the cardiovascular system university of teesside nurse practitioner course dr. phil jennings. james...
TRANSCRIPT
THE
CARDIOVASCULAR
SYSTEM
University of TEESSIDE
Nurse Practitioner Course
Dr. Phil Jennings. James Cook University Hospital
Introduction
• History Taking– Features of common symptoms– Presentation of common problems
• Examination Routine– What do to– Important physical signs
• Investigations – A quick look at X rays and ECGs
Symptoms: Chest Pain
• Important points to establish– Site– Radiation– Character– Exacerbating and
Relieving factors– Duration– Associated
symptoms
Symptoms: Chest Pain
CARDIAC
Angina
Myocardial Infarct
Pericarditis
Aortic dissection
PULMONARY
Pleurisy
Pulmonary Embolus
Pneumothorax GASTRO
Ulcer or Reflux
Gallstones
Pancreatitis
MUSCULOSKELETAL
Chostochondritis
Trauma
NON ORGANIC
Anxiety
Chest Pain: Angina
Angina pains are typically central crushing chest pains.
Patients describe angina as feeling like a heavy weight in the middle of the chest
Angina can present in unusual positions
Chest Pain: Angina
Angina pains commonly radiate to the arms, neck and jaw
Typically angina lasts for several minutes
Chest Pain: Angina
Angina pains normally occur during periods of physical exertion. This is the single most important factor to consider when deciding if a patient has angina or not
The term ‘unstable angina’ is used to describe pains which occur at rest and signifies severe coronary disease
Chest Pain: MI
• Features suggesting MI– The pains are usually more severe– There are more associated symptoms
such as sweating, nausea or vomiting– Duration is > 30 minutes– Usual relieving factors such as rest or
GTN spray do not help
Chest Pain: Pericarditis
• Pericarditis– Similar distribution to angina / MI– Often sharper or stabbing– Helped by sitting forward– Typically has a long duration– Often seen in otherwise well, young patients
without coronary disease– May be a history of a viral illness of fever
Chest Pain: Dissection
• Features of Dissection
– Pains are described as tearing and can be excruciating
– Often radiates through to the back
Symptoms: Palpitations
Important points to establish
Onset
Rate
Rhythm
Duration
Termination
Associated symptoms
Symptoms: Palpitations
Supraventricular
Atrial Fibrillation
Atrial Flutter
Atrial Tachycardia
Reentrant TachycardiaVentricular
Ventricular Ectopics
Ventricular Tachycardia
Symptoms: Palpitations
• Features of Atrial Fibrillation– Common. Especially elderly or IHD– Pulse is irregularly irregular in other words
unpredictable from one beat to the next– Can be an incidental finding or presents
with palpitations, fatigue, chest pain or breathlessness
– The mainstay of treatment is rate control and anticoagulation
– Electrical cardioversion may be used in some patients
Symptoms: Breathlessness
• Breathlessness or dyspnoea can have a number of causes– Heart Failure– Valve disease– Myocardial Ischaemia– Pericardial disease
There are also non cardiac causes of dyspnoea
- Pulmonary disease
- Anaemia, Obesity or being unfit
Symptoms: Breathlessness
• Important points to establish– Occurrence of symptoms:
• All the time• Woken from sleep• During exertion
– Assess normal exercise tolerance– Associated symptoms
• Chest pain, palpitations• Cough, wheeze, sputum,
haemoptysis• Ankle oedema
Symptoms: The End
Any Questions So Far ???
Examination
• Suggested CVS Exam routine– General Inspection– Hands– Pulse– BP– Head & Neck
• JVP, Carotids, Anaeimia, Cyanosis
– Praecordium– Auscultation– Extras
Examination
What is the most important start to any exam ??
Introduce yourself to the patient and let them know what you are about to do …
Exam: General Inspection
• If the patient is not exposed then ask if you may expose them
• The patient should be reclined at a 45º angle• Look for obvious
– Breathlessness– Pallor– Sweating– Scars– Props: Oxygen pipes, Inhalers, GTN spray
• Make some comments
Exam: Hands
• Start with the nails and look for clubbing
– Increased Curvature
– Loss of nail bed angle
– Fluctuant nail Beds
• Examine BOTH hands at eye level
Exam: Hands
• Cardiovascular causes of clubbing can be
– Congenital Cyanotic Heart Disease
– Atrial Myxoma– Endocarditis
Exam: Hands
• Next look for Splinter Haemorrhages
– A sign of systemic vasculitis which may indicate Infective Endocarditis.
