Cardiac Assessment Lab 24-25 PDF

CARDIAC HISTORY AND PHYSICAL EXAMINATION History – CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS – Chest Pain ,Dyspnea ,Edema of the Feet and Ankles, Palpitations and Syncope ,Cough and Hemoptysis ,Nocturia ,Cyanosis, Intermittent Claudication – PAST MEDICAL HISTORY – CURRENT H...

CARDIAC HISTORY AND PHYSICAL EXAMINATION History – CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS – Chest Pain ,Dyspnea ,Edema of the Feet and Ankles, Palpitations and Syncope ,Cough and Hemoptysis ,Nocturia ,Cyanosis, Intermittent Claudication – PAST MEDICAL HISTORY – CURRENT HEALTH STATUS AND RISK FACTORS – FAMILY HISTORY – SOCIAL AND PERSONAL HISTORY Physical examination of the heart GENERAL EXAMINATION Vital signs LOCAL EXAMINATION Inspection & palpation Auscultation  GENERAL EXAMINATION wash hands thoroughly with soap and water or clean them with antibacterial wash. introduce yourself to the patient, explaining that you are going to perform a cardiac examination. Have the patient undress down to the waist. Position the patient on the examination table at a 30- to 45- degree angle, and approach the patient from the right side. Have a general look at the patient first. Note whether the patient is comfortable or in any distress  General Appearance Body built (Obese/Cachectic) Decubitus (Orthopnea- Prayers' position- Squatting) Color: (Pallor- Cyanosis- Jaundice) Pallor: may indicate hypovolemia or anaemia with a concomitant decrease in the red blood cells’ oxygen carrying capacity Cyanosis : (bluish color) Central cyanosis: cyanosis is best observed in the lips, oral mucosa and the tongue.( in congenital heart diseases, cor-pulmonale, and advanced heart failure). – Peripheral cyanosis: low cardiac output. low blood flow to peripheries such as cardiogenic shock jaundice for example may present in the sclera as well as appearing in the lips, hard palate, under the surface of the tongue and may be indicative of hepatic engorgement as a result of right ventricular failure.  Inspection Nails (Finger clubbing ): (broadening of the distal phalanges of digits, giving them a drumstick or club – like appearance accompanied by abnormally curved and shiny nails ) indicates chronic poor oxygen perfusion to the distal tissues of the hand and feet. (as in patients with chronic cardiac conditions, such as cyanotic congenital heart disease). Blue clubbing associated with cyanotic congenital heart disease. The nails should also be inspected for other signs of cardiac disease for example evidence of splinter hemorrhages (small linear hemorrhages under the nail bed that are splinter like) and can indicate the presence of infective endocarditis.  Inspection Subcutaneous nodules (subcutaneous firm swelling in active Rheumatic fever ) Lower extremities (Cardiac edema in Right side heart failure) Neck: (Vigorous pulsations) Fever( Rheumatic fever, Infective endocarditis) Respiration (dyspnea may indicate left ventricular heart strain  Jugular venous distention Its importance lies in the fact that the internal jugular ( IJ) is in straight-line communication with the right atrium. The IJ can therefore function as a manometer, with distention indicating elevation of Central Venous Pressure (CVP). This in turn is an important marker of intravascular volume status and related cardiac function  The internal jugular veins are not directly visible, because they lie deep to the sternomastoid muscles in the neck The goals of the examination are to determine the highest point of visible pulsation in the internal jugular veins, to measure this point of visible pulsation as the vertical distance above the sternal angle. The patient is placed in the bed supine with the head of the bed elevated 45 degree. The patient is examined with the head slightly turned away from the examiner. The nurse uses tangential light to observe for the highest point of visible pulsation.  Next, the angle of Louis is located by palpating where the clavicle joins the sternum (suprasternal notch). The examining finger is slid down the sternum until a bony prominence is felt. This prominence is known as the angle of Louis. A vertical ruler is placed on the angle of Louis. Another ruler is placed horizontally at the level of the pulsation. The intersection of the horizontal ruler with the vertical ruler is noted, and the intersection point on the vertical ruler is read. Normal jugular venous pulsation should not exceed 3 cm above the angle of Louis.  Vital signs Examination of the pulse Pulse: is the pressure wave in the walls of the arterial system which are produced by left ventricular ejection and transmitted in the arterial walls towards the periphery. The pressure waves expands the arterial wall as it travels, this expansion can palpated as arterial pulse.  