cardiac examination within the role of the cardiology nurse practitioner victoria williams...
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Cardiac Examination Within the Role of the Cardiology
Nurse Practitioner
Victoria WilliamsCardiology Nurse Practitioner
University Hospital of Wales, Cardiff.
AIMS OF THE PRESENTATION
• To outline and demonstrate the importance of cardiac examination within the role of the nurse practitioner
• To instruct participants in the correct techniques for clinical examination.
Learning Outcomes
• To competently perform cardiac clinical examination on a well patient.
• To revise the underlying anatomy and physiology relating to cardiac pathology.
• To have an awareness of clinical signs and symptoms to enable appropriate referral to specialist services.
Background of the role.
• Established in 2010
• 4 members of staff
• All 4 practitioners are working towards Msc level qualification
• Co-ordination and management of nurse-led Acute Coronary Syndrome Unit
• Central point of contact from admission to discharge.
University Hospital of Wales
• Tertiary Cardiology centre
• Contracted to provide tertiary services to District General Hospitals within south east Wales
Advanced clinical skills
• All members of the team are at different stages of their Msc pathway
• all utilising advanced clinical skills as part of the role to enhance the service.
• Undertaking regular competency based training and assessment
Cardiology patients suitable to be clerked by the Nurse Practitioner
• Non-complex Acute Coronary Syndrome (ACS) patients
• ACS patients with additional co-morbidities
• Elective angiography patients
• Elective Pacing patients
Major Cardiovascular Presenting Complaints
• Chest Pain
• Dyspnoea
• Syncope
• Palpitations
• Peripheral oedema
Importance of taking a comprehensive History
• Obtaining an accurate history is the critical first step in determining the aetiology of a patient’s problem
• A large percentage of the time you will actually be able to make a diagnosis based on the history alone.
Complete cardiovascular history• Presenting complaint
• History of presenting complaint
• Past medical history
• Risk factors for Coronary Artery Disease
• Family history
• Drug history and allergies
• Social history
• Systems Review
SOCRATES
• Site• Onset• Character• Radiation [usually just if pain]. • Alleviating factors• Time course• Exacerbating factors• Severity• Associated symptoms. • Impact of symptoms on life: "Does it
interrupt your life".
Complete cardiovascular history• Presenting complaint
• History of presenting complaint
• Past medical history
• Risk factors for Coronary Artery Disease
• Family history
• Drug history and allergies
• Social history
• Systems Review
MJ THREADS:
• MI• Jaundice• TB• HTN • Rheumatic fever• Epilepsy• Asthma• Diabetes• Stroke
System Review
General• Weakness
• Fatigue
• Anorexia
• Change of weight
• Fever
• Lumps
• Night sweats
Cardiovascular• Pain
• Breathlessness
• Palpitations
• Syncope
• Ankle oedema
• Calf pain
• Orthopnea
• Intermittent claudication
System Review continued
Respiratory • breathlessness
• Wheeze
• Cough
• Sputum
• Haemoptysis
• Tachypnea
• infection
Gastro-intestinal/urinary• Loss of appetite• Weight loss• Nausea/vomiting• Pain• Indigestion• Changes in bowel habit• Haematemesis• PR bleeding• Swallowing difficulties• Dysphagia • Incontinence• Frequency• Urgency• Haematurea
System Review Continued
Neurological• Headaches• Dizzyness• Siezures• Collapse• Visual disturbances• Loss of balance• Muscle weakness
