Cardiac Examination Within the Role of the Cardiology

Nurse Practitioner

Victoria WilliamsCardiology Nurse Practitioner

University Hospital of Wales, Cardiff.

AIMS OF THE PRESENTATION

• To outline and demonstrate the importance of cardiac examination within the role of the nurse practitioner

• To instruct participants in the correct techniques for clinical examination.

Learning Outcomes

• To competently perform cardiac clinical examination on a well patient.

• To revise the underlying anatomy and physiology relating to cardiac pathology.

• To have an awareness of clinical signs and symptoms to enable appropriate referral to specialist services.

Background of the role.

• Established in 2010

• 4 members of staff

• All 4 practitioners are working towards Msc level qualification

• Co-ordination and management of nurse-led Acute Coronary Syndrome Unit

• Central point of contact from admission to discharge.

University Hospital of Wales

• Tertiary Cardiology centre

• Contracted to provide tertiary services to District General Hospitals within south east Wales

Advanced clinical skills

• All members of the team are at different stages of their Msc pathway

• all utilising advanced clinical skills as part of the role to enhance the service.

• Undertaking regular competency based training and assessment

Cardiology patients suitable to be clerked by the Nurse Practitioner

• Non-complex Acute Coronary Syndrome (ACS) patients

• ACS patients with additional co-morbidities

• Elective angiography patients

• Elective Pacing patients

Major Cardiovascular Presenting Complaints

• Chest Pain

• Dyspnoea

• Syncope

• Palpitations

• Peripheral oedema

Importance of taking a comprehensive History

• Obtaining an accurate history is the critical first step in determining the aetiology of a patient’s problem

• A large percentage of the time you will actually be able to make a diagnosis based on the history alone.

Complete cardiovascular history• Presenting complaint

• History of presenting complaint

• Past medical history

• Risk factors for Coronary Artery Disease

• Family history

• Drug history and allergies

• Social history

• Systems Review

SOCRATES

• Site• Onset• Character• Radiation [usually just if pain]. • Alleviating factors• Time course• Exacerbating factors• Severity• Associated symptoms. • Impact of symptoms on life: "Does it

interrupt your life".

Complete cardiovascular history• Presenting complaint

• History of presenting complaint

• Past medical history

• Risk factors for Coronary Artery Disease

• Family history

• Drug history and allergies

• Social history

• Systems Review

MJ THREADS:

• MI• Jaundice• TB• HTN • Rheumatic fever• Epilepsy• Asthma• Diabetes• Stroke

System Review

General• Weakness

• Fatigue

• Anorexia

• Change of weight

• Fever

• Lumps

• Night sweats

Cardiovascular• Pain

• Breathlessness

• Palpitations

• Syncope

• Ankle oedema

• Calf pain

• Orthopnea

• Intermittent claudication

System Review continued

Respiratory • breathlessness

• Wheeze

• Cough

• Sputum

• Haemoptysis

• Tachypnea

• infection

Gastro-intestinal/urinary• Loss of appetite• Weight loss• Nausea/vomiting• Pain• Indigestion• Changes in bowel habit• Haematemesis• PR bleeding• Swallowing difficulties• Dysphagia • Incontinence• Frequency• Urgency• Haematurea

System Review Continued

Neurological• Headaches• Dizzyness• Siezures• Collapse• Visual disturbances• Loss of balance• Muscle weakness

Musculoskeletal• Joint pains/stiffness• Recent injuries• Gait• swelling

System Review Continued

Genital • Pain/discomfort• Unusual bleeding• Menstruation• Sexual health• Erectile dysfunction

Clinical Examination

• Consent• Exposure• Position• Inspection• Palpation• Percussion• Auscultation

Establish the Stabilityof the Patient

• Airway

• Breathing

• Circulation

• Disability

• Exposure

• Comfortable/distressed• Dyspnoeic/fatigued• Pale/cyanosed• Dehydrated/volume

depleted• Congested/

oedematous/ volume overloaded

Inspection

Start with the hands:• Clubbing• Splinter haemorrhages• Palmer errythema • Muscle wasting• Janeway Lesion• Osler’s Nodes

