Advanced Assessment of the Cardiovascular System.ppt

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1、Advanced Assessment of the Cardiovascular System,Mary Beerman, RN, MN, CCRN NUR 602,Interesting facts.,The heart does not rest for more than a fraction of a second at a time During a lifetime it contracts more than 4 billion times Coronary arteries supply more than 10 million liters of blood to the

2、myocardium in a lifetime,Interesting facts.,Cardiac output (heart rate X stroke volume) can vary under physiologic conditions from 3 to 30 liters/minute Remember: Normal cardiac output for adults is 5-6 liters/minute Cardiac index corrects for body size (Cardiac output divided by body surface area),

3、Common Diseases of the Heart,Coronary artery disease Hypertension Rheumatic heart disease Bacterial endocarditis Congenital heart disease,OTHER VERY COMMON DISEASES OF THE HEART,CONGESTIVE HEART FAILURECARDIOMYOPATHYARRHYTHMIAS,Review Structure and Physiology of the Heart in textbook,Review of Sympt

4、oms,Chest Pain,This is the most important symptom of cardiac disease Pain could be from pulmonary, intestinal, gallbladder, or musculoskeletal sources but it may be from the heart itself Every complaint of chest pain must be taken very seriously!,Differential Diagnoses of Chest Pain,Angina Myocardia

5、l Infarction Other Ischemic C-V Origins Non-ischemic C-V Origins Pulmonary Gastrointestinal Psychogenic Neuromusculoskeletal,Differential Diagnosis of Chest Pain - ANGINA,Usually substernal Radiation chest, shoulders, neck, jaw,arms Deep, visceral (pressure) intense, not excruciating Duration- min.,

6、 not sec. (5-15 min.),Differential Diagnosis of Chest Pain - ANGINA,Associated with nausea, vomiting diaphoresis, pallor Precipitated by exercise & emotion Becomes Unstable when occurs during sleep, at rest, or increases in severity/frequency Relief with rest or NTG,Differential Diagnosis of CP Myoc

7、ardial Infarction,Same type of pain as angina Duration greater than 15 min. Occurs spontaneously, often sequela of unstable angina Relieved with Morphine, successful reperfusion of blocked coronary artery,Differential Diagnosis of CP Other C-V Ischemic Origins,Aortic Stenosis/Regurgitation Idiopathi

8、c Hypertrophic Subaortic Stenosis (IHSS) Uncontrolled Hypertension Severe Anemia/Hypoxia Tachycardia/Arrhythmias Pulmonary Hypertension,Differential Diagnosis of CP Nonischemic C-V Origins,Aortic Dissection Sudden, excruciating pain (knife-like, tearing) Migrating pain (depends on location of tear)

9、Frequently, hemodynamic instability Appearance of shock with normal or elevated BP Absent or unequal peripheral pulses,Differential Diagnosis of CP Nonischemic C-V Origins,Pericarditis Sharp or dull, retrosternal or precordial pain Radiates to trapezius ridge Aggravated by inspiration, coughing, rec

10、umbency, & rotation of trunk Lessened by sitting upright & leaning forward Relief - analgesics & anti-inflammatory meds,Differential Diagnosis of CP Nonischemic C-V Origins,Mitral Valve Prolapse Left anterior superficial, rarely visceral pain Variable in character Lasts minutes, not hours Spontaneou

11、s onset with no pattern Relieved with time,Differential Diagnosis of CP - Pulmonary,Pulmonary Embolus /Infarct Pneumothorax Pneumonia with pleural involvement Pleurisy,Differential Diagnosis of CP - Pulmonary,Pleuritic Pain Visceral Pain arising from inferior portion of pleura May be substernal and

12、radiate to costal margins or upper abdomen Lasts greater than 30 minutes Often occurs spontaneously with associated dyspnea Worsened with inspiration Relief time, rest, bronchodilators,Differential Diagnosis of CP - Gastrointestinal,Esophageal Spasm Substernal visceral (pressure) pain, radiates Dura

