Heart and Cardiovascular Assessment PDF

HEART AND CARDIOVASCULAR ASSESSMENT NR630 ADVANCED PHYSICAL ASSESSMENT REGIS UNIVERSITY ANATOMY AND PHYSIOLOGY REVIEW A&P AND AGE-RELATED CHANGES ANATOMY AND PHYSIOLOGY: LOCATION OF KEY FEATURES  STRUCTURE  Pericardium...

HEART AND CARDIOVASCULAR ASSESSMENT NR630 ADVANCED PHYSICAL ASSESSMENT REGIS UNIVERSITY ANATOMY AND PHYSIOLOGY REVIEW A&P AND AGE-RELATED CHANGES ANATOMY AND PHYSIOLOGY: LOCATION OF KEY FEATURES  STRUCTURE  Pericardium  Epicardium  Myocardium  Endocardium  Chambers  Two upper chambers are the right and left atria.  Two bottom chambers are the right and left ventricles.  Septum: divides right and left heart  Valves: permit the flow of blood in only one direction  Atrioventricular AV valves are which valves?  Semilunar which valves are these?  WHY ARE THE PULMONIC AND AORTIC VALVES CALLED SEMI-LUNAR IF THEY HAVE THREE CUSPS ? ▪ Semilunar Valve Structure ▪ The semilunar valves of the heart are made up of flaps or leaflets. The margins of leaflets are connected to the arterial wall in a manner that looks like a half-moon that's why they are described as “semilunar“. https://teachmeanatomy.info/thora x/organs/heart/heart-valves/ ANATOMY & PHYSIOLOGY (What makes it “tick”!) Functions of the heart & CV system ▪ Pumps blood to tissues to supply O2 & nutrients ▪ Remove CO2 & metabolic wastes 6  CARDIAC CYCLE ▪ Systole ▪ Diastole AGE RELATED CHANGES ASSESSMENT HISTORY, PHYSICAL, DDX  HISTORY OF PRESENT ILLNESS/ROS  Chest pain  Pain radiating to neck, left shoulder, arm, back  Nausea  Diaphoresis  Fatigue  Cough  Shortness of breath (dyspnea, orthopnea)  Edema  Loss of consciousness (transient syncope) associated with ? PAST MEDICAL HISTORY  Cardiac surgery and hospitalization  Rhythm disorder  Known coronary artery disease  Hypertension  Elevated cholesterol or triglycerides  Acute rheumatic fever, unexplained fever, swollen joints  Chronic illness such as diabetes FAMILY HISTORY  Long QT syndrome  Diabetes  Heart disease  Dyslipidemia  Hypertension  Congenital heart defects  Obesity  Family members with cardiac risk factors  ?MI if so, age?  Other disorders and outcome  PERSONAL AND SOCIAL HISTORY  Employment  Physical demands  Environmental hazards  Tobacco use  Nutritional status  Personality assessment  Relaxation activities  Use of alcohol and/or drugs  Exercise  How much, how intense?  Other activities?  INSPECTION Apical impulse Should be visible at about the midclavicular line in the left fifth intercostal space In some patients, it may be visible in the fourth left intercostal spaces It should not be seen in more than one space or beyond anatomical index Left ventricular hypertrophy (LVH) or other pathology Obscured by obesity, large breasts, or muscularity  PALPATION  Precordial palpation sequence  Apical impulse  If it is more vigorous than expected, characterize it as a heave or lift.  Point of maximal impulse (PMI)  Point at which the apical impulse is most readily seen or felt  Left ventricular hypertrophy (LVH) or other pathology if detected lateral to landmarks  Thrill: a fine, palpable, rushing vibration, a palpable murmur  Carotid artery palpation  AUSCULTATION: PAGE 521 BATES’  Listen with diaphragm AND bell  Bell will help you hear lower-pitched sounds  Auscultatory areas: ◦ Aortic valve area  Second right intercostal space at the right sternal border ◦ Pulmonic valve area  Second left intercostal space at the left sternal border ◦ Second pulmonic area  Third left intercostal space at the left sternal border ◦ Tricuspid areas  Fourth left intercostal space along the lower left sternal border  Slightly lower is a second area for the tricuspid ◦ Mitral (or apical) area  Apex of the heart in the fifth left intercostal space at the midclavicular line  AUSCULTATION CONTINUED  Assess overall rate and rhythm.  