Cardio 2


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Cardio 2

  1. 1. CARDIO VASCULAR SYSTEM1. INTRODUCTIONToday the patient with the heart disease can be assisted to live longer and achieve ahigherquality of life, than even a decade ago through advancements in diagnostic procedures thatallow earlier diagnosis , treatment can begin well before significant debilitation occurs.Newer treatments , technologies , and pharmco therapies are being developed rapidly , frothat we should to be update with new and current technologies .2.ANATOMY OF THE HEART2.1PositionThe outline of the heart can be marked on the surface by connecting four points in series Apex of the heart is indicated by a point 8.7 cm away from the midline in the left 5thintercostal space. A point on the right 6th costosternal junction . A point 1.25 cms away from the right margin of the sternum at the upper border of the rdright 3 costal cartilage. A point 1.25 cms away from the left margin of ten sternum at the lower border of the nd2 costal cartilage. The right margin of the heart is prolonged upwards and downwards for a shortdistance A lines connecting 4&2 indicates the coronary sulcus on the surface and the fourorifices of the heart .pulmonary , aortic, mitral and tricuspid valve . . 1
  2. 2. The heart is composed of three layers . The inner layer or endocardium ,consists of endothelial tissue and lines the inside of the heart and valves. The middle layer or myocardium is made of muscle fibers and is responsible for the pumping action . The exterior layer of the heart is called the epicardium The heart is encased in a thin ,fibrous muscle called the pericardium which is composed of two layers . Adhering to the epicardium is the visceral pericardium .enveloping the visceral pericardium is the parietal pericardium .,a tough fibrous tissue that attaches to the great vessels ,diaphragm , sternum ,and vertebral column and supports the heart in the mediastinum The space between these two layers (pericardial space) is filled with about 30 ml of fluid which lubricates the surface of the heart and reduce friction during systole .2.2 Heart chambers The four chamber of the heart constitute the right and left sided pumping systems . theright side of the heart ,made up of the right atrium and right ventricle , distributes venousblood to the lung via pulmonary for oxygenation . the right atrium receives blood returningfrom the superior vena cava ,inferior vena cava and coronary sinus . ..the left side of the heartcomposed of left atrium and left ventricle ,distributes oxygenated blood to the aorta . the leftatrium receives oxygenated blood from the pulmonary circulation via the pulmonary veins . The atria are thin walled because blood returning to these chambers generates lowpressure . in contrast , the ventricular walls are thicker because they generate greater pressureduring systole . the right ventricle contracts against low pulmonary vascular pressure and hasthinner walls than the left ventricle . Because the heart lies in a rotated position within the chest cavity , the right ventriclelies anteriorly and the left ventricle is situated posteriorly .the let ventricle si responsible forthe apex beat or the point of maximum impulse PMI,which is normally palpable in the leftmid clavicular line of the chest wall at the 5th intercostals space.2.3Heart valves The four valves in the heart permit blood to flow only in one direction . the valves arecomposed of thin leaflets of fibrous tissue , open and close in response to the movement ofblood and pressure chambers within the chambers . there are two types of valvesAtrioventricular &Semilunar valves2.4Atrioventricular valvesThe valves separate the atria from the ventricle are termed as Atrioventricular valves .thetricuspid valve has three cusps or leaflets , separates the right atria from the right ventricle .the mitral or bicuspid valve has two cusps this lies between the left atria and the left ventricleNormally when the ventricles contract , ventricle posture rises , closing the atrio ventricularvalve leaf lets. Two additionally structures , the papillary muscle and chordate tendinaemaintain valve closure . the papillary muscles located on the sides of the ventricular wallsare connected to the valve leaf lets by thin fibrous bands called chordate tendinae .During systole contractioin of the papillary muscles causes the chordate tendinae to be cometaut , keeping the valve leaflets approximated and closed. 2
  3. 3. 2.5Semilunar valve The two semilunar valves are composed of three half –moon –like leaflets . the valvebetween the right ventricle and the pulmonary artery is called the pulmoinc valve . the valvebetween the left ventricle and the aorta is called the aortic valve .2.6Coronary arteries The left and right coronary arteries and their branches supply arterial blood to theheart . these arteries originate from the aorta just above the aortic valve leaflets . the heart haslarge metabolic requirements , extracting approximately 70to 80% of the oxygen delivered.The left coronary arteries has three branches . the artery from the point of origin to the firstmajor branch is called the left main coronary artery . two bifurcations arise off the left maincoronary artery these are the left anterior descending artery , which courses down theanterior wall of the heart and the circumflex artery , which circles around to the lateral leftwall of the heart 3
