Cardiovascular Assessment Fall 2024 NSG 313 PDF

CARDIO- VASCULAR AND PERIPHERAL VASCULAR ASSESSMENT 9/29/24 REVIEW OF CARDIAC BLOOD FLOW 9 MINUTES ¡ https://youtu.be/2GMayj9O21o 9/29/24 THE HEART AND MAJOR BLOOD VESSELS – CENTRAL BEHIND STERNUM HEART IS RESPONSIBLE FOR MANY THINGS, SO WHEN IT IS...

CARDIO- VASCULAR AND PERIPHERAL VASCULAR ASSESSMENT 9/29/24 REVIEW OF CARDIAC BLOOD FLOW 9 MINUTES ¡ https://youtu.be/2GMayj9O21o 9/29/24 THE HEART AND MAJOR BLOOD VESSELS – CENTRAL BEHIND STERNUM HEART IS RESPONSIBLE FOR MANY THINGS, SO WHEN IT IS NOT WORKING IT WILL EFFECT ALL PARTS OF THE BODY. APEX IS AT THE TOP WHEN YOU ARE BORN, AND SLOWLY TURNS AS YOU AGE. APEX = APICAL PULSE 9/29/24 CARDIAC REVIEW ¡ Right side of the heart pumps blood to the lungs for gas exchange (pulmonary circulation) –removes CO2 from blood and replenishes oxygen supply ¡ Left side of the heart pumps blood to all other parts of the body (systemic circulation) ¡ Perfusion occurs when blood flows to tissues and organs promoting the diffusion of oxygen and CO2 ¡ Cardiac muscle cells have a unique ability to spontaneously generate an electrical impulse and conduct it through the heart. This regulates the events associated with the filling and emptying of the cardiac chambers ¡ This process is called the cardiac cycle ¡ Review Bates Chapter 14 9/29/24 CARDIAC CYCLE AND HEART SOUNDS ¡ S1 – closure of mitral and tricuspid valves – beginning of ventricular systole (contraction) – lub ¡ Heard at the apex ¡ S2 – closure of aortic and pulmonic valves – beginning of ventricular diastole (relaxation) – dub ¡ Heard at the aortic area ¡ S3 – ventricular gallop – indicates rapid ventricular filling and possible heart failure; - can be expected finding in children, young adults and pregnancy ¡ S4 –atrial gallop- reflects a strong atrial contraction and usually signifies a heart failure or active ischemia – rarely a normal finding ¡ S3 and S4 are harder to hear, more skilled 9/29/24 S3 AND S4 HEART SOUND ¡ https://youtu.be/o8eqYHCy7dw 1:19 minutes 9/29/24 HEART SOUNDS EXPLAINED START AT 6:15 ¡ https://youtu.be/H48WsyIjFs0 ¡ Diaphragm(larger) for S1 and S2 – best for high pitch ¡ Bell(smaller) for S3, S4, mitral stenosis – best for low pitched sounds ¡ All Patients Take Medicine – Aortic (S2), Pulmonic Valve (S2), Tricuspid Valve (S1), Mitral Valve/apex ¡ S2 = louder at base ¡ S1 = louder at apex, sounds at same time as carotid pulsation 9/29/24 TRADITIONAL AREAS OF AUSCULTATION 9/29/24 COMPONENTS OF A NORMAL ECG – NORMAL SINUS RHYTHM ¡ Each letter represents depolarization of different areas of the heart ¡ Electric conduction system stimulates and coordinates the contraction of cardiac muscle ¡ Sinus node acts as a pacemaker and automatically discharges an impulse 60-100/min 9/29/24 THE HEALTH HISTORY - CARDIAC SYSTEM ¡ Chest pain or discomfort - Cardiac? Respiratory? Gastrointestinal? Musculoskeletal? ¡ Arrhythmias – skipped beats, palpations; “my heart is racing” “my heart skips a beat” ¡ Dyspnea – not just a pulmonary symptom, something going on with the heart can effect breathing just as much as when something is going on with the lungs. ¡ Orthopnea – put the head up when the patient is having trouble breathing, to open up the lungs ¡ Cough – excess blood backs up into the lungs ¡ Edema in ankles and feet – hypervolemia. Cardiac swelling will be BILATERAL/BOTH LEGS. ¡ Nocturia – edema fluid travels to bladder while laying horizontal at night for bed ¡ Fatigue – from heart working so hard ¡ Cyanosis (blue) or pallor (pale) – late signs of heart disease 9/29/24 HEALTH HISTORY CONTINUED ¡ Murmur – defects affect the heart’s