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ASSESSMENT of CARDIOVASCULAR SYSTEM: Health History

Nursing History: MANIFESTATIONS OF HEART DISEASE


A. DYSPNEA
Labored or difficult breathing
Types:
Exertional
Orthopnea shortness of breath when lying down
Paroxysmal nocturnal dyspnea sudden dyspnea at night while lying down
Cheyne-stokes periodic breathing characterized by gradual increase in depth of respiration followed by a
decrease in respiration resulting in apnea
B. CHEST PAIN
Assessed according to:
LOCATION
Substernal, precordial, jaw, back localized or diffused
Radiation to the neck, jaw, shoulder, arm
CHARACTER/QUALITY
Pressure, tightness, crushing, burning or aching quality, heaviness, dullness, heartburn or indigestion
TIMING:ONSET, DURATION & FREQUENCY
Onset: sudden or gradual
Duration: how long does it last
Frequency: continuous or periodic
SETTING/PRECIPITATING FACTORS
Awake, at rest, sleep interrupted? With activity? With eating, exertion, exercise, elimination, emotional
upset?
INTENSITY/SEVERITY
Can range from 0 (no pain) to 10 (worst pain ever felt)
AGGRAVATING FACTORS
Activity, breathing, temperature
RELIEVING FACTORS
Medication (nitroglycerin, antacid), rest; there may be no relieving factors
ASSOCIATED SYMPTOMS
Fatigue, shortness of breath, palpitation, N&V, sweating, anxiety, lightheadedness or dizziness
c. EDEMA
Is the abnormal accumulation of serous fluid in the connective tissues
Causes:
CHF, Na+ retention, liver disease, hypoproteinemia, veous or lymphatic obstruction
Types:
Ascites: excessive fluid in the peritoneal cavity
Hydrothorax: excessive fluid in the pleural cavity
Anasarca: gross generalized edema
Edema grading:

D. PALPITATION
Are rapid, forceful or irregular heartbeats felt by the patient
E. HEMOPTYSIS
Is coughing up of blood
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Small quantities of dark-clotted blood indicate mitral stenosis
A mixture of blood and pus indicates pulmonary suppuration
Pink, frothy sputum indicates acute pulmonary edema
Blood-streaked sputum indicates acute pulmonary congestion
Frank hemoptysis is due to lung pathology
F. FATIGUE
Syncope and fainting may be caused by anoxemia or reduced cardiac output, resulting in inadequate circulation
Other pertinent data:
Cyanosis is the bluish discoloration of the skin and the mucus membranes
Abdominal pain or discomfort
Clubbing of fingers: the angle of the nail is 180 due to chronic hypoxia
Jaundice is the yellowish discoloration of skin and sclera

PHYSICAL ASSESSMENT OF THE HEART


Inspection and palpation
Aortic area 2nd ICS to the R of the sternum
Pulmonic area 2nd ICS to the L of the sternum
Right ventricular area a circle around the 5th cartilage to the patients L of midsternal line
Apical or L ventricular area 5th ICS at MCL
Observe for cardiac movement at the PMI location at the MCL 5th ICS
Feel for thrills vibration that occur as blood flow through a narrow or damaged vessels

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Percussion
Assess the size of cardiac area of dullness (CAD)

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AUSCULTATION
Check the rate and rhythm of apical pulse
Heart sounds
S1 1st heart sound closure of the AV valves, loudest at
the apex
S2 2nd heart sound, closure of semilunar valves, loudest
at the base
S3 ventricular gallop, 3rd heart sound, N in children,
abnormal in adult, caused by the oscillation of blood back
and forth between the walls of the ventricles initiated by
blood rushing in from the atria
S4 atrial gallop; 4th heart sound, N in children & YA, in adults associated with systemic or pulmonary
hypertension, MI or other cardiac disease; produced by the sound of blood being forced into a stiff or
hypertrophic ventricle

Murmurs sounds produced by vibrations within the heart and GV caused by turbulence of flow
Rubs sounds produced by interfacing of parietal and visceral surfaces of the pericardium

Heart rate
Normal = 60-100 bpm
Bradycardia= < 60 bpm
Tachycardia = > 100 bpm

PHYSICAL ASSESSMENT OF THE BLOOD VESSELS


Inspection
Color
Inadequate circulation may produce pallor, rubor or cyanosis,
Cyanosis is best visualized in good lighting
Vascular nail beds offer best visualization

Circulation in the extremities


note for:
Hair growth absence of hair growth means inadequate circulation
Clubbing results from prolonged hypoxia
Capillary refill less than 3 sec, prolonged filling time is indicative of inadequate circulation

Palpation
Edema: assess over bony prominence such as the medial malleolus, anterior tibia, sacrum
Press for 5 secs and measure for pitting
Pulse: carotid, dorsalis pedis, popliteal, posterior tibialis
Compare each side according to its rate, quality and symmetry of pulse
Temperature of lower extremities
Presence of varicosities

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Auscultation
N arteries do not produce sounds
Bruits are blowing sounds heard in conditions like AV fistula

Diagnostics
NON-INVASIVE: Electrocardiography (ECG)
A graphic recording of the electrical activity of the heart
Resting ECG presents a single recorded picture of the electrical activity of the heart
Preparation:
Secure electrodes to appropriate locations on the chest and extremities
Instruct the client to remain still during the test
Reassure the client that he or she will not receive any electrical shock or impulses
Remove all metallic materials in the clients body
Post-procedure:
none

