NSG210 Hinkle Ch. 21: Assessment of Cardiovascular Function

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 21, pp. 650-690 (textbooks/HINKLE_MS_CH21.pdf, also in textbooks/exam01/). Week 02 reading; on Exam 1 (CV assessment was 2 of 34 med-surg questions, but the content underlies heart failure and arrhythmias). Numbering note: the raw lecture plan lists “Ch. 22 - cardiovascular assessment,” but in the 15th edition assessment is Ch. 21; the exam01 folder holds Ch. 21. See also nsg210-week-02-summary.

Learning Outcomes

1. Describe cardiovascular structure, function, and cardiac risk factors.
2. Perform a comprehensive cardiovascular assessment.
3. Discriminate normal and abnormal findings by inspection, palpation, percussion, and auscultation.
4. Recognize major manifestations of cardiovascular dysfunction from history and physical findings.
5. Identify diagnostic tests and hemodynamic monitoring (CVP, pulmonary artery, arterial pressure) and nursing implications.

Key terms:

• Preload: stretch of ventricular fibers at end of diastole (volume)
• Afterload: resistance to ejection (systemic vascular resistance for LV, pulmonary vascular resistance for RV)
• Contractility: force of myocardial shortening
• Cardiac output: SV x HR; normal 4-6 L/min; stroke volume 60-130 mL
• Ejection fraction: normal 55-65%; under 40% means decreased LV function
• Hypertension: persistently over 130/80; hypotension: under 90/60 compromising perfusion
• Orthostatic hypotension: drop of 20 mm Hg systolic or 10 mm Hg diastolic or more on standing
• Pulse deficit: apical rate minus radial rate
• Depolarization: sodium in, potassium out; repolarization: potassium back in, sodium out
• Telemetry: continuous wireless ECG monitoring

I. Anatomic and Physiologic Overview

A. Heart structure

• About 300 g; in mediastinum on the diaphragm
• Layers: endocardium (inner, lines valves), myocardium (muscle, pumping), epicardium (outer)
• Pericardium: visceral and parietal layers; pericardial space holds about 20 mL of lubricating fluid
• Right side: receives deoxygenated blood from superior and inferior vena cava and coronary sinus, pumps to lungs via pulmonary artery (only artery carrying deoxygenated blood)
• Left side: receives oxygenated blood from 4 pulmonary veins, pumps to body via aorta
• LV is 2-3 times more muscular than RV (high-pressure system)
• RV lies anterior under the sternum; LV posterior
• Apical impulse (PMI): fifth intercostal space, left midclavicular line

B. Valves

• AV valves (open in diastole, close at start of systole): tricuspid (right), mitral or bicuspid (left); papillary muscles and chordae tendineae prevent regurgitation
• Semilunar valves (open in systole, close in diastole): pulmonic, aortic

C. Coronary arteries

• Arise from aorta just above aortic valve; perfused during diastole
• Tachycardia (over 100) shortens diastole and risks ischemia, especially with CAD
• Left main splits into left anterior descending (anterior wall) and circumflex (lateral wall)
• Right coronary artery supplies right side and inferior wall; posterior descending branch supplies posterior wall
• Coronary sinus drains venous blood into the right atrium

D. Conduction system

• Properties: automaticity (initiate), excitability (respond), conductivity (transmit)
• SA node (primary pacemaker, at junction of SVC and right atrium): 60-100/min
• Internodal pathways leads to AV node (delays impulse for atrial kick): 40-60/min
• Bundle of His leads to right and left bundle branches (left splits anterior and posterior) leads to Purkinje fibers
• Ventricular pacemaker sites: 30-40/min
• Fastest site sets the rate

E. Action potential

• Resting: sodium outside, potassium inside; inside negative
• Phase 0: rapid depolarization (sodium fast channels in myocytes; calcium slow channels in SA and AV nodes)
• Phase 1: early repolarization (potassium exits)
• Phase 2: plateau (calcium enters)
• Phase 3: final repolarization
• Phase 4: resting
• Effective (absolute) refractory period: phase 0 to mid-phase 3, no response
• Relative refractory period: end of phase 3; a strong stimulus can cause early depolarization (PVCs, risk of VT or VF especially with ischemia)

