Cardiovascular assessment and diagnostic procedures

CARDIOVASCULARASSESSMENT&
COMMON DIAGNOSTIC TEST
NURSING MANAGEMENT OF
PATIENTS ( ADULT INCLUDING
ELDERLY) WITHBLOODAND
CARDIO VASCULARPROBLEMS

Anatomic and physiologic
Overview…
 An understanding of the structures and function of the
heart in health and disease is essential to develop
cardiovascularassessment skills.

Anatomy and physiology of the
Heart
 The heart is a hollow , muscularorgan located in the
centre of the thorax, where it occupies the space
between the lungs ( Mediastinum) and diaphragm.
 It weighs approximately 300 g, the weight and size of
the heart are influenced by age, gender, body weight,
extent of physical exercise and conditioning and heart
disease.

Anatomy and physiology of the
Heart
The heart wall is arranged into three layers.
 Pericardium: is the sac that encloses the heart. It is also
known as the outermost layer of the heart.
 Myocardium: is the thickest layer of the heart made of
pure muscle and it gets damaged during a heart attack. It
makes up the bulk of the heart.
 Endocardium: is the thin layer of tissue heart that lines
the heart’s chambers and valves. The cardiac conduction
system is located in this layer of the heart.

Chambers of the heart
The heart consist mainly fourchambers
1)Two atria ( Right & left)
2)Two ventricles ( Right & left)

Heart valves
 The fourvalves in the heart permit blood to flow in
only one direction. The valves , which composed of
thin leaflets of fibrous tissue, open and close in
response to the movement of blood and pressure
changes within the chambers.

The Cardiac cycle
 The successive events that are taking place with that
are taking place with each beat are known as Cardiac
cycle.

Cardiac conduction system
 The cardiac conduction systemis a group of specialized
cardiac muscle cells in the walls of the heart that send
signals to the heart muscle causing it to contract.

Components of cardiac
conduction system
 SA node ( Sinoatrial node) Primary pacemakerof the heart
 AV node ( Atriovenricularnode) Secondary Primary
pacemakerof the heart
 Bundle of His.
 Bundle branches.
 Purkinje fibers.

The sinoatrial (SA) node
 The sinoatrial (SA) node, referred to as the primary pacemakerof
the heart, is located at the junction of the superior venacava and
the right atrium .
 The SA node in a normal resting heart has an inherent firing rate of
60 to 100 impulses per minute, but the rate can change in response
to the metabolic demands of the body

Cardiac conduction system
 Three physiologic characteristics of the cardiac
conduction cells account for this coordination:
1. Automaticity: ability to initiate an e le ctricalim pulse .
2. Excitability: ability to re spo nd to an e le ctricalim pulse .
3. Conductivity: ability to transm it an e le ctricalim pulse
fro m o ne cell to another.

Physiology of Cardiac Conduction
 Cardiac electrical activity is the result of the movement of
ions (charged particles such as sodium, potassium, and
calcium) across the cell membrane.
 The electrical changes recorded within a single cell result in
what is known as the cardiac action potential.

Coronary Arteries
 The left and right coronary arteries and theirbranches
supply arterial blood to the heart.
 These arteries originate fromthe aorta just above the
aortic valve leaflets.
 Patients, particularly those with coronary artery disease
(CAD), can develop myocardial ischemia (inadequate
oxygen supply) when the heart rate accelerates.

Normal coronary artery VS Narrowing
coronary artery

CardiovascularGlossary
Terminologies :
 Afterload: the amount of resistance to ejection of blood from the
ventricle.
 Apical impulse (also called point of maximum impulse [PMI]):
impulse normally palpated at the fifth intercostal space, left
midclavicular line; caused by contraction of the left ventricle.
 Baroreceptors: nerve fibers located in the aortic arch and carotid
arteries that are responsible for reflex control of the blood
pressure (BP).

 Cardiac catheterization: an invasive procedure used to
measure cardiac chamber pressures and assess patency
of the coronary arteries.
 Cardiac output: amount of blood pumped by each
ventricle in liters per minute; normal cardiac output is 5 L
per minute in the resting adult heart.

