Page 241 - Cardiac Nursing

009
1
1
009
0/0
6/2
6/2
M
M
Pa
6 A
0:4
0:4
6 A
0/0
1-2
44.
44.
p
1-2
21
21
xd
3
3
xd
q
q
q
Pa
ara
ara
t
p
t
10_
LWB
LWB K34 0-c 10_ p pp211-244.qxd 30/06/2009 10:46 AM Page 217 Aptara
LWBK340-c10_
0-c
K34
g
g
g
e 2
e 2
17
p
A
p
A
17
C HAPTER 1 0 / History Taking and Physical Examination 217
2
(Chapter 1) is essential. A cardiac physical assessment should as a BMI of 30 kg/m or more; overweight is a BMI of 25 kg/m 2
include an evaluation of: or more. 13
Larger BMI and abdominal fat distribution are associated with
■ The heart as a pump—reduced pulse pressure, cardiac enlarge-
increased cardiovascular risk. 14 In overweight people, waist cir-
ment, and presence of murmurs and gallop rhythms
cumference of 102 cm (40 inches) in men or 88 cm (35 inches)
■ Filling volumes and pressures—the degree of jugular venous
in women indicates increased risk of cardiovascular disease, Type
pressure and the presence or absence of crackles, peripheral
II diabetes mellitus, and metabolic syndrome (Chapter 39).
edema, and postural changes in blood pressure
■ Cardiac output—heart rate, blood pressure, pulse pressure, sys-
Head
temic vascular resistance, urine output, and central nervous sys-
tem manifestations The examination of the head includes assessment of facial charac-
■ Compensatory mechanisms—increased filling volumes, periph-
teristics, color, temperature, and eyes. Advanced practice nurses
eral vasoconstriction, and elevated heart rate may examine the fundi and retinal vasculature.
The order and techniques of examination proceed logically. Facial Characteristics
The precise order may vary with the setting and the condition of Examination of the facial characteristics may aid in the recognition
the patient. With practice, the focused cardiovascular examination of disorders affecting the cardiovascular system. Coronary heart
6
can be done in approximately 10 minutes:
disease is suggested by the presence of an earlobe crease in a person
■ General appearance younger than 45 years of age. Rheumatic heart disease with severe
■ Head mitral stenosis is associated with a malar flush, cyanotic lips, and
■ Arterial pulse slight jaundice from hepatic congestion. With severe aortic regur-
■ Jugular venous pressure gitation, head bobbing with each heartbeat (de Musset’s sign) may
■ Blood pressure be present. Infective endocarditis is associated with a “café au lait”
■ Peripheral vasculature complexion. Constrictive pericarditis and tricuspid valve disease tend
■ Heart to cause facial edema. Pheochromocytoma is associated with episodic
■ Lungs facial flushing, as well as severe hypertension and tachyarrhythmia.
■ Abdomen Systemic conditions may affect or reflect cardiovascular func-
6
tion or treatment. Systemic lupus erythematosus may present with
General Appearance a butterfly rash on the face and may suggest inflammatory heart
disease. Myxedema is characterized by dry, sparse hair; loss of lat-
Observe the general appearance of the patient while the history is be- eral eyebrows; a dull, expressionless face; and periorbital puffiness.
6
ing obtained. The patient’s appearance and responses provide cues to Because a myocardial effect of hypothyroidism is reduced cardiac
the cardiovascular status. Note general build, skin color, presence of output, heart failure may develop in these patients. Cushing’s syn-
shortness of breath, and distention of neck veins. Assess the patient’s drome is characterized by moon facies, hirsutism, acne, and cen-
level of distress. If he or she is in pain, the patient’s response to it may tripetal obesity with thin extremities. High blood pressure fre-
assist in the differential diagnosis. For example, moving about is a quently occurs with Cushing’s syndrome.
characteristic response to the pain of myocardial infarction, whereas
sitting quietly is more characteristic of angina, and leaning forward is Color
12
more characteristic of pericarditis. Some abnormalities of the arte- Cyanosis is the bluish discoloration seen through the skin and mu-
rial pulses may be observed unobtrusively. For example, patients with cous membranes when the concentration of reduced hemoglobin
severe aortic insufficiency may have bounding pulses that cause the exceeds 5 g/100 mL of blood. Peripheral cyanosis implies reduced
head to bob. Note appropriateness of weight; malnutrition and blood flow to the periphery. Because more time is available for the
6
cachexia are associated with chronic, severe heart failure. Skeletal tissues to extract oxygen from the hemoglobin molecule, the arte-
manifestations of Marfan’s syndrome, tall stature, and arachnodactyly, riovenous oxygen difference widens. Cyanosis of the nose, lips, and
may be observed. Level of consciousness should be described. Appro- earlobes is considered peripheral. Peripheral cyanosis may occur
priateness of thought content, reflecting the adequacy of cerebral per- physiologically with the vasoconstriction associated with anxiety or
fusion, is particularly important to evaluate. Family members who are a cold environment, or pathologically in conditions that reduce
most familiar with the patient can be of help in alerting the examiner blood flow to the periphery, such as cardiogenic shock.
to subtle behavior changes. The nurse also should be aware of the pa- Central cyanosis, as observed in the buccal mucosa, implies seri-
tient’s anxiety level, not only to attempt to put the patient more at ous heart or lung disease and is accompanied by peripheral cyanosis.
ease, but to realize its effects on the cardiovascular system. In severe heart disease, a right-to-left shunt exists in which blood
passes through the lungs without being fully oxygenated, as hap-
Height, Weight, and Waist Circumference pens in severe heart failure with interstitial pulmonary edema. In
Height and weight are best measured using a standing platform severe lung disease, changes produced by chronic obstructive airway
scale with a height attachment. Weak, immobile, or critically ill disease or fibrosis impede oxygenation. Pallor can denote anemia
patients may require a bed or chair scale for weighing, and it may (with concomitant decreased oxygen-carrying capacity) or an in-
be necessary to rely on the patient’s self-reported height. Weight is creased systemic vascular resistance. Jaundice can be associated with
an indicator of nutritional and fluid status; excessive weight indi- hepatic engorgement from right ventricular failure.
cates increased cardiovascular risk.
Body mass index (BMI) describes relative weight for height. Temperature
BMI is calculated as weight in kilograms (kg) divided by the Temperature reflects the balance of heat production and dissipa-
2
square of the height in meters (m ). In adults, obesity is defined tion in the body. Normal oral temperature is considered to be