Cardiovascular Disorder

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UNIT
Nursing Management of Patients with Cardiovascular Disorders

Chapter Chapter Chapter Chapter Chapter Chapter Chapter
37 38 39 40 41 42 43
Nursing Assessment of Patients with Cardiovascular Disorders 1052 Nursing Interpretation of the Electrocardiogram 1074 Diagnostic and Interventional Therapies for Cardiovascular Disorders 1119 Caring for the Patient with Coronary Artery Disorders 1158 Caring for the Patient with Cardiac Inflammatory Disorders 1219 Caring for the Patient with Heart Failure 1278 Caring for the Patient with Peripheral Vascular Disorders 1323
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Nursing Assessment of Patients with Cardiovascular Disorders

Kristine LEcuyer With contributions by: Kathleen Osborn
Outcome-Based Learning Objectives

After studying this chapter, the learner will be able to: 1. Compare and contrast the significance of cardiovascular assessment findings. 2. Evaluate the relationship of current health status and the presence of cardiac risk factors. 3. Describe the relationship of clinical manifestations to data obtained from the review of a patients social history. 4. Describe the essential components of a cardiovascular physical assessment.
NURSES NEED in-depth knowledge and skills in order to assess the cardiovascular status of their patients rapidly. Although the cardiovascular system is complex, its purpose is simple: to deliver oxygen and nutrients to the tissues and cells of the body. An understanding of cardiovascular anatomy and physiology is essential for cardiovascular assessment. Additionally, it is important to gather data about the patients medical history as well as the presenting symptoms, because they can provide clues to cardiac status. The relationship between the existence of risk factors and the patients susceptibility for disease is an important concept this chapter presents. A thorough physical examination, including inspection, palpation, and auscultation, helps to define an individuals ability to carry out the physiological function of the cardiovascular system. Nurses should be able to recognize normal assessment findings and, more importantly, to identify subtle abnormalities or deviations from normal that might indicate worsening of the patients condition. Accuracy in monitoring and reporting of data is essential, and nurses have access to a wide variety of noninvasive and invasive technological devices that assist in cardiovascular monitoring and assessment.
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Anatomy and Physiology of the Cardiovascular System

An in-depth cardiovascular assessment requires knowledge of cardiovascular anatomy and physiology, and an ability to integrate that knowledge into the current condition of each patient. As seen in Figure 371 , the heart is housed directly behind the central section of the thorax referred to as the mediastinum. Two-thirds of the heart lies to the left of the midline. The apex lies just above the diaphragm and the base of the heart lies approximately at the level of the third rib. The exact size of the heart varies among individuals, but on the average it is approximately 5 inches long and about 3 inches wide, resembling the size of a closed fist. The heart is a four-chambered muscular organ composed of two separate pumps, each having one atrium and one ventricle. The upper chambers (atria) of the heart are separated by the interatrial septum, and the ventricles are separated by the interventricular septum. The two atria are located at the base or top of the heart, and the lower chambers are located at the bottom or apex of the heart. The upper chambers are thin walled and re-
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Nursing Assessment of Patients with Cardiovascular Disorders 1053
1 2 3 4
Suprasternal notch Angle of Louis 3rd rib Intercostal space T Diaphragm P A
Av S B (M)
Atrioventricular (AV) valves: Tricuspid Bicuspid (Mitral) Semilunar (SV) valves: Pulmonic Aortic Chordae tendineae Papillary muscle
FIGURE 371
Diagram of heart in chest.
ceive blood as it returns to the heart. The right atrium receives blood from the systemic venous circulation, while the left atrium receives blood from the pulmonary circulation. The lower chambers have thicker walls and pump blood out of the heart. The right ventricle pumps blood into the pulmonary circulation, while the left ventricle pumps blood into the systemic circulation. Although each ventricle pumps the same volume of blood, the left ventricle has a larger, stronger muscle. This increased strength is needed because the left ventricle has to pump blood into the systemic circulation, which has five times greater pressure than the pulmonic circulation. The heart wall is composed of the three layers: 1. The epicardium: the smooth outer serous layer. 2. The myocardium: the middle muscular layer, which is the thickest of the three layers and is responsible for the hearts ability to contract. 3. The endocardium: the inner lining of the heart, which is composed of thin connective tissue. This smooth inner surface and the valves allow blood to flow more easily throughout the heart.
FIGURE 372
Cross section of heart.
Cardiac Valves
There are four valves in the heart (Figure 372 ). The purpose of the valves is to ensure that blood travels in only one direction as it passes through the heart. The valve opens to fill a chamber and then closes when the pressure in the chamber builds, thereby allowing blood to continue to flow in one direction. The atrioventricular (AV) valves are located between the atria and the ventricles (see Figure 372 ). These valves are referred to as the tricuspid valve and the bicuspid or mitral valve. The tricuspid valve lies between the right atrium and the right ventricle and is so named because it has three cusps. The mitral or bicuspid valve has only two cusps and is located between the left atrium and the left ventricle. The cusps of both the mitral and the tricuspid extend into the ventricles where they attach to the chordae tendineae. Chordae tendineae are cords of dense connective tissue that attach to the papillary muscles (see Figure 372 ). The chordae tendineae and the papillary muscle work
together to prevent the valve cusps from fluttering back into the atrium and thereby interrupting forward blood flow. The semilunar valves are the pulmonic and the aortic valves. Each semilunar valve contains moon-shaped cusps (semilunar). The pulmonic valve is located between the right ventricle and the pulmonary artery. The aortic valve is located between the left ventricle and the trunk of the aorta. As blood is filling the ventricular chamber, pressure is rising. The ventricular muscle fibers respond to an increase in blood volume by stretching to allow more fluid into the chamber (Starling law). As pressure in the ventricles increases, the ventricular muscles stretch. When the pressure in the right ventricle is greater than the pressure in the pulmonary system, and likewise, when the pressure in the left ventricle is greater than the pressure in the aorta, the AV valves (tricuspid and mitral) snap together to close as the semilunar valves (pulmonic and aortic) open. The ventricular muscles contract, and blood is ejected through the open pulmonic valve to the pulmonary artery and the pulmonary circuit, and through the open aortic valve to the aorta and the systemic circulation. Surrounding the heart is a two-layered sac referred to as the pericardial sac (Figure 373 , p. 1056). The outer layer, called the parietal pericardium, is in direct contact with the pleura (lung). This layer consists of a tough, nonelastic, fibrous connective tissue and serves to prevent overdistention of the heart. The thin, serous inner layer of the pericardium, called the visceral pericardium, lays directly on the epicardium or outer layer of the heart. There is a small amount of fluid between the heart wall and the pericardial sac (approximately 10 mL). This fluid acts as a lubricant to prevent friction during contractions.
Cardiac Circulatory System

The heart has its own circulatory system allowing for constant nourishment of blood to the cardiac muscle. The hearts circulatory system consists of coronary arteries and veins
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Nursing Management of Patients with Cardiovascular Disorders pulmonary artery and lungs, picks up oxygen, and travels to the left side of the heart. The systemic circulation consists of a network of arteries, capillaries, and veins. Blood leaves the heart, travels through these vessels delivering oxygen and nutrients to the tissues, and then returns to the right side of the heart to pick up more oxygen.
Transverse section of the heart Endocardium Myocardium Epicardium
LA
LV RA
Serous pericardium: Visceral Parietal Cavity of pericardial sac
Physiology of the Cardiovascular System

The right atrium is the central point in the body where unoxygenated blood from the systemic circulation returns. It then travels through the tricuspid valve to the right ventricle, through the pulmonic valve to the pulmonary arteries into the lungs, through the pulmonary alveolar-capillary network into the pulmonary veins, into the left atrium, through the mitral valve into the left ventricle, and finally out the aortic valve to the systemic circulation. Freshly oxygenated blood, traveling through the aortic valve, also enters into the coronary arteries to supply the myocardium with oxygen. Normally the myocardium extracts 75% of the available oxygen from the coronary arteries. This is more than is extracted from any other tissue in the body; the rest of the body extracts about 40%. If oxygen needs are not met from this near maximal extraction, then blood flow must be increased. With a healthy heart, blood flow is increased in two ways. First, the arteries are able to dilate, thereby increasing their capacity, and second, the myocardial muscle increases the force of the contraction, pumping more blood into the arteries. These two mechanisms result in an increase in the cardiac output and blood flow to the myocardium.
RV Lung
FIGURE 373
Layers of heart.
(Figure 374 . The sinuses or openings into the coronary arteries lie at the base of the aorta, just above the aortic valve. As blood leaves the heart with each beat, it travels through the coronary sinus to supply the cardiac muscle. The two main arteries are the right and left coronary arteries. The right coronary artery and its branches normally supply the right atrium and ventricle and a portion of the posterior wall of the left ventricle. The left coronary artery branches into the left anterior descending and the circumflex arteries, both of which feed the left atrium and the massive walls of the left ventricle. The left coronary artery carries 85% of the blood flow to the myocardium. The left anterior descending (LAD) artery feeds the anterior wall of the left ventricle and the interventricular septum. The circumflex artery feeds the lateral and posterior portions of the left ventricle. The pulmonary circulation consists of blood flow between the heart and lungs. Blood leaves the right ventricle, enters the
Cardiac Cycle
The pumping action of the heart consists of contraction and relaxation of the myocardial layer of the heart wall. Each contraction and relaxation is one cardiac cycle. During relaxation or diastole blood flows into the ventricles and the contraction that follows, termed systole, propels blood out of the heart. The heart functions as a unit because both atria contract simultaneously, and then both ventricles contract. When both atria contract the ventricles are filled to capacity, and then the ventricles contract and blood is ejected into both the pulmonary and the systemic circulation. At the time of ventricular contraction, the mitral and tricuspid valves are closed by the pressure from the contraction while the pulmonic and aortic valves are opened. The cardiac cycle represents the actual time sequence between ventricular contraction and ventricular relaxation.
Right coronary artery
Left main coronary artery Circumflex coronary artery Left anterior descending coronary artery
Autonomic Nervous System

The autonomic nervous system is a built-in control center for the body. Its purpose is to regulate functions of the body that are not under conscious control. There are two major divisions: the sympathetic and the parasympathetic nervous systems. Most of the organs of the body are innervated with both systems, although the blood vessels are innervated with only the sympathetic nervous system. The sympathetic nervous system (SNS) prepares the body for activity (flight or fight), whereas the
FIGURE 374
Coronary arteries.
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Nursing Assessment of Patients with Cardiovascular Disorders 1055 date and mode of onset of the symptoms to find out when and how the symptoms first began. For example, has the shortness of breath been a problem for many weeks, or is it a new occurrence? Have the symptoms changed in intensity or duration? Additionally, questions about the exacerbations, or what causes the symptoms to worsen, and alleviating factors are important. Specific Cardiovascular Clinical Manifestations Patients with cardiovascular disease often present to the health care professional with typical or common cardiovascular symptoms. Knowledge of these common symptoms, their usual presentation, and their etiology can help focus and guide the exam process.
1. Nurses should be particularly aware of the following common cardiovascular symptoms: chest pain, palpitations, dyspnea, orthopnea, cough, and nocturia. 2. The most severe symptoms should be assessed in greater depth and reported to the health care provider, if indicated.
parasympathetic nervous system (PSNS) regulates the calmer (rest and digest) functions. Because the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS) innervate the heart, neural impulses are not needed to maintain the cardiac cycle. In other words, the heart will beat in the absence of any nervous system connection. The SNS and the PSNS affect only the speed of the cardiac cycles and the diameter of the coronary arteries. It is said that these nervous systems only finetune the cardiac cycle.
Receptors and Neurotransmitters

