Cardiovascular- The Exam: Pulse and Heart Rhythm Flashcards
What are some things you are checking when you take the history from the patient?
Reviewing presenting symptoms, note time of onset, progression, natre of symptoms, insight into medical condition, level of activity in increasing or abating symptoms.
Specific areas to check during subjective interview (think cardiac pt.)
- Chest pain, SOB
- Fatigue, weakness
- Palpitations- awareness of pt. of heart rhythm abnormalities
- dizziness, syncope
- edema- especially in dependent body parts, sudden weight gain
- risk factors
- Past medical history- along with medications
- social history- living sitation and support, education level, employment, life style
- quality of life issues- functional mobility, ADLs
- social habits, smoking diet, past/present level of activity
10- observation and inspection of skin color- cyanosis, pallor, diaphoresis
Examine pulse: What should you note?
rate and rhythm
Examine pulse: What factors influence it?
- force of contraction
- volume and viscosity of blood
- diameter and elasticity of vessels
- emotions
- exercise
- blood temperature
- hormones
Examine pulse: how long should you check pulse?
palpate 30 sec for normal pulse
palpate 1-2 min for irregular pulse
Examine pulse: Apical pulse or point of maximal impulse (PMI)
- pt. supine
- palpate 5th interspace, midclavicular vertical line (apex of the heart)
- may displaced upward by pregnancy or high diaphragm
- may be displaced laterally in CHF, cardiomyopathy, ischemic heart disease
Examine pulse: Carotid pulse
- pt. supinehead elevated (that’s what the book says)
- palpate carotid artery between SCM and trachea
- assess one side at a time to reduce risk of brachycardia due to stimulation of carotid sinus baroreceptors> produces a reflex drop in pulse rate or blood pressure
Examine pulse: Brachial pulse
- Palpate over brachial artery. medial aspect of antecubital fossa
- best in infants
Examine Pulse: femoral pulse
palpate over femoral artery in inguinal region
Examine pulse: Popliteal pulse
palpate over popliteal artery, behind the knee with the knee flexed slightly
Examine pulse: Pedial pulse
- palpate over dorsalis pedis artery, dorsal medial aspect of foot
- used to monitor lower extremity circulation
Normal HR
Adults and teenager: 60-100 , 40-60 in aerobically trained
Children: 60-140
Newborn: average 127, range 90-164
Tachycardia
> 100
- exercise commonly results in tachycardia
- compensatory tachycardia can be seen with volume loss (surgery, dehydration)
Brachycardia
<60
What is postural tachycardia syndrome?
sustained HR increase equal to or greater than 30bpm within 10 min of standing (40 in teens)
3 pulse abnormalities
- Irregular pulse- varied force and/or frequency, may be due to arrhythmias or myocarditis
- Weak thready pulse- may be due to low stroke volume, cardiogenic shock
3, Bounding full pulse- may be due to shortened ventricular systole and decreased peripheral pressure, aortic insufficiency
What position should pt. be in when auscultating heart sounds?
supine
Auscultation landmarks
1 Aortic Valve- locate the 2nd R intercostal space at sternal border
2 Pulmonic Valve- locate the 2nd L intercostal space at sternal border
3 Tricuspid Valve- locate 4th L intercostal space at the sternal border
4 Mitral Valve- locate the 5th L intercostal space at the midclavical area
Auscultation: What is the S1 (lub) sound?
normal closure of mitral valve and tricuspid valves; marks beginning of systole. decreased first degree heart block.
Auscultation: What is S2 (dub) sound?
normal closure of aortic and pulmonary valves; marks end of systole. Decreased in aortic stenosis
Auscultation: Murmers (extra sounds)
- Systolic- falls between S1 and S2. May indicate valvular disease (ex:mitral valve prolapse) or could be normal
- Diastolic- falls between S1 and S2. Usually indicates valvular disease
- Grades of heart murmurs- grade 1 (softest) to grade 6 (audible w/ stethoscope off chest)
- Thrill- abnormal tremor accompanying a vascular or cardiac murmur; felt on palpation
Auscultation: What is bruit?
adventitious sound or murmur (blowing sound) of arterial or venous origin; common in carotid or femoral arteries; indicative of atherosclerosis.
Auscultation: explain gallop rhythm
abnormal heart rhythm with 3 sounds in each cycle; resembles the gallop of a horse
- S3: associated with ventricular filling. occurs soon after S2, in older individuals may be indicative of CHF
- S4: associated with ventricular filling and atrial contraction. Occurs before S1, indicative of CAD, MI, aortic stenosis or chronic hypertension
Examine heart rhythm: electrocardiogram (ECG)
12 lead ECG provides info about rate, rhythm, conduction, areas of ischemia and infarct, hypertrophy, electrolyte imbalances, and systemic pathologies (COPD, cerebral T-waves, ect.)