  4. 4. The right side of the heart is supplied by the right coronary artery ., which progressaround to the bottom or the inferior wall of the heart . the posterior wall of the heart receivesits blood supply by an additional branch from the right coronary artery called the posteriordescending artery . Superficial to the coronary arteries are the coronary veins . venous blood from theseveins returns to the heart primarily through the coronary sinus which is located posteriorlyin the right atrium .2.7Cardiac muscleThe myocardium is composed of specialised muscle tissue . microscopically it resemblesstriated muscle tissue which is conscious under control . functionally it resembles smoothmuscle because its contraction is involuntary. Therese fibers are arranged in aninterconnected manner that allows fro coordinated myocardial contraction and relaxationFunction of the heart conducting system The specialised heart cells of the cardiac conducting system methodologically generate andcoordinate the transmission of electrical impulses to the myocardial cells .the result issequential atrioventricular contractioin which provides for the most effective flow of blood ,thereby optimizing cardiac output . three physiologic characteristics of the cardiacconduction cells account for this co-ordinationAutomaticity : ability to initiate an electrical impulseExcitability : ability to respond to an electrical impulseConductivity : ability to transmit an electrical impulse from one cell to another . The sinoatrial node SA node referred to as the primary maker of the heart is located atthe junction of the superior vena cava and the right atrium . the SA node in a normal heartresting heart has an inherent firing rate of 60 to 100 impulses per minute , but the rate canchange in response to the metabolic demands of the body . The electrical impulses initiated by the SA node are conducted along the myocardialcells Of the atria via specialized tracts called inter nodal pathways . .the impulse causeelectrical stimulation and subsequent contraction of the atria .the impulses are then 4
  5. 5. conducted to the atrio ventricular node the AV consists of another group of specialisedmuscle cells similar to those of SA node The AV node coordinates the incoming electrical impulses from the atria and after aslight delay , relays the impulse to the ventricles . the impulse is the conducted through abundle of his that travel in the septum separating the left and right ventricles . the bundle ofhis divides into the left and right bundle branch . to transmit impulses to the largest chamberof the heart the left bundle branch bifurcates into the left anterior and left posterior bundlebranches . impulse travel through the bundle branches to reach the terminal point in theconduction system called purkinje fibers . .this is the point at which the myocardial fiber arestimulated causing ventricular contraction ; The heart rate is determined by the myocardial cells within the fastest inherent firingrate under normal circumstances the SA node has the highest inherent rate , the AV nodehas the second inherent rate and the ventricular rates has the lowest inherent rate3 PHYSIOLOGY OF THE HEART3.1Physiology of cardiac contraction Cardiac electrical activity is the result of the movement of ions across the cellmembrane . the electrical changes recorded within a single cell result what is known ascardiac action potential In the resting state , cardiac muscle cells are polarized , which meansan electrical difference exists between the negatively charged inside and the positivelycharged outside of the cell membrane . as soon as an electrical impulse is initiated , cellmembrane permeability changes and sodium moves rapidly into the cell , while potassiumcells exists the cell. The ionic exchange begins depolarization . contraction of themyocardium follows depolarization. The interaction between changes in membrane voltage and muscle contraction iscalled electro mechanical coupling . as one cardiac muscle cell is depolarized , it act as astimulus to its neighbouring cells causing it to depolarize . sufficient depolarization of asingle specialzed conduction system cells results in depolarization and contraction of theentire myocardium . Repolarisation return of cells to its resting stage occurs as the cellreturns to its baseline or resting state this corresponds to the relaxation of myocardial fibers.3.2Cardiac cycleBeginning with systole , the pressure inside the ventricles rises rapidly forcing theatrioventricular valves to close . as a result blood cease to flow from the right atria into the 5
  6. 6. ventricles and regurgitation of blood into the atria is prevented . the rapid rise of pressureinside the right and left ventricles forces the pulmonic and aortic valves to open and blood isejected into the pulmonary artery and aorta , respectively . the exist of blood is at first rapidthen as the pressure in each ventricle and its corresponding artery equalizes , the flow ofblood gradually decreases.At the end of the systole , pressure within the right and left ventricles rapidly decrease ,thislowers pulmonary and aortic pressure causing closure of the semilunar valves .During the diastole when the ventricles are relaxed the atrio ventricular valves are open ,blood returning from the veins flow into the atria and then into ventricles . 3.3Cardiac outputIt is the amount of blood pumped by each ventricle during a given period . the cardiacoutput in arresting adult is about 5l per minute but varies depending on the metabolic needsof the body . it is computed by stroke volume heart rate .Stoke volume is the amount of blood ejected per heart beat . the average resting strokevolume is about 70ml and the heart rate is 60 to 80 bpmElectrical Activity of the HeartWhen vertebrate muscles are excited, an electrical signal (called an "action potential") isproduced and spreads to the rest of the muscle cell, causing an increase in the level ofcalcium ions inside the cell. The calcium ions bind and interact with molecules associatedwith the cells contractile machinery, the end result being a mechanical contraction. Eventhough the heart is a specialized muscle, this fundamental principle still applies.One thing that distinguishes the heart from other muscles is that the heart muscle is a"syncytium," meaning a meshwork of muscle cells interconnected by contiguous cytoplasmicbridges. Thus, an electrical excitation occurring in one cell can spread to neighboring