Assessment of Cardiovascular Heart Chambers

Function ● The four chambers of the heart constitute the right- and
left-sided pumping systems.
Anatomic and Physiologic Overview ● The right side of the heart, made up of the right atrium and
right ventricle, distributes venous blood (deoxygenated
● The heart is a hollow, muscular organ located in the center of blood) to the lungs via the pulmonary artery (pulmonary
the thorax, where it occupies the space between the lungs circulation) for oxygenation.
(mediastinum) and rests on the diaphragm. ● The right atrium receives blood returning from the superior
● It weighs approximately 300 g (10.6 oz), although heart vena cava (head, neck, and upper extremities), inferior vena
weight and size are influenced by age, gender, body weight, cava (trunk and lower extremities), and coronary sinus
extent of physical exercise and conditioning, and heart (coronary circulation).
disease. ● The left side of the heart, composed of the left atrium and left
● The heart pumps blood to the tissues, supplying them with ventricle, distributes oxygenated blood to the remainder of
oxygen and other nutrients. The pumping action of the heart the body via the aorta (systemic circulation). The left atrium
is accomplished by the rhythmic contraction and relaxation of receives oxygenated blood from the pulmonary circulation
its muscular wall. via the pulmonary veins.
● During systole (contraction of the muscle), the chambers of ● The varying thicknesses of the atrial and ventricular walls
the heart become smaller as the blood is ejected. During relate to the workload required by each chamber
diastole (relaxation of the muscle), the heart chambers fill ● The atria are thin-walled because blood returning to these
with blood in preparation for the subsequent ejection. chambers generates low pressures. In contrast, the ventricular
● A normal resting adult heart beats approximately 60 to 80 walls are thicker because they generate greater pressures
times per minute. Each ventricle ejects approximately 70 mL during systole.
of blood per beat and has an output of approximately 5 L per ● The right ventricle contracts against low pulmonary vascular
minute. pressure and has thinner walls than the left ventricle.
● The left ventricle, with walls two-and-a-half times more
Anatomy of the Heart muscular than those of the right ventricle, contracts against
high systemic pressure.
● The heart is composed of three layers. ● Because the heart lies in a rotated position within the chest
● The inner layer, or endocardium, consists of endothelial cavity, the right ventricle lies anteriorly (just beneath the
tissue and lines the inside of the heart and valves. sternum) and the left ventricle is situated posteriorly.
● The middle layer, or myocardium, is made up of muscle ● The left ventricle is responsible for the apex beat or the point
fibers and is responsible for the pumping action. The exterior of maximum impulse (PMI), which is normally palpable in
layer of the heart is called the epicardium. the left midclavicular line of the chest wall at the fifth
● The heart is encased in a thin, fibrous sac called the intercostal space.
pericardium, which is composed of two layers. Adhering to
the epicardium is the visceral pericardium. Enveloping the Heart Valves
visceral pericardium is the parietal pericardium, a tough
fibrous tissue that attaches to the great vessels, diaphragm, ● ATRIOVENTRICULAR VALVES
sternum, and vertebral column and supports the heart in the ー The valves that separate the atria from the ventricles
mediastinum. are termed atrioventricular valves.
● The space between these two layers (pericardial space) is ー The tricuspid valve, so named because it is composed
filled with about 30 mL of fluid, which lubricates the surface of three cusps or leaflets, separates the right atrium
of the heart and reduces friction during systole. from the right ventricle.
ー The mitral, or bicuspid (two cusps) valve, lies between
the left atrium and the left ventricle.
ー Normally, when the ventricles contract, ventricular
pressure rises, closing the atrioventricular valve
leaflets.
ー Two additional structures, the papillary muscles and
the chordae tendineae, maintain valve closure.
ー The papillary muscles, located on the sides of the
ventricular walls, are connected to the valve leaflets by
thin fibrous bands called chordae tendineae.
ー During systole, contraction of the papillary muscles
causes the chordae tendineae to become taut, keeping
the valve leaflets approximated and closed.
● SEMILUNAR VALVES
ー The two semilunar valves are composed of three
half-moon-like leaflets.
 ー The valve between the right ventricle and the
pulmonary artery is called the pulmonic valve; the Function of the Heart: Conduction System
valve between the left ventricle and the aorta is called
the aortic valve. ● The specialized heart cells of the cardiac conduction system
methodically generate and coordinate the transmission of
electrical impulses to the myocardial cells.
Coronary Arteries ● The result is sequential atrioventricular contraction, which
provides for the most effective flow of blood, thereby
● The left and right coronary arteries and their branches supply
optimizing cardiac output.
arterial blood to the heart.
● Three physiologic characteristics of the cardiac conduction
● These arteries originate from the aorta just above the aortic
cells account for this coordination:
valve leaflets.
ー Automaticity: ability to initiate an electrical impulse
● The heart has large metabolic requirements, extracting
ー Excitability: ability to respond to an electrical impulse
approximately 70% to 80% of the oxygen delivered (other
ー Conductivity: ability to transmit an electrical impulse
organs consume, on average, 25%).
from one cell to another
● Unlike other arteries, the
● The sinoatrial (SA) node, referred to as the primary
coronary arteries are perfused
pacemaker of the heart, is located at the junction of the
during diastole.
superior vena cava and the right atrium. The SA node in a
● An increase in heart rate
normal resting heart has an inherent firing rate of 60 to 100
shortens diastole and can
impulses per minute, but the rate can change in response to
decrease myocardial perfusion.
the metabolic demands of the body.
● Patients, particularly those with
● The electrical impulses initiated by the SA node are
coronary artery disease (CAD),
conducted along the myocardial cells of the atria via
can develop myocardial
specialized tracts called internodal pathways.
ischemia (inadequate oxygen
● The impulses cause electrical stimulation and subsequent
supply) when the heart rate
contraction of the atria.
accelerates.
● The impulses are then conducted to the atrioventricular (AV)
● The left coronary artery has
node.
three branches.
● The AV node (located in the right atrial wall near the
● The artery from the point of origin to the first major branch is
tricuspid valve) consists of another group of specialized
called the left main coronary artery.
muscle cells similar to those of the SA node.
● Two bifurcations arise off the left main coronary artery.
● The AV node coordinates the
● These are the left anterior descending artery, which courses
incoming electrical impulses
down the anterior wall of the heart, and the circumflex artery,
from the atria and, after a slight
which circles around to the lateral left wall of the heart.
delay (allowing the atria time to
● The right side of the heart is supplied by the right coronary
contract and complete ventricular
artery, which progresses around to the bottom or inferior wall filling), relays the impulse to the
of the heart. ventricles. This impulse is then
● The posterior wall of the heart receives its blood supply by an conducted through a bundle of
additional branch from the right coronary artery called the specialized conduction cells
posterior descending artery. (bundle of His) that travel in the
● Superficial to the coronary arteries are the coronary veins. septum separating the left and
Venous blood from these veins returns to the heart primarily right ventricles.
through the coronary sinus, which is located posteriorly in the ● The bundle of His divides into the right bundle branch
right atrium. (conducting impulses to the right ventricle) and the left
bundle branch (conducting impulses to the left ventricle).
Cardiac Muscle ● To transmit impulses to the largest chamber of the heart, the
left bundle branch bifurcates into the left anterior and left
● The myocardium is composed of specialized muscle tissue. posterior bundle branches. Impulses travel through the bundle
● Microscopically, myocardial muscle resembles striated branches to reach the terminal point in the conduction system,
(skeletal) muscle, which is under conscious control. called the Purkinje fibers.
● Functionally, however, myocardial muscle resembles smooth ● This is the point at which the myocardial cells are stimulated,
muscle because its contraction is involuntary. causing ventricular contraction.
● The myocardial muscle fibers are arranged ● The heart rate is determined by the myocardial cells with the
in an interconnected manner (called a fastest inherent firing rate.
syncytium) that allows for coordinated ● Under normal circumstances, the SA node has the highest
myocardial contraction and relaxation. inherent rate, the AV node has the second highest inherent
● The sequential pattern of contraction and rate (40 to 60 impulses per minute), and the ventricular
relaxation of individual muscle fibers pacemaker sites have the lowest inherent rate (30 to 40
ensures the rhythmic behavior of the impulses per minute).
myocardium as a whole and enables it to
function as an effective pump.
● If the SA node malfunctions, the AV node generally takes ● The absolute refractory period is the time during which the
over the pacemaker function of the heart at its inherently heart cannot be restimulated to contract regardless of the
lower rate. strength of the electrical stimulus. This period corresponds
● Should both the SA and the AV nodes fail in their pacemaker with depolarization and the early part of repolarization.
function, a pacemaker site in the ventricle will fire at its During the latter part of repolarization, however, if the
inherent bradycardic rate of 30 to 40 impulses per minute. electrical stimulus is stronger than normal, the myocardium
can be stimulated to contract. This short period at the end of
repolarization is called the relative refractory period.
Physiology of Cardiac Conduction
● Refractoriness protects the heart from sustained contraction
(tetany), which would result in sudden cardiac death.
● Cardiac electrical activity is the result of the movement of
● Normal electromechanical coupling and contraction of the
ions (charged particles such as sodium, potassium, and
heart depend on the composition of the interstitial fluid
calcium) across the cell membrane.
surrounding the heart muscle cells.
● The electrical changes recorded within a single cell result in
● In turn, the composition of this fluid is influenced by the
what is known as the cardiac action potential.
composition of the blood. A change in serum calcium
concentration may alter the contraction of the heart muscle
fibers. A change in serum potassium concentration is also
important, because potassium affects the normal electrical
voltage of the cell.

● In the resting state, cardiac muscle cells are polarized, which

means an electrical difference exists between the negatively
charged inside and the positively charged outside of the cell Cardiac Hemodynamics
membrane.
● As soon as an electrical impulse is initiated, cell membrane ー An important determinant of blood flow in the cardiovascular
permeability changes and sodium moves rapidly into the cell, system is the principle that fluid flows from a region of
while potassium exits the cell. higher pressure to one of lower pressure. The pressures
● This ionic exchange begins depolarization (electrical responsible for blood flow in the normal circulation are
activation of the cell), converting the internal charge of the generated during systole and diastole.
cell to a positive one.
● Contraction of the myocardium follows depolarization. The CARDIAC CYCLE
interaction between changes in membrane voltage and muscle ● Beginning with systole, the pressure inside the ventricles
contraction is called electromechanical coupling. rapidly rises, forcing the atrioventricular valves to close.
