Assessment of the Assessment of the Cardiovascular SystemCardiovascular System

Surface anatomy of the heart

The human heart is a cone-shaped, hollow, The human heart is a cone-shaped, hollow, muscular organ located in the mediastinum muscular organ located in the mediastinum between the lungs. between the lungs.

It is approximately the size of an adult fist. It is approximately the size of an adult fist. The heart rests on the diaphragm, tilting The heart rests on the diaphragm, tilting

forward and to the left in the client's chest. forward and to the left in the client's chest. Each beat of the heart pumps approximately Each beat of the heart pumps approximately

60 mL of blood, or approximately 5 L/min. 60 mL of blood, or approximately 5 L/min. During strenuous physical activity, the heart During strenuous physical activity, the heart

can double the amount of blood pumped to can double the amount of blood pumped to meet the increased oxygen needs of the meet the increased oxygen needs of the peripheral tissuesperipheral tissues

RIGHT SIDERIGHT SIDE The right atrium is a thin-walled structure that receives The right atrium is a thin-walled structure that receives

deoxygenated venous blood (venous return) from all deoxygenated venous blood (venous return) from all peripheral tissues by way of the superior and inferior venae peripheral tissues by way of the superior and inferior venae cavae and from the heart muscle by way of the coronary cavae and from the heart muscle by way of the coronary sinus. Most of this venous return flows passively from the sinus. Most of this venous return flows passively from the right atrium, through the opened tricuspid valve, and to the right atrium, through the opened tricuspid valve, and to the right ventricle during ventricular diastole, or filling. The right ventricle during ventricular diastole, or filling. The remaining venous return is actively propelled by the right remaining venous return is actively propelled by the right atrium into the right ventricle during atrial systole, or atrium into the right ventricle during atrial systole, or contraction.contraction.

The right ventricle is a flat muscular pump located behind the The right ventricle is a flat muscular pump located behind the sternum. The right ventricle generates enough pressure sternum. The right ventricle generates enough pressure (approximately 25 mm Hg) to close the tricuspid valve, open (approximately 25 mm Hg) to close the tricuspid valve, open the pulmonic valve, and propel blood into the pulmonary the pulmonic valve, and propel blood into the pulmonary artery and the lungs. The workload of the right ventricle is artery and the lungs. The workload of the right ventricle is light compared with that of the left ventricle because the light compared with that of the left ventricle because the pulmonary system is a low-pressure system, which imposes pulmonary system is a low-pressure system, which imposes less resistance to flowless resistance to flow

LEFT SIDELEFT SIDE After blood is reoxygenated in the lungs, it flows After blood is reoxygenated in the lungs, it flows

freely from the four pulmonary veins into the left freely from the four pulmonary veins into the left atrium. Blood then flows through an opened mitral atrium. Blood then flows through an opened mitral valve into the left ventricle during ventricular valve into the left ventricle during ventricular diastole. diastole.

When the left ventricle is almost full, the left atrium When the left ventricle is almost full, the left atrium contracts, pumping the remaining blood volume contracts, pumping the remaining blood volume into the left ventricle. With systolic contraction, the into the left ventricle. With systolic contraction, the left ventricle generates enough pressure left ventricle generates enough pressure (approximately 120 mm Hg) to close the mitral (approximately 120 mm Hg) to close the mitral valve and open the aortic valve. Blood is propelled valve and open the aortic valve. Blood is propelled into the aorta and into theinto the aorta and into the systemic arterial systemic arterial circulationcirculation

Blood is propelled from the aorta throughout the Blood is propelled from the aorta throughout the systemic circulation to the various tissues of the systemic circulation to the various tissues of the body; blood returns to the right atrium because of body; blood returns to the right atrium because of pressure differences. pressure differences.

The pressure of blood in the aorta of a young The pressure of blood in the aorta of a young adult averages approximately 100 to 120 mm Hg, adult averages approximately 100 to 120 mm Hg, whereas the pressure of blood in the right atrium whereas the pressure of blood in the right atrium averages about 0 to 5 mm Hg. These differences averages about 0 to 5 mm Hg. These differences in pressure produce a pressure gradient, with in pressure produce a pressure gradient, with blood flowing from an area of higher pressure to blood flowing from an area of higher pressure to an area of lower pressure. an area of lower pressure.

The heart and vascular structures are responsible The heart and vascular structures are responsible for maintaining these pressuresfor maintaining these pressures

Blood flow through the heart

ATRIOVENTRICULAR VALVESATRIOVENTRICULAR VALVES The AV valves separate the atria from the The AV valves separate the atria from the

ventricles. ventricles. The tricuspid valve is composed of three leaflets The tricuspid valve is composed of three leaflets

and separates the right atrium from the right and separates the right atrium from the right ventricle. ventricle.

