Responses
to Altered
Tissue Perfusion
Assessment
The development of cardiac
problems within the individual is
very traumatic and anxiety
provoking.
Information pertaining to the
cardiovascular
system
will
enable the critical care nurse to
provide the delivery of more
Nurse proficiency is required in the
mental, emotional, and physical
assessment
of
the
individual
suffering from cardiovascular issues.
Strength in assessment skills and
techniques will guide patient care,
stabilize the patient’s condition, and
prevent additional cardiovascular
deterioration.
History and
Interview
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conducted in a nonthreatening and
nonintimidating manner.
The patient’s presenting symptoms
and complaints need to be explored
using an organized framework.
If the patient is experiencing active
chest pain, the OPQRST organized
assessment can be used so the
critical care nurse is consistent and
Onset
Precipitating factor
Quality
Sudden, sometimes predictable.
Stress, exercise, or exertion.
Frequently patients discomfort is heavy,
viselike, crushing, or squeezing. Women,
the elderly, and patients with diabetes may
have shortness of breath, mild indigestion.
May be silent.
Radiation
Poorly localized but may radiate to neck,
jaw, and down arms
Discomfort to agonizing pain. Have the
patient rate on a scale of 1–10.
Comes and ends abruptly. Usually
responds to rest, oxygen, and
nitroglycerin. Time of day when it occurs
(day/night/after a heavy meal).
Severity
Timing
Additional questions to ask:
what the patient did to relieve the pain or
discomfort?
Other associated symptoms such as
dyspnea or shortness of breath going up
and down stairs along with dizziness,
extreme sweating, or diaphoresis should be
noted.
Diet, medication, alcohol, tobacco use, and
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A one-word response of
“retired” needs further
clarification by asking what the
person did and what do they
do now.
The patient’s history, if
accurately obtained, will
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If patients are emotionally
distraught or in denial about
recent changes in their health
status, the nurse should allow them
some space and quiet time to
compose themselves for a few
minutes prior to seeking and
eliciting additional information.
Inspecti
on
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Observe the patient’s attitude, body
posture, facial expressions, weight, and
skin color.
If the patient appears obese or
overweight, this condition could
suggest a cardiac risk factor.
Facial expressions alone can indicate
apprehension or pain, as well as
lethargy, alertness, or confusion.
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Skin color such as pallor or cyanosis is an
important indicator of poor cardiac
perfusion.
Skin condition such as dry, scaly, cracked,
shiny, tented turgor, and absence of hair
growth are indicative or poor peripheral
circulation.
Skin temperature such as warm, cool, hot, or
redness can indicate secondary
complications like poor circulation and
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Skin color such as pallor or cyanosis is
an important indicator of poor cardiac
perfusion.
Skin condition such as dry, scaly,
cracked, shiny, tented turgor, and
absence of hair growth are indicative
or poor peripheral circulation.
Skin temperature such as warm, cool,
hot, or redness can indicate secondary
complications like poor circulation and
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A bulge over the chest wall could
signify a pacemaker or implantable
cardiac defibrillator (ICD).
Systematically assess the patient
for signs of edema, alterations in
fluid and nutritional status, and
cyanosis of the lips, conjunctiva,
mucous membranes, and nail
beds.
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Body posture and position will give an
indication of the effort the patient is
using to breathe easier or to relieve
discomfort. Respiratory rate, pattern,
and effort should also be observed and
recorded.
The only normal pulsation visualized
on the chest wall is the apical impulse,
also referred to as the PMI or point of
maximal impulse. It is a quick, localized,
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An abnormal pulsation that
can be seen on inspection of
the neck is jugular venous
distention (JVD).
With the patient lying supine
and the head elevated 30 to
45 degrees, you should not see
visible pulsation at the side of
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JVD is a response to increased
intrathoracic pressure during the
Valsalva maneuver and can
temporarily be seen normally
when a weightlifter bears down
while lifting weights.
If you see visible pulsations that
occur above the jaw line, this
might indicate an increase in
Locations of the Heart Valves
Valve
Location
Aortic
2nd ICS (intercostal space) to
right of sternum. Only region heart
sounds heard to right of sternum.
Pulmonic
2nd ICS, to the left of the sternum.
Right across from the aortic
area.
