Chapter 12 Nursing Assessment: Cardiovascular and Circulatory Function Cardiovascular Anatomy and Physiology

Anatomy and Physiology of the Vascular System

Arteries and arterioles Capillaries Venules and veins Circulatory needs of tissues

Question
Is the following statement true or false? Blood pressure in arteries is higher than blood pressure in veins.

Answer
True Rationale: Venous return to the heart exists in a low-pressure system in which backflow is prevented by valves. Arteries and arterioles are higher-pressure blood vessels.

Anatomy and Physiology of the Heart Coronary Arteries The Cardiac Conduction System
Question
The student nurse is assessing a patient who has a dysrhythmia. The student understands that electrical conduction of the heart usually originates in the SA node. What sequence completes the conduction? SA node to bundle of HIS to AV node to Purkinje fibers SA node to AV node to Purkinje fibers to bundle of HIS SA node to bundle of His to Purkinje fibers to AV node SA node to AV node to bundle of His to Purkinje fibers

Answer
D. SA node to AV node to bundle of His to Purkinje fibers Rationale: The normal cardiac conduction route proceeds from the SA node to the AV node. It then goes from the bundle of His to the Purkinje fibers.

Cardiac Output
CO = stroke volume (SV) heart rate (HR) SV is influenced by three interdependent factors: Preload: The pressure generated in the ventricles at the end of diastole and the resultant stretching of the muscle fibers Afterload: The amount of resistance to ejection of blood from the ventricle Contractility: The force generated by the contracting myocardium under any given condition

Cardiac Hemodynamics Assessment of the Cardiovascular System

Cardiovascular health problems are associated with multiple complaints: Chest pain Symptoms of acute coronary syndrome (ACS)

Assessment Parameters
Health history Family history Medications Nutrition and metabolism Elimination Activity

Cognition Sexuality Coping

Physical Assessment
Integumentary inspection and palpation Blood pressure: Pulse pressure Orthostatic changes Arterial pulses: Rate, rhythm, and quality Inspection of jugular venous pulsations Assessment of lungs and abdomen

Question
A patient's systolic pressure is 122 mm Hg and diastolic pressure is 75 mm Hg. What would the patients pulse pressure be? 122 98 197 47

Answer
D. 47 Rationale: Pulse pressure is the difference between the systolic and the diastolic pressures.

Heart Inspection and Palpation Heart Auscultation

Normal heart sounds: S1 and S2 S3 S4 Snaps and clicks Murmurs Friction rub

Locating and palpating apical pulse Heart Sound Physiology Heart Gallop Sound Diagnostic Evaluations
Cardiac biomarkers: Creatine kinase (CK) / CK-MB Myoglobin Troponin T and I LDL HDL Triglycerides Brain (B-type) natriuretic peptide (BNP)

Diagnostic Evaluations (contd)

Electrocardiogram (ECG) Stress testing Echocardiography Radionuclide imaging

Diagnostic Evaluations (contd)

Hemodynamic monitoring:

Central venous pressure monitoring Pulmonary artery pressure monitoring Intra-arterial blood pressure monitoring Doppler ultrasound studies

Hemodynamic Monitoring Phlebostatic Axis

Question Is the following statement true or false? Central venous pressure monitoring provides the care team with continuous systolic, diastolic, and mean arterial pressure (MAP) readings. Answer False Rationale: CVP is measured by positioning a catheter in the vena cava (superior or inferior) or right atrium. It reflects right ventricle preload. Intra-arterial blood pressure monitoring is used to obtain continuous systolic, diastolic, and mean arterial pressure (MAP) readings and blood samples.

