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 <50, 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 <120 & Diastolic <80 • Normal Systolic <130 & Diastolic <85 • 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 > of 20 mg or <

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 >180 or Diastolic >110

9. Hypertension (Children) • Normal = < 90th %ile: Systolic & /Diastolic • High Normal = 90-95th %ile • Hypertension = > 95th %ile

10. Cholesterol • Acceptable <170 mg/dl -(Child) <200 (Adult) • Borderline 170-199 mg/dl - (Child) 200-239 (Adult) • High >-200 mg/dl - (Child) >240 (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 <110 mg/dl • Borderline LDL 110-120 mg/dl • High LDL >-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 >left 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 • > 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 • > 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 @ 45 degree angle • (45-60) • Measure highest level of pulsations from sternal angle • Pressures > 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, Levine’s 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 - (<1 >10 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 - > 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