13、tion 5 to 60 minutes Spontaneous or provoked by cold liquids,exercise Mimics angina Relief with NTG,Differential Diagnosis of CP - Gastrointestinal,GERD/Hiatal Hernia Substernal & epigastric, rarely radiates Duration is 10-60 min. Provoked by recumbency, lack of food Relieved by food, antacid Peptic

14、 Ulcer Disease Substernal & epigastric pressure/burning Duration hours,Differential Diagnosis of CP - Gastrointestinal,PUD (Cont.) Precipitated by lack of food or “acidic” food Relief with antacids & food Biliary Disease Colicky or continuous, visceral epigastric & RUQ abdominal pain Radiates to bac

15、k & right shoulder Occurs spontaneous & after heavy meal Relief analgesics & time,Differential Diagnosis of CP - Psychogenic,Nonradiating, variable pain over chest Duration 2-3 minutes May be associated with numbness/tingling of hands & mouth Precipitated by stress, emotional tachypnea Relief by rem

16、oval of stimulus, relaxation Causes depression, anxiety, self gain,Differential Diagnosis of CP - Neuromusculoskeletal,Thoracic Outlet Syndrome Degenerative Joint Disease of cervical/thoracic spine Superficial pain in arms & neck Duration variable, gradually subsides Precipitated by head & neck move

17、ment, palpation Relief time, analgesia,Differential Diagnosis of CP - Neuromusculoskeletal,Herpes Zoster (Shingles) Pain follows dermatomal distribution of nerve Costochondritis (Tietzes syndrome) Superficial pain, reproducible with movement & palpation May be localized or in multiple locations Dura

18、tion variable Relief time, analgesia, anti-inflammatory meds,Ask These Questions about Chest Pain,Description of character Location Duration/Recurrence Precipitating factors Associated symptoms Relieving factors History of similar symptoms,Angina,Angina Pectoris is the true symptom of coronary arter

19、y disease. It is caused by hypoxia to the myocardium which leads to anaerobic metabolism and the production of lactic acid. The acid irritates the actual heart muscle and makes it hurt,Angina, cont,Angina is due to an imbalance of oxygen delivery TO the heart and the oxygen needs OF the heart Levine

20、s Sign-Patients will describe angina by clenching their first and placing it over the sternum.,PALPITATIONS,Palpitations,The uncomfortable sensations in the chest associated with a range of arrhythmias. Patients may describe palpitations as fluttering, skipped beats, pounding, jumping, stopping, or

21、irregularity,EXTRASYSTOLES,Premature atrial contractions (PACs) Premature ventricular contractions (PVCs),TACHYARRHYTHMIAS,Sinus Tachycardia Usually gradual onset and offset Paroxysmal Supraventricular Tachycardia (PSVT) Sudden, abrupt onset and offset Atrial Fibrillation Ventricular Tachycardia,CAU

22、SES of ATRIAL FIBRILLATION,Hypertension Hyperthyroidism Acute MI Pericarditis Coronary Artery Disease,Congestive Heart Failure Valvular Heart Disease Acute or Chronic ETOH abuse Post-operative state,ATRIAL FIBRILLATION,Major complication Peripheral embolization CVA May present as CVA, Transient isch

23、emic attack, Amaurosis fugax, ischemic limb, ischemic bowel or other viscera,VENTRICULAR TACHYCARDIA,Causes include: Acute myocardial ischemia/infarct Chronic Coronary artery disease Cardiomyopathy Prolonged QT interval (Congenital, drug-induced, acquired),VENTRICULAR TACHYCARDIA,May present as: Sud

24、den cardiac death VT degenerated into VF Syncope Wide complex tachycardiaOften hemodynamically well tolerated,BRADY - ARRHYTHMIAS,Heart BlockSinus Arrest,Common Causes of Palpitations - DRUGS,Bronchodilators tachycardia Beta Blockers, Calcium Channel Blockers bradycardia Digitalis bradycardia, toxic