F. Hemodynamics

• Blood flows from high to low pressure
• Cardiac cycle: diastole (all chambers relaxed, AV valves open, semilunar closed), atrial systole (“atrial kick” adds 15-25% of ventricular volume), ventricular systole (AV valves close, semilunar valves open)
• Heart rate: vagus nerve (parasympathetic) slows; sympathetic beta-1 stimulation, catecholamines, thyroid hormone speed up
• Baroreceptors (aortic arch, carotid bifurcation): high BP leads to parasympathetic response (lower HR and BP); low BP leads to sympathetic response (vasoconstriction, higher HR)
• Preload: Frank-Starling law - more stretch, stronger contraction (to a limit); decreased by diuresis, nitrates, blood loss, dehydration; increased by fluids and transfusion
• Afterload: inverse relationship with stroke volume; vasoconstriction raises it, vasodilation lowers it
• Contractility: increased by catecholamines, sympathetic activity, digoxin, dopamine, dobutamine; decreased by hypoxemia, acidosis, beta-blockers

G. Gerontologic and gender considerations (Table 21-1)

• Aging: slower SA node rate, slowed conduction (longer PR, wider QRS, bradycardia, heart block); LV hypertrophy and stiffness lowers CO and causes fatigue; stiff valves cause murmurs; S4 common; stiff arteries raise systolic BP and widen pulse pressure; baroreceptors less sensitive leads to orthostatic hypotension and falls; slower response to stress and exercise
• Women: smaller hearts and narrower coronary arteries; CAD develops about 10 years later than in men (estrogen raises HDL, lowers LDL, dilates vessels); risk rises after menopause; hormone therapy not recommended for CAD prevention

II. Health History

• ED: ECG within 10 minutes of arrival for suspected ACS
• Delays in seeking care: women, African Americans, older adults, socioeconomic barriers

Common symptoms of CVD:

• Chest pain or discomfort (angina, ACS, arrhythmias, valve disease)
• Pain in arms, back, neck, jaw, stomach (ACS)
• Dyspnea (ACS, cardiogenic shock, HF, valve disease)
• Edema, weight gain, abdominal distention (HF)
• Palpitations
• Unusual fatigue (“vital exhaustion”) - early warning of ACS, HF
• Dizziness, syncope, changes in LOC
• Women may have atypical symptoms: chest pain at rest; jaw, arm, neck, shoulder, back, or epigastric pain; nausea, vomiting, syncope, sweating, anxiety, fatigue

Assessing chest pain (Table 21-2):

• Ask quantity (0-10), location, quality, radiation, associated symptoms, precipitating events, duration, aggravating and relieving factors
• Location does not correlate well with cause; severity and duration do not predict seriousness (esophageal spasm may be a 10, MI a 4-6); conditions can coexist
• Angina: pressure, squeezing, fullness substernal; radiates to arms, jaw, shoulders, back, epigastrium; 5-15 minutes; triggered by exertion, emotion, heavy meal, temperature extremes; relieved by rest, nitroglycerin, oxygen
• ACS: same but more than 15 minutes, may occur at rest or asleep; with dyspnea, diaphoresis, palpitations, fatigue, nausea; relieved by morphine and reperfusion
• Pericarditis: sharp, severe; worse with inspiration, swallowing, coughing, trunk rotation; relieved by sitting upright, anti-inflammatories
• Pulmonary (pneumonia, PE): pleuritic pain worse with inspiration and cough; 30 minutes or more
• Esophageal: burning, mimics angina; worse lying down and with cold liquids; relieved by food, antacids, nitroglycerin
• Anxiety: stabbing to dull; with tingling, palpitations, sense of unreality
• Musculoskeletal (costochondritis): sharp, localized, hours to days; worse with movement, deep breath; relieved by rest, ice, heat, analgesics

Other history:

