ADVANCED HEALTH ASSESSMENT Cardiovascular Assessment

1
ADVANCED HEALTH ASSESSMENTCardiovascular
Assessment

• Heather Hull, ARNP. PNP

2
Cardiovascular Structure

• Heart Neck Vessels
• Arteries
• Veins
• Lymphatic Tissue

3
Most Common Problems

• Coronary Artery Disease
• Hypertension
• Rheumatic Heart Disease
• Bacterial Endocarditis
• Congenital Heart Disease

4
Risk Factors (Noncorrectable)

• Fam Hx (BP, stroke, CVD, MI-death lt50, DM,
  hyperlipids)
• PMH (DM, CAD, CHF, CHD, ARFever, m, arrhrythmia,
  CV surg, blood disorders, aneurysms, emboli,
  hypo-hyper thyroid)
• Age, Sex (Male)
• Personality type

5
Risk Factors (Correctable)

• Cigarette Smoking
• Essential HTN
• Hyperlipidemia (Reduced HDL-cholesterol)
• Nutrition/diet - obesity/body fat - Anaerobic
  exercise
• Environmental, stress, emotional, physical
  demands
• Menopause - estrogen replacement
• Drug use - alcohol, cocaine, Rx, OTC

6
Blood Pressure (Adults) NIH, 6th Report, 1997

• Optimal Systolic lt120 Diastolic lt80
• Normal Systolic lt130 Diastolic lt85
• High-Normal
• Systolic 130-139 or
• Diastolic 85-89

7
Blood Pressure

• Right Arm - 5-10 mg higher than Left
• Leg - 15-20 mg higher than arm
• Pulse Pressure -
• Orthostatic hypotension - sysolic gt of 20 mg or lt

8
Hypertension (Adults) NIH, 6th Report, 1997

• Stage I
• Systolic 140-159 or Diastolic 90-99
• Stage II
• Systolic 160-179 or Diastolic 100-109
• Stage III
• Systolic gt180 or Diastolic gt110

9
Hypertension (Children)

• Normal lt 90th ile Systolic /Diastolic
• High Normal 90-95th ile
• Hypertension gt 95th ile

10
Cholesterol

• Acceptable lt170 mg/dl -(Child) lt200 (Adult)
• Borderline 170-199 mg/dl - (Child) 200-239
  (Adult)
• High gt-200 mg/dl - (Child) gt240 (Adult)

11
HDL-Cholesterol

• 25 of total
• Protective
• Low Genetic, smoking, obesity, sedentary,
  hypertriglyceridemia, anabolic steroids,
  progestational agents, some beta-blocking agents

12
LDL-Cholesterol

• 70 of total
• Atherogenic
• Acceptable LDL lt110 mg/dl
• Borderline LDL 110-120 mg/dl
• High LDL gt-130

13
Cholesterol - Children

• Universal screening not recommended
• Family History of cholesterol above 240,
  premature CV D
• Lifestyle risk factors

14
Heart

• Left High Pressure
• Right Low Pressure

15
Pericardium

• Visceral (inner) insensitive to pain
• Parietal (outer) innervated by phrenic nerve
• Bottom adherent to diaphram
• Top attached to upper sternun

16
Impulse Conduction

• SV Node
• Conduction system
• AV node
• Right left bundle branches
• Purkinje fibers

17
Left ventricular apex

• PMI
• 5th ICS MCL Adults
• 4th ICS gtleft Infants

18
Listening Areas

• Aortic 2ICS-RSB (S2)
• Pulmonic 2ICS-LSB (S2)
• Tricuspid LLSB (S1)
• Mitral Apex (S1)

19
Cardiac Cycle

• S1 - closure of atrial ventricular AV valves
• Tricuspid Mitral
• S2 - closure of semilunar SL valves
• Aortic Pulmonic
• S3 - Normal in children young adults

20
Cardiac Cycle

• S3 - Can be normal in children young adults
• gt 30 years signifies volume overlead to ventricle
• Valvular lesions CHF
• SLOSH-ING-IN
• TENN E SSEE
• S1 S2 S3

21
Cardiac Cycle

• S4 - Can be normal in children (?) young adults
• gt 30 years signifies noncompliant or stiff
  ventricle
• Hypetrophy of ventricle CHF, CAD
• a- STIFF-wall
• KEN TU CKY
• S4 S1 S2

22
Sinus Arrhythmia

• Physiologic splitting of S2
• Increase with inspiration
• Decrease with expiration

23
Jugular Venous Pressure

• Reflects pressures in right side of heart
• Assess internal jugular pressure (not palpable)
• Pulsations best visible with client _at_ 45 degree
  angle
• (45-60)
• Measure highest level of pulsations from sternal
  angle
• Pressures gt 3-4 cm above sternal angle elevated

24
Heart Physical Assessment

• General
• BP
• Arterial Pulse
• JVD
• Inspection, palpation, percussion auscultation
• Edema

