Lesson 2 - Cardiac assessment Flashcards
CHEST PAIN
Location:
- is the pain in a specific area or is it diffuse
- are there areas of radiation
Severity:
- using a 1-10 pain scale is common practice
Description:
- tightness, squeezing, constriction, heaviness, pressure,
burning, indigestion
- is the pain sharp or dull
- some patients use images such as: chest in a vise, elephant on the
chest, ton of bricks on the chest
Provoking and Alleviating Factors: - what makes the pain worse or better - are there predictable or reproducible factors Type of Onset: - gradual or sudden onset
Occurrence and Duration:
- what was the activity at time of onset
- length of pain (minutes, hours)
- is the pain constant or intermittent
Angina - Common Description
squeezing aching
pressure
heaviness
Angina - Location
substernal, may radiate to both arms, jaw, neck, or back
Angina - Worsening Factors
physical effort
emotions smoking
hot or cold weather
eating
Angina - Alleviating Factors
rest
oxygen
nitroglycerine
Acute MI - Common Description
squeezing
heaviness tightness pressure
burning
Acute MI - Location
substernal, may radiate to both arms, jaw, neck, or back
Acute MI - Worsening Factors
physical effort
emotions smoking
hot or cold weather
eating
Acute MI - Alleviating Factors
oxygen
opioids
(such as Morphine)
Acute Pericarditis - Common Description
sharp and continuous, with a sudden onset
Acute Pericarditis - Location
substernal, may radiate to neck and left arm
Acute Pericarditis - Worsening Factors
lying down
deep breathing
Acute Pericarditis - Alleviating Factors
sitting up
leaning forward
anti-inflammatory
drugs
Dissecting Aortic Aneurysm - Common Description
sudden onset of excruciating and tearing pain
Dissecting Aortic Aneurysm - Location
retrosternal, epigastric or upper abdomen may radiate to back, neck,
shoulders
Dissecting Aortic Aneurysm - Worsening Factors
N/A
Dissecting Aortic Aneurysm - Alleviating Factors
surgery
analgesics
Pulmonary Embolism - Common Description
sudden onset of stabbing pain
Pulmonary Embolism - Location
over the affected lung area
Pulmonary Embolism - Worsening Factors
inspiration
Pulmonary Embolism - Alleviating Factors
analgesics
anticoagulants
Pneumothorax - Common description
sudden onset of severe and sharp pain
Pneumothorax - Location
lateral thorax
Pneumothorax - Worsening Factors
normal breathing
Pneumothorax - Alleviating Factors
analgesics
chest tube
Chest-wall syndrome - Common Description
gradual or sudden onset of sharp pain, often tender to touch
Chest-wall syndrome - Location
anywhere in the chest
Chest-wall syndrome - Wosening Factors
movement, palpation
Chest-wall syndrome - Alleviating Factors
analgesics
heat
time
Acute Anxiety - Common description
sudden onset of dull or stabbing pain
Acute Anxiety - Location
anywhere in the chest
Acute Anxiety - Worsening Factors
stress, increased respiratory rate
Acute Anxiety - Alleviating Factors
stress relief, slowing of respirations,
deep breathing
Other conditions that can also cause chest pain
esophageal spasm, hiatus hernia, cholecystitis, peptic ulcer, endocarditis, myocarditis, chest trauma
PALPITATIONS
- palpitations are an awareness or sense of feeling one’s own heartbeat
- they are usually felt over the precordium or in the throat
- might be described as
- heart skipping beats
- fluttering or flopping
- pounding or thumping
- they can be of short duration or they may be sustained
- the heart rate can be regular or irregular, fast or slow
- palpitations are quite common and might be insignificant
- they are often caused by stimulants (caffeine, alcohol, nicotine, bronchodilators,
nasal decongestants) - palpitations can be a symptom of an arrhythmia
- the presenting clinical picture determines the urgency of treatment
SYNCOPE
- a transient brief loss of consciousness due to cerebral anoxia
- often referred to by patient as “fainting spell”
- usually of short duration
- not all patients are fully unconscious during syncopal episodes
- some might feel “far away”, still hear sounds, still see blurred images of their
surroundings - accompanying phenomena can include pallor, nausea, diaphoresis, slow and
shallow respirations, slow and weak peripheral pulses, hypotension - syncope is often caused by vasodilatation, or overactivity of the
parasympathetic nervous system (PSNS) which results in a slow HR (heart
rate). This is often called a vasovagal attack - remember…HR x SV = CO
- so, ↓HR x SV = ↓CO
- if the HR is slow, less blood is being ejected by the LV
- the CO drops, so less oxygenated blood reaches the body,
including the brain - so, cerebral symptoms occur, such as syncope
- precipitating factors, associated phenomena, duration, medication history, and
past history can help determine the cause for syncopal episodes
PERIPHERAL EDEMA
- this is an abnormal accumulation of fluid in interstitial tissues, in the periphery
- can be a manifestation of right ventricular failure (explored further in Lesson 5)
- fluid collects in dependent areas, so the fluid distribution is determined by
