1. Cardiac Examination Within the Role of the Cardiology Nurse Practitioner
Victoria Williams
Cardiology Nurse Practitioner
University Hospital of Wales, Cardiff.

2. 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.

3. 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.

4. 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.
Talk a little bit about how the role was established and why
Discuss wider aspects of the role and then move onto talk about ACS unit objectives
Mention briefly the ACS unit

5. University Hospital of Wales
Tertiary Cardiology centre
Contracted to provide tertiary services to District General Hospitals within south east Wales

6. 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
Give a brief outline of advanced clinical skill:
Clerking
Independent prescribing
Triage of transfers
Requesting diagnostic interventions

7. 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

8. Major Cardiovascular Presenting Complaints
Chest Pain
Dyspnoea
Syncope
Palpitations
Peripheral oedema

9. 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.

10. 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
Talk a bit about each heading:
PC- ask the patient to describe in their own words what has brought them into hospital
HPC- SOCRATES
PMH- MITHREADS
Risk factors
FH-ihd cva diabetes
Drug history- allergies, over the counter, recreational, compliance, side effects.
Social – occupation, mobility, social circumstances, alcohol intake.
Systems review
PMH

11. 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".
Site: where, local/ diffuse, "Show me where it is worst".
Onset: rapid/ gradual, pattern, worse/ better, what did when symptom began.
Character: vertigo/ lightheaded, pain: sharp/ dull/ stab/ burn/ cramp/ crushing.
Radiation [usually just if pain].
Alleviating factors, "What do you do after it comes on?"
Time course: when last felt well, chronic: why came now.
Exacerbating factors, "What are you doing when it comes on?".
Severity: scale of 1-10.
Associated symptoms.
Impact of symptoms on life: "Does it interrupt your life".

12. 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
Talk a bit about each heading:
PC- ask the patient to describe in their own words what has brought them into hospital
HPC- SOCRATES
PMH

13. MJ THREADS: MI Jaundice TB HTN Rheumatic fever Epilepsy Asthma
Diabetes
Stroke

14. System Review General Cardiovascular Weakness Fatigue Anorexia
Change of weight
Fever
Lumps
Night sweats
Cardiovascular
Pain
Breathlessness
Palpitations
Syncope
Ankle oedema
Calf pain
Orthopnea
Intermittent claudication

15. 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

16. System Review Continued
Neurological
Headaches
Dizzyness
Siezures
Collapse
Visual disturbances
Loss of balance
Muscle weakness
Musculoskeletal
Joint pains/stiffness
Recent injuries
Gait
swelling

17. System Review Continued
Genital
Pain/discomfort
Unusual bleeding
Menstruation
Sexual health
Erectile dysfunction

18. Clinical Examination Consent Exposure Position Inspection Palpation
Percussion
Auscultation
C- introduce yourself to the patient explain what you are about to do and gain their consent
E- ask the patient to remove their clothes from the waist up
P- put the patient in a comfortable position and examine from the left hand side.

19. Establish the Stability of the Patient
Airway
Breathing
Circulation
Disability
Exposure
Comfortable/distressed
Dyspnoeic/fatigued
Pale/cyanosed
Dehydrated/volume depleted
Congested/ oedematous/ volume overloaded

20. Inspection Start with the hands: Clubbing Splinter haemorrhages
Palmer errythema
Muscle wasting
Janeway Lesion
Osler’s Nodes

21. Clubbing

22. Splinter Haemorrhages
Linear reddish brown lesions seen in nail bed. Prominent in this case of SBE

23. Janeway Lesion
Macular, blanching, not painful located on palms & soles (SBE)

24. Osler’s Nodes
Tender, papulopustules located on pulp of finger (SBE)

25. Exam: Hands Other points to note: Temperature Perfusion Pallor
Nicotine staining
Extensor tendon swellings (xanthomas)

26. Pulse Start by palpating the radial pulse Rate:
At this site asses
Rate
Rhythm
You should not asses volume at the radial artery
Rate:
Normal sinus bpm
Sinus bradycardia < 60 bpm
Sinus tachycardia > 100 bpm
Rhythm:
Sinus arrhythmia - varies with respiration
Intermittent irregularity – ectopic beats
Continuously irregular (irregularly irregular – atrial fibrillation)