25
Peripheral Vascular Assessment

• General
• Arterial Pulse
• Bruits Carotid, abdominal (ARIF)
• Lymphatics

26
Heart History

• Chest pain
• Irregularities of rhythm
• Dyspnea
• Syncope

27
Heart History

• Fatigue
• Dependent Edema
• Hemoptysis
• Cyanosis

28
Peripheral Vascular History

• Pain
• Skin temperature color
• Edema
• Ulceration
• Emboli
• Stroke
• Dizziness

29
OLD CART

• Chest pain, anxiety, dyspnea, diaphoresis,
  syncope/near syncope episodes, nausea, edema
  lymphadenopathy, fatigue, pallor, palpitations,
  leg ulcerations (atrophy, hair loss), diabetic
  neuropathy (esp. without sweat), claudication

30
Chest Pain

• Cardiac
• Vascular
• Pulmonary
• Gastrointestinal
• Neural
• Musculoskeletal
• Emotional

31
Chest Pain Attributes

• P - provocative-palliative factors
• Q - quality
• R - region
• S - severity
• T - Timing

32
Angina

• P - Exertion sustained before pain (lag),
• P - Emotion, eating, cold
• P - Subsides with rest, Nitroglycerine
• Q - Deep, pressure, squeeze, heavy, strangle,
• Q - Tight, Levines sign

33
Angina

• R - Substernal/retrosternal
• R - Mild to severe intensity, can radiate
• R - Jaw, arms, neck, back Diffuse
• R - Location stereotyped for individual
• R - Variations indicate change, unstable angina
• S - Mild to severe

34
Angina

• T - Episodic, seizes
• T - Duration is short 2-3 minutes
• T - (lt1 gt10 minutes)

35
Acute MI

• Steady, deep pain
• Lasts 20 minutes or longer
• May not be relieved by nitroglycerine
• Feeling chest contriction, crushing
• Nausea, vomiting diaphoresis
• May occur at rest, with exertion or stress

36
Pericarditis

• Deep constant or pleuritic pain
• Pericardial friction, may be related to resp.
• Increases with cough
• Sharp, stabbing
• Fever or recent infection
• Shallow breathing, sitting up, leaning forward
  relieves

37
Pulmonary

• Onset gradual or sudden (hours to days)
• Fever, infection, cough (sputum, blood)
• Pain over lung fields
• Mild - severe, sharp ache
• Air hunger, dyspnea, restlessness
• Splinting, moist air, rest, heat, sitting up may
  relieve

38
Respiratory Movement Pain

• Pleurisy, overuse, trauma
• Sharp, burning, stabbing, shooting, deep
• Crushing or tearing sensations

39
Musculoskeletal Chest Wall

• Tenderness to palpation of chest wall
• Chest wall maneuvers may precipitate pain
• Examples
• Rib Fracture, arthritis, muscle spasm or
  myositis,
• costochondritis, slipping cartilage

40
Gastrointestinal

• Gradual of sudden onset
• Esophagitis gastritis may occur after eating,
  leaning over
• Pain may be burning, retrosternal, epigastric or
  radiate
• Mild to severe
• Intermittment or continuous

41
Gastrointestinal

• Food, antacid, standing, belching may relieve
• Emotional stress, caffiene, spices, heavy meals,
• cold liquids, alcohol, exercise, smoking may
  aggrevate

42
Palpitations Arrhythmias

• Cardiac
• Thyrotoxicosis
• Hyypoglycemia
• Fever
• Anemia
• Anxiety

43
Palpitations

• May not indicate serious disease
• Other factors caffeine, tobacco, drugs

44
Dyspnea

• Cardiac Left ventricular failure, mitral
  stenosis.
• Paroxsysmal nocturnal dyspnea
• Orthopnea
• Dyspnea with exertion
• Trepopnea - gt better while lying on side

45
Dyspnea

• Pulmonary
• Emotional
• High-altitude
• Anemia

46
Syncope

• Fainting, dizziness, blackout
• Cardiac
• Metabolic
• Psychiatric
• Neurologic
• Orthostatic hypertension

47
Syncope

• Vasovagal -vasodepresson
• Micturation - visceral reflex
• Cough - chronic lung disease
• Carotid sinus - sensitivity (pressure)

48
Fatigue (most common)

• Decreased cardiac output
• CHF
• Mitral valvular disease
• Anxiety depression
• Anemia or chronic diseases

49
Dependent Edema

• CHF
• Worse as day progresses
• SOB

50
Edema

• 1 2mm
• 2 4mm
• 3 6 mm
• 4 8 mm

51
Hemoptysis

• Differentiate
• Hemoptysis
• Hematomesis

52
Cyanosis

• Lower extremities (differential R - L SHUNT PDA

53
Peripheral History

• Pain
• Skin changes
• Edema
• Ulceration
• Emboli
• Neurologic Symptoms

54
Physical Examination
55
Skin

• Cyanosis
• Xanthomata tendons
• Tuberous xanthomata
• Erythema marginatum Rheumatic fever
• Cold, clammy - low output states
• Widespread vasodilatation - high output states
• Pallor - anemia