The nerve endings of both the SNS and the PSNS secrete neurotransmitters. The SNS has two types of receptors at the nerve endings, the alpha- and the beta-receptors. These nerve endings are called adrenergic. The neurotransmitter for the SNS is norepinephrine, which causes an increase in heart rate and contractile force of the cardiac fibers. The PSNS nerve endings are known as cholinergic, and the neurotransmitter is acetylcholine, which causes the heart rate and blood pressure to go down.
History
A thorough history will help the nurse identify cardiovascular symptoms as well as current or potential problems that may affect cardiovascular function. Information learned from a thorough history and physical exam could help prevent undesirable responses to current therapies and treatment plans. The essential assessment data included in the cardiovascular history are outlined in this section.
Biographic and Demographic Data

Assessment of biographic and demographic data includes information regarding age, race, gender, and ethnicity, which can impact the susceptibility to some cardiovascular disorders. For example, African Americans have a higher incidence of hypertension than Caucasians (American Heart Association, 2005), and premenopausal women have a lower incidence of atherosclerotic coronary artery disease than men (American Heart Association, 2008). Additionally, the presenting symptoms of cardiovascular diseases in women are often atypical, which may either delay diagnosis or make diagnosis more difficult. For example, women more frequently present with shortness of breath.
Chief Complaint
During the assessment process the nurse obtains a complete description of the present illness, paying particular attention to the chief complaint, or the reason the patient is seeking health care. The chief complaint focuses the history-taking process and prioritizes treatment regimens. For example, if the patient is complaining of chest pain, then the history should include information regarding the nature of the pain, associated symptoms, exacerbating and alleviating factors, as well as radiation of the pain and intensity of the pain. It also is important to determine what brings the pain and what relieves it.
Presenting Symptoms
Symptomatology is the review of symptoms the patient is experiencing. A review of symptoms helps define the current functional status of the patient. The nurse needs to ask questions about the
The most life-threatening symptoms should be addressed first. If the patient is complaining of shortness of breath, it needs to be assessed immediately. Airway management and oxygen status must be stabilized before the remainder of the assessment is completed. The management of airway is discussed in Chapters 34, 35, and 36 . Next, the patient is asked about the presence, site, and intensity of pain. The primary cardiovascular concern is pain associated with cardiac muscle ischemia, referred to as angina pectoris. The clinical manifestations of angina vary among patients; therefore, specific questions must be asked during the assessment in order to ascertain the cause of the pain. Pain may be described as indigestion, burning, numbness, tightness, or pressure in the midchest, or as epigastric or substernal pain, which can radiate to the shoulder, neck, arms, jaw, or back. It is essential that the nurse inquires about what brings the pain on and what makes it go away. An in-depth discussion of angina-type chest pain, the assessment data, and treatment is included in Chapter 40 . Patients might deny the presence of chest pain but admit to sensations of chest discomfort; therefore, it is important to allow patients to present their symptoms in their own words prior to analyzing their symptoms. Palpitations are typically described by the patient as sensations of a racing heartbeat, irregular beats, or skipped beats. These sensations may be normal, or they may signify cardiac rhythm disturbances. The presence of dyspnea, or shortness of breath, may indicate an imbalance of arterial oxygen supply and demand. Orthopnea, the presence of dyspnea when the patient lies flat, is frequently a manifestation of cardiac disease. Often the degree of orthopnea is measured by the number of pillows (for example, 2- to 3-pillow orthopnea) necessary for the patient to use to breathe comfortably while sleeping. A cough may suggest pulmonary congestion resulting from fluid accumulation in the lungs due to either cardiac pump failure or fluid overload. If the patient has nocturia, the need to urinate often at night, it may indicate heart failure, although there are other disorders that cause frequent urination, such as an enlarged prostate. During the day as a patient is up and moving, fluid shifts to extremities and extravascular spaces, which serves to decrease fluid workload on a decompensated heart. At night, however, when the patient lies flat, fluid is returned
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to the central intravascular column, thereby increasing the amount of fluid to the kidneys. Patients with heart failure may report paroxysmal nocturnal dyspnea, which is acute dyspnea caused by lung congestion and edema that occurs suddenly at night, usually an hour or two after falling asleep. Edema, or fluid accumulation in the extravascular spaces of the body, may be due to decreases in venous return. Fluid retention is manifested by weight gain, a feeling of being bloated, or clothes or shoes that no longer fit comfortably. Changes in weight should be specifically addressed. Large, sudden weight gains correlate with volume overload. Dizziness, syncope (fainting), or light-headedness may be experienced with sudden changes of position, and all are related to decreased cardiac output, which decreases blood to the brain. Fatigue is a common complaint with cardiovascular patients. Fatigue is due to a decreased supply of oxygen to the tissues. Metabolic demands are higher in chronic cardiovascular conditions; however, due to a lowered cardiac output, demands are not met and the result is fatigue. The fatigue is usually progressive over time, and the patient may report decreased ability to complete usual activities of daily living. Additionally, patients may report a lack of energy or the need for more rest than usual. Medications such as diuretics, betaadrenergic blockers, calcium channel blockers, digoxin, and antihypertensives have long been thought to contribute to fatigue. For example, beta-adrenergic blockers block the response from the beta nerve receptors, which serves to slow down the heart rate and lower the blood pressure. This desired physiological change, which decreases the myocardial oxygen demand, also may cause an undesired side effect of fatigue. Interestingly, clinical trials have not supported the notion that beta-adrenergic blocker therapy is associated with substantial risks of side effects. In a quantitative review of randomized trials that tested beta-adrenergic blockers in myocardial infarction, heart failure, and hypertension, the authors found no significant increased risk of depressive symptoms and only small increased risks of fatigue and sexual dysfunction (Ko et al., 2002). Therefore, the risks of adverse effects (fatigue) should be considered in context with the well-documented benefits of medications such as beta-adrenergic blockers. Problems with the peripheral vascular system are frequently manifested with intermittent claudication. The patient reports pain in the muscles of the lower extremities associated with activity, which may be due to arterial insufficiency. Chapter 43 includes a complete discussion of both venous and arterial peripheral vascular disorders.
Childhood Illnesses and Immunizations

Childhood illnesses, congenital heart diseases, history of murmurs, cyanosis, streptococcal infections, anemia, and rheumatic fever should all be assessed. They can either exacerbate current cardiovascular conditions or contribute to the development of additional cardiovascular problems and disease states. Nurses should question the status of immunizations and make sure they are up-to-date.
Previous Illnesses and Hospitalizations

Heart failure, coronary artery disease (CAD), stroke, heart valve disease, mitral valve prolapse, previous myocardial infarction (MI), peripheral vascular disease (PVD), diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, dysrhythmias, murmurs, endocarditis, psychiatric illnesses, thrombophlebitis, deep vein thrombosis (DVT), and systemic or pulmonary emboli are all important components of or contributors to cardiovascular disease. Their presence, or a history of their presence, and the potential impact on the present health state must be assessed.
Diagnostic/Interventional Cardiac Procedures or Surgeries

Data from previous diagnostic tests, particularly for cardiovascular symptoms, should be obtained. The patient should be asked whether he had any cardiac studies or interventions in the past such as cardiac catheterizations, cardiac ultrasounds, electrocardiograms (ECGs), exercise tolerance tests (stress tests), or myocardial imaging. Previous chest x-rays or ECGs may be helpful to view for baseline data. Past surgeries, treatments, or hospital admissions should be explored. Assess for a history of previous percutaneous transluminal coronary angioplasty (PTCA), atherectomy stent placement, or valvuloplasty. See Chapter 39 for more information on diagnostic and interventional therapies for heart disease.
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Medications
The patients current and past medications should be reviewed. This includes over-the-counter (OTC) and any prescription medications. A medication list with the name and dose of each medication and the patients understanding of its purpose is helpful. The consumption of herbal remedies or dietary supplements should be specifically assessed because some cardiovascular complications have been linked to these substances. Consideration is made of other common medications and their potential side effects on cardiovascular status. Chart 371 outlines common medications and their side effects that affect the cardiovascular system.
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Past Medical History

Past medical history should be reviewed because many past illnesses or disorders of other systems of the body can affect the cardiovascular system directly or indirectly. Additionally, the clinical manifestations of other diseases may mistakenly be attributed to cardiovascular disorders. For example, it is important to determine the presence of respiratory disorders to assess a patients complaint of dyspnea properly, or a history of rheumatic heart disease may have damaged the heart valves. Unit 7 discusses respiratory management, and Chapter 41 discusses rheumatic fever and valve disorders.
Cultural Considerations
Health and well-being of a culturally diverse population can be promoted by incorporating the therapies that patients have traditionally used. The basis for many complementary therapies is to promote harmony, promote health, reduce anxiety, and increase comfort (Snyder & Miska, 2003). During the assessment phase, nurses must be able to gather information on the use of all therapies being used by a patient, including complementary and nontraditional therapies, as discussed in the Complementary and Alternative Therapies box, in order to plan care that is safe and comfortable.
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Nursing Assessment of Patients with Cardiovascular Disorders 1057 disease (CAD) at or under age 55, myocardial infarction, hypertension, stroke, diabetes mellitus, and/or lipid disorders. Collagen vascular diseases such as lupus or scleroderma may be important, because they are linked to the development of cardiac disease or pericarditis. Additionally, a family health history of noncardiac conditions such as asthma, renal disease, and obesity should be noted due to their impact on cardiovascular function.
CHART 371
Medication Anabolic steroids Antihistamines Aspirin Corticosteroids Decongestants
Common Medications and Side Effects That Affect Cardiovascular Status

Side Effect Increased total cholesterol, decreased HDL, hypertrophy Dysrhythmias, syncope Prolonged blood clotting time Sodium and fluid retention Hypertension and arrhythmias Cardiomyopathy Dysrhythmias Thrombophlebitis Dysrhythmias, hypotension Tachycardia, dysrhythmias Tachycardia, arrhythmias Dysrhythmias
Risk Factors
It is necessary to assess for the presence of risk factors to anticipate the likelihood of the development of cardiovascular disorders. Risk factors can be classified as either nonmodifiable or modifiable. Nonmodifiable risk factors are not subject to interventions to decrease their significance yet play an important role in the development of cardiovascular diseases. Nonmodifiable risk factors include such things as age, gender, family history, and race. Modifiable risk factors are those that can be treated with interventions to decrease their impact on the development of the disorder. Modifiable risk factors include cigarette smoking, hypertension (HTN), hypercholesterolemia, physical inactivity, diabetes, stress, and obesity. Chapter 40 includes a complete description of cardiac risk factors. Additionally, recent dental work or infection may put the patient at risk for development of cardiac complications such as endocarditis. Another risk factor associated with cardiovascular disorders is metabolic syndrome, as discussed in the Risk Factors box.
Doxorubicin (Adriamycin) Lithium Oral contraceptives Phenothiazines Recreational or abused drugs Theophylline preparations Tricyclic antidepressants
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Allergies
Certain diagnostic tests to evaluate heart disease use contrast media and medications, so the presence of any allergies, especially to radiographic contrast agents or iodine, should be assessed. Drug interactions or intolerance should also be noted. Information as to the nature of allergic reactions, such as rash, anaphylaxis, or dyspnea, is essential.
Social History
An assessment of social history is important because of the relationship between social history and the development of, acceleration of, and response to cardiovascular diseases. Risk factor assessment and history taking are done simultaneously. While taking a social history, nurses can gain valuable information from the patient about the presence of risk factors. Nurses then
Family History
The link between familial history of cardiovascular disease and the risk for similar events is well established (Williams et al., 2001). Specifically, the patient should be asked whether blood relatives have suffered from any of the following: coronary artery
ER LT A
LEMEN OMP TARY & C NATIV

