Nursing Cardiac Assessment

Physical Assessment

• The presentation covers physical assessment of the thorax, lungs, cardiovascular system, and abdomen.
• The presenter is Mrs. Keron Jones-Fraser, a PhD candidate, and a registered nurse (RN).

Thorax & Lungs

• Thorax is the portion of the body from the base of the neck to the diaphragm.
• The outer structure is the thoracic cage, and the inner structure is the thoracic cavity.
• Thoracic cavity includes the mediastinum, trachea, esophagus, heart, and great vessels.
• Lungs include three lobes on the right and two lobes on the left..

Vertical Reference Lines

• Vertical lines on the chest are used for describing locations.
• Mid-sternal line is over the breastbone.
• Right and left mid-clavicular lines extend downward from the mid-point of the clavicle, dividing each side of the anterior chest.
• Anterior axillary line follows the anterior axillary fold.

Thorax & Lungs (continued)

• Diaphragmatic excursion: measure the diaphragm's movement or distance to map out the lower lung border.
• Ask the client to exhale and hold it.
• Percussion test down along the scapular line, changes in sound signal the level of the diaphragm..
• Diaphragmatic excursion should measure 3 to 5 cm in adults. 7 to 8 cm in well-conditioned people.
• Inspection includes nasal flaring, pursed lip breathing, color and shape of nails, and color of face, lips, chest.

Thorax & Lungs (continued)

• Palpation of the posterior thorax checks for tenderness, sensation, crepitus, surface characteristics, fremitus, and chest expansion.

Thorax & Lungs (continued)

• Percussion of the posterior chest assesses tone, diaphragmatic excursion, breath sounds, and adventitious sounds.
• Normal breath sounds include bronchial, bronchovesicular, and vesicular sounds.

Adventitious Breath Sounds

• Crackles are discontinuous sounds (fine or coarse) heard during inspiration that may not clear with coughing.
• Wheezes are high-pitched, musical sounds that are usually heard during expiration
• Pleural friction rubs are low-pitched, dry, grating sounds heard during both inspiration and expiration.
• The source of crackles is from inhaled air suddenly opening small deflated airways coated with exudate.

Collecting Objective Data: Physical Exam (PE)

• Client preparation includes providing privacy, keeping hands warm for comfort, and remaining nonjudgmental.
• The necessary equipment is exam gown, drape, gloves, stethoscope, light source, mask, skin marker, and metric ruler.

Heart & Neck Vessels

• Heart is located in the mediastinum.
• Four chambers: Left atrium, left ventricle, right atrium, right ventricle.
• Two atrioventricular valves, two semilunar valves.
• Three layers: Epicardium, myocardium, endocardium.
• Neck vessels include carotid artery, jugular veins.
• Carotid artery pulse reflects ventricular systole, jugular venous pressure reflects right atrial pressure.

Heart Assessment Procedure

• Great vessels: Observe and evaluate jugular venous pulse, auscultate and palpate carotid arteries.
• Heart: Inspect and palpate for abnormal pulsations, apical pulse; auscultate heart rate and rhythm; listen to normal/abnormal heart sounds in different positions..

Palpation of the Heart

• Locate apical pulse using one finger pad.
• Confirm characteristics of apical pulse, detect other pulsations (e.g., thrills).
• Begin with general chest wall palpation.

Auscultation of the Heart

• Listen to the heart sounds in a quiet room using a stethoscope.
• Auscultate along the left sternal border between the second and fifth interspaces and at the apex..
• Evaluate the entire precordium (area over the heart).
• Position the client supine, then with the diaphragm of the stethoscope, listening along the left sternal border and at the apex.
• Listen in the left lateral decubitus position, bringing the left ventricle closer to the chest wall for apical pulse.

Heart Sounds

• Systole is ventricular contraction.
• Diastole is ventricular relaxation.
• S1 is mitral valve closure.
• S2 is aortic valve closure.
• S3 is a sound arising from rapid deceleration of blood in the ventricles,
• S4 is a sound preceding S1, which reflects atrial contraction.
• Murmurs are swishing or blowing sounds caused by forward flow through a stenotic valve, increased flow through a normal valve or backward flow through a valve that fails to close..

Peripheral Vascular

• Arteries carry oxygenated blood from the heart to the capillaries
• Major arteries of the arm include brachial, radial, ulnar, and of the leg: femoral, popliteal, dorsalis pedis, and posterior tibial.
• Veins carry deoxygenated blood to the heart. Types include deep, superficial, and perforator veins. Examples of the veins are femoral, popliteal, and saphenous.
• Lymphatic system includes lymphatic vessels and nodes. Capillaries and fluid exchange. Connects arterioles and venules.

Peripheral Vascular (continued)

• Subjective data includes lifestyle practices (tobacco use, regular exercise), medication use, and support use.
• Client preparation includes gown inquiry and explaining the procedure.
• Inspect for size, edema presence, skin color, and venous patterning.
• Palpate for temperature, capillary refill time and pulses (radial, ulnar, & brachial for epitrochlear lymph nodes, and Allen's test).

Leg Palpation

• Palpate skin color, hair distribution, lesions, ulcers, and edema.
• Palpate for superficial inguinal lymph nodes, temperature, pulses (femoral, popliteal, dorsalis pedis, posterior tibial)

Peripheral Vascular (continued)

• Inspect legs for varicosities, thrombophlebitis (by asking the client to stand).
• Evaluate manual compression test and trendelenburg test.
• Homan's sign: pain in the calf upon dorsiflexion of the foot

Peripheral Vascular Insufficiency

• Arterial insufficiency: intermittent claudication, sharp, unrelenting pain, diminished/absent pulses, skin characteristics like dependent rubor. These are pathologic changes in the arteries..
• Venous insufficiency: aching cramping pain, present pulses that might be difficult to palpate through edema.

Peripheral Vascular: Subjective Data History

• Past: Previous problems in the circulation. Heart, blood vessel treatment, surgeries.
• Family: Varicose veins, Diabetes, hypertension, coronary heart disease, high cholesterol/triglycerides

Abdomen

• Include information on GI function (pain, nausea, vomiting, diarrhea, constipation).
• Assess GI characteristics of stool, appetite, eating patterns, nutritional assessment including weight.
• Psychosocial, spiritual, and cultural factors. Assess knowledge about the patient and education needs.

Abdominal Quadrants

• The abdomen is divided into four or nine regions for assessment.

Abdomen Assessment Points (continued)

• Observe and inspect abdominal skin, overall contour, and symmetry.
• Perform auscultation after inspection and before percussion.
• Perform palpation last.

Abdomen Palpation (continued)

• Inspect skin, contour, symmetry, movement, umbilicus, bowel sounds, and vascular sounds.
• Rest the diaphragm of your stethoscope lightly on the right lower quadrant of the abdominal wall. Listen for bowel sounds for 30 seconds.

Abdomen Percussion (continued)

• Assess for normal sounds (clicks and gurgles, 5-34 per minute).
• Use bell of stethoscope to auscultate for bruits over the aorta, renal, iliac, and femoral arteries.
• Percussing for liver span to measure height of the liver by measuring distance on the right midclavicular line from the lung sound change to a dull tone. Mark this spot, usually at the fifth intercostal space.
• The height of the liver span correlates with the height of the person.
• Normal liver span ranges from 6 to 12cm , 10.5cm(male) and 7cm( female). ,
• Assess for splenic dullness by percussing for a dull note from the 9th to 11th intercostal space behind the left mid-axillary line.
• Assess for costovertebral angle tenderness.

Additional Information

• There are also video sections for cardiovascular assessment and auscultation of heart sounds.