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Focused Cardiovascular Assessment

Thiscoursehasbeenawarded2.0(two)contacthours Copyright2004byAMNHealthcareinassociationwithInteractMedical AllRightsReserved.Reproductionanddistribution OfthesematerialsareprohibitedwithouttheexpresswrittenauthorizationofAMNHealthcare. CourseExpires:October17,2014

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Disclaimer RN.comstrivestokeepitscontentfairandunbiased. Theauthor(s),planningcommittee,andreviewershavenoconflictsofinterestinrelationtothiscourse. ConflictofInterestisdefinedascircumstancesaconflictofinterestthatanindividualmayhave,which couldpossiblyaffectEducationcontentaboutproductsorservicesofacommercialinterestwithwhich he/shehasafinancialrelationship. Thereisnocommercialsupportbeingusedforthiscourse.Participantsareadvisedthattheaccredited statusofRN.comdoesnotimplyendorsementbytheproviderorANCCofanycommercialproducts mentionedinthiscourse. Thereisno"offlabel"usageofdrugsorproductsdiscussedinthiscourse. YoumayfindthatbothgenericandtradenamesareusedincoursesproducedbyRN.com.Theuseof tradenamesdoesnotindicateanypreferenceofonetradenamedagentorcompanyoveranother. Tradenamesareprovidedtoenhancerecognitionofagentsdescribedinthecourse. Note:Alldosagesgivenareforadultsunlessotherwisestated.Theinformationonmedications containedinthiscourseisnotmeanttobeprescriptiveorallencompassing.Youareencouragedto consultwithphysiciansandpharmacistsaboutallmedicationissuesforyourpatients. Acknowledgements RN.comacknowledgesthevaluablecontributionsof NadineSalmon,MSN,BSN,IBCLC,theClinicalContentSpecialistforRN.com.NadineisaSouthAfrican trainedRegisteredNurse,MidwifeandInternationalBoardCertifiedLactationConsultant.Nadine obtainedanMSNatGrandCanyonUniversity,withanemphasisonNursingLeadership.Herclinical backgroundisinLabor&DeliveryandPostpartumnursing,andshehasalsoworkedinMedicalSurgical NursingandHomeHealth.Nadinehasworkexperienceinthreecountries,includingtheUnitedStates, theUnitedKingdomandSouthAfrica.SheworkedfortheinternationalnursedivisionofAmerican MobileHealthcare,priortojoiningtheEducationTeamatRN.com.NadineisanurseplannerforRN.com andisresponsibleforallclinicalaspectsofcoursedevelopment.Sheupdatescoursecontenttocurrent standards,anddevelopsnewcoursematerialsforRN.com. LoriConstantineMSN,RN,CFNP,theoriginalauthorofthiscourse.

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Purpose&Objectives Thiscoursediscussesspecificcardiovascularhistoryquestionsandexamtechniquesforyouradult patient.Physicalexamtechniquessuchasinspection,palpation,percussion,andauscultationwillbe highlighted.Additionally,throughoutthecourseyouwilllearnhowalterationsinyourcardiovascular assessmentfindingscouldindicatepotentialcardiovascularproblems. Aftersuccessfulcompletionofthiscourse,youwillbeableto: 1. Outlineasystemicapproachtocardiovascularassessment. 2. Discusshistoryquestionsthatwillhelpyoufocusyourcardiovascularassessment. 3. Recognizeabnormalcardiovascularassessmentfindingsassociatedwithinspection, auscultation,percussion,andpalpation. Introduction Cardiovasculardiseaseistheleadingkillerforbothmenandwomenamongallracialandethnicgroups intheU.S.AccordingtotheCentersforDiseaseControl(CDC)studiesamongcoronaryheartdisease patients,90%ofpatientshavehadpriorexposuretoatleastoneheartdiseaseriskfactorthat contributedtotheirdisease. Athoroughcardiovascularassessmentwillhelptoidentifysignificantfactorsthatcaninfluence cardiovascularhealthsuchashighbloodcholesterol,cigaretteuse,diabetes,orhypertension(CDC, 2011).Therefore,acardiovascularexamshouldbeapartofeveryabbreviatedandcomplete assessment. Afocusedcardiovascularassessmentisusuallyindicatedafteracomprehensiveassessmentindicatesa potentialcardiovascularproblem.Thefocusedcardiovascularassessmentisalsoindicatedwhenan intervalorabbreviatedassessmentshowsachangeinstatusfromyourpreviousassessmentorthe reportyoureceived,whenanewsymptomemerges,orthepatientdevelopsanydistress. Anadvantageofthefocusedassessmentisthatitallowsyoutoaskaboutsymptomsandmovequickly toconductingafocusedphysicalexam.Basedupontheresultsofyourassessment,youmaychoosehow oftentoperformintervalassessmentstomonitorthepatientsidentifiedproblem.Keepinmindthatall assessmentsshouldconsiderpatientsprivacyandfosteropen,honestpatientcommunication.

