Focus on Nursing Assessment: Cardiovascular System

Focus on Nursing Assessment: Cardiovascular System
(Relates to Chapter 32, “Nursing Assessment: Cardiovascular System,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Structures and Functions of the Cardiovascular System
Heart Four chambers Composed of three layers Endocardium Myocardium Epicardium Structures The heart is a four-chambered hollow muscular organ normally the approximate size of a fist. It lies within the thorax in the mediastinal space that separates the right and left pleural cavities. The heart is composed of three layers: a thin inner lining, the endocardium; a layer of muscle, the myocardium; and an outer layer, the epicardium. The heart is covered by a fibroserous sac called the pericardium. This sac consists of two layers: the inside (visceral) layer of the pericardium (the epicardium), and the outer (parietal) layer. A small amount of pericardial fluid (approximately 10 to 15 mL) lubricates the space between the pericardial layers (pericardial space) and prevents friction between the surfaces as the heart contracts. The heart is divided vertically by the septum. The interatrial septum creates a right and a left atrium, and the interventricular septum creates a right and a left ventricle. The thickness of the wall of each chamber is different. The atrial myocardium is thinner than that of the ventricles, and the left ventricular wall is 2 to 3 times thicker than the right ventricular wall. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Blood Flow Through the Heart
The right atrium receives venous blood from the inferior and superior venae cavae and the coronary sinus. The blood then passes through the tricuspid valve into the right ventricle. With each contraction, the right ventricle pumps blood through the pulmonic valve into the pulmonary artery and to the lungs. Blood flows from the lungs to the left atrium by way of the pulmonary veins. It then passes through the mitral valve and into the left ventricle. As the heart contracts, blood is ejected through the aortic valve into the aorta and thus enters the systemic circulation. Fig Schematic representation of blood flow through the heart. Arrows indicate direction of flow. 1, The right atrium receives venous blood from the inferior and superior venae cavae and the coronary sinus. The blood then passes through the tricuspid valve into the right ventricle. 2, With each contraction, the right ventricle pumps blood through the pulmonic valve into the pulmonary artery and to the lungs. 3, Oxygenated blood flows from the lungs to the left atrium by way of the pulmonary veins. 4, It then passes through the mitral valve and into the left ventricle. 5, As the heart contracts, blood is ejected through the aortic valve into the aorta and thus enters the systemic circulation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Cardiac Valves The four valves of the heart serve to keep blood flowing in a forward direction. The cusps of the mitral and tricuspid valves are attached to thin strands of fibrous tissue termed chordae tendineae. Chordae are anchored in the papillary muscles of the ventricles. This support system prevents eversion of the leaflets into the atria during ventricular contraction. The pulmonic and aortic valves (also known as semilunar valves) prevent blood from regurgitating into the ventricles at the end of each ventricular contraction. Fig Anatomic structures of the heart and heart valves. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

Coronary Arteries and Veins
The myocardium has its own blood supply, the coronary circulation. Blood flow into the two major coronary arteries occurs primarily during diastole (relaxation of the myocardium). The left coronary artery arises from the aorta and divides into two main branches: The left anterior descending artery and the left circumflex artery. These arteries supply the left atrium, the left ventricle, the interventricular septum, and a portion of the right ventricle. The right coronary artery also arises from the aorta, and its branches supply the right atrium, the right ventricle, and a portion of the posterior wall of the left ventricle. In 90% of people, the atrioventricular (AV) node and the bundle of His, part of the cardiac conduction system, receive blood supply from the right coronary artery. For this reason, obstruction of this artery often causes serious defects in cardiac conduction. The divisions of coronary veins parallel those of coronary arteries. Most of the blood from the coronary system drains into the coronary sinus, which empties into the right atrium near the entrance to the inferior vena cava. Fig Coronary arteries and veins. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

