Cardiovascular Patient Assessment

• Cardiovascular assessment is part of a PT evaluation especially for cardiovascular patients

Objectives

• Describe PT evaluation aspects related to cardiovascular patients
• Recognise heart sounds and their significance
• Explain the cardiac auscultation procedure
• Identify pulse palpation locations
• Describe skin and edema assessment methods
• Explain BP measurement at rest, during activity, and for orthostatic assessment
• Explain how BMI and waist circumference relate to CV risk
• Identify the proper sequence and steps for emergency procedures, including CPR, rescue breathing, and AED use

Initial Evaluation: Medical Chart Review

• Review of medical chart during the initial evaluation including:
  • Diagnosis
  • Age
  • Medications
  • CC/HPI (Chief Complaint/History of Present Illness)
  • PMH/PSH ( Past Medical History/Past Surgical History). This includes co-morbidities and possible implications of disease processes
  • Risk Factor Analysis
  • Special Tests that have been performed
• Social History is important in initial evaluation
  • Including where patient lives and with whom
  • As well as their durable medical equipment (assistive devices, Oxygen)
• Prior activity level
• Sleep Patterns (orthopnea, PND)
• Hospital Course
  • Labs, Tests, Treatments/Interventions and Medications

Initial Evaluation: Patient Interview

• Patient interview is key to initial evaluation including:
  • Subjective feedback, "I feel..."
  • Pain levels
  • Verbal/non-verbal communication
  • Use open questions (how, why, when, where, what)
  • And close ended questions requesting minimal "Yes," or "No" responses,
  • Avoid leading questions that bias patient w/bias
• Objective/Physical Assessment also key in initial evaluation
  • Through Patient Observation
  • Of Lines/Tubes/Drains
  • And Monitoring equipment Orthostatic assessment of vital signs

Sample Social History Gathering

• An example interaction with a patient explaining the PT's role and inquiring about their feelings, living situation.
• Social Hx includes whether they live alone, who they live with, and type of residence (house or apartment) and floors
• Questions focused on home accessibility with questions regarding:
  • Stairs, elevators, railings, and the availability of equipment like canes, walkers, commodes, or shower chairs.

Initial Evaluation: Physical Assessment

• Physical assessments includes general observation/appearance, mental status, auscultation, and skin/vasculature
• Observations:
  • Heart/Lungs
  • Wounds
  • Pulses
  • Capillary refill _ Sensation
• Balance:
  • Sitting
  • Standing
• Coordination
• Functional Assessment
  • Bed mobility
  • Transfers
  • Ambulation including level and stairs

Initial Evaluation: Observation

• The level of respiratory distress provides valuable insights
• Look for: SOB(tachypnea)/DOE, Nasal flaring, Pursed lip breathing, Use of accessory muscles, Cyanosis
• Observation – Position plays a factor
  • Bed and Extremity positions
  • Tripod position indicates use of accessory muscles of respiration

Initial Evaluation: Observation

• Body Type:
  • Apple vs. Pear
  • Cachectic
• Head & Neck:
  • Especially the Jugular venous distention (JVD)
  • Is considered present if superficial veins distend above the level of the clavicles

Initial Evaluation: Mental Status

• Assess Level of consciousness
• Assess ability to follow directions

Auscultation

• Primarily done to listen for murmurs and crackles in the heart or lungs
• A stethoscope is used, particularly the Diaphragm and Bell portions

Heart Sounds

• Heart sounds that are audible originate from the sounds of blood moving thru the valve closures
• Sounds to Recognize Include:
  • 1st Heart Sound = S1
  • 2nd Heart Sound = S2
  • 3rd Heart Sound = S3
  • 4th Heart Sound = S4
• A loud 2nd heart sound is suggestive of pulmonary HTN

