Assess the following areas – general build and appearance of the client, as well as skin color; distress level; LOC; presence of SOB; position and verbal responses.
♦ Client with chronic heart failure may appear malnourished, thin and cachectic. Latest signs of severe heart failure are ascites, jaundice, and anasarca as a result of prolonged congestion of the liver. Heart failure may cause fluid retention and clients may have engorged neck veins and generalized dependent edema.
♦ CAD is suspected in client with yellow lipid-filled plaques on the upper eyelids (xanthelasma) or earlobe creases. Clients with poor CO and decreased cerebral perfusion may have mental confusion, memory loss and slowed verbal responses.
♦ Assess the client’s hands, arms, feet and legs for skin changes, clubbing, capillary filling and edema, skin mobility and turgor.
♦ Vascular changes of an affected extremity may include paresthesia, muscle fatigue and discomfort, pain, coolness, and loss of hair distribution from a reduced blood supply.
♦ Clubbing of the fingers and toes result from chronic O2 deprivation in the tissue beds. It can be identified by assessing the angle of the nailbed. The angle of the normal nail bed is 160°, with clubbing, the angle of the nailbed increases to > 180° and the base of the nail becomes spongy.
1. Postural BP – blood pressure normally drops when a client moves from a flat supine position to a sitting or standing position. Normally the client may report dizziness or lightheadedness, but these symptoms quickly pass and are transient.
Postural (orthostatic) hypotension – occurs when the client’s BP is not adequately maintained when moving from a lying to a sitting or standing position. It is defined as a BP fall of more than 10-15mmHg of the diastolic pressure and a 10% - 20% increase in HR.
2. Paradoxical BP – an exaggerated decrease in systolic BP by more than 10 mmHg (normal is 3-10mmHg) during the inspiratory phase of the respiratory cycle. It is sometimes referred to as pulsus paradoxus.
Various pulse patterns may be indicative of disease processes
Pulsus alterans: a regular rhythm but amplitude varies from beat to beat which may indicate left heart failure
Bigeminal pulse: a normal beat alternating with premature contractions, every other beat having a decreased amplitude. This may indicate cardiac dysrhythmia.
Pulsus paradoxus: a regular rhythm with decreased amplitude resulting in a drop in systolic BP on inspiration, and increased in expiration. It may be present with constrictive pericarditis, pericarditis, and severe COPD
Absent, weak, normal or bounding pulse: a bounding pulse may indicate increased cardiac output while a diminished or absent pulse may indicate a decreased CO or an occlusion.
Carotid pulse: should be visualized for pulsations, palpated for thrills, and auscultated for bruits. While inspecting the neck, assess for jugular vein distention.
Paradoxical splitting – an abnormal splitting of S 2 which is a characteristic of a wider split heard on expiration. It is heard in clients with severe myocardial depression causing early closure of the pulmonic valve or a delay in aortic valve closure. Common in MI, aortic stenosis, aortic regurgitation.
2. Gallops – diastolic filling sounds S 3 and S 4 are produced when blood enters a noncompliant chamber during rapid ventricular filling .
a. S 3 (Ventricular gallop) - is produced during the rapid filling phase of ventricular diastole when blood flows from the atrium to a noncompliant ventricle.
♦ It is probably a normal finding in children or young adults up to 40 years old. Over age 40 is considered pathological and may indicate ventricular overload as in mitral, aortic, or tricuspid regurgitation. It is heard just after S 2, early in diastole and may sound similar to “Ken-tuck-y”
b. S 4 (Atrial gallop) – always abnormal, usually associated with increased resistance to ventricular filling, such as with CHF, CAD, and aortic stenosis. It is heard in late diastole, but just before S 1 , and may sound similar to “Ten-ne-see”
3. Murmur – reflects turbulent blood flow through normal or abnormal valves.
♦ Grading of Murmur
Grade I – very difficult to hear, no thrill
Grade II – quiet but easily heard, no thrill
Grade III – fairly loud, no thrill
Grade IV – loud, possible thrill.
Grade V – very loud, accompanied by a palpable thrill and audible with the stethoscope partially off the client’s chest.
Grade VI – extremely loud, may be heard with the stethoscope slightly above the client’s chest
4. Pericardial Friction Rub – a harsh, scraping sound heard when the layers of the heart rub together due to an inflammatory process. Easily heard throughout the cardiac cycle in the lower sternum and apical areas.
