Lesson 1, Topic 1
In Progress

Closing Comments

April 11, 2024

Patient Coaching
According to the CDC, heart disease is the leading cause of death for adults. About 25% of all deaths are related to heart disease each year. Genetics, predisposition, and lifestyle factors—such as smoking, lack of exercise, and poor diet—play significant roles in the development of heart disease. Successful management of cardiovascular disease requires major lifestyle changes for most patients. The medical assistant can help by providing encouragement and support and using community resources to help the patient find assistance with these changes.
      Sources for information include the American Heart Association (www.heart.org) and the US Department of Agriculture (USDA) (www.nutrition.gov and www.myplate.gov). Because many patients learn best through visual aids, providing them with pictures, brochures, and pamphlets is an effective means of helping them in this learning process. Education interventions are always documented so that the provider or medical assistant can clarify or expand on the information upon a return visit.


Legal and Ethical Issues
Diagnostic procedures can have a marked effect on the patient’s treatment. When entrusted with performing testing procedures, the medical assistant assumes responsibility for the test’s accuracy and for performing the test precisely. This is an important role because the results submitted could strongly influence the plan of treatment.

FIGURE 25.19  (A) Pacemakers. (B) Chest x-ray of a patient with a permanent implanted pacemaker. From Frank ED, Long BW, Smith BJ: Merrill’s atlas of radiographic positions and radiologic procedures, ed 12, St. Louis, 2012, Mosby.

Patient-Centered Care
Two important aspects of patient-centered care are information and education. Many of the more common cardiovascular diseases require patients to be on medication for treatment. It is important that patients know the following:
            • Name of the medication
            • Reason for the medication
            • Side effects/adverse reactions to report to the provider
      When a patient is put on a new medication, providing information on the medication is important. The medical assistant should review the information with the patient. Also, giving the patient a handout to take home and a phone number to call if questions arise will promote patient-centered care.


Professional Behaviors
Critical thinking is a crucial part of professional behavior. The ability to question patients logically and comprehensively about possible cardiac signs and symptoms can greatly contribute to high-quality care. The provider relies on the medical assistant for initial information about the patient. Given the seriousness of cardiac conditions, medical assistants must use their knowledge about the topic to gather and analyze the patient’s comments so that the provider is better prepared to make an accurate diagnosis and develop an effective treatment plan.


Summary of Scenario

During the weeks that followed, Lizzy became more independent in practicum. She was very excited to interview for a medical assistant position in a cardiology department in a nearby city. During her last day with Rebecca, they celebrated her completion of the practicum. Lizzy shared that she was offered the medical assistant position, which she accepted.
      In the weeks that followed Lizzy’s last day, Rebecca thought about all the information she had shared with Lizzy. She realized that she, too, had learned a lot from the practicum experience and found that she really enjoyed mentoring students. Rebecca plans to talk with her supervisor about future opportunities to mentor students in the department.


Summary of Learning Objectives

1. Examine the anatomy of the cardiovascular system.

The cardiovascular system is a closed system that includes the following:

            • Blood vessels, consisting of arteries, arterioles, capillaries, venules, and veins that act as pipes to carry the blood around the body

            • A heart, which pumps the blood

            • Blood, which contains the nutrients for the cells and the waste products to be excreted

The heart, which is the size of a fist, is a complex muscular organ that pumps blood around the body. It is located in the mediastinum of the thoracic cavity, slightly left of the midline. The apex (pointed tip) of the heart rests just above the diaphragm. The heart has two sets of chambers, the atria and ventricles. The septum divides the heart into a right and left section. The heart wall is composed of three layers: the endocardium, the myocardium, and the epicardium.

2. Differentiate among the pulmonary, systemic, coronary, hepatic portal, and fetal circulations.

Pulmonary circulation begins as the blood returns from the body. The superior vena cava and the inferior vena cava bring deoxygenated blood from the body to the right atrium. The blood passes the tricuspid valve and empties into the right ventricle. When the ventricles contract, the blood in the right ventricle is pushed out past the pulmonary valve and enters the pulmonary artery trunk, which splits into the right and left pulmonary arteries. In the lungs, gas exchange occurs, and oxygenated blood returns to the lungs by the right and left pulmonary veins.

Then the systemic circulation starts. The oxygenated blood in the left atrium moves past the bicuspid or mitral valve and empties into the left ventricle before passing the aortic valve and emptying into the aorta. From here, the blood will move through the body before it returns to the heart. Blood from the head, neck, and upper extremities empties into the superior vena cava before returning to the right atrium. Blood from the lower body empties into the inferior vena cava before returning to the right atrium.

The coronary veins remove waste products from the heart tissue, and the coronary arteries bring nutrients and oxygen to the heart tissue. The liver (hepatic circulation) has a special role in filtering the blood and metaboliizing or breaking down substances.

