HA Objectives 2 PDF Cardiovascular Assessment (PDF)

Cardiovascular Understand all physical CV assessment techniques: incl. inspection and auscultation specifics. - Palpate and Auscultate the Carotid Artery o Use the bell, carotid bruits (stenosis narrowing or obstruction) and usually benign o Start with feeling t...

Cardiovascular Understand all physical CV assessment techniques: incl. inspection and auscultation specifics. - Palpate and Auscultate the Carotid Artery o Use the bell, carotid bruits (stenosis narrowing or obstruction) and usually benign o Start with feeling then listen - Neck: inspect neck for bulging or heaving veins (signs of JVD) o Palpate one side at a time o No percussion o Auscultate with bell for bruits - Inspect for Jugular Venous Pulse o Look of jugular venous distension (JVD) common on the right side § Increase pressure in the heart and or vein - Assessment – Precordium o Inspect: apical impulse and heaves or lifts (observable on inspection and may indicate (LVH) o Palpate for thrills - Auscultate systematically to listen rotate of heart o Sitting then lying supine, then left side-lying o Diaphragm then bell o Note Rate and Rhythm (regular, irregular, palpitations) o S1+S2 lub dub should be present o Note for S3 or S4 often “clicking” sounds o Note for murmurs (whooshing) - Auscultation: Other findings o Pericardial friction rub (pericarditis) – inflammation of the sac around the hear located at the left sternal boarder or apex o To Auscultate: pt leans forward, breath held in expiration, heard best with diaphragm - Vascular System o Inspect for sores, lesions, edema (sign of CHF), color (pallor, rubor, cyanosis, bronze (lack of perfusion)), and varicosities o Edema - non pitting, swollen, but does not “pit” when pressed § 1+= mild pitting, 2+= moderate pitting, 3+= deep pitting, 4+= very deep pitting - Abdominal Assessment: Auscultation for bruits with bell Recall factors in the subjective assessment process of the cardiovascular system. - Past medical history (PMH) o Cardiac disease/ surgery o Congenital or acquired disease (atrial septal defect, Rheumatic fever) - Family history o HX of (CVD or CAD), Who? What age? o Early deaths related to cardiovascular disease - Social History o Habits (smoking, alcohol use) o Activity o Occupation and level of activity associated with it - Medications o Are they taking any cardiac or antihypertensives? o Are they taking medications with cardiovascular side ebects? - Risk factors for heart disease (CAD): family history of CAD, smoking, diabetes. Elevated cholesterol total over 200, hypertension, lack of exercise, high fat, cholesterol, sodium diet (animal products are most risk for cardiac health) - Health Promotion: Blood pressure checks, Cholesterol screening, Weight management, Activity, Nutrition (DASH diets and Cardiac diets) - Review of Symptoms (ROS) : Chest pain palpitations, dyspnea, orthopnea (how many pillows?), cough, fatigue, edema, nocturia o Chest Pain in Women § MI and CAD are rare in mensurating women § Females may not exhibit “classic signs” of MI: shoulder, jaw, upper back pain, nausea, fatigue, and dyspnea o Peripheral Vascular: § Leg pain or cramps with activity or rest? Intermittent claudication: pain in calves with activity § Does the person report skin changes or hair loss It can indicate circulation loss Know anatomical landmarks for all cardiac auscultation points. - Aortic: 2nd intercostal space, right sternal boarder - Pulmonic: 2nd intercostal space, left sternal boarder  - Erb’s point: sounds coalesce together: 3rd intercostal space, left sternal boarder - Tricuspid: 4th intercoastal space, left sternal boarder - Mitral: 5th intercoastal space, left midclavicular line Understand murmur or bruit sounds and recall S1, S2, S3, S4; what is normal vs. abnormal. S1 & S2: lub dub, normal heart sounds S1 – First heart sound: “Lub” Closure of AV valves Beginning of systole Loudest at apex (but can be heard all over the precordium) nd S2 – 2 heart sounds – “Dub” Closure of semilunar valves End of systole Loudest at base (but can be heard all over the precordium) Abnormal: S3 – clicking sound, outside of “lub…dub” - Vibration due to rapid ventricular filling - Sounds like: “Ken-tuck-y” and low pitched - Physiologic: Children and young adults - Pathologic: Volume overload, CHF, and increased cardiac output (anemia, pregnancy) S4 – Atrial Gallop, sounds like “Tennessee” low pitched/apex - Atria contract and push blook into non-compliant ventricle - Create vibrations hear as S4 - Occurs presystolic or end diastole (before S1) - Occurs with coronary artery disease (CAD) Murmurs – caused by turbulent blood flow resulting in blowing or swooshing sounds