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Cardiovascular Assessment Cardiovascular Assessment
Dr Ibraheem Bashayreh
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Heart AnatomyHeart AnatomyFacts:
– The heart is about the size of a fist and weighs less than 1 pound
– The average bpm is 72– The average adult heart pumps about 6000-
7500 liters of blood per day through 60,000 miles of blood vessels each minute at rest.
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HeartHeart
Structure– Covered by pericardium
Parietal Visceral (epicardium)
– Outer heart layer: epicardium– Middle heart layer: myocardium– Inner layer: endocardium
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The internal anatomy of the heart.The internal anatomy of the heart.
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HeartHeart
Structure (continued)– Four hollow chambers
Two upper, atria Two lower, ventricles
– Divided by septum and valves
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HeartHeartFunction
– Right atrium receives deoxygenated blood
– Right ventricle pumps blood to lungs
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HeartHeart
Function (continued)– Left atrium receives oxygenated blood– Left ventricle pumps oxygenated blood to
body– AV valve closure: S1 heart sound– Semilunar valve closure: S2 heart sound– Coronary circulation
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The coronary arteriesThe coronary arteries..
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Peripheral Vascular SystemPeripheral Vascular System
Aorta, arteries, arterioles, capillariesVenules, veins, superior and inferior
vena cavaThree layers
– Intima– Media– Adventitia
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Structure of arteries, veins, and capillariesStructure of arteries, veins, and capillaries..
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Peripheral Vascular SystemPeripheral Vascular System
Function– Circulation– Peripheral vascular resistance: viscosity,
length, diameter– Blood pressure control
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Mechanical Properties of Mechanical Properties of the Heartthe Heart
Mechanical– Conduction system
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Mechanical Properties of Mechanical Properties of the Heart (continued)the Heart (continued)
Mechanical– SA node: pacemaker– Cardiac output (CO)– Heart rate (HR)– Stroke volume (SV): the volume of blood
pumped from one ventricle of the heart with each beat
– CO = HR x SV
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Mechanical Properties of Mechanical Properties of the Heart (continued)the Heart (continued)
Mechanical– Cardiac reserve– Preload– Starling’s law– Afterload– Contractility
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Electrical Properties of the Electrical Properties of the HeartHeart
Electrical properties:– Action potential– Polarization– Depolarization– Repolarization– Refractory period
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Electrical Properties of the Electrical Properties of the Heart (continued)Heart (continued)
Filling and pumping– Diastole – ventricular filling– Systole –ventricles eject blood
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The cardiac cycle. Ventricular filling occurs during diastole (1); blood is pumped The cardiac cycle. Ventricular filling occurs during diastole (1); blood is pumped out of the heart to the pulmonary and systemic circulation during ventricular out of the heart to the pulmonary and systemic circulation during ventricular systole (2).systole (2).
