Welcome back to our Cardiovascular Nursing Essentials series. Today, we're going to cover cardiovascular patient assessment. My name is Jenny Kennedy. I'm a nurse and VP of Care Transformation. These are my disclosures. We have three objectives today. We're going to review how to get an accurate cardiovascular HMP or history and physical. We are going to understand the proper elements of meta-reconciliation and also review some common risk scores and lab tests today. Again, each week you have some readings. There are some required out of the textbook and then some optional resources and things that I hope you'll find helpful. We're going to start with HMP, the history and physical because this is really the foundation of any assessment. It's really important that it's thorough and done well. As we get into this, I just want to remind you that even though this is really focused on an outpatient setting, we never want to forget our ABCs, that airway, breathing, and circulation. I think it is different if you're transitioning from an inpatient unit or a hospital department where you're used to being in front of patients all the time. Things can be a little bit different in a clinic setting. Anytime you start feeling unsure of yourself, always remember your ABCs so you know what to do with those and so I may just remind you during this course that those are your foundation and they can help you make decisions. It's to help us stay grounded and address what we need to address in the right priority. When we're talking with our patients, we really want to make a connection with them. Again, we know time is of the essence. We're rushed all day long, we're seeing a lot of patients. I think it's very important and I urge you to take the time to introduce yourself and make eye contact with your patient. Caveat, of course, is if you're on the phone, you can't make that eye contact, you can't make that in-person connection, but you can connect with them. Giving them your attention and listening to them, providing some feedback, make that connection. If that person is in the office with you, it's very comforting when they know you're listening that you're at the same level with them. Sometimes it helps if you can just to get on their level, try not to look down at them. Obviously, if you're getting vital signs, sometimes that's hard, but take away any intimidation. It's important how we communicate and ask questions. We want to be clear, we want to be concise. We want them to know what we're asking, so be prepared to deliver those questions in a very clear manner. Sometimes patients don't fully understand and their answer is not clear, so just make sure you're asking those clarifying questions when you need to. You'll get to know, if you don't already, what you need to anticipate. So if you're not getting the answer you need, try again and get some clarification to what they provided you. Always thank them for their time. Remember, these visits are stressful. They're here because they're not feeling well generally, so it is up to us to help put them at ease. Thank them for coming, thank them for their time, and make sure that you're following up with them if there's a delay between your time with them and the next provider. So as we start our assessment, we start with patient history. This is where we're really looking for, specifically, cardiovascular diseases. Doesn't mean that other issues are not important, but we're really focusing on that cardiovascular disease history. And you may find, they may tell you some things that are outside of kind of the realm, if you will, of cardiology, but they may provide insight into any kind of disease or new issues that they're having, so don't instantly disregard those. Take it all into consideration. But from a cardiology standpoint, we're really looking for things like, have they had a heart attack or an MI? Do they have a history of coronary artery disease? Any sort of valvular disease? Do they have a heart murmur? Is that something that's new? Have they had rheumatic fever? This is not quite common, but it can occur and can have repercussions. Do they have an enlarged heart or cardiomyopathy, heart failure, any sort of ectopy or extra ventricular contractions, those palpitations? Do they have a history of hypertension, any heart surgeries, or any other kind of vascular disease? So these are all keys that we should be picking up on as they tell an important story about your patient. So we wanna look at their past medical history, their chief complaint, what their present illness is, and then any functional assessment. So let's break that down a little bit. What we're trying to do is tell a patient's story of their past and current, and anticipate any acute health problems that they're having. So we do that, as we said, by their medical history. Okay, we do wanna make sure we're including family history, especially in cardiology, genetics are a large part. So we wanna get as much about their family history as possible. So the chief complaint is the reason that that patient is there to be seen. So we wanna do something with their own words. You can think of it in terms of a quotation mark, and you wanna know why they're being seen. So why are you here today? And an example is, I'm here because my cholesterol was high in my lab work last month. So that's an example. It's really the patient's own words. We wanna know the history of their current or present illness. So we're gonna ask open-ended questions. You know, how long has this been happening? When did it start? Does anything make it worse? So thinking on what that chief complaint is will drive those questions that you're asking. It's important to know the time when it started. You know, has this been a month-long thing? Has it been off and on? Is it a two-day? You know, that onset is important. The duration, is it constant or does it occur intermittently? The frequency, the quality, what does it feel like? Is it a, you know, if it's a pressure, an ache, a tingling, insight into the quality of what