– They can also be caused by trauma so remember to bear in mind the patient’s occupation
Exam: Hands
• Other points to note– Temperature– Perfusion– Pallor– Nicotine staining– Extensor tendon swellings
(xanthomas)
Exam: Pulse
• Start by palpating the radial pulse
• At this site asses– Rate– Rhythm
• You should not asses volume at the radial artery
Exam: Pulse
• Next move to the brachial artery to assess
– Volume– Character
Exam: Blood Pressure
• You may now want to measure the blood pressure
• A single measurement is acceptable unless the history suggests dissection
Exam: Head & Neck: FACE
Jaundice
Exam: Head & Neck: FACE
Anaemia
Exam: Head & Neck: FACE
Xanthelasma Arcus
Exam: Head & Neck: FACE
Cyanosis
Exam: Head & Neck: JVP
The JVP is best examined by looking across the neck.
A double waveform should be seen for each cardiac cycle
Exam: Head & Neck: JVP
Sternal Angle
Sternal Angle
Top of venous pulsation
Top of venous pulsation
Height
Of
JVP
In
cms
Exam: Head & Neck: JVP
• Carotid Pulsation– 1 per cardiac
cycle– Palpable– Position
independent– Does not enhance
with hepatojugualr– reflex
• JVP Pulsation– 2 per cardiac
cycle– Not palpable– Varies depending
on position– Enhances with
hepatojugular reflex
Exam: Praecordium
Look
For
Obvious
Deformity
Pigeon Chest Funnel Chest
Exam: Praecordium
Look
For
Obvious
Scars
Median Sternotomy
CABG, Valve, Tx
Lateral Thoracotomy
Coarct Repair
Exam: Praecordium
Locate Apex Examine for heave
Exam: Praecordium
1 2 3
1. Mid Clavicular Line
2. Anterior Axillary Line
3. Mid Axillary Line
2nd
3rd 4th 5th
Intercostal Spaces
Exam: Auscultation
Bell
Low pitched murmurs eg. Mitral Stenosis
Press hard enough only to make a seal with the skin
The ‘hole’ must be rotated to the bell in order for it to work
Exam: Auscultation
DiaphragmNormal / High pitched murmurs.
Use for general purpose auscultation
Exam: Auscultation
Earpiece
Angled to provide a better fit into the auditory cannal.
During use point forward unless you have an abnormal shaped head !
Exam: auscultation
1. Apex: Mitral Valve
2. Sternal Edge: Tricuspid Valve
3. L 2nd Space: Pulmonary Valve
4. R 2nd Space: Aortic Valve
BELL
&
DIAPHRAGM
Exam: auscultation
Heart Sounds:
Lub
Dub
First Second
Mitral Valve
Tricuspid Valve
Aortic Valve
Pulmonary Valve
Exam: auscultation
Heart Murmurs: Systolic
First Second
Pan Systolic Murmur
Mitral Regurgitation
Tricuspid Regurgitation
Exam: auscultation
Heart Murmurs: Systolic
First Second
Ejection Systolic Murmur
Aortic
StenosisPulmonary
Stenosis
VSD
Exam: auscultation
Heart Murmurs: Diastolic
First Second
Early Diastolic Murmur
Aortic Regurgitation
Exam: auscultation
Heart Murmurs: Diastolic
First Second
Mid Diastolic Murmur
Mitral
Stenosis
Exam: auscultation
Heart Murmurs: Extras
Mitral MurmursMitral Area
Patient in Left Lateral
Radiate to Axilla
Exam: auscultation
Heart Murmurs: Extras
Aortic MurmursAortic Area
Sit Patient Forward
Breath Held in Expiration
Radiates to Carotids
Exam: Extras
• Is there anything else you wish to do ?– Examine the peripheral pulses– Check for radio – radial or radio – femoral
delay– Listen at the lung bases– Check for sacral oedema– Check for peripheral oedema– Measure the BP if not already done
Investigations: CXRName Marker
Projection
Investigations: CXR
Cardiac
Silhouette
Lung
Fields
Investigations: CXR
Right
Hemidiaphragm
Left
Hemidiaphragm
Trachea
Right
HilumLeft
Ventricle
Left Atrial Appendage
Aortic
Knuckle
Investigations: CXR
Cardiac Thoracic
Normal Cardio – Thoracic Ratio (CTR) is up to 0.5
Investigations: ECG
Investigations: ECG
Calculating the Heart Rate
Divide 300 by the number of large squares inbetween R waves
300 / 2 = 150 bpm
300 / 6 = 60 bpm
Investigations: ECG
Rhythm
In sinus Rhythm
1 P wave for each QRS complex
Rate lies between 60 – 100 beats per minute
Investigations: ECGNormal ECG
Thankyou for your attention