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AssessmentAssessmentSubjective
– Health history– Chest pain– SOB– Leg pain– Pillows to sleep– Medications– Lifestyle: diet, alcohol use, exercise,
smoking, drugs
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Assessment (continued)Assessment (continued)
Objective– General appearance– Skin– Wounds– Pulses– Jugular vein distention– Edema– Breathing
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Diagnostic TestsDiagnostic Tests
TEE (transesophageal echocardiogram)– Monitor breathing, cough, gag reflex– Keep NPO until gag reflex returns
Doppler sonography: is a medical imaging technique that
uses ultrasound enhanced by the Doppler effect and is often provide helpful information about the flow and movement of blood and inner
areas of the body – Monitor BP– Wash extremities to remove gel after test completed
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Diagnostic Tests Diagnostic Tests (continued)(continued)
X-rays/CT scan/EBCT Electron beam computed tomography (EBCT) is used
to determine coronary calcium – Document client allergy to fish or shellfish– Pregnancy risk
Angiography/cardiac catheterization MRI
– Document presence of implanted electronic devices Radionuclear scans
– Increase fluids after the test
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MonitorsMonitorsTelemetry/Holter monitor
– Teach about purpose: is a portable device for continuously monitoring various electrical activity of the central nervous system for at least 24 hours (often for two weeks at a tim
– Dry skin– Remove hair– Avoid getting unit wet– When to phone the MD
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Ischemic Heart DiseaseIschemic Heart Disease
Dr Ibrahim Bashayreh
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Contents OverviewContents OverviewCoronary Artery DiseaseHeart AnatomyAtherosclerotic Plaque/AtheromaAngina PectorisMyocardial InfarctionSudden DeathOverall Management
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Coronary Artery DiseaseCoronary Artery Disease
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CAD: Statistics CAD: Statistics CAD is the largest killer of American males and females 13 million Americans have CAD 1.1 million MI’s per year Every 26 seconds an American will suffer from a
coronary event Every 60 seconds an American will die because of a
coronary event @ 42% of those having a coronary event will die from it @350K people die per year because of a coronary event in
the Emergency Department before even being admitted to the hospital
Death Rate in 2001:– 177 in 100,000
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CAD: Demographics and StatisticsCAD: Demographics and Statistics 84% of those who die from CAD are 65 or older If under the age of 65, 80% mortality rate with the first myocardial
infarction Within 1 year of initial MI:
– 25% of men and 38% of women will die Within 8 years of initial MI:
50% of men and women under 65 will die An average of 11.5 years of life are lost due to an MI IMPORTANT:
– 50% of men and 64% of women who have died suddenly via CAD DID NOT HAVE ANY PREVIOUS SYMPTOMS
Sudden Death:– Those with a previous history of MI have a 5-6 times Sudden Death
rate compared to the general population
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Exactly what is Coronary Artery Exactly what is Coronary Artery Disease (Ischemic Heart Disease) Disease (Ischemic Heart Disease)
and how/why does it occurand how/why does it occur??
Start with anatomy…
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DefinitionDefinition
" Ischaemia " refers to an insufficient amount of blood. The coronary arteries are the only source of blood for the heart muscle. If this coronary arteries are blocked, the blood supply will reduce.
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Key ConceptsKey ConceptsIschemic heart disease (IHD): caused by
coronary atherosclerotic plaque formation which leads to imbalance between O2 supply & demand– results in myocardial ischemia
Chest pain: cardinal symptom of myocardial ischemia caused by coronary artery disease (CAD)
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Ischemic CycleIschemic CycleIschemia / infarction
chest pain
Diastolic Dysfunction Systolic Dysfunction
cardiac output
catecholamines
MVO2
wall tension
LV diastolic pressurepulmonarycongestionpO2
(heart rate, BP)
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High blood cholesterol High blood pressure Smoking Obesity Lack of physical activity
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Risk FactorsRisk Factors
UncontrollableUncontrollable
•Sex
•Hereditary
•Race
•Age
ControllableControllable
•High blood pressure
•High blood cholesterol
•Smoking
•Physical activity
•Obesity
•Diabetes
•Stress and anger
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Why would there be an insufficient blood supply to the heart?– Remember that the coronary arteries are the
only source of fuel to the heart– The coronary arteries may become
partially/completely occluded: Atherosclerotic Plaques
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Atherosclerotic Plaque: Atherosclerotic Plaque: Definition and FormationDefinition and Formation
Focal accumulation of smooth muscle cells, foam cells, cholesterol crystals and lipid under the endothelium of the artery (within the Tunica Intima)
Given time, this plaque can protrude into the lumen of the vessel reducing blood flow
Often develops at branch points or curves within the vasculature blood is slowed and/or turbulent
