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Chapter 36

Assessment of the
Cardiovascular System
The Cardiovascular
 Anatomy and physiology
 Heart—its structure and function
Anatomy and Physiology of
the Heart
Anatomy of the Heart
Coronary Arteries
 Coronary artery blood
flow to the myocardium
occurs primarily during
diastole, when coronary
vascular resistance is
 To maintain adequate
blood flow through the
coronary arteries, mean
arterial pressure (MAP)
must be at least 60 mm
The Cardiovascular
 Cardiac output

 stroke volume
 Normal: 4 to 6 liters per minute
The Cardiovascular
 Cardiac Index

 CO divided by BSA
 Normal Range: 2.7 to 3.2
L/min/m2 of body surface area
 heart rate
The Cardiovascular
 Stroke volume  Stroke volume is the
amount of blood
ejected by the left
ventricle during each
 Heart rate, preload,
afterload, contractility,
stroke volume, and
cardiac output.
The Cardiovascular
 Preload
 According to Starling’s law of the heart, the
more the heart is filled during diastole the
more forcefully the heart contracts.
 Excessive filling of the heart results in
excessive left ventricular end-diastolic volume
and pressure.
 May result in decreased cardiac output
The Cardiovascular
 Afterload
 The amount of pressure or resistance the
ventricles must overcome to eject blood into
the peripheral blood vessels.
 A decrease in stroke volume can result from
an increase in afterload without the benefit of
compensatory mechanisms.
The Cardiovascular
 Contractility
 Increased by factors such as
 Sympathetic stimulation
 Calcium release
 Positive inotropic drugs
 Decreased by
 Hypoxia
 acidemia
Blood Pressure
 Blood pressure is the force of blood exerted
against the vessel walls.
 Systolic blood pressure
 Amount of pressure generated by the left ventricle to
distribute blood into the aorta
 Diastolic blood pressure
 The amount of pressure sustained by the arteries
during the relaxation phase of the heart
 Determined primarily by the ability of the heart to rest
while filling with blood.
 Increased by increased peripheral vascular resistance
Blood Pressure Regulation

 Autonomic nervous system

 Baroreceptors
 Chemoreceptors
 Renal system
 External factors also affect BP
Venous System

 Structure: a series of veins located

adjacent to the arterial system
 Function: completes the circulation of
blood by returning blood from the
capillaries to the right side of the heart
 Cardiovascular changes in the older adult:
only evident when the person is active or
under stress (Table 36-1)
Assessment Techniques

 History
 Demographic data
 Family history and genetic risk
 Personal history
 Diet history
 Socioeconomic status
Modifiable Risk Factors

 Cigarette smoking
 Physical inactivity
 Obesity
 Psychological factors
 Chronic disease (HOW!?)
Pain or Discomfort

 Pain or discomfort can result from

ischemic heart disease, pericarditis, and
aortic dissection.
 Chest pain can also result from
noncardiac conditions such as pleurisy,
pulmonary embolus, hiatal hernia, and

Pain or Discomfort
 Terms such as discomfort, heaviness,
pressure, indigestion, aching, choking,
strangling, tingling, squeezing,
constricting, or vise-like are all used to
describe pain.
 Women often do not experience pain in
the chest but rather feelings of discomfort
or indigestion.
Pain Assessment

 Onset
 Manner of onset
 Duration
 Frequency
 Precipitating factors
 Location
 Radiation
Pain Assessment (Continued)

 Quality
 Intensity, which can be graded from 0 to
10, associated symptoms, aggravating
factors, and relieving factors

 Can occur as a result of both cardiac and

pulmonary disease
 Difficult or labored breathing experienced
as uncomfortable breathing or shortness
of breath
 Dyspnea on exertion (DOE)
 Orthopnea: dyspnea when lying flat
 Paroxysmal nocturnal dyspnea after lying
down for several hours
Other Manifestations

 Fatigue
 Palpitations
 Weight gain
 Syncope
 Extremity pain
Physical Assessment
 General appearance
 Integumentary system
 Skin color
 Skin temperature
 Extremities
 Clubbing of fingers
 edema
 Skin integrity
 Etc.
Physical Assessment
 Blood pressure
 High Normal
 Systolic 130 to 139 mm Hg
 Diastolic 85 to 89mm Hg
 Pre-hypertension
 Systolic 120 to 139 mm Hg
 Diastolic 80 to 89 mm Hg
 Postural Hypotension
 Venous and arterial pulses: central and jugular
venous pressures, and jugular venous
 Assessment of the precordium (area over
the heart) involves:
 Inspection
 Palpation
 Percussion
 Auscultation
 Normal heart sounds
 Normal splitting may occur with both
 S1 – Closure of the mitral and tricuspid valves
 Beginning of ventriclar systole
 S2-closure aortic and pulmonic valves
 High pitched and best heard at the end of
ventricular systole
Auscultation of Heart Sounds
 Paradoxical splitting
 Abnormal splitting of S2/wider split
 Early closure of pulmonic valve
 Delayed closure of aortic valve
 Gallops
 S3 and S4
 S3
early sign of heart failure over 35 years of age
 S4
advancing age
 Murmurs
 Turbulent blood flow through normal or abnormal
 Pericardial friction rub
Serum Markers of
Myocardial Damage
 Troponin T and I
 Creatine kinase
 Myoglobin
 Serum lipids
 Homocysteine
 C-reactive protein (Marker of
Blood Coagulation Test
Blood Coagulation Test

 PT and INR
 Measures the activity of prothrombin, fibrinogen,
and factors V, VII, and X.
 Measures deficiencies in all coagulation factors
except VII and XIII
Allen Test
Cardiac Catheterization
 Client preparation
 Possible complications: myocardial
infarction, stroke, thromboembolism,
arterial bleeding, lethal dysrhythmias, and
 Follow-up care:
 bedrest, insertion site extremity kept straight
 Monitor vital signs
 Assess for complications
Other Diagnostic Tests

 Electrocardiography
 Electrophysiologic study
 Exercise electrocardiography
 Echocardiography
 Pharmacologic stress echocardiogram
 Transesophageal echocardiogram
 Imaging
Hemodynamic Monitoring

 Invasive system used in critical care areas

to provide quantitative information about
vascular capacity, blood volume, pump
effectiveness, and tissue perfusion
 Pulmonary artery catheter
 Systemic intra-arterial monitoring
 Impedance cardiography
Pulmonary Artery Catheter