CARDIAC ASSESSMENT

S. Buckley RN, MSN

Copyright 2008

HEART PACEMAKER CELLS AND RATES

• Normal Pacemaker is SA Node—Discharges at rate of 60-100 BPM

• AV Node at rate of 40-60 BPM

• HIS Bundle, Purkinje System at 30-40 BPM

• Accelerated Pacemakers may control pacing with premature beats

HEALTH HISTORY

• Childhood/adult illnesses

• Current medications

• Sleep pattern

VITAL SIGNS

• Orthostatic Vital Signs

• Neck Vein Distension

• Peripheral Pulses:

• 0 =Absent

• 1+=Barely Palpable

• 2+=Decreased

• 3+=Full (Normal)

• 4+=Bounding

AUSCULTATION LANDMARKS

• Aortic Area: 2nd Rt. ICS near the sternum

• Pulmonic Area: 2nd Lt. ICS near the sternum

• Tricuspid Area: 5th LT. ICS close to the sternum

• Mitral Area: Lt. mid-clavicular line at 5th ICS (Cardiac Apex)

• Erb’s Point: 3rd Lt. ICS near sternum

AUSCULTATION SOUNDS

First Heart Sound (S1): Closure of the tricuspid and mitral valve. Signals the beginning of systole.

Second Heart Sound (S2): Closure of the aortic and pulmonic valves. Signals the beginning of diastole.

Coronary Artery Blood Flow Requires:

ATHEROSCLEROSIS TERMS

• Coronary Artery Disease (CAD)

• Arteriosclerotic Heart Disease (ASHD)

• Cardiovascular Heart Disease (CVHD)

• Ischemic Heart Disease (IHD)

• Coronary Heart Disease (CHD)

• Acute Coronary Syndrome (ACS)

CORONARY ARTERY DISEASE DEVELOPMENT STAGES

• Fatty Streak: Earliest lesions characterized by lipid-filled smooth muscle cells. As streaks of fat develop within cells, a yellow tinge appears.

• Raised Fibrous Plaque: Beginning of progressive changes in the arterial wall caused by endothelial injury from ^BP, ^Cholesterol, Heredity, Smoking.

• Smooth Muscle Proliferation occurs and thickening of the arterial wall.

• Lipoproteins transport cholesterol into arterial intima.

• Lipids adhere to roughened damaged walls, causing lesion buildup.

• Collagen tissue, elastic fibers and smooth cells filled with fat cover the lesion.

• Thrombus forms on the arterial wall causing narrowing or occulsion

• Complicated Lesion: In this final stage the lesion darkens, hardens and becomes necrotic. This complex lesion may totally or partially occlude the artery.

• Gradual Occlusion versus Rapid Onset

INFLAMMATION THEORY

Normally LDL slides easily in and out of the intima. When there is too much LDL, the particles stick in the intima. Trapped LDL undergoes oxidation, sugar coating and chemical changes. To the immune system, these changes resemble and infection and prompt a defensive action.

The process of inflammation starts here. Monocytes cluster around trapped LDL forming a fatty pool in the intima.

A scab-like cap covers the plaque.

• Changes inside the fatty pool can make it swell to the point of bursting. Blood rushing past the plaque threaten to rip it off. High Blood Pressure, ^Heart Rate, and Smoking make the problem worse.

• Debris inside the plaque bursts through and spews into circulation forming clots.

LABORATORY TESTS

• C-Reactive Protein (CRP)• Creatine Kinase (CPK)• Troponin

• Triglycerides• Cholesterol• LDL• HDL

LABORATORY TESTS

.Homocysteine: A sulfur containing animo acid produced by breakdown of essential amino acid methionine found in dietary protein.

Cardiac Natriuretic Peptide Markers: (BNP)

Lipoprotein-Associated Phospholipse: (PLAC)

RISK FACTORS

• Elevated Serum Lipids

• Hypertension

• Cigarette Smoking

UNMODIFIABLE RISK FACTORS

• Age

• Gender

• Race

• Heredity

MODIFIABLE RISK FACTORS

• Elevated Lipids

• Hypertension

• Smoking

• Obesity

• Stress

• Diabetes

• Sedentary Life Style

MEDICATIONS

• Cholesterol conversion to bile acids in the liver.• Questran: Resins lower LDL and increase HDL.• Colestid: Lowers hepatic cholesterol content

and increases conversion to bile acids.

• Side Effects: GI, Constipation, Abdominal Pain.• Interferes With: Coumadin, Thiazides, Thyroid,

and B Blockers.• Use separate time of administration.

DRUGS THAT RESTRICT LIPOPROTEIN

• Niacin (B Vitamin) interferes with synthesis of cholesterol and triglycerides.

• Side Effects: Flushing, Pruritus, GI

• Atromid primarily affects triglyceride levels and decreases systhesis of lipids.

• Side Effects: Malaise, Nausea, Diarrhea, Increased Liver Enzymes

• Lopid: Lowers VLDL levels and increases HDL.

• Side Effects: GI.

• Statin: (Mevacor, Lipitor, Zocor, Lescol) competitive inhibitor of biosynthesis of cholesterol.

• Side Effects: GI, Insomnia, Increased Liver Enzymes, Opacity of Eye Lens.

• Aspirin: Anti-platelet, Anti-inflammatory

• Side Effects