The mitral (bicuspid) valve is composed of two The mitral (bicuspid) valve is composed of two leaflets and separates the left atrium from the left leaflets and separates the left atrium from the left ventricleventricle

During ventricular diastole, the valves act as During ventricular diastole, the valves act as funnels and facilitate the flow of blood from the funnels and facilitate the flow of blood from the atria to the ventricles. During systole, the valves atria to the ventricles. During systole, the valves close to prevent the backflow (regurgitation) of close to prevent the backflow (regurgitation) of blood into the atriablood into the atria

SEMILUNAR VALVESSEMILUNAR VALVES There are two semilunar valves: the pulmonic There are two semilunar valves: the pulmonic

valve and the aortic valve. valve and the aortic valve. The pulmonic valve separates the right ventricle The pulmonic valve separates the right ventricle

from the pulmonary artery. from the pulmonary artery. The aortic valve separates the left ventricle from The aortic valve separates the left ventricle from

the aorta. the aorta. Each semilunar valve consists of three cuplike Each semilunar valve consists of three cuplike

cusps, or pockets, around the inside wall of the cusps, or pockets, around the inside wall of the artery. These cusps prevent blood from flowing artery. These cusps prevent blood from flowing back into the ventricles during ventricular back into the ventricles during ventricular diastole. During ventricular systole, these valves diastole. During ventricular systole, these valves are open to permit blood flow into the pulmonary are open to permit blood flow into the pulmonary artery and the aortaartery and the aorta

Coronary arterial system

LEFT CORONARY ARTERYLEFT CORONARY ARTERY The LCA divides into two branches: the left anterior The LCA divides into two branches: the left anterior

descending (LAD) and the circumflex coronary artery (LCX). descending (LAD) and the circumflex coronary artery (LCX). The LAD branch descends toward the anterior wall and the The LAD branch descends toward the anterior wall and the apex of the left ventricle. It supplies blood to portions of the apex of the left ventricle. It supplies blood to portions of the left ventricle, ventricular septum, chordae tendineae, left ventricle, ventricular septum, chordae tendineae, papillary muscle, and right ventricle.papillary muscle, and right ventricle.

The LCX descends toward the lateral wall of the left The LCX descends toward the lateral wall of the left ventricle and apex. It supplies blood to the left atrium, the ventricle and apex. It supplies blood to the left atrium, the lateral and posterior surfaces of the left ventricle, and lateral and posterior surfaces of the left ventricle, and sometimes portions of the interventricular septum. In 45% sometimes portions of the interventricular septum. In 45% of people, the LCX supplies the sinoatrial (SA) node, and in of people, the LCX supplies the sinoatrial (SA) node, and in 10% of people it supplies the AV node. 10% of people it supplies the AV node.

Peripheral branches (diagonal and obtuse marginal) arise Peripheral branches (diagonal and obtuse marginal) arise from the LAD and LCX and form an abundant network of from the LAD and LCX and form an abundant network of vessels throughout the entire myocardiumvessels throughout the entire myocardium

RIGHT CORONARY ARTERYRIGHT CORONARY ARTERY The RCA originates from the right sinus of The RCA originates from the right sinus of

Valsalva, encircles the heart, and descends Valsalva, encircles the heart, and descends toward the apex of the right ventricle. toward the apex of the right ventricle.

The RCA supplies the right atrium, right The RCA supplies the right atrium, right ventricle, and inferior portion ofventricle, and inferior portion of the left the left ventricle. ventricle.

In most people (more than 50%), the RCA In most people (more than 50%), the RCA supplies the SA node and the AV node. supplies the SA node and the AV node.

Considerable variation in the branching Considerable variation in the branching pattern of the coronary arteries exists pattern of the coronary arteries exists among individualsamong individuals

Conduction system of the heart

The cardiac conduction system is composed of specialized The cardiac conduction system is composed of specialized tissue capable of rhythmic electrical impulse formation. It can tissue capable of rhythmic electrical impulse formation. It can conduct impulses much more rapidly than other cells located conduct impulses much more rapidly than other cells located in the myocardium. in the myocardium.

The SA node, located at the junction of the right atrium and The SA node, located at the junction of the right atrium and the superior vena cava, is considered the main regulator of the superior vena cava, is considered the main regulator of heart rate. The SA node is composed of pacemaker cells, heart rate. The SA node is composed of pacemaker cells, which spontaneously initiate impulses at a rate of 60 to 100 which spontaneously initiate impulses at a rate of 60 to 100 times per minute and myocardial working cells, which times per minute and myocardial working cells, which transmit the impulses to the surrounding atrial muscletransmit the impulses to the surrounding atrial muscle

An impulse from the SA node initiates the process of An impulse from the SA node initiates the process of depolarization and hence the activation of all myocardial depolarization and hence the activation of all myocardial cells. The impulse travels through both atria to the cells. The impulse travels through both atria to the atrioventricular (AV) node located in the junctional area. After atrioventricular (AV) node located in the junctional area. After the impulse reaches the AV node, conduction of the impulse the impulse reaches the AV node, conduction of the impulse is delayed briefly. This delay allows the atria to contract is delayed briefly. This delay allows the atria to contract completely before the ventricles are stimulated to contract. completely before the ventricles are stimulated to contract. The intrinsic rate of the AV node is 40 to 60 beats/min.The intrinsic rate of the AV node is 40 to 60 beats/min.

The Bundle of His is a continuation of the AV node The Bundle of His is a continuation of the AV node and is located in the interventricular septum. It and is located in the interventricular septum. It divides into the right and left bundle branches. divides into the right and left bundle branches.

The bundle branches extend downward through The bundle branches extend downward through the ventricular septum and fuse with the Purkinje the ventricular septum and fuse with the Purkinje fiber system. fiber system.

The Purkinje fibers are the terminal branches of The Purkinje fibers are the terminal branches of the conduction system and are responsible for the conduction system and are responsible for carrying the wave of depolarization to both carrying the wave of depolarization to both ventricular walls. Purkinje fibers can act as an ventricular walls. Purkinje fibers can act as an intrinsic pacemaker, but their discharge rate is intrinsic pacemaker, but their discharge rate is only 20 to 40 beats/min. only 20 to 40 beats/min.

