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Cardiac Cardiac Assessment Assessment Natalie Bermudez, RN, BSN, MS Natalie Bermudez, RN, BSN, MS Clinical Educator for Cardiac Telemetry Clinical Educator for Cardiac Telemetry

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Page 1: Cardiac Assessment - BMH/Tele

Cardiac AssessmentCardiac Assessment

Natalie Bermudez, RN, BSN, MSNatalie Bermudez, RN, BSN, MSClinical Educator for Cardiac TelemetryClinical Educator for Cardiac Telemetry

Page 2: Cardiac Assessment - BMH/Tele

Importance of AssessmentImportance 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

Page 3: Cardiac Assessment - BMH/Tele

Essentials of AssessmentEssentials 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!

Page 4: Cardiac Assessment - BMH/Tele

Key Points of AssessmentKey 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”

Page 5: Cardiac Assessment - BMH/Tele

Key Points of AssessmentKey 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

Page 6: Cardiac Assessment - BMH/Tele

HistoryHistory

• 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

Page 7: Cardiac Assessment - BMH/Tele

History of Present History of Present IllnessIllness

• 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

Page 8: Cardiac Assessment - BMH/Tele

OLDCARTSOLDCARTS

• O = Onset• L = Location• D = Duration• C = Character• A = Aggravating/Alleviating factors• R = Radiation• T = Timing• S = Site

Page 9: Cardiac Assessment - BMH/Tele

NOPQRSTNOPQRST

• 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

Page 10: Cardiac Assessment - BMH/Tele

Cardiovascular ComplaintsCardiovascular Complaints

Chest Pain or PressureChest 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

Page 11: Cardiac Assessment - BMH/Tele

Chest Pain or PressureChest 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 1st begin – today or a few days ago???

• MI may occur with activity or after a heavy meal • Periods of increased myocardial demand

Page 12: Cardiac Assessment - BMH/Tele

Chest Pain or PressureChest 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?

Page 13: Cardiac Assessment - BMH/Tele

Chest Pain or PressureChest 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

Page 14: Cardiac Assessment - BMH/Tele

Chest Pain or PressureChest 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

Page 15: Cardiac Assessment - BMH/Tele

Chest Pain or PressureChest 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.

Page 16: Cardiac Assessment - BMH/Tele

Chest Pain or PressureChest 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?

Page 17: Cardiac Assessment - BMH/Tele

DyspneaDyspnea

• 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?

Page 18: Cardiac Assessment - BMH/Tele

Cough and HemoptysisCough 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

Page 19: Cardiac Assessment - BMH/Tele

PalpitationsPalpitations

• 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

Page 20: Cardiac Assessment - BMH/Tele

SyncopeSyncope

• 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

Page 21: Cardiac Assessment - BMH/Tele

Physical AssessmentPhysical 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

Page 22: Cardiac Assessment - BMH/Tele

Physical AssessmentPhysical 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

Page 23: Cardiac Assessment - BMH/Tele

Vital SignsVital SignsBlood Pressure

Hypotensive or Hypertensive

Heart RateBradycardia or Tachycardia

Respiratory RateBradypneic or Tachypneic

O2 SaturationHypoxia/Hypoxemia

Page 24: Cardiac Assessment - BMH/Tele

Blood PressureBlood 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

Page 25: Cardiac Assessment - BMH/Tele

Blood PressureBlood PressureSystolic 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)

Page 26: Cardiac Assessment - BMH/Tele

Blood PressureBlood 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 perfusion

Inadequate perfusion may be a result of high or low blood pressures

Page 27: Cardiac Assessment - BMH/Tele

Blood PressureBlood PressureHypotension: SBP < 90 and/or DBP < 60

Hypertension: SBP > 140 and/or DBP > 90

Page 28: Cardiac Assessment - BMH/Tele

Blood PressureBlood 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

Page 29: Cardiac Assessment - BMH/Tele

Orthostatic Blood PressureOrthostatic 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

Page 30: Cardiac Assessment - BMH/Tele

Mean Arterial PressureMean Arterial PressureMean 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 = ______

Page 31: Cardiac Assessment - BMH/Tele

Mean Arterial PressureMean Arterial PressureMAP 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

Page 32: Cardiac Assessment - BMH/Tele

Noninvasive BP Noninvasive BP MeasurementMeasurement

Two Common Noninvasive Indirect Methods of B/P Measurement

Ausculatory & Palpatory

Page 33: Cardiac Assessment - BMH/Tele

Ausculatory BP MeasurementAusculatory 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

Page 34: Cardiac Assessment - BMH/Tele

Korotkoff’s SoundsKorotkoff’s Sounds

Page 35: Cardiac Assessment - BMH/Tele

Palpatory BP MeasurementPalpatory 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

Page 36: Cardiac Assessment - BMH/Tele

Invasive BP MeasurementInvasive BP MeasurementCommon 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!!!!

