Health history
•
Health History include –
•
Identifying information
•
Chief complaint or presenting problem
•
History of the present illness
•
Past history
•
Family history
•
Risk Factors
•
Personal and social history
•
Perceived health status
•
Functional patterns
Identifying Information
•
It includes -
•
Patient’s Name
•
Father/ Husbands Name
•
Age & Sex
•
Religious Or Cultural Group
•
Education
•
Occupation
•
Marital Status
•
Address
Chief complaint or presenting problem
•
Chief complaint is the reason of the
person has sought health care. It should be recorded within quotation marks
exactly as stated. The chief complaint also should indicate duration. Example -
“chest discomfort for 2 hours.”
•
An asymptomatic patient may present
because of –
•
Community Screening (e.g., “high
blood cholesterol discovered on finger-stick last month”)
•
Positive diagnostic result (e.g., “positive
calcium score on electron beam CT last week”).
•
A patient may have more than one chief
complaint.
•
Closely related complaints listed
together-“chest discomfort and weakness for 2 hours.”
•
If complaints are unrelated, - listed
separately in the order of importance to the patient.
Common Symptoms of CVD
•
The most common signs and symptoms of CVD
are –
•
Chest pain or discomfort (angina
pectoris, ACS, dysrhythmias, valvular heart disease)
•
Shortness of breath or dyspnea (ACS,
cardiogenic shock, HF, valvular heart disease)
•
Peripheral edema, weight gain, abdominal
distention due to enlarged spleen and liver or
ascites (HF)
•
Palpitations
(tachycardia from a variety of causes, including ACS, caffeine or other
stimulants, electrolyte imbalances, stress, valvular heart disease, ventricular
aneurysms)
•
Vital fatigue,
sometimes referred to as vital exhaustion (an early warning symptom of ACS, HF,
or valvular heart disease, characterized by feeling unusually tired or
fatigued, irritable, and dejected)
•
Dizziness, syncope, or changes in level of
consciousness (cardiogenic shock, cerebrovascular
disorders, dysrhythmias, hypotension, postural hypotension, vasovagal episode)
History of the Present Illness
•
First we ask the patient to tell the whole
story accurately and chronologically about incident. Listen to the patient. It
is best to let patients tell their stories in a comfortable manner.
•
The information that must be obtained when
describing any symptom is the time and manner of onset, frequency and duration,
location, quality, quantity, setting, associated symptoms, alleviating or
aggravating factors, pertinent negative responses, impact of the symptom on usual
or desired activities, and the meaning attributed to the symptom by the
patient.
Past Medical History
•
Childhood And Adult Illnesses,
•
Accidents And Injuries,
•
Current Health Status,
•
Medication history includes all
prescription and over-the-counter drugs, including botanical medicines,
supplements, and home remedies.
•
Allergy (e.g., to drugs, food,
environmental agents, or animals)
•
Health Maintenance
•
Always ask about major illnesses such as
chronic obstructive airway disease, diabetes mellitus, bleeding disorders, and
acquired-immuno deficiency syndrome (AIDS)
Family History
•
The major purpose of the family history is
to assess risk factors affecting the patient’s current or future health.
•
Family occurrences of diabetes, kidney
disease, tuberculosis, cancer, arthritis, asthma, allergies, mental illness,
alcoholism, and drug addiction are included.
•
family history of coronary heart disease,
myocardial infarction, or sudden death would be included in the history of
present illness for a patient presenting with chest discomfort.
Risk Factors
Non-modifiable
•
Family history of CAD
•
Increasing age
•
Gender -Male & postmenopausal
•
Race (higher in African Americans than
Caucasians)
Modifiable
•
Hyperlipidemia
•
Hypertension
•
Cigarette smoking,
•
exposure to tobacco
•
Diabetes mellitus
•
Obesity
•
Physical inactivity
Personal And Social History
•
The personal and social history includes -
•
Person’s response to illness is determined
in part by his or her cultural background, socioeconomic standing, education,
and beliefs about the illness.
•
Major elements include health habits, home
situation, and supports and resources.
•
Health habits include - cigarette smoking
alcohol, drug, or tobacco use; nutrition; sleep; and physical activity.
•
Special diets, such as low-sodium,
low-fat, low-carbohydrate, or high-protein diets, should be identified, and the
patient’s usual eating pattern should be described.
•
Occupational history
Psychological history
•
Perceived Health and Coping Challenges
•
The patient’s perception of his or her
current health status as either good or bad is helpful in assessing how he or
she views its effect on daily living.
Functional Patterns
•
Clinical information related to function
is collected in the following areas -
•
Health perception–health management
•
Nutrition–metabolism
•
Elimination
•
Activity–exercise
•
Cognitive–perceptual
•
Sleep–rest
•
Self-perception–self-concept
•
Roles and relationships
•
Sexuality
•
Coping–stress
•
Values–beliefs
Physical Examination
•
Assessment of physical findings confirms
or expands data obtained in the health history. It includes -
•
General appearance
•
Head
•
Arterial pulse
•
Jugular venous pressure
•
Blood pressure
•
Peripheral vasculature
•
Heart
•
Lungs
•
Abdomen
General Appearance
•
Patient’s appearance and responses provide
cues to the cardiovascular status.