● As one cardiac muscle cell is depolarized, it acts as a stimulus ● As a result, blood ceases to flow from the atria into the
to its neighboring cell, causing it to depolarize. ventricles and regurgitation (backflow) of blood into the atria
● Sufficient depolarization of a single specialized conduction is prevented.
system cell results in depolarization and contraction of the ● The rapid rise of pressure inside the right and left ventricles
entire myocardium. forces the pulmonic and aortic valves to open, and blood is
● Repolarization (return of the cell to its resting state) occurs as ejected into the pulmonary artery and aorta, respectively.
the cell returns to its baseline or resting state; this ● The exit of blood is at first rapid; then, as the pressure in each
corresponds to relaxation of myocardial muscle. ventricle and its corresponding artery equalizes, the flow of
● After the rapid influx of sodium into the cell during blood gradually decreases. At the end of systole, pressure
depolarization, the permeability of the cell membrane to within the right and left ventricles rapidly decreases. This
calcium is changed. lowers pulmonary artery and aortic pressure, causing closure
● Calcium enters the cell and is released from intracellular of the semilunar valves. These events mark the onset of
calcium stores. The increase in calcium, which occurs during diastole.
the plateau phase of repolarization, is much slower than that ● During diastole, when the ventricles are relaxed and the
of sodium and continues for a longer period. atrioventricular valves are open, blood returning from the
● Cardiac muscle, unlike skeletal or smooth muscle, has a veins flows into the atria and then into the ventricles.
prolonged refractory period during which it cannot be ● Toward the end of this diastolic period, the atrial muscles
restimulated to contract. contract in response to an electrical impulse initiated by the
● There are two phases of the refractory period, referred to as SA node (atrial systole).
the absolute refractory period and the relative refractory ● The resultant contraction raises the pressure inside the atria,
period. ejecting blood into the ventricles.
● Atrial systole augments ventricular blood volume by 15% to resultant vasoconstriction and increased heart rate elevate the
25% and is sometimes referred to as the “atrial kick.” At this BP.
point, the ventricular systole begins in response to
propagation of the electrical impulse that began in the SA Control of Stroke Volume
node some milliseconds previously.
● Stroke volume is primarily determined by three factors:
Cardiac Output preload, afterload, and contractility.
● Preload is the term used to describe the degree of stretch of
● Cardiac output is the amount of blood pumped by each the cardiac muscle fibers at the end of diastole.
ventricle during a given period. ● The end of diastole is the period when filling volume in the
● The cardiac output in a resting adult is about 5 L per minute ventricles is the highest and the degree of stretch on the
but varies greatly depending on the metabolic needs of the muscle fibers is the greatest.
body. ● The volume of blood within the ventricle at the end of
● Cardiac output is computed by multiplying the stroke volume diastole determines preload.
by the heart rate. ● Preload has a direct effect on stroke volume. As the volume
● Stroke volume is the amount of blood ejected per heartbeat. of blood returning to the heart increases, muscle fiber stretch
● The average resting stroke volume is about 70 mL, and the also increases (increased preload), resulting in stronger
heart rate is 60 to 80 beats per minute (bpm). Cardiac output contraction and a greater stroke volume.
can be affected by changes in either stroke volume or heart ● This relationship, called the Frank-Starling law of the heart
(or sometimes the Starling law of the heart), is maintained
until the physiologic limit of the muscle is reached.
Control of Heart Rate
● The Frank-Starling law is based on the fact that, within limits,
the greater the initial length or stretch of the cardiac muscle
● Cardiac output must be responsive to changes in the
cells (sarcomeres), the greater the degree of shortening that
metabolic demands of the tissues. For example, during
occurs.
exercise the total cardiac output may increase fourfold, to 20
● This result is caused by increased interaction between the
L per minute. This increase is normally accomplished by
thick and thin filaments within the cardiac muscle cells.
approximate doubling of both the heart rate and the stroke
● Preload is decreased by a reduction in the volume of blood
volume.
returning to the ventricles.
● Changes in heart rate are accomplished by reflex controls
● Diuresis, venodilating agents (eg, nitrates), and loss of blood
mediated by the autonomic nervous system, including its
or body fluids from excessive diaphoresis, vomiting, or
sympathetic and parasympathetic divisions.
diarrhea reduce preload.
● The parasympathetic impulses, which travel to the heart
● Preload is increased by increasing the return of circulating
through the vagus nerve, can slow the cardiac rate, whereas
blood volume to the ventricles. Controlling the loss of blood
sympathetic impulses increase it. These effects on heart rate
or body fluids and replacing fluids (ie, blood transfusions and
result from action on the SA node, to either decrease or
intravenous fluid administration) are examples of ways to
increase its inherent rate. The balance between these two
increase preload.
reflex control systems normally determines the heart rate.
● The second determinant of stroke volume is afterload, the
The heart rate is stimulated also by an increased level of
amount of resistance to ejection of blood from the ventricle.
circulating catecholamines (secreted by the adrenal gland)
● The resistance of the systemic BP to left ventricular ejection
and by excess thyroid hormone, which produces a
is called systemic vascular resistance.
catecholamine-like effect
● The resistance of the pulmonary BP to right ventricular
● The balance between these two reflex control systems
ejection is called pulmonary vascular resistance.
normally determines the heart rate. The heart rate is
● There is an inverse relationship between afterload and stroke
stimulated also by an increased level of circulating
volume. For example, afterload is increased by arterial
catecholamines (secreted by the adrenal gland) and by excess
vasoconstriction, which leads to decreased stroke volume.
thyroid hormone, which produces a catecholamine-like effect.
● The opposite is true with arterial vasodilation: afterload is
● Heart rate is also affected by central nervous system and
reduced because there is less resistance to ejection, and stroke
baroreceptor activity.
volume increases.
● Baroreceptors are specialized nerve cells located in the
● Contractility is a term used to denote the force generated by
aortic arch and in both right and left internal carotid arteries
the contracting myocardium under any given condition.
(at the point of bifurcation from the common carotid arteries).
● Contractility is enhanced by circulating catecholamines,
● The baroreceptors are sensitive to changes in blood pressure
sympathetic neuronal activity, and certain medications (eg,
(BP).
digoxin, intravenous dopamine or dobutamine).
● During elevations in BP (hypertension), these cells increase
● Increased contractility results in increased stroke volume.
their rate of discharge, transmitting impulses to the medulla.
Contractility is depressed by hypoxemia, acidosis, and certain
This initiates parasympathetic activity and inhibits
medications (eg, beta-adrenergic blocking agents such as
sympathetic response, lowering the heart rate and the BP.
atenolol [Tenormin]).
● The opposite is true during hypotension (low BP).
● The heart can achieve a greatly increased stroke volume (eg,
Hypotension results in less baroreceptor stimulation, which
during exercise) by increasing preload (through increased
prompts a decrease in parasympathetic inhibitory activity in
venous return), increasing contractility (through sympathetic
the SA node, allowing for enhanced sympathetic activity. The
 nervous system discharge), and decreasing afterload (through ● For this patient, the health history, physical assessment, and
peripheral vasodilation with decreased aortic pressure). The important nursing interventions (eg, cardiac monitoring,
percentage of the end-diastolic volume that is ejected with administration of intravenous medications) are performed
each stroke is called the ejection fraction. With each stroke, simultaneously.
about 42% (right ventricle) to 50% (left ventricle) or more of
the end-diastolic volume is ejected by the normal heart. The Health History and Clinical Manifestations
ejection fraction can be used as an index of myocardial
contractility: the ejection fraction decreases if contractility is ● For the patient experiencing an acute MI, the nurse obtains
depressed. the health history using a few specific questions about the
onset and severity of chest discomfort, associated symptoms,
Gender Differences in Cardiac Structure and Function current medications, and allergies.
● At the same time, the nurse observes the patient’s general
● Compared with a man’s heart, a woman’s heart tends to be appearance and evaluates hemodynamic status (heart rate and
smaller. It weighs less and has smaller coronary arteries. rhythm, BP). Once the condition of the patient stabilizes, a
These structural differences have significant implications. more extensive history can be obtained.
● Because the coronary arteries of a woman are smaller, they ● With stable patients, a complete health history is obtained
occlude from atherosclerosis more easily, making procedures during the initial contact. Often, it is helpful to have the
such as cardiac catheterization and angioplasty technically patient’s spouse or partner available during the health history
more difficult, with a higher incidence of postprocedure interview. Initially, demographic information regarding age,
complications. gender, and ethnic origin is obtained.
● In addition, the resting rate, stroke volume, and ejection ● The family history, as well as the physical examination,
fraction of a woman’s heart are higher than those of a man’s, should include assessment for genetic abnormalities
and the conduction time of an electrical impulse coursing associated with cardiovascular disorders.
from the SA node through the AV node to the Purkinje fibers ● Height, current weight, and usual weight (if there has been a
is briefer. recent weight loss or gain) are established.
● Another significant difference between the genders is the ● During the interview, the nurse conveys sensitivity to the
physiologic effects of estrogen on the cardiovascular system. cultural background and religious practices of the patient.
Two important effects of estrogen, regulation of vasomotor This removes barriers to communication that may result if the
tone and of response to vascular injury, may be the interview is based only on the nurse’s personal frame of
mechanisms that protect women against the development of reference.
atherosclerosis. ● Patients from different cultural and ethnic groups may have
● An additional, potentially beneficial effect of estrogen is its different ways of describing symptoms such as pain and may
action on the liver, which results in improved lipid profiles. engage in different health practices before seeking formal
● On the other hand, less favorable effects of estrogen include medical attention.
an increase in coagulation proteins and a decrease in ● The baseline information derived from the history assists in
fibrinolytic protein, which enhance the risk of thrombus identifying pertinent issues related to the patient’s condition
formation. and educational and self-care needs.
● Progesterone also has vascular effects, but its role in the ● Once these problems are clearly identified, a plan of care is
development of CVD is unclear at this time. instituted. During subsequent contacts or visits with the
● Beneficial effects of estrogen disappear after menopause, as patient, a more focused health history is performed to
evidenced by the increased incidence of CVD in this determine whether goals have been met, whether the plan
population. However, because of health risks associated with needs to be modified, and whether new problems have
hormone replacement therapy, the American Heart developed.
Association does not recommend its use as a primary or ● During the interview, the nurse asks questions to evaluate
secondary prevention intervention for CVD cardiac symptoms and health status.