Tricuspid
4th ICS to the left of the sternum,
4th intercostal space
Mitral
5th ICS, MCL (midclavicular line);
PMI
Palpati
on
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achieved by the nurse using a light
sense of touch and a relaxed,
unhurried approach.
used to assess pulsations in the
neck, thorax, abdomen, and
extremities.
It is also used to assess skin turgor,
capillary refill, temperature of the
skin, and the presence and amount
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Pulse strength and volume is
usually graded on a scale of (0
to +3) and includes the
bilateral assessment of the
following arteries: carotid,
brachial, radial, ulnar,
popliteal, dorsalis pedis,
posterior tibial, and femoral.
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Palpation should be done using
the fingertips and intensity of the
pulse graded on a scale of 0 to 4
+:0 indicating no palpable pulse; 1
+ indicating a faint, but detectable
pulse; 2 + suggesting a slightly
more diminished pulse than
normal; 3 + is a normal pulse; and
4 + indicating a bounding pulse.
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An abnormal tremor or vibration felt on
palpation in the lower left abdominal area is
known as a thrill and can indicate a cardiac
murmur or abdominal aortic aneurysm.
Use the pads of the fingers to assess pulse
function. Never assess the carotid pulses
simultaneously because doing so will obstruct
oxygenated blood fl ow to the brain,
especially if these arteries are compromised
by arteriosclerosis or plaque.
A patient with cardiac failure can gain as
much as 10 or more pounds of excess body
Percussi
on
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Generally, and with good
reason, this assessment
technique is omitted when
caring for the cardiovascular
patient. If assessment is
needed a chest x-ray provides
the necessary data for
cardiac enlargement
Auscultati
on
Normal Heart Sounds
The first heart sound, or S1, is the
single sound (lub) produced when
the mitral and tricuspid valves
close. The second heart sound or
S2 (dub) is heard loudest as the
semilunar valves close.
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Both S1 and S2 are high-pitched and
are heard best using the diaphragm of
The Two Normal Heart Sounds
Sound
Heart cycle
Location
Closure
S1
S2
Lub
Dub
Systole
Diastole
Apex
Base
Mitral/tricuspid
valves
Aortic/pulmonic
Abnormal Heart
Sounds
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Abnormal heart sounds are referred to as
S3 and S4 or “gallops” when auscultated
during tachycardia.
are low-pitched ventricular filling sounds
that can occur during diastole and may
be caused by pressure changes, valvular
dysfunctions, and conduction deficits.
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S3 heart sound resembles a dull,
low-frequency, thudlike sound, as in
ventricular galloping, for example,
“lub-dub, lub-dub,” or “Kentucky,
Kentucky, kentucky.”
A finding of S3 is normal in
children and young adults and
usually disappears by the mid-30s.
The finding of an S3 gallop in an
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4th heart sound has a hollow, low-frequency,
snappy sound.
It is an atrial gallop produced by atrial
contractions forcing blood into a noncompliant
ventricle that is resistant to filling.
The sound increases in intensity during
inspiration.
It is heard late in diastole prior to the onset of S1
of the next cardiac cycle, and has the rhythm of
the word “Tennessee,” or “le-lub-dub.”
An S4 can benormal in an elderly person.
It can also been heard in a myocardial infarction
Other Heart Sounds
Murmurs
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are prolonged extra sounds that
occur during systole or diastole.
are heard loudest over the valve that
is affected.
Are vibrations caused by turbulent
blood flow through the cardiac
chambers.
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Other causes include fever, anemia,
exercise, or structural defects such as
a patent foramen ovale.
Intensity of a murmur is measured on
a scale of 1 to 6.
The higher the number, the louder the
murmur.
A grade 1 can barely be heard even
with turning the patient to his or her
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A grade 4 can usually be felt
through the chest wall, and a grade
6 can be heard at the bedside
without a stethoscope.
Are also characterized by systolic or
diastolic timing, high or low pitch,
location, radiation, and quality, for
example, “blowing,” “harsh,” or
“grating.”
Pericardial Friction Rubs
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is described as a high-pitched
back-and-forth scratching or grating
sound that is equivalent to cardiac
motion
within the pericardial sac.
is accompanied by chest pain
secondary to pericardial
inflammation or effusion that can
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Can be auscultated at Erb’s point,
which is the 3rd intercostal space to
the left of the sternum.
