Download Assessment of clients with CVS conditions

Assessment of clients with CVS
conditions
NSG 409
spring 2015
Wejdan Khater, RN, PhD.
5/24/2017
Wejdan A.Khater
Group Activiities

What makes people at risk for heart
diseases??

So what do you need to Assess Patients for
possible Cardiac problems ??
Wejdan A.Khater
5/24/2017
Case Study


At 6:45 a.m., your unit is dispatched for a 50-yearold male with chest pain. You and your partner
proceed to the scene, with a response time of
approximately eight minutes. The closest hospital
from the scene is 40 miles away.
You arrive at the scene, A middle-aged male
answers the door and identifies himself as the
patient. You note that he is diaphoretic and anxious,
and is clenching his fist against the center of his
chest.
Wejdan A.Khater
5/24/2017
Group Activity

1. What is the significance of the patients
clenched fist in the center of his chest?
Wejdan A.Khater
5/24/2017
Case Study (cont…)
You sit the patient down and perform an initial
assessment
Blood pressure: 160/92 mmHg.
Pulse: 112 beats/min, strong and regular.
Respirations: 22 breaths/min and unlabored.
Oxygen saturation: 99% (on 100% oxygen).
Signs and symptoms: Chest pressure, restlessness,
diaphoresis, tachycardia, hypertension.
Allergies: None. He is not allergic to aspirin.
Medications: Nitroglycerin (as needed) and Vasotec.
Wejdan A.Khater
5/24/2017
Think Of

How could this patient's current blood
pressure and heart rate affect his
condition?
Wejdan A.Khater
5/24/2017
Case Study (cont…)
Pertinent past history: "I have high blood
pressure and the doctor told me I may have a
heart attack if I don't start exercising. He gave
me the nitro to take when I have chest pain."
Last oral intake: "I ate supper last night, but
can't remember the exact time."
Events leading to the present illness: "I was
asleep when the pressure in my chest woke
me up."
Wejdan A.Khater
5/24/2017
Case Study (cont…)

Level of consciousness: Conscious and alert to
person, place and time; restless and anxious.
Chief complaint: "My chest feels tight and I feel
really weak."
Airway and breathing: Airway is patent;
respirations are slightly increased and unlabored.
Oxygen saturation: 97% (on room air).
Circulation: Radial pulse is rapid, strong and
regular; skin is cool, clammy and pale.
Wejdan A.Khater
5/24/2017
Focused History and Physical
Examination

Onset: "This began suddenly. It woke me from my sleep."
Provocation/Palliation: "This pressure in my chest is constant.
Nothing that I do makes it better or worse."
Quality: "My chest feels very tight."
Radiation/Referred: "The pressure stays in my chest. I don't hurt
anywhere else."
Severity: Seven on a 0--10 scale.
Time of onset: "This began about an hour ago."
Interventions prior to EMS arrival: None.
Chest exam: No sign of trauma, chest wall is symmetrical and
nontender.
Breath sounds: Clear and equal bilaterally to auscultation.
Jugular veins: Normal, not distended.
Wejdan A.Khater
5/24/2017
Case Study (cont…)

After confirming no history of bleeding
disorders or allergies, you administer 324 mg
of aspirin to the patient. The patient remains
conscious and alert, but is becoming
increasingly restless. You attach the patient to
a cardiac monitor and interpret his cardiac
rhythm as sinus tachycardia at 110 beats per
minute.
Wejdan A.Khater
5/24/2017
Case Study (Cont…)

After administering 0.4 mg of nitroglycerin
sublingually to the patient, you and your
partner attach the remaining ECG leads and
obtain a 12-lead tracing of the patient's cardiac
rhythm. As your partner stands up to retrieve
the stretcher from the ambulance, you tell him
that it looks as though the patient may be
having an anterior wall MI.
Wejdan A.Khater
5/24/2017
Think!!!

What are the physiologic effects of
nitroglycerin?
Wejdan A.Khater
5/24/2017
Case Study (cont..)

