cardiac, lungs, pvs assessment
TRANSCRIPT
DEBBIE KING MSN, FNP-C, PNP-CFALL 2009
Cardiac, Thorax, Peripheral Vascular System Assessment
Chest Exam
Visual Inspection/Palpation Skin for cyanosis, venous distention, nail beds for
capillary refill Asymmetry of the chest cage (A/P & lateral) PMI (point of maximal impulse) at the left 5th ICS
at the midclavicular line usually (may be slightly displaced in the muscular, pregnant, obese and elderly)
Place patient in the supine position to palpate the heart
Palpate for thrills at the apex, left sternal border, and the base (prominent impulses may suggest heart enlargement)
Land Marks
Count interspaces Identify your ...
o Midsternal lineo Midclavicular lineo Anterior axillary
lineo Midaxillary line
Auscultation
Five ausculatory areas Aortic valve area- second right intercostal space
at the right sternal boarder Pulmonic valve-2nd left ICS at LSB Second pulmonic area-3rd LICS at LSB Tricuspid area- 4th LICS Lower LSB Mitral or apical area- apex:5th LICS at the
midclavicular line
Auscultation
Systole: the ventricles contract The right ventricle pumps blood into the pulmonary
arteries (pulmonic valve is open)
The left ventricle pumps blood into the aorta(aortic valve is open)
Diastole: the ventricles relax Blood flows from the right atrium → right ventricle
(tricuspid valve is open)
Blood flows from the left atrium → left ventricle (mitral valve is open)
Auscultation
Use the diaphragm, then the bell to assess the 5 cardiac areas Patient sitting, leaning slightly forward Best to focus on heart sounds during expiration-
best for high pitch murmurs Patient supine Patient left lateral recumbent, best to hear low
pitched sounds in diastole with bell Other positions-PRN Inch don’t jump
Heart Sounds
S1 Mitral/Tricuspid close (atrioventricular valves)
S2 Aortic/Pulmonic close (semilunar valves close) S2 splitting inspiration (physiologic) expiration
(pathologic) S2 splitting common and normal in children and young adults
S3 Atrial ejection “Ken-tuc-ky”S4 Ventricle filling “Tenn-es-see”
S3 & 4 should be quiet and may be difficult to hear.
Heart Murmurs
Disruption of blood flow through the heart due to Stenosis - narrowed or thicken, stiff valve Regurg - slack valve leaflets causing
retrograde flow Other causes – pregnancy, anemia,
thyrotoxicosis, CAD, Arteritis Evaluate using the bell and the diaphragm
Murmur Grading
Grade I –barely audible in quiet roomGrade II – quiet but clearly audibleGrade III – moderately loudGrade IV – loud, associated with thrillGrade V – very loud, thrill easily palpableGrade VI – very loud audible w/stethoscope
not contacting chest wall, thrill palpable & visible
Characteristics of murmurs
Timing & duration (early, mid, or late systolic) Refer all diastolic murmurs!
Pitch (high, medium, or low)Intensity (grades)Pattern (crescendo, decrescendo)Quality (harsh, raspy, vibratory, blowing,
musical)Location (anatomic landmarks)Radiation (anatomic landmarks )Variation w/respiratory phase (intensity,
quality, timing)
Murmurs
Most are innocent, esp. in children and young athletes Result of vigorous myocardial contraction
Some are benign- result of a mild anomaly
Comparison of systolic Murmurs
Right sided chamber with inspiration gets louder With expiration gets softer
Hypertrophic cardiomyopathy With Valsalva gets louder With rapid squat to stand for 30 sec gets louder With standing to squatting rapidly gets softer Passive leg elevation to 45 degree gets softer
Mitral regurg With handgrip gets louder
Aortic stenosis Diagnosis made by exclusion
Chest Pain(Rarely originates in the heart)
Differential Diagnosis Angina Pectoris
Cardiac risk factors, specific onset, forces pt to stop, relief with nitro, often in am, more likely if cold
Musculoskeletal Trauma, vague onset, >with effort, continues with rest, heat and
Advil helpful, worse with day of physical effort, worse with cold damp temps
Gastrointestinal Indigestion, vague, related to food, lasts hours, unrelated to effort,
may awaken, relief with antacids, no other triggers, occurs any time Pulmonary
Pneumonia, asthma, pleurisy, cancer, list is endless. Improves with bronchodilators, antibiotics ECT
Chest Pain-Specific diagnosis
Angina Coronary
insufficiency MI Mitral valve prolapse Dissection of the
aorta Pericarditis Pleurisy Pneumothorax Cocaine use Shoulder disorder
Emphysema Hiatal hernia Reflux Esophageal spasm Cholecystitis Ulcer Pancreatitis Pneumonia Embolus Cervical
radiculopathy Costochondritis
History for patient with chest pain
History of present illness Describe the Pain, onset, frequency, location, severity,
associated symptoms
Past medical historyFamily historyPersonal and social history
Peripheral Vascular System Blood Vessels
Palpate the arterial pulses, the best are close to the surface and over boney areas Carotid-most useful, close to the heart Brachial Radial Femoral Popliteal Dorsalis pedis Posterior tibial
Peripheral Vascular System Palpation
Palpate with the digital pads of the second and third fingers
You may use the thumb and is sometimes helpful with moving vessels
Palpate firmly without occluding the arteryLack of symmetry suggests impaired circulationFemoral is as strong as radial if its not or its absent
suggests coarctation of the aortaMay also measure capillary refill time to assess
severity of arterial occlusion
Techniques of Examination – Palpate Pulses
Femoral pulse Press deeply below inguinal ligament, midway between
anterior superior iliac spine and symphysis pubis Popliteal pulse
Flex knee some, leg relaxed Place fingertips of both hands to meet midline behind
knee and press deeply into popliteal fossa Dorsalis pedis pulse
Feel dorsum of foot, lateral to extensor tendon of great toe Posterior tibial pulse
Curve fingers behind and slightly below medial malleolus of ankle
Evaluation of pulses
Rate – 60-90 bpmRhythm – regularContour – pulse wave should be smooth,
rounded or domed shapeAmplitude – scale of 0-4
4 = bounding 3 = full, increased 2 = expected 1 = diminished 0 = absent or no pulse
Pulse Abnormalitiesbradycardia less than 60,tachycardia over
100
Alternating pulse Weak/strong
Left ventricular failure
Pulsus bisferiens Two strong separated with dip
Aortic regurg with or without stenosis
Bigeminal pulse Two pulses rapid followed by
longer interval Ventricular premature beats
Bounding pulse Rapid rise, brief peak, rapid fall
Atherosclerosis, PDA, hyperthyroid, anxiety, fever, anemia
Labile pulse Amplitude increased with
sitting or standing Not associated with disease
Paradoxic pulse Decreases on inspiration
COPD, pericarditis or effusion
Trigeminal pulse Three beats then pause
Often benign, or severe disease
Water-hammer pulse Jerky pulse with full
expansion then sudden collapse Aortic regurgitation, patent ductus arteriosus
History of present illness with abnormal pulse findings
Leg pain or cramps (claudication) Describe- onset, duration, what relieves,
character IE burning or cramping, skin changes or hair loss or sores ECT
DizzinessSevere headachesSwollen anklesTreatment attempted
Compartment syndrome
The Ps Pallor Pain Pulselessness Paresthesias if major artery occluded Paralysis, is rare
Auscultation for Bruits
CarotidThyroidTemporalAbdominal aortaRenal IliacFemoral
Auscultation for bruits
Should be done after the cardiac assessmentUsually low pitched and hard to hearUse the bell directly over the artery
Auscultation of the neck
Carotid bruits heard best at the anterior margin of the sternocleidomastoid muscle as the patient holds their breath, may be one of three types A murmur transmitted from aortic stenosis, ruptured chordae
tendineae of the mitral valve or severe aortic regurg Vigorous left ventricular ejection-heard more in children Obstructive disease in carotid arteries-complete obstruction will
eliminate May also hear a venous hum
Heard at medial end of clavicle and anterior border of sternocleidomastoid muscle
Usually of no significance, but in adults may mean anemia, thyrotoxicosis or intracranial arteriovenous malformation
Confused with bruits
Inspection of Extremities
Color (pink)Skin texture (elasticity)Nail changes (brittle, cracked, dry)Presence of hair (lack of)Muscular atrophy (thinning, wasting)Edema or swelling (fat ankles)Varicose veins (dilated or swollen)
Techniques of Examination - Arms
Inspect both arms from fingertips to shoulders
Note the following:
o Size, symmetry, and any swelling
o Venous pattern
o Color of skin and nail beds; texture of skin
Palpate radial pulse
Use finger pads on flexor surface of wrist
Partially flex patient’s wrist
Compare pulse in both arms
Techniques of Examination-Arms
Palpate brachial pulse
Flex elbow slightly
Palpate artery medial to biceps tendon in antecubital crease
Epitrochlear nodes
Flex elbow 90°
Support forearm
Feel in groove between biceps and triceps muscle, 3 cm above medial epicondyle
Techniques of Examination-Legs
Patient should lay down, draped so external genitalia is covered and legs are fully exposed
MUST remove patient’s stockings or socks
Inspect both legs from groin and buttocks to feet
Note the following: Size, symmetry, and any swelling
Venous pattern/venous enlargement Pigmentation, rashes, scars, or ulcers
Color and texture of skin, color of nail beds, distribution of hair on lower legs, feet, and toes
Techniques of Examination-Legs
Palpate superficial inguinal nodes
Horizontal/vertical groups
Note size, consistency, and discreteness and tenderness
Nontender, discrete nodes up to 1-2 cm are palpable in normal people
Palpation of extremities Summary
Warmth Pulse qualityTenderness along a superficial veinPitting edema
1+ slight pitting, disappears rapidly 2+ slightly deeper pit, disappears in 10-15 sec 3+ noticeable deep, last > 1 min. (extremity
looks full & swollen) 4+ deep pit lasting 2-5 min., grossly distorted
(if edema is unilateral suspect occlusion of a major vein & edema w/o pitting suspect arterial disease or occlusion)
Evaluation of Edema
Compare one foot and leg with the other Note relative size and prominence of veins,
tendons, and bonesCheck for pitting edema
Press firmly with thumb for 5 seconds over dorsum of each foot, behind medial malleolus and shins
Severity of edema graded on four-point scale (slight to very marked)
Evaluation of Edema
If edema is present, look for causes Recent deep venous thrombosis Chronic venous insufficiency Lymphedema
Note color of skin Local area of redness Brownish areas near ankles Ulcers and where Thickness of skin
Blood Pressure
Bilateral measurements, supine & standing Better to use a larger cuff than smaller
Measured by the width of the bladder than the cloth Mercury column is most reliable, but no longer
permitted Aneroid sphygmomanometer lose accuracy with
age and use Preferred position is seated and the cuff at heart
level Advise patients not to have caffeine, rushing, ECT
before the appointment
How to take a BP
Both arms with arms flexed and supported, free of clothing Use the appropriate size cuff that is snug and secure Center the deflated bladder over the brachial artery, just
medial to the biceps tendon, with the lower edge 2-3cm above the antecubital
Checking the palpable systolic pressure first with avoid being mislead in auscultatory gap Inflate to 20-30 mm HG above the point where you do not feel
pulse. Deflate slowly until you feel pulse. Place bell over brachial artery pausing for 30 seconds inflate
to 20-30 MM Hg over the palpable systolic pressure Deflate slowly
Review Korotkoff sounds
JVD measurement
Evaluate jugular vein distention (JVD) Use a ruler at least 15 cm long Use a light for tangential illumination across the neck Patient is initially in supine position which results in
engorgement of veins. Raise the head of the bed gradually until pulsations are
seen between the jaw and the clavicle Palpating the contralateral carotid pulse helps distinguish
them from the carotid pulsation To assess for hepatojugular distention which is seen in right heart
failure; apply firm and sustained pressure to the midepigastric area with patient breathing normal, if RHF is present the JVD will get measure larger
CHEST & LUNG EXAM
HPI, PMH, FHX, Social & Personal HXHave pt sit up w/o support, w/o shirt.Clothing is a barrierWarm hands, warm stethoscope,
lightingLook for landmarks: refer to text
Midsternal line, R&L midclavicular lines, R&L anterior, midaxillary, and posterior lines, vertebral line, R&L scapular lines
Anatomy and Physiology
Anatomy of the chest wall
Anatomy and Physiology (cont.)
To locate findings around the circumference of the chest, imagine a series of vertical lines
Lungs, fissures, and lobes Each lung is divided roughly in
half by an oblique (major) fissure
The right lung is further divided by the horizontal (minor) fissure
These fissures divide the lungs into lobeso The right lung is divided
into upper, middle, and lower lobes
o The left lung is divided into upper and lower lobes
Anatomy and Physiology (cont.)
Chest -Bone Structures
Anatomy of the chest to assess Larynx Trachea Manubrium Sternum Xiphoid Clavicle Acromion Process Scapula Ribs
Anatomy of the back to assess Scapular –height and prominence Spinal curve and muscle equality
Scoliosis Kyphosis
Chest –Muscles to assess
Anterior Sternocleidomastoid Scalenus Pectoralis minor Intercostal muscles Serratus anterior Rectus abdominus
Posterior Serratus posterior
superior Intercostal Transverse Diaphragm Serratus Posterior inferior
Anatomic/Topographic Landmarks of the chest
Suprasternal notchClavicleSecond ribBody of sternumNippleXiphoid
ClavicleManubriumManubriosternal
junction or angle of Louis
Costal angle
Inspection of Chest
Size & shape: barrel chest-result of compromised respiration, structural Carinatum pectus or pigeon chest Pectus excavatum or funnel chest
Symmetry: (AP < transverse diameter) Skin color - inspect nails, lips, & supernumerary nipples
(pink, no pallor or cyanosis) Superficial venous patterns (heart disorder, vascular disorder
or disease) Prominence of ribs (underlying fat clue to nutritional state) Bone and muscle landmarks Anatomic/Topographic landmarks
Respirations and Chest Movement
Rate – normal 12-20 bpmRhythm/pattern – note movement of chest,
expansion should be bilaterally symmetric, breathes easily w/o distress, breathing should be even, non labored.
Use of accessory musclesNo bulging of the Intercostal muscles.
Descriptions of abnormal Respirations
Dyspnea- SOB-difficult, labored-lung or cardiac issues, sedentary life style, obesity.
Orthopnea-SOB when pt lies down, sleeps on more than 1 pillow.
Paroxysmal nocturnal dyspnea-sudden onset of SOB after a period of sleep
Platypnea- dyspnea increases in upright position.
Irregular patterns of respirations
Tachypnea- increased RR 20 rpmBradypnea- slower than 12 rpmHyperpnea- faster than 20 breaths, deep
breathing.Kussmaul- rapid, deep, labored- Metabolic
acidosis.Hypopnea- abnormally shallow breaths IE: pleurisy.Cheyne-Stokes- depth along with apnea, seriously
ill pt’s.Air trapping- difficulty in getting breath out d/t
prolonged inefficient expiratory effort.
Palpation of Thorax
Feel for pulsations, areas of tenderness (rib fx), bulges, depressions, unusual movements, and unusual positions.
Crepitus-crackly or crinkly sensation Pleural friction rub- inflammation of pleural surfaces
(leather rubbing on leather) Thoracic expansion
Assess both anterior and posterior Thumbs should move equally
Tactile fremitus Use palmar or ulnar aspects at the same time, or move dominant
hand Ask patient to say ‘99’ Should be symmetrical fremitus
Palpation of Thorax
Position of trachea Put index finger in suprasternal notch and move
gently side to side at the upper edges of each clavicle and in the spaces above to the inner borders of the sternocleidomastoid muscles Spaces should equal on both sides, trachea should be
midline directly over the suprasternal notch Simultaneously palpating with both thumbs on
either side of the thyroid, again the thyroid should be midline, but may deviate slightly to the right
Percussion
Compare bilaterally Use one side as control for the other Patient sitting head bent arms folded in front Move systematically side to side at intervals of several
centimetersDullness- thud like- atelectasis, asthma, pleural
effusion, pneumothoraxResonance- hollow-heard all areas of lungsHyperresonance- booming-hyperinflation
(asthma, emphysema, pneumothorax).Tympanic- drum like-usually over abdomen
Percussion
Diaphragmatic excursion. Patient takes a deep breath and holds Percuss scapular line until dullness is heard Mark this point Allow patient to breath normally Repeat deep breath then exhale and hold Percuss up from the mark until resonance is
heard Mark the area Repeat on other side in real practice, one side for
the video
SMELL
Smell the breath Fruity-ketoacidosis Fishy-uremia Halitosis-Tonsillitis, gingivitis, GERD Feculent-intestinal obstruction Putrid- sinusitis, FB, cancer lung abscess Cinnamon-pulmonary TB
Auscultation
Thoracic Landmarks Anterior thorax Right lateral thorax Posterior thorax
Procedure- use diaphragm Patient upright, same position as percussion breathe slow and deep Comfortable pace Elderly begin low and go up All others begin up and go low Use side to side as in percussion listening to ins and exp
AuscultationNormal breath sounds
Vesicular-most lung fields, soft pitch with low intensity
Bronchovesicular-main bronchus and upper right posterior lung-medium pitch E=I
Bronchial/tracheal- heard only over trachea, high pitch E is louder than I
Abnormal Breath Sounds
Crackles- heard during middle or end of inspiration, not cleared by cough.
Rhonchi- loud, low, coarse, coughing may clear.Wheeze-musical-louder during inspiration
A more significant finding if heard in expirationPleural Friction rub- dry rubbing.Hamman Sign- crackling, clicking crunching
and gurgling with heart beat, heard better when pt lies or leans to left and indicates mediastinal emphysema
Cough
Preceded by deep inspiration, followed by closure of the glottis and contraction of the chest and abdominal muscles the spasmodic expiration, forcing opening of the glottis.
May be voluntary, but usually reflexive to irritants Differentials of coughs include:
Infection Irritants and allergens Compression Congenital malformation Acquired abnormally- yelling, FB, tumor Neurogenic or vocal cord paralysis
Cough description
Dry or Moist- may have sputumOnset- acute or slow onsetFrequency –seldom or oftenRegularity –irregular is the most common,
regular is seen in pertussisPitch/loudness- loud/quiet, high or low pitchPostural- worse when supine with PNDQuality- brassy with compression, hoarse
with croup, inspiratory whoop with pertussis
Other Breath Sounds
Bronchophony- increased loudness of spoken words
Whispered pectoriloquy- with consolidation even a whisper can be heard
Egophony- nasal quality E to A with increased intensity also seen with consolidation All the above will be diminished with blockage such
as in emphysemaCroup- seal like bark