Download Cardiac Assessment Outline

Cardiac Assessment
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Prevalence of CVD
– More than 71 million Americans have one or more types of cardiovascular disease (CVD)
– CVD includes Hypertension (HTN), Coronary Artery Disease (CAD), Heart Failure (HF), stroke and congenital
cardiovascular defects
• Key Compoments
– Health History
– Physical Exam
– Lab Tests
– Diagnostic testing
• Anatomic Review
– Chambers
– Anatomic Review
– Pericardium
• 30 ml of fluid
– Cardiac Conduction Pathway
SA Node (60-100)
AV node (40-60)
Bundle of His (20-40)
Purkinje fibers
Assessment
– Key Components
– Health History
– Physical Exam
– Lab tests
– Diagnostic tests
– Health History
• The patient is usually the best source for obtaining a health history. Patient’s family and prior medical
records can be helpful.
• Components
• Family history
• Age
• Gender
• Symptoms
• Their impression of how they’re doing
• History of Present Illness
– General health status questions
– CV history
– Review of present illness
– Survey of lifestyle, risk factors for CAD
• Common Clinical Manifestations
– Chest pain or discomfort
• Crushing, stabbing, indigestion
• Men vs. Women
• Men usually have more specific kinds of pain, more striking
• Women usually have more diffuse pain, generalized, easily overlooked
– Shortness of breath
– Peripheral edema and weight gain
– Palpitations
• When you can feel your heart going nuts
– Fatigue
– Dizziness, syncope
– Change in level of consciousness
• Assessment Questions for Cardiac Pain
– P: position/location (where? And provocation (what makes it worse?))
– Q: quality (describe the pain)
– R: radiate? Relief? (does the pain radiate anywhere, and if so, where? What gives you relief)
– S: severity (pain scale); other symptoms
– T: timing (when did it start?) (important one, time is muscle)
Physical Examination
– Head to toe exam
• Because the heart affects just about every part of your body, think tissue perfusion and what not
– 10 minutes/10 areas
• In the ideal world 10 mins would be awesome, but in the real world you won’t have this long
– Inspect, palpate, and auscultate
– Evaluates effectiveness of heart as a pump, filling volumes and pressures, cardiac output and compensatory
mechanisms
• Ten Areas to Assess
– General appearance
– Cognition
– Skin
– Blood pressure
– Arterial pulses
– Jugular Venous Distention
– Heart
– Extremities
– Lungs
– Abdomen
• General Appearance (1) and Cognition (2)
• Level of distress
• Level of consciousness
• Thought processes (is heart able to propel enough oxygen to the brain?)=cerebral perfusion
• Anxiety
• Important if the pt has a sense of impending doom! Often if that’s what they are feeling there is a reason for it.
Don’t ignore them and placate them telling them it will be ok…
• Inspection of Skin
• Pallor
• Cyanosis (peripheral and central)
• Turgor
• Not as accurate in an older person because their skin naturally loses elasticity
• Temperature and moisture
• Ecchymosis (bruising)
• Many cardiac pts are on anti-coagulants
• Blood Pressure
• What is BP?
• The pressure on the walls of the blood vessels during systole and diastole. Can be measured directly (art
line) and indirectly (BP cuff)
• What factors affect BP?
• Normal range 100/60 to 135/85 mm Hg
• Formula for MAP
• Think about adding this into your charting
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• Formula is 2xDiastole + Systolic / 3
• You want this above 60 at the minimum
• What is pulse pressure?
• What is normal range of pulse pressure?
• Increased and decreased pulse pressure
Pulse Pressure
• Difference between systolic and diastolic pressure
• Normal is 30-40 mm Hg
• Indicator of cardiac output
• When pulse pressures narrow could be because of cardiac tamponade
• Examples:
• 140/90 = pulse pressure of 50
• 124/79 = pulse pressure of 45
Pulsus Paradoxus
• Decrease in systolic BP on inspiration (greater than 10 mm Hg).
• Due to increased work of breathing, hypovolemia, pericardial effusion/tamponade
Postural BP changes
• Postural hypotension occurs when there is a significant decrease in blood pressure after the patient assumes an
upright posture
• Many causes, most common are decreased volume in circulatory system or inadequate vasoconstrictor
mechanisms
• Symptoms include dizziness, lightheadedness, or syncope
• Procedure for measuring
Documenting Orthostatic Vital Signs
• You can draw little stick
Orthostatic Hypotension
• Systolic greater than 15 and the HR increases 20… if you have this you can be diagnosed with ortho hypo. Will also
call this a Tilt Test.