● Cardiac Signs and Symptoms
ー Patients with cardiovascular disorders commonly have
Assessment one or more of the following signs and symptoms:
○ Chest pain or discomfort (angina pectoris, MI,
● The assessment of the acutely ill cardiac patient will be
valvular heart disease)
different from that of a patient with stable or chronic cardiac
○ Shortness of breath or dyspnea (MI, left ventricular
conditions. For example, the assessment performed by an
failure, HF)
emergency department nurse caring for a patient who is
○ Edema and weight gain (right ventricular failure,
experiencing an acute myocardial infarction (MI) must be
HF)
very focused and must be performed rapidly.
○ Palpitations (dysrhythmias resulting from
● The nurse must assess the patient for complications
myocardial ischemia, valvular heart disease,
associated with the MI, screen the patient for
ventricular aneurysm, stress, electrolyte
contraindications to coronary artery reperfusion strategies
imbalance)
including thrombolytic therapy or primary percutaneous
○ Fatigue (earliest symptom associated with several
transluminal coronary angioplasty (PTCA), and evaluate the
CV disorders)
patient’s response to medical and nursing interventions.
 ○ Dizziness and syncope or loss of consciousness ー Is the patient independent in taking medications? Are
(postural hypotension, dysrhythmias, vasovagal the medications taken as prescribed?
effect, cerebrovascular disorders ー Does the patient understand why the medication
● Not all chest discomfort is related to myocardial ischemia. regimen is important? Are doses ever forgotten or
When a patient has chest discomfort, questions should focus skipped, or does the patient ever decide to stop taking
on differentiating a serious, life-threatening condition such as a medication?
MI from conditions that are less serious or that would be ● An aspirin a day is a common nonprescription medication
treated differently. The following points should be that improves patient outcomes after an MI. However, if
remembered when assessing patients with cardiac symptoms: patients are not aware of this benefit, they may be inclined to
○ Women are more likely to present with atypical stop taking aspirin if they think it is a trivial medication.
symptoms of MI than are men. ● A careful medication history will often uncover common
○ There is little correlation between the severity of the medication errors and causes for nonadherence to the
chest discomfort and the gravity of its cause. Elderly medication regimen.
people and those with diabetes may not have pain with
angina or MI because of neuropathies. Fatigue and Nutrition and Metabolism
shortness of breath may be the predominant symptoms
in these patients. ● Dietary modifications, exercise, weight loss, and careful
○ There is poor correlation between the location of chest monitoring are important strategies for managing three major
discomfort and its source. cardiovascular risk factors: hyperlipidemia, hypertension, and
○ The patient may have more than one clinical condition hyperglycemia (diabetes mellitus). Diets that are restricted in
occurring simultaneously. sodium, fat, cholesterol, and/or calories are commonly
○ In a patient with a history of CAD, the chest prescribed. The nurse should obtain the following
discomfort should be assumed to be secondary to information:
ischemia until proven otherwise. ー The patient’s current height and weight (to determine
body mass index), waist measurement (assessment for
Health Perception and Management obesity), BP, and any laboratory test results such as
blood glucose, glycosylated hemoglobin (diabetes),
● In an effort to determine how patients perceive their current total blood cholesterol, high-density and low-density
health status. The nurse might ask some of the following lipoprotein levels, and triglyceride levels
questions: (hyperlipidemia).
ー Do you have any health problems? If so, what do you ー How often the patient self-monitors BP, blood glucose,
think caused them? and weight as appropriate to the medical diagnoses.
ー How has your health been recently? ー The patient’s level of awareness regarding his or her
ー Have you noticed any changes from last year? from 5 target goals for each of the risk factors and any
years ago? problems achieving or maintaining these goals.
ー Do you have a cardiologist or primary health care ー What the patient normally eats and drinks in a typical
provider? day and any food preferences (including cultural or
ー How often do you go for checkups? ethnic preferences).
ー Do you use tobacco or consume alcohol? ー Eating habits (canned or commercially prepared foods
ー What are your risk factors for heart disease? versus fresh foods, restaurant cooking versus home
ー What do you do to stay healthy and take care of your cooking, assessing for high sodium foods, dietary
heart? intake of fats).
ー What prescription and over-the-counter medications ー Who shops for groceries and prepares meals.
are you taking?
ー Do you take vitamins or herbal supplements? Elimination
● Some patients may not be aware of their own medical
diagnosis. For example, patients may not realize that their ● Typical bowel and bladder habits need to be identified.
heart attack was caused by CAD. ● Nocturia (awakening at night to urinate) is common for
● Patients who do not understand that their behaviors or patients with HF.
diagnoses pose a threat to their health may be less motivated ● Fluid collected in the dependent tissues (extremities) during
to make lifestyle changes or to manage their illness the day redistributes into the circulatory system once the
effectively. patient is recumbent at night.
● On the other hand, patients who perceive that their modifiable ● The increased circulatory volume is excreted by the kidneys
cardiovascular risk factors have contributed to their health (increased urine production).
conditions may be more likely to change these behaviors. The ● Patients need to be aware of their response to diuretic therapy
patient’s ability to recognize cardiac symptoms and to know and any changes in urination. This is vitally important for
what to do when they occur is essential for effective self-care patients with HF. Patients may be taught to modify (titrate)
management. their dose of diuretics based on urinary pattern, daily weight,
● An additional issue to consider is the patient’s medication and symptoms of dyspnea.
history, dosages, and schedules. ● To avoid straining, patients who become easily constipated
need to establish a regular bowel regimen.
● When straining, the patient tends to bear down (the Valsalva selfcare. Is the patient’s short-term memory intact? Is there
maneuver), which momentarily increases pressure on the any history of dementia?
baroreceptors. This triggers a vagal response, causing the ● Is there evidence of depression or anxiety? Can the patient
heart rate to slow down and resulting in syncope in some read?
patients. ● What is the patient’s preferred learning style? What
● For the same reason, straining during urination should be information does the patient perceive as important? Providing
avoided. Because many cardiac medications can cause the patient with written information can be a valuable part of
gastrointestinal side effects or bleeding, the nurse asks about patient education, but only if the patient can read and
bloating, diarrhea, constipation, stomach upset, heartburn, comprehend the information.
loss of appetite, nausea, and vomiting. ● Related assessments include possible hearing or visual
● Patients taking platelet-inhibiting medications such as aspirin impairments. If vision is impaired, patients with HF may not
and clopidogrel (Plavix); intravenous platelet aggregation be able to weigh themselves independently nor keep records
inhibitors and anticoagulants such as low-molecular-weight of weight, BP, pulse, or other data requested by the health
heparin (ie, dalteparin [Fragmin]), enoxaparin (Lovenox), care team.
heparin, or warfarin (Coumadin) are screened for bloody
urine or stools. Self-Perception and Self-Concept

Activity and Exercise ● Personality factors are associated with the development of
and recovery from CAD.
● As the nurse assesses the patient’s activity and exercise ● Most commonly cited is “type A behavior,” which is
history, it is important to note that decreases in activity characterized by competitive, hard-driving behaviors and a
tolerance are typically gradual and may go unnoticed by the sense of time urgency. Although this behavior is not an
patient. Therefore, the nurse needs to determine whether there independent risk factor for CAD, anger and hostility
has been a change in the activity pattern during the last 6 to (personality traits common in people with “type A behavior”)
12 months. do affect the heart. People with these traits react to frustrating
● The patient’s subjective response to activity is an essential situations with an increase in BP, heart rate, and
assessment parameter. New symptoms or a change in the neuroendocrine responses. This physiologic activation, called
usual angina or angina equivalent during activity is a cardiac reactivity, is thought to trigger acute cardiovascular
significant finding. events.
● Fatigue, associated with low ejection fraction and certain ● During the health history, the nurse discovers how patients
medications (eg, beta-blockers), can result in activity feel about themselves by asking questions such as:
intolerance. Patients with fatigue may benefit from having ー How would you describe yourself?
their medications adjusted and learning energy conservation ー Have you changed the way you feel about yourself
techniques. since your heart attack or surgery?
● Additional areas to ask about include possible architectural ー Do you find that you are easily angered or hostile?
barriers and challenges in the home, and what the patient How do you feel right now?
does for exercise. If the patient exercises, the nurse asks ー What helps to manage these feelings?
additional questions: What is the intensity, and how long and ● To fully evaluate this health pattern, assistance from a
how often is exercise performed? psychiatric clinical nurse specialist, psychologist, or
● Has the patient ever participated in a cardiac rehabilitation psychiatrist may be necessary.
program? Functional levels are known to improve for almost
all patients who participate in a cardiac rehabilitation Roles and Relationships
program, and attendance is highly recommended.
● Patients with disabilities may require an individually tailored ● Determining the patient’s social support systems is vitally
exercise program. important in today’s healthcare environment.
● Hospital stays for cardiac illnesses have shortened.
Sleep and Rest ● Many invasive diagnostic cardiac procedures, such as cardiac
catheterization and percutaneous transluminal coronary
● Clues to worsening cardiac disease, especially HF, can be angioplasty (PTCA) are performed as outpatient procedures.
revealed by sleep-related events. ● Patients are discharged back into the community with activity
● Determining where the patient sleeps or rests is important. limitations, such as driving restrictions, and with greater
● Recent changes, such as sleeping upright in a chair instead of nursing care and educational needs. These needs have
in bed, increasing the number of pillows used, awakening significant implications for people who are independent
short of breath at night (paroxysmal nocturnal dyspnea under normal circumstances, and for people who are at higher
[PND]), or awakening with angina (nocturnal angina), are all risk for problems, such as older adults.
indicative of worsening HF. ● To assess support systems, the nurse needs to ask:
ー Who is the primary caregiver?
Cognition and Perception ー With whom does the patient live?
ー Are there adequate services in place to provide a safe
● Evaluating cognitive ability helps to determine whether the home environment?
patient has the mental capacity to manage safe and effective
 ー The nurse also assesses for any significant effects the ● People with depression have an increased risk of MI and
cardiac illness has had on the patient’s role in the heart disease–related death, compared to people without
family. depression.
ー Are there adequate finances and health insurance? The ● It is postulated that people who are depressed feel hopeless
answers to these questions will assist the nurse in and are less motivated to make lifestyle changes and follow
developing a plan to meet the patient’s home care treatment plans, explaining the association between mortality
needs. and depression.
● Stress initiates a variety of physiologic responses, including
Sexuality and Reproduction increases in the circulation of catecholamines and cortisol,
and has been strongly linked to cardiovascular events.