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History Thepurposeofthecardiovascularhealthhistoryistoprovideinformationaboutyourpatients cardiovascularsymptomsandhowtheydeveloped.Acompletecardiovascularhistorywillgiveyou indicationstopotentialorunderlyingcardiovascularillnessesordiseasestates.Obtaininga cardiovascularhistorywillguideyouthroughyourfocusedphysicalexam.Inadditiontoobtainingdata aboutthepatientscardiovascularstatus,youshouldobtaininformationaboutotherfactorsthatcan impactphysicalstatusincludingspiritualneeds,culturalidiosyncrasies,andfunctionallivingstatus. PastHealthHistory Itisimportanttoaskquestionsaboutyourpatientspasthealthhistory.Thepasthealthhistoryshould elicitinformationaboutthefollowingissues:hypertension,elevatedbloodcholesterolortriglycerides, heartmurmurs,congenitalheartdisease,rheumaticfeverorunexplainedjointpainsasachildoryouth, recurrenttonsillitisandanemia.Youwillalsowanttoaskaboutthepatientshistoryofheartdisease, whenandhowitwastreated,lastEKG,stresstests,andserumcholesterollevels.Askthepatientthe reasonsforanyprevioushospitalizationsandthenatureofthetreatmentsreceivedwhileinthe hospital.Askaboutcardiaccatheterizations,echocardiograms,stresstests, andcardiacsurgeries(Kaplow&Hardin,2007). CurrentLifestyleandPsychosocialStatus Currentlifestyleandpsychosocialissuestoexplorewhenconductingyourfocusedcardiovascularhealth historyinclude: Nutrition:Haveyourpatientdescribetheirdailydiet.Askabouttheirusualweightandany recentweightgainorweightloss. Smoking:Askyourpatientiftheysmokecigarettesorothertobacco.Ascertainthepackperyear smokinghistory.Thisisdonebymultiplyingthenumberofyearsyourpatienthassmokedwith thenumberofpacksperdaytheyhavesmoked(CancerTreatmentCentersofAmerica,2011). Alcohol:Askhowmuchalcoholthepatientnormallydrinksperdayorperweek.Askabout whenthelastdrinkwasandtheusualnumberofdrinks perepisode. Exercise:Askaboutyourpatient'sactivitylevelandusualamountofexercisedonedailyor weekly.Askwhattypeofexercisetheyparticipatein. Drugs:Askyourpatientaboutallmedicationtheytakeincludingantihypertensives,beta blockers,calciumchannelblockers,digoxin,diuretics,aspirin,anticoagulants,overthecounter drugs,herbalsupplements,orstreetdrugs. SmokersPackPerDayHistory 2packsperdayx10years=20packyearhistory 1packperdayx20years=20packyearhistory 3packsperdayx7years=21packyearhistory

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FamilyHistory Familyhistoryisanimportantfactorusedinidentifyingyourpatientsriskforcertaincardiovascular diseases(Kaplow&Hardin,2007). Askyourpatientaboutanycardiovascularfamilyhistorysuchashypertension,obesity,diabetes, coronaryarterydisease,orsuddendeath. TestYourself: Whichofthefollowingdiseasesisassociatedwithcardiovasculardisease? A. B. C. D. AssessmentofChestPainUsingPQRSTMnemonic Hypothyroidism LungCancer Diabetes(correct) InflammatoryBowelDisease

When examining the cardiovascular system, the mnemonic PQRST, is very useful in assessing chest pain. It provides a methodology in which communication to other healthcare providers will be most efficient and informative. Assess the following characteristics with each new report of pain and following any intervention: (P) Provocative or Palliative: What makes the symptom(s) better or worse? (Q) Quality: Describe the symptom(s). (R) Region or Radiation: Where in the body does the symptom occur? Is there radiation or extension of the symptom(s) to another area of the body? (S) Severity: On a scale of 1-10, (10 being the worst) how bad is the symptom(s)? (T) Timing: Does it occur in association with something else (e.g. eating, exertion, movement)?

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ProvocativeorPalliativeFactors Askthepatientaboutwhatstartsorworsensthepain.Chestdiscomfortprovokedbyexertionisaclassic symptomofangina,althoughesophagealpaincanalsoresultfromexertion.Otherfactorsthatmay provokeischemicpaininclude: Cold Emotionalstress Sexualintercourse Smoking Meals However,discomfortthatreliablyoccurswitheatingismostlikelyrelatedtoanuppergastrointestinal disease.Painmadeworsebyswallowingislikelyofesophagealorigin. Factorsthatinfluencepainshouldalsobeestablished.Painthatrespondstosublingualnitroglycerinor cessationofactivitystronglysuggestsacardiacischemicetiology,whilepericarditispaintypically improveswithsittingupandleaningforward. PracticePearl Patientswithahistoryofcoronaryheartdiseasetendtohavethesamequalityofchestpainwith recurrentepisodes. QualityofPain Thepatientwithmyocardialischemiaoftendeniesfeelingchestpainandmaydelayseeking treatment.Typicaldescriptionsofchestpainfrommyocardialischemiamayinclude: SqueezingAbandlikesensationisfeltaroundthechest. TightnessThereisasensationofaknotbeingpresentinthecenterofthechest. PressureAsensationofalumpinthroatoraheavyweightonthechest. ChestConstrictionTheLevinesignisdisplayedbyapatientsufferingfromchestpaincausedbya myocardialinfarction.Thepatienttypicallypressesaclenchedfistagainstthechesttoillustratethe sensationofpressureandconstrictioninthechest. BurningInfarctionpainisoftenmistakenforheartburnorindigestion,especiallyinwomen.

