Cardiovascular & Pulmonary Exam
Pulse
Things you need to document (3)
Pt position
Quality &/or regularity of measurement
The side & location
Definitions
Pulse rhythms
regularity of heart contractions
(can be Irregular or Regular)
Pulse force (LV)
Resting Pulse
Normal quanitites
Adults
Kids (1-8 yrs)
80-100 bpm
Infants (0-1yrs)
100-120 bpm
Highly trained athletes or individuals taking đ˝ blockers:
60-100 bpm
Abnormal
Bradycardia
Tachycardia
<60 bpm
more than 100 bpm
Intensity when palpating the peripheral pulse
Influenced by (2):
BP
Other physiological factors (like temperature outside)
Grading
Can be described as (4):
weak, strong, bounding, and thready
0-4 scale
0 - absent, not palpable
1+ diminished, barely palpable
2+ : easily palpable, normal pulse
3+ : full, increased strength
4+ : bounding, cannot be obliterated
Palpitations areas
Carotid
Brachial
Between med epicondyle & bicep tendon
Radial & ulnar
Femoral
distal to inguinal ligament; approx. halfway from ASIS to pubis
Popliteal
Popliteal fossa
Posterior tibial
Post. to medial malleolus
Dorsal pedis
lateral to EHL tendon, near 2nd tarsal metatarsal joint
Max & target HR
Max HR Calculation (2)
206.9 â (0.67 X age); updated formula
220 â age; old formula
Target HR
Typically between 60% - 80% of HRmax
Calculation
Karvonen method: Target Heart Rate = [(max HR â resting HR) Ă %Intensity] + resting HR
Documentation example
HR: 82 bpm, 1+, regular, (R) radial artery, seated
Respiration
Observe & Document (4)
Rate
Rhythum
Depth
normal depth
usually less than half cpacity
Adult normal
12-20 breath/min
Body position
Children (ages 1-8) normal
15-30 breath/min
Infants (< 1 yr. old)
25-50 breath/min
Abnormal
when it too high is called...
Tachypnea
Infants > 50 breaths/min
Children > 40 breaths/min
Adults > 20 breaths/min
when it too low is called...
bradypnea
Adults < 12 breaths/min
Children < 15 breaths/min
Infants < 25 breaths/min
Regular: breaths at typical intervals
Irregular: breaths at variable intervals
3 desriptions
deep, normal, and shallow
Documentation example
RR (seated): 14 breaths/min, regular, shallow
(RR: Respiration rate)
Limitations of pulmonary function (4):
click to edit
SCIâconsider innervation C 3,4,5 (phrenic) which acts on diaphargm
Structural Deformity (scoliosis, kyphosis)
Poor Posture
Pain
Respiratory Dysfunctions (5)
click to edit
Dyspnea:
Orthopnea:
Paroxysmal nocturnal dyspnea: (PND)
Apnea:
what is OSA:
SOB
Difficulty breathing while lying flat
sudden dyspnea and orthopnea while sleeping
Absence of breathing, often while sleeping
Obstructive Sleep Apnea
What is one respiratory cycle
1 rise & 1 fall
Thready definition
40-60bpm
O2 Saturation
Definition
Degree to which hemoglobin is bound to oxygen in circulating blood
Normal amount
97%-100%
What is the partial pressure & abbreviation
PaO2 90â100 mmHg
S/S of lower O2
95% (2 signs) & partial pressure
90% (8 signs) & partial pressure
75-85% (adding 5 signs) & partial pressure
70% or under
% (80 mmHg)âTachycardia, Tachypnea
(60mm Hg) Tachycardia, Tachypnea, Malaise, Restleness, Impaired judgment, decline in coordination, vertigo, nausea
(40-50mmHg)âAbove sxâs, difficulty with respiration, cardiac dysrhythmia, confusion, tissue damage
Life threatning
Important to considering when choosing the finger to asses (2)
Choose finger that is not too cold and doesnât have dark nail polish or acrylic nails
Documentation (6 things)
SpO2 percentage, laterality, location, patient position, HR, room air (RA) or #L of supplemental O2
"number of L of supplemental O2" refers to the number of liters per minute (L/min) the pt is given O2
BP
Definition
measure of arterial pressure when the left ventricle contracts (peak of systole) and when the heart is at rest between contractions (diastole)
measured in
millimeters of Mercury: mmHG
Measured in
millimeters of Mercury: mmHG
Documentation
Systolic BP/Diastolic BP mmHg
