ST Assessment of the Heart and Vascular System PDF

ASSESSMENT OF THE HEART AND VASCULAR SYSTEM NURS 1090  UNIT OUTCOMES Demonstrate the ability to assess the heart and peripheral vascular system. Identify physical assessment changes in the older adult related to the vascular system  CURRENT HEALTH HISTORY: OTHER CARDIOVASCUL...

ASSESSMENT OF THE HEART AND VASCULAR SYSTEM NURS 1090  UNIT OUTCOMES Demonstrate the ability to assess the heart and peripheral vascular system. Identify physical assessment changes in the older adult related to the vascular system  CURRENT HEALTH HISTORY: OTHER CARDIOVASCULAR SYMPTOMS Palpitations Syncope Excess fatigue Leg pain or cramps Cough Paresthesia Dyspnea, Varicose veins orthopnea Discoloration of extremities Edema of feet Ulcers or non-healing wounds Weight gain (in lower extremities)  CURRENT HEALTH HISTORY Observe overall presentation of the patient Assess for chest pain Characteristics of pain Midsternal, deep pressure or ache May radiate to both arms, neck or jaw Initiate care immediately  HEALTH HISTORY RELATED TO THE CARDIOVASCULAR SYSTEM Allergies Past medical history Heart disease, diabetes, lung disease, obesity, hypertension Surgical history or chest trauma Previous diagnostic or lab tests Medications  HEALTH HISTORY RELATED TO THE CARDIOVASCULAR SYSTEM Family History note age and cause of death for blood relatives Social History Nutritional Assessment Risk Factors  PHYSICAL EXAM CARDIOVASCULAR SYSTEM Assessment techniques Inspection, palpation, and auscultation Inspection and palpation often performed together Cardiac Assessment Inspection, palpation, auscultation Vital sign measurement (review) Apical pulse Vascular System Assessment Capillary refill Arterial pulses Peripheral edema CARDIOVASCULAR ASSESSMENT Inspection Anterior chest 5th ICS (intercostal space), left midclavicular line PMI: point of maximum impulse; apical pulse Visible pulsations May/may not be visible Palpation Apical impulse; Point of Maximum Impulse (PMI) Use fingertips May not be palpable in all patients  ANATOMICAL LANDMARKS Sternal Angle (Angle of Louis) at the 2nd ribs Intercostal spaces Mid-clavicular line Auscultation Patient should be supine or sitting Auscultation should not be performed through clothing Always explain what you will be doing The examination area must be quiet enough to hear subtle sounds through a stethoscope Warm your stethoscope before putting it on the patient! Keep tubing untangled and off the client’s body and clothing  AUSCULTORY SITES Aortic (2ICS-RSB) 2nd intercostal space, right sternal border Pulmonic (2ICS-LSB) 2nd intercostal space, left sternal border Tricuspid (4/5ICS-LSB) 4th/5th intercostal space, left sternal border Mitral (5ICS-MCL) 5th intercostal space, midclavicular line. Apical; Apex; Point of Maximum Impulse (PMI) CARDIAC AUSCULTATION SITES https://www.youtube.com/w atch?v=K_BWCw7s1Xo  HEART VALVES (NOTE: THE BICUSPID IS ALSO CALLED THE MITRAL) HEART SOUNDS: NORMAL S1: “Lub” Low-pitched and dull in quality Closure of the mitral and tricuspid valves Heard best at the apex (bottom) of the heart S2 “Dub” Higher-pitched and shorter Closure of the pulmonic and aortic valves Heard best at RSB at 2nd/3rd intercostal spaces S1 + S2 = 1 Heartbeat Count for 1 full minute Note if regular or irregular ABNORMAL HEART SOUNDS Examples S3 “Ventricular gallop”: Extra sound heard after S2 Low-pitched S4 “Atrial gallop” Extra sound heard that immediately precedes S1 HEART SOUNDS https://www.youtube.com/ watch?v=zNHI-l_c-ls  MURMURS  ‘Swishing’ or ‘blowing’ sounds May be heard at beginning, middle or end of cardiac