Conduction System The conduction system is specialized nerve tissue responsible for creating and transporting the electrical impulse, or action potential. This impulse initiates depolarization and subsequently cardiac contraction. The electrical impulse is initiated by the sinoatrial (SA) node (the pacemaker of the heart). Each impulse generated at the SA node travels through intraatrial pathways to depolarize the atria, resulting in a contraction. The electrical impulse travels from the atria to the AV node through internodal pathways. The excitation then moves through the bundle of His and the left and right bundle branches. The left bundle branch has two fascicles (divisions): Anterior and posterior. The action potential diffuses widely through the walls of both ventricles by means of Purkinje fibers. The efficient ventricular conduction system delivers the impulse within 0.12 second. This triggers a synchronized ventricular contraction. The climax of the cardiac cycle is the ejection of blood into the pulmonary and systemic circulation. It ends with repolarization, when the contractile fiber cells and the conduction pathway cells regain their resting polarized condition. Cardiac muscle cells have a compensatory mechanism that makes them unresponsive or refractory to restimulation during the action potential. During ventricular contraction, an absolute refractory period occurs, during which cardiac muscle does not respond to any stimuli. After this period, cardiac muscle gradually recovers its excitability, and a relative refractory period occurs by early diastole. Fig Location of pain during angina or myocardial infarction. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Electrocardiogram The electrical activity of the heart can be detected on the body surface through the use of electrodes and is recorded on an electrocardiogram (ECG). The letters P, QRS, T, and U are used to identify the separate waveforms. The first wave, P, begins with the firing of the SA node and represents depolarization of the fibers of the atria. The QRS complex represents depolarization from the AV node throughout the ventricles. Impulse transmission through the AV node is delayed, which accounts for the time interval between the end of the P wave and the beginning of the QRS wave. The T wave represents repolarization of the ventricles. The U wave, if seen, may represent repolarization of the Purkinje fibers, or it may be associated with hypokalemia. Intervals between these waves (PR, QRS, and QT intervals) reflect the length of time it takes for the impulse to travel from one area of the heart to another. These time intervals can be measured, and deviations from these time references often indicate pathology. Fig Location of pain during angina or myocardial infarction. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

Mechanical System Systole: Contraction of myocardium Diastole: Relaxation of myocardium Cardiac output: Amount of blood pumped by each ventricle in 1 minute CO = SV × HR Cardiac index: CO divided by body surface area For the normal adult at rest, CO is maintained in the range of 4 to 8 L/min. The normal CI is 2.8 to 4.2 L per minute per meter squared (L/min/m2). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

Factors Affecting Cardiac Output
Preload Volume of blood in ventricles at the end of diastole Contractility Afterload Peripheral resistance against which the left ventricle must pump Preload determines the amount of stretch placed on myocardial fibers. Contractility can be increased by epinephrine and norepinephrine released by the sympathetic nervous system. Increasing contractility raises the SV by increasing ventricular emptying. Afterload is affected by size of the ventricle, wall tension, and arterial blood pressure. If the arterial blood pressure is elevated, the ventricles will meet increased resistance to ejection of blood, increasing the work demand. Eventually, this results in ventricular hypertrophy, an enlargement of cardiac muscle tissue without an increase in CO or the size of the chambers. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Audience Response Question A patient is receiving a drug that decreases afterload. To evaluate the effect of the drug, the nurse monitors the patient’s: 1. Heart rate. 2. Lung sounds. 3. Blood pressure. 4. Jugular vein distention. Answer: 3 Rationale: Afterload is affected by size of the ventricle, wall tension, and arterial blood pressure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

Blood vessels Arteries, arterioles Veins, venules Capillaries Arteries carry blood away from the heart and, except for the pulmonary artery, carry oxygenated blood. Veins carry blood toward the heart and, except for the pulmonary veins, carry deoxygenated blood. Small branches of arteries and veins are arterioles and venules, respectively. Blood circulates from the heart into arteries, arterioles, capillaries, venules, and veins, and then back to the heart. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