cells.Another defining characteristic is the presence of pacemaker cells. These are specializedmuscle cells that can generate action potentials rhythmically.Under normal circumstances, a wave of electrical excitation originates in the pacemaker cellsin the sinoatrial (S-A) node, located on top of the right atrium. Specialized muscle fiberstransmit this excitation throughout the atria and initiate a coordinated contraction of the atrialwalls. Meanwhile, some of these fibers excite a group of cells located at the border of the leftatrium and ventricle known as the atrioventricular (A-V) node. The A-V node is responsiblefor spreading the excitation throughout the two ventricles and causing a coordinatedventricular contraction. ASSESSMENT The assessment of the acutely ill cardiac patient will be different from that of a patient witha stable or chronic conditions4 History collection The nurse obtain the health history from the patient about the onset and severity of chest discomfort , associated symptoms current medications and allergies The nurse observes the general appearance and evaluates hemodynamic status 6
  7. 7. With a table patients , a complete health history is obtained during the initial contact It is helpful to have the patient’s spouse or family members available during history Initially demographic information regarding age , gender and ethnic origin is obtained The family history including genetic abnormalities should be obtained . Height , weight should be obtained During the interview the nurse conveys the sensitivity to the cultural background and religious practices of the patient this removes barrier to communication . The baseline information derived from the history assists in identifying patient condition and educational , self care needs . once the problem has been clearly identified a plan of care is started . during subsequent contacts or visits with the patient , a more focused health history is performed to determine whether goals have been met whether the plan needs to be modified and whether new problems have arised . When a patient has chest discomfort ,questions should focus on differentiating a serious life threatening condition such as MI from conditions that are less serious or that would be treated differently The following points should be remembered when assessing patients with cardiac symptom Women are likely to present with atypical symptoms of MI than men There is little coordination between the severity of the chest and the gravity of its cause Elderly and people and those with diabetes may not have pain with angina or MI because of neuropathies . fatigue and shortness of breath may be the predominant symptom in these patients There is poor correlation between the location of chest discomfort and its source . History of present health concern COLDPSA Character – describe the sign or symptom . how does it feel , look ,, sound, smell and so forth? Onset – when did it begin Location – where is it ? d oes it radiate ? Duration – how long does it last? Does it recur? Severity – how bad is it ? Pattern – what makes it better ? what makes it worse ? Associated factors- what other symptoms occur with it ?Chest pain: Chest pain can be cardiac , pulmonary ,Do you experience chest pain ? muscular , gatroin testinal in origin angina isWhen did it start? usually described as a sensation of squeezing 7
  8. 8. Describe the type of pain , location , radiation , around the heart . a steady severe pain ‘and aduration and how often you experience the pain . sense of pressure . it may radiate to the leftdoes activity make the pain worse ? shoulder and down the left arm or to the jaw .Did you have perspiration with the chest pain ? diaphoresis and pain worsened by activity usually related to cardiac chest painPalpitations It may occur with the abnormalities of you experience palpitations . heart’s attempt to increase cardiac output by increasing the heart rate it cause the patient to feel anxiousQther symptoms Faitgue may result from compromise cardiac Do you tired easily ? output fatigue related to decreased cardiacDo you experience fatigue? output is worse in the evening or as the dayDescribe when the fatigue is started . was it progressessudden or gradual ?Do you notice it at any particular time of dayDo you have difficulty in breathing Dyspnea may result from CCF , pulmonary disorder , CAD, MI,..dyspnea may occur at rest , during sleep or with mild , moderate , or extreme exertionDo you wake up at night to urinate? Increased renal perfusion during periods ofHow many times a day ? rest or recumbence may cause nocturia . decreased frequency may be related to decreased CODo you experience dizziness It may indicate decreased blood flow to the brain due to myocardial damage . , however, there are several other causes fro dizziness such as inner ear syndromes , decreased cerebral blood flow , and hypertension .Do you experience swelling in your feet , ankles It may occur as a result of heart failure,or legsDo you have frequent heart burn ? Cardiac pain may be overlooked or misWhen does it /occur ? interpretated as gastro intestinal problemsWhat relieves it ?How often you experience itPast health history Congenital or acquired defects affect the heart’s ability to pump, decreasing theHave you been diagnosed with a heart defect or oxygen supply to the tissues.a murmur?Have you ever had rheumatic fever It results in inflammation of the all layers of the hearthave you ever had an ECG It helps to identify any myocardial changesHave you ever had a blood test outside? Elevated cholesterol level indicates the risk for developing atherosclerosisDo you take medications for heart disease? To know any adverse effects sometimes clients may skip diuretics because of frequent urinationDo you monitor your own blood pressure or Self monitoring is necessary for the personheart rate? who is on cardiotonic or anti hypertensive medications 8