•
Level of distress
•
Level of consciousness
•
Height, Weight, and Waist Circumference
Head
•
The examination of the head includes -
•
Facial Characteristics
•
Color
•
Temperature
•
Eyes
Arterial Pulse
•
Information about pulse rate, rhythm,
amplitude and contour, and obstruction to blood flow is obtained from palpation
of the arterial pulse.
•
Pulse Rate.
•
Normal pulse rate at rest - between 60 -
100 (avg. 70) / minute
•
Increased in conditions or activities such
as exercise, fever, and stress
•
Decreased in - Hypothermia, certain drugs,
and heart blocks
•
Pulse Rhythm
•
Pulse rhythm is normally regular.
Physiologic variation can occur with respiration.
•
The pulse rate may increase during
inhalation and slow during exhalation.
•
This physiologically irregular rhythm is
termed sinus arrhythmia.
•
Pulse Quality=Pulse Amplitude and Contour
-Pulses are described in a variety of ways.
The simplest classification is absent, present, and bounding.
•
0-to-4 scale is often used, and pulses are
graded as follows:
•
Absent (0),
•
Diminished (1),
•
Normal (2),
•
Moderately Increased (3)
•
Markedly Increased(4)
•
Carotid Pulse -
•
The carotid artery is best for assessing
pulse wave amplitude and contour.
•
Peripheral Circulation –
•
In the legs, assess femoral, popliteal,
dorsalis pedis, and posterior tibial pulses
•
In the arms, assess brachial, radial, and
ulnar pulses.
•
Jugular Venous Pressure –
•
Jugular venous pressure reflects filling
volume and pressure on the right side of the heart.
•
Jugular veins act like manometers; blood
in the jugular veins assumes the level that corresponds to the right atrial
(central venous) pressure.
•
The normal jugular venous pressure is less
than 9 cm H2O.
Blood Pressure
•
Systemic arterial blood pressure can be
measured by-
•
Indirectly or non-invesive
•
Directly or invesive
•
Normal B.P. 18 + age = 100-120/60-80 mm
Hg,
•
prehypertension = 120-139 /80- 90 mm Hg
•
Hypertension = >140/90 mm Hg
•
Hypotension = < 90/60 mm Hg
•
Blood pressure is measured indirectly by
sphygmomanometer and stethoscope.
•
Sphygmomanometer
•
Bladder and Cuff
•
The inflatable bladder fits inside a
nondistensible covering, termed the cuff
•
Size and placement of the bladder
•
The bladder width should be 40% of the
circumference of the limb (usually the arm).
•
too narrow for the size of the limb
reflect a falsely elevated BP.
•
too wide reflect an erroneously low BP.
•
Bladder length should be approximately
twice that of width, or 80% of the limb circumference
•
cuff size is determined by patient size,
not patient age
•
Manometers
•
There are two types
•
Mercury manometers - the most reliable
•
Aneroid manometers -Advantages of that it
is easily seen, is conveniently portable, and, with the cuff, composes one
unit. Unfortunately, the calibration of the dial frequently becomes inaccurate.
•
Electronic devices for measuring blood
pressure - do not require use of a stethoscope and may be used by patients for
self-monitoring of blood pressure.
•
Technique
•
blood pressure should be recorded in both
arms. Subsequently, the arm with the higher blood pressure should be used.
•
Bladder and Cuff Position
•
The deflated cuff is placed snugly around
the arm
•
The bladder covering the inner aspect of
the arm and the brachial artery.
•
The lower margin of the cuff should be 2.5
cm above the antecubital space.
•
Arm Position is at heart level,
•
Falsely elevated pressures are obtained if
the arm is lower than the heart;
•
falsely low pressures are measured if the
arm is higher than the heart.
•
Palpation
•
BP is taken by the brachial or radial
artery is palpation
•
Once the brachial pulse is obtained, the
cuff is inflated rapidly.
•
The pressure at which the pulse disappears
should be noted, but the cuff inflation should continue for another 30 mm Hg
before the actual measurement of the blood pressure begins.
•
The point at which the brachial pulse is
first detected on expiration is the systolic blood pressure. Diastolic blood
pressure cannot be determined accurately by palpation.
•
Palpated blood pressures are charted using
“P” as diastolic pressure (e.g., 90/P).
•
Auscultation
•
BP is taken by the help of
sphygmomanometer and stethoscope
•
Korotkoff sounds are the sounds created by
turbulence of blood flow within the vessel caused by constriction of the blood
pressure cuff.
•
Systolic blood pressure is the highest
point at which initial tapping is heard in two consecutive beats during
expiration.
•
Diastolic blood pressure is equated with
disappearance of Korotkoff sounds.
•
Auscultatory gap is a temporary
disappearance of sound that occurs during the latter part of phase I and phase
II.
