* Cardiac assessment
* Inspection
* Palpation of the apical pulse and PMI
at the 5th ICS LMCL
* Auscultation for the heart sounds
 S1 and S2
* Auscultation for the heart valves
 PV
 AV
 TV
 MV
* Inspection & Palpation
* Inspection of the anterior chest wall may
reveal the location of the apical impulse or
PMI
* Palpation is to confirm the characteristics
of the apical impulse
 Is also valuable for detecting thrills
and the timing of S1 & S2.
* Palpation
* First palpate for heaves, lifts or thrills
using your fingerpads. Hold them flat on
the body surface
* Check for thrills, formed by the turbulence
of underlying murmurs by pressing the
ball of your hand firmly on the chest.
* Palpation
* Firm pressure for an S1 & S2.
* When palpating for S1 & S2, place your
right hand on the chest wall & your left
index & middle fingers on the right
carotid artery in the lower third of the
neck.
 Identify S1 which occurs before the
carotid upstroke.
 S2 occurs after the carotid
upstroke.
* Palpation
* Assess the right ventricle by palpating the
right ventricle area at the lower left sternal
border & in the subxiphoid area,
pulmonary artery in the left 2nd ICS & the
aortic area in the right 2nd ICS
* PMI
* The apex beat is palpable in only 25% to
40% of healthy adults in the supine
position and in 50% of healthy adults in
the left lateral decubitus position,
especially those who are thin.
* PMI
* Once you have found the apical impulse,
make finer assessments with your
fingertips, and then with one finger.
* PMI
* LOCATION
 Supine
 Pregnancy or a high left diaphragm
may displace the apical impulse
upward and to the left.
 Lateral displacement from cardiac
enlargement in congestive heart
failure, cardiomyopathy, ischemic
heart disease
* Percussion
* Starting well to the left on the chest,
percuss from resonance toward cardiac
dullness in the 3rd, 4th, & 5th ICS.
* The right border of the heart is usually
aligned with the sternum & can’t be
percussed.
* Auscultation
* Best to identify heart sounds
* Best to use locations such as “Base of the
heart”, Apex or parasternal border to
describe your findings.
* Inching your stethoscope
 Starting at the apex & inching to
the base: move the stet from the
PMI medially to the left sternal
border, superiorly to the 2nd ICS
then across the sternum to the 2nd at
the right sternal border
* Auscultation
* Inching your stethoscope
 Alternatively, you can start at the
base & inch your stet to the apex:
with your stet in the right 2nd ICS
close to the sternum, move along
the left sternal border in each
interspace from the 2nd through the
5th & then to the apex
* Know your stet!
* The Diaphragm
 Picks up high pitched sounds such
as S1 & S2
* The Bell
 More sensitive to the low-pitched
sounds of S3 & S4.
* Cardiac disorders

* Coronary artery disease
* CAD
 results from the focal narrowing of
the large and medium-sized
coronary arteries due to deposition
of atheromatous plaque in the
vessel wall.
