Guided Lecture Notes
Chapter 25 , Assessment of Cardiovascular Function
Learning Objective 1. Describe the relationship between the anatomic structures and the physiologic function of the cardiovascular system.
· Review the pattern of blood flow through the body.
· Review the anatomy and function of the structures of the heart. (Refer to PowerPoint slides 2 and 3 , Fig ure 25- 1.)
· Describe the anatomy and function of the coronary arteries.
o Anatomy of the heart
§ Heart chambers
§ Heart valves
· Atrioventricular valves
· Semilunar valves
§ Coronary arteries
§ Myocardium
o Function of the heart
§ Cardiac electrophysiology
· Cardiac action potential
· Refractory periods
§ Cardiac hemodynamics
· Cardiac cycle
· Cardiac output
o Control of heart rate
o Control of stroke volume
· Explain the cardiac conduction system. Trace the pattern of normal impulse conduction through the heart. Briefly relate this pattern to the ECG tracing. (Refer to PowerPoint slide 4 , Fig ure 25- 3.)
· iClicker question (Refer to PowerPoint slides 5 and 6.)
· Explain the cardiac action potential. Define and discuss the terms listed. (Refer to PowerPoint slides 7 and 8.)
· Describe the movement of the ions in relation to depolarization and repolarization. (Refer to PowerPoint slide 9 , Fig ure 25- 4.)
· Describe the pressure changes that occur in the vessels and chambers of the heart with systole and diastole. (Refer to PowerPoint slide 10, Fig ure 25- 2.)
· Define cardiac output and the terms listed. (Refer to PowerPoint slide 11 and 12.)
· Explain the factors that affect cardiac output. (Refer to PowerPoint slides 13 and 14.)
· iClicker question (Refer to PowerPoint slides 15 and 16.)
Learning Objective 2. Incorporate assessment of cardiac risk factors into the health history and physical assessment of the patient with cardiovascular disease.
· When discussing the assessment of the patient with cardiovascular disease, mention that the assessment must be modified to the needs of the patient and the clinical situation.
· Describe the health history as it applies to cardiovascular disease.
· List and differentiate modifiable and nonmodifiable cardiac risk factors. (Refer to PowerPoint slide 17.)
· Describe the most common clinical manifestations related to cardiac dysfunction. (Refer to PowerPoint slide 18.)
· iClicker question (Refer to PowerPoint slides 19 and 20.)
Learning Objective 3. Explain the proper techniques to perform a comprehensive cardiovascular assessment.
· Discuss the complete assessment of the patient as it applies to the cardiac system. (Refer to PowerPoint slide s 21 and 22.)
o Assessment of the cardiovascular system
§ Health history
· Common chief complaints
o Chest pain
o Symptoms of acute coronary syndrome
· Past health, family, and social history
o Age-related changes
o Medications
o Nutrition
o Elimination
o Activity and exercise
o Sleep and rest
o Self-perception and self-concept
o Roles and relationships
o Sexuality and reproduction
o Coping and stress tolerance
o Prevention strategies
Learning Objective 4. Discriminate between normal and abnormal assessment findings identified by inspection, palpation, percussion, and auscultation of the cardiovascular system.
§ Physical assessment
· General appearance
· Inspection of the skin
· Blood pressure
o Pulse pressure
o Postural blood pressure changes
· Arterial pulses
o Pulse rate
o Pulse rhythm
o Pulse quality
o Pulse configuration
o Effect of vessel quality on pulse
o Palpation of arterial pulses
· Jugular venous pulsations
· Heart inspection and palpation
· Heart auscultation
o Normal heart sounds
§ S1: first heart sound
§ S2: second heart sound
o Abnormal heart sounds
§ S3: third heart sound
§ S4: fourth heart sound
§ Opening snaps and systolic clicks
§ Murmurs
§ Friction rub
o Auscultation procedure
o Interpretation of heart sounds
· Inspection of the extremities
· Assessment of other systems
o Lungs
o Abdomen
Learning Objective 5. Recognize and evaluate the major manifestations of cardiovascular dysfunction by applying concepts from the patient’s health history and physical assessment findings.
· Discuss the assessment of functional health patterns as these relate to the cardiovascular disease.
· Discuss the specific questions that may be asked in assessment of the patient’s perception and management of his or her health as this relates to cardiovascular disease (Refer to PowerPoint slides 23 and 24.)
Learning Objective 6. Discuss the clinical indications, patient preparation, and other related nursing implications for common tests and procedures used to assess cardiovascular function and diagnose cardiovascular diseases.
· List and explain the common laboratory tests used to assess the cardiovascular system. Include indications and nursing implications in this discussion. Include patient preparation and posttest care. For example, state that the patient is NPO prior to lipid profile.
· Ask students if they know their cholesterol and other blood lipid levels. Use the students’ answers to emphasize health promotion and patient teaching.
· Relate the results of tests to the nursing care of the patient.
