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CARDIO ASSESSMENT STUDY
Pulses
The pulse is a wave of blood created by contraction of the left ventricle of the heart. When taking pulse, note the rate, rhythm, volume, arterial wall elasticity, and presence of absence of bilateral equality.
Pulse sites:
- Temporal: where temporal artery passes over the temporal bone of head. - Carotid: at the side of neck where the carotid artery runs between the trachea and the sternocleidomastoid muscle; most commonly auscultated pulse - Apical: at the apex of heart - Adult: left side of chest, ~3 into the left of sternum, at the fifth intercostal space - Elderly: may be further left if enlarged heart - Children <4: apex is left of midclavicular line - Children 4-6: apex is at midclavicular line - Children 5-9: located at 4-5 intercostal space
- Brachial: at the inner aspect of biceps muscle of arm
- Radial: where radial artery rungs alongside radial bone
- Femoral: where the femoral artery passes alongside the inguinal ligament.
- Popliteal: where popliteal artery passes behind the knee.
- Posterior tibial: on medial surface of the ankle where posterior tibial artery passes behind the medial malleolus.
- Dorsalis pedis: where the dorsalis pedis artery passes over the bones of foot, on an imaginary line drawn from middle of ankle to the space between big and second toes.
Pulse 4-Point Scale:
- 0 – absent
- 1+ - palpable, but thready and weak, easily obliterated
- 2+ - normal, easily identified
- 3+ - increased pulse, moderate pressure for obliteration
- 4+ - full, bounding; cannot obliterate
Factors Affecting Pulse:
- Age - Sex - Exercise
- Fever - Medications - Hypovolemia/Dehydration - Stress - Position - Pathology
Tachycardia: An excessively fast heart rate (110/min or higher)
Bradycardia: A heart rate of less than 60/min
Apical Pulse
Apical pulse should be assessed for clients whose peripheral pulse is irregular or unavailable and for clients with known cardiovascular, pulmonary, or renal diseases. It is commonly assessed prior to administering medications that affect heartrate. Also, it is used for newborns, infants, and children up to 3 years old.
- CANNOT be delegated to UAP
- Pulse deficit = difference between apical and radial pulse
Heart Sounds and Location for Auscultation
Heart sounds & corresponding description:
- S 1 - dull, high pitched, sounds like “lub”
- S 2 - higher pitch, sounds like “dub”
- Systole - normally silent interval between S 1 and S 2 - ventricles are contracting
- Erb’s Point : 3rd left intercostal space
- Tricuspid Area : 4th left intercostal space
- Mitral/Apical Area : 5th left intercostal space
Abnormal Findings:
- Ventricular gallop (after S2) - caused by premature rush of blood into a ventricle that is stiff or dilated as result of heart failure and hypertension. - Murmur - sustained swishing or blowing sounds heard at beginning, middle and end of the systolic or diastolic phase is caused by increased blood flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or heart chamber, or backward flow through a valve that fails to close o Grade 1 – barely audible in a quiet room o Grade 2 – quiet but clearly audible o Grade 3 – moderately loud o Grade 4 – loud, with associated thrills o Grade 5 – very loud; thrill easily palpable o Grade 6 – very loud; audible with stethoscope not in contact with chest; thrill palpable and visible - Dysrhythmia/Arrythmia – failure of heart to beat at regular successive intervals - Thrill – continuous palpable sensation that resembles the purring of a cat - Bruit – blowing sound; as blood passes through the narrowed section, it creates turbulence
- Atrial fibrillation - the electrical impulses in the atria is chaotic and originates from multiple sites and the rhythm is irregular because of multiple pacemaker sites and unpredictable conduction to the ventricles. It decreases cardiac output by altering preload and contractility
- Ventricular tachycardia – life threatening; decreases cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death increases
Peripheral Vascular System
Assessing the peripheral vascular system includes measuring blood pressure, palpating peripheral pulses, and inspecting the skin and tissues to determine perfusion (blood supply) to the extremities.
Components of a peripheral vascular check:
- Assess the adequacy of blood flow to the extremities by measuring arterial pulses and inspecting the condition of the skin and nails
- Assess the integrity of the venous system
- Assess the arterial pulse in the extremities to determine sufficiency of the entire arterial circulation
- An abnormal artery is hard, inelastic, or calcified
- If circulation in the upper extremities become blocked, the hands do not receive adequate blood flow resulting in cyanosis and pallor
Basic factors influencing perfusion:
- Perfusion relates to the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs
- Hemorrhage and dehydration cause a decrease in circulating blood volume and a decrease in stroke volume
- The myocardium not getting enough blood flow and not getting adequate oxygen and nutrients
- Poor conduction system of the heart
- Cardiac output = stroke volume x HR o If one goes up, they all go up
Peripheral Pulses: symmetric pulse volume, full pulsations.
