Assessment of Cardiovascular System

Assessment of Cardiovascular System. Arterial & Peripheral Vascular, Review

 

         Inspection, palpation, and auscultation are performed in a systematic manner using certain cardiac landmarks. The cardiac landmarks, as seen in Figure 27-43, are defined as follows:

1. Aortic area is the second intercostal space (ICS) to the right of the sternum.

2. Pulmonic area is the second ICS to the left of the sternum.

3. Erb’s point is located in the third ICS to the left of the sternum.

4. Tricuspid area (right ventricular area or septal area) is the fifth ICS to the left of the sternum.

5. Mitral area (left ventricular or apical area) is the fifth ICS at the left midcavicular line. Whereas the mitral area is correlated anatomically with the apex of the heart, the aortic and pulmonic areas are correlated anatomically with the base of the heart. Assessment proceeds either from the base of the heart to the apex or from the apex to the base. When auscultating for cardiac sounds (S1 and S2) listen for:

S1, which is usually a quieter sound than S2 in the aortic and pulmonic areas

• A split S2 sound that may be heard in the pulmonic area during inspiration

• S1, which is usually louder than S2 in the tricuspid and mitral areas

• A split S2 sound that may be heard in the tricuspid area

 

 

Figure 27-43 Cardiac landmarks: A, aortic area; P, pulmonic area;

E, Erb’s point; T, tricuspid area; and M, mitral area.

 

         Additional heart sounds (S3 and S4) may be heard during auscultation. S3 (also called a ventricular gallop) may be heard in the tricuspid and mitral areas during the early to mid-diastole following the S2 sound. S3 is heard best when the client is in the left lateral recumbent position, and the sound resembles the pronunciation of the word “Kentucky” (lub-dub-by).

         S4 (also called atrial diastolic gallop) may be heard in the tricuspid and mitral areas during the late phase of diastole, before S1 of the next cardiac cycle. S4 is heard best when the client is in the supine position, and the sound resembles the pronunciation of the word “Tennessee” (le-lub-dub). An S3 can be a normal physiological sound in children and young adults; in adults it may be indicative of cardiac dysfunction (Estes, 2002). An S4 may occur with or without any evidence of cardiac decompensation or it can be indicative of decompensation that is seen in conditions that increase the resistance to filling because of poorly compliant ventricles such as coronary artery disease and heart failure (Estes, 2002).

 

 

         There are distinct abnormal findings found on palpation and auscultation. During palpation the nurse should assess for thrills (vibrations that feel similar to what one feels when a hand is placed on a purring cat) and heaves (lifting of the cardiac area secondary to an increased workload and force of left ventricular contraction). Abnormal heart sounds relative to stenosis (a narrowing or constriction of a blood vessel or valve) or regurgitation (the backward flow of blood through a diseased heart valve, also known as insufficiency) can be heard during auscultation as a click (a high-pitched systolic sound created by the opening of the valve) or a murmur (swishing or blowing sounds of long duration heard during the systolic and diastolic phases created by turbulent blood flow  through a valve). Other abnormal sounds heard on auscultation are a pericardial friction rub (high-pitched, multiphasic, scratchy or grating sound that does not change with respirations) and bruits (blowing sounds  that are heard when the blood flow becomes turbulent as it rushes past an obstruction).

 

         Murmurs are characterized by their:

• Location: area where the murmur is heard loudest (e.g., mitral, pulmonic).

• Radiation: transmission of sound from a specific valve to other adjacent structures (mitral murmurs can radiate to the axilla).

• Timing: phase in the cardiac cycle. If the murmur occurs simultaneously with the pulse, it is a systolic murmur. If the murmur is not related to the pulse, it is a diastolic murmur.

• Intensity: the loudness or intensity (see the display for a grading of murmurs).

• Quality: sound produced (harsh, rumbling, blowing, or musical).

• Pitch: high, medium, or low (auscultated with the bell of stethoscope for low-pitched murmurs and the diaphragm for high-pitched murmurs).

• Configuration: pattern that the murmur makes over time; described as crescendo (soft to loud), decrescendo (loud to soft), crescendo-decrescendo (soft to loud to soft), and plateau (sustained sound) (Estes, 2002).

 

 

         Table 27-15 presents the specific areas to be examined and the normal and key findings of assessment of the heart and vascular system. See the accompanying display for common terms associated with cardiac assessment.

 

TABLE 27-15

Assessment of Heart and Vascular System: Normal and Key Findings

 

 

 

Taking a Pulse

 

 ASSESSMENT

1. Assess client for need to monitor pulse because certain diseases or conditions, such as history of heart disease or cardiac dysrhythmias, chest pain, invasive cardiovascular  diagnostic tests, infusion of large volume of IV fluids, or hemorrhage, can cause an increased risk for alterations in pulse.

2. Assess for signs and symptoms of cardiovascular alterations such as dyspnea, chest pain, orthopnea, syncope, palpitations, edema of extremities, cyanosis or fatigue because these signs may indicate a deficit in cardiac or vascular function.

3. Assess client for factors such as age, medications, exercise, change in position, or fever that may affect the character of the pulse. This enables the nurse to accurately assess for the significance of an alteration in pulse.

4. Assess for the appropriate site for measuring pulse so that the pulse will be accurate.

5. Assess the baseline heart rate and rhythm in the client’s chart in order to compare it with the current measurement.

 

> DIAGNOSIS

1.4.2.1 Decreased Cardiac Output, due to alteration in the rate and rhythm of pulse.

1.4.1.1 Altered Cardiopulmonary Tissue

Perfusion.

 

> PLANNING

Expected Outcomes:

1. Pulse rate, quality, rhythm, and volume will be within normal range for the client’s age group.

2. The client will be comfortable with the procedure and demonstrate an understanding regarding its importance.

 

Equipment Needed (see Figure 1-3-2):

• Watch with a second hand

• Stethoscope

• Alcohol swab

• Gloves

 

 

Figure 1-3-2 A watch with a second hand is used to count

pulse.Use a stethoscope to assess apical pulse.Gloves and alcohol

swabs reduce the transmission of microorganisms.