•
Measurement of Pulse Pressure
•
Pulse pressure is the difference between
the systolic and diastolic blood pressures, expressed in millimeters of
mercury.
•
For example, if the blood pressure is
120/80 mm Hg, the pulse pressure is 40 mm Hg.
•
Pulse pressure reflects stroke volume,
ejection velocity, and systemic vascular resistance.
•
Use pulse pressure as a noninvasive
indicator of the patient’s ability to maintain cardiac output.
•
Pulse pressure is increased in many
situations- seen in sinus bradycardia, complete heart block, aortic
regurgitation, anxiety, exercise, and catecholamine infusion, which are
examples of situations characterized by increased stroke volume.
•
Conditions such as atherosclerosis, aging,
and high blood pressure widen the pulse pressure because of decreased
distensibility of the aorta, arteries, and arterioles.
•
A narrowed pulse pressure also can be
caused by many factors: reduced ejection velocity in heart failure, shock, and
hypovolemia; mechanical obstruction to systolic outflow in aortic stenosis,
mitral stenosis, and mitral insufficiency; peripheral vasoconstriction in shock
and with certain drugs.
•
Measurement of Postural Blood Pressure
•
Postural (orthostatic) hypotension occurs
when the blood pressure drops after an upright posture is assumed. It usually
is accompanied by dizziness, lightheadedness, or syncope.
•
The three most commonly causes of postural
hypotension, seen in the cardiac patient are
•
(1) Intravascular volume depletion, which
often results from aggressive diuretic therapy, inadequate intake, or
intravascular to extravascular fluid shift;
•
(2) Inadequate vasoconstrictor mechanisms,
which may be a primary pathologic process but also result from immobility; and
•
(3) Autonomic insufficiency, which is
often related to the sympathetic blocking drugs used in the cardiac patient.
•
Normal postural responses are-
•
Increased heart rate of 5 to 20 beats per
minute (to offset reduced stroke volume and to maintain cardiac output),
•
Drop in systolic pressure of less than 10
mm hg, and an increase in diastolic pressure of approximately 5 mm hg.
•
Orthostatic is defined as a drop in
systolic pressure of 20 mm hg or greater or a drop in diastolic pressure of at
least 10 mm hg within 3 minutes of standing,
•
Example of postural blood pressure
recordings showing either vlolume depletion or inadequate vasoconstrictor
mechanisms:
|
Patient
Position
|
Hart
Rate
|
Blood
Pressure
|
|
Supine
|
70 bpm
|
120/70 mm of Hg
|
|
Sitting
|
90 bpm
|
100/55 mm of Hg
|
|
Standing
|
94 bpm
|
98/52 mm of Hg
|
Heart
•
The heart is examined by inspection,
palpation, and auscultation of the chest wall. A systematic approach is used to
examine the chest wall in the following six areas. These important landmarks –
•
Aortic area,
•
Pulmonic area,
•
Erb’s point,
•
Tricuspid area,
•
Mitral (apical) area and
•
Epigastric area
•
Aortic area —
second intercostal space to the right of the sternum.
•
Pulmonic area—second
intercostal space to the left of the sternum
•
Erb’s point—third
intercostal space to the left of the sternum
•
Tricuspid area—lower
half of the sternum along the left parasternal area
•
Mitral (apical) area—left
fifth intercostal space at the midclavicular line
•
Epigastric area—below
the xiphoid process
Inspection & palpation
•
The patient lies supine, with the head of
the bed slightly elevated.
•
Each area of the precordium is inspected
and then palpated.
•
Apical Impulse – The
Apical impulse is the result of the heart rotating, moving forward and striking
against the chest wall during systole. The apical impulse is normally felt as a
light pulsation, 1 to 2 cm in diameter.
•
Thrills
- A vibration or purring sensation may be felt over areas where abnormal,
turbulent blood flow is present. It is best detected by using the palm of the
hand. This vibration is called a thrill and is associated with a loud murmur.
Depending on the location of the thrill, it may be indicative of serious valvular
heart disease, an atrial or ventricular septal defect (abnormal opening), or
stenosis of a large artery, such as the carotid artery.
Heart Auscultation
•
The purpose of cardiac auscultation is to
determine heart rate and rhythm and evaluate heart sounds.
•
Normal heart sounds, referred to as S1
and S2, are produced by closure of the AV valves and the semilunar
valves, respectively. The period between S1 and S2
corresponds with ventricular systole.
•
S1—First Heart Sound - Tricuspid
and mitral valve closure creates the first heart sound (S1). The
word “lub” is used to replicate its sound. S1 is usually heard the
loudest at the apical area. The intensity of S1 increases during
tachycardias or with mitral stenosis.
•
S2—Second Heart Sound - Closure
of the pulmonic and aortic valves produces the second heart sound (S2),
commonly referred to as the “dub” sound. The aortic component of S2
is heard the loudest over the aortic and pulmonic areas.