When a pericardial friction rub is
heard, report it to the health care
provider immediately as
anticoagulant therapy may need to
be stopped.
can indicate bleeding in the
Other Vascular Sounds—Bruit
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an extracardiac vascular sound that is high
pitched and swishing in its characteristics.
caused by either increased blood flow through a
normal vessel or blood flow through a partially
occluded or torturous vessel.
Assess for bruits over the carotid, renal, and
femoral arteries.
can indicate stenosis of these vessels or
aneurysm.
can also be heard over a patent AV shunt for
Diagnostic
and
Laboratory
Tools
Arterial Blood Gases or ABGs
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Respiratory issues such as pulmonary congestion can
develop in individuals with cardiovascular deficits, thereby
compromising their health status.
may be indicated to monitor levels of blood oxygenation.
If the patient has an intraarterial line usually placed in the
radial or femoral arteries, arterial blood gas samples can be
obtained from these lines using sterile techniques.
Chest X-Ray
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significant in determining the following: cardiac
structure and size, dilation of the main
pulmonary artery, pulmonary congestion,
pleural
or cardiac effusion, the presence or position of
pacemakers, intracardiac lines, and pulmonary
artery catheters.
the oldest noninvasive method used to visualize
heart images.
EKG, ECG—Electrocardiogram
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noninvasive, 12-lead EKG is recommended
and is always valuable in providing
cardiac diagnostic information.
Electrical conduction changes that occur
within the heart are recorded and
monitored on rhythm strips.
Diagnosis of an acute MI can be seen with
an ECG.
Interpretin
g EKG
Sinus Tachycardia
Sinus tachycardia is a heart rate greater than
100 beats per minute that originated from
the sinus node.
Rate: 100 to 180 beats per minute
P Waves precede each QRS complex
PR interval is normal
QRS complex is normal
Conduction is normal
Rhythm is regular
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Sinus Tachycardia
Causes of sinus tachycardia may include
exercise, anxiety, fever,
drugs, anemia, heart
failure, hypovolemia and shock. Sinus
tachycardia is often asymptomatic.
Management however is directed at the
treatment of the primary cause. Carotid
sinus pressure (carotid massage) or a
Sinus Bradycardia
Sinus bradycardia is a heart rate less than 60 beats
per minute and originates from the sinus node (as the
term “sinus” refers to sinoatrial node). It has the
following characteristics
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Rate is less than 60 beats per minute
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P Waves precede each QRS complex
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PR interval is normal
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QRS complex is normal
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Conduction is normal
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Rhythm is regular
Sinus Bradycardia
Causes may include drugs, vagal stimulation,
hypoendocrine states, hypothermia, or sinus
node involvement in MI. This arrhythmia may
be normal in athletes as they have
quality stroke volume. It is often asymptomatic
but manifestations may include:
syncope, fatigue, dizziness. Management
includes treating the underlying cause and
administering anticholinergic drugs
Premature Atrial Contraction
Premature Atrial Contraction are ectopic beats
that originates from the atria and they are not
rhythms. Cells in the heart starts to fire or go
off before the normal heartbeat is supposed
to occur. These are called heart palpitations
and has the following characteristics:
Premature and abnormal-looking P waves
that differ in configuration from normal P
waves
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Premature Atrial Contraction
Causes includes coronary or valvular
heart diseases, atrial ischemia, coronary
artery atherosclerosis, heart failure,
COPD, electrolyte imbalance and
hypoxia. Usually there is no treatment
needed but may include procainamide
and quinidine administration
(antidysrhythmic drugs) and carotid
Atrial Flutter
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Atrial flutter is an abnormal rhythm that occurs in
the atria of the heart. Atrial flutter has an atrial
rhythm that is regular but has an atrial rate of 250
to 400 beats/minute. It has sawtooth appearance.
QRS complexes are uniform in shape but often
irregular in rate.
Normal atrial rhythm
Abnormal atrial rate: 250 to 400 beats/minute
Sawtooth P wave configuration
QRS complexes uniform in shape but irregular in
Atrial Flutter
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Causes includes heart failure, tricuspid valve or
mitral valve diseases, pulmonary embolism, cor
pulmonale, inferior wall MI, carditis
and digoxin toxicity.
