Cardiovascular Assessment PPT - E1

Subjective Assessment + History

pain, dyspnea, cough, fatigue, edema, color, cardiac Hx, family Hx, risk factors

Using OLDCART for chest pain

Onset?

Location? → can you point to it, does it radiate?

Duration? → constant? intermittent?

Characteristics? → how does it feel?

Associated symptoms?

Relief? → what makes it better/worse? rest? movement? breathing? lying flat?

Treatment? → what treatment have you had?

Using OLDCART for dyspnea

“Do you get short of breath?”

Onset?

Location → does it originate in your throat or chest?

Duration? → constant? any particular time of day? awakens you from sleep?

Characteristics? mucus, urge to cough?

Associated manifestations? → wheezing, chest pain, nausea?

Relief? → is it related to position?

*Orthopnea: how many pillows do you sleep with at night?

Treatment?

Using OLDCART for cough

“Do you have a cough?”

Onset?

Location?

Duration? → frequency?

Characteristics? → type: productive/nonproductive

Associated manifestations?

Relief? → what makes it better/worse?

Treatment

Using OLDCART for edema

“Any swelling in feet or legs?”

Onset?

Location?

Duration? → recent changes, time of day, do your shoes feel tight at the end of the day?

Characteristics? → how much swelling?

Associated symptoms?

Relief? → is there decreased swelling in a.m.?

Treatment?

Asking about fatigue

Do you tire easily?

Onset?

Related to time of day?

Asking about cyanosis/pallor

Have you noticed OR has anyone ever told you that your face has turned blue/gray?

Asking about cardiac Hx

Look for: HTN, high cholesterol, murmurs, congenital heart disease, rheumatic fever

Heart disease: treatments?

Heart tests? ECG, cholesterol, echo…

Asking about family Hx

“Does anyone of your family have/have a history of?”… Hypertension, Obesity, Diabetes, Coronary Artery Disease, sudden death under age 40

Asking about personal risk factors

Nutrition: high fat, sodium, weight

Smoking: PPD, how long, cigarettes or other, have you ever quit?

Alcohol: how many drinks per day/week? how many drinks per episode? ever been told you have a drinking problem?

Exercise

Drugs: prescriptions (antihypertensives, digoxin, ASA, OTC, street drugs)

Asking about Peripheral Vascular: Leg Pain or Cramps

-Type of pain

-What causes the pain?

-Has the amount of pain changed recently?

-Does the pain wake you up at night?

Using OLDCART for swelling in arms / legs

Onset? → when did it start?

Location? → where is it?

Duration? → time of day? constant or intermittent?

Characteristics? → what brings it on?

Associated manifestations? → pain, heat, redness, ulceration, hardened skin?

Relief? → what relieves the swelling?

Treatment? → what helps? how is it being treated?

Asking about skin changes on arms / legs

-What color change is present? → red, blue, brown, pallor

-Temperature

-Veins

-Leg sores or ulcers

Changes in older adults

-Gradual BP rise → arteriosclerosiis

-Palpate carotid cautiously

-A-P diameter may increase w/ aging, making AP more difficult to palpate

-LVH (enlarges)

-Dysrhythmias

-Orthostatic hypotension

Physical EXAM: Observe, Palpate, & Auscultate the Carotid Arteries

Palpate one side at a time! DO NOT COMPROMISE BLOOD FLOW

-feels smooth w/ rapid upstroke and slower down stroke

-Normal = 2+ (moderate)

-Auscultate the carotid → as pt. to hold breath while you listen so you don’t mistake a breath for a bruit

use the BELL of the stethoscope

Carotid artery bruits

ABNORMAL blood flow sounds with a narrowed/blocked artery

Hearing carotid artery bruits

Audible at occluded of approx. 30-50%

Loudness increases until occlusion is 60-70%, then it decreases

Bruit disappears w/ 100% occlusion

occlusion = blockage

EXAM: Inspect for Jugular Vein Distention (JVD)

Jugular venous pressure - significant distention indicates CHF

*assess JVD w/ head elevated 45 degrees

EXAM: Inspect Anterior Chest

Observe for pulsations → you may or may not see apical pulse (AP)

*heave indicates ventricular hypertrophy + increased workload

EXAM: Palpation

palpate the apical pulse - PMI (Point of Max. Impulse)

-locate using 1 finger pad

location: usually 4th or 5th interspace, abt. midclavicular line

should occupy only 1 intercostal space

SIZE: 1x2 cm

AMPLITUDE: short, gentle tap

DURATION: short, first ½ of systole

EXAM: Palpate Across Precordium

-use the palm of hand

-should NOT feel a thrill (vibration)

EXAM: Auscultation

Listen as you inch along the 5 areas

1) Aortic valve

2) Pulmonic valve

3) Erb’s point (2nd pulmonic area)

