Pearls For Cardiac History and Physical Exam

Leslie L Davis, PhD, RN, ANP-BC, FAANP, FAHA Associate Professor of Nursing Univ of NC in Greensboro

There are no disclosures relevant to this presentation.

1 Objective

• Review key aspects of nursing assessments (history taking & physical exam) for caring for patients with cardiovascular conditions.

2 History Taking: Questions to Ask • History of Present Illness: – Age when 1st experienced symptoms or told they had a cardiovascular condition; when (if ever) did they start treatment – or discomfort; ; – Dizziness; pre-syncope; syncope – Symptoms of stroke or transient ischemic attacks (TIAs) – Leg pain or cramps; swollen ankles; recent change in weight – # of pillows they sleep on at night; # of times they get up to urinate at night

3 History Taking: Questions to Ask • Past Medical/Surgical History: – Cardiac surgery or hospitalizations; prior cardiac evaluations; – Past history of stroke, TIA, coronary disease, , atrial fib or other cardiac dysrhythmias, , dyslipidemia, thrombophlebitis, peripheral vascular/arterial disease, congenital heart disease, long QT syndrome – Kidney disease; Endocrine conditions (such as diabetes or thyroid disease) – Last eye exam (dilated exam preferred)

4 History Taking: Questions to Ask • Family History: – Other family members with high BP or cardiac conditions at a young age • men < 55 yrs of age • women < 65 yrs of age – Kidney disease or endocrine conditions (thyroid or diabetes)

5 History Taking: Questions to Ask • Personal and Social History – Assess current and past history of tobacco, alcohol, & drug use – Current living arrangements – If woman of child bearing years, LMP & current use of any birth control – Current employment status & exposure to environmental hazards and/or physical or emotional stress – How they pay for their or health care expenses – Nutritional status, including usual food/beverage intake, including sodium – Exercise: type, amount, frequency, intensity

6 History Taking: Questions to Ask

• • Current medications – Includes over-the-counter (OTC) meds, herbals, & home remedies. • Meds taken in the past for cardiovascular conditions • What, if anything, they take when in pain • Do they measure their at home; if so, what device do they use & what are the numbers typically.

7 Tips for a good physical exam

• Develop a systematic approach

• Be methodical

• Take your time to get good data

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• Temperature • – Full minute – Apically versus radially • • Blood pressure – Manually versus Electronically

9 Inspection

• Inspect other organs to yield some info about the cardiovascular system – General • Any acute distress? – Eyes – Neck – Skin – Nails – Nail beds

10 Xanthelasma

https://en.wikipedia.org/wiki/Xanthelasma#/media/File:Xanthelasma.jpg

• Yellowish deposit of cholesterol under skin • Typically on or around eyelids

11 Jugular Distention

• Head of bed/table at 45 degree angle • Head turned to side • Measure highest point which pulsation can be detected in the internal jugular vein

• “Normal” ~ 6-8 cm H20

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https://en.wikipedia.org/wiki/Cyanosis#/media/File:Cynosis.JPG

13 (Head to Toe)

• Radial – Note rate/rhythm/character • Carotid pulses – Note rate/rhythm/character • Chest wall – Apex then precordium (valve areas) • Abdomen – Edema, pulsations • Ankles – Pulses, presence of edema

14 Palpation – continued

• Peripheral pulses – Palpate pulses bilaterally (or not)? – Checking for edema – Rating of pulses/edema

15 Palpation – continued

• Carotid – How to palpate the carotid – Synchronous with ______– Patient to breath or not? – Checking for

16 Palpation of Chest Wall

• Patient supine • Proximal 4 fingers with GENTLE pressure • Start at apex – advancing towards base via sternal border • Thrills, heaves, or lifts • Apical impulse / Point of maximal impulse

17 Palpation of Abdomen

• Soft, rounded abdomen? • Pulsations? • Edema? • Tenderness?