  9. 9. Family history A genetic pre disposition prone forIs there a history of hypertension ,MI, CAD developing heart disease .,DM,in your familyLifestyle and health practices It increase the risk for heart diseaseDo you smoke ? how many cigarettes per day ?and for how many years?What tyoe of stress do you have in your lifestyle ?Describe what you usually eat in a 24 – hourperiod ?How much alcohol you consume ?Do you exercise /Describe your daily activities ? Has your heart disease affects your sexualactivity ?How many pillows do you use to sleep at night ? If heart function is compromised , cardiacDo you feel rested in the morning ? output to the kidneys is reduced duringDo you get up to urinate in the morning ? episodes of activity 5 PHYSICAL EXAMINATION A physical examination is performed to confirm the data obtained in the health history . in addition to observing the patient’s general appearance , a cardiac physical examination should include an evaluation of the following Effectiveness of the heart as a pump Filling volumes and pressures. Cardiac output Compensatory mechanism. The examination which proceeds logically from head to toe can be performed in ten minutes with practice and covers the following Preparing the client Explaining the procedure to the patient Provide privacy in case of assessing female patients in addition the client will be asked to assume a left lateral position , sitting up and leaning forward so that the examiner can ascultate for the presence of any abnormal heart sounds .. Equipment Sthetscope . Small pillow . Examination light Watch with second Centimeter ruler . Physical examination Assessment Normal findings Abnormal findings Inspection The apical impulse may or Pulsation , which may also 9
  10. 10. Inspect pulsations not be visible if apparent ,it be called heaves or lifts ,With the client in supine would be in the mitral area other than apical pulsation orposition with the head of the left midclavicular line 4th , 5th considered abnormal shouldbed elevated between the 30 intercostals space . the apical be evaluated .and 45 degrees , stand on the impulse is the result of theclient’s right side and look left ventricle moving towardsfor the apical impulse and during systole.any abnormal pulsations .Palpation ThePalpate the apical impulseremain on the client’s rightside and ask the client toremain supine . use thepalmar surfaces your hand topalpate the apical impulse inthe mitral area 4th , 5thintercostals space at the midclacvicular linePalpation : Making sure that your hands are warm and with the patient rsupine, feel the precordium . Use the proximal halves of the four finger held gently together , or the whole hand Touch gently and let the cardiac movements rise to your hand because sensation will decrease as you increase pressure. Begin at the apex , move to the left sterna border and then move to the base , going down to the right sterna border and into the epigastrium or axillae . Feel for the apical impulse and identify its location by the intercostals space and the distance from the mid sterna line Determine the width of the area in which is felt . usually it is palpable . within a small radius Not more than 1 cm . the impulse is usually gentle and brief . if it is vigorous characterize it as heave or lift . in many adults it may not be able to feel because of the thickness of the chest wall . An apical impulse that is more forceful and widely distributed fills systole or is displaced laterally downwards may indicate increased cardiac output or left ventricular hypertrophy . A lift along the left sternal border may caused by right ventricular hypertrophy . A loss of thrust may be related to overlying fluid or air or to displacement beneath the sternum . Displacement to the right without a loss organ in thrust suggests dextro cardia , diaphragmatic hernia , distended stomach , or a pulmonary abnormality the point at which the apical impulse is most readily see or felt should be described as the point of maximal impulse PMI. 10
  11. 11. Feel for a thrill : a fine palpable , rushing vibration , s palpable murmur , often but not always , over the base of the heart in the area of the right or left 2nd intercostals space .. it grnerally indicates a disruption of of the expected blood fllow related to some defect in the closure of one of the semilunar valves , pulmonary hypertension , or atrial septal defect . While palpate the precordium , use your other hand to palpate the carotid artery so that you can describe the carotid pulse in relation to the cardiac cycle . Percussion It is limited in defining the eborderrs of the heart or determining its size , because the shape of the chest is relatively rigid and can make more malleable heart conform . Left ventricular size is determined by the location of the apial impulse . The right ventricular tends to enlarge in the antero posterior diameter rather than laterally thus determining the value of percussion of the right heart border.a chest x- ray is more useful in determining the heart bordersCharacteristics of painTypes Character and Duration Precipitating Relieving location and events measures radiation Substernal or 5-15 mt Usually related Rest , NTG, retrostenal pain to exertion , oxygen spreading across emotion , eating chest, may cold radiate to inside of arm , , neck or jaw Substernal pain More than 15 mt Occurs Morhine or pain over spontaneously sulphate , precordium but may be successful may spread sequelae to reperfusion of widely unstable angina blocked throughout chest coronary Artery . pain in hands and shoulders may be present Sharp severe Intermittent Sudden onset , it Sitting upright , substernal pain increases with analgesia, anti or pain to the swallowing , inflammatory left of sternum coughing , and medications ,may be felt in rotation of epigastrium and trunk may be referred to neck ,arms, and backPleuritic pain Pain arises from 30+min Often occurs Rest time , inferior portion spontaneously treatment of of pleura , may pain occurs or underlying 11