Comparison of Artery, Vein, and Capillary
Arteries and Arterioles. The large arteries have thick walls that are composed mainly of elastic tissue. This elastic property cushions the impact of the pressure created by ventricular contraction and provides recoil that propels blood forward into the circulation. Large arteries also contain some smooth muscle. Examples of large arteries are the aorta and the pulmonary artery. The innermost lining of the arteries is the endothelium. The endothelium serves to maintain hemostasis, promote blood flow, and, under normal conditions, inhibit blood coagulation. Capillaries. The thin capillary wall is made up of endothelial cells, with no elastic or muscle tissue. Many miles of capillaries are present in an adult. The exchange of cellular nutrients and metabolic end products takes place through these thin-walled vessels. Veins and Venules. Veins are large-diameter, thin-walled vessels that return blood to the right atrium. The venous system is a low-pressure, high-volume system. The larger veins contain semilunar valves at intervals to maintain the blood flow toward the heart and to prevent backward flow. The amount of blood in the venous system is affected by a number of factors, including arterial flow, compression of veins by skeletal muscles, alterations in thoracic and abdominal pressures, and right atrial pressure. Fig Comparative thickness of layers of the artery, vein, and capillary. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

Regulation of the cardiovascular system Autonomic nervous system Baroreceptors Chemoreceptors Autonomic Nervous System. The autonomic nervous system consists of the sympathetic nervous system and the parasympathetic nervous system. Stimulation of the sympathetic nervous system increases the HR, the speed of impulse conduction through the AV node, and the force of atrial and ventricular contractions. In contrast, stimulation of the parasympathetic system (mediated by the vagus nerve) causes a decrease in HR by slowing the SA node rate and thus conduction through the AV node. Baroreceptors. Baroreceptors in the aortic arch and carotid sinus (at the origin of the internal carotid artery) are sensitive to stretch or pressure within the arterial system. Stimulation of these receptors (e.g., volume overload) sends information to the vasomotor center in the brainstem. This results in temporary inhibition of the sympathetic nervous system and enhancement of the parasympathetic influence, causing a decreased HR and peripheral vasodilation. Decreased arterial pressure causes the opposite effect. Chemoreceptors. Chemoreceptors are located in the aortic and carotid bodies. They are capable of initiating changes in HR and arterial pressure in response to increased arterial CO2 pressure (hypercapnia) and, to a lesser degree, decreased arterial O2 pressure (hypoxia) and decreased plasma pH (acidosis). When the chemoreceptor reflexes are stimulated, they subsequently stimulate the vasomotor center to increase cardiac activity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

