Assessing CVPV_lecture.pdf

Assessing the Cardiovascular & Peripheral Vascular Systems AMANDA ROHDE, DNP, AGNP, CRNP, CNE ThePhoto by PhotoAuthor is licensed under CCYYSA. Assessing the Heart and Neck Vessels Objectives  Discuss risk factors for coronary artery disease (CAD) acros...

Assessing the Cardiovascular & Peripheral Vascular Systems AMANDA ROHDE, DNP, AGNP, CRNP, CNE ThePhoto by PhotoAuthor is licensed under CCYYSA. Assessing the Heart and Neck Vessels Objectives  Discuss risk factors for coronary artery disease (CAD) across cultures, considering SDOH, and ways to reduce one’s risks  Discuss case study and patient presentation as they relate to cardiovascular assessments  Interview a client for an accurate history of the heart and neck vessels  Perform a physical assessment of the heart and neck vessels using the correct techniques of inspection, auscultation, palpation, and percussion  Differentiate between normal and abnormal findings of the heart and neck vessels  Describe findings frequently seen when assessing the older client’s heart and neck vessels Heart Disease Causes and Symptoms Subjective Data Objective Data Pathophysiology Potential Diagnosis Chest pain or Abnormal VS Obstruction of Coronary Artery discomfort Abnormal EKG Flow Disease or Occlusion Chest pain Abnormal VS Myocardial STEMI or discomfort Abnormal EKG Ischemia / infarct NSTEMI Fatigue Abnormal VS Myocardial Cardiomyopathy SOB Edema relaxation / Heart Failure Extra heart sounds contraction Palpitations Abnormal VS Abnormal cardiac Atrial fibrillation Fatigue Abnormal EKG rate or rhythm Tachycardia Coronary Artery Disease  Risk factors  Subjective & Objective Findings  Myocardial Ischemia (cell injury) vs. Myocardial Infarction (cell death) o Chest pain (same for all patients?) o EKG changes: STEMI or NSTEMI o Labs: elevated cardiac enzymes (troponin) o Interventions (time sensitive?) ▪ Cath lab (imaging, stent placement, angioplasty) ▪ Coronary Artery Bypass Graft (CABG) ▪ Medications (antilipidemics, anticoagulants) ▪ Heart Transplant CAD and Social Determinants of Health (SDOH)  Culture/Ethnicity  Income/Employment  Education  Living Environment  Community/Neighborhood  Transportation  Social Support  Access to care  Opportunities to learn throughout the lifespan  The 5 A’s of Smoking Cessation Ask about current smoking status REDUCE Advise to quite; provide information on Risk Factors: benefits of quitting - Consider lifestyle Assess willingness to quit risk factors Assist with finding resources and making a plan - Assess readiness to quit for change Arrange for follow-up appointments to help - Educate on risk with adherence to plan for quitting reduction Left Ventricular Hypertrophy Left Ventricle wall thickening oHeart muscle overworked (why/how?) oStiff and/or weak LV muscle oAffects cardiac output Subjective Findings oSOB w/ activity oFatigue oChest pain oHeart palpitations oDizziness or fainting Objective Findings oDisplaced apical pulse oChange in heart rhythm Case Study Mrs. Lim is a 63 yo female who was admitted to your unit with complaints of fatigue, shortness of breath, and leg swelling PMH: Hyperthyroidism, High Cholesterol, Obstructive Sleep Apnea You are the nursing student who is sent to take a history of the patient's current illness and conduct a focused physical exam. Let's follow her case... Case Study: History Taking What SUBJECTIVE data would you collect for a focused cardiac exam?  C O L D S P A & Focused ROS o Ask about presence of chest pain!  Lifestyle o Diet & exercise o PO intake (fluid, sodium) o Preventative healthcare o Tobacco & alcohol use  Family history o Cardiac disease What else do you want to know? o Obesity o Diabetes o Varicose veins Case Study: Mrs. Lim's HPI (Subjective)  About three days ago I was unable to get my shoes on because my feet were so swollen. I've been wearing slippers since then  I've been sleeping on my recliner chair because I feel like I'm drowning when I'm lying flat in bed  I couldn't catch my breath going upstairs to my bedroom, so I slept in the living room last night  My chest doesn't hurt but I feel really tired, and my legs feel heavy  This has only happened to me once before, but it was during vacation, so I just thought it happened because it was so hot there  What other questions do you have for Mrs. Lim? Case Study: Physical Exam What OBJECTIVE data would you gather for a focused cardiac exam?  