advanced cardiac assessment Flashcards
potential s/s of CV problems
fatigue fluid retention leg pain syncope dyspnea irregular heart beat pain
what formation are we getting from the health assessment?
elimination medications nutrition activity, exercise sleep, rest coping, stress tolerance perception of self, self-concept roles/relationship sexuality, reproductive prevention strategies
risk factor assessment
tobacco use (smoking, chewing) elevated serum levels HTN sedentary lifestyle obesity stressful lifestyle diabetes mellitus
modifiable risk factors
smoking obesity htn cholesterol levels physical activity oral contraceptives personality type
non-modifiable risk factors
genetics and age
non-modifiable risk factors
Age
50% MI patients over 65
80% mortality from MI over 65
Gender
Men>Women
Premenopause MI rare
Race and ethnicity
African-American > Caucasian
Caucasian > Asian
Family history
High risk for CAD and MI if in nuclear family
self concept, health promotion and management questions
What type of health issues do you have? Are you able to identify any family history or behaviors that put you at risk of this health problem?
What are your risk factors for heart disease? What do you do to stay healthy?
How is your health? Have you noticed any changes?
Do you have a cardiologist or primary health care provider? How often do you go for check-ups?
Do you use tobacco or alcohol?
What medications do you take? (all!)
How is illness affecting your ADLs and life in general
physical assessment
Vital signs – BP, HR & temp Includes orthostatic (postural) BP & HR Pulse Assessment Bruits Heart Sounds Lung sounds Med use Sleeping
blood pressure assessment
Size of cuff important! If must repeat, wait 1-2 minutes Arm at level of heart If elevated, lowers pressure If dependent, raises pressure
Palpable BP
pulse pressure
Is the difference between the systolic and diastolic numbers
Not significant by itself, need to use in the whole picture of the patient
More interested in acute change in pulse pressure.
Usually 30-40 mm Hg
A decrease may indicate heart failure, shock, or hypovolemia
Increase may be seen with anything that increases stroke volume
Stiffness in the aorta d/t artheroschlerosis
Anemia
Hyperthroidism
Pregnancy
postural blood pressure
Pt should be resting for 5 minutes prior to taking the first reading.
Always check supine measurements first
Check supine, sitting, and then standing
Record both pulse and BP with each posture change
Don’t remove cuff between measurements
When person stands, measure w/in a minute, and then again after 2 minutes
Techno way – Tilt Table
normal response postural blood pressure
Normal response is:
A transient increase in heart rate of 5 – 20 beats per minute
A drop in systolic pressure of < 10 mm Hg, and
An increase in diastolic pressure of 5 mm Hg
postural blood pressure may be accompanied by
Orthostasis (orthostatic or postural hypotension) may be accompanied by dizziness, lightheadedness, or syncope
3 most common causes are
Intravascular volume depletion
Inadequate vasoconstrictor mechanisms
Autonomic insufficiency
orthostasis occurs when…
There is a drop in systolic pressure of 20mm Hg or greater,
A drop in diastolic pressure of at least 10 mm Hg
The pulse rises > 20 bpm
how to diagnose postural blood pressure
Change from lying to sitting is not sufficient to make a diagnosis of orthostasis
But, it may be used as a screening test!
Volume depletion (as with diuretics) may be suspected when heart rate increases, and systolic pressure decreases by 15mm Hg
physical assessment pulses
Rate – should be 60 – 100 beats/min. What about children?
Rhythm – regular
Amplitude – refers to strength
Equality - same on both sides.
pulse locations
Radial Most frequent site for assessment, but affected by peripheral and cardiac factors Apical At PMI (5th intercostal space) Carotid Do NOT assess both sides at one time!
adddional peripheral pulse locations
Assessed in legs and arms Femoral Popliteal Dorsalis pedis Posterior tibialis Brachial Ulnar * Remember to assess the abdomen for a pulse - aortic aneurysms Allen’s Test
pulse characteristics (amplitude)
Amplitude (Strength) (0-4 scale) Absent = 0 (Doppler) Diminished = 1+ Normal = 2+ Moderately increased = 3+ Markedly increased = 4+
apical-radial rate
ess in all cardiac patients initially, and in those with irregular rhythms
May indicate that not every contraction is strong enough to produce peripheral change
Pulsus Alterans – regular alteration of weak and strong beats w/o changes in cycle length.