ability to pump, decreasing oxygen supply to the tissues ¡ Congenital heart disease/defects ¡ Rheumatic fever – heart valves can become permanently damaged from a group A Beta Hemolytic streptococci infection. Results in inflammation of all layers of the heart which impairs contraction and valve function. Disease children can have that causes long-term damage to the heart. ¡ Hypertension ¡ Hypercholesteremia – lipid profile ¡ Diabetes 9/29/24 LIFESTYLE AND HABITS ¡ Diet – obesity ¡ Smoking ¡ Alcohol usage ¡ Exercise ¡ Drug use – OTC, prescribed, illicit 9/29/24 FAMILY HISTORY CARDIAC DISEASE IS VERY GENETIC ¡ Hypertension ¡ MI – myocardial infarction or heart attack; impaired perfusion – blood flow is blocked to the heart ¡ CAD- coronary artery disease ¡ Hyperlipidemia – high cholesterol ¡ Diabetes Mellitus – diabetes is Greek for siphon and mellitus means honeyed or sweet – the body’s inability to produce or respond to the hormone insulin – causing elevated blood glucose levels 9/29/24 CHEST SYMPTOM ETIOLOGY ¡ Cardiac ¡ Respiratory ¡ Gastrointestinal ¡ Musculoskeletal 9/29/24 CHEST PAIN – THE SYMPTOM THAT TAKES PRIORITY ¡ Angina pectoris – pain on exertion that is relieved with rest ¡ Myocardial infarction – chest pain and pressure; atypical presentations–immediate action needed ¡ Women tend to have different symptoms than men with MI – upper body pain, back, neck, jaw or stomach pain ¡ Acute coronary syndrome ¡ Acute aortic dissection – anterior chest pain, tearing, ripping radiating to the back or neck ¡ Often signifies coronary artery disease (CAD) ¡ It should be assumed that the chest pain is due to cardiac ischemia until determined otherwise. Could be life threatening due to lack of O2 causing damage to cells in the heart muscle. Chest pain always takes priority over other patients. 9/29/24 NON CARDIAC CHEST PAIN ¡ Pleuritic – inflammation of the parietal pleura – sharp knife like – often severe ¡ GERD – irritation of the esophageal mucosa due to reflux gastric acid – retrosternal – may radiate to the back – burning, squeezing. Giving patient GI cocktail and seeing relief will prove that this is GERD and not a cardiac problem. ¡ Chest wall pain – costochondritis – below the breast, along costal cartilages – stabbing, dull, aching ¡ Anxiety – below left breast or across the anterior chest – stabbing, dull, aching 9/29/24 CHEST PAIN ¡ Do you have any pain or discomfort in your chest? ¡ Onset - If yes, when did this start and have you had this before? Does it wake you up at night? ¡ Location - Ask the patient to point to the pain – does it radiate? ¡ Duration – How long does the pain last? Is the pain related to activity? ¡ Characteristic - How intense is the pain on a scale of 0-10? What does it feel like? Stabbing, pressure? ¡ Aggravating/additional factors - Are there any associated symptoms? Nausea, sweating (diaphoresis), lightheadedness, palpitations? ¡ Relieving factors – does taking an antacid relieve the pain? Does rest relieve the pain? ¡ Treatment – what have you done to relieve the pain? Medication? 9/29/24 Pain comes from chest and radiates down. 9/29/24 DYSPNEA – POSSIBLE CARDIO SYMPTOM ¡ Do you ever have difficulty breathing or shortness of breath? ¡ When does it occur? ¡ What were you doing when you became short of breath? – “Complains of SOB on slight exertion” ¡ How many pillows do you use to sleep at night? Orthopnea ¡ Have you ever awoken suddenly due to shortness of breath? Paroxysmal nocturnal dyspnea (PND). Have to sit up to get a breath. ¡ Associated lower leg edema – most likely due to hypervolemia. They have excess fluid, which effects the way they breath. 