 Contractility: ability of the cardiac muscle to shorten in
response to an electrical impulse.
 Hypertension: blood pressure greater than
 140/90 mm Hg
 Hypotension: a decrease in blood pressure to
 less than 100/60 mm Hg

 Murmurs: sounds created by abnormal, turbulent flow of
blood in the heart.
 Myocardial ischemia: condition in which heart muscle cells
receive less oxygen than needed.
 Myocardium: muscle layer of the heart responsible for the
pumping action of the heart.
 Postural (orthostatic) hypotension: a significant drop in blood
pressure (usually 10 mm Hg systolic or more) after an upright
posture is assumed.

 Preload: degree of stretch of the cardiac muscle fibers at the
end of diastole.
 Sinoatrial (SA) node: primary pacemaker of the heart,
located in the right atrium.
 Stroke volume (SV): amount of blood ejected from the
ventricle per heartbeat; normal stroke volume is 70 mL in the
resting heart.
 Venodilating agent: medication causing dilation of veins.

 Telemetry: the process of continuous electrocardiographic
monitoring by the transmission of radio waves from a battery-
operated transmitter worn by the patient.
 Diastole: period of ventricular relaxation resulting in ventricular
filling.
 Systole: period of ventricular contraction resulting in ejection of
blood from the ventricles into the pulmonary artery and aorta.

 ACE (angiotensin-converting enzyme) inhibito r - A
m e dicine that lo we rs blo o d pre ssure by inte rfe ring
with the bre akdo wn o f a pro te in-like substance
invo lve d in blo o d pre ssure re g ulatio n.
 Acquired heart disease orCongenital heart
disease (CHD) - Heart disease that arises after
birth, usually from infection or through the build-up
of fatty deposits in the arteries that feed the heart
muscle.

 Aneurysm - A sac-like protrusion from a blood vessel or the
heart, resulting from a weakening of the vessel wall or heart
muscle.
 Angina orangina pectoris - Chest pain that occurs when
diseased blood vessels restrict blood flow to the heart.
 Antiarrhythmics - Medicines used to treat patients who have
irregular heart rhythms.

 Aortic valve - The valve that regulates blood flow from the
heart into the aorta.
 Arrhythmia (ordysrhythmia) - An abnormal heartbeat.
 Arteriosclerosis - A disease process, commonly called
"hardening of the arteries", which includes a variety of
conditions that cause artery walls to thicken and lose
elasticity.

 Beta-blocker - An antihypertensive medicine that limits the
activity of epinephrine, a hormone that increases blood pressure.
 Biopsy - The process by which a small sample of tissue is taken
for examination.
 Bradycardia - Abnormally slow heartbeat.
 Cardiac arrest - The stopping of the heartbeat, usually because
of interference with the electrical signal (often associated with
coronary heart disease).

 Cardiac enzymes - Complex substances capable of speeding
up certain biochemical processes in the heart muscle.
 When myocardial tissue is damaged ( e.g. due to MI) cellular
injury results in the release of intracellular enzymes and
proteins in to the blood stream Abnormal levels of these
enzymes signal heart attack.

 Cardiac output - The amount of blood the heart pumps through
the circulatory system in one minute.
 Cardiomegaly - An enlarged heart. It is usually a sign of an
underlying problem, such as high blood pressure, heart valve
problems, or cardiomyopathy.
 Cardiomyopathy - A disease of the heart muscle that leads to
generalized deterioration of the muscle and its pumping ability.

 Cardiopulmonary resuscitation (CPR) - An emergency life
saving procedure that can maintain a person's breathing and
heartbeat when cardiac and respiratory arrest.
 Carotid artery - A major artery (right and left) in the neck
supplying blood to the brain.

 Coronary artery disease (CAD) - A narrowing of the arteries that
supply blood to the heart. The condition results from a buildup
of plaque and greatly increases the risk of a Mi or heart attack.
 Defibrillator - A device that helps restore a normal heart rhythm
by delivering an electric shock.

Cardiovascular assessment
Introduction:
 Cardiovascular disease is the leading killer for both men and
women among all racial and ethnic groups in the world wide.
 According to the Centers for Disease Control (CDC) studies
among coronary heart disease (CAD) patients, 90% of
patients have had prior exposure to at least one heart disease
risk factor that contributed to their disease.

 A thorough cardiovascularassessment
will help to identify significant factors
that can influence cardiovascularhealth
such as high blood cholesterol, cigarette
use, diabetes, orhypertension. Therefore,
a cardiovascularexamshould be a part of
every abbreviated and complete
assessment.

Cardiovascularassessment
"An evaluation of the condition, function, and
abnormalities of the heart and circulatory system.”

