UVA NUCO 2330 - Cardiovascular

Assessment Vital Signs ● Provides info about oxygenation and perfusion Techniques ● Assess aspects of respiratory status, like breathing effort ● Unexpected CV findings may present as a respiratory symptom ○ Ex. SOB with heart failure ● Assess aspects of integumentary system, like color, moisture, and edema ○ Could indicate CV compromise Equipment ● ● ● ● Stethoscope Doppler Clock/watch Penlight Anatomy Blood Flow Through the Heart Deoxygenated Blood ● Deoxygenated blood from the body returns to the heart via the IVC and SVC into the RA ● During diastole, blood flows into the RA through the tricuspid valve and into the RV ○ Relaxation; AV valves open ● During systole, the trisucpid valve closes ○ Contraction; SL valves open ● Ventricular blood ejects via the pulmonic valve into the pulmonary arteries and to lungs Oxygenated Blood ● Blood is oxygenated at lungs, then returns to the LA via pulmonary veins ● During diastole, blood flows from the LA via the mitral valve and into the left ventricle ● During systole, the mitral valve closes ● Ventricular blood ejects via the aortic valve into the aorta and the rest of the body Heart Layers Pericardium ● Encases the heart ● Double-layered sac that protects from infection or damage ● Serous fluid in between that reduces friction with heart muscle contraction/relaxation Myocardium ● Thick muscular middle layer ● Contracts and pushes blood out to the rest of the body Endocardium ● Innermost layer ● Lines the heart and blood vessels Chambers Atria ● Collecting chambers ● Receive blood from the vena cava and pulmonary veins Ventricles ● Pumping chambers ● Send blood to the lungs/rest of the body Vessels Superior & Inferior Vena Cava ● Largest veins ● Return unoxygenated blood from throughout the body to the right atrium Pulmonary Artery ● Transports unoxygenated blood from the right ventricle to the lungs ● Oxygen and carbon dioxide exchange to oxygenate blood ● Then returns to the left side of the heart through the pulmonary vein Aorta ● Largest artery; emerges from left ventricle ● Arches behind the heart and branches into multiple vessels ● Deliver oxygenated blood to every area of the body Valves Atrioventricular (AV) Valves ● ● ● ● ● Separate atria and ventricles Tricuspid is between the RA and RV Bicuspid/mitral is between the LA and LV Open when the heart is filling with blood during diastole Closed when the heart pumps during systole Semilunar (SL) Valves ● ● ● ● Between the ventricles and arteries Pulmonic valve is between the RV and pulmonary artery Aortic valve is between the LV and aorta Open when the herat contracts during systole to allow blood ejection from the heart Vascular System ● Provides oxygen and removes waste products from tissues ● Arteries (and arterioles): Strong, sturdy vessels with elastic fibers ○ Allow for expansion and contraction in response to pressure changes ● Veins (and venules): Not as strong as arteries; can relax and hold more blood ○ Decreases workload on the heart ○ Low-pressure system ● Blood flow to the heart is maintained by valves and skeletal muscle contraction ● Capillaries: Small vessel type; connection between the arterial and venous system ○ Diameter of a single RBC Physiology ● Dual pumping system: Mechanical pump and electrical conduction ● Work cooperatively to provide circulation and perfusion by regulating HR and rhythm ● When in diastole, ventricles relax and AV valves are open, allowing ventricles to till ● ● ● ● Once filled to capacity in diastole, ventricular pressures rise, causing AV valves to close Systole begins, and all four valves are closed for a moment Until pressure forces SL valves open; blood flows into the pulmonary artery and aorta Cardiac output: Amount of blood pumped by the heart per minute ○ Usually 4-6 L per minute ○ Affected by metabolic demands, like stress, illness, or exercise Electrical Conduction ● Provides stimulus for contraction ● Cells generate and transmit impulses across the base, down the body, and to the apex ● The sinoatrial (SA) node near the SVC above the RA begins impulse and determines HR ○ Usually 60-100 bpm ● Impulses travel across the atria, causing contraction ● Travel to the AV node, at the AV junction near the tricuspid valve ● Impulses fan out at a rate of 40-60/min to the apex ● Move through the R/L bundle of His and Purkinje fibers, stimulating ventricular contraction Heart Sounds ● Labeled based on the phase of the cardiac cycle ● S1: AV valves closing at the beginning of systole ● S2: Sound of SL valves closing at the end of systole Fluid Balance ● The distribution and uptake of oxygen, nutrients, and waste occurs via capillary beds within the