Cardiac AssessmentBy: Bryan Mae H. Degorio, RN, MAN

A. Risk Factor Analysis for Cardiovascular Diseases Gender and Age Family history of hypertension Family history of heart attack Family history of diabetes mellitus Cholesterol level Serum triglycerides Frequency of recreational activity Frequency of occupational exercise Cigarette smoking Stress at home and at work Behavioral pattern Use of oral contraceptives Air pollution Sleep Pattern

B. Biographic and Demographic Data- Name, age, sex, place of birth, race, marital status,

occupation and ethnic group

Race- heart disease has twice mortality to Native Americans - Black die twice in stroke compared to

white

Age- coronary artery disease are more fatal to those who have developed it young

- cardiovascular disease are common among the elderly

-NO such this as congenital RHDC. Past Health History

1. Childhood Illnesses- previous streptococcal infection and corrected congenital heart diseases

2. Immunization- cardiovascular disorders needs revaccination of influenza every 6-10 years

3. Major Illnesses and Hospitalization- pt. with DM, obstructive lung diseases, kidney problem, anemia, HPN, stroke, gout, thrombophlebitis, collagen diseases and bleeding disorders

-surgical procedures, OB history (complications of prev. pregnancy due to CVD), outpatient interventions and Dx procedures

4. Medication- use of herbs, OTC and recreation drug-note for the route, dosage and frequency of use

5. Allergies- foods, drugs and note for manifestation during acute attack

D. Family Health History

Provide insight for genetic, environmental and lifestyle related diseases that contribute to the occurrence of cardiac problem

Note for history of DM, HPN, stroke and kidney disorders in the family

Modifiable: stress, weight, cholesterol level, smoking and abuse

Non-modifiable: heredity, age, sex and raceE. Psychosocial History

1. Occupation- occupation stress, workload, job orientation (hard labor or sedentary work), occupational hazard, jobs that might not be compatible with existing CVD

2. Geographical Location- death caused by cardiac event where they live (ex: US and Philippines)

3. Environment

Home hazard such as area for repair, presence of stairs, and light condition

Transportation (mode and access to health care facility)

Neighborhood – noise pollution

Access to facility- hospital, church, grocery and pharmacy

Nurturing environment-conducive place for recovery

4. Exercise

Type of exercise (isotonic, isometric, isokinetic, passive, aerobic and anaerobic)

Aerobic exercises – lower the chance of developing coronary artery disease

Note: anaerobic exercises- increase of 50- 100% 0f the baseline HR at least 30 min. 3-5 times a week

Consult physician if to be performed by 40 y/o and above

Effects of sedentary lifestyle- increases the lethality of MI

5. Nutrition

Assess for caloric intake, Na, cholesterol and saturated fat including caffeine intake

Assess for economic and cultural status before recommending for dietary changes

Foods such as fruits, vegetables, low fat dairy products and saturated fat reduces the BP significantly

6. Habits

Smoking- nicotine and tar, assess for # of packs/day and the how long the client has been smoking-it increases coronary artery disease and worsen hypertension

Caffeine -↑the risk atherosclerosis

- ↑ HR and BP thus precipitating angina, palpitation and dysrhythmias- limit caffeine intake to 8 oz of coffee/day to those with known diseases

Alcoholism- an intake of 100 mg of alcohol (3 beer) may increase heart rate and BP-ask for daily and weekly consumption of alcohol - Note: client may lie about the type and amount of alcohol consumed (denial)

Physical Assessment- Cardiac Physical assessment includes the following:

General appearance

PB, pulses, jugular veins

Percuss, palpate and auscultate the heart

Evaluation of edema- How it is done?

Position client in supine position, stand at client’s side and elevate bed

From head to toe

Prepare the equipment- stethoscope, penlight, ruler and application stick

A. General Appearance- Restlessness, can the client lie or sit upright, signs of

pain, cyanosis, pallor and presence of dyspneaB. Head, Neck, Nails and Skin

Head- eyes, earlobe, lips and buccal mucosaa. Note for:

1. Arcus senilis – a light gray ring around the iris (may indicate cholesterol deposit)

2. Xanthelasma – yellow raised plaqued around the eyelids ( duse to lipid deposits)

Skin- assess foe central and peripheral cyanosisa. Central cyanosis- assess the skin, buccal

mucosa and nasal mucosa May indicate severe heart

and lung diseasesb. Peripheral cyanosis- check the nailbed,

earlobe and lips Indicates peripheral

vasocionstriction (ex: reynauds disease)

