmill

Evaluates cardiac workload and response to stress

Test stopped when target heart rate is achieved

Pharmacologic stress testing used if exercise not tolerated

Indications

• Angina

• Heart failure

• Myocardial infarction

• Dysrhythmias

Stress Testing Considerations

Preprocedure

• Obtain informed consent

• Explain treadmill exercise and recommend athletic clothing

• Pharmacologic agents may include dipyridamole, adenosine, regadenoson, or dobutamine

• Fast 2 to 4 hours prior per facility policy

• Avoid tobacco, alcohol, and caffeine

• Encourage adequate rest the night before

Intraprocedure

• Apply 12 lead ECG

• Monitor for dysrhythmias

• Instruct client to report chest pain, shortness of breath, or dizziness

Postprocedure

• Continue ECG monitoring

• Check blood pressure until stable

• Provider reviews results with client

Hemodynamic Monitoring (Image)

Hemodynamic Monitoring

Uses indwelling catheters to assess:

• Blood volume

• Perfusion

• Fluid status

• Cardiac pumping effectiveness

Key parameters:

• Central venous pressure (CVP)

• Pulmonary artery pressure (PAP)

• Pulmonary artery wedge pressure (PAWP)

• Cardiac output (CO)

• Intra arterial blood pressure

Mixed venous oxygen saturation (SvO₂)

• Indicates balance between oxygen supply and demand

• Measured via pulmonary artery catheter with fiber optics

Monitoring System Components

• Pressure transducer

• Pressure tubing

• Monitor

• Pressure bag and flush device

Arterial Lines

• Common insertion sites: radial, brachial, femoral

• Provide continuous blood pressure monitoring

• Allow arterial blood sampling

• Pressures differ from cuff readings

• Nursing care

  • Verify waveform accuracy

  • Monitor circulation distal to site

  • Assess for bleeding

  • Maintain secure connections

  • Not used for IV fluid administration

Pulmonary artery (PA) catheters

Inserted into large vein and threaded through right atrium and ventricle into pulmonary artery

Multiple lumens and ports allow measurement and sampling

Proximal lumen

• Measures CVP

• Infuses IV fluids

• Obtains venous blood samples

Distal lumen

• Measures PAP and PAWP

• Not used for IV fluids

Balloon inflation port

• Used intermittently for PAWP

• Keep deflated and locked when not in use

Thermistor

• Measures temperature differences to calculate CO

Additional infusion ports may be present

Indications for PA Catheter

• Serious or critical illness

• Heart failure

• Post CABG

• ARDS

• Acute kidney injury

• Burn injury

• Trauma

CVP

PAP

PAWP

Hemodynamic Monitoring Considerations

Ensure client understanding and obtain informed consent

Assemble and purge monitoring system

Maintain sterile technique

Position client supine or Trendelenburg

Administer sedation and analgesia as prescribed

Level transducer at phlebostatic axis (4th intercostal space, midaxillary line)