Blood pressure Measurement of arterial blood pressure Pulse pressure Mean arterial pressure The arterial blood pressure (BP) is a measure of the pressure exerted by blood against the walls of the arterial system. The systolic blood pressure (SBP) is the peak pressure exerted against the arteries when the heart contracts. The diastolic blood pressure (DBP) is the residual pressure in the arterial system during ventricular relaxation (or filling). Measurement of Arterial Blood Pressure. BP can be measured by invasive and noninvasive techniques. The invasive technique consists of catheter insertion into an artery. The catheter is attached to a transducer, and the pressure is measured directly. Noninvasive, indirect measurement of BP can be done with a sphygmomanometer and a stethoscope. {Instruct students on how to take BP} Pulse pressure is the difference between the SBP and DBP. It is normally about one third of the SBP. If the BP is 120/80, the pulse pressure is 40. An increased pulse pressure may occur during exercise or in individuals with atherosclerosis of the larger arteries as the result of increased SBP. Decreased pulse pressure may be found in heart failure or hypovolemia. Mean arterial pressure (MAP) refers to the average pressure within the arterial system that is felt by organs in the body. It is not the average of the diastolic and systolic pressures because the duration of diastole exceeds that of systole at normal HRs. MAP is calculated as follows: MAP = (SBP + 2 DBP) ÷ 3. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Gerontologic Consideration
Age alters the cardiovascular response to physical and emotional stress. Heart valves become thick and stiff. Frequent need for pacemakers Less sensitive to β-adrenergic agonist drugs Increase in SBP; decrease or no change in DBP With increased age, the amount of collagen in the heart increases and elastin decreases. These changes affect the contractile and distensible properties of the myocardium. One of the major age-associated alterations in the cardiovascular response to physical or emotional stress is a decrease in CO and SV caused by decreased contractility and HR response to increased stress. Cardiac valves become thicker and stiffer from lipid accumulation, degeneration of collagen, and fibrosis. The aortic and mitral valves are most frequently affected. The number of pacemaker cells in the SA node decreases with age. By age 75, a person may have only 10% of the normal number of pacemaker cells. The number and function of β-adrenergic receptors in the heart decrease with age. Therefore the older adult not only has a decreased response to physical and emotional stress but also is less sensitive to β-adrenergic agonist drugs. Arterial and venous blood vessels thicken and become less elastic with age. Arteries increase their sensitivity to vasopressin (antidiuretic hormone). Both of these changes contribute to a progressive increase in SBP and a decrease or no change in DBP with age. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Assessment of Cardiovascular System
Subjective data Health information History of present illness Past health history Past and current medications Surgery or other treatments History of Present Illness. You should ask the patient what problem has brought him/her to the health care facility or provider. Fully explore all symptoms the patient is experiencing, as well as how long they have persisted. Ask the patient to describe what alleviates (e.g., rest) or intensifies (e.g., activity) any symptoms. Past Health History. Many illnesses affect the cardiovascular system directly or indirectly. Ask the patient about a history of chest pain, shortness of breath, fatigue, alcoholism and/or tobacco use, anemia, rheumatic fever, streptococcal throat infection, congenital heart disease, stroke, palpitations, dizziness with position change, syncope, hypertension, thrombophlebitis, intermittent claudication, varicosities, and edema. Medications. Assess the patient’s current and past use of medications. This includes over-the-counter (OTC) drugs, herbal supplements, and prescription drugs. For example, aspirin, which prolongs the blood clotting time, is contained in many drugs used to alleviate cold symptoms. A medication assessment should list the name of the drug, the dose, and the patient’s understanding of its purpose and side effects. Many noncardiac drugs can adversely affect the cardiovascular system and should be assessed. Surgery or Other Treatments. Ask the patient about specific treatments, past surgeries, or hospital admissions related to cardiovascular problems. Any admissions or outpatient procedures for diagnostic workups or cardiovascular symptoms should be explored. It should be noted whether an ECG or a chest x-ray has been done for baseline data. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Functional health patterns (Table 32-3) Health perceptionhealth management pattern Nutritional-metabolic pattern Elimination pattern Activity-exercise pattern Sleep-rest pattern Cognitive-perceptual pattern Health Perception–Health Management Pattern. You should ask the patient about the presence of cardiovascular risk factors. Major risk factors include elevated serum lipids, hypertension, tobacco use, sedentary lifestyle, and obesity. Stressful lifestyle and diabetes mellitus should also be investigated. Nutritional-Metabolic Pattern. Being underweight or overweight may indicate potential cardiovascular problems. Thus it is important to assess the patient’s weight history (e.g., over the past year) in relation to height. Elimination Pattern. The patient on diuretics may report increased urinary elimination and/or nocturia. Investigate any problems with incontinence or constipation, including any use of medications for constipation. Activity-Exercise Pattern. The benefit of exercise for cardiovascular health is indisputable, with sustained aerobic exercise being most beneficial. Inquire about the types of exercise done; the duration, intensity and frequency of each; and the occurrence of any unwanted effects. Sleep-Rest Pattern. Cardiovascular problems often disrupt sleep. Paroxysmal nocturnal dyspnea (attacks of shortness of breath especially at night that awaken the patient) and Cheyne-Stokes respiration are associated with heart failure. Many patients with heart failure may need to sleep with their head elevated on pillows or in a chair. Cognitive-Perceptual Pattern. It is important to ask both the patient and the caregiver about cognitive-perceptual problems. Any pain associated with the cardiovascular system (e.g., chest pain, claudication) should be reported. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17

