cardiovascular system assessment and diagnostic investigations and nursing interventions for the diagnostics

1. Assessment, history taking, physical
examination, and investigations related to
cardiovascular system
Submitted by:-
Sonam

2. Assessment, history taking, physical examination,
and investigations related to cardiovascular system
 The cardiovascular system is comprised of the heart and the
blood vessels. It is the primary means of transport around the
body and it distributes blood to all regions of the body. Blood is
the means of transport of oxygen, nutrients, hormones and waste
products.
 A thorough cardiovascular assessment will help to identify
significant factors that can influence cardiovascular health

3. ANATOMY & PHYSIOLOGY
Layers of heart:-
 Endocardium
 Myocardium
 Epicardium
Pericardium
 Visceral pericardium
 Parietal pericardium
Pericardial space, normally filled with about 20 ml of fluid,
known as pericardial fluid.

4.  Heart chambers
 Receiving chambers
 Discharging chambers
 Septum
 Interatrial septum
 Interventricular septum
 Action of the heart
 Systole
 Diastole
 Heart sounds- lub and dub sounds

5. HEART VALVES:-
 Atrioventricular valves
 bicuspid valve
 Tricuspid valve
 Semilunar valves
 Pulmonary
 Aortic
 BLOOD FLOW THROUGH THE HEART
a) Systemic circulation
b) Pulmonary circulation
c) Coronary circulation

6.  CARDIAC CYCLE
CO= HR × SV
 CONDUCTION SYSTEM
 Sinoatrial node or pacemaker.
 Atrioventricular Node (AV node)
 AV bundle, or bundle of His
 Purkinje fibers

7. ASSESSMENT- HISTORY TAKING
AMD PHYSICAL EXAMINATION
 An evaluation of the condition, function, and abnormalities
of the heart and circulatory system
 Frequency and extent of nursing assessment is based on
several factors. That Includes-
1)severity of patient symptoms
2) presence of risk factors
3) practice setting
4) purpose of assessment

8. HEALTH HISTORY
A. History of present illness
B. History of past illness
C. Medical and surgical history
D. Current lifestyle and psychosocial status
E. Family history
F. Sleep and rest
G. Cognition and perception
H. Sexuality and reproduction
I. Coping and stress tolerance
J. Nutrition and metabolism
K. Elimination

9. PHYSICAL EXAMINATION
 Physical examination is conducted to confirm information
obtained from the health history, the patients current baseline
condition, and in subsequent assessment to evaluate the
patient's response to treatment.
 General appearance
- Level of consciousness
-Mental status & Signs of distress
- Height, Weight and BMI
 Vital signs ( Temperature, pulse, respirations and Blood
pressure)

10.  Assessment of skin and extremities-
- Six P's(pallor, pain, pulselessness, paresthesia,
poikilothermia, paralysis)
-Hematoma
- Edema( pitting edema, sacral edema, peripheral edema)
-Capillary refill time
-Clubbing of fingers and toes , brittle nails
-Hair loss, dry and scaling skin, atrophy of the skin, skin
color changes, & ulceration.
 Head, neck- The most important observation to be made in
the neck region is the assessment of jugular venous pulse.

11.  Blood pressure ( assess postural blood pressure changes) and
Arterial pulses(pulse rate, rhytm, amplitude, contour,
palpation of arterial pulses)
 Assessment of heart and chest
 INSPECTION
 PALPATION
 PERCUSSION
 AUSCULTATION
-S1 sound
-S2 sound
-S3 sound
-S4 sound

13.  Opening snaps- abnormal diastolic sounds heard during
opening of an AV valve
 Systolic clicks- stenosis of one or more semilunar valves
creates a short, high pitched sound in early systole,
immediately after S1.
 Murmurs- created by turbulent flow of blood in the
heart
 Friction rub-a harsh, grating sound that can be heard in
both systole and diastole.

14. INVESTIGATIONS
Diagnostic investigations in cardiology are methods of
identifying heart conditions associated with unhealthy,
pathologic, heart function.
 Non- Invasive
 Electrocardiogram
 Ambulatory ECG
Monitoring
 Cardiac stress test
 Echocardiogram
 Doppler echocardiography
 Chest X-ray
 Magnetic resonance
imaging
 Computed tomography
 Invasive
 Laboratory tests
 Transesophageal
echocardiography
 Cardiac catheterization
 Angiography

