Assessment of the Cardiovascular System

1. Assessment of the Cardiovascular System

2. Cardiovascular System: Assessment • Patient history • Medications • Nutritional history • Family history and genetic risk • Current health problems: • Pain or discomfort • Dyspnea, DOE, orthopnea, PND • Fatigue • Palpitations • Edema • Syncope • Extremity pain

3. Cardiovascular System: Physical Examination • Vital signs • Skin • Extremities

4. Coronary Artery Disease • Type of blood vessel disorder that is included in the general category of atherosclerosis • Characterized by a focal deposit of cholesterol and lipids within the intimal wall of the artery

5. Nonmodifiable Risk Factors • Age • Gender • Ethnicity • Genetic predisposition

6. Modifiable Risk Factors • Elevated serum lipids • Hypertension • Tobacco use • Physical inactivity • Obesity • Stress

7. Cardiac Catheterization

8. Percutaneous Coronary Intervention (PCI)

9. Percutaneous Coronary Intervention • Unfractionated heparin or low molecular weight heparin is given in conjunction with PCI to maintain the open vessel

10. Intracoronary Stents • Expandable mesh-like structure designed to maintain vessel patency by compressing the arterial wall and resisting vasoconstriction • Often inserted in conjunction with balloon angioplasty and placed over the angioplasty site to hold the vessel open

11. Intracoronary Stents

12. Coronary Artery Bypass Graft (CABG) Surgery

13. Coronary Artery Bypass Graft Surgery

14. CABG (Cont’d) • Preoperative care • Operative procedures • Postoperative care: • Management of F&E imbalances, hypothermia, bleeding, cognitive dysfunction

15. Ambulatory and Home Care • Cardiac rehabilitation • Health teaching • Health care resources

16. Valvular Heart Disease • Mitral stenosis • Mitral regurgitation • Mitral valve prolapse • Aortic stenosis • Aortic regurgitation

17. Assessment • May become suddenly ill or slowly develop symptoms over many years. • Question patient about attacks of rheumatic fever and infective endocarditis and about possibility of IV drug abuse. • Obtain chest x-ray, echocardiogram, and cardiac catheterization.

18. Common Nursing Diagnoses • Decreased Cardiac Output related to valvular incompetence • Activity Intolerance related to insufficient oxygenation secondary to decreased cardiac output

19. Nonsurgical Management • Nonsurgical management focuses on prevention of recurrent rheumatic fever and infective endocarditis • Prophylactic antibiotic • Management of atrial dysrhythmias • Anticoagulant therapy • Rest with limited activity • Percutaneous Transluminal Balloon Valvuloplasty

20. Surgical Management • Reparative procedures • Replacement procedures • Mechanical valves • Biologic valves

21. Heart Valves

22. Acute Intervention and Ambulatory Care • Home care management • Health teaching • Health care resources

23. Infective Endocarditis • Infection of the endocardial layer of the heart • Occurs primarily in patients who abuse IV drugs, have had valve replacements, have experienced systemic infections and older people • Possible ports of entry—oral cavity, skin rash, lesion, abscess, infections, surgery, or invasive procedures including IV line placement

24. Clinical Manifestations • Low-grade fever • Murmur • Osler’s nodes • Splenic infarction • Neurologic changes • Petechiae • Splinter hemorrhages • Janeway’s lesions • Roth’s spots

25. Diagnostic Assessment • Blood culture • Echocardiography • The most reliable criteria for diagnosing endocarditis include positive blood cultures, a new or changed cardiac murmur, and evidence of endocardial involvement by echocardiography

26. Interventions • Antimicrobials. • Patient’s activities are balanced with adequate rest.

27. Surgical Management • Removing the infected valve • Repairing or removing congenital shunts • Repairing injured valves and chordae tendineae • Draining abscesses in the heart or elsewhere

28. Peripheral Arterial Disease • Involves thickening of artery walls, which results in a progressive narrowing of the arteries of the upper and lower extremities

29. Aortic Aneurysms • Aneurysm – outpouching or dilation of the vessel wall • Fusiform aneurysm • Saccular aneurysm • Pseudoaneurysm • Abdominal aortic aneurysm • Thoracic aortic aneurysm

30. Arterial Aneurysms

31. Assessment of Abdominal Aortic Aneurysm (AAA) • Often asymptomatic – frequently found on routine exam when patient is evaluated for an unrelated problem. • Pain is in the abdomen, flank, or back. • Abdominal mass is pulsatile. • Rupture is the most frequent complication and is life threatening.

32. Assessment of Thoracic Aortic Aneurysm • Often asymptomatic • Most common symptom is deep, diffuse chest pain extending to the interscapular area • Assess for shortness of breath, hoarseness, and difficulty swallowing. • Occasionally a mass may be visible above the suprasternal notch. • Sudden excruciating back or chest pain is symptomatic of thoracic rupture.

33. Conservative Therapy • Initiated for small aneurysms (< 5cm) • Monitor the growth of the aneurysm. • Decreasing BP

34. Abdominal Aortic Aneurysm Resection • Preoperative care • Operative procedure • Postoperative care: • Monitor vital signs • Assess for complications • Assess for signs of graft occlusion or rupture

35. Thoracic Aortic Aneurysm Repair • Preoperative care • Operative procedure • Postoperative care assessments: • Vital signs • Complications • Sensation and motion in extremities • Respiratory distress • Cardiac dysrhythmias

36. Endovascular Aneurysm Repair • Eligibility requirements • Benefits • Complications

37. Aortic Dissection • Arises from a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall • Sudden, severe onset of excruciating chest and/or back pain radiating to the neck or shoulders • Pain described as “sharp” and “worst ever”

38. Aortic Dissection • Initial goals of therapy for acute aortic dissection without complications include: • Pain management • Blood pressure control • Decrease in the velocity of left ventricular ejection • Surgical treatment

39. Peripheral Artery Disease of the Lower Extremities • Femoral popliteal area is the site most commonly affected • Intermittent claudication • Paresthesia

40. Physical Assessment • Hair loss and thin, shiny, taut skin • Severe arterial disease—extremity is cold and gray-blue or darkened; pallor may occur with extremity elevation; dependent rubor when limb in dependent position; rest pain

41. Diagnostic Studies • Imaging assessment

42. Nonsurgical Management • Risk factor modification • Exercise • Drug therapy • Percutaneous transluminal angioplasty • Atherectomy

43. Surgical Therapy • Postoperative care: • Assessment for graft occlusion • Promotion of graft patency • Treatment of graft occlusion • Monitoring for compartment syndrome • Assessment for infection

44. Venous Thromboembolism • Deep vein thrombosis (DVT) • Virchow’s triad

45. Clinical Manifestations • Calf or thigh “fullness” or pain • Unilateral edema of the leg • Paresthesias • Warm skin • Checking Homans’ sign—not advised • Localized edema • Venous duplex ultrasonography • MRI • D-dimer

46. Nonsurgical Management • Rest, drug therapy, preventive measures • Drug therapy includes: • Unfractionated heparin therapy • Low–molecular weight heparin • Warfarin therapy • Thrombolytic therapy

47. Surgical Management • Thrombectomy • Inferior vena caval interruption

48. Shock • Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism • “Whole-body” response. • Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency.

49. Classification of Shock by Origin of the Problem • Hypovolemic • Cardiogenic • Distributive • Obstructive

50. Hypovolemic Shock • Occurs when there is a loss of intravascular fluid volume • Commonly caused by hemorrhage and GI loss