Page 37: Cardiac Assessment - BMH/Tele

Factors Affecting BP: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

Page 38: Cardiac Assessment - BMH/Tele

Factors Affecting BP: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)

Page 39: Cardiac Assessment - BMH/Tele

Heart RateHeart 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)

Page 40: Cardiac Assessment - BMH/Tele

Characteristics of a PulseCharacteristics of a Pulse

Pulse should be characterized as:• Thready, weak, strong, or bounding

• Equal bilaterally or not

• Rhythm regular or irregular

Page 41: Cardiac Assessment - BMH/Tele

Heart Rate & Blood Heart Rate & Blood PressurePressure

Blood pressure is directly affected by the heart rate

Heart rate is directly affected by blood pressure

What does this mean…?

Page 42: Cardiac Assessment - BMH/Tele

Heart Rate & Blood Heart Rate & Blood PressurePressure

• 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

Page 43: Cardiac Assessment - BMH/Tele

Factors Affecting Heart Rate: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

Page 44: Cardiac Assessment - BMH/Tele

Respiratory RateRespiratory 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)

Page 45: Cardiac Assessment - BMH/Tele

Breathing RatesBreathing 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)

Page 46: Cardiac Assessment - BMH/Tele

Breathing RatesBreathing 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)

Page 47: Cardiac Assessment - BMH/Tele

Factors Affecting RRFactors 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)

Page 48: Cardiac Assessment - BMH/Tele

Oxygen SaturationOxygen SaturationNormal = 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)

Page 49: Cardiac Assessment - BMH/Tele

Pulse OximeterPulse Oximeter2-Part Sensor

1. 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 SaO2.

(Kozier et al, 2002)

Page 50: Cardiac Assessment - BMH/Tele

Factors Affecting 0Factors Affecting 022 Sat: 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)

Page 51: Cardiac Assessment - BMH/Tele
Page 52: Cardiac Assessment - BMH/Tele

InspectionInspection

Lips/TongueLips/TongueBlue-tinged?

Dry/Cracked?

Consider:Cyanosis – lack of circulation

Dehydration

Page 53: Cardiac Assessment - BMH/Tele

InspectionInspection

Skin:Skin:

Consider:Cardiac or Vascular insufficiency

Dehydration

Cyanosis/Pale?

Redness?

Hair Distribution?

Turgor?

Page 54: Cardiac Assessment - BMH/Tele

WARM and DRYNo Congestion

Normal Perfusion

WARM and WETCongestion

Normal Perfusion

COLD and DRYNo Congestion

Low Perfusion

COLD and WETCongestion

Low Perfusion

Assessment of Cardiac Perfusion and Pulmonary Congestion

Page 55: Cardiac Assessment - BMH/Tele

InspectionInspection

Neck:Neck:Jugular Vein Distension?

Consider:Right-sided heart failure

Hypervolemia

Cardiac Tamponade

Constrictive Pericarditis

Page 56: Cardiac Assessment - BMH/Tele

Inspection/PalpationInspection/PalpationNails:Nails:Clubbing?

Color?

Thickness?

Capillary Refill?Consider:

Cardiac or Vascular insufficiency

Chronic cardiac or pulmonary disease

Page 57: Cardiac Assessment - BMH/Tele

Capillary RefillCapillary Refill

If greater than 3 seconds may indicate:

•Dehydration

•Shock

•PVD

•Hypothermia

Page 58: Cardiac Assessment - BMH/Tele

InspectionInspection

AbdomeAbdomen:n:

Ascites?

Pulsating Mass? Consider:

Right-sided heart failure

Abdominal Aortic Aneurysm

Page 59: Cardiac Assessment - BMH/Tele

InspectionInspectionLower Extremities:Lower Extremities:

Cyanosis/Pale?

Redness?

Hair Distribution?

Turgor?

Edema?

Consider:Cardiac or Vascular insufficiency

Left-sided Heart Failure

Page 60: Cardiac Assessment - BMH/Tele

Inspection/PalpationInspection/PalpationLegs/Ankles/Legs/Ankles/

Feet:Feet:

Edema?