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RegionorRadiationofPain Painthatlocalizestoasmallareaofthechestismorelikelytoberelatedtoachestwallorpleuralorigin ratherthantheheart. Ischemiccardiacpainisadiffusetypeofnonlocalizedpain. Thepainofmyocardialischemiaoftenradiatestotheneck,throat,lowerjaw,teeth,upperextremities, orshoulder. Ifthechestpainisradiatingtoseveralareas,thereisanincreasedchancethatthepatientishavinga myocardialinfarction(MI). SeverityandAssociatedSymptoms Usinga10pointnumericpainratingscaleorvisualanalogscaleoftenhelpspatientsdescribethe intensityofpain.The10pointscoregradespaininseverityrangingfrom0(nopain)to10(most excruciating).Theseverityofpaindoesnotnecessarilycorrelatewiththedegreeofischemia.Asmany as1/3ofmyocardialinfarctionsmaygoundetectedbythepatient.Somepatientshavedifficultyputting anumberonthepaininwhichcaseanadjectiveratingscalemaybemosthelpful.TheNumericPain Scalebelowisarepresentationofonesuchnumericalscale. NumericalPainScale

SeverityandAssociatedSymptoms Othersymptomsthatmaybeassociatedwithmyocardialischemiamayinclude: Nausea Vomiting Diaphoresis Syncope Palpitations Exertionaldyspnea Fatigue Weakness Dizziness Lightheadedness

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Timing Knowingtheonsetofchestpainisimportanttohelptodeterminethecauseandtreatmentofthepain. Ischemicpainismostoftengradualwithanincreasingintensityovertime.Acrescendopatternofpain canalsobecausedbyesophagealdisease.Painassociatedwithpneumothorax,aorticdissection,or acutepulmonaryembolismtypicallyhasanabruptonsetwiththeinitialsensationbeingthemost intense. Understandingthedurationofpainandanypatternsarealsohelpful.Thepainfrommyocardial ischemiagenerallylastsforafewminuteswhereasthepainfromanMImaybemoreprolonged.Chest discomfortthatonlylastsforafewsecondsorpainthatisconstantfordaysorweeksisnotgenerally duetoischemia.Myocardialischemiamayhaveacircadianpattern.Itismorelikelytooccurinthe morningthanintheafternoon,correlatingwithanincreaseinsympathetictone.However,thispattern maynotbeexhibitedinpatientswithdiabetesorpatientstakingbetablockersasthepatients sympathetictoneisaltered. Ifthepatientisunabletoqualifyandquantifytheirpain,thefollowingquestionsmaybeusefulin gettingneededinformationregardingtheirpain. ChestPainintheElderly Itshouldbenoted,however,thattypicalclinicalmanifestationssuchaschestpainoccurinonly50%of elderlypatientswithcoronaryarterydisease(CAD)(Milner,2001).Whenpainispresentinanolder patientitisfrequentlyvagueandpoorlylocalizedorlocalizedtotheabdomenorepigastricarearather thanthesubsternalarea.Elderlypatientsexperiencinganginaormyocardialischemiamaydescribetheir symptomssimplyas:exertionaldyspnea(mostcommon),fatigue,syncope,nausea,anorexia,confusion, ordyspneaatrest. Whatgetsthepainstarted? Whathelpsthepainstop(rest,sittingupandleaningforward)? Wouldyoudescribeitasmoreofadullpressureorsqueezingormoreofasharp,stabbing,or rippingfeeling? Doesthispainfeelsimilartowhenyouhadyourpreviousheartattack? Isthepainmostlyinoneareaordoyoufeelitupintoyourneckandarms? With0beingnopainand10beingthemostexcruciatingpainever,whatnumberwouldyou givethepaintodescribetheseverity? Whenapplyinganumberisdifficult:Wouldyoudescribethepainasmild,moderate,or severe? Areyoufeelingnauseous,dizzy,lightheaded,shortofbreath,ortired? Doesthepainstartoffgraduallyandgetworse,orviceversa? Howlongdoesthepainlast? Whendoesthepainusuallyoccurmorning,afternoon,ornight?

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TestYourself: Chestpainintheelderlyisusuallywelldefined. A. True B. False(Correct) OtherSymptoms:Dyspnea Dyspnea(shortnessofbreath)thataccompanieschestpainmayalsobeduetoanumberofpulmonary disorders. Askyourpatientthefollowingquestionsrelatedtodyspnea: Doyouevergetshortofbreath? Whattypesofactivityandhowmuchactivitybringsontheshortnessofbreath? Doestheshortnessofbreathcomeonsuddenlyorunexpectedly? Doesthedyspneacomeandgoorisitconstant? Istheshortnessofbreathassociatedwithchangeinposition? Doestheshortnessofbreathwakeyouupatnight? Doestheshortnessofbreathinterferewithactivitiesofdailyliving? PracticePearl Paroxysmalnocturnaldyspnea(PND)occursatnightwithcongestiveheartfailure.Layingdown increasesthevolumeofthoracicblood.Theweakenedheartcannotaccommodatethisgreater volume.Yourpatientwillcomplainofsleepingforabouttwohoursandthenarisingsuddenly needingfreshair. OtherSymptoms:OrthopneaandCoughing Orthopnea Askyourpatienthowmanypillowsheorshesleepsonatnight.Orthopneaistheinabilitytobreathe wheninalyingposition. Cough Doesyourpatienthaveaconsistentcough?Havethepatientdescribethefrequency,timing,severityof cough,andanysputumproduction.Ifthepatientdoeshavesputumproductionaskaboutthecolorof thesputum,ifithasanodor,andifitisbloodtinged. PracticePearl Hemoptysisisoftenpulmonaryinnature,butmayoccurwithcardiogenicpulmonaryedema.

