Interactive session: Cardio- respiratory examination and clinical skills update Louise Best Cardiac Advanced Nurse Practitioner Brighton and Sussex University Hospital NHS Trust
Interactive session: Cardio-respiratory examination and
clinical skills update
Louise Best
Cardiac Advanced Nurse Practitioner
Brighton and Sussex University Hospital NHS Trust
Learning Focus
Assessing breathlessness
Assessing fluid status
Cardio-respiratory assessment
Case study
Breathlessness
Also known as dyspnoea, is a subjective, usually distressing sensation or awareness of difficulty with breathing. Usually inappropriate to a given level of exertion.
Breathlessness can be classified by its speed of onset:
Acute breathlessness- when it develops over minutes.
Subacute breathlessness- when it develops over hours or days.
Chronic breathlessness- when it develops over weeks or months.
(Nice, 2017)
Assessment Structure
Taking a history (80% of the diagnosis)
Many models available for a structured review; Medical Model, Calgary-Cambridge, Pendleton, Neighbour + Many more!
• Ancient Dictum
‘Listen to the patient and he will
tell you the diagnosis’
(Voltaire)
Red flags
Stridor
Altered level of consciousness or acute confusion
Significant respiratory effort (particularly if the person is becoming exhausted)
Nasal flaring or tracheal tug
Intercostal indrawing
Elevated respiratory rate, tachycardia and hypotension
Inability to speak or fragmented speech
Oxygen saturation less than 92%
Cyanosis
Unrelieved chest pain
Peak expiratory flow rate less than 50% predicted
Presenting complaint- Principle complaint
History of presenting complaint- details, effects of complaint on ADLs, associated symptoms, SOCRATES or PQRST
Past/previous medical history- Past illnesses, hospitalisation, operations, past treatments
Drug history and allergies- prescription medication, OTC, herbal remedies, any side effects or problems, allergies
Social history- occupation, marital status, accommodation, hobbies, social life, smoking and alcohol consumption, diet, sleeping and wellbeing
Family history- age and health, or age and cause of death (parents, grandparents, siblings, children, grandchildren)
Systems review- General, skin, HEENT, neck, breasts, respiratory, CVC, GI, peripheral vascular, urinary, genital, MSK, psychiatric, neurological, haematological, endocrine.
Initial enquiry of symptoms
Can use assessment tools such as Socrates and PQRST
Onset- sudden or gradual
Location- radiation
Duration- frequency, chronology
Characteristics- quality, severity
Aggravating and precipitating factors
Relieving factors
Current situation (improving or deteriorating)
Effects on ADLs
Previous diagnosis or similar episodes
Previous treatments and efficacy
Specific Symptoms
Shortness of Breath
Number of stairs they can climb or distance they can walk.
Posture- orthopnea or tripoding
Shortness of breath at rest
Association with Paroxysmal Nocturnal Dyspnea (PND)
Associated swelling of ankles or recent weight gain
New York Heart Association (NYHA) Functional Classification
Class Patient Symptoms
I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea
IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases
Cough
Quality
Severity
Timing
Duration
Sputum
Colour
Amount
Consistency
Purulence, odour, foul taste
Time of day, worse?
Haemoptysis
Amount of blood
Frank blood mixed with sputum
Association with leg pain, chest pain, SOB
Chest Pain
Associated symptoms
Relation to effort, exercise, meals, bending over
Explore the pain carefully- SOCRATES
Cyanosis
Central vs peripheral
When does it occur?
Any recent changes in pattern of?
Associated wheeze?
Fainting and Syncope
Weakness, light-headedness, loss of consciousness
Relation to postural changes, vertigo or neurological symptoms
Orthopnea?
Is dyspnea that occurs when the patient is lying down and improves when the patient sits up.
Classically quantified by the number of pillows used for sleeping, or by the fact the patient needs to sleep sitting upright.
Need to ensure that this is due to SOB and not other causes.
Paroxysmal nocturnal dyspnea (PND)
Describes episodes of sudden dyspnea and orthopnea that awaken the patient from sleep.
Usually 1-2 hours after going to bed, prompting the patient to sit up, stand up, or go to the window for air.