• Risk factors: nonmodifiable (age, male gender, heredity, race) and modifiable (smoking, hypertension, cholesterol, diabetes, obesity, inactivity)
• Genetic disorders (Chart 21-1): hypertrophic cardiomyopathy, long QT, Brugada, familial hypercholesterolemia, Marfan, factor V Leiden; ask about sudden unexplained death in family
• Medications: names, purpose, adherence; dual antiplatelet therapy (aspirin for life plus clopidogrel, prasugrel, or ticagrelor for 1-12 months) after ACS or stents - stress adherence
• Nutrition: BMI, waist, lipids, glucose, A1C, sodium and fat intake
• Elimination: nocturia in HF; straining (Valsalva) triggers vagal response, bradycardia, syncope; ask about GI bleeding and bloody urine or stools on antiplatelets or anticoagulants
• Activity: compare with 6-12 months ago; exertional angina or dyspnea suggests CAD
• Sleep: orthopnea, PND (worsening HF); sleep-disordered breathing (snoring, daytime sleepiness, morning headache) linked to hypertension, CAD, HF, arrhythmias; bring CPAP to hospital
• Self-perception, roles, social support (depression with poor support worsens outcomes)
• Sexuality: sexual activity is low-intensity exercise; encourage discussion; cardiac rehab helps
• Reproductive: preeclampsia, preterm birth, or small-for-gestational-age infant raises later CVD risk; oral contraceptives in smokers over 35
• Depression: PHQ-2 (little interest or pleasure; feeling down) each scored 0-3; score of 3 or more leads to PHQ-9 and referral
• Stress: Social Readjustment Rating Scale - under 150 slight risk, 150-299 moderate, 300 or more high risk

III. Physical Assessment

Evaluate: heart as a pump, filling volumes and pressures, cardiac output, compensatory mechanisms.

A. General appearance

• LOC and mental status (poor cerebral perfusion)
• Distress: pain, dyspnea, anxiety
• BMI (over 30 obese) and waist (men over 40 inches, women over 35 inches)

B. Skin and extremities (Table 21-3)

• Six Ps of acute arterial obstruction: pain, pallor, pulselessness, paresthesia, poikilothermia (cold), paralysis - check frequently after catheterization or PCI
• Access sites: small bruises expected; large hematoma is serious
• Pitting edema: press 5 seconds over dorsum of foot, behind medial malleolus, shin, or sacrum; graded 0 to 4+ (1+ about 0.25 inch to 4+ about 1 inch or more)
• Capillary refill: normal within 2 seconds; prolonged in cardiogenic shock and HF
• Clubbing: chronic hemoglobin desaturation (congenital heart disease)
• Cool skin and diaphoresis: low CO with vasoconstriction
• Central cyanosis (tongue, buccal mucosa): serious cardiac disorder (pulmonary edema, cardiogenic shock)
• Peripheral cyanosis: vasoconstriction (cold, anxiety, low CO)
• Pallor: anemia or poor arterial perfusion; pallor on elevating legs 60 degrees suggests PAD
• Dependent rubor: PAD
• Venous ulcers: superficial, irregular, medial malleolus, red-yellow base
• Arterial ulcers: painful, deep, round, pale to black base
• Xanthelasma: yellow plaques on eyelids, high cholesterol
• Hair loss, brittle nails, shiny atrophic skin: chronic arterial or venous insufficiency

C. Blood pressure

• Normal under 120/80
• Stage 1 hypertension: 130-139 systolic or 80-89 diastolic
• Stage 2 hypertension: 140 or higher systolic or 90 or higher diastolic
• Pulse pressure: normal about 40 mm Hg; narrow (vasoconstriction compensating for low stroke volume - shock, HF, hypovolemia, mitral regurgitation, aortic or mitral stenosis); wide (high stroke volume - anxiety, exercise, bradycardia; vasodilation - fever, septic shock)

Orthostatic BP (Chart 21-3):

• About 500 mL pools in legs on standing; normal response - HR rises 5-20, systolic unchanged or drops up to 10, diastolic rises about 5
• Orthostatic hypotension: sustained drop of at least 20 systolic or 10 diastolic within 3 minutes of standing, usually with dizziness or syncope; fall risk
• Causes: reduced preload from overdiuresis, bleeding, vasodilators (nitrates)
• Procedure: supine 10 minutes, measure; sit with legs dependent 2 minutes, measure; stand, measure immediately and every 2 minutes up to 10 minutes; return supine if symptomatic; document each position

