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Cardiac Assessment Toni Standley RN ANP MSN Porter Adventist Hospital.

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Presentation on theme: "Cardiac Assessment Toni Standley RN ANP MSN Porter Adventist Hospital."— Presentation transcript:

1 Cardiac Assessment Toni Standley RN ANP MSN Porter Adventist Hospital

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3 Cardiovascular Assessment Obtaining health history Obtaining health history Physical exam Physical exam Assessment of patients heart and vascular system Assessment of patients heart and vascular system

4 Obtaining a Health History Introduce yourself Introduce yourself Chief complaint Chief complaint Cardiac risks Cardiac risks Other ailments Other ailments Personal and family history Personal and family history

5 Chest Pain Assessment another side story Description Description Location Location Duration Duration Radiation Radiation Pain scale Pain scale Intensity Intensity

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7 Chest Pain Assessment cont. Associated Symptoms Associated Symptoms Precipitating Factors Precipitating Factors Alleviating Factors Alleviating Factors

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9 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

10 Congestive Heart Failure assessment Weight Gain Weight Gain Difficulty Breathing Difficulty Breathing PND PND Swelling Swelling Medication Compliance Medication Compliance Diet/Salt Intake Diet/Salt Intake Oxygen Use Oxygen Use

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12 BNP Relationship to NYHA Objective Vs. Subjective Evaluation Triage BNP package insert.

13 Cardiac Risks a side story Hypertension Hypertension Hyperlipidemia Hyperlipidemia Diabetes Diabetes Smoking Smoking Obesity Obesity Age Age Family history Family history

14 MEDICATIONS - A side story Beta Blockers Beta Blockers Aspirin Aspirin Ace Inhibitors/ ARBS Ace Inhibitors/ ARBS Diuretics Diuretics Statins Statins Calcium channel blockers Calcium channel blockers Plavix Plavix Antiarrythmics/Digoxin Antiarrythmics/Digoxin

15 PERSONAL AND FAMILY HISTORY - A side story Married? Married? Children? Children? Occupation? Occupation? Activities? Activities? Living arrangements? Living arrangements? Caffeine intake? Caffeine intake? ETOH intake? ETOH intake? Family medical history? Family medical history?

16 Performing a Physical Assessment Consistent, Methodical Approach Consistent, Methodical Approach Regular Practice Regular Practice Stethoscope with a Bell and Diaphragm Stethoscope with a Bell and Diaphragm Appropriate size blood pressure cuff Appropriate size blood pressure cuff

17 Performing a Physical Assessment Consistent, Methodical Approach Consistent, Methodical Approach Vital signs Vital signs EKG EKG Lab values Lab values Previous/recent tests – treadmills, cardiac catherizations, by-pass surgery, previous hospitalizations. Previous/recent tests – treadmills, cardiac catherizations, by-pass surgery, previous hospitalizations.

18 Assessing the Heart pay attention! Inspection: Inspection: –Overly thin? –Obese? –Alert? –Anxious? Inspect patients precordium: Inspect patients precordium: –Pulsations? –Symmetry of Movement? –Retractions or Heaves?

19 Assessing the Heart continues… Palpation with the Heart: 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

20 Assessing the Heart continues… Percussion Percussion –Begin Anterior Axillary Line –Continue toward Sternum along the 5 th Intercostal Space –Dullness over Midclavicular Line; left border of the heart –Difficult in Obese and Female patients

21 Assessing the Heart continues… Auscultation 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

22 Heart Sounds Anatomy

23 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Basic Heart Sound S 1 –Heard at the beginning of Systole –Closure of Mitral and Tricuspid Valves

24 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Basic Heart Sound S 1 –Heard at the beginning of Systole –Closure of Mitral and Tricuspid Valves

25 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Basic Heart Sound S 2 –Heard at the End of Systole –Closure of Pulmonic and Aortic Valves

26 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Basic Heart Sound S 2 –Heard at the End of Systole –Closure of Pulmonic and Aortic Valves