Functional health patterns Self-perceptionself-concept pattern Role-relationship pattern Sexuality-reproductive pattern Copingstress tolerance pattern Values-belief pattern Self-PerceptionSelf-Concept Pattern. If a cardiovascular event is acute, the patient’s self-perception may be affected. Invasive diagnostic and palliative procedures often lead to body image concerns for the patient. Role-Relationship Pattern. The patient’s gender, race, and age are all related to cardiovascular health and are important basic information. In addition, information on the patient’s marital status, role in the household, employment status, number of children and their ages, living environment, and caregivers assists you in identifying strengths and support systems in the patient’s life. Sexuality-Reproductive Pattern. You should ask the patient about the effect of the cardiovascular problem on sexual patterns and satisfaction. It is common for the patient to have a fear of sudden death during sexual intercourse, causing a major alteration in sexual behavior. CopingStress Tolerance Pattern. Ask the patient to identify areas that cause stress and the usual methods of coping with stress. Values-Beliefs Pattern. Individual values and beliefs, which are greatly affected by culture, may play a significant role in the level of real or potential conflict a patient faces when dealing with a diagnosis of cardiovascular disease. Some patients may attribute their illness to punishment from God; others may feel that a “higher power” may assist them. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

Objective data Physical examination Vital signs Peripheral vascular system Inspection Palpation Auscultation Vital Signs. After the patient’s general appearance has been observed, vital signs, including BP, heart and respiratory rates, and temperature, are taken. Orthostatic (postural) BPs and HRs should be measured while the patient is supine, sitting with legs dangling, and standing. Inspection. Inspect the skin (color, hair distribution, and venous pattern), extremities (edema, dependent rubor, clubbing of the nail beds, varicosities, and lesions such as stasis ulcers), and large veins in the neck (internal and external jugular). Palpation. Palpation of the upper and lower extremities for temperature, moisture, pulses, and edema should be done bilaterally to assess for symmetry. Edema is assessed by depressing the skin over the tibia or medial malleolus for 5 seconds. Palpation of the pulses in the neck and extremities provides information on arterial blood flow. The pulses should be palpated to assess the rhythm (e.g., regular, irregular) and force. Auscultation. An artery that has a narrowed or bulging wall may create turbulent blood flow. This abnormal flow can create a buzzing or humming called a bruit. It can be heard with a stethoscope placed over the vessel. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Common Sites for Palpating Arteries
Fig Common sites for palpating arteries. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Assessment of the Cardiovascular System
Physical examination (cont’d) Thorax Inspection Palpation Percussion Auscultation Inspection and Palpation. An overall inspection and palpation of the bony structures of the thorax is the initial step in the examination. Next, inspect and palpate the areas where the cardiac valves project their sounds by identifying the intercostal spaces (ICSs). Next, the epigastric area, which lies on either side of the midline just below the xiphoid process, is inspected and palpated. Next, the precordium, which is located over the heart, is inspected for heaves. Percussion. The borders of the right and left sides of the heart can be estimated by percussion. Auscultation. The first heart sound (S1), which is associated with closure of the tricuspid and mitral valves, has a soft lub sound. The second heart sound (S2), which is associated with closure of the aortic and pulmonic valves, has a sharp dup sound. S1 signals the beginning of systole. S2 signals the beginning of diastole. {See next slide for more on auscultation} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

Cardiac Auscultatory Areas
The following auscultatory areas can be located: The aortic area in the second ICS to the right of the sternum, the pulmonic area in the second ICS to the left of the sternum, the tricuspid area in the fifth left ICS close to the sternum, and the mitral area in the left midclavicular line at the fifth ICS. A fifth auscultatory area is Erb’s point, located at the third left ICS near the sternum. Normally, no pulsations are felt in these areas unless the patient has a thin chest wall. S1 and S2 are heard best with the diaphragm of the stethoscope because they are high pitched. When auscultating the apical area, you should simultaneously palpate the radial pulse. A judgment about the rhythm (regular or irregular) is made while listening. Normally, no sound is heard between S1 and S2 during the periods of systole and diastole. The S3 heart sound is a low-intensity vibration of the ventricular walls usually associated with decreased compliance of the ventricles during filling. The S4 heart sound is a low-frequency vibration caused by atrial contraction. It precedes S1 of the next cycle and is known as an atrial gallop. Fig Orientation of the heart within the thorax and cardiac auscultatory areas. Red lines indicate the midsternal line (MSL), midclavicular line (MCL), and anterior axillary line (AAL). ICS, intercostal space; PMI, point of maximal impulse. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