  12. 12. be referred to increases with cause, costal margins inspiration bronchodilators or upper abdomen , patient may be able to localise painEsophageal pain Substernal pain 5-60 min Recumbency , Food , antacid, may be cold liquids, NTG relieves projected exercise pain around chest to shouldersAnxiety Pain over chest 2-3 min Stress, Removal of may be variable, emotional , stimulus , does not radiate tachhypnea, relaxation , patient may complaints of numbness and tingling of hands and mouthGeneral appearance Cognition Skin BP Arterial pressures Jugular venous pulsations and pressures Heart Extremities. Lungs . Abdomen .Inspection The room should be quiet because subtle , low pitched sounds are hard to hear Stand to the patient’s right , a thorough examination of the heart requires the patient to assume a variety of position s sitting erect, and leaning forward, lying supine , and being in the left lateral recumbent position ‘in most adults the apical impulse should be visible at the midclavicular line in the 5th intercostals space , but it is easily obscured by obesity , large breasts, or muscularity . in some patient s it may be visible in the 4th left inter costal space. The apical impulse may become visible only when the patient sits up and the heart is brought closer to the anterior wall A readily visible and palpable impulse when the is supine suggests an intensity that may be the result of a problem and also important to assess the inspection of skin .Palpation Making sure that your hands are warm and with the patient supine , feel the precordium . use the proximal halves of the four fingers held gently together or the 12
  13. 13. whole hand . touch gently and let the cardiac movements rise to your hand , because sensation will decrease as you increase pressure . Start at the apex, move to the left sterna border and then to the base , going down to the right sterna order and into the epigastrium . Feel fro the apical impulse and identify its location , by the intercostals space and the distance from the mid sternal line .the impulse is generally gentle and brief . Feel fro a trill , a fine palpable, rushing vibration , a palpable murmur , often , but not always over the base of the heart in the area of the right or left 2nd intercostals space . it generally indicates disruption of the expected blood flow related to some effect in closure of the semilunar valve While palpating the precordium , use your other hand to palpate the carotid artery . it is located just medial to the and below the angle of the jaw.Percussion Percussion is of limited value in defining the borders of the heart or determining its size , because the shape of the chest is relatively rigid and can make the more malleable heart conform ‘left ventricular heart size is better judged by the location of the apical impulse . The right ventricular tends to enlarge in the antero posterior diameter , rather than laterally .thus diminishing the value of percussion of the right heart border . a chest x- ray is far more useful in defining the heart borders . Begin tapping at the anterior axillary line, moving medially along the inter costal spaces toward the sternal border . the change from a resonant to a dull sound marks the cardiac border . Note theses points with pencil and the outline of the heart is visually defined . On the left the loss of resonance will generally be close to the point of maximal impulse at the apex of the heart . measure this point from the mid sterna line at each inter costal spaces.Auscultation Always place a comfortable warm stethoscope on the naked chest . Comfort is important make the patient is warm and relaxed before beginning. Instruct the patient when to breathe comfortably and when to hold the breath in expiration and inspiration . Listen carefully for each sound , isolating each component of the cardiac cycle , especially while the respirations are momentarily suspended . the following sequence is suggested . o Patient sitting up and leaning slightly forward and preferably in expiration : this is the best position to hear relatively high –pitched murmurs with the stethoscope diaphragm . o Patient supine : listen in all five areas . o Patient left lateral recumbent : listen in all five areas . this is the best position to hear the low pitched filling sounds in diastole with the stethoscope bell o Other positions depend on your findings 13
  14. 14. o Patient right lateral recumbent: this is the best position for evaluating right rotated heart of dextro cardia . listen in all five areasAs you examine each of the five auscultatory areas , , remember to inch along . a fullevaluation cannot be obtained by jumping from one isolated area to the next . at each sitepause and listen selectively for each component of the cardiac cycle . let your stethoscopefollows the sounds wherever they lead o Assess the rate and rhythm of the heart , noting the auscultatory area in which you are listening each time . o Instruct the patient to breathe normally and then hole the breath in expiration o Concentrate on systole, listening for any extras sounds or murmurs. S1 marks the beginning of systole . o Concentrate on diastole , which is a longer interval than systole , listening for any extra sounds or murmurs . o Inhale the patient to inhale deeply ,listening closely for s2 to become two components during inspiration . split s2 is best heard in the pulmonic auscultatory area . o Basic heart sounds are characterized in much the same way as respiratory and other body sounds by pitch , intensity , duration , and timing in the cardiac cycle .5.1 General appearance and cognition The nurse observes the patient’s level of distress , level of consciousness and thought process as an indication of the heart’s ability to propel oxygen to the brain The nurse observes for evidence of anxiety along with any emotional factors . 