Nursing 201Nursing 201Advanced Cardiac Advanced Cardiac

2.0 Nursing assessment and management 2.0 Nursing assessment and management of patients with dysfunctions of circulation, of patients with dysfunctions of circulation, and undergoing related diagnostic tests.and undergoing related diagnostic tests.

Laurie Brown RN, MSN, MPA-HA, CCRN Fall 2005

This is important!This is important!

There are three systems that must There are three systems that must work together for the heart to beat work together for the heart to beat efficiently:efficiently:

1.1. Circulatory Circulatory

2.2. ConductionConduction

3.3. Coronary Coronary

Review of the Cardiovascular Review of the Cardiovascular SystemSystem

Route of blood from the heart: Route of blood from the heart:

Arteries, arterioles, capillaries, venules, veins Arteries, arterioles, capillaries, venules, veins

Distribution of the Total Blood VolumeDistribution of the Total Blood Volume

Heart - Approx 9 % of blood volume at any given time.Heart - Approx 9 % of blood volume at any given time.

Arteries and veins act simply as conduits for Arteries and veins act simply as conduits for blood!blood!

Only capillaries directly serve cells by exchanging Only capillaries directly serve cells by exchanging materials with them. materials with them.

Cardiac TissuesCardiac Tissues

Connective tissuesConnective tissues – form the fibrous – form the fibrous skeleton and valves.skeleton and valves.

Cardiac muscleCardiac muscle – produces the – produces the contractile force of the heart.contractile force of the heart.

Epithelial tissueEpithelial tissue – lines the cardiac – lines the cardiac chambers and covers the outer chambers and covers the outer surfaces of the heart. surfaces of the heart.

Arterial SystemArterial System

General FeaturesGeneral Features

Elastic Arteries Elastic Arteries Muscular Arteries Muscular Arteries Arterioles Arterioles

Exterior Anatomy of the Exterior Anatomy of the HeartHeart

Anatomy of the HeartAnatomy of the Heart

Valves of the HeartValves of the Heart

TricuspidTricuspid – Directs the flow of blood from – Directs the flow of blood from the right atrium to the left ventricle.the right atrium to the left ventricle.

Mitral ValveMitral Valve – Directs the flow of blood from – Directs the flow of blood from the left atrium to the left ventricle.the left atrium to the left ventricle.

Pulmonic (semilunar)Pulmonic (semilunar) – Lies between the – Lies between the right ventricle and the pulmonary artery.right ventricle and the pulmonary artery.

Aortic ValveAortic Valve (semilunar) –(semilunar) – Lies between the Lies between the left ventricle and the aortic artery.left ventricle and the aortic artery.

Circulation in the HeartCirculation in the Heart

1. Oxygen-poor blood 1. Oxygen-poor blood (shown in blue) flows (shown in blue) flows from the body into the from the body into the right atrium.right atrium.

2..Blood flows through 2..Blood flows through the right atrium into the the right atrium into the right ventricle.right ventricle.

3. The right ventricle 3. The right ventricle pumps the blood to the pumps the blood to the lungs, where the blood lungs, where the blood releases waste gases and releases waste gases and picks up oxygen.picks up oxygen.

3. The newly oxygen-3. The newly oxygen-rich blood (shown in rich blood (shown in red) returns to the red) returns to the heart and enters the heart and enters the left atrium.left atrium.

4. Blood flows 4. Blood flows through the left atrium through the left atrium into the left ventricle.into the left ventricle.

5. The left ventricle 5. The left ventricle pumps the oxygen-pumps the oxygen-rich blood to all parts rich blood to all parts of the body.of the body.

TheTheCirculatorCirculatory Systemy System

Coronary CirculationCoronary Circulation

Coronary Blood FlowCoronary Blood Flow

Coronary Blood Flow is directly linked Coronary Blood Flow is directly linked to oxygen demand.  to oxygen demand. 