Holter monitoring
Continuous ambulatory ECG monitoring over time (usual 24 hours) with a small, timed, portable ECG recording
devices
Preparation:
Secure electrodes to appropriate locations on the chest
Instruct the pt to continue normal activity and maintain a log of activities and record any symptoms

stress test
Continuous multi-lead ECG monitoring during controlled and supervised exercise, usually on a treadmill
Preparation:
Obtain a written consent
Instruct the client to eat a light meal 1-2 hours before the exam (no caffeine, alcohol or smoking)
Instruct the client to wear comfortable clothing and rubber-soled walking shoes
During the test:
Secure electrodes to appropriate locations on the chest
Obtain baseline BP and Ecg tracing
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Instruct client to exercise as instructed and report any pain, weakness, shortness of breath, or other symptoms
immediately
Monitor BP and ECG continuously, record at frequent intervals and with any symptoms or changes in vital signs,
ST segments or cardiac rhythm
Post-procedure nursing care:
Continue to monitor ECG and BP until the client returns completely to baseline and is symptom-free
Once stable, patients may resume their usual activity

Echocardiogram
Study performed to assist in the diagnosis of cardiovascular disorders.
It allows visualization of the internal cardiac structures for size, shape, position, and movement.
All four valves, both ventricles, and the left atrium, as well as the velocity of the blood flow, can be examined during
the movement of the transducer over the chest.
Client preparation:
Instruct the client to remain still during the test
Secure electrodes for simultaneous ECG tracing
Explain that there are no pain or electrical shocks.
Lubricant placed on the skin will feel cold
Post-procedure:
Cleanse the lubricant from the clients chest wall

Phonocardiography
A graphic recording of the heart sounds with simultaneous ECG
Client preparation:
Instruct the patient to remain quiet and still during the test
Secure electrodes for simultaneous tracing
Explain that there will be no pain or electrical shocks

Cardiac catheterization
invasive, but often definitive test for diagnosis of cardiac disease.
A catheter is inserted into the right or left side of the heart to obtain information.
a. Right-sided catheterization:
the catheter is inserted into an antecubital vein and advanced into the vena cava, right atrium, and right ventricle with
further insertion into the pulmonary artery.
b. Left-sided catheterization:
performed by inserting the catheter into a brachial or femoral artery;
the catheter is passed retrograde up the aorta and into the left ventricle
Purpose:
to measure intracardiac pressures and oxygen levels in various parts of the heart;
with injection of a dye, it allows visualization of the heart chambers, blood vessels, and course of blood flow
(angiography).
Nursing care: pretest
a. Confirm that informed consent has been signed.
b. Ask about allergies, particularly to iodine, if dye being used.
c. Keep client NPO for 12 hours prior to test.
Nursing care: pretest
d. Temporarily suspend metformin for dye and surgical procedures; do not restart until oral intake has resumed and renal
function is normal.
e. Record height and weight, take baseline vital signs, and monitor peripheral pulses.
f. Inform client that a feeling of warmth and fluttering sensation as catheter is passed is common.

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Nursing care: posttest
a. Assess circulation to the extremity used for catheter insertion.
b. Check peripheral pulses, color, sensation of affected extremity every 15 minutes for 4 hours.
c. If protocol requires, keep affected extremity straight for approximately 8 hours.
d. Observe catheter insertion site for swelling and bleeding; a sandbag or pressure dressing may be placed over insertion
site.
e. Assess vital signs and report significant changes from baseline.

Coronary Angiography/Arteriography
An invasive procedure during which the physician injects a dye intro the coronary arteries and immediately takes a
series of x-ray films to assess the structure of the arteries
Preparation
Obtain written consent and explain the procedure
Assess the client for history of allergies to dye or shellfish
Initiate IV site with fluids as ordered

Post-procedure:
Same as cardiac cath post-procedure care

Aortography
Injection of radiopaque contrast medium into the aorta to visualize the aorta, valve leaflets, and major vessels on a

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movie film.
Purpose:
to determine and diagnose aortic valve incompetence, aneurysms of the ascending aorta, abnormalities of
major branches of the aorta.

Nursing care: pretest


a. Confirm that informed consent has been signed.
b. Inform client that a dye will be injected and to report any dyspnea, numbness, or tingling.
Nursing care: posttest
a. Assess the puncture site frequently for bleeding or inflammation.
b. Assess peripheral pulses distal to the injection site every hour for 8 hours posttest.

Cardiac nuclear scan


Radionucleotide imaging
to identify ischemic/infracted tissue.

a safe, radioactive material called a tracer is injected through a vein into your bloodstream.
The tracer then travels to your heart.
The tracer releases energy, which special cameras outside of your body detect.
The cameras use the energy to create pictures of different parts of your heart

Bone marrow aspiration


Used to determine the presence and size of WBC, RBC and megakaryocytes as they develop in the bone marrow
Sites for bone marrow aspiration:
Sternum
Iliac crest
Tibia
During withdrawal of aspirate, the client will experience burning sharp pain
After the needle is removed, a pressure dressing is applied over the puncture site, where only minimal bleeding
should occur
Is the patient has thrombocytopenia, pressure is applied for 3-5 minutes
Most clients experience little to no pain after the procedure
Some people complain of tenderness and ache at the aspiration site for a few days

magnetic resonance imaging (MRI)


Uses a strong magnetic field to examine both the physiologic and the anatomic properties of the heart
Preparation:
Screen out patient to determine whether he/she has pacemaker, metal plates, prosthetic joints, or other metallic
implants, as these can be dislodged if exposed to MRI
Explain to the client to expect intermittent clanking or thumping sounds from the magnetic coils may be
annoying to clients, often offered with headsets for listening to music
During procedure:
Instruct patient to remain still and not to move

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