 

 

 

 

> CLIENT EDUCATION NEEDED:

 

1. Ask the client to relax and sit or lie quietly while you take his pulse rate.

2. Explain the normal pulse range to the client when telling him what his pulse rate is. This eases the client’s concerns regarding whether or not he is “normal.”

3. If the client is taking any medications that affect pulse rate, this is a good time to review the name and purpose of this medication.

4. If taking a pulse at a site other than radial explain to the client the reason for using an alternate site.

5. Have the client breathe normally through the nose, especially if taking an apical  ulse. Breathing through the nose decreases breath sounds, making the heart sounds easier to hear.

 

 

 

> CRITICAL THINKING SKILL

Introduction

A pulse deficit exists when the heart is not ejecting enough blood volume to initiate a peripheral pulse wave. If untreated, this can lead to serious complications.

Possible Scenario

You are taking a radial pulse on a client who was admitted to the coronary care unit. The client’s pulse volume is weak and thready. The radial pulse is slow and irregular. You are concerned and take an apical pulse as well. His apical pulse is faster than his radial pulse and is regular. You check the nursing record, but see no mention of this finding.

Possible Outcome

You chart your findings and report them immediately to the client’s physician. He  confirms your finding of a pulse deficit and orders immediate intervention to increase this client’s cardiac ejection volumes.

Prevention

Remember that the nature of the pulse volume, rate, and regularity is a valuable tool in assessing a client’s overall health and in diagnosing disease states.

 

 

 

> NURSING TIPS

• Warm the bell of the stethoscope with your hands prior to placing it on the client’s chest.

• Take a carotid pulse on only one side of the neck at a time in order to prevent cerebral blood flow impairment (see Figure 1-3-7).

• When taking pedal pulses, a firm touch is generally preferable to reduce any tickling sensations.

• A Doppler device may be necessary to detect a pulse on elderly or obese clients (see Figure 1-3-8).

• Do not palpate the radial pulse with your thumb because your own pulse may be felt.

 

COMMON ERRORS—ASK YOURSELF

Possible Error:

You count the pulse of a client with a cardiac arrhythmia for 15 seconds and then multiply the rate by 4 to obtain a one-minute pulse rate.

Ask Yourself:

How do I prevent this error?

Prevention:

Count the heart rate for at least 30 seconds to increase the probability of noting irregularities. Some irregularities do not occur in less than 15-second intervals. Occasional premature beats or brief runs of supraventricular tachycardia can be missed.

Ask Yourself:

How do I respond to this error?

Prevention:

Count the pulse for a full minute noting the regularity or irregularity of the beats.

 

 

 

Figure 1-3-7 Take a carotid pulse on only side of the neck at

a time.

 

 

Figure 1-3-8 A vascular Doppler device is used to detect

pulses in elderly or obese patients.

 

Taking Blood Pressure

 

 

 

 

> OVERVIEW OF THE SKILL

Blood pressure measurement is performed during a physical examination, at initial assessment, and as part of routine vital signs assessment. Depending on the client’s condition, the blood pressure is measured by either a direct or indirect technique. The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed. The most common site for indirect blood pressure measurement is the client’s arm over the brachial artery. When the client’s condition prevents auscultation of the brachial artery, the nurse should assess the blood pressure in the forearm or leg sites. When pressure measurements in the upper extremities are not accessible, the popliteal artery, located behind the knee, is the site of choice. The nurse can also assess blood pressure in other sites, such as the radial artery in the forearm and the posterior tibial or dorsalis pedis artery in the lower leg. Because it is difficult to auscultate sounds over the radial, tibial, and dorsalis pedis arteries, these sites are usually palpated to obtain a systolic reading. The direct method requires an invasive procedure in which an intravenous catheter with an electronic sensor is inserted into an artery and the artery-transmitted pressure on an electronic display unit is read. Hypotension is defined as a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure. Orthostatic hypotension or postural hypotension refers to a sudden drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when the client moves from a lying to a sitting position or from a sitting to a standing position. Hypertension refers to a persistent systolic pressure

greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. For a diagnosis of hypertension to be made, the client must have a sustained elevation in blood pressure over a period of time.

 

> ASSESSMENT

1. Assess the condition of the potential blood pressure (BP) site so that a site with an injury or surgery proximal to the site can be avoided.

2. Assess the artery for any compromise to it so that compressing the artery briefly will not cause decrease in circulation.

3. Assess the distal pulse to check if it is intact and palpable.

4. Assess the circumference of the extremity for the right size cuff to be used so an accurate reading can be obtained.

5. Assess for factors that affect blood pressure such as age, anxiety, fear, medications, smoking, eating or exercising within 30 minutes prior to BP assessment, and postural changes so that an accurate reading can be obtained.

6. Determine client’s baseline blood pressure by reading the medical record so that a comparison can be made with each BP reading (see Figure 1-5-2).

> DIAGNOSIS

1.4.1.1 Altered Cardiopulmonary Tissue

Perfusion.

1.4.2.1 Decreased Cardiac Output.

8.1.1 Knowledge Deficit of Blood Pressure

Control.