Thus these intrinsic pacemakers seldom initiate Thus these intrinsic pacemakers seldom initiate an electrical impulsean electrical impulse

Mechanical properties of the Mechanical properties of the heartheart

The electrical and mechanical properties of The electrical and mechanical properties of cardiac muscle determine the function of the cardiac muscle determine the function of the cardiovascular system. The heart is able to adapt cardiovascular system. The heart is able to adapt to various pathophysiologic conditions (e.g., to various pathophysiologic conditions (e.g., stress, infections, and hemorrhage) to maintain stress, infections, and hemorrhage) to maintain adequate blood flow to the various body tissues. adequate blood flow to the various body tissues.

Blood flow from the heart into the systemic Blood flow from the heart into the systemic arterial circulation is measured clinically as arterial circulation is measured clinically as cardiac output (CO), the amount of blood pumped cardiac output (CO), the amount of blood pumped from the left ventricle each minute. CO depends from the left ventricle each minute. CO depends on the relationship between heart rate (HR) and on the relationship between heart rate (HR) and stroke volume (SV); it is the product of these two stroke volume (SV); it is the product of these two variables:variables:

Cardiac output = Heart rate x Stroke volumeCardiac output = Heart rate x Stroke volume

CARDIAC OUTPUT AND CARDIAC INDEXCARDIAC OUTPUT AND CARDIAC INDEX Cardiac output (CO) is the volume of blood Cardiac output (CO) is the volume of blood

(in liters) ejected by the heart each minute. (in liters) ejected by the heart each minute. In adults, the CO ranges from 4 to 7 L/min. In adults, the CO ranges from 4 to 7 L/min.

Because cardiac output requirements vary Because cardiac output requirements vary according to body size, the cardiac index is according to body size, the cardiac index is calculated to adjust for differences in body calculated to adjust for differences in body size. size.

The cardiac index can be determined by The cardiac index can be determined by dividing the CO by the body surface area. dividing the CO by the body surface area.

The normal range is 2.7 to 3.2 L/min/m2 of The normal range is 2.7 to 3.2 L/min/m2 of body surface areabody surface area

HEART RATEHEART RATE Heart rate refers to the number of times the ventricles contract each Heart rate refers to the number of times the ventricles contract each

minute. The normal resting heart rate for an adult is between 60 and minute. The normal resting heart rate for an adult is between 60 and 100 beats/min. Increases in heart rate increase myocardial oxygen 100 beats/min. Increases in heart rate increase myocardial oxygen demand. demand.

Heart rate is extrinsically controlled by the autonomic nervous system, Heart rate is extrinsically controlled by the autonomic nervous system, which adjusts rapidly when necessary to regulate cardiac output. The which adjusts rapidly when necessary to regulate cardiac output. The parasympathetic system slows the heart rate, whereas sympathetic parasympathetic system slows the heart rate, whereas sympathetic stimulation has an excitatory effect. An increase in circulating stimulation has an excitatory effect. An increase in circulating endogenous catecholamine (e.g., epinephrine and norepinephrine) endogenous catecholamine (e.g., epinephrine and norepinephrine) usually causes an increase in heart rate, and vice versa.usually causes an increase in heart rate, and vice versa.

Other factors, such as the central nervous system (CNS) and Other factors, such as the central nervous system (CNS) and baroreceptor (pressoreceptor) reflexes, influence the effects of the baroreceptor (pressoreceptor) reflexes, influence the effects of the autonomic nervous system on heart rate. Pain, fear, and anxiety can autonomic nervous system on heart rate. Pain, fear, and anxiety can increase heart rate. increase heart rate.

The baroreceptor reflex acts as a negative-feedback system. If a client The baroreceptor reflex acts as a negative-feedback system. If a client experiences hypotension, the baroreceptors in the aortic arch sense a experiences hypotension, the baroreceptors in the aortic arch sense a lessened pressure in the blood vessels. A signal is relayed to the lessened pressure in the blood vessels. A signal is relayed to the parasympathetic system to have less of an inhibitory effect on the parasympathetic system to have less of an inhibitory effect on the sinoatrial (SA) node; this results in a reflex increase in heart ratesinoatrial (SA) node; this results in a reflex increase in heart rate

STROKE VOLUMESTROKE VOLUME Stroke volume is the amount of blood Stroke volume is the amount of blood

ejected by the left ventricle during ejected by the left ventricle during each systole. Severaleach systole. Several variables variables influence stroke volume and, influence stroke volume and, ultimately, CO. ultimately, CO.

These variables include heart rate, These variables include heart rate, preload, afterload, and contractilitypreload, afterload, and contractility

PRELOADPRELOAD Preload refers to the degree of myocardial fiber stretch at Preload refers to the degree of myocardial fiber stretch at

the end of diastole and just before contraction. The stretch the end of diastole and just before contraction. The stretch imposed on the muscle fibers results from the volume imposed on the muscle fibers results from the volume contained within the ventricle at the end of diastole. contained within the ventricle at the end of diastole. Preload is determined by left ventricular end-diastolic Preload is determined by left ventricular end-diastolic (LVED) volume.(LVED) volume.

An increase in ventricular volume increases muscle fiber An increase in ventricular volume increases muscle fiber length and tension, thereby enhancing contraction and length and tension, thereby enhancing contraction and improving stroke volume. improving stroke volume.

This statement is derived from Starling's law of the heart: This statement is derived from Starling's law of the heart: the more the heart is filled during diastole (within limits), the more the heart is filled during diastole (within limits), the more forcefully it contracts. the more forcefully it contracts.