The patient's chest pressure is unrelieved
following two more doses of sublingual
nitroglycerin. You place him on the stretcher
and load him into the ambulance. En route to
the hospital, you continue oxygen therapy and
successfully establish an IV of normal saline
with an 18-gauge catheter. Reassessment of
his blood pressure reveals a reading of 140/88
mmHg.
Wejdan A.Khater
5/24/2017
Case Study (cont…)

Because three doses of nitroglycerin failed to
relieve his pain, you administer 2 mg of
morphine sulfate via IV push. Within 10
minutes, the patient tells you that the pressure
in his chest has improved and is now a "3" on a
0--10 scale. With an estimated time of arrival at
the ED of 20 minutes, you begin an IV infusion
of nitroglycerin at 10 µg/min and perform an
ongoing assessment .
Wejdan A.Khater
5/24/2017
Case Study (cont…)

The patient's condition continues to improve en
route to the hospital. You ask him if he has a
history of ulcers, bleeding disorders, recent
surgeries or stroke. He tells you that other than
his high blood pressure and occasional chest
pain, he has no other medical problems. You
call your radio report to the receiving facility
and continue to monitor the patient.
Wejdan A.Khater
5/24/2017
Think !!!

Why are you asking the patient these
specific questions?

Are there any special considerations for
this patient?
Wejdan A.Khater
5/24/2017
History









Chief complains
Chest pain
Dyspnea
Edema of the ankle and feet
Palpitation & syncope
Cough & hemoptysis
Nocturia
Cyanosis
Intermittent claudication
Wejdan A.Khater
5/24/2017
Chief complains & history of present illnesses







N: normal base line
O: onset
P:precipitating and Palliative factors
Q: Quality & Quantity
R: Region& Radiation
S: Severity
T: Time
Wejdan A.Khater
5/24/2017
In fact, roughly half of the chest pain cases
seen by doctors are of cardiac origin. The
remaining 50% is referred to as non-cardiac
chest pain (NCCP).
So, where is the pain coming from?!!
How to differentiate between cardiac and non
cardiac chest pain

Wejdan A.Khater
5/24/2017
Group Activities

After reading the Article discuss in group how
to differentiate cardiac pain from non Cardiac
Pain
(7 minutes discussion)
Wejdan A.Khater
5/24/2017
Chest Pain






The most common symptoms of Patients with CVD
A result of an imbalance between oxygen supply and
oxygen demand, it usually develops over time
NOPQRST
Chest pain caused by CAD is often precipitated by
physical or emotional exertion , a meal or being out in
the cold.
Usually located in the substernal region often radiates
to the neck, left arm, the back, or jaw.
The quality of cardiac chest pain is often described as
heaviness, tightness, squeezing, or choking sensation.
Wejdan A.Khater
5/24/2017
Chest Pain

When asked about time, the patient with cardiac chest
pain reports the pain lasting anywhere from 30
seconds to hours.

if the patient reports the pain is made worse by lying
down, moving, or deep breathing, it may be caused by
pericarditis. If the pain is retrosternal and accompanied
by sudden shortness of breath and peripheral
cyanosis, it may be caused by a pulmonary embolism.
Wejdan A.Khater
5/24/2017
History (cont)

Dyspnea: Subjective complains of the difficulty in
breathing not just SOB.
–
In patients with cardiac disease, it is the
result of inefficient pumping of the left
ventricle, which causes a congestion of
blood flow in the lungs.
–
Orthopnea
Paroxysmal nocturnal dyspnea
–
Wejdan A.Khater
5/24/2017
History (cont)






Edema of the feet and ankles
Palpitation and syncope: awareness of irregular
or rapid heart beat.
Cough & hemoptysis.
Nocturia.
Cyanosis:
– Central vs Peripheral
Intermittent claudication: results when blood
supply to excerciing
muscles is inadequate 5/24/2017
Wejdan A.Khater
Past Health History
 Child
hood illnesses
 Past medical problems
 Past surgeries
 Past diagnostic test
Wejdan A.Khater
5/24/2017
Current health status
Use of medications
 Allergies to food
 Tobacco, alcohol, substances use
 Diet
 Sleep patterns
 Exercise
 Activities