> PLANNING

Expected Outcomes:

1. An accurate estimate of the arterial pressure at diastole and systole will be obtained.

2. BP is withiormal range for the client.

3. Client will be able to understand why the BP is taken and what it means.

 

 

Equipment Needed (see Figure 1-5-3):

• Stethoscope

• Mercury sphygmomanometer with bladder and cuff

• Gloves if required

• Alcohol swabs

 

> CLIENT EDUCATION NEEDED:

1. Teach the client to refrain from eating, drinking, or smoking 30 minutes before the procedure.

2. Ask the client to sit or lie down in a warm, quiet room.

3. Ask the client to rest for 5 minutes before taking the measurement.

4. Calmly explain the procedure.

5. Advise the client regarding the correct size blood pressure cuff to use at home for his individual anatomy.

6. Advise the client to take his blood pressure at the same site using the same cuff for consistency.

7. Teach the client that the “top number” in a blood pressure reading is always higher than the “bottom number.”

 

 

Figure 1-5-2 Be aware of blood pressure related factors, such

as age, anxiety, and medications prior to taking a blood pressure

reading.

 

 

Figure 1-5-3 Sphygmomanometer, stethoscope, and gloves

 

 

 

Figure 1-5-4 Select proper cuff size. An obese client

may need a larger size cuff to obtain an accurate reading.

 

 

Figure 1-5-5 Palpate the brachial artery to determine

placement of the stethoscope.

 

 

 

Figure 1-5-8 Compress the pump to inflate the blood

pressure cuff.

 

 

Figure 1-5-9 Deflate the cuff completely and wait at

least 2 minutes before taking a second reading.

 

 

 

> EVALUATION

• Evaluate the blood pressure reading for accuracy by comparing with the medical record.

• Evaluate the client’s blood pressure for being within the normal range.

• Identify variations in the client’s blood pressure of more than 5 to 10 mm Hg from one arm to the other.

• Evaluate if the client’s blood pressure changes significantly when he or she stands up.

• Report abnormal measurements to charge nurse, physician, or qualified practitioner.

> DOCUMENTATION

Vital Signs Flow Sheet

• Record the blood pressure measurement.

• Record the site where recording was done.

• Record the method of obtaining the pressure— auscultation or palpation.

> CRITICAL THINKING SKILL

Introduction

The routine of taking a blood pressure may become a mindless task. It is an important physical assessment tool.

Possible Scenario

Paul is a morbidly obese middle-aged client. He has a history of Type II diabetes and hypertension. He is being admitted to the hospital for observation of his blood sugar and blood pressure. You are performing his admission evaluation including vital signs. You use a blood pressure cuff that is in the room to take Paul’s blood pressure, even though it barely covers his arm.

Possible Outcome

Your reading shows a drastically elevated blood pressure—the admitting orders call for transfer to intensive care and Nipride therapy for a blood pressure this high. The client reports that when he took his pressure earlier in the day it was much lower. You ask another nurse to check Paul’s blood pressure.He notes that the cuff you used is too small for Paul’s arm and brings the correct size cuff from the nurses’ station. This reading is much lower. Subsequent readings with the correct size cuff show no immediate intervention is necessary.

Prevention

A blood pressure reading must be accurate to be an effective diagnostic tool. Taking a blood pressure reading on obese patients with an average size adult cuff can give a falsely elevated reading. In addition, a blood pressure cuff that is too small for the client’s arm will often come unfastened as it is inflated. Be sure to use the correct size cuff for the client.

 

 

COMMON ERRORS—ASK YOURSELF

Possible Error:

When taking a blood pressure reading the cuff is low enough on the arm that the stethoscope bell must be slid underneath the bottom edge of the cuff to be properly placed over the artery.

Ask Yourself:

How do I prevent this error?

Prevention:

Be sure to use the correct size cuff and be sure to position it correctly on the client to prevent the stethoscope from contacting the cuff.

Ask Yourself:

How do I respond to this error?

Prevention:

Remove the cuff and reapply it, fitting it firmly on the upper arm so that the antecubital space is visible and repeat the blood pressure reading.

Long-Term Care Variations:

• Be aware of any injuries, disease process, or appliances that may contraindicate a blood pressure reading at the chosen site.

 

> NURSING TIPS

• Do not take an apical blood pressure on an arm with an AV shunt, IV, or if the client has a history of surgery or injury to the breast, axilla, or arm.

• The tubes extending from the blood pressure cuff bladder are not always centered on the bladder itself. It is not accurate to assume that the area between these tubes represents the center of the cuff bladder. Be sure to center the bladder by palpating the bladder itself.

• False high readings occur when the mercury column in the manometer is not positioned flat on a firm surface, when it is read above eye level, or when the extremity is below the heart’s apex level.

• False low readings occur when the extremity is above the heart’s apex level, when the cuff is too wide for the extremity, or when the mercury column in the manometer is read below eye level.

• If the nurse fails to recognize the auscultatory gap, the temporary disappearance of sounds at the end of Korotkoff ’s Phase I and beginning of Phase II, the systolic pressure is read at a false low.

• There are many different types and brands of BP measurement devices. Become familiar with the ones you will be working with.

• If an electronic blood pressure device is used, be sure to assess the accuracy of the machine. Use the same equipment when comparing a client’s blood pressure.

COMMON ERRORS—ASK YOURSELF

Possible Error:

When taking a blood pressure reading the cuff is low enough on the arm that the stethoscope bell must be slid underneath the bottom edge of the cuff to be properly placed over the artery.

Ask Yourself:

How do I prevent this error?

Prevention:

Be sure to use the correct size cuff and be sure to position it correctly on the client to prevent the stethoscope from contacting the cuff.

Ask Yourself:

How do I respond to this error?

Prevention:

Remove the cuff and reapply it, fitting it firmly on the upper arm so that the antecubital space is visible and repeat the blood pressure reading.

 

> NURSING TIPS

• Do not take an apical blood pressure on an arm with an AV shunt, IV, or if the client has a history of surgery or injury to the breast, axilla, or arm.

• The tubes extending from the blood pressure cuff bladder are not always centered on the bladder itself.

It is not accurate to assume that the area between these tubes represents the center of the cuff bladder. Be sure to center the bladder by palpating the bladder itself.

• False high readings occur when the mercury column in the manometer is not positioned flat on a firm surface, when it is read above eye level, or when the extremity is below the heart’s apex level.