E TH ERAPIES
Herbal Products
cosamine with chondroitin. The women reported using an average of 3.2 prescribed medicines and 3.8 nonprescribed medicines. The most frequently used nonprescribed medicines taken regularly were multivitamins, calcium, vitamin E, vitamin C, and aspirin. Interestingly, there were no differences in demographic characteristics and health status for users and nonusers of herbal products except that herbal product users were more concerned with memory problems than were nonusers (Yoon & Claydell, 2001). The implications for nurses are that it is important for health care providers to be knowledgeable about the use of herbal products to provide comprehensive health care. In order to make these needed adaptations of care, nurses must be knowledgeable and committed to provide culturally competent care.
ONE OF THE MOST important complementary therapies that should be addressed during assessment is the use of herbal products. There is a known risk of interaction between herbal products and conventional medications. Research Support: A study by Yoon and Claydell (2001) explored the use of herbal products for medicinal purposes and compared differences in demographic characteristics and health status of herbal product users and nonusers among community-dwelling older women. In 1998, a random sample of 86 women aged 65 years and older who lived independently in a north central Florida county was selected. Questionnaires were completed for the 86 subjects. Findings indicated that herbal products had been used by 45% of the sample in the previous 12 months. The average number of herbal products used by the 45% was 2.5. Herbal products were used to prevent health problems (41%), to treat illness (23%), and for both prevention and treatment (36%). The three most commonly used herbal products were ginkgo biloba or ginkgo biloba with other combinations, garlic tablets and cloves, and glu-
References
Yoon, S., & Claydell, H. (2001). Herbal products and conventional medicines used by community-residing older women. Journal of Advanced Nursing, 33(1), 5159.
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Nursing Management of Patients with Cardiovascular Disorders sors should be explored. Stress and tension regardless of their etiology cause vasoconstriction, which increases afterload, oxygen consumption, and release of catecholamines, which in turn can contribute to the development of cardiac symptoms. Another occupational hazard that should be considered is exposure to noxious or harmful substances, and the potential effect of them on the cardiovascular system.
RISK FACTORS Related to Metabolic Syndrome

The metabolic syndrome describes a cluster of risk factors that significantly increases the incidence of an acute cardiac event and other diseases related to plaque buildup in artery walls (e.g., stroke and peripheral vascular disease) and type II diabetes. The metabolic syndrome has become increasingly common in the United States. It is estimated that over 50 million Americans have it (American Heart Association [AHA], 2008a). The Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (ATP III) defines and describes the importance of metabolic syndrome. Individuals having three or more of the following criteria are defined as having the metabolic syndrome (National Institutes of Health, 2001; AHA, 2006): Abdominal obesity: waist circumference > 102 cm in men and > 88 cm in women Hypertriglyceridemia: > 150 mg/dL (1.69 mmol/L) High high-density lipoprotein (HDL) cholesterol: < 40 mg/dL (1.04 mmol/L) in men and < 50 mg/dL (1.29 mmol/L) in women High blood pressure: > 130/85 mmHg High fasting glucose: > 110 mg/dL (>6.1 mmol/L) Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor1 in the blood) Proinflammatory state (e.g., elevated C-reactive protein in the blood). Abdominal obesity, elevated triglycerides, and insulin resistance (a metabolic disorder in which the body is unable to use insulin efficiently) are major features in metabolic syndrome and have a complex relationship. Fat accumulation in the lower body (pearshaped) is subcutaneous, whereas fat accumulation in the abdominal area (apple-shaped) is largely visceral fat. Excess abdominal fat disrupts the normal balance and functioning of several hormones, including lipids and insulin. Abdominal fat and circulating triglycerides both increase with age, and recent studies have confirmed their relationship as major metabolic risk factors (Kahn & Valdez, 2003). Therefore, waist circumference measurement, as a measure of abdominal fat, is a useful tool in physical assessment and is a reliable, inexpensive indicator that helps identify those at risk for lipid accumulation. While assessing risk factors, nurses should be aware that individuals with metabolic syndrome are at a greater risk for developing cardiovascular disease than are individuals without metabolic syndrome (Kahn, Buse, Ferrannini, & Stern, 2005). Other conditions commonly associated with metabolic syndrome include physical inactivity, aging, hormonal imbalance, and genetic predisposition. Metabolic syndrome is discussed in depth in Chapter 40 .
Culture
Nurses should be prepared to care for a diverse group of people, because the numbers of patients from other cultures in the health care system have increased. There is a great deal of variation in cultural consistency of different demographic areas. Beliefs and values related to health, illness, and death, as well as daily habits, nutritional preferences, and health practices, may exist that are culturally important to the patient, but conflict with the health care environment or even the function of the cardiovascular status. Nurses may need to ask questions about upcoming religious celebrations or rituals that might affect dietary patterns or preferences (Smith-Stoner, 2006). For example, the patient should be asked about the salt content in the food, because an increased amount may precipitate an episode of heart failure or high blood pressure. As nurses are caring for more diverse populations, they need to be knowledgeable about the health practices of other cultures and religions.
Environment
Environment and lifestyle issues are also strongly correlated with the risk for cardiovascular disease. Environmental conditions such as living conditions and the presence of any cardiovascular toxins may need to be addressed. It is understood that heart disease develops as a result of complex interactions between genes and the environment in which we live (Bhatnagar, 2006). Environmental risk factors are not limited to the better known risk factors of smoking, poor diet, and lack of exercise, but also include exposure to pollutants and chemicals. Similarly to the response to secondhand smoke, cardiovascular tissues are extremely sensitive to environmental chemicals and pollutants; therefore, environmental exposures should be routinely considered during cardiovascular assessment. Specifically, nurses should assess for exposure to particulate matter, arsenic, or metals. Further research is needed to determine the relationship of environmental chemicals and cardiovascular toxicity (Bhatnagar, 2006).
Habits
Lifestyle habits and dietary habits such as the use of tea, coffee, alcohol, recreational drugs, over-the-counter drugs, and smoking should be discussed and documented. If the patient smokes, the number of pack years of smoking (packs smoked per day multiplied by the years smoked) should be calculated. The patients attitude about smoking and any attempts to stop smoking should be documented. The presence of secondhand smoke also must be assessed. Alcohol use, including type of beverages, amount, frequency, and any change in the reaction to it should be assessed. The use of habit-forming drugs and recreational drugs should be noted.
have an important role in assisting patients to recognize unhealthy habits that require education in order to modify or change to prevent the progression and complications associated with the development of cardiovascular disorders. As nurses develop relationships with patients, they are in a unique position to offer assistance in risk factor analysis and lifestyle modification. The identification of the presence of modifiable risk factors, as well as the patients ability and interest in adopting lifestyle changes, forms a framework for the nursing discharge teaching plan discussed in the subsequent cardiac disorder chapters.
Occupation
Job stress is a common condition that promotes the occurrence of cardiovascular events. Previous and recent job-related stres-
Exercise
The practice of engaging in physical activity has long been known to reduce the risk of cardiovascular events. Low levels of physical activity as well as consumption of excess calories, combined with inherited genes, cause obesity. Obesity, especially ab-
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dominal obesity, is a predisposing factor for the development of cardiovascular disease as well as hypertension and type II diabetes mellitus. The physical activity patterns of a patient, including the type of exercise, the duration and frequency of the exercise, and the presence of any cardiovascular symptoms, should be documented. Any decrease in previous abilities or changes in the response to physical activity should be noted, because they may be indications of the advent or progression of heart disease. In 1996 with revisions in 1999, the Surgeon General of the United States Public Health Service published a report on physical activity and health. This report contains a comprehensive review of scientific evidence about the relationship between physical activity and health status in an attempt to heighten Americas awareness of this important public health issue. The report makes it clear that current levels of physical activity among Americans remain low; however, the emphasis is that people can benefit from even moderate levels of physical activity, and that even greater health benefits can be achieved by increasing the amount (duration, frequency, or intensity) of physical activity (Centers for Disease Control and Prevention [CDC], 2008). The report suggests that adults should strive to meet either of the following physical activity recommendations. Adults should engage in moderate-intensity physical activities for at least 30 minutes on 5 or more days of the week (Centers for Disease Control and Prevention, 1999). OR Adults should engage in vigorous-intensity physical activity 3 or more days per week for 20 or more minutes per occasion (U.S. Department of Health and Human Services [DHHS], 2004).
NATIONAL GUIDELINES for Diet American Heart Association 2006 Diet and Lifestyle Recommendations
Achieve an Overall Healthy Eating Pattern Choose an overall balanced diet with foods from all major food groups, emphasizing fruits, vegetables, and grains. Consume a variety of fruits, vegetables, and grain products. Eat at least 5 daily servings of fruits and vegetables. Eat at least 6 daily servings of grain products, including whole grains. Include fat-free and low-fat dairy products, fish, legumes, poultry, and lean meats. Eat at least 2 servings of fish per week. Achieve a Healthy Body Weight Maintain a level of physical activity that achieves fitness and balances energy expenditure with caloric intake; for weight reduction, expenditure should exceed intake. Limit foods that are high in calories and/or low in nutritional quality, including those with a high amount of added sugar. Achieve a Desirable Cholesterol Level Limit foods with a high content of saturated fat and cholesterol. Substitute with grains and unsaturated fat from vegetables, fish, legumes, and nuts. Limit cholesterol to 300 milligrams (mg) a day for the general population and 200 milligrams a day for those with heart disease or its risk factors. Limit trans fatty acids. Trans fatty acids are found in foods containing partially hydrogenated vegetable oils such as packaged cookies, crackers, and other baked goods; commercially prepared fried foods; and some margarines. Achieve a Desirable Blood Pressure Level Limit salt intake to less than 6 grams (2,400 milligrams sodium) per day, slightly more than 1 teaspoon a day. If you drink, limit alcohol consumption to no more than one drink per day for women and two drinks per day for men.
Source: American Heart Association. (2006). Dietary guidelines: At-a-glance. Retrieved January 21, 2008, from http://www.americanheart.org/presenter.jhtml?identifier=851.
Nutrition
It is important to assess the patients weight and diet history. An assessment of weight in comparison to height and build must be completed. Being overweight or underweight either may be related to certain cardiovascular disorders or may put the patient at risk for developing certain cardiac problems. Usual dietary intake including amounts of salt, saturated fats, triglycerides, and fluids should be determined. It may be important to identify which dietary habits are related to cultural preferences and which habits are the results of the environment or social situations. For example, an executive may consume many meals at restaurants while out with clients, and a construction worker might eat many meals at fast-food restaurants. In addition, the patients attitudes and plans in relation to diet should be discussed. Food intake patterns should be accountable to exercise patterns and should be complementary. The National Guidelines box outlines the dietary guidelines for Americans released by the American Heart Association in 2000. Choosing healthy foods can help to prevent the three major risk factors for heart attackhigh blood cholesterol, high blood pressure, and excess body weight. Because heart disease and high blood pressure are major risk factors for stroke, these dietary guidelines also help prevent stroke (American Heart Association, 2006).
Personal Factors
Baseline cognitive functioning, recent life changes especially within the last 12 months, sleep-rest patterns, and relationship
issues should all be considered. Emotional state, such as the evidence of psychological stress, anger, anxiety, or depression, causes the release of catecholamines, which results in vasoconstriction, thereby increasing cardiac workload and potentially resulting in a decreased cardiac output. Perception of illness and its meaning for the future should also be noted. Personality type may also be a consideration for cardiovascular assessment. Type A personality behavior has been associated with increased incidence of cardiovascular disease. Researchers have found conflicting evidence to support or refute this notion. Gallacher, Sweetman, Yarnell, Elwood, and Stansfeld (2003) suggest that increased exposure to circumstances that induce extreme cardiovascular activity, as seen in type A personality behavior, may be a trigger that precipitates coronary events rather than affecting the process of atherosclerosis. The role of stress and the manner in which an individual deals with life stressors may also have an important role. Individuals with type
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Nursing Management of Patients with Cardiovascular Disorders signs of peripheral arterial or venous vascular disorders. Arterial vascular disease is suspected when the skin is pale, shiny, with sparse hair growth. Venous vascular diseases cause an edematous limb with deep red rubor, brown discoloration, and leg ulcerations (Urden, Lough, & Stacy, 2006). Chapter 43 includes an in-depth description of peripheral vascular disease.
A personality may respond to stress with hostility or aggression, which may exaggerate sympathetic and hemodynamic responses leading to greater cardiovascular reactivity (Schroeder et al., 2000).
Physical Examination
A thorough physical examination is the foundation for accurate assessment of the cardiovascular system and encompasses skills of inspection, palpation, and auscultation. Percussion is not utilized for assessment of the cardiovascular system.
Inspection of Skin and Extremities