From heart failure, pericardial effusion
bruits
A blowing sound that occurs with turbulent blood flow – suggests partial obstruction to blood flow.
A palpable thrill
Arteries are normally silent
when is the only time it is okay or normal to hear a bruit
Only time you want to hear this is during hemodialysis… this is good we should expect to hear this
Blowing sound
jugular venous pulse
Can give valuable information about right heart hemodynamics.
Best to use Right internal jugular vein
Observing pulsations of skin
Head of bed is elevated >30 degrees
Measure # of cm above sternal angle; over 3cm is abnormal
May indicate heart failure, fluid overload
heart assessment
ALL PEOPLE EAT TURKEY ALWAYS?
heart assessment
Aortic- 2nd ICS on RSB
Pulmonic- 2nd ICS on LSB
Tricupid- 4th ICS on LSB
Mitral- 5th ICS on LSB
heart sounds review
Stethoscope diaphragm for high-pitched sounds; particularly S1 and S2
Bell used for low-pitched sounds (esp. S3 and S4) and some murmurs
first heart sounds = S1
Closure of the mitral and tricuspid valves
Onset of systole
Loudest at apex
second heart sound = S2
Closure of aortic and pulmonic valves
Beginning of diastole
Loudest over pulmonic area
third heart sound = S3
Physiologic – children, fit athletes, well exercised people
Pathologic – new onset, or found after 40
fourth heart sound = S4
Least common
HTN and stiff walls from cardiovascular damage S1 and S2 sounds
Abnormal heart sounds 3rd heart sound
Immediately follows S2: “lub-dup-TA”
Physiologic = may be normal finding in children, and adults < 40 yrs
Heard best with bell at apex; press lightly; left lateral position
Pathologic = when heard in people > 40 yrs., is usually indicative of myocardial failure
AKA ‘Gallop’ rhythm
‘Sloshing In’
3rd Heart Sound
abnormal heart sounds 4th heart sound
Immediately precedes the S1: “TA-lub-dup” or a – STIFF - wall
Heard best with bell also
May indicate Aortic stenosis, scar tissue, and hypertension
4th Heart Sound
how are murmurs produced
Are sounds produced by abnormal turbulence
Bruit is within vessel
Murmur is across valve
Location of murmur tells you what valve is troubled.
Can sound like a whoosh, click, mechanical
how are murmurs classified by
Classified by: Timing in cardiac cycle Pitch (low, medium, high) Location Apex, sternum… Quality Soft, blowing, harsh, mechanical Duration Throughout cycle or at the beginning Intensity (scale of I - VI)
when do you know if a murmur is mitral
If murmur is heard at apex between S1 and S2, then is a systolic murmur, and probably mitral.
diagnostic lab studies cardiac markers
Cardiac markers CK (CPK)(creatine kinase) CK-MM CK-MB CRP Troponin – T, troponin – I Homosysteine
diagnostic lab studies serum lipids
Serum lipids
Cholesterol guidelines
LDL<160 : primary prevention, 1 or no risk factors
LDL<130: primary prevention, 2 or more risk factors
LDL<100: secondary prevention, person with known CAD
HDL should be >35
Medications used only for high levels of LDL cholesterol
other diagnostic studies tests
EKG Cardiac Stress Testing Exercise Stress Test Pharmacologic Stress Test Holter monitor/loop recorder (ILR/ ICM) CXR Echocardiogram/TEE Myocardial Perfusion Imaging MRI PET scan CT scan Cardiac catheterization (R&LHC w/LV) EPS
