Pengkajian Sistem Kardiovaskular

(Pengkajian data Subyektif, lihat Guideline dari University of Melbourne)

Perkenalkan diri pada klien Meminta “informal consent” dari klien Mencuci tangan dengan sabun atau “chemical agents” Pertahankan privasi klien. Tutup sampiran/tirai. Menginspeksi penampilan umum klien, warna kulit wajah, warna bibir dan kelembaban bibir, adanya

diaphoresis, adanya edema, inspeksi warna kuku, inspeksi tampaknya varicouse vena-vena superficial, inspeksi adanya clubbing finger

Inspeksi adanya distensi vena jugularis. Ukur bila terjadi distensi JV Palpasi capillary refill time Palpasi edema perifer Palpasi arteri-arteri berikut ini (frekuensi, ritme, kekuatan, simetris atau tidak di kedua arteri) :

Lakukan secara berurutan!Arteri karotis (kanan dan kiri dikaji masing-masing)Arteri radialisArteri brachialisArteri femoralisArteri poplitealArteri dorsalis pedis

Palpasi suhu dan kelembaban kulit area dada Palpasi apical pulse ICS 5 kiri garis midklavikula Palpasi Cardiac Thrill and Heaves Auskultasi arteri karotis dengan menggunakan bell stetoskop (apakah ada murmur manifestasi

terjadinya stenosis aortic) Auskultasi dengan menggunakan diafragma:

Lakukan secara berurutan!ICS 2 kanan garis sternalICS 2 kiri garis sternalICS 3 kiri garis sternalICS 4 kiri garis sternalICS 5 kiri garis sternalICS 5 kiri garis midklavikula

Auskultasi dengan menggunakan bell stetoskop di lokasi yang sama (di atas) Lakukan evaluasi obyektif dan subyektif Mencuci tangan Dokumentasi

Addition:

Assessment Techniques for the cardiovascular system

• Subjective– Interview/ history– Identify cardiovascular risk factors – Identify previous illness or surgery– Identify medications required for maintenance– Identify symptoms being experienced– Personal habits (nutrition, smoking, alcohol, exercise and stress)Investigate daily activities; exercise and leisure patterns

Limitations on activity or exercise

Consider health perception (?normal age related changes)

Consider health maintenance strategies (eg: medication history)

Complaints

Past medical history

Contributing factors

Medications: Inotropics (lanoxin), antiarrhythmics, antianginals, antihypertensives (norvasc, captopril), antilipemics, etc.

Cardiac Risk Factors

• Age more than half of those with MI are 65 or older; 4/5 who die are over 65Gender Male over women Coronary heart disease is number 1 cause of death for American women. Significant for Indonesian women as well.

Hereditary hypercholesteremia is a risk factor for cardiovascular disease

• Afroamericans have greater risk• Elevated BP• Elevated serum cholesterolCigarette smoking30-40% of 500,000 deaths annually can be attributed to smoking (USA statistic)

Smoking low tar or low nicotine does NOT reduce risk

When a smoker quits smoking, risk drops quickly to level of non-smoker.

• Obesity• Glucose intolerance• Diabetes

• Elevated fibrinogen• Left ventricular hypertrophy• Cocaine use

• Personality factors (not a proven risk factor) (less proven: sense of time pressure, chronic impatience, easily upset, always in a hurry

Protective Factors:

• Elevated HDL• Exercise• Estrogen• Moderate alcohol use risks of alcohol are such that we never recommend a nondrinker start drinking alcohol. If they already drink alcohol then we emphasize that should be less than 2 per day. Alcohol may increase HDL. Drinking more than recommend has serious health consequences.

Interview Questions

• How many flights of stairs can you climb without stopping?• Would you describe any chest pain or distress that you ever have.• How is your blood pressure?• How often do you wake at night to void?• How does your body feel during exercise?• Do you know your blood levels of cholesterol and triglycerides are?

Interview Check List

– shortness of breath– cough– tire easily– recent changes in energy level– smoke– exercise– skin changes on arms or legs– heart gallops– shortness of breath while lying flat– swelling

See any leg pain (regarding DVT-Deep Vein Thrombosis) or Leg ulcers/ varicose veins. Coolness of extremities from arterial disease.

Leg ulcers occur with chronic arterial and chronic venous disease.

Blue/ashen- may occur with myocardial infarction or low cardiac output

Common Cardiovascular Signs and Symptoms

Effect of symptoms on activity and exercise

Palpitations: feel the heart pounding like after excessive caffeine or a bad scare.

