cardiac examination

what are the four things that are apart of dyspnea?

• dyspnea on exertion

• orthopnea

• paroxysmal nocturnal dyspnea

• bendopnea

what is dyspnea on exertion?

more short of breath than should be with movement

what is orthopnea?

SOB in supine, the more pillows, the more severe (ex 2 pillow orthopnea)

what is paroxysmal nocturnal dyspnea?

gasping for air in the middle of the night (often due to heart failure)

what is bendopnea?

SOB when bending over (often due to heart failure)

what goes along with wheezing?

pulmonary edema

what side effect can BP med lisinopril cause?

dry cough

what type of cough goes along with cardiac problems?

• due to heart failure or pulmonary edema

  • frothy sputum

  • worsens in supine

why is fatigue a symptom of cardiac problems?

due to generalized weakness, the heart cant send enough blood out to muscles

why is edema a symptom of cardiac problems?

heart fails to pump blood effectively, leading to fluid buildup in the lower extremities, abdomen, or lungs

it accumulates in the LE, abdomen and sacral areas

what are palpitations?

irregular, fast or “extra” heart beat

what is syncope?

loss of consciousness, fainting or lightheadedness caused by cerebral hypoperfusion

what is cyanosis?

• bluish discoloration of lips and nail beds

• can be gray tones along gum line in darker skinned people

what is claudication?

cramping or burning in LE

what are the two types of chest pain?

cardiac vs non cardiac

what is chest pain?

pressure, squeezing, constriction, heaviness or tightness that occurs anywhere above the waist

what symptoms go along with chest pain?

SOB, weakness, lightheadedness or sweating

what is chest pain often associated with?

exercise/PA, heavy meals, emotional stress, nausea, vomiting, diaphoresis, dyspnea, fatigue, pallor or syncope

what are the four types of angina?

• stable angina

• unstable angina

• variant (prinzmetal or vasospastic)

• silent ischemia

what is stable angina?

consistent pattern, predictable for at least 2 months, foes away with rest or meds

what is unstable angina?

no pattern, new or severe, doesnt always go away with rest or meds, may occur at rest! medical emergency!!!!

what is variant angina?

at night, normally midnight to the morning, spasm of the coronary artery, goes away

what is silent ischemia?

no chest pain

when does angina occur?

when the heart does not get enough oxygen

what is angina often associated with?

exercise/PA, heavy meals, cold weather, emotional stress, or at reset

what is angina described as?

pressure, squeezing, constriction, heaviness or tightness that occurs anywhere above the waist

what are symptoms of angina?

SOB, weakness/fatigue, lightheadedneass/syncope, nausea, vomiting or sweating

what is chest pain like in women?

• chest pain but not always

• nausea or vomiting

• indigestion/stomach

• unusual shortness of breath

• fainting

• extreme fatigue

• irregular heath beat (arrhythmia)

what is chest pain like in men?

• squeezing chest pressure or pain

• jaw, neck or back pain

• n/v

• SOB

what are the 5 other types of chest pain?

• pericarditis

• aortic dissection

• pleuritic chest pain

• MSK chest pain

• GERD

what is pericarditis?

• inflammation of the pericardial sac

• sharp stabbing pain in the chest and back btw the shoulder blades

• it is better when you lean forward, and worse in supine

what is aortic dissection?

• ripping or tearing sensation in back between shoulder blades or chest

what is pleuritic chest pain?

inflamed pericardium that hearts to breath, cough or sneeze

what is MSK chest pain?

can it be provoked?

rib fx

intercostal strain

shoulder pain

what is GERD?

• acid in esophagus

• burning in center of chest

• obesity, pregnancy, after eating

what should you look for during a patient’s history?

• ask more about patient symptoms

• current and PLOF

• hx of falls?

• lifestyle/job

• social history

  • ex: living enviro

  • working/retired

  • tobacco use

  • family history

what should you look for in a chart review?

current med problems (diagonosis, date, hospital course)

past med/surg history

meds

diagnostic and lab tests

what are traditional cardiac risk factors?

• smoking

• physical inactivity

• obesity

• bad diet

• HTN

• elevated cholesterol

  • elevated LDL, low HDL

• diabetes

• stress

• family history

• age

• gender

• race

what are pulses?

wave of blood in the artery created by contraction of the LV during the cardiac cycle

can peripheral pusles be felt?

yes! palpating an artery using the index and 3rd finger!

what is apical pulse?

apical pulse is the central pulse located at the apex of the heart that can be heard via a stethoscope

used when peripheral pulses are weak or inaccessible

what is heart rate?

• # of times the ventricle contracts

• can be measured via palpation

  • radial artery is the most common

• measured for 30 seconds or 1 min intervals

  • rate rhythm, quality

• can also be measured from EKG

what is bradycardia?

less than 60 BPM!!!

• exercise training, severe CAD, meds or arrythmia

what is tachycardia?

more than 100 BPM!!!!

• deconditioning, stress, caffeine, heart failure, anemia, meds, arrhythnias, low oxygen

• higher HR increases the work of the heart

what is normal HR for infants (birth -1 year)?

100=180 bpm

if HR is less than 50 or greater than 110, what should you do?

check with the medical team before proceeding

what is HR above 120 mean?

it is considered a precaution for exercise

what is the numerical scale for grading pulse quality (strength)?

• 0=absent

• 1+=thready

• 2+= weak

• 3+= normal

• 4+= bounding

how do you find the apical pulse?

• position the patient in sitting or supine

• locate where the pulse should be

• place the bell of diagphram of the stethoscope over the apex of the heart

• count the beats for 60 seconds

  • lub dub is 1 beat

what are factors that can influence HR?

