Interactive session: Cardio- respiratory examination and clinical skills update

Louise Best Cardiac Advanced Nurse Practitioner Brighton and Sussex University Hospital NHS Trust Learning Focus

Assessing breathlessness

Assessing fluid status

Cardio-respiratory assessment

Case study Breathlessness

Also known as dyspnoea, is a subjective, usually distressing sensation or awareness of difficulty with breathing. Usually inappropriate to a given level of exertion.

Breathlessness can be classified by its speed of onset: Acute breathlessness- when it develops over minutes. Subacute breathlessness- when it develops over hours or days. Chronic breathlessness- when it develops over weeks or months.

(Nice, 2017) Assessment Structure

Taking a history (80% of the diagnosis)

Many models available for a structured review; Medical Model, Calgary- Cambridge, Pendleton, Neighbour + Many more!

• Ancient Dictum ‘Listen to the patient and he will tell you the diagnosis’

(Voltaire)

Red flags

 Stridor  Altered level of consciousness or acute confusion  Significant respiratory effort (particularly if the person is becoming exhausted)  Nasal flaring or tracheal tug  Intercostal indrawing  Elevated respiratory rate, tachycardia and hypotension  Inability to speak or fragmented speech  Oxygen saturation less than 92%  Cyanosis  Unrelieved chest pain  Peak expiratory flow rate less than 50% predicted Presenting complaint- Principle complaint

History of presenting complaint- details, effects of complaint on ADLs, associated symptoms, SOCRATES or PQRST

Past/previous medical history- Past illnesses, hospitalisation, operations, past treatments

Drug history and allergies- prescription medication, OTC, herbal remedies, any side effects or problems, allergies

Social history- occupation, marital status, accommodation, hobbies, social life, smoking and alcohol consumption, diet, sleeping and wellbeing

Family history- age and health, or age and cause of death (parents, grandparents, siblings, children, grandchildren)

Systems review- General, skin, HEENT, neck, breasts, respiratory, CVC, GI, peripheral vascular, urinary, genital, MSK, psychiatric, neurological, haematological, endocrine. Initial enquiry of symptoms

Can use assessment tools such as Socrates and PQRST  Onset- sudden or gradual  Location- radiation  Duration- frequency, chronology  Characteristics- quality, severity  Aggravating and precipitating factors  Relieving factors  Current situation (improving or deteriorating)  Effects on ADLs  Previous diagnosis or similar episodes  Previous treatments and efficacy Specific Symptoms Shortness of Breath

Number of stairs they can climb or distance they can walk.

Posture- orthopnea or tripoding

Shortness of breath at rest

Association with Paroxysmal Nocturnal Dyspnea (PND)

Associated swelling of ankles or recent weight gain New York Heart Association (NYHA) Functional Classification

Class Patient Symptoms I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath). II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath). III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases Cough

Quality

Severity

Timing

Duration Sputum

Colour

Amount

Consistency

Purulence, odour, foul taste

Time of day, worse? Haemoptysis

Amount of blood

Frank blood mixed with sputum

Association with leg pain, chest pain, SOB Chest Pain

Associated symptoms

Relation to effort, exercise, meals, bending over

Explore the pain carefully- SOCRATES Cyanosis

Central vs peripheral

When does it occur?

Any recent changes in pattern of?

Associated wheeze? Fainting and Syncope

Weakness, light-headedness, loss of consciousness

Relation to postural changes, vertigo or neurological symptoms Orthopnea?

Is dyspnea that occurs when the patient is lying down and improves when the patient sits up.

Classically quantified by the number of pillows used for sleeping, or by the fact the patient needs to sleep sitting upright.

Need to ensure that this is due to SOB and not other causes. Paroxysmal nocturnal dyspnea (PND)

Describes episodes of sudden dyspnea and orthopnea that awaken the patient from sleep.

Usually 1-2 hours after going to bed, prompting the patient to sit up, stand up, or go to the window for air.

There may be associated wheezing and coughing.