9/29/24 DYSPNEA ¡ Heart failure ¡ Coronary Artery Disease (CAD) ¡ Myocardial ischemia or Myocardial Infarction ¡ Pulmonary disorders 9/29/24 COUGH ¡ Can result from fluid leaking into the lung ¡ Left sided heart failure can cause fluid to leak into the lungs – fine crackles or rales may be auscultated ¡ Describe your cough ¡ Do you cough up mucus? If yes, describe the mucus ¡ When does it occur? Any particular time of day? ¡ Ask if they cough up blood – this is a sign of a more severe lung problem. 9/29/24 PALPITATIONS ¡ An unpleasant awareness of the heartbeat ¡ Skipping, racing, fluttering, pounding, stopping of the heart ¡ Does not necessarily mean heart disease – patient who is very anemic will have palpitations. ¡ Some of the more serious of arrhythmias such as ventricular tachycardia, often do not produce palpitations ¡ Did they start gradually or come on suddenly? 9/29/24 EDEMA – ACCUMULATION OF EXCESSIVE FLUID IN EXTRAVASCULAR INTERSTITIAL SPACE ¡ Location, timing, setting of the swelling and associated symptoms ¡ Dependent edema – appears in the lowest body parts: the feet and lower legs when sitting or the sacrum if the person is bedridden. Tell patient to put legs up, to dissipate fluid. ¡ Cause may be cardiac (heart failure), PVD, nutritional due to low albumin or positional ¡ When does the swelling occur? Is it worse at night or in the morning? ¡ Do your shoes get tight throughout the day? ¡ Are the rings tight on your fingers? ¡ Are your eyelids puffy or swollen in the morning? ¡ Have you had to let out your belt? – have you gained any weight? 9/29/24 9/29/24 How to document Pitting Edema: Used to see trends from previous shifts – show improvement/worsening ¡1+ 2 mm depression ¡2+ 4 mm depression ¡3+ 6 mm depression ¡4+ 8 mm depression 9/29/24 NOCTURIA – URINATION AT NIGHT ¡ It is dependent edema that is mobilized at night and returned to the kidneys for excretion during the night when the patient is reclining (lying down) ¡ Do you get up more than once during the night to urinate? ¡ How many times? 9/29/24 FLUID BALANCE AND FLUID VOLUME DEFICIT ¡ Homeostasis ¡ Intake should = output. Any fluid we take in, we should expect to put out the same amount. ¡ Maintaining balance between body fluids in volume and composition is critical ¡ Disturbances or imbalances can alter cardiovascular, neurologic, renal, and neuromuscular function ¡ When dehydrated (hypovolemic/don’t have enough fluid), the cells send a message to the hypothalamus which releases ADH to tell the kidneys to remove less water from the blood results in ↓ output and more concentrated, dark urine 9/29/24 FLUID VOLUME EXCESS - HYPERVOLEMIA ¡ If poor heart function, body cannot compensate for excesses of fluid/fluid will start to back up. ex. Heart failure, pulmonary edema ¡ Effects lab values such as hematocrit and electrolytes - hemodilution ¡ May hear a 3rd heart sound or S3 gallop ¡ Crackles in lower lung bases ¡ Distended neck veins – JVD – jugular venous distention ¡ Dyspnea and orthopnea ¡ Increased respiratory rate and blood pressure – to much fluid = vitals going up ¡ Treatment – depends – often diuretics ¡ Loop diuretics - furosemide ¡ K+ sparing diuretics - spironolactone ¡ Thiazide diuretics – hydrochlorothiazide (HCTZ) 9/29/24 HYPERVOLEMIA 9/29/24 FVE AND FVD 9/29/24 OTHER ASSOCIATED SYMPTOMS ¡ Fatigue – overwhelming feeling of exhaustion – may signal the heart is not adequately supplying the body with oxygen and nutrients ¡ Cyanosis or pallor – signs of poor oxygenation of the body – face, lips, fingers ¡ Nausea and vomiting ¡ Syncope – passing out ¡ Diaphoresis - sweating 9/29/24 PERIPHERAL VASCULAR