● Although people recovering from cardiac illnesses or ● Therefore, patients need to be assessed for presence of
procedures are concerned about sexual activity, they are less negative and positive emotions, as well as sources of stress.
likely to ask their nurse or other health care provider for ● This is achieved by asking questions about recent or ongoing
information to help them resume their normal sex life. stressors, previous coping styles and effectiveness, and the
● Lack of correct information and fear lead to reduced patient’s perception of his or her current mood and coping
frequency and satisfaction with sexual activity. Therefore, ability.
nurses need to initiate this discussion with patients and not ● To adequately evaluate this health pattern, consultation with a
wait for them to bring it up in conversation. psychiatric clinical nurse specialist, psychologist, or
● At first, inform the patient that it is common for people with psychiatrist may be indicated.
similar heart problems to worry about resuming sexual
activity. Then ask the patient to talk about his or her Prevention Strategies
concerns.
● The most commonly cited reasons for changes in sexual ● Additional features of the health history include identification
activity are fear of another heart attack or sudden death; of risk factors and measures taken by the patient to prevent
untoward symptoms such as angina, dyspnea, or palpitations; disease.
and problems with impotence or depression. ● The nurse’s questions need to focus on the patient’s health
● In men, impotence may develop as a side effect of cardiac promotion practices.
medications (beta-adrenergic blocking agents) and may ● Epidemiologic studies show that certain conditions or
prompt patients to stop taking them. behaviors (ie, risk factors) are associated with a greater
● Other medications can be substituted, so patients should be incidence of coronary artery, peripheral vascular, and
encouraged to discuss this problem with their health care cerebrovascular disease.
provider. Often, patients and their partners do not have ● Risk factors are classified by the extent to which they can be
adequate information about the physical demands related to modified by changing one’s lifestyle or modifying personal
sexual activity and ways in which these demands can be behaviors.
modified. ● Once a patient’s risk factors are determined, the nurse
● The physiologic demands are greatest during orgasm, assesses whether the patient has a plan for making necessary
reaching 5 or 6 metabolic equivalents (METs). This level of behavioral changes and whether assistance is needed to
activity is equivalent to walking 3 to 4 miles per hour on a support these lifestyle changes. For example, tobacco use is
treadmill. the most common avoidable cause of CAD.
● The METs expended before and after orgasm are ● The first step in treating this health risk is to identify patients
considerably less, at 3.7 METs. who use tobacco products and those who have recently quit.
● Having this information may make patients and their partners Because 70% of smokers visit a health care facility each year,
more comfortable with resuming sexual activity. nurses have ample opportunities to assess patients for tobacco
● A reproductive history is necessary for women of use. For those who use tobacco, it is imperative to ask
childbearing age, particularly those with seriously whether they are willing to quit.
compromised cardiac function. These women may be advised ● For patients who have obesity, hyperlipidemia, hypertension,
by their physicians not to become pregnant. and diabetes, the nurse determines any problems the patient
● The reproductive history includes information about previous may be having following the prescribed management plan (ie,
pregnancies, plans for future pregnancies, oral contraceptive diet, exercise, and medications). It may be necessary to
use (especially in women older than 35 years of age who are clarify the patient’s responsibilities, assist with finding
smokers), and use of hormone replacement therapy. additional resources, or make alternative plans for risk factor
modification.
Coping and Stress Tolerance ● Comprehensive secondary prevention strategies (early
diagnosis and prompt intervention to halt or slow the disease
● It is important to determine the presence of psychosocial process and its consequences) aimed at reducing
factors that adversely affect cardiac health. cardiovascular risk factors improve overall survival, improve
● Anxiety, depression, and stress are known to influence both quality of life, reduce the need for revascularization
the development of and recovery from CAD. procedures (coronary artery bypass surgery and PTCA), and
● High levels of anxiety are associated with an increased reduce the incidence of subsequent MIs.
incidence of CAD and increased in-hospital complication ● The overall benefits of secondary prevention also apply to
rates after MI. other patient groups with atherosclerotic vascular disease,
 including patients with transient ischemic attacks, stroke, and ● The nurse also observes for evidence of anxiety, along with
peripheral vascular disease (the leading cause of disability any effects emotional factors may have on cardiovascular
and death in these patients being CAD). status.
● Despite these findings, only one third of eligible patients, ● The nurse attempts to put the anxious patient at ease
over the long term, adhere to risk factor interventions. Patient throughout the examination.
compliance increases significantly with a team approach that
includes long-term follow-up with office or clinic visits and Inspection of the Skin
telephone contact.
● Examination of the skin begins during the evaluation of the
Physical Assessment general appearance of the patient and continues throughout
the assessment. It includes all body surfaces, starting with the
● A physical examination is performed to confirm the data head and finishing with the lower extremities. Skin color,
obtained in the health history. In addition to observing the temperature, and texture are assessed. The more common
patient’s general appearance, a cardiac physical examination findings associated with cardiovascular disease are as
should include an evaluation of the following: follows.
○ Effectiveness of the heart as a pump ➢ Pallor — a decrease in the color of the skin — is
○ Filling volumes and pressures caused by lack of oxyhemoglobin. It is a result of
○ Cardiac output anemia or decreased arterial perfusion. Pallor is best
○ Compensatory mechanisms Indications that the heart observed around the fingernails, lips, and oral mucosa.
is not contracting sufficiently or functioning In patients with dark skin, the nurse observes the
effectively as a pump include reduced pulse pressure, palms of the hands and soles of the feet.
cardiac enlargement, and murmurs and gallop rhythms ➢ Peripheral cyanosis — a bluish tinge, most often of
(abnormal heart sounds). the nails and skin of the nose, lips, earlobes, and
● Indications that the heart is not contracting sufficiently or extremities — suggests decreased flow rate of blood to
functioning effectively as a pump include reduced pulse a particular area, which allows more time for the
pressure, cardiac enlargement, and murmurs and gallop hemoglobin molecule to become desaturated. This
rhythms (abnormal heart sounds). may occur normally in peripheral vasoconstriction
● The amount of blood filling the atria and ventricles and the associated with a cold environment, in patients with
resulting pressures (called filling volumes and pressures) are anxiety, or in disease states such as HF.
estimated by the degree of jugular vein distention and the ➢ Central cyanosis — a bluish tinge observed in the
presence or absence of congestion in the lungs, peripheral tongue and buccal mucosa — denotes serious cardiac
edema, and postural changes in BP that occur when the disorders (pulmonary edema and congenital heart
individual sits up or stands. disease) in which venous blood passes through the
● Cardiac output is reflected by cognition, heart rate, pulse pulmonary circulation without being oxygenated.
pressure, color and texture of the skin, and urine output. ➢ Xanthelasma — yellowish, slightly raised plaques in
Examples of compensatory mechanisms that help maintain the skin — may be observed along the nasal portion of
cardiac output are increased filling volumes and elevated one or both eyelids and may indicate elevated
heart rate. Note that the findings on the physical examination cholesterol levels (hypercholesterolemia).
are correlated with data obtained from diagnostic procedures, ➢ Reduced skin turgor occurs with dehydration and
such as hemodynamic monitoring. aging.
● The examination, which proceeds logically from head to toe, ➢ Temperature and moistness are controlled by the
can be performed in about 10 minutes with practice and autonomic nervous system. Normally the skin is warm
covers the following areas: and dry. Under stress, the hands may become cool and
○ General appearance moist. In cardiogenic shock, sympathetic nervous
○ Cognition system stimulation causes vasoconstriction, and the
○ Skin skin becomes cold and clammy. During an acute MI,
○ BP diaphoresis is common.
○ Arterial pulses ➢ Ecchymosis (bruise) — a purplish-blue color fading to
○ Jugular venous pulsations and pressures green, yellow, or brown over time — is associated
○ Heart with blood outside of the blood vessels and is usually
○ Extremities caused by trauma. Patients who are receiving
○ Lungs, and anticoagulant therapy should be carefully observed for
○ Abdomen unexplained ecchymosis. In these patients, excessive
bruising indicates prolonged clotting times
(prothrombin or partial thromboplastin time) caused
General Appearance and Cognition
by an anticoagulant dosage that is too high.
● Wounds, scars, and tissue surrounding implanted devices
● The nurse observes the patient’s level of distress, level of
should also be examined. Wounds are assessed for adequate
consciousness, and thought processes as an indication of the
healing, and any scars from previous surgeries are noted. The
heart’s ability to propel oxygen to the brain (cerebral
skin surrounding a pacemaker or implantable cardioverter
perfusion).
 defibrillator generator is examined for thinning, which could ー Assess postural BP changes with the patient sitting on
indicate erosion of the device through the skin. the edge of the bed with feet dangling and, if
appropriate, with the patient standing at the side of the
Blood Pressure bed.
ー Wait 1 to 3 minutes after each postural change before
● Systemic arterial BP is the pressure exerted on the walls of measuring BP and heart rate.
the arteries during ventricular systole and diastole. ー Be alert for any signs or symptoms of patient distress.
● It is affected by factors such as cardiac output, distention of If necessary, return the patient to a lying position
the arteries, and the volume, velocity, and viscosity of the before completing the test.
blood. ー Record both heart rate and BP and indicate the
● BP usually is expressed as the ratio of the systolic pressure corresponding position (e.g., lying, sitting, standing)
over the diastolic pressure, with normal adult values ranging and any signs or symptoms that accompany the
from 100/60 to 140/90 mm Hg. postural change.