• False low readings occur when the extremity is above the heart’s apex level, when the cuff is too wide for the extremity, or when the mercury column in the manometer is read below eye level.

• If the nurse fails to recognize the auscultatory gap, the temporary disappearance of sounds at the end of Korotkoff ’s Phase I and beginning of Phase II, the systolic pressure is read at a false low.

• There are many different types and brands of BP measurement devices. Become familiar with the ones you will be working with.

• If an electronic blood pressure device is used, be sure to assess the accuracy of the machine. Use the same equipment when comparing a client’s blood pressure.

 

 

Assessment of peripheral Vascular System

and Lymphatic System

Anatomy overview

The vascular system serves several purposes:

Ø     To provide conduits for blood to travel from the heart to
nourish the various tissues of the body

Ø     To carry cellular wastes to the excretory organs

Ø     To allow lymphatic flow to drain tissue fluid back into the circulation

Ø     To return blood to the heart for recirculation

This system of conduits depends on an efficient heart and patent blood vessels to regulate and maintain systemic and re­gional blood flow and temperature.

The vascular system consists of the vessels of the body.

Vessels are tubes for transporting fluid, such as the blood or lymph.

    Function – transporting the blood or lymph :

v    Delivery of oxygen to the tissues

v    Delivery of nutrients to the tissues

v    Elimination of carbon dioxide from cells

v    Elimination of waste products from cellular metabolism

 

The vascular system is divided into the arterial system and the venous system. In the arterial system, blood moves from the larger conduits to a network of smaller blood vessels. In the venous system, blood travels from the capillar­ies to the venules and to the larger system of veins, eventually returning in the venae cavae to the heart for recirculation.

 

ARTERIAL SYSTEM

■ Structure

The high-pressure blood vessels of the arterial vascular sys­tem may be classified according to their size and wall struc­ture. The large arteries, such as the aorta and femoral arteries, follow relatively straight routes and have few branches.

Smaller arteries, such as the internal iliac and mesenteric ar­teries, divide from larger ones and have multiple branches.

Arteries may branch into arterioles or anastomose with other arteries. The arterioles branch into terminal arterioles, which join with capillaries and ultimately with venules to form the capillary network. The exchange of nutrients across the capillary membrane occurs primarily by three processes: osmosis, filtration, and diffusion.

■ Function

The arterial system delivers blood to various tissues for nourishment. At the tissue level, nutrients, chemicals, and body defense substances are distributed and exchanged for cellular waste products, depending on the needs of the par­ticular tissue. The arteries transport the cellular wastes to the excretory organs (e.g., kidneys and lungs) to be reprocessed or removed. The arteries also contribute to temperature reg­ulation in the tissues. Blood can be either directed toward the skin to promote heat loss or diverted away from the skin to conserve heat.

■ Blood Pressure

Blood pressure is the force of blood exerted against the ves­sel walls. Pressure in the larger arterial blood vessels is greater (about 80 to 100 mm Hg) and decreases as blood flow reaches the capillaries (about 25 mm Hg). By the time blood enters the right atrium, blood pressure is approximately 0 to 5 mm Hg.

■   INDIRECT MEASUREMENT OF BLOOD PRESSURE

The blood pressure in the arterial system is determined pri­marily by the quantity of blood flow or cardiac output (CO), as well as by the resistance in the arterioles:

Blood pressure = Cardiac output x Peripheral vascular resistance

Any factor that increases CO or total peripheral vascular re­sistance increases blood pressure. In general, blood pressure is maintained at a relatively constant level; therefore an in­crease or decrease in total peripheral vascular resistance is as­sociated with a decrease or an increase in CO, respectively.

Three mechanisms mediate and regulate blood pressure:

Ø     The autonomic nervous system, which excites or inhibits sympathetic nervous system activity in response to im­pulses from chemoreceptors and baroreceptors

Ø     The kidneys, which sense a change in blood flow and ac­tivate the renin-angiotensin-aldosterone mechanism

Ø     The endocrine system, which releases various hormones (e.g., catecholamine, kinins, serotonin, and histamine) to stimulate the sympathetic nervous system at the tissue level

Systolic blood pressure represents the amount of pres­sure/force generated by the left ventricle to distribute blood into the aorta with each contraction of the heart; diastolic blood pressure represents the amount of pressure/force sus­tained by the arteries during the relaxation phase of the heart. In the adult, systolic pressure is normally 90 to 135 mm Hg, and diastolic pressure is normally 60 to 85 mm Hg. Blood pressure is expressed as systolic pressure/diastolic pressure.

Systolic pressure is affected by a number of factors, in­cluding CO. When CO decreases, systolic pressure also de­creases. Diastolic pressure is primarily determined by the amount of vasoconstriction in the periphery. An increase in peripheral vascular resistance increases diastolic pressure and cardiac workload.

 

REGULATION OF BLOOD PRESSURE

The autonomic nervous system (ANS) and the renal system are primarily responsible for regulating blood pressure. Ex­ternal factors can also affect blood pressure.

Autonomic nervous system. Blood pressure is regulated by balancing the sympathetic and parasympathetic nervous systems of the autonomic nervous system. Changes in sympathetic and parasympathetic activity are responses to messages sent by the sensory receptors in the various tissues of the body. These receptors, including the baroreceptors, chemoreceptors, and stretch receptors, respond differently to the biochemical and physiologic changes of the body.

Baroreceptors in the arch of the aorta and at the origin of the internal carotid arteries are stimulated when the arterial walls are stretched by an increased blood pressure. Impulses from these baroreceptors inhibit the vasomotor center, which is located in the pons and the medulla. Inhibition of this cen­ter results in a drop in blood pressure.

