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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 ♥ Description ♥ Location ♥ Duration ♥ Radiation ♥ Pain scale ♥ Intensity another side story Chest Pain Assessment ♥ Associated Symptoms ♥ Precipitating Factors ♥ Alleviating Factors cont. Heart Failure Defined “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.” E. Braunwald Congestive Heart Failure ♥ Weight Gain ♥ Difficulty Breathing ♥ PND ♥ Swelling ♥ Medication Compliance ♥ Diet/Salt Intake ♥ Oxygen Use assessment BNP Relationship to NYHA Objective Vs. Subjective Evaluation Median [BNP] (pg/ml) 1200 1000 800 600 400 200 0 NYHA I Triage BNP package insert. NYHAII NYHA III NYHA IV Cardiac Risks ♥ Hypertension ♥ Hyperlipidemia ♥ Diabetes ♥ Smoking ♥ Obesity ♥ Age ♥ Family history a side story 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 ♥ Inspection: – – – – Overly thin? Obese? Alert? Anxious? ♥ Inspect patient’s precordium: – Pulsations? – Symmetry of Movement? – Retractions or Heaves? pay attention! 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 Assessing the Heart continues… ♥ 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 Assessing the Heart continues… ♥ 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 Assessing the Heart continues… ♥ Auscultation continues… – Basic Heart Sound S1 – Heard at the beginning of Systole – Closure of Mitral and Tricuspid Valves Assessing the Heart continues… ♥ Auscultation continues… – Basic Heart Sound S1 – Heard at the beginning of Systole – Closure of Mitral and Tricuspid Valves Assessing the Heart continues… ♥ Auscultation continues… – Basic Heart Sound S2 – Heard at the End of Systole – Closure of Pulmonic and Aortic Valves Assessing the Heart continues… ♥ Auscultation continues… – Basic Heart Sound S2 – Heard at the End of Systole – Closure of Pulmonic and Aortic Valves Assessing the Heart continues… ♥ Auscultation continues… – Abnormal Heart Sound S3 ; Ventricular Gallop Rhythm – End of Diastole – Immediately after S2 – Heard Best: ♥ over Mitral Area ♥ with Bell Assessing the Heart continues… ♥ Auscultation continues… – Abnormal Heart Sound S3 ; Ventricular Gallop Rhythm – End of Diastole – Immediately after S2 – Heard Best: ♥ over Mitral Area ♥ with Bell Assessing the Heart continues… ♥ 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 Assessing the Heart continues… ♥ 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 Assessing the Heart continues… ♥ Auscultation continues… – Aortic valvular stenosis murmer – Heard best at 2nd right interspace – Harsh rough quality with a cresendodecresendo medium – Heard best with the Diaphragm – Radiates to the Carotid Arteries Assessing the Heart continues… ♥ Auscultation continues… – Aortic valvular stenosis murmer – Heard best at 2nd right interspace – Harsh rough quality with a cresendodecresendo medium – Heard best with the Diaphragm – Radiates to the Carotid Arteries Assessing the Heart 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 Assessing the Heart 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 Assessing the Heart continues… ♥ Auscultation continues… – Aortic Insufficiency – Heard best at the 3rd left Interspace – High Pitched Blowing Sound – Radiates toward the Sternum – Heard best with the Diaphragm Assessing the Heart continues… ♥ Auscultation continues… – 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) ♥ 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 1. Burnett JC, J Hypertens 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 Peripheral vasoconstriction Hemodynamic alterations Myocardial toxicity Morbidity and mortality BNP Remodeling and progressive worsening of LV function Heart failure symptoms The Natriuretic Peptide System is Overwhelmed in Acute Decompensated Heart Failure ANP BNP Endothelin Aldosterone Angiotensin II Epinephrine Adapted from Burnett JC, J Hypertens 1999 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