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

2. 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

3. 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

4. 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)

5. 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.

6. 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

7. 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)

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

9. ?
What do we measure?
Consider Invasive vs. Non-Invasive methods

10. 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

11. 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

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

13. 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

14. Pulsus paradoxus

15. BLOOD PRESSURE

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

17. 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

18. 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

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

20. ARTERIAL BP

21. Normal Square Wave Test

22. Under/ Over damped waveforms

23. 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

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

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

26. 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.,

27. 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)

28. CVP waveform

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

30. 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

31. 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

32. 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

33. 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! 

34. 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)

35. Any questions?