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Cardiac Assessment:More Than Just Heart Sounds                                   Telemetry                                ...
Importance of Assessment• RNs are the 24/7 surveillance system  for the patient (Linda Aiken)• RNs are rescue workers (Suz...
Essentials of Assessment• Empathic listening• Ability to interview patients of different  ages, moods, and backgrounds• Te...
Key Points of Assessment• Listen to the patient, they will often  help in leading to a diagnosis• Focus on the patient, no...
Key Points of Assessment• Be proactive; anticipate your patients  needs  – Act before your patients gets into trouble• Whe...
History• Drives the physical assessment as well  as the diagnostic studies and treatment• Lays the groundwork for the nurs...
History of Present Illness• Why is the patient seeking care?• Have patient describe in his/her own wordsPresenting Symptom...
OLDCARTS•   O = Onset•   L = Location•   D = Duration•   C = Character•   A = Aggravating/Alleviating factors•   R = Radia...
NOPQRST•   N = Normal•   O = Onset•   P = Precipitating, Provoking, Palliative•   Q = Quality or Quantity•   R = Radiation...
Cardiovascular ComplaintsChest Pain or Pressure• Most common symptom in CV presentation• Utilize the NOPQRST method of ass...
Chest Pain or PressureOnset• Start suddenly or gradually – most angina starts at  low intensity and builds• Time of day th...
Chest Pain or PressurePrecipitation, Provoking, Palliation• Chest pain caused by CAD is often precipitated by  exertion   ...
Chest Pain or PressureQuality and Quantity• Angina or ischemic discomfort is often described as  heaviness, pressure, tigh...
Chest Pain or PressureRadiation and Region• Substernal region in the most common location for  discomfort with cardiac ori...
Chest Pain or PressureSeverity and Other Symptoms• Severity is subjective• Ischemic pain can range from mild to severe• Ra...
Chest Pain or PressureTime and Treatment• Length of time since onset of symptoms• How long do the symptoms last?• Treated ...
Dyspnea• Can be due to pulmonary or cardiac problems• Symptoms occur with activity or rest?• If with activity, what level?...
Cough and Hemoptysis• Heart Failure or Pulmonary Embolus• Signs of Left-Sided HF• Wet or dry cough• Frequency – chronic or...
Palpitations• Awareness of heartbeat• May occur with fast or normal heart rate• May be regular or irregular• May occur wit...
Syncope• Distinguish between dizziness, fainting and  syncope• Room spinning or whirling indicates a  vestibular disorder•...
Physical Assessment• Find a systematic approach that works for you• Always begin your shift with a thorough  physical asse...
Physical Assessment• Find a systematic approach that works for you• Always begin your shift with a thorough  physical asse...
Vital Signs Blood Pressure Hypotensive or Hypertensive   Heart Rate  Bradycardia or TachycardiaRespiratory Rate   Bradypne...
Blood PressureBlood pressure is a measurement of the   force exerted by blood as it pulsates through the arteries (Kozier ...
Blood Pressure   Systolic blood pressure (SBP) is the    pressure of the blood as a result of       contraction of the ven...
Blood PressureBlood pressure is affected by factors such as CO [preload, contractility, afterload]; distension of the arte...
Blood PressureHypotension: SBP < 90 and/or DBP < 60Hypertension: SBP > 140 and/or DBP > 90
Blood Pressure• Technique for measuring blood pressure  is important  – Sitting up  – Arm at the level of the heart with s...
Orthostatic Blood Pressure• Technique for measuring orthostatic BP  – Use the same arm  – Wait at least 5 minutes between ...
Mean Arterial Pressure        Mean Arterial Pressure (MAP)               Range = 70 – 110 mmHg     The average pressure of...
Mean Arterial PressureMAP is the average arterial pressure during a                cardiac cycle   MAP is considered to be...
Noninvasive BP    MeasurementTwo Common Noninvasive Indirect   Methods of B/P Measurement    Ausculatory & Palpatory
Ausculatory BP MeasurementExternal pressure is applied to a superficial    artery (most commonly the brachial). The stetho...
