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 < 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

Cardiac Assessment - BMH/Tele Cardiac Assessment - BMH/Tele Presentation Transcript

  • Cardiac Assessment Natalie Bermudez, RN, BSN, MS Clinical Educator for Cardiac Telemetry
  • 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
  • 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!
  • 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”
  • 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
  • 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
  • History of Present Illness
    • Why is the patient seeking care?
    • Have patient describe in his/her own words
    • Presenting Symptoms:
    • Ask patient to describe symptoms
    • Use a systematic approach to evaluating symptoms
      • OLDCARTS
      • NOPQRST
  • OLDCARTS
    • O = Onset
    • L = Location
    • D = Duration
    • C = Character
    • A = Aggravating/Alleviating factors
    • R = Radiation
    • T = Timing
    • S = Site
  • 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
  • Cardiovascular Complaints
    • Chest 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
  • Chest Pain or Pressure
    • Onset
    • 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 1 st begin – today or a few days ago???
    • MI may occur with activity or after a heavy meal
      • Periods of increased myocardial demand
  • Chest Pain or Pressure
    • Precipitation, 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?
  • Chest Pain or Pressure
    • Quality 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
  • Chest Pain or Pressure
    • Radiation 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
  • Chest Pain or Pressure
    • Severity 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.
  • Chest Pain or Pressure
    • Time and Treatment
    • Length of time since onset of symptoms
    • How long do the symptoms last?
    • Treated in the past for the same symptoms?
  • 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?
  • 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
  • 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
  • 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
  • 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
  • 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
  • Vital Signs Blood Pressure Hypotensive or Hypertensive Heart Rate Bradycardia or Tachycardia Respiratory Rate Bradypneic or Tachypneic O 2 Saturation Hypoxia/Hypoxemia
  • Blood Pressure
    • Blood pressure is a measurement of the force exerted by blood as it pulsates through the arteries (Kozier et al, 2002),
    • SBP = CO x SVR
  • 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 rest
    • DBP is the lower pressure that is present at all times within the arteries
    • (Kozier et al, 2002, p. 33)
  • Blood Pressure
    • Blood 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 perfusion
    • Inadequate perfusion may be a result of high or low blood pressures
  • Blood Pressure
    • Hypotension: SBP < 90 and/or DBP < 60
    • Hypertension: 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 support
      • Place cuff over brachial artery
      • Use appropriate cuff size
        • Too small – falsely elevated BP
        • Too big – falsely decreased BP
  • 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
  • Mean Arterial Pressure
    • Mean Arterial Pressure (MAP)
    • Range = 70 – 110 mmHg
    • The average pressure of the arteries
    • MAP = (2 x DBP) + SBP
    • 3
    • MAP is multiplied by 2 because diastolic phase lasts longer than the systolic phase
    • If B/P 120/75, then MAP = ______
  • Mean Arterial Pressure
    • MAP is the average arterial pressure during a cardiac cycle
    • MAP is considered to be the perfusion pressure seen by organs in the body
    • MAP that is > 60 mmHg is enough to sustain the organs of the average person
    • If MAP is < 60 mmHg, then the organs are not being adequately perfused and they will become ischemic
  • Noninvasive BP Measurement
    • Two Common Noninvasive Indirect Methods of B/P Measurement
    • Ausculatory & Palpatory
  • Ausculatory BP Measurement External 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
  • Korotkoff’s Sounds
  • Palpatory BP Measurement Used 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
  • 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!!!!
  • 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
  • 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)
  • Heart Rate Pulse 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)
  • Characteristics of a Pulse
    • Pulse should be characterized as:
    • Thready, weak, strong, or bounding
    • Equal bilaterally or not
    • Rhythm regular or irregular
  • Heart Rate & Blood Pressure Blood pressure is directly affected by the heart rate Heart rate is directly affected by blood pressure What does this mean…?
  • 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
  • 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
  • Respiratory Rate Respiratory 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)
  • Breathing Rates Eupnea – 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)
  • Breathing Rates Cheyne-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)
  • 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)
  • Oxygen Saturation Normal = 95% - 100% Below 70% is life threatening Pulse oximeter - measures arterial blood oxygen saturation Can detect hypoxemia before clinical signs & symptoms are apparent (Kozier et al, 2002)
  • Pulse Oximeter
    • 2-Part Sensor
    • Two light-emitting diodes (LEDs) – one red and one infrared
    • Transmit light through nails, tissue, venous blood, & arterial blood
    • 2. 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 SaO 2 .
    • (Kozier et al, 2002)
  • Factors Affecting 0 2 Sat:
    • Hemoglobin : regardless of low Hemoglobin levels, if the hemoglobin is fully saturated the SaO 2 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)
  •  
  • Inspection Lips/Tongue Blue-tinged? Dry/Cracked? Consider: Cyanosis – lack of circulation Dehydration
  • Inspection Skin: Consider: Cardiac or Vascular insufficiency Dehydration Cyanosis/Pale? Redness? Hair Distribution? Turgor?
