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Assessing the CV Patient, :!: when lying flat, blood travels up from the…
Assessing the CV Patient
1. What is Heart Failure?
pathophysiology
the heart thickens and cannot pump blood as good as it used to; this leads to a low body BP. to compensate, blood vessels will constrict and increase afterload, but this actually makes it even harder for the heart to pump blood through an even smaller tube now. kidneys are not getting enough blood, so they start to retain sodium and water to increase BP and and get some blood pumping down there; the lungs are also not getting enough blood, so they fill up with water and become congested
types
systolic dysfunction
diastolic dysfunction
definition of HF
complex clinical syndrome including dyspnea, congestion, fatigue; low cardiac output unable to meet the body's demands; impairs filling OR ejection of the right OR left heart ventricles
intrinsic vs extrinsic causes
6. Jugular Venous Pressure
interpretation: reflects RA pressure
causes of increased JVP
hypervolemia, right ventricle dysfunction, pericardial diseases, tricuspid valve disease, obstructed vena cava
technique: 30 degree angle, measure from sternal angle; normal should be < 4cm
JVP is assessed via the right internal jugular vein; it reflects pressure in the right atrium; reflects function of the
right heart
3. Functional Assessment
NYHA classification
class I-IV
class II: slight limitation, comfortable at rest
class III: marked limitation of physical activity; comfortable at rest reduced activity can cause sx
class I: no limitation to physical activity
class IV: severe limitation; sx present even at rest
specific activity Scale (METs)
examples of activities per class
class II: 5-6 METs; garden, gold, walks
class III: 2-4 METs; mopping, pushing a lawnmower, showering, walking a bit
class I: >7 METs; carries heavy stuff, shovels snow, skis, jogs
class IV: <2 METs; cannot perform any of the above
quantitative
measure of sx limitation
5. Assessing Edema
abdomen
ascites
,
hepatomegaly
, bloating, early satiety, gaining weight over short period of time despite not eating more
peripheral (legs)
pitting edema bilaterally, swelling, does not resolve overnight, shoes don't fit
lungs
evaluate pulmonary fxn to rule out other causes
sx of SOB, PND, orthopnea, cough, fluid in lungs, crackles or rhochi on auscultation
edema technique
press over malleolus/shins for more than 5 secs using thumb, rate severity (pitting vs non-pitting), inspect skin
2. Symptom Assessment
orthopnea
SOB when lying flat, relieved by upright position sitting/standing
key questions to ask
can you lie flat without SOB? how many pillows do you use? do you need to sleep sitting up?
paroxysmal nocturnal dyspnea (PND)
SOB
suddenly awakening
after 1-2 hours of sleep, resolves after sitting upright for 10+ mins
associated sx: coughing, wheezing, choking, gasping for air
dyspnea
evaluating severity (rest vs exertion)
establish a baseline of activities: are they SOB when dressing/bathing, or just when doing strenous work and walking uphill
tips for pt-centered language
"short of breath", "can't get enough air in", "running out of air", "puffing", "winded"
subjective sensation, not always linked with tachypnea/hyperventilation
fatigue
non-specific: often confused with SOB
decreased energy, increased naps, limited function
4. Fluid Assessment
hypervolemia vs hypovolemia table
hypervolemia
not lightheaded; high JVP; crackles, SOB, orthopnea, PND, S3, ascites, bloating; peripheral edema; low Na, high SCr, high BP, increased weight gain
hypovolemia
lightheadedness; drop in systolic BP by 20 or diastole by 10; increased HR, JVP is below SA; reduced urine output;
hypo/hyper Na, high SCr, weight LOSS
edema: mechanisms
high intravascular hydrostatic pressure
(in the context of heart failure)
edema present in lungs, abdomen, legs, sacrum, testicles
7. Cardiac Auscultation
heart sounds
S2: AV/PV closure (end systole)
S3: early diastole, volume overload (HFrEF)
"Ken-tuck-y"; ventricular gallop; fluid overload
S1: MV/TV closure (start systole)
S4: late diastole, stiff ventricle (HTN, HFpEF)
"tenn-es-see"; atrial gallop
:!: when lying flat, blood travels up from the legs to the heart, making the heart overwhelmed and over pressured; this also causes the lungs to get congested, which leads to orthopnea and PND