Korotkoff’s Sounds
Palpatory BP MeasurementUsed when Korotkoff’s sounds cannot be   heard and electronic equipment to  amplify the sound (i.e...
Invasive BP Measurement      Common Invasive Methods of B/P              Measurement:          • Arterial B/P Monitoring  ...
Factors Affecting BP:• Age: Increased r/t arterial wall rigidity      • Sex: Male BP > Female B/P        • Exercise: Incre...
Factors Affecting BP:• Obesity: Predisposed to hypertension• Diurnal Variations: lowest in AM, peaks      in late afternoo...
Heart RatePulse is the term used to describe rate,  rhythm, and volume of the heartbeat  A pulse is produced by ventricula...
Characteristics of a PulsePulse should be characterized as:• Thready, weak, strong, or bounding• Equal bilaterally or not•...
Heart Rate & Blood     PressureBlood pressure is directly affected by the                heart rate Heart rate is directly...
Heart Rate & Blood      Pressure• HR is Within Defined Parameters if 60–  100  – Bradycardia if HR < 60  – Tachycardia if ...
Factors Affecting Heart Rate:    Age: increased age, decreased HR      • Sex: Male HR < Female HR               • Exercise...
Respiratory RateRespiratory rate is calculated by counting  the number of inspirations/respirations                 per mi...
Breathing RatesEupnea – normal RR that is quiet, rhythmic, and                  effortless  Tachypnea – rapid respirations...
Breathing RatesCheyne-Stoke – Fast, deep respirations of 30 – 170 seconds punctuated by periods of apnea           lasting...
Factors Affecting RR    • Age: rate & depth decrease with age      • Exercise: Increased rate & depth              • Fever...
Oxygen Saturation          Normal = 95% - 100%      Below 70% is life threatening Pulse oximeter - measures arterial blood...
Pulse Oximeter              2-Part Sensor2. Two light-emitting diodes (LEDs) – one            red and one infrared Transmi...
Factors Affecting 02 Sat:• Hemoglobin: regardless of low Hemoglobin   levels, if the hemoglobin is fully saturated        ...
Inspection   Lips/Tongue     Blue-tinged?    Dry/Cracked?      Consider:Cyanosis – lack of circulation        Dehydration
Inspection               Skin:                              HairCyanosis/Pale?            Distribution?  Redness?         ...
Assessment of Cardiac Perfusion and       Pulmonary CongestionWARM and DRY        WARM and WET  No Congestion       Conges...
Inspection         Neck:Jugular Vein Distension?          Consider:     Right-sided heart failure          Hypervolemia   ...
Inspection/Palpation   Nails:   Clubbing?     Color?  Thickness?Capillary Refill?              Consider:       Cardiac or ...
Capillary RefillIf greater than 3 seconds may indicate:  •Dehydration  •Shock  •PVD  •Hypothermia
InspectionAbdomen: Ascites? Pulsating  Mass?             Consider:         Right-sided heart failure        Abdominal Aort...
InspectionLower Extremities:       Cyanosis/Pale?           Redness?    Hair Distribution?            Turgor?            E...
Inspection/PalpationLegs/Ankles/Feet:     Edema?     Pulses?    Sensation?       Consider:      Pain?                 DVT ...
PalpationUpper Extremities:         Pulses?       Sensation?       Consider:Peripheral Vascular Disease           DVT
Edema 4-Point ScaleGrade Description   Depth of Indentation  0    None         N/A  1+   Trace        Up to ¼-inch  2+   M...
Pulse Points•Carotid            Evaluation for:•Radial             •Presence•Brachial           •Laterality•Femoral       ...
Pulse 4-Point Scale Grade           Description   0                Absent  1+       Palpable, but thready and            w...
Terminology of Pulse     Variations•Pulsus Magnus – strong and bounding•Pulsus Parvus – thready•Pulsus Alternans – large a...
General PointsWhen assessing heart sounds: •Need a quiet room •Stand to the right of the patient •Having patient roll slig...
Heart Sounds
First Heart SoundsS1 = Lub •Closure of the mitral and tricuspid valves •Beginning of ventricular systole and atrial diasto...
