Cardiac Assessment Toni Standley RN ANP MSN Porter Adventist Hospital.

Cardiac Assessment

Toni Standley RN ANP MSN

Porter Adventist Hospital

Cardiovascular Assessment

♥Obtaining health history

♥Physical exam

♥Assessment of patient’s heart and vascular system

Obtaining a Health History

♥ Introduce yourself♥Chief complaint♥Cardiac risks♥Other ailments♥Personal and family history

Chest Pain Assessment another side story

♥Description♥Location♥Duration♥Radiation♥Pain scale♥ Intensity

Chest Pain Assessment cont.

♥Associated Symptoms

♥Precipitating Factors

♥Alleviating Factors

“The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.”

E. Braunwald

Heart Failure Defined

Congestive Heart Failure assessment

♥Weight Gain♥Difficulty Breathing♥PND♥Swelling♥Medication Compliance♥Diet/Salt Intake♥Oxygen Use

BNP Relationship to NYHA Objective Vs. Subjective

Evaluation

Triage BNP package insert.

NYHA I NYHAII NYHA III NYHA IV

Cardiac Risks a side story

♥Hypertension ♥Hyperlipidemia♥Diabetes♥Smoking♥Obesity♥Age♥Family history

MEDICATIONS - A side story

♥ Beta Blockers♥ Aspirin♥ Ace Inhibitors/ ARBS♥ Diuretics♥ Statins♥ Calcium channel blockers♥ Plavix♥ Antiarrythmics/Digoxin

PERSONAL AND FAMILY HISTORY - A side story

♥Married?♥ Children?♥ Occupation?♥ Activities?♥ Living arrangements?♥ Caffeine intake?♥ ETOH intake?♥ Family medical history?

Performing a Physical Assessment

♥Consistent, Methodical Approach♥Regular Practice♥Stethoscope with a Bell and

Diaphragm♥Appropriate size blood pressure cuff

Performing a Physical Assessment

♥Consistent, Methodical Approach♥Vital signs♥EKG♥Lab values♥Previous/recent tests – treadmills,

cardiac catherizations, by-pass surgery, previous hospitalizations.

Assessing the Heart pay attention!

♥ Inspection:– Overly thin?– Obese?– Alert?– Anxious?

♥ Inspect patient’s precordium:– Pulsations?– Symmetry of Movement?– Retractions or Heaves?

Assessing the Heart continues…

♥Palpation with the Heart:– Gentle Touch – Find Apical Pulse; associated with first heart

sound and carotid pulsation

– Heaves– Thrills– Fine Vibrations; purring of the cat

♥Percussion– Begin Anterior Axillary Line– Continue toward Sternum along the 5th

Intercostal Space– Dullness over Midclavicular Line; left

border of the heart

– Difficult in Obese and Female patients

♥Auscultation– Methodical Approach and Lots of

Practice– Auscultate over the 4 Cardiac Valves– Use Bell for Low Pitch Sounds and

Diaphragm for High Pitch Sounds– Listen with Patient in 3 Positions; on back

with HOB, 30 to 45 degrees, sitting up and lying on left side

Heart Sounds Anatomy

♥Auscultation continues…

– Basic Heart Sound S1

– Heard at the beginning of Systole– Closure of Mitral and Tricuspid Valves

– Heard at the End of Systole– Closure of Pulmonic and Aortic Valves

– Abnormal Heart Sound S3 ; Ventricular Gallop Rhythm

– End of Diastole– Immediately after S2

– Heard Best: ♥over Mitral Area♥with Bell

– Abnormal Heart Sound S3 ; Ventricular Gallop Rhythm

– End of Diastole– Immediately after S2

– Heard Best: ♥over Mitral Area♥with Bell

♥ Auscultation continues…

– Abnormal Heart Sound S4 ; Summation Gallop

– Early in Diastole– Precedes S1

– Heard Best: ♥ over Mitral Area♥with Bell

– Associated with increased left Atrial Pressure caused by noncompliant LV; Hypertension, Cardiomyopathies and Ischemic Heart Disease

♥ Auscultation continues…

– Abnormal Heart Sound S4 ; Summation Gallop

– Early in Diastole– Precedes S1

– Heard Best: ♥ over Mitral Area♥with Bell

– Associated with increased left Atrial Pressure caused by noncompliant LV; Hypertension, Cardiomyopathies and Ischemic Heart Disease