A great deal of information can be obtained about the status of the cardiovascular system by simply observing and touching the patient. An experienced nurse is able to assess general appearance quickly, including facial expressions, body posture and mentation, as well as color and temperature, and clubbing of the nail beds. Then it is necessary to relate the findings to the patients current cardiovascular status.
General Appearance
General appearance includes a brief visual inspection of a patients physical appearance. Observations of a patient who looks unwell, lethargic, exhausted, or breathless are important findings and may indicate reduced cardiac output or heart failure. An obese person who has fat evenly distributed over the body is vulnerable for serious cardiovascular health consequences. Additionally, an accumulation of abdominal (visceral) fat, measured by waist circumference, is a known risk factor for cardiovascular and other diseases. Interestingly, recent studies suggest that variances in fat distributions (abdominal vs. peripheral) may exhibit different influences on lipid metabolism. Laszlo et al. (2004) studied 1,356 women aged 60 to 85 years and found that abdominal fat mass promoted atherogenesis, whereas peripheral fat deposits actually counteracted atherogenesis. The women with peripheral fat deposits rather than central fat deposits showed a negative correlation with glucose and lipid metabolites. The authors concluded that the localization or distribution of the fat mass is an important consideration in obese patients and should be considered during any risk appraisal. Observation of facial expression may indicate important findings, such as the assessment of apprehension, pain, or fear. Body posture may indicate the amount of effort it takes to breathe. For example, a patient in acute heart failure may need to sit upright, whereas a patient with pericarditis may lean forward in order to breathe comfortably (Urden, Lough, & Stacy, 2006). Mentation Adequate functioning of all subsystems of the body indicates the individual organ is receiving adequate cardiac output. For example, normal neurological function indicates adequate cerebral perfusion. A quick and easy method to estimate baseline cognitive function is to assess the patients orientation to person, place and time, and situation. Confusion could indicate hypotension or low cardiac output.
Cyanosis Cyanosis is a bluish tinge to the skin due to deoxygenated hemoglobin in the blood vessels close to the skin surface; it can be either central or peripheral. Central cyanosis, which is noted on the lips or tongue, is often characteristic of impaired gas exchange. Central cyanosis may result from a cardiac right-to-left shunt due to septal defects, in which deoxygenated venous blood mixes with blood from the left heart and is ejected into the systemic circulation. In heart failure with significant pulmonary congestion, oxygenation of blood in the pulmonary vascular bed can be impaired, which leads to deoxygenated blood returning to the left heart and being pumped out into the systemic circulation. Peripheral cyanosis, which occurs in the extremities or under the nail beds, may indicate poor circulation. The room where the examination is taking place must have a comfortable temperature because nail beds can become cyanotic with cold temperatures. Pallor Pallor suggests poor perfusion, which may be related to peripheral vascular disease (a narrowing in the blood vessels outside the heart); a release of catecholamines and subsequent vasoconstriction; or a low hemoglobin and hematocrit. All of these conditions should be thoroughly assessed. Additionally, temperature changes such as generalized warmth or coolness may indicate altered peripheral perfusion. Nail Beds Clubbing of nail beds is easily assessed and appears as swelling of the subcutaneous tissue over the base of the nail and absence of the normal angle between the nail and the nail base. The presence of clubbing indicates long-term oxygen deficiencies such as congenital heart defects or pulmonary diseases with hypoxemia.
Neck Veins
The right external and internal jugular veins (Figure 375 ) are used to assess for jugular venous distention (JVD) and jugular venous pressure (JVP) or pulse. Although these terms are often used interchangeably, there is a physiological significance in distinguishing between JVD and JVP. Anatomically, the right jugular veins drain blood from the head into the right atrium of the heart. Both veins reflect activity on the right side of the heart. The internal jugular vein lies in a straight path to the right atrium, but because it is buried beneath the sternomastoid muscle, it is difficult to visualize. The external jugular vein curves a few times before entering the right atrium, and because it is located closer to the skin it is easier to visualize. Findings from neck vein assessment are helpful in confirming suspicions of heart failure; however, the information must be put in context of the presenting symptoms and current health status. The importance of volume status and cardiovascular function is an important hemodynamic concept. Chapter 42 includes an in-depth discussion of the significance of distended neck veins with heart failure.
Color and Appearance of Skin and Extremities

The skin and mucous membranes are inspected for color and temperature. Extremities should be assessed bilaterally for equal temperature and appearance. The extremities are inspected for
8 8
CHAPTER 37
Nursing Assessment of Patients with Cardiovascular Disorders 1061 column of blood in the internal jugular vein. Observe the highest point of pulsation during exhalation. The vertical difference between this location and the sternal angle (see Figure 375 ) is measured in centimeters. The normal measurement should be 4 centimeters or less. A measurement of more than 4 centimeters suggests increased JVP, an increase in pressure in the right heart, and therefore an increased CVP. Because the distance between the sternal angle and the mid-right atrium is approximately 5 centimeters, to measure CVP, 5 centimeters is added to the measurement of JVP. The upper limit of normal is a CVP measurement of 9 centimeters (JVP of 4 plus 5 centimeters) (Garg & Garg, 2000). An example of how this finding is reported is JVP estimated at 9 centimeters with the head of the bed elevated to 45 degrees. Abdominojugular Reflux The assessment of the abdominojugular reflux (sometimes called hepatojugular reflux) can also be used as a noninvasive technique to assess cardiovascular volume status. In heart failure, or volume overload, blood volume that normally is pumped proficiently by the heart begins to be displaced throughout the body as a mechanism to minimize cardiac workload. Volume may be displaced in the abdomen, particularly the hepatic system, which has a large capacity to hold fluid. The technique to observe abdominojugular reflux is done by compressing the right upper abdomen for 15 to 30 seconds. Observe for JVD before, during, and after abdominal compression. This pressure causes volume in the abdomen to be pushed back to the right atrium. The failing heart will not be able to accommodate this increase in volume, and the pressure will be reflected in the jugular veins. Sustained JVD (longer than 10 seconds) with abdominal compression is another indicator that aids the diagnosis of cardiac failure (Urden et al., 2006).
Venous pressure
External jugular vein Internal jugular vein
Sternal angle
30
FIGURE 375
Jugular veins.
Jugular Venous Distention Jugular venous distention (JVD) is assessed by visually observing the right external jugular (REJ) vein. Generally noting that this vein is full or overdistended is sufficient for the nursing assessment and provides useful information pertaining to hemodynamic volume status of the cardiovascular system. The REJ vein is always distended when the patient is lying flat and is eliminated as the patient becomes more upright. From a flat position, slowly elevate the head of the bed and observe the right external jugular vein, noting the degree of elevation at which the distention is eliminated (30, 45, 60, or 90 degrees). The finding is reported by noting the highest height of the head of the bed (HOB) when JVD was appreciated; for example, presence of JVD was noted with HOB elevated to 45 degrees (Urden et al., 2006).
The finding of JVD during inspection of the neck veins can contribute to diagnosis of right heart failure. Treatment to reduce volume, such as diuretics or vasodilators, may be needed. The finding of JVD may also help to explain other findings noted during the exam, such as shortness of breath (SOB), diaphoresis, or confusion.
Palpation of Skin and Extremities

Palpation of the skin and extremities during a cardiovascular assessment includes an assessment of edema, skin turgor, capillary refill, and the arterial pulses for abnormalities associated with cardiovascular disorders.
Edema
Edema is defined as an increase in interstitial fluid that is clinically evident. Although there are many types of edema, cardiovascular patients typically experience edema associated with the accumulation of fluid in the extracellular spaces, particularly the skin of the extremities, as seen earlier. Edema of the skin can be painful, and it interferes with normal blood circulation. Edema is an important assessment finding because it is indicative of an underlying disease process and requires treatment. Normally two-thirds of the bodys water is in the cells (intracellular), while one-third is outside the cells (extracellular). Extracellular fluid consists of water in the plasma and in the tissues (interstitial). Fluid exchange between these compartments is governed by a balance of hydraulic and oncotic pressures as well as the permeability of the capillary wall that separates them. When any of the factors are altered, excess fluid may be moved into the plasma and interstitial spaces. Changes in capillary hydraulic pressure can occur with heart failure. Capillary permeability can be increased as a consequence of the inflammatory process, which can be initiated as a response to numerous events
Jugular Venous Pressure The right internal jugular (RIJ) vein is used to assess jugular venous pulses and jugular venous pressure. The RIJ lies deep in skin and soft tissues, and its pulsations are transmitted to the overlying tissues. These pulsations are produced by the right atrial and right ventricular activity (Garg & Garg, 2000). Changes in pulsations can be a diagnostic tool for the skilled practitioner. Assessment of RIJ for jugular venous pressure (JVP) provides valuable information as well; and it is a more reliable indicator of central venous pressure (CVP), or the pressure that exists in the central venous system, than is the right external vein assessment. To examine the JVP, stand on the patients right side, and turn the patients head slightly to the left. The neck muscles should be relaxed. The head of the bed should be elevated high enough to visualize the top of the
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Systemic Circulation
including exposure to allergens. The kidneys play an important role in body fluid distribution as the kidneys respond to changes in blood pressure and volume by adjusting retention of sodium. Therefore, sodium balance is of utmost importance in cardiovascular disease processes involving the development or potential development of edema. The skin can feel puffy and tight. Edema can be localized in one area of the body or can be generalized throughout. Dependent edema occurs when there is an increase in extracellular fluid volume in a dependent limb or area. Edema is assessed by firmly placing a thumb against a dependent area of the body (arms, hands, legs, feet, ankles). When the pressure is released, an indentation on the skin may be observed. When the indentation remains on the skin after releasing pressure, it is referred to as pitting edema. The degree of pitting edema can be rated on a 4-point scale (Chart 372).
Arteries Apical
Radial
Skin Turgor
Palpation of the skin turgor, or elasticity, reflects the skins state of hydration. A small section of the patients skin (anterior chest, under clavicle, or abdomen) is pinched between the examiners thumb and forefinger. As the skin is slowly released, the speed at which the skin returns to its original contour is observed. It should return to normal rapidly. If there is poor skin turgor, the skin returns to its original contour very slowly. Dehydration, scleroderma, or aging can decrease skin turgor.
Pedal Posterior tibal
FIGURE 376
Arterial pulses.
Capillary Refill
Capillary refill, the rate at which blood refills empty capillaries, is a quick method of assessing blood flow to the peripheral microcirculation. The tip of the finger is compressed until blanching of the nail bed is noted. When pressure is released, a return of color should be noted within 2 to 3 seconds. A delayed return of color is a sign of vasoconstriction or poor peripheral perfusion. A delayed capillary refill may be observed in heart failure, peripheral vascular disease (PVD), or shock. pulse feels like a tap, whereas a vessel that is narrowed or bulging will vibrate. The rate and rhythm of arterial pulses are palpated. The examiner counts the number of pulsations in a minute to determine the heart rate. At the same time, a judgment is made as to the regularity of the pattern of pulses and the intervals between pulses. Pulses can be normal or abnormal. Abnormalities in rate and rhythm of arterial pulses may indicate inadequate cardiac output or cardiac dysrhythmias.
Arterial Pulses
Palpation of the pulses in the neck and extremities provides information about arterial blood flow, particularly volume and pressure within the vessels. Arterial pulses are palpated bilaterally to compare characteristics of the arteries on the right and left sides of the body (Figure 376 ). The volume of the pulsations is judged and recorded as normal, bounding, thready, or absent. Additionally, a common scale can be used for documentation of pulses. A score of 0 indicates an absent pulse. A score of 1+ indicates a pulse is present, but it is weak and thready. A score of 2+ indicates a pulse is present and normal in amplitude. A score of 3+ indicates a full and bounding pulsation. A normal
Inspection and Palpation of the Precordium