Second Heart SoundsS2 = Dub •Closure of the aortic and pulmonic valves •End of ventricular systole •Beginning of ventricul...
Third Heart SoundsS3 = Lub DubDa •Ventricular gallop •Caused by increased atrial or ventriuclar filling •May be normal in ...
Fourth Heart SoundsS4 = DaLub Dub •Atrial gallop •Occurs during late ventricular diastole •Caused by atrial contraction an...
Murmurs
Systolic Murmurs        a)Midsystolic        •   Innocent murmurs (normal heart)        •   Physiologic murmurs (pregnancy...
Diastolic Murmurs        a)Early diastolic        •   Aortic regurgitation        b) Middiastolic        •   Aka presystol...
Continuous Murmurs
Grading MurmursGradation of                            Description Murmurs               Very faint, heard only after list...
Respiratory Assessment •Auscultate anteriorly and posteriorly •Patient should be sitting up!
Normal Breath SoundsBronchial (upper)  •Expiratory longer than inspiratory  •Loud and higher in pitchBronchovesicular (mid...
Adventitious SoundsCrackles (Rales) •Discontinuous •Intermittent, non-musical, brief •Like dots in time •Crackles that do ...
Adventitious SoundsWheezes •Continuous •Musical •High-pitched with hissing or shrill quality •Narrowing of airways
Adventitious SoundsRhonchi •Continuous •Relatively low-pitched •Snoring quality •Suggest secretions in large airways
Abdominal AssessmentAuscultation: •Normal sounds – clicks & gurgles •Occur at 5- to 15-second intervals •Absent = no sound...
Abdominal AssessmentPalpation: •Soft, firm, or rigid •No masses or tenderness •Rebound pain (may suggest peritoneal inflam...
Genitourinary Assessment •Intake and output   •Indicates both renal and cardiac function •Foley catheter   •Check for orde...
ReferencesBickley, L. S. (2007). Bates’ pocket guide to physical examination and history   taking, (5th ed.). Philadelphia...
Cardiac Assessment - BMH Tele
Cardiac Assessment - BMH Tele
Cardiac Assessment - BMH Tele
Cardiac Assessment - BMH Tele
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Cardiac Assessment - BMH Tele

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  • Thorough cardiac assessment Head – to – Toe Fashion
  • Blood pressure tells us about adequate perfusion B/P that is too low can cause poor perfusion SBP &lt; 90 is considered unstable if symptomatic Elevated B/P can cause problems such as stroke Different factors cause elevations in B/P Pulse Too low or too high can cause poor perfusion Different factors cause elevations in pulse rates RR -elevated RR’s can indicate compensation for a cardiac problem 02 sat -low O2 sat’s may reflect poor perfusion or other cardiac disorders
  • Brief synopsis of a head – to – toe cardiac assessment tool Identifies key assessment findings that could indicate cardiac problems
  • Transcript of "Cardiac Assessment - BMH Tele"

    1. 1. Cardiac Assessment:More Than Just Heart Sounds Telemetry Course Natalie Bermudez, RN, BSN, MS Clinical Educator for Cardiac Telemetry
    2. 2. Importance of Assessment• RNs are the 24/7 surveillance system for the patient (Linda Aiken)• RNs are rescue workers (Suzanne Gordon)• RNs are the integrators of all things (Maggie McClure)• RNs are the coordinators of care
    3. 3. Essentials of Assessment• Empathic listening• Ability to interview patients of different ages, moods, and backgrounds• Techniques for examining different body systems• Clinical Reasoning (I.e. critical thinking) – Putting it all together!
