2023 Lecture 1 Cardiac Assessment (1)

Page 1: Title Slide

• Assessment of Canadian Function
  • Presenter: Shannon Bang
  • Date: Fall 2005

Page 2: Learning Outcomes for Chapter 33

• Physiological Integrity
  • Review cardiovascular anatomy and physiology (A&P): structures of the heart, blood flow, and relevant terms.
  • Perform a focused physical assessment for patients with cardiovascular (CV) problems — collecting subjective and objective data.
  • Identify assessment findings that suggest decreased cardiac output.
  • Interpret laboratory test findings for patients with suspected or actual cardiovascular diseases and their clinical implications.

Page 3: Cardiovascular Anatomy and Physiology

• Overview of Circulation
  • Capillaries - involved in gas exchange.
  • Pulmonary circuit includes:
  • Pulmonary arteries (carry deoxygenated blood to lungs)
  • Pulmonary veins (carry oxygenated blood back to the heart)
  • Heart chambers:
  • Right atrium and ventricle for deoxygenated blood.
  • Left atrium and ventricle for oxygenated blood.
  • Vessels:
  • Aorta to systemic arteries convey oxygenated blood.
  • Systemic veins return deoxygenated blood to the heart.

Page 4: Cardiac Output

• Cardiac Output (CO): 4-7 L/min
  • Formula: CO = Heart Rate (HR) x Stroke Volume (SV)
  • Factors affecting cardiac output:
  • Preload
  • Afterload
  • Contractility
  • Questions for Discussion: What interventions can affect HR, preload, afterload, and contractility?

Page 5: Autonomic Nervous System

• Sympathetic Nervous System
  • Release of catecholamines:
  • Epinephrine
  • Norepinephrine
  • Results in the "fight or flight" response.

Page 6: Stress Response and Heart Rate

• Response Steps:
  1. Stress triggers the brain to signal adrenal glands.
  2. Adrenaline is released into the bloodstream.
  3. Adrenaline acts on heart cells through receptors.
  4. Result: Increased heart rate and fight-or-flight reactions.

Page 7: Sympathetic Nervous System Effects

• Beta Adrenergic Receptors:
  • Beta 1 (Heart): Increases heart rate, contractility, conduction velocity, and automaticity.
  • Beta 2 (Arteries/Vessels): Causes vasodilation and bronchodilation, stimulates renin release.

Page 8: Parasympathetic Nervous System

• Cholinergic System (Acetylcholine):
  • Promotes non-stressful conditions.
  • Decreases heart rate and force of heart contractions, decreases rate of breathing, and lowers blood pressure.

Page 9: Preload and Afterload

• Definitions:
  • Preload: The volume of blood in the ventricles at the end of diastole.
  • Afterload: The pressure the heart must generate to eject blood.

Page 10: Arteriolar Tone

• Vasoconstriction: Increased resistance and decreased flow.
  • Caused by myogenic activity, increased oxygen, and sympathetic stimulation, among other factors.
• Vasodilation: Decreased resistance and increased flow.
  • Triggered by metabolites (NO, histamine) and other factors.

Page 11: Contractility

• Contractility: Force of contraction.
  • Higher contractility leads to increased cardiac output.
  • Normal Ejection Fraction (EF): 50%-65%.

Page 12: Decreased Cardiac Output Symptoms

• Indicators:
  • Altered Level of Consciousness (LOC)/Cognition: ranging from restlessness to unresponsiveness, disorientation, and syncope.
  • Urinary output < 0.5 ml/kg/hr.
  • Tachycardia.
  • Decreased BP.
  • Skin changes: pale, central cyanosis, cold/clammy/diaphoretic.
  • Weak pulses.

Page 13: Pulse Sites

• Common Pulse Locations:
  • Carotid
  • Brachial
  • Radial
  • Ulnar
  • Femoral
  • Popliteal
  • Posterior tibial
  • Dorsalis pedis

Page 14: Blood Pressure (BP) Concepts

• Blood Pressure Equation: BP = CO x Afterload
  • Systolic BP: Maximum pressure during ventricular contraction.
  • Diastolic BP: Minimum pressure during ventricular relaxation.
  • Discuss when BP is considered too low or high.
  • Orthostatic Hypotension: Risks and prevention strategies.

Page 15: Blood Pressure Categories

• Classification (per AHA Guidelines 2017):
  • Normal: SBP <120 mm Hg and DBP <80 mm Hg
  • Elevated: SBP 120-129 mm Hg and DBP <80 mm Hg
  • Hypertension: Stage 1: SBP 130-139 mm Hg, DBP 80-89 mm Hg; Stage 2: SBP ≥140 mm Hg, DBP ≥90 mm Hg.