5.2 Inspection of the skin It includes assessing the skin color , temperature , and texture . Pallor – decrease in color of the skin is caused by lack of oxyhemoglobin it is observed in the finger, nails, lips and oral mucosa . in patient ‘s with dark skin , the nurse observes in the palm of the hands and soles of the feet Peripheral circulations –it occurs due to decreased flow rate of blood to a particular area which allows more time for the hemoglobin molecule to become desaturated . Central cyanosis – a bluish tinge observed in the tongue and buccal mucosa denotes serious cardiac disorders . Xanthelasma – yellowish slightly raised plaques in the skin , may be observed along the nasal portion of one or both eyelids and may indicate elevated cholesterol levels. Reduced skin turgors with dehydration and aging Temperature and moisteness . Ecchymosis – patients who are receiving anti coagulant therapy should be observed for unexplained ecchymosis. Wounds ,scars and tissue should be examined 5.3 Blood pressure BP can be measured with the use of invasive arterial monitoring systems by asphygmomanometer and stethoscope 14
  15. 15. Assess for pulse pressures and postural blood pressure changes.5.4 Arterial pressures Assess the pulse rate which varies from patient to patient Asses the pulse rhythm. For the initial cardiac examination or if the pulse rhythm is irregular , the heart rate should be counted by auscultating the apical pulse for a full minute while simultaneously palpting the radial pulse . Assess the pulse quality , it should be assessed bilaterally ,scales can be used to assess the strength of the pulse such as Pulse not palpable or absent o +1 weak , thread pulse difficult to palpate o +2 diminished pulse cannot be obliterated o +3 easy to palpate o +4 strong bounding pulse may be abnormal Assess for pulse configuration . the true configuration of the pulse is best appreciated by palpating over the carotid artery rather than the distal radial artery .5.5 Jugular venous pulsations This provides a mean of estimating central venous pressures which reflects right ventricular end diastolic pressure Assess for jugular venous pulsations and distension 5.6 Heart inspection and palpation Aortic area to determine the correct intercostals space at the angle of Louis by locating the bony ridge near the sternum , at the junction of the body and manubrium . from this angle locate the 2nd intercostals space by sliding one finger to the left or right of the sternum Pulmonic areas -2nd intercostals space to the left of the sternum Erb’s point -3rd intercostals space to the left of the sternum Right ventricular or tricuspid area -4th an 5th intercostals spaces to the left of the sternum Left ventricular or apical area – the PMI, location on the chest where heart contractions can be palpated Epigastric area – below the xiphoid process.5.7 Percussion Normally only left border of the heart can be detected by percussion . it extends from the sternum to the mid clavicular line in the 3rd to 5th intercostals spaces Unless the nurse detects a displaced apical impulse and suspects cardiac enlargement , percussion is omitted5.8 Cardiac auscultation Auscultate the heart sounds and be in a position to differentiate from the abnormal sounds During auscultation the patient remain supine position , using the diaphragm of the stethoscope , the examiner starts at the apical area and progress upward along the left 15
  16. 16. sternal border to the pulmonic and aortic valve , the auscultatory findings , particularly murmurs should be documented by o Location on chest wal o Timing of sound either during systole or diastole . o Intensity of the sound o Quality and location of the sound 5.9 Inspection of the extremities The hands , arms , legs and feet are observed for skin and vascular changes o Decreased capillary refill o Vascular changes such as quality of pulse , numbness, paraesthesia , decrease in temperature , pallor , and loss of movement. o Haemotoma o Peripheral edema o Clubbimg of fingers o Lower extremity ulcers5.10 Other SystemsLungs Tachypnea Cheyne stroke respiration Hemotypsis Cough Crackles Wheezes Abdomen Hepato jugular reflex Bladder distension6. DIAGNOSTIC EVALUATIONDiagnostic studies and procedures are used to confirm the data obtained by the history andphysical examination . some test are easy used to interpreted by expert clinicians . all testsshould be explained to the patient .6.1 Laboratory tests It may be performed for the following reasons o To assist in diagnosing an acute MI o To identify abnormalities of the blood o To assess the degree of inflammation o To monitor serum level of medications o To screen generally for abnormalities 16
  17. 17. Blood chemistry Lipid profileCholesterol, triglycerides, and lipoproteins should be measure to evaluate person risk foratherosclerosis Cholesterol levelsit is a lipid required for hormone synthesis and cell membrane formation elevated cholesterollevel are known to increase the risk for CAD disease.Normal level cholesterol=200mg/dl HDL =35-65mg/dl Triglyceride =40-150mg/dl Serum electrolyte levelSodium , potassium and calcium ions are vital to cellular dpolarization and repolarization theeffect of an elevated potassium leads t o myocardial depression and ventricular irritability ,both hypo and hyperkalemia leads to ventricular fibrillation or caridac stand stillMagnesium is integral to the absorption of calcium and the maintenance of potassium stores Blood urea nitrogen level BUN is an end product of protein metabolism and is excreted by the kidneys .In the patient with cardiac disease , an elevated BUN level may reflect reduced renalperfusion Serum glucose levelIt should be monitored because cardiac patient may also have diabetes . Coagulation studies PTT &aPTT are used to obtain the activity of the intrinsic pathwayPT measures the extrinsic pathway and also used to monitor the effects of therapeutic anti-coagulation with warfarinINR International Standardized Ratio provides a standard method for reporting PT levels . itis maintained between 2.0 &3.0 fro patient with deep vein thrombosis , pulmonary embolism, valvular heart disease , and between 2.5 &3.5 for patients with mechanical prosthetic heartvalve replacements. Hematologic studiesComplete blood count6.2Chest x-ray and fluoroscopy A chest x-ray reveals size, contour , position of the heart . it reveals cardiac and pericardialcalcifications of the pulmonary circulation 17