15. Electrocardiogram:-
graphical representation of electrical activity of the heart

16. Normal Wave

17. Features Description Causes
P wave(0.08- 0.10 sec) Impulse travels from the
SA node towards the AV
node, and spreads from
the right atrium to the left
atrium
Atrial depolarization
[contraction]
QRS complex( 0.08-
0.10 sec)
From beginning of Q
wave to end of S wave
Ventricular
depolarization
T wave Relaxation of ventricles Ventricular repolarization
PR interval (0.20 sec) Onset of P wave to
onset of Q wave
Isoelectric line
Atrial depolarization and
conduction through AV
node
QT interval (0.4- 0.43
sec)
Onset of Q wave and
end of T wave
Electrical activity in
ventricles [
depolarization and
repolarization]
ST segment End Of S wave and
onset of T wave
Isoelectric line
Ventricles already
depolarized

18. HEART RATE INTERPRETATION-
 The six second method:-
Count no. of R waves in 6 sec ( 30 boxes) and multiply by 10.
E.g. 7 R waves in 6 sec, then HR= 7×10= 70

19.  Large box method
 For ventricular rate, count no. of large boxes between two
consecutive R waves, then divide the no. by 300.
E.g If 4 large boxes , then HR= 300/4= 75
 For atrial rate, Count the large boxes between two
consecutive P waves and divide by 300

20.  Small box method
 For ventricular rate, count the no. of small boxes between
two consecutive R waves and divide by 1500.
 For atrial rate, count the no. of small boxes between two
consecutive P waves and divide by 1500.
Regularity of rhythm
 Observe the two consecutive R waves.
 If the no. of small boxes varies between the R-R intervals,
then it is irregular rhythm.

21. Calculate the heart rate?

22. Placement of electrodes

23.  Smoke over fire and clouds over grass
Nursing interventions:-
- remove all metallic objects
- clipping of the hairs
- apply conduction gel
-check functioning of the
ECG machine
-Advise not to panic
-maintain privacy of the
patient
- advise to lie down supine.
-do not over bones

24. Holter monitoring

25.  Nursing interventions
- normal activities should not be limited since its purpose is to
record how the heart works under various actual conditions
over a period of time.
- remove while taking shower and swimming.
- note down the time of activities
- patient is advised to take the Holter to the physician after the
allotted time so that physician will connect the holter to a
screen and will observe the ECG throughout the assigned
period.

26. Cardiac Stress test
 The cardiac stress
test is done with
heart stimulation,
either by exercise on
a treadmill, pedalling
a stationary bicycle,
or with intravenous
pharmacological
stimulation, with
patient connected to
electrocardiogram.

27. Helps to determine-
• Presence of CAD
• causes of chest pain
• Effectiveness of antiarrhythmic or antianginal
medications
• Functional capacity of heart after MI or surgery
contraindications-
• Severe acute stenosis
• Severe HTN
• HF, Unstable angina
• Acute myocarditis or pericarditis

28. 1. EXERCISE STRESS TEST
 During the test, patient walks on treadmill (most common).
 The goal is to increase the heart rate to the “target heart
rate” which is 80% to 90% of the maximum predicted heart
rate based on patient’s age and gender.
 During the test , two or more ECG leads for heart rate,
rhythm and ischemic changes ,BP, skin temperature,
physical appearance, perceived exertion and symptoms like
chest pain, dyspnea, dizziness etc. are monitored.
 When significant ECG abnormalities occurs, it is said to be
positive.

29.  Nursing interventions-
-advise fasting for at least four hours
- avoid stimulants
- medication can be taken with sips of water
- certain medications are advised not to take such as beta
adrenergic blocker, before the test
- explain procedure
- terminate, when target heart rate is reached, if there are
significant changes in ECG or pt. experiences signs of
MI.
-after test monitor the patient for 15 to 20 min

30. 2. PHARMACOLOGICAL STRESS TEST
 Two vasodilating agents, dipyridamole and adenosine is
administered IV to mimic the effects of exercise in
physically disabled or deconditioned.
 These are the agents of choice used in conjugation with
radionuclide imaging.
 Dobutamine can also be used.
Nursing interventions:
- At least four hour fasting
- Avoid caffeine intake in any form.
- Stop medication 24 to 48 hr before the test.

31. Echocardiography
 It is the diagnostic
procedure which uses
ultrasound waves to
produce 2D 0r 3D
images of the heart
muscle.
 It determines size,
shape, movement of
valves and heart
chambers and flow of
blood through the
heart.

32. TYPES OF ECHOCARDIOGRAM
Trans-thoracic echocardiogram(TTE):
 Echocardiogram of
the heart through the
thorax external to
the body.
 Non-invasive,
painless, highly
accurate and quick.