Clubbing

Splinter Haemorrhages

Linear reddish brown lesions seen in nail bed. Prominent in this case of SBE

Janeway Lesion

Macular, blanching, not painful located on palms & soles (SBE)

Osler’s Nodes

Tender, papulopustules located on pulp of finger (SBE)

Exam: Hands

• Other points to note:

• Temperature• Perfusion• Pallor• Nicotine staining• Extensor tendon swellings (xanthomas)

PulseRate:• Normal sinus 60-100 bpm• Sinus bradycardia < 60 bpm• Sinus tachycardia > 100 bpmRhythm:• Sinus arrhythmia - varies with respiration• Intermittent irregularity – ectopic beats• Continuously irregular (irregularly irregular – atrial

fibrillation)

• Start by palpating the radial pulse

• At this site asses• Rate• Rhythm

• You should not asses volume at the radial artery

Carotid Palpation

• Carotid upstroke:

– brisk, normal or delayed

– volume: normal, increased or decreased

Exam: Head & Neck: FACE

• Jaundice

Exam: Head & Neck: FACE

Anaemia

Exam: Head & Neck: FACE

ARCUS XANTHELASMA

Exam: Head & Neck: FACE

• Cyanosis

Exam: Head & Neck: JVP

The JVP is best examined by

looking across the neck.

A double waveform should be seen for each cardiac cycle

Exam: Head & Neck: JVP

• Carotid Pulsation

• 1 per cardiac cycle• Palpable• Position independent• Does not enhance with hepato-jugular reflex

• JVP Pulsation

• 2 per cardiac cycle• Not palpable• Varies depending on position• Enhances with hepato-jugular reflex

Inspection of the chest

LookFor

ObviousDeformity

Pigeon Chest (pectus Carinitum)

Funnel Chest (Pectus excavatum)

Inspection of the chest

Look for obvious Scars:

Median Sternotomy

CABG, Valve, TX

Lateral Thoracotomy

Coarct repair

Palpation

Locate Apex Palpate for heaves and thrills

Exam: Praecordium

2nd

3rd 4th 5th

Intercostal Spaces

1 2 3

1 Mid Clavicular Line

2 Anterior Axillary Line

3 Mid Axillary Line

Auscultation

bell

Low pitched murmurs eg. Mitral StenosisPress hard enough only to make a seal with the skin

The ‘hole’ must be rotated to the bell in order for it to work

Exam: Auscultation

Diaphragm

Normal / High pitched murmurs. Use for general purpose auscultation

Exam: auscultation

1. Apex: Mitral Valve2. Sternal Edge:

Tricuspid Valve3. L 2nd Space:

Pulmonary Valve4. R 2nd Space: Aortic

Valve

Exam: auscultation

• Heart SoundsLub (S1)

Dub (S2)

First Second

Mitral Valve

Tricuspid Valve

Aortic Valve

Pulmonary Valve

Heart Murmurs: Systolic

Mitral Regurgitation

Tricuspid Regurgitation

First Second

Pan Systolic Murmur

Heart Murmurs: Systolic

First Second

Ejection Systolic Murmur

Aortic

Stenosis

Pulmonary

Stenosis

VSD

Heart Murmurs: Diastolic

First Second

Early Diastolic Murmur

Aortic Regurgitation

Heart Murmurs: Diastolic

First Second

Mid Diastolic Murmur

MitralStenosis

Auscultation

Mitral Murmurs

• Mitral Area

• Patient in Left Lateral

• Radiate to Axilla

Auscultation

Aortic Murmurs

• Aortic Area

• Sit Patient Forward

• Breath Held in Expiration

• Radiates to Carotids

• Any Questions?

Thank you for your attention.