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Atheroma/ Atherosclerotic Atheroma/ Atherosclerotic PlaquePlaque
Where does the plaque begin? within the Tunica Intima, the innermost wall of the artery
What is a plaque made of?– Superficial fibrous cap made of
smooth muscle cells, collagen, elastin and proteins
Also contains Macrophages, Foam Cells, T Cells
Foam cells are one of the first cells found at the site of the fatty streak, which is the beginning of atherosclerotic plaque formation in vessels
– Necrotic Center of cholesterol crystals, lipids, Apolipoprotein B LDL
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Atheroma: ContinuedAtheroma: Continued As the atheroma within the coronary arteries
enlarges, the blood flow to the heart decreases and therefore so does the O2 supply
The heart is not in danger of hypoxia until 50% of the vessel is occluded
As the heart senses a decrease in O2, there is attempted compensation:– Increase Heart Rate– Increase Blood Pressure – Aggravation/Worsening of the atheroma
When 70% of the artery is occluded, Angina Pectoris will occur
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Ischemic Heart DiseaseIschemic Heart Disease
Classification = mainly 4 types– Myocardial infarction (MI)– Sudden cardiac death– Angina pectoris – Chronic IHD with heart failure
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Angina PectorisAngina Pectoris At least 70% occlusion of coronary artery
resulting in pain. What kind of pain?– Chest pain– Radiating pain to:
Left shoulder Jaw Left or Right arm
Usually brought on by physical exertion as the heart is trying to pump blood to the muscles, it requires more blood that is not available due to the blockage of the coronary artery(ies)
Is self limiting usually stops when exertion is ceased
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Angina Pectoris ContinuedAngina Pectoris Continued
Angina Pectoris can be Stable or Unstable:
Stable:– The pain and pattern of events is unchanged
over a period of time (months years)Unstable:
– The pain and pattern is changing, be it in duration, intensity or frequency
– A Myocardial Infarction waiting to happen
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Myocardial InfarctionMyocardial Infarction
Partial or total occlusion of one or more of the coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle
When an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels
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Myocardial Infarctions: Myocardial Infarctions: StatisticsStatistics
250,000 deaths per year. 30% mortality within the first 2 hours 45 Minutes of Ischemia:
– Cardiac muscle death occurs How is the Diagnosis Made?
– Electrocardiographic changes ST elevation
– Myocardial enzyme elevation Creatine kinase Troponin C Reactive Protein
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MI, Atheroma MI, Atheroma When there is an atheroma, as mentioned before
there can be rupture resulting in thrombus formation because of the build up of platelets
When there is breakage of the thrombus there is emboli formation
An emboli can travel to the brain (cerebral infarct) can remain in the heart (myocardial infarct) or even travel to the extremities cutting off blood supply
As the area beneath the is disrupted atheroma hemorrhages, there can is increased risk of abscess formation and infection
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Complications of Complications of Myocardial InfarctionsMyocardial Infarctions
Infarction leading to inability of the heart to function properly leading to Heart Failure
Angina/PainCardiogenic shock Ventricular aneurysm and ruptureEmbolism FormationArrhythmias Myocardial Infarctions can
lead to Ventricular Fibrillation (shockable!)
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Sudden DeathSudden Death Sudden Death :
– 250,000 deaths in the US per year are caused by what is referred to as “sudden” cardiac death
– Sudden Cardiac Death is also known as a “Massive Heart Attack” in which the heart converts from sinus rhythm to ventricular fibrillation
– In V-Fib, the heart is unable to contract fully resulting in lack of blood being pumped to the vital organs
– V-Fib requires shock from defibrillator “SHOCKABLE RHYTHM”
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Many people are able to manage coronary artery disease with lifestyle changes and medications.
Other people with severe coronary artery disease may need angioplasty or surgery.
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Management of Ischemic Management of Ischemic Heart DiseaseHeart Disease::
Pharmaceuticals:– Beta Blockers
Act either selectively or non-selectively on Beta receptors:– Beta 1 cardiac muscle increase rate and contraction– Beta 2 dilates bronchial smooth muscle
– Ca++ Channel Blockers Acts on vasculature blocking Ca++ and causing vasodilation
– Nitrates Vasculature vasodilation
– Anti-Hypercholesterolemia HMG CoA Reductase Inhibitors reduction in “manmade”
cholesterol thus helping to reduce atheroma formation– Antiplatelet Medication:
Clopidogrel (Plavix) Aspirin
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Surgical TreatmentSurgical Treatment
1) Stenting
2) Angioplasty (balloon)
3) Bypass surgery
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Management of Ischemic Management of Ischemic Heart Disease:Heart Disease:
Lifestyle:– Diet– Exercise Preventive treatment• Low fat, low cholesterol diet• Cessation of smoking• Red wine (in moderation)
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Nursing AssessmentNursing Assessment1.