Several 1- to 2-mm collections of tissue have been identified in the bifurcations of the carotid arteries and along the aortic arch. These carotid and aortic bodies contain specialized chemoreceptors that are sensitive primarily to hypoxemia (a de­crease in the partial pressure of arterial oxygen [Pao₂]). When stimulated, the carotid chemoreceptors send impulses along Hering’s nerves, and the aortic chemoreceptors send impulses along the vagus nerves to activate a vasoconstrictor response.

The chemoreceptors are also stimulated by hypercapnia (an increase in partial pressure of arterial carbon dioxide [Paco₂]) and acidosis. However, the direct effect of carbon dioxide on the central nervous system is 10 times stronger than the effect it produces by stimulating the chemoreceptors.

Stretch receptors found in the venae cavae and the right atrium are sensitive to pressure or volume changes. When a client is hypovolemic, the stretch receptors in the blood ves­sels sense a reduced volume or pressure and send fewer im­pulses to the central nervous system. This reaction stimulates the sympathetic nervous system to increase heart rate and constrict the peripheral blood vessels.

Renal system. The renal system also helps to regu­late cardiovascular activity. When renal blood flow or pres­sure decreases, the kidneys retain sodium and water. Blood pressure tends to rise because of fluid retention and because of activation of the renin-angiotensin-aldosterone mechanism. Vascular volume is also regulated by the release of antidi-uretic hormone (vasopressin) from the posterior pituitary gland.

External factors. Other factors can influence the activity of the cardiovascular system. Emotional behaviors (e.g., excitement, pain, anger) stimulate the sympathetic ner­vous system to increase blood pressure and heart rate. In­creased physical activity such as exercise increases blood pres­sure and pulse rate. Body temperature can affect the metabolic needs of the tissues, thereby influencing the delivery of blood. In hypothermia, tissues require fewer nutrients and blood pressure sure falls. In hyperthermia, the metabolic requirement of the tissues is greater, and blood pressure and pulse rate rise.

 

VENOUS SYSTEM

■ Structure

The venous system is composed of a series of veins that are located adjacent to the arterial system. A second superficial venous circulation runs parallel to the subcutaneous tissue of the extremity. These two venous systems are connected by communicating veins that provide a means for blood to travel from the superficial veins to the deep veins. Blood flow is di­rected toward the deep venous circulation.

The venules collect blood from the capillaries and the ter­minal arterioles. White blood cells also enter and exit the body tissues at the venules.

Venules branch into veins, which are low-pressure blood vessels. Veins have the ability to accommodate large shifts in volume with minimal changes in venous pressure. This flexi­bility allows the venous system to accommodate the adminis­tration of intravenous (IV) fluids and blood transfusions, blood loss, and dehydration. All veins in the superficial and deep venous systems in the legs (except the smallest and the largest veins) have valves that direct blood flow back to the heart; this prevents retrograde flow (backflow).

■ Function

The primary function of the venous system is to complete the circulation of blood by returning blood from the capillaries to the right side of the heart. The venous system also acts as a reservoir for a large portion of the blood volume. In contrast to the arterial system, which consists of a high-pressure, con­tinuous flow system through relatively rigid conduits, the ve­nous system consists of a low-pressure, intermittent flow sys­tem through collapsible tubes that work against the effects of gravity.

Gravity exerts an increase in hydrostatic pressure (capil­lary blood pressure) when the client is in an upright position, which delays venous return. Hydrostatic pressure is lessened when the client is lying down, and thus there is less hindrance of venous return to the heart.

Cardiovascular Changes Associated with Aging

A number of physiologic changes in the cardiovascular sys­tem occur with advancing age. Many of these changes result in a loss of cardiac reserve. Thus these changes are usually not evident when the older adult is resting. They become apparent only when the person is physically or emo­tionally stressed and the heart cannot meet the increased metabolic demands of the body.

LYMPHATICS

n     A completely separate vascular system.

n     It retrieves excess fluid from the tissue spaces and returns it to the blood stream.

Lymphatic ducts and drainage patterns

Functions of the lymphatic system:

à       To converse fluid and plasma proteins that leak out of the capillaries.

à       To form the major part of the immune system that defends body against infection.

à       To absorb lipids from the intestinal tract.

Lymphoid tissue:

    Lymph nodes:

§        Filter the fluid before it comes back to the bloodstream

§        Filter out microorganisms

    Tonsils:

§        Pharyngeal (adenoid)

§        Palatine

§        Lingual

    Spleen

    Peyer’s patches (Lymphoid tissue in intestines)

    Tymus gland

    Bone marrow

 

ASSESSMENT TECHNIQUES

Taking client’s complaints and history

n     Ask: “Any leg pain (cramps)? Where?”

n     Detail: pain type, onset (gradual/sudden), aggravating/ relieving factors (activity, walking, dangling, rubbing), associated signs (skin changes, sexual malfunction), relation to time of day, claudication distance.

 

 

 

History

The nurse obtains a thorough history, which includes demo­graphic data, personal and family history, diet, socioeconomic status, and a functional assessment. The focus of the history is on obtaining information relative to client’s risk factors and symptoms of cardiovascular disease.

■ DEMOGRAPHIC DATA

Demographic data include the client’s age, sex, and ethnic origin. The incidence of conditions such as coronary artery disease (CAD) and valvular disease increases with age (AHA, 1998). The incidence of CAD also varies with the client’s sex. Women who are premenopausal have a lower incidence of CAD than do men.

CULTURAL CONSIDERATIONS

Information about the client’s ethnic or cultural back­ground is important because some disease conditions may be more prevalent in specific ethnic groups. For example, African Americans and Mexican Americans have a higher incidence of hypertension than do Caucasians (AHA, 1998). The nurse should be aware that some clients may refer to their hyper­tension as “high blood.”

Age, sex, ethnic background, and family history of cardio­vascular disease are considered nonmodifiable or uncontrol­lable risk factors for cardiovascular disease. Modifiable risk factors (e.g., high blood pressure and excessive blood choles­terol), if controlled, can reduce the risk of heart disease.