May be due to: - Increased blood velocity (children) - Decreased viscosity (sickle cell anemia) - Structural defects o Prolapse o Stenosis o Defective opening or regurgitation o Increased if thin o Decreased if obese, muscular, or fluid Dysrhythmias – often palpable/audible w stethoscope as irregular rhythms, extra beats, or skipped beats Atrial fibrillation – a common dysrhythmia. Irregular; able to hear/feel palpations o Note: usually occurs as a dangerous tachycardia Understand reasons for AV fistula, how to assess one, and safety issues related to assessing persons with them. AV – arterial venous, used for dialysis - Do not take BP on arm with AV fistula, or perform IV/ phlebotomy sticks - Do auscultate for a bruit - Do listen palpate for a thrill Know all palpated pulse points, their anatomical locations, and how to assess them. Pulses: Palpate bilaterally – left and right o 0 = absent, 1+ = weak, 2+ = normal, 3+ = increased, 4+ = bounding Upper Extremities: Radial pulse for most Brachial pulse in some cases Unable to palpate radial pulse Neonates - Lower extremity: o Dorsalis pedis or posterior tibial o May also palpate popliteal or femoral pulse - Precordium o Inspect the apical impulse for heaves or lifts o Palpate for thrills (vibration – turbulent blood flow w murmur) Understand the procedure for carotid artery assessment. - Cardiovascular assessment includes carotid arteries and jugular veins  - Carotid arteries feed the brain and reflect ebiciency of cardiac function - Palpate 1 side of the neck at a time – Not both together - Auscultate with the bell for bruits o Bruit maybe causes by atherosclerosis o A venous hum in pediatric patients is a normal finding Describe AAA aneurysms, subjective risks for, objective assessment of. - Abdominal Assessment: Auscultation middle of the abdomen for bruits with bell - AAA = Abdominal Aortic Aneurysm: auscultate for a bruit (whooshing sound) due to turbulent blood flow - Family History and Smoking are main subjective risks Recall what each part of the normal sinus cardiac waveform indicates. ECG Waves are labeled PQRST - P wave: depolarization of atria (atria and sa node) - P-R interval: from beginning of P wave to beginning QRS complex (time necessary for atrial depolarization plus time for impulse to travel through AV node to ventricle) - QRS complex: depolarization of ventricles - T wave: repolarization of ventricles - SA node à Atria à AV Node à Bundle of HIS à Bundle Branches à Ventricles Sinus – P-waves before each QRS spike Normal Sinus Rhythm – P waves present and rate 60 – 100 Sinus Tachycardia / Sinus Bradycardia – sinus rhythm falls above (tachy) or below (brady) the 60-100 range. Atrial Fibrillation – irregular palpation, HAS NO P-WAVES, pt is weak with SOB, risk for stoke Notice, no P-Waves in A- Fib… Tachycardia Recall causes, presentation, and S&S of JVD. - Jugular veins move blood from the head to the superior vena cava, then to the heart and lungs - JVD – increased pressure in the superior vena cava, causing the vein to bulge, and often seen on the right side - Cause of excess fluid or blockage - Height of the JVD can be measured to indicate CVP. Increase blood volume and high CVP are signs of heart failure - Main takeaway: signs are bulging or heaving veins Other: Not in objectives Developmental concerns - Infant o Initial murmurs § PDA – patent ductus arteriosus: blood bypassing fetal lungs § PFO – patent foramen ovale: opening between right and left atrias o Auscultate heart rate for 1 full minute o Infants hearts are more horizontally positioned, apex is higher (4th ICS) - Pregnancy o Increase heart rate, blood volume, and pulse rate, 10-20 BPM is expected o Blood pressure is the lowest during the 2nd trimester then increases § Have a pregnant person lie on left side to measure bp § PIH – pregnancy-induced hypertension is an increase of >30mm/Hg systolic or >15mm/Hg diastolic § Preeclampsia is a concern = HTN and proteinuria are hallmarks o Edema – varicosities (3rd trimester) - Geriatric: increased systolic blood pressure, increased incidence of arrhythmias, and decrease pulse due to arteriosclerosis (hardening of arteries) Diagnostic Tests: - EKG/ECG, Holter (24hr EKG) - Orthostatic BP checks - Exercise stress test (EST) - Chemical stress test (use medications to stimulate the heart) - Echocardiogram - Cardiac enzyme labs (e.g. troponins) - Allen Test – Radial and ulnar circulation  - Homan’s Test – asses for DVT CHF – Congestive Heart Failure - Causes: AMI: acute myocardial infarction - Hypertension - Valvar disease - Thyroid disease Assessment Techniques Differentiate inspection, auscultation, percussion, and palpation (IAPP) including which technique