Management if the patient is unstable with
ventricular rate of greater than 150 bpm, prepare for
immediate cardioversion. If patient is stable, drug
therapy may include calcium channel blocker,
beta-adrenergic blockers, or antiarhythmics.
Anticoagulation may be necessary as there would be
Atrial Fibrillation
Atrial fibrillation is disorganized and uncoordinated
twitching of atrial musculature caused by overly rapid
production of atrial impulses. This arrhythmia has the
following characteristics:
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Atrial Rate: 350 to 600 bpm
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Ventricular Rate: 120 to 200 bpm
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P wave is not discernible with an irregular baseline
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PR interval is not measurable
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QRS complex is normal
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Rhythm is irregular and usually rapid unless
Atrial Fibrillation
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Causes includes atherosclerosis, heart
failure, congenital heart disease, chronic obstructive
pulmonary disease, hypothyroidism and
thyrotoxicosis. Atrial fibrillation may be
asymptomatic but clinical manifestation may
include palpitations, dyspnea, and pulmonary
edema. Nursing goal is towards administration of
prescribed treatment to decrease ventricular
response, decrease atrial irritability and eliminate
the cause.
Premature Junctional
Contraction
Premature Junctional Contraction (PJC) occurs when
some regions of the heart becomes excitable than
normal. It has the following characteristics.
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PR interval less than 0.12 seconds if P wave precedes
QRS complex
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QRS complex configuration and duration is normal
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P wave is inverted
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Atrial and ventricular rhythms irregular
Atrioventricular Blocks
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AV blocks are conduction defects
within the AV junction that impairs
conduction of atrial impulses to
ventricular pathways. The three types
are first degree, second degree and
third degree.
First Degree AV Block
Rate is usually 60 to 100 bpm
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PR intervals are prolonged for usually 0.20 seconds
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QRS complex is usually normal
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Rhythm is regular
First degree AV block is asymptomatic and may be
caused by inferior wall MI or ischemia,
hyperkalemia, hypokalemia, digoxin toxicity, calcium
channel blockers, amiodarone and use of
antidysrhythmics. Management includes correction of
underlying cause. Administer atropine if PR interval
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Second Degree AV Block Mobitz I
(Wenckebach)
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Atrial rhythm is regular
Ventricular rhythm is irregular
Atrial rate exceeds ventricular rate
PR interval progressively but only slightly, longer with each
cycle until QRS complex disappears (dropped beat)
PR Interval shorter after dropped beat.
Clinical manifestations include vertigo, weakness, and an
irregular pulse. This may be caused by Inferior wall MI,
cardiac surgery, acute rheumatic fever, vagal stimulation.
Treatment includes correction of underlying cause, atropine or
temporary pacemaker for symptomatic bradycardia and
discontinuation of digoxin if appropriate.
Second Degree AV Block
Mobitz II
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Atrial rhythm is regular
Ventricular rhythm maybe regular or irregular
depending on the degree of block
P-P interval constant
QRS complex periodically absent or disappears
Clinical manifestations same as Mobitz I. Causes
includes: severe coronary artery diseases, anterior
wall MI, acute myocarditis and digoxin toxicity.
Treatment includes: atropine, epinephrine,
and dopamine for symptomatic bradycardia.
Third Degree AV Block (Complete Heart
Block)
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Atrial rhythm regular
Ventricular rhythm regular and rate slower than
atrial rate
No relation between P waves and QRS complexes
NO constant PR interval
QRS interval normal or wide and bizarre
Manifestations include: hypotension, angina and
heart failure. This may be caused by congenital
abnormalities, rheumatic fever, hypoxia, MI, LEv’s
disease, Lenegre’s disease and digoxin toxicity.
Premature Ventricular
Contractions (PVC)
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Atrial rhythm regular
Ventricular rhythm regular and rate slower than
atrial rate
No relation between P waves and QRS complexes
NO constant PR interval
QRS interval normal or wide and bizarre
Manifestations include: hypotension, angina and
heart failure. This may be caused by congenital
abnormalities, rheumatic fever, hypoxia, MI, LEv’s
disease, Lenegre’s disease and digoxin toxicity.