Cuff Size rule
Bladder length (part that has the tubes coming out)
80% of arm circumference
How far down arm
40% between acrominin & olecranon
Categories
Abnormal
Hypotention
Hypertention
Can be due to (4):
Chronic untreated HTN diseases (5)
CAD, PAD, kidney disease, atherosclerosis, retinopathy
Stages (3)
Stage 1
Systolic: 130-139 OR Diastolic: 80-89
Stage 2
140-179 OR 90-119
Hypertensive Crises (consult doctor immediately)
180 or higher OR 120 or higher
Normal
Systolic: 90-119 AND Diastolic: 60-79
age, genetics, smoking, unrelated disease process
Elevated
120-129 AND less than 80
SBP < 90 mmHG OR DBP < 60 mmHG
*Changes during exercise
Normal (2)
what can occur with the SBP when going from supine to sit to stand when pt has been on bedrest for days
might drop bc pt is going against gravity
what is this called
Orthostatic hypotension
Symptoms (6)
2 Important postural things
Seated/supine for 5 min
elevate arm to level of heart
lightheaded, dizzy, syncope (fainting), blurred vision, numbness/tingling extremities
Timeline & decrease specifics
SBP increases, then levels off
DBP <10mmHg change
Abnormal (2)
SBP (3)
DBP (2)
Additional Cardiovascular &Pulmonary Exam
Temp
Ranges
Normal
Adult: 97.7-99.5 degrees Fahrenheit (Typically, 98.6 degrees F (37 degrees C)
Adult febrile values
Definition
Febrile = fever
Febrile if > or =100 deg F
Afebrile if <100 degrees F
Routes of measurement (6):
oral, tympanic membrane (ear), axilla (armpit) , temporal (forehead), rectal
Documentation (3)
reading, degrees Fahrenheit, location/method of reading
Edema vs Effusion â
Edema
Effusion
Definition
observable swelling & accumulation of fluid in
Interstitial spaces
Definition
fluid accumulation within a joint capsule
or cavity (due to injury or inflammation)
Most common area is...
Distal LEs
Pitting Edema
Definition
Visible indentation remains when finger is pressed into area and removed
Non-pitting Edema
definition
no indentation remains when pressure is removed
When does this typically occur
post-injury
Measuring factors (3)
Measure baseline circumferentially (area of largest swelling, above, and below)
Measure non-affected side for comparison
Remeasure in future sessions to track increase or decrease
Measuring
Position (2)
Seated or supine
How to describe location
using bony landmarks and precise distance above/below bony landmarks for most accurate reassessment
What to use & how
flexible tape measure; Pull tape measure firmly so there are no gaps, not so tight to cause indentation
Units
cm
Assessment (4 steps)
- Patient seated or supine (record position of pt)
- Press thumb firmly into the patientâs skin and hold 5 seconds
- Remove pressure and determine depth of the indentation
- Make note of how long it takes for indentation to disappear
Scale
Describers (4)
Trace (1+)
Mild (2+)
Moderate (3+)
Severe (4+)
Depth of indent
Slight indentation
Description & Time of rebound
Barely see indent, skin rebounds quickly
Depth of indent
0-0.6 cm
Description & Time of rebound
Easily see indent, skin rebounds <15 sec
Depth of indent
0.6-1.3cm
Description & Time of rebound
Easily see indent, skin rebounds 15-30 sec
Depth of indent
1.3-2.5cm
Description & Time of rebound
Easily see indent, skin rebounds >30 sec
Ankle Brachial Index (ABI)
Reason for measuring (2)
to identify presence and/or severity of impaired arterial blood flow to extremities
Highly sensitive and specific for identifying PAD
Ratio
SBP in LE: SBP in UE
S/S of PAD (2)
increased pain when LEs are elevated
pain in LE or BLE when walking
Risks of PAD (2)
increased risks of thrombi (clots)
can lead to (2)
increased risk of myocardial infarction(MI), or ischemic stroke (CVA)
arterial insufficiency wounds
Procedure (5 steps)
- pt in supine
- Take BP in UE; record SBP c stethoscope or doppler
- Cuff around leg above malleoli; same side as UE
- locate post. tib or dorsal pedis a.
