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Study Guide for Cardiac Assessment
Anatomy and Physiology
Base
Apex
Pericardium
- Parietal
- Visceral
Precordium, Apex, and Base
Anatomy and Physiology
Chambers of the heart
- Right and left atria
- Right and left ventricles
Heart Valves
- Semilunar valves
- Pulmonic
- Aortic
- Atrioventricular valves (A-V)
- Tricuspid
- Mitral
Conduction
Heart has unique ability: automaticity
SA node has intrinsic rhythm, it is called the pacemaker
Current flows in orderly sequence, SA to AV to bundle of His, right and left bundle branches, and then through ventricles
Electrical impulse stimulates heart to do its work, which is to contract
Small amount of electricity spreads to body surface, and can be measured and recorded on electrocardiograph (ECG)
ECG
ECG waves arbitrarily labeled PQRST, which stand for
- P wave: depolarization of atria
- P-R interval: from beginning of P wave to beginning of
- QRS complex (time necessary for atrial depolarization plus time for impulse to travel through AV node to ventricles)
- QRS complex: depolarization of ventricles
- T wave: repolarization of ventricles
Electrical events slightly precede mechanical events in heart
Conditions Related to Coronary Circulation
Ischemia
Infarction
Angina
Cardiac Output
CO = SV x HR
- CO = Cardiac Output
- Stroke Volume (SV)
- Volume of blood ejected by the ventricles in one cardiac cycle
- Heart Rate (HR)
- Number of cardiac cycles in one minute
Problems Associated with Decreased Cardiac Output
Loss of blood volume
- ______
- Hemorrhagic
- Burns, Emesis, etc.
Heart Rate
- Tachycardia
- Bradycardia
Pump Issues
- Coronary Circulation
- Angina Pectoris
- ______
- Congestive Heart Failure (CHF)
- Trauma
- Direct
- Indirect
Peripheral Vasculature
Arterial system
- Arteries
- Arterioles
- Capillaries
Venous system
- Veins
- Venules
Subjective Data
Chest pain
Palpitations
Syncope
Dyspnea
Orthopnea
Cough
Fatigue
Cyanosis or pallor
Edema
Vascular
- Claudication
- DVT
Past cardiac history
Family cardiac history
Personal habits (cardiac risk factors)
Chest Pain…Cardiac? Something Else?
Chest Pain - Cardiac
- Angina, MI, pericarditis
Other concerns
- Differentiate between cardiac, respiratory, musculoskeletal, gastrointestinal or psychosomatic
Past Health History
Medical
- Cardiac specific: AAA, angina, CAD, CHF, HTN, MI, PVD, hyperlipidemia
- Noncardiac specific: bleeding or blood disorder, DM, gout, renal artery disease, CVA, or thyroid disease
Surgical
- Prior cardiovascular procedures: aneurysm repair, coronary bypass graft surgery (CABG), heart transplant, valve replacement, implantable or internal cardioverter or defibrillator (ICD)
Common medications
- Antianginals or vasodilators
- Antidysrhythmics
- Anticoagulants
- Antihypertensives
- Antilipemics
- Diuretics
- Inotropics
- Thrombolytics
Communicable diseases
Childhood illnesses
Allergies
- Aspirin
- ______
- Seafood
- Betadine
- Latex
Family Health History
Assess for the following diseases
- Aneurysm – AAA (abdominal aortic aneurysm)
- CAD (coronary artery disease)
- CVA (stroke)
- HTN (hypertension)
- CHF (congestive heart failure)
- MI or sudden cardiac death
- MVP (mitral valve prolapse)
- Rheumatic fever
Social History
Alcohol, drug, or tobacco use
Sexual practices
Work and home environment
Stress
Health Maintenance Activities
Sleep
Diet
Exercise
Health checkups
Patient Education
Risk factor modification
Heart Smart diet
Exercise
Sexual activity
Risk Factors
______
- HTN, hyperlipidemia, tobacco use, physical inactivity, diet, glucose intolerance, stress, sedentary lifestyle, obesity
Nonmodifiable
- Age, gender, race, family history
AssessmentEquipment
Stethoscope
Sphygmomanometer
Watch with second hand
Assessment tips
Explain procedure
Ensure room is quiet and well lit
Expose patient’s chest only
Position patient in a supine or sitting position
Stand to the patient’s ______
Assessment of the Precordium and Peripheral vasculature
Inspection
Palpation
Auscultation
Inspection
Assess the following areas: aortic , pulmonic, midprecordial, tricuspid, and mitral
Normal findings: no visible ______except for the PMI in the mitral area
Palpation
Assess for pulsations, thrills, ______
Assess the following areas: aortic , pulmonic, midprecordial, tricuspid, and mitral
Normal findings
- No pulsations, thrills, or heaves palpated, except in the mitral area where the apical impulse may be palpated
Landmarks – APE To Man
A=Aortic 2nd ICS RSB
P=Pulmonic 2nd ICS LSB
E= Erb’s point 3rd ICS LSB
T= Tricuspid 4th ICS LSB
M= Mitral 5th ICS MCL
Auscultation
Warm stethoscope
Listen to all ______cardiac landmarks
Listen for at least a few cardiac cycles in each area
Listen first for S1 and S2, then for possible S3 and S4. Finally listen for murmurs, clicks and friction rubs
Normal Systolic Sound: S1
S1 – blood heaves against the closed mitral and tricuspid valves in the heart
High pitched – heard with diaphragm
Heard best at Apex –______area
LUB – dub
Normal Diastolic Sound: S2
Represents closure of aortic and pulmonic valves
Heard best at Base –______area
lub – DUB
Auscultation: Normal Findings
Aortic: S2 is louder than S1
Pulmonic: S2 is louder than S1
Midprecordial (______) both aortic and pulmonic murmurs by be heard
Tricuspid: S1 is louder than S2
Mitral: S1 is louder than S2
Mitral and tricuspid: S3 (gallop) may be heard in children, young adults, and pregnant women. S4 may indicate cardiac decompensation
Evaluating Cardiac Sounds
Rate
- Bradycardia
- Tachycardia
Rhythm
Murmurs, Gallops Clicks or Rubs
Abnormal Finding - Murmur
Blowing, whooshing, or rasping sounds
The result of vibrations caused by abnormal blood flow patterns
- valve does not close tightly (such as with mitral regurgitation)
- an irregularity in the shape of a heart chamber or one of the great vessels (such as an aortic aneurysm)
Blood is flowing through a narrowed opening or a stiff valve (such as with aortic stenosis).