Heart Sounds: Systolic

• S1 and S2 are normal heart sounds, and relatively high pitched
  • Commonly referred to as "Lub-Dub"
• When listening for the sounds you should use the diaphragm side of the stethoscope
• S1: "Lub" sound originates with the Atrioventricular valves closing
  • Closing of MV (Mitral Valve) and TV (Tricuspid Valve)
• S2: "Dub" sound originates with the Semilunar valves closing
  • Closing of AV (Aortic Valve) and PV (Pulmonic Valve)
• Differentiating involves noting that S1 tends to be shorter in duration than S2
• S2 is then longer in duration that S1
• Auscultation allows for ventricles to fill Splitting can occur with S1 or S2

Heart Sounds: S1 vs S2

• S1 correlates with the "Lub" sounds
• "Lub" sounds arise from the closure of the atrioventricular valves indicating the beginning of systole
• S1 is usually loudest at the Mitral area (cardiac apex) where S1 is louder than S2 Has two components, Tricuspid and Mitral
• Auscultation uses the diaphragm with firm pressure
• S2 correlates withe sounds arising from the closure of the semilunar valves
• Indicating the end of systole.
• S2 loudest at the Aortic and Pulmonic area where S2 is louder than S1
  • Has two components, Aortic and Pulmonic
• Auscultation uses the diaphragm with firm pressure

Heart Sounds: Abnormal Sounds

• S3, S4 often indicates presence of diastolic sounds, and are low frequency and soft
  • Use the bell shaped side of the stethoscope
• S3 (lub-dub-dub):
  • Is heard in early diastole
• S4 (la-lub-dub):
  • Is heard in late diastole

Heart Sounds: Gallop Rhythms

• Additional abnormal sounds include:
  • S3= LUB-DUB-DUB(S1, S2, S3)
  • Is AKA Gallop S3, or a "ventricular gallop"
• Representing loss of ventricular compliance, heard immediately after S2
• S3 occurs early in diastole
  • And is produced during passive LV filling
• Usually normal in children, young adults, and well trained athletes
  • But abnormal among older patients with heart disease.
• It can be a key diagnostic sign for CHF, as well as for Mitral regurgitation, Ventricular Septal Defect, or Congenital Heart Block
• Best heard in the Mitral area with patient in left lateral decubitus, following exercise where S3 is louder than S2
• Low pitch – use bell to auscultate (LIGHT PRESSURE)

Heart Sounds: Atrial Gallop

• S4= LALUB-DUB:
  • Is aka Gallop S4, or “atrial gallop” which represents increased resistance to ventricular filling before S1
• It occurs late in diastole during active LV filling and is rarely normal
• When abnormal, usually the patient is:
  • Children
  • Or adults
  • Typically common in patients with hypertensive cardiac disease, CAD, and with pulmonary disease, as well as MI or post bypass surgery.
• Conditions typically associated includes:
  • AS(Aortic Stenosis)
  • PS (Pulmonary Stenosis)
  • Hypertrophic cardiomyopathy (HCM)
• Low pitch – use bell to auscultate (LIGHT PRESSURE)
• The Summation Gallop arises from the S1, S2, S3 and S4 sounds
• Is due to the S3 and S4 frequencies being superimposed rhythmically Often resulting in a quadruple rhythm, mimicking the sound of a galloping horse
• Usually is found in patients with tachycardia
• And tends to be associated with cardiac disease, stenotic lesions, MI, CHF

Heart Sounds: Murmurs

• Murmurs generate a "whoosh" turbulence that is not related to valve closing
• They tend to be caused by turbulent blood flow and are Described by:
  • Position in cardiac cycle (systolic vs. diastolic)
  • Duration (Entire phase, Start/stop w/in phase)
  • Quality (sharp, snapping, dull, rumbling, blowing, musical, scratchy, harsh, soft, swishing) Intensity/Loudness (based on Levine scale)
• Causes Include:
  • High rates of flow through normal and abnormal valves
  • Forward flow through constricted and/or irregular shaped valves into a dilated vessel (stenosis)
  • Backward flow through an incompetent valve (REGURGITATION)
  • Decreased viscosity leading to an increased turbulence (FLUID OVERLOAD)

Ejection vs Opening Sounds

• Systolic Murmurs: include Aortic Stenosis, Mitral Valve Prolapse, Mitral Regurgitation, Pulmonary Stenosis, Ventricular Septal Defect, and Atrial Septal Defect
• Diastolic Murmurs: include Aortic Regurgitation and Mitral Stenosis
• Ejection sounds occur during the systole phase
  • Arise due to forceful/rapid ejection of blood, typically past an obstruction
    • And results in high frequency sounds .