Inspection and palpation of the bony structures of the thorax, including the sternoclavicular joints, the manubrium, and the upper part of the sternum, are performed using clinical reference points. The precordium is assessed for pulsations, heaves, and thrills described below, which may indicate vessel abnormalities.
Clinical Reference Points

The normal clinical reference points or landmarks of the chest wall, as well as specific auscultatory areas, should be noted on every patient during cardiovascular assessment in a consistent manner. Experience enhances the ability to identify abnormalities and their significance to cardiovascular disorders (Figures 377 and 378).
CHART 372
0 1 2 3 4 No pitting 0
1 1 1
Scale for Rating Edema
Point of Maximal Impulse (PMI)

The mitral valve area of the thorax is palpated for the point of maximal impulse (PMI). This pulsation is normally located at the left fifth intercostal space (ICS) at the midclavicular line (MCL) (see Figure 377 ). With the patient in a sitting position, the nurse uses fingertips to identify the PMI. Sometimes having the patient lean slightly forward enhances the PMI. The
/4 pitting (mild)
1
/4 /2
/2 pitting (moderate)
1 pitting (severe)
Greater than 1 pitting (severe)
CHAPTER 37
Nursing Assessment of Patients with Cardiovascular Disorders 1063 tory sensation from turbulent blood flow across cardiac valves. Thrills are typically described as the throat of a purring cat. Findings in various clinical reference points may indicate specific cardiac disorders. The respiratory system is observed simultaneously, because the purpose of the cardiovascular system is to deliver oxygen to the tissues that was received from the respiratory system. Alterations in rate and depth of respirations may indicate cardiovascular, respiratory, or neurological disorders.
Right sternal border (RSB), 2nd intercostal space (ICS) Left sternal border (LSB), 2nd ICS LSB, 3rd ICS LSB, 4th ICS
2 3 4 5 6 7
Auscultation of the Precordium

Auscultation involves listening to the sounds produced by different body areas. Cardiac auscultation is an efficient, noninvasive manner to assess both normal and abnormal heart sounds. Although the technique is simply performed with only a stethoscope, a great deal of practice and expertise is required to appreciate and differentiate cardiac abnormalities associated with valvular alterations. The art of auscultation includes the ability to discriminate subtle differences in intensity, pitch, location, radiation, duration, timing, and intervals of heart sounds (OConnor, 1998). Generally, nurses should be able to perform the technique proficiently, be able to recognize normal auscultatory sounds, and most importantly be alert to variations from normal that can provide valuable clinical clues and may indicate a change or deterioration in cardiac status. The skill of auscultation begins with good technique and a quiet environment. The stethoscope should be of good quality with a bell, a diaphragm, and comfortable earpieces. The stethoscope must be applied directly to the skin; listening over clothing will obscure the sound. The patient should be in a comfortable position and asked to lie still and not talk. Imagine the position of the heart and the cardiac valves under the chest wall (see Figure 378 ). Find the angle of Louis, felt as a ridge just below the suprasternal notch (see Figure 375 ). Feel the ribs on each side of this angle and the intercostal space below each rib. Using the bell and the diaphragm of the stethoscope, listen to heart sounds at each auscultatory area (see Figure 378 ), first with the diaphragm for high-pitched sounds and then with the bell with very light pressure for low-pitched
Midclavicular line (MCL), 5th ICS Point of maximal impulse
2 3 4 5 6
FIGURE 377
Clinical reference points for palpation.
PMI is normally felt as a single pulsation or light tap, and is 1 to 2 centimeters in diameter. The position and the diameter of the PMI should be recorded in relation to the MCL and ICSs. If the patient has an enlarged heart (cardiomegaly) due to heart failure, ventricular hypertrophy, or pregnancy, the PMI may be enlarged or displaced laterally and downward. The PMI may also be visualized as a pulsation on the chest in a patient with cardiovascular disease.
2 3 4 5
Heaves and Thrills

The precordium is inspected for pulsations, heaves, and thrills. Although rare, pulsations may be visualized on the chest wall, particularly in thin patients, and may be caused by pulmonary hypertension or a significant aneurysm. Heaves or lifts, which are normally not seen or felt over the precordium, are sustained lifts of the chest wall in the precordial area due to forceful cardiac contractions that cause a slight to vigorous movement of the sternum and ribs. Heaves may be caused by ventricular enlargement or hypertrophy. A thrill describes a palpable vibra-
FIGURE 378
Auscultatory areas.
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Nursing Management of Patients with Cardiovascular Disorders area. The nurse should be in the habit of listening to all the auscultatory areas with the diaphragm and then again with the bell.
sounds at each auscultatory site. Listen for the normal S1 and S2 heart sounds at each site, and note the intensity, the presence of split sounds, and the effect of the respiratory cycle on the regularity of the sounds. Also note the time between the S1 and S2 for regularity. Listen for extra heart sounds and abnormal heart sounds at each site. If abnormal sounds are heard, note the timing, pitch, loudness, duration, and location on the chest wall. If a murmur is heard, note where it can be heard best and whether it is a low-, medium-, or high-pitched sound. The presence of any pericardial friction rubs should also be noted.
Normal Heart Sounds: S1 and S2

Normal heart sounds are created by the turbulence of blood flow as the cardiac valves open and close during the cardiac cycle. As the valves move, some turbulence in blood flow is created. (See the Cardiac Valves section at the beginning of the chapter.) Two heart sounds can be heard with each cardiac cycle. The first heart sound is referred to as S1 and the second heart sound, S2. S1 is a called a systolic sound because it signals the beginning of systole. When the pressures in the pulmonary artery and the right ventricle begin to equalize, and the pressures in the aorta and the left ventricle begin to equalize, systolic ejection tapers off and the semilunar valves snap shut. This signals the beginning of diastole, which allows the AV valves to open and diastolic ventricular filling to begin. The closing of the AV valves is heard as the S2, or second heart sound (Chart 373, p. 1067). The S1 and the S2 are both high-pitched sounds heard best with the diaphragm. The S1 is normally loudest over the apex or mitral area, while the S2 is best heard over the base of the heart, or the aortic area. Distinguishing S1 from S2 It is helpful during auscultation to differentiate the S1 from the S2. When there is an abnormality, it must be described as a sys-
Requirements for Auscultation

In order to understand cardiac auscultation, nurses need to have knowledge of the physiology of the cardiac cycle, the normal landmarks of the chest (see Figure 377 , p. 1065), and the auscultatory sites on the chest wall that correspond to specific valve sounds (see Figure 378 , p. 1065). When listening to dynamic blood flow across cardiac valves, the sounds associated with the closure of the valves are not heard directly over that valve area, but rather in the direction of the flow of blood. It is helpful to imagine the physical position of the heart under the chest wall, as well as the path or direction of blood flow (Figure 379 ). Because sound is not transmitted through bone, the best auscultatory area of a particular valve would be the nearest tissue area in line with the path of blood flow. The key to a good auscultatory exam is to listen to one sound at a time in each auscultatory
Cardiac blood flow paths Systemic venous circulation
Pulmonary circulation
Pulmonary circulation
Right atrium
Left atrium Right ventricle
Left ventricle
Systemic venous circulation Systemic atrial circulation
Interventricular septum
FIGURE 379
Cardiac blood flow path.
CHAPTER 37
CHART 373
Heart Sounds
S1 S2
Summary of Heart Sounds

Cardiac Cycle Timing S1 Start of systole Ausculation Site Best at apex with diaphragm Position Position does not affect the sound Pitch High
LUB S1
dub S2
S2
End of systole
Both at 2nd intercostal space (ICS); pulmonary component best at left sternal border (LSB); aortic component best at RBS with diaphragm
Sitting or supine
High
lub S1
DUB S2
Split S1
Beginning of systole
If normal, at 2nd ICS, LSB abnormal if heard at apex
Better heard in the supine position
High
T S1 S2
Fixed Split S2
End of systole
Both at 2nd ICS: pulmonary component best at LSB; aortic component best at right sternal border (RSB) with diaphragm
High
S1
S2
Paradoxial Split S2
End of systole
Both at 2nd ICS; pulmonary component best at LSB; aortic component best at RSB with diaphragm
High
P2 A2
Expiration
S1 S2
Wide Split S2
End of systole
Both at 2nd ICS; pulmonary component best at LSB; aortic component best at RSB with diaphragm
High
Inspiration
S1 S2
S1
S2 S3
S3
Early diastole right after S2
Apex with the bell
Auscultated better in left lateral position or supine
Low
S1 S4
S2
S4
Late diastole right before S1
Apex with the bell
Auscultated better in left lateral position or supine
Low
tolic sound (occurring with or after the S1) or a diastolic sound (occurring with or after the S2). By determining where in the cardiac cycle the abnormality occurs, the listener can better estimate which cardiac valve is affected. For example, if the nurse
hears an abnormality of the S1 sound, she would know there is an alteration in either the mitral or the tricuspid valve. The S1 and the S2 sounds can be differentiated by three methods. The first is timing. During the cardiac cycle, the amount of time
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Nursing Management of Patients with Cardiovascular Disorders sounds like lub-dub-dee or Ken-tuc-ky. S3s are heard early in diastole because they are associated with abnormalities of ventricular filling, and they are sometimes called ventricular gallops. S3s are markers of systolic dysfunction. When there is ventricular systolic dysfunction, the ventricle is not able to empty sufficiently with each systolic contraction. During each consecutive diastolic filling period, turbulence occurs as the new load of blood attempts to enter when the previous load of blood has not completely left the ventricle. An S3 heard over the left ventricle in children and young adults is normal, although after ages 35 to 40, the presence of a third heart sound is usually abnormal and may indicate systolic dysfunction. An S3 and the presence of increased JVD are regarded as specific signs of heart failure. The presence of an S3 in an older person may be the only clue to abnormal left ventricular function (OConnor, 1998). S4 S4 occurs late in diastole just before the S1 and is heard best in the apex (Figure 3710 ). One cardiac cycle (S4, S1, S2) sounds like dee-lub-dub or Ten-nes-see. S4s are heard late in diastole because they are associated with the atrial kick component of diastole, and they are sometimes called atrial gallops. S4s are markers of diastolic dysfunction. An S4 occurs when the atria attempt to pump blood into a stiff, noncompliant ventricle that is resistant to further volume expansion. Diastolic dysfunction may occur with ventricular hypertrophy associated with hypertension, with aortic stenosis, or with altered ventricular compliance associated with ischemia. Normal fourth heart sounds are common in older adults and are associated with an age-related decrease in left ventricular compliance (OConnor, 1998). A fourth heart sound is almost always abnormal in children and may contribute to a decrease in ventricular compliance. An S4 cannot be heard during atrial fibrillation, because S4s are associated with atrial contraction against a noncompliant ventricle. Summation Gallop Summation gallops occur when both an S3 and an S4 are heard (S4, S1, S2, S3) (see Figure 3710 ); in other words, there is a combined ventricular and atrial gallop. A summation gallop is associated with advanced heart failure. The S3 and S4 may be heard as two distinct sounds in diastole or, in the case of tachycardia, as a single mid-diastolic sound. Summation gallops are sometimes described as galloping hooves. Pericardial Friction Rubs Pericardial friction rubs are due to inflammation of the pericardial sac surrounding the heart in conditions such as pericarditis. Pericarditis is described in detail in Chapter 41 . Pericardial friction rubs are a transient high-pitched sound heard best at the left sternal border. The sound that is produced is a squeaky, rubbing, muffled sound. Pericardial friction rubs are heard best with the patient leaning forward or lying on the left side. Pericardial friction rubs may be a transient assessment finding.
spent in diastole is longer than the amount of time spent in systole. Therefore, there should be a pause between the S2 and the next S1 (see Figure 3710 ). Of course this method is accurate only when the heart rate is slow enough to appreciate the diastolic pause. If, however, the heart rate is accelerated, the S1 can be identified by palpating either the PMI (point of maximal impulse) or the carotid arterial pulsation. As the practitioner is listening with the stethoscope on the chest wall to the heart sound, she should be palpating these pulsation points. When the pulsation is felt, the S1 is heard. Pulse points, further downstream, such as the radial artery should not be used to establish correlation, because they are too far away from the heart and are not likely to correspond with the S1.
Split Heart Sounds: Split S1 and Split S2