 PERSONAL AND FAMILY HISTORY

The nurse reviews the client’s history, noting any major ill­nesses such as diabetes mellitus, renal disease, anemia, high blood pressure, stroke, bleeding disorders, connective tissue diseases, chronic pulmonary diseases, heart disease, and thrombophlebitis. These conditions can influence the client’s cardiovascular status.

The nurse asks about previous treatment for cardiovas­cular disease, identifies previous diagnostic procedures (e.g., electrocardiography and cardiac catheterization), and requests information about any medical or invasive treat­ment of cardiovascular disease. It is important for the nurse to ask specifically about recurrent tonsillitis, streptococcal infections, and rheumatic fever, because these conditions may lead to valvular abnormalities of the heart. In addi­tion, the nurse inquires about any known congenital heart defects. Many clients with congenital heart problems are living into adulthood because of improved treatment and surgical modalities.

Clients are asked in detail about their medication history, beginning with any current or recent use of prescription or over-the-counter (OTC) medications or herbal/natural prod­ucts (e.g., ginseng). The nurse inquires about known sensitiv­ities to any drug and the nature of the reaction (e.g., nausea, rash). Clients should be asked whether they have recently used cocaine or any IV “street” drugs, because they may be associated with chest pain or endocarditis.

The nurse also asks female clients whether they are taking oral contraceptives or an estrogen replacement. There is an increased incidence of myocardial infarction (MI) and stroke in women over the age of 35 who take oral contraceptives, but only if they smoke, have diabetes, or have hypertension

The nurse reviews the family history and obtains informa­tion about the age, health status, and cause of death of immediate family members. A family history of hyperten­sion, obesity, diabetes, or sudden cardiac death is especially significant.

DIET HISTORY

A diet history includes the client’s recall of food and fluid in­take during a 24-hour period, self-imposed or medically pre­scribed dietary restrictions or supplementations, and the amount and type of alcohol consumption.

The dietitian re­views the type of foods selected by the client for the amount of sodium, sugar, cholesterol, fiber, and fat. The nurse or di­etitian also explores the client’s attitude toward food, knowl­edge level of essential and nonessential dietary elements, and willingness to make changes in the diet. Cultural beliefs and economic status can influence the choice of food items and therefore must be reviewed. Family members or significant others who are responsible for shopping and cooking are in­cluded in this discussion.

SOCIOECONOMIC STATUS

The social history includes information about the client’s do­mestic situation, such as marital status, number of children, household members, living environment, and occupation. The nurse also identifies support systems. It is especially impor­tant to explore the possibility that the client might have diffi­culty paying for medications or treatment.

The nurse asks about the client’s occupation, including the type of work performed and the requirements of the specific job. For instance, does the job involve lifting of heavy ob­jects? Is the job emotionally stressful? What does a day’s work entail? Does the client’s job require him or her to be out­side in extreme weather conditions?

MODIFIABLE RISK FACTORS

Personal habits that are risk factors for heart disease include cigarette smoking, physical inactivity, obesity, and type A be­havior. These factors are considered modifiable or control­lable risk factors. The nurse inquires about each of the fol­lowing modifiable risk factors.

Cigarette Smoking

Cigarette smoking is a major risk factor for cardiovascular disease, specifically CAD and peripheral vascular disease (PVD) (AHA, 1998). According to the U.S. Department of Health and Human Services (DHHS), cigarette smoking is directly responsible for 21% of all deaths from CAD. Three compounds in cigarette smoke have been implicated in the development of CAD: tar, nicotine, and carbon monoxide.

The risks to the cardiovascular system from cigarette smoking appear to be dose related, noncumulative, and tran­sient. The smoking history should include the number of cig­arettes smoked daily, the duration of the smoking habit, and the age of the client when smoking started. A person who smokes fewer than 4 cigarettes per day has twice the risk of cardiovascular disease of a person who does not smoke; a per­son who smokes more than 20 cigarettes per day has four times the risk. Typically, the nurse records the smoking his­tory in pack-years, which is the number of packs per day mul­tiplied by the number of years the client has smoked.

The nurse should inquire about the client’s desire to quit, past attempts to quit, and the methods used. The nurse may ascertaiicotine dependence by asking questions such as the following:

•  How soon after you wake up in the morning do you smoke?

•  Do you find it difficult not to smoke in places where smoking is prohibited?

•  Do you smoke when you are ill?

Three to four years after a client has stopped smoking, his or her cardiovascular risk appears to be similar to that of a person who has never smoked. The nurse asks clients who do not currently smoke whether they have ever smoked and when they quit.

Physical Inactivity

A sedentary lifestyle is also considered a significant risk fac­tor in the development of heart disease. Regular physical ac­tivity promotes cardiovascular fitness and produces beneficial changes in blood pressure and levels of blood lipids and clot­ting factors.

Unfortunately, few people in the United States engage in the recommended exercise guidelines: 30 minutes daily of light to moderate exercise, which is equivalent to a 30-minute brisk walk. According to the American Heart As­sociation, only 22% of Americans engage in this much exer­cise five times a week, and only 15% engage in vigorous physical activity (enough to promote cardiopulmonary fit­ness) three times a week (AHA, 1998). Therefore more peo­ple are at risk for CAD from physical inactivity than from any other factor.

The nurse questions clients concerning the type of exercise in which they engage, the period for which they have participated in the exercise, and the frequency and in­tensity of the exercise.

Obesity

Approximately 104 million Americans adults are overweight when defined as a body mass index (BMI) of 25 to 30. An­other 42 million Americans are obese, which is defined as a BMI greater than 30 (AHA, 1998). Obesity in the American population has increased 36% in the last 30 years; it is partic­ularly a problem for African-American females, Mexican Americans, and native Hawaiians (AHA, 1998).

Obesity is as­sociated with hypertension, hyperlipidemia, and diabetes; all are known contributors to cardiovascular disease.