Abnormal Heart Sounds
•
Abnormal sounds develop during systole or
diastole when structural or functional heart problems are present. These sounds
are S3, or S4 gallops, opening snaps, systolic clicks, and murmurs.
•
S3 and S4
gallop sounds
•
These are heard during diastole.
•
These sounds are created by the vibration
of the ventricle and surrounding structures as blood meets resistance during
ventricular filling.
•
S3—Third Heart Sound –
•
occurs early in diastole during the rapid
ventricular filling
•
It is heard immediately after S2
“Lub-dub DUB” (S3)
•
It represents a normal in children and
adults up to 35 or 40 years of age & called a physiologic S3.
•
In older adults, it is a sign of
pathophysiology, most commonly due to volume overload of one or both
ventricles.
•
S4—Fourth Heart Sound
•
occurs late in diastole
•
S4 occurs just before S1
“LUB (S4) lub-dub”
•
It is due to ventricular hypertrophy
caused by hypertension, CAD, cardiomyopathies, aortic stenosis, and numerous
other conditions.
•
When both S3 and S4
are present, creating a quadruple rhythm, which sounds like “LUB lub-dub DUB”.
During tachycardia, all four sounds combine into a loud sound, referred to as a
summation gallop.
Opening Snaps and Systolic Clicks
•
Normally no sound produced when valves
open.
•
Diseased valve leaflets create abnormal
sounds as they open during diastole or systole.
•
Opening snaps
are abnormal diastolic sounds heard during opening of an AV valve. For example,
mitral stenosis can cause an opening snap, which is an unusually high-pitched
sound very early in diastole. This sound caused by high pressure in the left atrium
that abruptly displaces or “snaps” open a rigid valve leaflet. Hearing a murmur
or the sound of turbulent blood flow expected following the Opening snap. An
opening snap heard best using the diaphragm to the apical area.
•
Systolic Click -
stenosis of one of the semilunar valves creates a short, high-pitched sound in
early systole, immediately after S1. This sound called systolic
click. It is the result of the opening of a rigid and calcified aortic or
pulmonic valve during ventricular contraction.
Murmurs
•
Murmurs created by turbulent flow of
blood. The causes of the turbulence may be a critically narrowed valve, a
malfunctioning valve that allows regurgitant blood flow, a congenital defect of
the ventricular wall, a defect between the aorta and the pulmonary artery, or
an increased flow of blood through a normal structure (eg, with fever,
pregnancy, hyperthyroidism).
Friction Rub
•
A harsh, grating sound that can be heard
in both systole and diastole is called a friction rub. It is caused by abrasion
of the inflamed pericardial surfaces from pericarditis. Pericardial friction
rub can be heard best using the diaphragm of the stethoscope, with the patient
sitting up and leaning forward.
Chest Percussion
•
Normally, only the left border of the
heart can be detected by percussion. It extends from the sternum to the
mid-clavicular line in the third to fifth intercostal spaces. The right border
lies under the right margin of the sternum and is not detectable. Enlargement
of the heart to either the left or right usually can be noted.
Inspection of the Extremities
•
Inspect nailbeds for color, splinter
hemorrhages, clubbing, and capillary refill.
•
Color—pale nailbeds may be indicative of
anemia, whereas cyanotic may be indicative of decreased oxygenation.
•
Splinter hemorrhages are thin brown lines
in nailbed and are associated with endocarditis.
•
Clubbing (swollen nail base and loss of
normal angle) is associated with pulmonary or cardiovascular disease.
•
Capillary refill indicates an estimate of
the rate of peripheral blood low.
•
Inspect and palpate for edema—if pitting
edema, describe degree of edema in terms of depth of pitting that occurs with
slight pressure:
•
1+ or mild—0 to ¼ inch (0 to 0.6 cm),
•
2+ or moderate—½ inch (1.3 cm),
•
3+ to 4+ or severe—¾ to 1 inch (2 to 2.5
cm)
Diagnostic Evaluation
•
Laboratory Tests
•
Chest X-Ray and Fluoroscopy
•
Electrocardiography
•
Cardiac Stress Testing
•
Echocardiography
•
Radionuclide Imaging
•
Cardiac Catheterization
•
Electro-physiologic Testing
•
Hemodynamic Monitoring
Laboratory tests
Cardiac Biomarker Analysis
•
Myocardial cells that become necrotic from
prolonged ischemia or trauma release specific enzymes
•
Creatine kinase [CK]),
•
CK isoenzymes (CK-MB),
•
LDH and
•
Proteins (myoglobin, troponin T, and
troponin I)
•
These substances leak into the
interstitial spaces of the myocardium and are carried by the lymphatic system
into general circulation. As a result, abnormally high levels of these
substances can be detected in serum blood samples.
CK-MB (creatine kinase, myocardial muscle)
•
An elevation in value indicates myocardial
damage.
•
An elevation occurs within 4 to 6 hours
and peaks 18 to 24 hours following an acute ischemic attack.
•
Normal value is 0% to 5% of total; total
CK is 26 to 174 units/L.