Vital signs 1-Taking the pulse How to take your pulse Rate (60-90 b/min) Rhythm Volume / Amplitude Equality Palpate all peripheral pulses : Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis. What is a normal pulse? 90 b/min, regular ,average volume ,and equal in both sides  examination of radial pulse Hold the for arm of the subject while the hand is slightly flexed and pronated. Press the radial artery ,at the wrist region ,against the bone using the three middle fingers till you feel the maximal pulsation. The use of the middle fingers offer a larger sensitive palpatory surface ,whereas the use of the thumb should be avoided since it has its own pulsation. Expressed as follow Pulse is 75\min ,regular ,average volume ,equal on both sides, the arterial wall is not palpable and no special characters. Rating Scale Used for Assessing Strength of Pulses 0 Absent 1 Palpable but thready, weak, easily obliterated 2 Normal, not easily obliterated 3 Full, bounding, easily palpable, cannot obliterate  Vital signs Blood pressure Definition It is the lateral pressure exerted by blood on the arterial walls and it is fluctuating during the cardiac cycle Systolic blood pressure : It is the highest pressure through out the cycle, it occurs in ventricular systole. Normal range 100 – 140 mmHg Average 120 mmHg  Diastolic blood pressure It is the lowest pressure through out the cardiac cycle , it occurs during ventricular diastole Normal range 60-90 mmHg Average 80 mmHg. The Mean arterial Pressure: is a the sum of systole plus twice the diastolic pressure divided by 3 MAP = SBP + 2 (DBP) 3 Methods of blood pressure measeurment Invasive or direct methode: using a catheter inserted into an artery (which is used during cardiac surgeries) Non invasive or indirect method : Palpatory step Auscultatory step  Sphygmomanometer  stethoscope  1-Wash hands; identify client; explain procedure to client; assist client to a comfortable position with forearm supported at heart level and palm up. Variations in blood pressure can occur with client in different positions. Blood pressure increases when the arm is below heart level and decreases when above heart level. Expose the upper arm completely. Wrap deflated cuff around upper arm with center of bladder over brachial artery. Lower border of cuff should be about 2 cm above antecubital space  I-Palpatory step : ✓Radial artery is palpated ✓ Cuff is inflated until radial pulse disappears Pressure is increased further by 20 mm Hg Pressure is then released slowly through opening of valve ✓Mercury column is noted when the pulse reappears and is felt ✓Systolic pressure is obtained  II-Auscultatory step : ✓ Stethoscope placed over the brachial artery in cubital fossa. ✓Pressure is raised by 20 mm Hg after pulse disappears to occlude the Brachial artery. ✓ Pressure is released from cuff through opening of the valve ✓ first apearence of the sound indicates Systolic pressure ✓ When further deflated – amplitude and duration of oscillations is reduced--- Diastolic BP  Korotkoff’s sounds It is sounds heard during deflation of the cuff while measuring the blood pressure Causes Change the stream (silent )flow into turbulent (noisy)flow due to compression of brachial artery by inflated cuff ,increasing the velocity of blood through the constricted segment  Korotkoff’s sounds 1st phase: 1st appearance of low frequency clear ,sharp tapping sounds It indicates Systolic pressure 2nd phase: Softer and longer sounds. 3rd phase: Clear louder sounds. Maximum intensity  Korotkoff’s sounds 4th phase: Initial muffling of the sounds. 5th phase Complete disappearance of sounds. It indicates Diastolic Blood pressure LOCAL EXAMINATION Location of Angle of louis. PALPATION skin can be palpated to also demonstrate the presence of oedema. Oedema can be classified as either pitting or non-pitting. Non-pitting does not depress on palpation and is indicative of a localised inflammatory response and the skin is also red, warm and tender. Pitting oedema is found in the dependent body parts and the depression made on palpation remains. Pitting oedema is indicative of congested cardiac failure. Pulses Precordium Carotid Artery Palpation  LOCAL EXAMINATION Palpation of the Precordium to Determine the Location of the Point of maximum Pulse (PMI). The PMI is normally located in the fifth intercostal space medial to the midclavicular line The palm of your right hand is placed across the patient's left chest so that it covers the area over the heart. The heel should rest along the sternal border with the extended fingers lying below the left nipple. Once you have located the PMI assess the location ,diameter and amplitude of the impulse. A normal impulse is felt as a light tap extending over 1cm. An area greater than 3cm should be considered pathological and usually reflects left ventricular enlargement.  