27 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Abnormal Heart Sound S 3 ; Ventricular Gallop Rhythm –End of Diastole –Immediately after S 2 –Heard Best: over Mitral Area over Mitral Area with Bell with Bell

28 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Abnormal Heart Sound S 3 ; Ventricular Gallop Rhythm –End of Diastole –Immediately after S 2 –Heard Best: over Mitral Area over Mitral Area with Bell with Bell

29 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Abnormal Heart Sound S 4 ; Summation Gallop –Early in Diastole –Precedes S 1 –Heard Best: over Mitral Area over Mitral Area with Bell with Bell –Associated with increased left Atrial Pressure caused by noncompliant LV; Hypertension, Cardiomyopathies and Ischemic Heart Disease

30 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Abnormal Heart Sound S 4 ; Summation Gallop –Early in Diastole –Precedes S 1 –Heard Best: over Mitral Area over Mitral Area with Bell with Bell –Associated with increased left Atrial Pressure caused by noncompliant LV; Hypertension, Cardiomyopathies and Ischemic Heart Disease

31 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Aortic valvular stenosis murmer –Heard best at 2 nd right interspace –Harsh rough quality with a cresendo- decresendo medium –Heard best with the Diaphragm –Radiates to the Carotid Arteries

32 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Aortic valvular stenosis murmer –Heard best at 2 nd right interspace –Harsh rough quality with a cresendo- decresendo medium –Heard best with the Diaphragm –Radiates to the Carotid Arteries

33 Assessing the Heart continues… Auscultation continues… Auscultation continues… –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

34 Assessing the Heart continues… Auscultation continues… Auscultation continues… –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

35 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Aortic Insufficiency –Heard best at the 3 rd left Interspace –High Pitched Blowing Sound –Radiates toward the Sternum –Heard best with the Diaphragm

36 Assessing the Heart continues… Auscultation continues… Auscultation continues… –Aortic Insufficiency –Heard best at the 3 rd left Interspace –High Pitched Blowing Sound –Radiates toward the Sternum –Heard best with the Diaphragm

37 Assessing the Vascular System Inspection 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

38 Assessing the Vascular System cont. Palpitation 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)

39 Assessing the Vascular System cont. Auscultation 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

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

41 Upon Diagnosis..

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

43 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: B-Type Natriuretic Peptide (BNP) is a cardiac neurohormone specifically secreted from the cardiac ventricles as a response to: ventricular volume expansionventricular volume expansion pressure overloadpressure overload resultant increased wall tension 1resultant increased wall tension 1 FDA cleared the first BNP test for use as a diagnostic aid in 2000 FDA cleared the first BNP test for use as a diagnostic aid in 2000

44 BNP Function BNP Function Found primarily in the cardiac ventricles Found primarily in the cardiac ventricles Is strongly induced during ventricular-wall tension or stretch Is strongly induced during ventricular-wall tension or stretch Potent natriuretic, diuretic, and vasorelaxant peptide Potent natriuretic, diuretic, and vasorelaxant peptide Inhibits sympathetic tone, renin- angiotensin axis, and synthesis of vasoconstrictor molecules Inhibits sympathetic tone, renin- angiotensin axis, and synthesis of vasoconstrictor molecules Maisel et, al Reviews in Cardiovascular Medicine 2003

45 Heart Failure Pathophysiology Myocardial injury Fall in LV performance Activation of RAAS, SNS, ET, AVP, and others Myocardial toxicity Peripheral vasoconstriction Hemodynamic alterations Remodeling and progressive worsening of LV function Heart failure symptoms Morbidity and mortality BNP

46 The Natriuretic Peptide System is Overwhelmed in Acute Decompensated Heart Failure Adapted from Burnett JC, J Hypertens 1999 Angiotensin II Endothelin ANPBNP Aldosterone Epinephrine

47 Documentation of the Cardiovascular Assessment AMI COR Measures 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

48 Documentation of the Cardiovascular Assessment CHF Core Measures CHF Core Measures –ACE/ARB Contraindicated –ACE/ARB if EF <40% –Discharge Instruction –LVF –Smoking Cessation or N/A

49 The End


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