Frequency  Intensity  Duration  Pathology  HEART SOUNDS  Basic heart sounds  S1 or S2 most distinct  Splitting  S3 and S4 difficult to hear  Extra heart sounds  Gallops  Mitral snaps  Ejection clicks  Friction rubs S3 AND S4 EXPLAINED: DIASTOLIC SOUNDS ▪ S3=“Sloshing in” usually indicates systolic heart failure ▪ S3 MAY be a physiologic finding in those under 40 years of age ▪ S4=“A stiff wall” indicates diastolic heart failure ▪ Corresponds to increased left ventricular and end diastolic stiffness with decreased compliance ▪ S3 and S4 are best heard with the Bell of the stethoscope 21 S3 AND S4  ASSESSING MURMURS The bell is used to hear low-pitched sounds. Use for mid-diastolic murmur of mitral stenosis or S3 in heart failure. The diaphragm, by filtering out low-pitched sounds, highlights high-pitched sounds.  Use for analyzing the second heart sound, ejection and midsystolic clicks and for the soft but high-pitched early diastolic murmur of aortic regurgitation. 23 DESCRIBING HEART MURMURS  Timing  murmurs are longer than heart sounds  can be distinguished by simultaneous palpation of the carotid arterial pulse  systolic, diastolic, continuous  Shape  crescendo (grows louder), decrescendo, crescendo- decrescendo, plateau  Location of maximum intensity  is determined by the site where the murmur originates  e.g. A, P, T, M listening areas 24 DESCRIBING HEART MURMURS  Radiation  May radiate to remote areas, including neck (carotids), back, axilla or other locations on the chest wall  Reflects the intensity of the murmur and the direction of blood flow  Intensity  graded on a 6 point scale  Grade 1 = very faint  Grade 2 = quiet but heard immediately  Grade 3 = moderately loud  Grade 4 = loud  Grade 5 = heard with stethoscope partly off the chest  Grade 6 = no stethoscope needed  *Note: Thrills are assoc. with murmurs of grades 4 - 6 25 DESCRIBING HEART MURMURS  Pitch  high, medium, low  Quality  blowing, harsh, rumbling, and musical  Others:  i. Variation with respiration  Right sided murmurs change more than left sided  ii. Variation with position of the patient  iii. Variation with special maneuvers  Valsalva/Standing => Murmurs decrease in length and intensity  EXCEPT: Hypertrophic cardiomyopathy and Mitral valve prolapse 26  MURMUR: SYSTOLIC OR DIASTOLIC? ▪ Systolic  May be physiologic OR pathologic  SX’s? ▪ MR = Mitral (valve) regurgitation ▪ Payton Manning = Physiologic murmur ▪ AS = Aortic Stenosis ▪ MVP = Mitral Valve Prolapse ▪ Diastolic  ALWAYS pathologic ARMS ▪ AR = Aortic Regurgitation (Pulmonic regurg as well) ▪ MS = Mitral Stenosis https://www.med.ucla.edu/wilkes/intro.html This link allows you to listen to each type of murmur. PHYSIOLOGIC OR INNOCENT MURMURS ▪ 50% of children ages 3-4 have physiologic murmur ▪ Systolic only ▪ Asymptomatic and do not radiate ▪ Disappear with certain position change/maneuvers ▪ Grade 1-3/6 ▪ Venous hum (non-valvular turbulence of blood in jugular veins) ▪ Still’s murmur VALVULAR PATHOPHYSIOLOGY* STENOSIS REGURGITATION Caused by stiffened, non- Caused by turbulent blood compliant valve flow Usually has a distinct start Completely fills that phase and end point of cardiac cycle Aortic stenosis is the most Mitral regurg the most common stenotic heart common regurgitant heart valve valve  Associated with aging, HTN  Blood moves retrograde to the left atrium  May lead to low cardiac output HEART MURMUR PHYSIOLOGY HEART MURMUR VIDEOS ▪ http://www.youtube.com/watch?v=rcHtce4t3ak ▪ https://youtu.be/6YY3OOPmUDA ▪ https://www.med.ucla.edu/wilkes/intro.html 32  AGE RELATED CONSIDERATIONS  Infants  Heart rates vary with eating, sleeping, and waking.  