Cardiovascularassessment
 The assessment of the acutely ill cardiac patient will be
different fromthat of a patient with stable orchronic
cardiac conditions.
 ( Forexample, the assessment performed by an emergency
department nurse caring fora patient who is experiencing
an acute myocardial infarction (MI) must be very focused
and must be performed rapidly.)

Nursing history
 The purpose nursing history in a cardiovascular
assessment is to provide information about yourpatient’s
cardiovascularsymptoms and how they developed. A
complete cardiovascularhistory will give you indications
to potential orunderlying cardiovascularillnesses or
disease states.

History of present illness
1. The client history is the single most important aspect
in evaluating chest discomfort and othersigns &
symptoms. The quality, location, duration, and
modifying factors are essential to making a correct
diagnosis.

Past Health History
 It is important to askquestions about patient’s past
health history.
 The past health history should elicit information
about the following issues: (hypertension, elevated
blood cholesterol ortriglycerides, heart murmurs,
congenital heart disease, rheumatic feveror
unexplained joint pains as a child oryouth, recurrent
tonsillitis and anemia. )

Past medical history
 Medical and surgical history:
1. Assess childhood and adult illness, hospitalizations, trauma and
injuries.
2. Does the client have HTN, DM, hyperlipidemia, COPD, etc.
3. Review of Allergies ( Drugs, foods, environmental agents.)
4. Medications ( Current & previous prescribed drugs, duration
,dosage, and side effects , OTC medications , herbal medications ,
vitamin & mineral supplementation etc.

Current Lifestyle and Psychosocial
Status
 Nutrition
 Smoking
 Alcohol
 Exercise
 Drugs

Family history
 Family History Family history is an important factorused
in identifying yourpatient’s riskforcertain cardiovascular
diseases.
 Askto patient about any cardiovascularfamily history
such as hypertension, obesity, diabetes, coronary artery
disease, orsudden death.

SLEEP AND REST
 Clues to worsening cardiac disease, especially HF, can
be revealed by sleep-related events. Determining where
the patient sleeps or rests is important.
 Recent changes, such as sleeping upright in a chair
instead of in bed, increasing the number of pillows used,
awakening short of breath at nigh (paroxysmal nocturnal
dyspnea [PND]), or awakening with angina (nocturnal
angina), are all indicative of worsening HF.

COGNITION ANDPERCEPTION
 Evaluating cognitive ability helps to determine whether the
patient has the mental capacity t manage safe and
effective self-care.
 Is the patient’s short-term memory intact? Is there any
history of dementia? Is there evidence of depression or
anxiety.

SEXUALITY ANDREPRODUCTION
 Although people recovering fromcardiac illnesses or
procedures are concerned about sexual activity, they are
less likely to asktheirnurse orotherhealth care provider
forinformation to help themresume theirnormal sex
life.

COPING ANDSTRESS TOLERANCE
 It is important to determine the presence of
psychosocial factors that adversely affect cardiac
health.
 Anxiety, depression, and stress are known to
influence both the development of and recovery
from CAD.

NUTRITION ANDMETABOLISM
 Dietary modifications, exercise, weight loss, and careful
monitoring are important strategies formanaging three major
cardiovascularriskfactors:
 Hyperlipidemia, hypertension, and hyperglycemia (diabetes
mellitus). Diets that are restricted in sodium, fat, cholesterol,
and/orcalories are commonly prescribed. The nurse should
obtain the following information:

ELIMINATION
 Typical bowel and bladderhabits need to be
identified. Nocturia (awakening at night to
urinate) is common forpatients with HF.
 Fluid collected in the dependent tissues
(extremities) during the day redistributes into the
circulatory system once the patient is recumbent
at night.

 When assessing the cardiovascular system, other systems, such
as the circulatory and respiratory systems, also need to be
evaluated to provide a comprehensive and holistic picture.
 Use fundamental technique of physical examination
1. INSPECTION
2. PALPATION
3. PERCUSSION
4. AUSCULTATION

Physical Examination
 General appearance
 Vital sings ( Temperature, pulse, respirations and Blood
pressure)
 Head, neck and skin. (The most important observation to
be made in the neck region is the assessment of jugular
venous pulse).
 Chest
 Extremities ( Inspect nail beds for color, splinter
hemorrhage, clubbing ,and capillary refill.)

Circulatory Assessment: Inspection
 Performing a visual assessment of the circulatory system
is an important component of comprehensive
cardiovascularassessment.
 Areas forevaluation you may inspect include skin color,
location of any lesions, bruises orrash, symmetry of
motion, size of body parts, and any abnormal findings,
sounds, and odors.