Chapter 13 Nursing Management: Patients With Hypertension Epidemiology of Hypertension

65 million adults in the U.S. and 1 billion individuals worldwide have hypertension Control of hypertension is known to be undermanaged BP of less than 120/80 mm Hg diastolic is considered normal BP of 120 to 139/80 to 89 mm Hg is defined as prehypertension BP of 140/90 mm Hg or higher constitutes hypertension

Pathophysiology of Hypertension
BP is the product of cardiac output multiplied by peripheral resistance Peripheral vascular resistance (PVR) is related to the diameter of the blood vessel and the viscosity of the blood Management aims to decrease peripheral resistance, blood volume, or the strength, force, and rate of myocardial contraction 95% of patients have primary hypertension

Factors that control BP Risk Factors

Hypertension is multifactorial, but some risk factors include: Age Obesity African American race Oral contraceptive use Question A community health nurse is teaching a group of adults about hypertension. What is a risk factor that the nurse should mention? Cardiac dysrhythmias Hyponatremia Hyperkalemia Dyslipidemia Answer

D. Dyslipidemia Rationale: Hypertension often accompanies other risk factors for atherosclerotic heart disease, such as obesity, diabetes mellitus, metabolic syndrome, and a sedentary lifestyle. Electrolyte imbalances and dysrhythmias are not identified as risk factors for hypertension.

Clinical Manifestations and Assessment

Accurate BP measurement is essential. There are typically no symptoms of hypertension, but signs of target organ damage may exist: Coronary artery disease Left ventricular hypertrophy Pathologic changes in the kidneys Cerebrovascular involvement Retinal changes Question Is the following statement true or false? One of the criteria used to differentiate prehypertension from hypertension is the absence of characteristic signs and symptoms of high blood pressure. Rationale: Patients with prehypertension and hypertension alike often lack obvious clinical signs and symptoms, apart from an elevated blood pressure.

Assessment of Hypertension (contd)

Laboratory tests include: Urinalysis Evaluation for microalbuminuria or proteinuria Blood chemistry (analysis of sodium, potassium, BUN and creatinine, fasting glucose, and total and high-density lipoprotein [HDL] cholesterol levels) 12-lead ECG

Medical and Nursing Management

Lifestyle modifications: Smoking cessation, weight loss, reduced alcohol and sodium intake, and regular physical activity Pharmacologic therapy: Diuretics, calcium channel blockers, beta blockers, ACE inhibitors Encouraging self-management: Written action plan, self-monitoring, and regular review
Question Your patient has been diagnosed with prehypertension. What would you encourage this patient to do to aid in preventing progression to a hypertensive state? Manage stress more effectively Exercise routinely Eat less protein and more vegetables Drink more wate Answer B. Exercise routinely Rationale: Physical activity has a demonstrated effect on blood pressure. It is not necessary for the patient to increase fluid intake or avoid protein. Sympathetic stimulation (eg, stress) increases blood pressure, but exercise is superior to stress reduction in avoiding hypertension.

Complications of Hypertension
Blood vessel damage (heart, kidneys, brain, and eyes) Myocardial infarction Heart failure Left ventricular hypertrophy Renal failure Stroke

Impaired vision

Hypertensive Crises
Defined as a systolic blood pressure of greater than 180 mm Hg or a diastolic blood pressure of greater than 120 mm Hg Hypertensive emergency is a situation in which BP is higher than 180/120 mm Hg and must be lowered quickly to halt or prevent damage to the target organs Hypertensive urgency describes a situation in which BP is severely elevated but there is no evidence of impending or progressive target organ damage Both are managed with continuous intravenous infusion of a short-acting titratable antihypertensive agent

Chapter 14 Nursing Management: Patients With Coronary Vascular Disorders Coronary Atherosclerosis
The most common cause of cardiovascular disease Atheromas or plaques protrude into the lumen of the vessel Thrombi may form and obstruct blood flow, leading to sudden cardiac death or an acute MI The anatomic structure of the coronary arteries makes them particularly susceptible to the mechanisms of atherosclerosis

Coronary Atherosclerosis Coronary blood supply Risk Factors

Nonmodifiable: Age Gender Race Family history Modifiable: Diabetes, hypertension, smoking, obesity, physical inactivity, and high cholesterol

Risk Factor: Metabolic Syndrome

Consists of three or more of the following: Insulin resistance Abdominal obesity Dyslipidemia Hypertension Proinflammatory state Prothrombotic state

Pathophysiology of Cardio Vascular Disease

Question The nurse is caring for a patient who had a recent MI. The nurse is aware that the plaque that likely contributed to this event is mostly made up of: Lipids Dead leukocytes Interferons Adipose tissue Answer A. Lipids Rationale: Atherosclerosis begins as monocytes and lipids enter the intima of an injured vessel. A fibrous tissue develops, and this causes plaques to form on the inner lumen of vessel walls.