Lactate dehydrogenase (LDH)
•
Elevations in LDH levels occur 24 hours
following myocardial infarction and peak in 48 to 72 hours.
•
Normally, LDH1 is lower than LDH2; when
the serum concentration of LDH1 is higher than LDH2, the pattern is indicated
as “flipped,” signifying myocardial necrosis.
•
The normal value of LDH in conventional
units is 140 to 280 international units/L
Troponin
•
Troponin is composed of three proteins —
•
Troponin C,
•
Cardiac troponin I, and
•
Cardiac troponin T
•
Troponin I especially has a high affinity
for myocardial injury; it rises within 3 hours and persists for up to 7 days.
•
Normal values are low, with troponin I
being lower than 0.6 ng/mL and troponin T normally ranging from 0 to 0.2 ng/mL;
thus, any rise can indicate myocardial cell damage.
Myoglobin
•
Myoglobin is an oxygen-binding protein
found in cardiac and skeletal muscle.
•
The level rises within 1 hour after cell
death, peaks in 4 to 6 hours, and returns to normal within 24 to 36 hours (even
faster in some clients).
Lipid Profile
•
The lipid profile measures serum
cholesterol, triglyceride, and lipoprotein levels.
•
The lipid profile is used to assess the
risk of developing coronary artery disease.
•
The desirable range -
•
Serum cholesterol is lower than 200 mg/dl,
•
Low-density lipoprotein cholesterol lower
than 130 mg/dl
•
High-density lipoprotein cholesterol at 30
to 70 mg/dl
Blood urea nitrogen
•
The blood urea nitrogen level is elevated
in heart disorders that adversely affect renal circulation, such as heart
failure and cardiogenic shock.
B-type natriuretic peptide (BNP)
•
BNP is released in response to atrial and
ventricular stretch; it serves as a marker for congestive heart failure.
•
BNP levels should be lower than 100 pg/mL;
the higher the level, the more severe the congestive heart failure (CHF).
Electrocardiography
12-Lead ECG Monitoring
•
The Dutch physiologist Einthoven was one
of the first to represent heart electrical conduction as two charged
electrodes, one positive and one negative.
•
The body can be likened to a triangle,
with the heart at its centre, and this has been called Einthoven’s triangle.
ECG Leads
•
The 12-lead ECG consists of six limb leads
and six chest leads.
•
limb leads
•
The limb leads examine electrical activity
along a vertical plane. The standard bipolar limb leads (I, II, III) record
differences in potential between two limbs.
•
I = right arm–left arm (positive);
•
II = right arm–left leg (positive);
•
III = left arm–left leg (positive).
•
The three augmented unipolar limb leads
(aVR, aVL, aVF) record activity between one limb and the other two limbs to
increase the size of the potentials.
•
Chest leads (praecordial leads)
•
The six unipolar chest leads (praecordial
leads) are designated V1–6 and examine electrical activity along a horizontal
plane from the right ventricle, septum, left ventricle and the left atrium.
They are positioned in the following way
•
V1 = 4th intercostal space, to the right
of the patient’s sternum;
•
V2 = 4th intercostal space, to the left of
the patient’s sternum;
•
V3 = equidistant between V2 and V4;
•
V4 = 5th intercostal space on the
midclavicular line;
•
V5 = 5th intercostal space, anterior
axillary line;
•
V6 = 5th intercostal space on the
midaxilla line.
ECG Paper
•
Amplitude (voltage) in the ECG is measured
by a series of horizontal lines on the ECG. Each line is 1 mm apart and
represents 0.1 mV.
•
Duration of activity within the ECG is
measured by a series of vertical lines. Each line is 1 mm apart and represents
0.04 sec.
ECG Waves and Intervals
•
P wave: sequential
depolarization of the right and left atria (P=0.08-0.1 Sec. 2-3 mm in
amplitude)
•
PR interval: time
interval from onset of atrial depolarization (P wave) to onset of ventricular
muscle depolarization (QRS complex) =0.12-0.2 sec
•
QRS complex: right
and left ventricular depolarization (Amplitude as high as 25 mm, duration
(width of the QRS complex) with Normal Conduction 0.08 – 0.11 sec.)
•
ST-segment: Time
between completion of depolarization and onset of repolarization (Point where
ST takes off from QRS= J point)
•
T wave: ventricular
repolarization
•
QT interval: duration
of ventricular depolarization and repolarization = 0.35 – 0.45 sec.
•
U wave: origin
of this wave is still being debated!
•
PP interval: rate
of atrial or sinus cycle
•
RR interval: rate
of ventricular cycle
ECG Interpretation
•
Heart rate:- Count
the R waves on a 6 sec strip and multiply by 10 to calculate the rate.
•
Rhythm (regularity) — To
assess regularity, The R-R interval should not differ by more than 0.12 sec.
•
Atrial activity — Observe
for the presence or absence of P waves.
•
AV node activity: —the
duration of the P-R interval
•
Ventricular activity: — Measure
the QRS interval And Q wave (if present) = less than 0.04 sec.