- Asymmetric volumes indicate impaired circulation. - Absence of pulsation indicates arterial spasm or occlusion. - Decreased, weak, thready pulsations indicate impaired cardiac output. - Increased pulse volume indicates hypertension, high cardiac output, or circulatory overload.
Peripheral arm veins: Presence of distention and nodular bulges at the calves in dependent position, veins collapse when limbs elevated, symmetric in size, limbs not tender.
- Distended veins in thigh and/or lower leg or on posterolateral part of calf or from knee to ankle, swelling of one calf or leg, tenderness on palpation, pain in calf muscles with forceful dorsiflexion of the foot, warmth and redness over vein.
- No one sign or symptom consistently confirms or excludes the presence of DVT
Skin of hands and feet: Pink skin color, skin temperature not excessively warm or hot, no edema, texture is resilient and moist.
- Cyanotic skin indicates venous insufficiency - pallor that increases with limb elevation, dependent rubor, a dusky red color when limb is lowered indicates arterial insufficiency
Jugular Vein Distention: How to Assess and Indications
Inspecting the jugular veins for pulsations and distention can assess the adequacy of function of the right side of the heart and venous pressure.
Best to examine the right internal jugular vein because it follows a more direct anatomical path to the right atrium of the heart
Bilateral jugular vein distention can indicate right-sided heart failure.
Inspect the jugular veins for distention while patient is in semi-Fowler’s (15°- 45°) – 30° is used most frequently
- Normally, when a patient lies in supine position, the external jugular vein distends and becomes easily visible. They should NOT be distended in semi-Fowler’s
When to Use a Doppler Ultrasound:
A Doppler ultrasound is used for pulses that are difficult to assess, such as when you have difficulty palpating some of the peripheral pulses.
ABDOMINAL ASSESSMENT
Abdominal assessment
- Abdominal pain is the most common symptoms that patients report when seeking medical care, assess organs anteriorly and posteriorly
- Tip of the xiphoid process to symphysis pubis are the boundaries of the abdominal cavity
- Gastric ileus = stop of peristalsis 1. Inspection a. Skin - look at color, scars, venous patterns, lesions, striae i. taut appearance indicates edema b. Umbilicus - note the position, shape, color, signs of inflammation, discharge, or protruding masses i. NOTE: everted umbilicus indicates distension, and hernias cause upward protrusion of the umbilicus c. Look for color changes: jaundice, cyanosis, etc. d. Symmetry i. If distension is found, measure with a tape measure around the abdomen. ii. inspect for contour, symmetry, and surface motion of the abdomen, noting any masses, bulging, or distension iii. enlarged organs or masses - have the patient take a deep breath and hold it because it forces the diaphragm downward reducing the size of the abdominal cavity. e. Movement and pulsations - closely inspect for peristaltic movement and aortic pulsation by looking across the abdomen from the side 2. Auscultation - perform before you palpate a. Bowel motility - peristalsis, normal sounds should sound like soft gurgling or clicks irregularity for 5-35 time a min i. AUSCULTATE FOR 5 CONTINUOUS MINUTES to determine hypoactive or absent bowel sounds ii. Best time to listen is in between meals iii. Hypoactive or absent sounds indicate a lack of peristalsis. iv. Hyperactive sounds are loud growling sounds called “borborygmi” which indicate increased GI motility. b. Vascular Sounds i. bruits in the abdominal area can reveal aneurysm or stenotic vessels ii. Normally there are no vascular sounds over the aorta or femoral arteries 3. Palpation i. primarily detects area of abdominal tenderness, distension, or masses. ii. Use light palpation over each abdominal quadrant to detect areas of tenderness. iii. Use systemic palpation approach for each quadrant and assess for muscular resistance, distention, tenderness, superficial organs and masses iv. Rebound tenderness - peritoneal irritation as with appendicitis, pancreatitis, injury to area v. Normal findings - Smooth consistent softness and nontender without masses.