Nailsa. Capillary refill

Or blunch test Check capillary refill before giving

pulse oximeter Normal- 2 seconds

b. Clubbing of finger Normal- 160⁰ 180⁰ ↑- associated with prolong

oxygen deprivation Can be due to COPD or chronic

anemia c. Skin Turgor

Can be done by lifting a fold of skin over the sternum or lower arm or abdomen then release

N⁰- goes back immediately (2-3 seconds

Late- indicate dehydration, malnutrition and advancing age

d. Temperature Warm- associated with venous

disorders and thyrotoxicosis Cold- arterial occlusive disorders

and hypothyroidism

Edemaa. Note for the location of edema:

Lower extremities- mobile patients Buttocks or scapular – bed ridden

patients Peripheral edema- RSCHF Pulmonary edema (dyspnea and

crackles)- LSCHFC. Blood Pressure

- Measure BP initially in both arm- identify presence of coarctation, aneurysm, occlusive disorders and errors in reading

1. Postural Blood Pressure Done when extracellular volume depletion

and decrease vascular tone is suspected Position client in supine, sitting and standing Note the position while taking the blood

pressure Abnormal finding: A drop in blood pressure of

more than 10-15 mm Hg systolic and more than 10 mm Hg for diastolic pressure indicates postural hypotension

Hypotension is usually accompanied by 10-20% increase in the heart rate

2. Paradoxical Blood Pressure (Pulsus Paradoxus) An abnormal ↓of more than 10 mm Hg of

the systolic blood pressure during expiration Associated with : pericardial tamponade,

constrictive pericarditis and pulmonary hypertension

D. Pulses- Note bilateral pulse- Assess for pulse deficit by counting apical pulse

simultaneously with radial pulse- Note for weakness, thready and if it is bounding

E. Neck1. Neck Veins

Neck vein distention can be used to estimate CVP (Central Venous Pressure)

The amount of distention reflects pressure and volume changes in the Right Side of the Heart

a. External jugular Vein- easy to detect but can be altered by little changes in position

b. Internal Jugular Vein- most reliable indication of CVP

How it is done: 1. Elevate the head by 15-30⁰2. 45-90⁰ for those with increase right

atrial pressure3. Internal jugular vein is just located or

lies deep in the sternocleidomastoid4. Place the ruler on the sternal angle5. Measure the pulsation6. N⁰- < 3-4 cm and an ↑ indicates RSCHF

and pericardiac tamponade7. Contralateral distention indicates

onbstructions 2. Carotid Artery

Indicates adequacy of stroke volume and patency of the arteries

Palpate one side at a time- simultaneous palpation stimulates carotid sinuses causing bradycardia and sinus arrest

Note for Bruits- a blowing sound heard using the diaphragm of the stethoscope

It indicates narrowing of carotid arteryF. Chest

1. Pericardium

Note for size, symmetry and evidence of any pulsation – record its location in relation to MCL and IS

PMI (Point of Maximal Impulse)- 5th Intercostal

Space MCL It is associated to left ventricular

contraction Prominent in thin and obscure in fat of

have large breast 2 fingerbreadths below the nipple or 2

cm If deviated- can be due to Right or left

Sided Cardiomegaly

Note for presence of heaves or lifts These are visible pulsation associated to

pulmonary hypertension

Thrills These are rushing vibration palpated in

5 cardiac auscultatory region that may indicate murmur

Represent turbulent blood flow through the heart especially across an abnormal heart valves

2. Heart Sounds

Cardiac Auscultatory Site Aortic- second intercostals space Right

of the sternum

Pulmonic area- second intercostals space Left of the sternum

Erb’s Point- 3rd intercostals space Left of the sternum

Tricuspid area- 5th intercostal space on the left side of the sternum

Mitral area- 5th intercostals space MCL left side

Notes: Low pitch- Bell of the stethoscope High pitch- diaphragm

Normal Heart Sounds: First Heart Sound (S₁)

a. Closure of the AV valves during ventricular contraction

b. Heard best at mitral and tricuspid region

c. It is equivalent to carotid artery pulsation or upstroke of R wave in QRS complex

d. Its intensity varies according to certain pathologic condition such as stenosed AV valves

Second Heart Sound (S2)a. The closure of the semilunar

valves during ventricular relaxationb. It marks the end ventricular systole

and onset of diastole (ventricular filling)

c. Best heard in aortic and pulmonic area using the diaphragm

Physiologic Splitting of S₂a. Normalb. Due to delayed closure of the

pulmonic valvesc. Best heard during inspiration

- causes negative pressure in the thoracic cavity→ pulling of blood on the right ventricles→ delayed emptying→ delayed closure of the pulmonic valves as heard as split second heard sound

