Assessment OF THE Cardiovascular System PDF

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ASSESSMENT OF THECARDIOVASCULAR SYSTEMThe frequency and extent of the nursing assessment of the cardiovascular system are based on several factors, including the severity of the patient’s symptoms, the presence of risk factors, the practice setting, and the purpose of the assessment. Although the ke...

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ASSESSMENT OF THE CARDIOVASCULAR SYSTEM The frequency and extent of the nursing assessment of the cardiovascular system are based on several factors, including the severity of the patient’s symptoms, the presence of risk factors, the practice setting, and the purpose of the assessment. Although the key components of the cardiovascular assessment remain the same, the assessment priorities vary according to the needs of the patient. For example, an emergency department nurse caring for a patient who is admitted with symptoms associated with acute coronary syndrome (ACS—a term used for any condition brought on by a sudden blockage of blood flow to the heart) performs a rapid and focused assessment because treatment of ACS is time-dependent.

Health History Nurses practicing in settings where patients with CVD are seen must be expert at recognizing cardiac symptoms as well as expediting timely and, oftentimes, lifesaving care. Likewise, patients must be able to recognize when they are experiencing these symptoms and know how to manage them. All too often, patients fail to appreciate the significance of new or worsening cardiac symptoms. This problem results in prolonged delays in seeking treatment. Major barriers to seeking prompt lifesaving care include lack of knowledge about personal risk and symptoms of heart disease, attributing symptoms to a benign source, denying symptom significance, and feeling embarrassed about having symptoms (Gillis, Arslanian-Engoren, & Struble, 2014). Box 12-1 discusses results of a study testing the effect of an educational intervention on Latinas’ knowledge of CVD risk factors and prevention strategies.

Common Complaints Common CVD signs and symptoms, with related medical diagnoses in parentheses, are covered in the section below.  Chest pain or discomfort (ACS that includes unstable angina and acute MI, arrhythmias, valvular heart disease)  Pain or discomfort in other areas of upper body, including one or both arms, back, neck, jaw, or stomach (ACS)  Dizziness, syncope, or changes in level of consciousness (ACS, cardiogenic shock, cerebrovascular disorders, arrhythmias, hypotension, postural hypotension, vasovagal episode)  Intermittent claudication or rest pain in lower extremities, especially at night (peripheral arterial disease [PAD])  Palpitations or tachycardia (ACS, caffeine or other stimulants, electrolyte imbalances, HF, stress, valvular heart disease, ventricular aneurysm)

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Peripheral edema (HF, PAD), weight gain (HF), or ascites and abdominal distension due to enlarged liver and spleen (HF) Shortness of breath or dyspnea, with or without chest pain (ACS, cardiogenic shock, HF, pulmonary edema, valvular heart disease) Unusual fatigue characterized by feeling more tired or fatigued than usual (early warning symptom of ACS, HF, valvular heart disease)

Chest Pain Chest pain and chest discomfort are common symptoms caused by a number of cardiac and noncardiac problems. Table 12-2 identifies the characteristics of common causes of chest pain. To differentiate among these causes of pain, the nurse asks the patient to identify the quantity (0 = no pain to 10 = worst pain), location, and quality of pain. It is important to identify the events that precipitated symptom onset, the duration of the symptom, measures that aggravate or relieve the symptom, and associated signs and symptoms, such as diaphoresis or nausea. The nurse should keep the following points in mind when assessing patients with chest pain or discomfort:  The severity and duration of chest pain or discomfort does not predict the seriousness of its cause. For example, a patient experiencing esophageal spasm may rate chest pain as a “10/10,” whereas, a patient experiencing an acute MI may report only mild to moderate chest pressure.  More than one cardiac condition may occur simultaneously. During an acute MI, patients may report chest pain from myocardial ischemia (inadequate oxygen supply to the tissues), shortness of breath from HF, and palpitations from arrhythmias. Both HF and arrhythmias are complications of acute MI.