25、ity causes brady-dysrhythmias,Common Causes of Palpitations More DRUGS,Antidepressants Prolong QT intervalOTC medications Antihistamines, Decongestants, Weight Loss preparations Extrasystoles, Tachy-dysrhythmias,Common Causes of Palpitations OTHER,TobaccoCaffeineThyroid disorders,Paroxysmal Nocturna

26、l Dyspnea (PND),Occurs at night or when patient is supine. Patient awakens after being asleep about 2 hours and is “smothering”. Runs to window to get more air This is a specific sign of congestive heart failure,Orthopnea,Dyspnea when lying down Ask all patients: “How many pillows do you use in orde

27、r to sleep?” To quantify the orthopnea, record “3-pillow orthopnea for the past month”,Dyspnea on Exertion (DOE),This is usually due to chronic CHF or severe pulmonary disease Quantify the severity by asking, “How many level blocks can you walk before you get short of breath? How many could you walk

28、 six months ago?”,How to Chart about Dyspnea,“The patient has had 1-block dyspnea on exertion for the past six months. Before 6 months ago, the patient was able to walk 4 blocks without shortness of breath. In addition, during the past month the patient has noted 4-pillow orthopnea. Previously he wa

29、s able to sleep with just two pillows.”,Common Causes of Congestive Heart Failure,Uncontrolled Hypertension Myocardial ischemia/infarct Arrhythmias Lack of compliance Diet Drugs Fluid overload,More Common Causes of Congestive Heart Failure,Blood loss, Anemia Pulmonary embolism Systemic infection Val

30、vular heart disease Nonischemic Dilated Cardiomyopathy Renal Artery Stenosis,SYNCOPE,Syncope,Fainting or syncope is the transient loss of consciousness that is due to inadequate cerebral perfusion Syncope can be from cardiac or non-cardiac causes,Common Causes of Syncope,Cardiac Neurocardiogenic Ort

31、hostatic Hypotension Metabolic Neurologic Psychogenic,Common Causes of Syncope - CARDIAC,Obstruction to Blood Flow Valvular stenosis Hypertrophic cardiomyopathy Prosthetic valve dysfunction Atrial myxoma,Obstruction to Blood Flow (cont) Pericardial tamponade Pulmonary hypertension Pulmonary emboli C

32、ongenital heart disease Pump failure (MI or ischemia),Common Causes of Syncope - CARDIAC,Common Causes of Syncope - CARDIAC,Arrhythmias Brady-arrhythmias Sinus bradycardia Sick sinus syndrome Atrioventricular block (AVB) Pacemaker malfunction Drug-induced bradycardia Tachy-dysrhythmias VTach, SVT,Co

33、mmon Causes of Syncope - NEUROCARDIOGENIC,VasovagalVasodepressorCarotid sinus hypersensitivitySituational Cough, Micturition, Defecation, Deglutition,Vasovagal Syncope,This is the most common type of fainting and is one of the most difficult to manage. It has been estimated that 40% of all syncopal

34、events are vasovagal in nature This occurs during periods of sudden, stressful, or painful experiences such as getting bad news, trauma, blood loss, sight of blood,Vasovagal Syncope, cont,There is warning that the fainting is about to occurpallor, nausea, weakness, blurred vision, lightheadedness, p

35、erspiration, yawning, diaphoresis, hyperventilation, or a “sinking feeling”,Carotid Sinus Syncope,This may occur in the elderly who may have a hypersensitive carotid sinus If they are wearing a tight shirt or collar or turn their neck in a certain way, there is increased stimulation of the carotid s

36、inus, a sudden fall in systolic blood pressure, and a decrease in heart rate.,Common Causes of Syncope Orthostatic Hypotension,Volume depletionAntihypertensive medicationsAntidepressant medications,Common Causes of Syncope METABOLIC,HypoglycemiaHyperventilationHypoxia,Common Causes of Syncope,NEUROL