Conclusion
 Integrating the cardiovascular health history and physical
exam takes practice. It is not enough to simply ask the right
questions and perform the physical exam.
 As the patient’s nurse, you must critically analyze all of the
data you are obtaining, synthesize the data into relevant
problem focus, and identify a plan of care for your patient
based upon this synthesis.

Common Manifestations of
cardiovasculardisease
 Chest pain: ( in clients with cardiac disease , chest pain is the
most common clinical manifestations.)
 Shortness of breath ordyspnea (MI, left ventricular failure)
 Edema and weight gain (right ventricular failure, HF)
 Palpitations (valvular heart disease, ventricular aneurysm,
stress and myocardial ischemia and electrolyte imbalance)


Fatigue (earliest symptom associated with several
cardiovascular disorders)
 Dizziness and syncope orloss of consciousnes:
(postural hypotension, dysrhythmias, vasovagal
effect, cerebrovascular disorders)

Riskfactors of cardiovascular
disorders
 Non-modifiableriskfactors:
1.Positivefamilyhistoryforprematurecoronaryarterydisease
2. Increasingage
3. Gender(menandpostmenopausalwomen)
4. Race(higherincidenceinAfricanAmericans thanin
Caucasians)

Modifiable riskfactors
 Hyperlipidemia
 Hypertension
 Cigarette smoking
 Elevated blood glucose level (i.e., diabetes mellitus)
 Obesity
 Physical inactivity
 Type A personality characteristics, particularly hostility
 Use of oral contraceptives

Common diagnostic studies in a cardiovascular
disorders
 Diagnostic tests and procedures are used to confirmthe data
obtained by history and physical assessment. Some tests are
easy to interpret, but others must be interpreted by expert
clinicians.
 All tests should be explained to the patient. Some necessitate
special preparation before they are performed and special
monitoring by the nurse afterthe procedure.

LABORATORY TESTS
Laboratory tests may be performed forthe following
reasons:
 To assist in diagnosing an acute MI. (Angina pectoris, chest
pain resulting from an insufficient supply of blood to the
heart, cannot be confirmed by either blood or urine
studies.)
 To identify abnormalities in the blood that affect the
prognosis of a patient with a cardiac condition.

 To assess the degree of inflammation.
 To screen for risk factors associated with atherosclerotic
coronary artery disease.
 To determine baseline values before performing
therapeutic interventions.
 To monitor serum levels of medications.
 To assess the effects of medications (e.g., the effects of
diuretics on serum potassium levels).
 To screen generally for abnormalities.

Cardiac Enzymes(cardiac
biomarkers) and isoenzymes
 Cardiac enzymes also known as cardiac biomarkers.
 Cardiac enzymes (the old name), or cardiac biomarkers
(the new name), are blood tests that are used to detect
damage to heart muscle cells. These tests are most
useful in diagnosing
myocardial infarctions (heart attacks), but they are now
also being used to detect heart cell damage from other
causes, as well — such as from traumatic injury or
myocarditis.

 Cardiac enzymes are markers found in the blood.
 They are tested when Myocardial Infarction (MI) is
suspected.
 The markers are normally present at all times, however,
they are significantly elevated during a damage of the heart
muscle.


If Myocardial Infarction is suspected, enzyme
markers are drawn several times usually six hours
apart.
 They are few different enzymes and their levels are
elevated hours after the initial heart damage.

Types of cardiac enzymes orcardiac biomarkers
 Troponin– contractile protein, two types:
1. TROPONIN T: found in the cardiac and skeletal muscle,
elevated during kidney and skeletal muscle damage, early
rise after 3-4 hours, peak is 24 hours.
2. TROPONIN I found only in cardiac muscle, more specific
but rises later,4-6 hours, peak is at 18 hours.

 Creatine Phosphokinase (CK-MB) is highly
specific test for MI, elevation of 4% and higher
indicate MI.
 The time to rise is 4-6 hours, time to peak is 24
hours.

CK- isoenzymes
 CK isoenzymes are more specific than CK. There are
Three CK isoenzymes they are:
1) CK-MM(Found in skeletal muscle)
2) CK-MB( Found in myocardium)
3) CK-BB (Found in brain)
* Creatine Phosphokinase (CK-MB) is highly specific test
forMI, elevation of 4% and higherindicate MI. The time
to rise is 4-6 hours, time to peakis 24 hours.