There may be associated wheezing and coughing.
The episode usually subsides but may recur on subsequent nights.
Extremities
Oedema
Site
Relation of oedema to activity or time of day
Intermittent claudication
Tingling
Leg cramps or pain at rest
Presence of varicose veins
Fluid status
Weight changes
Input/output
Fluid restriction?
Oedema
Diuretics?
Physical Assessment
Preparation
Explain the procedure to the patient and consent
Infection control
Universal precautions
Patient position- think about how often you are asking the patient to change position
Examine from the right side- standard position for physical assessment
Lighting
Equipment
Privacy and dignity
Vital Signs
Respiratory rate
SpO2
Heart rate
Blood pressure ( + lying and standing)
Temperature
Peak flow
Weight
General Appearance
Acutely or chronically ill
Degree of comfort or distress
Position to aid respiration
Diaphoresis
Ability to talk a normal-length sentence without stopping to take a breath
Colour
Nutritional status
Hydration status
Mental status
Inspection
Colour- cyanosis
Shape of chest- pectus excavatum, pectus carinatum, barrel chest
Symmetry of chest movement
Rate, rhythm and depth of respiration, respiratory distress
Intercoastal indrawing
Use of accessory muscles
Precordium: visible pulsations
Chest wall scars, bruising, signs of trauma
Jugular venous pressure (JVP) (<4 cm?)
Colour of conjunctiva (Jaundice, anaemia)
Extremities
- Hands- oedema, cyanosis, clubbing, nicotine stains, cap refill <3 seconds
Inspection
- Feet and legs – changes in foot colour with changes in leg position
i.e., blanching with elevation, rubor with dependency, ulcers, varicose veins, oedema (check sacrum if patient is bedridden), colour (pigmentation, discoloration), distribution of hair
Skin – rashes, lesions, xanthomas
Pectus carinatum Pectus excavatum Barrel Chest
Inspection: Assessing jugular venous distension
• Estimating the jugular venous distension provides important information about the patient’s volume status and cardiac function
• The JVD reflects CVP/RAP (normally < 7mmHg or 9cm H20). The sternal angle is 5 cm above the right atrium so the normal JVD should be no more than 4 cm
• Assess the JVD with the patient lying at an angle of 30 - 450. The internal jugular vein lies lateral to the carotid artery and beneath the sternomastoid muscle. At 30- 450 it should be just visible above the clavicle.
Assessing the Jugular veins
Jugular venous distension
Distinction between jugular venous and carotid pulses
• Internal Jugular Vein• Not palpable• Two peaks per cycle (in sinus rhythm)
• ‘a’ wave (right atrial contraction)• ‘v’ wave (right atrial filling when tricuspid valve closed)
• Affected by compressing the abdomen• Pulsation diminished by pressure at root of neck• Changes with respiration
• Carotid Artery• Palpable• One peak per cycle• Not affected by compressing the abdomen• Pulsation unaffected by pressure at root of neck• No changes with respiration
Causes of elevated JVD?