Zero system to atmospheric pressure

Obtain baseline readings

Compare arterial and noninvasive blood pressure

Document client response

Intraprocedure Monitoring

• Watch for signs of altered hemodynamics

Manifestations of Altered Hemodynamics

• Preload indicators

  • Right heart: CVP

  • Left heart: PAWP

• Elevated preload

  • Crackles

  • Jugular vein distention

  • Hepatomegaly

  • Peripheral edema

  • Taut skin turgor

• Decreased preload

  • Poor skin turgor

  • Dry mucous membranes

• Afterload indicators

  • Right heart: pulmonary vascular resistance

  • Left heart: systemic vascular resistance

• Elevated afterload

  • Cool extremities

  • Weak peripheral pulses

• Decreased afterload

  • Warm extremities

  • Bounding peripheral pulses

Postprocedure Nursing Actions

• Obtain chest x ray to confirm placement

• Continuous monitoring of vital signs, heart rhythm, and oxygenation

• Compare arterial and noninvasive blood pressure

• Maintain catheter integrity

• Observe and document waveforms

• Report waveform changes promptly

• Document catheter placement each shift and after transport

• Secure all connections

• Obtain hemodynamic readings with client supine

• Head of bed may be elevated 15 to 30 degrees

• Level and zero transducer with position changes

• Trend values over time

• Correlate findings with physical assessment

Expected Hemodynamic Values

• CVP: 8 to 12 mm Hg

• Pulmonary artery systolic: 15 to 28 mm Hg

• Pulmonary artery diastolic: 5 to 16 mm Hg

• PAWP: 6 to 15 mm Hg

• Cardiac output: 3 to 6 L/min

• SvO₂: 60 to 80 percent

• Older adults may have lower values due to reduced intravascular volume

Hemodynamic Monitoring Complications

Infection or sepsis

• Caused by poor aseptic technique

• Nursing actions

  • Change dressings per protocol

  • Use surgical aseptic technique

  • Monitor WBC and temperature

  • Perform hand hygiene

  • Collect cultures as ordered

  • Administer antibiotics

  • Provide IV fluids

  • Administer vasopressors for sepsis related vasodilation

Embolism

• Caused by clot or air entry

• Nursing actions

  • Flush system with 0.9 percent sodium chloride per protocol

    • Can include heparin

  • Avoid air introduction

  • Monitor for pneumothorax

  • Monitor for dysrhythmias during insertion or movement

Angiography

Invasive diagnostic procedure to evaluate presence and degree of coronary artery blockage

Can also include arterial, venous, cerebral, liver, or extremity angiograms

Catheter inserted into femoral, brachial, or radial vessel and threaded to right or left heart

Contrast media injected and visualized under fluoroscopy to identify narrowing or occlusion

Indications

• Unstable angina with ECG changes

  • T wave inversion

  • ST segment elevation or depression

• Confirmation of location and extent of heart disease

Angiography Considerations

Preprocedure Nursing Actions

• Maintain NPO for at least 4 hr (aspiration risk)

• Obtain baseline vital signs

• Auscultate heart and lung sounds

• Assess and document peripheral pulses

• Verify informed consent

• Ensure client and family understand the procedure

• Assess renal function prior to contrast administration

• Contrast considerations

  • Iodine contrast is not automatically contraindicated with shellfish allergy

  • Further assessment required

• Administer premedications if prescribed

  • Methylprednisolone

  • Diphenhydramine

• Metformin management

  • Clarify provider orders

  • Often withheld before and up to 48 hr after procedure (risk of lactic acidosis)

Client Education (Preprocedure)

• Mild sedative and local anesthetic will be used

• Warmth or flushing may occur with dye injection

• Groin is the most common access site

• Pressure will be applied after procedure

• If no vascular closure device, keep extremity straight for prescribed time

Intraprocedure Nursing Actions

• Administer sedatives and analgesics as prescribed

• Continuous monitoring

  • Vital signs

  • Heart rhythm

  • Chest pain

• Be prepared to treat dysrhythmias

• Ensure resuscitation equipment and emergency medications are available

Postprocedure Nursing Actions

• Vital signs monitoring

  • Every 15 min x4

  • Every 30 min x2

  • Every hour x4

  • Then every 4 hr per protocol

• Assess affected extremity at same intervals

  • Bleeding or hematoma

  • Thrombosis (pedal pulse, color, temperature)

• Maintain bed rest

  • Supine position

  • Extremity straight for prescribed time

• Vascular closure device may be used to promote hemostasis

• Older adults may require pain management due to arthritis during prolonged bed rest

• Continuous cardiac monitoring

  • Reperfusion after angioplasty can cause dysrhythmias

• Administer medications as prescribed to prevent clot formation

  • Aspirin

  • Clopidogrel or other antiplatelets (ticagrelor, prasugrel, cangrelor)

  • Heparin

  • Enoxaparin

  • GP IIb/IIIa inhibitors (eptifibatide)

• Monitor urine output and hydrate

  • Contrast acts as an osmotic diuretic

• Assist with sheath removal

  • Apply pressure for prescribed time

  • Observe for vagal response (hypotension, bradycardia)

• Withhold metformin for 48 hr after procedure

Client Education (Postprocedure)