Clinical Manifestations of Atherosclerosis

Ischemia: An inadequate blood supply that deprives the cardiac muscle cells of oxygen needed for their survival Angina pectoris: Chest pain that is brought about by myocardial ischemia Classic signs and symptoms of myocardial ischemia include acute onset of chest pain, shortness of breath, extreme fatigue, diaphoresis, and nausea and vomiting

Lipoproteins and atherosclorosis Prevention and Medical and Nursing Management

Control cholesterol levels: Diet, exercise, medication, smoking cessation Manage hypertension Manage diabetes

Angina Pectoris
Almost always associated with a significant obstruction of a major coronary artery Anginal pain can have widely varying characteristics Diagnosis is usually by history, ECG, and cardiac biomarker analysis
Question When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why she experiences chest pain with exertion. The nurse informs the patient that exertion: Increases the heart's oxygen demands Causes vasoconstriction of the heart Increases blood flow to the mesenteric area Reduces the effectiveness of medications Answer A. Increases the heart's oxygen demands Rationale: Physical exertion increases the myocardial oxygen demand. If the patient has arteriosclerosis of the coronary arteries, then blood supply is diminished to the myocardium, resulting in pain. Exercise does not cause vasoconstriction, reduced effectiveness of medications, or increased blood flow to the mesenteric area.

Management of CAD and Angina

Nitrates Beta blockers Calcium channel blockers Antiplatelet medications and anticoagulants Oxygen administration

Percutaneous Coronary Interventions (PCIs)

Percutaneous transluminal coronary angioplasty Intracoronary stent implantation Nursing care Percutaneous Coronary Intervention
Question Is the following statement true or false? A patient who has undergone a PCI has had one or more coronary vessels replaced with new, patent vessels. Answer False Rationale: During a PCI, an occluded coronary artery is opened and reperfusion to the area that has been deprived of oxygen is reestablished. The vessel itself is not replaced.

Surgical Procedures: Coronary Artery Revascularization

Coronary artery bypass graft (CABG): Indications

Qualification criteria

Bypass graft veins CABG Cardiopulmonary Bypass Nursing Process: The Postoperative Cardiac Surgery Patient
Initial postoperative care focuses on hemodynamic stability and recovery from general anesthesia Later care focuses on the monitoring of cardiopulmonary status, pain management, wound care, progressive activity, and nutrition Frequent, multisystemic assessment is imperative

Nursing Interventions: The Postoperative Cardiac Surgery Patient

Restoring cardiac output Maintaining adequate tissue perfusion Maintaining body temperature Preventing infection Preventing fluid and electrolyte imbalances Preventing impaired gas exchange Promoting cerebral circulation Pain control

Myocardial Infarction (MI)

Pathophysiology, risk factors, and manifestations are similar to those of angina. Diagnosis and categorization of MI is based on ECG changes and analysis of cardiac biomarkers (CK-MB, myoglobin, troponin). ECG analysis results in diagnosis of: Unstable angina ST-segment elevation MI (STEMI): NonST-segment elevation MI (Non-STEMI)

Effects of MI on conduction ECG Changes Management of MI

Medications include aspirin, nitroglycerin, morphine, beta blockers, ACE inhibitors, and statins Thrombolytics Analgesics Reperfusion therapy Cardiac rehabilitation Nursing care focuses on relieving pain, promoting respiratory function, promoting tissue perfusion, reducing anxiety, and monitoring for complications
Question The nurse caring for a patient with an MI knows that the top priority in the care of this patient is what? Balancing intake and output Decreasing energy expenditure of the myocardium Balancing myocardial oxygen supply with demand Decreasing nutritional need of myocardial muscle Answer C. Balancing myocardial oxygen supply with demand Rationale: Balancing myocardial oxygen supply with demand (eg, as evidenced by the relief of chest pain) is the top priority in the care of the patient with an MI. This supersedes interventions related to nutrition, fluid balance, or energy expenditure.