SYSTEM VEINS AND LYMPHATIC SYSTEM Veins tend to be weaker in lower extermeties 9/29/24 VEINS ¡ Blood vessels that carry deoxygenated, nutrient- depleted, waste-laden blood from the tissues back to the heart ¡ Upper body veins carry blood to the SVC – superior vena cava ¡ Blood from the lower body drains upward into the IFC – inferior vena cava ¡ Blood in veins is at a much lower pressure than in the arteries and vein walls are thinner This Photo by Unknown Author is licensed under CC BY ¡ Veins can expand if blood volume increases which helps decrease the workload of the heart 9/29/24 VENOUS SYSTEM Veins from the arms, upper trunk and head and neck drain in the superior vena cava Veins from the legs and lower trunk drain upward into the inferior vena cava Because leg veins have weaker wall structure, they are susceptible to irregular dilatation (varicosities), compression, ulceration, and invasion by tumors The deep veins of the legs carry approximately 90% of the venous return from the lower extremities Venous stasis occurs if the venous mechanisms do not work properly, and venous return is impeded = DVT and varicose veins 9/29/24 9/29/24 VTE PROPHYLAXIS – VENOUS THROMBOEMBOLISM ¡ VTE includes DVT and PE – most preventable complication in hospitalized patients and a major cause of mortality and morbidity, IF you don’t use VTE prophylaxis. ¡ Highest Risk: Post-op patients, obese, bedridden or prolonged traveling hours, major ortho surgery, trauma to hip, pelvis or leg fractures, pregnancy, solid tumor malignancies, certain medications and hormones, and patients taking heparin which can lead to HIT (heparin- induced thrombocytopenia: given Heparin to prevent VTE causes patients platelets to go low, leading to them throwing a clot). ¡ Prevention: Compression stockings, early progressive ambulation, vena cava filters, leg elevation, SCD This Photo by Unknown Author is licensed under CC BY-ND (sequential compression devices) ¡ Anticoagulants – LMWH, enoxaparin for example – subcutaneous injection. Only parental injection given with an air bubble. 9/29/24 EDEMA DUE TO DEEP VEIN THROMBOSIS (DVT) ¡ Blood clot in a deep vein can cause edema in the region of the clot ¡ Usually unilateral- calf and ankle swelling ¡ Measure calf and/or ultrasound for high-risk patients ¡ Dislodgment of the thrombus can travel to the lungs = pulmonary embolus 9/29/24 This Photo by Unknown Author is licensed under CC BY-SA 9/29/24 LYMPHATIC SYSTEM ¡ Part of the circulatory system ¡ Lymphatic capillaries, lymphatic vessels and lymph nodes ¡ Primary function is to drain excess fluid and plasma proteins from bodily tissues and return them to the venous system ¡ During normal circulation more fluid leaves the capillaries that veins can absorb ¡ Draining the excess fluid prevents edema – a buildup of fluid in the interstitial spaces ¡ Lymphatic vessels and capillaries pass through filters known as lymph nodes where different waste products are destroyed ¡ Lymph nodes in head and neck will be discussed in HEENT lecture 9/29/24 SUPERFICIAL LYMPH NODES OF ARMS AND LEGS 9/29/24 CARDIOVASCULAR PHYSICAL ASSESSMENT 9/29/24 ACTIVE LEARNING – PHYSICAL EXAM ¡ Each student interviews and then does a cardiac exam on their partner ¡ Inspection ¡ Palpation ¡ Auscultation 9/29/24 COMPONENTS OF CARDIOVASCULAR EXAMINATION ¡ Examination of the face – looking for edema, cyanois around lips ¡ Examination of the great vessels of the neck – jugular and carotid ¡ Inspection and palpation of the precordium ¡ Auscultation of heart sounds ¡ Inspection for peripheral edema ¡ Blood pressure, heart sounds, pulses (6) This Photo by Unknown Author