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ASSSESSMENT OF THE CARDIAC SYSTEM

INTRODUCTION- According to World Health Organization estimates, 17 million people


worldwide die of CVD each year. By 2010, CVD is estimated to be the leading cause of death in developing countries. The prevalence and complications of CVD have significant implications for nurses using their physical assessment skills. Assessment of the cardiovascular system involves incorporating data from history taking, relating the information to the physical examination and diagnostic tests, and correlating the data with the underlying pathophysiology.

HISTORY
The history of CVD is inseparable from the clients total health history. Significant cardiovascular data are obtained by assessment of the following areas: risk factor analysis, biographical and demographic data, current health, past health history, family health history, psychosocial history, and review of systems. RISK FACTOR ANALYSIS RISK FACTOR Gender and age Family history of heart attack Family history of diabetes Blood Pressure Weight Cholesterol level Percentage of fat in diet Cigarette smoking Use of oral contraceptives HIGH RISK Women after menopause One relative, before age 60 One or more relatives with type 1 diabetes Systolic: 160-200 mm Hg Diastolic: 90-110 mm Hg 30%-40% overweight 240-280 30%-50% 20-40 per day Younger than 40 and use oral contraceptives HIGHEST RISK Men older than 60 Two relatives, before age 60 One or more relatives with type 2 diabetes Systolic: >200 mm Hg Diastolic: >110 mm Hg 50% or more overweight Over 280 Over 50% Over 40 per day Older than 40 and use oral contraceptives

BIOGRAPHICAL AND DEMOGRAPHIC DATA Biographical and demographic data include name, age, gender, place of birth, race, marital status, occupation, and ethnic background. CURRENT HEALTH Documenting the progression of the first manifestations to the current complaints.

Chief complaint- Inquire about the chief complaint or complaints to establish priorities for
intervention and to evaluate how well the client understands the presenting condition.

Symptom analysis- Following are the more common cardiac manifestations.


Chest Pain- Chest pain is one of the most important manifestations of cardiac disease. Angina pectoris is the true manifestation of coronary artery disease. Angina is caused by myocardium ischemia, an imbalance of oxygen supply and demand as the coronary arteries support myocardial tissue.

Timing- Note the time the pain begins and ends to determine the duration of discomfort. Generally, the pain of MI lasts longer than 30 minutes. Angina is usually relieved within 5 to 15 minutes by rest, with or without the use of vasodilator drugs such as nitroglycerin.

Quality Chest pain may be described as a strange feeling, indigestion, a dull heavy pressure, burning, crushing, constricting, aching, stabbing, or tightness. Angina pectoris characteristically has a crescendo pattern at onset.

Quantity- To better quantify chest pain, ask the client to use a scale of 1(least severe) to 10(more severe). Location- The site of discomfort provides additional information for determining its cause. Anginal pain is ordinarily retrosternal. Precipitating or Aggravating Factors- Emotional or sexual excitement, temperature extremes, exertion, deep sleep, position changes, deep breathing, straining during bowel movements, or eating may trigger the onset of chest pain. Relieving Factors- Anginal pain may be reduced by rest, vasodilator drugs such as nitroglycerin, oxygen, and a change in position. Associated Manifestations- Ask the client whether other manifestations accompany the onset of chest pain, for example, anxiousness, shortness of breath, nausea, vomiting, diaphoresis, vertigo, palpitations. Irregularities of Heart Rhythm-Palpitations- Palpitations are uncomfortable sensations in the chest associated with a wide range of dysrhythmias. Respiratory Manifestations-Dyspnea- Dyspnea is defined as shortness of breath or labored breathing.

Exertional dyspnea- Also known as dyspnea on exertion it occurs during mild to moderate exercise or activity and disappears with rest. Orthopnea- Orthopnea (difficult breathing) results from an increase in hydrostatic pressure in the lungs when the person is lying flat and is relieved when the person assumes an upright or semivertical position. Paroxysmal Nocturnal Dyspnea- Paroxysmal nocturnal dyspnea is dyspnea during sleep that awakens the sleeper with a terrifying breathing attack. Syncope- Syncope, or fainting, is a transient loss of consciousness related to inadequate cerebral perfusion. Other Associated Manifestations- Cyanosis is a bluish discolouration. Hemoptysis refers to coughing up of blood.