33. Transducer converts echo into electrical impulse that are
recorded and displayed on a monitor, simultaneously an ECG is
recorded to assist the interpretation.
Procedure takes 30 to 45 min.
Nsg. Interventions
-Explain procedure to the patient
-Apply gel to skin, helps transmit sound waves
-Advise the patient to turn to left side and hold the breath

34. Trans-esophageal echocardiogram(TEE)
Echocardiogram
of the heart by
inserting a small
transducer through
the mouth and into
the esophagus.
Invasive and must
be performed
under supervision.

35. Nursing interventions-
 Topical anesthesia should be given
 Advise the patient to swallow while inserting the transducer untill
positioned in esophagus
 Fasting for at least 6 hrs.
 Take informed consent
 Remove dentures if present
 Insert an IV access
 Provide emotional support
 Monitor the level of consciousness, BP, ECG, RR, spO2.
AFTER PROCEDURE-
 advise bed rest, head elevated at 45°.
 Assess vital signs and consciousness
 Assess gag reflex, withhold food , untill fully alert, give sips of water when
gag reflex appears.
 Sore throat is normal for 24 hrs , if persists, report to physician.

36. Doppler Echocardiography
It uses doppler ultrasonography to examine the heart
A test in which very high frequency sound waves are
bounced off by heart and blood vessels. The returning
sound waves (echoes) are picked up and turned into
pictures showing blood flow through the arteries or the
heart itself.
Assessment of
Abnormal communications between the left and
right side of the heart
Cardiac valve areas and function
Valvular regurgitation
Cardiac output
Ejection fraction

37. Nursing interventions
 Obtain patient's history of drug allergies, surgeries, bleeding
disorders and medicine uses.
 Verify the patient's understanding of the procedure and obtain
informed consent.
 Help the patient remove and store any jewelry, denture; appliance
and clothes.
 Assist the patient in a recumbent left lateral position.
 Assess cardiac rhythm, vital signs, and oxygen saturation at 1-3
min intervals during the procedure.
 Assess cardiac rhythm, vital signs level of consciousness; oxygen
saturation at east every 15 min. until the patient is awake and his or
her condition is stable.

38. Chest X-ray

39. Views
PA or posterior-anterior view:
 Patient stands with his chest
against the container of the film
 The X-ray beam from the
machine comes from the
posterior/back and moves
through the chest to the
anterior/front.
Lateral view:
 Patient stands sideways in front
of the film with arms raised up.
 The X rays penetrate the chest
from the sides.

40. Radionuclide imaging
 It involves the use of radioisotopes to non-invasively
evaluate coronary artery perfusion, to detect myocardial
ischemia and infarction, and to assess the left ventricular
function.
 Thallium 201 and technetium 99m.
 Radio isotopes are unstable atoms that give off small
amounts of energy in the form of gamma rays as they decay
 Gamma sscintillation camera detects Radioisotopes

41. It involves:-
 Myocardial perfusion imaging(MPI)
-Positron emission tomography(PET)
-Single photon emission computed tomography(SPECT)
 Equilibrium radionuclide angiocardiography (ERNA)
 Computed Tomography(CT)
 Magnetic resonance angiography (MRA)

42. Myocardial perfusion imaging
 non-invasive imaging test that shows how well blood flows
through (perfuse) the heart muscle. It can show areas of the
heart muscle that aren’t getting enough blood flow. This test is
often called a nuclear stress test. It can also show how well
the heart muscle is pumping.
 There are 2 techniques for MPI:
 Positron emission tomography(PET)
 Single photon emission computed tomography(SPECT)

43.  The main difference between SPECT and PET scans is
SPECT scans measure gamma rays, and PET scans produce
small particles called positrons.
 Nursing interventions:-
- refrain from Tobacco use and caffeine intake
- explain the procedure and insert an IV access
- inject radioisotope, place the electrodes.
- radioisotope takes 1 hour to get absorbed.
- patient should lie still to obtain clear images of heart.

44. It is used in combination with stress test to compare images obtained
when the heart is resting to images of heart in a stressed state

45. Cardiac CT scan (CCT)
 A three-dimensional image of the inside of the heart is
generated from a large series of two-dimensional X-ray
picture taken around a single axis of rotation.
 It is an imaging method that uses x-rays to create cross-
sectional pictures of the heart.
 It provides accurate anatomic images of the four chambers
of the heart, valves, arteries, veins and pericardium.