•
General notable aspects of ECG -
•
Observe whether the isoelectric line is
present between the S and T waves.
•
Examine the T wave to see whether it is
positive, and less than 0.16 sec.
•
Examine the duration of the Q-T interval.
Cardiac Stress Test
•
The cardiac stress test procedures —
•
The exercise stress test-
the patient walks on a treadmill (most common), pedals a stationary bicycle
•
The pharmacologic stress test-
If the client is unable to tolerate exercise, an intravenous (IV) infusion of
dipyridamole (Persantine), or adenosine (Adenocard) is given to dilate the
coronary arteries and simulate the effect of exercise. That is called
Pharmacologic Stress Testing
•
These are noninvasive ways to evaluate the
response of the cardiovascular system to stress.
•
The stress test helps determine the
following –
•
Presence of CAD,
•
Cause of chest pain,
•
Functional capacity of the heart after an
MI or heart surgery,
•
Effectiveness of antianginal or
antiarrhythmic medications,
•
Dysrhythmias that occur during physical
exercise, and
•
Specific goals for a physical fitness
program.
•
Contraindications to stress testing
include -
•
Severe aortic stenosis,
•
Acute Myocarditis or pericarditis,
•
Severe hypertension,
•
Suspected left main CAD,
•
HF, and
•
Unstable angina
•
Because complications of stress testing
can be life-threatening -
•
MI,
•
Cardiac arrest,
•
HF,
•
Severe dysrhythmias
•
The goal is to increase the heart rate to
the “target heart rate,” which is 80% to 90% of the maximum predicted heart
rate based on the patient’s age and gender.
•
During the test, the following are
monitored:
•
Two or more ECG leads for heart rate,
rhythm, and ischemic changes;
•
BP;
•
Skin temperature;
•
Physical appearance;
•
Perceived exertion;
•
Symptoms, including chest pain, dyspnea,
dizziness, leg cramping, and fatigue.
•
The test is terminated when the target
heart rate is achieved or when the patient experiences chest pain, extreme
fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST-segment
changes on the ECG, or other complications.
•
When significant ECG abnormalities occur
during the stress test (ST-segment depressions or elevations), the test result
is reported as positive and further diagnostic testing such as a cardiac
catheterization is required.
•
Note : - Theophylline and other xanthines,
such as caffeine, block the effects of dipyridamole and adenosine and must be
avoided before these pharmacologic stress tests.
•
Preprocedure interventions
•
Obtain an informed consent if required.
•
Provide adequate rest the night before the
procedure.
•
Instruct the client to eat a light meal 1
to 2 hours before the procedure.
•
Instruct the client to avoid smoking,
alcohol, and caffeine before the procedure.
•
Instruct the client to ask the physician
about taking prescribed medication on the day of the procedure; theophylline
products are usually held 12 hours before the test and calcium channel blockers
and b-blockers are usually held for 24 hours.
•
Instruct the client to wear nonconstrictive,
comfortable clothing and supportive rubber-soled shoes for the exercise stress
test.
•
Instruct the client to notify the
physician if any chest pain, dizziness, or shortness of breath occurs during
the procedure.
•
Postprocedure interventions:
•
Instruct the client to avoid taking a hot
bath or shower for at least 1 to 2 hours.
Echocardiography
•
Echocardiography is a noninvasive
ultrasound test that is used to measure the ejection fraction and examine the
size, shape, and motion of cardiac structures
•
Traditional Echocardiography -
Echocardiography involves transmission of high-frequency sound waves into the
heart through the chest wall and recording of the return signals.
•
Transesophageal Echocardiography -
A significant limitation of traditional echocardiography is the poor quality of
the images produced. Ultrasound loses its clarity as it passes through tissue,
lung, and bone. An alternate technique involves threading a small transducer
through the mouth and into the esophagus.
•
It is particularly useful for diagnosing –
•
Pericardial effusions;
•
Determining chamber size and
•
The etiology of heart murmurs;
•
Evaluating the function of heart valves,
including prosthetic heart valves; and
•
Evaluating ventricular wall motion
Radionuclide Imaging
•
Radionuclide imaging studies involve –
•
Magnetic resonance imaging (MRI)
•
Computed Tomography (CT scan)
•
Positron emission tomography (PET scan)
•
Magnetic Resonance Angiography
Cardiac Catheterization
•
Cardiac catheterization is an invasive
diagnostic procedure in which radiopaque arterial and venous catheters are
introduced into selected blood vessels of the right and left sides of the
heart.
•
Catheter is inserted into a peripheral
vein for a right heart catheterization or an artery for a left heart
catheterization.
•
Angiography - Angiography
allows x-ray visualization of the heart, aorta, inferior vena cava, pulmonary
artery and vein, and coronary arteries after injection of contrast medium.