- Take SBP at ankle
Documentation example
ABI (Doppler): (R) 128/124=1.03; (L) 120/122= 0.98
ABI Values
1.4 or higher
Abnormal; distal vessel calcification
1.0--1.3
Normal
0.8â0.9
Minimal to moderate arterial insufficiency
0.6â0.8
Moderate arterial insufficiency; minimal perfusion (intermittent claudication likely); compression contraindicated
<0.5
Severe arterial insufficiency (wound healing unlikely, critical limb ischemia, rest pain) compression contraindicated
< 0.4
Critical arterial insufficiency (necrosis likely)
RPE
Definition
rate of perceived exertion
Scale
from 0 (rest) to 10 (max;hardest race)
6 min walking test
Measures of cardiovascular endurance and tolerance for exercise
Standard procedure
set up 30 m course, count number of laps
very weak force in combination with a typically rapid and difficult-to-count rate
what type of pts have this
hypovolemic, such as after severe hemorrhage
Two mins after strenuous but submaximal exercise, the pulse rate should be
at least 22 bpm less than the maximal pulse rate achieved
Accessory mm. that sometimes used (3)
Upper traps, scalenes, SCM
Common in pts c (3 diseases)
heart failure, mitral stenosis, or pulmonary edema
when does it usually occur
around same time; often 1-2 hrs after going to bed
Common in pts c (3 diseases)
chronic obstructive pulmonary disease
(COPD), heart failure, or mitral stenosis
how long does it usually last
less than min but sometime more
Caused by
obstruction or by dysfunction of the central nervous system
% of people in US c HTN
33%
Can be affected by (8)
anxiety, caffeine intake, nicotine, dehydration,
exertion, pain, body position, and time of day
Hypothermia (rectal temp)
under 95 degrees
Hyperthermia (rectal temp)
106 or higher
one lap is 60 m (so back and forth from the 30m)
count how many laps in 6min, multiple by 60 to get the amount of meters
Documentation:
6MWT: 740m (two 10-sec breaks; use of standard walker)
*Response to Activity
normal
how does HR rise during increasing workload
abnormal
what are abnormal HR responses to increasing workload (4)
nearly linear until submax. effort
what happens when we reach sub max. effort
HR rises faster
submax effort is also what
the anerobic threshold (doesn't use aerobic metabolism anymore)
how much does it increase per MET
Increases ~ 8-12 bpm/met
is rise greater during UE work or LE
UE
what is 1 MET
the O2 consumption at rest (during sitting)(3.5 mL O2/kg/min)
what activities are considered 2 METs (2 examples)
walking and easy ADL's
what activity are considered 3 METs
walking up flight of stairs
how many METs is usually used in acute care
2 METs
is rise greater during static or dynamic work
dynamic
rapid rate of rise
what does this indicate (2 things)
lower stroke volume
endurance impairments
what is the relationship between HR and O2 consumption
linear relationship
how will HR rise for a sedentary individual compared to a trained individual
HR will rise more quickly
why
bc they have a lower VO2 max
definition of VO2 max
highest amount of O2 a person can use during intense exercise
what can HR be affected by (3)
disease
inactivity
medications
what 3 things meds can be used for that will affect HR
asthma
fevor
low blood volume
what type of medication is sometimes used for asthma
beta adrenergics
what does this do
stimulate beta 1 receptors, which increases the rate of HR rise
what is the most popular medication that affects HR
Beta blockers
what does it do
blocks the normal HR response by lowering the rate of HR rise
Very slow rate of rise in untrained individual that is blunted
what is this called
chronotropic incompetence
Decrease with increased work
is this common or rare
very rare
irregular (2 types)
Regularly irregular
Irregularly irregular
when can this occur
with arrythmia
example
like a skip in beat every 3-5 beats in an arrythmia pt
usually seen in what patient
pts with atrial fibrillations
how much does it increase per MET