Abnormal Heart Sounds Pathologic Splitting

a. Wide splitting of S₂b. Heard best during inspiration and

expiration with an increase during inspiration

c. Associated with bundle branch block→ delayed ventricular impulse transmission→ delayed depolarization→ late closure of pulmonic valves

d. Associated with atrial septal defects

e. Fixed Splitting- due to prolong emptying of the right ventricle

f. Paradoxical Splitting- due to stenosed aortic valve which is heard best during expiration

Gallopa. Diastolic filling sounds (S₃ and S₄)b. Due to sudden changes of inflow

volume causing vibration of the valves and the ventricular supporting structures producing low pitch sound either early (S₃) or late (S₄) as diastole

S₃a. during passive and rapid filling of the ventricles

b. Early gallop that is heard during early diastolec. It follow immediately after S₂ and is dull and low pitch

soundd. N⁰ in children and young adulte. Older than 30- it is considered a characteristics of Left

ventricular dysfunction such as CHF, MI and Valvular incompetence

S₄a. Occurs in the later stage of diastole during atrial

contraction and active filling of the ventriclesb. Heard immediately before S₁ and is referred as atrial

gallopc. It is associated with ventricular hypertrophy, ischemia

and fibrosisd. Never heard in the absence of atrial contraction

Quadruple Rhythm Is noted when both S₃ and S₄ are audible Client with this heart sound often have

tachycardia which causes the diastolic filling sound to fuse forming summation gallop that maybe louder than S₁ and S₂

It resembles the sound of a galloping horse

Clicks- are extracardiac sound that can be heard anytime during the cardiac cycle in client with aortic stenosis, valve prolapsed and prosthetic valves

Pericardial Friction Rub Is produced by inflammation of the

pericardial sac It is describe as a scratchy, grating,

rasping and much like “squeaky leather” sound

Heard through the respiratory cycle not like pleural friction rub that occur during inspiration

The roughened parietal and visceral layers of the pericardium against each other during cardiac motion

Murmur Is heard as consequence of the turbulent

blood flow through the heart and blood vessels

It is caused by:a. ↑ rate or velocity of the blood

flowb. Abnormal forward and backward

flow in the stenosed or incompetent valves

c. Dilated chamberd. Flow through abnormal passage

between heart chambers (VSD, ASD and TOF)

Systolic murmura. Also called “benign murmur”b. Often caused by vigorous

contraction of the myocardium or strong blood flow

c. Common in children and adults younger than 50 and pregnant women

Diaslotic Murmura. A pathologic condition and is

produced by the mitral and tricuspid valve stenosis or aortic and pulmonic insufficiency

Note the characteristics:

a. Loudnessb. Locationc. Pitch- high or low, musical, harsh,

blowing or buzzingd. Place and duratione. Quality- crescendo, decrescendo or

plateauf. Radiation- sounds radiate to other

part of the body (aortic radiates to carotid artery and mitral murmur radiates to axilla)

g. Variation- changes occur with movement

Grade the Loudnessa. Grade I- faintb. Grade II- Faint heard immediatelyc. Grade III- Moderately loudd. Grade IV- Loude. Grade V- Very loud, heard only

with stethoscopef. Grade VI- very loud, heard even

without stethoscope3. Lungs

Tahcypnea

Crackles Adventitious sound heard in a fluid filled

lungs Common in LSCHF and heard well in the base

of the lungs

Blood Tinged Sputum May indicate acute pulmonary edema

accompanied by crackles

Cheyne-Stoke Respiration Deep breathing with period of apnea Common in patients with heart failure and

anemia4. Abdomen

Ascitis due to fluid accumulation in the peritoneal

cavity can be due to chronic right ventricular failure

Bowel Sounds ↓ indicate potassium depletion Loud bruits above the umbilicus may indicate

aortic aneurysm or stenosis5. Do the Following:

Allen’s Test Use to assess blood supply to the upper

extremities particularly the hand As the pt have close fist (tight)→ compress

the ulnar and radial artery→ have the client open his hands (n⁰- pale and mottled- released the radial pulse- n⁰ hands regain color in about 6 seconds)

Homan’s sign Pain in the calfs Done by compressing the gastrocnemius or

quickly dorsiflexion Note for pain