Question

A Black 50-year-old female client is admitted to the health care facility with mitral valve prolapse. The client states that a week ago she became dizzy and began to perspire while at work. She was working at the computer in her office on a major project that was due that day. The client attributed the episode to the stress and anxiety she was experiencing from finishing the project, so she put a cold wet towel around her neck and continued working. The next day, she woke up with a headache and felt a little tightness in her chest. She took an aspirin, and the symptoms subsided. The client became alarmed today when the tightness in her chest felt more like a pain. The client’s presenting symptoms include fatigue, headaches, and sharp chest pains.

VS: BP 160/90 mm Hg, HR 110 beats/min, RR 24 breaths/min, Temp. 98.0° F (36.7°C), Pulse Ox 96%, skin is warm; the nurse notes the client is perspiring. Her weight is 30 lb over what it should be. She gives a history of having a murmur since she was little but that it never caused her any problems. She takes cholesterol and blood pressure–lowering medications daily.

Questions:

1. What are the correct landmarks for auscultation of heart sounds in this client?

2. When teaching this client about coronary heart disease (CHD), which risk factors are important for the nurse to emphasize?

3. To develop a client-specific plan of care, what additional information is important for the nurse to know about this patient?

4. What abnormal/concerning findings do you note in the case study above?

5. What nursing diagnostic statement(s) will guide your plan of care?
6. What interventions will you initiate based on this priority?
7. How will you assess the efficacy of these interventions?

Answer 1

1 .

Proficiency in the use of a stethoscope to listen to heart sounds and the ability to differentiate between normal and abnormal heart sounds are essential skills for any physician. Correct placement of the stethoscope on the chest corresponds to the sound of cardiac valves closing. The heart has two main sounds: S1 and S2. The first heart sound (S1) occurs as the mitral and tricuspid valves (atrioventricular valves) close after blood enters the ventricles. This represents the start of systole. The second heart sound (S2) occurs when the aortic and pulmonary valves (semilunar valves) close after blood has left the ventricles to enter the systemic and pulmonary circulation systems at the end of systole. Traditionally, the sounds are known as a "lub-dub."

Auscultation of the heart is performed using both diaphragm and bell parts of the stethoscope chest piece. The diaphragm is most commonly used and is best for high-frequency sounds (such as S1 and S2) and murmurs of mitral regurgitation and aortic stenosis. The diaphragm should be pressed firmly against the chest wall. The bell best transmits low-frequency sounds (such as S3 and S4) and the murmur of mitral stenosis. The bell should be applied with a light pressure.

CITE THIS VIDEO | REPRINTS AND PERMISSIONS

JoVE Science Education Database. Physical Examinations I. Cardiac Exam II: Auscultation. JoVE, Cambridge, MA, (2020).

PROCEDURE

1. Position the patient at 30-45 degrees.

2. Make sure the area being examined is exposed, and never auscultate through the gown.

3. Place the stethoscope in the defined anatomical landmarks (Figure 1). A good rule of thumb to find the second intercostal space is to locate the angle of Louis (manubriosternal joint), which is at this level. Palpate across and down with your fingers to locate the other intercostal spaces described.

. Auscultation surface landmarks.

1. Aortic area
   1. Place the diaphragm of the stethoscope at the 2nd intercostal space, right sternal edge. This is the anatomical landmark for the aortic valve.
   2. Listen for at least 5 sec for the second heart sound, which represents the aortic valve closing.
2. Pulmonic area
   1. Place the diaphragm of the stethoscope at the 2nd intercostal space, left sternal edge. This is the anatomical landmark for the pulmonary valve.
   2. Listen for at least 5 sec for the second heart sound, which represents the pulmonary valve closing.
3. Tricuspid area
   1. Place the diaphragm of the stethoscope at the 4th - 5th intercostal space, left sternal edge. This is the anatomical landmark for the tricuspid valve.
   2. Listen for at least 5 sec for the first heart sound, which represents the tricuspid valve closing.
4. Mitral area
   1. Place the diaphragm of the stethoscope at the 5th intercostal space, mid-clavicular line (same area as the apex beat). This is the anatomical landmark for the mitral valve.
   2. Listen for at least 5 sec for the first heart sound, which represents the mitral valve closing.