Because the right and left heart are two separate pumps that function simultaneously, it is normal to hear the closure of two valves, the right and left AV valves, and the right and left semilunar valves, as one sound. Many conditions can alter the timing of the cardiac cycle on the right or left side of the heart causing one valve to close slightly later than normal. When this happens, the sounds of S1 (closure of the tricuspid and mitral valves) or the sounds of S2 (closure of the pulmonic and aortic valves) are heard separately, referred to as a split heart sound. The S1 is normally heard as a single sound, although there might be a slight split between the mitral component (M1) and the tricuspid component (T1) of the S1. The S2 exhibits a normal split on inspiration. This is called a physiological split, because it is associated with a normal physiological pattern. This physiological split S2, heard best over the pulmonic area, is a result of asymmetry with the closure of the aortic (A2) and pulmonic (P2) valve sounds that make up the S2 (A2P2). On inspiration, there is an increase in intrathoracic pressure that causes an increase in venous return to the right heart. The increased volume causes a delay in ventricular emptying, and thus the pulmonic valve closure (P2) is slightly delayed. This effect is removed, however, during expiration; the A2 and P2 should be closer in synchrony, and the two components of the second heart sound are heard as one. Numerous other conditions, such as ventricular septal defects (VSDs), bundle branch blocks, and ventricular failure, can cause abnormal splitting of the S2.
Extra Heart Sounds

Extra heart sounds are classified in relation to their timing in the cardiac cycle. Although the presence of an S3 or S4 can be normal, these extra heart sounds often signify cardiac disorders. Therefore, nurses should be knowledgeable about these sounds, as well as their significance in relation to heart disease, in order to detect and report their presence. Third and fourth heart sounds, if present, are both heard during diastole. S3 and S4 are low-frequency soft sounds, which are best heard by applying the stethoscope softly on the skin or just firmly enough to create a skin seal. It is easier to detect the S3 or the S4 by positioning the patient in the left lateral position, which brings the heart closer to the heart wall. S3s and S4s are not affected by respirations and are heard as single sounds. S3 S3 is heard early in diastole just after the S2 and is heard best in the apex (see Figure 3710 ). One cardiac cycle (S1, S2, S3,
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Abnormal Heart Sounds: Murmurs

Murmurs are audible vibrations heard over the heart and great vessels. Murmurs are caused by turbulent blood flow across a diseased valve (stenosis or regurgitation), turbulence caused by increased blood flow through normal structures, or blood flow into a dilated chamber (Chart 374). Whereas murmurs are aus-
CHAPTER 37
Nursing Assessment of Patients with Cardiovascular Disorders 1067 would be best heard at the corresponding valves auscultatory site (Chart 375). When a murmur is auscultated, the etiology can be suggested by understanding the physiology of the cardiac cycle and heart sounds. For example, during systole the aortic valve is open, allowing blood to flow from the left ventricle through the aortic valve to the aorta, and the mitral valve is closed, preventing blood from flowing back into the left atrium. If the aortic valve were stenotic, the sound would be a harsh murmur during systole over the aortic valve area. Likewise, if the mitral valve were regurgitant, one would typically hear a gurgling sound over the mitral valve area. During the assessment the nurse should evaluate for head bobbing up and down in synchrony with the heartbeat, because this is characteristic of severe aortic regurgitation (DAmico & Barbarito, 2007). Systolic murmurs, heard during systole, include mitral regurgitation, tricuspid regurgitation, aortic stenosis, and pulmonic stenosis. Diastolic murmurs, heard during diastole, include mitral stenosis, tricuspid stenosis, aortic regurgitation, and pulmonic regurgitation. Innocent Murmurs Some murmurs may be classified as innocent or functional murmurs. An innocent murmur is a sound made by the blood circulating in the heart chambers or valves, or through the blood vessels near the heart. Innocent murmurs are often soft and may vary or disappear with position changes, whereas pathologic murmurs are generally louder and seldom disappear with position changes. Innocent murmurs are harmless, asymptomatic, and are commonly heard in children. Further diagnostic tests may be performed to rule out other conditions. When a murmur is heard, it is important to describe the sound properly. Murmurs should be described in terms of their timing in the cardiac cycle, the auscultatory location they are heard best, frequency, intensity, radiation, and quality. A summary of murmurs associated with valve disorders is presented in Chart 376 (p. 970).
CHART 374
TIMING
Classification of Murmurs
Timing within the cardiac cycle. Systolic or diastolic (early, mid, late, continuous). Systolic murmurs are often benign. Diastolic murmurs are never benign.
LOCATION
Auscultatory area the murmur is best heard. Aortic, pulmonic, mitral, tricuspid. Presence of murmurs at specific valve sites leads to the identification of the affected valve.
FREQUENCY
High-pitched or low-pitched sound. Low-pitched murmurs are caused by a low velocity of blood flow. High-pitched murmurs are caused by a rapid velocity of blood flow.
QUALITY
Descriptive quality of the sound. Harsh, rumbling, musical, soft, blowing, gurgling. Quality may indicate regurgitation or stenosis.
PATTERN RADIATION
Configuration of sound if one were to draw it. Crescendo, decrescendo, diamond shaped. Sounds may be radiated to the neck, back, shoulders, sternal border, jaw, arm, or left axilla. Some murmurs radiate in the direction of the bloodstream, by which they are produced.
INTENSITY
Grading scale of loudness I/VI Very soft, barely audible. II/VI Soft, but loud enough to be appreciated. III/VI Loud, easily heard, no thrills or vibrations. IV/VI Loud, soft palpable thrill. V/VI Loud, heard with stethoscope barely touching chest wall; palpable thrill. VI/VI Very loud, can be heard with stethoscope fully off chest wall, pronounced palpable thrill.
Gender Implications/Gender Differences

Before the 1980s, it was believed that cardiovascular disease (CVD) affected primarily men. This was due in large part to the fact that most research studies involved men. It is now well known that women respond uniquely to CVD as well as to other diseases. Women experience the signs and symptoms associated with CVD differently than men. More women have asymptomatic and undiagnosed CVD. It is difficult to apply preventive cardiovascular care to women who have not been identified as having CVD. Mortality
cultatory sounds caused by vibrations or turbulence in the heart and great vessels, bruits are auscultatory sounds associated with vibrations or turbulence in a blood vessel outside the heart. Murmur Etiology Murmurs are due to valve abnormalities of stenosis or regurgitation. Many different physiological conditions can lead to these alterations. A stenotic valve is one whose valve leaflets are hardened, calcified, or narrowed. Blood flow is obstructed as it is forced through a narrowed, stenotic valve orifice. Valve regurgitation occurs when the valve leaflets fail to close completely. This causes valve insufficiency, and a portion of the systolic blood volume is allowed to flow backward. Causes of abnormal valves are discussed in Chapter 41 . As blood flows through these two different types of valve alterations, the sounds generated are very distinct. For example, blood flowing through a stenotic valve would sound very harsh because blood is being forced through a narrow opening, whereas blood flowing through a regurgitant valve would sound softer and have more of a gurgling quality. The sounds associated with particular valve disorders
CHART 375
Valve Opening and Closing with Cardiac Cycle

CLOSED Tricuspid Mitral (regurgitation) Abnormality Regurgitation is unable to completely close Stenosis is unable to completely open
OPEN SYSTOLE Pulmonic Aortic (stenosis)
DIASTOLE
Tricuspid Mitral (stenosis)
Pulmonic Aortic (regurgitation)
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CHART 376
Summary of Murmurs Associated with Valve Disorders
This is due to the cardioprotective effect of estrogen in premenopausal women. (Genetic predispositions to cardiovascular disease are discussed in the Genetic Considerations box.)
AORTIC STENOSIS 1. Midsystolic, crescendo-decrescendo 2. Harsh 3. Usually heard best in the aortic area 4. Often heard widely over the chest 5. Often radiates to the carotid arteries 6. Loudness unrelated to severity AORTIC REGURGITATION 1. Present in early diastole 2. Decrescendo configuration 3. High-pitched blowing 4. Heard best with the patient leaning forward; often faint 5. Loudness along Left Lower Sternal Border (LLSB) MITRAL STENOSIS 1. Long, rumbling diastolic murmur 2. Low pitched 3. Heard best with bell 4. Localized to mitral area (apex) 5. Often accompanied by a diastolic thrill in the area 6. Crescendo occurs in late diastole MITRAL REGURGITATION 1. Pansystolic 2. Loudest in mitral area (apex) 3. Radiates to left axilla 4. Usually blowing in quality 5. Systolic thrill usually present in mitral area INNOCENT MURMUR 1. Short, soft, systolic 2. Normal S1 and S2 3. Normal ECG and chest x-ray 4. Crescendo-decrescendo 5. Heard in primary aortic area
Gerontological Considerations
The number of elderly people over age 65 in the population of the United States has been steadily increasing. Therefore, it stands to reason that the number of elderly patients cared for in health care settings will also increase. The gerontological population has unique considerations, which are important in cardiovascular assessment. Physiological changes associated with aging include myocardial hypertrophy; an increase in collagen and scarring; a decrease in elasticity; fibrotic and sclerotic changes of the atria and ventricles; calcification, sclerosis, or fibrosis of the cardiac valves; and rigidity and fibrosis of the vessels of the arterial system. These changes can lead to a drop in cardiac output, systolic or diastolic murmurs, increased frequency of dysrhythmias, and altered blood flow dynamics, all of which affect tissue perfusion. For example, elderly persons may have elevations in systolic or diastolic blood pressures. Additionally, in the response to injury or shock, the heart becomes less able to respond or initiate the stimulation of catecholamines needed to increase heart rate and contractility (Whetstone & Boswell, 2002). It is not uncommon to hear an S4 in an elderly person due to decreased compliance of the left ventricle or a systolic murmur due to aortic or mitral valve abnormalities. Thickened myocardial fibers can also affect the conduction system of the heart and cause cardiac irritability and dysrhythmias. Diseases affecting other body systems can
GENETIC CONSIDERATIONS for Cardiovascular Disease