Premature Ventricular
Contractions (PVC)
Early or premature ventricular contractions are caused by increased
automaticity of ventricular muscle cells. PVCs usually are not considered
harmful but are of concern if more than six occur in 1 minute, if they
occur in pairs or triplets if they are multifocal or if they occur or near a T
wave.
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Atrial rhythm is regular
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Ventricular rhythm is irregular
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QRS complex premature, usually followed by a complete
compensatory pause
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QRS complex is also wide and distorted, usually >0.14 second.
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Premature QRS complexes occurring singly, in pairs, or in threes
Clinical manifestations includes palpitations, weakness, lightheadedness
but it is most of the time asymptomatic. Management
includes assessment of the cause and treat as indicated. Treatment is
Ventricular Tachycardia
Ventricular tachycardia (VT) is three or more consecutive PVCs. it is
considered a medical emergency because cardiac output (CO) cannot
be maintained because of decreased diastolic filling (preload).
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Rate is 100 to 250 beats per minute
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P wave is blurred in the QRS complex but the QRS complex has no
associate with P wave.
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PR Interval is not present
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QRS complex is wide and bizarre; T wave is in the opposite direction
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Rhythm is usually regular
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May start and stop suddenly
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Clinical manifestations of VT includes lightheadedness, weakness,
dyspnea and unconsciousness. Causes includes MI, aneurysm, CAD,
rheumatic heart diseases, mitral valve prolapse, hypokalemia,
hyperkalemia, and pulmonary embolism. Anxiety may also caused VT.
Pulseless Ventricular
Tachycardia
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Management for Pulseless VT: Initiate
cardiopulmonary resuscitation; follow
ACLS protocol for defibrillation, ET
intubation and administration of
epinephrine or vasopressin.
Ventricular Tachycardia with
Pulse
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Management with Pulse VT: If
hemodynamically stable, follow
ACLS protocol for
administration of amiodarone,
if ineffective, initiate
synchronized cardioversion.
Ventricular Fibrillation
is rapid, ineffective quivering of ventricles that may be rapidly fatal.
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Rate is rapid and uncoordinated, with ineffective contractions
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Rhythm is chaotic
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QRS complexes wide and irregular
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P wave is not seen
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PR interval is not seen
Causes of ventricular fibrillation is most commonly myocardia ischemia
or infarction. It ma result from untreated ventricular tachycardia,
electrolyte imbalances, digoxin or quinide toxicity, or hypothermia.
Clinical manifestations may include loss of consciousness,
pulselessness, loss of blood pressure, cessation of respirations,
possible seizures and sudden death.
Start CPR is pulseless. Follow ACLS protocol for defibrillation, ET
intubation and administration of epinephrine or vasopressin.
Echocardiograms
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a noninvasive study that uses ultrasonic
waveforms to obtain and display images of
cardiac structures, heart motion, and
abnormalities such as aortic and mitral valve
stenosis, mitral valve prolapse and
regurgitation, aortic insufficiency, atrial
septal defects, and pericardial effusions.
Echocardiograms
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three types of echocardiographic methods in
use: (1) the M-mode, which is a single, vertical
ultrasound beam that produces cardiac
views of chamber size and wall thickness, as
well as valve functioning; (2) the 2-D or
2-dimensional mode, which is a planar
ultrasound beam that provides a wider view
of the heart and its structures; (3) the
Doppler method, which is used to
Indication
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Detect and evaluate valvular abnormalities
Detect atrial tumors
Measure the size of the heart chambers
Evaluate chambers and valves in congenital
heart disorders
Diagnose hypertrophic and related
cardiomyopathies
Evaluate cardiac function or wall motion
after myocardial infarctions
Interfering factors
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Patient doing unnecessary movement during the procedure.
Incorrect placement of the transducer over the desired test
area.
Metallic objects within the examination field, which may hinder
organ visualization and cause unclear images
Patients who are dehydrated, resulting in failure to
demonstrate the boundaries between organs and tissue
structures.
Patients who have a severe chronic obstructive pulmonary
disease have a significant amount of air and space between
the heart and the chest cavity. Airspace does not conduct
ultrasound waves well.