Causes of elevated JVD
• Heart failure
• Fluid overload
• Superior vena cava obstruction
• Constrictive pericarditis
• Cardiac tamponade
• Tricuspid valve regurgitation
Additional manoeuvres
• Abdomino-jugular test (hepato-jugular reflux)
• Kussmauls’s sign
Hepato jugular reflex
• Is a more sensitive indicator of right heart function
• Sit the pt at 20-30° trunk elevation
• Firm, gentle pressure is applied over R upper quadrant for 30-60 seconds and observe jugular vein
• Normal – initial venous distension is quickly followed by collapse as the RV adjusts to the increased venous return
• Abnormal – sustained rise in JVD of at least 4cm or more, or a fall of 4cm or more after pressure release
Elevated JVD and HJR
Palpation
Tracheal position (midline)
Chest wall tenderness or crepitus
Chest expansion
Tactile fremitus
Spinal abnormality- Scoliosis, Kyphosis, Lordosis
Nodes
Masses
Apical beat:
- Point of maximum impulse (PMI) normally located at the fifth intercostal space, mid-clavicular line
- Assess quality and intensity of apical beat
- Apical beat (PMI) may be laterally displaced, which indicates cardiomegaly
Palpation
Identify and assess pulsations and thrills
Hepatomegaly, right upper quadrant (RUQ) tenderness
Assess peripheral pulses – radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis
Check for synchrony of radial and femoral pulses
Oedema: pitting (rated 0 to 4) and level (how far up the feet and legs the oedema extends); sacral oedema
Chest expansion
Palpation: cardiac oedema
• Ankle oedema
• Sacral oedema
• Scrotal oedema
• Pulmonary oedema
Oedema
• The collection of an abnormal amount of tissue fluid• Accumulates in the extracellular spaces between cells and leads to local swelling• Tissue fluid is in dynamic equilibrium with plasma – balance of fluid escaping from blood vessels and
fluid being returned to blood vessels and drained away by lymphatic vessels• HF – increased venous pressure• Pulmonary oedema and peripheral oedema• Peripheral oedema – sign of right sided HF or CCF• Accumulates at the lowest part of the body
• feet, ankles
• sacrum
• Pitting – swelling that can be displaced by firm pressure and which leaves a pit when the finger is removed
• Differential diagnosis• stasis oedema – elderly, immobile – lack of muscle pump activity• low albumin
Useful questions
Have you had any swelling anywhere? When does it occur? Is it worse in the morning or night? Do your shoes get tight?Are your rings tight on your fingers?Are your eyelids puffy or swollen in the mornings?Have you had to let your belt out? Have your clothes got tight around the middle?
Has the patient recorded daily weights? Oedema may not be obvious until several litres of extra fluid have accumulated
Grading oedema
Grade +1 Slight indentation
Grade +2 Moderately pitting lasts for a few seconds
Grade +3 Deep indentation that returns slowly to its original contour
Grade +4 An even deeper indentation that returns more slowly to original contour
Percussion of lung fields
Percuss and posteriorly and anteriorly
Resonant note- Normal air filled lung
Dull note – Heard over solid organs. Indicative of consolidation
Stoney dull- duller than ‘standard’ dull sound. Indicative of a pleural effusion
Hyperresonance- pathological percussion sound indicative of hyper-inflated lungs from advanced COPD, emphysema, or a pneumothorax
Auscultation of lungs
• Listen for sounds of normal air entry before trying to identify abnormal sounds
• Degree of air entry throughout the chest (should be equal)
• Quality of breath sounds (e.g., bronchial, bronchovesicular, vesicular)
• Ratio of inspiration to expiration
• Adventitious sounds:
- Wheezes (rhonchi), crackles (rales), pleural rub, stridor, decreased breath sounds, absent breath sounds
Lung lobes
Anterior Landmarking Posterior landmarking
Auscultation of the heart
• Listen to normal heart sounds before trying to identify murmurs
• Auscultate at aortic, pulmonic, Erb’s point, tricuspid, and mitral. Attempt to identify:
- Rate and rhythm
- S1 and S2 sounds and their intensity
- Added heart sounds (S3 and S4), splitting of S2
- Murmur
- Pericardial rub
Auscultation landmarks
1. Aortic area• 2nd i/c space RSB
2. Pulmonic area• 2nd i/c space LSB
3. Erb’s point• 3rd i/c space LSB
4. Tricuspid area• 4th i/c space LSB
5. Mitral area• 5th i/c space mid-clavicular line
Heart sounds
• Use diaphragm and bell of stethoscope
• Normal heart valves make ‘no sound’ on opening, only on closing – S1 & S2
• Abnormal heart sounds are due to:• Movement of blood across an abnormal valve
• Movement of blood through an abnormal channel
• Movement of blood within an abnormal chamber
Cardiac auscultation
• Listen at each of the auscultatory sites with both the bell and the diaphragm; use an inching approach if needed....
• To differentiate between S1 and S2 simultaneous palpation of the carotid pulse may be helpful. The first heart sounds precedes the pulse, the second sound follows it.
• Use the diaphragm for high pitched sounds – S1 and S2 and most systolic murmurs.