    4. 4. Key Points of Assessment• Listen to the patient, they will often help in leading to a diagnosis• Focus on the patient, not the task; be observant• Be a detective; dig for clues• Don’t take anything for GRANTED! – Always check things out, especially “gut feelings”
    5. 5. Key Points of Assessment• Be proactive; anticipate your patients needs – Act before your patients gets into trouble• When possible, round with the physician – Discuss any abnormal findings, especially when you’re not sure of their significance
    6. 6. History• Drives the physical assessment as well as the diagnostic studies and treatment• Lays the groundwork for the nurse- patient relationship• Provides key information• Should not be bypassed
    7. 7. History of Present Illness• Why is the patient seeking care?• Have patient describe in his/her own wordsPresenting Symptoms:• Ask patient to describe symptoms• Use a systematic approach to evaluating symptoms – OLDCARTS – NOPQRST
    8. 8. OLDCARTS• O = Onset• L = Location• D = Duration• C = Character• A = Aggravating/Alleviating factors• R = Radiation• T = Timing• S = Site
    9. 9. NOPQRST• N = Normal• O = Onset• P = Precipitating, Provoking, Palliative• Q = Quality or Quantity• R = Radiation or Region• S = Severity or other Symptoms• T = Time and Treatment
    10. 10. Cardiovascular ComplaintsChest Pain or Pressure• Most common symptom in CV presentation• Utilize the NOPQRST method of assessment • N = Normal • O = Onset • P = Precipitation, Provoking, Palliation • Q = Quality and Quantity • R = Radiation and Region • S = Severity and other Symptoms • T = Time and Treatment
    11. 11. Chest Pain or PressureOnset• Start suddenly or gradually – most angina starts at low intensity and builds• Time of day that discomfort started - some MI’s occur in the morning after the patient rises and begins activity• When did the discomfort 1st begin – today or a few days ago???• MI may occur with activity or after a heavy meal • Periods of increased myocardial demand
    12. 12. Chest Pain or PressurePrecipitation, Provoking, Palliation• Chest pain caused by CAD is often precipitated by exertion • Other precipitants are exposure to cold or heavy meals• Associated factors – does the discomfort change with inspiration or position change?• What relieves the discomfort? – • NTG, how many; if no relief, ask about storage of NTG• Does the discomfort change with activity change, such as rest?
    13. 13. Chest Pain or PressureQuality and Quantity• Angina or ischemic discomfort is often described as heaviness, pressure, tightness, or squeezing• Stabbing, intermittent, knife-like descriptions are not likely to be due to cardiac ischemia• Remember – Ask the patient to describe the discomfort
    14. 14. Chest Pain or PressureRadiation and Region• Substernal region in the most common location for discomfort with cardiac origin• Anginal or ischemic discomfort is likely to radiate to the jaw, either arm, or back• However, discomfort is not always substernal even if it is of cardiac origin• Region of discomfort is usually larger than a fingertip and often the size of a hand or closed fist
    15. 15. Chest Pain or PressureSeverity and Other Symptoms• Severity is subjective• Ischemic pain can range from mild to severe• Rate on a scale of 0 – 10• Assess for other symptoms – nausea, vomiting, dyspnea, diaphoresis, etc.
    16. 16. Chest Pain or PressureTime and Treatment• Length of time since onset of symptoms• How long do the symptoms last?• Treated in the past for the same symptoms?
    17. 17. Dyspnea• Can be due to pulmonary or cardiac problems• Symptoms occur with activity or rest?• If with activity, what level?• Decreased activity tolerance demonstrated by DOE might be anginal• Onset gradual or sudden?• Orthopnea - Difficulty breathing when flat• PND – dyspnea that occurs 1-2 hours into sleep, relieved by sitting• How many pillows does the patient use?
