Assessment of the cardiovascular system Foundations of Critical Care Nursing Hajni Hideg Practice Education Sister- CTICU

Objectives: To understand the importance of thorough CVS assessment To discuss CVS assessment with ‘Look, listen and feel approach’ and the components of basic CV assessment To discuss assessment of pulse, BP, arterial BP, central venous pressure and haemodynamic monitoring in more detail

Introduction A thorough CVS assessment will help to identify significant factors that can influence CV system and whole body Always use observations in conjunction with “whole patient” observations Trends in observations not “one-off’s” Baseline observations are very important Accurate observations, safety checks

Methods History!!! Systemic approach! Look, listen and feel! (Inspection, auscultation, palpation/percussion) Patient and equipment (safety checks) Invasive and non-invasive methods Laboratory tests, ABG Diagnostic studies (ECG, TTE,TOE, Catheter lab reports, CXR)

History Past medical history, family history Admission diagnosis and history e.g AVR and sev. aortic regurg. Procedure details, ejection fraction - <50 % considered abnormal The amount of blood pushed out of the LV in percentage.

Patient assessment: 1. Look / Inspection General appearance and Skin – colour(cyanosis? pale?), turgor, haematoma, bleeding, oedema Cap refill <2 secs (to assess adequacy of circulation with poor CO) Jugular venous distension Urine volume and quality Monitoring With all equipment available we can forget about looking at our patient

Patient assessment: 2. Listen / Auscultation Heart sounds S1+S2 (‘lab-dub’), HR, rhythm, murmurs A murmur is an abnormal heart sound generated by turbulent blood flow. The sound may indicate that blood is flowing through a damaged or overworked heart valve (whoosing sound, benign/abnormal)

Patient assessment: 3. Feel Skin – temperature, peripheries Pulses – rate and volume; carotid, radials, pedal pulses

? What do we measure? Consider Invasive vs. Non-Invasive methods

Non-invasive methods Pulse rate & volume ECG, heart sounds Cerebral perfusion & mentation Skin perfusion & temperature Blood pressure Unprovoked urine volume & quality Oxygen saturation (SpO2) Capillary refill Jugular venous distension

Invasive methods Arterial Blood Pressure Central Venous Pressure (CVP) Pulse pressure Arterial Blood Gases (Lactate, pH, electrolytes, Hb) Serum biochemistry (cardiac enzymes), clotting, FBC Core temperature Urine volume via catheter Invasive haemodynamic monitoring – PA catheter, Lidco

PULSE Rate Different in client groups Influenced by neural, chemical & physical factors Normal 60-100 bpm Tachycardia > 100 bpm Bradycardia < 60 bpm Rhythm – sequence of beats Regular Irregular Note the pattern of irregularity

PULSE Amplitude Reflection of pulse strength & SV Palpate main arterial pulse Carotid Femoral Difficult to palpate SV < 20 ml Diminished pulse SV 20 – 40 ml Bounding pulse SV > 100 ml Pulsus alterans- strong and weak beat occurring alternately Causes: left ventricular failure, toxic myocarditis, paroxysmal tachycardias Pulsus paradoxus- abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration Causes: Tamponade, pericarditis, COPD

Pulsus paradoxus

BLOOD PRESSURE

BLOOD PRESSURE Pressure = Flow x Resistance Blood Pressure = Cardiac Output x Peripheral Resistance Measurement errors (cuff size, transducer placement, pressure bag)

False low reading False high reading Error in technique * * & pain Artery below heart level Artery above heart level Cuff too long Cuff too short Cuff too narrow No systolic estimation Over inflation of cuff Deflation too slow Deflation too fast Re inflation without rest Crossed legs Unsupported arm Tight clothing on upper arm False low reading False high reading Error in technique

ARTERIAL BP Transduced - Device transforms one form of energy into another (Transmits physiological signal from patient and converts to electrical signal in monitor) Level transducer Phlebostatic axis- 4th intercostal space & mid anterior/posterior chest wall Zero procedure To atmospheric pressure & eliminate hydrostatic pr. Check distal area for Warmth Colour Pulse Pain Capillary refill Modified Allan’s test-5-15 secs

ARTERIAL BP Wave form components Anacrotic limb Peak systolic pressure Dicrotic notch- closure of aortic valve Diastole (Square wave test)

ARTERIAL BP

Normal Square Wave Test

Under/ Over damped waveforms

ARTERIAL BP Numerical Components Non Numerical Components Systolic Represent maximum stretch of blood vessel wall Diastolic Represent compliance of blood vessel wall Mean Non Numerical Components Morphology of the waveform

MEAN ARTERIAL PRESSURE Normal MAP = 70-100 mmHg MAP is used in calculating SVR SVR= 80*(MAP-CVP)/CO MAP calculated by: (SBP+2xDBP)/3

Complications of arterial lines Disconnection & Bleeding Inappropriate injection of drugs Arterial Occlusion Air Emboli Nerve Damage Haematoma Pain Infection

Pulse pressure Difference between systolic & diastolic value Normal = 30 – 50 mmHg Narrow Pulse pressures = < 30 mmHg Vasoconstriction e.g. hypovolaemia, Cardiogenic shock, tamponade Wide Pulse Pressures = > 50 mmHg Poor compliance of artery wall, extreme vasodilation, AV reg.,

CENTRAL VENOUS PRESSURE A catheter inserted into one of the central veins Most commonly sits in superior vena cava in RA Transduced Used to estimate blood volume – ‘preload’ cardiac function –dec. compliance will need higher filling pressure to achieve adequate preload CVP is influenced by: right heart function intrathoracic pressure patient positioning Trends rather than absolute values! Interpret alongside other parameters (poor indicator for fluid responsiveness)

CVP waveform

Complications of CVC’s Pneumothorax Thrombophlebitis Misplacement of the catheter Air emboli Bleeding, haematoma Damage to vein Dysrhythmias Infection - Sepsis Removal procedure !!!

Perfusion Supply of Oxygen to the organs O2 carried by haemoglobin in red blood cells Need to maintain flow Inadequate flow leads to organ dysfunction, multiple organ failure and death. Early detection of this is therefore vital Skin Capillary Refill Core to shell temperature gradient < 20C Larger temperature gradient indicate decreased CO and shutdown Cerebral perfusion Metabolic markers of perfusion Urine Output

Haemodynamic monitoring Lidco (use of lithium as an indicator CO estimation,waveform analysis,need art l) Pulmonary artery catheter (gold st. Invasive, thermodilution method) CO SV SVR SVO2, DO2 - perfusion Core temperature - PAC

Indications for haemodynamic monitoring Early detection of problems Provision of additional information (Can measure CO,CI,SV, SVR, DO2, SVO2) Diagnosis To guide or limit therapeutic interventions Data can track responses to treatment

Summary Always use observations in conjunction with “whole patient” observations Baseline observations are very important Accurate & meaningful observations, safety checks Look, listen and feel! Read and practice! 

Reading: Mallett, J. (2013) Critical Care Manual of Clinical Procedures and Competencies Jevon, P. and Ewens, B. (2012) Monitoring the critically ill patient, (3rd Ed)

Any questions?