18 Edema

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• Use – To define the cardiac border

– Limited value for cardiac exam

– Primarily used for assessing pts with heart failure

20 Percussing Liver Border

• Upper liver border – Percuss down from right 2nd ICS (mid-clavicular) until dullness heard • Lower liver border – Percuss up from right iliac fossa (mid-clavicular) until dullness heard • Measure distance between the two dull areas • normally 6-12 cm (generally ~ 10)

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• Take your time • Don’t try to listen to everything at once • Inch along – don’t jump from one spot to the next • Listen – Sitting up – Then supine – Then left lateral position

22 Auscultation - continued

• Five areas – Aortic area: 2nd ICS to the ®) – Pulmonic area: 2nd ICS to the (L) – Second pulmonic area: 3rd ICS (L) – Tricuspid area: 4th ICS to the (L) – Mitral (or apical) area: 5th ICS mid-clavicular

23 24 Auscultation - continued

• Pearls – Close your eyes – Move head around – If having a hard time listening: • Turn to left lateral position and listen at PMI • Sit them up and lean them forward • Have them hold their breathe • Close the door and quiet bystanders

25 Auscultation - continued

• Assess – Rate & Rhythm – Have them breathe normally – Listen to S1 while palpating carotid – Concentrate on (S1 – S2) – Check for extra – Listen to

26 Auscultation - continued

• S1: – Best heard at the apex (mitral area) – Correlates with carotid pulse – AV valves closing (between atria and ventricles) • S2: – Best heard at base (top) – Semi-lunar valves closing

– A2 – P2

Atrioventricular = AV; aortic sound = A2 ; pulmonic heart sound = P2

27 Auscultation - continued

• S3: – Ken-tuc-ky – Best heard left lateral at the apex – Softer than S 4 – Use bell – Passive phase of filling ventricles – What does it mean?

28 Auscultation - continued

• S-4: – Tenn-es-see – Typically “louder” (higher pitch than S3) – Best heard supine or left lateral – Listen at the apex; with a bell – Vigorous atrial ejection – What does it mean?

29 Sequence of Heart Sounds

S4 – S1 ------S2 – S3 “lub” “dub”

30 Auscultation - continued

• Rubs – Rough parietal or visceral surfaces – During both systole & diastole – Overlies all cardiac sounds – History very important

31 Auscultation - Murmurs

• Systolic murmurs –Mitral Regurg –Tricuspid Regurg –Aortic

32 Systolic Murmurs….a little fun….

• Mr. • Turtle • Asks for more time

This Photo by Unknown Author is licensed under CC BY-SA

33 Auscultation - Murmurs

• Diastolic murmurs –Mitral Stenosis –Tricuspid Stenosis –Aortic Regurg

34 Diastolic Murmurs….a little fun…. May MiSs These Soft Murmurs As they are hard to hear

This Photo by Unknown Author is licensed under CC BY-SA 35 Grading Description Murmurs Very faint, heard only after listening very intently; may not be heard in all positions. Likely only heard if Grade 1 the patient "bears down" (performs a ) Quiet, heard after placing the on the Grade 2 chest by more experienced clinicians Grade 3 Moderately loud. Grade 4 Loud, with palpable thrill Very loud, with thrill. Grade 5 May be heard when stethoscope is partly off the chest. Very loud, with thrill. Grade 6 May be heard with stethoscope entirely off the chest. 36 Murmurs – other terminology

• Timing & duration (where in relation to systole) • Pitch (high, medium, low) • Intensity (grades) • Pattern (crescendo, decrescendo) • Quality (harsh, raspy, machinelike, vibratory, musical, blowing) • Location (anatomic landmarks) • Radiation (to axilla or carotids)

37 Tips for Sounds

• Sit patient up if possible • Listen to anterior and posterior fields • Make sure they are taking deep breathes with their mouth open • Door closed & bystanders quiet • DON’T listen through clothing

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