gravity and ambulation - ambulatory patients experience edema in the legs and feet
- bedridden patients develop edema over the sacrum
- greater degrees of edema can extend to the abdomen (ascites), the torso and
the face (anasarca) - edema of the arm is most likely due to superior vena cava syndrome or
thrombophlebitis - edema that develops in one leg only is likely due to thrombophlebitis or
venous insufficiency
OTHER SIGNS & SYMPTOMS
- often, cardiac patients have other phenomena associated with chest pain
- these can include a combination of several complaints, signs and symptoms
- some common associated phenomena are:
- dyspnea (with activity or at rest)
- cough
- decreased breath sounds
- diaphoresis
- changes in skin color (ie: pallor, cyanosis, ashen, grey, waxy tone)
- weakness, fatigue
- dizziness, headache
- anxiety, sense of impending doom
- nausea, vomiting
Inspection
- examine the chest for:
- symmetry of respiratory movement
- the presence of intercostal retractions
- heaves (strong outward thrusts of the chest wall)
- pulsations
- the PMI (point of maximum impulse) is located at the left 5th intercostal space,
medial to the mid-clavicular line - at the PMI, you may see the apical pulse (especially in those with thin chest
walls) - the pulsation is difficult to see in the obese or those with hyper-inflated chests
(ie. emphysema) - the PMI can be displaced by lung or rib cage abnormalities (ie. pneumothorax,
thoracic scoliosis)
Palpation
- ensure a gentle touch so as not to conceal or mask any findings
- palpate the apical pulse over the PMI
- if present, note its location, rate, strength, and regularity of rhythm
- palpate for heaves (localized forward chest thrusts)
- these can indicate a hypertrophied L ventricle
- palpate for thrills
- vibrations that feel like the throat of a purring cat
- thrills are abnormalities that may indicate a heart murmur
- murmurs can be the result from various conditions
- commonly, a murmur results from turbulent blood flow across a valve
Auscultation
- general auscultation tips include:
- ensure the patient’s chest is bare of clothing
- ensure the stethoscope is in full contact with the chest and its tubing is not
touching any surfaces - you may choose to close your eyes, to improve your concentration
- when listening for a specific sound, concentrate on that sound only (ie. when
listening for S1, try to ignore S2) - to not miss any auscultatory areas, use a systematic approach that will remain
the same for each patient assessment - the stethoscope’s diaphragm is used to hear high pitched sounds (S1 and S2)
- the bell of the stethoscope best detects low frequencies (S3, S4, murmurs)
- remember…the bottom of the heart is the apex, the top of the heart is the base
HEART SOUNDS
- normal heart sounds (LUB and DUB) are produced by closure of valves
- sounds can be heard across the precordium, but there are 4 areas to auscultate
to best hear the 4 valves:
1) aortic valve
- 2nd right ICS (intercostal space)
2) pulmonic valve
- 2nd left ICS
3) tricuspid valve
- lower left sternal border
4) mitral valve
- 5th left ICS, just medial to the midclavicular line
- this is the PMI, and the apical heart rate is best heard here
Normal Heart Sounds
There are 2 normal heart sounds (S1 and S2)
S1
- this is the first normal heart sound (LUB)
- it is associated with closure of the mitral & tricuspid valves
- the sound relates to the valves snapping back after atrial contraction
- S1 corresponds with the end of ventricular diastole and the onset of ventricular
systole - it is heard over all areas of the precordium, but it is heard loudest at the heart’s
apex (over the mitral area) because it corresponds to closure of the mitral valve
S2
- this is the second normal heart sound (DUB)
- the sound is produced by closure of the aortic and pulmonic valves (these
valves close at the end of ventricular systole) - S2 indicates the end of ventricular systole
- as such, it corresponds with the onset of ventricular diastole
- the sound can be heard over all areas of the precordium, but it is heard loudest
at the base of the heart (over the aortic area) because it corresponds to closure
of the aortic valve
Abnormal (adventitious) Heart Sounds
- these are vibration-like sounds that occur within the ventricles
- the sounds are called S3 and S4
- only S3 or S4 may be heard, or they may both be present and audible
- the sounds are created by gushes of blood entering stiffened or resistant
ventricles - the sounds are not produced by valve closure
- blood enters the ventricles on two occasions:
1. during atrial diastole (80% blood volume passively flows into ventricles)
2. during atrial systole (remaining 20% of blood is ejected into ventricles)
S3
- this sound is also called a ventricular gallop
- it is caused by ventricular filling, during atrial diastole, in the congested heart
(ie. heart failure, pulmonary edema) - because of the congestion in the ventricles, the ventricles have difficulty
accommodating the initial 80% blood volume from the atria - the sound occurs during ventricular diastole/filling/relaxation, quickly after S2