Indication
•
CAD,
•
Assess coronary artery patency, and
determine the extent of atherosclerosis
•
Evaluate cardiac valvular and septal
defects
•
Evaluate disease associated with the
aortic arch
•
Evaluate previous cardiac surgery or other
interventional procedures
•
Monitor pulmonary pressures and cardiac
output
•
Perform angioplasty, perform atherectomy,
or place a stent
•
Quantify the severity of atherosclerotic,
occlusive coronary artery disease
•
Allow infusion of thrombolytic drugs into
an occluded coronary
Contraindication
•
This procedure is contraindicated for:
•
Patients with allergies to shellfish or iodinated
contrast medium.
•
Patients with bleeding disorders.
•
Patients who are pregnant or suspected of
being pregnant, the risk of radiation exposure to the fetus.
•
Elderly and compromised patients who are
chronically dehydrated before the test, because of their risk of
contrast-induced renal failure.
•
Patients who are in renal failure.
NURSING IMPLICATION
PRETEST:
•
Positively identify the patient using at
least two unique identifiers before providing care, treatment, or services.
•
Inform the patient that the procedure
assesses cardiovascular function.
•
Obtain a history of the patient’s
complaints, including a list of known allergens
•
Obtain a history of results of the
patient’s cardiovascular and respiratory system, symptoms, and results of
previously performed laboratory, diagnostic test and surgical procedures.
•
Note any recent procedures that can
interfere with test results, including examinations using iodine-based contrast
medium or barium. Ensure that barium studies were performed more than 4 days
before angiography.
•
Record the date of last menstrual period
and determine the possibility of pregnancy in premenopausal women.
•
Obtain a list of the patient’s current
medications, including anticoagulants, aspirin and other especially those known
to affect coagulation. Such products should be discontinued by medical
direction for the appropriate number of days prior to a surgical procedure.
Note the last time and dose of medication taken.
•
Review the procedure with the patient.
Address concerns about pain and explain that there may be moments of discomfort
and some pain experienced during the test and takes approximately 30–60 min.
•
Explain that an IV line may be inserted to
allow infusion of IV fluids, anesthetics, or sedatives. Usually normal saline
is infused.
•
Inform the patient that a burning and
flushing sensation may be felt throughout the body during injection of the
contrast medium. After injection of the contrast medium, the patient may
experience an urge to cough, flushing, nausea, or a salty or metallic taste.
•
Instruct the patient to remove jewelry and
other metallic objects from the area to be examined.
•
Instruct the patient to fast and restrict
fluids for 2 to 4 hr prior to the procedure.
•
This procedure may be terminated if chest
pain, severe cardiac arrhythmias, or signs of a cerebrovascular accident occur.
•
Make sure a written and informed consent
has been signed prior to the procedure and before administering any
medications.
INTRATEST:
•
Ensure the patient has complied with
dietary and fluid restrictions for 2 to 4 hr prior to the procedure.
•
Ensure that the patient has removed
external metallic objects from the area to be examined prior to the procedure.
•
If the patient has a history of allergic
reactions to any substance or drug, administer ordered prophylactic steroids or
antihistamines before the procedure. Use nonionic contrast medium for the
procedure.
•
Have emergency equipment readily
available.
•
Instruct the patient to void prior to the
procedure and to change into the gown, robe, and foot coverings provided.
•
Instruct the patient to cooperate fully
and to follow directions. Instruct the patient to remain still throughout the
procedure because movement produces unreliable results.
•
Record baseline vital signs, and continue
to monitor throughout the procedure.
•
Establish an IV fluid line for the
injection of emergency drugs and of sedatives.
•
Administer an antianxiety agent, as
ordered, if the patient has claustrophobia. Administer a sedative to a child or
to an uncooperative adult, as ordered.
•
Place electrocardiographic electrodes on
the patient for cardiac monitoring. Establish a baseline rhythm; determine if
the patient has ventricular arrhythmias.
•
Using a pen, mark the site of the
patient’s peripheral pulses before angiography; this allows for quicker and more
consistent assessment of the pulses after the procedure.
•
Place the patient in the supine position
on an exam table. Cleanse the selected area, and cover with a sterile drape.
•
A local anesthetic is injected at the
site, and a small incision is made or a needle inserted under fluoroscopy.
•
Ask the patient to inhale deeply and hold
his or her breath while the x-ray images are taken, and then to exhale after
the images are taken.
•
The contrast medium is injected, and a
rapid series of images is taken
•
Instruct the patient to take slow, deep
breaths if nausea occurs during the procedure.
•
Monitor the patient for complications
related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm).
•
The needle or catheter is removed, and a
pressure dressing is applied over the puncture site at least 15 mint.
•
Observe the needle/catheter insertion site
for bleeding, inflammation, or hematoma formation.
POST-TEST:
•
A report of the results will be sent for
further discuss the results with the patient.
•
Instruct the patient to resume usual diet,
fluids, medications, and activity as directed
•
Monitor vital signs and neurologic status
every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered. Take
temperature every 4 hr for 24 hr. Compare with baseline values.
•
Observe for delayed allergic reactions,
such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations,
nausea, or vomiting.
•
Instruct the patient to immediately report
symptoms such as fast heart rate, difficulty breathing, skin rash, itching, or
decreased urinary output.