Arterial pulses
• Locations are = radial, brachial, carotid, femoral, pedal, popliteal
• Rate
• Normal rate varies from a low of 50 bpm in healthy, young, athletic adults to in excess of 100 bpm after
exercise or periods of excitement
• Rhythm
• Rate may increase during inhalation and decrease during exhalation
• Called sinus arrythmia
• Most common in children and young adults
• If pulse is irregular, auscultate the apical pulse for a full minute while palpating radial pulse (mid
clavicular line around the 4th or 5th intercostal space)
• Quality
• Varying subjective scales are used to describe the amplitude or quality of the pulse
• Assess bilaterally
• On a 0-4 scale (this is scale from the book, but Covenant is 3+ scale)
• : no palpable pulse
• +1
weak, thready, difficult to palpate
• +2
diminished
• +3
easy to palpate
• +4
strong, bounding (may be abnormal)
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Pulsus Alternans
• A variation in the strength of a contraction resulting in alternating pulse strength
• Might be strong, weak, strong, weak, etc.
• Sign of left ventricular failure
• Pulsus Deficit
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Progressive stage of pulsus alternans; not all beats are palpable
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Now it would be weak, absent, weak, absent
• Assessing Carotid Bruits
• Carotid arteries are assessed by ascultation for bruits
• A bruit is a high-pitched “sh-sh”
• Produced as blood flows through partially occluded vessel
• Jugular Venous Distention (JVD)
• Right-sided heart function assessment
• Often distended while pt is supine
• Normally will disappear with more than 30 degree elevation of head
• Obvious distention of the veins when head is elevated 45-90 degrees indicates abnormal increase in the volume of
the venous system
• Most commonly occurs with Rt. Sided heart failure, but may occur with obstruction of blood flow in the SVC or
with acute massive PE
• Jugular Vein Distention (JVD) is what it’s called when they have it, more than the normal distention
Cardiac Auscultation (know these)
• Areas of auscultation (ICS = intercostals space; MCL = mid-clavicular line)
• Mitral
• Apex, PMI, 5th ICS/MCL
• Tricuspid
• 4th and 5th ICS, left sternal border
• Aortic
• 2nd ICS, right sternal border
• Pulmonic
• 2nd ICS/left sternal border
• APe To Man
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PMI (point of maximum impulse)
• Location on chest where heart contractions can be palpated
• Apical impulse (point of maximal impulse)
• 5th ICS to the left of the sternum at the mid-clavicular line
Auscultation Technique
1. Stethoscope
• Diaphgram (larger surface area)-used for higher frequencies (S1, S2, splits, pericardial friction rubs)
• Bell (smaller side) for lower frequencies, rest lightly or it becomes a diaphgram
2. Location APE to MAN
3. Know your bases
• base is at 2nd ICS/sternum
• Apex is 5th ICS/MCL
4. Palpate carotid pulse to help ID S1/S2
5. Be quiet and patient! Takes lots of practice.
Improving Auscultation Skills
• 1. Use systematic approach and do it the same each time
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2. Have patient supine
3. Listen at each point for S1, S2 and extra heart sounds
4. Use diaphragm first, then the bell
5. Use the same order each time
6. Accentuate sounds by positioning patient on left side with knees flexed
Cardiac Auscultation
• Normal heart sounds are S1 and S2
• Produced by closing of the heart valves
• Time between S1 and S2=systole (shorter)
• Time between S2 and S1=diastole (longer)
• S1 Heart Sound
• LUB
• Caused by closure of mitral and tricuspid valves
• Heard best at apex of heart (apical area)
• Increases in intensity when valve leaflets are rigid or when ventricular contractions occur when valve is caught wide
open
• S2 Heart Sound
• DUB
• Closing of aortic and pulmonic valves
• Heard the strongest at the base of the heart (aortic and pulmonic area)
• Splitting of S1 and S2
• Two components of each normal heart sound
• S1 closure of mitral and tricuspid valve
• S2 closure of pulmonic and aortic vale
• Left sided sounds usually louder than right because they occur milliseconds before right
• Splitting of these two sounds may occur
• Splitting accentuated by inspiration
• Gallop Sounds
• Heart sound comes in triplets and sound like the gallop of a horse
• Low-frequency; heard best with bell of stethoscope
• Occur during diastole
• S3 gallop is heard immediately after the S2
• S4 is heard immediately before the S1
• S3 Heart Sound
“Ken-tuc-ky”
Lub-dub-by
S1-S2-S3
• S4 Heart Sounds
“Ten-nes-see”
(le-lub-dub)
(S4-S1-S2)
• Friction Rub
– Heard in pericarditis
– Harsh, grating sound
– Heard in both systole and diastole
– Caused by abrasion of pericardial surfaces
– Heard best with diaphragm and with patient sitting up and leaning forward
• Murmurs
– Created by turbulent flow of blood
• Can be from valve that is stenotic, tight and small
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• Can be from regurgitation, blood flows back from the ventricles to the atria
Characterized by
• Location-where is it heard the loudest
• Where APe To Man is important
• Timing-systolic/diastolic
• Are you hearing it during systole, diastole, or both?
• Intensity-grading scale (I/VI to VI/VI)
• I Very faint, heard only in quiet environment
• II Quiet, but clearly audible
• III Moderately loud
• IV Loud; may be associated with palpable thrill
• V Very Loud; thrill easy palpable
• VI Very loud; may be heard with stethoscope off the chest, thrill palpable and visible
• Pitch-high/low (diaphragm/bell)
• Quality
• Radiation? Axilla, neck
Extremities
• Inspect for vascular changes
– Decreased capillary refill (normal is >3 seconds)
– Hematoma
– Peripheral edema
– Clubbing of fingers or toes (indicates chronic hypoxia)
– Lower extremity ulcers (can be a sign of vascular problems)
– Edema
• Is it bilateral or unilateral?