D. Arterial pulses

• Rate: 50 in athletes to over 100 with exercise or excitement; recheck at end of exam if anxious
• Rhythm: sinus arrhythmia (faster on inspiration) is normal in young people
• Irregular rhythm: count apical pulse for 1 full minute while palpating radial; pulse deficit common with atrial fibrillation, atrial flutter, PVCs
• Amplitude scale: 0 absent; +1 diminished, thready; +2 normal; +3 moderately increased, full; +4 bounding; document location and scale (for example “left radial +3/+4”)
• Doppler if pulse absent or hard to find
• Contour: best at carotid; aortic stenosis gives a feeble pulse with narrow pulse pressure; aortic insufficiency gives a “water hammer” (collapsing) pulse
• Palpate temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial; light touch; dorsalis pedis absent in about 10% of people
• Quality and Safety Nursing Alert: never palpate both temporal or both carotid arteries at the same time (reduces cerebral blood flow)

E. Jugular venous pulsations

• Reflect CVP (right-sided filling pressure)
• Normally visible supine with HOB at 30 degrees
• Distention at 45-90 degrees means elevated CVP: right-sided HF, hypervolemia, pulmonary hypertension, pulmonic stenosis

F. Heart inspection and palpation (Fig. 21-5)

• Aortic area: second intercostal space, right sternal border (find angle of Louis first)
• Pulmonic area: second intercostal space, left sternal border
• Erb point: third intercostal space, left sternal border
• Tricuspid area: fourth and fifth intercostal spaces, left sternal border
• Mitral (apical) area: fifth intercostal space, left midclavicular line
• Epigastric area: below the xiphoid
• Apical impulse 1-2 cm, felt in one intercostal space; left lateral position helps
• Palpable in two or more spaces, or below the fifth space or lateral to the MCL: LV enlargement
• Two separate paradoxical pulsations: ventricular aneurysm
• Broad forceful impulse: LV heave or lift
• Thrill: palpable vibration with a loud murmur (valve disease, septal defect, carotid stenosis)

G. Auscultation

• Count apical rate for 1 minute
• S1 (“lub”): mitral and tricuspid closure; loudest at apex; reference point; louder in tachycardia and mitral stenosis
• S2 (“dub”): aortic and pulmonic closure; loudest at base (aortic and pulmonic areas)
• Physiologic split S2: widens on inspiration, disappears on expiration; fixed split is abnormal (valve disease, septal defect, bundle branch block); best heard at pulmonic area
• S3 (“lub-dub-DUB,” ventricular gallop): early diastole, rapid filling into a noncompliant ventricle; normal in children and adults under 35-40; in older adults suggests HF; bell, left lateral position at apex
• S4 (“LUB-lub-dub,” atrial gallop): late diastole, atrial contraction into a stiff ventricle; hypertrophy from hypertension, CAD, cardiomyopathy, aortic stenosis; bell at apex, left lateral; common in older adults
• Summation gallop: S3 and S4 merge during tachycardia
• Gallops are low pitched: use the bell lightly
• Opening snap: high-pitched early diastolic sound from stiff AV valve (mitral stenosis); diaphragm
• Systolic click: early systole, calcified aortic or pulmonic valve; mid-late click in mitral valve prolapse
• Murmurs: turbulent flow (stenotic or regurgitant valve, septal defect, high flow from fever, pregnancy, hyperthyroidism); described by location, timing, intensity, pitch, quality, radiation (Chart 21-4)
• Murmur grades: 1 very faint; 2 quiet but readily heard; 3 moderately loud; 4 loud, may have thrill; 5 very loud, heard with stethoscope partly off chest, thrill; 6 heard with stethoscope off chest, thrill
• Regurgitation murmurs blowing; mitral stenosis rumbling; aortic stenosis can radiate to neck
• Pericardial friction rub: harsh grating sound in systole and diastole from pericarditis; best with diaphragm, patient sitting up and leaning forward
• Procedure: quiet room, diaphragm then bell, all areas; then left lateral at apex for S3, S4, mitral murmur