Symptoms of Acute Coronary Syndrome Nurses must take complaints of patients with cardiac symptoms seriously until the cause is determined. Because CAD is so prevalent, all patients reporting new or worsening cardiac symptoms, particularly those at risk for CAD or who have a history of CAD, should be evaluated initially for ACS. There are several distinct characteristics of ACS symptoms that need to be kept in mind during assessment: 

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The majority of patients with ACS experience prodromal symptoms sometimes a month or more prior to developing this acute event. Prodromal symptoms include unusual fatigue, shortness of breath, sleep disturbances, anxiety, or fleeting chest discomfort (aching, pressure) that comes and goes. Because these symptoms are less severe than what is experienced during ACS, patients often attribute them to a benign problem, such as stress, and fail to seek medical care. Nurses should include a question regarding presence of prodromal symptoms when assessing patients with cardiac symptoms. Approximately 50% of men and women with ACS experience chest symptoms, whereas the remainder may develop a variety of symptoms such as upper back, shoulder, arm, or neck pain; epigastric burning; or shortness of breath. There are many misconceptions that men and women have about their cardiac risk factors and signs and symptoms of heart disease. During the onset of ACS, people experience a group of at least four or more symptoms that can include chest discomfort or pain; upper back, shoulder, arm, or neck pain; epigastric

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burning or indigestion; shortness of breath; unusual fatigue; and diaphoresis. The combination of symptoms can vary from person to person (Gillis, Arslanian-Engoren, & Struble, 2014). Neuropathies in elderly patients and those with diabetes may prevent these patients from experiencing pain or discomfort associated with myocardial ischemia. Instead, they may report unusual fatigue or shortness of breath. In some patients, ACS may be asymptomatic, which is referred to as silent ischemia. A 12-lead electrocardiogram (ECG) and serum laboratory analysis of cardiac biomarkers are necessary to determine if the patient with ACS symptoms is experiencing unstable angina or acute MI.

History Epidemiologic studies show that certain conditions or behaviors (i.e., risk factors) are associated with a greater incidence of CAD, cerebrovascular disease, and PAD (AHA, 2016). The nurse might ask some of the following questions:  How is your health? Have you noticed any changes from last year? From 5 years ago?  Do you have a cardiologist or primary health care provider? How often do you go for checkups?  What are your risk factors for heart disease? What do you do to reduce these risk factors? Box 12-2 lists risk factors for CVD and treatment goals. Patients who lack understanding of their risk factors and diagnosis may be less motivated to make lifestyle changes or manage their cardiac disease effectively. On the other hand, patients who have this awareness and believe that they have the power to modify their risk factors may be more likely to engage in prevention measures. Once patients’ risk factors are identified, the nurse determines if patients have a plan for making necessary lifestyle changes and if assistance is needed to support these changes.

Family History The nurse inquires about a history of cardiac disease in the patient’s family, including:  A history of sudden death in family members of all ages with or without symptoms or known CAD  A family member with a biochemical or neuromuscular condition (e.g., hemochromatosis [excessive iron retention in the body] or muscular dystrophy)  DNA mutation or other genetic testing that was performed on any family member Cardiovascular disorders associated with genetic abnormalities include familial hypercholesterolemia, hypertrophic cardiomyopathy, long QT syndrome, hereditary hemochromatosis, and elevated homocysteine levels (discussed later in this chapter).

Social History Medications

Nurses collaborate with other health care providers to obtain a complete list of the patient’s medications, including dose and frequency. Vitamins, herbals, and over-the-counter medications are included on this list. During this aspect of the health assessment, the nurse solicits answers to the following questions to ensure that patients are taking their mediations safely and effectively:  Is the patient independent in taking medications?  Are the medications taken as prescribed?  Does the patient know what side effects to report to the prescriber?  Does the patient understand why the medication regimen is important?  Are doses ever forgotten or skipped, or does the patient ever decide to stop taking a medication?  An aspirin a day is a common nonprescription medication that improves patient outcomes after an acute MI. However, if patients are not aware of this benefit, they may be inclined to stop taking aspirin if they think it is a trivial medication. A careful medication history often uncovers common medication errors and causes for nonadherence to the medication regimen.