• Press down firmly, chart depth of indent in mm and time of recovery
• Scale of 1+ to 4+
Lungs
• Tachypnea
• Cheynes-Stokes respirations
– Pattern of rapid breathing followed by a period of apnea, associated with L sided heart failure
• Hemoptysis
– Are they coughing up a pink, frothy sputum? R/t R pulmonary edema
• Cough
– Dry hacking can be associated with heart failure due to irritation of the small airways
• Crackles
• Wheezes
– Associated with bronchospam
Abdomen
• Hepatojugular reflux
– Caused by Liver engorgement due to decreased venous return
– Firm pressure over RUQ for 30-60 seconds
– Increase of JVD of 1 cm or more
– Indicates right side of heart is unable to compensate for increased volume, backs up into the jugulars
– Basically, when you push on the RUQ does the jugular distention get worse?
• Bladder distention
– Urine output indicator of CO
– Bladder scan or palpate for oval mass in suprapubic area
• If you suspect this you may need to get a bladder scan, whether they are emptying or not
Diagnostic Evaluations
Lab Tests
• Timing of testing relative to onset of symptoms is important
• Creatine kinase (CK) and its isoenzyme CK-MB are most specific in acute MI and the first levels to increase
• Myoglobin-early MI marker (1-3 hrs after acute MI onset), peaks in 4-12 hrs; normal after 24 hrs
• Troponin T or I-advantage: only found in cardiac muscle. Detected 3-4 hrs post MI, peak in 4-24 hrs, elevated for 1-3 weeks
Chest X-Ray
• Used to determine size, contour, and position of the heart
– Looks at cardiac silhouette, should be between 1/3rd and ½ of the whole chest
• Does not diagnose MI but can help diagnose complications (HF)
ECG
• Used to assess the cardio-vascular system
• Graphic recording of the electrical activity of the heart
• Standard 12-lead can diagnose multiple problems
• Patients age, gender, BP, height, weight, symptoms and medications are important to interpretation
Stress testing
• Cardiac stress test procedures include
– Exercise stress test
– Pharmacological stress test (give thallium)
– Mental or emotional stress test
– Non-invasive evaluation of CV response to stress
– Contraindications: severe aortic stenosis, acute myocarditis or pericarditis, severe HTN, left main CAD, HF and
unstable angina
Echocardiogram
• Non-invasive ultrasound exam of the heart
• Determines size, shape and motion of cardiac structures
• Sometimes done with stress test, obtaining images while resting and while stressed
• Ventricular wall motion during stress but not during rest result in a positive result
• Can help detect mitral valve stenosis and regurgitation, mitral valve prolapse, cardiomyopathy, heart failure, cardiac
tamponade and many other cardiac disorders
Cardiac Catheterization
• Invasive diagnostic procedure
• Radiopaque catheters are placed into blood vessels in right and/or left sides of the heart guided by fluoroscopy, dye is
inserted.
• Left-side cath used to obtain pressure readings in left atrium and ventricle. LV ejection fraction is calculated. Coronary
arteries are examined. Femoral artery is normally used.
• Right-side cath: obtains readings from the rt side of heart, including CO and O2 saturations. Femoral vein is commonly
used.
• Most commonly used to diagnose CAD, assess coronary artery patency and determine the extent of atherosclerosis
Angiography
• Injection of contrast agent into vascular system to outline heart and blood vessels
• Selective angiography-specific heart chamber or blood vessel is studied
• Commons sites
– Aortography
– Coronary arteriography
– Right heart catheterization
– Left heart catheterization
Coronary Angiography
• Nucleus Medical Media (2010). Coronary Artery Angiography Procedure. SMART Imagebase. Retrieved Jul 20, 2010, from
http://ebsco.smartimagebase.com/coronary-artery-angiography-procedure/view-item?ItemID=12047
Nursing Interventions
• Before cardiac catheterization:
– Fast 8-12 hours
– Inform patient of expected duration
– What to expect during procedure
• After cardiac catheterization
– Assess site of catheter access for bleeding or hematoma
– Peripheral pulses assessed Q 15 minutes X 1 hr then every 1-2 hrs until pulse is stable
– Assess color and temperature of affected extremity
– Watch for dysrhythmias
– Encourage rehydration (contrast is osmotic diuretic)
– 2-6 hrs bedrest with affected extremity straight
– Monitor BUN and creatinine, I’s and O’s (renal failure r/t contrast agent)
• Patient Education
– Do not bend at the wait to lift, strain, or lift heavy objects for 24 hrs.
– Avoid baths, showers ok
– Call MD for bleeding, swelling, new bruising or pain, temp. > 101.5
– Learn about lifestyle changes to manage disease and/or reduce risk for future heart problems