• Leave dressing in place for 24 hr

• Avoid strenuous activity as instructed

• Report immediately

  • Bleeding at insertion site

  • Chest pain

  • Shortness of breath

  • Color or temperature changes in extremity

• Activity restrictions

  • No lifting over 10 lb if groin access

  • No lifting over 5 lb if arm or wrist access

• Resume metformin only as prescribed

If Stent Placement Performed

• Take antiplatelet therapy as prescribed (up to 12 months)

• Take medications at the same time daily

• Attend scheduled lab monitoring

• Bleeding precautions

  • Soft toothbrush

  • Wear shoes out of bed

• Lifestyle modifications

  • Weight management

  • Low fat, low sodium diet

  • Regular exercise

  • Smoking cessation

The nurse is teaching the client who is scheduled for a coronary angiography. Which of the following statements should the nurse make?​​​​​​​

a

"You should have nothing to eat or drink for 2 hours prior to the procedure.”

b

“You will be given general anesthesia during the procedure.”

c

“You should not have this procedure done if you are allergic to eggs.”

d

“You will need to keep your affected leg straight following the procedure.”

d

“You will need to keep your affected leg straight following the procedure.”

The nurse is teaching the newly licensed nurse about caring for the client who is to have a CVP line placed. Which of the following statements by the newly licensed nurse indicates an understanding?

a

"Air should be instilled into the monitoring system prior to the procedure.”

b

“The client should be positioned on the left side during the procedure.”

c

“The transducer should be level with the second intercostal space after the line is placed.”

d

“A chest x-ray is needed to verify placement after the procedure.”

d

“A chest x-ray is needed to verify placement after the procedure.”

Angiography Complications

Artery Dissection

• Perforation of artery by catheter

• Can lead to cardiac tamponade or emergency CABG

• Manifestations

  • Severe hypotension

  • Tachycardia

• May require balloon occlusion and reversal of anticoagulation

Cardiac Tamponade

• Fluid accumulation in pericardial sac

• Manifestations

  • Hypotension

  • Jugular venous distention

  • Muffled heart sounds

  • Paradoxical pulse (≥10 mm Hg systolic drop with inspiration)

• Hemodynamic findings

  • Equalized and elevated intracardiac and PAP pressures

• Nursing Actions

  • Notify provider immediately

  • Administer IV fluids

  • Obtain chest x ray or echocardiogram

  • Prepare for pericardiocentesis

  • Monitor hemodynamics and heart rhythm

  • Monitor for dyspnea and provide oxygen

Hematoma Formation

• Local clot formation at insertion site

• Nursing Actions

  • Assess sensation, color, capillary refill, and pulses distal to site

  • Inspect groin at prescribed intervals

  • Apply pressure for bleeding

  • Notify provider

Allergic Reaction to Contrast Media

• Manifestations

  • Chills

  • Fever

  • Rash

  • Wheezing

  • Tachycardia or bradycardia

• Nursing Actions

  • Monitor closely

  • Maintain resuscitation readiness

  • Administer diphenhydramine or epinephrine if prescribed

External Bleeding

• Nursing Actions

  • Monitor site for bleeding or swelling

  • Apply direct pressure

  • Keep extremity straight

Embolism

• Dislodged plaque or clot

• Nursing Actions

  • Monitor for chest pain

  • Monitor vital signs and SaO₂

Restenosis

• Reocclusion of treated vessel

• Can occur immediately or weeks later

• Nursing Actions

  • Monitor ECG

  • Assess chest pain

  • Notify provider

  • Prepare for return to cath lab

Retroperitoneal Bleeding

• Bleeding into retroperitoneal space from femoral puncture

• Nursing Actions

  • Assess for flank pain and hypotension

  • Notify provider immediately

  • Apply firm pressure

  • Administer IV fluids and blood products

• Client Education

  • Keep leg straight

  • Report chest pain or shortness of breath

Acute Kidney Injury

• Caused by nephrotoxic contrast agent

• Nursing Actions

  • Monitor urine output

  • Monitor BUN, creatinine, electrolytes

  • Promote hydration (oral or IV)

Cardiac Catheters (image)