37、OGIC Epilepsy Cerebrovascular diseasePSYCHOGENIC,Ask These Questions about Syncope,“What were you doing just before you fainted?” “Have you had recurrent fainting spells? How often do they happen?” “Was there an abrupt onset to the fainting, or did you feel it coming?” “Did you totally lose consciou

38、sness?”,Syncope Questions, cont,“In what position were you in when you fainted?” (possible orthostatic hypotension?) Was the fainting preceded by other symptoms like nausea, chest pain, palpitations, confusion, numbness, or hunger?,more syncope questions.,“Was fainting episode witnessed by anyone? W

39、ho? “Did you have warning that you were going to faint?” “Did you have any black, tarry BMs before or after the fainting episode? “Did you experience any loss of urine or stool during the fainting episode?”,And Just One More,“On regaining consciousness, did you know where you were and who people wer

40、e around you?”,Fatigue,This is a common symptom of decreased cardiac output. A common complaint from people with CHF and mitral valve disorder Fatigue may be the presenting symptom of a woman having an MI Not at all specific to heart disease, but you must consider it always,Common Causes of Fatique,

41、Cardiac Anxiety/Depression Anemia Chronic Diseases,Dependent Edema,When peripheral venous pressure is high, fluid leaks out from the veins into tissues This is often the presenting symptom of right ventricular failure Edema will begin in legs and gets worse as the day progresses. Least evident in th

42、e a.m. after sleeping with the legs flat, worse as gravity pulls fluid to legs.,More about Dependent Edema,This indicates that there is excess fluid volume and 3rd spacing of fluids. People on bedrest will have edema of their sacral area In severe right or bi-ventricular heart failure, people often

43、have abdominal distension, liver engorgement, constipation, and anorexia Anasarca may develop. Gross generalized edema,Ask These Questions about Dependent Edema,“When did you first notice the swelling?” “Do both legs swell equally?” “Did the swelling appear suddenly?” “What time of the day is it wor

44、se?” “Does it disappear after sleeping?” “Does propping your legs up make it go away?”,More Questions about Edema.,“What medicines do you take now?” “Do you have any kidney, heart, or liver disease?” “Do you have shortness of breath? Pain in your legs? Ulcers on your legs?”,And, More Questions about

45、 Edema,Have you noticed a difference in how your clothes fit, especially around the waist? Have you noticed recent problems with constipation? How is your appetite?,More and More,Do you add salt to food at mealtime and/or when cooking Do you eat out in restaurants or get take-out food frequently? Do

46、 you read labels on food before purchasing?,Physical Exam for Edema,Press fingers into the dependent areas for 2-3 seconds. If pitting is present, the fingers will sink into the tissue and when fingers are removed, the impression of the fingers will remain Edema is quantified from 1+ to 4+ depending

47、 on how deep the indentation is,The Physical Examination,Inspection,General Appearance,Is the patient in acute distress? Is breathing labored or easy? Is there use of accessory muscles? Is there cyanosis? Pallor? Are xanthomata present (stony hard, yellowish masses on extensor tendons of the fingers

48、. Due to hypercholesterolemia,Inspection.,Inspect nails. Splinter hemorrhages are associated with infective endocarditis Inspect the face. People with supravalvular aortic stenosis have wide-set eyes, stabismus, low-set ears, upturned nose, hypoplasia of the mandible Moon face suggests pulmonic sten

49、osis,More inspection.,Expressionless face with puffy eyelids and loss of the outer 1/3 of the eyebrow is seen in hypothyroidism Inspect eyes. Yellow plaques on eyelids (xanthelasma) may be due to hyperlipoproteinemia Opacities of the cornea may be sarcoidosis,and more inspection.,Conjunctival hemorrhage is commonly seen with infective endocarditis Petechiae on the palate may be seen with infectious endocarditis High arched palate may be seen with Marfans Syndrome Arm Breadth greater that body height is also seen in Marfans,