Dyspnea on exertion… affected by position (lying down allows blood to return to heart circulation and leads to overload) Particularly important if it comes with exertion. Need to specify how much exercise it takes before there is dyspnea. Does the dyspnea interfere with ADLs. Does it happen at night (paroxysmal nocturnal dyspnea- lying down increases blood volume to the heart and the weakened heart cannot accommodate the increased load)

Cough (mitral stenosis/ fluid overload) sputum production can be cardiac or pulmonary. Mitral stenosis leads to hemoptysis

Dizziness (inadequate cerebral brain flow) - Inadequate oxygen to the brain could lead to dizziness

Intermittent Claudication: pain in calves while walking A severe pain in calf muscles occurring during walking but subsides with rest. It results from inadequate blood supply which may be due to arterial spasm, atherosclerosis, arteriosclerosis or an occlusion.

Nocturia: heart failure Recumbency at night promotes fluid reabsorption and excretion; this occurs with heart failure in the person who is ambulatory during the day

Edema; heart failure Edema is dependent when due to heart failure. Cardiac edema is worse at evening and better in the morning after elevating legs all night.

Orthopnea- inability to lay flat to sleep discomfort with breathing when reclined: seen in grave cardiac disease, bronchial and cardiac asthma, pulmonary edema, severe emphysems, pneumonia, angine pectoris.

Chest Pain- angina occurs when heart’s vascular supply cannot keep up with metabolic demand. Chest pain can also be pulmonary, musculoskeeltal, or GI

Palpitations- especially important if associated with pain. Heart skips may be V-tach; abnormal heart rhythm. Can also be brought on my drugs or caffeine

Syncope- Fainting, Transient loss of consciousness due to inadequate blood flow to the

Vital Signs

• Temperature : heart rate increases with temperature• Heart rate and rhythm– Potential errors (see below)• Respiratory rate• Blood pressure– Potential errors– Orthostatic changes– Bilateral arms

Assessment techniques for the Cardiovascular System

• Objective– Inspection

• General

• Detailed

– Pulse; blood pressure

– Peripheral vascular assessment

– Precordium

Inspection

• General Appearance

– Behavior

– Posture and gait

– Hygiene and grooming

– Skin

• General

• Hands and nails

• Lower extremities

Inspection

Skin and mucous membrane

– color pale means not enough oxygen. Not enough hemoglobin?– edema– nail beds– petechiaeColor of mucous membranes–Or not being circulated?

Where do we evaluate mucous membranes? Mouth, inside of eyelids.

Edema may be from the vascular system not returning plasma to the vascular system in the capillary beds.

1. Inspection

• Precordium– Identify landmarks – Thorax: size, shape, and symmetry– Pulsations

Cardiovascular Assessment: Palpation

• Palpation to assess:

• Peripheral vascular– assess arms and legs

• Precordium – assess heart

2. Palpation

• Peripheral vascular– Pulses– (more on the following slides)– Capillary refill – Symmetry- always compare side to side• Precordium– Atrial impulse– Lifts/heaves- other chest movements other than atrial impulse

Palpate Arterial Pulses

• Brachial artery• Carotid artery• Femoral artery

• Radial artery• Popliteal artery• Posterior Tibial artery• Dorsalis Pedis artery

Palpate Arterial Pulses

Compare side to side/ upper to lower

• Rate• Rhythm• Contour• Amplitude (force): graded 0 to 4

Amplitude

• 4= bounding• 3= full, increased• 2= expected• 1= diminished• 0= absent; not palpable

3. Cardiovascular Assessment: Auscultation of the precordium

Auscultate

Myocardium

– Flow of blood– Function of valves and chambers– Blood vesselsPercussion can be done to evaluate size of heart for heart enlargement. However, since CXR is more accurate, percussion is not covered in this course.

Cardiovascular Assessment

• AuscultationHeart sounds

S1 and S2

S1 best heard at apex. The sound results from theclosure of atrioventricular valves and marks onset of systole

S2 –best heard at base and is the result of closure of semilunar valves. It marks onset of diastole

S3 and S4

S3 is heard mid diastolic. S3 is normal in children and young adults but is pathophysiological and represents systolic dysfunction over 40. S3 in adults is from abnorml filling of ventricle due to elevated LVEDP. S3 is best heard at the apex in the left lateral position and using the bell of the stethoscope.

S4 is heard in late diastolic. It is pathophysiological and results from diastolic dysfunction. The sounds comes from a Stiff, non-compliant ventricle with resistance to volume expansion

• Murmurs • Vascular bruits• Clicks and snaps• Pericardial rubsPlease read Jarvis pages 507- 511. For interest only, read pages 519-524.