o Secondary energy source o Protects vital organs o Supports cell growth
- Vitamins/Minerals - Act as catalysts in biochemical reactions
Healthy Diets/Habits:
- Constipation: 2000 to 3000mL of water per day. High fiber foods (approx 20g). Encourage physical activity/exercise - Diarrhea : High fiber bulk foods (cereal, grains…), encourage fluid intake due to dehydration and loss of electrolytes
- Normal : adopt an appropriate calorie level with a variety of nutrient dense foods and beverages among all the food groups
- Encourage fruits, vegetables, whole grain, products, seafood, and fat free or low fat milk
- Eat a variety of proteins, including lean meats, seafood, poultry, eggs, legumes, nuts, seeds, and soy products
- Limit saturated and trans fats
Factors that affect nutrition
- Development
- Sex
- Ethnicity
- Culture
- Beliefs about food
- Personal preference
- Religion
- Lifestyle
- Economics
- Medications and therapy
- Health
- Alcohol consumption
- Advertising
- Psychological factors
Promote Nutritional Intake:
- Keeping a patient’s environment free of odors
- Providing oral hygiene as needed to remove unpleasant tastes, odors
- Maintaining patient comfort
- Offering smaller, more frequent meals often helps
- Help the patient select foods that reduce the altered taste sensations or nausea.
- When a patient experiences anorexia, encourage other nurses or care providers to converse and engage them in conversation.
Assessment of Patient Appetite:
- Food preferences
- Meals/day
- Portion sizes
- Special diet
- Food preparation/grocery shopping (do they do it themselves)
- Changes in appetite
- Changes in weight
- Allergies
- Changes in taste
- Medications
- Nutritional or herbal supplements
- Mealtime is a great opportunity to educate the patient on the topic, instruct them about therapy diets, medications, energy conservation measures, or adaptive devices to help feel independent
Special Diets:
- Clear liquid - clear, fat free broth, bouillon, coffee, tea, carbonated beverages (coke & sprite), clear fruit juices, gelatin, fruit ices, popsicles o often used for clients after certain surgeries or in acute stages after infection. This diet relieves thirst, prevents dehydration, and minimizes stimulation of the GI tract.
- Full liquid - same as clear with the addition of smooth- textured dairy products (example ice cream) strained or blended cream soup, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt o for clients who have GI disturbances or cannot tolerate solid or semi-solid foods.
- Dysphagia stages, thickened, pureed - same as clear and full liquid but with the addition of scrambled eggs, pureed meats, vegetables and fruits and mashed potatoes and gravy
- Mechanical soft - same as clear and full liquid but with the addition of all cream soups, ground or finely diced meats. Flaked fish, cottage cheese, cheese, rice, potatoes, etc.
- Soft/low residue - the addition of low fiber, easily digested food such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables o for clients who have difficulty chewing and swallowing
- High fiber - addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits
- Low sodium - 4g (no salt added), 2g, 1g (500mg) vary from no salt added to 500mg
- Low cholesterol - 300mg/ day
- Diabetic – nutrition recommendations
- Gluten free – no wheat, oats, rye, barely
- Regular – no restrictions
Input/Output
- Assessment of I&O is a way to evaluate bladder emptying, renal function, and fluid and electrolyte balance - Intake measurements include all oral liquids and semiliquid, enteral feedings and parenteral fluids - Output includes not only urine but any fluid that leaves the body that can be measured such as vomitus, gastric drainage tubes, and wound drains - Urine output of less than 30 mL per hour for more than 2 consecutive hours or excessive urine output is polyuria o 1 oz = 30 mL o 1 cup = 8 oz
o Large bore: place tube in warm basin while preparing client to allow tubing to become more pliable and flexible.
- Determine how far to insert tube by marking distance from the tip of nose to the tip of earlobe; then tip of earlobe to the tip of xiphoid. This approximates the distance from the nares to stomach.
- Insert tube: lubricate the tip of tube with water-soluble lubricant or water, some agencies will use a lidocaine anesthetic to numb the area. Water-soluble (versus oil soluble) will dissolve if it accidentally enters the lungs, oil could cause respiratory complications if it entered the lungs.
- Insert tube: insert with its natural curve downward into the nostril, ask client to hyperextend neck and gently advance to nasopharynx, once the tube meets the oropharynx, client may gag or retch, have the client tilt their head forward and encourage them to drink water and swallow. Pass the tube 5-10cm with each swallow until it reaches needed length.
- Confirm placement with an x-ray. If small bore tube is used, leave stylet or guidewire in place until confirmed placement.
- Aspirate stomach contents and check pH (pH is another way to determine location, gastric pH is usually 1-5, a pH of 6+ would indicate placement lower in the GI tract or in the respiratory tract. pH cannot differentiate between gastric and esophageal placement. Aspirate can also be tested for bilirubin which should be ~ 1.5mg/dL.
- Air bolus test - place stethoscope over epigastrium and inject 10-30mL of air into tube and listen for a whooshing sound.
- Secure tube: tape to bridge of nose and attach tube to client’s gown.
- Attach tube to suction source or feeding apparatus or clamp end of tubing.
- Document all information such as insertion, means of confirming placement, how it was tolerated, what has come out.
NG Tube Maintenance:
- Inspect nostril for discharge or irritation. - Clean nostril and tube with moistened, cotton-tipped applicators. - Apply water soluble lubricant to nostril if it appears dry or encrusted.
- Change adhesive as required.
- Give frequent mouth care.
- If suction is being used: o Irrigate tube as frequently as agency policy states, prior to irrigating, recheck tube placement. o Salem sump: irrigate the vent lumen with air to maintain patency of suctioning as indicated by agency policy.
Tube feeding:
- Usual: hand hygiene, verify client, provide privacy, check orders, etc.
- Assess tube placement: check pH (wait one hour after medication and use pH meter rather than pH paper if client is on continuous feeding).
- Assess residual feeding: aspirate and measure contents if tube is placed in stomach, if 100mL or more is withdrawn, consult with charge nurse or refer to agency policy before proceeding. Reinstall gastric contents if agency policy or provider order, if client is on continuous feeding, check gastric residual every 4-6 hours.
- Administer feeding: Check expiration date, warm feeding to room temperature, and clean top of feeding with alcohol before opening if using an open system to minimize risk of contaminants.
- Feeding bag (open system): o Apply label with date, time of start of feeding, and initials. Hang bag about 30 cm above tube’s point of insertion, clam tubing and add formula to bag, open the clamp and run feeding through the tubing, attach bag to feeding tube and regulate drip by adjusting clamp to the drop factor on the bag if not placed on a pump.
- Syringe (open system): o Remove plunger from syringe and connect to a punched or clamped NG tube. o Add feeding to syringe barrel and permit feeding to flow in slowly at the prescribed rate. Raise or lower syringe to adjust flow as needed. Pinch or clamp tubing to stop flow for a minute of experiencing discomfort.
Labs to Monitor
- Urine for sugar and acetone - hyperglycemia can occur if sugar content of feeding is too high - hematocrit - urine specific gravity - increase as a result of dehydration - serum BUN - sodium levels - formula often has high protein content which when paired with inadequate fluid intake, kidneys may not be able to excrete nitrogenous wastes adequately
Blood Glucose Monitoring
Monitoring blood glucose is important because it helps with diabetes management.
Steps to Monitoring Blood Glucose:
- Perform hand hygiene
- Check expiration on test strips
- Perform quality control
- Hand hygiene and don gloves
- Wipe patient’s finger with alcohol wipe
- Prick finger with lancet
a. Vesicular : soft, breezy, low-pitched, normal. Best heard over the periphery of the lung. Created by air moving through small airways. Inspiration greater than expiration b. Bronchovesicular : blowing sounds that are medium pitched of medium intensity. Best heard posteriorly between scapulae and anteriorly over bronchioles lateral to sternum at first and second intercostal space. Inspiration and expiration are equal c. Bronchial : bronchial sounds are loud and high pitched with hollow quality. Heard only over trachea. Inspiration shorter than expiration
- Abnormal lung sounds a. Crackles : (cough does NOT clear) bubble popping sounds. i. Diseases: pneumonia or bronchitis. ii. Fine crackles: high pitched fine, short, interrupted crackles heard over during the end of inspiration. iii. Medium crackles: lower, moister sounds during the middle of inspiration; not cleared with coughing iv. Coarse crackles: loud, bubbly sounds heard during inspiration; not cleared with coughing v. Inspiration>Expiration b. Rhonchi : (cough DOES clear) primarily heard of trachea and bronchi; if loud enough, able to be heard over most of the lung. i. Loud, low-pitched, rumbling, coarse sounds are heard either during inspiration or expiration ii. Diseases: COPD, pneumonia, and cystic fibrosis. iii. Breaks secretions with percussions iv. Clears with coughing and suctioning v. Inspiration<Expiration c. Wheezes : heard over all lung fields, severely narrowed or obstructed airway, high- pitched, musical sounds, heard continuously during inspiration and expiration, i. Usually louder on expiration ii. Diseases: asthma, bronchitis, and COPD. iii. Sibilant wheeze – high pitched, musical sounds head primarily on expiration iv. Sonorous wheeze – snoring sound v. Asthma (I>E) vi. COPD, and Emphysema (I<E) d. Pleural friction rub : heard over anterior lateral lung field due to inflamed pleura. i. Dry rubbing or grating heard over inspiration or expiration. ii. Does not clear with coughing iii. heard loudest over the lower lateral anterior surface iv. Diseases: viral or bacterial infections causing inflammation; pleurisy e. Stridor - obstruction or constriction of the trachea (medical emergency) i. I>E
Alterations in Respiratory Function
- Bradypnea: rate of breathing is regular but abnormally slow (less than 12 breaths/min)
- Tachypnea: rate of breathing is regular but abnormally rapid (more than 20 breaths/min)
- Hyperpnea: respirations are labored, increased in depth, and increased in rate (occurs normally in exercise)
- Apnea: respirations cease for several seconds
- Hyperventilation: rate and depth of respirations increase
- Hypoventilation: respiratory rate is abnormally low, and ventilation is depressed
- Cheyne-Stokes: rate and depth are irregular with alternating periods of apnea and hyperventilation. Usually due to injury to the brain stem.