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OtherSymptoms:Fatigue,Edema,CyanosisandPallor Fatigue Askyourpatientiftheytireeasily.Ifso,askaboutwhenthefatiguestarted.Wasitsuddenorgradual? Hastherebeenanyrecentchangeinenergylevel?Alsoaskaboutthetimeofthedaythefatigueis relatedto,e.g.allday,morningoreveningtoestablishthepresenceofacircadianrhythm,whichmay indicateischemia. PracticePearl Cardiacrelatedfatigueisworseintheevening.Fatiguetoanxietyordepressionoccursalldayoris worseinthemorning. Edema,Cyanosis,andPallor Doesyourpatienthaveanyswellingorskincolorchanges?Cyanosisorpalloroccurswithmyocardial infarctionorlowcardiacoutput.Ifthepatienthasswelling,askaboutitslocation.Isitinthefeetand legs?Ifso,whenwasitfirstnoticed?Askaboutanyrecentchangeintheswelling,ifitisunilateralor bilateral,andiftheswellingsubsidesaftersleepingorrestingwithfeetup.Alsoaskaboutany associatedsymptomswiththeswellingsuchasdyspnea. PracticePearl Cardiacrelatededemaisworseintheeveningandbetterinthemorningafterrestingwiththefeet up. OtherSymptoms:Nocturia Doesyourpatientgetupatnighttourinate?Askhowlongthishasbeenoccurringandiftherehave beenanyrecentchangesinthispattern. PracticePearl Recumbencypromotesfluidreabsorptionandexcretion.Nocturiaoccurswithheartfailureinthe patientwhoisambulatoryduringtheday.

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Pediatric,Pregnant,andAgingPatients Additionalhistoryquestionsyoumaywishtoaskregardingyourinfant,pediatric,pregnant,oraging patientarelistedontheleftsidebuttons. ContentadaptedfromJarvis,1996. AdditionalHistoryforInfants Mothershealthduringpregnancy?Unexplainedfeverorrubellainthefirsttrimester?Other infections,hypertension,drugstaken? Evernoticedanycyanosiswhilefeeding,nursingorcrying? Doesthebabyeatorplaywithouttiring? Isthebabygrowingaccordingtonormalforageandgender? Werethebabysmotormilestonesachievedasexpected Howmanynapsperdayandlengthofnaps?

AdditionalHistoryforChildren ActivityIsthechildabletokeepupwithsameagedplaymates?Isthechildwillingorreluctant toplay?Doesthechildpreferquietplay?Doesthechildeverhavebluespells? Anyunexpectedjointpainorunexplainedfever? Doesthechildhavefrequentheadachesornosebleeds? Doesthechildhavefrequentrespiratoryinfections?Anyproventobestrepinfections? Anyfamilyhistoryofcongenitaldiseases? Anyoneinthefamilywithchromosomalabnormalities?

AdditionalHistoryforPregnantPatients BloodPressureDidyouhavehighbloodpressureinthisorotherpregnancies?Whatwasyour bloodpressurebeforeyourpregnancy? Hasyourpressurebeenmonitoredinthispregnancy? Anyproteinintheurine? Anyexcessiveweightgain? Haveyouhadanyswellinginthefeet,legsorface? Haveyouexperiencedanyfaintnesswiththispregnancy? Haveyouexperiencedanydizzinesswiththispregnancy?

AdditionalHistoryforElderlyPatients HeartandLungdiseaseIsthereahistoryofheartdisease,hypertension,coronaryartery disease,emphysema,bronchitis? Doyoutakeanymedicationsforyourillness? Whatarethesideeffectsofthemedication(s)? Haveyourecentlystoppedtakinganyofyourmedications?Ifso,whichonesandwhy?

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Doyourillnessesinterferewithyouractivitiesofdailyliving? Doesyourhomehaveanystairs?Howoftendoyouneedtoclimbthem?

ThePhysicalExam Whenassessingthecardiovascularsystem,othersystems,suchasthecirculatoryandrespiratory systems,alsoneedtobeevaluatedtoprovideacomprehensiveandholisticpicture. Inperformingacardiacassessment,avisualunderstandingoftheheartmaybeuseful: A:Aorta B:Leftventricle C:Rightventricle D:Pulmonaryartery ThecoronaryarteryRamusinterventricularisanteriorcanbeseeninthegroove(sulcus interventricularis)betweentheventricles. (wikimedia.org,2007) AssessmentofTheNeckVessels:Inspection Wheninspectingtheneckvessels,lookforanyabnormalitiesyoucanobservewithyoureyes,ears,or nose. Themostimportantobservationtobemadeintheneckregionistheassessmentofjugularvenous pulse.Fromthejugularveinsyoucanestimatecentralvenouspressure(CVP)andestimatethehearts efficiencyasapump. Ataglance,ifthepatientissittinginthesupinepositionat45degreesorhigher,youshouldnotbeable toseejugularvenouspulsationsunlessthereisunderlyingpathology.