Systolic vs Diastolic Clicks

• Systolic Click
  • Is caused by the prolapsed mitral (or tricuspid) valve that falls backward into the atria, and leads to regurgitant blood flowing forcefully past the prolapsed valve which causes turbulence.
  • Its sounds are heard as single or multiple "clicking” sounds during systole
  • Mitral valve prolapse is more common in females, usually benign
• Pericardial friction rub is caused by an increase in the pericardial fluid in the pericardial sac which is often associated with pericarditis.
  • This often Impairs filling of the ventricles during diastole
  • The filling ventricles “rub” against the engorged pericardial sac and produces leathery or squeaky sound Occurring during diastole, and usually also during systole when there is marked pericardial fluid present

Auscultation Procedure

_ Create a quiet environment and ask patient breathes quietly to listen better

• Expose areas for auscultation ensuring there is bare skin for auscultation
• To avoid extra sounds from clothing
• Use the diaphragm rather than the bell Ensure pt is in a supine or semi-fowlers position
• Good for most heart sounds
• Ensure to start the process from apex of heart, working superiorly toward the base

Auscultation Procedure Locations

• The most common auscultation locations include:
  • Aortic: 2nd ICS, and right sternal border
  • Pulmonic: 2nd ICS, and left sternal border
  • Tricuspid: 4th (and often also including the 5th) ICS, left sternal border
  • Mitral: cardiac apex/PMI, 5th ICS, medial to the line from the midclavicular line
  • Erb's Point (best for S2 heart sound) at the Left sternal border, 3 rd ICS

Vascular Assessment

• Trophic changes and Pigmentation

• One should assess the skin for:

  • Abnormal pigmentation
  • Dermatitis
  • Ulceration
  • Coloration and changes with position of the limb/body
  • Loss of hair from the area
  • Thickened nail bed
  • Hemosiderin
  • Presence of any Incisions, wounds, or dressings
  • Whether the site is exhibiting signs of Pallor or Diaphoresis/flushing

• Skin Assessment looks for presence of cyanosis (lips, tounge) and/or hypoxemia

• Also looks for clubbing (pulmonary HTN, CF)

• Peripheral cyanosis

• May indicate Inadequate CO leading to decreased peripheral perfusion (PVD)

  • Possibly with varicosities, or PAD – CAD and/or obesity, male patients using tobacco as well as Raynaud's phenomenon

Skin Assessment: Edema

• Edema presence can be classified as Pitting vs non-pitting
• That is present in the Extremities or Abdomen
  • Note: Anasarca – severe, generalized, massive (total body) edema
• Pitting edema evaluation and grading requires two fingers against a particular area
• The assessment will usually take two to three seconds (if an indentation occurs then the edema is classified as "pitting”)
• Once qualified the, further graded based on depth of "pit" & how long it remains.
• This includes:
  • 1+ = ~2mm in depth or very shallow); disappears rapidly
  • 2+ = ~4mm in depth; skin rebounds in < 15 sec
  • 3+ = ~6 mm in depth; extremity looks grossly swollen; skin rebounds in varying times found (15-30 sec, > 1 min)
  • 4+ = ~8 mm in depth (or more); skin rebounds in varying times found (> 30 sec, may last > 2 min)