VS  Fluid Status  Heart Sounds o Edema Ø Extra Heart Sounds—S3, S4 o Weight gain (sudden?) Ø Murmurs o Jugular Venous Pressure/Distention  Cardiac Rhythm Ø EKG, telemetry?  Considerations for Older Adults o Caution palpating head and neck  Lung Sounds vessels (avoid occluding vessel) Ø Crackles o Difficult to get apical pulse (d/t increased chest diameter) Inspection & Palpation of head and neck vessels  Inspect & Palpate o Carotids o Jugular vein  Auscultate for bruits o BEFORE palpating  Measure Jugular Venous Pressure Auscultation of heart sounds  Produced by valve closure o Normal heart sounds: “lub, dub” (S1, S2) o Extra heart sounds: gallops (S3, S4)  Auscultate to identify o “Normal” S1, S2 o Abnormal sounds Case Study: Mrs. Lim's Physical Exam Findings (Objective)  Vital Signs: o Pulse Ox = 93% on RA, Respirations 24/min o BP 150/96, HR = 79  3+ pitting edema  S3 heart sounds  Crackles in bilateral lung bases  Up 18 lbs from her "dry weight"  Decreased sensation in lower extremities  Unable to palpate apical impulse  Weakened lower extremity pulses (1+), bounding upper extremity pulses (4+)  Dry and cracking skin on BLE  Jugular Venous Distention (JVD)  EKG: normal sinus rhythm Physical Exam: Normal vs Abnormal Findings Normal Findings Abnormal Findings  Inspection  Inspection o No JVD o Prominent Jugular Vein pulsations/JVD  Auscultation  Auscultation o S1, S2 o Extra Heart Sounds (S3, S4) o No murmurs, clicks, rubs o Adventitious Heart Sounds o Aortic pulse at 4th/5th ICS o Aortic pulse displaced o No carotid bruits o Carotid bruits  Palpation  Palpation o No lift, heave, or thrill o Palpable lift, heave, or thrill o Lymphnodes soft, movable, non-tender o Lymphnodes firm, tender, unmovable Murmurs & Grading Grading = 1 – 6 (Sometimes referred to as I – VI) Case Study The cardiologist comes to examine Mrs. Lim... When leaving the room, she confirmed your finding of an intermittent S3 heart sound, but also noted the presence of a Stage II diastolic murmur, which is new. She thinks the patient's new murmur is associated with Aortic regurgitation  What causes a diastolic murmur? o Weakened heart valve or chamber o Increased blood velocity (d/t increased fluid volume)  Where would you place your stethoscope to auscultate for an Aortic murmur? o Left sternal border, 3rd or 4th ICS (Erb's Point) o Sound is heard where blood flows back into the Left ventricle from the Aortic valve Case Study: The Nursing Process What are some priority When would you need to interventions that you expect notify the provider? to perform while caring for Mrs. Lim?  Increased need for supplemental oxygen  Restrict fluid intake  Hypotension  Strict I/O's  Chest pain  Daily weights  Changes in cardiac rhythm  O2 supplementation  Changes in mental status  Administer diuretics  Decreased urine output Case Study: Diagnosis & Plan of Care Mrs. Lim was diagnosed with Acute Heart Failure & Stage II Diastolic Murmur. Before discharge, you will provide patient education for continued care at home and follow up. What will you prioritize?  Fluid Restrictions  Medications  Diet changes  Physical activity  When to seek emergency care Assessing the Peripheral Vascular System Learning Objectives Discuss risk factors associated with peripheral vascular disease across the cultures and ways to reduce one’s risks. Interview a client for an accurate nursing history of the peripheral vascular system. Perform a physical assessment of the peripheral vascular system using the correct techniques. Differentiate between normal and abnormal findings of the peripheral vascular system. Describe the findings frequently seen with assessing the older client’s peripheral vascular system.  