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![Page 1: Cardiac Examination Within the Role of the Cardiology Nurse Practitioner Victoria Williams Cardiology Nurse Practitioner University Hospital of Wales,](https://reader037.fdocuments.us/reader037/viewer/2022110100/56649e245503460f94b132e8/html5/thumbnails/1.jpg)
Cardiac Examination Within the Role of the Cardiology
Nurse Practitioner
Victoria WilliamsCardiology Nurse Practitioner
University Hospital of Wales, Cardiff.
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AIMS OF THE PRESENTATION
• To outline and demonstrate the importance of cardiac examination within the role of the nurse practitioner
• To instruct participants in the correct techniques for clinical examination.
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Learning Outcomes
• To competently perform cardiac clinical examination on a well patient.
• To revise the underlying anatomy and physiology relating to cardiac pathology.
• To have an awareness of clinical signs and symptoms to enable appropriate referral to specialist services.
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Background of the role.
• Established in 2010
• 4 members of staff
• All 4 practitioners are working towards Msc level qualification
• Co-ordination and management of nurse-led Acute Coronary Syndrome Unit
• Central point of contact from admission to discharge.
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University Hospital of Wales
• Tertiary Cardiology centre
• Contracted to provide tertiary services to District General Hospitals within south east Wales
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Advanced clinical skills
• All members of the team are at different stages of their Msc pathway
• all utilising advanced clinical skills as part of the role to enhance the service.
• Undertaking regular competency based training and assessment
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Cardiology patients suitable to be clerked by the Nurse Practitioner
• Non-complex Acute Coronary Syndrome (ACS) patients
• ACS patients with additional co-morbidities
• Elective angiography patients
• Elective Pacing patients
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Major Cardiovascular Presenting Complaints
• Chest Pain
• Dyspnoea
• Syncope
• Palpitations
• Peripheral oedema
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Importance of taking a comprehensive History
• Obtaining an accurate history is the critical first step in determining the aetiology of a patient’s problem
• A large percentage of the time you will actually be able to make a diagnosis based on the history alone.
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Complete cardiovascular history• Presenting complaint
• History of presenting complaint
• Past medical history
• Risk factors for Coronary Artery Disease
• Family history
• Drug history and allergies
• Social history
• Systems Review
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SOCRATES
• Site• Onset• Character• Radiation [usually just if pain]. • Alleviating factors• Time course• Exacerbating factors• Severity• Associated symptoms. • Impact of symptoms on life: "Does it
interrupt your life".
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Complete cardiovascular history• Presenting complaint
• History of presenting complaint
• Past medical history
• Risk factors for Coronary Artery Disease
• Family history
• Drug history and allergies
• Social history
• Systems Review
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MJ THREADS:
• MI• Jaundice• TB• HTN • Rheumatic fever• Epilepsy• Asthma• Diabetes• Stroke
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System Review
General• Weakness
• Fatigue
• Anorexia
• Change of weight
• Fever
• Lumps
• Night sweats
Cardiovascular• Pain
• Breathlessness
• Palpitations
• Syncope
• Ankle oedema
• Calf pain
• Orthopnea
• Intermittent claudication
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System Review continued
Respiratory • breathlessness
• Wheeze
• Cough
• Sputum
• Haemoptysis
• Tachypnea
• infection
Gastro-intestinal/urinary• Loss of appetite• Weight loss• Nausea/vomiting• Pain• Indigestion• Changes in bowel habit• Haematemesis• PR bleeding• Swallowing difficulties• Dysphagia • Incontinence• Frequency• Urgency• Haematurea
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System Review Continued
Neurological• Headaches• Dizzyness• Siezures• Collapse• Visual disturbances• Loss of balance• Muscle weakness
Musculoskeletal• Joint pains/stiffness• Recent injuries• Gait• swelling
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System Review Continued
Genital • Pain/discomfort• Unusual bleeding• Menstruation• Sexual health• Erectile dysfunction
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Clinical Examination
• Consent• Exposure• Position• Inspection• Palpation• Percussion• Auscultation
