Cardiac Assessment

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

Importance 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

Essentials 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!

Key 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 Dont take anything for GRANTED!
Always check things out, especially gut feelings

Key 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 youre not sure of their significance

History
Drives the physical assessment as well as the diagnostic studies and treatment Lays the groundwork for the nursepatient relationship Provides key information Should not be bypassed

History of Present Illness

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

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

NOPQRST
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

Cardiovascular Complaints Chest 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

Chest Pain or Pressure

Onset

Start suddenly or gradually most angina starts at low intensity and builds
Time of day that discomfort started - some MIs 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

Chest 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?

Chest 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

Chest 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

Chest 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.

Chest 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?

Dyspnea
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?

Cough 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

Palpitations
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

Syncope
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

Physical 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 patients privacy

Room should be quiet Perform assessment from patients right side

Physical 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 patients privacy

Room should be quiet Perform assessment from patients right side

Vital Signs
Blood Pressure
Hypotensive or Hypertensive

Heart Rate

Respiratory Rate O2 Saturation

Hypoxia/Hypoxemia Bradypneic or Tachypneic

Bradycardia or Tachycardia

Blood Pressure
Blood pressure is a measurement of the force exerted by blood as it pulsates through the arteries (Kozier et al, 2002),
SBP = CO x SVR

Blood Pressure
Systolic 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)

Blood Pressure
Blood 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

Blood Pressure
Hypotension: SBP < 90 and/or DBP < 60
Hypertension: SBP > 140 and/or DBP > 90

Blood 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

Orthostatic 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

Mean Arterial Pressure

Mean 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 = ______

Mean Arterial Pressure

MAP 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

Noninvasive BP Measurement
Two Common Noninvasive Indirect Methods of B/P Measurement Ausculatory & Palpatory

Ausculatory BP Measurement
External 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. Korotkoffs sounds

Korotkoffs Sounds

Palpatory BP Measurement
Used when Korotkoffs 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

Invasive BP Measurement
Common 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!!!!

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

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)

Heart Rate
Pulse 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)

Characteristics of a Pulse
Pulse should be characterized as:
Thready, weak, strong, or bounding Equal bilaterally or not Rhythm regular or irregular

Heart Rate & Blood Pressure

Blood pressure is directly affected by the heart rate Heart rate is directly affected by blood pressure

What does this mean?

Heart Rate & Blood Pressure

HR is Within Defined Parameters if 60100
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

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

Respiratory Rate
Respiratory 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)

Breathing Rates
Eupnea 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)

Breathing Rates
Cheyne-Stoke Fast, deep respirations of 30 170 seconds punctuated by periods of apnea lasting 20 60 seconds Kussmauls fast (over 20 per minute), deep (resembling sighs), labored respirations without a pause

(Goldberg et al, 1997, p. 764)

Factors 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)

Oxygen Saturation
Normal = 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)

Pulse Oximeter
2-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)

Factors Affecting 02 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)

Inspection
Lips/Tongue
Blue-tinged?

Dry/Cracked?

Consider:
Cyanosis lack of circulation Dehydration

Inspection
Skin:
Cyanosis/Pale?
Hair Distribution?

Redness?

Turgor?

Consider:
Cardiac or Vascular insufficiency

Dehydration

Assessment of Cardiac Perfusion and Pulmonary Congestion

WARM and DRY
No Congestion Normal Perfusion

WARM and WET

Congestion Normal Perfusion

COLD and DRY

No Congestion Low Perfusion

COLD and WET

Congestion Low Perfusion

Inspection

Neck:
Jugular Vein Distension?
Consider:
Right-sided heart failure

Hypervolemia
Cardiac Tamponade Constrictive Pericarditis

Inspection/Palpation
Nails:
Clubbing?
Color?

Thickness?
Capillary Refill?

Consider:
Cardiac or Vascular insufficiency Chronic cardiac or pulmonary disease

Capillary Refill
If greater than 3 seconds may indicate:
Dehydration Shock PVD

Hypothermia

Inspection
Abdomen:
Ascites?

Pulsating Mass?

Consider:
Right-sided heart failure Abdominal Aortic Aneurysm

Inspection
Lower Extremities:
Cyanosis/Pale? Redness? Hair Distribution? Turgor? Edema?

Consider:
Cardiac or Vascular insufficiency Left-sided Heart Failure

Inspection/Palpation
Legs/Ankles/Feet:
Edema? Pulses? Sensation?

Consider:
DVT Heart Failure Peripheral Vascular Disease

Pain?

Palpation
Upper Extremities:
Pulses?

Sensation?

Consider:
Peripheral Vascular Disease DVT

Edema 4-Point Scale

Grade Description
0 1+ 2+ 3+ 4+ None Trace Mild Moderate Severe

Depth of Indentation
N/A Up to -inch - to -inch - to 1-inch Greater than 1-inch

Pulse Points
Carotid Radial Brachial Evaluation for: Presence Laterality

Femoral
Popliteal Posterior Tibial Dorsalis Pedis

Strength

Pulse 4-Point Scale

Grade Description

0
1+

Absent
Palpable, but thready and weak; easily obliterated Normal, easily identified; not easily obliterated Increased pulse; moderate pressure for obliteration Full, bounding; cannot obliterate

2+
3+ 4+

Terminology of Pulse Variations

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)

General Points
When 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

Heart Sounds

First Heart Sounds

S1 = 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

Second 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 Erbs point

Third Heart Sounds

S3 = 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

Fourth Heart Sounds

S4 = 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

Murmurs

Systolic Murmurs
a)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

Diastolic Murmurs
a)Early diastolic
Aortic regurgitation

b) Middiastolic

Aka presystolic
Mitral stenosis

c) Late diastolic
Tricuspid stenosis Mitral stenosis Left-to-right shunts

Continuous Murmurs

Grading Murmurs
Gradation of Murmurs Grade 1 Grade 2
Grade 3 Grade 4 Grade 5 Grade 6

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

Quiet, but heard immediately after placing the stethoscope on the chest
Moderately loud Murmur is very loud, with palpable thrill 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 Murmur is exceptionally loud, with palpable thrill, and can be heard with the stethoscope just removed from contact with the chest.

Respiratory Assessment

Auscultate anteriorly and posteriorly Patient should be sitting up!

Normal Breath Sounds

Bronchial (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

Adventitious 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

Adventitious Sounds
Wheezes
Continuous

Musical
High-pitched with hissing or shrill quality Narrowing of airways

Adventitious Sounds
Rhonchi
Continuous

Relatively low-pitched
Snoring quality Suggest secretions in large airways

Abdominal 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

Abdominal Assessment
Palpation:
Soft, firm, or rigid No masses or tenderness Rebound pain (may suggest peritoneal inflammation or peritonitis)

Inspection:
Concave, flat, protuberant, distended???

Genitourinary Assessment
Intake and output
Indicates both renal and cardiac function

Foley catheter
Check for orders and insertion date

References
Bickley, 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). Koziers and erbs 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 braunwalds heart disease. St. Louis, MO: Saunders Elsevier. Smeltzer et al. (2008). Brunner and suddarths textbook of medical-surgical

nursing, (11th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.