interstitial tissues ● The lymphatic system, running alongside the circulatory system, absorbs excess fluid and protein from the tissues and returns it to the circulatory system via subclavian veins Health History Present Health Conditions Cardiac Ask about: ● Current heart problems ● Chest pain ● Pain in the upper body (arms, back, jaw, neck, stomach) ● SOB or dyspnea ● Changes in skin color ● Swelling in legs and feet ● Recent weight gain ● Experiencing fast heart beats or skipped beats ● Dizziness or fainting episodes ● Cough ● More fatigue than normal ● Need to empty the bladder at night Peripheral Vascular ● ● ● ● ● ● Pain or cramping in the legs (thighs, calves, feet, buttocks) Changes in skin color Changes in skin temperature on arms, legs, hands, or feet Bulging or crooked veins Sores or open areas on the legs Swelling in the arms or legs Past Health History ● ● ● ● High cholesterol, triglycerides, or BP Past diagnosis with a heart disease/condition Past infection or viral illness that affected the heart Diabetes Family History ● Immediate family HTN or cardiovascular problems ● Sudden death at a young age Other Questions ● Substance use (smoking, vaping, chewing, drinking) ● Typical amount of exercise Neck Vessels Inspect ● Note jugular veins and carotid arteries ● Start to the client’s right and inspect the neck for tone, symmetry, veins, and pulsations Jugular Veins ● Ask the client to turn their head away from you and use a penlight to inspect the jugular vein area for pulsations (on top of the SCM muscle) Carotid Arteries ● While inspecting, observe for visible pulsations ● Carotid pulse is generated from blood pushing into the aorta ● Stronger than venous flow through veins, so pulsation is expected Expected Findings ● Jugular veins will be without distention, may see slight pulsation ● Visible pulsations in the carotid area Unexpected Findings ● Full, bulging, and bounding jugulars on one or both sides can indicate right-sided HF ○ Jugular veins return blood to the SVC and RA ● An absence of pulsation in the carotid artery indicates decreased force of blood flow Palpate ● The carotid pulse is in the groove between the SCM muscle and throat ○ Lower third of the anterior neck ● Use the index and middle finger of your dominant hand and palpate for pulse strength ● Palpate each artery individually to prevent obstruction of blood flow; compare strength Expected Findings ● Pulse strength should be moderate and bilaterally equal Unexpected Findings ● A bounding pulse can indicate a condition affecting heart function ○ Ex. fluid overload due to HF ● A diminished pulse can indicate a blockage, narrowing, or low circulating blood volume ○ Seen in shock Anterior Chest Assessment Irregularities Heaves ● Vigorous, sustained thrust of the ventricle against the chest wall during contraction ● Caused by an increased workload on the heart Thrills ● Palpable vibration caused by turbulent blood flow Inspection ● Look for symmetry of movements and visible pulsations ● Visualize the apical impulse or point of maximal impulse (PMI), the apex ○ At the left fifth intercostal space along the midclavicular line ○ Observe for visible pulsations Expected Findings ● Symmetrical chest movements ● Visible gentle pulsations in the PMI area Expected Variation ● PMI may not be visible depending on body shape ○ Ex. obese, muscular Unexpected Findings ● Visualizing prominent, forceful thrusting in the PMI area ○ Lift or heave Chest Pain Questions ● Can you show me where you are having the pain? ○ How would you describe it, sharp, dull, or crushing? ○ How long does it last? ○ What would you rate the pain from 1-10? ● Did you notice other symptoms before the pain, such as indigestion, nausea, choking, chest heaviness, weakness, pain, numbness, or tingling in the upper extremities? ● Does the pain radiate anywhere? Does it become worse when breathing in or out? ● Is there anything that relieves the pain, like resting, repositioning, or medicine? ● Does it occur with exercise or physical exertion? Do you notice that any foods bring on this type of pain? Does it occur while you’re resting? ● Have you noticed any symptoms occurring with the pain, like nausea, sweating, SOB, feelings of your heart skipping beats, weakness, or dizziness? Measurement ● Assess vital signs and pulse oximetry Inspection ● Inspect color of the skin, lips, and mucous membranes for oxygenation ● Observe respiratory effort; HF can cause increased distress due to fluid overload ● Assess for peripheral edema and jugular vein distention; HF fluid overload Additional Nursing Actions ● Remain with the client and stop all activity ● Assist them into a semi-Fowler’s position ○ Decreases