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Cardiac Assessment
Toni Standley RN ANP MSN
Porter Adventist Hospital
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Cardiovascular Assessment
♥Obtaining health history
♥Physical exam
♥Assessment of patient’s heart and vascular system
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Obtaining a Health History
♥ Introduce yourself♥Chief complaint♥Cardiac risks♥Other ailments♥Personal and family history
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Chest Pain Assessment another side story
♥Description♥Location♥Duration♥Radiation♥Pain scale♥ Intensity
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Chest Pain Assessment cont.
♥Associated Symptoms
♥Precipitating Factors
♥Alleviating Factors
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“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
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Congestive Heart Failure assessment
♥Weight Gain♥Difficulty Breathing♥PND♥Swelling♥Medication Compliance♥Diet/Salt Intake♥Oxygen Use
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BNP Relationship to NYHA Objective Vs. Subjective
Evaluation
Triage BNP package insert.
0
200
400
600
800
1000
1200
Med
ian
[B
NP
] (p
g/m
l)
NYHA I NYHAII NYHA III NYHA IV
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Cardiac Risks a side story
♥Hypertension ♥Hyperlipidemia♥Diabetes♥Smoking♥Obesity♥Age♥Family history
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MEDICATIONS - A side story
♥ Beta Blockers♥ Aspirin♥ Ace Inhibitors/ ARBS♥ Diuretics♥ Statins♥ Calcium channel blockers♥ Plavix♥ Antiarrythmics/Digoxin
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PERSONAL AND FAMILY HISTORY - A side story
♥Married?♥ Children?♥ Occupation?♥ Activities?♥ Living arrangements?♥ Caffeine intake?♥ ETOH intake?♥ Family medical history?
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Performing a Physical Assessment
♥Consistent, Methodical Approach♥Regular Practice♥Stethoscope with a Bell and
Diaphragm♥Appropriate size blood pressure cuff
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Performing a Physical Assessment
♥Consistent, Methodical Approach♥Vital signs♥EKG♥Lab values♥Previous/recent tests – treadmills,
cardiac catherizations, by-pass surgery, previous hospitalizations.
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Assessing the Heart pay attention!
♥ Inspection:– Overly thin?– Obese?– Alert?– Anxious?
♥ Inspect patient’s precordium:– Pulsations?– Symmetry of Movement?– Retractions or Heaves?
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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
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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
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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
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Heart Sounds Anatomy
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Assessing the Heart continues…
♥Auscultation continues…
– Basic Heart Sound S1
– Heard at the beginning of Systole– Closure of Mitral and Tricuspid Valves
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Assessing the Heart continues…
♥Auscultation continues…
– Basic Heart Sound S1
– Heard at the beginning of Systole– Closure of Mitral and Tricuspid Valves
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Assessing the Heart continues…
♥Auscultation continues…
– Basic Heart Sound S2
– Heard at the End of Systole– Closure of Pulmonic and Aortic Valves
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Assessing the Heart continues…
♥Auscultation continues…
– Basic Heart Sound S2
– Heard at the End of Systole– Closure of Pulmonic and Aortic Valves
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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
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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
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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
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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
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Assessing the Heart continues…
♥Auscultation continues…
– Aortic valvular stenosis murmer– Heard best at 2nd right interspace– Harsh rough quality with a cresendo-
decresendo medium– Heard best with the Diaphragm– Radiates to the Carotid Arteries
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Assessing the Heart continues…
♥Auscultation continues…
– Aortic valvular stenosis murmer– Heard best at 2nd right interspace– Harsh rough quality with a cresendo-
decresendo medium– Heard best with the Diaphragm– Radiates to the Carotid Arteries
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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
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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
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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
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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
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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
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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)
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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
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Upon Diagnosis…
♥ Assessment: - Angina? - Myocardial Infarction or ACS - Decompensated CHF - Pericarditis - Atrial Fibrillation or other arrythmias - Valvular Heart disease or endocarditis
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Upon Diagnosis..
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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
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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:
• ventricular volume expansion
• pressure overload
• resultant increased wall tension1
♥ FDA cleared the first BNP test for use as a diagnostic aid in 2000
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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
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Heart Failure Pathophysiology
Myocardial injury Fall in LV performance
Activation of RAAS, SNS, ET,AVP, and others
Myocardial toxicity Peripheral vasoconstrictionHemodynamic alterations
Remodeling andprogressive
worsening ofLV function Heart failure symptomsMorbidity and mortality
BNP
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The Natriuretic Peptide System is Overwhelmed in Acute
Decompensated Heart Failure
Adapted from Burnett JC, J Hypertens 1999
Angiotensin II
EndothelinANP BNP
Aldosterone
Epinephrine
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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
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Documentation of the Cardiovascular Assessment
♥CHF Core Measures– ACE/ARB Contraindicated– ACE/ARB if EF <40%– Discharge Instruction– LVF– Smoking Cessation or N/A
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The End