Wejdan A.Khater
5/24/2017
Health Assessment
 Family
history (HTN, CAD, MI, PVD,
arrythmias)
 Social and personal history (family
composition, coping patterns,
cultural beliefs, living environment)
Wejdan A.Khater
5/24/2017
Risk Factors



Uncontrollable(e.g age, heredity, gender, race)
Can be modified(smoking, HTN, DM, high
blood cholesterol, physical activities,
obesity…)
Other factors (e.g stress, sex hormones, birth
control bills, alcohol intake)
Wejdan A.Khater
5/24/2017
Physical Exam


Inspection
– General appearance
– Jugular venous distension
(JVD)
– Skin
– Extremities
Palpation
– Pulses
– Point of maximal impulse
(PMI)


Wejdan A.Khater
Percussion
Auscultation
– Good stethoscope
– Positioning
– Normal tones – S1/S2
– Extra tones – S3/S4
– Murmurs
– Rubs
5/24/2017
30
Inspection
General appearance
 Jugular venous distention
 Inspect chest
 Inspect extremities
 Inspect skin
Patient may have dextrocardia-heart
situated on the right side.

Wejdan A.Khater
5/24/2017
Jugular venous distention


JVP reflects right atrial pressure and provides an
indications of heart hemodynamics.
A level more than 3 cm above the angle of Louis
indicates an abnormally high volume in the venous
system
 Supine 30-45 degrees, remove pillow
 Turn head away from examiner, shine light across
neck to highlight pulsation
 Locate Angle of Louis & position a vertical ruler on
reference point
 2nd ruler horizontal to level of pulsation
Wejdan A.Khater
5/24/2017
Jugular venous distention


JVP reflects right atrial pressure and provides an
indications of heart hemodynamics.
Normal JVP should not exceed 3 cm above the angle
of louis.




Supine 30-45 degrees, remove pillow
Turn head away from examiner, shine light across neck to
highlight pulsation
Locate Angle of Louis & position a vertical ruler on reference
point
2nd ruler horizontal to level of pulsation
Wejdan A.Khater
5/24/2017
Jugular venous pressure


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Hypovolemic patients may need to lie flat
before you see the veins
When JVP increases, the patient may need to
be elevated 60-90 degrees.
Increased JVP may suggest Rt side HF,
tricuspid stenosis or superior vena cava
obstruction, pericaridal effusion,
In patients with COPD, veins collapsed with
inspiration and pressure elevated during
expiration.
Wejdan A.Khater
5/24/2017
Jugular venous pressure



Unilateral distension of jugular vein may be
due to local obstruction or kinking.
jugular venous pressure of more than 1 cm
while pressure is applied to the abdomen for
60 seconds (hepatojugular or abdominojugular
test) indicates the inability of the heart to
accommodate the increased venous return.
Factors influencing the JVP includes total body
volume, right atrial contraction, and the
distribution of blood volume through the
pulmonic artery
Wejdan A.Khater
5/24/2017
Inspection (Cont)

Inspect chest:
– Apical pulse: At left
4th or 5th ICS at MCL
Wejdan A.Khater
5/24/2017
Palpation

Palpate pulses bilaterally
– Temporal
– Carotid * important to only palpate one side at a time
– Brachial
– Radial
– Ulnar
– Femoral
– Popliteal
– Dorsalis pedis
– Posterior tibial
Wejdan A.Khater
5/24/2017
Palpation
–
–
pulsus alternans is a pulse that alternates in
strength with every other beat; it is often found
in patients with left ventricular failure.
Pulsus paradoxus is a pulse that disappears
during inspiration but returns during expiration.
 Pulsus
paradoxus is a sign that is indicative of
several conditions, including cardiac
tamponade, pericarditis, chronic sleep apnea,
andobstructive lung disease (e.g. asthma, COPD)
Wejdan A.Khater
5/24/2017
Palpation