Examine heart rhythm: components of normal cardiac cycle (normal sinus rhythm)
- P wave- atrial depolarization
- PR interval- time required for impulse to travel from atria through conduction system to Purkinje fibers
- QRS wave- ventricular depolarization
- ST segment- beginning of ventricular repolarization
- T wave- ventricular repolarization
- QT interval- time for electrical systole
Examine heart rhythm: calculate HR with ECG
number of intervals between QRS complexes in a 6 second strip and multiply by 10
use longest strip possible for irregular HR
Examine heart rhythm: the etiology of arrhythmias
ischemic conditions of myocardium, electrolyte imbalance, acidosis or alkalosis, hypoxemia, hypotension, emotional stress, drugs, alcohol, caffeine
Examine heart rhythm: where do ventricular arrythmias originate from and what do they significantly affect?
- originate from ectopic focus in the ventricles (outside normal conduction system)
- significant in adversely affecting cardiac output
Examine heart rhythm: premature ventricular contractions (PVCs)
- premature beat from ventricle
- occurs occassionally in majority of normal population
- on ECG: no P wave , a bizarre and wide QRS that s premature followed by long compensatory pause.
- Serious PVCs: >6 perminute, paired or in sequential runs, multifocal, very early PVC
Examine heart rhythm: ventricular tachycardia (VT)
- a run of 3 or more PVCs occurring sequentially
- very rapid hr 150-200
- may occur paroxysmally (abrupt onset)
- usually the result of an ischemic ventricle
- on ECG: wide bizarre QRS waves, no P waves. -Seriously compromised cardiac output
What is NSVT?
Non-sustained ventricular tachycardia
- 3 or more consecutive beats in duration
- terminating spontaneously in less than 30 sec.
What is sustained ventricular tachycardia?
-VT>30 sec in duration and/or requiring termination due to hemodynamic compromise in less than 30 sec.
What is VF?
Ventricular fibrillation
- a pulseless emergency situation requiring emergency medical treatment: CPR, defrillation, and meds
- characterized by chaotic activity of ventricle originating from multiple foci; unable to determine rate
- On ECG: bizzare erratic activity w/o QRS complexes.
- no effective cardiac output
- clinical death in 4-6 min
What is an atrial arrhythmia (supraventricular)?
rapid and repetitive firing of one or more ectopic foci in the atria (outside the sinus node)
What characterizes atrial arrhythmias?
- P waves are abnormal (variable in shape) or not identifiable (afib)
- rhythm may be irregular : chronic or occuring paroxysmally.
- Rate: rapid w/ atrial tachycardia (140-250); fribrillation (>300 bpm)
- cardiac output is usually maintained if rat is controlled; may precipitate ventricular failure in an abnormal heart
What are AV blocks?
- abnormal delays or failure to conduct through normal conducting system
- 1st, 2nd, 3rd (complete) degree AV blocks, bundle branch blocks
- if ventricular rate is slowed, cardiac output decreased
- 3rd degree block- complete heart block is life threatening; requires medications and pacemaker.
What is the importance of determining ST segment changes?
- With impaired coronary perfusion (ischemia or injury), the ST segment becomes depressed
- ST segment depression can be upsloping, horozontal, or downsloping.
- ST segment depression or elevation greater than 1 mm measured at the J point in 2 consecutive leads is considered abnormal, except in leads V2-V3
What changes will you see in ECG with an acute MI?
acute ST elevations present in leads over the infarcted area
How do potassium levels affect ECG changes?
Hyperkalemia- widens QRS, flattens P wave, T wave becomes peaked
Hypokalemia- flattened T waves , produces U wave
How do calcium levels affect ECG changes?
Hypercalcemia- widens QRS, shortens QT interval
Hypocalcemia- prolongs QT interval
How does hypothermia affect ECG changes?
elevates ST segment
How do digitalis, quinidine, beta blockers, nitrates, and antiarrhythmic medications affect ECG
Digitalis- depresses ST segment, flattens or inverts T wave, QT shortens
Quinidine- QT lengthens, T wave flattens or inverts, QRS lengthens
Beta blockers- decreases HR, blunts HR response to exercise
Nitrates- increases HR
Anti-arrhythmics- prolong QRS and QT intervals
What is Holter monitoring?
- continuous ambulatory ECG monitoring via tape recording of cardiac rhythm for up to 24 hours
- evaluates: cardiac rhythm, transient symptoms, pace maker function, and effect of medications.