Lactic dehydrogenase(LDH)
 There is LDH1 and LDH2, normally LDH2 is greater
than LDH1, if LDH1 is greaterthan LDH2 than the
person is positive forMI.
 Howeverincrease in level occurs 48 to 72 hrs after
the onset of symptoms

Myoglobin
 Myoglobin is a muscle protein with high
sensitivity, but low specificity (can be elevated
during other muscle injuries).
 Time to rise is 1-4 hours Peak time 6-12 hours

Otherbiochemical Markers

BNP( B- type natriuretic peptide) – BNP is
synthesized in the ventricular myocardium and
released as a response to increased wall stress.
 An increased BNP level indicate patients at the
risk of developing sudden cardiac death.

C-reactive protein (CRP)
 C-reactiveprotein(CRP) is aninflammatorymarker
that maybeanimportant riskfactorfor
atherosclerosis andischemic heart disease.
 CRPis aninflammatorymarkerproducedbythe
liverinresponseto systemic cytokinases.
 ElevatedCRPis associatedwithAMI, stroke, and
theprogressionof peripheral vasculardisease.

Blood Chemistry
1. Lipidprofile(The lipoproteins are referred to as low-density
lipoproteins (LDL) and high-density lipoproteins (HDL). The risk
of CAD increases as the ratio of LDL to HDL or the ratio of total
cholesterol (LDL +HDL) to HDL increases).
2. Cholesterol levels : Cholesterol (normal level, less than 200
mg/dL) is a lipid required for hormone synthesis and cell
membrane formation.

3. Serumelectrolytelevels
 Sodium, potassium, and calcium are ions that are vital to
cellular depolarization and repolarization.
 In addition, the serum sodium concentration reflects
relative fluid balance.
 Generally, hyponatremia (low sodium level) indicates
fluid excess, and hypernatremia (high sodium level)
indicates fluid deficit

BLOODUREA NITROGEN LEVEL (BUN)
 Blood urea nitrogen (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 renal perfusion (from
decreased cardiac output) or intravascular fluid volume
deficit (from diuretic therapy or dehydration)

SERUMGLUCOSE LEVEL
 The serum glucose level is important to monitor,
because many patients with cardiac disease also
have diabetes mellitus.

RADIOLOGY ANDIMAGING
1. Chest X-ray

1. Chest X-ray
1. The chest X-ray is a noninvasive tool used to visualize
internal structures, such as the heart, lungs, soft tissues,
and bones.
2. A chest x-ray usually is obtained to determine the size,
contour, and position of the heart.
3. It does not help diagnose acute MI but can help
diagnose some complications (e.g., HF).
4. Correct placement of cardiac catheters, such as
pacemakers and pulmonary artery catheters, is also
confirmed by chest x-ray.

ECG
 The ECG is a diag no stic to o luse d in asse ssing the
cardio vascular syste m .
 It is a g raphic re co rding o f the e le ctricalactivity o f the he art;
an ECG can be re co rde d with 1 2, 1 5, o r 1 8 le ads, sho wing
the activity fro m tho se diffe re nt re fe re nce po ints.
 The ECG is o btaine d by placing dispo sable e le ctro de s in
standard po sitio ns o n the skin o f the che st walland
e xtre m itie s. The he art’s e le ctricalim pulse s are re co rde d as a
tracing o n spe cialg raph pape r.

ECG
 The standard 12-lead ECG is the most commonly
used tool to diagnose dysrhythmias, conduction
abnormalities, enlarged heart chambers,
myocardial ischemia or infarction, high or low
calcium and potassium levels, and effects of some
medications.

ECG
 To enhance interpretation of the ECG, the patient’s
age, gender, BP, height, weight, symptoms, and
medications (especially digitalis and antiarrhythmic
agents) should be noted on the ECG requisition.

Continuous ECG monitoring is standard for patients who
are at high risk for dysrhythmias.

TELEMETRY
 In addition to hardwire monitoring systems, the
ECG can be continuously observed by telemetry,
the transmission of radio waves from a battery-
operated transmitter worn by the patient to a
central bank of monitors.

CARDIAC STRESSTESTING(cardiopulmonary
exercise test)

CARDIAC STRESSTESTING
 Normally, the coronary arteries dilate to four times their
usual diameter in response to increased metabolic
demands for oxygen and nutrients.
 Coronary arteries with atherosclerosis, however, dilate
much less, compromising blood flow to the myocardium
and causing ischemia.
 Therefore, abnormalities in cardiovascular function are
more likely to be detected during times of increased
demand, stress.