- Kussmaul’s: respirations are abnormally deep, regular and increased in rate
- Biot’s: abnormally shallow for two or three breaths, followed by an irregular period of apnea
Abnormal Findings
- Barrel chest: COPD, may be normal in some older adults
- Cyanosis: decreased cardiac output or hypoxia
- Clubbing of nail beds : chronic hypoxemia
- Retractions: increased work of breathing, dyspnea
- Asymmetry: chest wall injury
- Pursed lip breathing: associated with chronic lung disease
- Flaring nares: air hunger, dyspnea
- Elevation of clavicles: increased work of breathing
Factors influencing respiration
- Developmental Factors o Infants and Toddlers o School-Age Children and Adolescents o Young and Middle-Age Adults o Older Adults
- Lifestyle Factors o Nutrition o Hydration o Exercise o Smoking, Substance Abuse, and Stress (BAD)
- Environmental Factors
Nursing Interventions to promote respiration
- Dyspnea Management
- Airway Maintenance
- Mobilization of Pulmonary Secretions
- Hydration
- Humidification
o Flow rates should be 6 L or more to avoid rebreathing exhaled carbon dioxide retained in the mask.
- Nonbreather face mask – They are beneficial for short periods of time. A disadvantage is that the bag can twist or kink. o Delivers highest concentration of oxygen 60-90% 10-15 L/min
o Apply the mask by placing it over the patient’s mouth and nose. Then bring straps over the patient’s head and adjust to form a comfortable but tight seal. o Capable of delivering higher concentrations of oxygen for a short period of time. o Frequently inspect the reservoir bag to make sure that the bag is inflated. It the bag is deflated, then the patient is breathing in large amounts of exhaled carbon dioxide.
- Venturi mask – They provide a specific amount of oxygen with humidity. A disadvantage is that the mask and humidity can irritate the skin o 24-60% 4-12L/min o Apply the mask by placing it over the patient’s mouth and nose. Then bring straps over the patient’s head and adjust to form a comfortable but tight seal. o Delivers more precise oxygen concentrations o Typically used for patients with COPD who need low, constant oxygen concentrations.
- CPAP – Helps to maintain a steady stream of pressure through a patient's breathing cycle. o It is beneficial for patients with OSA (obstructive sleep apnea), heart failure, and preterm infants with underdeveloped lungs. o The mask must fit a specific way to ensure that the patient is being treated properly. o 21-100% o Equipment includes a mask that fits over the nose or both nose and mouth with ear loops and a ciao machine that delivers air to the mask. o The smallest mask with a proper fit is the most effective. It must be tight enough to form a seal on the face so that the air does not escape but not so tight as to cause pressure injury formation or necrosis where the mask is against the face.
Suctioning
- Endotracheal tubes – They are short term artificial airways used to administer invasive mechanical ventilation, relieve upper airway obstruction, protect against aspiration, or clear secretions. o It is usually removed within 14 days but sometimes it is used for a longer time if the patient is still showing progress towards weaning from invasive mechanical ventilation and extubation. o The tube is passed through the patient’s mouth, past the pharynx, and into the trachea. - Tracheostomy – It is beneficial for long term assistance from an artificial airway. o A common complication is when there is a partial or total airway obstruction caused by a buildup of respiratory secretion. If this happens, the inner tube can be removed and cleaned or replaced with a temporary spare inner tube that should be kept at the patient’s bedside.
o A surgical incision is made into the inferior border of the cricoid cartilage of the trachea, and a short tracheostomy tube is inserted. o Tracheostomy suctioning should be done as necessary to clear secretions. o Patients with a tracheostomy are not able to speak because the tube is placed under the vocal cords.
- Oropharyngeal, nasopharyngeal o Perform oropharyngeal and nasopharyngeal suctioning when a patient is able to cough effectively but is unable to clear secretions by expectorating o Apply suction after a patient has coughed o Once the pulmonary secretions decrease and a patient is less fatigued, he or she is then able to expectorate or swallow the mucus, and sectioning is no longer necessary. o Use clean technique