they're feeling. Is it associated with a specific location? Is there anything that makes it better or worse? Those are all keys that can indicate to us what's going on. And I always like to stress this, that we're not only concerned about their physical symptoms, their history in terms of health, but we wanna look at their psychosocial and their functional assessment. This is gonna give us a lot of insight into how well they're gonna be able to take care of themselves. And these are things like, do they need access to resources? Do they have transportation? Do they need patient assistance for medications? Do they have a support system, someone who can help them, guide them, encourage them? What is their own health perception? Are they engaged and want to make change and do things to help them feel better? Or are they just, well, this is the way I am and this is how I'm gonna be. All these things can help us get information and how we can best help them. We also wanna be alert for any psychosocial or behavioral issues. I really wanna stress this because there's so much stress and anxiety in the world right now that I think it's very important that we're addressing these. So if you're identifying maybe a patient that's really anxious and they're saying that they're having a hard time coping or dealing with things, bring that up. Maybe internally there's some resources, maybe there's some therapy or things that can help those patients. So make sure we're doing comprehensive assessments and not to discredit those functional and psychosocial pieces. So medication reconciliation is one of the most challenging things. And one of the reasons is because it's evolving and changing and patients forget, it's hard to keep up with everything. But it's important that your facility or your group has a formal process. You wanna make sure that you're creating the most accurate list possible based on what their current medications are. And so this does take some time as well. It is best practice to have your patients bring in bottles. Of course, sometimes they forget or they don't want to haul all those bottles in. So a list will be sufficient. And it's important that we're assessing anything that they're taking. So that's not just their scheduled prescriptions, it's their PRN medications that they're taking as needed. It's any supplements. There's a lot of interactions with vitamins and herbs and a lot of nutrition things right now. They can interact with their prescriptions. So we need to know what they're taking. And then over the counter, again, people may pop pills for back pain. Maybe they're taking Advil every day. We need to know that, that has implications. So make sure you're getting a full comprehensive list. And we're talking about verifying every medication. So that doesn't mean just, is this your accurate list? You have to go through each medication and you got to clarify their doses. So how often are they taking it? When was the last time they took it? And you want to include the PRNs too. We need to know when they're taking those. How often is it occasionally or do they need it more frequently? And you want to make notes and reconcile any differences that you're having and make sure your provider reviews those and they should do that with their workflow. But again, this is really important. It's confusing. You do the best you can. I know sometimes there's been additional steps required like calling pharmacies, can be an inconvenience but it's very important as we're deciding what these patients need. Is there something that's contributing to their current illness? Is there something we need to change? So cannot stress the importance of this reconciliation. Last module, we did start talking a little bit about the patient assessment and we're going to get a little bit deeper. While we are focused on a cardiovascular assessment we have to assess from head to toe. Many of the assessment components will give you an insight into what's going on with those patient. What is important to note is it doesn't mean you have to ask about each thing. It means you are observing while you're talking or communicating with your patients. Obviously this is more easily done while a patient's in person but you can get a sense of some of these things while you're talking on the phone. General appearance. This is something usually I like to do as I enter the room and I introduce myself. I'm really taking in, okay, how is their color? Do they look yellow? Do they look pale, dusky, blue? That will tell you a lot about their condition. What's their build? Are they small framed, maybe looking weak? Are they obese, large? What is their general build? And then looking for any additional clues that their breathing is increased. So are there cues that they're short of breath? Are they using those accessory muscles? Are you seeing them taking exaggerated breaths? Do they have extended neck veins? Sometimes obviously when we have extra fluid on they'll have distention in their jugular veins. Do you see any of these things noticeably? All of that can be done without actually asking the patient that. Additionally, their mental status. So is a patient confused? Are they forgetting things? Are they dizzy, lightheaded? Are they having vision changes? Those are important things to note as well. When we're looking at the heart, we're looking for obviously those sounds, regularity. So checking pulse, EKG is needed. Is their rhythm regular or irregular? If it's irregular, is that something that's new or is that common or they've had it already? What's the rate? We know that normal rate for a heart is between 60 to 100. Is it below that or above that? Cause those are indicators something is off, right? Is there a murmur? Is it a new murmur or is it something they've had? If you're not really experienced at hearing murmurs, take the time, there's lots of websites. We've left a link to one in the resource page that you can listen and try to better your ear at picking up on murmurs and heart sounds. Additional sounds like