AAutoregulationutoregulation helps to maintain helps to maintain normal coronary blood flow normal coronary blood flow whenever coronary perfusion whenever coronary perfusion pressure changes due to changes in pressure changes due to changes in aortic pressure. aortic pressure.

AutoregulationAutoregulation

Autoregulation is defined as…Autoregulation is defined as…

The intrinsic ability of an organ to The intrinsic ability of an organ to maintain a constant blood flow despite maintain a constant blood flow despite changes in perfusion pressure. changes in perfusion pressure.

Control of an event such as blood flow Control of an event such as blood flow through a tissue (e.g., cardiac muscle) through a tissue (e.g., cardiac muscle) by alteration of the tissue.by alteration of the tissue.

Coronary Blood FlowCoronary Blood Flow

Heart SoundsHeart Sounds

Heart sounds… Heart sounds… are caused by the are caused by the closure of heart valves. closure of heart valves.

The first sound (lub), or S1, is caused by The first sound (lub), or S1, is caused by closure of the atrioventricular (AV) closure of the atrioventricular (AV) valves. valves.

The second sound (dup), or S2, is caused The second sound (dup), or S2, is caused by the closure of the semilunar valves. by the closure of the semilunar valves.

Murmurs and Stenosis… Murmurs and Stenosis…

A valve that does not A valve that does not close efficiently, results close efficiently, results in the backflow of in the backflow of blood (i.e., blood (i.e., insufficiency or insufficiency or regurgitation). regurgitation).

A valve that does not A valve that does not open wide enough may open wide enough may cause turbulent cause turbulent backflow secondary to backflow secondary to obstruction or obstruction or narrowing (i.e., narrowing (i.e., stenosis). stenosis).

Landmarks

Pericardial Friction RubPericardial Friction Rub

Non-infective Infective Autoimmune

Scratching, grating, squeaking, high pitched sound

Non-infective Infective Autoimmune

Scratching, grating, squeaking, high pitched sound

Definitions…Definitions…

Cardiac outputCardiac output Pre-loadPre-load After-loadAfter-load Cardiac reserveCardiac reserve Starling’s law of the heartStarling’s law of the heart Pulse deficitPulse deficit Pulse pressurePulse pressure

Physiology of Circulation Physiology of Circulation (cont.)(cont.)

Peripheral Resistance Peripheral Resistance

Opposition to flow Opposition to flow

A measure of the amount of friction blood A measure of the amount of friction blood encounters as it passes through the vessels.encounters as it passes through the vessels.

Most friction is encountered in the peripheral Most friction is encountered in the peripheral

circulation (peripheral resistance (PR)).circulation (peripheral resistance (PR)). Sources of resistance… Sources of resistance…

Physiology of Circulation Physiology of Circulation (cont.)(cont.)

Blood PressureBlood Pressure

Force per unit area exerted on the wall of a Force per unit area exerted on the wall of a vessel by its contained blood expressed in mm vessel by its contained blood expressed in mm Hg.Hg.

Usually means systemic arterial blood pressure Usually means systemic arterial blood pressure

in the largest arteries near the heart.in the largest arteries near the heart. The differences in blood pressure within the The differences in blood pressure within the

vascular system provided the driving force that vascular system provided the driving force that keeps blood moving through the body. keeps blood moving through the body.

Physiology of CirculationPhysiology of Circulation

Blood FlowBlood Flow

Actual volume of blood flowing through the Actual volume of blood flowing through the entire circulation or any part of it (a vessel, entire circulation or any part of it (a vessel, an organ, etc.) in a given period of time an organ, etc.) in a given period of time (ml/min).(ml/min).

Equals cardiac output (CO) when applied to Equals cardiac output (CO) when applied to

the entire circulation. the entire circulation.

Varies widely among individual body organs Varies widely among individual body organs as determined by their immediate needs. as determined by their immediate needs.