    18. 18. Cough and Hemoptysis• Heart Failure or Pulmonary Embolus• Signs of Left-Sided HF• Wet or dry cough• Frequency – chronic or new onset• Occurs only with activity?• Sputum (amount, color, and consistency)• Hemoptysis – blood-streaked, frothy pink, frank • May be present with mitral valve stenosis, pulmonary embolus, pulmonary hypertension, or tuberculosis
    19. 19. Palpitations• Awareness of heartbeat• May occur with fast or normal heart rate• May be regular or irregular• May occur with aortic or mitral regurgitation, pregnancy• Tachydysrhythmias may result in palpitations • A-Fib or A-Flutter with RVR, SVT, VT
    20. 20. Syncope• Distinguish between dizziness, fainting and syncope• Room spinning or whirling indicates a vestibular disorder• Fading off or blacking out is usually caused by insufficient blood supply to the brain • Hypotension or marked bradycardia or tachycardia • Usually occurs when systolic BP < 70 mmHg • Suspect orthostatic hypotension if occurs with position changes • Vasovagal stimulation
    21. 21. Physical Assessment• Find a systematic approach that works for you• Always begin your shift with a thorough physical assessment (baseline)• Always complete assessment with respect for patient’s privacy• Room should be quiet• Perform assessment from patients right side
    22. 22. Physical Assessment• Find a systematic approach that works for you• Always begin your shift with a thorough physical assessment (baseline)• Always complete assessment with respect for patient’s privacy• Room should be quiet• Perform assessment from patients right side
    23. 23. Vital Signs Blood Pressure Hypotensive or Hypertensive Heart Rate Bradycardia or TachycardiaRespiratory Rate Bradypneic or Tachypneic O2 Saturation Hypoxia/Hypoxemia
    24. 24. Blood PressureBlood pressure is a measurement of the force exerted by blood as it pulsates through the arteries (Kozier et al, 2002), SBP = CO x SVR
    25. 25. Blood Pressure Systolic blood pressure (SBP) is the pressure of the blood as a result of contraction of the ventricles Diastolic blood pressure (DBP) is the pressure when the ventricles are at restDBP is the lower pressure that is present at all times within the arteries (Kozier et al, 2002, p. 33)
    26. 26. Blood PressureBlood pressure is affected by factors such as CO [preload, contractility, afterload]; distension of the arteries; and the volume, velocity, and viscosity of the blood (Smeltzer et al, 2008, p. 799) Blood pressure is an indicator of adequate or inadequate perfusionInadequate perfusion may be a result of high or low blood pressures
    27. 27. Blood PressureHypotension: SBP < 90 and/or DBP < 60Hypertension: SBP > 140 and/or DBP > 90
    28. 28. Blood Pressure• Technique for measuring blood pressure is important – Sitting up – Arm at the level of the heart with support – Place cuff over brachial artery – Use appropriate cuff size • Too small – falsely elevated BP • Too big – falsely decreased BP
    29. 29. Orthostatic Blood Pressure• Technique for measuring orthostatic BP – Use the same arm – Wait at least 5 minutes between measurements – Lying, sitting, standing• Orthostatic Hypotension if: – Fall of SBP > 20 mmHg – Fall of DBP > 10 mmHg
    30. 30. Mean Arterial Pressure Mean Arterial Pressure (MAP) Range = 70 – 110 mmHg The average pressure of the arteries MAP = (2 x DBP) + SBP 3MAP is multiplied by 2 because diastolic phase lasts longer than the systolic phase If B/P 120/75, then MAP = ______
    31. 31. Mean Arterial PressureMAP is the average arterial pressure during a cardiac cycle MAP is considered to be the perfusion pressure seen by organs in the bodyMAP that is > 60 mmHg is enough to sustain the organs of the average personIf MAP is < 60 mmHg, then the organs are not being adequately perfused and they will become ischemic
    32. 32. Noninvasive BP MeasurementTwo Common Noninvasive Indirect Methods of B/P Measurement Ausculatory & Palpatory
    33. 33. Ausculatory BP MeasurementExternal pressure is applied to a superficial artery (most commonly the brachial). The stethoscope, or a Doppler device,is placed over the artery and the pressure is assessed by listening for the 5 phases of sounds a.k.a. Korotkoff’s sounds
    34. 34. Korotkoff’s Sounds
    35. 35. Palpatory BP MeasurementUsed when Korotkoff’s sounds cannot be heard and electronic equipment to amplify the sound (i.e. doppler) is not available The pulses are palpated, instead of auscultated The first palpation is the SBP DBP is not able to be assessed
    36. 36. Invasive BP Measurement Common Invasive Methods of B/P Measurement: • Arterial B/P Monitoring • Pulmonary Artery Pressure Monitoring • Cardiac Output Monitoring • Cardiac Catheterization • Central Venous Pressure Monitoring (Donofrio et al, 2005) Cardiac Telemetry Patients are not monitored invasively!!!!