The nurse weighs the client, calculates the BMI, and ex­amines the pattern of obesity, also known as the waist-hip ra­tio. Chapter 61 describes these assessments in detail.

Type A Personality

Researchers have identified that people with type A personal­ities are more vulnerable to the development of heart disease. Type A personalities are highly competitive, overly concerned about meeting deadlines, and are often hostile or angry. The nurse might ask the client: “Have you ever experienced road rage?” or “How do you respond when you have to wait for an appointment?” The chronic anger and hostility displayed by type A people appear to be most closely associated with car­diovascular disease. The constant arousal of the sympathetic nervous system as a result of anger may influence blood pres­sure, serum fatty acids and lipids, and clotting mechanisms. The nurse observes the client and determines his or her re­sponse to stressful situations.

Objective data

Preparation:

n           Environment

n     Should be warm (about 22°C) and draftless to prevent vasodilatation or vasoconstriction.

n           Privacy

n     Make sure the female’s breasts and client’s genitals remain draped.

n           Order of exam

n     Begin with observations peripherally and move toward the heart.

1.     Pulse and blood pressure

2.     Extremities – peripheral vascular assessment

3.     Neck vessels

4.     Precordium – (portion of body over heart and thorax)

n           Equipment needed:

n     Tourniquet or blood pressure cuff

n     Stethoscope

n     Paper tape measure

n     Doppler ultrasonic stethoscope

 

Arteries accessible to examination on hand

Arteries accessible to examination on leg

Veins accessible to examination

v    Jugular veins

v    Veins in the arm:

Ø     Superficial – in the subQ tissue, responsible for most of the venous return

Ø     Deep

v    Veins in the leg:

Ø     Deep veins: femoral, popliteal; responsible for most of the venous return

Ø     Superficial: great and small saphenous

Ø     Perforators: connecting veins that join the two sets. They have one-way valves ► blood ► into the deep veins.

Groups of peripheral lymph nodes:

1.     Auricular: anterior and posterior

2.     Sublingual.

3.     Submandibular.

4.     Cervical: anterior and posterior.

5.     Supra- and subclavian.

6.     Axillary.

7.     Epithrochlear.

8.     Inguinal.

9.     Popliteal.

Assesment:

n     Inspection and palpation

n     Amount in each group

n     Size

n     Shape

n     Consistency

n     Movable/connected with surrounding tissues

n     Pain/tenderness

n     Signs of inflammation: swelling and redness above the node

The nurse assesses the client’s hands, arms, feet, and legs for skin changes, vascular changes, clubbing, capillary filling, and edema. Skin mobility and turgor are affected by the fluid status of the client. Dehydration and aging reduce skin turgor, and edema decreases skin mobility. Vascular changes in an af­fected extremity may include paresthesia, muscle fatigue and discomfort, numbness, pain, coolness, and loss of hair distri­bution from a reduced blood supply.

Clubbing of the fingers and toes results from chronic oxy­gen deprivation in these tissue beds. Clubbing is characteris­tic in clients with advanced chronic pulmonary disease, con­genital heart defects, and cor pulmonale. Clubbing can be identified by assessing the angle of the nail bed. The angle of the normal nail bed is 160 degrees. With clubbing, this angle increases to greater than 180 degrees, and the base of the nail becomes spongy.

Capillary filling of the fingers and the toes is an indicator of peripheral circulation. Pressing or blanching the nail bed of a finger or a toe produces a whitening effect; when pressure is released, a brisk return of color should occur. If color returns within 3 seconds, peripheral circulation is considered intact. If the capillary refill time exceeds 3 seconds, the lack of cir­culation may be due to arterial insufficiency from atheroscle­rosis or spasm. Older adults typically have a prolonged capil­lary refill. Rubor (dusky redness) that replaces pallor in a dependent foot suggests arterial insufficiency.

Peripheral edema is a common finding in clients with car­diovascular problems. The location of edema helps the nurse to determine its potential cause. Bilateral edema of the legs may be seen in clients with heart failure or chronic venous in­sufficiency. Abdominal and leg edema can be seen in clients with heart disease and cirrhosis of the liver. Localized edema in one extremity may be the result of venous obstruction (thrombosis) or lymphatic blockage of the extremity (lymph-edema). Edema may also be noted in dependent areas, such as the sacrum, when a client is confined to bed.

The nurse documents the location of edema as precisely as possible (e.g., midtibial or sacral) and the number of centime­ters from an anatomic landmark. Although some health care severe (or 1 + , 2+, 3 + , or 4+), there is no universal scale. In addition, these values are not precise and are subjective. In­stead of using a grading scale, the nurse determines whether the edema is pitting (the skin can be indented) or nonpitting, the depth of the pit (in millimeters), and the amount of time the pit lasts (in seconds).

 

 BLOOD PRESSURE

Arterial blood pressure is measured indirectly by sphygmomanometry.

Normal blood pressure in adults older than 45 years of age ranges from 90 to 140 mm Hg for systolic pressure and from 60 to 90 mm Hg for diastolic pressure (AHA, 1998). A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption. Approximately 50 million Americans (one out of every 5 Americans) have hypertension, which is defined as a blood pressure greater than 140/90 mm Hg. Although the cause of hypertension is not known in 90% of people, it can be effectively controlled with lifestyle modification and/or medication. Hypertension is a cause of approximately 5 million deaths each year on its own and is a major contributor to the development of coro­nary artery disease and heart failure.

A blood pressure less than 90/60 mm Hg may be inade­quate for providing proper and sufficient nutrition to body cells. In certain circumstances, such as shock and hypoten­sion, the Korotkoff sounds are less audible or are absent. In these cases the nurse might palpate the blood pressure, use an ultrasonic device (Doppler device), or obtain a direct meas­urement by arterial catheter. When blood pressure is palpated, the diastolic pressure is usually not obtainable.