4. Other auscultation areas:

Auscultation of the lungs and major arteries also provides essential information of the function of the cardiovascular system.

1. Auscultate with the diaphragm of the stethoscope at the bases of the lungs. Listen for any crepitations or crackles, which indicate fluid in the lungs (pulmonary edema), a sign of heart failure.
2. Auscultate with the bell of the stethoscope at the carotid arteries. Frequently, a murmur that is present from the aortic valve may be heard. Also, auscultate here for a bruit (a swishing sound produced by turbulent blood flow), which is a sign of carotid artery stenosis.
3. Auscultate for abdominal bruits at the renal arteries and femoral arteries to assess for peripheral vascular disease.

2 .

What are the risk factors for coronary artery disease?

Non-modifiable risk factors (those that cannot be changed) include:

• Male gender. Men have a greater risk of heart attack than women do, and men have heart attacks earlier in life than women. However, beginning at age 70, the risk is equal for men and women.
• Advanced age. Coronary artery disease is more likely to occur as you get older, especially after Age 65.
• Family history of heart disease. You have an increased risk of developing heart disease if you have a parent with a history of heart disease, especially if they were diagnosed before Age 50. Ask your doctor when it's appropriate for you to start screenings for heart disease so it can be detected and treated early.
• Race. African Americans have more severe high blood pressure than Caucasians and, therefore, have a higher risk of heart disease. The risk of heart disease is also higher among Mexican Americans, American Indians, native Hawaiians, and some Asian Americans. This is partly due to higher rates of obesity and diabetes in these populations.

Modifiable risk factors (those you can treat or control) include:

• Cigarette smoking and exposure to tobacco smoke
• High blood cholesterol and high triglycerides – especially high LDL ("bad") cholesterol over 100 mg/dL and low HDL ("good") cholesterol under 40 mg/dL. Some patients who have existing heart or blood vessel disease, and other patients who have a very high risk, should aim for an LDL level less than 70 mg/dL. Your doctor can provide specific guidelines.
• High blood pressure (140/90 mmHg or higher)
• Uncontrolled diabetes (HbA1c >7.0)
• Physical inactivity
• Being overweight (body mass index [BMI] 25–29 kg/m2) or being obese (BMI higher than 30 kg/m2)
• NOTE: How your weight is distributed is important. Your waist measurement is one way to determine fat distribution. Your waist circumference is the measurement of your waist, just above your navel. The risk of cardiovascular disease increases with a waist measurement of over 35 inches in women and over 40 inches in men.
• Uncontrolled stress or anger
• Unhealthy Diet

The more risk factors you have, the greater your risk of developing coronary artery disease.

Coronary heart disease is a common term for the buildup of plaque in the heart’s arteries that could lead to heart attack. But what about coronary artery disease? Is there a difference?

The short answer is often no — health professionals frequently use the terms interchangeably.

However, coronary heart disease , or CHD, is actually a result of coronary artery disease, or CAD, said Edward A. Fisher, M.D., Ph.D., M.P.H., an American Heart Association volunteer who is the Leon H. Charney Professor of Cardiovascular Medicine and also of the Marc and Ruti Bell Vascular Biology and Disease Program at the NYU School of Medicine.

With coronary artery disease, plaque first grows within the walls of the coronary arteries until the blood flow to the heart’s muscle is limited. View an illustration of coronary arteries. This is also called ischemia. It may be chronic, narrowing of the coronary artery over time and limiting of the blood supply to part of the muscle. Or it can be acute, resulting from a sudden rupture of a plaque and formation of a thrombus or blood clot.

The traditional risk factors for coronary artery disease are high LDL cholesterol, low HDL cholesterol, high blood pressure, family history, diabetes, smoking, being post-menopausal for women and being older than 45 for men, according to Fisher. Obesity may also be a risk factor.

“Coronary artery disease begins in childhood, so that by the teenage years, there is evidence that plaques that will stay with us for life are formed in most people,” said Fisher, who is former editor of the American Heart Association journal, ATVB. “Preventive measures instituted early are thought to have greater lifetime benefits. Healthy lifestyles will delay the progression of CAD, and there is hope that CAD can be regressed before it causes CHD.”

