Chapter 26Part 2 Assessment of Cardiovascular

FunctionReview of Cardiovascular

Assessment & Care

THE CARDIAC CHAMBERS

THE CARDIAC CHAMBERS

Valves in Diastole

• Upper Semi-Lunar valves closed in diastole.

• Coronary ostia now exposed allowing myocardial oxygenation.

• Note-Myocardial perfusion always occurs in DIASTOLE

Lower A. V. Valves open in Diastole.

• Note that all valves with 3 cusps except the Mitral.

• Chordae Tendinae

Valves in Systole

• Upper Semi-Lunar valves open in Systole.

• Lower A.V. valves closed in Systole as ventricles empty.

• Note coronary ostia behind the cusps of the aortic valve.

Great Vessel and Cardiac Chamber Pressures

Intra-Ventricular Pressures

Pressure Variations throughout the Cardiac Cycle at each Chamber

Lab Studies

• Cardiac biomarkers• CK and CK-MB• Myoglobin• Troponin T and I • Lipid profile• Brain (B-type) natriuretic peptide• C-reactive protein 1-3 Avg Risk, >3 High Risk• Homocysteine – normally 5-15 micromoles/L

Electrocardiography

• 12-lead ECG• Continuous monitoring: hardwire and telemetry• Signal-averaged ECG• Continuous ambulatory monitoring• Transtelephonic monitoring• Wireless mobile monitoring• Cardiac stress testing

– Exercise stress testing – Pharmacologic stress testing

IW Ischemic ST Changes

Acute ILWMI

Treatment

Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply.

• Medications• Oxygen• Reduce and control risk factors.• Reperfusion therapy may also be done.

Medications

• NitroglycerinSee Chart 28-5

• Beta-adrenergic blocking agents• Calcium channel blocking agents• Antiplatelet and anticoagulant medications &

Thrombolytics.• Aspirin• Clopidogrel and ticlopidine• Heparin• Glycoprotein IIB/IIIa agents

Nursing Process: The Care of the Patient with Angina Pectoris: Planning

• Goals include the immediate and appropriate treatment of angina, prevention of angina, reduction of anxiety, awareness of the disease process, understanding of prescribed care, adherence to the self-care program, and absence of complications.

Treatment of Anginal Pain

• Treatment of anginal pain is a priority nursing concern.

• Patient is to stop all activity and sit or rest in bed.• Assess the patient while performing other

necessary interventions. Assessment includes VS, observation for respiratory distress, and assessment of pain. In the hospital setting, ECG.

• Administer oxygen.• Administer medications as ordered or by protocol,

usually NTG.

Anxiety

• Use a calm manner• Stress-reduction techniques• Patient teaching• Addressing patient spiritual needs may

assist in allaying anxieties• Address both patient and family needs

Patient Education

• Lifestyle changes and reduction of risk factors • Explore, recognize, and adapt behaviors to avoid

to reduce the incidence of episodes of ischemia.• Teaching regarding disease process• Medications• Stress reduction• When to seek emergency care• See Chart 28-7

Acute Coronary Syndrome

• An area of the myocardium is permanently destroyed by cessation of blood flow in a coronary artery due to rupture of a plaque and subsequent occlusion of the artery by a thrombus.

• In unstable angina, the plaque ruptures but the artery is not completely occluded. Unstable angina and acute myocardial infarction are considered the same process but at different point on the continuum.

• The term “acute coronary syndrome” includes unstable angina and myocardial infarction.

Effects of Ischemia, Injury, and Infarction on ECG

Treatment of ACS / MI

• Obtain diagnostic tests including ECG within 10 minutes of admission to the ED.

• Oxygen• Aspirin, nitroglycerin, morphine, beta-blockers• Angiotensin-converting enzyme inhibitor within

24 hours• Evaluate for percutaneous coronary intervention

or thrombolytic therapy.• As indicated; IV heparin or LMWH, clopidogrel

or ticlopidine, glycoprotein IIb/IIIa inhibitor• Bed rest

Nursing Process: The Care of the Patient with ACS: Diagnosis

• Nursing Process: The Care of the Patient with ACS: Diagnosis

• Ineffective cardiac tissue perfusion• Risk for fluid imbalance• Risk for ineffective peripheral tissue

perfusion• Death anxiety• Deficient knowledge

Cardiac Catheterization

• Invasive procedure used to measure cardiac chamber pressures and assess patency of the coronary arteries

• Requires ECG and hemodynamic monitoring; emergency equipment must be available

• Assessment prior to test; allergies, blood work• Assessment of patient after procedure: circulation,

potential for bleeding, potential for dysrhythmias • Activity restrictions• Patient education before & after procedure

See Chart 26-4

Hemodynamic Monitoring

• CVP• Pulmonary artery pressure • Intra-arterial BP monitoring

Complex Distal RCA/PDA Lesion

Multiple Prox. Complex LAD Lesions Involving 2nd Diagonal

Post Stent to Proximal LAD

Intra. Venous Ultra Sound

• Allows assessment of coronary artery diameter.

• Allows assessment of stent apposition

• Helps assess the sizing of stents

Intra Venous Ultra Sound

• Assesses plaque ulceration for dissection

• Assesses coronary for calcium burden

Intra-venous Ultrasound

• Shows advanced calcified plaque in severely stenotic lesion

Pre Stent Angiogram RCA

Post Stent Angiogram RCA

Case Study 2, Mr. Alfred Torres

A 40 Y/O Man with Family History of MIPresentation• A 40-year-old White male, smoker whose only prior history is Htn,

treated with Norvasc. He presents with retro-sternal chest pain, occasionally at rest, sometimes with exertion when he feels brief shortness of breath, which resolves with rest. There is no radiation, nausea or diaphoresis associated with episodes. He has a strong family history of MI. He is slightly overweight . His father had an MI at age 40. The patients Blood Pressure is moderately elevated but his blood glucose and thyroid levels are normal. His lipid profile shows elevations of his LDL, as well as low levels of HDL. His Calcium score is 125.

Assessment Data

• BMI = 25• BP =158/92, HR = 86• Rapid CT Ca Score =125 • Labs:• TC =255• HDL = 27• LDL = 120• TG = 251• FBG = 125

Meds:• Norvasc 5 qd

Clinical Decision Point

• What further diagnostic aides could be applied on an out-patient basis not mentioned?

• What information could be gained?

• Should any medications be started? If So which ones?

Results

• He had a Thallium Stress Test, which showed a mild reversible ischemic abnormality at the apex.

• His echo demonstrated normal LV Function and normal valvular function, with moderate diastolic dysfunction.

• Medications to be started would be the addition of Altace 2.5 mg daily & Lipitor 40 mg HS. Prn Ntg.

• Whats the Dx?, What Next?

Next Step a Diagnostic Cath

• Cath scheduled for next week.• Friday, 2 PM at work Mr Torres gets into an

argument with his supervisor and immediately begins c/o severe retrosternal chest heaviness accomp by Nausea and diaphoresis. His co-workers call 911.

• EMS arrives within 6 minutes and transports him to the nearest Heart Station.