Vascular Assessment: Pulses

• Palpation or use of Doppler enables grading pulse on the following scale:
  • 0 = no palpable pulse
  • 1+ = faint, but detectable pulse
  • 2+ = slightly more diminished pulse than normal
  • 3+ = normal pulse
  • 4+ = bounding pulse
• Auscultation is also key in assessing vascular activity
  • Checking for Bruit and "Thrill" which means something is being palpated
• Temperature can be used to asses if there are gross differences Palpation Sites
  • Carotid, Brachial, Radial, Femoral, Popliteal, Dorsalis pedis and Posterior tibial pulses And the Apical Pulse
• The point of maximal impulse (PMI) which you palpate or auscultate

Pulse Assessment

• Carotid: use light pressure as you can cause a vagal response
• Brachial: cubital fossa medial to the biceps tendon
• Radial: medial to the radial styloid process on the palmar surface of the forearm
• Femoral: just inferior to the inguinal ligament half way between the ASIS and the pubic tubercle
• Popliteal: in the popliteal fossa with the Knee flexed
• Dorsalis pedis: between the ext hallicus longus and the ext digitorum longus on the dorsum of the foot (Absent in 10% of population)
• Posterior tibial: posterior and inferior to medial malleolus Assessments of arterial pulses include considering: Rate, Regularity, and Quality
• Newborn (0-3 months): 100-150 bpm
• Infants (3-12 months): 80-120 bpm
• Children (1 – 10 years): 70-130 bpm
• Children > 10 years & Adults: 60-100 bpm

Vascular Assessment pt II

• Measuring blood pressure involves:
• Korotkoff sounds -sound heard over an artery
• Use correct cuff size, and note that too wide a cuff will result too low a reading
• While too small a cuff will result too high a reading
• Blood pressure can Be taken at Brachial, Thigh and Calf
• However, there are precautions when taking Brachial: Mastectomy, DVT, in presence of IV lines, AV fistula, and Fracture cases As well as with Lymphedema, Lymph node dissection or Sentinel node dissections

Blood Pressure: Classifications

• A blood pressure category of normal indicates the patient's: Systolic is less than 120 and Diastolic is less than 80
• An elevated range indicates the patient's: Systolic is 120 -129 and Diastolic is still less than 80
• High Blood Pressure (Hypertension) Stage 1 patient's reading: Systolic is 130-139 or Diastolic 80-89
• High Blood Pressure (Hypertension) Stage 2 patient's reading: Systolic is 140 or higher or Diastolic is 90 or higher
• Hypertensive Crisis requires you to consult the doctor immediately due to reading: Systolic is higher than 180 and/or Diastolic is higher than 120

Blood Pressure: Norms by Age

• For children under 10 years, the following guidelines apply
• 0-12 months: 65-100 mmHg / 45-65 mmHg
• 1-12 years: 90-120 mmHg / 55-75 mmHg
• And after 12+ years: 110-135 mmHg / 65-85 mmHg
• Orthostatic or Postural Vitals are useful for when you evaluate body's response to position changes especially suspicion of intravascular volume loss. This includes checking for:- Decreased SBP (20 mmHg or greater) Decreased DBP (10 mmHg or greater) Increase HR often occurs in response to sudden drop in BP (often 20 bpm or greater)
• Recommendations for BP assessment include, taking it when a pt is:
  • In supine
  • 1 min post standing
  • 3 min post standing after

Taking Ankle/Thigh Blood Pressures

• When taking a thigh blood pressure you must ensure the patient is in a:
• Pt supine w/ hip+knees flexed, or in prune position
• Place the cuff proximal to the popliteal artery (2-3 cm)
• Then using a Doppler or stethescope listen near the popliteal artery to assess Taking an ankle Blood pressure
• Place the patient supine
• Place the cuff above the malleoli (2-3 cm)
• Then you can palpate of posterior tibial or dorsalis pedis artery
• However, be aware that Doppler is the only way to accurately measure pressure.

Diagnostic Testing and Measures

• Capillary Refill Time
• Allen Test
• Waist Circumference or Peripheral limb measurements
• ABI = ankle brachial index
• BMI = body mass index
• Waist Circumference The Capillary Refill Test (Nail Blanch Test) measures: Time for capillary bed to refill after being by pressure
• This test is an Indication of perfusion to extremities
• Procedure relies on applying firm pressure to nail bed or bony prominence release pressure pressure
• and the checking if Time for nail or skin to regain full color.
• Usually full color returns in less than 2 seconds.