Postural Blood Pressure

Clients may report dizziness or lightheadedness when they move from a flat, supine position to a sitting or a standing po­sition at the edge of the bed. Normally these symptoms are transient and pass quickly; pronounced symptoms may be due to orthostatic (postural) hypotension. Postural hypotension occurs when blood pressure is not adequately maintained while moving from a lying to a sitting or standing position. It is defined as a decrease of more than 20 mm Hg of the sys­tolic pressure or more than 10 mm Hg of the diastolic pres­sure, as well as a 10% to 20% increase in heart rate. The causes of postural hypotension include medications, depletion of blood volume, prolonged bedrest, and age-related changes or disorders of the autonomic nervous system.

To detect orthostatic changes in blood pressure, the nurse first measures the blood pressure when the client is supine. After remaining supine for at least 3 minutes, the client changes position to sitting or standing. Normally systolic pressure drops slightly or remains unchanged as the client rises, whereas diastolic pressure rises slightly. After the posi­tion change, a time delay of 1 to 5 minutes should be permit­ted before auscultating blood pressure and palpating the radial pulse. The cuff should remain in the proper position on the client’s arm. The nurse observes and records any signs or symptoms of distress. If the client is unable to tolerate the po­sition change, he or she is returned to the previous position of comfort.

Paradoxical Blood Pressure

Paradoxical blood pressure is defined as an exaggerated de­crease in systolic pressure by more than 10 mm Hg during the inspiratory phase of the respiratory cycle (normal is 3 to 10 mm Hg). Certain clinical conditions that potentially alter the filling pressures in the right and left ventricles may produce a paradoxical blood pressure. Such conditions include pericar-dial tamponade, constrictive pericarditis, and pulmonary hy­pertension. During inspiration, the filling pressures normally

decrease slightly. However, the decreased fluid volume in the ventricles resulting from these pathologic conditions pro­duces an exaggerated or marked reduction in cardiac output.

Hepatojugular reflux is determined by locating the internal jugular vein after positioning the client with the head of the bed elevated to 45 degrees. The nurse compresses the right upper abdomen for 30 to 40 seconds. Sudden distention of the neck veins after abdominal compression is usually indicative of right-sided heart failure.

Pulse Pressure

The difference between the systolic and diastolic values is re­ferred to as pulse pressure. A normal pulse pressure for an adult is 30 to 40 mm Hg. This value can be used as an indi­rect measure of cardiac output. A more precise measurement, proportional pulse pressure, is calculated as follows:

Proportional pulse pressure = (Systolic blood pressure – Diastolic blood pressure)/ Systolic blood pressure

A proportional pulse pressure less than 25% usually indi­cates a cardiac index of less than 2.2, as well as a critically low cardiac output (Stevenson & Braunwald, 1998). Nar­rowed pulse pressure is rarely normal and results from in­creased peripheral vascular resistance or decreased stroke vol­ume in clients with heart failure, hypovolemia, or shock. Narrowed pulse pressure can also be seen in clients who have mitral stenosis or regurgitation. An increased pulse pressure may be seen in clients with slow heart rates, aortic regurgita­tion, atherosclerosis, hypertension, and aging.

Ankle Brachial Index

The ankle brachial index (ABI) can be used to assess the vascular status of the lower extremities. The nurse applies a blood pressure cuff to the lower extremities just above the malleoli and measures the systolic pressure by Doppler ul­trasound at both the dorsalis pedis and posterior tibial pulses. The higher of these two pressures is then divided by the higher of the two brachial pulses to obtain the ankle brachial index:

 

 

 

 

 

 

 

 

 

 

 

 

 

Normal values for ABI are 1 or higher, because blood pres­sure in the legs is usually higher than blood pressure in the arms. ABI values less than 0.80 usually indicate moderate vascular disease, whereas values less than 0.50 indicate severe vascular compromise.

VENOUS AND ARTERIAL PULSATIONS

Venous Pulsations

The nurse observes the venous pulsations in the neck to assess the adequacy of blood volume and central venous pressure (CVP). The nurse can assess jugular venous pressure (JVP) to estimate the filling volume and pressure on the right side of the heart . The right internal jugular vein is usu­ally used to estimate JVP.

Arterial Pulsations

Assessment of arterial pulsations gives the nurse information about vascular integrity and circulation.

For clients with sus­pected or actual vascular disease, all major peripheral pulses, including the temporal, carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis pulses, need to be assessed for presence or absence, amplitude, con­tour, rhythm, rate, and equality. The nurse examines the pe­ripheral arteries in a head-to-toe approach with a side-to-side comparison.

A hypokinetic pulse is a weak pulsation indicative of a nar­row pulse pressure. It is seen in clients with hypovolemia, aortic stenosis, and decreased cardiac output.

A hyperkinetic pulse is a large, “bounding” pulse caused by an increased ejection of blood. It is seen in clients with a high cardiac output (with exercise or thyrotoxicosis) and in those with increased sympathetic system activity (with pain, fever, or anxiety).

In pulsus alternans, a weak pulse alternates with a strong pulse despite a regular heart rhythm. It is seen in clients with severely depressed cardiac function. Clients may be asked to hold their breath to exclude any false readings. The nurse may palpate the brachial or radial arteries to assess this condition, but it is more accurately assessed by auscultation of blood pressure.

Auscultation of the major arteries (e.g., carotid and aorta) is necessary to assess for bruits. Bruits are swishing sounds that may develop iarrowed arteries and are usually associated with atherosclerotic disease. The nurse can assess for the ab­sence or presence of bruits by placing the bell of the stetho­scope over the skin of the carotid artery while the client holds his or her breath. Normally there are no sounds if the artery has uninterrupted blood flow. A bruit may develop when the inter­nal diameter of the vessel is narrowed by 50% or more, but this does not indicate the severity of disease in the arteries. Sever­ity is determined by Doppler flow studies and arteriography.