Cardiovascular Exam: History, Systems Review, Tests, and Measures PDF

Cardiovascular and Pulmonary Physical Therapy 173 ↓ rate and ↓ force of myocardial contraction → ↓ decreased myocardial metabolism ➤ Decreased speed of conduction through the AV node Causes va...

Cardiovascular and Pulmonary Physical Therapy 173 ↓ rate and ↓ force of myocardial contraction → ↓ decreased myocardial metabolism ➤ Decreased speed of conduction through the AV node Causes vasoconstriction of coronary arteries and dilation of peripheral blood vessels Sympathetic stimulation (β-adrenergic) Control located in the medulla oblongata: cardioacceleratory center Via T1-T4 cord segments- innervates the SA node, AV node, conduction pathways, and myocytes ➤ Sympathetic receptors located in the SA node and in the myocardium Releases epinephrine and norepinephrine ↑ rate and↑force of myocardial contraction → ↑ increased myocardial metabolism Causes vasodilation of the coronary arteries and vasoconstriction of the peripheral blood vessels (increased peripheral vascular resistance) ➤ Drugs that mimic sympathetic function: sympathomimetics; include α- and β-agonists ‡ β-agonists: asthma ➤ Drugs that suppress sympathetic function: sympatholytics; include β-blockers (antagonists) Additional control mechanisms Baroreceptors (also called pressoreceptors): main mechanism for controlling HR ➤ Located in the walls of the internal carotid artery (above the carotid bifurcation) and aortic arch; and carotid sinus ➤ Stimulated by stretching of the vessel wall from changes in blood pressure (BP) ‡ ↑ BP results in parasympathetic stimulation, sympathetic inhibition, ↓ HR and force of contraction, and ↓ peripheral resistance ‡ ↓ BP results in sympathetic stimulation, ↑ HR, and vasoconstriction of periph- eral blood vessels Chemoreceptors Located in the carotid body and aortic body Respond to changes in blood chemicals, such as oxygen (O2), carbon dioxide (CO2), lactic acid, and hydrogen ion (H+) ➤ ↑ CO2, ↓ O2, or ↓ pH (elevated lactic acid) → ↑ HR ➤ ↑ O2 → ↓ HR Body temperature ↑ temperature → ↑ HR ↓ temperature → ↓ HR Ways to assess ➤ Rectal and tympanic membrane temperatures are 0.5°F to 0.9°F higher than oral temperature ➤ Axillary temperature is approximately 1.1°F lower then oral temperature ➤ Normal healthy adult ‡ Oral temperature: 98.6°F ‡ Rectal and tympanic membrane temperatures: 99.5°F ‡ Axillary temperature: 97.6°F Peripheral resistance Influenced by arterial blood volume (viscosity of blood and diameters of arterioles and capillaries) ↑ resistance → ↑ arterial blood volume and pressure ↓ resistance → ↓ arterial blood volume and pressure Cardiovascular Exam: History, Systems Review, Tests, and Measures Medical record review Past medical history, medical problems, physician examination Medications (dosage, schedule, type) Book_5566_Ch07.indd 173 18-04-2024 22:18:02  174 NPTE Final Frontier – Mastering the NPTE Laboratory tests Example: Creatine kinase-myocardial band (CK-MB) and troponin tests indicate myo- cardial infarction (MI) Diagnostic studies (X-ray, electrocardiogram [ECG], exercise tolerance test [ETT], cardiac catheterization) Patient interview History Clinical presentation: ask for onset, progression, nature of symptoms, any activity that increases or decreases symptoms Chest pain, palpitations, shortness of breath (SOB) ➤ Palpitations: awareness by patient of abnormal HR General fatigue and weakness Dizziness, syncope: due to inadequate cerebral blood flow Edema: especially in dependent body parts and lower extremities Sudden weight gain Past medical and surgical history: other diagnoses, surgeries, comorbidities Social history: current living arrangement, support system, cultural beliefs and behaviors, education level, employment status, lifestyle, risk factors Quality of life (QOL), cognition Risk factors: smoking history, diet, activity level Table 55. Cardiovascular Disease Risk Factors. Nonmodifiable Modifiable Age Cigarette smoking ◦ Males: >45 years Hypertension ◦ Females: >55 years ◦ >140/90 mmHg → increased risk Family history of cardiac event Hyperlipidemia ◦ First-degree male relative 35 in (>89 cm) for females Diabetes: increased risk if ◦ HbA1C >7% Abbreviations: BMI, body mass index; CAD, coronary artery disease; HbA1C, hemoglobin A1C; HDL, high-density lipoprotein; LDL, low- density lipoprotein. Physical Examination: Cardiovascular (CV) System Examine skin Check for signs and symptoms (S/S) of ↓ CO and ↓ O2 saturation Cyanosis: blue color of skin, nail beds, lips, and tongue Book_5566_Ch07.indd 174 18-04-2024 22:18:02  Cardiovascular and Pulmonary Physical Therapy 175 ➤ Central cyanosis: O2 saturation < 80% Pallor: washed-out, white appearance ➤ Anemia, internal hemorrhage Diaphoresis: excessive sweating and cool, clammy skin Bilateral peripheral edema: congestive heart failure (CHF), RV failure Unilateral peripheral edema: thrombophlebitis, lymphedema, deep vein thrombosis (DVT) Examine pulse Influenced by age, sex, force of contraction, volume and viscosity of blood, diameter and elasticity of vessels, emotions, stress, exercise, medications, blood temperature, and hormones Determine pulses Regular rhythm: palpate for 30 seconds Abnormal rhythm: palpate for 1 to 2 minutes Sites to take pulse: radial artery, carotid artery, temporal artery, brachial artery, femo- ral artery, popliteal fossa, dorsalis pedis artery, posterior tibial artery, apical pulse point (over the apex of the heart) ➤ Apical pulse: point of maximal impulse ‡ Patient supine, palpate at 5th intercostal space, midclavicular vertical line ‡ Most accurate ‡ Used when peripheral pulses are weak or imperceptible, or when other sites are not accessible or are difficult to palpate ‡ Displaced upward with pregnancy or high diaphragm ‡ Displaced laterally with CHF, cardiomyopathy, or ischemic heart disease ➤ Radial pulse: most common site ‡ Palpate radial artery at distal radius at the base of the thumb ➤ Carotid pulse ‡ Palpate carotid artery on either side of the lower neck between the trachea and sternocleidomastoid muscle ‡ Assess one side at a time to reduce the risk of reflex drop of pulse rate or blood pressure due to stimulation of baroreceptors ➤ Temporal pulse: used by anesthesiologist for monitoring during surgery ‡ Palpate temporal artery superior and lateral to the eye (over the temporal bone) ➤ Brachial pulse: typically used to measure BP ‡ Palpate brachial artery medial aspect of the antecubital fossa; elbow should be slightly flexed and supported ➤ Femoral pulse: used to monitor lower-extremity circulation and during cardiac arrest ‡ Typically examined with patient supine lying ‡ Palpate femoral artery inferior to inguinal ligament, midway between the ­anterior superior iliac spine and pubic symphysis ➤ Popliteal pulse: popliteal artery is deep and, therefore, difficult to palpate at times ‡ Used to monitor lower-extremity circulation ‡ Typically examined with patient in prone position with knee flexed ‡ Palpate popliteal artery inferior aspect of popliteal fossa ➤ Pedal pulse (dorsalis pedis): used to monitor foot circulation ‡ Palpate dorsalis pedis artery, or dorsal, medial aspect of foot lateral to the tendon of extensor hallucis longus; ankle is slightly dorsiflexed ➤ Posterior tibial pulse: used to monitor foot circulation; weak or absent pulse indicative of arterial disease ‡ Palpate posterior tibial artery inferior to medial malleolus Book_5566_Ch07.indd 175 18-04-2024 22:18:02  176 NPTE Final Frontier – Mastering the NPTE Table 56. Grading Scale for Peripheral Pulse. Grade Description 0 Absent, not palpable 1+ Diminished, barely palpable 2+ Normal, easily palpable 3+ Full pulse, increased strength 4+ Bounding pulse Determine heart rate (HR) Normal Adults: 60 to 100 bpm (average is 80 bpm); 40 to 60 bpm in aerobically trained individuals Newborns: 80 to 180 bpm (average is 130 bpm) Tachycardia: >100 bpm Compensatory tachycardia: due to volume loss (surgery, dehydration) Postural tachycardia syndrome: sustained HR increase of ≥30 bpm within 10 minutes of standing Bradycardia: 120 Treat as medical emergency Abbreviations: DBP, diastolic blood pressure; HTN, hypertension; SBP, systolic blood pressure. Hypotension Decrease in BP below normal; SBP 10 mmHg ➤ Assess BP and HR when patient has been supine at rest for 5 minutes ➤ Then, have the patient move directly into standing position. Repeat assessment of BP and HR after 3 minutes in standing position S/S: light-headedness, dizziness, pallor, diaphoresis, syncope, loss of balance, leg weakness ➤ If patient experiences S/S, have them move from standing to a sitting position or from sitting with legs elevated to a reclined position Examine respiration Table 58. Normal Respiration Rates. Adult 12–20 br/min Child 20–30 br/min Newborn 30–40 br/min Abbreviation: RR, respiration rate. Book_5566_Ch07.indd 178 18-04-2024 22:18:03