Review: Arteries  Carry oxygenated, nutrient- rich blood from the heart to the capillaries  Major arteries of arm: brachial, radial, ulnar  Major arteries of the leg: femoral, popliteal, dorsalis pedis, posterior tibial https://study.com/academy/lesson/major-arteries-of-the- body.html Review: Veins  Carry deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart  Three types of veins o Deep veins ▪ Femoral & Popliteal o Superficial veins ▪ Saphenous veins o Perforator veins ▪ Connect superficial + deep veins https://www.alamy.com/stock-photo-human-veins- artwork-55438792.html Review: Lymphatic system Lymphatic capillaries, lymphatic vessels, lymph nodes Capillaries and fluid exchange Small blood vessels Form the connection between the arterioles and venules Allow the circulatory system to maintain vital equilibrium Peripheral Vascular System: Risk Factors Peripheral Vascular System: Reduce Risk Factors Diet Eat foods low in saturated fats Weight Maintain a healthy weight management Exercise Exercise regularly: aim for >30 min at least 5 times/week, after getting provider approval Smoking cessation Quit smoking if you're a smoker Blood sugar If you have Diabetes, keep blood sugar under control Cholesterol levels Lower your cholesterol and blood pressure levels, if elevated Ask your healthcare provider about screening with an Ankle-Brachial Index (ABI) measurement once you Screening reach 50 yrs of age Case Study Mr. Pars is a 59 yo male who came to the community clinic with complaints of skin discoloration on his legs and changes in sexual function PMH: Hypertension, Diabetes, CAD, High Cholesterol, COPD You are the nursing student who is sent to take a history of the patient's current illness and conduct a focused physical exam. Let's follow his case... Case Study: History Taking What SUBJECTIVE data would you collect for a focused peripheral vascular exam?  C O L D S P A & Focused ROS Ø Lifestyle o Skin changes (discoloration) o Diet & physical activity levels o Changes in hair distribution o Preventative healthcare o Leg pain, heaviness, or aching o Smoking, etoh intake o Varicose veins o Stress & coping mechanisms o Leg sores or open wounds o Medications (oral birth control) o Swelling in legs or feet Ø Family history o Swollen glands or nodules o Cardiovascular & Peripheral vascular disease (vericose veins, PAD) o Sexual function/activity changes o Obesity Diabetes, HTN, CAD, elevated cholesterol/ What else do you want to know? o triglycerides Case Study: Mr. Pars' HPI (Subjective)  About six months ago, my son noticed that the skin on my feet and lower legs was changing color  There is also this dark wound where I stubbed my toe last month. It doesn't seem like it's healing  When I walk home from the parking garage or go up the stairs at work, I get a sharp pain behind my knees  Honestly, I was dealing with all of those other things just fine. But when I started having issues with my performance in the bedroom, I decided I really needed to come see you about all this stuff  What other questions do you have for Mr. Pars? Case Study: Physical Exam What OBJECTIVE data would you gather for a focused peripheral vascular exam?  Upper extremities o Inspect: size, edema, venous pattern, skin color, clubbing o Palpate: temperature, cap refill, pulses, epitrochlear lymphnodes  Lower extremities o Inspect: color, hair distribution, edema, lesions/ulcers, thrombophlebitis, varicose veins o Auscultate: femoral artery for bruit o Palpate: temperature, pulses, superficial lymphnodes § If pulses nonpalpable, locate with doppler  Considerations for Older Adults?? (hair distribution, lymphnodes, variscosities) Inspection & Palpation of the Upper Extremities: Performing an Allen's Test A. Occlude radial and ulnar arteries while client makes a fist. B. Continue occluding arteries while client releases fist. C. Remove pressure on ulnar artery while observing color return to palm. Inspection & Palpation of the Lower Extremities: Testing for Arterial Insufficiency  Test for arterial insufficiency by elevating the legs (A)  Followed by having client dangle the legs (B)  Marked pallor of foot when elevated—seen in