is used for which assessment type, in which order. Inspection – Always begin with inspection - Inspect: Symmetry, posture, Gait, Facial expression, Color - Auscultation - Percussion – tapping the person’s skin o Assess underlying (organs, masses, solid/dense, air fluid, size, pain) o Yields a characteristic sound (depicting location, size, and density) o Short, sharp strokes o Ex: eliciting deep tendon reflex and CostoVertebral Angle (CVA) - Palpation for: Texture, Temperature (back of hands), Moisture, Organ site and location, Vibration or pulsations, rigidity, crepitation, lumps or masses, tenderness or pain o How: use warm hands, slow and systematic, light à deep, calm and gentle approach, palpate tender areas last Differentiate which IAPP assessments are appropriate within person centered scenarios. Elders – consider lighting, sounds, limit position changes, and consider how much assessment or deep breathing they can tolerate Ill Person – Consider pts comfort level and conduct a focused assessment Correlate elicited percussion tones with associated densities of anatomical structures. - Characteristic sounds: Resonant (air in lungs), tympany (viscous organ), dull (dense liver), flat (solid; bone, mass, muscle) Differentiate diaphragm vs. bell of stethoscope and which is most useful for specific assessments. - Diaphragm – press firmly on pt skin, used for high pitched sounds  o Ex: Breath, Bowel, Heart - Bell – press lightly on skin, used of low pitched sounds o Murmur happens at the heart, bruits are at other locations o Ex: extra heart sounds Apply knowledge of stethoscope use in client safety and dignity-centered assessment scenarios. - Warm stethoscope and minimize external noises - Stethoscope to skin is the best approach - Ensure privacy - May need to vary pressure when using diaphragm - Ask pt to displace body parts (breast) for auscultation or ask for permission and use back of gloved hand Recall importance of order of assessment sequence with pediatric and infant persons. Pediatrics: - Least invasive 1st o Respiration à Pulse à Temperature à O2 à Blood Pressure - Say ahhh! - Lungs - ROM (range of motion) Teens: Independence and awkwardness Mental Status Recall all terminology presented regarding mental status assessment. What to Assess - LOC - first to determine depth of assessment needed o Alert o Lethargic – drowsy, not fully alert, drifts to sleep when not stimulated o Obtunded – sleeping; dibicult to arouse (loud/vigorous stimuli): acts confused when aroused o Stupor – semi-comatose, spontaneously unconscious, responds only to shaking or pain, has appropriate motor response (ie. Swipes away painful stimuli, ex: IV starts), groans, mumbles, reflexes intact o Coma – completely unconscious, no response to pain or external stimuli  - Labile: emotions shift rapidly (flat to wild in a short amount of time) - Flat abect: depression (no emotional response) deadpan facial expression - GCS: a LOC tool; objective and used in acute settings Analyze scenarios involving mental status findings and fall risk assessment. Q: Which is more a fall risk, a GCS of 15 or 3? A: a GCS of 15 because they are more alert and mobile, a GCS of 3 is unresponsive and not mobile Q: Which has a higher fall risk a GCS of 14 or 15 A: 14 Apply the Glasgow Coma Scale (GCS) to assessment situations. GCS is an objective tool used in acute setting to determine LOC - Assess Eye opening response - Best verbal response - Best motor response - A score of 15 is the highest; 8< is comatose, 3 is totally unresponsive Categorize LOC within the context of mental status assessment. What to assess after LOC is determined: (ABCT) Appearance, Behavior, Cognition, and Thought Process - Appearance: posture, body movements, dress (for setting, age, situation), Hygiene, Pupils - Behavior: facial expression, eye contact, speech (pace, word choice, articulation) o Look at body language, ask “how do you feel today?” o mood/ abnormalities: § Depression § Flat abect – blunted lack of emotion § Elation - joy and optimism § Lability – rapid shift of emotions § Anxiety – worried § Euphoria – excessive feelings of well-being - Cognition: Orientation to person, place, time [O x3], situation [Ox4] o Recent memory – 24 hours; appt time, breakfast o Remote memory – long term; anniversary, first job o New memory – (4 unrelated words 5/10/30 min) o Judgement – plans for future, job, family, should be realistic  - Thought Processes and Perceptions o Thought content: do thoughts make sense? o Perceptions: should be consistently aware of reality. § Ask: How people treat you, Do other people talk to you, Do you feel like your being watched, followed or controlled, Is your imagination active, and