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AssessmentofTheNeckVessels:Auscultation Whenauscultating,ensureyourroomisquiet,auscultateoverbareskin,andlistentoonesoundata time.Yourbellordiaphragmshouldbeplacedonyourpatientsskinfirmlyenoughtoleaveaslightring ontheirskinwhenremoved.Beawarethatyourpatientshairmayalsointerferewithtrue identificationofcertainsounds.Thediaphragmisusedtolistentohighpitchedsoundsandthebellis bestusedtoidentifylowpitchedsounds(Kaplow&Hardin,2007).Also,remembertocleanyour stethoscopebetweenpatients. Auscultatethecarotidarteriesinpersonsmiddleagedorolder,orthosewithahistoryofcardiovascular disease.Youarelisteningforthepresenceofabruit,whichisablowingorswishingsound,indicating turbulentbloodflow.Youmayneedtoaskyourpatienttoholdtheirbreathforashorttimesothatyou donotconfusetrachealbreathsoundswithabruit.Typically,abruitisabsent. TestYourself: Abruitisoftenconfusedwith: A. B. C. D. AssessmentofTheNeckVessels:Palpation Palpation,anothercommonlyusedphysicalexamtechnique,requiresyoutotouchyourpatientwith differentpartsofyourhandusingdifferentstrengthpressures.Duringlightpalpation,youpresstheskin aboutinchto3/4inchwiththepadsofyourfingers.Whenusingdeeppalpation,useyourfingerpads andcompresstheskinabout1inchesto2inches.Palpationallowsyoutoassesstheneckfor tenderness,abnormaltemperature,excessivemoisture,pulsations,ormasses. Palpatethecarotidarteriesverygentlyandneveratthesametime.Feelthecontourandamplitudeof thepulse.Normally,thecontourissmoothwitharapidupstrokeandnormalstrength(+2).Findings shouldbesimilarbilaterally. Therightbundlebranchspreadsthewaveofdepolarizationtotherightventricle.Likewise,theleft bundlebranchspreadsthewaveofdepolarizationtoboththeinterventricularseptumandtheleft ventricle.Theleftbundlefurtherdividesintothreebranchesorfasicles.Thebundlebranchesfurther divideintoPurkinjefibers. Rales Crackles Wheezes Trachealbreathsounds(Correct)

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CirculatoryAssessment:Inspection Performingavisualassessmentofthecirculatorysystemisanimportantcomponentofa comprehensivecardiovascularassessment.Areasforevaluationyoumayinspectincludeskincolor, locationofanylesions,bruisesorrash,symmetryofmotion,sizeofbodyparts,andanyabnormal findings,sounds,andodors. Beginbyinspectingthepatientsskinforcolor,warmth,andmoisture.Cool,clammyskinresultsfrom vasoconstriction.Warm,moistskinresultsfromvasodilation.Flushingofapatientsskinmaybedueto medications,excessheat,anxiety,orfear.Pallorcanresultfromanemiaorincreasedperipheralvascular resistancecausedbyatherosclerosis.Dependentrubor(redness)maybeasignofchronicarterial insufficiency.Peripheralcyanosismaycauseabluishdiscolorationtothelipsandextremities.Inspect theoralmucousmembranesforcyanosisthatmaynotbereadilyapparentontheskin.Examine underneaththetongue,insidethecheeks,andthenailbedsforsignsofperipheralcyanosis. Therearetwotypesofcyanosisthatmayoccurincompromisedpatients:centralandperipheral.Central cyanosisisconsistentwithreducedoxygenintakeortransportfromthelungs.Peripheralcyanosis suggestsconstrictionoftheperipheralarteries.Thisisusuallyfromstress,cold,oranxiety.Itmayalso befromhypovolemia,shock,orvasoconstrictivediseases. Notethepresenceofanyedema.Inspectyourpatientshairdistributionontheirskin.Lackofhairmay alsoindicatearterialinsufficiency. Next,assessarterialperfusiontothelowerextremities.Haveyourpatientliesupineonaflatsurface andelevateoneofhislegsabovehisheartforaboutoneminute.Youmayneedtoassistwiththis movement.Thenaskhimtositupanddanglehislegsoverthebedandinspectthecolorofbothlegs. Thelegthatwaselevatedshouldshowslightpallorincomparisontotheotherleg.Thecolorofbothlegs shouldbeaboutthesameinabouttenseconds,oncetheveinshavehadtimetofill. Edemacanresultfrommanydiseaseprocessesincludingheartfailure,liverfailure,orbyvenous insufficiency,varicosities,andthrombophlebitis. CirculatoryAssessment:Auscultation Auscultateyourpatientsbloodpressure.Thesystolicreadingreflectsthepressureexertedbytheleft ventricleduringcontraction.Thediastolicreadingreflectsthepressureinthearterieswhentheheartis atrest. Bloodpressureislowestinthenewborn,andriseswithage,weightgain,stress,anxiety,andduring exercise.