However, excessive filling of the ventricles results in However, excessive filling of the ventricles results in excessive LVED volume and pressure and a decreased excessive LVED volume and pressure and a decreased cardiac outputcardiac output

AFTERLOAD. AFTERLOAD. Afterload is the pressure or resistance that the Afterload is the pressure or resistance that the

ventricles must overcome to eject blood through ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood the semilunar valves and into the peripheral blood vessels. The amount of resistance is directly vessels. The amount of resistance is directly related to arterial blood pressure and the diameter related to arterial blood pressure and the diameter of the blood vessels.of the blood vessels.

Impedance, the peripheral component of afterload, Impedance, the peripheral component of afterload, is the pressure that the heart must overcome to is the pressure that the heart must overcome to open the aortic valve. The amount of impedance open the aortic valve. The amount of impedance depends on aortic compliance and total systemic depends on aortic compliance and total systemic vascular resistance, a combination of blood vascular resistance, a combination of blood viscosity and arteriolar constriction. viscosity and arteriolar constriction.

A decrease in stroke volume can result from an A decrease in stroke volume can result from an increase in afterload without the benefit of increase in afterload without the benefit of compensatory mechanismscompensatory mechanisms

CONTRACTILITYCONTRACTILITY Contractility also affects stroke volume and Contractility also affects stroke volume and

CO. CO. Myocardial contractility is the force of Myocardial contractility is the force of

cardiac contraction independent of preload. cardiac contraction independent of preload. Contractility is increased by factors such as Contractility is increased by factors such as

sympathetic stimulation and calcium sympathetic stimulation and calcium release. release.

Factors such as hypoxia and acidemia Factors such as hypoxia and acidemia decrease contractilitydecrease contractility

Structure of the capillary bed

Blood Pressure Blood Pressure

Blood pressure is the force of blood Blood pressure is the force of blood exerted against the vessel walls.exerted against the vessel walls.

The blood pressure in the arterial The blood pressure in the arterial system is determined primarily by the system is determined primarily by the quantity of blood flow or cardiac output quantity of blood flow or cardiac output (CO), as well as by the resistance in the (CO), as well as by the resistance in the arterioles:arterioles:

Blood pressure = Cardiac output x Blood pressure = Cardiac output x Peripheral vascular resistancePeripheral vascular resistance

Blood Pressure Blood Pressure RegulationRegulation

Autonomic nervous systemAutonomic nervous system– BaroreceptorsBaroreceptors– ChemoreceptorsChemoreceptors

Renal systemRenal system Endocrine systemEndocrine system External factors also affect BPExternal factors also affect BP

Venous SystemVenous System

Structure: a series of veins located Structure: a series of veins located adjacent to the arterial systemadjacent to the arterial system

Function: completes the Function: completes the circulation of blood by returning circulation of blood by returning blood from the capillaries to the blood from the capillaries to the right side of the heartright side of the heart

Cardiovascular changes in the Cardiovascular changes in the older adult: only evident when the older adult: only evident when the person is active or under stress person is active or under stress

Assessment Techniques Assessment Techniques

HistoryHistory Demographic dataDemographic data Family history and genetic riskFamily history and genetic risk Personal historyPersonal history Diet historyDiet history Socioeconomic statusSocioeconomic status

Modifiable Risk FactorsModifiable Risk Factors

Cigarette smokingCigarette smoking Physical inactivityPhysical inactivity ObesityObesity Psychological factorsPsychological factors Chronic diseaseChronic disease

Pain or Discomfort Pain or Discomfort

Pain or discomfort can result from Pain or discomfort can result from ischemic heart disease, ischemic heart disease, pericarditis, and aortic dissection.pericarditis, and aortic dissection.

Chest pain can also result from Chest pain can also result from noncardiac conditions such as noncardiac conditions such as pleurisy, pulmonary embolus, hiatal pleurisy, pulmonary embolus, hiatal hernia, and anxiety.hernia, and anxiety.

(Continued)(Continued)

Pain or Discomfort Pain or Discomfort (Continued)(Continued)

Terms such as Terms such as discomfort, discomfort, heaviness, pressure, indigestion, heaviness, pressure, indigestion, aching, choking, strangling, tingling, aching, choking, strangling, tingling, squeezing, constrictingsqueezing, constricting, or , or vise-likevise-like are all used to describe pain.are all used to describe pain.

Women often do not experience pain Women often do not experience pain in the chest but rather feelings of in the chest but rather feelings of discomfort or indigestion.discomfort or indigestion.

Pain AssessmentPain Assessment

OnsetOnset Manner of onsetManner of onset DurationDuration FrequencyFrequency Precipitating factorsPrecipitating factors LocationLocation RadiationRadiation

(Continued)(Continued)

Pain AssessmentPain Assessment

(Continued)(Continued)

QualityQuality Intensity, which can be graded Intensity, which can be graded

from 0 to 10, associated from 0 to 10, associated symptoms, aggravating factors, symptoms, aggravating factors, and relieving factorsand relieving factors

Dyspnea Dyspnea

Can occur as a result of both cardiac Can occur as a result of both cardiac and pulmonary disease and pulmonary disease

Difficult or labored breathing Difficult or labored breathing experienced as uncomfortable experienced as uncomfortable breathing or shortness of breathbreathing or shortness of breath

Dyspnea on exertion (DOE)Dyspnea on exertion (DOE) Orthopnea: dyspnea when lying flatOrthopnea: dyspnea when lying flat Paroxysmal nocturnal dyspnea after Paroxysmal nocturnal dyspnea after

lying down for several hourslying down for several hours

Other Manifestations Other Manifestations

FatigueFatigue PalpitationsPalpitations Weight gainWeight gain Syncope Syncope Extremity painExtremity pain

Physical AssessmentPhysical Assessment General appearanceGeneral appearance The nurse assesses the following areas: general build and The nurse assesses the following areas: general build and

appearance, skin color, distress level, level of consciousness, appearance, skin color, distress level, level of consciousness, shortness of breath, position, and verbal responses.shortness of breath, position, and verbal responses.

