Cardiovascular Assessment 46, Venous 58,

what history does the nurse need for cardiac?

• Chest pain 

• Dyspnea, effects of dyspnea on lifestyle

• Orthopnea 

  • Shortness of breath, so severe that the  person MUST sit up

• Paroxysmal Nocturnal Dyspnea (PND) r/t heart failure 

  • Shortness of breath after being recumbent awhile OR

  • Compensating by sleeping on several pillows or in a recliner

• Fatigue with activity

• Edema (fluid retention)

• Blood lipid/cholesterol levels & results

what is Paroxysmal Nocturnal Dyspnea (PND)?

a sudden, severe feeling of shortness of breath that wakes a person from sleep, usually one to two hours after lying down

what does history of cardiac palpitations mention?

• The heart feels like it skips beats or there are extra beats or a fluttering sensation in the chest

what does EKG history mention?

• Diagnosed with an abnormal heart rate or rhythm

• Pacemaker

• Cardioverter Defibrillator

what does high blood pressure history mention?

Medications used for treatment, side effects of medications, & compliance

what does history of coronary artery disease?

• Angina (chest pain with activity)

• Heart Attack (Myocardial Infarction, MI)

• Cardiac procedure (angioplasty, stenting) or surgery (bypass)

• Heart failure (CHF)

• Family history of heart disease prior to age 50, sudden death, diabetes, high blood pressure (hypertension, HTN), & high cholesterol

What other cardiac history does nurses need to know?

Heart murmur or rheumatic fever or heart valve problems or replacement

• Antibiotic prophylaxis for invasive procedures with certain valvular problems

• Diabetes, Heart Disease, & Stroke

What are some cardiac health hazards?

• Smoking, cocaine, diet high in saturated fats, sedentary lifestyle, diabetes

how to auscalate for carotid arteries?

• Auscultate for a Carotid Bruit (pronounced brew wee) with the bell of the stethoscope

  • Ask the patient to hold their breath

what are jugular veins facts?

• Remove the pillow(s) if the neck is flexed

• The external jugular veins are flat with the head of the bed elevated 30-45 degrees

• Pulsations are visible above the clavicle & have 2 waves

what are jugular vein distention JVD facts?

• Veins may bulge to the angle of the jaw

• State the number of cm above the clavicle

• Caused by fluid overload or heart (pump) failure

how to locate point of maximum impulse (PMI)?

• May NOT be visible or palpable with the finger pads depending on body build

• Located in the 5^th left intercostal space (LICS) at the midclavicular line (MCL)

  • Normal size is < a “quarter”

• Located in the 4^th LICS  left  of the MCL up to age 7

• Downward or lateral displacement indicates cardiac enlargement (cardiomegaly)

what is an abnormal palpitation of precordium?

• Lifts or Heaves – Abnormal

what are thrills?

• Associated with a heart murmur

• Palpate with the palm or ulnar (pinkie) side of the fist

• Vibrations that feel like a purring cat’s neck

what position is cardiac auscultation done?

• 45^o supine

• Sitting, leaning forward or left lateral decubitus

  • May facilitate hearing murmurs or distant (soft) heart sounds

are heart valves directly under auscultation sites?

• Heart valves are NOT directly under the auscultation sites

what is AoRtic auscultation?

• 2^nd right intercostal space (RICS) at the sternal border

what is a PuLmonic auscultation?

• 2^nd left intercostal space (LICS) at the sternal border

what is Erb’s Point auscultation?

• 3^rd LICS at the sternal border

what is an epigastric auscultation?

• Just below the Xiphoid process at the midsternal line (MSL) to auscultate for an Aortic Bruit

what is the tricuspid auscultation?

• 4^th or 5^th LICS at the sternal border

what is mitral (apical) auscultation?

• 5^th LICS at the midclavicular line (MCL)

what is the normal heart rate?

• 60-100 beats/minute, Regular Rhythm

what is irregular rhythm?

Premature beats cause occasional irregularity

what is atrial fibrillation?

upper chambers beat chaotically and out of sync in lower chambers

what is the S1?

• Closure of Mitral & Tricuspid (atrioventricular) valves

• Occurs simultaneously with the pulse

• Louder at the Mitral (apex) & Tricuspid areas

  • S₁ is louder than (>) S₂ 

• Occurs with the onset of systole

• NOT normally split

what is S2?

• Closure of the Aortic & Pulmonic (semilunar) valves

• Does NOT occur simultaneously with the pulse

• Louder at the Aortic & Pulmonic areas

  • S₂ is louder than (>) S₁ 

• Occurs with the onset of diastole

• Physiologic splitting (2 sounds close together) may occur during inspiration

what is distant heart sounds?

• Soft & hard to hear

• r/t obesity, emphysema or decreased cardiac output

what is S3 heart sound?

• NORMAL in children

• Indicates left ventricular failure or fluid overload in adults

• Low pitched 

  • Best heard with the bell in the mitral or tricuspid areas

• Early diastolic sound

• Mnemonic: Kentucky

• LUB -duppa

what is S4 heart sound?