– Aortic valvular stenosis murmer– Heard best at 2nd right interspace– Harsh rough quality with a cresendo-

decresendo medium– Heard best with the Diaphragm– Radiates to the Carotid Arteries

– Aortic valvular stenosis murmer– Heard best at 2nd right interspace– Harsh rough quality with a cresendo-

decresendo medium– Heard best with the Diaphragm– Radiates to the Carotid Arteries

– Mitral Insufficiency or Regurgitation– Heard best at the Apex or Mitral Area– High Pitched Blowing Quality Murmur– Radiates toward the Axilla– Heard best with the Diaphragm

– Aortic Insufficiency– Heard best at the 3rd left Interspace– High Pitched Blowing Sound– Radiates toward the Sternum– Heard best with the Diaphragm

Assessing the Vascular System

♥ Inspection– Similar to cardiac System– Inspect the Skin; Lesions, scars, clubbing,

and edema of the extremities

– Inspect the Neck; carotid artery, jugular veins

– JVD; Patient on back with HOB 30 to 45 degrees

Assessing the Vascular System cont.

♥Palpitation– Patient skin; capillary refill, temperature,

texture and turgor

– Arms and Legs; temperature and edema 1 to 4 plus

– Arterial pulses; carotid, radial, femoral, popliteal, posterior tibial and dorsalis pedis

– Grade pulses; 1+ (weak) to 4+ (bounding)

Assessing the Vascular System cont.

♥Auscultation– Use the Bell– Listen over each artery; hum or bruit – Assess Upper abdomen for abnormal

pulsation; possible abdominal aortic aneurysm

– Femoral and popliteal pulses; checking for bruit and other abnormal sounds

Upon Diagnosis…

♥ Assessment: - Angina? - Myocardial Infarction or ACS - Decompensated CHF - Pericarditis - Atrial Fibrillation or other arrythmias - Valvular Heart disease or endocarditis

Upon Diagnosis..

In conclusion…

♥ Plan: - Telemetry: (LifePak) - Labs: Troponins, BNP, electrolytes, lipids: - Treadmill tests: Nuclear, stress echo - Echocardiograms: - Cardiac catherization - Medication adjustments - Diet – I/O – Daily weights

B-TYPE NATRIURETIC PEPTIDE (BNP)

1. Burnett JC, J Hypertens 2000

♥ B-Type Natriuretic Peptide (BNP) is a cardiac neurohormone specifically secreted from the cardiac ventricles as a response to:

• ventricular volume expansion

• pressure overload

• resultant increased wall tension1

♥ FDA cleared the first BNP test for use as a diagnostic aid in 2000

BNP Function

♥ Found primarily in the cardiac ventricles

♥ Is strongly induced during ventricular-wall

tension or stretch

♥ Potent natriuretic, diuretic, and vasorelaxant

peptide

♥ Inhibits sympathetic tone, renin- angiotensin

axis, and synthesis of vasoconstrictor molecules

Maisel et, al Reviews in Cardiovascular Medicine 2003

Heart Failure Pathophysiology

Myocardial injury Fall in LV performance

Activation of RAAS, SNS, ET,AVP, and others

Myocardial toxicity Peripheral vasoconstrictionHemodynamic alterations

Remodeling andprogressive

worsening ofLV function Heart failure symptomsMorbidity and mortality

The Natriuretic Peptide System is Overwhelmed in Acute

Decompensated Heart Failure

Adapted from Burnett JC, J Hypertens 1999

Angiotensin II

EndothelinANP BNP

Aldosterone

Epinephrine

Documentation of the Cardiovascular Assessment

♥ AMI COR Measures– ACE/ARB contraindicated or for LVSD– ASA on arrival or Contraindicated and on

Discharge– Beta Blocker on Admission and Discharge and

if Contraindicated– LDL Assessment– Lipid Lowering Medication and/or if

Contraindicated– Smoking Cessation or N/A

Documentation of the Cardiovascular Assessment

♥CHF Core Measures– ACE/ARB Contraindicated– ACE/ARB if EF <40%– Discharge Instruction– LVF– Smoking Cessation or N/A

The End

Cardiac Assessment Toni Standley RN ANP MSN Porter Adventist Hospital.

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