cycle Causes: 1) Increased blood flow through normal valve 2) Blood flow through defective valves, septal defects or enlarged chamber Describe what you hear and where you hear it Blowing, humming, rubbing, clicks, extra heart sounds REVIEW OF APICAL PULSE Listen at each cardiac landmark Inch the stethoscope head from each point to the next Note the “lub-dub” of the heartbeats at each point Note rhythm Regular or Irregular Count the apical rate for 1 minute Usually at the apex of the heart—what is the landmark for the Apical? ASSESSMENT OF THE PERIPHERAL VASCULAR SYSTEM Techniques used: Inspection and palpation Assess all extremities side to side noting symmetry General skin color Lesions: breaks in skin integrity, ulcers Discolored areas Hair distribution Tortuous (twisted) or distended veins Edema ASYMMETRY Tortuous veins Discoloration; edema (varicosities)  CIRCULATORY ASSESSMENT: THE “P’S” Pain Pallor Pulselessness Paresthesias: numb or “pins & needles” Paralysis: inability to move the part Polar: temperature  ASSESSING CAPILLARY REFILL Technique to evaluate adequacy of peripheral blood flow to the fingers/toes 1.Compress nail bed for about 5 seconds (blanch) 2.Release pressure and observe how quickly normal color returns 3. Should be immediate or less than 3 sec Assess each extremity and compare If the toenails are too thick or discolored to assess, use the side of the toe www.nlm.nih.gov What can impede/alter assessment of capillary refill??  PALPATION OF PERIPHERAL ARTERIAL PULSES Locate and palpate arterial pulses Use the Doppler if unable to palpate manually Note symmetry, compare one side to the other Use pads of 2nd and 3rd fingers; do not use thumb Note strength and rhythm  GRADING SCALE FOR PULSES 0: absent 1: diminished/barely palpable 2: normal/expected 3: full/increased 4: bounding What should the nurse do first if pulses are absent?  Carotid Radial REMEMBER Brachial YOUR PERIPHERAL Popliteal PULSE Dorsalis Pedis SITES Posterior Tibial  RADIAL PULSE Radial: Palpate along radial bone on thumb side of wrist. Use this site for Apical-Radial Pulse Assessment: Used to determine if pulse deficit present – radial rate slower than apical— What could cause this?? ASSESSMENT OF EDEMA Collection of fluid on top of dermal vessels Locations: periorbital, arm, hand, sacrum, pre-tibial, ankle, pedal Symmetry Extent: measure circumference and how far up the extremity it extends Pitting edema: when pressure from examiner’s fingers leaves an indentation in edematous area ASSESSING FOR PITTING EDEMA  Depth and duration  Use index finger to press (firmly) for several seconds and release 1+: 0 – 2mm: trace to mild, disappears quickly 2+: to 4mm: mild to moderate, may last 10 – 15 seconds 3+: to 6mm: moderate to severe, can last up to a minute 4+: 8mm+: severe, can last several minutes PITTING EDEMA  CARDIAC ASSESSMENT: EXPECTED CHANGES – OLDER ADULT Inspection/Palpation PMI difficult to palpate because the A/P diameter of the chest widens  CARDIAC ASSESSMENT: EXPECTED CHANGES – OLDER ADULT Auscultation Gently lift breast tissue to place stethoscope Heart sounds may be muffled due to an increase in air space in the lungs (widened AP diameter) Occasional irregular heart rhythms Arrhythmias—what is a common arrhythmia? tachyarrhythmias Murmurs due to valvular sclerosis VASCULAR ASSESSMENT: EXPECTED CHANGES – OLDER ADULT Thicker, less elastic, and more dilated veins Dependent edema Varicosities Peripheral circulation decreases Weak peripheral pulses LAB PRACTICE Heart Identify correct landmarks Inspect, palpate auscultate Vascular system Capillary refill Peripheral pulses Edema