S4
- this sound is also referred to as an atrial gallop
- it occurs during atrial contraction, as the remaining 20% of blood is being
propelled into the ventricles - it is heard with increased resistance to ventricular filling when the ventricles
cannot accommodate the last 20% volume of blood from the atria - S4 is commonly heard after MI, because the ventricular damage leads to altered
ventricular expansion and compliance - S4 is heard prior to S1
Other abnormal sounds that may be heard during a cardiac assessment
- murmur: caused by turbulent blood flow across a narrowed valve
- bruit: heard over an artery, usually caused by narrowing of the artery
- friction rub: grating leathery sound heard loudest at the left sternal border, that
usually indicates pericarditis
JUGULAR VENOUS PRESSURE (JVP) ASSESSMENT
- the venous system delivers ‘used-up’ unoxygenated blood from the body back
to the heart - the first chamber to receive this blood is the RA (R atrium)
- the internal jugular vein leads into the RA
- the pulsation level of the internal jugular vein is used to assess and determine
the JVP - pulsations in the jugular veins change in response to positioning and breathing
- normally, this vein is only visible with the patient laying flat, and not seen when
sitting or standing - pulsations in the internal jugular vein will vary with changes in position
- this is unlike the carotid artery, which does not change pulsation with movement
or breathing
To observe the JVP
- assess the patient with his head elevated 30 to 45 degrees
- ensure adequate lighting to visualize the pulsating
- locate the suprasternal notch (indentation just above the manubrium)
- turn the patient’s head slightly, away from the side being examined
- normally, pulsations are not visualized higher than 4-5cm above the
suprasternal notch - higher levels of pulsating are referred to as elevated JVP, and indicate
distension of the venous system - we are assessing the pressure in the internal jugular vein, and because this
vein leads into the RA, elevated JVP usually indicates high right-sided cardiac
pressures - in other words, venous blood is ‘struggling’ to empty into the RA, usually
because of congestion in the RA, and as such, we can detect pulsating in the
jugular vein - elevated JVP is most commonly visualized with R sided heart failure,
R sided MI, and cor pulmonale
ASSESSMENT of ARTERIAL PULSES
- apply gentle pressure to prevent obscuring the pulse
- ensure a systematic approach (ie. starting at the top of the body and working
downward) - compare both sides of the body for rate, rhythm, strength and character
Rate:
- irregular rates should be counted over a full minute
- normal adult rates are 60-100 beats/minute (the intrinsic rate of the SA node)
- always compare R side to L side
Rhythm:
- pulses should be regular, or very slightly irregular
- occasional irregularities may indicate arrhythmias
- patients in ‘atrial fibrillation’ always have an irregular rhythm (this arrhythmia will
be explored later in the course)
Strength:
- strength is graded according to a universal scale:
- 4+ is a bounding pulse
- 3+ refers to a pulse with increased strength
- 2+ is normal
- 1+ reflects a weak pulse
- 0 indicates the absence of a pulse
Character:
- can help with a diagnosis
- examples of character might include:
- absent pulse:
- can indicate aortic dissection, atherosclerosis
- pulsus alternans
- alternating high and low volume beats
- can indicate L sided heart failure
- pulsus paradoxus:
- reduction of pulse pressure on inspiration
- common in cardiac tamponade
Never …….
NEVER palpate both carotid arteries at once!
NEVER apply firm pressure on the carotid arteries. This can lead to a sudden and severe drop in the patient’s heart rate and syncope
Lesson Summary:
Chest pain can be a symptom of numerous conditions. Understanding its cause is useful in caring for the cardiac patient.
Palpitations are an awareness of one’s heartbeats. These beats may have a slow rate, a fast rate, be regular or irregular, short-lived or sustained.
Syncope refers to a temporary loss of consciousness, resulting from cerebral anoxia.
Peripheral edema is an abnormal accumulation of fluid within the tissues, and may be a sign of cardiac disease.
Closure of the mitral and tricuspid valves produces the first heart sound (LUB)
Closure of the aortic and pulmonic valves produces the second sound (DUB)
Abnormal heart sounds are not created by valve closure. They are sounds that are created within the ventricles.
The internal jugular vein is used to assess JVP. The patient is lying at a 30-45 degree angle when JVP is being assessed.
Elevated JVP is common in patients with R sided heart failure, R sided MI, and cor pulmonale
When assessing arterial pulses, both sides must be compared for rate, rhythm, strength, and character.
Concurrent assessment of the carotid arteries often leads to syncope and even loss of consciousness.
Arterial pulses
Carotid Brachial Radial Femoral Popliteal Dorsalis Pedis Posterior Tibial