Living a healthy lifestyle that incorporates good nutrition, weight management and getting plenty of physical activity can play a big role in avoiding CAD.

“Coronary artery disease is preventable,” agreed Johnny Lee, M.D., president of New York Heart Associates, and an American Heart Association volunteer. “Typical warning signs are chest pain, shortness of breath, palpitations and even fatigue.”

3 .

How is Coronary Artery Disease (CAD) Diagnosed?

Your cardiologist (heart doctor) can tell if you have coronary artery disease by

• talking to you about your symptoms, medical history, and risk factors
• performing a physical exam
• performing diagnostic tests

Diagnostic tests help your doctor evaluate the extent of your coronary heart disease, its effect on the function of your heart, and the best form of treatment for you. They may include:

• Electrocardiograph tests, such as an electrocardiogram (ECG or EKG) or exercise stress tests, use the electrocardiogram to evaluate the electrical activity generated by the heart at rest and with activity.
• Laboratory Tests: include a number of blood tests used to diagnose and monitor treatment for heart disease.
• Invasive Testing, such as cardiac catheterization, involve inserting catheters into the blood vessels of the heart in order to get a closer look at the coronary arteries.

Other diagnostic tests may include:

• Nuclear Imaging produces images by detecting radiation from different parts of the body after the administration of a radioactive tracer material.
• Ultrasound Tests, such as echocardiogram use ultrasound, or high frequency sound wave, to create graphic images of the heart's structures, pumping action, and direction of blood flow.
• Radiographic Tests use x-ray machines or very high tech machines (CT, MRI) to create pictures of the internal structures of the chest.

Tests used to predict increased risk for coronary artery disease include: C-reactive protein (CRP), complete lipid profile and calcium score screening heart scan.

How is coronary artery disease treated?

Treatment of coronary artery disease involves reducing your risk factors, taking medications as prescribed, possibly undergoing invasive and/or surgical procedures, and seeing your doctor for regular visits. Treating coronary artery disease is important to reduce your risk of a heart attack or stroke.

Reduce your Risk Factors

Reducing your risk factors involves making lifestyle changes. Your doctor will work with you to help you make these changes.

• If you smoke, you should quit.
• Make changes in your diet to reduce your cholesterol, control your blood pressure, and manage blood sugar if you have diabetes. Low-fat, low-sodium and low-cholesterol foods are recommended. Limiting alcohol to no more than one drink a day is also important. A registered dietitian can help you make the right dietary changes. Cleveland Clinic offers nutrition programs and classes to help you reach your goals.
• Increase your exercise/activity level to help achieve and maintain a healthy weight and reduce stress. But, check with your doctor before starting an exercise program. Ask your doctor about participating in a cardiac rehabilitation program.
• Test your 10 year risk for heart attack.

Take Medications as Prescribed

If lifestyle changes aren't enough to control your heart disease, medications may be prescribed to treat certain risk factors, such as high cholesterol or high blood pressure. Your doctor will determine the best medications for you based on your personal needs, presence of other health conditions and your specific heart condition.

Common interventional procedures to treat coronary artery disease include balloon angioplasty (PTCA) and stent or drug-eluting stent placement. These procedures are considered nonsurgical because they are done by a cardiologist (heart doctor), who accesses the heart using a long, thin tube (catheter) that is inserted into a blood vessel, rather than by a surgeon through an incision. Several types of balloons and/or catheters are available to treat the plaque build-up within the vessel wall. If you require an interventional treatment, your physician will determine the type that is best for you based on your individual needs.

Coronary artery bypass graft (CABG) surgery

One or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient's own arteries and veins located in the chest, arm or leg. The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.

When these traditional treatments are not options for you, doctors may suggest other less traditional therapies, such as enhanced external counterpulsation (EECP).