A great deal is known about the independent risk factors for the development of cardiovascular disease. Advances made in the area of genetics since the Human Genome Project in 1988 have helped scientists understand the genetic causes of cardiovascular disease. It has become clear that most cardiovascular diseases result from various genetic causes (Allen, 2000). Gene mutations and the interaction of genes and the environment are currently being examined. For example, polygenic disorders, such as hypertension, are caused by the combined effect of more than one mutated gene. Interestingly, the nature and severity of polygenic disorders vary significantly and are unpredictable in nature (Allen, 2000). Coronary artery disease is an example of a multifactorial disorder. Multifactorial disorders may have a genetic component, but the presentation is largely affected by environmental factors. For example, multifactorial disorders may include an interaction of genetic factors (genetic abnormalities that result in lipid disorders, hypertension, and obesity) with nongenetic factors such as smoking, increasing age, and physical activity. Through a thorough cardiovascular assessment, and potentially future genetic testing, inherited cardiovascular diseases or the susceptibility to diseases can be identified. The hope is that early detection and diagnosis will identify individuals at risk. Then prevention or modulation of the effects can be undertaken by the implementation of a treatment plan, education, and counseling. The goal of genetic testing would be to save lives through preventive treatment and therapeutic interventions. Nurses can complete family history assessments and initiate appropriate referrals for genetic counseling.
rates of CVD, particularly from sudden death, are currently higher in women than in men (DAmore and Mora, 2006). DAmore and Mora (2006) suggest that women previously deemed at intermediate risk for the development of CVD from standard available guidelines, but who have concerning features in their medical history such as a strong family history, may benefit from stress testing, which may provide further gender-specific prognostic information. Further studies are needed to identify gender-specific predictors of cardiac disease, and more comprehensive approaches to CVD prevention and treatment are needed for women. Although, many of the gender-specific differences in CVD are not well explained, it is well understood that postmenopausal women are at greater risk of developing CVD than are premenopausal women.
CHAPTER 37
Nursing Assessment of Patients with Cardiovascular Disorders 1069 course about the symptoms. The nurse uses skillful interview techniques to explore and investigate each symptom further. Any symptom analysis would be incomplete without a thorough description of its characteristics.
affect the heart and blood vessels. Diabetes mellitus is one example of a disease that can have damaging effects on the peripheral vasculature, and another is chronic obstructive lung disease, which contributes to right-sided heart failure. Normal physiological changes in the elderly can contribute to the significance of cardiovascular signs and symptoms. For example, loss of muscle mass is a normal physiological change but can contribute to symptoms of weakness of fatigue. It is essential to encourage a healthy diet and regular exercise program. The gerontological population is more susceptible to cognitive impairments that make them more vulnerable to the effects of cardiac diseases and their treatments (Garrett, 1997). Dementia and delerium are common cognitive impairments found in the geriatric population. Cognitive losses of dementia affect the overall ability of an individual to interact successfully with the environment. The way the individual responds to stimuli from touch or stimuli from the environment may vary among individuals and should be considered prior to the exam (Garrett, 1997). The nurse needs to understand that there may be limitations in the patients abilities to learn and apply new knowledge. It will be much more difficult for the individual who is cognitively impaired to manage the complexities of his cardiovascular disease and its treatment. Changes in cerebral perfusion due to atherosclerosis may also be present. When cognitive impairments such as dementia or delerium are suspected, the ability to provide accurate information for the health history will be altered (Garrett, 1997).
Implications for Health Promotion

A good time to discuss the concept of health promotion with a patient is during a cardiovascular exam. Assessment can be a time to review current health status, examine problem areas, identify risk factors that need to be modified, identify possible health goals, discuss options, and potentially develop a plan of care. During a health assessment nurses need to provide health education and supply the patient with educational materials. Nurses are in a unique position to help patients recognize health problems or potential health problems. When abnormalities or positive findings are discovered during the health history process, an opportunity exists to discuss the issue in greater detail. Nurses should also recognize their role in promoting healthy lifestyles and their abilities to empower a patient and her family to make needed changes in their lives. Be aware that certain health topics are very personal, and some nurses have difficulty discussing these sensitive issues with patients. As the populations that are served in health care settings continue to change and nurses are caring for more diverse populations, they need to be knowledgeable about the health practices of other cultures. Integrating culturally competent care includes incorporation of complementary therapies into the plan of care that will ultimately help nurses accomplish the goal of health promotion for all patients.
Critical Thinking Related to Cardiovascular Assessment

Critical thinking is essential in order to prioritize the most significant clinical manifestations that need further investigation. Cardiovascular clinical manifestations can range from conditions as benign as an innocent murmur to life-threatening disorders such as heart failure. It is imperative that the nurse be able to distinguish normal from abnormal, benign from serious. The nurse must rely on critical thinking skills in interpreting the patients symptoms and assessment findings to determine possible and potential patient diagnoses and to consider the appropriate actions to take. Analysis of these data allows the nurse to make a diagnosis and then follow up with an intervention. It is imperative that the nurse communicate and collaborate with other members of the health care team in developing and implementing a plan of care. Because cardiac disease manifestations can mimic other abnormalities such as pulmonary disease, the nurse must question each symptom and then compare and contrast symptoms. For example, when the patient reports a sudden onset of chest pain, the nurse must possess knowledge of the difference in manifestations between the causes of cardiac versus pulmonary chest pain and assess the patient for each of them. Making an assumption that the pain is cardiac in nature would be inappropriate and shortsighted. Effective critical thinking skills include being curious and not making any assumptions. Regardless of the health problem, each symptom identified should be thoroughly described in order for the nurse to gain a full understanding. The nurse can say to the patient, Tell me more about the problem, or How did it start? The patient usually proceeds with a dis-
Cardiovascular Monitoring
Cardiovascular monitoring is an integral part of nursing management and includes many technologies used to augment the physical exam. Monitoring devices range from simple noninvasive monitoring, including assessment of heart rate, blood pressure, and pulse oximetry, to more invasive monitoring, such as hemodynamic monitoring using indwelling pulmonary artery catheters and arterial catheters. Chapter 24 includes a complete discussion of invasive hemodynamic monitoring. The goal of cardiovascular monitoring is to obtain the data needed to complete the cardiovascular assessment in a timely fashion, in the safest, most cost-efficient manner.
Assessment of Heart Rate

Counting the number of pulsations of the heart per minute determines heart rate. Assessment of heart rate should be performed when the patient is at rest in a calm environment. Many factors can alter the heart rate. For example, exercise, pain, and anxiety can cause an increase in circulating catecholamines, which may elevate heart rate and blood pressure. Endocrine and metabolic conditions can also affect the heart rate. The heart normally beats 60 to 100 times per minute. Heart rates less than 60 beats per minute (bradycardia) may be caused by hypoxia, parasympathetic stimulation, or beta-adrenergic blocker medication (Docherty, 2002a), although many well-conditioned athletes have resting heart rates well below 60 beats per minute. Bradycardia may not be clinically significant, unless accompa-
1070 UNIT 8
Nursing Management of Patients with Cardiovascular Disorders tolic blood pressure, which represents the lowest blood pressure that occurs when the heart relaxes between beats. Accuracy in the measurement of BP is imperative because these data often guide medical and nursing practice. Many therapeutic decisions are made based on BP recordings. Although the skill of measuring blood pressure appears simple, there are many possible causes of errors and inaccuracies (Chart 377). Inaccuracies in BP assessment can lead to underestimation or overestimation of blood pressure, causing errors in the diagnosis and treatment of cardiovascular conditions. The American Heart Association has published standard recommendations and a step-by-step protocol for the indirect measurement of blood pressure (Chart 378). Guidelines provide a consistent, uniform technique for measuring blood pressure. However, nurses should be periodically retrained in determination of blood pressure. Retraining of blood pressure observers has been shown to reduce variability of blood pressure due to human error (Jones, Apperl, Sheps, Roccella, & Lenfant, 2003). It is important for nurses to understand that the BP in an artery is a dynamic number and changes throughout the day. It is the lowest during sleep. It rises on waking and can rise with excitation, nervousness, or activity. Therefore, a single reading of high blood pressure is not used to make a diagnosis of hypertension. Treatment of hypertension includes lifestyle management including dietary changes and exercise as well as a variety of medications (angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers). Chapter 21 contains an in-depth discussion of hypertension guidelines and treatment.
nied by systolic blood pressure of less than 90 mmHg, which would indicate that the slow rate is compromising cardiovascular function (Docherty, 2002). Heart rates over 100 beats per minute are termed tachycardia, and some causes are exercise, pyrexia, hypovolemia, anxiety, and pain. Other clinical conditions that increase oxygen demand, such as myocardial ischemia or respiratory distress, may also cause tachycardia (Docherty, 2002a). Tachycardia can compromise cardiovascular status by decreasing diastolic filling time and increasing oxygen consumption, which may cause a reduction in stroke volume and eventually a drop in cardiac output. The regularity of the pulse should also be assessed. Irregularities suggest an alteration in cardiac conduction and should be further evaluated. Electrocardiogram (ECG) monitoring is a noninvasive method used to assess the heart rate and rhythm, and is commonly utilized in acute care settings. Interpretation and analysis of the ECG is discussed in Chapter 38 .
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Assessment of Blood Pressure

Arterial blood pressure (BP) is a measure of the pressure exerted by blood against the walls of the arterial system as it is ejected from the left ventricle. Blood pressure is a dynamic, multidimensional indicator of a persons cardiovascular state (Thomas, Liehr, DeKeyser, Frazier, & Friedmann, 2002). Assessment of blood pressure reflects the events of the pulsatile cardiac cycle and is expressed as systolic/diastolic. The systolic blood pressure (SBP) is the peak pressure exerted against the arteries when the heart ventricles contract during systole. The diastolic blood pressure (DBP) is the residual pressure existing in the arterial system at the end of diastole when the ventricles are relaxed and are filling with blood from the atria. The recording of blood pressure can provide important information about blood volume, cardiac output, and peripheral resistance. It is a critical component of vital signs and therefore is a basic parameter for nurses physical assessments (Thomas et al., 2002). When the systolic and diastolic blood pressures are elevated, so is the risk of developing cardiovascular disorders. High blood pressure causes the heart to work harder and directly damages the smooth muscle that lines the cardiovascular system (see Chapter 21 and Chapter 40 ). Hypertension must be treated promptly to prevent complications such as the development of atherosclerotic cardiovascular disease, myocardial infarction, and stroke. Blood pressure can be measured in several ways: either indirectly by use of auscultatory methods such as mercury column or aneroid (clock-face) sphygmomanometers or by use of oscillatory methods such as the electronic automatic blood pressure cuffs that produce a digital readout, or directly by use of invasive monitoring devices. In many clinic and hospital settings the most common way to obtain blood pressure recordings is by auscultation with the use of an indirect sphygmomanometer. Pressure is exerted on the main artery of the arm by the inflated blood pressure cuff. The stethoscope is used to listen for Korotkoff s sounds, which change in tone and volume as the cuff is deflated and blood flow is gradually restarted. The first sound heard is the systolic blood pressure, which represents the highest blood pressure that occurs each time the heart beats. The second recording is the dias-
Classification of Blood Pressure