46. Procedure is performed by placing the patient on a table that
moves into a structure that holds x-ray and scanning equipment.
Nursing interventions-
 Iv hydration
 Renal function test
 IV access if contrast is to be given
 Premedicate with steroids and antihistamines in case of
hypersensitivity
 Lie still during procedure
 Hold the breath when said to do so

48.  Electron Beam Computed Tomography
(EBCT or Ultrafast CT)
 An EBCT scan shows calcification of coronary arteries that
may be indicative of atherosclerosis.EBCT is a faster type
of CT scanning, which takes an x-ray of the heart in about
one-tenth of a second. Ordinary CT scanning can take
anywhere from 1 to 10 seconds. EBCT takes pictures so
quickly that it can avoid blurred pictures caused by the
beating of the heart, a problem with a regular CT scan.

49. Cardiac Magnetic Resonance Imaging
 Cardiovascular magnetic resonance imaging (CMR) /
cardiac MRI, is a medical imaging technology that uses
powerful magnets and radio waves to create pictures of the
body.
 It gives the detailed picture of the heart , including
chambers and valves.
 The images can be stored on a computer or printed on film

51. Magnetic resonance angiography
 MRA uses the same technology as MRI to study the blood
vessels
 Used to examine the physiologic and anatomic properties
of the heart.
 Uses powerful magnetic field and computer generated
pictures to image the heart and great vessels .
 MRA dye highlights the blood vessels, by differentiating
them from tissues around .

53. Nursing interventions
 Screen patients for contraindications like presence of a
pacemaker, metal plates, prosthetic joints or metallic implants
that can be dislodged if exposed to MRA.
 Patient is instructed to remove any jewelry, watches or other
metallic items.
 Patient must be positioned supine on a table that is placed into
an enclosed imager or tube containing the magnetic field.
 Transdermal patches should be removed from skin to prevent
burning.
 The patient who is claustrophobic may need to receive a mild
sedative before undergoing an MRI.
 Patient may be offered a headset to listen to music. Patient is
instructed to remain motionless.

54. Laboratory tests
1. BLOOD TESTS-
 SERUM CHOLESTROL :
o Total cholesterol : 150 – 200 mg/dL
o TGL : 100- 200 mg/dL
o HDL : 35 – 70 mg/dL (in men),
: 35 - 85 mg/dL(in women)
o LDL : Up to 160 mg/dL
o VLDL : 20 – 40 mg/dL
o Advise patient for a 12 hour fasting before the blood
specimen for lipid profile.

55.  CLINICAL IMPLICATION :
• Elevated cholesterol level (HYPERCHOLESTEROLEMIA
)
 Coronary heart disease
 Hypothyroidism
 Diabetes mellitus
 Cholestasis
 Hepatocellular disease
 Biliary cirrhosis
 Glomerulonephritis
 Werner’s syndrome
 Obesity
 Chronic renal failure

56.  Blood chemistries ( Sodium, potassium, calcium,
magnesium, BUN, creatinine, glucose fasting.)
 Coagulation studies(PT, aPTT, PTT,INR)
 Hematologic studies(CBC)

57.  Brain (B-type) natriuretic peptide (BNP)- It is a
neurohormone that helps regulate BP and fluid volume. It is
primarily secreted from the ventricles in response to increases
preload with resulting elevated ventricular pressure. A BNP
level > 100 pg/ml is suggestive of HF.
 C- Reactive Protein- A protein produced by liver in response
to systemic inflammation. People with high levels of
CRP(3.0mg/dl) maybe at greater risk of CVD compared to
people with moderate (1.0 to 3.0mg/dl) or low( less than
1.0mg/dl) levels of hs-CRP.

58. 2. Cardiac Enzyme tests
HOW IT WORKS:-
 When the heart muscle
is damaged, enzymes
are released from the
heart muscle cells into
the bloodstream.
Types-
-Creatinine kinase (CK)
-Protein troponin (Tnl)
-Protein myoglobin

59. 1. Creatinine Kinase and its isoenzymes
There are three creatinine kinase (CK) isoenzymes:
 CK-MM(skeletal muscle)
 CK-MB( heart muscle)
 CK-BB( Brain tissue)
-CK-MB is the cardiac specific isoenzyme.
-Elevated CK-MB is an indicator of acute MI; the level
begins to increase with in few hours and peaks within
24hrs of an MI.
CK-MB normal value- 2-6 ng/mL( males) and 2-5 mcg/L
(females)

60. 2. Myoglobin
 It is the heme protein that helps transport oxygen. It is found in
cardiac and skeletal muscles.
 It is not very specific in indicating an acute cardiac event.
3. Troponin
 It is a protein found in myocardium, regulates the myocardial
contractile process.
 There are three isomers of troponin: C, I, and T.
 Troponin I and T are specific for cardiac muscles, and these
biomarkers are currently recognized as reliable and critical
markers of myocardial injury.