The episode usually subsides but may recur on subsequent nights. Extremities

Oedema . Site . Relation of oedema to activity or time of day Intermittent claudication Tingling Leg cramps or pain at rest Presence of varicose veins Fluid status

Weight changes

Input/output

Fluid restriction?

Oedema

Diuretics? Physical Assessment Preparation

Explain the procedure to the patient and consent Infection control Universal precautions Patient position- think about how often you are asking the patient to change position Examine from the right side- standard position for physical assessment Lighting Equipment Privacy and dignity Vital Signs

Respiratory rate SpO2 Heart rate Blood pressure ( + lying and standing) Temperature Peak flow Weight General Appearance

Acutely or chronically ill Degree of comfort or distress Position to aid respiration Diaphoresis Ability to talk a normal-length sentence without stopping to take a breath Colour Nutritional status Hydration status Mental status Inspection

 Colour- cyanosis  Shape of chest- pectus excavatum, pectus carinatum, barrel chest  Symmetry of chest movement  Rate, rhythm and depth of respiration, respiratory distress  Intercoastal indrawing  Use of accessory muscles  Precordium: visible pulsations  Chest wall scars, bruising, signs of trauma  Jugular venous pressure (JVP) (<4 cm?)  Colour of conjunctiva (Jaundice, anaemia)  Extremities - Hands- oedema, cyanosis, clubbing, nicotine stains, cap refill <3 seconds Inspection

- Feet and legs – changes in foot colour with changes in leg position i.e., blanching with elevation, rubor with dependency, ulcers, varicose veins, oedema (check sacrum if patient is bedridden), colour (pigmentation, discoloration), distribution of hair

 Skin – rashes, lesions, xanthomas Pectus carinatum Pectus excavatum Barrel Chest Inspection: Assessing jugular venous distension • Estimating the jugular venous distension provides important information about the patient’s volume status and cardiac function

• The JVD reflects CVP/RAP (normally < 7mmHg or 9cm H20). The sternal angle is 5 cm above the right atrium so the normal JVD should be no more than 4 cm • Assess the JVD with the patient lying at an angle of 30 - 450. The internal jugular vein lies lateral to the carotid artery and beneath the sternomastoid muscle. At 30- 450 it should be just visible above the clavicle. Assessing the Jugular veins Jugular venous distension Distinction between jugular venous and carotid pulses • Internal Jugular Vein • Not palpable • Two peaks per cycle (in sinus rhythm) • ‘a’ wave (right atrial contraction) • ‘v’ wave (right atrial filling when tricuspid valve closed) • Affected by compressing the abdomen • Pulsation diminished by pressure at root of neck • Changes with respiration • Carotid Artery • Palpable • One peak per cycle • Not affected by compressing the abdomen • Pulsation unaffected by pressure at root of neck • No changes with respiration Causes of elevated JVD?

Causes of elevated JVD • Heart failure • Fluid overload • Superior vena cava obstruction • Constrictive pericarditis • Cardiac tamponade • Tricuspid valve regurgitation Additional manoeuvres • Abdomino-jugular test (hepato-jugular reflux) • Kussmauls’s sign Hepato jugular reflex

• Is a more sensitive indicator of right heart function • Sit the pt at 20-30° trunk elevation • Firm, gentle pressure is applied over R upper quadrant for 30-60 seconds and observe jugular vein • Normal – initial venous distension is quickly followed by collapse as the RV adjusts to the increased venous return • Abnormal – sustained rise in JVD of at least 4cm or more, or a fall of 4cm or more after pressure release Elevated JVD and HJR Palpation

 Tracheal position (midline)  Chest wall tenderness or crepitus  Chest expansion  Tactile fremitus  Spinal abnormality- Scoliosis, Kyphosis, Lordosis  Nodes  Masses  Apical beat: - Point of maximum impulse (PMI) normally located at the fifth intercostal space, mid- clavicular line - Assess quality and intensity of apical beat - Apical beat (PMI) may be laterally displaced, which indicates cardiomegaly Palpation