● The average normal BP usually cited is 120/80 mm Hg. An ● Normal postural responses that occur when a person stands
increase in BP above the upper normal range is called up or goes from a lying to a sitting position include:
hypertension, whereas a decrease below the lower range is ○ A heart rate increase of 5 to 20 bpm above the resting
called hypotension. rate (to offset reduced stroke volume and maintain
cardiac output);
○ An unchanged systolic pressure, or a slight decrease of
Pulse Pressure
up to 10 mm Hg; and
○ A slight increase of 5 mm Hg in diastolic pressure
● The difference between the systolic and the diastolic
● A decrease in the amount of blood or fluid in the circulatory
pressures is called the pulse pressure.
system should be suspected after diuretic therapy or bleeding,
● It is a reflection of stroke volume, ejection velocity, and
when a postural change results in an increased heart rate and
systemic vascular resistance.
either a decrease in systolic pressure by 15 mm Hg or a drop
● Pulse pressure, which normally is 30 to 40 mm Hg, indicates
in the diastolic pressure by 10 mm Hg. Vital signs alone do
how well the patient maintains cardiac output.
not differentiate between a decrease in intravascular volume
● The pulse pressure increases in conditions that elevate the
and inadequate constriction of the blood vessels as a cause of
stroke volume (anxiety, exercise, bradycardia), reduce
postural hypotension.
systemic vascular resistance (fever), or reduce distensibility
● With intravascular volume depletion, the reflexes that
of the arteries (atherosclerosis, aging, hypertension).
maintain cardiac output (increased heart rate and peripheral
● Decreased pulse pressure is an abnormal condition reflecting
vasoconstriction) function correctly; the heart rate increases,
reduced stroke volume and ejection velocity (shock, HF,
and the peripheral vessels constrict.
hypovolemia, mitral regurgitation) or obstruction to blood
● However, because of lost volume, the BP falls. With
flow during systole (mitral or aortic stenosis)
inadequate vasoconstrictor mechanisms, the heart rate again
● A pulse pressure of less than 30 mm Hg signifies a serious
responds appropriately, but because of diminished peripheral
reduction in cardiac output and requires further
vasoconstriction the BP drops.
cardiovascular assessment.
● The following is an example of a postural BP recording
showing either intravascular volume depletion or inadequate
Postural Blood Pressure Changes vasoconstrictor mechanisms:
○ Lying down, BP 120/70, heart rate 70
● Postural (orthostatic) hypotension occurs when the BP drops ○ Sitting, BP 100/55, heart rate 90
significantly after the patient assumes an upright posture. ○ Standing, BP 98/52, heart rate 94
● It is usually accompanied by dizziness, lightheadedness, or ● In autonomic insufficiency, the heart rate is unable to increase
syncope. to completely compensate for the gravitational effects of an
● Although there are many causes of postural hypotension, the upright posture.
three most common causes in patients with cardiac problems ● Peripheral vasoconstriction may be absent or diminished.
are a reduced volume of fluid or blood in the circulatory Autonomic insufficiency does not rule out a concurrent
system (intravascular volume depletion, dehydration), decrease in intravascular volume.
inadequate vasoconstrictor mechanisms, and insufficient ● The following is an example of autonomic insufficiency as
autonomic effect on vascular constriction. demonstrated by postural BP changes:
● Postural changes in BP and an appropriate history help health ○ Lying down, BP 150/90, heart rate 60
care providers differentiate among these causes ○ Sitting, BP 100/60, heart rate 60
● The following recommendations are important when
assessing postural BP changes:
Arterial Pulses
ー Position the patient supine and flat (as symptoms
permit) for 10 minutes before taking the initial BP and
● Factors to be evaluated in examining the pulse are rate,
heart rate measurements.
rhythm, quality, configuration of the pulse wave, and quality
ー Check supine measurements before checking upright
of the arterial vessel.
measurements.
ー Do not remove the BP cuff between position changes,
but check to see that it is still correctly placed.
☆ PULSE RATE ● Light palpation is essential; firm finger pressure can easily
● The normal pulse rate varies from a low of 50 bpm in healthy, obliterate the dorsalis pedis and posterior tibial pulses and
athletic young adults to rates well in excess of 100 bpm after confuse the examiner.
exercise or during times of excitement. ● In approximately 10% of patients, the dorsalis pedis pulses
● Anxiety frequently raises the pulse rate during the physical are not palpable. In such circumstances, both are usually
examination. If the rate is higher than expected, it is absent together, and the posterior tibial arteries alone provide
appropriate to reassess it near the end of the physical adequate blood supply to the feet.
examination, when the patient may be more relaxed. ● Arteries in the extremities are often palpated simultaneously
☆ PULSE RHYTHM to facilitate comparison of quality.
● The rhythm of the pulse is as important to assess as the rate.
Minor variations in regularity of the pulse are normal. Heart Inspection and Palpation
● The pulse rate, particularly in young people, increases during
inhalation and slows during exhalation. This is called sinus ● The heart is examined indirectly by inspection, palpation,
arrhythmia. percussion, and auscultation of the chest wall. A systematic
● For the initial cardiac examination, or if the pulse rhythm is approach is the cornerstone of a thorough assessment.
irregular, the heart rate should be counted by auscultating the Examination of the chest wall is performed in the following
apical pulse for a full minute while simultaneously palpating six areas:
the radial pulse. ➢ Aortic area — second intercostal space to the right of
● Any discrepancy between contractions heard and pulses felt the sternum. To determine the correct intercostal
is noted. Disturbances of rhythm (dysrhythmias) often result space, start at the angle of Louis by locating the bony
in a pulse deficit, a difference between the apical rate (the ridge near the top of the sternum, at the junction of the
heart rate heard at the apex of the heart) and the peripheral body and the manubrium. From this angle, locate the
rate. second intercostal space by sliding one finger to the
● Pulse deficits commonly occur with atrial fibrillation, atrial left or right of the sternum. Subsequent intercostal
flutter, premature ventricular contractions, and varying spaces are located from this reference point by
degrees of heart block. palpating down the rib cage
☆ PULSE QUALITY ➢ Pulmonic area — second intercostal space to the left
● The quality, or amplitude, of the pulse can be described as of the sternum
absent, diminished, normal, or bounding. It should be ➢ Erb’s point — third intercostal space to the left of the
assessed bilaterally. Scales can be used to rate the strength of sternum
the pulse. ➢ Right ventricular or tricuspid area — fourth and
● The following is an example of a 0-to-4 scale: fifth intercostal spaces to the left of the sternum
○ 0 pulse not palpable or absent ➢ Left ventricular or apical area — the PMI, location
○ +1 weak, thready pulse; difficult to palpate; obliterated on the chest where heart contractions can be palpated
with pressure ➢ Epigastric area — below the xiphoid process
○ +2 diminished pulse; cannot be obliterated
○ +3 easy to palpate, full pulse; cannot be obliterated
○ +4 strong, bounding pulse; may be abnormal
● The numerical classification is quite subjective; therefore,
when documenting the pulse quality, it helps to specify a
scale range (eg, “left radial +3/+4”).
☆ EFFECT OF VESSEL QUALITY ON PULSE
● The condition of the vessel wall also influences the pulse and
is of concern, especially in older patients. Once rate and
rhythm have been determined, the nurse assesses the quality
of the vessel by palpating along the radial artery and
comparing it with normal vessels. Does the vessel wall
appear to be thickened? Is it tortuous?
● To assess peripheral circulation, the nurse locates and ● For most of the examination, the patient lies supine, with the
evaluates all arterial pulses. head slightly elevated.
● Arterial pulses are palpated at points where the arteries are ● The right-handed examiner is positioned at the right side of
near the skin surface and are easily compressed against bones the patient and the left-handed examiner at the left side. In a
or firm musculature. systematic fashion, each area of the precordium is inspected
● Pulses are detected over the temporal, carotid, brachial, and then palpated.
radial, femoral, popliteal, dorsalis pedis, and posterior tibial ● Oblique lighting is used to assist the examiner in identifying
arteries subtle pulsation.
● A reliable assessment of the pulses of the lower extremities ● A normal impulse that is distinct and located over the apex of
depends on accurate identification of the location of the the heart is called the apical impulse (PMI).
artery and careful palpation of the area. ● It may be observed in young people and in older people who
are thin. The apical impulse is normally located and
auscultated in the left fifth intercostal space in the
midclavicular line.
 circumstance in which ventricular contraction occurs
at a time when the valve is caught wide open.
ー The latter circumstance occurs, for example, when a
premature ventricular contraction interrupts the normal
cardiac cycle.
ー S1 varies in intensity from beat to beat when atrial
contraction is not synchronous with ventricular
contraction. This is because the valve may be fully or
partially closed on one beat and open on the
subsequent one as a function of irregular atrial activity.
ー S1 is easily identifiable and serves as the point of
● Abnormal, turbulent blood flow within the heart may be reference for the remainder of the cardiac cycle.
palpated with the palm of the hand as a purring sensation. ● S2—Second Heart Sound
● This phenomenon is called a thrill and is associated with a ー Closing of the aortic and pulmonic valves produces the
loud murmur. second heart sound (S2).
● A thrill is always indicative of significant pathology within ー Although these two valves close almost
the heart. Thrills also may be palpated over vessels when simultaneously, the pulmonic valve usually lags
blood flow is significantly and substantially obstructed and slightly behind. Therefore, under certain
over the carotid arteries if aortic stenosis is present or if the circumstances, the two components of the second
aortic valve is narrowed. sound may be heard separately (split S2).
ー The splitting is more likely to be accentuated on
Chest Percussion inspiration and to disappear on exhalation. (More
blood is ejected from the right ventricle during
● Normally, only the left border of the heart can be detected by inspiration than during exhalation.)
percussion. ー S2 is heard loudest at the base of the heart. The aortic
● It extends from the sternum to the midclavicular line in the component of S2 is heard clearly in both the aortic and
third to fifth intercostal spaces. pulmonic areas, and less clearly at the apex. The
● The right border lies under the right margin of the sternum pulmonic component of S2, if present, may be heard
and is not detectable. only over the pulmonic area. Therefore, one may hear
● Enlargement of the heart to either the left or right usually can a “single” S2 in the aortic area and a split S2 in the
be noted. pulmonic area
● In people with thick chests, obesity, or emphysema, the heart ● Gallop Sounds
may lie so deep under the thoracic surface that not even its ー If the blood filling the ventricle is impeded during
left border can be noted unless the heart is enlarged. In such diastole, as occurs in certain disease states, then a
cases, unless the nurse detects a displaced apical impulse and temporary vibration may occur in diastole that is
suspects cardiac enlargement, percussion is omitted. similar to, although usually softer than, S1 and S2.
ー The heart sounds then come in triplets and have the
Cardiac Auscultation acoustic effect of a galloping horse; they are called
gallops.
☆ HEART SOUNDS ー This may occur early in diastole, during the
● The normal heart sounds, S1 and S2, are produced primarily rapid-filling phase of the cardiac cycle, or later at the
by the closing of the heart valves. time of atrial contraction.