PAST HEALTH HISTORY- Ask the client about the following areas: Childhood and Infectious Diseases- In addition to the usual information about common childhood diseases and immunizations, ask about the clients experiences with rheumatic fever, scarlet fever, and severe streptococcal infections. These conditions are associated with structural mitral valve disease. Immunizations- Clients with chronic conditions, such as cardiovascular disorders, should be vaccinated yearly against influenza. Major illnesses and Hospitalizations- Note conditions that influence the clients current cardiovascular performance, that is, diabetes mellitus, chronic obstructive lung disease, kidney disease, anemia, hypertension, stroke, gout and thrombophlebitis. Medications- Evaluate the use of prescription medications, over-the-counter medications, herbals, and recreational drugs. For example, ask clients whether they are currently taking heart pills, or blood pressure medications.

Allergies- Note and describe any environmental, food, or drug allergies. Clearly document the manifestations of an allergic reaction, such as rashes, itching, or anaphylaxis.

FAMILY HEALTH HISTORY Specifically, inquire about a family history of heart disease, high BP, stroke, diabetes, or kidney disease. A detailed health history of the clients family can provide insight into possible genetic, environmental and lifestyle conditions contributing to a cardiac condition.

PSYCHOSOCIAL HISTORY- The psychosocial history includes: Occupation- Inquire about all occupations the client has had and the duration of each job worked. Geographic Location- When one lives is significantly related to death caused by cardiac events. Environment- Ask the client about following: The home, such as safety issues, type of dwelling (number of steps), state of repair, exits for fire, heating and cooling adequacy. The neighborhood, in regard to noise, pollution, and violence.

Exercise- Ask about the type and amount of exercise routinely engaged in during an average week before and after the onset of current manifestations. Nutrition- Assess excess or deficit caloric intake and the clients approximate intake of foods high in sodium, cholesterol, saturated fat and caffeine. Habits- If the client smokes, inquire about the duration of the smoking habit and the number of cigarettes smoked daily. REVIEW OF SYSTEMS Ask about past problems involving the cardiovascular system, including chest pain, palpitations, fatigue, edema, shortness of breath, orthopnea, wheezing, fainting, weight gain, heart murmurs, hypertension, paroxysmal nocturnal dyspnea, and history of rheumatic fever.

PHYSICAL EXAMINATION
The cardiac physical examination includes the following: General Appearance- Begin with inspection. Look at the client and consider the following: Does the client lie quietly, or is there restlessness or continual moving about? Does the facial expression reflect pain or obvious manifestations of respiratory distress? Are there manifestations of significant cyanosis or pallor?

Level of Consciousness- Note the clients general level of consciousness (LOC). The level of consciousness reflects the adequacy of cerebral perfusion and oxygenation. Weight Management- Measure the clients weight, height, and waist circumference, and calculate body mass index (BMI). Head, Neck, Nails and Skin- When examining the head, pay particular attention to the eyes, ear lobes, lips and buccal mucosa. Examine the eyes for arcus senilis (a light gray ring around the iris, possibly caused by cholesterol deposits) and xanthelasma (yellow raised plaques around the eyelids resulting from lipid deposits). Observe the skin and mucous membranes for abnormalities such as central or peripheral cyanosis. Assess skin turgor (elasticity) by lifting a fold of skin over the sternum or lower arms and releasing it.

Edema- Edema occurs in right-sided heart failure when the excess intravascular volume begins to increase capillary hydrostatic pressure and forces fluid into the interstitium. Inspect dependent areas for edema. In the mobile client, edema is best seen in the feet, ankles, and lower legs. In the chair-ridden or bed-ridden client, edema may be palpated over the sacrum, abdomen, or scapula.

Blood Pressure- Measure BP in both arms initially to rule out dissecting aortic aneurysm, coarctation of the aorta, vascular obstruction, vascular obstruction, vascular outlet syndromes, and errors in measurement. Pulse- Pulse characteristics can vary. If the pulse is irregular, assess for a pulse deficit by taking apical and radial pulses simultaneously, noting differences in rate.

Respirations- Note the rate, rhythm, depth, and quality of the breathing pattern. Variations in the respiratory rate and character may indicate heart failure or pulmonary edema.

Head and Neck Neck Veins- Neck vein distension can be used to estimate central venous pressure (CVP). A relaxed supine position 15 to 30 degrees maximizes jugular vein prominence.

Carotid Arteries- Carotid artery examination indicates the adequacy of stroke volume and the patency of the arteries. Using your fingertips, gently palpate the carotid arteries one side at a time.