  18. 18. Fluoroscopy allows visualization of the heart on a x- ray screen . it shows cardiac andvascular pulsations and unusual cardiac contours6.3 ElectrocardiographyIt is a diagnostic tool in assessing the cardio vascular system . it is a graphic recording of theelectrical activity of the heart , an ECG can be recorded with 12,15, or 18 leads , showing theactivity from the different reference points . it is obtained by placing disposable electrodes ina standard positions on the skin , chest wall , and extremities . the heart electrical activity arerecorded in a graph paper.6.4 Cardiac stress testingIt is a non invasive procedures to evaluate the effectiveness of cardiovascular systemresponse to stress. It helps to determine the followings CAD Cause of chest pain Functional capacity of the heart after an MI or heart surgery Effectiveness of antiarrthymic or antianginal medications Dysrhythmias.6.5 EchocardiographyIt is anon invasive ultrasound test that is used to examine the size, shape , and motion ofcardiac structures .It is apaticularly useful tool in diagnosing pericardial effusion determining the etiologicalfactors for heart murmurs, evaluating the function fo prosthetic heart valves , determining thechamber size , and evaluating the ventricular wall motion ,It involves transmission of high frequency sound waves into the heart through the chest walland recording the return signals . the ultrasound is generated by the hand held tranducerapplied to the front of the chest . an ECG is recorded simultaneously to assist withinterpreting the echo cardiogram6.6 Radio nuclide imaging .It involves the use of radio isotopes to evaluate coronary artery perfusion noninvasively todetect MI and to assess left ventricular function . thallium 201 and technetium 99m are two ofthe most common radio isotopes used in cardiac nuclear studies . as they decay they give offsmall amounts of energy in the form of gamma rays , when they are injected intravenously 18
  19. 19. into the blood stream the energy emitted by the radioisotope can be detected by a gammascintillation camera positioned over the body6.7Computed tomographyCT scanning or electron beam CT , uses x-ray to provide cross sectional images of the chest ,including the heart and great vessels . these techniques used to evaluate cardiac massages anddisease of the aorta and pericardium .Nursing role Patient preparation is the primary role in of the nurse for these tests The procedure is non invasive an painless To obtain adequate images , the patient must lie perfectly still during the scanning process. An intravenous line is necessary if contrast enhancement is to be used6.8Positron emission tomography It is anon invasive scanning method that was used in the past primarily to study neurologic function . more recently it has been used to diagnose cardiac dysfunction . it provides specific information about myocardial perfusion During a PET scan , radioisotopes are administered by injection , one compound is used to determine blood flow in the myocardium and another shows the metabolic functionNursing interventions Instruct the patient to refrain from using tobacco or ingesting caffeine for 4 hours before the procedure Reassure the patient6.9Magnetic resonance imagingIt is a noninvasive painless technique that is used to examine both the anatomic andphysiologic properties of the heart ..It is valuable in diagnosing the diseases of the aorta, heart muscle , pericardium , as well ascongenital heart lesion s6.10Cardiac catheterization 19
  20. 20. It is an invasive procedure in which radio opaque arterial and venous catheters are introducedinto selected blood vessels of the right and left side of the heart . most commonly thecatheters are inserted percutaneously through the blood vessels or via cut down procedure ifthe patient ha spoor vascular access. During catheterization , the patient has an IV line inplace for the administration of sedatives , fluids , heparin , and other medications .radioopaque isotopes are used to visualize the coronary arteries , some contrast against iodine.diagnostic catheterization are commonly preferred for an out patient basis and require 2 to 6hours of bed rest.Patients hospitalized for angina or acute MI may also rquire cardiac catheterization , . afterthe procedure , these patient usually return to the hospital rooms for recovery.6.11AngiographyCardizc catheterization , is usually performed with angiography , a technique of injecting acontrast agent into the vascular system to outline the heart and blood vessesls. When aparticular heart chamber or blood vessels is singled out for study the procedure is known asselective angiography. . common sietesare the aorta, coronary arteies, and the right and leftsides of the heart .6.12 AortographyAn aortogram is a form of angiography that outlines the lumen of the aorta and the majorarteries arising from it . the catheter may be introduce into the aorta using the translumbar orretrograde brachial or femoral artery approach .Right heart catheterization ,It usually precedes with left heart catheterization , it involves the passage of catheter from anantecubital or femoral vein into the right atrium right ventricle , pulmonary artery,pulmonary arterioles.Left heart catheterization ,It is performed to evaluate the patency of the coronary artery and the function of the leftventricles & the mitral and aortic valves. . after the procedure , the catheter is withdrawn andarterial hemostasis is achieved using manual pressure or other techniques.Nursing interventionsBefore catheterization , Instruct the patient to usually fast fro 8-12 hours before the procedure Prepare the [patient . Reassure the patient with mild sedatives. Encourage the patient to experience certain fears and anxieties .After catheterization , Observe the catheter access 20