Clients with chronic heart failure may appear malnoutrished, Clients with chronic heart failure may appear malnoutrished, thin, and cachectic. thin, and cachectic.

Latent signs of severe heart failure are ascites, jaundice, and Latent signs of severe heart failure are ascites, jaundice, and anasarca (generalized edema) as a result of prolonged anasarca (generalized edema) as a result of prolonged congestion of the liver. congestion of the liver.

Heart failure may cause fluid retention, and clients may have Heart failure may cause fluid retention, and clients may have engorged neck veins and generalized dependent edema.engorged neck veins and generalized dependent edema.

Coronary artery disease is suspected in clients with yellow, Coronary artery disease is suspected in clients with yellow, lipid-filled plaques on the upper eyelids (xanthelasma) or ear-lipid-filled plaques on the upper eyelids (xanthelasma) or ear-lobe creases. lobe creases.

Clients with poor cardiac output and decreased cerebral Clients with poor cardiac output and decreased cerebral perfusion may experience mental confusion, memory loss, perfusion may experience mental confusion, memory loss, and slowed verbal responsesand slowed verbal responses

Physical AssessmentPhysical Assessment Integumentary systemIntegumentary system Skin colorSkin color

– If there is normal blood flow or adequate perfusion to a If there is normal blood flow or adequate perfusion to a given area in light-colored skin, it appears pink, perhaps given area in light-colored skin, it appears pink, perhaps rosy inrosy in color, and it is warm to the touch. Decreased flow color, and it is warm to the touch. Decreased flow is depicted as cool, pale, and moist skin. Pallor is is depicted as cool, pale, and moist skin. Pallor is characteristic of anemia and can be seen in areas such characteristic of anemia and can be seen in areas such as the nail beds, palms, and conjunctival mucous as the nail beds, palms, and conjunctival mucous membranesmembranes

– A bluish or darkened discoloration of the skin and A bluish or darkened discoloration of the skin and mucous membranes in Caucasians is referred to as mucous membranes in Caucasians is referred to as cyanosis. cyanosis. This condition results from an increased This condition results from an increased amount of deoxygenated he moglobin. Dark-skinned amount of deoxygenated he moglobin. Dark-skinned individuals may express cyanosis as a graying of the individuals may express cyanosis as a graying of the same tissuessame tissues

Physical AssessmentPhysical Assessment– Central cyanosis involves decreased oxygenation of the Central cyanosis involves decreased oxygenation of the

arterial blood in the lungs and appears as a bluish tinge of arterial blood in the lungs and appears as a bluish tinge of the conjunctivae and the mucous membranes of the the conjunctivae and the mucous membranes of the mouth and tongue. Central cyanosis may indicate mouth and tongue. Central cyanosis may indicate impaired lung function or a right-to-left shunt found in impaired lung function or a right-to-left shunt found in congenital heart conditions. Because of impaired congenital heart conditions. Because of impaired circulation, there is a marked desaturation of hemoglobin circulation, there is a marked desaturation of hemoglobin in the peripheral tissues, which produces a bluish or in the peripheral tissues, which produces a bluish or darkened discoloration of the nail beds, earlobes, lips, and darkened discoloration of the nail beds, earlobes, lips, and toes.toes.

– Peripheral cyanosis occurs when blood flow to the Peripheral cyanosis occurs when blood flow to the peripheral vessels is decreased by peripheral peripheral vessels is decreased by peripheral vasoconstriction. The clamping down of the peripheral vasoconstriction. The clamping down of the peripheral blood vessels results from a low cardiac output or an blood vessels results from a low cardiac output or an increased extraction of oxygen from the peripheral tissues. increased extraction of oxygen from the peripheral tissues. Peripheral cyanosis localized in an extremity is usually a Peripheral cyanosis localized in an extremity is usually a result of arterial or venous obstructionresult of arterial or venous obstruction

Physical AssessmentPhysical Assessment

Skin temperatureSkin temperature– Skin temperature can be assessed for Skin temperature can be assessed for

symmetry by touching different areas of symmetry by touching different areas of the client's body (e.g., arms, hands, legs, the client's body (e.g., arms, hands, legs, and feet) with the dorsal surface of the and feet) with the dorsal surface of the hand or fingers. hand or fingers.

– Decreased blood flow results in Decreased blood flow results in decreased skin temperature. Skin decreased skin temperature. Skin temperature is lowered in several clinical temperature is lowered in several clinical conditions, including heart failure, conditions, including heart failure, peripheral vascular disease, and shockperipheral vascular disease, and shock

Physical AssessmentPhysical Assessment

ExtremitiesExtremities– The nurse assesses the client's hands, arms, The nurse assesses the client's hands, arms,

feet, and legs for skin changes, vascular feet, and legs for skin changes, vascular changes, clubbing, capillary filling,changes, clubbing, capillary filling, and edema. and edema.

– Skin mobility and turgor are affected by the Skin mobility and turgor are affected by the fluid status of the client. fluid status of the client.

– Dehydration and aging reduce skin turgor, and Dehydration and aging reduce skin turgor, and edema decreases skin mobility. edema decreases skin mobility.

