Cardiovascular Nursing

1. Cardiovascular Nursing Assessment

2. Health History • Identify present and potential health problems • Identify possible familial and lifestyle risk factors • Involve the client in planning long-term health care

3. Health History Patient Health History should be obtained: • High Blood Pressure • Congestive Heart Failure • Previous Heart Attack • Previous Heart Surgery or procedures (Stent, Valvuloplasty) • Atrial Fibrillation, Atrial Flutter or other dysrhythmias • Palpitations • Dizziness, lightheadedness (presyncope), or passing out (syncope) • Full list of medications • Family hx.

4. Cardiovascular Assessment • Requires a full head to toe assessment • Every body function is dependant on the cardiovascular system • Subjective vs. Objective data • Subjective data- verbal statements provided by the patient • Objective data- observable and measurable data

5. Signs & Symptoms of Cardiovascular Deficits • Chest Pain • Palpitations • Cyanosis • Dyspnea

6. AssessmentSubjective Data • Pain is whatever the patient says it is. • Pain (chest, back, jaw, abdomen or extremities)

7. Assessment- Subjective Data • Extremities • 3 of the 5 “P’s of Peripheral Artery Disease” • Pain • Parasthesia • Alteration in sensation • Numbness, tingling, pins and needles • Paralysis

8. AssessmentSubjective Data • Dyspnea • At rest • Exertional- with activity • Orthopnea- short of breath while lying down • Paroxysmal Nocturnal Dyspnea- awakening suddenly short of breath and sweating

9. AssessmentSubjective Data • Ask pt. to: Describe Chest Pain (CP) or Shortness of Breath (SOB) in as much detail as possible.

10. AssessmentSubjective Data • Is patient c/o: • Fainting (Syncope) • Palpitations • Fatigue

11. Assessment - Objective Data • Head to Toe Assessment • Skin • Cyanosis • Turgor • Temperature • Diaphoresis • Integrity • Skin breakdown

12. Jugular Vein Distention JVD

13. JVD ABNORMAL NORMAL

14. Cardiac Assessment Heart Sounds (listen with both the bell and diaphragm of your stethoscope) • Right upper sternal border, Left upper sternal border, Left lower sternal border

15. Are there any abnormal heart sounds? Murmurs Rubs Are there any additional heart sounds? Gallops Is the heartbeat regular, regularly irregular, or irregularly irregular? Assessment- Objective Data

16. Assessment - Objective Data

17. Assessment Objective Data • Respiratory • Rate and ease of breathing • Appearance of dyspnea • Coughing • Frothy Sputum • Abnormal breath sounds • Diminished • Crackles/Rales • Wheezing

18. Assessment - Objective Data Post tibial Pulses Dorsalispedis Pulses Popliteal pulses Femoral pulses Ulnar pulses Radial pulses Brachial pulses Carotid pulses

19. Check Pulses: Carotid Right/ Left Brachial R/L Radial R/L Ulnar R/L Point of Maximum Impulse (PMI) Femoral R/L (groin crease or slightly above crease) Popliteal (behind the knee) Post Tibial (medial ankle) Dorsalis Pedis (top of foot) Pulse Strength 0 Absent pulse 1+ Thready pulse 2+ Weak pulse 3+ Normal pulse 4+ Bounding pulse OR 0 Absent Pulse 1+ Weak Pulse 2+ Normal Pulse AssessmentObjective Data

20. AssessmentObjective Data • Edema • 1+ trace edema-barely perceptible (2mm) • 2+mild edema-deeper pit that rebounds in 10-15 seconds (4mm) • 3+moderate edema-deep pit that lasts 30-60 seconds before it rebounds (6mm) • 4+severe edema-an even deeper pit lasting as long as 2-5 minutes before rebounding (8 mm)

21. AssessmentObjective Data Check for Homan’s sign Pain=Positive Homan’s Sign If Positive: Notify RN or Practitioner and do not check Homan’s Sign Again! Capillary Refill of finger tips and toes (actually any area) Normal: < 3 seconds Slow: 3-5 seconds Abnormal: >5 seconds

22. Assessment Objective Data • Allen’s Test • Tests the ability of the ulnar artery to supply the hand with adequate blood supply

23. AssessmentObjective Data • Vital Signs • Heart Rate (full minute) Normal 60-100 bpm • Apical Pulse • Radial Pulse • Pulse deficit is the difference between the above two • Blood Pressure Normal 90-139/60-89 mmHg • Mean Arterial Pressure (MAP) (2 * DBP) + SBP 3

24. Blood Pressure No sound BP cuff inflated to 160 mmHg 120 mmHg First sound 50 mmHg No sound • Korotkoff sounds: heard during blood pressure determination using a stethoscope and sphygmomanometer. • Originates within from the blood passing through the vessel or • Produced by a vibrating motion of the arterial wall

25. Orthostatic Hypotensionaka Postural Hypotension • Have the client in supine position for 3-5 minutes, then measure the HR and BP • Then, have the client in the sitting position for 3-5 minutes and then measure the HR and BP. Monitor for dizziness. • Then, have the client stand for 3-5 minutes. If the client is having severe dizziness, STOP! (if they have a syncopal episode, they are at risk for injury). Otherwise, measure the HR and BP after 3-5 minutes.

26. Orthostatic Hypotension • A client is considered to have orthostatic hypotension if: • HR increases by 10-20% from baseline • SBP decreases by 10-15 mmHg from baseline • DBP decreases by 10 mmHg from baseline