Nursing Responsibilities
Before the procedure
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The following interventions are done prior and
during the study:
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Explain the procedure to the patient. Inform the
patient that echocardiography is used to evaluate
the size, shape, and motion of various cardiac
structures. Tell who will perform the test, where it will
take place, and that it’s safe, painless, and is
noninvasive.
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No special preparation is needed. Advise the patient
Nursing Responsibilities
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Encourage the patient to cooperate. Advise the patient to
remain still during the test because movement may distort
results. He may also be asked to breathe in or out or to briefly
hold his breath during the exam.
Explain the need to darkened the examination field. The room
may be darkened slightly to aid visualization on the monitor
screen, and that other procedure (ECG and
phonocardiography) may be performed simultaneously to time
events in the cardiac cycles.
Explain that a vasodilator (amyl nitrate) may be given. The
patient may be asked to inhale a gas with a slightly sweet odor
while changes in heart functions are recorded.
Nursing Responsibilities
During the procedure
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Inform that a conductive gel is applied to the chest
area. A conductive gel will be applied to his chest
and that a quarter-sized transducer will be placed
over it. Warn him that he may feel minor discomfort
because pressure is exerted to keep the transducer
in contact with the skin.
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Position the patient on his left side. Explain that
transducer is angled to observe different areas of
the heart and that he may be repositioned on his
Nursing Responsibilities
After the procedure
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The nurse should be aware of these post-procedure
nursing interventions after an echocardiogram, they
are as follows:
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Remove the conductive gel from the patient’s
skin. When the procedure is completed, remove the gel
from the patient’s chest wall.
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Inform the patient that the study will be interpreted by
the physician. An official report will be sent to the
requesting physician, who will discuss the findings with
Normal results
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For mitral valve: Anterior and posterior mitral
valve leaflets separating in early diastole and
attaining maximum excursion rapidly, then
moving toward each other during ventricular
diastole; after atrial contraction, mitral valve
leaflets coming together and remaining
together during ventricular systole.
For aortic valve: Aortic valve cusps moving
anteriorly during systole and posteriorly during
Normal results
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For pulmonic valve: Movement occurring
posterior during atrial systole and ventricular
ejection, cusp moving anteriorly, attaining its
most anterior position during diastole.
For ventricular cavities: Left ventricular cavity
normally an echo-free space between
the interventricular septum and the posterior
left ventricular wall.
Right ventricular cavity: Normally an echo-free
Abnormal results:
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In mitral stenosis: Valve narrowing abnormally
because of the leaflets’ thickening and disordered
motion; during diastole, both mitral valve leaflets
moving anteriorly instead of posteriorly.
In mitral valve prolapse: One or both leaflets
ballooning into the left atrium during systole.
In aortic insufficiency: Aortic valve leaflet fluttering
during diastole.
In stenosis: Aortic valve thickening and generating
more echoes.
Abnormal results:
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In bacterial endocarditis: Disrupted valve motion and fuzzy
echoes usually on or near the valve.
Large chamber size: May indicate cardiomyopathy, valvular
disorders, or heart failure: small chamber size: may indicate
restrictive pericarditis.
Hypertrophic cardiomyopathy: Identified by a systolic anterior
motion of the mitral valve and asymmetrical septal
hypertrophy.
Myocardial ischemia or infarction: May cause absent or
paradoxical motion in ventricular walls.
Pericardial effusion: Fluid accumulates in the pericardial
space, causing an abnormal echo-free space.
TEE—Transesophageal
Echocardiography
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combines ultrasound with endoscopy.
A transducer, or echoscope, is attached to a
flexible tube similar to a gastroscope. This
tube is advanced (under local anesthesia)
into the esophagus where high-quality
images of intracardiac structures and the
thoracic aorta are produced.
interference of the Chest wall, bones, and
air-filled lungs is eliminated.
TEE—Transesophageal
Echocardiography
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Stress tests are considered to be noninvasive and
are performed to determine cardiovascular disease
as well as the patient’s functional ability in
performing activities of daily living (ADLs).
also known as exercise electrocardiography, and for
those individuals who can tolerate exercise, the test
involves Pedaling a stationary bike or walking on a
treadmill while connected to an EKG machine.
Physical stress is placed on the heart and oxygen
demands to the heart are increased. Any physical
TEE—Transesophageal
Echocardiography
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Inadequate cardiac perfusion is also noted via a
camera scanner or the EKG machine.