Enhanced external counterpulsation (EECP)

For patients who have persistent angina symptoms and have exhausted the standard treatments without successful results, EECP may stimulate the openings or formation of small branches of blood vessels (collaterals) to create a natural bypass around narrowed or blocked arteries. EECP is a noninvasive treatment for people who have chronic, stable angina; who are not receiving adequate relief from angina by taking nitrate medications; and who do not qualify for a procedure such as bypass surgery, angioplasty or stenting.

5 .

Treatment aims to ease symptoms, improve coronary artery blood flow and prevent complications. Immediate management, combined with cardiac rehabilitation and secondary prevention, can improve patients’ outcomes and quality of life. Nurses have a key role in:

• Facilitating and administering prompt treatment to patients;
• Promoting the swift recognition of deterioration;
• Providing holistic care and psychosocial support;
• Encouraging patients to engage in healthy secondary-prevention behaviours.

Nursing care priorities

Acute hospital admission

Keeping clear and comprehensive notes is crucial to ensure all nurses caring for patients with ACS know the patients’ clinical status, areas of concerns and management plan. Nurses caring for patients who recently had coronary angiography should monitor radial or femoral access sites and be able to recognise complications. Close communication with cardiac catheterisation laboratory staff and the coronary care unit is crucial. Nurses receiving these patients need clear information about the type of procedure they had, any complications, medications and IV fluids, and whether they have received anticoagulants or GPIs, which will put them at greater risk of bleeding (Macdonald et al, 2016).

General priorities for patients with ACS are haemodynamic monitoring and close observation of vital signs. A review of fluid status can provide information about renal perfusion, as some patients may present with, or develop, heart failure. In patients with diabetes, capillary blood glucose levels should be regularly checked; some may be put on IV insulin if their blood glucose is >11mmol/L. Patients recently diagnosed with diabetes should be referred to the diabetes specialist nurse.

Symptom monitoring is important to achieve pain relief with GTN or morphine. Swift recognition of any cardiac changes on the serial ECGs is also a key aspect of nursing care. Patients considered at high risk should be managed where continuous cardiac monitoring is available as they are at risk of arrhythmias, which can precede a cardiac arrest. Patients at intermediate risk may be managed in a medical assessment unit, where they are likely to receive serial ECGs. Nurses caring for patients with ACS should have ECG interpretation skills, as ECG changes or arrhythmias are signs of potential deterioration.

Other elements of nursing care include ongoing management of IV cannulas, central venous pressure lines, urinary catheters and wounds and dressings.

Patients are likely to be anxious and frightened. Nurses should be calm and reassuring, and ensure pain and other symptoms are well controlled. They play a central role in providing psychosocial support; when possible, they should give patients a chance to speak about their experiences, address their concerns and relay these to the multidisciplinary team.

Discharge and secondary prevention in MI patients

There are several things to consider when patients with a confirmed MI (either NSTEMI or STEMI) are ready to be discharged home (Box 2). Secondary prevention should be at the heart of nurses’ strategies. Patients need to understand their condition and be encouraged to make any lifestyle changes needed, which will be crucial to prevent recurrence. They will be discharged with much information, but the priority is for them to understand:

• They have had an acute MI;
• Results of any investigations;
• How their condition will be managed.

Patients are likely to go home with several drugs and many will need to take them for the rest of their lives. These drugs usually comprise dual antiplatelet therapy, beta-blockers, statins and ACE inhibitors. Some patients will also need aldosterone antagonists. Nurses must ensure patients:

• Understand the dosages and administration routes;
• Know not to discontinue treatment without medical advice.

Where possible relatives should be involved in discussions, as they can often help with lifestyle changes. Patients should receive advice on travel and be made aware of the rules about driving after an MI. They should also be advised to seek urgent medical assessment if any chest pain recurs.

Advice can be reinforced with written information, such as booklets from the British Heart Foundation, and patients can be signposted to support groups and websites such as NHS Choices as appropriate (Scottish Intercollegiate Guidelines Network, 2016).

Nurses should address patients’ concerns and refer them to cardiac nurses or dietitians for specialist advice, as well as the primary care team for ongoing secondary prevention. They should also encourage them to attend a cardiac rehabilitation programme; this is particularly so for hard-to-reach groups – older people, women, some ethnic groups, people in rural areas, those of lower socioeconomic status – in which attendance is lower than average