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CirculatoryAssessment:Auscultation Whenauscultatingbloodpressure,besuretochooseanappropriatesizecufftoavoidfalsereadings. Somehelpfulhintswhenassessingbloodpressureinclude: Nevertakeabloodpressureinanarmonthesamesideasamastectomy. Nevertakeabloodpressureinanarmwithanarteriovenousfistulaorshunt,orinanarmwitha peripherallyinsertedcentralcatheter. IfeitherthesystolicBPisover140orthediastolicpressureisover90onrepeated measurements,thepatientisconsideredtohaveStage1Hypertension(highbloodpressure). Hypertensionisriskfactorforheartdisease,stroke,andkidneydisease. Diet,exercise,and,whennecessary,medicationscancontrolbloodpressure.

BloodPressureClassificationinAdults Category Normal PreHypertension StageIHypertension StageIIHypertension Systolic <120 120139 140159 >160 Diastolic And<80 Or8089 Or9099 Or>100

ClassificationandManagementofBloodPressureinAdults.NationalInstituteofHealth(2003). CirculatoryAssessment:Palpation Thenextpartofthecirculatorysystemexaminationispalpation. Beginbypalpatingtheperipheralarteries.Theseincludethebrachial,radial,femoral,popliteal,dorsalis pedis,andposteriortibial. Notethecontourandamplitudeofeachpulsation.Theseshouldfeelsimilarbilaterally. Asyoumoveawayfromthecoreofthebody,youmaynoticethatthecontourorupstrokeofthe pulsationislessrapid.Thisisnormal,butitisimportanttoassessthatthearterieshavesimilarstrength bilaterally.

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TestYourself: Whenassessingnormalcirculationintheextremities,youanticipatefindingthat: A. B. C. D. ThePrecordium:InspectionandAuscultation Inspection Inspecttheanteriorchestforpulsations.Youmayormaynotseetheapicalpulse.Ifitisvisible,youwill seeitinthefourthorfifthintercostalsspace. Auscultation Beforeyoubeginyourauscultationoftheprecordium,prefaceyourexambytellingthepatientyouwill belisteninginmanydifferentplacesforwhatmightbeawhile.Then,youmustidentifytheareasyou needtoausculate.YoumaywanttoinchyourstethoscopeinaZpatternacrosstheprecordium,from thebaseofthehearttotheapex.Concentratetothesoundofthelubandthedub.Theluborfirst heartsoundisknownasS1.TheduborthesecondheartsoundisknownasS2. HeartSounds:S1 S1,thelubofthelubdub,isproducedbytheclosureoftricuspidandmitralvalves. AlterationsyoumayauscultatethatinvolveS1areasfollows: S1isaccentuatedinexercise,anemia,hyperthyroidism,andmitralstenosis. S1isdiminishedinfirstdegreeheartblock. S1splitismostaudibleintricuspidarea(Tlubdub) Bloodflowissimilarbilaterally.(Correct) Thecontourandamplitudeofpulsationsaregreaterontheleftsideofthebody. Thecontourandamplitudeofpulsationsaregreatontherightsideofthebody. Asyoumovefurtherawayfromthecoreofthebody,thecontourpulsationsaremorerapid.

(Kaplow&Hardin,2007) HeartSounds:S2 S2,thedubofthelubdub,isproducedbytheclosureofaortic&pulmonicvalves. AlterationsyoumayauscultatethatinvolveS2areasfollows: NormalphysiologicalsplittingofS2isbestheardatpulmonicarea.Itoccursoninspiration(lub Tdub,lubdub). SplittingofS2soundcanoccurwhentheaorticandpulmonaryvalvesdonotcloseatthesame time(Kaplow&Hardin,2007).Thiscanindicatepulmonicstenosis,atrialseptaldefect,right ventricularfailure,orleftbundlebranchblock.

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HeartSounds ListentoactualheartsoundsusingtheAuscultationAssistant http://www.wilkes.med.ucla.edu/intro.html Thisgreattoolwillexposeyoutomanydifferentnormalandabnormalheartsounds. HeartSounds:S3 Thethirdheartsoundisproducedbytherapidfillingoftheventricle(thatisnotcompletelyempty) duringearlydiastole(Kaplow&Hardin,2007).S3isalsoknownasaventriculargallop(lubDUBtaor Kentucky). S3isnormalinpregnancy,children,adultslessthanthirtyyearsold,duringexercise,anxiety,oranemia. Itisheardbestattheapexintheleftlateraldecubitusposition,usingthebell. PathologicS3occursinpeopleovertheageof40,usuallyduetomyocardialfailure. HeartSounds:S4 ThefourthheartsoundistypicallyheardinlatediastolebeforeS1,asaresultofincreasedventricular resistancetoatrialfilling,duetoeitherdecreasedventricularcomplianceorincreasedventricular volume.Itislowpitchedandbestheardwiththebell.S4isalsoknownasanatrialgallop(talubDUB orTennessee). S4isoftennormalinolderadultsandisheardbestattheapexintheleftlateraldecubitusposition. PathologicalS4maybecausedbycoronaryarterydisease,hypertension,cardiomyopathy,oraortic stenosis. TestYourself: Whichheartsoundisknownastheatrialgallop? A. B. C. D. S1 S2 S3 S4(Correct)