The umbilical cord contains two umbilical arteries and one umbilical vein. The arteries carry the fetal blood to the placenta. The umbilical vein carries oxygen and nutrient-rich blood to the baby. The waste, oxygen, and nutrient exchange occur in the placenta. Other structures that are unique to the growing baby include the following:

• Ductus venosus: Shifts the majority of the blood from the umbilical vein and empties it into the inferior vena cava, thus bypassing the immature liver

• Foramen ovale: A small flaplike opening in the interatrial septum that allows blood to move from the right atrium to the left atrium, thus bypassing the immature lungs

• Ductus arteriosus: A short vessel that connects the pulmonary artery with the aorta, and most of the blood is redirected from the pulmonary artery to the aorta, thus bypassing the immature lungs

3. Examine the anatomy of the blood.

Blood is made up of two components:

            • Liquid portion: Plasma is the liquid portion of whole blood; it also contains plasma proteins (e.g., albumin, globulins, clotting factors, and complement), inorganic substances, electrolytes, organic substances, and waste products

            • Formed elements: Includes red blood cells (RBCs), white blood cells (WBCs), and platelets

The two major classification systems for blood typing are the ABO and the Rh systems. With the ABO system, each person has the A, B, ABO, or O blood type. With the Rh system, a person is either Rh-positive or Rh-negative.

4. Examine the physiology of the conduction system.

The electrical cells in the SA node generate the impulse that starts the heartbeat. When the SA node discharges the impulse, it travels in many directions through the heart muscle. The Bachmann bundle, a specialized internodal tract, takes the impulse to the left atrium. Other internodal tracts take the impulse quickly to the atrioventricular (AV) node. In the AV node, the impulse moves very slowly and then moves to the bundle of His. After the impulse passes through the bundle of His, it enters the right and left bundle branches. The right bundle branch brings the impulse to the right ventricle. The left bundle branch brings the impulse to the left ventricle. The bundle branches split into many Purkinje fibers.

The cardiac cells cycle through three states or steps in the same sequence for each impulse:

            • Polarized state: Before the impulse hits the cells, they are in a polarized or “waiting” state.

            • Depolarized state: When the impulse hits the cells, the cells’ charges change. The change of the cells’ charges allows the impulse to move through the cell, causing action potential, also called depolarization.

            • Repolarized state: After the impulse passes over the cell, the ions move back to their original location. This causes the cell’s charge to change. This recovery phase is called the repolarized state.

5. Examine the physiology of the blood, including coagulation and the factors that affect the blood pressure.

The process required to form a blood clot is complicated. First, a damaged vessel will constrict to slow the flow of blood through the vessel. Aggregation of platelets will occur, and the platelets will adhere to the injured area, forming a platelet plug. Platelets release clotting factors, which aid in the process of coagulation. The injured blood vessel tissue also activates clotting factors in the blood plasma. The interaction between the clotting factors works to form fibrin. The fibrin net traps red blood cells and more platelets to form a thrombus.

The following factors affect the blood pressure:

            • Blood volume: The amount of circulating blood has a direct influence on blood pressure. The greater the blood volume, the more force it makes on the arterial walls. If the blood volume is low, less force or pressure will be on the arterial walls.

            • Strength of ventricular contractions: The greater the force of the contraction, the more blood is pumped into the arteries. This increases the blood pressure. If the left ventricular contraction is weak, less blood is pumped out of the heart, and thus the blood pressure is lower.

            • Resistance to blood flow: Any factor that increases the resistance for blood to flow through the arteries will increase the blood pressure. Factors that increase resistance include the size of the lumen of the arteries, the elasticity of the arterial walls, and the viscosity of the blood.

6. Analyze the life span changes to the cardiovascular system.

As a child grows and matures, the heart rate decreases. The systemic vascular resistance increases with age. This means that the resistance for blood flow increases, and thus the blood pressure increases with age. As a person ages, the heart and blood vessels undergo changes. Heart changes that occur include a loss of some SA node cells and an increase in the left ventricle size. Normal ECG changes can occur with age. Valves can become thicker and stiffer, causing a heart murmur. Arterial walls become stiffer, thus increasing the blood pressure.

7. Examine heart diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

Common signs and symptoms include angina, bradycardia, tachycardia, palpitation, cyanosis, pallor, dyspnea, orthopnea, shortness of breath, diaphoresis, edema, and syncope. Diseases and disorders of the heart include arrhythmias, cardiomyopathy, congenital heart defects, congestive heart failure, heart valve disorders (e.g., aortic insufficiency, mitral valve prolapse, and rheumatic fever), metabolic syndrome, and myocardial infarction. Additional diseases include cardiac tamponade, endocarditis, and pericarditis. Refer to this chapter for more information on these disorders.

8. Examine blood vessel diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

Diseases and disorders of the blood vessels include atherosclerosis-related diseases, deep vein thrombosis, and varicose veins. Additional diseases and disorders include aneurysms, esophageal varices, and Raynaud disease. Refer to this chapter for more information on these diseases.

9. Examine blood pressure–related diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

Blood pressure-related diseases and disorders include hypertension, hypotension, postural orthostatic tachycardia syndrome, and shock. There are several types of shock, including anaphylactic, cardiogenic, hypovolemic, neurogenic, and septic. Refer to this chapter for more information on these diseases.