• age

• sex

• emotion/stress/pain

• exercise

• medications

• systemic or local heat

what is HR recovery post exercise?

• a measure of the heart’s ability to return to normal after exertion

• expressed as max HR minus HR at 1 minute into recovery

• >12-18 beats decrease ar 1 minute is normal

• <12 beat decrease at 1 minute = abnormal (increased risk for CAD and death)

• does not appear to be affected by betablockers in patients with heart failure

what is a HR normal response post exercise?

>12-18 beats decrease at 1 minute into recovery

what is an abnormal HR response post exercise?

< 12 beat decrease at 1 minute = abnormal (increase risk for CAD or death)

what is blood pressure?

• pressure exerted by circulating blood upon the walls of blood vessels

• baroreceptos

  • RAAS

what is the equation for BP?

BP=CO x TPR

what is systolic BP?

the highest pressure in the artery that occurs during ventricular stroke

what values of resting systolic BP should you hold activity?

below 80, or above 180

what is dyastolic BP?

the lowest pressure in the artery that occurs during ventricular diastole

what values of resting dyastolic BP should you hold activity?

if below 40 or above 110

what is mean arterial pressure?

the average pressure exerted by the blood as it travels through the arteries

what is the equation for MAP?

MAP = SBP + (2xDBP) / 3

what is normal MAP?

70-100 mmHG

what does it mean if MAP is less than 60?

CLINICAL HYPOTENSION

• decreased perfusion of vital organs

what is BP recovery post exercise?

• SBP should return to pre-exercise levels, or it may be 10-20 mmHG lower than the initial value within 6 minute of recovery

• delay in SBP recovery may indicate ischemic abnormality and or a poor prognosis

what is pulse pressure?

SBP-DBP

• force the heart generates when it contracts

what is normal pulse pressure?

40-60 mmHg

what is elevated PP?

over 60 mmHg

increased CV risk

what is low PP?

less than 40

heart failure, blood loss

does PP increase or decrease with exercise?

increases with exercise

what is rate pressure product?

• index of myocardial oxygen consumption

• RPP = HR x SBP

• increase with activity

• can decrease at a given workload with training

what are factors that influence BP?

• blood volume

• diameter and elasticity of the arteries

• cardiac output

• age

• exercise

• valsalva

• arm position

• technique of taking BP

what is normal BP?

less than 120/less than 180

what is elevated BP?

120-129/less than 80

what is high BP? (stage 1)

130-139/80-89

what is high BP (stage 2)?

140 or higher/90 or higher

what is hypertensive crisis?

higher than 180/higher than 120

what is the palpatory method of BP?

• palpate radial artery

• inflate cuff when radial pulse disappears

• inflate cuff 30 mmHg grater than where the pulse disappeared

• slowly deflate the cuff until the pulse returns (denoted SBP)

• DBP and MAP cant be obtaned

• BP= 130/P

what are clinical considerations for taking BP?

• IV or PICC

• dialysis shunt or fistula

• edema or lymphedema

• s/p mastectomy or lymph node resection

• open wounds

  • obesity (take on forearm)

what is orthostatic hypotension?

also called postural hypotension!

consider assessing BP and HR in sitting positions

assess in lying down, standing, standing, mayvbe sitting in acute care

what is respiratory rate?

• number of breaths taken per minute measures by watching the rise and fall of the chest

• don’t let the patient know youre taking it, it might change their breathing!

what iis normal RR?

12-18 breaths per min

what is bradypnea?

less than 10-12 breaths per min

causes: opioids, hyperthyroidism, brain disorders

what is tachypnea?

greater than 18-24 breaths per min

causes: pain, emotions, fever, respiratory conditions, hypoxia

what to think about when assessing respiratory rate?

rate: count for at least 30 seconds and then multiple x 2

depth: shallow vs deep

rhythm: regular vs irregular

soundL not any audible sounds

what value of resp rate should yo use caution with?

above or equal to 35

what value of resp rate should you hold activity with?

above or equal to 45

what should the modified borg scale be used for?

the talk test to monitor RR

what is normal SpO2?

over 95

what is the cut off for needing supplemental O2?

less than 88% SpO2

what is pulse oximetry?

non invasive monitor that measures the amount of hemoglobin saturated with oxygen

what are factors than can affect the accuracy of pulse oximetry?

• poor circulation/lowBP

• skin pigmentation

• skin thickness

• skin temp

• current tobacco use

• fingernail polish/fake nails

• WB on AD

what is jugular venous dystention?

• indication of increased volume in the venous system or right sided heart failure

• in the supine position with head of bed at 45 degrees and instruct them to turn their head to the left.

what does the capillary refill test do?

tests peripheral perfusion adn circulatory status by measuring how quickly blood returns to the capillaries after being compressed

Normal: refills within 2 seconds

delayed: longer than 2 seconds

where can you auscultate the aortic valve?

to the R of the sternum

where can you auscultate the pulmonary valve?

to the L of the sternum

where can you auscultate the tricuspid valve?

right by the xiphoid, fourth or fifth intercostal

where can you ausculate the mitral valve?

the apex of the heart, 5th intercostal on L side

what is S1?

lub of lub dub

• associated with the closure of the mitral and tricuspid valves (onset of ventricular systole)

what is S2?

dub of lub dub

• assosicated with the closure of the aortic and pulmonary valves (start of ventricular diastole)

what is S3?

dub right after S2 of LUB DUB DUB

• normal in healthy children/YA, but can indicated non compliant LV (HEART FAILURE)

• heard best with the bell of the stethoscope at the apex of the heart in the left lateral position