1. Gather information about all facets of the client’s activities, especially those that precede and precipitate attacks of anginal pain.2. Assess the risk factors in the client’s history and modifications possible to reduce risk.3. If chest discomfort is present at the time of the interview, further collection of data is delayed until pain and dysrhythmias are resolved.4. A complete physical assessment is performed to identify the presence of chest, epigastric, jaw, back, or arm discomfort which is then rated on a subjective scale of 1 to 10 in intensity. The client is questioned regarding nausea, vomiting, diaphoresis, dizziness, weakness, palpitations, and SOB
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Nursing Diagnosis Nursing Diagnosis
1. Pain related to myocardial ischemia.
2. Altered tissue perfusion: related to imbalance between myocardial oxygen supply and demand.
3. Anxiety related to fear of death and knowledge deficit
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Nursing Plan and InterventionsNursing Plan and Interventions Goals
1. Prevention of pain.2. Improved tissue perfusion as evidenced by absence of chest pain and absence of dysrhythmias.3. Reduction of anxiety and increased knowledge of disease process.
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Nursing Interventions Nursing Interventions 1. The nurse must teach the client the link between symptoms and
activity and the need to avoid activities known to cause angina, such as sudden exertion, exposure to cold, and emotional excitement.
2. Medications used in the treatment of angina include nitrates, beta-blockers, calcium channel blockers, and platelet antiaggregants. Administer cardiac medication as prescribed and be alert for adverse side effects, particularly their effect on blood pressure. Teach the client the symptoms to be aware of and what measures to take.
3. Encourage the client to remain on bedrest in order to decrease cardiac workload and oxygen consumption.
4. Administer oxygen therapy as prescribed.
5. Evaluate vital signs hourly to determine the hemodynamic effect of the drugs and the client’s tissue perfusion.
6. Nursing care should be planned so that minimal time is spent away from the bedside due to the high level of client anxiety, as well as the unstable condition of the patient.
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Nursing InterventionsNursing Interventions7. Clients with unstable angina are at high risk for myocardial
infarction (MI) and sudden death. The nurse watches for development of heart failure and dysrhythmias.
8. Relieving pain is the top priority for the client with an acute MI, and medication therapy is administered to accomplish this goal.
9. Maintain patent IV for administration of fluids and vasodilators and anticoagulant therapy (Nitroglycerin and heparin). They relieve pain and they aid in minimizing permanent injury to the myocardium.10. Prepare for possible emergency heart catheterization or CABG.
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Nursing InterventionsNursing Interventions
11. Whether CABG is planned as an elective procedure or performed on an emergency basis, the nurse should try to alleviate the client’s and the family’s anxiety and assist them in understanding the need for this life-saving procedure.
12. The nurse describes the postoperative course, emphasizing the close monitoring and use of sophisticated equipment. The client is encourage to tell the nurse about any discomfort post-op.
13. Encourage the client and family members to verbalize their fears and concerns.
14. Teach the client the nature of the illness and the facts needed to reorganize living habits in order to reduce the frequency and severity of anginal attacks, delay the progress of the disease, and avoid other complications.
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Evaluation Evaluation
1. Verbalizes relief of chest pain.
2. No signs of respiratory difficulties.
3. Modifies lifestyle in order to prevent future attacks.
4. Demonstrates increased knowledge of disease process and reduction in anxiety.
5. Absence of complications.
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،نسأل الله أن يعلمنا ما ينفعنا
،وأن ينفعنا بما علمنا
وأن يزيدنا علما
وفي النهايةوفي النهاية