4). Tricuspid valve

5) Mitral valve

5 areas of exam auscultation

1) Aortic valve → 2nd R intercostal space

2) Pulmonic valve → 2nd L intercostal space

3) Erb’s Point (2nd pulmonic area) → 3rd L intercostal space

4) Tricuspid valve → 4th L intercostal space

5) Mitral valve → 5th intercostal space (midclavicular line) (APEX)

When auscultating the aortic valve, where are we listening

2nd R intercostal space

When auscultating the pulmonic valve, where are we listening

2nd L intercostal space

When auscultating the Erb’s point (second pulmonic are), where are we listening

3rd L intercostal space

When listening to the tricuspid valve, where are we listening

4th L intercostal space

When listening to the mitral valve, where are we listening

5th L intercostal space, midclavicular line, APEX (bottom of heart)

Auscultation Examination Visual

“All Physicians Enjoy Taking Money”

Details for doing an Auscultation Examination

-Note the rate and rhythm

-Listen for 1 sound at a time

-ID S1 + S2 (lub dub) → S1 coincides w/ carotid artery pulse

-Assess S1 + S2 separately

-Listen for extra heart sounds, murmurs, etc.

S1 Heart Sound

-beginning of systole / AV valves close (tricuspid + mitral)

Loudest at the APEX (bottom tip of heart)

S2 Heart Sound

-end of systole (diastole) / SL valves close (pul. + aortic)

Loudest at the BASE

S3 Heart Sound

Ventricular filling causes vibrations during diastole in early filling due to increased pressure in atria.

Present in CHF

“KEN” “TUCK” “Y”

S4 Heart Sound

Occurs at the end of diastole — ventricles resistant filling.

Common after MI

Murmurs

-caused by turbulent blood flow

-gentle blowing, swooshing sound heart on chest wall

-structural defects in the valves or unusual openings occur in chambers

*listen w/ bell of stethoscope

things that cause increased blood velocity where you may hear a heart murmur

exercise, thyrotoxicosis

things that cause decreased blood viscosity where you may hear a heart murmur

Anemia

Structural defects in valves where you may hear a murmur

Structural defects: narrowed valve, incompetent valve

Heart Sounds in Older Adults

-S4 common even w/ no disease

-50% systolic murmur

-Premature ectopic beats common

Premature ectopic beats

extra or early heartbeats that happen when a cell outside the heart's normal pacemaker triggers an early electrical signal

*common in older adults

EXAM: Inspect & Palpate Arms

Capillary refill: < 3 secs

Hands should be pink, warm

Palpate radial pulses bilaterally

Allen test if indicated

Pulse amplitude 0-3

EXAM: Inspect & Palpate Legs

-compare leg size, symmetry

-warm, pink

-capillary refill < 3

-edema 1+ to 4+ scale for pitting

-varicosities

depression of a 1+ edema scale

2mm

depression of a 2+ edema scale

4mm

depression of a 3+ edema scale

6mm

depression of a 4+ edema scale

8mm

EXAM: Palpate pulses of lower extremities

-Dorsalis Pedis

-Post tibial

-Popliteal

-Femoral

*use of pulse amplitude

Pulse Amplitude

3+ → bounding

2+ → brisk, expected (NORMAL)

1+ → diminished, weak or intermittent

0 → absent, unable to palpate

The “Missing” pulse

doppler pulse will sound like a “swish” rather than a beat or lub-dub

Venous stasis ulcer

a type of chronic wound that occurs due to insufficient blood flow of external veins

Arterial insufficiency

a condition where there is inadequate blood flow to the arteries, often leading to tissue damage or ulcers.

Varicose veins image

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Deep Vein Thrombosis (DVT) image

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CHF ppt. summarization slide

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Common Signs/Symptoms of HF (view img)

SOB, swelling of feet / legs, chronic lack of energy, difficult sleeping at night due to breathing issues, swollen or tender abdomen w/ loss of appetite, cough w/ frothy sputum, increased urination at night, confusion and/or impaired memory

Modifiable risk factors of Hypertension (HTN)

obesity, physical activity, smoking, excess dietary Na+, insufficient intake of K+, excess alcohol consumption

Hypertension (HTN) Non-modifiable factors

age

family Hx of HTN and/or CVD

Modifiable risk factors of Coronary Heart Disease (CHD)

DM, systolic/diastolic HTN, smoking, obesity, physical inactivity

Non-modifiable factors of Coronary Heart Disease

increasing age

Hx of cardiovascular disease

family Hx of early HD

Risk factors used to assess the 10 yr coronary heart disease (CHD) risk score

age

gender

height, weight, waist circumference (of BMI)

smoking

Hx of CVD or DM

Systolic / Diastolic BP

Total cholesterol, LDL, and HDL cholesterol

Triglycerides

Family Hx of early HD

Unusual chamber openings where you may hear a murmur

Unusual openings: dilated chamber, wall defect