exertion and oxygen demand of the heart, enhancing respiration ● Notify the rapid response team and provider ● Administer oxygen via a non-rebreather mask to decrease tissue damage ● Ensure IV access in case of an emergency ● Place the client on a continuous ECG to assess changes in heart rhythm Heart Sounds Prepare ● Have a clean stethoscope and watch ready in a quiet environment ● Explain that you will be taking time to listen to their whole heart, not just one location Auscultate ● While at their right side, auscultate the anterior chest with the diaphragm ○ Used to listen to high-pitched heart sounds, like S1, S2, and some murmurs ● The bell is used to identify lower-pitched sounds, like S3 and S4 ● Valve sounds can be auscultated across the precordium Method: Z-Pattern ● ● ● ● ● Start at the base of the heart in the aortic area (second ICS at the right sternal border) Move to the pulmonic area (second ICS at the left sternal border) Move to Erb’s point (third ICS at the left sternal border); second pulmonic area Move to the tricuspid area (fourth ICS at the left lower sternal border) Move to the mitral area (fifth ICS in the left midclavicular area) ○ Auscultate for one minute to identify S1 and S2 sounds ● Note the rate, rhythm, and pitch of the apical pulse and any unexpected findings Expected Findings ● ● ● ● ● ● ● S1: Dull, low-pitched sound; best heard at the apex/PMI area S2: Higher-pitched sound; best heard at the base of the heart Systole: Silent period between S1 and S2 Diastole: Silent period between S2 and next S1 Heart base sounds Apical pulse (AP) rate should be 60-100 bpm with a regular rhythm Note the intensity of S1 and S2 Unexpected Findings ● Abnormal HR ● Adventitious heart sounds, like clicks, rubs, murmurs, or gallops (S3/S4) ○ Can indicate heart disease or valve malfunction ○ Holosystolic murmur ○ Midsystolic click ○ Ventricular gallop ○ Atrial gallop ● Pericardial friction rub, indicating pericardium inflammation Extremities & Peripheral Pulses Preparation ● Have a stethoscope and a watch with a second hand Inspection ● Inspect the upper and lower extremities ● Note skin tone and bilateral symmetry of size ● Inspect hair and skin texture; note changes in distribution or ulcers ○ Especially on the front of the chins ○ Helpful in diagnosing peripheral venous or arterial disease ● If the client has diabetes, ask about a history of non-healing ulcers ● Inspect fingernaiols for color and shape Expected Findings ● Bilateral symmetry ● Intact skin and consistent coloring ● Smooth, intact nail surface with slight curve ○ Color consistent with skin tone ● Thin and sparse or thick and diffuse hair Expected Variation ● Presence of hair on the lower extremities; should be even Unexpected Findings ● ● ● ● Asymmetry, indicating edema or atrophy, signifying an underlying condition Lighter/darker extremity skin tone, indicating decreased circulation or CV condition Lack of hair, thin shiny skin, thickened skin, or ulcerations; decreased circulation Dilated twisted veins in the lower extremities; weakened valves in the venous system ● Pale or blue nail beds; hypoxia ● Swelling at the base of the nail causing clubbing, incidcating chronic low oxygen levels Palpation ● Upper and lower extremities ● Temperature, texture, turgor, moisture, capillary refill, edema, and arterial pulses Pulses Strength of blood flow from the heart to the rest of the body Pulse Measurement ● ● ● ● ● 0: Absent, impalpable 1+: Weak, thready, diminished 2+: Normal, brisk pulse (expected) 3+: Increased, strong 4+: Bounding, full volume Pulse Sites Compare corresponding extremity pulses ● Radial: In the groove on the humb side of the forearm just below the wrist ● Brachial: In the bend of the elbow, in the antecubital fossa, on the inner aspect of the arm between the biceps and triceps ● Femoral: Halfway between the pubis and anterior superior iliac spines, slightly below the inguinal ligament; use firm pressure ● Popliteal:Behind the knee in the poplitea fossa; use firm pressure ○ Easier if the client is positioned prone ● Posterior tibial: In the groove behind the ankle bone (malleolus) and the Achilles tendon; use light touch ● Dorsalis pedis: On top of the foot, between the extensor tendons of the first and second toes; use light touch Doppler ● ● ● ● If unable to palpate, determines if an arterial pulse is present Apply a small amount of ultrasound gel and turn on the volume Place the tip of the transducer at a ninety-degree angle on the skin Lightly reposition the tip until you locate the pulse; a pulsating whooshing sound Expected Findings ● ● ● ● Consistent skin temperature bilaterally Skin should be smooth and dry with rapid recoil and no