The Cardiac CycleThe Cardiac Cycle

1. Isovolumetric ventricular contraction

2. Ventricular ejection

3. Isovolumetric relaxation

4. Ventricular filling

5. Atrial systole

1. Isovolumetric ventricular contraction

2. Ventricular ejection

3. Isovolumetric relaxation

4. Ventricular filling

5. Atrial systole

Ejection fraction (EF)Ejection fraction (EF)

The ejection fraction (EF) represents The ejection fraction (EF) represents the amount of blood pumped out of the the amount of blood pumped out of the heart (left ventricle) with each beat. In heart (left ventricle) with each beat. In the healthy heart, it is aroundthe healthy heart, it is around 70%.70%.

An EF below 55% is considered An EF below 55% is considered abnormal.abnormal.

What is congestive heart What is congestive heart failure?failure?

Taber’s defines heart failure as…

“The inability of the heart to circulate blood effectively enough to meet the body's metabolic needs”.

Taber’s defines heart failure as…

“The inability of the heart to circulate blood effectively enough to meet the body's metabolic needs”.

Symptoms of Heart FailureSymptoms of Heart Failure

Shortness of breath Shortness of breath (dyspnea)(dyspnea)

FatigueFatigue Edema – associated Edema – associated

with fluid overloadwith fluid overload LightheadednessLightheadedness HypoxiaHypoxia OrthopneaOrthopnea Cognitive changesCognitive changes Other…Other…

Auto-regulatory Mechanisms Auto-regulatory Mechanisms of of

The HeartThe Heart

The heart is supplied by the two The heart is supplied by the two branches of the autonomic nervous branches of the autonomic nervous system.system.

The The sympatheticsympathetic (adrenergic) (adrenergic) The The parasympatheticparasympathetic, or (cholinergic), or (cholinergic)

Changes Associated With Changes Associated With Aging…Aging…

Decreased vessel Decreased vessel elasticityelasticity

Increased calcification of Increased calcification of vesselsvessels

Impaired valve functionImpaired valve function Decreased muscle tone Decreased muscle tone

(including the heart(including the heart Decreased baroreceptor Decreased baroreceptor

response to blood response to blood pressure changes pressure changes

Decreased conduction Decreased conduction ability of the heartability of the heart

Other stuff…Other stuff…

Contractility:Contractility:

The ability of muscle cells to contract The ability of muscle cells to contract after depolarization. This ability after depolarization. This ability depends on how much the muscle depends on how much the muscle fibers are stretched at the end of fibers are stretched at the end of diastole.diastole.

The inherent ability of cardiac muscle The inherent ability of cardiac muscle fibers to shorten or contract.fibers to shorten or contract.

Cardiac Risk FactorsCardiac Risk Factors

Non-modifiableNon-modifiable

ModifiableModifiable

OtherOther

Cardiac TestingCardiac Testing

Blood Tests Electrical Structure Pressure Blood Flow Ischemic Tissue

CK or CK-MB LDH (LDH1, LDH2) AST (SGOT) Lipids PT/PTT ABGs Electrolytes CBC Troponin & Myoglobin C-reactive protein (CRP) Homocysteine B Type Natriuretic Peptid

Laboratory TestsLaboratory Tests

TestsTests

EKG Stress Test Transesophageal

Echocardiography Echocardiography Phonocardiography

EKG Stress Test Transesophageal

Echocardiography Echocardiography Phonocardiography

RadiographicRadiographic

X-ray Fluoroscopy Angiography

Cardiac Cath DSA (Digital

Subtraction Angiography)

X-ray Fluoroscopy Angiography

Cardiac Cath DSA (Digital

Subtraction Angiography)

Cardiac TestingCardiac Testing

AngiographyAngiography AngioplastyAngioplasty BiopsyBiopsy VO2 maxVO2 max

TestsTests

Nuclear Cardiography Technetium Pyrophosphate

Scanning Thallium Imaging MUGA Scan

Nuclear Cardiography Technetium Pyrophosphate

Scanning Thallium Imaging MUGA Scan

TestsTests

Positron Emission Tomography (PET)

