CARDIAC ASSESSMENT

Sanil Varghese

ANATOMY AND

PHYSIOLOGY OF HEART

Coronary Blood Flow

• Two coronary arteries originate from aorta– Right coronary artery (RCA)

• Posterior descending artery (PDA)

– Left main (LM) coronary artery• Left anterior descending

(LAD)• Circumflex (LCX)

Cardiac Conduction System

Electrophysiologic Properties of Cardiac Cells

• Excitability• Automaticity• Contractility• Refractoriness • Conductivity

CARDIAC CYCLE

• Systole• Diastole

Cardiac Output

• Volume of blood ejected per minute• Averages between 4-8L/min• CO = Stroke volume X heart rate =70 ml X 60 beats/min =4,200 ml/min

Stroke Volume Is Determined By Three Factors

• Preload• Afterload• Contractility

Preload

• Degree of stretch of myocardial fibers• Determined by the volume of blood in left ventricle

(LV) at end of diastole• Increased volume –> increased preload-> increased

cardiac output (CO)• Decreased volume –> decreased preload –>

decreased cardiac output (CO)• Compliance of myocardial cells also affects preload

Afterload

• Resistance or pressure the ventricles must overcome to pump blood out

• Left ventricle affected by systemic vascular resistance (SVR)

• Right ventricle affected by pulmonary vascular resistance (PVR)

Autonomic Nervous System (ANS) Regulation of Cardiovascular System

• Heart rate – chronotropic effect• Contractility – inotropic effect• Conduction velocity at AV node –

dromotropic effect• Afterload - vascular resistance – arterial

vasoconstriction and dilation• Preload – venous constriction and

dilation

Cardiovascular Assessment

• The practice setting and severity of patient’s symptoms determine focus of questions and extent of health history

Steps

• History collection• Risk factors analysis• Biographical and

demographical data• Current health

history

• Past health history• Family history• Psychosocial history

Common Symptoms Of Cardiovascular Disease

• Chest discomfort or pain• Palpitations• Syncope• Fatigue• Dyspnea• Cough, hemoptyosis• Weight gain • Edema• Nocturia

Dyspnea

• Often associated with myocardial ischemia

• Primary symptom of pulmonary congestion from LV failure

• Other causes– Fever– Anemia– Pulmonary disorders– Obesity

• Different forms of dyspnea– Exertional dyspnea (DOE)– Orthopnea– Paroxysmal nocturnal dyspnea (PND)

Weight Gain, Dependent Edema and Nocturia

• As heart fails, fluid accumulates• Increase of 3 lbs or more in 24 hr or 5 lbs in one

week• Inquire about weight gain, fitting of shoes, or

tightening of clothes around waist• Nocturia - kidneys inadequately perfused by weak

heart and receive increased blood flow during night –> output increases

Past Medical History

• Inquire about previous illnesses– Rheumatic fever, autoimmune diseases– Diabetes, kidney disease, HTN, dyslipidemia– Lung disorders– Clotting disorders

• Explore previous hospitalizations and surgeries• Evaluate use of medications, OTC drugs, herbs,

recreational drugs– Are meds taken as prescribed– Financial problems– Knowledge about meds

• Any allergies

Family Health History

• Inquire about diabetes, kidney disease, stroke, heart disease, hypertension (HTN)

• Inquire about health of parents and siblings

Psychosocial History

• Education• Occupation• Marital status, children and relationships• Coping and stress tolerance• Health habits – diet, exercise, smoking,

alcohol use

General Appearance

• Look at the client and consider– Does the client lie quietly or is he restless?– Can the client lie flat or must be upright?– Do facial expressions reflect pain or distress?– Are there signs of cyanosis or pallor?

• Note level of consciousness (LOC)

Inspection Of Skin and Nails

• Assess skin color– Pallor– Cyanosis

• Peripheral cyanosis-nose, ears, periphery• Central cyanosis-mucous membranes, lips

• Assess skin temperature and moistness• Assess for ecchymosis• Assess for wounds, scars, implanted devices

• Assess eyes– Arcus senilis-gray

ring around iris– Xanthalasma-

yellow raised plaques around eyelids

Peripheral cyanosis

Central cyanosis

Capillary refill

Clubbing

Skin turgor

Splinter hemorrhage

Roth’s spots

Assess Vital Signs

• Measure BP in both arms initially• Determine pulse pressure• Perform postural checks • Assess pulse– Rate– Rhythm– Quality

BP

Pulse Quality Scale

• 0 pulse not palpable or absent• +1 weak, thready, difficult to palpate• +2 diminished• +3 easy to palpate, full pulse• +4 strong, bounding pulse

Assess Neck Vessels

• Determine jugular venous pressure– Gives an estimate of right heart function and CVP– Measurements >3 cm are elevated – jugular venous

distention (JVD)• Assess for hepatojugular reflux (HJR)– Rise of more than 1 cm in internal jugular vein indicates

HJR• Assess carotid arteries– Assess amplitude of pulse– Auscultate for bruits

Inspection and Palpation of Precordium

• Purpose is to determine presence of normal and abnormal pulsations or thrills

• Normally, palpate point of maximal impulse (PMI) at 5th, left intercostal space, midclavicular

• A thrill indicates diseased valve or obstructed vessel

JVP Measurement

PMI – Point Of Maximum Intensity

Cardiac Auscultation

• S1

– Caused by closure of mitral and tricuspid valves– Signifies beginning of systole– Best heard over apical area (left, midclavicular, 5th ICS)

• S2

– Caused by closure of aortic and pulmonic valves– Signifies beginning of diastole– Best heard over base area (“A” and “P” areas, 2nd ICS)

Heart sounds auscultation

Gallop Sounds

• S3 – Ventricular gallop– Heard in early diastole right after S2

– Normal in children and young adults– Characteristic of LV failure

• S4 – Atrial gallop– Heard in late diastole right before S1

– Heard during atrial contraction as atria force blood into resistant ventricles

– Characteristic of HTN, heart failure, pulmonary disease

Pericardial Friction Rub

• Produced by inflammation of pericardial sac

• Heard during systole and diastole

• Best heard with diaphragm with client sitting up and leaning forward

Assess Respiratory Status

• Respiratory findings frequently exhibited by cardiac clients – Tachypnea– Dyspnea– Crackles– Cough– Hemoptysis– Wheezing

• Assess O2 saturation

Abdominal Assessment

• Inspection may reveal ascites• Palpation may reveal an enlarged liver• Assess for elevated JVD and HJR• Auscultate for bruit over umbilicus

• Potential complications– Dysrhythmias– Perforation of heart or vessels– Hemorrhage– Spasm of vessels– Thrombus or embolus formation– Infection

Thank you