Nutrition and Metabolism Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes mellitus. Diets that are restricted in sodium, fat, cholesterol, and/or calories are commonly prescribed. The nurse obtains the following information:  How often the patient self-monitors BP, blood glucose, and weight as appropriate to the medical diagnoses  The patient’s knowledge regarding target goals for each of the risk factors, and any problems achieving or maintaining these goals  What the patient normally eats and drinks in a typical day, and any food preferences (including cultural or ethnic preferences)  Eating habits (canned or commercially prepared foods versus fresh foods, restaurant cooking versus home cooking, assessing for high-sodium foods, dietary intake of fats)  Who shops for groceries and prepares meals

Elimination Typical bowel and bladder habits need to be identified. Nocturia (awakening at night to urinate) is common in patients with HF. Fluid collected in the dependent tissues (extremities) during the day redistributes into the circulatory system once the patient is recumbent at night. The increased circulatory volume is excreted by the kidneys (increased urine production). When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow, which may lead to syncope in some patients. Straining during urination can produce the same response. Because many cardiac medications can cause GI side effects or bleeding, the nurse asks about bloating, diarrhea, constipation, stomach upset, heartburn, loss of appetite, nausea, and vomiting. Patients taking platelet-inhibiting medications such as aspirin and clopidogrel (Plavix); platelet aggregation inhibitors such as abciximab (ReoPro), eptifibatide (Integrilin), and tirofiban

(Aggrastat); and IV anticoagulants such as low–molecular-weight heparin (i.e., dalteparin [Fragmin], enoxaparin [Lovenox]), heparin, or oral anticoagulants (i.e., warfarin [Coumadin] rivaroxaban [Xarelto] or apixaban [Eliquis]) are screened for bloody urine (hematuria) or stools (red, black, or tarry), epistaxis (nosebleed), or unusual bruising.

Activity and Exercise Changes in patients’ activity tolerance may be gradual and go unnoticed. The nurse determines if there are recent changes by comparing the patient’s current activity level with that performed in the past 6 to 12 months. New symptoms or a change in the usual symptoms during activity is a significant finding. Activity-induced angina or shortness of breath (SOB) may indicate CAD, which requires medical attention. Arterial insufficiency is suspected if the patient experiences intermittent claudication, described as a lower extremity muscular, cramping pain that occurs with activity and is relieved by rest. Angina and intermittent claudication occur when there is tissue ischemia or inadequate arterial blood supply, in the setting of increased demand (e.g., exercise, stress, or anemia). As the tissues are forced to function without adequate nutrients and oxygen, muscle metabolites and lactic acid are produced. Pain is experienced as the metabolites aggravate the nerve endings of the surrounding tissue. Rest pain is a persistent pain in the anterior portion of the foot at rest that can worsen at night and indicates significant arterial insufficiency and a critical state of ischemia. Fatigue, associated with a low left ventricular EF (less than 40%) and certain medications (e.g., beta-adrenergic blocking agents), can result in activity intolerance. Patients with fatigue may benefit from having their medications adjusted and learning energy-conservation techniques. Additional areas to explore include the presence of architectural barriers in the home (stairs, multilevel home), the patient’s involvement in cardiac rehabilitation, and the patient’s typical exercise pattern, including intensity, frequency, and duration.

Sleep and Rest Clues to worsening cardiac disease, especially HF, can be revealed by sleep-related events. Determining where the patient sleeps or rests and any recent changes in sleep habits is important. Worsening HF is characterized by pulmonary congestion resulting in dyspnea at rest or when lying down. Orthopnea is the term used to indicate the need to sit upright or stand to avoid dyspnea. Thus, patients with worsening HF will report that they sleep upright in a chair instead of in bed; increase the number of pillows used; awaken from sleep with sudden onset of dyspnea, often associated with coughing and wheezing, called paroxysmal nocturnal dyspnea (PND); or awaken with angina (nocturnal angina). PND occurs at night and is caused by the reabsorption of fluid from dependent areas of the body (arms and legs) back into the circulatory system within hours of lying in bed. This sudden fluid shift increases preload and places too great a demand on the heart of patients with HF, causing sudden pulmonary congestion. There is mounting evidence pointing to the cardiac consequences associated with sleepdisordered breathing (SDB). SDB is an abnormal respiratory pattern due to intermittent episodes of upper airway obstruction causing apnea and hypopnea (shallow respirations) during sleep. These abnormal sleep events cause intermittent hypoxemia, sympathetic nervous system activation, and increased intrathoracic pressure that puts mechanical stress on the heart and large artery walls.