H. Other systems

• Lungs: pink frothy sputum (pulmonary edema); dry hacking cough (pulmonary congestion); crackles starting at bases; wheezes (interstitial edema or nonselective beta-blockers like propranolol)
• Abdomen: ascites (right or biventricular HF), hepatosplenomegaly; hepatojugular reflux - press RUQ 30-60 seconds, JVP rise of 1 cm or more is positive; bladder distention (scan or palpate) when urine output drops
• Older adults: more readily palpable pulses; apical impulse may be hard to feel with COPD or kyphoscoliosis; isolated systolic hypertension over 55; orthostatic hypotension; S4 common; 60% have murmurs (often soft systolic ejection from aortic sclerosis)

IV. Diagnostic Evaluation

A. Laboratory tests (Table 21-4)

• Cardiac biomarkers: CK, CK-MB, myoglobin, troponin T and I released from necrotic myocardium (see Ch. 23)
• BUN 8-20 mg/dL: elevated with low CO or volume deficit; normal creatinine with high BUN suggests volume deficit
• Creatinine: men 0.6-1.2, women 0.4-1.0 mg/dL; more sensitive renal measure
• Calcium 8.8-10.4 mg/dL: low slows nodes, impairs contractility (HF); high (thiazides) potentiates digoxin toxicity, heart block, VF
• Magnesium 1.8-2.6 mg/dL: low (diuretics, digoxin) predisposes to atrial and ventricular tachycardias; high (antacids, cathartics) depresses contractility, heart block, asystole
• Potassium 3.5-5.0 mEq/L: low (loop and thiazide diuretics) causes arrhythmias including VT and VF and digoxin toxicity; high (supplements, renal failure, spironolactone, ACE inhibitors) causes heart block, asystole, ventricular arrhythmias
• Sodium 135-145 mEq/L: low means fluid excess (HF, thiazides); high means fluid deficit
• aPTT 21-35 seconds: monitors unfractionated heparin; therapeutic 1.5-2.5 times baseline; increase dose under 50 seconds, decrease over 100 seconds
• PT 11-13 seconds and INR 0.8-1.2: monitor warfarin; therapeutic INR usually 2-3.5 depending on diagnosis
• Hematocrit men 42-52%, women 36-48%; hemoglobin men 14-17.4, women 12-16 g/dL; low values cause more angina or MI
• Platelets 140,000-400,000: watch for thrombocytopenia on aspirin, clopidogrel, glycoprotein IIb/IIIa inhibitors
• WBC 4,500-11,000

Lipids (12-hour fast):

• Total cholesterol = HDL + LDL + 20% of triglycerides
• LDL deposits cholesterol in artery walls; HDL carries it to the liver (protective)
• Triglycerides rise after meals, with stress, diabetes, alcohol, obesity
• Statins first-line; also ezetimibe, bile acid sequestrants, PCSK9 inhibitors

Other markers:

• BNP: released from ventricles with increased pressure; over 100 pg/mL suggests HF; also elevated with PE, MI, LVH
• hs-CRP: inflammation; under 1 mg/L low, 1-3 moderate, 3 or more high CVD risk
• Homocysteine (12-hour fast): under 12 optimal, 12-15 borderline, over 15 high risk; linked to low folate, B6, B12

B. Imaging and ECG

• Chest x-ray: heart size and position, calcifications, pulmonary changes, HF; confirms pacemaker and PA catheter placement
• Fluoroscopy: guides catheter and pacing lead placement
• 12-lead ECG: arrhythmias, conduction problems, chamber enlargement, ischemia, injury, infarction, electrolyte and drug effects; 15-lead adds right-sided leads (right ventricular and posterior MI); 18-lead adds posterior leads; note age, gender, BP, medications on requisition

Continuous ECG monitoring:

• Hardwire (ED, ICU, progressive care) and telemetry (wireless, patient can walk; batteries changed every 24-48 hours)
• Monitors multiple leads, ST segments (depression = ischemia, elevation = evolving MI), graded alarms
• Quality and Safety Nursing Alert: monitoring does not detect chest pain or dyspnea; patients must report new symptoms
• Lead II best shows P waves (atrial activity); V1 best shows ventricular depolarization (PVCs, tachycardias, bundle branch blocks)
• Lead colors: RA white, LA black, RL green, LL red, V1 brown
• Electrode application (Chart 21-5): clean skin with soap and water, clip (not shave) hair, attach lead wires before placing, check gel is moist, change every 24 hours and rotate sites, hypoallergenic if sensitive
• Do not place over incisions, implanted devices, wounds, or inflamed skin; remove metal electrodes before MRI
• Alarm fatigue: most alarms are false; reduce artifact with skin prep; customize alarms (for example turn off irregular-rhythm alarm in AF; set rate alarms just above and below baseline); respond to all alarms including “inop” alarms (leads off, low battery)
• Clean or disposable lead wires (infection)

Ambulatory monitoring:

• Holter: continuous 24-48 hours with symptom diary; not real time
• ECG patch: 7-14 days, waterproof, catches more arrhythmias
• Intermittent event monitors (patient-activated) and loop recorders (record before and after activation; some auto-detect)
• Implantable loop recorder (for example Reveal LINQ): subcutaneous, about 3-year battery, for infrequent symptoms
• Smartphone and smartwatch rhythm strips
• Pacemakers and ICDs transmit remotely

C. Stress testing

• Diseased coronary arteries cannot dilate to meet demand; stress reveals ischemia
• Facilities must be ready for ACLS (MI, arrest, HF, arrhythmias)

Exercise stress test:

• Treadmill or bicycle to target HR; monitor ECG, BP, symptoms
• Stop for target HR or ischemia signs; abnormal: chest pain, ventricular arrhythmia, ST depression, failure of HR or BP to rise
• Prep: fast several hours; no tobacco or caffeine; may hold beta-blockers, calcium channel blockers, digoxin up to 48 hours per provider; walking shoes; monitor 10-15 minutes afterward

Pharmacologic stress test:

• For patients who cannot exercise
• Vasodilators (dipyridamole, adenosine, regadenoson) used with nuclear imaging; side effects chest pain, headache, flushing, nausea, heart block, dyspnea; reversed with IV aminophylline; adenosine half-life under 10 seconds
• No caffeine, chocolate, decaf coffee or tea, sodas for 24 hours (blocks vasodilators - test would be rescheduled); NPO at least 3 hours; hold theophylline, aminophylline, dipyridamole 24-48 hours if tolerated
• Dobutamine: raises HR, contractility, BP; used with echocardiography or if bronchospasm prevents holding theophylline

D. Radionuclide imaging

• Myocardial perfusion imaging (SPECT or PET) compares rest and stress images
• Fixed defect (same at rest and stress): infarcted, no perfusion
• Reversible defect (appears with stress, gone at rest): ischemia - positive test, usually leads to catheterization
• SPECT: most common; 80-90% sensitive for ischemia; technetium or rubidium tracer; supine with arms overhead; no radiation precautions afterward
• PET: higher resolution; compares blood flow and glucose metabolism (viable ischemic tissue shows low flow, high metabolism); blood glucose must be normal; no alcohol or caffeine 24 hours; discuss insulin with provider; claustrophobia
• MUGA (equilibrium radionuclide angiocardiography): LV function, wall motion, EF
• Not for pregnant or nursing women