Musculoskeletal• Joint pains/stiffness• Recent injuries• Gait• swelling
System Review Continued
Genital • Pain/discomfort• Unusual bleeding• Menstruation• Sexual health• Erectile dysfunction
Clinical Examination
• Consent• Exposure• Position• Inspection• Palpation• Percussion• Auscultation
Establish the Stabilityof the Patient
• Airway
• Breathing
• Circulation
• Disability
• Exposure
• Comfortable/distressed• Dyspnoeic/fatigued• Pale/cyanosed• Dehydrated/volume
depleted• Congested/
oedematous/ volume overloaded
Inspection
Start with the hands:• Clubbing• Splinter haemorrhages• Palmer errythema • Muscle wasting• Janeway Lesion• Osler’s Nodes
Clubbing
Splinter Haemorrhages
Linear reddish brown lesions seen in nail bed. Prominent in this case of SBE
Janeway Lesion
Macular, blanching, not painful located on palms & soles (SBE)
Osler’s Nodes
Tender, papulopustules located on pulp of finger (SBE)
Exam: Hands
• Other points to note:
• Temperature• Perfusion• Pallor• Nicotine staining• Extensor tendon swellings (xanthomas)
PulseRate:• Normal sinus 60-100 bpm• Sinus bradycardia < 60 bpm• Sinus tachycardia > 100 bpmRhythm:• Sinus arrhythmia - varies with respiration• Intermittent irregularity – ectopic beats• Continuously irregular (irregularly irregular – atrial
fibrillation)
• Start by palpating the radial pulse
• At this site asses• Rate• Rhythm
• You should not asses volume at the radial artery
Carotid Palpation
• Carotid upstroke:
– brisk, normal or delayed
– volume: normal, increased or decreased
Exam: Head & Neck: FACE
• Jaundice
Exam: Head & Neck: FACE
Anaemia
Exam: Head & Neck: FACE
ARCUS XANTHELASMA
Exam: Head & Neck: FACE
• Cyanosis
Exam: Head & Neck: JVP
The JVP is best examined by
looking across the neck.
A double waveform should be seen for each cardiac cycle
Exam: Head & Neck: JVP
• Carotid Pulsation
• 1 per cardiac cycle• Palpable• Position independent• Does not enhance with hepato-jugular reflex
• JVP Pulsation
• 2 per cardiac cycle• Not palpable• Varies depending on position• Enhances with hepato-jugular reflex
Inspection of the chest
LookFor
ObviousDeformity
Pigeon Chest (pectus Carinitum)
Funnel Chest (Pectus excavatum)
Inspection of the chest
Look for obvious Scars:
Median Sternotomy
CABG, Valve, TX
Lateral Thoracotomy
Coarct repair
Palpation
Locate Apex Palpate for heaves and thrills
Exam: Praecordium
2nd
3rd 4th 5th
Intercostal Spaces
1 2 3
1 Mid Clavicular Line
2 Anterior Axillary Line
3 Mid Axillary Line
Auscultation
bell
Low pitched murmurs eg. Mitral StenosisPress hard enough only to make a seal with the skin
The ‘hole’ must be rotated to the bell in order for it to work
Exam: Auscultation
Diaphragm
Normal / High pitched murmurs. Use for general purpose auscultation
Exam: auscultation
1. Apex: Mitral Valve2. Sternal Edge:
Tricuspid Valve3. L 2nd Space:
Pulmonary Valve4. R 2nd Space: Aortic
Valve
Exam: auscultation
• Heart SoundsLub (S1)
Dub (S2)
First Second
Mitral Valve
Tricuspid Valve
Aortic Valve
Pulmonary Valve
Heart Murmurs: Systolic
Mitral Regurgitation
Tricuspid Regurgitation
First Second
Pan Systolic Murmur
Heart Murmurs: Systolic
First Second
Ejection Systolic Murmur
Aortic
Stenosis
Pulmonary
Stenosis
VSD
Heart Murmurs: Diastolic
First Second
Early Diastolic Murmur
Aortic Regurgitation
Heart Murmurs: Diastolic
First Second
Mid Diastolic Murmur
MitralStenosis
Auscultation
Mitral Murmurs
• Mitral Area
• Patient in Left Lateral
• Radiate to Axilla
Auscultation
Aortic Murmurs
• Aortic Area
• Sit Patient Forward
• Breath Held in Expiration
• Radiates to Carotids
• Any Questions?
Thank you for your attention.