Some sources indicate that results of exercise
testing are more effective when combined with
radionuclide scanning, such as the intravenous
injection of thallium.
When thallium is used, it is measured for its rate of
absorption by the heart muscle.
Poorly perfused areas of the heart either do not
absorb the thallium or do so much more slowly than
Stress Tests
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noninvasive and are performed to determine cardiovascular disease
as well as the patient’s functional ability in performing activities of
daily living (ADLs).
also known as exercise electrocardiography, and for those individuals
who can tolerate exercise, the test involves Pedaling a stationary bike
or walking on a treadmill while connected to an EKG machine.
Physical stress is placed on the heart and oxygen demands to the
heart are increased. Any physical symptoms that develop are
observed.
Inadequate cardiac perfusion is also noted via a camera scanner or
the EKG machine.
Some sources indicate that results of exercise testing are more
effective when combined with radionuclide scanning, such as the
Cardiac Catheterization
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a study to measure pressures in the heart and to
visualize flow of blood via a dye injected into the
heart chambers or coronary arteries.
tells how the heart is functioning and whether any of
the coronary arteries is blocked. An extensive
medical/surgical history must be done prior to this
test as well as laboratory values for coagulation (PT,
PTT), bleeding (H&H), and kidney function (BUN and
creatinine).
Baseline coagulation studies tell if the patient will be
Cardiac Catheterization
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Potential hidden bleeding into the groin is monitored by the
H&H and lastly, since the dye is nephrotoxic, kidney function
must be screened to see if the patient can excrete the dye. The
patient’s heart is accessed through a femoral puncture. If the
patient has a right-heart catheterization, the femoral vein is
punctured, and if it is a left sided heart catheterization, the
femoral artery is punctured. Once the pressures are obtained,
dye is injected to see the function of the chambers of the heart
and visualize the coronary arteries (left-sided heart
catheterization only).
The patient is observed at this time for rhythm disturbances,
flushing, and hypotension from the dye.
Post procedure, the nurse is responsible
for
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Monitoring vital signs and heart
rhythm
Assessing the patient for the presence
of chest pain
Checking the femoral site frequently for
bleeding and hematoma formation
Assessing all peripheral pulses for
compromised circulation or embolus
Post procedure, the nurse is responsible
for
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Monitoring color, movement, sensation, and
temperature of extremities paresthesias are the first
signs of neurovascular compromise
Forcing IV or oral fluids to excrete the dye injected
Maintaining the patient on bedrest (length
according to protocol) to pre
vent disturbance of clot formation at the insertion
site
Log rolling the patient if the patient needs to be
turned or placed on a bedpan
Central Venous Pressure (CVP)
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Central venous pressure (CVP) describes the
pressure of blood in the thoracic vena cava,
near the right atrium of the heart. CVP
reflects the amount of blood returning to the
heart and the ability of the heart to pump
the blood into the arterial system.
Objectives
To serve as a guide for fluid
replacement in seriously ill patients.
To estimate blood volume deficits.
To determine pressures in the right
atrium and central veins.
To evaluate for circulatory failure (in
context with total clinical picture of a
patient)
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Indications
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Patients having Cardiovascular
disorders
Nursing Alert: Don’t rely on CVP alone,
use them in conjunction with other
assessment data. Report abnormal
findings to the doctor.
Equipment:
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Venous pressure tray
Cut-down tray
Infusion solution and infusion set
3-way or 4-way stopcock (a pressure transducer may
also be used)
IV pole attached to bed
Arms board
Adhesive tape
ECG monitor
Carpenter’s level (for establishing zero point)
Nursing Interventions
Assemble equipment
according to
manufacturer’s directions.
Explain that the
procedure is similar to an
IV and that the patient
may move in bed as
desired after passage of
the CVP catheter.
Nursing Interventions
Place the patient in a position of
comfort. This is the baseline used for
subsequent readings.
Serial CVP readings should be made
with the patient in the same position.
Inaccuracies in CVP readings can be
produced by changes in positions,
coughing, or straining during the
reading.
Attached manometer to the IV pole.
The zero point of the manometer
should be on a level with the patient’s
right atrium.