Causes of shifted apex: 1.Causes outside the heart -Chest and abdominal diseases which may pull or push the heart -Fibrosis and collapse pull the heart towards the lesion -Pleural effusion and pneumothorax push the heart away from the lesion -Deformities of the chest such as kyphoscoliosis or funnel sternum may displace the apex beat. -Mediastinal lesions ; e.g; tumors or aortic anueurysm , may cause downward displacement. -Abdominal distension by pregnancy, ascitis etc can displace the apex upwards and to the left side. 2.Causes from the heart ( cardiac enlargement) Left ventricular hypertrophy shifts the apex downwards and outwards. Right ventricular hypertrophy shifts the apex mainly outwards.  LOCAL EXAMINATION Palpation: Carotid Artery Palpation: The carotid artery should be inspected and palpated The carotids can be located by sliding the second and third finger of either hand along the side of the trachea at the level of the thyroid cartilage (i.e. adams apple). The pulsations should be easily palpable. Auscultation  Auscultation The four areas where sounds are best heard are The aortic area: auscultated best in the second intercostal space close to the sternum on the right of the sternum The pulmonary area: auscultated best at the second intercostal space to the left of the sternum The tricuspid area: located at the lower left sternal border, approximately the fourth to fifth intercostal space The mitral area (apex of heart): located in the fifth left intercostal space, medial to the midclavicular line  Auscultation Firstly with the diaphragm of the stethoscope listen over the 2nd right intercostal space close to the sternum - the region of the aortic valve. Then move the stethoscope to the other side of the sternum and listen in the 2nd left intercostal space - the location of the pulmonic valve. Move the stethoscope down along the sternum and listen over the left 4th intercostal space: the region of the tricuspid valve. Finally, position the stethoscope over the 5th intercostal space, left midclavicular line and auscultate the mitral area at the apex of the heart. Repeat this sequence with the bell of the stethoscope  Auscultation The first heart sound, S1 : (the lub of the lub-dub), is associated with the closure of the mitral and tricuspid valves and corresponds with the onset of ventricular systole. The S1 sound is normally louder and longer and lower pitched when auscultated at the apex or even in the tricuspid region. The second heart sound, S2: (the dub of lub-dub), is associated with the closure of the aortic and pulmonary valves and corresponds with the start of ventricular diastole. The S2 sound has greatest intensity when auscultated at the aortic or pulmonary regions.  Extra Heart Sounds A third heart sound (S3) S3 is most commonly associated with left ventricular failure and it occurs early in diastole while the ventricle is rapidly filling as the blood enters a non compliant left ventricle (immediately following S2 and sounding like lub-de-dub). The S3 sound is low pitched and must be auscultated with the bell of the stethoscope. It is often called a ventricular gallop. It is considered to be normal in healthy children or young adults up to the ages of 20-30 and it is called a physiologic third heart sound.  Extra Heart Sounds The fourth heart sound : S4 is a sound created by blood trying to enter a stiff, non- compliant left ventricle during atrial contraction. It's most frequently associated with left ventricular hypertrophy that is the result of long standing hypertension. (just before S1 and sounding like la- lub-dub) S4, is known as the atrial gallop  Extra Heart Sounds Either sound can be detected by gently laying the bell of the stethoscope over the apex of the left ventricle and listening for low pitched "extra sounds" that either follow S2 (i.e. an S3) or precede S1 (i.e. an S4). both an S3 and S4 simultaneously is referred to as a summation gallop.  Murmurs These are sounds that occur during systole or diastole as a result of turbulent blood flow. and fall into 2 broad groups: – Leaking backwards across a valve that is supposed to be closed. These are referred to as regurgitant or insufficiency murmurs (e.g. mitral regurgitation, aortic insufficiency). – Flow disturbance across a valve that will not open fully/normally. These valves suffer from varying degrees of stenosis (e.g. aortic stenosis).