Cardiopulmonary Flashcards
History - Cardio
- PMH
- Family history
- Living environment
- Social/Health habits
- Primary complaint (CV related or something else); Ex: DVT, Dyspnea, etc.
- Functional status
- Medications
Warning Signs: Suggestive of CVP Disease
- Chest pain (Angina): Unstable vs stable
- Currently on medications
- Pacemaker or ICD
- Hx of blood clots: either in extremity or lungs
- Light-headed when getting up: Orthostatic hypotension
- Unusual shortness of breath: dyspnea
- Muscle pain with mild exertion: Intermittent claudication
- Difficulty breathing at night: Paroxysmal nocturnal dyspnea
- Edema in B LE
Chest pain (Angina): Unstable vs stable
Stable: Complain chest pain, provide rest, pain goes down or take a med and pain goes down
Unstable: Rest and meds don’t relieve pain
Currently on Medications
Beta blockers [reduce HR]
- Use RPE to measure reaction to exercise
Nitroglycerin
- Before exercise: MAKE SURE THEY HAVE TAKEN IT
- 3 Doses, 1 every 5 minutes to reduce symptoms. No change in symptoms call ER
Warning Signs - Cardio: During Exercise
No increase in HR with increase with workload
Decrease in SBP with increase in workload
Usual SOB
Poor color: Decreased Perfusion (Pale skin, no blood supply)
Ataxia
Confusion
Chest Pain or Leg Pain
- Decrease with rest (Symptoms come on during exertion levels. Thinking ischemia. Goes away with rest.)
Observation: Posture - Cardio
Breathless (Dyspnea scale) or labored breathing
- At rest vs activity
Specific postures
- Ex: Doesn’t like to lie down due to SOB (Orthopnea)
- Ex: Resting elbows on knees or hands on counter
Hypertrophy of secondary accessory muscles (SCM and scalenes)
Jugular vein distension
Scars around chest or back indicative of heart or lung surgery
Pacemaker
Observation - Cardio: Integument
Cyanosis: Blueish discoloration due to hypoxemia (due to hypoxemia (lips or nails)
Nail clubbing: due chronic cardiac or pulmonary disease
Hair loss on lower extremity: due to perioheral artery disease (PAD)
LE or UE Peripheral Edema: “pump failure”
Peripheral Edema
Most common in legs and feet
Pitting: Visible indentation remains when finger is pressed into area and removed
Nonpitting: no indentation remains when pressure is removed
Common causes of pitting edema:
Heart disease
Kidney and liver disease
Chronic venous insufficency
Deep vein thrombosis
Immobilization and inactivity (Cerebrovascular accident, Spinal Cord Injury)
Pitting Edema Assessment
Trace (1+)
Slight indentation, skin rebounds quickly
Mild (2+)
0.0-0.6 cm indentation, skin rebounds in <15 seconds
Moderate (3+)
0.6-1.3 cm indentation, skin rebounds in less than 15 seconds
Severe (4+)
1.3-2.5 cm indentation, skin rebounds in >30 seconds
Core Vital Signs - Cardio
Pulse
Respiration
BP
Temperature
Pain
Walking Speed
Core Vital Signs: Pulse
Where can you take it
Carotid, Brachial, Radial, Femoral, Popliteal, Dorsal Pedis, Posterior tibial A.
Assess three things: HR, Rhythm, Force
Pulse Rate
Normal: 60-100 bpm
Tachycardia >100
Bradycardia <60
Pulse Rhythm
Regular
Regularly irregular: Regular for 3 beats irregular for 1
Irregular: Not normal consistently
Core Vital Signs - Cardio: Respiration
Observe chest rising and falling
Patient should be unaware you are assessing
Common respiratory difficulties to assess for:
Dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Apnea
Assess 3 things: Rate, Rhythm, Depth
Orthopnea
Difficulty breathing while laying flat
Paroxysmal Nocturnal Dyspnea
Sudden dyspnea and orthopnea while sleeping
Apnea
Absence of breathing, often with breathing
Systole
Arterial pressure when the left ventricle contracts
Diastole
Arterial pressure when the heart is at rest between contractions
Normal Blood Pressure Assessment
Slight differences between arms
Normal exercise response
- Systolic pressure rises and levels off
- Diastolic pressure rises by no more than 10 mmHg
Pulse pressure = SBP – DBP
- Typically, about 30-40 mmHg
- For every 10mmHg rise in pulse BP – there is a 22% increase in the hazard ratio for CVD death.
Orthostatic Postural Hypotension
- Take BP in supine (5 minutes)
- Then take BP standing ~1 minute
- And again BP standing ~3 minutes
*Postural hypotension is defined by - Decrease in systolic BP > or equal 15-20 mmHg OR
- Ex: 120/80 to 100/80
- Decrease in diastolic BP > or equal 10 mmHg OR
- Lightheadedness/dizziness
- 20 point increase in HR
With patients with a history of Orthostatic hypertension or other cardio disorders or immobilization take BP in sitting
Core Vital Signs: Priority
- MOST new patients at evaluation especially if they have warning signs
- Reassess on a regular basis if abnormal values are found
Vascular Assessment
- Pulses
- Edema
- Pulse Oximetry: Assess for oxygen saturation
- Auscultation of Carotid Artery: Assess for Bruitis
- Assessment for DVT
- Perfusion/Dehydration
- Ankle Brachial Index
Capillary nail refill test
Press on nail top and bottom, release, look for refill
Rubor Dependency Test
When legs elevated, legs become pale, means no or reduced blood supply to lower leg
Skin Turgor
Pull back of hand, looking for dehydration
Pulse Oximetry: Oxygen Saturation
Oxygen Saturation: The % of hemoglobin (Hb) saturated with O2
Normal: 97-99%
Cardiovascular/Pulmonary Disease: 90-95%
90% and below: Hypoxemia may require supplemental oxygen
Oxygen Saturation can also be assessed by arterial blood gas (ABG) analysis
Auscultation of Carotid Artery
Assess for bruit: often, but not always, a sign of arterial narrowing which is a risk factor for stroke
Place the BELL of the stethoscope over each carotid artery. You may use the diaphram if the patient’s neck is highly contoured.
Ask the patient to stop breathing momentarily
Listen for a blowing or rushing sound. Do not be alerted by heart sounds or murmurs transmitted from the chest.
Assessment for DVT
Can occur in UE or LE
Especially concerned for patients who:
Have been inactive or bedridden for periods of time
Has undergone recent surgery
Use Wells’ CDR for DVT
If high probability, refer immediately for diagnostic US
Score is equal or less than 0: Low probability
Score 1-2: Moderate probability
Score equal or greater than 3: High probability
Ankle-Brachial Index (ABI)
Compares blood pressure measures taken from the arms and the legs
Identify the presence or severity of impaired arterial blood flow (ischemia) to extremities
Reduced blood flow can lead to peripheral arterial disease (PAD)
Risk factor for myocardial infarction (MI), stroke, or lower extremity wounds
Cardiac Assessment
Blood pressure
Pulses
Auscultation of heart sounds
Jugular vein distention (JVD)
EKG
Ausculation of Heart Sounds
Assess 4 positions with the bell of the stethescope
Heart Sounds [S1 & S2]
Normal “Lub and Dub”: S1 and S2
S1 (Lub) = closure of Mitral and tricuspid
S2 (Dub) = closure of Aortic and Pulomnic
Jugular Vein Distribution (JVD)
JVD is when the increase pressure of the superior vena cava causes the jugular vein to bulge, making it most visible on right side
Observe and measure the distance from pulsation to sternal angle with patient reclined 45 degrees
Abnormal if > 4 cm
Heart Failure (“pump failure”)
Pulmonary Assesssment
Respiration
Auscultation of Lung Sounds
Auscultation of Tracheal Sounds
Auscultation of Lung sounds
Normal: Normal quiet whishing of airflow
Bronchophoy: say 99
If you can clearly hear something than something is wrong
Abnormal sounds:
Crackles: Secretions in small or middle airways
Wheezes: High pitched whistle due to aie going through a narrowed or constricted airway
Decreased breath sounds can be due to:
Chronic Obstructive Pulmonary Disease (COPD)
Pneumothorax
Auscultations of Tracheal Sounds
Assess inferior to the Thyroid cartilage
Normal: Loud, harsh, turbulent sound heard over the sternal notch
Outpatient Setting, when prescribing exercise - Cardio
Assess risk and risk factors
Low risk
Men younger than 45, women younger than 55
Less than or equal to 1 Risk Factor and no symptoms
Moderate
Men older than 45, Women older than 55
2 or more RF
High
Known CV, pulmonary, metabolic disease or signs and symptoms of CV disease including:
Chest Pain
SOB with mild exertion
Syncope
Ankle Edema
Palpations
Cardiovascular Risk Factors
Family Hx of CVD
Smoking
Hypertension
Dyslipidemia
Fasting Glucose
Obesity
Sedentary