Precordium: with the palmer aspect of the four
fingers palpate:
– The Apex, base, and left sternal border for any
additional pulsation.
– During palpation of these areas, the nurse feels
for a thrill, which is a palpable vibration. A thrill
usually represents a disruption
– in blood flow related to a defect in one of the
semilunar valves.
Wejdan A.Khater
5/24/2017
Palpation

Apical Impulse: Point of maximum Impulse
(PMI)
– Location: At left 4th or 5th ICS at MCL
– Size: 1 x 2 cm
– Amplitude: short, gentle tap
– Duration: short
Wejdan A.Khater
5/24/2017
Palpation
Right
2nd
ICSaortic
area
Left 2nd
ICSpulmonic
area
Epigastric
(subxiphoi
d)
Wejdan A.Khater
Left
sternal
border
right
ventricular
area
Apex
Left
Ventricul
ar Area
5/24/2017
palpation
Palpation of Carotid pulse
 Carotid pulse should not be
assessed simultenous because
This can obstruct flow to the
Brain

Wejdan A.Khater
5/24/2017
Percussion





Percuss for Cardiac Enlargement
Lt. Anterior axillary line 5th intercostal space &
toward the sternal border
Resonance over lung – dull over heart
Normal – lt. Border of cardiac dullness 5th
interspace MCL: @ 2nd interspace dullnes
coincides with the lt. Sternal border
2nd interspace to 5th MCL
Wejdan A.Khater
5/24/2017
Auscultation
–
1.
2.
3.
Supine position with bed elevated
Listen with the diaphragm at the right 2nd interspace
near the sternum (aortic area).
Listen with the diaphragm at the left 2nd interspace
near the sternum (pulmonic area).
Listen with the diaphragm at the left 3rd, 4th, and 5th
interspaces near the sternum (tricuspid area).
Wejdan A.Khater
5/24/2017
Auscultation
1.
2.
3.
Listen with the diaphragm at the apex (PMI) (mitral
area).
Listen with the bell at the apex.
Listen with the bell at the left 4th and 5th interspace
near the sternum
Wejdan A.Khater
5/24/2017
Auscultation
Wejdan A.Khater
5/24/2017
Auscultation
Aortic – 2nd rt. Interspace
 Pulmonary – 2nd lt. Interspace
 Erb’s Point – 3rd lt. Interspace
 Tricuspid – 5th interspace
lt. Lower sternal border
 Apical – 5th interspace
lt. MCL

Wejdan A.Khater
5/24/2017
Heart sounds
Wejdan A.Khater
5/24/2017
Heart sounds

S1:
–
–

S2:
–
–

loud sounds
produced by AV valves
loud sounds
produced by semilunar valves
S3, S4:
–
–
soft sounds
blood flow into ventricles and atrial contraction
Wejdan A.Khater
5/24/2017
First & Second Heart Sound
Wejdan A.Khater
5/24/2017
First heart sound

First Heart sound S1 (Lub):
– Is timed with the closure of (AV valves ; mitral &
tricuspid) at the beginning of ventricular systole.
– Louder than S2 at the apex (mitral valve closure is
responsible for most of the sound produced).
– Loud S1: The intensity of the 1st heart sound may
be increased when PR interval is shortened, as in
tachycardia or in mitral stenosis due to valve leaflets
thickened.
– Splitting of S1 sound may be casued by delay in the
conduction of impulses through the right bundle
branch
Wejdan A.Khater
5/24/2017
First Heart Sound
–
–
–
–
–
Soft S1: is heard when the PR interval is prolonged.
Split S1: is heard when right ventricular emptying is
delayed. The mitral valve closes before the tricuspid
valve and splits the sound into its two components.
Splitting S1 is best heard over the tricuspid area.
Coincide (correlate) with (upstroke) of carotid artery
pulse.
Coincide with the R wave of the QRS complex of the
ECG
52
Wejdan A.Khater
5/24/2017
Second heart sound