edema Capillary refill in less than 2 seconds Pulses should be palpable, regular, symmetrical, and +2 amplitude Unexpected Findings ● ● ● ● ● ● Excessively hot or cool temperature Rough or scaly skin texture The lack of body hair on an extremity, indicating a circulation disorder Turogor that tents; fluid volume deficit Delayed capillary refill; decreased perfusion Diaphoresis for no apparent reason, could be cardiac event or HF ○ Especially with systemic symptoms like N/V and lightheadedness ● Absent, weak, bounding, or asymmetrical pulses ● Edema in the lower extremities or ankles; inspect for pitting Edema of Lower Extremity Subjects of Questions ● ● ● ● ● ● When edema occurs; after prolonged sitting/standing, worse in evening/morning Location of edema What alleviates or aggravates it Redness, change in pigmentation, or warmth in area Pain with swelling, describe and rate SOB or unexpected weight gain Inspection ● Note location and if unilateral or bilateral ○ One-sided can indicate blood clot/infection ○ Bilateral can suggest heart disease ● Observe color ○ Reddened areas can indicate infection or superficial blood clot ○ Pallor or cyanosis can indicate inadequate circulation ● Observe for venous distention ● Inspect feet and legs for ulcers, which can signify compromised circulation ● Observe hair distribution on the legs Palpation ● Palpate above and below visible edematous area ○ Note location and degree of swelling ● Determine pitting ● Palpate for skin temperature ○ Warmth is associated with infection or blood clots ○ Coolness is associated with inadequate circulation ● Palpate the pulse strength above and below; compare to other extremity Additional Nursing Actions ● Measure circumference of edematous area at the largest point ○ Measure the other extremity in the same area ● Notify the provider of findings ● Encourage client to change positions as much as possible ○ Improve perfusion and decrease risk of skin breakdown Vascular Ulcer on Lower Extremity Question Subjects ● ● ● ● ● When ulcer was first noticed Increase or decrease in size Drainage Application of dressing and frequency of changing Pain, including intensity and alleviation/aggravation Inspection ● Note location, color, border, and depth ● Measure the size using a cm tape measure ● Inspect surrounding tissues ○ Note color of skin, hair distribution, and edema Venous Ulcer ● ● ● ● At medial or lateral ankle Irregular or flat wound border Ulcer wound pink Ankle or leg edema ● Ankle discoloration ● No report of pain at rest ● Pedal pulses present Arterial Ulcer ● ● ● ● ● ● ● Located at the end of toes Regular, even border Ulcer wound pale Foot cool Hair loss Pain reported at rest Pedal pulses absent Palpation ● Surrounding skin for edema and determine pitting extent ● Temperature of surrounding skin ● All pulses in the leg and compare to other extremity Additional Nursing Actions ● ● ● ● ● Gently cleanse with mild soap and lukewarm water Ensure client uses protected footwear when ambulating Instruct clients to avoid bathing in hot water or using heating pads to avoid further injury Teach the client to avoid crossing their legs and wearing constrictive clothing Notify provider of findings Health Promotion Yearly Screenings ● Recommended screenings, like BP monitoring and glucose/cholesterol screening ● Elevated low-density lipoprotein (LDL) cholesterol elevation increases risk for heart disease by accumulating on the lining of blood vessels ● Diabetes increases the risk of heart disease Exercise ● Strengthens heart muscle and forceful blood flow that prevents plaque buildup ● 150-300 mins of moderate physical intensity per week ● Muscle-strengthening exercises twice a week Stress Reduction ● Causes release of chemicals associated with heart disease and HTN development ● Improves sleep and decreases anxiety levels ● Include physical relaxation (ex. Sports, hobbies, yoga, meditation, laughing) Dietary Changes ● Obesity is strongly correlated to CV disease process ● Diet should have fruits, vegetables, whole gains, and low-fat dairy/meat products ● Limit the intake of: ○ Saturated and trans fats (ex. Fried and processed foods) ○ Sugar and processed carbohydrates ○ 2-3 g of sodium a day (avoid canned/processed foods) ○ < 2 drinks of alcohol per day for males and 1 for females ■ Chronic consumption can lead to HTN, dysrhythmia, or blood clots ● Mediterranean diet can increase likelihood of CV disease ○ White meat, seafood, fruits, vegetables, extra-virgin olive oil, nuts, and wine Tobacco Cessation ● Chemicals can contribute to CV disease by damaging cells ○ Secondhand smoke as well ● Within a few years, the risk of CV disease is equal to someone who never smoked