56
Nails

• Splinter hemorrhages (endocarditis)
• Clubbing (cyanotic CHD, chronic pulm infections,
  cirrhosis)

57
Face Eyes

• Hypercholesterolemia (Xanthelasma, arcus senilis)
• Lens displacement (Marfans )
• Hypertelorism (CHD)

58
Mouth Neck

• Petichiae SBE
• High arched palate (CHD)
• Webbing (Turners)

59
Fundscopic Exam (Keith-Wagener changes)

• KW I minimal arteriolar narrowing
• KW II nicking KW I
• KW III flaming hemorrhages, cotton wool patches
• KW IV papilledema KW I, II, III

60
Extremities Lesions

• Rheumatic nodules
• Oslers nodes
• Xanthoma tuberosum
• Varicose veins
• Leg ulcerations (ischemic vs stasis)
• Ear creasing before age 60
• Arachnodactyly (Marfans, CHD)

61
Abdominal Vascular

• Ascities
• Abdominal bruits
• Systemic venous congestion - enlargement,
  tenderness, friction rub
• Hepatojugular reflux (manual compression test)
• Jugular Venous Distention

62
Peripheral

• Pulses
• Temperature
• Bruits
• Lymph nodes
• Lymphangitis
• Edema, Lymphedema

63
Cardiac Exam

• Observation Palpation
• Precordial Areas - Aortic, Pulmonic, Erbs,
  Tricuspid, Mitral
• PMI
• Pulsations, Heaves, Thrusts, Thrills

64
Ausculation

• Quite, comfortable
• After history observation
• All valve areas - sitting, leaning forward,
  supine left lateral decubitus
• Only 1 event at a time (close eyes)
• Diaphram Bell
• Special Maneuvers

65
Ausculatation

• Abnormalities in Rate Rhythm
• Abnormalities in S1 S2
• Ejection Clicks Murmurs
• Regurgitant Murmurs
• Variations in S2 Splitting
• Pericardial Friction Rubs

66
Murmurs

• Timing
• Duration
• Intensity
• Pitch
• Location
• Radiation
• Relationships - respiration, body position

67
Intensity Grade I-VI (I/VI)

• I
• II
• III
• IV - Thrill
• V - Thrill, M with stethoscope
• VI - Thrill, M without stethoscope

68
Pathological Correlations

• S1
• S2 - Splitting
• Systolic Clicks
• Diastolic Opening Snaps
• Murmurs - ejection, regurgitant, diastolic AV,
  diastolic semilunar

69
Special (Physiologic) Maneuvers

• Respiration
• Inspiration - venus return enhanced right-sided
  murmurs may increase
• Expiration - Decrease in venus return right-
  sided murmurs may decrease. Left sided murmurs
  may increase

70
Valsalva Maneuver

• During straining phase, venus return diminishes
  left ventricular volume is reduced
• Hypertrophic obstructive cardiomyopathy murmur
  may increase

71
Standing from Squatting

• Left ventricular volume is reduced secondary to
  reduced venus return
• Mitral valve prolapse may be enhanced in
  absence of murmur may produce mitral
  insufficiency murmur. Click of mitral valve
  prolapse will move toward first sound with the
  standing position

72
Passive Leg Raising

• Increased venus return increased left
  ventricular right ventricular volume
• May enhance murmur of tricuspid regurgitation

73
Handgrip

• After one minute of patients strongest possible
  grip
• May reduce murmur of aortic stenosis, increase
  murmur of aortic regurgitation mitral
  regurtitation. May increase murmur of VSD

74
Arterial Occlusion

• Bilateral, upper arms, 20-40 mm hg above BP
• Intensity noted after 20 seconds
• May increase murmur of mitral regurgitation

75
Innocent Murmurs

• Systolic (except for venous hum)
• Common - Children, teenage high output
  conditions
• Grade III or less
• Pulmonary or LLSB
• Altered by position
• Absence of cardiac enlargement

76
Innocent Murmurs

• Normal EKG or chest X-ray
• Short, Systolic, Soft
• If in doubt - echo
• Physiologic splitting of S2

77
Children - Physiologic Murmurs

• Stills Vibratory Murmur - Systolic, LLSB apex,
  intensifies during supination, early school age
• Venous Hum - Continuous at clavicles, disappears
  with supiatio, compression of jugular vein or
  turning head, early school years
• Pulmonary Flow Murmur - older chidren, LUSB,
  louder in supine position
• PPP -Physiologic Peripheral Pulmonic Stenosis
  Murmur - newborns

78
Children - Common Organic Murmurs

• ASD
• VSD
• PDA
• Pulmonic Stenosis
• Aortic Stenosis
• Coarctation of Aorta