Auscultation must be systematic. Extra sounds are soon “tuned out” by the brain so that you no longer hear them. Pay close attention. Get comfortable. Listen for a long time.

Listen for normal heart soundsfirst. Begin with S1, S2. Listen for rate and rhythm. Then S3, S4, Murmurs and other extra sounds.

Auscultation: Special Positioning

Jugular Venous Pulse

From the jugular veins you can assess the central venous pressure and thus judge the heart’s effciency as a pump. Although the external jugular vein is easier to see, the internal jugular vein is attached more diretly to the superior vena cava and thus is more reliable for assessment. You cannot see the internal jugular vein itself, but you can ses its pulsation. Position the patient supine anywhere for a 30-45 degree angle, whereever you can best see the pulsations. Remove the pillow to avoid flexing the nect. Turn the head slightly away from the examined light.Look for pulsations; distinguish internal jugular vein from carotid artery. There is increased pressure with heart failure. (Jarvis, 2004)

youtube.com

• Search for: – Examination of neck vessels– Cardiovascular assessment– Drparth2008• Aortic stenosis• Mitral stenosis• Etc.If any part of the cardiovascular assessment does not make sense, I encourage you to search youtube. There are excellent teaching videos to be found there. Remember that you will also be able to practice in lab on other students. Please plan to learn together. Some of you have more experience with cardiac assessment. Share your wisdom with your classmates!

Cardiovascular Assessment

• Other assessment tools and diagnostics– Pulse oximetry – Vital signs including JVP/CVP– Tilt Table Testing– CXR– Echocardiography

- stress echocardiogram

-transesophageal

– Holter monitor– Blood examination• FBE, (Hb, platelets, WWC), Hct, cholesterol; cardiac (injury) markersYou do not need to learn about all these tests. They are here so that you realize there is much assessment data in the patient’s chart for you to include. Do you have a basic understanding of what these are? Do not worry too much about these.

Cardiovascular Assessment

• Other assessment tools and diagnostics--Nuclear Imaging

• Thallium or cardiolite stress test

• PET scan (Positron emission tomography)– Coronary angiogram/catheterization

– MRI– Stress Tests

• Dobutamine

• Persantine (nuclear medicine)

Infant: Cardiovascular

• The heart is positioned more horizontal; apex is higher (4th intercostal space)• Fetal shunts should close by 10-15 hours• Assessment– Skin color- especially while crying– Apical impulse location– Sinus arrhythmia normal in newborn– Murmurs common in immediate newborn period– Growth charts – Activity: motor milestones, naps, play without tiringHow was mother’s health during pregnancy?

Any rubella or other infections?

Hypertension? Drug use?

Cyanosis while feeding?

Expected growth?

Activity as expected?

Some shunts take 48 hours to close: this is very big concern for early releaes from hospital

Early Childhood: Cardiovascular

• Interview– Growth chart – Activity- fatigue, cyanosis, rest required– Unexplained joint pain or fever– Frequent headaches or nosebleeds– Chest pain with exercise• Physical Examination– Heart location- reaches adult position age 7 years– Murmurs- not always sign of cardiac disease

– Heart rateMurmurs in childhood may be benign. Features of concern in infants include feeding intolerance, failure to thrive, respiratory symptoms or cyanosis. In older children, chest pain (especially with exercise), syncope, exercise intolerance or a family history of sudden death in young people should prompt a complete examination.

The Aging Adult: Cardiovascular

• Systolic blood pressure rises• Left ventricular wall thickness increases• No change in resting heart rate or cardiac output• Decreased ability to respond to exercise• Incidence of cardiovascular disease increases with age• Physical examination– Use caution when palpating carotid artery– Difficult to palpate apical impulse– Systolic murmurs are common

Examples of Nursing Diagnoses related to Activity & Exercise

• Activity Intolerance• Anxiety• Decreased Cardiac Output• Fatigue• Fluid Volume Excess• Knowledge Deficit• Self- Care Deficit• Ineffective (Peripheral) Tissue Perfusion• Health Seeking Behaviors• Effective individual therapeutic regimen managementHealth Seeking Behaviors- the state in which an individual in stable health actively seeks ways to alter personal health habits and or environment to move toward a higher level of wellness.

Effective Individual therapeutic regimen management: a pattern in which the individual integrates into daily living a program for treatment of illness and its sequel that is satisfactory for meeting health goals.