Cardiac Assessment

Risk Factors for any cardiac or vascular problem
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Terms in this set (33)
Risk Factors for any cardiac or vascular problem
-Nonmodifiable
Age - Older
Gender - Male
Ethnic - African and Hispanic
Family History/Genetics
-Modifiable
Sedentary Life Style - B/P & Lipids
Smoking-tar, nicotine, and carbon monoxide
Pack Years # of pack per day x years smoked
Addiction vs Habit- can quit for 3 days then start back is habit, do it every morning when wake up, ect
Attempts to quit in past- what have done in past to quit+ what has/hasn't worked
After 3-4 years, same as nonsmoker
Diet-Fat, salt, fluid, alcohol, caffeine
Obesity
Control over HTN and DM- meds, diet, exercise
Psychological - stress, anxiety, competitive, deadlines
IV Drug use - infective
General appearance ( would do this first)
Shows if cardiac output is good or decreased
If decreased will be
-SOB
- Distress level
- decreased LOC
-Skin color- cyanotic skin
- Build- and may appear malnourished and thin as oxygen and nutrients are not effectively pumped to the tissue
* Chronic R sided HF may have problems with fluid build up in the stomach so might have ascites or be jaundice and anasarca (generalized edema)
Inspection of fluid
Fluid: location my help determine cause
-Neck - JVD; mostly right sided HF
~have pt lay supping, raise HOB 30- 45 degrees, have patient look away and look for distention and pulsation
~ pulsation- can palpate radial pulse at same time if matches the radial it is a coradid pulse if does not match it is jugular
-Extremities
~ if both lower extremeties are swollen may think CHF or venous insufficiency
~ If abdomen, jugular, and lower is swollen Right sided FH and curosis
~ Only 1 leg maybe venous obstruction
-Pitting vs Non
~ Grade the pitting Edema- is it better or worse 1+ edema= 2 ml, 2 + edema + 4 ml, # times 2
Inspection of thorax
Thorax
-Symmetry
-Scars (surgical & other) over sternum
Irregularities
Inspection of nails
Nails
-Color- should be nice and pink
-Clubbing- A sign of chronic oxygen depravation signs of chronic pulmonary disease, heart defects, CHF with poor CO
Look at angle of nail, if greater then 180 degrees is clubbing, nail bed straitens out and is spongey
To test, have pt hold both ring fingers side to side. Hold up to light. IF present light shines through If can see "diamond" = NO clubbing.
-Thickness- if think is clubbing
Inspection of skin
Skin
Color (pink, pale, mottled, dusky, cyanotic- appear grayish on darker skins), blue mucous membrane
Temperature (warm, cool)- assessed with back of hand
Moisture (dry, diaphoretic)
Hair- if no hair on feet, hands, or toes is sign of cubbing
* for darker skinned patients check... pallor - mucous membranes; cyanosis: tongue, mouth, palms of hands and soles of feet; Jaudince - Oral mucosa, NOT the sclera
Inspection of the precordium( area over the heart)
-Pulses over the aortic, pulmonic, & tricuspid is ABNORMAL
-Pulses in Mitral area (Apex) is NORMAL
AKA - Apical impulse or Point of Maximal Impulse (PMI)
-PMI - Left, 5th intercostal space, midclavicular line!!! If appears in more than one intercostal space, may indicate left ventricular hypertrophy
What to evaluate for the Auscultation
HR
Rhythm
Cardiac cycle ( systolic/ diastole)
Valvular function
Diaphragm
Bell
Diaphragm- high pitched-> normal sounds ( s1+s2 and high pitched murmors)
Bell- Low pitched ( S3, S4 and murmurs)
** Listen once with the diaphragm and then go back a second time and listen with the bell
Aortic area
2nd intercostal space right of the sternum