Indication to cardiac stress test
(1) CAD cause of chest pain
(2) Functional capacity of the heart after an MI or heart surgery
(3) Effectiveness of antianginal or antiarrhythmic medications
(4) Dysrhythmias that occur during physical exercise,and
(5) specific goals for a physical fitness program. For cardiac
rehabilitation.

Contraindications to cardiac stress testing
1. Include severe aortic stenosis, acute myocarditis or
pericarditis, severe hypertension.
2. CAD, HF, and unstable angina. Because complications
associated with stress testing can be life-threatening (MI,
cardiac arrest,
HF, and severe dysrhythmias), testing facilities must have staff
and equipment ready to provide advanced cardiac life support.

Exercise Stress Testing
 In an exercise stress test, the patient walks on a treadmill
(most common) or pedals a stationary bicycle or arm crank.
 Exercise intensity progresses according to established
protocols

Treadmill Cardiac Exercise test

Pedals a stationary bicycle orarm crank

NURSING ROLES IN CARDIAC STRESS OR
EXERCISE TESTING
1. In preparation for the exercise stress test, the patient is
instructed to fast for 4 hours before the test and to avoid
stimulants such as tobacco and caffeine. Medications may be
taken with sips of water.
2. The physician may instruct patients not to take certain cardiac
medications, such as beta-blockers, before the test. Clothes
and sneakers or rubber-soled shoes suitable for exercising are
to be worn. Women are advised to wear a bra that provides
adequate support.

NURSING ROLES IN CARDIAC STRESS OR
EXERCISE TESTING
3. The nurse describes the equipment used and the sensations
and experiences that the patient may have during the test.
4. The nurse explains the monitoring equipment used, the need
to have an intravenous line placed, and the symptoms to
report.

ECHOCARDIOGRAPHY(Ultrasound
Cardiography)

ECHOCARDIOGRAPHY (Ultrasound Cardiography)
 Echocardiography is a noninvasive ultrasound test that is used
to examine the size, shape, and motion of cardiac structures.
 It is a particularly useful tool for diagnosing pericardial
effusions, determining the etiology of heart murmurs,
evaluating the function of prosthetic heart valves, determining
chamber size, and evaluating ventricular wall motion.
 Types includetwo-dimensional (2-D) andM-mode.

Cardiac MRI
Magnetic resonance imaging (MRI) is used to evaluate diseased
heart muscle. It is possible that this technology will eventually
replace cardiac catheterization.

Dopplerultrasound can be used to evaluate arterial and
peripheral venous patency as well as valvularcompetence.

Oscillometry
 Degree of arterial occlusion may be measured by an
oscillometer, which measures pulse volume. One extremity
may be compared with the other to evaluate arterial patency.

Other non – invasive imagining studies
 Myocardial Perfusion Imaging
 CT-scan
 Positron Emission Tomography
 Positron emission tomography ( (PET) is a no ninvasive
scanning m e tho d that was use d in the past prim arily to study
ne uro lo g ic dysfunctio n. Mo re re ce ntly, and with incre asing
fre q ue ncy, PET has be e n use d to diag no se cardiac dysfunctio n)

Invasive cardiac diagnostic procedures..
1. Cardiac catheterization
2. Right Heart Catheterization
3. Angiography
4. Hemodynamic monitoring
A) central venous pressure monitoring
B) pulmonary artery pressure monitoring
C) intra-arterial blood pressure monitoring

Cardiac catheterization
 Cardiac catheterization is a invasive diagnostic
procedure.
 in which a catheteris introduced into the heart
and blood vessels to measure oxygen
concentration, saturation, tension, and pressure in
the various heart chambers; detect shunts;
provide blood samples foranalysis; and determine
CO and pulmonary blood flow.

 Catheter advancement is guided by fluoroscopy.
Most commonly, the catheters are inserted
percutaneously through the blood vessels, or via a
vascular cut down procedure if the patient has
poor vascular access.