rubs, S3s, S4s, all of those can be indicators that something is going on with that patient's heart. We do wanna know about their lungs. Is their breathing rate regular? Again, we talked about accessory muscles. Are they belly breathing? Are they really working hard to breathe? Is it fast? Sometimes that can be the case when they're just coming, like if they have a long way to walk from the parking deck to the appointment or something, we do expect it to be increased, but we expect it to come down. Listening to lung sounds, right? We want clear, but are they diminished? Are there crackles? Is their core wheezing? Anything like that. All those things that would indicate a patient is having a difficult time breathing. So we also want to make sure that we're not ignoring the abdomen. We overlook that often in cardiology, but the abdomen is a place that people like to store volume or fluid. So an insight into their bowel and bladder habits may be kind of uncomfortable, but it's something we need to know. Constipation, bloating, nausea, those are all things patients may complain of if they're holding extra fluid. We also want to check for distention. Is it hard, extended, firm, painful sometimes, and is there any edema in the abdomen? So make sure that you're assessing that, and then we're looking at our peripheral vasculature. So that's our pulses, our extremities. How is the pulse strength? Is there swelling? You know, we talk about swelling in the feet, but also sometimes in the hands. Patients may get rings that are too tight on their fingers. Is there hyperpigmentation or clubbing? These are all issues with fluid or circulation that we want to look for. So as I mentioned, we're focused on cardiology or cardiovascular, but there's head to toe assessment that plays or indicates things are going on within a patient that are related to their cardiology or cardiovascular system. And so it's important that we are not hyperfocused and forgetting the full picture. So there are some tools I wanted to talk to you guys about, some risk scores and calculators. And there's great resources. There's a lot of websites. ACC has this great website. And mostly your providers will be doing this, but I think it's important that you're aware of what these tools are, what these risk scores and calculators mean, because you'll likely be seeing them in a lot of the notes. So we're just going to go over a few of them briefly so you're familiar with them. This is one of the most common ones. It's the ASCVD Risk Estimator Plus. Again, this can be found on the ACC. There's an app, so providers can just go in and plug in the information, and it will calculate a score. So this score calculates or estimates a patient's 10-year risk for ASCVD. Ideally, we do it at their initial visit as a reference point and then at follow-up visits. So obviously, that may not happen for each patient, but that's really how it's intended and how best used, because it gives us the ability to forecast the potential impact of certain interventions and compare it to that patient's risk. So it's incorporating changes in risk factor levels over time. You can see it takes into account age, sex, race, all of the demographic things, but it also takes into account their blood pressure, cholesterol, history, including diabetes, smoker. Are they on cholesterol medication or hypertension medication? So it's really a great tool. You can see that there is low- to high-risk categories based on what their score is, low being less than 5% or high being greater than or equal to 20%. So this is just a very helpful tool to help estimate a patient's risk for ASCVD. Another one you'll probably see commonly is the CHAS-VAS2 calculator. This is looking at certain components and deciding basically what a patient's risk for ischemic stroke is when they have atrial fibrillation. So it's going to help a provider understand how high of a risk they have for a stroke and be able to determine what they should do in terms of anticoagulation. So you can see the acronym is CHAS-VAS2, and that's congestive heart failure. So again, more calculators, easy apps, you just plug in yes or no, and if it is a yes, they get a point, so it's a point system. So if they have congestive heart failure, do they have hypertension as defined by blood pressure greater than 140 over 90 on two separate occasions? Are they 75 years or older? Do they have diabetes? Do they have a history of stroke, TIA or TE? Do they have vascular disease? Are they between 65 to 74 years? And what is their sex? So females actually at a higher risk. So it's going to calculate their CHAS-VAS score. So anything obviously ideal would be zero or low. Moderate is one. So you can see if you have two or more things, you're already at a high risk. So a score of one really does warrant strong consideration for oral anticoagulation to prevent or lessen the risk of ischemic stroke. So other common tools, HazBled is one that estimates in conjunction with anticoagulations, their risk for major bleeding for those patients that are on anticoagulation, so it kind of provides a risk benefit for using anticoagulation. Kansas City cardiomyopathy questionnaire is also the KCCQ-12. So this is really an interesting quality of life kind of measurement that we use on heart failure patients. So really trying to assess the patients, how they feel their life is and the impact of heart failure on their lives. StopBang is a really validated score for screening of obstructive sleep apnea, not central but obstructive, and it looks at snoring, daytime fatigue, any witnessed apnea, their age, neck circumference. So larger neck circumference is higher risk for sleep apnea. Males are more at risk than females and BMI. These are great tools. That's a great one to, if you have a sleep program, incorporate into your workup and refer to a sleep study or a sleep center. Sometimes a couple programs will establish a workflow to allow patients to be seen at the sleep center. LACE score is actually a tool that's used on the inpatient side. I only bring