The right atrium is at the midaxillary
line, which is about 1/3 of the
distance from the anterior to the
posterior chest wall.
Mark the midaxillary line on the The maxillary line is an external
patient with an indelible pencil. reference point for the zero
level of the manometer (which
coincides with level of the right
atrium).
The CVP catheter is connected
to a 3-way stopcock that
communicates to an open IV
and to a manometer.
Or, the CVP catheter may be
connected to a transducer and
an electric monitor CVP wave
either digital or calibrated CVP
wave read out.
Start the IV flow and fill
the manometer 10 cm
above anticipated reading
(or until the level of 20cm,
HOH is reached). Turn the
stopcock and fill the
rubbing with fluid.
The CVP site is surgically cleansed.
The physician, introduces the CVP
catheter percutaneously or by direct
venous cutdown and threaded
through an antecubital, subclavian, or
internal or external jugular vein into
the superior vena cava just before it
enters the right atrium.
If the catheter is inserted through the
subclavian or internal jugular vein,
place patient in a head-down position
to increase venous filling and reduced
risk of air embolism. The correct
catheter placement can be confirmed
by fluoroscopy or chest x-ray.
When the catheter enters the thorax
an inspiratory fall and expiratory rise
in venous pressure are observed.
The fluid level fluctuates with
respiration. If rises sharply with
coughing/straining.
The patient may be
When the tip of the
monitored by ECG during catheter contacts the wall
catheter insertion.
of the right atrium it may
produce aberrant
impulses and disturb
cardiac rhythm.
The catheter may be
Label dressing with time
sutured and taped in
and date of catheter
place. A sterile dressing is insertion.
applied.
The infusion is adjusted to
The infusion may cause a
flow into the patient’s vein by significant increase in
a slow continuous drip.
venous pressure if permitted
to flow too rapidly.
Measuring
Central
Venous
Pressure
Place the patient in the
identified position and
confirm zero point.
Intravascular pressures
are measured to the
atmospheric pressure at
the middle of the right
atrium; this is the zero
point or external
reference point.
The zero point or baseline
for the manometer should
be on level with the patient’s
right atrium. The middle of
the right atrium is the
midaxillary line in the 4th
intercostals space.
Position the zero
point of the
manometer at the
level of the right
atrium.
All personal taking
the CVP
measurement use the
same zero point.
Turn the stopcock so that the IV
solution flows into the manometer
filling to about the 20-25cm level.
Then turn the stopcock so that the
solution in manometer flows into
the patient.
Observe the fall in the height of the
column of fluid in the manometer.
Record the level at which the
solution stabilizes or stops moving
downward. This is the central
venous pressure. Record CVP and
the position of the patient.
The column of fluid will fall until it meets
an equal pressure (i.e. the patient’s
central venous pressure). The reading
is reflected by the height of a column of
fluid in the manometer when there’s
open communication between the
catheter and the manometer. The fluid
in the manometer will fluctuates slightly
with the patient’s respirations. This
confirms that the CVP is not obstructed
by clotted blood.
The CVP my range from
5-12cm. HOH.
The change in CVP is a more
useful indication of adequacy of
venous blood volume and
alterations of cardiovascular
function. CVP is a dynamic
measurement. The normal values
may change from patient to
patient. The management of the
patient’s not based on one
reading but on repeated serial
readings in correlation with
patient’s clinical status.
Assess patient’s clinical condition.
Frequent changes in
measurements (interpreted within
the context of the clinical situation)
will serve as a guide to detect
whether the heart can handle its
fluid load and whether hypovolemia
or hypervolemia is present.
CVP is interpreted by considering the
patient’s entire clinical picture,
hourly urine output, heart rate, blood
pressure, cardiac output measurements.
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A CVP zero indicates that patient is
hypovolemia (verified if rapid infusion
causes patient to improve)
A CVP above 15-20cm. HOH may be
due to either hypervolemic or poor
cardiac contractility.
Turn the stopcock again
to allow IV solution to
flow from solution bottle
into the patient’s veins.
When readings are not
being made, flow is from a
very slow micro drip to the
catheter, by-passing the
manometer.
Charting
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Location of insertion site
Type and size of needle or cannula used for insertion
Time of insertion
Appearance of needle insertion site