arterial insufficiency (C)  Persistent rubor of dependent foot—seen in arterial insufficiency (D) C D Arterial vs Venous Insufficiency Finding Arterial Insufficiency Venous Insufficiency Pain Ranges from: Intermittent Aching or cramping pain Claudication --> sharp, Feeling of heaviness unrelenting, constant pain Pulses Diminished Present? Absent May be difficult to palpate with presence of edema Skin Dependent rubor Diaphoresis Characteristics Discoloration (red/purple) Discoloration (darkened) Shiny, thin skin Varicose veins Necrotic wounds Edema Sparse or absent hair Lesions/Ulcers (non-healing) Inspection & Palpation of the Lower Extremities: Arterial vs Venous Disease PAD PVD Case Study: Mr. Pars' Physical Exam Findings (Objective)  Skin on lower extremities is cool to touch, thin, and shiny  Dry, black wound on Left big toe  Decreased hair on lower extremities  Nonpalpable Left pedal pulse—found w/ doppler; 2+ Right pedal pulse  Dependent rubor  Varicose veins on bilateral lower extremities  Presence of a Left femoral artery bruit  Decreased sensation in lower extremities  Positive (+) Allen's Test in upper extremities  No signs of DVT or thrombophlebitis in BLE Physical Exam: Normal vs Abnormal Findings Normal Findings Abnormal Findings  Warm to touch  Cool to the touch  Presence of hair  Absence of hair  Dry  Diaphoretic  Appropriate color for ethnicity  Discoloration, mottling  2+ pulses  Pulses less than 2+  Absence of bruit  Presence of bruit  Cap refill < 2 sec  Delayed cap refill  No clubbing  Clubbing  Skin intact  Skin breakdown Case Study The Nurse Practitioner comes to examine Mr. Pars... When leaving the room, they confirmed your finding of a Left femoral bruit and nonpalpable Left pedal pulse. The NP also wants to schedule a diagnostic test (penile doppler Ultrasound) to check for blood flow to the penis, during and after erection. In addition to this, blood tests will be ordered to assess the progression of Mr. Pars diagnosis of Diabetes.  What could be some causes of Erectile Dysfunction, other than PAD? o Stress or other mental health concerns o Chronic diseases such as Diabetes, Hypertension, High cholesterol, or Sleep Apnea o Structural abnormalities or defects of the penis  Why are we assessing his diabetes status in relation to PAD? o Diabetic neuropathy could be the cause of decreased sensation or non-healing wounds o Uncontrolled Diabetes increases the risk of cardiovascular problems, including PAD Case Study: The Nursing Process What are some priority What findings might require Mr. interventions that you expect Pars to be referred to a to perform while caring for Mr. specialty provider or to the Pars? hospital?  Assess for decreased or absent  Loss of sensation to lower extremity peripheral perfusion  Significantly changes in VS  Offer comfort measures: warm  Infection or gangrene of wound blanket, pain management (assess for osteomyelitis)  Perform wound care on Left toe  Absent lower extremity pulses, even  Explain purpose/procedure of with doppler further diagnostic testing  Changes in bowel and/or bladder  Offer reassurance about treatment function options for ED  Chest pain, SOB or other  Educate on risk reduction cardiovascular symptoms Case Study: Diagnosis & Plan of Care Mr. Par was diagnosed with Peripheral Artery Disease & Erectile Dysfunction Before he leaves the clinic, you will provide patient education for continued care at home and follow up. What will you prioritize?  Quit smoking if you’re a smoker; seek a smoking cessation program  If you have diabetes, keep your blood sugar in good control  Exercise regularly. Aim for 30 minutes at least five times a week with approval of health care provider  Maintain normal cholesterol and blood pressure levels if elevated  Eat a well-rounded diet and foods that are low in saturated fat  Maintain a healthy weight  Ask your health care provider about screening with an ABI measurement  DO NOT take medications prescribed for ED with other fast-acting vasodilators (Nitroglycerin tabs) Questions? This Photo by Unknown author is licensed under CC BY-NC.