 Identify and assess pulsations and thrills  Hepatomegaly, right upper quadrant (RUQ) tenderness  Assess peripheral pulses – radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis  Check for synchrony of radial and femoral pulses  Oedema: pitting (rated 0 to 4) and level (how far up the feet and legs the oedema extends); sacral oedema

Chest expansion Palpation: cardiac oedema

• Ankle oedema • Sacral oedema • Scrotal oedema • Pulmonary oedema Oedema

• The collection of an abnormal amount of tissue fluid • Accumulates in the extracellular spaces between cells and leads to local swelling • Tissue fluid is in dynamic equilibrium with plasma – balance of fluid escaping from blood vessels and fluid being returned to blood vessels and drained away by lymphatic vessels • HF – increased venous pressure • Pulmonary oedema and peripheral oedema • Peripheral oedema – sign of right sided HF or CCF • Accumulates at the lowest part of the body • feet, ankles • sacrum • Pitting – swelling that can be displaced by firm pressure and which leaves a pit when the finger is removed • Differential diagnosis • stasis oedema – elderly, immobile – lack of muscle pump activity • low albumin Useful questions

Have you had any swelling anywhere? When does it occur? Is it worse in the morning or night? Do your shoes get tight? Are your rings tight on your fingers? Are your eyelids puffy or swollen in the mornings? Have you had to let your belt out? Have your clothes got tight around the middle?

Has the patient recorded daily weights? Oedema may not be obvious until several litres of extra fluid have accumulated Grading oedema

Grade +1 Slight indentation

Grade +2 Moderately pitting lasts for a few seconds

Grade +3 Deep indentation that returns slowly to its original contour

Grade +4 An even deeper indentation that returns more slowly to original contour Percussion of lung fields

Percuss and posteriorly and anteriorly

Resonant note- Normal air filled lung

Dull note – Heard over solid organs. Indicative of consolidation

Stoney dull- duller than ‘standard’ dull sound. Indicative of a pleural effusion

Hyperresonance- pathological percussion sound indicative of hyper-inflated lungs from advanced COPD, emphysema, or a pneumothorax Auscultation of lungs

• Listen for sounds of normal air entry before trying to identify abnormal sounds • Degree of air entry throughout the chest (should be equal) • Quality of breath sounds (e.g., bronchial, bronchovesicular, vesicular) • Ratio of inspiration to expiration • Adventitious sounds: - Wheezes (rhonchi), crackles (rales), pleural rub, stridor, decreased breath sounds, absent breath sounds Lung lobes Anterior Landmarking Posterior landmarking Auscultation of the heart

• Listen to normal heart sounds before trying to identify murmurs • Auscultate at aortic, pulmonic, Erb’s point, tricuspid, and mitral. Attempt to identify: - Rate and rhythm - S1 and S2 sounds and their intensity - Added heart sounds (S3 and S4), splitting of S2 - Murmur - Pericardial rub Auscultation landmarks

1. Aortic area • 2nd i/c space RSB 2. Pulmonic area • 2nd i/c space LSB 3. Erb’s point • 3rd i/c space LSB 4. Tricuspid area • 4th i/c space LSB 5. Mitral area • 5th i/c space mid-clavicular line Heart sounds

• Use diaphragm and bell of stethoscope • Normal heart valves make ‘no sound’ on opening, only on closing – S1 & S2 • Abnormal heart sounds are due to: • Movement of blood across an abnormal valve • Movement of blood through an abnormal channel • Movement of blood within an abnormal chamber Cardiac auscultation

• Listen at each of the auscultatory sites with both the bell and the diaphragm; use an inching approach if needed.... • To differentiate between S1 and S2 simultaneous palpation of the carotid pulse may be helpful. The first heart sounds precedes the pulse, the second sound follows it. • Use the diaphragm for high pitched sounds – S1 and S2 and most systolic murmurs. • Use the bell for low pitched sounds – third heart sound and mitral stenosis Normal Heart sounds