– Vascular changes in an affected extremity may Vascular changes in an affected extremity may include paresthesia, muscle fatigue and include paresthesia, muscle fatigue and discomfort, numbness, pain, coolness, and loss discomfort, numbness, pain, coolness, and loss of hair distribution from a reduced blood supplyof hair distribution from a reduced blood supply

Physical AssessmentPhysical Assessment Blood pressureBlood pressure Normal blood pressure in adults older than 45 Normal blood pressure in adults older than 45

years of age ranges from 90 to 140 mm Hg for years of age ranges from 90 to 140 mm Hg for systolic pressure and from 60 to 90 mm Hg for systolic pressure and from 60 to 90 mm Hg for diastolic pressure. diastolic pressure.

A blood pressure that exceeds 135/85 mm Hg A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and increases the workload of the left ventricle and oxygen consumption.oxygen consumption.

A blood pressure less than 90/60 mm Hg may be A blood pressure less than 90/60 mm Hg may be inadequate for providing proper and sufficient inadequate for providing proper and sufficient nutrition to bodynutrition to body cells. In certain circumstances, cells. In certain circumstances, such as shock and hypotension, the Korotkoff such as shock and hypotension, the Korotkoff sounds are less audible or are absent. In these sounds are less audible or are absent. In these cases the nurse might palpate the blood pressure, cases the nurse might palpate the blood pressure, use an ultrasonic device (Doppler device), or use an ultrasonic device (Doppler device), or obtain a direct measurement by arterial catheterobtain a direct measurement by arterial catheter

Physical AssessmentPhysical Assessment Venous and arterial pulses: central and Venous and arterial pulses: central and

jugular venous pressures, and jugular jugular venous pressures, and jugular venous distentionvenous distention

The nurse observes the venous pulsations The nurse observes the venous pulsations in the neck to assess the adequacy of blood in the neck to assess the adequacy of blood volume and central venous pressure (CVP). volume and central venous pressure (CVP). The nurse can assess jugular venous The nurse can assess jugular venous pressure (JVP) to estimate the filling volume pressure (JVP) to estimate the filling volume and pressure on the right side of the heart. and pressure on the right side of the heart.

The right internal jugular vein is usually The right internal jugular vein is usually used to estimate JVPused to estimate JVP

PrecordiumPrecordium Assessment of the precordium Assessment of the precordium

(area over the heart) involves:(area over the heart) involves:– InspectionInspection– PalpationPalpation– Percussion Percussion – AuscultationAuscultation

Normal heart soundsNormal heart sounds Paradoxical splittingParadoxical splitting Gallops and murmursGallops and murmurs Pericardial friction rubPericardial friction rub

Normal heart soundsNormal heart sounds The first heart sound (S1) is created by the closure of The first heart sound (S1) is created by the closure of

the mitral and tricuspid valves (atrioventricular the mitral and tricuspid valves (atrioventricular valves). valves).

When auscultated, the first heart sound is softer and When auscultated, the first heart sound is softer and longer; it is of a low pitch and is best heard at the longer; it is of a low pitch and is best heard at the lower left sternal border or the apex of the heart. lower left sternal border or the apex of the heart.

It may be identified by palpating the carotid pulse It may be identified by palpating the carotid pulse while listening. S1 marks the beginning of ventricular while listening. S1 marks the beginning of ventricular systole and occurs right after the QRS complex on systole and occurs right after the QRS complex on the electrocardiogram (ECG).the electrocardiogram (ECG).

The first heart sound can be accentuated or The first heart sound can be accentuated or intensified in conditions such as exercise, intensified in conditions such as exercise, hyperthyroidism, and mitral stenosis. hyperthyroidism, and mitral stenosis.

A decrease in sound intensity occurs in clients with A decrease in sound intensity occurs in clients with mitral regurgitation and heart failure.mitral regurgitation and heart failure.

Normal heart soundsNormal heart sounds The second heart sound (S2) is caused mainly by the closing The second heart sound (S2) is caused mainly by the closing

of the aortic and pulmonic valves (semilunar valves). of the aortic and pulmonic valves (semilunar valves). S2 is characteristically shorter. It is higher pitched and is S2 is characteristically shorter. It is higher pitched and is

heard best at the base of the heart at the end of ventricular heard best at the base of the heart at the end of ventricular systole.systole.

The splitting of heart sounds is often difficult to differentiate The splitting of heart sounds is often difficult to differentiate from diastolic filling sounds (gallops). A splitting of S1 from diastolic filling sounds (gallops). A splitting of S1 (closure of the mitral valve followed by closure of the (closure of the mitral valve followed by closure of the tricuspid valve) occurs physiologically because left tricuspid valve) occurs physiologically because left ventricular contraction occurs slightly before right ventricular contraction occurs slightly before right ventricular contraction. ventricular contraction.

However, closure of the mitral valve is louder than closure However, closure of the mitral valve is louder than closure of the tricuspid valve, so splitting is often not heard. of the tricuspid valve, so splitting is often not heard.

Normal splitting of S2 occurs because of the longer systolic Normal splitting of S2 occurs because of the longer systolic phase of the right ventricle. Splitting of S1 and S2 can be phase of the right ventricle. Splitting of S1 and S2 can be accentuated by inspiration (increased venous return), and it accentuated by inspiration (increased venous return), and it narrows during expiration.narrows during expiration.

Abnormal heart soundsAbnormal heart sounds

PARADOXICAL SPLITTING. PARADOXICAL SPLITTING. Abnormal splitting of S2 is referred to as Abnormal splitting of S2 is referred to as

paradoxical splitting and is characteristic paradoxical splitting and is characteristic of a wider split heard on expiration. of a wider split heard on expiration.