    37. 37. Factors Affecting BP:• Age: Increased r/t arterial wall rigidity • Sex: Male BP > Female B/P • Exercise: Increases B/P• Medications: Some Increase, some decrease • Stress: Increases B/P • Race: African American males – increased after age 35
    38. 38. Factors Affecting BP:• Obesity: Predisposed to hypertension• Diurnal Variations: lowest in AM, peaks in late afternoon/early evening• Fever/Heat/Cold: Increased with fever (increased metabolic rate), decreased w/ external heat (vasodilation), and increased with cold (vasoconstriction)
    39. 39. Heart RatePulse is the term used to describe rate, rhythm, and volume of the heartbeat A pulse is produced by ventricular contraction which creates a wave of blood through the arteries The pulse reflects the heartbeat (Kozier et al, 2002, p. 23)
    40. 40. Characteristics of a PulsePulse should be characterized as:• Thready, weak, strong, or bounding• Equal bilaterally or not• Rhythm regular or irregular
    41. 41. Heart Rate & Blood PressureBlood pressure is directly affected by the heart rate Heart rate is directly affected by blood pressure What does this mean…?
    42. 42. Heart Rate & Blood Pressure• HR is Within Defined Parameters if 60– 100 – Bradycardia if HR < 60 – Tachycardia if HR > 100• Blood pressure affects HR and HR affects BP – If HR > 100, then BP decreases – If HR < 60, then BP decreases – If BP decreases then HR increases
    43. 43. Factors Affecting Heart Rate: Age: increased age, decreased HR • Sex: Male HR < Female HR • Exercise • Fever: Increased heart rate (peripheral vasodilation r/t elevated temp) • Medications• Hypovolemia/Dehydration: Increased heart rates • Stress • Position: Higher when standing
    44. 44. Respiratory RateRespiratory rate is calculated by counting the number of inspirations/respirations per minute Normal range is 15 – 20 bpm Depth & Rhythm (pattern) (Kozier et al, 2002)
    45. 45. Breathing RatesEupnea – normal RR that is quiet, rhythmic, and effortless Tachypnea – rapid respirations, marked by shallow breaths (> 20 per minute) Bradypnea – abnormally slow breathing (< 8 per minute) Apnea – cessation of breathing (Kozier et al, 2002, p. 31)
    46. 46. Breathing RatesCheyne-Stoke – Fast, deep respirations of 30 – 170 seconds punctuated by periods of apnea lasting 20 – 60 seconds Kussmaul’s – fast (over 20 per minute), deep(resembling sighs), labored respirations without a pause (Goldberg et al, 1997, p. 764)
    47. 47. Factors Affecting RR • Age: rate & depth decrease with age • Exercise: Increased rate & depth • Fever: Increased • Medications: Narcotics cause respiratory depression • Stress: Increased rate & depth• Homeostasis (acidosis/alkalosis): Increased or decreased rate (Kozier et al, 2002)
    48. 48. Oxygen Saturation Normal = 95% - 100% Below 70% is life threatening Pulse oximeter - measures arterial blood oxygen saturationCan detect hypoxemia before clinical signs & symptoms are apparent (Kozier et al, 2002)
    49. 49. Pulse Oximeter 2-Part Sensor2. Two light-emitting diodes (LEDs) – one red and one infrared Transmit light through nails, tissue, venous blood, & arterial blood2. Photodetector (opposite side of LEDs)Measures the amount of red and infrared light absorbed by oxygenated & deoxygenated hemoglobin in arterial blood and reports it as SaO2. (Kozier et al, 2002)
    50. 50. Factors Affecting 02 Sat:• Hemoglobin: regardless of low Hemoglobin levels, if the hemoglobin is fully saturated the SaO2 will still be “normal” • Circulation: Will be inaccurate if the area under the sensor has impaired circulation• Activity: Shivering or excessive movement of the sensor site may interfere with accurate readings (Kozier et al, 2002, p. 39)