Does not necessarily indicate a disease or disorder, and all heart disorders do not cause murmurs.
If difficult to hear
- Place in lateral recumbent position – low pitched, mitral – use bell
- Lean patient forward – high pitched, aortic or pulmonic – use diaphragm
Murmurs – Seven Descriptive Characteristics
Location (where it is loudest)
Radiation (from valves to adjacent anatomic areas)
Timing (systolic, diastolic)
Loudness/Intensity
Quality (description)
______(high, low)
Pattern (crescendo, decrescendo)
Grading Intensity of Murmurs
The intensity of murmurs range from grade 1/6 to 6/6. A murmur is said to be at least Grade 4/6 if associated with a ______
Abnormal Finding
Click
- ______Heart valves – mitral and aortic most common
- Click noted especially with mechanical valves, human tissue valves produce sounds similar to human valves – but may produce a murmur
Pericardial friction rub
- Caused by rubbing together of the inflamed visceral and parietal layers of the pericardium
- Noted in ______
- Characterize based on location, radiation, timing, quality and pitch
- Does not change with respiration
Bruits
Forpersons middle-aged or older, or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for presence of a bruit
- This is a blowing, swishing sound indicating blood flow turbulence; normally none is present
Lightly apply bell of stethoscope over carotid artery
Avoid compressing artery
- artificial bruit and could compromise circulation
Ask person to hold an exhaled breath so that tracheal breath sounds do not mask
Sometimes you can hear normal heart sounds transmitted to neck; do not confuse these with a bruit
Assessment of Arterial Pulses
Evaluate carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
Patient position
Characteristics: rate, rhythm, amplitude, symmetry
Other CV assessments
Carotid and Popliteal pulses
Dorsalis Pedis and Post-Tibial pulses
Capillary Refill
Peripheral Edema
CMS Check
C (______)
M (Motor function) – neuro function
S (Sensation)- neuro function
Homan’s Sign
Sharply dorsiflex foot toward tibia
- Should be no pain in calf muscle
- Tenderness could indicate DVT
If DVT suspected, measure calf circumference with nonstretchable tape measure
Notify ______
Not routine assessment; used in OB
Cardiovascular assistive devices
Artificial pacemakers, ICD
Hemodynamic monitoring
Antiembolic stockings
Chest tubes
EKG monitoring
IV Catheters
Infants
Heart rate best auscultated because radial pulses are hard to count accurately; use small (pediatric size) diaphragm and bell
- 170 bpm or more with crying or being active to 70 to 90 bpm with sleeping
Expect heart sounds to be louder in infants than in adults because of infant’s thinner chest wall.
Murmurs are relatively common in first 2 to 3 days because of fetal shunt closure
Children
Physiologic ______is common in children
Heart murmurs that are innocent (or functional) in origin are very common through childhood
- Most innocent murmurs have these characteristics
- Soft, relatively short systolic ejection murmur
- Medium pitch; vibratory
- Best heard at left lower sternal or midsternal border, with no radiation to apex, base, or back
Pregnancy
Enlarging uterus elevates diaphragm and displaces heart up and to left and rotates it on its long axis
- Heart sounds
- Exaggerated splitting of S1 and increased loudness of S1
- A loud, easily heard ______
- Heart murmurs
- Systolic murmur in 90% which disappears soon after delivery
Aging Adults
Chest often increases in anteroposterior diameter with aging
- More difficult to palpate apical impulse
- S4 often occurs in older people with no known cardiac disease
Systolic murmurs common, occurring in over 50% of aging people
Peripheral blood vessels grow more rigid with age, resulting in a condition called arteriosclerosis
Documentation
Chest symmetrical with no visible pulsations, masses, heaves, or scars. No tenderness from palpation of anterior and posterior thorax. No thrills. The abdominal aorta is not enlarged to palpation and there are no bruits. Apical pulse 2+, regular, 64 B/M. Positive S1 and S2. No murmurs, rubs, gallops, or S3 and S4 sounds. No jugular vein distension or carotid bruits. Carotid, brachial, radial, femoral pulses equal and present at a 1+ bilaterally equal. Popliteal, posterior tibial, dorsalis pedis present at a 1+ in left leg. Edema present at +1 in lower left leg. No edema in right leg. Capillary refill <2 seconds in fingers bilaterally and in toes. Negative Homan’s sign. No assistive devices present. ------Carl Smith, ADNS CVTC
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