Paradoxical splitting of S2 is heard in Paradoxical splitting of S2 is heard in clients with severe myocardial depression clients with severe myocardial depression that causes early closure of the pulmonic that causes early closure of the pulmonic valve or a delay in aortic valve closure. valve or a delay in aortic valve closure.

Such conditions include myocardial Such conditions include myocardial infarction, left bundle branch block, aortic infarction, left bundle branch block, aortic stenosis, aortic regurgitation, and right stenosis, aortic regurgitation, and right ventricular pacing.ventricular pacing.

Abnormal heart soundsAbnormal heart soundsGALLOPS AND MURMURS. GALLOPS AND MURMURS. GALLOPS. Diastolic filling sounds (S3) and (S4) are produced GALLOPS. Diastolic filling sounds (S3) and (S4) are produced

when blood enters a noncompliant chamber during rapid when blood enters a noncompliant chamber during rapid ventricular filling. ventricular filling.

The third heart sound (S3) is produced during the rapid passive The third heart sound (S3) is produced during the rapid passive filling phase of ventricular diastole when blood flows from the filling phase of ventricular diastole when blood flows from the atrium to a noncompliant ventricle. The sound arises from atrium to a noncompliant ventricle. The sound arises from vibrations of the valves and supporting structures. vibrations of the valves and supporting structures.

The fourth heart sound (S4) occurs as blood enters the ventricles The fourth heart sound (S4) occurs as blood enters the ventricles during the active filling phase at the end of ventricular diastole.during the active filling phase at the end of ventricular diastole.

S3 is termed ventricular gallop, and S4 is referred to as atrial S3 is termed ventricular gallop, and S4 is referred to as atrial gallop. gallop.

These sounds can be caused by decreased compliance of either These sounds can be caused by decreased compliance of either or both ventricles. or both ventricles.

The nurse can best hear left ventricular diastolic filling sounds The nurse can best hear left ventricular diastolic filling sounds with the client on his or her left side. The bell of the stethoscope with the client on his or her left side. The bell of the stethoscope is placed at the apex and at the left lower sternal border during is placed at the apex and at the left lower sternal border during expiration.expiration.

Abnormal heart soundsAbnormal heart sounds

The auscultation of both S3 and S4, The auscultation of both S3 and S4, called a called a summation summation or a or a quadruple quadruple gallop, gallop, is an indication of severe heart is an indication of severe heart failure. failure.

If the quadruple rhythm is present and If the quadruple rhythm is present and the client has tachycardia (a the client has tachycardia (a shortened diastole), the two sounds shortened diastole), the two sounds may actually fuse to produce a rhythm may actually fuse to produce a rhythm that sounds like a horse galloping.that sounds like a horse galloping.

Abnormal heart soundsAbnormal heart sounds MURMURS. Murmurs reflect turbulent blood flow through normal or MURMURS. Murmurs reflect turbulent blood flow through normal or

abnormal valves. They are classified according to their timing in abnormal valves. They are classified according to their timing in the cardiac cycle: systolic murmurs (e.g., aortic stenosis and the cardiac cycle: systolic murmurs (e.g., aortic stenosis and mitral regurgitation) occur between S1 and S2, whereas diastolic mitral regurgitation) occur between S1 and S2, whereas diastolic murmurs (e.g., mitral stenosis and aortic regurgitation) occur murmurs (e.g., mitral stenosis and aortic regurgitation) occur between S2 and S1. between S2 and S1.

Murmurs can occur during presystole, midsystole, or late systole Murmurs can occur during presystole, midsystole, or late systole or di-or di- astole or can last throughout both phases of the cardiac astole or can last throughout both phases of the cardiac cycle. They are also graded according to their intensity, depending cycle. They are also graded according to their intensity, depending on their level of loudness.on their level of loudness.

The nurse describes the location of a murmur by where it is best The nurse describes the location of a murmur by where it is best heard on auscultation. heard on auscultation.

Some murmurs transmit or radiate from their loudest point to Some murmurs transmit or radiate from their loudest point to other areas, including the neck, the back, and the axilla. other areas, including the neck, the back, and the axilla.

The configuration is described as crescendo (increases in The configuration is described as crescendo (increases in intensity) or decrescendo (decreases in intensity). intensity) or decrescendo (decreases in intensity).

The quality of murmurs can be further characterized as harsh, The quality of murmurs can be further characterized as harsh, blowing, whistling, rumbling, or squeaking. They are also blowing, whistling, rumbling, or squeaking. They are also described by pitch, usually high or low.described by pitch, usually high or low.

Abnormal heart soundsAbnormal heart sounds PERICARDIAL FRICTION RUB. PERICARDIAL FRICTION RUB. A pericardial friction rub A pericardial friction rub

originates from the pericardial sac and occurs with the originates from the pericardial sac and occurs with the movements of the heart during the cardiac cycle. Rubs are movements of the heart during the cardiac cycle. Rubs are usually transient and are a sign of inflammation, infection, or usually transient and are a sign of inflammation, infection, or infiltration. infiltration.

Pericardial friction rubs may be heard in clients with Pericardial friction rubs may be heard in clients with pericarditis resulting from myocardial infarction and cardiac pericarditis resulting from myocardial infarction and cardiac tamponade.tamponade.

The three phases of cardiac movement — atrial systole, The three phases of cardiac movement — atrial systole, ventricular diastole, and ventricular systole — can produce ventricular diastole, and ventricular systole — can produce three components of a rub. three components of a rub.