Chapter 15
Nursing Management: Patients With Complications From Heart Disease

Heart Failure (HF)

Defined as the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients Indicates myocardial disease, in which there is a problem with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) that may or may not cause pulmonary or systemic congestion Formerly known as congestive heart failure (CHF) Over 5 million people in the United States have HF

Types of HF
Systolic heart failure: Characterized by a weakened heart muscle. Diastolic heart failure: Characterized by a stiff and noncompliant heart muscle Assessment of the ejection fraction (% of blood ejected with each contraction) is performed to assist in determining the type of HF Question Is the following statement true or false? A patient with systolic HF is likely to have a heart that is unable to contract strongly enough to ensure adequate circulation and tissue perfusion. Rationale: In systolic HF, the patients heart muscle is too weak to meet the patients complete metabolic needs.

Pathophysiology
HF results from various underlying factors and the compensatory mechanisms that are put in place Compensatory mechanisms tend to ultimately exacerbate the signs and symptoms of HF

Risk Factors
Major risk factors: Age, male sex, hypertension, left ventricular hypertrophy, myocardial infarction, valvular heart disease, and obesity Minor risk factors: Excessive alcohol consumption, smoking, high cholesterol, diabetes, toxins, sleep-disordered breathing, chronic kidney disease, low socioeconomic status, psychological stress, sedentary lifestyle, and genetics

Question
The nurses assessment of an older adult patient reveals multiple risk factors for HF. Which of the following risk factors should the nurse address in patient teaching? The patients age The patients racial background The patients sex The patients diabetes management

Answer
D. The patients diabetes management Rationale: Age, sex, and race are nonmodifiable risk factors for HF. Diabetes management is an area that is amenable to education and nursing interventions.

Clinical Manifestations and Assessment

Dyspnea Cyanosis Cachexia Tachycardia Elevation in jugular venous pressure S3 heart sound Crackles Edema Dizziness or lightheadedness

Heart response to fluid overload

Management of HF
Lifestyle changes Medications: ACE inhibitors, beta blockers, diuretics, and digitalis Nursing assessment prioritizes symptoms of pulmonary and systemic fluid overload, health history, and monitoring of intake and output Question You are writing a teaching plan for a patient diagnosed with heart failure. What would be a priority inclusion in the teaching plan? Self-care Cardiac rehabilitation Dressing changes Nutrition Answer A. Self-care Rationale: Long-term management of HF requires extensive self-care by patients; nutrition would be one aspect of this self-care. Cardiac rehabilitation is more commonly used in the recovery of patients who have undergone cardiac surgery. Dressing changes are not relevant to HF.

Pulmonary Edema
Pathophysiology Clinical manifestations and assessment Management of symptoms follows the similar clinical management plan for treating acute decompensated heart failure

Cardiogenic Shock
Occurs when decreased CO leads to inadequate tissue perfusion and initiation of the shock syndrome Pathophysiology Manifestations Management

Pericardial Effusion and Cardiac Tamponade

Pericardial effusion is the accumulation of fluid in the pericardial sac Cardiac tamponade is the resultant compression of the heart Treatment includes pericardiocentesis and/or pericardiotomy

Cardiac Tamponade Pericardiocentesis Cardiac Arrest

Occurs when the heart ceases to produce an effective pulse and circulate blood Consciousness, pulse, and blood pressure are lost immediately

Emergency Management of Cardiac Arrest: Cardiopulmonary Resuscitation

The ABCDs of basic CPR are: Airway Breathing Circulation Defibrillation