Heard over pulmonic area (2nd left ICS)

Loud S2: The intensity of the 2nd heart sound may be
increased in the presence of aortic or pulmonic valvular
stenosis.
–
–
Is produced by vibrations initiated by the
closure of semilunar valves (Aortic &
Pulmonic).
Loudest at the base.
Wejdan A.Khater
5/24/2017
Second Heart Sound
Physiological Normal splitting of S2 may
occur with Inspiration (aortic & pulmonic
valves closes separately).
During inspiration, there is an increase in
venous return to the RT side of the heart,
which causes a delay in the emptying of the
A2
RV and the closure of the Pulmonic valve P2
which cause splitting.
–

S1
Wejdan A.Khater
S2
Inspiration
5/24/2017
Third heart sound (Cont)

S3 (Ventricular gallop):
–
–
Indicates decrease ventricular compliance
(ventricles cannot distend to accept rapid
inflow of blood). This causes turbulent flow,
resulting in the vibration of the AV valvular
structures or ventricles them selves, producing
a low-pitch sound.
S3 may be physiological or pathological.
Wejdan A.Khater
5/24/2017
Third heart sound (Cont)

S3 often indicates volume overload
secondary to congestive heart failure
or valvular regurgication.
Wejdan A.Khater
5/24/2017
4th Heart Sound

S4 (Atrial Gallop)
– Is a late diastolic sound that occurs just
prior to S1.
– It is a low-frequency sound heard best
heard at the apex in left lateral position with
the bell.
– The presence of S4 usually indicates
cardiac disease secondary to a decrease in
ventricular compliance caused by either
ventricule hypertrophy or myocardial
Wejdan A.Khater
5/24/2017
4th Heart Sound

S4 (Atrial Gallop)
– when contraction of the atrium forces
the final amount of blood into the
ventricles. The vibration occurs
because the ventricle is too full to
contain the additional blood. This can
occur in pathologic states such as
ventricular hypertrophy.
Wejdan A.Khater
5/24/2017
4th Heart Sound (cont)
Could be normal in adults > 40 with NO
evidence of cardiac disease
– Pathologic S4 occur with patients who
have CAD, HTN, and aortic stenosis.
– S4 is heard best at the lower left
sternal border & becoming louder
during inspiration.
–
Wejdan A.Khater
5/24/2017
Additional Heart Sounds
 Summation
Gallop: S3 & S4 present when
there is a rapid heart rates as ventricular
diastole shortens, S3 & S4 fuse together and
become audible as a single sound. Heard on
apex.

Friction Rubs: A pericardial friction rub is a
high pitched, scratchy sound produced by
inflamed pericardial surface layers which
rubbing together.
Wejdan A.Khater
5/24/2017
Murmurs

a.
b.
Sounds are produced either by:
the forward flow of blood through a narrowed
or constricted valve into a dilated vessels
chamber.
the backward flow of blood through an
incompetent valve or septal defect.
Wejdan A.Khater
5/24/2017
Murmurs

Describe the following attributes of Murmurs:
1.
Timing:
1.
Systolic murmur (occurs between S1 & S2)
–
2.
Diastolic murmur (occurs between S2 and S1).
–
2.
3.
4.
Midsystolic, pansysolic, late systolic
Early diastolic, middiastolic, or late diastolic
Location of Maximal Intensity: The site where murmur
originates (heard best).
Radiation: from point of maximum intensity still the sound
heard.
Pitch: high, medium, or low.
Wejdan A.Khater
5/24/2017
Murmurs
5.
Intensity: the grade on 6-point scale to describe the intensity of murmur
6.
Quality: blowing, harsh, rumbling, or musical.
Wejdan A.Khater
5/24/2017