Vascular Access

Type and site depend on therapy characteristics

• Medication type

• pH and osmolarity

• Duration of therapy

Goal

• Minimize catheter insertions

• Reduce complication risk

Central Intravenous Therapy

• Used for rapid hemodilution in the superior vena cava

• Confirm tip placement with x ray before use

• Inserted using sterile technique

• Locations include OR, bedside, or outpatient setting

• Types

  • Nontunneled percutaneous CVC

  • Tunneled CVC (Hickman, Groshong)

  • PICC

  • Implanted port

Nontunneled Percutaneous CVC

• Length: 18 to 25 cm

• Lumens: 1 to 5

• Short term use (<6 weeks)

• Insertion sites

  • Subclavian

  • Jugular

• Tip location: distal third of SVC

• Indications

  • Emergent or trauma use

  • Blood administration

  • Chemotherapy

  • Antibiotics

  • Total parenteral nutrition

Tunneled Percutaneous CVC

• Long term use

• Catheter tunneled subcutaneously with cuff

  • Tissue growth anchors catheter

  • Reduces infection risk

• No dressing required after healing

• Groshong catheter

  • Pressure sensitive valve

  • Prevents blood reflux

  • No clamp required

• Indications

  • Frequent or long term vascular access

Peripherally Inserted Central Catheter (PICC)

• Length: 45 to 74 cm

• Single or multiple lumens

• Duration: up to 12 months

• Insertion site

  • Basilic or cephalic vein

  • At least one fingerbreadth above or below antecubital fossa

• Tip location: lower third of SVC

• Indications

  • Long term antibiotics

  • Chemotherapy

  • TPN

• Insert early to preserve peripheral veins

Vascular Access Considerations

Preprocedure

• Verify informed consent

• Cleanse site with chlorhexidine

• Ensure sterile equipment

• Restrict room traffic during insertion

Postprocedure

• Confirm placement with x ray

• Assess site for redness, swelling, drainage, tenderness

• Clean port with alcohol for 15 seconds and allow to dry

• Use transparent dressing

  • Change every 7 days or as needed

• Do not immerse arm in water

• Avoid BP measurements or venipuncture in PICC arm

Flushing Guidelines (INS)

• Use 10 mL syringe

• Flush with 10 mL normal saline

  • Before, between, and after medications

• Flush with 20 mL normal saline after blood draws

• Flush with 5 mL heparin (10 units/mL) when not in use

• Do not flush if resistance is met

Implanted Port

Description

• Small reservoir with thick septum

Placement

• Implanted in chest wall pocket

• Catheter tip in SVC

Indications

• Long term therapy (≥1 year)

• Common for chemotherapy

Accessing the Port

• Only trained personnel

• Use mask and aseptic technique

• Use noncoring (Huber) needle

• Confirm blood return before infusion

Maintenance

• Flush with heparin or saline after each use

• Flush at least monthly when not in use

Vascular Access Complications

Phlebitis

• Causes

  • Chemical (pH, osmolarity)

  • Bacterial

  • Mechanical

• Manifestations

  • Erythema

  • Pain or burning

  • Warmth

  • Edema

  • Induration or red streak

  • Slowed infusion

  • Fever

• Prevention

  • Hand hygiene

  • Regular site assessment

  • Sterile dressing changes

  • Chlorhexidine skin prep

Occlusion

• Blockage from thrombosis or emboli

• Nursing Actions

  • Flush per policy

  • Do not force flush

  • Use 10 mL syringe to avoid catheter rupture

Mechanical Complications

• Dislodgement of port or catheter tip

• Nursing Actions

  • Use only noncoring needle for ports

• Client Education

  • Report swelling, port movement, or inability to access port

  • Report gurgling sounds or neck or ear pain immediately

A nurse is teaching a newly licensed nurse about vascular access devices.  Match the following vascular access devices with the associated characteristics.

Used for short-term access

Percutaneous inserted central catheter (PICC)

Nontunneled percutaneous central venous catheter

Percutaneous inserted central catheter (PICC)

Surgically inserted into the chest wall

Nontunneled percutaneous central venous catheter

Used for short-term access

Nontunneled percutaneous central venous catheter

Inserted above or below the antecubital fossa

Percutaneous inserted central catheter (PICC)

Surgically inserted into the chest wall

Implanted port