* Lipid risk factor
 Hypercholesterolemia
* Nonlipid risk factors
 Family History
 Postmenopausal state
 Gender: Male
 Age = M:45; W: 55
* Behavioral factors
 Sedentary Lifestyle/Stress
* Behavioral factors
* Sedentary lifestyle
 A type of lifestyle where an
individual does not receive regular
amounts of physical activity
* CDC recommendations:
 Minimum of 150mins of moderate
exercise
 75 minutes of more vigorous
exercise
 Walking 10,000 steps a day
(approx 5 miles)
* Article posted by John Hopkins Medicine,
Physical Inactivity contributes to the
following health conditions:
 Physical inactivity may increase
the risk of certain cancers
 Physical inactivity may contribute
to anxiety & depression
 Physical inactivity has been shown
to a risk factor for certain
CARDIOVASCULAR DISEASES
* Article posted by John Hopkins Medicine,
Physical Inactivity contributes to the
following health conditions:
 People who engage in more
physical activity are less like to
develop CORONARY HEART
DISEASE
 People who are more active are
less likely to be overweight or
obese
 Sitting too much may cause a
decrease in skeletal muscle mass
 Physical inactivity is linked to
HIGH BLOOD PRESSURE &
ELEVATED CHOLESTEROL
LEVELS
* Lipid risk factor
 Hypercholesterolemia
* Nonlipid risk factors
 Family History
 Postmenopausal state
 Gender: Male
 Age = M:45; W: 55
* Behavioral factors
 Sedentary Lifestyle/Stress
 Cigarette smoking
 Hypertension
 Obesity
 Diabetes Mellitus
* Pathophysiology of Atherosclerosis
* Stable angina
 Predictable consistent pain that
occurs in & relieved by REST
 Squeezing, burning, tightening
chest pain that radiates to neck,
jaw, arms, shoulders, throat &
back
 Last for 1-5 minutes
* Common sites
* Abdl. aorta & iliac arteries
* Proximal coronary arteries
* Thoracic aorta, femoral & popliteal
arteries
* Internal carotid arteries
* Vertebral, basilar & MCA
* Signs & Symptoms
* Substernal or precordial pain radiating to
the left shoulder
* Pressure, heaviness, tightness, squeezing
* Management
* REST
* Oxygen
* Semi-fowlers
* Drugs  Administer no more than 3 Nitro tablets, 5
 Antiplatelet mins. apart.
 Nitrates  Others: beta-blockers & Ca channel
 Rapid acting: NTG blockers
(nitrostat, amyl nitrate)
 Long acting: ISORDIL per
orem; stat > SL * Treatment (AMI)
 Transderm nitro  If no respirations and heartbeat -
perform CPR
* Management  Oxygen (2-4L) and proper positioning
* REST (semi-Fowler’s)
* Oxygen  vital signs + EKG strip
* Semi-fowlers  pain medications
* Drugs  Other meds: thrombolytics, nitrates, beta-
 BAB (Propanolol) blockers, Ca channel blockers, ASA
 CCB (VND)  Obtain cardiac enzymes
 Others  Provide a quiet, restful environment.
 Antithyroid hormones
* Health Education
* Low fat diet to curtail obesity
* 5 – 6 small meals instead of 3 main meals * Angina vs. AMI
* Stop smoking! Medical interventions:
* Stress>Nore>Vasoc • PTCA
* Regular exercise • CABG
* Myocardial infarction • Intra-Aortic balloon pump
* Intra-Aortic Balloon Pump
* Angina vs. AMI  Increases coronary blood flow
* Angina  Decreases myocardial oxygen demand
 Chest discomfort caused by inadequate  by reducing the after load
blood supply to myocardium
 Mild to severe intensity * Initial Dx Exams
 Relieved by rest CXR: cardiomegaly; pulmonary congestion
 Relieved by nitroglycerine CBC: dilutional hyponatremia, hyperkalemia
 Typically short duration ECG: ventricular hypertrophy
 Radiates shoulders & down arms 2 D echo: ejection fraction
* AMI
 Caused by sudden interruption of coronary * Nursing Actions
blood flow * Monitor signs of respi distress
 Severe substernal pain  administer O2
 Pain not relieved by rest  HOB elevated
 Pain relieve by MSO4  Monitor ABG
 May persist for hours * Monitor signs of altered CO
 Radiates to shoulders & down arms  Pulmonary edema
 Triad’s  Arrhytmias (tachy&brady)
 ECG
* Angina vs. AMI  Heart sounds
* Treatment (Angina)  Monitoring CVP & PCWP if
 Provide immediate rest indicated
 2-4 liters of oxygen * Evaluate Fluid Status
 Take VS  Strict MIO
 Record an EKG (Twave inversion)  Daily weights
  Assess for edema & severe
diaphoresis
 Monitor Electrolytes & Hematocrit
 Strict fluid restrictions
* Meds as prescribed:
 Antiarrhytmics
 Diuretics
 Inotropics
 Iron & FA to improve nutritional
status
 Potassium supplements to prevent
digitalis toxicity
* Reduce cardiac demands
 Schedule nursing interventions to
allow adequate rest
 Provide quiet & restful
environment
* Promote adequate nutrition
* Maintain high calorie diet, low sodium
* Refer family to a community health nurse
for following care after discharge