 Pressures and oxygen saturations in the four heart
chambers are measured.
 Cardiac catheterization is used to diagnose CAD,
assess coronary artery patency, and determine the
extent of atherosclerosis based on the percentage of
coronary artery obstruction.
 These results determine whether revascularization
procedures including PTCA or coronary artery bypass
surgery may be of benefit to the client.

vascularcut downprocedureincardiac
catheterization

Indications & contra indications to cardiac
catheterization
1. Angiographyis usuallycombinedwithheart catheterizationfor
coronaryarteryvisualization.
Contraindications forcardiac catheterizationinclude:
1. Uncontrolled ventricular irritability.
2. Uncorrected electrolyte hyperkalemia, hypokalemia,
hypercalcemia, or hypocalcemia.
3. Digoxin toxicity.
4. Decompensated heart failure.
5. Severe renal insufficiency or anuria, unless renal
dialysis will be performed following procedure.

Relative contraindications forcardiac
catheterization include:
1. Recent stroke (within the past month).
2. Active GI bleeding.
3. Active infection.
4. Uncontrolled hypertension.
5. Patient's refusal of therapeutic intervention.

Pre-intervention
 The patient is assessed before the procedure for previous
reactions to contrast agents or allergies to iodine-containing
substances (e.g., seafood).
 If the patient has a suspected or known allergy to the substance,
antihistamines or methylprednisolone (Solu-Medrol) may be
administered before the procedure.
 Take inform consent with adequate explanation about procedure,
duration, and complication.
 Evaluate patient's emotional status before catheterization.

Pre- intervention
 In addition, the following blood tests are performed
to identify abnormalities that may complicate
recovery: BUN and creatinine levels, INR or PT,
PTT, hematocrit and hemoglobin values, platelet
count, and electrolyte levels.

Inter- intervention
1. During cardiac catheterization, the patient has an intravenous line in
place for the administration of sedatives, fluids, heparin, and other
medications.
2. Noninvasive hemodynamic monitoring that includes BP and
multiple ECG tracings is necessary to continuously observe for
dysrhythmias or hemodynamic instability.
3. Resuscitation equipment must be readily available during the
procedure. Staff must be prepared to provide advanced cardiac life
support measures as necessary.

Post- interventions
 Record blood pressure measurement and apical pulse
every 15 minutes (or more frequently) until vital signs are
stable to discern dysrhythmias.
 Check peripheral pulses in affected extremity (dorsalis
pedis, posterior tibial pulse in the lower extremity, and
radial pulse in upper extremity); evaluate extremity
temperature, color, and complaints of pain, numbness, or
tingling sensation to determine signs of arterial
insufficiency.

Post - interventions
 Observe the catheter access site for bleeding or
hematoma formation, and assess the peripheral pulses in
the affected extremity (dorsalis pedis and posterior tibial
pulses in the lower extremity, radial pulse in the upper
extremity) every 15 minutes for 1 hour, and then every 1
to 2 hours until the pulses are stable.

Post - intervention
 Watch cut down sites for hematoma formation. Question
patient about increase in pain or tenderness at site.
 Assess for complaints of chest pain and report
immediately. MI may occur and is a serious complication
of cardiac catheterization.
 Enforce activity restrictions, which are based on
coagulation status and whether a vascular closure
method was employed (2 to 24 hours).

Post - intervention
 Evaluate complaints of back, thigh, or groin pain
(may indicate retroperitoneal bleeding).
 Be alert for signs and symptoms of vagal reaction
(nausea, diaphoresis, hypotension, bradycardia);
treat as directed with atropine and fluids.

Post - intervention
 Instruct the patient to report chest pain and
bleeding or sudden discomfort from the catheter
insertion sites immediately.
 Encourage fluids to increase urinary output and
flush out the dye.

Coronary angiography

Coronary angiography is interventional diagnostic
procedure in which a radio contrast is injected
directly into the coronary arteries, allowing
visualization and quantification of stenosis and/or
obstruction.

HEMODYNAMIC MONITORING
 Critically ill patients require continuous assessment of
their cardiovascular system to diagnose and manage
their complex medical conditions.
 This is most commonly achieved by the use of direct
pressure monitoring systems, often referred to as
hemodynamic monitoring.
 Central venous pressure (CVP), pulmonary artery
pressure, and intra-arterial BP monitoring are common
form of hemodynamic monitoring.

OR
 Hemodynamic monitoring is the assessment of the
patient's circulatory status; it includes measurements of
heart rate, intra-arterial pressure, PAP, and pulmonary
capillary wedge pressure (PCWP), central venous
pressure (CVP), CO, and blood volume.

Cardiovascular assessment and diagnostic procedures

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