Usually only one or two components can be heard. Usually only one or two components can be heard. A short, high-pitched scratchy sound is produced with each A short, high-pitched scratchy sound is produced with each

movement; the loudest component is heard in systole. movement; the loudest component is heard in systole. The nurse may be most able to auscultate the rubs when the The nurse may be most able to auscultate the rubs when the

client sits, leans forward, and exhales. client sits, leans forward, and exhales. A pericardial friction rub is better heard with the diaphragm of A pericardial friction rub is better heard with the diaphragm of

the stethoscope.the stethoscope.

Serum Markers of Serum Markers of Myocardial DamageMyocardial Damage

TroponinTroponin Creatine kinase Creatine kinase MyoglobinMyoglobin Serum lipidsSerum lipids HomocysteineHomocysteine C-reactive proteinC-reactive protein Blood coagulation testsBlood coagulation tests

Cardiac CatheterizationCardiac Catheterization Client preparationClient preparation Possible complications: Possible complications:

myocardial infarction, stroke, myocardial infarction, stroke, thromboembolism, arterial thromboembolism, arterial bleeding, lethal dysrhythmias, bleeding, lethal dysrhythmias, and deathand death

Follow-up care:Follow-up care:– Restricted bedrest, insertion site Restricted bedrest, insertion site

extremity kept straightextremity kept straight– Monitor vital signsMonitor vital signs– Assess for complicationsAssess for complications

Other Diagnostic TestsOther Diagnostic Tests ElectrocardiographyElectrocardiography The electrocardiogram (ECG) is a routine The electrocardiogram (ECG) is a routine

part of every cardiovascular evaluation and part of every cardiovascular evaluation and is one of the most valuable diagnostic tests. is one of the most valuable diagnostic tests.

Various forms are available: resting ECG, Various forms are available: resting ECG, continuous ambulatory ECG (Holter continuous ambulatory ECG (Holter monitoring), exercise ECG (stress test), and monitoring), exercise ECG (stress test), and signal-averaged ECG. signal-averaged ECG.

The resting ECG provides information about The resting ECG provides information about cardiac dysrhythmias, myocardial ischemia, cardiac dysrhythmias, myocardial ischemia, the site and extent of myocardial infarction, the site and extent of myocardial infarction, cardiac hypertrophy, electrolyte cardiac hypertrophy, electrolyte imbalances, and the effectiveness of cardiac imbalances, and the effectiveness of cardiac drugs.drugs.

A normal ECG pattern in lead II

ElectrocardiographyElectrocardiography RESTING ELECTROCARDIOGRAPHYRESTING ELECTROCARDIOGRAPHY The ECG graphically records the electrical current The ECG graphically records the electrical current

generated by the heart. This current is measured by generated by the heart. This current is measured by electrodes that are placed on the skin and electrodes that are placed on the skin and connected to an amplifier and strip chart recorder. connected to an amplifier and strip chart recorder.

In the standard 12-lead ECG, five electrodes In the standard 12-lead ECG, five electrodes attached to the arms, legs, and chest measure attached to the arms, legs, and chest measure current from 12 different views or leads: three current from 12 different views or leads: three bipolar limb leads, three unipolar augmented leads, bipolar limb leads, three unipolar augmented leads, and six unipolar precordial leads. and six unipolar precordial leads.

Placement of the leads allows the health care Placement of the leads allows the health care provider to view myocardial electrical conduction provider to view myocardial electrical conduction from different axes or positions, identifying sections from different axes or positions, identifying sections of the heart in which electrical conduction is of the heart in which electrical conduction is abnormal.abnormal.

Standard ECG limb leads

Unipolar augmented ECG leads

Unipolar precordial ECG leads

ElectrocardiographyElectrocardiography AMBULATORY ELECTROCARDIOGRAPHYAMBULATORY ELECTROCARDIOGRAPHY Ambulatory ECG (also called Holter Ambulatory ECG (also called Holter

monitoring) allows continuous recording of monitoring) allows continuous recording of cardiac activity during an extended period cardiac activity during an extended period (usually 24 hours) while the client is (usually 24 hours) while the client is performing his or her usual activities of performing his or her usual activities of daily living (ADLs). daily living (ADLs).

The ambulatory ECG allows the assessment The ambulatory ECG allows the assessment and correlation of dyspnea, chest pain, and correlation of dyspnea, chest pain, central nervous system symptoms (e.g., central nervous system symptoms (e.g., lightheadedness and syncope), and lightheadedness and syncope), and palpitations with actual cardiac events and palpitations with actual cardiac events and the client's activities.the client's activities.

Other Diagnostic TestsOther Diagnostic Tests

Electrophysiologic studyElectrophysiologic study Exercise electrocardiographyExercise electrocardiography EchocardiographyEchocardiography

– Pharmacologic stress Pharmacologic stress echocardiogramechocardiogram

– Transesophageal echocardiogramTransesophageal echocardiogram ImagingImaging

Components of a hemodynamic monitoring system

Hemodynamic Hemodynamic MonitoringMonitoring

Invasive system used in critical Invasive system used in critical care areas to provide quantitative care areas to provide quantitative information about vascular information about vascular capacity, blood volume, pump capacity, blood volume, pump effectiveness, and tissue perfusioneffectiveness, and tissue perfusion

Pulmonary artery catheterPulmonary artery catheter Systemic intra-arterial monitoring Systemic intra-arterial monitoring Impedance cardiography Impedance cardiography