  21. 21. Evaluate temperature, color of the site . Monitor for dys rhythmias. Instruct the patient to report any chest pain and bleeding or discomfort . Encourage fluids to increase urinary output and flush out the dye6.13 Hemodynamic monitoringCritically ill patient require continuous assessment of their cardiovascular system to diagnoseand manage their complex medical conditions. This is mostly achieves by central venouspressure monitoring , CVP, pulmonary artery pressure monitoring , intra arterial BPmonitoringTo perform invasive monitoring specialized equipment is necessary which includes A CVP , pulmonary or arterial catheter .A flushed system composed of intravenous solution , tubing’s stopcocks, .A pressure bag placed around the flush solution that is maintained at 300 mm of hgA transducer to convert the pressure coming from the artery or heart chamber into anelectrical signal.An amplifier or monitor which increase size of the electrical signal for display .Central venous pressure monitoringIt is used to assess the right ventricular function and venous blood return to the heart thiscan be measured by connecting either a catheter positioned in the vena cava or the proximalpart of a pulmonary monitoring system . before insertion of CVP , the site is prepared byshaving , a local anesthetic may be usedThe physician threads a single lumen multilumen catheter through the external jugular ,cubital or femoral vein into the vena cava just above or within the right atrium .Nursing interventionsOnce the CVP catheters is secured and a dry sterile dressing is applied .It is confirmed by chest x-ray and the site is inspected daily for infectionDressing should be changed under aseptic techniques.To measure the CVP the transducer or the zero mark on the manometer must be used at astandard reference point called the phlebostatic axis . after locating this position , the nursemay make an ink mark on the patient’s chest to indicate the location it can be measuredcorrectly with the patient at supine position up to a 45 degreeThe range for normal CVP is 0- 8 mm H gPulmonary artery pressure monitoringIt is used for assessing the left ventricular function ‘it is achieved by using a pulmonary arterycatheter and pressure monitoring system .the catheter is inserted into a large vein , thecatheter is inserted into the vena cava and right atrium . in the right atrium the balloon isinflated and the catheter is carried rapidly by the flow of blood through the tricuspid valveinto the right ventricle through the pulmonic valve and into a branch of pulmonary artery 21
  22. 22. Normal pulmonary pressure is 25/9 mmHg with a man pressure 15 mmHgIntra arterial blood pressure monitoring It is used to ontain direct and continuous BP measurements in critically ill patients who havesevere hypertension or hypotensionOnce an arterial site is selected ,collateral circulation to the area must be confirm before thecatheter is placedWith the Allen test the nurse compresses the radial and ulnar arteries simultaneously andasks the patient to make a fist causing the hand to blanch . .After the patient opens the fist the nurse releases the pressure on the ulnar artery whilemaintaining pressure on the radial artery .the patient’s hand will turn pink if the ulnar arteryis present .Nursing intervention sProper aseptic methods should be followedA transducer is attached , pressures are measure in millimeters7. CONCLUSION So far we discussed about the cardio vascular assessment , throughout the continuum ofcare , whether in a home , hospital , or rehabilitation setting , all patients with cardio vasculardisease require similar assessments .an accurate and timely assessment provides the datanecessary to identify diagnoses, formulate a plan of care and evaluate the respose of thepatient to the care needed. 22
  23. 23. 8. BIBLIOGRAPHY1. 1. Fuller (2000) ,J, Health Assessment , A Nursing Approach , 3rd edn , Philadelphia : Lippincott Williams and Wilkins publishers , Pp2. Weber , J , (2007 ) Health Assessment In Nursing , 3rd edn , Philadelphia : Lippincott Williams and Wilkins publishers , Pp:3. Seidel , H.M (1999) Physical Examination , 5th edn Missouri : Mosby Publishers Pp4. Smeltzer .C. Suzzane , Hinkle .I . Janice et al , Textbook Of Medical – Surgical Nursing 11th edn , Philadelphia : Lippincott Williams and Wilkins publishers , Pp: 23
  25. 25. Submitted date on 22-2-11 INDEXS.NO CONTENT PAGE NO1 Introduction2 Anatomy Of The Heart 2.1position 2.2 Heart Chambers 2.3heart Valves 2.4atrioventricular Valves 2.5semilunar Valve 2.6coronary Arteries 2.7cardiac Muscle3 Physiology Of The Heart 3.1physiology Of Cardiac Contraction 3.2cardiac Cycle 3.3cardiac Output4 History Collection 4.1 Health Perception And Management 4.2 Nutrition And Metabolism 4 .3 Elimination 4.4 Activity And Exercise 4.5 Sleep And Rest 4.6 Cognition And Perception5 Physical Examination 5.1 General Appearance Band Cognition 5.2 Inspection Of The Skin 5.3 Blood Pressure 5.4 Arterial Pressures 25
  26. 26. 5.5 Jugular Venous Pulsations 5.6 Heart Inspection And Palpation 5.7 Percussion 5.8 Cardiac Auscultation . 5.9 Inspection Of The Extremities 5 .10 Other Systems6 .Diagnostic Evaluation 6.1 Laboratory Tests 6.2chest X-Ray And Fluoroscopy 6.3 Electrocardiography 6.4 Cardiac Stress Testing 6.5 Echocardiography 6.6 Radio Nuclide Imaging . 6.7computed Tomography 6.8positron Emission Tomography 6.9magnetic Resonance Imaging 6.10cardiac Catheterization 6.11angiography 6.12 Aortography 6.13 Hemodynamic monitoring7 Conclusion 228 Bibliography 23 26
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