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CARDIAC SYSTEM

13

Upper Systemic Circulation __

Superior Vena Cava

Anenes

Liver Circulation

Inferior Vena Cava

Intestinal Circulation

Lower Systemic Circulation

Figure 1-4. Schematic of systemic circulation. (Draw'J by Barbara Cocanoll"

Ph.D., University of Massachusetts, Lowel1, Department of Physical Therapy.)

Cardiac Evaluation

Cardiac evaluarion consists of patient history, physical examination (which consists of observation, palpation, BP measurement, and heart sound auscultation), laboratory rests, and diagnostic

procedures.

Patiellt History

In addition to the general charr review presented in Appendix I-A,

pertinent information about patients with cardiac dysfunction that

should be obtained before physical examination includes the

following'· 10-12:

• Presence of chest pain (see Appendix X for an expanded

description of characteristics and etiology of chest pain)

14 ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

1. Location, radiation

2. Character and quality (crushing, burning, numbing, hot)

and frequency

3. Angina equivalents (what the patient feels as angina, e.g.,

jaw pain, shortness of breath, dizziness, lightheadedness, diaphoresis, burping, nausea, or any combination of these)

4. Aggravating and alleviating factors

5. Precipitating factors

• Medical treatment sought and its outcome

• Presence of palpitations

• Presence of cardiac risk factors (Table 1-4)

• Family history of cardiac disease

Table 1-4. Cardiac Risk Faccors

Major

Independent

Risk FactOrs

Predisposing Risk Factors

Conditional Risk Factors

Smoking

Physical inactivity

Elevated triglycerides

Hypertension

Obesity

Small LDL parricles

Elevated serum

Body mass index

Elevated homocysteine

cholesterol,

>30 kglm'

Elevated lipoprotein (a)

roral (and LDLI

Abdominal obesity (waisthip ratio)

Decreased high

Men >40 in.

Elevated inflammatory

density lipopromarkers

tein cholesterol

Diabetes mellitus

Women >35 in.

C-reactive protein

Advancing age

Family history of prema

Fibrinogen

ture heart disease

Psychosocial factors

Ethnic characteristics

LDL = low-density lipoprotein.

Source: Data from SM Grundy, R Pasternak, P Greenland, et al. Assessment of cardiovascular risk by use of multiple-risk-factOr assessmenr equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology, Circulation 1999; 100: 1481-1492.

CARDIAC SYSTEM

15

o History of dizziness or syncope

o Previous myocardial infarction (MI), cardiac studies, or procedures

Clinical Tip

• When discussing angina with a patient, use the patient'S

terminology. If the patient describes the angina as "crushing" pain, ask the patient if he or she experiences the crushing feeling during treatment as opposed to asking the

patient if he or she has chest pain.

o The common medical record abbreviation for chest

pain is CPo

Physical Exam;1Iatio1l

Observation

Key components of the observation portion of the physical examination include the following··7:

1 .

Facial color, skin color and rone, or the presence of diaphoresis

2.

Obvious signs of edema in the extremities

3.

Respiratoty rate

4.

Signs of trauma (e.g., paddle burns or ecchymosis from cardiopulmonary resuscitation)

5.

Presence of jugular venous distention, which results from

the backup of Auid into the venous system from right-sided CHF

(Figure 1-5)

a. Make sure the patient is in a semirecumbent position (45

degrees).

b. Have the patient turn his or her head away from the side

being evaluated.

c. Observe pulsations in the internal jugular neck region.

Pulsations are normally seen 3-5 em above the sternum. Pul-

1 6 ACUTE CARE HANDBOOK FOR PHYSICAL TI-IERAPISTS

CaroHd artery

In1ernal jugular veJn

External Jugular vein

Sternal angle

Figure 1-5. Measurement of iugular venous distention (J VPJ. The J VP reading is the maximum height, in centimeters, above the sternal angle at which venous pulsations are visible.

sations higher than this or absent pulsations indicate jugular

venous distention.

Palpation

Palpation is the second component of the physical examination and is

used to evaluate and identify the following:

•

Pulses for circulation qua�ty, HR, and rhythm (Table 1-5, Figure 1-6)

•

Exttemities for pitting edema bilaterally (Table 1-6)