Chest Precordium- Perform inspection and palpation of the precordium together to determine the presence of normal and abnormal pulsations. Right ventricular enlargement can produce an abnormal pulsation that may be seen as a sustained thrust along the left sterna border. Termed heaves or lifts these pulsations may be found with various disorders, such as valvular disease and pulmonary hypertension.

Heart Sounds- Auscultation of the precordium yields valuable information about normal or abnormal heart rate and rhythm. Normal Heart Sounds- The first heart sound (S1) is linked to closure of the mitral and tricuspid valves. Phonetically, if both heart sounds are appreciated as lub-dup S1 is lub. The second heart sound (S2) is related to closure of the pulmonic and aortic valves and is heard best with diaphragm at the aortic area. Phonetically, it is the dup of the heart sounds. Gallops- A gallop sound that occurs in early diastole, during passive, rapid filling of the ventricles, is known as the third heart sound (S3). It is heard with the bell at the apex and with the client in the left lateral recumbent position. An S3 gallop is considered a normal finding in children and young adults. A fourth heart sound or S4 gallop occurs in the later stage of diastole, during atrial contraction and active filling of the ventricles. This soft, low-pitched sound is heard immediately before S1 and is also referred to as an atrial gallop. Murmurs- Murmurs are caused by Abnormal forward or backward flow. Flow through an abnormal passage between heart chambers.

Systolic murmurs, also called benign murmurs, are often caused by vigorous myocardial contraction or strong blood flow. Lungs- Because the cardiovascular and respiratory systems are related, assessment of CVS must include evaluation of respiratory system. Tachypnea- Tachypnea, or rapid respirations, is often associated with pain and anxiety accompanying myocardial ischemic pain.

Crackles- Crackles frequently signal left ventricular failure and usually occur just after the onset of an S3 gallop. Cheyne-Stokes Respirations- Cheyne-Stokes respirations are characterized by abnormal periods of deep breathing alternating with periods of apnea. Abdomen- Overweight and obesity are associated with insulin resistance. However, the presence of obesity is more highly correlated with elevated BMI. Inspection and Palpation- Inspection may reveal abdominal distension. Palpation may confirm the presence of ascites and an enlarged liver. Auscultation- Auscultation can yield the following clues about cardiovascular function. Decreased bowel sounds may accompany potassium (K+) depletion. Loud bruits, heard with the bell just over the umbilicus, may indicate an aortic obstruction or aortic aneurysm.

DIAGNOSTIC TESTS
The following are the four most common types of diagnostic procedures used in the diagnosis of CVD. Laboratory tests Graphic procedures Radiographic studies Hemodynamic studies

LABORATORY TESTS- Laboratory tests are used to diagnose a variety of cardiovascular ailments. Identify concurrent disorders. Evaluate the effectiveness of intervention.

Complete Blood Cell Count The red blood cell count or erythrocyte count is usually decreased in rheumatic fever and infective endocarditis. An elevated hematocrit can result from obstructive lung disease and conditions of vascular volume depletion with hemoconcentration. The white blood cell count is elevated in infectious and inflammatory diseases of the heart.

Cardiac Enzymes Cardiac enzymes are present in high concentrations in myocardial tissue.

Myoglobin is a useful marker of myocardial necrosis that is rapidly released from the circulation within 1 to 2 hours of infarction. The enzymes most commonly used to detect myocardial infarction are creatine kinase (CK) and lactic acid dehydrogenase (LDH). Elevated CK-MB indicates myocardial damage. Of the five isoenzymes for LDH, only LDH1 and LDH2 are cardiac-specific. The use of troponin has led to increased specificity in the detection of myocardial infarction.

Blood Coagulation Tests Blood coagulation tests are used to examine the ability of blood to clot. Evaluate coagulation tests such as prothrombin time and partial thromboplastin time. Serum Lipids Clinical evidence provided by epidemiologic and angiographic studies show that an elevated blood cholesterol is a major risk factor in the development of artherosclerosis. C-Reactive Protein Elevation of C-reactive protein (CRP), an acute-phase protein measure of the presence and degree of inflammation. Serum Electrolytes Potassium The serum potassium level decreases as a result of diuretic therapy, vomiting, diarrhea and alkalosis. A characteristic change on the ECG is a U wave. A high serum potassium level is usually associated with kidney disorders. Hyperkalemia can lead to a tall T wave on the ECG.