Murmurs are common until 48 hours of age.  Children  Sinus arrhythmia a physiologic event of childhood  Some murmurs are innocent; it increases in intensity with activity and diminishes when the child is quiet (still murmur).  Older Adult  Diaphragm is raised and heart is transverse in obese adults.  S4 heart sound is more common.  May indicate decreased left ventricular compliance OTHER ASSESSMENTS Jugular vein pressure – assess JVD which reflects increased filling volume and pressure on (R) side of heart  JVD associated with (R) HF, SVC obstruction (Normal is 3-10cm H20) Pulse deficit – the difference between apical HR and peripheral pulse-associated with Afib, and heart blocks Pulse pressure – the difference between systolic & diastolic pressure 35 JUGULAR VENOUS PRESSURE 36 OTHER ASSESSMENTS Respiratory: Lung sounds = rate, rhythm, quality, sputum GI: Abdomen Peripheral Vascular: Lower extremities Evaluate for peripheral edema Varicosities Distal pulses DIAGNOSTIC PROCEDURES  EKG 12 Lead  Continuous cardiac monitoring aka Holter monitor  Chest x-ray – detects enlargement of heart & pulmonary congestion  Echocardiography – ultrasound that reveals size, shape and motion of cardiac structures  Evaluates cardiac wall thickness, valve structure, differentiates murmurs  TEE – transesophageal echocardiography provides a clearer image because less tissue for sound waves to pass through  Angiography / cardiac catherization  Determines coronary lesion size, location, evaluate (L) ventricular function, measures heart pressures  Exercise tolerance test  Radionuclide Imaging (thallium treadmill) 38  LAB STUDIES  Cardiac enzymes = enzymes are released when cells are damaged (MI). Enzymes are found in many tissues/muscles, and some are specific to cardiac tissue.  Serial measurement can aid in dx, and monitor course of MI  Cardiac enzymes = CPK – MB (CK-MB),myoglobin, Troponin  In general, the greater the rise in the serum level of an enzyme, the greater the degree or extent of damage to the muscle.  LDH 39 LAB STUDIES  Electrolytes  LDH  Lipid panel (HDL, LDL, Total Cholesterol, Triglycerides)  CBC  C – Reactive Protein (CRP)  BNP- Human B-Natriuretic Peptide  Blood coags-PT/PTT/INR 40 PRACTICE QUESTION #1  A physiologic murmur has which of the following characteristics?  A. Occurs late in systole  B. Noted in a localized area of auscultation  C. Becomes softer when a patient moves from supine to standing  D. Frequently obliterates S2 PRACTICE QUESTION #2  You are examining an elderly woman and find a grade 3/6 crescendo-decrescendo systolic murmur with radiation to the neck. This is most likely caused by:  A. Aortic stenosis  B. Aortic regurgitation  C. Anemia  D. Mitral stenosis PRACTICE QUESTION #3  A patient has an audible diastolic murmur best heard in the mitral listening point. There is no audible click. His status has been monitored for the past 2 years. This murmur is probably:  A. Mitral valve prolapse  B. Acute mitral regurgitation  C. Chronic mitral regurgitation  D. Mitral stenosis PALPATING THE CAROTID & CAROTID BRUIT ASSESSMENT https://youtu.be/0s1y5zh7m4Y RECORDING YOUR FINDINGS ▪ Structures ▪ Color ▪ Pulsations ▪ Palpation ▪ Heart sounds REFERENCES ▪ Bickley, Lynn S. (2021). Bates' guide to physical examination and history taking (13th Ed.) Lippincott Williams & Wilkins. ▪ Thomas SL, Heaton J, Makaryus AN. Physiology, Cardiovascular Murmurs. [Updated 2021 Jul 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525958/ ▪ https://www.ncbi.nlm.nih.gov/books/NBK525958/