5. Ejection clicks- heard in early systole, may signify aortic valve dysfunction
6. Opening snaps- heard in early diastole, associated with stenosis of mitral valve
A. Laboratory Tests – this is done to establish a diagnosis, to detect concurrent disease, to assess risk factors and to monitor response to treatment.
1. Serum Cardiac Enzymes – events leading to cellular injury cause a release of enzymes from intracellular storage.
a. Creatine Kinase (CK) – an enzyme specific to cells of the brain, the myocardium, and the skeletal muscles. The presence of CK in the blood indicates tissue necrosis or injury and CK levels follow a predictable rise and fall during a specified period of time.
CK-MB – most specific enzyme analyzed in acute MI. the first enzyme levels to increase.
2. Lactate Dehydrogenase (LDH) – is widely distributed in the body and is found in the heart, liver, kidneys, brain and erythrocytes.
LDH1 and LDH2 are found in the heart. If the serum level of LDH1 is higher than the concentration of LDH2, the pattern is said to have flipped, signifying myocardial damage.
3. Aspartate Aminotransferase (AST) – previously known as serum glutamic-oxaloacetic transaminase (SGOT). Like LDH, it is not specific to cardiac muscle tissue.
Elevated lipid levels are considered a CAD risk factor. Cholesterol, triglycerides and the CHON components of HDL and LDL are evaluated to assess the client’s degree of risk for CAD. A serum cholesterol greater than 260mg/dl gives a client three times greater risk of CAD than a serum level of 200mg/dl.
A nonfasting blood sample for the measurement of serum cholesterol level is acceptable. However, if triglycerides are to be evaluated, the physician obtains the specimen after a 12-hour fast.
3. Blood Coagulation Tests – evaluate the ability of the blood to clot and are important in clients with a greater tendency to form thrombi. They are also important for clients receiving anticoagulant therapy.
a. Prothrombin Time (PT) – is used when initiating and maintaining therapy with oral anticoagulants such as Na Warfarin (Coumadin, Warfilone). It measures the activity of the prothrombin, fibrinogen and other clotting factors.
☻ 11-16 secs
b. Partial Thromboplastin Time (PTT) – is assessed in clients receiving Heparin (Hepalcan). It measures deficiency in all coagulation factors, except factors VII and XIII.
☻ 60-70 secs
c. activated Partial Thromboplastin Time (aPTT) - most specific for heparin treatment
4. Arterial Blood Gases (ABG) – determination of tissue oxygen, CO2 removal and acid-base status is essential to appropriate intervention and treatment
5. Serum Electrolytes
Cardiac effects of hypokalemia include increased electrical instability, ventricular dysrythmias, the appearance of U wave on the ECG and an increased risk of digitalis toxicity. The effects of hyperkalemia in the myocardium include slowed ventricular conduction and contraction, followed by asystole (cardiac standstill).
Cardiac manifestations of hypocalcemia are ventricular dysrythmias, prolonged QT interval and cardiac arrest. Hypercalcemia shortens the QT interval and causes AV block, digitalis hypersensitivity and cardiac arrest.
Serum sodium values reflect fluid balance and may be decreased, indicating a fluid excess in clients with heart failure.
6. Complete Blood Count (CBC)
The erythrocyte count is usually decreased in rheumatic fever and subacute infective endocarditis. It is increased in heart disease characterized by inadequate tissue perfusion.
Decreased Hgb and Hct levels indicate anemia and can manifest as angina or aggravate heart failure.
The leukocyte count is typically elevated after MI and in various infections and inflammatory disease of the heart (e.g., pericarditis, infective endocarditis)
2. Cardiac Fluoroscopy – a simple x-ray examination that reveals the action of the heart. It is used to place and position intracardiac catheters and IV pacemaker wires and can also be helpful in identifying abnormal structures, calcifications and tumors of the heart.
3. Angiography or arteriograph is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins and the heart chambers. This is traditionally done by injecting a radio-opaque contrast agent into the blood vessel and imaging using X-ray based techniques such as fluoroscopy. The word itself comes from the Greek words angeion , "vessel", and graphein , "to write or record". The film or image of the blood vessels is called an angiograph , or more commonly, an angiogram .
a. The radiologist will explain the procedure and the risks to the client before signing the consent.
b. Assess for allergy reaction to iodine-containing substances such as sea foods .
c. Shave and scrub the area that will be catheterized.
d. Most often, the femoral artery is used. The nurse must document VS and mark and describe pedal pulses in the client’s medical record.