    51. 51. Inspection Lips/Tongue Blue-tinged? Dry/Cracked? Consider:Cyanosis – lack of circulation Dehydration
    52. 52. Inspection Skin: HairCyanosis/Pale? Distribution? Redness? Turgor? Consider: Cardiac or Vascular insufficiency Dehydration
    53. 53. Assessment of Cardiac Perfusion and Pulmonary CongestionWARM and DRY WARM and WET No Congestion Congestion Normal Perfusion Normal PerfusionCOLD and DRY COLD and WET No Congestion Congestion Low Perfusion Low Perfusion
    54. 54. Inspection Neck:Jugular Vein Distension? Consider: Right-sided heart failure Hypervolemia Cardiac Tamponade Constrictive Pericarditis
    55. 55. Inspection/Palpation Nails: Clubbing? Color? Thickness?Capillary Refill? Consider: Cardiac or Vascular insufficiency Chronic cardiac or pulmonary disease
    56. 56. Capillary RefillIf greater than 3 seconds may indicate: •Dehydration •Shock •PVD •Hypothermia
    57. 57. InspectionAbdomen: Ascites? Pulsating Mass? Consider: Right-sided heart failure Abdominal Aortic Aneurysm
    58. 58. InspectionLower Extremities: Cyanosis/Pale? Redness? Hair Distribution? Turgor? Edema? Consider: Cardiac or Vascular insufficiency Left-sided Heart Failure
    59. 59. Inspection/PalpationLegs/Ankles/Feet: Edema? Pulses? Sensation? Consider: Pain? DVT Heart Failure Peripheral Vascular Disease
    60. 60. PalpationUpper Extremities: Pulses? Sensation? Consider:Peripheral Vascular Disease DVT
    61. 61. Edema 4-Point ScaleGrade Description Depth of Indentation 0 None N/A 1+ Trace Up to ¼-inch 2+ Mild ¼- to ½-inch 3+ Moderate ½- to 1-inch 4+ Severe Greater than 1-inch
    62. 62. Pulse Points•Carotid Evaluation for:•Radial •Presence•Brachial •Laterality•Femoral •Strength•Popliteal•Posterior Tibial•Dorsalis Pedis
    63. 63. Pulse 4-Point Scale Grade Description 0 Absent 1+ Palpable, but thready and weak; easily obliterated 2+ Normal, easily identified; not easily obliterated 3+ Increased pulse; moderate pressure for obliteration 4+ Full, bounding; cannot obliterate
    64. 64. Terminology of Pulse Variations•Pulsus Magnus – strong and bounding•Pulsus Parvus – thready•Pulsus Alternans – large amplitude followed by lowamplitude (with a regular rhythm)•Pulsus Bisferiens – double-peaked systolic impulse(cardiomyopathy)•Water-Hammer pulse – rapid rising and collapsing(aortic regurgitation)
    65. 65. General PointsWhen assessing heart sounds: •Need a quiet room •Stand to the right of the patient •Having patient roll slightly to the left accentuates S3, S4 and mitral murmurs, especially mitral stenosis •Having patient lean forward accentuates aortic regurgitation •Right-sided heart sounds are better heard on inspiration •Left-sided heart sounds are better heard during expiration
    66. 66. Heart Sounds
    67. 67. First Heart SoundsS1 = Lub •Closure of the mitral and tricuspid valves •Beginning of ventricular systole and atrial diastole •Palpate the carotid pulse to assist with ID •Occurs just before carotid pulse •Best heard in mitral area
    68. 68. Second Heart SoundsS2 = Dub •Closure of the aortic and pulmonic valves •End of ventricular systole •Beginning of ventricular diastole •Best heard at pulmonic area and Erb’s point
    69. 69. Third Heart SoundsS3 = Lub DubDa •Ventricular gallop •Caused by increased atrial or ventriuclar filling •May be normal in children and pregnancy •Best heard in left lateral decub position •Associated with R or L ventricular failure, ischemia, aortic regurg, mitral regurg, or systolic dysfunction
    70. 70. Fourth Heart SoundsS4 = DaLub Dub •Atrial gallop •Occurs during late ventricular diastole •Caused by atrial contraction and propulsion of blood into a noncompliant, stiff ventricle •Best heard in left lateral decub position •Associated with restrictive cardiomyopathy, ischemia, and aortic stenosis
    71. 71. Murmurs
