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 𝛽 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 – (0.67 X age); updated formula
220 – age; old formula


Target HR

Typically between 60% - 80% of HRmax

Calculation

Karvonen method: Target Heart Rate = [(max HR − resting HR) × %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

SCI—consider 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 90—100 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)—Tachycardia, Tachypnea

(60mm Hg) Tachycardia, Tachypnea, Malaise, Restleness, Impaired judgment, decline in coordination, vertigo, nausea

(40-50mmHg)—Above sx’s, 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 doesn’t 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 ❌

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)

  1. Patient seated or supine (record position of pt)
  1. Press thumb firmly into the patient’s skin and hold 5 seconds
  1. Remove pressure and determine depth of the indentation
  1. 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)

  1. pt in supine
  1. Take BP in UE; record SBP c stethoscope or doppler
  1. Cuff around leg above malleoli; same side as UE
  1. locate post. tib or dorsal pedis a.
  1. 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

0.8—0.9

Minimal to moderate arterial insufficiency

0.6—0.8

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 – 5 min of positional change:↓SBP ≥ 20 mmHG, ↓ DBP ≥ 10 mmHG

Definition

postural hypotension; rapid drop of systolic BP when changing positions

why does this happen ❌

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