Sodium- The serum sodium level reflects water balance and may decrease with heart failure, stress, excessive intravenous infusion of hypotonic fluids and vomiting. Calcium- Serum calcium level decreases as a result of multiple transfusions of citrated blood, renal failure, alkalosis and laxative. Blood Urea Nitrogen and Creatinine Blood urea nitrogen (BUN) and serum creatinine are indicators of renal function. They are elevated in kidney diseases. Elevated levels are also associated with diabetes, hypertension. Blood Glucose Diabetes mellitus is a major risk factor for the development of atherosclerosis.

ELECTROCARDIOGRAM ECG is a common noninvasive test. The ECG is an essential tool in evaluating the heart rhythm. There are several types of ECGs: continuous monitoring, 12-lead, signal-averaged, and Holter monitoring. Analysis of ECG waveforms allows identification of disorders of cardiac rate, rhythm and conduction.

EXERCISE ELECROCARDIOGRAM (STRESS TESTING) Exercise tolerance testing defines the bodys reaction to measured increases in acute exercise. Stress testing is used to evaluate the functional capacity of clients with or without heart disease. Exercise testing may consist of single or multiple stages. A single-stage test is one in which the exercise workload is constant throughout.

CARDIAC DIAGNOSTIC IMAGING Chest X-Ray Studies- Chest X-Ray films help to determine the size and position of the heart. Anatomic changes in the heart can be seen. Magnetic Resonance Imaging- Although MRI is one of the most expensive noninvasive diagnostic options. MRI is commonly used for examination of the aorta and detection of tumors, aneurysms, masses, cardiopathies and pericardial disease. Positron Emission Tomography- The positron emission tomographic (PET) scanner is a diagnostic imaging tool that allows visualization of regional physiologic function and biochemical changes that often separate normal from diseased myocardium. Echocardiography- Echocardiography, a noninvasive diagnostic procedure, is used to evaluate structural and functional changes in a wide variety of heart ailments. An echocardiogram is obtained by placing a transducer on several areas of the chest wall. The echocardiogram records the structure and motion of that area in relation to its distance from the anterior chest wall. Cardiac Catheterization- This complex procedure involves insertion of a catheter into heart and surrounding vessels to obtain detailed information about the structure and performance of the heart, the valves, and the circulatory system.

Angiography- Angiocardiography involves IV injection of contrast material into the heart during cardiac catheterization. Coronary angiography involves injection of contrast material directly into the coronary arteries during cardiac catheterization. HEMODYNAMIC STUDIES Hemodynamic status is assessed with four parameters: Central Venous Pressure (CVP) Pulmonary Artery (PA) pressure Cardiac Output Intra-arterial Pressure

Central Venous Pressure CVP is the pressure within the superior vena cava. It reflects the pressure under which the blood is returned to the superior vena cava and right atrium. CVP can be measured with a central venous line placed in the superior vena cava. Normal CVP pressure is 2 to 12 mm Hg. A decrease in CVP indicates a decrease in circulating volume, which may result from fluid imbalance, hemorrhage or severe vasodilation. An increase in CVP indicates an increase in blood volume because of a sudden shift in fluid balance, excessive IV fluid infusion, and renal failure.

Pulmonary Artery Pressure During diastole, blood flows freely from the PA through the pulmonary capillaries, left atrium, and open mitral valve to the left ventricle. Therefore the pressure in the left ventricle at the end of diastole approximates the diastolic pressure in the PA, pulmonary capillaries, and left atrium. PA pressure measurements can assist in determining whether the ventricle is understretched (in need of fluids), overstretched (in need or diuretics), or appropriately stretched (at maximal function).

Cardiac Output Measurement Cardiac Output is the amount of blood pumped out of the left ventricle into the arterial system every minute. That is, cardiac output is equal to the stroke volume (volume of blood pumped out with each beat) multiplied by the heart rate.

If the stroke volume of the left ventricle is between 50 and 90 ml (average, 70 ml) and the heart rate is 80 beats/ min, the normal cardiac output of the left ventricle is approximately 4 to 8 L/min.

Intra-Arterial Pressure Monitoring Systemic intra-arterial monitoring is a common method for obtaining BP measurements in the acutely ill client. This method provides continuous detection of arterial BP via an indwelling catheter. It is of greatest benefit for clients whose cuff BP measurements are undetectable or unreliable.

REFERENCES
1. Joyce M. Black & Jane Hokanson Hawks; Medical-Surgical Nursing, Clinical Management for Positive Outcomes; 7th edition; Volume 2; Pp- 1560-1598.

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