•
Assess extremities for signs of ischemia
or absence of distal pulse caused by a catheter-induced thrombus.
•
Instruct the patient in the care and
assessment of the site and to observe for bleeding, hematoma formation, bile leakage,
and inflammation. Any pleuretic pain, persistent right shoulder pain, or
abdominal pain should be reported.
•
Instruct the patient to apply cold
compresses to the puncture site as needed, to reduce discomfort or edema.
•
Instruct the patient to maintain bed rest
for 4 to 6 hr after the procedure or as ordered.
•
oronary arteries, and the right and left
sides of the heart.
Haemodynamic Monitoring
•
The reasons for haemodynamic monitoring
are -
•
To establish a precise health-related
diagnosis;
•
To determine appropriate therapy; and
•
To monitor the response to that therapy.
Central venous pressure (CVP) monitoring
•
Preload in the right ventricle is
generally measured as CVP.
•
Monitoring of central venous pressure by
the insertion of central venous catheter in central vain of body.
•
Central venous catheters are inserted to
facilitate the monitoring of CVP, as well as facilitating the administration of
large amounts of IV fluid or blood; providing long-term access for fluids,
drugs, specimen collection; and/or parenteral feeding.
•
Normal value of CVP is – 0 to +8 mm of Hg
‘OR’ 0 to +10 Cm H2O.
•
A CVP less than 0 may be due to
vasodilatation (increased volume capacitance) or hypovolemia. A CVP in a normal
range but in the face of signs consistent with vasoconstriction may be due to
hypovolemia.
•
A CVP greater than 10 may be due to the
heart's inability to function as a pump or fluid over-load, vasoconstriction
(decreased volume capacitance), pericardial effusion and positive pressure
ventilation.
•
locations can be used for central venous
access
•
The commonest sites in critically ill
patients are –
•
Subclavian Vein Approaches
•
Internal Jugular Vein Approaches
•
Other less common sites are -
•
The antecubital Vein (may be used when the
patient can’t be positioned supine),
•
The femoral vein (associated with high
infection risk),
•
The external jugular vein (the high
incidence of anomalous anatomy).
•
Internal jugular cannulation has a high
success rate for insertion but more complications. Because, there are a number
of key structures adjacent to the vein, including the vagus nerve (located
posteriorly to the internal jugular vein); the sympathetic trunk (located
behind the vagus nerve); and the phrenic nerve (located laterally to the
internal jugular). Damage can also occur to the sympathetic chain, which leads
to Horner’s syndrome (constricted pupil, ptosis, and absence of sweat gland
activity on that side of the face).
•
The subclavian approach is used often,
perhaps because of a reported lower risk of catheter-related bloodstream
infection. There is also a risk of pneumothorax, which rises if the patient is
receiving intermittent positive pressure ventilation (IPPV).
•
Complications of any central venous access
catheters include air embolism, pneumothorax, hydrothorax and haemorrhage.
Pulmonary Artery Pressure (PAP) Monitoring
•
It began in the 1970s, led by Dr’s Swan,
Ganz and colleagues
•
PAP is monitored by using a pulmonary
artery catheter (PAC)
•
Pulmonary artery cauterization facilitates
assessment of -
•
The preload or filling pressure of the left
ventricle through the pulmonary artery wedge (occlusion) pressure.
•
By using a thermodilution PAC - cardiac
output (CO) and other haemodynamic measurements can also be calculated.
•
Complications of PACs,
•
all the complications of central lines
•
additionally associated with -
•
Higher incidence of dysrhythmia
(particularly due to cold bolus injectate, which irritates myocardium),
•
valve damage,
•
pulmonary vascular occlusion,
•
emboli/infarction (reported incidence of
0.1%–5.6%) and,
•
knotting of the catheter (very rarely).
•
PAP monitoring is indicated for adults in
severe hypovolaemic or cardiogenic shock, where there may be diagnostic
uncertainty, or where the patient is unresponsive to initial therapy.
•
The PAP is used to guide administration of
fluid, inotropes and vasopressors.
•
PAP monitoring may also be utilised in
other cases of haemodynamic instability when diagnosis is unclear.
•
It may be helpful when clinicians want to
differentiate hypovolaemic from cardiogenic shock or, in cases of pulmonary
oedema, to differentiate cardiogenic from non-cardiogenic origins.
•
It has been used to guide haemodynamic
support in a number of disease states such as shock, and to assist in assessing
the effects of fluid management therapy.
Pulmonary Capillary Wedge Pressure (PCWP) Monitoring
•
Also known as Pulmonary artery occlusion
pressure (PAOP),
•
Measured by the pulmonary artery catheter
balloon is inflated with 1–1.5 mL air
•
The inflated balloon isolates the distal
measuring lumen from the pulmonary arterial pressures, and measures pressures
in the capillaries of the pulmonary venous system, and indirectly the left
atrial pressure.
•
Complication including all PAC completion
associated with- Risk of air embolism and distal pulmonary vasculature ischemia
and infarction.
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