Have you heard your name when alone § Screen for Anxiety Disorders Start with asking the first two questions of the GAD scale Screen for depression and suicidal thoughts o Hallucinations – sensory perception which there is no external stimuli § Seeing an image of a person or object that is not there § Hearing voices or music when where is non o Illusions – misrepresentation of an actual existing stimulus by a sense § Faces on money are moving § Tree limbs talking to them o Aging adults should NOT have any decline in general knowledge and abilities; but may take longer to respond o Delirium – ACUTE confusional change (drugs, acute illness) usually resolves when cause is treated; Reversible o Dementia – gradual progressive process, causing decreased cognitive function, not reversible, not a part of normal aging - Possible Contributing Factors to Cognitive Deficits: o Meds: Antipsychotics, anti-epileptics, ETOH, sedatives, marijuana, cocaine, opiates, nicotine. o Illnesses: acute or chronic o Delirium/Dementia o Baseline behavior: find out whether their strange behavior is normal. Age & Culture (language): not maintain eye contact, looking around, appearing nervous o Education? o Culture? o Sensory deficits Recall normal findings in a Mini Mental Status Exam (MMSE). - Orientation to time – “Tell me the time?” o One point for each year, season, date, day of the week, and month  - Place Orientation – “Where are you” o One point for each state, county, town, building, and floor or room - Register 3 Objects – Name three objects slowly and clearly o One point for each object repeated - Serial Sevens – Ask the person to count backwards from 100 by 7, or spell world backwards o One point for each correct answer - Recall 3 Objects - Ask pt to repeat objects listed earlier them o One point for each object repeated - Naming – point to your watch and pencil and ask what this is o One point for each correct answer - Repeating a Phrase – Ask pt to say “no, ifs, and or buts” o One point if phrase is repeated successfully on the first try - Verbal commands – place paper in right hand, fold in half, and place on the floor o One point for each correct action - Written Commands – show the person a piece of paper with “CLOSE YOUR EYES” printed on it o One point if the person closed their eyes - Writing – Ask person to write a sentence o One point if the sentence has a verb, subject, and makes sense - Drawing – draw two intersecting pentagons Scoring: 30 possible points A score of 24+ is considered normal Average score of 27 in cognitively intact people - MMSE is usually done every 90 days in a nursing home Other that is not an objective: Be able to diberentiate CAGE subjective questionnaire that screes for alcohol history and CIWA objective assessment tool to address alcohol detox and withdrawal syndrome screening - CAGE – Cut down, annoyed, guilty, eye-opener o Screens for alcohol history and psychosocial associations - CIWA – Clinical Institute Withdrawal Assessment o Tool used to treat/assess alcohol withdrawal, detox o Used to assess level of risk and type of treatment given GI/Abdomen Differentiate locations of various GI organs/structures, (e.g. RUQ, RLQ, LUQ, LLQ, Suprapubic, Epigastric) for contextualization to assessment findings. o RUQ: Liver, Gallbladder, Duodenum, Head of pancreas, Right Kidney, Adrenal Glands, Part of ascending colon o LUQ: Stomach, Spleen, Left lobe of liver, Body of Pancreas, Left Kidney, Adrenal gland, Part of transverse and descending colon o RLQ: Cecum, Appendix, Right ovary and tube, Right ureter, Right spermatic cord o Midline: Aorta, Uterus, Bladder Recall meanings of terminology related to the GI system and its assessment. GERD - Recall which organs can be affected by S&S of pain/sensitivity in specific locations. Incorporate GI system objective and objective findings withing assessment-based scenarios. Recall standard order of objective GI assessment. Inspect à Auscultate (RLQ, RUQ,LUQ,LLQ) à Then… à Percuss à Palpate Most to least invasive to hear and feel the true GI Differentiate assessment findings related to stool color and consistency. Apply knowledge of GI system structures’ order to assessment scenarios, i.e. which organ precedes which. o Mouth à Esophagus à Stomach à Small intestine (duodenum, jejunum, ileum) à Large intestine (cecum, colon, rectum) à Anus Recall ostomy assessment principles. : need to know where the ostomy is coming from Characterize expected auscultation findings for GI system r/t diet and condition. Know how to assess densities of GI organs and what various percussion sounds indicate. Recall cautions with spleen assessment. Recall special tests: Murphy’s, iliopsoas, and others.