Slide 1

CARDIAC ASSESSMENT

MR. SUDHIR KHUNTIA

INTRODUCTION:- Assessment of the cardiovascular system is one of the most important areas of the nurses daily patient assessment. Report your findings as clearly as possible. Charting your results clearly is essential for others to be able to assess the problem, and good documentation is also essential for the treatment of the patient as well as for the nursing care.

PHYSICAL EXAMINATION

General:-

Build (obesity or wasting); shortness of breath; difficulty in talking; note whether they look ill.

Look for pallor, jaundice, sweatiness and clamminess, and for xanthelasma around the eyes.

Cyanosis

This is seen below the fingernails and toenails but also in the lips, cheeks, ears and nose.

It may increase in the cold and on exertion.

Face

Malar flush - redness around the cheeks (mitral stenosis).

Xanthomata - yellowish deposits of lipid around the eyes, palms, or tendons (hyperlipidaemia).

Corneal arcus - a ring around the cornea (normal ageing or hyperlipidaemia).

Proptosis - forward projection or displacement of the eyeball (Graves' disease)

Hands Finger clubbing.

Janeway lesions - macules on the back of the hands (infective endocarditis).

Osler's nodes - tender nodules in the fingertips (infective endocarditis).

Pulse

Rate: average 72/minute in adults, faster in children and may slow in old age. Also slower in athletes. Compare with apex rate.

Rhythm:Respiratory variations are common in healthy individuals (if there is noticeable quickening in inspiration and slowing in expiration, this is termed sinus arrhythmia).

Peripheral pulses:

Femoral pulses (radial femoral delay in coarctation) and foot and ankle pulses.

Listen over the renal and femoral artery for murmurs.

Check blood pressure

This should be measured in the brachial artery, using a cuff around the upper arm.

A large cuff must be used in obese people, because a small cuff will result in the blood pressure being overestimated.

Systolic pressure is at the level when first heard (Korotkoff I) and the diastolic pressure is when silence begins (Korotkoff V).

In patients with chest pain, or if ever the radial pulses appear asymmetrical, the pressure should be measured in both arms because a difference between the two may indicate aortic dissection.

Chest examination

Check the level of the jugular venous pressure.

Chest examination:

Look to see if the chest wall is deformed (eg, funnel chest) and moves equally (inequality of expansion is usually due to respiratory disease).

Note the respiratory rate; it is related to the pulse rate in the ratio of about 1:4 and remains constant in the same individual.

Ask the patient to breathe out and, using both hands resting lightly on the side walls of the chest with thumbs meeting in the middle, ask them to breathe in to assess the expansion of the chest on full inspiration by noting how far the examiner's thumbs move apart.

Feel over the anterior chest wall for any thrills associated with cardiac murmurs.

Auscultation of the heart -

Examination of other areas

Abdomen - see also separateAbdominal Examination

Palpate the abdomen for hepatomegaly and splenomegaly (congestive cardiac failure), or spleen alone (infective endocarditis).

Feel for enlargement of the aorta (aneurysm); feel with the hands flat either side of the aorta - feel for pulsation and tenderness.

Investigations

These may include:

Blood tests (for fasting glucose and/or haemoglobin, renal function, LFTs, TFTs, lipid profile, cardiac enzymes, ESR or CRP).

12-lead ECG and ambulatory ECG monitoring, exercise ECG testing.

Ambulatory blood pressure monitoring chest x-ray

Spirometry.

Echocardiogram.

Cardiac catheterization.

Angiography.

Electrocardiography(ECGorEKG*) is the process of recording the electrical activity of theheartover a period of time using electrodesplaced on the skin. These electrodes detect the tiny electrical changes on the skin that arise from the heart muscle's electro physiologic pattern of depolarizingduring eachheart beat. It is a very commonly performedcardiologytest.

MAIN PATTERN

The 12 lead ECG is used to classify MI patients into one of three groups:

those with ST segment elevation or new bundle branch block (suspicious for acute injury and a possible candidate for acute reperfusion therapy withthrombolyticsor primaryPCI),

those with ST segment depression or T wave inversion (suspicious for ischemia), and

those with a so-called non-diagnostic or normal ECG. However, a normal ECG does not rule out acute myocardial infarction.