E. CT, MRA, echocardiography

• Coronary CT angiography: contrast; check renal function, IV hydration if needed; premedicate (steroids, antihistamines) with prior contrast reaction; beta-blocker to slow HR; breath-holding; expect flushing, metallic taste, nausea
• Electron beam CT: coronary calcium score; for low to intermediate risk patients
• MRA: aorta, myocardium, pericardium, congenital lesions; screen implanted devices and metal; remove jewelry and transdermal patches with aluminum backing (nitroglycerin, clonidine, fentanyl - burns); claustrophobia; noise
• Transthoracic echocardiogram: EF, chamber size, valves, wall motion, pericardial effusion; Doppler shows flow direction and regurgitation; painless, 30-45 minutes; may turn to left side
• Stress echo: positive if wall motion abnormality with stress but not at rest
• Transesophageal echocardiogram (TEE): clearer images; NPO 6 hours; consent; IV; remove dentures; topical anesthetic and sedation; monitor LOC, BP, ECG, RR, SpO2; afterward HOB 45 degrees, no food or fluid until gag reflex returns (about 2 hours), start with sips of water; sore throat up to 24 hours; report persistent sore throat, dyspnea, dysphagia; needs a ride home; risk of aspiration, respiratory depression, esophageal perforation; ask about dysphagia or chest radiation

F. Cardiac catheterization

• Invasive; diagnoses structural and functional disease; guides PCI or CABG
• Pre-procedure labs: electrolytes, glucose, BUN, creatinine, aPTT, PT, INR, CBC
• Contrast-induced nephropathy (CIN): risk with CKD, diabetes, HF, hypotension, dehydration, nephrotoxic drugs, older age; defined as creatinine rise of 25% or more or 0.5 mg/dL within 48-72 hours; prevent with IV saline hydration
• Prior contrast reaction: premedicate with antihistamine and corticosteroid
• Right heart cath: via vein to RA, RV, pulmonary artery; pressures, oxygen saturations, myocardial biopsy; risks arrhythmias, venous spasm, infection, perforation
• Left heart cath: via radial or femoral artery to aorta and LV; coronary angiography, ventriculography; risks arrhythmias, MI, perforation, embolization
• Hemostasis: radial compression band (about 2 hours); femoral manual pressure, mechanical compression, closure devices or patches

Before:

• NPO 8-12 hours; needs ride home if outpatient; lies on hard table under 2 hours
• Expect palpitations when catheter touches endocardium; may be asked to cough and deep breathe; contrast causes a hot flushed feeling and sensation of needing to void that passes within 1 minute

After:

• Check access site for bleeding or hematoma, distal pulses, VS: every 15 minutes for 1 hour, every 30 minutes for 1 hour, then hourly for 4 hours
• Compare temperature, color, capillary refill, sensation with the other limb; report pain, numbness, tingling
• Watch for arrhythmias; vasovagal reaction (bradycardia, hypotension, nausea from full bladder or pressure on site) - elevate legs, IV fluid bolus, atropine
• Femoral with manual or mechanical pressure: bed rest up to 6 hours, leg straight, HOB no higher than 30 degrees, may log roll; closure devices allow earlier ambulation; radial approach allows sitting up soon after
• Report chest pain or bleeding; monitor creatinine and I&O for CIN; assist first time out of bed (orthostatic hypotension)
• Home teaching (Chart 21-6): radial - normal activity next day, avoid strenuous wrist use a few days; femoral - no bending at waist, straining, or heavy lifting 24 hours; no tub baths; for bleeding, sit or lie down and press firmly 10 minutes, call 911 if heavy (do not drive); report swelling, new bruising, pain, temperature 101 F or more

G. Electrophysiology study

• Invasive; for syncope, palpitations, survivors of sudden cardiac death; distinguishes atrial from ventricular tachycardia; evaluates inducibility, AV node function, drug effectiveness, need for ICD or ablation