• Low pitched 

• Best heard with bell in mitral or tricuspid areas

• Late diastolic sound just before S₁

• Mnemonic: Tennessee

• daLUB-dup

what is summation gallop?

• S₃ & S₄ plus a rapid heart rate

• Summation Gallop Sound

what is the cause of murmurs?

• Turbulent blood flow r/t:

what is stenotic (narrowed) valve?

• Think of a garden hose with a narrow spray

what is incompetent or regurgitant valve?

• Does NOT close completely & leaks

what is abnormal passageway?

• Patent Ductus Arteriosus 

• Ventricular Septal Defect (hole between the ventricles) 

• in which there is a mix between aorta and left pulmonary

what is dilated chamber?

• Aortic Aneurysm (a bulge in the blood vessel)

  • Bruit (pronounced brew wee) 

what increase the flow?

pregnancy

anemia

what are the best heart auscultation sites for a murmur?

what is a systolic murmur?

• Between S₁ & S₂

• Equal / same

what is a Pan or Holosystolic Murmur?

• Heard during the entire systolic or diastolic period

• May obscure S₁ or S₂

• _longer

what is a diastolic murmur?

• Between S₂ & S₁

what to mention for quality?

• Blowing

• Harsh

• Machinery-Like (Patent Ductus Arteriosus)

• Rumbling

• Musical

• Vibratory

what is the Grade (Scale of 1/6 or I/VI ?

• 1/6 - Very soft.  May be missed

• 2/6 - Soft but heard with concentration

• 3/6 - Easily heard but NO thrill

• 4/6 - Easily heard, thrill present

• 5/6 - Heard with the stethoscope partially off the chest, thrill present

• 6/6 - Heard with the stethoscope completely off the chest, thrill present

what is Crescendo/Decrescendo Murmur?

• Know definitions & images

• Crescendo Murmur-Increases in intensity

• Decrescendo Murmur-Decreases in intensity

• Crescendo/Decrescendo Murmur

  •  Diamond shaped

what are Nursing Diagnoses r/t Cardiac Assessment?

• Decreased cardiac output

• Risk for decreased cardiac output

• Excess fluid volume 

what are symptoms in which require immediate response?

• Chest Pain, Dyspnea, or Central Cyanosis

  • Call a Rapid Response or Code Chest for chest pain

  • Do NOT call the provider first

What is the history risk factors for venous problems?

• Prolonged standing

• Aching legs, especially at the end of day

• Heredity (Family history)

• Previous deep vein thrombosis (DVT, venous thromboembolism (VTE, blood clot) or pulmonary embolism (clot that travels to the lung & blocks pulmonary circulation)

  • Oral contraceptives & smoking (DVT risk)

• Previous venous procedure or surgery for a venous problem

what are self-care activities for venous problems?

• Elevating the legs

• Walking

• Wearing support hose 

what is edema?

• Swelling r/t fluid in the interstitial spaces r/t increased venous pressure

• Pitting vs. non-pitting

• Indentation remains with pitting edema

• Generalized vs. dependent edema in body parts that are lower

what is unilateral edema?

• Unilateral leg edema, redness, warmth, & discomfort 

  • Possible deep vein thrombosis (deep clot - DVT) also referred to as a venous thromboembolism (VTE)

  • Measure the thigh & calf circumferences

what lymphedema?

• Swelling, including the foot r/t impaired drainage of lymphatic fluid 

how would you describe edema?

• 0-4+ scales are NOT standardized 

  • Use your agency’s scale

how would you describe edema?

• 0-4+ scales are NOT standardized 

  • Use your agency’s scale

what is Brownish Discoloration of the Shins?

• r/t ↑ venous pressure causing RBCs to leak into the tissues

what are varicose veins?

enlarged, swollen, and twisted blood vessels that usually bulge just under the skin of the legs and feet

what does ankle ulcers look like?

• Moist & weepy

what is Venous Stasis Dermatitis?

• Edema, pruritus (itching), dryness, scaliness, brownish discoloration, & ankle ulcers

what is the Nursing Diagnoses r/t the Venous System?

risk for thrombosis

what is intermittent claudication?

• Leg pain that occurs when walking r/t ischemia (insufficient blood flow (oxygen).

what to look out for in lower extremities of intermittent claudication?

• Thin shiny skin

• Absence of hair

• Muscle atrophy

• Paresthesias

  • Numbness, tingling, or burning sensations

what is elevated pallor?

paleness of the skin or soles of the feet when lifted above the heart

what is dependent rubor?

a light red or dusky-red discoloration of the foot or lower leg that appears when the limb hangs down in a dependent position, but fades to a normal color or paleness when the leg is elevated

describe Pallor r/t Raynaud’s Vasoconstriction?

describe Rubor r/t Raynaud’s Vasodilation?

describe Punched Out Toe Ulcer r/t Ischemia?

what is mottling?

• Splotchy discoloration r/t impaired arterial circulation

what happens prior arterial surgery?

• Arterial Bypass

  • Surgery that bypasses the blocked area in an artery

• Amputation

what are self-care activities for peripheral arterial?