● The time between S1 and S2 corresponds to systole. This is ー A gallop sound occurring during rapid ventricular
normally shorter than the time between S2 and S1 (diastole). filling is called a third heart sound (S3); it represents a
● As the heart rate increases, diastole shortens. normal finding in children and young adults. Such a
● In normal physiology, the periods of systole and diastole are sound is heard in patients who have myocardial
silent. Ventricular disease, however, can give rise to transient disease or in those who have HF and whose ventricles
sounds in systole and diastole that are called gallops, snaps, fail to eject all of their blood during systole.
or clicks. ー An S3 gallop is heard best with the patient lying on the
● Significant narrowing of the valve orifices at times when they left side.
should be open, or residual gapping of valves at times when ー Gallop sounds heard during atrial contraction are
they should be closed, gives rise to prolonged sounds called called fourth heart sounds (S4).
murmurs. ー An S4 is often heard when the ventricle is enlarged or
● S1—First Heart Sound hypertrophied and therefore resistant to filling. Such a
ー Closure of the mitral and tricuspid valves creates the circumstance may be associated with CAD,
first heart sound (S1), although vibration of the hypertension, or stenosis of the aortic valve. On rare
myocardial wall also may contribute to this sound. occasions, all four heart sounds are heard within a
ー Although S1 is heard over the entire precordium, it is single cardiac cycle, giving rise to what is called a
heard best at the apex of the heart (apical area). quadruple rhythm.
ー Its intensity increases when the valve leaflets are made ー Gallop sounds are very low-frequency sounds and may
rigid by calcium in rheumatic heart disease and in any be heard only with the bell of the stethoscope placed
 very lightly against the chest. They are heard best at the examiner listens for extra sounds in systole and then in
the apex, although occasionally, when emanating from diastole
the right ventricle, they may be heard to the left of the ● Sometimes it helps to ask the following questions: Do I hear
sternum. snapping or clicking sounds? Do I hear any high-pitched
● Snaps and Clicks blowing sounds? Is this sound in systole, or diastole, or both?
ー Stenosis of the mitral valve resulting from rheumatic ● The examiner again proceeds to move the stethoscope to all
heart disease gives rise to an unusual sound very early of the designated areas of the precordium, listening carefully
in diastole that is high-pitched and is best heard along for these sounds.
the left sternal border. ● Finally, the patient is turned on the left side and the
ー The sound is caused by high pressure in the left atrium stethoscope is placed on the apical area, where an S3, an S4,
with abrupt displacement of a rigid mitral valve. The and a mitral murmur are more readily detected. Once an
sound is called an opening snap. abnormality is heard, the entire chest surface is reexamined to
ー It occurs too long after S2 to be mistaken for a split S2 determine the exact location of the sound and its radiation.
and too early in diastole to be mistaken for a gallop. It Also, the patient, who may be concerned about the prolonged
almost always is associated with the murmur of mitral examination, must be supported and reassured.
stenosis and is specific to this disorder. ● The auscultatory findings, particularly murmurs, are
ー In a similar manner, stenosis of the aortic valve gives documented by identifying the following characteristics:
rise to a short, high-pitched sound immediately after ○ Location on chest wall.
S1 that is called an ejection click. This is caused by ○ Timing of sound as either during systole or during
very high pressure within the ventricle, displacing a diastole; described as early, middle, or late. (If heard
rigid and calcified aortic valve. throughout the systole, the sound is often referred to as
● Murmurs pansystolic or holosystolic.)
ー Murmurs are created by the turbulent flow of blood. ○ Intensity of the sound (I, very faint; II, quiet; III,
The causes of the turbulence may be a critically moderately loud; IV, loud; V, very loud; or VI, heard
narrowed valve, a malfunctioning valve that allows with stethoscope removed from the chest).
regurgitant blood flow, a congenital defect of the ○ Pitch, described as high, medium, or low.
ventricular wall, a defect between the aorta and the ○ Quality of the sound, commonly described as blowing,
pulmonary artery, or an increased flow of blood harsh, or musical
through a normal structure (eg, with fever, pregnancy, ○ Location of radiation of the sound away from where it
hyperthyroidism). is heard the loudest
ー Murmurs are characterized and consequently described
by several characteristics, including timing in the Inspection of the Extremities
cardiac cycle, location on the chest wall, intensity,
pitch, quality, and pattern of radiation. ● The hands, arms, legs, and feet are observed for skin and
● Friction Rub vascular changes. The most noteworthy changes include the
ー In pericarditis, a harsh, grating sound that can be heard following:
in both systole and diastole is called a friction rub. ー Decreased capillary refill time indicates a slower
ー It is caused by abrasion of the pericardial surfaces peripheral flow rate from sluggish reperfusion and is often
during the cardiac cycle. observed in patients with hypotension or HF. Capillary
ー Because a friction rub may be confused with a refill time provides the basis for estimating the rate of
murmur, care should be taken to identify the sound and peripheral blood flow. To test capillary refill, briefly
to distinguish it from murmurs that may be heard in compress the nail bed so that it blanches, and then release
both systole and diastole. the pressure. Normally, reperfusion occurs within 3
ー A pericardial friction rub can be heard best using the seconds, as evidenced by the return of color.
diaphragm of the stethoscope, with the patient sitting ー Vascular changes from decreased arterial circulation
up and leaning forward. include decrease in quality or loss of pulse, discomfort or
☆ AUSCULTATION PROCEDURE pain, paresthesia, numbness, decrease in temperature,
● During auscultation, the patient remains supine and the pallor, and loss of movement. During the first few hours
examining room is as quiet as possible. after invasive cardiac procedures (eg, cardiac
● A stethoscope with a diaphragm and a bell is necessary for catheterization), affected extremities should be assessed
accurate auscultation of the heart. for vascular changes frequently.
● Using the diaphragm of the stethoscope, the examiner starts ー Hematoma, or a localized collection of clotted blood in the
at the apical area and progresses upward along the left sternal tissue, may be observed in patients who have undergone
border to the pulmonic and aortic areas. invasive cardiac procedures such as cardiac
● If desired, the examiner may choose to begin the examination catheterization, PTCA, or cardiac electrophysiology
at the aortic and pulmonic areas and progress downward to testing. Major blood vessels of the arms and legs are
the apex of the heart. selected for catheter insertion. During these procedures,
● Initially, S1 is identified and evaluated with respect to its systemic anticoagulation with heparin is necessary, and
intensity and splitting. Next, S2 is identified, and its intensity minor or small hematomas may occur at the catheter
and any splitting are noted. After concentrating on S1 and S2, puncture site. However, large hematomas are a serious
complication that can compromise circulating blood
 volume and cardiac output, requiring blood transfusions. tissue), but they may progress to all portions of the
All patients who have undergone these procedures must lung fields.
have their puncture sites frequently observed until ○ Wheezes: Compression of the small airways by
hemostasis is adequately achieved. interstitial pulmonary edema may cause wheezing.
ー Peripheral edema is fluid accumulation in dependent areas Beta-adrenergic blocking agents (beta-blockers), such
of the body (feet and legs, sacrum in the bedridden as propranolol (Inderal), may precipitate airway
patient). Assess for pitting edema (a depression over an narrowing, especially in patients with underlying
area of pressure) by pressing firmly for 5 seconds with the pulmonary disease.
thumb over the dorsum of each foot, behind each medial ☆ ABDOMEN
malleolus, and over the shins. Pitting edema is graded as ● For the cardiac patient, two components of the abdominal
absent or as present on a scale from slight (1+ = 0 to 2 examination are frequently performed.
mm) to very marked (4+ = more than 8 mm). Peripheral ○ Hepatojugular reflux: Liver engorgement occurs
edema is observed in patients with HF and in those with because of decreased venous return secondary to
peripheral vascular diseases such as deep vein thrombosis right ventricular failure. The liver is enlarged, firm,
or chronic venous insufficiency. nontender, and smooth. The hepatojugular reflux
ー Clubbing of the fingers and toes implies chronic may be demonstrated by pressing firmly over the
hemoglobin desaturation, as in congenital heart disease. right upper quadrant of the abdomen for 30 to 60
ー Lower extremity ulcers are observed in patients with seconds and noting a rise of 1 cm or more in
arterial or venous insufficiency. Chapter 31 provides a jugular venous pressure. This rise indicates an
complete description of differentiating characteristics inability of the right side of the heart to
ー Peripheral edema is fluid accumulation in dependent areas accommodate increased volume
of the body (feet and legs, sacrum in the bedridden ○ Bladder distention: Urine output is an important
patient). Assess for pitting edema (a depression over an indicator of cardiac function, especially when urine
area of pressure) by pressing firmly for 5 seconds with the output is reduced. This may indicate inadequate
thumb over the dorsum of each foot, behind each medial renal perfusion or a less serious problem such as
malleolus, and over the shins. Pitting edema is graded as one caused by urinary retention. When the urine
absent or as present on a scale from slight (1+ = 0 to 2 output is decreased, the patient needs to be
mm) to very marked (4+ = more than 8 mm). Peripheral assessed for a distended bladder or difficulty
edema is observed in patients with HF and in those with voiding. The bladder may be assessed with an
peripheral vascular diseases such as deep vein thrombosis ultrasound scanner or the suprapubic area palpated
or chronic venous insufficiency. for an oval mass and percussed for dullness,
ー Clubbing of the fingers and toes implies chronic indicative of a full bladder.
hemoglobin desaturation, as in congenital heart disease.
ー Lower extremity ulcers are observed in patients with Laboratory Tests
arterial or venous insufficiency.
● Laboratory tests may be performed for the following reasons:
Other Systems ー To assist in diagnosing an acute MI. (Angina pectoris,
chest pain resulting from an insufficient supply of blood to
☆ LUNGS the heart, cannot be confirmed by either blood or urine
● Findings frequently exhibited by cardiac patients include the studies.)
following: ー To identify abnormalities in the blood that affect the
○ Tachypnea: Rapid, shallow breathing may be noted in prognosis of a patient with a cardiac condition
patients who have HF or pain, and in those who are ー To assess the degree of inflammation
extremely anxious. ー To screen for risk factors associated with atherosclerotic
○ Cheyne-Stokes respirations: Patients with severe left coronary artery disease
ventricular failure may exhibit Cheyne-Stokes ー To determine baseline values before performing
breathing, a pattern of rapid respirations alternating therapeutic interventions
with apnea. It is important to note the duration of the ー To monitor serum levels of medications
apnea. ー To assess the effects of medications (e.g., the effects of
○ Hemoptysis: Pink, frothy sputum is indicative of acute diuretics on serum potassium levels)
pulmonary edema. ー To screen generally for abnormalities
○ Cough: A dry, hacking cough from irritation of small ☆ CARDIAC ENZYME ANALYSIS
airways is common in patients with pulmonary ● Plasma cardiac enzyme analysis is part of a diagnostic profile
congestion from HF. that also includes the health history, symptoms, and
○ Crackles: HF or atelectasis associated with bed rest, electrocardiogram (ECG), associated with acute MI.
splinting from ischemic pain, or the effects of pain ● Enzymes are released from injured cells when the cell
medications and sedatives often results in the membranes rupture. Most enzymes are nonspecific in relation
development of crackles. Typically, crackles are first to the particular organ that has been damaged.
noted at the bases (because of gravity’s effect on fluid ● Certain isoenzymes, however, come only from myocardial
accumulation and decreased ventilation of basilar cells and are released when the cells are damaged, such as by
sustained hypoxia resulting in infarction or by trauma.