• Use the bell for low pitched sounds – third heart sound and mitral stenosis
Normal Heart sounds
S1- caused by closure of the tricuspid and mitral valve
S2 – is caused by closure of the pulmonic and aortic valves
Splitting of the second heart sound
• S2 is caused by closure of the pulmonic and aortic valves
• Physiological splitting of S2 occurs because LV contraction slightly precedes RV contraction during inspiration. Hence the splitting of S2 should disappear on expiration
• Increased S2 splitting occurs when RV contraction occurs late
• Listen for lub d/dub (inspiration), lub – dup (expiration)
Third heart sound (S3)
• S3 is a low-pitched sound best heard with the bell of the stethoscope at the apex. S3 occurs during the phase of rapid ventricular filling during early-diastole
• A third heart sound is a normal finding in children, young adults and during pregnancy. It is generally abnormal after the age of 30 years
• It is often heard post acute MI and in heart failure and is often accompanied by a tachycardia when it is called a gallop rhythm
• Listen for lub-dup-dum…….
Fourth heart sound (S4)
• The fourth heart sound is always pathological
• It is caused by forceful atrial contraction and is heard in LVH, hypertension and hypertrophic cardiomyopathy. It is never heard if the patient is in atrial fibrillation
• Listen for da-lup-dup…….
Evaluating ‘murmurs’
• Murmurs are sounds which occur due to turbulent blood flow
• Note when in the cardiac cycle the extra sound occurs:• Systolic murmurs
• Diastolic murmurs
• Pansystolic murmur
• Innocent murmurs
Ejection systolic murmurs
• Aortic stenosis
• Pulmonary stenosis
• Hypertrophic cardiomyopathy
Pan systolic murmur
• Causes:• Mitral regurgitation
• Tricuspid regurgitation
• Ventricular septal defect
• Ruptured ventricular septum (post MI)
• Characteristics:• Loud, blowing harsh sound. May be associated with a thrill
Pericardial Rub
Due to inflammation of the pericardium, whereby the two layers of the pericardium ‘rub’ together against each other.
• Sounds like sand paper, or crunchy snow
• Best heard with the patient sitting up or learning forward
• Associated with chest pain
Signs and symptoms requiring immediate treatment/investigation
• Severe dyspnea and inability to lay flat
• Tracheal shift
• Unable to maintain SpO2 greater than > 92% on room air
• Severe increasing fatigue
• Cyanosis (central cyanosis is not detectable until oxygen saturation is less than 85%)
• Silent chest or crackles throughout lung fields
• Decreased level of consciousness
• Diminishing respiratory effort
• Recent hospitalization for congestive heart failure (CHF)
• Pregnancy or postnatal period
• Immunosuppressed, elderly or very frail
• Significant comorbidities, unable to cope at home, living alone, or poor/deteriorating condition
Diagnostic tests
Chest x-rayElectrocardiogram (ECG)Hemoglobin (Hb)U&Es, liver function and thyroid functionCardiac troponinsArterial blood gas (ABG)Sputum for MC&SECHO
CXR
• Chest x-ray findings include pleural effusions, cardiomegaly (enlargement of the cardiac silhouette), Kerley B lines(horizontal lines in the periphery of the lower posterior lung fields), upper lobe pulmonary venous congestion and interstitial oedema.
A good mnemonic to remember these principles is ABCDE:
• A - alveolar oedema (bat wing opacities)
• B - Kerley B lines
• C - cardiomegaly
• D - dilated upper lobe vessels
• E - pleural effusion
Case Study
•70 year old male
•HPC – increasing fatigue, dyspnoea on exertion
•PMH - history of hypertension (well controlled on ACE and beta-blocker), high cholesterol (on statin), type II diabetes (diet control), hypothyroidism (on Thyroxine), THR two months ago
Case study continued
•Vital signs: T 370, HR 94 regular, BP 116/64, RR 24, Sats 92% on air, cap refill 3 secs
•Physical assessment findings: (abnormal findings only noted)•Pale mucous membranes, bilateral ankle
oedema,JVD +5cm, Apex noted 6th intercostal space mid-clavicular line, Apical thrill palpated, S3 heard at apex.
Case study continued
• Clinically significant abnormalities?
• Investigations?
• Differential diagnoses?
Thank you!
Any Questions?