· Discuss other common laboratory tests and their implications for patients with cardiovascular disease (Refer to PowerPoint slide 25 , Table 25- 4.)
· List and explain the types of electrocardiography. Describe the clinical indications, patient preparation, and nursing implications for each. (Refer to PowerPoint slides 26 and 27.)
o Electrocardiography
§ Continuous electrocardiographic monitoring
· Hardwire cardiac monitoring
· Telemetry
· Lead systems
· Ambulatory electrocardiography
· Transtelephonic monitoring
· Wireless mobile cardiac monitoring systems
· List and explain the diagnostic tests used to assess the cardiovascular system. Include indications and nursing implications for each. (Refer to PowerPoint slide 28.)
o Radionuclide imaging
o Myocardial perfusion imaging
o Test of ventricular function and wall motion
o Computed tomography (CT)
o Positron emission tomography (PET)
o Magnetic resonance angiography (MRA)
· Describe the specific nursing care of the patient undergoing a cardiac catherization. (Refer to PowerPo int slides 29 and 30.)
o Nursing responsibilities before cardiac catheterization include the following:
§ The patient is instructed to fast, usually for 8 to 12 hours, before the procedure. If catheterization is to be performed as an outpatient procedure, a friend, family member, or other responsible person must transport the patient home.
§ The patient is informed of the expected duration of the procedure and advised that it will involve lying on a hard table for less than 2 hours.
§ The patient is reassured that IV medications are given to maintain comfort.
§ The patient is informed about sensations that will be experienced during the catheterization. Knowing what to expect can help the patient cope with the experience. The nurse explains that an occasional pounding sensation (palpitation) may be felt in the chest because of extra heart beats that almost always occur, particularly when the catheter tip touches the endocardium. The patient may be asked to cough and to breathe deeply, especially after the injection of contrast agent. Coughing may help disrupt a dysrhythmia and clear the contrast agent from the arteries. Breathing deeply and holding the breath help lower the diaphragm for better visualization of heart structures. The injection of a contrast agent into either side of the heart may produce a flushed feeling throughout the body and a sensation similar to the need to void, which subsides in 1 minute or less.
§ The patient is encouraged to express fears and anxieties. The nurse provides teaching and reassurance to reduce apprehension.
o Nursing responsibilities after cardiac catheterization may include the following:
§ The catheter access site is observed for bleeding or hematoma formation. Peripheral pulses are assessed in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, and then every 1 to 2 hours until the pulses are stable.
§ Temperature, color, and capillary refill of the affected extremity are evaluated frequently, per local nursing standards. The patient is assessed for affected extremity pain, numbness, or tingling sensations that may indicate arterial insufficiency. Any changes are reported promptly.
§ Dysrhythmias are screened carefully by observing the cardiac monitor or by assessing the apical and peripheral pulses for changes in rate and rhythm. A vasovagal reaction, consisting of bradycardia, hypotension, and nausea, can be precipitated by a distended bladder or by discomfort from manual pressure that is applied during removal of an arterial or venous catheter. The vasovagal response is reversed by promptly elevating the lower extremities above the level of the heart, infusing a bolus of IV fluid, and administering IV atropine to treat the bradycardia.
§ Bed rest is maintained for 2 to 6 hours after the procedure. If manual or mechanical pressure is used, the patient must remain on bed rest for up to 6 hours with the affected leg straight and the head of the bed elevated no greater than 30 degrees. For comfort, the patient may be turned from side to side with the affected extremity straight. If the cardiologist deployed a percutaneous vascular closure device or patch, the nurse checks local nursing care standards and anticipates that the patient will have fewer activity restrictions. The patient may be permitted to ambulate within 2 hours. Analgesic medication is administered as prescribed for discomfort.
§ The patient is instructed to report promptly chest pain and bleeding or sudden discomfort from the catheter insertion sites.
§ The patient is monitored for contrast agent-induced nephropathy by observing for elevations in serum creatinine levels. Oral and IV hydration is used to increase urinary output and flush the contrast agent from the urinary tract; accurate intake and output are recorded.
§ Patient safety is assured by instructing the patient to ask for help when getting out of bed the first time after the procedure. The patient is monitored for bleeding from the catheter access site and for orthostatic hypotension, indicated by complaints of dizziness or lightheadedness.
Learning Objective 7. Compare the various methods of hemodynamic monitoring (e.g., central venous pressure, pulmonary artery pressure, and arterial pressure monitoring) with regard to indications for use, potential complications, and nursing responsibilities.
· Explain and compare hemodynamic monitoring: CVP, PA, and arterial pressure monitoring. (Refer to PowerPoint slide 31.)
· Describe how to obtain a reading for each. (Refer to PowerPoint slide s 32 and 33 , Figure s 25-10 and 25-12.)
· State normal values. Discuss interpretation of data.
· Discuss the potential complications, required nursing assessments, and the nursing responsibilities related to each of these monitoring procedures.