The National Heart, Lung, and Blood Institute (NHLBI) has classified two levels of high blood pressure. A blood pressure reading below 120/80 mmHg is considered normal. Blood presCHART 377
Inaccuracies in Measurement of Blood Pressure
Inaccuracies in measurement of blood pressure are common clinical problems and can occur due to human error or device error for numerous reasons: Inappropriately sized cuffs (too wide or too narrow) Incorrect cuff positioning Incorrect cuff wrapping (too loose or uneven) Failure to allow a rest period before measurement Deflating the cuff too quickly or too slowly Inaccurate inflation level Not measuring in both arms Failure to palpate maximal systolic pressure before auscultation Improper position of the arm (above or below heart level) Poor observer concentration Lack of repeated measurements Poorly fitting stethoscope.
Sources: Jones, D. W., Apperl, L. J., Sheps, S. G., Roccella, E. J., & Lenfant, C. (2003). Measuring blood pressure accurately: New and persistent challenges. JAMA, 289(8), 10271030; McAlister, F. A., & Straus, S. E. (2001). Measurement of blood pressure: An evidenced based review. British Medical Journal, 322(7291), 908911.
CHAPTER 37
CHART 378
Technique for Measurement of Blood Pressure
The intent and purpose of the measurement should be explained to the subject in a reassuring manner, and every effort should be made to put the subject at ease. The sequential steps for measuring the blood pressure in the upper extremity, as for routine screening and monitoring purposes, should include the following: 1. Have paper and pen at hand for immediate recording of the pressure. 2. Seat the subject in a quiet, calm environment with her bared arm resting on a standard table or other support so the midpoint of the upper arm is at the level of the heart. 3. Estimate by inspection or measure with a tape the circumference of the bare upper arm at the midpoint between the acromion and olecranon process (between the shoulder and elbow), and select an appropriately sized cuff. The bladder inside the cuff should encircle 80% of the arm in adults and 100% of the arm in children under 13 years old. If in doubt, use a larger cuff. If the available cuff is too small, this should be noted. 4. Palpate the brachial artery and place the cuff so that the midline of the bladder is over the arterial pulsation; then wrap and secure the cuff snugly around the subjects bare upper arm. Avoid rolling up the sleeve in such a manner that it forms a tight tourniquet around the upper arm. Loose application of the cuff results in overestimation of the pressure. The lower edge of the cuff should be 1 inch (2 centimeters) above the antecubital fossa (bend of the elbow), where the head of the stethoscope is to be placed. 5. Place the manometer so that the center of the mercury column or aneroid dial is at eye level and easily visible to the observer, and the tubing from the cuff is unobstructed. 6. Inflate the cuff rapidly to 70 mmHg, and increase by 10 mmHg increments while palpating the radial pulse. Note the level of pressure at which the pulse disappears and subsequently reappears during deflation. This procedure, the palpatory method, provides a necessary preliminary approximation of the systolic blood pressure to ensure an adequate level of inflation when the actual, auscultatory measurement is made. The palpatory method is particularly useful to avoid underinflation of the cuff in patients with an auscultatory gap and overinflation in those with very low blood pressure. 7. Place the earpieces of the stethoscope into the ear canals, angled forward to fit snugly. Switch the stethoscope head to the low-frequency position (bell). The setting can be confirmed by listening as the stethoscope head is tapped gently. 8. Place the head of the stethoscope over the brachial artery pulsation, just above and medial to the antecubital fossa but below the lower edge of the cuff, and hold it firmly in place, making sure that the head makes contact with the skin around its entire circumference. Wedging the head of the stethoscope under the edge of the cuff may free up one hand but results in considerable extraneous noise. 9. Inflate the bladder rapidly and steadily to a pressure 20 to 30 mmHg above the level previously determined by palpation, and then partially unscrew (open) the valve and deflate the bladder at 2 mm/s while listening for the appearance of the Korotkoffs sounds. 10. As the pressure in the bladder falls, note the level of the pressure on the manometer at the first appearance of repetitive sounds (Phase I), at the muffling of these sounds (Phase IV), and when they disappear (Phase V). During the period the Korotkoffs sounds are audible, the rate of deflation should be no more than 2 millimeters per pulse beat, thereby compensating for both rapid and slow heart rates. 11. After the last Korotkoffs sound is heard, the cuff should be deflated slowly for at least another 10 mmHg, to ensure that no further sounds are audible, and then rapidly and completely deflated. The subject should be allowed to rest for at least 30 seconds. 12. The systolic (Phase I) and diastolic (Phase V) pressures should be immediately recorded, rounded off (upward) to the nearest 2 mmHg. In children, and when sounds are heard nearly to a level of 0 mmHg, the Phase IV pressure should also be recorded. All values should be recorded together with the name of the subject, the date and time of the measurement, the arm on which the measurement was made, the subjects position, and the cuff size (when a nonstandard size is used). 13. The measurement should be repeated after at least 30 seconds, and the two readings averaged. In clinical situations additional measurements can be made in the same or opposite arm, and in the same or an alternative position.
Source: Perloff, D., Grim, C., Flack, J., Frohlich, E., Hill, M., McDonald, M., et al. (Writing Group). (1993). Human blood pressure determination by sphygmomanometry (American Heart Association, Product Code: 2460-2467). Dallas, TX: American Heart Association.
sures under 140/90 mmHg are classified as either normal or prehypertension. Prehypertension is systolic blood pressures between 120 and 137, or diastolic readings between 80 and 89. Hypertension is considered when the blood pressure reading in 140/90 mmHg. These classifications are for adults over age 18 who are not on medicine for high blood pressure, are not having a short-term serious illness, and do not have other conditions such as diabetes or kidney disease. An exception to this classification is that a blood pressure of 130/80 mmHg or higher is considered high blood pressure in persons with diabetes and chronic kidney disease (NHLBI, 2008). Classifications, preven-
tion, and management of hypertension are discussed in detail in Chapter 21 .
Health Promotion: Preventing Hypertension

The National High Blood Pressure Education Program (NHBPEP), established in 1972, is a cooperative effort among professional and voluntary health agencies, state health departments, and many community groups. The NHBPEP is administered and coordinated by the National Heart, Lung, and Blood Institute (NHLBI). The goal of the NHBPEP is to reduce death and disability related to high
8 8
1072 UNIT 8
blood pressure through programs of professional, patient, and public education. Another goal of the NHBPEP is to achieve the Healthy People 2010 heart disease and stroke objectives for the nation (DHHS, 2004). Strategies to meet the programs goal include developing and disseminating science-based-educational materials and developing partnerships among the program participants.
Assessment of Oxygen Delivery

Pulse oximetry allows noninvasive estimation of hemoglobin oxygen saturation, or SpO2, which is the amount of hemoglobin saturated with oxygen (Figure 3710 ). These devices work by using a light sensor containing two sources of light (red and infrared) that are absorbed by hemoglobin and then transmitted through the tissue to a photodetector. The amount of light transmitted through the tissue is converted to a digital value, which represents the percentage of hemoglobin saturated with oxygen (Lynn-McHale & Carlson, 2005). Normal oxygen saturation values are 97% to 99% in a healthy individual, but a value of 95% is clinically acceptable in a patient with a normal hemoglobin level (Lynn-McHale & Carlson, 2005). It should be reinforced that tissue oxygenation is not reflected by oxygen saturation because the affinity of hemoglobin to oxygen may actually either impair or enhance the way oxygen is released at the tissue level. Additionally, oxygen saturation does not reflect a patients ability to ventilate, and thus its clinical use is limited in patients with obstructive pulmonary disease (Lynn-McHale & Carlson, 2005). SpO2 values, however, are often monitored to allow for observations of trends and changes over time. For example, in a patient with emphysema, an SpO2 of 93% might be considered a normal baseline. If however, he had an exacerbation of symptoms and his SpO2 dropped to 90% or lower, the finding would be significant and reportable. Oxygen saturation can be measured from several sites, including fingers, toes, and earlobes. It is important to remember that some situationssuch as low perfusion, low temperature, anemia, discoloration of the nail bed, and even carbon monoxide poisoning,will affect the ability of the sensor to estimate venous oxygen saturation accurately. The device should not be used on the same extremity as a blood pressure cuff, which may interrupt blood supply (Docherty, 2002b). The accuracy of the measurement is dependent on peripheral circulation, which may be compromised in a critically ill adult. Pulse oximetry, as a simple, noninvasive monitoring device, can be used continuously to assess adequacy of oxygen delivery. It may also be employed as a substitute for frequent arterial blood gas analysis, which involves needlesticks to obtain arterial blood (Docherty, 2002b). Therefore, pulse oximetry is efficient in that it can save nursing time, cost, and patient discomfort.
FIGURE 3710
Pulse oximeter.
Summary
A thorough and accurate cardiovascular assessment is an important nursing tool. Findings from cardiovascular assessments can lead to early identification of potentially life-threatening conditions and provide an opportunity for timely application of
preventative measures and treatment modalities. Cardiovascular assessment skills are mandatory in acute care as well as in many other nursing settings. Experience with cardiovascular assessment allows a nurse to validate and interpret findings in order to implement appropriate therapeutic interventions. Nurses may implement preventative strategies, initiate treatment plans, or provide education or counseling.
CHAPTER 37
NCLEX REVIEW
1. The nurse determines a male patient with hypertension and hypertriglyceridemia meets the criteria for metabolic syndrome when the cardiovascular assessment demonstrates which finding?
1. 2. 3. 4. Random blood sugar is 150mg/dL. Waist circumference is 110 cm. High density lipids, HDLs, are 52mg/dL. Fasting blood sugar is 100mg/dL.
3. A patient in the reports having difficulty sleeping at night secondary to becoming short of breath when lying down. In order to further assess the degree of orthopnea, the nurse should ask which question.
1. 2. 3. 4. How often do you wake up at night? How many pillows do you sleep on? Do you experience palpitations that awaken you? How often do you get up to urinate during the night?
2. When assessing the medication history of a patient with heart disease the nurse would be most concerned when the patient reports frequent use of which medication?
1. 2. 3. 4. Proton pump inhibitor Antacids Bulk forming laxatives Decongestants
4. When auscultating heart sounds the nurse hears a third heart sound and recognizes the patient has which condition?
1. 2. 3. 4. Diastolic dysfunction Systolic dysfunction Conduction defect of the SA node Dysfunctional mitral valve
Answers for review questions appear in Appendix 5
KEY TERMS
abdominojugular reflux p.1063 auscultation p.1065 bruits p.1069 cyanosis p.1062 dyspnea p.1057 edema p.1058 heaves p.1065 jugular venous pressure (JVP) p.1062 murmurs p.1068 nocturia p.1057 orthopnea p.1057 palpitations p.1057 syncope p.1058 thrills p.1065 turgor p.1064
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REFERENCES
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Cardiovascular Disorder

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Cardiovascular Disorder

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Nursing Management of Patients with Cardiovascular Disorders

Nursing Assessment of Patients with Cardiovascular Disorders

Outcome-Based Learning Objectives

Anatomy and Physiology of the Cardiovascular System

Nursing Assessment of Patients with Cardiovascular Disorders 1053

Suprasternal notch Angle of Louis 3rd rib Intercostal space T Diaphragm P A

Diagram of heart in chest.

Cross section of heart.

Cardiac Circulatory System

Transverse section of the heart Endocardium Myocardium Epicardium

Serous pericardium: Visceral Parietal Cavity of pericardial sac

Physiology of the Cardiovascular System

Right coronary artery

Autonomic Nervous System

Receptors and Neurotransmitters

Biographic and Demographic Data

Nursing Management of Patients with Cardiovascular Disorders

Childhood Illnesses and Immunizations

Previous Illnesses and Hospitalizations

Diagnostic/Interventional Cardiac Procedures or Surgeries

Past Medical History

Common Medications and Side Effects That Affect Cardiovascular Status

LEMEN OMP TARY & C NATIV

RISK FACTORS Related to Metabolic Syndrome

Nursing Assessment of Patients with Cardiovascular Disorders 1059

Inspection of Skin and Extremities

Color and Appearance of Skin and Extremities

External jugular vein Internal jugular vein

Palpation of Skin and Extremities

Nursing Management of Patients with Cardiovascular Disorders

Pedal Posterior tibal

Inspection and Palpation of the Precordium

Clinical Reference Points

Scale for Rating Edema

Point of Maximal Impulse (PMI)

Greater than 1 pitting (severe)

Auscultation of the Precordium

Midclavicular line (MCL), 5th ICS Point of maximal impulse

Clinical reference points for palpation.

Heaves and Thrills

Normal Heart Sounds: S1 and S2

Requirements for Auscultation

Cardiac blood flow paths Systemic venous circulation

Left atrium Right ventricle

Systemic venous circulation Systemic atrial circulation

Cardiac blood flow path.

Nursing Assessment of Patients with Cardiovascular Disorders 1065

Summary of Heart Sounds

If normal, at 2nd ICS, LSB abnormal if heard at apex

Better heard in the supine position

Better heard in the supine position

Better heard in the supine position

Better heard in the supine position

Early diastole right after S2

Apex with the bell

Auscultated better in left lateral position or supine

Late diastole right before S1

Apex with the bell

Auscultated better in left lateral position or supine

Split Heart Sounds: Split S1 and Split S2

Extra Heart Sounds

Abnormal Heart Sounds: Murmurs