Page 16: Cardiac Cycle

• Heart Sounds:
  • S1: AV valve closure during systole; best heard at the mitral area.
  • S2: Semilunar valve closure; best heard at Erb's point.
  • AV valves: Tricuspid/Mitral; Semilunar: Pulmonic/Aortic.

Page 17: Heart Sounds Auscultation

• Auscultation Sites:
  • Aortic Area: Right 2nd ICS
  • Pulmonic Area: Left 2nd ICS
  • Erb's Point: Left 3rd ICS
  • Tricuspid Area: Left lower sternal border
  • Mitral Area: Left 5th ICS, medial to MCL.

Page 18: Patient Care Overview

• Focus on Patients with Acute Coronary Syndrome (ACS)
  • Refer to Chapter 38 for detailed guidelines.

Page 19: Learning Outcomes for Chapter 38

• Health Promotion and Maintenance:
  • Differentiate between modifiable and non-modifiable risk factors for coronary artery disease (CAD).
  • Develop patient teaching plans for cardiovascular risk modification.
• Psychosocial Integrity:
  • Assess responses to acute coronary events, especially myocardial infarction (MI).
• Physiological Integrity:
  • Compare stable vs. unstable angina and MI manifestations.
  • Interpret assessment findings in CAD patients.
  • Prioritize nursing care for chest pain patients.
  • Teach about drug therapy for CAD.

Page 20: Statistics on Heart Disease

• Heart disease: Leading cause of death in the US for both genders.
• Death occurs every 38 seconds.
• 20% mortality within one year post-myocardial infarction (MI).
• High rates of undiagnosed CAD among those experiencing MI; 47% of cardiac deaths occur prior to hospital arrival.

Page 21: Coronary Artery Anatomy

• Right Coronary Artery (RCA):
  • Supplies blood to the right atrium and ventricle, bottom portion of the left ventricle, and back of the septum.
• Left Coronary Artery:
  • Splits into circumflex artery and left anterior descending artery (LAD). Supplies blood to the left atrium, and front/bottom of the left ventricle.

Page 22: Coronary Artery Disease (CAD)

• Pathophysiology:
  • Hardening, inflammation, narrowing, and clot development leading to ischemia.
  • Arteriosclerosis: Hardened arteries; Atherosclerosis: Plaque development causing narrowing and inflammation, leading to loss of oxygen (ischemia).

Page 23: Plaque Development Process

• Fatty Streaks:
  • Development in arterial walls; triggers white blood cells and plaque formation.
  • Potential for thrombosis when plaque ruptures.

Page 24: Non-Modifiable Risk Factors for CAD

• Includes:
  • Family history of cardiovascular disease
  • Advancing age (>45 for men, >55 for women)
  • Gender and race.

Page 25: Modifiable Risk Factors for CAD

• Includes:
  • Smoking
  • Hyperlipidemia
  • Hypertension
  • Physical inactivity
  • Obesity
  • Diabetes (Metabolic Syndrome)
  • Stress/Depression

Page 26: Assessment Questions

• Key Questions for Nurses:
  • Which modifiable risk factors will be assessed for patient teaching?
  • A. Older age
  • B. Tobacco use
  • C. Gender
  • D. High-fat diet
  • E. Family history
  • F. Obesity

Page 27: Cholesterol Overview

• Cholesterol: A waxy substance found in blood and all body cells; needed for hormone production and cell membrane formation.
• Sources: Diet and liver.

Page 28: Lipoproteins

• LDLs (Low-Density Lipoproteins): Stick to artery walls and contribute to plaque buildup.
• HDLs (High-Density Lipoproteins): Carry LDLs to the liver for breakdown; higher HDL levels are protective against heart disease.

Page 30: Medications Affecting Lipoprotein Metabolism

• Interventions Include:
  • Diet and exercise (fruits, vegetables, whole grains)
  • Niacin: flushing as a side effect.
  • Omega-3 fatty acids (fish)
  • Statins: dosing instruction and side effects (GI upset, liver damage).

Page 32: Angina Pectoris

• Definition: Chest pain due to cardiac origin; results from ischemia of myocardium.
  • Symptoms may radiate to arm and jaw, with associated shortness of breath, anxiety, or nausea.

Page 33: Assessment of Angina

• Differences:
  • Stable angina vs. unstable angina; assessing pain characteristics between both types.