Untreated SDB has been linked to CAD, hypertension, HF, and arrhythmias. SDB is treated by the use of continuous positive airway pressure (CPAP) and mandibular advancement devices (MAD). These devices maintain an open airway during sleep, preventing hypoxemia and resulting abnormal elevations in BP. The cardinal signs of SBD are loud, disruptive snoring and apnea lasting 10 seconds or more. Obesity and large neck circumference are two important risk factors for SDB (Ayas, Owens, & Kheirandish-Gozal, 2015). During the health history, the nurse assesses for SDB by asking high-risk patients if they snore loudly, have frequent bouts of awakening from sleep, waking with a headache, or experience severe daytime sleepiness (hypersomnolence). For patients with a diagnosis of SDB, the nurse determines if the patient has been prescribed a CPAP or MAD and the frequency of its use. Patients who are being admitted to the hospital or going for an ambulatory surgical procedure should be instructed to bring their sleep aid devices with them.

Cognition and Perception Evaluating cognitive ability helps determine whether the patient has the capacity to manage safe and effective self-care independently. Is the patient’s short-term memory intact? Is there any history of dementia? Is there evidence of depression or anxiety? Can the patient read? Can the patient read English? What is the patient’s reading level? What is the patient’s preferred learning style? What information does the patient perceive as important? Providing the patient with written information can be a valuable part of patient education but only if the patient can read and comprehend the information. Related assessments include possible hearing or visual impairments. If vision is impaired, patients with HF may not be able to weigh themselves independently or keep records of weight, BP, pulse, or other data requested by the health care team.

Self-Perception and Self-Concept Self-perception and self-concept are related to the cognitive and emotional processes that people use to formulate their beliefs and feelings about themselves. It is important for the nurse to understand patients’ beliefs and feelings about their health as these concepts are key determinants of patients’ adherence to new medical regimens and lifestyle changes (e.g., smoking cessation, weight reduction, exercise), which are necessary for effective self-management after an acute cardiac event. Patients who have misperceptions about the health consequences of their cardiac illness are at risk for nonadherence to their treatment plan. Responses of patients to the following questions will guide the nurse in planning interventions to assure that patients are prepared to manage their illness and that adequate services are in place to support the patient’s recovery and self-management needs.  What is your cardiac problem, and what do you think has contributed to this problem?  What consequences do you think this illness will have on your current lifestyle (leisure and physical activities, work, role in the family and social relationships)?  How much of an influence do you think you have on controlling this illness?

Sexuality and Reproduction A common problem for patients with cardiac diseases is a decrease in frequency of and satisfaction with sexual activity. These changes are associated with inadequate information, depression, and fear

of having a cardiac event (e.g., AMI, sudden death) or development of bothersome symptoms (e.g., chest discomfort, shortness of breath, palpitations). In men, impotence may develop as a side effect of cardiac medications (e.g., beta-blockers); some men will stop taking their medication as a result. Other medications may be substituted so patients should be encouraged to discuss this problem with their health care providers. Patients and their partners may not have adequate information about the physical demands related to sexual activity and ways in which these demands can be modified. The physiologic demands are greatest during orgasm, reaching 5 or 6 metabolic equivalents (METs), which is equivalent to walking 3 to 4 miles per hour on a treadmill. The METs expended before and after orgasm are considerably less, at 3.7 METs. Sharing this information may make the patient and his or her partner more comfortable about resuming sexual activity (Steinke et al., 2013). A reproductive history is necessary for women of childbearing age, particularly those with seriously compromised cardiac function. These women may be advised by their health care providers not to become pregnant. The reproductive history includes information about previous pregnancies, plans for future pregnancies, oral contraceptive use (especially in women older than 35 years of age who smoke), menopausal status, and use of hormone therapy.

Coping and Stress Tolerance Anxiety, depression, and stress are known to influence both the development of and recovery from CAD and HF. High levels of anxiety are associated with an increased incidence of CAD and inhospital complications after MI. Patients with a diagnosis of an acute MI and depression have an increased risk of rehospitalization and death, more frequent angina, more physical limitations, and po...