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AbnormalHeartSoundsSummationGallop&OpeningSnap SummationGallop AsummationgallopisproducedwhenS3&S4mergeintoonesound.Itoftenoccursatratesgreater than100beatsperminute.Itmayoccurinheartfailureandpericarditis.Summationgallopsoccurin 15%ofallmyocardialinfarctionsandarecommonfollowingcardiacsurgery.Theyarebestheardwith patientleaningforward,holdingbreathafterfullexpiration. OpeningSnap Attheendofventricularsystole,whentheaorticandpulmonicvalvesclose,S2isproduced. ImmediatelyafterS2,theheartrelaxes,andventricularpressurefallsbelowthatofatrialpressure.This allowstheatrioventricularvalvestoopen.Thisisthestartofdiastole.Normally,youcannothearthese valvesopen.However,ifthemitralvalvebecomesstenoticorabnormallynarrowedtheywillcreatean openingsnap.Thissoundusuallyprecedesthedevelopmentofadiastolicmurmurassociatedwith mitralstenosis.Oncethevalvebecomesseriouslyimpairedandinflexible,theopeningsnapdisappears (Kowalak,Johnson&Sussman,2002). AnOpeningSnapisanabnormalheartsoundduetoastenoticvalveopening.Whenanormalcardiac valveopens,thereisnosoundcreated. AbnormalHeartSounds:EjectionClick&MidSystolicClick EjectionClick Similartoanopeningsnap,anejectionclickiscausedbystenoticvalveleaflets.Thissoundisproduced whentheaorticorpulmonicvalvesopenatthebeginningofsystole.Itisabriefhighfrequencysound bestheardwiththediaphragmovertheaorticorpulmonaryarteryorErbspoint,orneartheapexover themitralarea(Kowalak,Johnson&Sussman,2002). MidSystolicClick Amidsystolicclickoccurswhenthemitralvalvesleafletsandcordaetendenaetense.Theanterioror posteriororbothleafletscanprolapse.Everyonceinawhilemultipleclicksoccur.Theyareheardinmid tolatesystole.Theyarebestheardoverthetricuspidareaandtowardsthemitralarea.Theyarecrisp, highfrequencysounds(Kowalak,Johnson&Sussman,2002). AbnormalHeartSounds:PericardialFrictionRub&MediastinalCrunch PericardialFrictionRub Apericardialfrictionrubisusuallyheardbestandissometimespalpableoverthetricuspidandxyphoid areas.Itoccurswheninflamedpericardialsurfacesrubtogether.Therubbingofthesesurfacesproduce thecharacteristic,highpitched,gratingnoises.Todifferentiateapericardialfrictionrubfromapleural frictionrub,havethepatientholdhisorherbreath.Whentheydothis,apericardialfrictionrubwill continue,apleuralfrictionrubwillcease(Kowalak,Johnson&Sussman,2002).

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MediastinalCrunch Amediastinalcrunchisproducedduetodisplacedairunderthesurfaceoftheskinnearthe mediastinum.Patientswithmediastinalcrunchoftenhavesubcutaneousemphysema.Youcanassess forthisbypalpatingcrepitationintheneck.Thenoisehasacrunchingqualityandisheardbestalong theleftsternalborder.Itmaybelouderoninspiration(Kowalak,Johnson&Sussman,2002). AbnormalHeartSounds:Murmurs Amurmurisanabnormalheartsoundcausedbyturbulentbloodflow.Thesoundmayindicatethat bloodisflowingthroughadamagedoroverworkedheartvalve,thattheremaybeaholeinoneofthe heart'swalls,orthatthereisanarrowinginoneoftheheart'svessels. Someheartmurmursareaharmlesstypecalledinnocentheartmurmurswhicharecommoninchildren andusuallydonotrequiretreatment. AuscultationofMurmurs Ifyouauscultateamurmur,itisimportanttoassessanddocumentthefollowingqualitiesofthe murmur: Timing:Aretheysystolicordiastolic? Anatomicallocationofmaximumintensity:Whereisthemurmurbestheard? Frequency:Whatisthepitchofthemurmur? Radiation:Canyouhearthemurmurinotherlocationssuchastheneckorupperchest? Quality:Isthemurmurharsh,soft,orblowing? Intensity:Describetheloudnessofthemurmuronascaleof1to6,asindicatedbyLevine's6point gradingscale: Grade 1 2 3 4 5 6 Intensity VeryFaintEasilyMissed QuietBarelyAudible ModeratelyloudbuteasilyheardsameintensityasS1orS2 Loud,butusuallynothrillpresent Veryloud,thrillpresent HeardwithstethoscopeoffchestThrillpresent

(Lippincott,Williams&Wilkins,2005)

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TimingandQualityofCommonMurmurs Thefollowingtabledepictsthetimingandqualityofcommonmurmurs.

ThePrecordium:PalpitationandPercussion Palpation Palpatetheapicalpulse,normallyinthefourthorfifthintercostalspace,midclavicularline.Itshouldbe feltasashort,gentletap.Itcanbepalpatedinabouthalfofpeople.Itismoredifficulttopalpatein obesepatientsorthosewiththickchestwalls.Stress,fever,anxiety,hyperthyroidism,andanemiamay increasetheamplitudeanddurationoftheapicalpulse.Whentheapicalpulseispalpatedlowerinthe thoraciccageandhasagreateramplitudethanexpected,itisoftenduetocardiacpathology. Percussion Youmayusepercussiontooutlinethecardiacborder.Typically,however,achestxraycanrevealthe sameresults.Therearetimes,however,thatchestxraysarenotavailableandpercussionmaybeone ofyouronlytoolstoassesscardiacsize. Toperformeffectivepercussion,pressthedistalpartofthemiddlefingerofyournondominanthand firmlyonthebodypart,keepingtherestofthehandoffthebodysurface.Usingthemiddlefingerofthe dominanthand,tapquicklyanddirectlyoverthepointwheretheothermiddlefingermakescontact withthepatientsskin.Dullnessshouldbeheardovertheareawheretheheartislocated.