Pulses?

Sensation?

Pain?

Consider:DVT

Heart Failure

Peripheral Vascular Disease

Page 61: Cardiac Assessment - BMH/Tele

PalpationPalpation

Upper Extremities:Upper Extremities:

Pulses?

Sensation?

Consider:Peripheral Vascular Disease

DVT

Page 62: Cardiac Assessment - BMH/Tele

Edema 4-Point ScaleEdema 4-Point Scale

Grade 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

Page 63: Cardiac Assessment - BMH/Tele

Pulse PointsPulse Points•Carotid

•Radial

•Brachial

•Femoral

•Popliteal

•Posterior Tibial

•Dorsalis Pedis

Evaluation for:

•Presence

•Laterality

•Strength

Page 64: Cardiac Assessment - BMH/Tele

Pulse 4-Point ScalePulse 4-Point ScaleGrade 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

Page 65: Cardiac Assessment - BMH/Tele

Terminology of Pulse Terminology of Pulse VariationsVariations

•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)

Page 66: Cardiac Assessment - BMH/Tele
Page 67: Cardiac Assessment - BMH/Tele

General PointsGeneral 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

Page 68: Cardiac Assessment - BMH/Tele
Page 69: Cardiac Assessment - BMH/Tele

Heart Sounds

Page 70: Cardiac Assessment - BMH/Tele

First Heart SoundsFirst 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

Page 71: Cardiac Assessment - BMH/Tele

Second Heart SoundsSecond Heart Sounds

S2 = 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

Page 72: Cardiac Assessment - BMH/Tele

Third Heart SoundsThird 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

Page 73: Cardiac Assessment - BMH/Tele

Fourth Heart SoundsFourth 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

Page 74: Cardiac Assessment - BMH/Tele

Murmurs

Page 75: Cardiac Assessment - BMH/Tele

Systolic Murmursa)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

Page 76: Cardiac Assessment - BMH/Tele

Diastolic Murmursa)Early diastolic• Aortic regurgitation

b) Middiastolic• Aka presystolic

• Mitral stenosis

c) Late diastolic• Tricuspid stenosis

• Mitral stenosis

• Left-to-right shunts

Page 77: Cardiac Assessment - BMH/Tele

Continuous Murmurs

Page 78: Cardiac Assessment - BMH/Tele

Grading MurmursGrading MurmursGradation of

MurmursDescription

Grade 1 Very faint, heard only after listener has "tuned in"; may not be heard in all positions

Grade 2 Quiet, but heard immediately after placing the stethoscope on the chest

Grade 3 Moderately loud

Grade 4 Murmur is very loud, with palpable thrill

Grade 5 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 6 Murmur is exceptionally loud, with palpable thrill, and can be heard with the stethoscope just removed from contact with the chest.

Page 79: Cardiac Assessment - BMH/Tele

Respiratory AssessmentRespiratory Assessment

•Auscultate anteriorly and posteriorly

•Patient should be sitting up!

Page 80: Cardiac Assessment - BMH/Tele

Normal Breath SoundsNormal Breath SoundsBronchial (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

Page 81: Cardiac Assessment - BMH/Tele

Adventitious SoundsAdventitious 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

Page 82: Cardiac Assessment - BMH/Tele

Adventitious SoundsAdventitious Sounds

Wheezes•Continuous

•Musical

•High-pitched with hissing or shrill quality

•Narrowing of airways

Page 83: Cardiac Assessment - BMH/Tele

Adventitious SoundsAdventitious Sounds

Rhonchi•Continuous

•Relatively low-pitched

•Snoring quality

•Suggest secretions in large airways

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Page 85: Cardiac Assessment - BMH/Tele

Abdominal AssessmentAbdominal 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

Page 86: Cardiac Assessment - BMH/Tele

Abdominal AssessmentAbdominal Assessment

Palpation:•Soft, firm, or rigid

•No masses or tenderness

•Rebound pain (may suggest peritoneal inflammation or peritonitis)

Inspection:

•Concave, flat, protuberant, distended???

Page 87: Cardiac Assessment - BMH/Tele

Genitourinary Assessment Genitourinary Assessment

•Intake and output•Indicates both renal and cardiac function

•Foley catheter•Check for orders and insertion date

Page 88: Cardiac Assessment - BMH/Tele

ReferencesReferencesBickley, 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.