S1- caused by closure of the tricuspid and mitral valve

S2 – is caused by closure of the pulmonic and aortic valves Splitting of the second heart sound

• S2 is caused by closure of the pulmonic and aortic valves

• Physiological splitting of S2 occurs because LV contraction slightly precedes RV contraction during inspiration. Hence the splitting of S2 should disappear on expiration

• Increased S2 splitting occurs when RV contraction occurs late • Listen for lub d/dub (inspiration), lub – dup (expiration) Third heart sound (S3)

• S3 is a low-pitched sound best heard with the bell of the stethoscope at the apex. S3 occurs during the phase of rapid ventricular filling during early-diastole • A third heart sound is a normal finding in children, young adults and during pregnancy. It is generally abnormal after the age of 30 years • It is often heard post acute MI and in heart failure and is often accompanied by a tachycardia when it is called a gallop rhythm • Listen for lub-dup-dum……. Fourth heart sound (S4)

• The fourth heart sound is always pathological • It is caused by forceful atrial contraction and is heard in LVH, hypertension and hypertrophic cardiomyopathy. It is never heard if the patient is in atrial fibrillation • Listen for da-lup-dup……. Evaluating ‘murmurs’

• Murmurs are sounds which occur due to turbulent blood flow • Note when in the cardiac cycle the extra sound occurs: • Systolic murmurs • Diastolic murmurs • Pansystolic murmur • Innocent murmurs Ejection systolic murmurs

• Aortic stenosis

• Pulmonary stenosis

• Hypertrophic cardiomyopathy Pan systolic murmur

• Causes: • Mitral regurgitation • Tricuspid regurgitation • Ventricular septal defect • Ruptured ventricular septum (post MI) • Characteristics: • Loud, blowing harsh sound. May be associated with a thrill Pericardial Rub

Due to inflammation of the pericardium, whereby the two layers of the pericardium ‘rub’ together against each other.

• Sounds like sand paper, or crunchy snow • Best heard with the patient sitting up or learning forward • Associated with chest pain Signs and symptoms requiring immediate treatment/investigation

• Severe dyspnea and inability to lay flat • Tracheal shift • Unable to maintain SpO2 greater than > 92% on room air • Severe increasing fatigue • Cyanosis (central cyanosis is not detectable until oxygen saturation is less than 85%) • Silent chest or crackles throughout lung fields • Decreased level of consciousness • Diminishing respiratory effort • Recent hospitalization for congestive heart failure (CHF) • Pregnancy or postnatal period • Immunosuppressed, elderly or very frail • Significant comorbidities, unable to cope at home, living alone, or poor/deteriorating condition Diagnostic tests

Chest x-ray Electrocardiogram (ECG) Hemoglobin (Hb) U&Es, liver function and thyroid function Cardiac troponins Arterial blood gas (ABG) Sputum for MC&S ECHO CXR

• Chest x-ray findings include pleural effusions, cardiomegaly (enlargement of the cardiac silhouette), Kerley B lines (horizontal lines in the periphery of the lower posterior lung fields), upper lobe pulmonary venous congestion and interstitial oedema. A good mnemonic to remember these principles is ABCDE: • A - alveolar oedema (bat wing opacities) • B - Kerley B lines • C - cardiomegaly • D - dilated upper lobe vessels • E - pleural effusion Case Study

• 70 year old male

• HPC – increasing fatigue, dyspnoea on exertion

• PMH - history of hypertension (well controlled on ACE and beta-blocker), high cholesterol (on statin), type II diabetes (diet control), hypothyroidism (on Thyroxine), THR two months ago Case study continued

• Vital signs: T 370, HR 94 regular, BP 116/64, RR 24, Sats 92% on air, cap refill 3 secs • Physical assessment findings: (abnormal findings only noted) • Pale mucous membranes, bilateral ankle oedema,JVD +5cm, Apex noted 6th intercostal space mid-clavicular line, Apical thrill palpated, S3 heard at apex. Case study continued

• Clinically significant abnormalities?

• Investigations?

• Differential diagnoses? Thank you!

Any Questions?