Relationship of Electrocardiogram, Cardiac Cycle, and Heart Sounds
Fig Relationship of electrocardiogram, cardiac cycle, and heart sounds. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

Diagnostic Studies of Cardiovascular System
Noninvasive studies Blood studies Chest x-ray Electrocardiogram Resting ECG Ambulatory ECG monitoring Event monitor or loop recorder Exercise or stress testing 6-minute walk test Blood Studies. When cells are injured, they release their contents, including enzymes and other proteins, into the circulation. These biomarkers are useful in the diagnosis of myocardial injury and necrosis: Creatine kinase (CK) enzymes, cardiac-specific troponin, myoglobin, triglycerides, cholesterol, phospholipids, apolipoprotein A-l (apo A-l), the ratio of apo A-I to apolipoprotein B (apo B), lipoprotein-associated phospholipase A2 (Lp-PLA2), C-reactive protein (CRP), homocysteine (Hcy), and three natriuretic peptides. Chest X-ray. A radiographic picture can depict cardiac contours, heart size and configuration, and anatomic changes in individual chambers. {See next slide} Electrocardiogram. The basic P, QRS, and T waveforms are used to assess cardiac function. Deviations from the normal sinus rhythm can indicate abnormalities in heart function. Many types of electrocardiographic monitoring may be used, including resting ECG, ambulatory ECG monitoring, and exercise or stress testing. A resting ECG helps identify at one point in time primary conduction abnormalities, cardiac dysrhythmias, cardiac hypertrophy, pericarditis, myocardial ischemia, site and extent of MI, pacemaker performance, and effectiveness of drug therapy. Continuous ambulatory ECG (Holter monitoring) can provide diagnostic information over a longer period of time than a standard resting ECG. An event monitor or loop recorder may be useful to document less frequent ECG events. Exercise testing is a method used to evaluate the cardiovascular response to physical stress. A 6-minute walk test may be used for patients with heart or peripheral arterial disease to measure response to medical interventions and to determine functional capacity for daily physical activities. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

Audience Response Question A patient arrives at an urgent care center after experiencing unrelenting substernal and epigastric pain and pressure for about 12 hours. The nurse reviews laboratory results with the understanding that at this point in time, a myocardial infarction would by indicated by peak levels of: 1. Troponin T. 2. Homocysteine. 3. Creatine kinase-MB. 4. Type b natriuretic peptide. Answer: 1 Rationale: Troponin is the biomarker of choice in the diagnosis of myocardial infarction. Troponin is a myocardial muscle protein released into the circulation after injury. Troponin levels peak at 10 to 24 hours. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

Noninvasive studies Echocardiogram Nuclear cardiology Echocardiogram. The echocardiogram uses ultrasound waves to record the movement of the structures of the heart. The echocardiogram provides information about abnormalities of (1) valvular structure and motion, (2) cardiac chamber size and contents, (3) ventricular muscle and septal motion and thickness, (4) pericardial sac, and (5) ascending aorta. {See next slide for figure of echocardiogram} Nuclear Cardiology. One of the most common nuclear imaging tests is the multigated acquisition (MUGA) or cardiac blood pool scan. This test provides information on wall motion during systole and diastole, cardiac valves, and EF. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

Echocardiogram Apical four-chamber two-dimensional echocardiographic view in a normal patient. Fig Apical four-chamber two-dimensional echocardiographic view in a normal patient. LA, Left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium; RV, right ventricle; TV, tricuspid valve. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

Noninvasive studies (cont’d) Magnetic resonance imaging Computed tomography MRI. Although not widely used because of equipment size and access, magnetic resonance imaging (MRI) can detect and localize areas of MI in a three-dimensional view. It is sensitive enough to gauge even small MIs not apparent with SPECT imaging and can assist in the final diagnosis of MI and the assessment of EF. It is also beginning to play a role in prediction of recovery from MI and in the diagnosis of congenital heart and aortic disorders. Its utility for the diagnosis of CAD is still being studied. Computed Tomography Angiography. Computed tomography angiography (CTA) with spiral technology is a noninvasive scan used to quantify calcium deposits in coronary arteries. Electron beam computed tomography (EBCT), also known as ultrafast CT, uses a scanning electron beam to quantify calcification in the coronary arteries and heart valves. A calcium score is formulated for a segment of a coronary artery, a specific coronary artery, or the entire coronary system. Currently, EBCT testing is used primarily for risk assessment in asymptomatic patients and to assess for heart disease in patients with atypical symptoms potentially due to cardiac causes. {See next slide for figure} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

Computed Tomography Examples of coronary calcification of the left anterior descending coronary artery (large arrow) and the left circumflex artery (small arrow), as seen on electron beam computed tomography. Fig Examples of coronary calcification of the left anterior descending coronary artery (large arrow) and left circumflex artery (small arrow) as seen on electron beam computed tomography. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

Invasive studies Cardiac catheterization and coronary angiography Intracoronary ultrasound Fractional flow reserve Electrophysiology study Blood flow and pressure measurements Cardiac Catheterization. It provides information about CAD, coronary spasm, congenital and valvular heart disease, and ventricular function. Cardiac catheterization is also used to measure intracardiac pressures and O2 levels, as well as CO and EF. Intracoronary Ultrasound. Intracoronary ultrasound (ICUS), also known as intravascular ultrasound (IVUS), is an invasive procedure performed in the catheterization laboratory in conjunction with coronary angiography. The 2-D or 3-D ultrasound images provide a cross-sectional view of the arterial walls of the coronary arteries. Fractional Flow Reserve. Fractional flow reserve (FFR) is a procedure that is done during a cardiac catheterization. It involves using a special wire that can measure pressure and flow in the coronary artery. Electrophysiologic Study. Electrophysiologic study (EPS) is the direct study and manipulation of the electrical activity of the heart using electrodes placed inside the cardiac chambers. It provides information on SA node function, AV node conduction, and ventricular conduction. Blood Flow and Pressure Measurements. Peripheral Vessel Blood Flow. Duplex imaging is useful in the diagnosis of occlusive disease in the peripheral blood vessels and for the diagnosis of thrombophlebitis. Peripheral vessel blood flow is assessed by injecting contrast media into the appropriate arteries or veins (arteriography or venography). Hemodynamic Monitoring. Bedside hemodynamic monitoring of pressures of the cardiovascular system is frequently used to assess cardiovascular status and monitor patient response to interventions. Invasive hemodynamic monitoring using intraarterial and pulmonary artery catheters can be used to monitor arterial BP, intracardiac pressures, and CO. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

Audience Response Question A patient returns to the cardiac observation area following a cardiac catheterization with coronary angiography. Which of the following assessments would require immediate action by the nurse? 1. Pedal pulses are 2+ bilaterally. 2. Apical pulse is 54 beats/minute. 3. Mean arterial pressure is 72 mm Hg. 4. ST-segment elevation develops on the ECG. Answer: 4 Rationale: ST elevation on ECG indicates myocardial ischemia or injury with partial or total occlusion of a coronary artery. This assessment finding requires immediate action. Actions would include assessment for chest pain, 12-lead ECG, administration of nitroglycerin or morphine, and notification of the health care provider. Option 1 would need further assessment but is not critical unless the patient is symptomatic (chest pain, shortness of breath, hypotension, etc.). Options 2 and 3 are normal findings. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33 33

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