Resting ECG (12 Leads ECG) – An electrocardiogram ( ECG or EKG ) is a recording of the electrical activity of the heart over time produced by an electrocardiograph , usually in a noninvasive recording via skin electrodes. Its name is made of different parts: electro , because it is related to electrical activity, cardio , Greek for heart, gram , a Greek root meaning "to write".
provides information about cardiac dysrythmias, myocardial ischemia, the site and extent of MI, cardiac hypertrophy, electrolyte imbalance and effectiveness of cardiac drugs.
Time interval for impulse to go from the SA to the AV node
normal 0.12-0.20 secs
Time interval for impulse to go from AV node to stimulate Purkinjie fibers
Less than 0.12 secs
Time interval from beginning of depolarization to the end of repolarization
Duration: <0.44 sec
end of the S to the beginning of the T
Represents the beginning of ventricular repolarization
B. Ambulatory ECG (Holter Monitoring) – allows continuous recording of cardiac activity during an extended period (usually 24 hours) while the client is performing the usual ADL. Preparation: b.1. Encourage the client to maintain a normal day’s schedule. b.2. Instruct to keep a diary, or log, in which to note the time of activities, such as eating, sleeping, walking, and working and to record any symptoms such as chest pain, lightheadedness, fainting and palpitations b.3. Instruct the client to avoid operating heavy machinery, using electric shavers and hair dryers and bathing or showering. These activities may interfere with the ECG recorder
c. Exercise ECG (Stress Test/Exercise Tolerance Test)- assesses the CV response to an increases workload. The stress test helps to determine the heart’s functional capacity and screens for asymptomatic CAD. Dysrythmias that develop during exercise may be identified and the effectiveness of antidysrythmic drugs can be evaluated.
c.1. The client must be adequately informed about the purpose and the risks involved. A written consent must be obtained.
c.2. Assure the client that the procedure is performed in a controlled environment with prompt nursing and medical attention available.
c.3. Instruct the client to get plenty of rest the night before the procedure. The client should not eat anything after going to bed or at least within 2 hours before the test. The client should not smoke or drink alcohol or caffeine-containing beverages on the day of the test.
c.4. Advise client to wear comfortable, loose clothing and rubber-soled, supportive shoes.
c.5. instruct the client to tell the physician if any symptoms, such as chest pain, dizziness, SOB and an irregular HR are experienced during the test.
c.6. Emergency supplies such as cardiac drugs, defibrillator and other equipment necessary for resuscitation are available in the room in which the stress test is performed.
7. Echocardiography – is a non-invasive, risk-free test and is easily performed at a client’s bed side or an outpatient basis.
often referred to in the medical community as a cardiac ECHO or simply an ECHO , is a sonogram of the heart. Also known as a cardiac ultrasound , it uses standard ultrasound techniques to image two-dimensional slices of the heart.
Right Atrial, Pulmonary Artery, and Pulmonary Wedge Pressures - a pulmonary artery catheter is a triple-lumen or quadruple-lumen catheter with the capacity to measure right atrial and indirect left atrial pressures or pulmonary artery wedge pressure (PAWP). The CO may also be obtained from the catheter.
RA pressure is measured by a pressure sensor on the catheter inside the RA. Normal RA pressure ranges from 1-8 mmHg. Increased RA pressures may occur with right ventricular failure, whereas low right atrial pressure is usually indicative of hypovolemia
Normal pulmonary artery pressure (PAP) is 20-30mmHg systolic and 8-12mmHg diastolic, with a mean of 10-20mmHg and may be constantly visible on the monitor
Pulmonary capillary wedge pressure (PCWP) provides an indirect estimate of left atrial pressure (LAP). Normal PCWP is 8-12mmHg Elevated PCWP are usually indicative of pulmonary congestion.
b. CVP Monitoring – CVP is similar to RA pressure, but CVPs are measured in cm H2O rather than mmHg. A normal CVP is 3-8 cm H2O. Central venous pressure (CVP) describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system.
Elevated CVPs may indicate hypervolemia, low CVP may indicate hypovolemia.
How to Obtain a CVP Reading?
b.1. position the H2O manometer so that
the zero mark on the air-fluid
interface is at the same height
as the phlebostatic axis.
b.2. Turn the stopcock to fill the manometer with IVF.
b.3. Turn the stopcock to record the CVP. With each respiration, the fluid level in the manometer should fluctuate. When the level has stabilized, read the highest level of the fluid columns.
b.4. Return the stopcock to resume the flow of IVF to the client.