MRI CAT Scan

Positron Emission Tomography (PET)

MRI CAT Scan

Small Pericardial Effusion

Hemodynamic MonitoringHemodynamic Monitoring

Physical AssessmentPhysical Assessment

General appearanceGeneral appearance Mental StatusMental Status Vital signsVital signs PulsesPulses Heart rate and rhythm Heart rate and rhythm PerfusionPerfusion EdemaEdema Lung soundsLung sounds Other…Other…

Case Study… FREDCase Study… FRED

82 y/o male w/30 + year history of COPD presents to the ER with C/O SOB and chest pain and now is to be admitted to your unit. He has a IV at TKO and O2 per NP at 2L. He was given a Nitro and an aspirin in the ER.

FredFred

Admitting Dx: CHF, R/O MI Past Medical Hx: Mild CHF, COPD x 30

years, CAD, HTN PE: Skin pink and dry, brisk capillary refill,

oriented x 4, S3 heart sounds, SOB with any exertion, audible expiatory and inspiratory wheezes, crackles at bases bilaterally, 1+ pitting edema to mid calf

FREDFRED

1. Chief Complaint2. Cardiac (Medical) History3. Tests (Labs & others)4. Medications5. Physical exam 6. Vital signs7. Nursing Diagnosis

1. Chief Complaint2. Cardiac (Medical) History3. Tests (Labs & others)4. Medications5. Physical exam 6. Vital signs7. Nursing Diagnosis

Admitting Dx: CHF, R/O MI

Past Medical Hx: Mild CHF, COPD x 30 years, CAD, HTN

Vital signs: 184/94, 122, 30, T 99.1 ABGs on RA - 7.55, CO2 26, O2 54

PE: Skin pink and dry, brisk capillary refill, oriented x 4, S3 heart sounds, SOB with any exertion, audible expiatory and inspiratory wheezes, crackles at bases bilaterally, 1+ pitting edema to mid calf

Q-R-S-T-A-A-AQ-R-S-T-A-A-A

Quality - - dull/squeezing Region – radiation

changing right arm/left arm

Severity/Setting rest vs exertion after meals scale of pain

Q-R-S-T-A-A-AQ-R-S-T-A-A-A Time

sudden/gradual onset Alleviators

Position Aggravators

food/position/exertion/people constant/episodic

Associated Symptoms SOB, cough, temp, nausea, diarrhea

Application - Chief Application - Chief Complaints…Complaints…

What are Fred’s What are Fred’s chief complaints? chief complaints?

Cardiac HistoryCardiac History

Ask about his Ask about his personal history, personal history, family history and family history and social history.social history.

Fred - MedicationsFred - Medications

What medications is he currently taking?

Diuretic, ACE inhibitor, ß-blocker, K+, Bronchodilators and Glucocorticoids

What medications is he currently taking?

Diuretic, ACE inhibitor, ß-blocker, K+, Bronchodilators and Glucocorticoids

Physical ExamPhysical Exam

What we know…What we know… SOB (subjective and objective)SOB (subjective and objective) Vital signsVital signs ABG’sABG’s Skin…PerfusionSkin…Perfusion Mental statusMental status Heart soundsHeart sounds Lung soundsLung sounds EdemaEdema

Nursing DiagnosisNursing Diagnosis

What nursing What nursing diagnosis would be diagnosis would be appropriate for appropriate for Fred at this time? Fred at this time?

Remember, ND’s Remember, ND’s serve to guide and serve to guide and direct nursing care!direct nursing care!

Which question should you ask a Which question should you ask a client experiencing palpitations?client experiencing palpitations?

A. Family history of high blood pressure or heart problems

B. Activity when symptoms beginsC. Anything that makes symptoms more or less

severeD. Amount of coffee or tea consumed each day