SHREYAS COLLEGE OF NURSING G.E ROAD SUPELA, BHILAI, CARDIAC ASSESSMENT

GUIDE BY: PRESENTED BY: MRS. SHEFALI CHARAN LECTURER MR. JEEVAN LAL M.Sc. NURSING M. Sc. NURSING FINAL YEAR(MEDICAL SURGICAL NURSING)

Health History:-1. Current Health Status

-chest pain- shortness of breath- swelling of ankles or feet- heart palpitations- fatigue

2. Past Health History

Congenital heart disease

- Rheumatic fever

- Heart murmur

- High blood pressure, high cholesterol, diabetes mellitus

- Confusion

- Fatigue

3. Family History

4. Personal Habits

Techniques of Examination The patient should be supine with upper body elevated at a 15-30E angle.

The room must be quiet, warm, and have good lighting.

You should stand to the right of the patient being examined.Inspection and Palpation of the Heart

The finger pads are more sensitive in detecting pulsations.

Inspect and Palpate for: Pulsations- these are more visible when patients are thin. A thick chest wall or increased AP diameter can obscure them. Pulsations may indicate increased blood volume or pressure.

Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs.

Thrills- these are the vibrations of loud cardiac murmurs. They feel like the throat of a purring cat. Thrills occur with turbulent blood flow.

AREAFINDINGSAortic (2nd inter coastal space to the right of the sternum)A pulsation could indicate an aortic aneurysmA thrill could indicate aortic stenosis

You should inspect and palpate at the following areas:

Pulmonary (2nd inter coastal space to the left of the sternum)A pulsation could indicate pulmonary hypertensionA thrill could indicate pulmonic stenosis

Tricuspid (4-5th inter coastal space, lower half of the sternum)A sustained systolic lift could indicate right ventricular enlargement.A systolic thrill could indicate a ventricular septal defect.

Mitral (5th intercoastal space at mid clavicular line)Increased pulsation could indicate increased output, anxiety, fever, or pregnancy.A thrill could indicate mitral regurgitation, or mitral stenosis.

Epigastric (below xiphoid process)Increased aortic pulsation could indicate right ventricular pulsation of right ventricular enlargement and aortic regurgitation.

-

Sternoclavicular (top of sternum at junction of clavicles)Pulsation of aortic arch may be felt in a thin client.

1. Aortic Area 2nd right interspace close to the sternum.2. Pulmonic Area 2nd left interspace.3. ERB's Point 3rd left interspace.4. Tricuspid Area 5th left interspace close to the sternum.5. Mitral Area (Apical) 5th left interspace medial to the MCL

Auscultation of the Heart

1. With your stethoscope, identify the first and second heart sounds (S1 and S2) at the aortic and pulmonic areas (base). S2 is normally louder than S1. S2 is considered the dub of 'lub-DUB.' S2 is caused by the closure of the aortic and pulmonic valves.AUSCULATION OF HEART WITH STETHOSCOPE

2. Identify the heart rate.tachycardiabradycardia

3. Identify the rhythm.if it is irregular, try to identify the pattern.Do early beats appear on a regular rhythm?Does the irregularity vary consistently with respiration?Is rhythm totally irregular?Contd.

4. Listen to S1 first, then S2 at the previously mentioned areas using the diaphragm and then the bell.note its intensity.are there any splitting sounds check during inspiration where S2 usually splits at pulmonic and ERB's point.A thick chest wall or increased AP diameter may make S2 inaudible.Contd

ALTERATION IN S1, S2, S3, S4, and murmur sound

S.NOALTERATION IN S1ALTERATION IN S2LISTEN FOR S3LISTEN FOR S4LISTEN FOR MURMUR1.S1 is accentuated in exercise, anemia, hyperthyroidism and mitral stenosisNormal physiological splitting of S2 is best heard at pulmonic area. It occurs on inspiration.A physiologic S3 is frequently heard in children and in pregnant women.It occurs before S1It is low pitched and best heard with the bellHeart murmur are heart sound produced when blood flows across one of the heart valves that is loud enough to be heard with a stethoscope.

2.S1 is diminished in first degree heart blockSplitting of S2 can indicate pulmonic stenosis, atrial septal defect, right ventricular failure.It occurs early in diastole during rapid ventricular filling. It is heard best at the apex in the left lateral decubitus position.It may be caused by coronary artery disease, hypertension, myocardiopathy, or aortic stenosis.3. S1 split is most audible in tricuspid areaA pathologic S3 occurs in people over the age of 40. Cause is usually myocardial failureSounds like dee-lub-dub(or Tennessee)

S.NOASSESSMENT OF EXTRA HEART SOUNDFEATURES OF SOUNDS1.Ejection clickHigh pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves.2.Opening snapHigh pitched additional sound may be herd after the A2 (aortic) component of the second heart sound (S2), which correlates to the forceful opening of the mitral valve.3.Mid systolic clickHigh frequency sound in mid systole.

Assessment of Extra Heart Sounds: