Question

perform a history of a cardiac problem that your instructor has provided you or one that you have experienced, and you will perform a cardiac assessment. You will document your subjective and objective findings, note any abnormal findings.

Answer 1

CARDIAC ASSESSMENT

1) Subjective Data

• Chest Pain
• Dyspnea
• Orthopnea
• Cough
• Fatigue
• Cyanosis
• Edema
• Nocturia
• Past Medical History
• Family history
• Risk factors

i) Chest Pain

• When did it start?
• How long have you had it this time?
• Have you had this type of pain before?
• How often?
• How would you describe it: crushing, stabbing buring, viselike?
• What brought on this pain? Activity, rest, emotional upset, after eating, during sex, cold weather?
• Any associated symptoms? Grey or pail skin, sweating, heart skips beat, shortness of breath, nausea or vomiting, racing of heart?
• Pain made worse by moving arms or neck, breathing, lying flat?
• Pain relieved by rest or nitroglycerin? How many tablets?

ii) Dyspnoea

• Shortness of breath
• What type of activity and how much brings on SOB?
• How much activity brought it on 6 months ago?
• Does the SOB come on unexpectedly?
• Duration: Constant or does it come and go?
• Seem to be affected by position: lying down?
• Awaken you from sleep at night?
• Does the shorness of breath interfere with ADLs?

iii) Orthopnea

• The need to assume a more upright position to breathe
• How many pillows do you use when sleeping or lying down?

iv) Cough

• Duration: how long have you had it?
• Frequency: Is it related to time of day?
• Type: Dry, hacking, barky, hoarse, or congested?
• Do you cough up mucus? Color? Any odor? Any blood?
• Associated with: activity, position (lying down), anxiety, talking?
• Does activity make it better or worse (sit, walk exercise)?
• Relieved by rest or medication?

v) Fatigue

• Do you seem to tire easily? Able to keep up wit your family and co-workers?
• Onset: Whe did fatigue start?
• Sudden or gradual?
• Has any recent change occurred in energy level?
• All day, morning, evening

vi) Cyanosis

• Ever noted your facial skin turn blue or ashen?

vii) Edema

• Any swelling of you feet and legs?
• When did you first notice this?
• Any recent change?
• What time of day does the swelling occur?
• Do your shoes feel tight at the end of the day?
• How much swelling would you say there is?
• Are both legs equally swollen?
• Does the swelling go away with: rest, elevation, after a night's sleep?
• Any associated symptoms: SOB?
• Does the shortness of breath occur before leg swelling or after?

viii) Nocturia

• Do you awaken at night with an urgent need to urinate?
• How long has this been occurring?
• Any recent change?

ix) Past Medical History

• Any past history of: hypertension, elevated cholesterol or tryglycerides, heart nurnur, congenital heart disease, rheumatic fever or unexplaine djoint pains as a child or youth, recurrent tonsillitis, anemia
• Ever had heart idsease?
• When was this?
• Treated by medication or heart surgery?
• When were your last ECG, stress ECG, serum cholesterol measurements, or other heart tests?

x) Family History

• Do anyone in your family has had cardiac problems?
• Whether consanginous marriage?
• Any family members has had DM, HTN or hyperlipidemia?

xi) Risk factors

• Aging
• High blood pressure
• High blood cholesterol
• Cigarette smoking
• Lack of physical activity
• Unhealthy diet
• Obesity or overweight
• Diabetes
• Family history of chest pain, heart disease or stroke
• History of high blood pressure, preeclampsia or diabetes during pregnancy
• COVID-19 infection

2) Objective Data

i) Know the landmarks

• The landmarks of the chest (thorax) include the ribs, clavicle, manubrium, Angle of Louis, the body of the sternum, and xiphoid process.
• There are twelve (12) pairs of ribs. There are seven (7) true ribs and five (5) false ribs.
• The manubrium provides a place for the first rib and clavicle to attach to the sternum.
• The Angle of Louis is the joint between the manubrium and the body of the sternum.
• The body of the sternum is just below the manubrium.
• And the xiphoid process is the lowest bone of the sternum.
• The nurse can easily palpate the manubrium, the body of the sternum, and xiphoid process in some people.
• There are several terms to become familiar with related to the landmarks of the chest (thorax). First, is the term costal which refers to the ribs.
• Next, is the intercostal space. This is the area between the ribs.

ii) Assess the vital signs

• A good set of vital signs are important for any patient but especially for a patient with cardiovascular symptoms or complications.
• Always take a full set of vital signs including blood pressure, heart rate (pulse, apical pulse), respiratory rate and temperature.
• It is usually a good idea to take a manual blood pressure when a patient is experiencing cardiac symptoms.
• Also, obtain a weight unless a baseline weight has already been taken.
• Also, take an orthostatic blood pressure.
• An orthostatic blood pressure should include the heart rate and blood pressure in the standing, sitting and lying position.
• Be sure to be efficient with measuring and the charting of your findings especially if they are baseline measurements.
• If your measurements are not the baseline measurements, compare them to the baseline measurements.

3) Physical Examination

i) Assess the vessels of the neck

• The neck vessels include the jugular veins and the carotid arteries.
• The jugular veins drain blood from the face, head, and neck and empty into the superior vena cava.
• The jugular veins are an assessment tool to measure central venous pressure (CVP) or right atrial pressure.
• Monitoring right atrial pressure gives an idea of fluid balance in the body.

ii) Inspect the Jugular Veins

• Inspect for the internal jugular veins and the external jugular veins.
• The internal and external jugular veins are usually not visible in most patients.
• Use inspection to look for any distention.
• The patient should be elevated to about a 45-degree angle.
• The jugular veins are usually flattened and disappear at this angle.
• This is a normal finding.
• The veins will become distended with an increased in central venous pressure.

iii) Palpate the Carotid Arteries

• Use palpation to assess the carotid artery.
• The carotid artery is located on each side of the neck lateral to the trachea.
• The patient should be at a 45-degree angle.
• Use the fingertips to palpate the carotid artery.
• Remember to apply gentle pressure.
• Applying too much pressure may occlude the pulsation.
• You should be able to palpate a pulse on each side.
• Palpate only one carotid artery at a time.
• An absence pulse may indicate an obstruction.

Next, assess the carotid artery for a thrill or bruit.

iv) Feel the Thrill – Auscultate the Bruit

• The thrill is a vibration against your fingers. It can feel like a buzzing or humming under the skin.
• Use the same method as palpating the carotid arteries.
• If you feel a thrill, listen for a bruit.
• As a result of hearing a thrill, you should listen for a bruit.
• Use a stethoscope to auscultate a bruit.
• A bruit sounds like rushing fluid in a rhythm. It can sometimes sound like a fetal heart tone.
• Turbulent blood flow causes a bruit.
• Normally, a patient should not have a carotid thrill or bruit.

v) Inspect and Palpate the Chest (Thorax)

a) Inspect the Chest

• Inspect the chest for pulsations.
• Look for pulsations at the five landmarks. Inspect the chest with the patient in a high, mid and low Fowler’s position.
• First, observe the second intercostal space at the right sternal border.
• Next, move to the second intercostal space at the left sternal border.
• Then, inspect the third and fourth intercostal space at the left sternal border.
• Finally, move to the fifth intercostal space at the midclavicular line where the apex of the heart is located.
• This is the point of maximal impulse.
• Covered below is the assessment of the apical pulse and point of maximal impulse.
• Inspect the chest for rises or lifts at those landmarks or anywhere else.
• These pulsations are called heave or lifts.
• You can visualize or palpate a heave or a lift.

b) Palpate the Chest

• Next, palpate the chest.
• Feel for pulsations over the five landmarks.
• Place the patient in a high, mid or low Fowlers position to palpate the chest wall.
• Use the fingerpads or the palm of the hand to palpate the chest wall.
• You are feeling for pulsations, lifts or heaves.
• First, feel over the second intercostal space at the right sternal border.
• Next, move to the second intercostal space at the left sternal border.
• Then, palpate the third and fourth intercostal space at the left sternal border.
• There should be no pulsations present at these landmarks.
• Finally, move to the fifth intercostal space at the midclavicular line where the apex of the heart is located.
• When you palpate at this location you should feel a slight tapping sensation.
• This tapping sensation coincides with the heartbeat.
• This is the apical pulse.
• The apical pulse should be the only pulsation felt on the chest wall.

c) Assess the Point of Maximal impulse – Apical Pulse

• Although apex means peak, the apex of the heart is at the bottom.
• The base is the top.
• The apical pulse is located at the fifth intercostal space midclavicular line.
• This is also called the point of maximal impulse (PMI).
• Also, the mitral valve can be auscultated at this location.
• Note the location and characteristics of the apical pulse.
• An enlarged heart and pregnancy can displace the apical pulse.
• During a cardiovascular assessment, it would be a good idea to count the heart rate by auscultating the apical pulse with your stethoscope and compare to peripheral pulse.

d) Auscultate the Chest

Use the stethoscope to auscultate the chest for the apical pulse. Note the rate, rhythm, and any extra heart sounds. The rate will be normal (60-100), fast (tachycardia >100), or slow (bradycardia <60). The rhythm will be regular or irregular.

Next, auscultate over the five landmarks of the chest.

1. First, auscultate the aortic valve. This is located at the second intercostal space right sternal border.
2. Second, auscultate the pulmonary valve. It is located at the second intercostal space left sternal border.
3. Third, auscultate Erb’s point. Erb’s point is located at the third intercostal space left sternal border.
4. Fourth, auscultate the tricuspid valve. This is located at the fourth intercostal space at the left sternal border.
5. Fifth, auscultation of the mitral valve. The mitral valve is located at the fifth intercostal space midclavicular line. This is the same placement as the apical pulse and the point of maximal impulse.

Next, auscultate the heart sounds. You are listening for S1 and S2 heart sounds. The closure of the heart valves produces the S1 and S2 heart sounds. Use the diaphragm of the stethoscope to hear these sounds the best. If you think your patient may have an extra heart sound (S3 or S4), use the bell of the stethoscope. Also, note any abnormal heart sounds.

ABNORMAL FINDINGS IN A PATIENT WITH CORONARY ARTERY DISEASE

1) Subjective data

• chest pain or discomfort that occurs regularly with activity, after eating, or at other predictable times
• chest tightness
• heaviness
• pressure
• numbness
• fullness
• squeezing
• fatigue
• sleep disturbances
• shortness of breath
• indigestion
• anxiety

Risk factors

• high blood pressure
• smoking
• diabetes
• lack of exercise
• obesity
• high blood cholesterol
• poor diet
• depression
• family history
• excessive alcohol.

Lab Results

• Elevated C-reactive protein
• Elevated triglycerides
• Elevated homocysteine
• Elevated lipoprotein-a