Rises ~ 8-12 mm Hg/met
is Response greater during U/E or L/E work
U/E work
is Response greater during static or dynamic work
static
Within 2 â 5 min of positional change:âSBP ⼠20 mmHG, â DBP ⼠10 mmHG
Definition
postural hypotension; rapid drop of systolic BP when changing positions
why does this happen â
bc blood pools in the LE from laying down
can increase during what type of activity
heavy resistance activity
rapid rate of rise
blunted
exertional hypotension (> 10 mm Hg decrease) while exercising increases
increase or decrease more than 10mmHg while doing aerobic exercise
what can a progressive rise (>10 mmHg) indicate
can indicate resistance to blood flow in the heart, which means increased blockages in coronary arteries
does the HR increase or decrease
increase to try to maintain the BP when getting up
what can this indicate
that stroke volume is not able to handle the work load that could be from a pump dysfunction
what to do when this occurs
call doctor
Reasons for Use (3)
click to edit
Management of hypertension
Management of angina
Management post MI or CABG to lower workload on heart
how does this affect morbidity and mortality of post MI or CABG pts
how does beta blockers help this
definition
chest pain or discomfort caused by a temporary decrease in blood flow to the heart muscle
bc it lowers the workload on the heart which decreases the myocardial O2 consumption needed to pump blood
what is morbidity
research shows it improves their morbidity and mortality
Refers to the state of being diseased or unhealthy
Effects (4)
click to edit
Lowers HR
Lowers Systolic BP
Decreases Contractility of myocardium
how does this occur
Limits ventricular remodeling
by Blocking stimulation of beta 1 and beta 2 adrenergic receptor sites
how does this happen
by decreasing early ventricular dilatation
why
bc it decreases the abnormal ventricular remodeling with injury to heart muscle
why does this happen
because the sympathetic chains on the heart are blocked
where are the sympathetic receptors on the heart
at the SA and AV nodes as well as throughout the whole heart muscle
what do the sympathetic chains normally do (3)
increase force of contractions
increase HR
increase conduction velocity throughout the heart
where are the parasympathetic chains
only at the AV and SA nodes of heart
Side effects (12)
click to edit
Fatigue, weakness, drowsiness, impotence
Insomnia, depression, memory loss, nightmares
Bradycardia, hypotension, peripheral vasoconstriction
Bronchospasm
why can peripheral vasoconstiction occur
bc the body can attempt to compensate by constricting blood vessels in the periphery to maintain blood pressure
why can this occur
because the beta 2 receptors are blocked in the lungs, causing the vessels in the lungs to construct
does this make it harder ir easier to breath
harder, since the SNS usually dilates the vessels in the lungs so more airflow can occur
what is common with their medications name
usually all end in -ol
what are the 2 most common BB
Carteolol (cartrol)
metoprolol (toprol)
*Response to Activity
Normal
no change or minimal decrease
Abnormal
decrease with increasing activity (decrease of 4 percentage points)
what decrease is clinically significant
< 90%, is clinically significant
what is severly abnormal
SpO2 drops below 88%
*Response to activity
normal
should correspond to HR changes
abnormal
what will happen to RR if there is a drop in SpO2
resting rate of what may indicate a clinical instability
24
increases
what does this indicate
that O2 cannot get into the circulatory system quick enough
how will HR & RR respond
it will increase
What if SpO2 drops and HR does not change and RR does not change?
what do you do
put the pulse oximeter on another finger and retest
What if SpO2 drops and HR DOES increase and RR DOES increase?
what do you do
sit them down if not on supplemental O2; if on supplemental O2 titrate O2
why
body trying to get more O2