H. Hemodynamic monitoring

• CVP, pulmonary artery, intra-arterial BP; critical care
• System: pressurized flush (bag at 300 mm Hg delivers 3-5 mL/hour), transducer, monitor
• Level the transducer stopcock at the phlebostatic axis (fourth intercostal space at midaxillary line); mark the chest; zero to atmospheric pressure; readings valid with HOB up to 60 degrees if re-leveled after position changes
• Complications: pneumothorax (central insertion), infection (risk rises after 72-96 hours), air embolism (stopcock handling)
• Infection prevention (Table 21-5): hand hygiene; chlorhexidine with alcohol skin prep; chlorhexidine-impregnated dressing; change gauze every 2 days, transparent at least every 7 days or when damp, loose, soiled; scrub hubs before access; change tubing about every 96 hours; daily 2% chlorhexidine bath; do not submerge
• CVP: normal 2-6 mm Hg; reflects right ventricular preload; high (over 6) - hypervolemia or right-sided HF; low (under 2) - hypovolemia (dehydration, bleeding, vomiting, diarrhea, overdiuresis); subclavian preferred, femoral avoided; chest x-ray confirms position
• Pulmonary artery catheter: assesses LV function, shock etiology, response to therapy; balloon (max 1.5 mL air) floats catheter through RA, RV, into PA; distal port measures PA pressures; proximal port in RA (CVP, infusions); thermodilution cardiac output (5-10 mL saline injected in 4 seconds)
• Quality and Safety Nursing Alert: after wedge pressure, confirm balloon deflated and PA waveform returned

High-Yield Numbers

• PMI: fifth intercostal space, left midclavicular line; 1-2 cm
• SA node 60-100; AV node 40-60; ventricles 30-40
• Cardiac output 4-6 L/min; stroke volume 60-130 mL; EF 55-65%, under 40% decreased
• Atrial kick 15-25% of ventricular filling
• Pericardial fluid about 20 mL
• BP: normal under 120/80; stage 1 130-139/80-89; stage 2 140/90 or higher; hypotension under 90/60
• Pulse pressure about 40 mm Hg
• Orthostatic: drop of 20 systolic or 10 diastolic within 3 minutes; supine 10 minutes before first reading
• Capillary refill 2 seconds or less
• Pulse scale 0 to +4; edema 0 to 4+
• Hepatojugular reflux positive if JVP rises 1 cm or more with 30-60 seconds of pressure
• ECG within 10 minutes for suspected ACS
• Labs: K+ 3.5-5.0; Na+ 135-145; Mg 1.8-2.6; Ca 8.8-10.4; BUN 8-20; INR 0.8-1.2 (warfarin target 2-3.5); aPTT therapeutic 1.5-2.5 times baseline; platelets 140,000-400,000
• BNP over 100 pg/mL suggests HF; hs-CRP 3 mg/L or more high risk; homocysteine over 15 high risk
• Lipid and homocysteine tests need a 12-hour fast
• Telemetry battery 24-48 hours; electrodes changed every 24 hours
• Holter 24-48 hours; patch 7-14 days; implantable loop recorder about 3 years
• CIN: creatinine rise 25% or 0.5 mg/dL within 48-72 hours
• Cath: NPO 8-12 hours; femoral bed rest up to 6 hours, HOB 30 degrees or less; checks every 15 minutes x 1 hour, every 30 minutes x 1 hour, hourly x 4 hours; bleeding at home - press 10 minutes
• TEE: NPO 6 hours; HOB 45 degrees after; no food until gag reflex returns (about 2 hours)
• CVP 2-6 mm Hg; PA balloon max 1.5 mL; flush bag 300 mm Hg, 3-5 mL/hour
• Murmur grades 1-6; thrill at grade 4 and above

Priority Nursing Actions and Red Flags

• Six Ps in a limb after catheterization: acute arterial occlusion - report immediately
• Large hematoma or bleeding at access site: apply pressure, notify provider
• Vasovagal reaction after cath: elevate legs, fluids, atropine
• Never palpate both carotids at once
• New S3 in an older adult: heart failure
• Pericardial friction rub: pericarditis
• Pulse deficit: atrial fibrillation or PVCs - count apical for a full minute
• Respond to every monitor alarm, including leads-off and low battery
• Caffeine before vasodilator stress test: test must be rescheduled
• TEE: no oral intake until gag reflex returns
• Rising creatinine after contrast: contrast-induced nephropathy
• Remove transdermal patches and metal before MRI
• Hypokalemia and hypomagnesemia on diuretics: arrhythmias, digoxin toxicity
• Assess for depression (PHQ-2) in CAD and HF

Medications and Agents in This Chapter

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• nsg210-hinkle-ch22-arrhythmias-outline
• nsg210-hinkle-ch17-respiratory-assessment
• INDEX