• Foot inspection

• Well fitting shoes

• Protect the feet from injury

• Podiatrist should trim thick nails 

what to inspect and palpate of extremities?

• Skin, Hair, & Temperature

• capillary refill - Press on the nail bed for 5 seconds

  • Color should return in < 2 seconds

how to do temporal pulse?

• Located in the hollow spot in front of the ear

how to do carotid pulse?

• Located in the groove next to the trachea

• Palpate 1 side at a time to prevent decreased blood flow to the brain

Why would you palpate both radial pulses?

to check for symmetry and compare the strength of blood flow in both arm

what is the femoral pulse?

• Located in the crease in the groin

• Decreased or absent in coarctation (narrowed area) of the aorta

• Check babies & children, especially if the BP is elevated 

what is the popliteal pulse?

• Deep in the popliteal space & slightly lateral to the medial tendon

what is the posterior tibial pulse?

• Medial (inner) ankle behind the medial malleolus 

what is dorsalis pedis (pedal) pulse?

• On top of the foot on a line between the big toe & second toe

• Absent in some normal individuals

what is the pulse grading scales?

what is the allen test?

• Tests radial/ulnar artery competence

  • Compress both arteries  

  • Have the patient open & close the hand until it blanches (gets pale)

  • Release 1 artery

• Normal

  • Immediate return of color upon release of arterial compression

• Repeat & release the other artery

what is the ankle brachial index?

• Ankle systolic/Brachial systolic

  • Use the Doppler for systolic blood pressure readings

  • For each leg, use the  HIGHEST reading of the posterior tibial or dorsalis pedis BP

  • Use the HIGHEST brachial systolic reading 

    • It does NOT need to be on the same side as the leg.

• Decreased in Peripheral Artery Disease (PAD)

what are Nursing Diagnoses r/t the Peripheral Arterial System?

• Ineffective tissue perfusion

• Risk for ineffective tissue perfusion

• Risk for peripheral neurovascular dysfunction

what is immediates response required for peripheral arterial?

• Cold, pulseless, cyanotic extremity

how to do a brief scan of cardiovascular system?

1. involves assessment of level of consciousness,

2. colour changes,

3. sometimes pulse and blood pressure.

what position for carotid arteries assesment?

seated position or in the high-fowlers position with the client looking straight ahead.

For carotid auscultations, what are the steps?

1. ask patient to breathe in and out, hold their breathe

• this is b/c a bruit can be similar to breathing

2. use bell, to listen

3. repeat on other side

what is important to remember for palpation of carotid arteries?

First, if you hear a bruit when auscultating the carotid arteries, do not palpate the carotid artery. Only proceed with palpation if you do not hear a bruit.

what does elevated central venous pressure (CVP) indicate?

fluid retention,

right ventricle contractile dysfunction that can be associated with heart failure, pericarditis, pulmonary hypertension,

and tricuspid stenosis.

what does low CVP indicate?

volume depletion (e.g., hemorrhage, dehydration).

what are ways to assess CVP?

• an invasive procedure called pulmonary artery catheterization (critically ill)

• A non-invasive way to assess the CVP is by inspecting the jugular veins

how to do a jugular veins inspection?

1. Assist the client into a supine position with the head of bed in a position at least 30 degrees and no higher than 45 degrees.

2. Remove the client’s pillow so their head is laying flat against the bed in a neutral position.

3. Stand on the right side of the bed and ask the client to gently turn their head to the left.

4. Use tangential lighting to highlight pulsations.

5. Begin by inspecting the right external jugular pulsation, as it is most visible. The vein should be flat or not visible; a bulging vein can suggest high CVP.

6. repeat on other side

what is jugular venous pulsation influenced by?

influenced by blood volume, cardiac function of the right ventricle, and venous compliance.

Venous is:

• not palpable

• double wave

• varies with respiration

• disappears when repositioned into sitting

arterial is:

• palpable

• one brisk wave

• doesn’t vary with respiration

• not affected by position change

• limited location

what is the position of patient when doing a heart assessment?

The assessment is typically performed in a supine position with the client’s head on a pillow.

What type of approach should the nurse follow that focuses on physical and emotional safety when performing a cardiovascular assessment?

Trauma-informed approach.

involves integrating an understanding of the need for physical and emotional safety; choice and control; and empowerment

how to palpate for precordium?

Use the metacarpophalangeal surface of your fingers starting at the base of the heart. Leave them in place as long as you need to, but usually about two to three seconds and then move onto the sternal border and then the apex.

• identify any vibrations

how to palpate for apical pulse?

1. put finger pads at 4th intercostal

2. Ask the client to hold their breath after taking a large breath in and out. You should feel the pulsation quite quickly if it is palpable.

3. Document: “Gentle tap of apical impulse, short duration, one smooth pulsation, 1–2 cm² at apex.”

where is the apical pulse located?

5th intercostal space, left midclavicular line

what sound is best heard in apex?

S1 sound

what sound is best heard in base?

S2 sound

Peripheral vascular system - arteries

• rounded appearance

• thick walls

• carries blood way from heart

• lower oxygen concentration in pulmonary arteries

• high pressure

• valves not present