Pulmonic area2nd intercostal space left of the stenumErbs point3rd intercostal space left of sternumTricuspid area5th intercostal left of the sternumApical/Mitral area5th intercostal space mid clivecular lineS1Closing of the tricuspid and bicuspid( mitral/apical) valves apical is best place to hear heart beat If fast can figure s1 by feeling carotid and listening beginning og the ventricular systolic and the injection phase consider that it intensify with exercise, hyperthyroidism, and mitral stenosis might decrease intensity due to mitral valve regurgitation, heart failure If diff hearing have patient lean forward or roll on the left sideS2Closing of the pulmonic and the aortic valve Shorter then s1 and best heard at erbs point signifies beginning of ventricular diastole * There is a longer pause after the s2S3 and S4ABNORMAL diastolic filling sounds... Produced when blood enters a noncompliant chamber during rapid ventricular filling ** presence of both s3 and s4 indicates severe heart failureS 3S3 - Ventricular Gallup; represents decrease in L ventrical compliance - early sign of heart failure or ventral septal defect - Sounds like "Kentucky" or "Lub-dub-dee"s4S4 - atrial Gallup; may be heard in pts with HTN, anemia, ventricular hypertrophy, MI, aortic or pulmonic stenosis, and PE; May also be heard with older age as ventricle stiffensMurmurturbulent blood flow through normal or abnormal valves. May sound like swishing or blowing... Classified as systolic (aortic stenosis, mitral regurg) which occurs between S1 and S2 OR diastolic (mitral stenosis, aortic regurg) which occur between S2 and S1; May also last throughout the whole cardiac cycle depending on severity; Intensity grading from 1 - very faint to VI Extremely loud (heard with stethescope above pt's chest and thrill may be palpable.) While grading is not part of nurse assessment, where best heard is important...Clickingmay be heard with synthetic valve replacement, a clicking noiseRuboccurs when inflammation or infection present. Occurs from rubbing of heart on precordium.PulsesCarotid Brachial Radial Ulnar Femoral Popliteal Post Tib PedalPulse Rating0 = absent 1+= diminished Diminished - hypokinetic - weak indicative of narrow pulse pressure (hypovolemia, aortic stenosis, decreased CO) 2+= normal 3+= full pulse/slightly increased 4+= bounding Increased - hyperkinetic - bounding - caused be increased ejection of blood/CO (exercise, sepsis, thyrotoxicosis) OR with increased sympathetic activity (fever, pain, anxiety) *Check pulses bilaterally except for carotidCapillary Refill< 3 seconds is normal > 3 seconds= vasulesationWarmth/ Colorshould be pink warm and dryAuscultation of Major Arteries * Bruits*Major arteris include carotids and aorta: Bruits are swishing sounds from turbulent blood flow in narrowed or atherosclerotic arteries. Use the BELL of the stethescope. Have pt hold breath. Should be no sounds.Blood pressure * If to high*Increases the work of the heart to overcome the resistance of those arteries and increase the oxygen demand of the heartBlood Pressure * if to low*Pressure might not be able to enough to provide oxygen and nutrients to the body - If b/p is too low to "hear" you can use invasive arterial line OR use "Doppler" to estimate the SYSTOLIC onlyPulse Pressure-Pulse Pressure: Difference between systolic and diastolic values. Normal is approx 30-40. Can be indirect measure of CO. -Narrowed pulse pressure results from increased peripheral resistance or decreased stroke volume in pts with CHF, hypovolemia, or shock; also with mitral valve stenosis or regurg. - Incrased PP may occur with SLOW HR, aortic regurg, atherosclerosis, HTN, and aging (systolic is much HIGHER than diastolic).Mean Arterial Pressure ( MAP)MAP - average pressure in artery during a single cardiac cycle (one heart beat) Should be 60-70mmHg to adequately perfuse major body organs (heart, kidneys, brain) * Diastolic + 1/3 mmHG of pulse pressureOrthostatic hypotesnsionTo measure orthostatics: Lay flat for at least 3 min then take BP,Then have sit or stand. Wait atleast 1 min, then recheck HR and BP. Assess for s/s of dizziness. If severe, sit down immediately. Ortho static defined as decrease of 20 or more points in systolic; 10 or more diastolic; OR incrase of 10-20% + in HR ... Positive may indicate dehydration/low volume; S/E of medication; prolonged bed rest; or age related changesAnkle-Brachial Index ( ABI)ABI - used to assess vascular status of LE. - B/P cuff applied to LE just above malleolus of the ankle Systolic is measured by doppler of pedal and post tib. The higher of the two is divded by the higher of the two brachial pulses to get ABI. - Normal is 1 or greater b/c as pressure in legs is usually higher than in arms. - If < 0.8, indicates moderate PAD and < 0.5 indicates severe vascular disease.