10. Examine blood diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

Common signs and symptoms of blood diseases and disorders include fatigue, weakness, pale skin, lightheadedness, shortness of breath (SOB), bruising, bleeding, fever, weight loss, leukopenia, leukocytosis, anemia, erythrocytosis, thrombocytopenia, and thrombocytosis. Diseases of the blood include anemia (e.g., aplastic, hemolytic, iron deficiency, sickle cell, thalassemia, vitamin B12 deficiency, and pernicious), hemophilia, idiopathic thrombocytopenic purpura, and leukemia (e.g., acute lymphocytic, acute myeloid, chronic lymphocytic, and chronic myeloid). Additional blood disorders include hemolytic disease of the fetus and newborn, polycythemia vera, and Von Willebrand disease.

11. Examine the medical assistant’s role in assisting with examinations, diagnostic procedures, and treatments for cardiology diseases and disorders.

The cardiovascular examination begins with the medical assistant measuring the patient’s height and weight, temperature, radial pulses, respirations, and blood pressure in both arms. A large part of the provider’s examination focuses on subjective symptoms.

Some of the diagnostic procedures include angiography, cardiac catheterization, Doppler ultrasound, echocardiogram, nuclear stress test, and nuclear ventriculography. An electrocardiography can be done as a resting ECG, an exercise stress test, or with a Holter monitor. Medical laboratory tests include cholesterol and prothrombin testing, cardiac enzymes test, and lipid profile.

Treatments include medication, pacemakers, and implantable cardioverter-defibrillators (ICDs). A pacemaker uses low-energy electrical pulses to assist the heart when arrhythmias, tachycardia, or bradycardia occurs. An implantable cardioverter-defibrillator (ICD) is similar to a pacemaker in that it uses low-energy electrical pulses to treat arrhythmias. However, ICDs differ from pacemakers because they can also use high-energy pulses when a life-threatening arrhythmia occurs.

 

Procedure 25.1  Determine a Patient’s Orthostatic Vital Signs
Tasks
Perform orthostatic vital signs and document them in the patient’s health record.
Equipment and Supplies
            • Patient’s health record
            • Sphygmomanometer
            • Stethoscope
            • Watch with a second hand
            • Alcohol wipes
            • Exam table


Procedural Steps
1. Wash hands or use hand sanitizer.

PURPOSE: To ensure infection control.

2. Assemble the equipment and supplies needed. Clean the earpieces and diaphragm of the stethoscope with alcohol wipes.

PURPOSE: For infection control and to follow Standard Precautions.

3. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have about the procedure.

PURPOSE: Identification of the patient prevents errors, and explanations are a means of gaining implied consent and patient cooperation.

4. Help the patient lie comfortably in a supine position on the examination table. Pull out the table extender, if necessary, so that patients can rest their feet. Allow the patient to rest in this position for 5 minutes.

PURPOSE: Allowing the patient to rest before beginning will allow their blood pressure to come to baseline for this position.

5. Take the patient’s pulse and blood pressure with the patient lying down. Do not remove the cuff from the arm.

PURPOSE: Allowing the cuff to stay on the arm will allow the same arm to be used in additional measurements without putting it on and taking it off the arm.

6. Help the patient into a sitting position, and ask if the patient is experiencing any dizziness, weakness, or visual changes with the position change. Watch for any change in skin coloring or the patient’s behavior.

PURPOSE: This identifies any symptoms of hypotension the patient may be experiencing.

7. Once the patient has been sitting for 1 minute, repeat the pulse and blood pressure.

PURPOSE: This will provide blood pressure readings in the new position.

Note: If the patient has symptoms associated with the position change or the sitting blood pressure is less than 90 systolic and/or 60 diastolic, have the patient lie back down and immediately notify the provider.

8. Assist the patient to a standing position. Ask the patient about dizziness, weakness, or visual changes associated with the position change. Note any change in the patient’s appearance or behavior.

9. Immediately repeat the blood pressure and pulse readings after the patient has stood up.

PURPOSE: A quick change in positioning with an immediate read of BP and pulse will indicate if the patient is experiencing orthostatic hypotension.

10. Ask the patient to continue standing and repeat the pulse and blood pressure measurements after 3 minutes.

PURPOSE: BP and pulse readings that return to normal after the patient has stood for a few minutes indicate a different problem than if the readings stay low (or high).

11. Clean the earpieces and the head of the stethoscope with an alcohol wipe, and return both the cuff and the stethoscope to storage.

12. Wash hands or use hand sanitizer.

PURPOSE: To ensure infection control.

13. Clearly document each blood pressure and pulse reading, along with the position and any symptoms the patient experienced in the patient’s health record.

PURPOSE: Documenting the reading, along with the position and symptoms experienced, will allow the provider to make connections in positional BP/P and make diagnostic and treatment decisions.

Documentation Example3/9/20XX 2:20 p.m. (Lying) BP 120/72 right arm, (adult cuff); P: 68 regular, 1+. (Sitting 1 min) BP 116/ 64; P: 84 regular, 1+. (Standing, initial VS) BP 110/58; P: 96 regular, 1+. (Standing 3 min) BP 112/66; P: 88 regular, 1+. Had dizziness initially after standing that resolved within 1 min. Pt resting on the exam table. Dr. Walden notified. —————————————————————————————————————