27. Carotid Palpation Carotid upstroke: – brisk, normal or delayed
– volume: normal, increased or decreased

28. Exam: Head & Neck: FACE
Jaundice

29. Exam: Head & Neck: FACE
Anaemia

30. Exam: Head & Neck: FACE
XANTHELASMA
ARCUS

31. Exam: Head & Neck: FACE
Cyanosis

32. Exam: Head & Neck: JVP
The JVP is best examined by looking across the neck.
A double waveform should be seen for each cardiac cycle

33. 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

34. Inspection of the chest
Look
For
Obvious
Deformity
pectus excavatum may be due to an overgrowth of costal cartilage, which displaces the sternum posteriorly. Abnormalities of the diaphragm, rickets, or elevated intrauterine pressure are also theorized to cause posterior displacement of the sternum
INDICATIVE OF CONGENITAL HEART DISEASE
Other children have palpitations that might be related to mitral valve prolapse that commonly occurs with pectus excavatum. A flow murmur may also be detectible in some patients. This flow murmur is related to the close proximity of the sternum to the pulmonary artery resulting in transmission of a systolic ejection murmur.[10
Funnel Chest (Pectus excavatum)
Pigeon Chest (pectus Carinitum)

35. Inspection of the chest
Look for obvious Scars:
Median Sternotomy
CABG, Valve, TX
Lateral Thoracotomy
Coarct repair

36. Palpate for heaves and thrills
Palpation
Locate Apex
Palpate for heaves and thrills
MENTION TO ROLL THE PATIENT OVER ONTO LEFT SIDE TO FEEL THE APEX MORE EAILY
HEAVES- feels like the heart is pushing up against your hand
THRILLS – feel like a cat purring

37. 2 Anterior Axillary Line
Exam: Praecordium
1 2 3
1 Mid Clavicular Line
2 Anterior Axillary Line
3 Mid Axillary Line
2nd
3rd
4th
5th
Intercostal Spaces

38. 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

39. Exam: Auscultation Diaphragm Normal / High pitched murmurs.
Use for general purpose auscultation

40. Exam: auscultation Apex: Mitral Valve Sternal Edge: Tricuspid Valve
L 2nd Space: Pulmonary Valve
R 2nd Space: Aortic Valve
First listen with the diaphragm then the bell