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RecordingFindings Itisimportanttoaccuratelyandthoroughlyrecordanddocumentyourfindingsfromthecardiovascular exam. Standarddocumentationensuresthatallmembersofthehealthcareteaminterpretthefindings accurately.Indocumentingmurmurs,Levine'ssixpointgradingscaleisthemostaccuratewaytorecord findings,asistheuseofastandard4pointscaletoassessanddocumentedema. Rememberthatyourrecordingsarepartofthemedicalrecord,andshouldbeasobjectiveandaccurate aspossible. Conclusion Integratingthecardiovascularhealthhistoryandphysicalexamtakespractice.Itisnotenoughtosimply asktherightquestionsandperformthephysicalexam.Asthepatientsnurse,youmustcriticallyanalyze allofthedatayouareobtaining,synthesizethedataintorelevantproblemfocus,andidentifyaplanof careforyourpatientbaseduponthissynthesis.Astheplanofcareisbeingcarriedout,reassessments mustoccuronaperiodicbasis.Howoftenthesereassessmentsoccurisuniquetoeachpatient,based upontheirphysicaldisorder. IMPORTANTINFORMATION: Thispublicationisintendedsolelyfortheeducationaluseofhealthcareprofessionalstakingthiscourse fromRN.cominaccordancewithRN.comtermsofuse.Theguidanceprovidedinthispublicationis generalinnature,andisnotdesignedtoaddressanyspecificsituation.Asalways,inassessingand respondingtospecificpatientcaresituations,healthcareprofessionalsmustusetheirjudgment,aswell asfollowthepoliciesoftheirorganizationandanyapplicablelaw.Organizationsusingthispublicationas apartoftheirowneducationalprogramshouldreviewthecontentsofthispublicationtoensure accuracyandconsistencywiththeirownstandardsandprotocols.Thecontentsofthispublicationare thecopyrightedpropertyofRN.comandmaynotbereproducedordistributedwithoutwritten permissionfromRN.com. Healthcareproviders,hospitalsandhealthcareorganizationsthatusethispublicationagreetohold harmlessandfullyindemnifyRN.com,includingitsparents,subsidiaries,affiliates,officers,directors, andemployees,fromanyandallliabilityallegedlyarisingfromorrelatinginanywaytotheuseofthe informationorproductsdiscussedinthispublication.

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References

AmericanAssociationofCriticalCareNurses(1998).TheCardiovascularSystem.InJ.Alspach (Ed.),Corecurriculumforcriticalcarenursing (5thed.,Rev.,pp.137338).Philadelphia:Saunders. AuscultationAssistant.(2004).Availableathttp://www.wilkes.med.ucla.edu/intro.html. BlumJ,SchadlerA,PrushCooperS.(2001).AssessmentandManagementofAcuteCardiac ChestPain.CritCareNursClinofNorthAm.13(2):25969. CancerTreatmentCentersofAmerica.(2011).Riskfactorsforlungcancer.RetrievedMay4, 2011,fromhttp://www.cancercenter.com/lungcancer/lungcancerriskfactors.cfm CentersforDiseaseControl.(2006).HeartDiseasefactSheet.RetrievedOctober10,2007from: http://www.cdc.gov/dhdsp/library/pdfs/fs_heart_disease.pdf Jarvis,C.(1996).Physicalexaminationandhealthassessment.Philadelphia:W.B.Saunders. Kaplow,RandHardin,S.(2007).CriticalCareNursing:SynergyforOptimalOutcomes.MA.Jones andBartlett. Kowalak,J.;Johnson,P.&Sussman,T.(Eds.).(2002).Auscultationskills:Heartandbreath sounds.(2nded).(pp.2694).Springhouse,PA:Springhouse. Lippincott,Williams&Wilkins(2005). HeartSoundsMadeIncrediblyEasy.PA. McCaffery,M.&Pasero,C.(Eds.).(1999).Pain:ClinicalManual(2nded.). (pp1718,63,108113).St.Louis:Mosby. MilnerKA,FunkM,RichardsS,VaccarinoV,KrumholzHM.(2001).Symptompredictorsofacute coronarysyndromesinyoungerandolderpatients.NursRes,50(4):233241. NationalInstituteofHealth(NIH),2003.NationalHighBloodPressureEducationProgram (2003).PartoftheSeventhReportoftheJointCommitteeonPrevention,Detection. Evaluation,andTreatmentofHighBloodPressure.U.S.DepartmentofHealthandHuman services,NationalInstitutesofHealth,NationalHeart,LungandBloodInstitute.Retrievedand updatedMay5,2011from:http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf Shaw,M.(1998)Assessmentmadeincrediblyeasy!Springhouse,PA:Springhouse.

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