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Establish the Stabilityof the Patient
• Airway
• Breathing
• Circulation
• Disability
• Exposure
• Comfortable/distressed• Dyspnoeic/fatigued• Pale/cyanosed• Dehydrated/volume
depleted• Congested/
oedematous/ volume overloaded
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Inspection
Start with the hands:• Clubbing• Splinter haemorrhages• Palmer errythema • Muscle wasting• Janeway Lesion• Osler’s Nodes
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Clubbing
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Splinter Haemorrhages
Linear reddish brown lesions seen in nail bed. Prominent in this case of SBE
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Janeway Lesion
Macular, blanching, not painful located on palms & soles (SBE)
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Osler’s Nodes
Tender, papulopustules located on pulp of finger (SBE)
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Exam: Hands
• Other points to note:
• Temperature• Perfusion• Pallor• Nicotine staining• Extensor tendon swellings (xanthomas)
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PulseRate:• Normal sinus 60-100 bpm• Sinus bradycardia < 60 bpm• Sinus tachycardia > 100 bpmRhythm:• Sinus arrhythmia - varies with respiration• Intermittent irregularity – ectopic beats• Continuously irregular (irregularly irregular – atrial
fibrillation)
• Start by palpating the radial pulse
• At this site asses• Rate• Rhythm
• You should not asses volume at the radial artery
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Carotid Palpation
• Carotid upstroke:
– brisk, normal or delayed
– volume: normal, increased or decreased
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Exam: Head & Neck: FACE
• Jaundice
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Exam: Head & Neck: FACE
Anaemia
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Exam: Head & Neck: FACE
ARCUS XANTHELASMA
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Exam: Head & Neck: FACE
• Cyanosis
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Exam: Head & Neck: JVP
The JVP is best examined by
looking across the neck.
A double waveform should be seen for each cardiac cycle
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Exam: Head & Neck: JVP
• Carotid Pulsation
• 1 per cardiac cycle• Palpable• Position independent• Does not enhance with hepato-jugular reflex
• JVP Pulsation
• 2 per cardiac cycle• Not palpable• Varies depending on position• Enhances with hepato-jugular reflex
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Inspection of the chest
LookFor
ObviousDeformity
Pigeon Chest (pectus Carinitum)
Funnel Chest (Pectus excavatum)
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Inspection of the chest
Look for obvious Scars:
Median Sternotomy
CABG, Valve, TX
Lateral Thoracotomy
Coarct repair
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Palpation
Locate Apex Palpate for heaves and thrills
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Exam: Praecordium
2nd
3rd 4th 5th
Intercostal Spaces
1 2 3
1 Mid Clavicular Line
2 Anterior Axillary Line
3 Mid Axillary Line
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Auscultation
bell
Low pitched murmurs eg. Mitral StenosisPress hard enough only to make a seal with the skin
The ‘hole’ must be rotated to the bell in order for it to work
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Exam: Auscultation
Diaphragm
Normal / High pitched murmurs. Use for general purpose auscultation
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Exam: auscultation
1. Apex: Mitral Valve2. Sternal Edge:
Tricuspid Valve3. L 2nd Space:
Pulmonary Valve4. R 2nd Space: Aortic
Valve
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Exam: auscultation
• Heart SoundsLub (S1)
Dub (S2)
First Second
Mitral Valve
Tricuspid Valve
Aortic Valve
Pulmonary Valve
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Heart Murmurs: Systolic
Mitral Regurgitation
Tricuspid Regurgitation
First Second
Pan Systolic Murmur
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Heart Murmurs: Systolic
First Second
Ejection Systolic Murmur
Aortic
Stenosis
Pulmonary
Stenosis
VSD
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Heart Murmurs: Diastolic
First Second
Early Diastolic Murmur
Aortic Regurgitation
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Heart Murmurs: Diastolic
First Second
Mid Diastolic Murmur
MitralStenosis
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Auscultation
Mitral Murmurs
• Mitral Area
• Patient in Left Lateral
• Radiate to Axilla
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Auscultation
Aortic Murmurs
• Aortic Area
• Sit Patient Forward
• Breath Held in Expiration
• Radiates to Carotids
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• Any Questions?
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Thank you for your attention.