it out because it really assesses a readmission risk. So if you see the LACE score, it's commonly documented in your EHR. It might be helpful to you because it can show you your patients that are more vulnerable for being readmitted. So just wanted, it's a very common tool. Just wanted to call that out should you see it and how it applies to the outpatient setting. And now we're going to talk about some common lab assessments. A lot of these will be familiar, but I just want to go over a few critical things and maybe how you can prepare your patients. Chemistry panels, so these are your BMPs or CMPs. These look at all of your electrolytes. So your sodium, your magnesium, your potassium, all those really important things that we need to monitor, especially with certain medications. We're going to look at kidney function, glucose. Some of them will check liver enzymes. So the frequency is dependent on what goes on with that patient and really not a lot of patient prep. These are pretty easy. They can be drawn anytime. There's no fasting or anything like that. There is a little mnemonic there if you want a reference for some information on how to, the normal ranges. CBCs, again, complete blood count. We're looking at the number of red blood cells. And this is important because the hemoglobin in the red blood cells carries oxygen. And sometimes our cardiac patients are anemic, so they're lacking the ability to get oxygen to the rest of their body. Like a CMP or BMP, really no preparation required. You know, it can also flag for increased white blood cells, so it can show if there's any infection going on or other abnormalities within the blood cells. Cholesterol or lipid panels, very frequent, really measuring the fats in the blood. And it can relate to the risk that a person would have of developing a heart attack or other heart disease. And again, the frequency depends really on that patient. So it's not uncommon to see it every three months, six or 12, depending on if we're making medication adjustments, if they've had a recent cardiovascular event. So it's really dependent on each patient. We have ideal ranges here. So total cholesterol, really less than 200 is what we're aiming for. Our LDL should really be less than 100. HDL above 40 and between 60. So there's kind of a sweet spot there. And then triglycerides less than 150. This one does require a 12-hour fast. So that is something that's important to note, that if your patient needs to plan a little bit for that and fast for 12 hours before that sample is drawn. Next is a BNP. BNP is actually a protein that is found in our heart and blood vessels. So it helps us to get rid of fluids by relaxing those blood vessels. And when there's damage to the heart, your body secretes higher levels of BNP. So this is most commonly associated as a way to measure heart failure in patients. Most systems, a lot of systems have transitioned to pro-NT BNPs. So you may see that. They're a little bit different values, but similar function. There again with these, there's no real patient prep required. This is going to be done if they suspect a patient is in a heart failure exacerbation. I do want to stress that you cannot only rely on these numbers because in patients that have chronic heart failure or are obese, these numbers will be elevated. So you cannot base a decision just based on the BNP. So it's a tool that can be used, but you should not solely base your diagnosis on a BNP. Troponin T or I, these are cardiac enzymes. These are very common, obviously, if there's concern for any kind of myocardial damage. So if they are elevated, that does mean that there has been some sort of damage. So these are generally drawn in a ED or a hospital. So if your patient is coming in for follow-up, you may see these results in their chart. And again, they're usually drawn in series of three if a patient is having chest pain. So you can take a look at that to kind of give you some more insight into what their hospitalization was like or if they actually had any myocardial damage. So that's our cardiac enzymes. And then we've got PTINR and PTT. These are really our blood kind of thickness or thinness values. So we use PT or prothombin time when our patients are on Coumadin. We're really trying to get them to a goal INR. So it really looks at that normalized ratio in terms of clotting time. So we want it to be that generally 2 to 3 range, sometimes 2.5 to 3.5 for certain scenarios like bowels and such. PTT, these really we're not measuring this for with Coumadin, but it does measure clotting time for other factors usually used with Heparin or pre-procedure. Really no patient preparation is needed. This can be collected by venipuncture or a finger stick if it's an INR check for Coumadin adjustment. Some other labs that I just want you to be aware of, we do sometimes, especially if a patient's on a new medication that's associated with potential toxicity, we may draw labs for amiodarone or ditch levels to ensure that they don't have too much of the drug in their blood. C-reactive protein is an indicator of inflammation and can be related to some cardiac diseases. Lipoprotein A, which we will talk about a little bit later in another module, but this is another kind of more recent lab for cholesterol management. Genetic testing is one that's evolving, especially in cardiomyopathy and heart failure space, where we are finding a lot of links to familial or inherited cardiomyopathies. And then you may also have some cardio-oncology labs. Again, with cardiomyopathy, we can see some chemo-induced issues and other cardiotoxicity. So just to be familiar that there are other common labs that you may see with your patients. And with that, we are concluding module two. I thank you for your time today. If you have any questions or concerns, please email us at academy at medaxiom.com. Look forward to seeing you in the next module. Thanks.

cardiovascular assessment

history and physical examinations

medication reconciliation

risk scores

lab assessments

patient comfort