General inspection:
- Perform an end of bed assessment
- Colour
-Oedma- legs & sacrum- less mobile pts - JVP- assessing right side of the heart
- Resp rate
- Posture
What does JACCOL stand for?
Jaundice
Anaemia
Clubbing
Cyanosis
Oedema
Lymphoednopathy
Inspection of face
- Cyanosis
- Anaemia- check under eyelids in POC
- Xanthelsama- cholesterol deposits in the eye
- Corneal arcus- greyness around pupils- build up of cholesterol
Hands
- Cap refill- <2secs
- Janeway lesions- non painful lesions on hand and feet
- Splinter haemorrhages- ineffective endocarditis
- Clubbing- indication of lack of 02 (COPD,HF)
- Osler nodes- painful
-Nicotine staining - Palmer erythema- redness of palms
- Think infection, Think ENDOCARDITIS!
Oedema
- Is there pitting?
- If it takes longer than 2mins to return to normal, it’s a 4+
- Fluid accumulation
- May be a sign of HF or lymph drainage issue- chemotherapy
Inspect the chest
Pt may present with;
- dizziness, headache which is worse when they lean over
-breathlessness,
-torched vessels on the pts chest that look like snakes
-head, neck & arms appear swollen with a reddish complexion
* This condition is superior vena cava obstruction, pt is not getting proper drainage of blood into the heart from above the chest line.
* Common in lung cancer pts
* Pt needs to go in to get that obstruction removed
JVP
- Looking at the function of the right atrium
- Measure of central venous pressure
- Get pt to lay semi recumbent (45 degrees) and turn their face to the left.
- Look from the sternal angle upwards and see how high it goes.
- JVP should be <4cm
- Raised JVP may be late sign of pneumothorax, HF, MI, pericarditis
PALPATION
- Temperature
- Pulses-is it the same on both sides? Rate, rhythm, depth
- Heaves
- Thrills
- Apical beat
Pulses
- Pts with type 2 heart block would have an irregularly irregular pulse
- A collapsing heart beat indicates an issue with the aorta- aortic regurgitation * perform this by feeling pts pulse then rapidly raising their arm above heart level. * Assess in pt who have syncope
Heaves & Thrills
Thrill: If you feel a murmur but it doesn’t mov your hand. (Palpable murmur)- Feel with hand at the point just before the fingers.
Heaves: If your hand actually lifts whilst feeling the murmur, it’s know as a heave. - Feel with palm of hand. Commonly seen in pts with rheumatic fever, endocarditis
Apex beat
- Get pt to lean forward
- Tests for ventricular hypertrophy- looking for displacement
- 5th intercostal space, mid claviclular
- Athletes who have retired who don’t maintain the level of exercise they used to do get muscle wasting.
Auscultation
- Check heart sounds on syncope pts- think aortic stenosis
- Dizziness particularly on exertion
- orthostatic hypertension
- Check on people with connective tissue disease
Bruits
- Sound of blood flowing through a narrowed position in an artery.
- Whosshing sound
- Disordered blood flow
- Pts may have this with a AAA as well as a tearing pain & pulsating mass
- Sites for auscultation: Aorta, Renal, Femoral & Iliac arteries
- Common site for an aneurysm is the arch of the aorta as this is where the blood is expelled form the heart and is getting hit at great force
Left sided HF
Common S&S:
- Confusion, tacahycardia, fatigue, cyanosis, orthopnea, cough, crackles, wheeze, bloody mucus, tachypnea
- Basal (lower lobe) crackles
- Pursed lips as they are trying to increase pressure to get air in
- Peripheral oedema as there is so much fluid backed up and the right side is decompensating
- confusion to hypoxia
- wheeze as the oedema has irritated the airway, causing bronchospams
* Be cautious with salbutamol as it causes tachycardia and these pt are already compensating too much
* Furosemide- loop diuretic, fluid shift , however fast acting. So explain, that urination is an issue with this drug.
Heart valves:
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1. Aortic- Prevents blood returning to LV during V relaxation
2. Pulmonary- During ventricular relaxation, it prevents blood returning to RV
3. Tricuspid- between RA & RV, Prevents blood from returning to the RA during V contraction
4. Mitral (Bicuspid)- During V contraction, it prevents blood from returning to the LA.
Heart sounds
- LubDub
S1- Lub (valve opening)
S2- Dub (valve closing)
S3- not pathological, heard immediately after S2
S4- Always pathological, just before lub sound - Systolic murmur is when ventricle is contracting
- Diastolic murmur is when ventricle is relaxing
Volume doesn’t correlate to how pathological the murmur is.
- A lag may indicate an aneurysm
Grades of murmur intensity
- Grade 1:heard by experts
- Grade 2: Heard by non expert in quiet environments
- Grade 3: Easily heard, no thrill
- Grade 4: A loud murmur, with a thrill (palpable murmur)
- Grade 5: Very loud, often heard over a large area with a thrill
- Grade 6: Extremely loud, heard without stethoscope
What is aortic dissection and what are some common causes of it?
- This is where a tear develops in the innermost layer of the aorta, the tunica intima and the high pressured blood flowing through the aorta now goes through this false lumen.
- Causes: Rheumatic fever, ineffective endocarditis, aortic stenosis, degenerative aortic valve disease, trauma, Marfans syndrome, aortic dilation, hypertension & post surgical.
Ineffective endocarditis
- It’s an infection that occurs to the inner layer of the heart and vegetation starts to form impeding valvular function, always bacterial
- Mitral valve is affected in pts who got this from dental work or post surgical.
- People at greater risk are IV drug users, the tricuspid valve is most likely to be affected in these cases.
- Pt likely to present as pyrexia with systemic signs of infection, Osler nodes, chest pain, malaise, janeway lesions, splinter haemorrhages, heart murmur (mitral).
Peripheral artery disease
Assess the 5P’S: Pulse, Paralysis, Parathesia, Pain, Pallor
- Shiny skin- due to a perfusion issue
- Healing is impaired as WBC are reduced
- Pale, bluish skin colour
- May be uni/bilateral
- Weak/absent pulse in legs/feet
Raynauds syndrome
- Type of peripheral artery disease
- Caused by vasospams, causing pallor & paratheisa or digits
- Triggered by stress or the cold :(
- Effects are reversible in raynauds, should self resolve! So, should not get necrosis
- Usually in the hands, may affect toes & ears
- Bilateral involvement, if unilateral, it’s not Raynauds!
Oedema
- Check the JVP
- If oedema is unilateral, think trauma, infection (cellulitis), long lie, DVT, AF
- If oedema is bilateral, think HF, electrolyte imbalance, lymphatic obstruction, chronic meds (NSAIDS), inferior vena cava syndrome
Palpitations:
Red flags:
- Recent hx of MI or cardiac surgery- think infection/damage from surgery
- Associated syncope
- FHX of SADS
- WPW (pain whilst exercising) , LQTS, BRUGADA
- Structural/ functional heart disease (cardiomyopathy, aortic stenosis)
Fits, Faints & Funny turns
- What acc happened, was it witnessed, how long for?
- Any seizure like activity?- Postictyl?
- First occurrence?
- Any FMHX?, DHX?
- What were they doing at the time, environmental causes?
- If they twist, more likely to be a syncope
Cardiogenic causes: - Postural hypotension, neurocardiogenic syncope, arrhythmias?
