Cardiopulmonary Final Review

Cardiac Exam
Symptom descriptors angina, SoB, night dyspnea, orthopnea, link to exertion, palpitation, syncope/dizzy,
sweating
Dyspnea scale 1+ PT cant notice, 2+ PT notices, 3+ moderate but pt continues, 4+ pt cant
continue
Angina scale 1+ not noticeable, 2+ bothersome, 3+ very uncomfortable, 4+ worst pain ever
Observation
Posture, thoracic deformity, accessory muscles
Affect
Skin color, clubbing, edema, incisions, JVD
RR, breathing pattern, cough
Gait speed, rest requirements
Palpation
Pulses (0 absent, 1+ weak, 2+ norm, 3+ increased, 4+ bounding) & PMI
Skin temp & diaphoresis
Pitting edema grading 1+ barely, 2+ rebound <15sec, 3+ rebound 15-30sec, 4+ rebound >30sec
Sternal points (sternal, aortic, pulmonic, Rvent, Lvent, epigastric)
Vitals temp, HR (60-100 norm), RR(~12-16 norm), BP(< 120/80 norm, 140-159/90-99 HTN I), pain
Auscultation
Heart sounds
Aortic R 2nd space Pulmonary L 2nd space
Tricuspid L 4th space Mitral at PMI point
S4 (late diastole, HTN / cardiomyopathy), S 1 (lub, AV valve close at start of systole), S2 (dub,
semilunar valve close at end of systole), S 3 (early diastole, vent fail / tachy, MR)
Adventitious murmur, click, snap
Differentiate CP and associated symptoms
Cardiac symptoms Central cyanosis, night dyspnea, palpitation, UE / jaw pain, unusual sweating, syncope
Pulmonary symptoms Peripheral cyanosis, stridor, wheezing, activity limitation
Worse: deep breath, trunk / pleural stretch
Better: quadruped, lean forward, hold breath
Bi-system symptoms dyspnea/orthopnea, cough, chest pain,
peripheral edema
Anginas
Chronic, stable known onset / level of demand nitroglycerin
Stable set level of activity nitroglycerin, rest, no stress
Unstable at rest or differ from prior onset nitroglycerin
Prinzmetal early morning, no exertion link, 2o vasospasm
MI last 30+min, not relieved by nitroglycerin, sense of doom
GI pain worse after eating, supine, acid-food
Acute Lecture
Pulmonary artery cathether / Swan Ganz
Internal jugular subclavian R atrium
Pulm A pressure, wedge pressure (LVEDvol), LVEDP
** if LVEDP >12 no supine, move & percuss carefully
R heart catheter (Swan Ganz is 1 type)
Continuous venous O2 sat monitor (normal = 60-80%, but arterial normal = 95-98%)
Arterial line
Radial artery or femoral artery
Systemic BP
** DONT disconnect!!!, no hip >60o if femoral, infection, check manually if weird reading
Central venous line
Subclavian vein, internal jugular vein or femoral vein

Cardiopulmonary Final Review

R atrial pressure
** Move carefully
Intravenous line
Superficial vein
Immediate blood input of fluids, electrolytes, medication, nutrition
** Must be changed every 3-4days
Percutaneous intra-cardiac catheter (PICC)
Forearm vein R atrium
Prevent multi-sticking
** no submersion, watch for bleeds, phlebitis, infection, blocking, clotting, arrhythmia
Intra-aortic balloon pump (IABP)
Femoral artery descending aorta (just below subclavian)
Inflate / deflate timed to cardiac cycle perfusion
** usually not PT Tx, no hip , check radial pulses
Extra-corporeal membrane oxygenation (ECMO)
**bleeding, clotting, infection
ABG measures
pO2 (87.5) / pCO2 (40) / HCO3- (24) / pH (7.4) / SaO2 (97)
I & O affecters fluid retention, oral/IV intake fluid shift, sweat, wound drain, diarrhea/vomit,
hemorrhage, urine
Pacemakers
Placement coding
1st letter chamber placed in (O none, A atrium, V ventricle, D dual)
2nd letter chamber sensed (O none, A atrium, V ventricle, D dual)
3rd letter pacemaker response to sensed activity (O none, I inhibit, T trigger, D dual)
4th & 5th letters - programmability
Demand pacemaker kicks in when HR too low can HR when SA no cant (chronotropic incompetence)
Pacemaker precautions
Re-eval every 3-6mo check function, batter lasts 5-8yr
Avoid full contact sport
Avoid electromagnetic interference cell phone, MRI, TENS, therapeutic radiation, subway brakes
**Airport carry ID cardOK to go through security, but dont stand in scanner long
Pacemaker indications
Usually for brady, sinus node dysfunction (sinus arrest, SSS, chronotropic incompetence), block,
CHF
SSS sinus brady, tachy, or alternating
Pacemaker for brady, meds/ablation for tachy
1st Degree block Good Pwave, 1P:1QRS, consistent long PRinterval
2nd Degree block I PRinterval until QRS dropped
2nd Degree block II 2+P:1QRS, regular PRinterval when QRS does happen
3rd Degree block atrial rate & ventricular rate independent
Linked signs/Sx syncope, dizzy, energy, fatigue, exercise intolerance, SoB, palpitation, confusion
Know the medication chart
Exercise Tests and VO2
Ventilation pathologies COPD, pneumonia, asthma, CF, ARDS, neuromuscular Dz, restrictive Dz
Heart pathologies CAD, CHF, dysrhythmia, mycarditis, cardiomyopathy
Vascular pathologies PVD, DVT, DMII
Muscle / endurance pathologies immobilization, CHF, MD, nutritional Dz, myositis, DMII
VO2 factors age, gender ( 15-30% less), heredity, body composition, endurance training, O 2 transport Dz
NO exercise testing
Significant EKG change
Acute PE / infarct

Cardiopulmonary Final Review

Unstable angina
Acute myocarditis / pericarditis
Uncontrolled dysrhythmia
Dissecting aneurysm
Symptomatic severe AS
Systemic infection
Uncontrolled CHF
Careful exercise testing
L main artery disease
Atrioventricular block
Moderate valve stenosis
Ventricular aneurysm
Abnormal electrolytes
Uncontrolled metabolic disease
Severe HTN at rest (>200/110)
Chronic infections
Tachy or brady
Mental / physical impairments
Dz exacerbated by exercise
Walking tests
3m or 10m walk test community ambulation requires 0.5-1.22m/sec
6min (or 12min or 2min) walk test self-pacednot very great motivationally
10m walk shuttle or 20m run shuttle externally pacedmore motivational
1mi walk test
Step tests external pacing (metronome)
Stop testing a healthy adult if
Angina
Failure of normal HR
systolic BP by 10+mmHg
Rhythm change
Excessive BP (>250/115)
Complaint of fatigue
SoB, wheezing, cramps, claudication
Equipment failure
Cyanosis