Diagnostic Testing and Measures pt II

• Allen Test
• Assesses for Vascular Insufficiency
• Place sitting pt and have then open/close hand several times, then hold in closed position
  • As you compress radial and ulnar arteries release hand and you release pressure on one of the arteries, and note that there is immediate flushing of the area.
• In a positive test the pt will have delayed or absent flushing and may indicate occlusion in related arteries
• Peripheral Limb Measurement looks for Girth changes due to edema
• Compare leg to leg or arm to arm often using the same landmarks each time Ankle Brachial Index (ABI)
• Is obtained by dividing the systolic pressure at the ankle by the brachial systolic pressure.
  • You should usethe highest brachial pressure to work
• Note that the Ankle SBP is normally higher than Brachial SBP Make sure you are testing when pt is supine as well

Ankle Brachial Index (ABI)

• The ABI provides use of Doppler and will help amplify the sounds when used to measure a patient pressure
• Calculation is Ankle SBP / Brachial SBP (ex: 140 mmHg / 130 mmHg = 1.08)
• And lower calculation would indicate disease( ex:110 mmHg / 130 mmHg = .85)
• Is useful for evaluate:
  • Claudication or a Vascular component of rest pain,
  • Evaluate appropriateness and safety for exercise and for use of compression garments
  • And/or checking Tissue health when distal perfusion testing for would healing is needed Normal reading for lower extremeties _ 60 mmHg is normal _ 80 mmHg is normal

Ankle Brachial Index (ABI)

• AHA: 0.90 or less clinical suspicion for PAD
• Normal: 1.0 - 1.1
• Borderline: 0.91 - 0.99
• Abnormal:
• Less than <0.9 or >1.3
  • If above> 1.3, the vessels test unreliably due to presence of calcified vessels (diabetes) causing falsely elevated pressures
• If Below<0.9 suggests significant narrowing in 1 or more blood vessels with claudication
• Often with rest pain or severe occlusive disease causing ischemic to gangrenous extremities
• Acute Care Handbook reads numbers as follows:

/=1.0-1.3 equals normal function with normal range /= 0.7-0.8 equals borderline perfusion <=0.5 indicates cases with severe ischemia <=0.4 indicates critical limb ischemia

• While review books reads >/=1.30 as Rigid arteries. The values indicate a need for U/S check for PAD The rest follows a: 1.0-1.3 normal without blockage 0.8-0.99 Mild Blockage showing beginning stage for PAD 0.4-0.79 Moderate Blockage, associated with intermittent claudication <=0.4 Severe blockage, Suggestive of severe PAD, may have claudication pain at rest. What is Body Mass Index (BMI)? Meausres weight relative to Height ratio = Body mass index (BMI) is a measure of body fat based on height and weight A reliable indicator of body fatness for most people and Used to screen for weight categories that may lead to health problems Calculated via Weight/Height² and Expressed in kg/m² or lb/in²
• Weight status categories on BMI are the same for all ages and for men and women And it Correlates to direct measures of body fat, such as underwater weighing and dual energy x-ray absorptiometry (DXA). Underweight when its Lessthan 18.5 Normal weight = 18.5-24.9; Overweight when its equal or between 25-29.9;

BMI Categories

Obesity: Is a BMI of 30 or greater, which can be calculated via online BMI calculator.

• The additional Waist Circumference enables assessing abdominal fat
• And also is useful re: estimating decreased abdominal fat even without changes in BMI by positioning patient in standing
• tape measure around abdomen at level of iliac crest at end of normal exhalation Results in higher risk when more than 102 cm (>40 inches) for men And greater than> 88 cm (> 35 inches) for women Results in higher risk for Type 2 DM, HTN, dyslipidemia, and cardiovascular disease