 ● The isoenzymes leak into the interstitial spaces of the ー Triglycerides (normal range, 40 to 150 mg/dL), composed
myocardium and are carried into the general circulation by of free fatty acids and glycerol, are stored in the adipose
the lymphatic system and the coronary circulation, resulting tissue and are a source of energy.
in elevated serum enzyme concentrations. ー Triglyceride levels increase after meals and are affected by
● Creatine kinase (CK) and its isoenzyme CK-MB are the stress. Diabetes, alcohol use, and obesity can elevate
most specific enzymes analyzed in acute MI, and they are the triglyceride levels. These levels have a direct correlation
first enzyme levels to rise. with LDL and an inverse one with HDL.
● Lactic dehydrogenase and its isoenzymes also are analyzed ● Serum Electrolyte Levels
in patients who have delayed seeking medical attention, ー Sodium, potassium, and calcium are ions that are vital to
because these blood levels rise and peak in 2 to 3 days, much cellular depolarization and repolarization.
later than CK levels. ー In addition, the serum sodium concentration reflects
● Myoglobin, an early marker of MI, is a heme protein with a relative fluid balance. Generally, hyponatremia (low
small molecular weight. This allows it to be rapidly released sodium level) indicates fluid excess, and hypernatremia
from damaged myocardial tissue and accounts for its early (high sodium level) indicates fluid deficit.
rise, within 1 to 3 hours after the onset of an acute MI. ー Serum potassium is affected by renal function and may be
● Myoglobin peaks in 4 to 12 hours and returns to normal in 24 decreased by diuretic agents that are used to treat HF. A
hours. Myoglobin is not used alone to diagnose MI, because decrease in potassium causes cardiac irritability and
elevations can also occur in patients with renal or predisposes the patient receiving a digitalis preparation to
musculoskeletal disease. However, negative results are digitalis toxicity and dysrhythmias.
helpful in ruling out an early diagnosis of MI. ー The effect of an elevated serum potassium concentration is
● Troponin I is measured in a laboratory test that has several myocardial depression and ventricular irritability.
advantages over traditional enzyme studies. Troponin I is a ー Both hypokalemia and hyperkalemia can lead to
contractile protein found only in cardiac muscle. After ventricular fibrillation or cardiac standstill.
myocardial injury, elevated serum troponin I concentrations ー Calcium is necessary for blood coagulability and
can be detected within 3 to 4 hours; they peak in 4 to 24 neuromuscular activity. Hypocalcemia and hypercalcemia
hours and remain elevated for 1 to 3 weeks. These early and can cause dysrhythmias
prolonged elevations make very early diagnosis of MI ー Magnesium is integral to the absorption of calcium and the
possible or allow for late diagnosis if the patient has delayed maintenance of potassium stores. It is required in the
seeking treatment metabolism of adenosine triphosphate, playing a major
☆ BLOOD CHEMISTRY role in protein synthesis, carbohydrate metabolism, and
● Cholesterol levels muscular contraction.
ー Cholesterol (normal level, less than 200 mg/dL) is a lipid ー Initial symptoms of hypermagnesemia are lethargy and
required for hormone synthesis and cell membrane decreased neuromuscular activity. On the ECG,
formation. hypomagnesemia lengthens the QT interval, predisposing
ー It is found in large quantities in brain and nerve tissue. the patient to life-threatening dysrhythmias.
ー Two major sources of cholesterol are diet (animal ● Blood Urea Nitrogen Level
products) and the liver, where cholesterol is synthesized. ー Blood urea nitrogen (BUN) is an end product of protein
Elevated cholesterol levels are known to increase the risk metabolism and is excreted by the kidneys.
for CAD. ー In the patient with cardiac disease, an elevated BUN level
ー Factors that contribute to variations in cholesterol levels may reflect reduced renal perfusion (from decreased
include age, gender, diet, exercise patterns, genetics, cardiac output) or intravascular fluid volume deficit (from
menopause, tobacco use, and stress levels. diuretic therapy or dehydration).
ー LDLs (normal level, less than 130 mg/dL) are the primary ー The cause of elevated BUN is determined from the serum
transporters of cholesterol and triglycerides into the cell. creatinine: high BUN and high creatinine reflect renal
ー One harmful effect of LDL is the deposition of these impairment, high BUN and normal creatinine reflect
substances in the walls of arterial vessels. intravascular fluid volume deficit.
ー Elevated LDL levels are associated with a greater ● Serum Glucose Level
incidence of CAD. In people with known CAD or ー The serum glucose level is important to monitor, because
diabetes, the primary goal for lipid management is many patients with cardiac disease also have diabetes
reduction of LDL levels to less than 100 mg/dL. mellitus.
ー HDLs (normal range in men, 35 to 65 mg/dL; in women, ー In addition, the serum glucose level may be mildly
35 to 85 mg/dL) have a protective action. They transport elevated in stressful situations, when mobilization of
cholesterol away from the tissue and cells of the arterial endogenous epinephrine results in conversion of liver
wall to the liver for excretion. Therefore, there is an glycogen to glucose. Serum glucose levels are drawn in a
inverse relationship between HDL levels and risk for fasting state.
CAD. ー Glycosylated hemoglobin is an important measure to
ー Factors that lower HDL levels include smoking, diabetes, monitor in people with diabetes, because it reflects the
obesity, and physical inactivity. In patients with CAD, a blood glucose levels over 2 to 3 months. Hemoglobin A1C
secondary goal of lipid management is the increase of is the common name for this test.
HDL levels to more than 40 mg/dL. ー The goal of diabetes management is to maintain the
hemoglobin A1C below 7% (normal range 4%–6%),
 reflecting consistent near-normal blood glucose levels. ☆ CHEST X-RAY AND FLUOROSCOPY
This is particularly important for primary and secondary ● A chest x-ray usually is obtained to determine the size,
prevention of CVD. contour, and position of the heart. It reveals cardiac and
● Coagulation Studies pericardial calcifications and demonstrates physiologic
ー The formation of a thrombus is initiated by injury to a alterations in the pulmonary circulation. It does not help
vessel wall or to the tissue. These events activate the diagnose acute MI but can help diagnose some complications
coagulation cascade, a complex series of interactions (eg, HF).
among phospholipids, calcium, and various clotting factors ● Correct placement of cardiac catheters, such as pacemakers
that converts prothrombin to thrombin. and pulmonary artery catheters, is also confirmed by chest
ー The coagulation cascade has two pathways, the intrinsic x-ray.
pathway and the extrinsic pathway. Coagulation studies ● Fluoroscopy allows visualization of the heart on an x-ray
are routinely performed before invasive procedures, such screen. It shows cardiac and vascular pulsations and unusual
as cardiac catheterization, electrophysiology testing, and cardiac contours.
coronary or cardiac surgery. ● Fluoroscopy is useful for positioning intravenous pacing
ー Partial thromboplastin time (PTT) and activated partial electrodes and for guiding catheter insertion during cardiac
thromboplastin time (aPTT) measure the activity of the catheterization.
intrinsic pathway. The values of PTT and aPTT are used to ☆ ELECTROCARDIOGRAPHY
assess the effects of heparin therapy. Patients receiving ● The ECG is a diagnostic tool used in assessing the
heparin have their PTT or aPTT levels maintained at 1.5 to cardiovascular system.
2.5 times their baseline values (reference range, 25 to 38 ● It is a graphic recording of the electrical activity of the heart;
seconds). an ECG can be recorded with 12, 15, or 18 leads, showing the
ー Prothrombin time (PT) measures the extrinsic pathway activity from those different reference points.
activity and is used to monitor the effects of therapeutic ● The ECG is obtained by placing disposable electrodes in
anticoagulation with warfarin (Coumadin). standard positions on the skin of the chest wall and
ー Laboratory results of PT also include the International extremities.
Normalized Ratio (INR). ● The heart’s electrical impulses are recorded as a tracing on
ー The INR provides a standard method for reporting PT special graph paper.
levels, eliminating the variation of PT results from ● The standard 12-lead ECG is the most commonly used tool to
laboratory to laboratory. diagnose dysrhythmias, conduction abnormalities, enlarged
ー The INR, rather than the PT alone, is used to monitor heart chambers, myocardial ischemia or infarction, high or
patients receiving warfarin therapy. The INR is maintained low calcium and potassium levels, and effects of some
between 2.0 and 3.0 for patients with deep vein medications.
thrombosis, pulmonary embolism, valvular heart disease, ● A 15-lead ECG adds 3 additional chest leads across the right
or atrial fibrillation, and between 2.5 and 3.5 for patients precordium and is a valuable tool for the early diagnosis of
with mechanical prosthetic heart valve replacements. right ventricular and posterior left ventricular infarction.
● Hematologic Studies ● The 18-lead ECG adds 3 posterior leads to the 15-lead ECG
ー The complete blood cell count (CBC) identifies the total and is very useful for early detection of myocardial ischemia
number of white and red blood cells, the platelet count, and injury.
and the hemoglobin and hematocrit. The CBC is carefully ● To enhance interpretation of the ECG, the patient’s age,
monitored in patients with CVD. gender, BP, height, weight, symptoms, and medications
ー White blood cell counts are monitored in (especially digitalis and antiarrhythmic agents) should be
immunocompromised patients, including patients with noted on the ECG requisition.
transplanted hearts, and in situations where there is ☆ CARDIAC STRESS TESTING
concern for infection (eg, after invasive procedures or ● Normally, the coronary arteries dilate to four times their usual
surgery). diameter in response to increased metabolic demands for
ー The red blood cells carry hemoglobin, which transports oxygen and nutrients.
oxygen to the cells. ● Coronary arteries with atherosclerosis, however, dilate much
ー The hematocrit is a measure of the relative proportion of less, compromising blood flow to the myocardium and
red blood cells and plasma. Low hemoglobin and causing ischemia. Therefore, abnormalities in cardiovascular
hematocrit levels have serious consequences for patients function are more likely to be detected during times of
with CAD, such as more frequent angina episodes. increased demand, or “stress.”