    • WARM and DRY
    • No Congestion
    • Normal Perfusion
    • WARM and WET
    • Congestion
    • Normal Perfusion
    • COLD and DRY
    • No Congestion
    • Low Perfusion
    • COLD and WET
    • Congestion
    • Low Perfusion
    Assessment of Cardiac Perfusion and Pulmonary Congestion
  • Inspection Neck: Jugular Vein Distension? Consider: Right-sided heart failure Hypervolemia Cardiac Tamponade Constrictive Pericarditis
  • Inspection/Palpation Nails: Clubbing? Color? Thickness? Capillary Refill? Consider: Cardiac or Vascular insufficiency Chronic cardiac or pulmonary disease
  • Capillary Refill
    • If greater than 3 seconds may indicate:
      • Dehydration
      • Shock
      • PVD
      • Hypothermia
  • Inspection Abdomen: Ascites? Pulsating Mass? Consider: Right-sided heart failure Abdominal Aortic Aneurysm
  • Inspection Lower Extremities: Cyanosis/Pale? Redness? Hair Distribution? Turgor? Edema? Consider: Cardiac or Vascular insufficiency Left-sided Heart Failure
  • Inspection/Palpation Legs/Ankles/Feet: Edema? Pulses? Sensation? Pain? Consider: DVT Heart Failure Peripheral Vascular Disease
  • Palpation Upper Extremities: Pulses? Sensation? Consider: Peripheral Vascular Disease DVT
  • Edema 4-Point Scale Greater than 1-inch Severe 4+ ½- to 1-inch Moderate 3+ ¼- to ½-inch Mild 2+ Up to ¼-inch Trace 1+ N/A None 0 Depth of Indentation Description Grade
  • Pulse Points
    • Carotid
    • Radial
    • Brachial
    • Femoral
    • Popliteal
    • Posterior Tibial
    • Dorsalis Pedis
    • Evaluation for:
    • Presence
    • Laterality
    • Strength
  • Pulse 4-Point Scale Increased pulse; moderate pressure for obliteration 3 + Full, bounding; cannot obliterate 4 + Normal, easily identified; not easily obliterated 2 + Palpable, but thready and weak; easily obliterated 1 + Absent 0 Description Grade
  • Terminology of Pulse Variations
    • Pulsus Magnus – strong and bounding
    • Pulsus Parvus – thready
    • Pulsus Alternans – large amplitude followed by low amplitude (with a regular rhythm)
    • Pulsus Bisferiens – double-peaked systolic impulse (cardiomyopathy)
    • Water-Hammer pulse – rapid rising and collapsing (aortic regurgitation)
  •  
  • General Points
    • When assessing heart sounds:
      • Need a quiet room
      • Stand to the right of the patient
      • Having patient roll slightly to the left accentuates S 3 , S 4 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
  •  
  • Heart Sounds
  • First Heart Sounds
    • S 1 = 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
  • Second Heart Sounds
    • S 2 = 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
  • Third Heart Sounds
    • S 3 = Lub Dub Da
      • 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
  • Fourth Heart Sounds
    • S 4 = Da Lub 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
  • Murmurs
  • Systolic Murmurs
    • 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
  • Diastolic Murmurs
    • Early diastolic
    • Aortic regurgitation
    • b) Middiastolic
    • Aka presystolic
    • Mitral stenosis
    • c) Late diastolic
    • Tricuspid stenosis
    • Mitral stenosis
    • Left-to-right shunts
  • Continuous Murmurs
  • Grading Murmurs Murmur is exceptionally loud, with palpable thrill, and can be heard with the stethoscope just removed from contact with the chest. Grade 6 Murmur is extremely loud, with palpable thrill, and can be heard if only the edge of the stethoscope is in contact with the skin, but cannot be heard if the stethoscope is removed from the skin Grade 5 Murmur is very loud, with palpable thrill Grade 4 Moderately loud Grade 3 Quiet, but heard immediately after placing the stethoscope on the chest Grade 2 Very faint, heard only after listener has &quot;tuned in&quot;; may not be heard in all positions Grade 1 Description Gradation of Murmurs
  • Respiratory Assessment
        • Auscultate anteriorly and posteriorly
        • Patient should be sitting up!
  • Normal Breath Sounds
    • Bronchial (upper)
      • Expiratory longer than inspiratory
      • Loud and higher in pitch
    • Bronchovesicular (middle)
      • Equal inspiratory and expiratory
    • Vesicular (lower)
      • Soft or low pitched
      • Heard through inspiration and 1/3 expiration
  • Adventitious Sounds
    • Crackles (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
  • Adventitious Sounds
    • Wheezes
      • Continuous
      • Musical
      • High-pitched with hissing or shrill quality
      • Narrowing of airways
  • Adventitious Sounds
    • Rhonchi
      • Continuous
      • Relatively low-pitched
      • Snoring quality
      • Suggest secretions in large airways
  •  
  • Abdominal Assessment
    • Auscultation:
      • 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
  • Abdominal Assessment
    • Palpation:
      • Soft, firm, or rigid
      • No masses or tenderness
      • Rebound pain (may suggest peritoneal inflammation or peritonitis)
    • Inspection:
      • Concave, flat, protuberant, distended???
  • Genitourinary Assessment
      • Intake and output
        • Indicates both renal and cardiac function
      • Foley catheter
        • Check for orders and insertion date
  • References
    • Bickley, L. S. (2007). Bates’ pocket guide to physical examination and history taking, (5 th 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, (5 th 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, (11 th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.