is licensed under CC BY-NC 9/29/24 INSPECTION ¡ Skin color, lips, mouth, conjunctiva ¡ Eyes – xanthelasma (yellow/brown patches in eye, shows high cholesterol), orbital edema ¡ Capillary refill ¡ Clubbing of fingernails – chronically low blood levels of O2 – COPD patients (pulmonary or cardiac exam) ¡ Neck veins – looking for distention or visible pulsations ¡ Precordium – inspecting for visible pulsations; pulsations usually absent except for the apical impulse ¡ Inspection of apical impulse – PMI (Point of Maximal Impulse) 9/29/24 MAJOR NECK VESSELS INCLUDING CAROTID ARTERY AND JUGULAR VEINS ¡ Assessment of the pulses of these vessels reflects the integrity of the heart muscle ¡ Carotid artery pulse ¡ One side at a time, or patient pay pass out 9/29/24 INSPECTION OF JVP ¡ Provides volume status and cardiac function ¡ Reflects pressure in right atrium or CVP ¡ Best assessed in right internal jugular vein ¡ Patient sitting in the supine position at 30 to 45 ○ angle 9/29/24 JVD – JUGULAR VENOUS DISTENTION ¡ When does it distend? Increases with heart failure, pulmonary hypertension, tricuspid stenosis and pericardial compression or tamponade ¡ Tamponade – abnormal accumulation of fluid between the layers of the pericardium which places pressure on the heart and if severe can impair cardiac pumping function ¡ To estimate the level of the JVP – find the highest point of oscillation in the internal jugular vein 9/29/24 This Photo by Unknown Author is licensed under CC BY PALPATION ¡ Temperature of upper and lower extremities with dorsum of hands – bilateral coolness, unilateral? ¡ Apical impulse or PMI ¡ Carotid artery – one side at a time ¡ Capillary refill < 2 seconds – if prolonged can = decreased oxygenation and impaired perfusion ¡ Arterial pulses – bounding +4/ increased, strong +3 / normal +2 /weak, thready, diminished +1 9/29/24 APICAL IMPULSE OR POINT OF MAXIMAL IMPULSE 9/29/24 LOCATING THE PMI 9/29/24 POINT OF MAXIMAL IMPULSE OR PMI ¡ The cardiac apex (bottom of heart) produces the apical impulse ¡ Identified during palpation of the precordium ¡ The impulse locates the left border of the heart at the 5th intercostal space, close to the midclavicular line and 7-9 cm for the midsternal line ¡ Common not to be able to feel this in a cardiac healthy person ¡ Easily felt in children and slender individuals 9/29/24 SIGNIFICANCE OF PMI ¡ Diameter may be as large as a quarter (1-2.5cm) ¡ PMI > 2.5 cm is evidence of left ventricular hypertrophy (LVH) or enlargement ¡ Displacement of the PMI lateral to the midclavicular line > 10cm lateral to the midsternal line also suggests LVH ¡ COPD patients may have PMI palpable in the xiphoid or epigastric area as a result of right ventricular hypertrophy 9/29/24 SITES FOR CARDIAC PALPATION 9/29/24 CAPILLARY REFILL ¡ Pink tone should return almost immediately (2 seconds – respiratory or cardiac diseases caused by hypoxia 9/29/24 ARTERIAL PULSES 9/29/24 GRADING OF PULSES – WHAT DOES IT MEAN? ¡ Bounding (+4) radial, carotid and femoral pulses in = aortic insufficiency and hypervolemia ¡ Bounding pulse may indicate decreased elasticity of the arterial walls often seen with aging ¡ Asymmetric diminished (+1) pulses in arterial occlusion from atherosclerosis or embolism 9/29/24 9/29/24 9/29/24 9/29/24 9/29/24 9/29/24 9/29/24 9/29/24 NECK PALPATION ¡ Assessment Vessels of the Neck ¡ Carotid Artery ¡ Palpate gently ¡ Palpate one side at a time ¡ Feel the amplitude of the pulse ¡ Should be same bilaterally ¡ Palpate for Thrill (BUZZING) 9/29/24 PALPATE HEART RATE AND RHYTHMS ¡ Sinus tachycardia 100-180 ¡ Normal sinus rhythm – 60-100 ¡ Sinus bradycardia -