Ch. 27- Assessment of cardiac system

priority concept for cardiac conditions

• perfusion

• f&e balance

when a pacer goes rouge what takes over

supra-ventricular tachy (for short spurts)

Troponin

• lab specific to the death of cardiac cells

• heart attack when these are elevated

• re-check 3x in cardiac pt’s (looking for increase)

mean arterial pressure

• norm level= 60-70

• must be in normal range to maintain perfusion of major body organs

what electrolyte imbalance causes dysrhythmias

increased or decreased potassium

Preload

• the amount of blood returning to your heart to be pumped out

• the stretch on the heart muscle before it contracts at the end of diastole

what determines preload

• the amount of blood returning to the heart from both venous systems (right side of heart & pulm system)

Afterload

• the pressure/resistance the ventricles must overcome to eject blood through the valves and into peripheral tissues

• directly r/t BP

leading cause of death for women

CVD

nonspecific CV symptoms seen in women

• fatigue

• malaise

• anxiety

• SOB

• dyspnea on exertion

• back/jaw pain

• plus other s/s as men

hormonal changes after menopause r/t heart problems

• women lose protective effects of estrogen which increases risk

healthy soldier effect

• past research showed that the health requirement for the military could reduce mortality later in life 10-30 yrs after service ended

• not that relevant anymore and male veterans now are at higher risk for CVD that nonveterans

major risk factors for CVD

Hyperlipidemia – Elevated LDL, low HDL

Hypertension – High BP increases cardiac workload

Obesity – BMI > 30 increases strain on the heart

Physical Inactivity – Sedentary lifestyle contributes to poor cardiac health

Smoking – Increases vasoconstriction and plaque buildup

Diabetes Mellitus – Accelerates atherosclerosis

Family History – First degree relatives with CVD before age 55 (men) or 65 (women)

Psychological Stress – Chronic stress triggers increased cortisol and BP

what are some other risk factors for CVD (women)

• Pregnancy-related complications (pre-eclampsia)

• Loss of estrogen

• delayed tx (women, esp for MI)

• after age 52 (women)

• diabetes, high BP, and stress impacts women worse

what might a pt with heart disease look like

• edema

• cyanosis

• fatigue bc can’t perfuse

• SOA

• chest pain

role of genetics in factors for CVD

• can contribute to having CVD

• significatn association between familial cardiac hx and CVD

• several genes are linked to heart disease, stroke, and HTN

triad in women having an MI

• indigestion

• chronic fatigue

• can’t catch breath/dyspnea

ECG is not a reliable indicator of MI because…

• doesnt show an active MI

• only detect damage and changes in rhythm after the damage has occured

• recurrent strep throat

• mitral valve prolapse

• cocaine

• smoking

• diabetes

• syncope

• constant anger & anxiety

… all increase risk for?

heart attack

what might be the only symptom of a MI in females

• dyspnea on exertion

ACTION ALERT! the cause of chest pain should be considered ____ until proven otherwise

ischemic

ACTION ALERT! when assessing angina, what should you ask about

• have you ever had this before

• is there discomfort, heaviness, pressure, or indigestion

current health problems identified by pt with CVD

• pain/discomfort

• dysnpnea, doe, orthopnea, pnd

• fatigue

• palpitation

• weight gain

• syncope

• extremity pain

• psyhological factors

• edema

syncope in older adults

• 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 vlasalva maneuver may stimulate a vagal response

• decrease in BP & HR can result, which can produce syncope

• may also result from orthostatic or postprandial (aftern eating) hypotension

risk factors for CVD

• age

• gender

• ethnicity

• family hx

• diabetes

• smoking

• physical inactivity

• obesity

• psychological variables

• hot headed

• cocaine use

• recurrent strep (rheumatic fever)

what questions to ask the pt with CVD

• have you ever had this pain before… if yes, alleviating fx?

  • if no, cardiac workup

• what were you doing before the pain started

• fluid retension and generalized edema (anasarca)

• beta blockers, birth control, or hormone therapy?

• o2 level?

• what meds?

• do you feel SOB?

• *do you smoke?

• *do you have diabetes?

• *do you feel dizzy/have you passed out before?

• fam hx?

almost half of women who have heart attacks will

die by the end of the first year following the event

fluid intake r/t heart failure

• managing fluid intake is critical because heart isnt pumping efficiently leading to fluid buildup

Monitoring fluid intake in a pt w HF can help prevent..

• fluid overload

  • Excess fluid worsens symptoms like SOB, swelling, and fatigue

• increased strain on the heart

  • Too much fluid makes the heart work harder... worsening HF s/s

• fluid retention

  • Kidneys don’t function well in HF… makes body retain more water & sodium

best indactor of fluid balance..

weight (need to have daily weight of HF pt’s)

2.2 weight gain is = to

1kg = 1L of fluid

what to assess, general appearance

• build

• skin color

• distress level

• LOC

• SOB

• position

• verbal responses

what to asses, skin

• color & temp

• cyanosis and rubor

• best places to check= nail beds, mucous membranes, and conjunctival mucosa

what to assess, extremeties

• clubbing

• decreased hair distribution

• muscle fatigue and discomfort

• numbness

• coolness

to listen for bruit…

• bruit= swishing sounds that occur from turbulent blood flow in narrowed or atherosclerotic arteries

• place stethoscope over pt carotid artery LIGHTLY, have them take breath and hold

  • should only hear heart beat

what to assess for w venous and arterial pulses

• central venous pressure

• jugular venous pressure

• arterial pulses

• auscultating major arteries

weak pulse is seen in pt’s w

• hypovolemia

• aortic stenosis

• decreased CO

a bounding (hyperkinetic) pulse is seen in pt’s with

• High CO

• exercise

• sepsis

• thyrotoxicosis

• pain

• fever

• anxiety

key concepts of s1

• closure of mitral & tricuspid

• best heard at apex

• aligns w carotid

• marks beginning of ventricular systole

• occurs right after qrs complex

key concepts s2

• closing of aortic and pulmonic

• heard best at base

• end of ventricular systole

split heart sounds

• closure of mitral then tricuspid

• accentuated by inspiration and narrows during expiration

s3 occurs when

after s2

s1, s2, s3

• normal in people <35 and in pregnancy

s4 occurs

before s1

s4, s1, s2

• heard in pt’s w HTN*

• anemia*

• Mi

• aortic or pulmonic stenosis

• pulmonary emboli

• LV is stiff (hypertrophy) *

during the psychosocial assessment, ask…

• what is the pt feeling

• is the pt still able to work

• what are the pt’s fears

• what is the pt’s support system

Troponin T & I

(should be close to 0) These are the gold standard for MI diagnosis. They will be elevated 3-6 hrs, peaks at 24 hrs, and lasts 7-14 days). 

troponin T

• more specific to cardiac muscle

• can be elevated in other conditions like kidney disease, chronic muscle disease

• primarily used to assess heart damage in acute coronary syndrome (ACS) or heart attacks

Troponin I

• highly specific to heart muscle injury

• less likely to be elevated for other conditions

• more precise marker for heart attacks

troponin trends overtime are

more efficient than a singular lab

what is HSTn1

• hypersensitivity troponin, can detect very low levels

• useful w mild s/s or w s/s that are not obvious

• greater than 14ng/L consider admission to the hospital for further observation or more evaluation

why are serum lipids used r/t heart disease

they assess the risk for CAD

elevated HDL levels are

not bad for the heart, low HDL levels are bad for the heart

elevated LDL levels are

bad for the heart

serum markers for myocardial damage

• troponin T

• troponin 1

• creatine kinase & myoglobin (CK & MB) - indicate myocardial injury; peak 12-24 hours

• HSTn1

• BNP - elevated in heart failure (>100)

• serum lipids

• homocysteine

• highly sensitive C reactive proteins

subcategories of serum lipids

• total cholesterol

• triglycerides

• HDL

• LDL

highly sensitive C reactive protein (CRP)

• marker of inflammation & CVD risk

• helpful in determining tx outcomes in pt’s at risk for AD and managing statin therapy after an MI

diagnostic assessments

• PA and lateral CXR

• angiography (Examines blood vessels for blockages or narrowing)

• ateriography (Uses X-rays to examine arteries in the brain, heart, kidneys, and other body parts)

• cardiac catheterization

what is PA and lateral CXR

• post-anterior and left lateral x-rays of the chest

• determine size, silhouette and position of the heart

Recognizing denial & what to do

PTs with new cardiac diagnosis may deny the severity of their condition. Use therapeutic communication and acknowledge feelings but provide clear, factual education. Offer emotional support and coping strategies. Encourage family involvement in discussions. 

what is cardiac catheterization

• most definitive but most invasive test in diagnosis of heart disease

• confirms suspected heart disorder

• determines location and extent of disease

• assesses stable to severe angina unresponsive to tx

• uncontrolled HF, ventricular dysrhythmias, cardiogenic shock r.t acute MI

• to determine best therapeutic option

• evaluates effects on medical or invasive tx on cardiac funciton

Post Angiography & Cardiac Catheterization Care

o Monitor insertion site (e.g., radial or femoral artery) for bleeding and hematoma formation

o Check distal pulses, skin color, and temperature to ensure adequate perfusion.

o Keep the affected limb immobilized for the recommended period.

o Monitor vital signs (HR, BP, O2 sat) closely for changes.

o Avoid lifting anything heavier than 5 pounds for a few days

Complications of Cardiac Catheterization

• Hematoma Formation: Firm mass/swelling at insertion site → Apply direct pressure

• Bleeding: Assess dressing and site every 15 min for the first hour, then hourly

• Retroperitoneal Bleeding: Sudden hypotension, tachycardia, flank pain

• Allergic Reaction to Contrast Dye: Rash, itching, anaphylaxis (monitor closely)

• Acute Kidney Injury: Due to contrast → Encourage hydration, monitor creatinine

Emergency actions of cardiac catheterization

• If bleeding does not stop, apply firm manual pressure and notify the provider.

• For hypotension or signs of shock, initiate IV fluids and prepare for potential intervention

what can we teach our pt’s to reduce heart disease risk

Exercises: aim for 150 minutes/week if moderate-intensity exercise

Diet: increase fruits, veggies, whole grains, and lean protein. Reduce saturated fats, sodium, and processed foods, Encourage healthy fats like omega-3s from fish.

Smoking Cessation: Offer nicotine replacement therapy 9NRT), counseling, or support groups

Medications (as needed): Statins for hyperlipidemia, antihypertensives for BP control, and antiplatelets (aspirin, clopidogrel) for high-risk patients.

what to do if the pt experiences s/s of cardica ischemia

• contact rapid response or provider

• remain w the pt and obtain a 12 lead ECG for pt’s w chest pain or dysrhythmias

• for bleeding or hematoma: hold steady firm pressure until rapid arrives

• neuro changes indicating stroke like visual disturbances, slurred speech, swallowing difficulties, extremity weakness, should also be reported immediately

chest discomfort in angina often presents as
(stable vs unstable)

 pressure, squeezing, substernal, radiates to arm/jaw, rest & nitroglycerin relieves it, <15 minutes, and may have mild dyspnea with it 

• Stable angina: occurs with exertion and is relieved by rest or nitroglycerin

• Unstable angina: occurs at rest and does not resolve easily.

chest discomfort in MI usually presents as

crushing, heavy, burning, same location as angina but more severe, no relief, >30 minutes, and may have dyspnea, nausea, diaphoresis, and anxiety