Pearls For Cardiac History and Physical Exam...Auscultation - Murmurs •Diastolic murmurs –Mitral Stenosis –Tricuspid Stenosis –Aortic Regurg Grading Murmurs Description Grade

Tips for Hx Taking_Physical Exam_L

Davis

9/25/2019

For Personal Use Only; Do not reproduce

without permission from L Davis 1

Pearls For Cardiac History and Physical Exam

Leslie L Davis, PhD, RN, ANP-BC, FAANP, FAHA

Associate Professor of Nursing

Univ of NC, Chapel Hill

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There are no disclosures relevant to this presentation.

Goals for Talk

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

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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

– Chest pain or discomfort; shortness of breath; palpitations

– 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

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History Taking: Questions to Ask• Past Medical/Surgical History:

– Cardiac surgery or hospitalizations; prior cardiac evaluations;

– Past history of stroke, TIA, coronary heart disease, heart failure, atrial fib or other cardiac dysrhythmias, valvular heart disease, 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)

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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)

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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 medications or health care expenses

– Nutritional status, including usual food/beverage intake, including sodium

– Exercise: type, amount, frequency, intensity

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History Taking: Questions to Ask

• Allergies

• 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 blood pressure at home; if so, what device do they use & what are the numbers typically.

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Tips for a good physical exam

• Develop a systematic approach

• Be methodical

• Take your time to get good data

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Vital Signs

• Temperature

• Heart rate

– Full minute

–Apically versus radially

• Respiratory rate

• Blood pressure

–Manually versus Electronically

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Inspection

• Inspect other organs to yield some info about the cardiovascular system

– General

• Any acute distress?

– Eyes

– Neck

– Skin

– Nails

– Nail beds

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Xanthelasma

• Yellowish deposit of cholesterol under skin

• Typically on or around eyelids

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

Jugular Vein 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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Palpation (Head to Toe)

• Radial pulses

– 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

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Palpation – continued

• Peripheral pulses

– Palpate pulses bilaterally (or not)?

– Checking for edema

– Rating of pulses/edema

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Palpation – continued

• Carotid arteries

– How to palpate the carotid artery

– Synchronous with S1

– Patient to breath or not?

– Checking for bruits

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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

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Palpation of Abdomen

• Soft, rounded abdomen?

• Pulsations?

• Edema?

• Tenderness?

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Percussion

• Use

– To define the cardiac border

– Limited value for cardiac exam

– Primarily used for assessing pts with heart failure

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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

• Liver span normally 6-12 cm (generally ~ 10)

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Auscultation

• 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

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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

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• 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

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• Assess

– Rate & Rhythm

– Have them breathe normally

– Listen to S1 while palpating carotid pulse

– Concentrate on systole (S1 – S2)

– Check for extra heart sounds

– Listen to diastole

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• 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

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• 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?

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• 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?

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Sequence of Heart Sounds

S4 – S1 ---------S2 – S3

“lub” “dub”

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• Rubs

–Rough parietal or visceral surfaces

–During both systole & diastole

–Overlies all cardiac sounds

–History very important

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Auscultation - Murmurs

• Systolic murmurs

–Mitral Regurg

–Tricuspid Regurg

–Aortic Stenosis

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Auscultation - Murmurs

• Diastolic murmurs

–Mitral Stenosis

–Tricuspid Stenosis

–Aortic Regurg

Grading Murmurs

Description

Grade 1

Very faint, heard only after listening very intently;may not be heard in all positions. Likely only heard if the patient "bears down" (performs a Valsalva maneuver)

Grade 2Quiet, heard after placing the stethoscope on the chest by more experienced clinicians

Grade 3 Moderately loud.

Grade 4 Loud, with palpable thrill

Grade 5Very loud, with thrill. May be heard when stethoscope is partly off the chest.

Grade 6Very loud, with thrill. May be heard with stethoscope entirely off the chest.

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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)

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Tips for Lung 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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References▪ Grubbs, L. & Davis, LL. (2019). Cardiac and peripheral vascular

systems. In M. J. Goolsby & L. Grubbs (Eds.) Advanced assessment: Interpreting findings and formulating differential diagnoses. 4th Edition. FA Davis Company.

• Ball J, Dains JE, Flynn JA. Solomon BS, Stewart RW. (2019). Seidel’s guide to physical examination: an interprofessional approach. 9th edition. St Louis, Missouri: Elsevier.

• Splers C. (2011). Cardiac auscultation British Journal of Nursing, 6(10): 482-486.

• Reimer-Kent J. (2013). Heart sounds: Are you listening? part one. Canadian Journal of Cardiovascular Nursing, 23(2): 3-6.

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Documents

Pearls For Cardiac History and Physical Exam...Auscultation - Murmurs •Diastolic murmurs –Mitral Stenosis –Tricuspid Stenosis –Aortic Regurg Grading Murmurs Description Grade