61. Cardiac Angiography
 Cardiac Angiography or arteriography is
a medical imaging technique used to visualize
the lumen of the blood vessels [ arteries, veins] and
the heart chambers.
 This is done by injecting a radio-opaque contrast
agent[dye which absorbs the x-rays] into the blood
vessel and imaging using a camera and X-ray based
techniques such as fluoroscopy.

62. Types
 Aortogram- It is a form of angiography that
outlines the lumen of the aorta and the major
arteries arising from it.
 Coronary arteriography- It involves the
introduction of a catheter into a right or left
brachial or femoral artery, which is then passed
into ascending aorta and manipulated into right or
left coronary arteries. It helps to evaluate degree of
atherosclerosis and congenital abnormalities.

63. Cardiac Catheterization
 The catheter is put into the femoral artery /vein [near
groin] or brachial artery/vein[above elbow].
 The catheter is then guided through the blood vessels
until it reaches the area to be studied [aorta, coronary
arteries, left ventricle and atrium and inferior vena
cava , right atrium and ventricles, pulmonary artery
etc]

64.  Right heart catheterization- It involves the passage of
catheter from an ante cubital or femoral vein into the right
atrium, right ventricle, pulmonary artery and pulmonary
arterioles. Pressures and O2 saturation levels of each of
these areas are obtained and recorded.
 Left heart catheterization- It is performed to evaluate
the patency of the coronary arteries and function of the left
ventricle and the mitral and aortic valves. It is performed by
retrograde catheterization of the left ventricle. In this
approach catheter is inserted into the right brachial artery or
a femoral artery and advances it into the aorta and left
ventricle.

65. Uses
 Mainly used to detect abnormalities of blood flow :
 A tear in a blood vessel (which can cause blockage or
internal bleeding)
 Hemorrhages
 Aneurysms
 Stenosis
 Pattern of blood flow to a tumor.
 Abnormal position of blood vessels
 Abnormal branching of blood vessels since birth
 Changes in the blood vessels of injured heart.

66. Nursing interventions-
• Informed consent
• Assess for allergies to radiopaque dye or iodine
• Fasting for 6-8 hrs
• Note down height and weight to calculate the amount of
dye
• Local anesthesia should be given
• Inform the patient that he may feel flushed and warm
• Monitor vitals and cardiac rhythm
• Assess peripheral pulses and chest pain
• Monitor for bleeding and hematoma
• Encourage fluid intake
• Keep extremities straight for 4-6 hrs, to prevent arterial
occlusion.

67. Electrophysiology Studies
 Invasive Procedure
 To distinguish atrial from ventricular tachycardia when the
determination cannot be made from 12 lead ECG.
 To evaluate how readily a life-threatening dysrhythmia
(e.g., ventricular tachycardia, ventricular fibrillation) can be
induced.
 To evaluate AV node function; to evaluate the effectiveness
of antiarrhythmic medications in suppressing the
dysrhythmia.
 To determine the need for other therapeutic interventions,
such as a pacemaker, implantable cardioverter defibrillator,
or radiofrequency ablation.

68. CONCLUSION:
 Consideration must be given to the presenting symptoms,
lifestyle expectations, impact of treatment selection, risks,
benefits. The history and physical examination have been
the foundation of medical diagnosis.
 However, as laboratory tests and diagnostic imaging has
expanded, investigation skills have been found to be very
much helpful in diagnosing the person for cardiovascular
disease and timely intervention can be provided to the
patient with the help of advancements in the diagnostic
test and appropriate history and physical examination.

69. BIBLIOGRAPHY-
 Brunner and Siddharths. textbook of medical and surgical
nursing. 13th edition.New Vol. I. Delhi:Reed Elsevier India Pvt.
Ltd.; 2014. Pg. No. 657- 691
 Colledge, N. R., Walker, B. R., Ralston, S., & Davidson,
S. Davidson's principles and practice of medicine. Edinburgh:
Churchill Livingstone/Elsevier; 2010. Pg. No. 275-311
 Lewis. Medical Surgical Nursing:Assessment And Management
Of Clinical Problems.Vol. I. New Delhi:Elsevier; 2015. Pg. No.
418- 441.
 http://www.heart.org/HEARTORG/Conditions/HeartAttack/Diag
nosingaHeartAttack/Myocardial-Perfusion-Imaging-MPI-
Test_UCM_446352_Article.jsp#.Wa7wdbIjHIU
 http://www.texasheart.org/HIC/Topics/Diag/dipet.cfm
 Research hyperlinks:
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855646/
 https://lupinepublishers.com/cardiology-
journal/pdf/ACR.MS.ID.000135.pdf

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