ー Platelets are the first line of protection against bleeding. ● The cardiac stress test procedures—the exercise stress test,
Once activated by blood vessel wall injury or rupture of the pharmacologic stress test, and, more recently, the mental
atherosclerotic plaque, platelets undergo chemical changes or emotional stress test—are noninvasive ways to evaluate
that form a thrombus. the response of the cardiovascular system to stress.
ー Patients are prescribed medications to inhibit platelet ● The stress test helps determine the following:
function, including aspirin, clopidogrel (Plavix), and ○ CAD,
intravenous GP IIb/IIIa inhibitors (abciximab [ReoPro], ○ Cause of chest pain,
eptifibatide [Integrilin], tirofiban [Aggrastat]); therefore, it ○ Functional capacity of the heart after an MI or heart
is essential to monitor for thrombocytopenia (low platelet surgery,
counts).
 ○ Effectiveness of antianginal or antiarrhythmic to mimic the effects of exercise by maximally dilating the
medications, coronary arteries. The effects of dipyridamole last about 15 to
○ Dysrhythmias that occur during physical exercise, 30 minutes.
○ Specific goals for a physical fitness program. ● The side effects are related to its vasodilating action and
● Contraindications to stress testing include severe aortic include chest discomfort, dizziness, headache, flushing, and
stenosis, acute myocarditis or pericarditis, severe nausea.
hypertension, suspected left main CAD, HF, and unstable ● Adenosine has similar side effects, although patients report
angina. Because complications associated with stress testing these symptoms as more severe. A unique property of
can be life-threatening (MI, cardiac arrest, HF, and severe adenosine is that it has an extremely short half-life (less than
dysrhythmias), testing facilities must have staff and 10 seconds), so any severe effects rapidly subside.
equipment ready to provide advanced cardiac life support ● Dipyridamole and adenosine are the agents of choice used in
● Exercise Stress Testing conjunction with radionuclide imaging techniques.
ー In an exercise stress test, the patient walks on a treadmill ● Theophylline and other xanthines, such as caffeine, block the
(most common) or pedals a stationary bicycle or arm effects of dipyridamole and adenosine and must be avoided
crank. Exercise intensity progresses according to before either of these pharmacologic stress tests.
established protocols. ● Dobutamine (Dobutrex) is another medication that may be
ー The goal of the test is to increase the heart rate to the used for patients who cannot exercise.
“target heart rate.” This is 80% to 90% of the maximum ● Dobutamine, a synthetic sympathomimetic, increases heart
predicted heart rate and is based on the age and gender of rate, myocardial contractility, and BP, thereby increasing the
the patient. metabolic demands of the heart.
ー During the test, the following are monitored: two or more ● It is the agent of choice when echocardiography is used
ECG leads for heart rate, rhythm, and ischemic changes; because of its effects on altering myocardial wall motion (due
BP; skin temperature; physical appearance; perceived to enhanced contractility).
exertion; and symptoms including chest pain, dyspnea, ● In addition, dobutamine is used for patients who have
dizziness, leg cramping, and fatigue. bronchospasm or pulmonary disease and cannot tolerate
ー The test is terminated when the target heart rate is having doses of theophylline withheld.
achieved or when the patient experiences chest pain, ● Nursing Interventions
extreme fatigue, a decrease in BP or pulse rate, serious ー In preparation for the pharmacologic stress test, patients
dysrhythmias or ST segment changes on ECG, or other are instructed not to eat or drink anything for at least 4
complications. hours before the test. This includes chocolate, caffeine,
ー When significant ECG abnormalities occur during the caffeine-free coffee, tea, carbonated beverages, or
stress test (ST segment depressions), the test result is medications with caffeine (eg, Anacin, Darvon).
reported as positive and further diagnostic testing is ー If caffeine is ingested before a dipyridamole or adenosine
required. stress test, the test will have to be rescheduled. Patients
● Nursing Interventions taking aminophylline or theophylline are instructed to stop
ー In preparation for the exercise stress test, the patient is taking these medications for 24 to 48 hours before the test
instructed to fast for 4 hours before the test and to avoid (if tolerated). Oral doses of dipyridamole are to be
stimulants such as tobacco and caffeine. Medications may withheld as well.
be taken with sips of water. ー Patients are informed about the transient sensations they
ー The physician may instruct patients not to take certain may experience during infusion of the vasodilating agent,
cardiac medications, such as beta-blockers, before the test. such as flushing or nausea, which will disappear quickly.
ー Clothes and sneakers or rubber-soled shoes suitable for ー The patient is instructed to report any other symptoms
exercising are to be worn. Women are advised to wear a occurring during the test to the cardiologist or nurse.
bra that provides adequate support. ー An explanation of echocardiography or radionuclide
ー The nurse describes the equipment used and the sensations imaging is also provided as necessary.
and experiences that the patient may have during the test. ー The stress test may take about 1 hour, or up to 3 hours if
ー The nurse explains the monitoring equipment used, the imaging is performed.
need to have an intravenous line placed, and the symptoms ☆ ECHOCARDIOGRAPHY
to report. ● Echocardiography is a noninvasive ultrasound test that is
ー The type of exercise is reviewed, and patients are asked to used to examine the size, shape, and motion of cardiac
put forth their best exercise effort. If the test is to be structures.
performed with echocardiography or radionuclide ● It is a particularly useful tool for diagnosing pericardial
imaging, this information is reviewed as well. After the effusions, determining the etiology of heart murmurs,
test, patients are monitored for 10 to 15 minutes. Once evaluating the function of prosthetic heart valves,
stable, they may resume their usual activities. determining chamber size, and evaluating ventricular wall
☆ PHARMACOLOGIC STRESS TESTING motion.
● Physically disabled or deconditioned patients will not be able ● It involves transmission of high-frequency sound waves into
to achieve their target heart rate by exercising on a treadmill the heart through the chest wall and recording of the return
or bicycle. signals.
● Two vasodilating agents, dipyridamole (Persantin) and ● The ultrasound is generated by a hand-held transducer
adenosine (Adenocard), administered intravenously, are used applied to the front of the chest.
 ● The transducer picks up the echoes, converts them to ● In addition, the following blood tests are performed to
electrical impulses, and transmits them to the identify abnormalities that may complicate recovery: BUN
echocardiography machine for display on an oscilloscope and and creatinine levels, INR or PT, aPTT, hematocrit and
recording on a videotape. hemoglobin values, platelet count, and electrolyte levels
● An ECG is recorded simultaneously to assist with interpreting ● Diagnostic cardiac catheterizations are commonly performed
the echocardiogram. on an outpatient basis and require 2 to 6 hours of bed rest
● Echocardiography may be performed with an exercise or before ambulation.
pharmacologic stress test; resting and stress images are ● For most patients, bed rest for 6 hours compared to 2 hours
obtained. has no advantage with regard to groin bleeding
● Myocardial ischemia from decreased perfusion during stress complications.
causes abnormalities in ventricular wall motion and is easily ● However, variations in time to ambulation are most often
detected by echocardiography. related to the size of the catheter used during the procedure,
● A stress test using echocardiography is considered positive if the anticoagulation status of the patient, other patient
abnormalities in ventricular wall motion are detected during variables (eg, advanced age, obesity, bleeding disorder), the
stress but not during rest. method used for hemostasis of the arterial puncture site after
● These findings are highly suggestive of CAD and require the procedure, and institutional policies.
further evaluation, such as a cardiac catheterization. ● The use of smaller (4 or 6 Fr) catheters, which are more
☆ COMPUTED TOMOGRAPHY amenable to shorter recovery times, is common in diagnostic
● Computed tomography (CT), also called computerized axial cardiac catheterization
tomographic (CAT) scanning or electron-beam computed ● Patients hospitalized for angina or acute MI may also require
tomography (EBCT), uses x-rays to provide cross-sectional cardiac catheterization.
images of the chest, including the heart and great vessels. ● After the procedure, these patients usually return to their
● These techniques are used to evaluate cardiac masses and hospital rooms for recovery.
diseases of the aorta and pericardium. ● In some cardiac catheterization laboratories, an angioplasty
☆ MAGNETIC RESONANCE IMAGING may be performed immediately after the catheterization if
● Magnetic resonance imaging (MRI) is a noninvasive, painless indicated.
technique that is used to examine both the physiologic and ☆ ANGIOGRAPHY
anatomic properties of the heart. ● Cardiac catheterization is usually performed with
● MRI uses a powerful magnetic field and computer-generated angiography, a technique of injecting a contrast agent into the
pictures to image the heart and great vessels. vascular system to outline the heart and blood vessels.
● It is valuable in diagnosing diseases of the aorta, heart ● When a particular heart chamber or blood vessel is singled
muscle, and pericardium, as well as congenital heart lesions. out for study, the procedure is known as selective
● The application of this technique to the evaluation of angiography. Angiography makes use of cineangiograms, a
coronary artery anatomy, cardiac blood flow, and myocardial series of rapidly changing films on an intensified fluoroscopic
viability in conjunction with pharmacologic stress testing is screen that record the passage of the contrast agent through
being investigated. the vascular site or sites.
☆ CARDIAC CATHETERIZATION ● The recorded information allows for comparison of data over
● Cardiac catheterization is an invasive diagnostic procedure in time.
which radiopaque arterial and venous catheters are introduced ● Common sites for selective angiography are the aorta, the
into selected blood vessels of the right and left sides of the coronary arteries, and the right and left sides of the heart.
heart.
● Catheter advancement is guided by fluoroscopy. Most
commonly, the catheters are inserted percutaneously through
the blood vessels, or via a cutdown procedure if the patient
has poor vascular access.
● Pressures and oxygen saturations in the four heart chambers
are measured.
● Cardiac catheterization is used to diagnose CAD, assess
coronary artery patency, and determine the extent of
atherosclerosis based on the percentage of coronary artery
obstruction. These results determine whether
revascularization procedures including PTCA or coronary
artery bypass surgery may be of benefit to the patient.
● Radiopaque contrast agents are used to visualize the coronary
arteries; some contrast agents contain iodine. The patient is
assessed before the procedure for previous reactions to
contrast agents or allergies to iodine-containing substances
(eg, seafood).
● If the patient has a suspected or known allergy to the
substance, antihistamines or methylprednisolone
(Solu-Medrol) may be administered before the procedure.