41. Exam: auscultation Heart Sounds Diastole Systole First Second Lub (S1)
Dub (S2)
Diastole
Systole
These are the first heart sound (S1) and second heart sound (S2), produced by the closing of the AV valves (tricuspid and mitral (bicuspid), and semilunar valves the (aortic valve and pulmonary valve) ( respectively. In addition to these normal sounds, a variety of other sounds may be present including heart murmurs, adventitious sounds, and gallop rhythms S3 and S4.
It is caused by the sudden block of reverse blood flow due to closure of the atrioventricular valves, i.e. tricuspid and mitral (bicuspid), at the beginning of ventricular contraction, or systole. When the ventricles begin to contract, so do the papillary muscles in each ventricle. The papillary muscles are attached to the tricuspid and mitral valves via chordae tendineae, which bring the cusps or leaflets of the valve closed (chordae tendineae also prevent the valves from blowing into the atria as ventricular pressure rises due to contraction). The closing of the inlet valves prevents regurgitation of blood from the ventricles back into the atria. The S1 sound results from reverberation within the blood associated with the sudden block of flow reversal by the valves.[1] If T1 occurs slightly after M1, then the patient likely has a dysfunction of conduction of the right side of the heart such as a right bundle branch block.
The second heart tone, or S2, forms the "dub" of "lub-dub" and is composed of components A2 and P2. Normally A2 precedes P2 especially during inspiration when a split of S2 can be heard. It is caused by the sudden block of reversing blood flow due to closure of the semilunar valves (the aortic valve and pulmonary valve) at the end of ventricular systole, i.e. beginning of ventricular diastole. As the left ventricle empties, its pressure falls below the pressure in the aorta. Aortic blood flow quickly reverses back toward the left ventricle, catching the pocket-like cusps of the aortic valve, and is stopped by aortic (outlet) valve closure. Similarly, as the pressure in the right ventricle falls below the pressure in the pulmonary artery, the pulmonary (outlet) valve closes. The S2 sound results from reverberation within the blood associated with the sudden block of flow reversal.
Splitting of S2, also known as physiological split, normally occurs during inspiration because the decrease in intrathoracic pressure increases the time needed for pulmonary pressure to exceed that of the right ventricular pressure. A widely split S2 can be associated with several different cardiovascular conditions, including right bundle branch block and pulmonary stenosis.
Rarely, there may be a third heart sound also called a protodiastolic gallop, ventricular gallop, or informally the "Kentucky" gallop as an onomatopoeic reference to the rhythm and stress of S1 followed by S2 and S3 together (S1=Ken; S2=tuck; S3=y).
"lub-dub-ta" or "slosh-ing-in" If new indicates heart failure or volume overload.
It occurs at the beginning of diastole after S2 and is lower in pitch than S1 or S2 as it is not of valvular origin. The third heart sound is benign in youth, some trained athletes, and sometimes in pregnancy but if it re-emerges later in life it may signal cardiac problems like a failing left ventricle as in dilated congestive heart failure (CHF). S3 is thought to be caused by the oscillation of blood back and forth between the walls of the ventricles initiated by inrushing blood from the atria. The reason the third heart sound does not occur until the middle third of diastole is probably that during the early part of diastole, the ventricles are not filled sufficiently to create enough tension for reverberation.
It may also be a result of tensing of the chordae tendineae during rapid filling and expansion of the ventricle. In other words, an S3 heart sound indicates increased volume of blood within the ventricle. An S3 heart sound is best heard with the bell-side of the stethoscope (used for lower frequency sounds). A left-sided S3 is best heard in the left lateral decubitus position and at the apex of the heart, which is normally located in the 5th left intercostal space at the midclavicular line.[2] A right-sided S3 is best heard at the lower-left sternal border. The way to distinguish between a left and right-sided S3 is to observe whether it increases in intensity with inspiration or expiration. A right-sided S3 will increase on inspiration whereas a left-sided S3 will increase on expiration.
The rare fourth heart sound when audible in an adult is called a presystolic gallop or atrial gallop. This gallop is produced by the sound of blood being forced into a stiff/hypertrophic ventricle.
"ta-lub-dub" or "a-stiff-wall"
It is a sign of a pathologic state, usually a failing left ventricle, but can also be heard in other conditions such as restrictive cardiomyopathy. The sound occurs just after atrial contraction ("atrial kick") at the end of diastole and immediately before S1, producing a rhythm sometimes referred to as the "Tennessee" gallop where S4 represents the "Ten-" syllable. It is best heard at the cardiac apex with the patient in the left lateral decubitus position and holding his breath. The combined presence of S3 and S4 is a quadruple gallop, also known as the "Hello-Goodbye" gallop. At rapid heart rates, S3 and S4 may merge to produce a summation gallop
First
Second
Mitral Valve
Tricuspid Valve
Aortic Valve
Pulmonary Valve

42. Heart Murmurs: Systolic
Mitral Regurgitation
Tricuspid Regurgitation
Gradations of Murmurs[1](Defined based on use of an acoustic, not a high-fidelity amplified electronic stethoscope)
GradeDescription
Grade 1Very faint, heard only after listener has "tuned in"; may not be heard in all positions. Only heard if the patient "bears down" or performs the Valsalva maneuver.
Grade 2 Quiet, but heard immediately after placing the stethoscope on the chest.
Grade 3 Moderately loud.
Grade 4 Loud, with palpable thrill (i.e., a tremor or vibration felt on palpation)
Grade 5 Very loud, with thrill. May be heard when stethoscope is partly off the chest.
Grade 6Very loud, with thrill. May be heard with stethoscope entirely off the chest.
First
Second
Pan Systolic Murmur

43. Heart Murmurs: Systolic
Aortic
Stenosis
Pulmonary
VSD
First
Second
Ejection Systolic Murmur

44. Heart Murmurs: Diastolic
Aortic Regurgitation
First
Second
Early Diastolic Murmur

45. Heart Murmurs: Diastolic
Mitral
Stenosis
First
Second
Mid Diastolic Murmur

46. Auscultation Mitral Murmurs Mitral Area Patient in Left Lateral
Radiate to Axilla

47. Auscultation Aortic Murmurs Aortic Area Sit Patient Forward
Breath Held in Expiration
Radiates to Carotids

48. Any Questions?

49. Thank you for your attention.