    72. 72. Systolic Murmurs a)Midsystolic • Innocent murmurs (normal heart) • Physiologic murmurs (pregnancy, fever, anemia) • Aortic stenosis, HCM, pulmonic stenosis b) Pansystolic • Regurgitation (mitral or tricuspid) • Ventricular Septal Defect c) Late Systolic • Mitral valve prolapse
    73. 73. Diastolic Murmurs a)Early diastolic • Aortic regurgitation b) Middiastolic • Aka presystolic • Mitral stenosis c) Late diastolic • Tricuspid stenosis • Mitral stenosis • Left-to-right shunts
    74. 74. Continuous Murmurs
    75. 75. Grading MurmursGradation of Description Murmurs Very faint, heard only after listener has "tuned in"; may not be heard Grade 1 in all positions Quiet, but heard immediately after placing the stethoscope on the Grade 2 chest Moderately loud Grade 3 Murmur is very loud, with palpable thrill Grade 4 Murmur is extremely loud, with palpable thrill, and can be heard if Grade 5 only the edge of the stethoscope is in contact with the skin, but cannot be heard if the stethoscope is removed from the skin Murmur is exceptionally loud, with palpable thrill, and can be heard Grade 6 with the stethoscope just removed from contact with the chest.
    76. 76. Respiratory Assessment •Auscultate anteriorly and posteriorly •Patient should be sitting up!
    77. 77. Normal Breath SoundsBronchial (upper) •Expiratory longer than inspiratory •Loud and higher in pitchBronchovesicular (middle) •Equal inspiratory and expiratoryVesicular (lower) •Soft or low pitched •Heard through inspiration and 1/3 expiration
    78. 78. Adventitious SoundsCrackles (Rales) •Discontinuous •Intermittent, non-musical, brief •Like dots in time •Crackles that do not clear with cough indicate abnormal lung tissue such as fluid (pulmonary edema) •If clears with cough, atelectasis or secretions
    79. 79. Adventitious SoundsWheezes •Continuous •Musical •High-pitched with hissing or shrill quality •Narrowing of airways
    80. 80. Adventitious SoundsRhonchi •Continuous •Relatively low-pitched •Snoring quality •Suggest secretions in large airways
    81. 81. Abdominal AssessmentAuscultation: •Normal sounds – clicks & gurgles •Occur at 5- to 15-second intervals •Absent = no sounds detected within 2 minutes •Hypoactive = less than normal •Hyperactive = more than normal •Listen for bruits
    82. 82. Abdominal AssessmentPalpation: •Soft, firm, or rigid •No masses or tenderness •Rebound pain (may suggest peritoneal inflammation or peritonitis)Inspection: •Concave, flat, protuberant, distended???
    83. 83. Genitourinary Assessment •Intake and output •Indicates both renal and cardiac function •Foley catheter •Check for orders and insertion date
    84. 84. ReferencesBickley, L. S. (2007). Bates’ pocket guide to physical examination and history taking, (5th ed.). Philadelphia, PA: Lippincott, Wilkins, and Williams.Davis, L. (2004). Cardiovascular nursing secrets: Your cardiovascular questions answered by exoerts you trust. St. Louis, MO: Elsevier Mosby.Donofrio, J., Haworth, K., Schaeffer, L., & Thompson, G. (Eds.). (2005). Cardiovascular care made incredibly easy. Ambler, PA: Lippincott, Williams, and Wilkins.Goldberg, K., Johnson, P., & Lear-Olimpi, M. (1997). Handbook of clinical skills. Springhouse, PA: Springhouse Corporation.Kozier, B., Erb, G., Berman, A., & Snyder, S. (2002). Kozier’s and erb’s techniques in clinical nursing: Basic to intermediate skills, (5th ed.). Upper Saddle, NJ: Prentice Hall.Moser, D. K., & Riegel, B. (2008). Cardiac nursing: A companion to braunwald’s heart disease. St. Louis, MO: Saunders Elsevier.Smeltzer et al. (2008). Brunner and suddarth’s textbook of medical-surgical nursing, (11th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.
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