Page 34: Electrocardiography (ECG)

• Purpose:
  • Evaluates heart rhythm and identifies non-perfused heart regions (myocardial infarction).

Page 35: Stress Testing

• Objective:
  • Assess changes in ST segments or dysrhythmias through stress (treadmill/stationary bike or medication-induced).

Page 37: Nursing Implications for Stress Testing

• Preparation:
  • Fasting 2 hours prior, avoiding stimulants.
  • Hold beta blockers and calcium channel blockers.
  • Comfortables clothing and shoes
  • Post-test monitoring for 15 minutes.

Page 38: Cardiac Catheterization

• Description:
  • Invasive procedure to diagnose heart disease via injected dye and imaging.
  • Assess pressures, EF, and extent of atherosclerosis.

Page 39: Catheterization Setup

• Components:
  • Brachial artery for access; introducer sheath either in groin or arm.

Page 40: Angiography Procedure

• Process:
  • Dye injected into coronary arteries to visualize blockage sites via X-ray images.

Page 41: Coronary Angioplasty Process

• Pre-Stenting and Post-Stenting Comparison:
  • 99% proximal LAD stenosis followed by stenting procedure.

Page 42: Nursing Care Before Procedure

• Prerequisites:
  • Assess for allergies and obtain consent; establish IV for heparin.
  • Monitor kidney function and manage Metformin usage pre and post.

Page 43: Complications from Cardiac Procedures

• Possible Complications:
  • Include dysrhythmias, bleeding, dye reactions, ischemia, renal failure, myocardial infarction, and stroke.

Page 44: Post-Angiogram Care

• Post-Procedure Protocols:
  • Keep patient leg flat for 2-6 hours, monitor the site, and vital signs.
  • Ensure hydration to flush out dye.

Page 45: Nursing Diagnoses for Angina

• Priority Nursing Diagnoses: Address differences between angina and myocardial infarction.
  • Common goal: Increase blood supply and decrease demand.

Page 46: Interventions for Angina

• Focus on:
  • Reducing heart demands (rest), increasing oxygen supply (medications).
  • Monitoring and modifying risk factors.

Page 47: Platelet Aggregation Inhibitors

• Key Medications:
  • Aspirin: daily use, with precautions for GI bleeding and contraindications in asthma.
  • ADP receptor inhibitors (e.g., Clopidogrel) associated with bleeding risks.

Page 48: Nitrates for Angina Management

• Mechanism:
  • Dilates veins and arteries to increase coronary blood flow and reduce blood pressure.
  • Available in various forms (sublingual, spray, IV, topical).

Page 49: Nitrate Side Effects

• Common Adverse Effects:
  • Hypotension, orthostatic hypotension, headache, and tolerance requiring careful administration.

Page 50: Patient Teaching for Nitrates

• Administration Guidance:
  • Must wet mouth before taking.
  • Recommended dosing and safety precautions.

Page 51: Beta Blockers Information

• Overview:
  • Block epinephrine, reducing HR and BP; various types, including cardiac selective.

Page 52: Beta Blockers Side Effects

• Key Side Effects:
  • Bradycardia, bronchoconstriction, hypotension, potential blood sugar influence.

Page 54: Myocardial Infarction Clinical Manifestations

• Subjective Signs:
  • Chest pain unrelieved by typical interventions, fatigue, dyspnea, and anxiety.

Page 55: Objective Clinical Findings in MI

• Indicators:
  • Altered general appearance: pallor, cool, clammy skin and diaphoresis.
  • ST segment changes and increased cardiac enzymes.

Page 56: Cardiac Enzymes

• Markers for Muscle and Myocardial Damage:
  • CK (Creatine Kinase), Myoglobin, and Troponin; indicative of muscle and myocardial injuries.

Page 57: Chest Pain Protocol

• Emergency Response:
  • Rapid response team activation; immediate EKG and definitive measures for suspected STEMI.

Page 58: Nursing Process for MI

• Key Considerations:
  • Determine primary nursing diagnosis, anticipated outcomes, and potential complications following MI.

Page 59: Anticoagulants Overview

• Function and Side Effects:
  • Prevent clot formation; includes Heparin and monitoring protocols prior.

Page 60: Heparin Protocols for Angina/NSTEMI

• Dosage Management:
  • Specific weight-based protocols with careful monitoring for dosing errors and anticoagulant activity.

Page 61: Patient Self-Management Recommendations

• Focus Areas:
  • Medications (aspirin, statins, beta blockers), lifestyle changes (diet, smoking cessation), and cardiac rehabilitation.