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22 AClJfE CARE HANDBOOK FOR PHYSICAL THERAPISTS

0--

Supine

Sitting

Standing

Figure 1-7. Orthostatic blood pressure symbols.

• The same extremity should be used when serial BP

recordings will be compared for an evaluation of hemodynamic response.

• A BP record is kept on the patient's vital sign flow sheet.

This is a good place to check for BP trends throughout the

day and, depending on your hospital's policy, to document

BP changes during the therapy session.

•

An auscultatory gap is the disappearance of sounds

between phase 1 and phase 2 and is common in patients

with high BP, venous distention, and severe aortic stenosis.

Its presence can create falsely low systolic pressures if the

cuff is not inflated high enough (which can be prevented

by palpating for the disappearance of the pulse prior to

measurement), or falsely high diastolic pressures if the

therapist stOps measurement during the gap (prevented by

listening for the phase 3 to phase 5 transitions). 13

Auscultation

Evaluation of heart sounds can yield information about the patient'S

condition and tolerance to medical treatment and physical therapy

through the evaluation of valvular function, rate, rhythm, valvular

compliance, and ventricular compliance.4 To listen to heart sounds,

a stethoscope with both a bell and a diaphragm is necessary. For a

review of normal and abnormal heart sounds, refer to Table 1-9.

The examination should follow a systematic pattern using both the

bell (for low-pitched sounds) and diaphragm (for high-pitched

sounds) and should cover all auscultatory areas, as illustrated in

CARDIAC SYSTEM

23

Table 1-9. Normal and Abnormal Heart Sounds

Sound

Location

Description

5 1 (normal)

All areas

First heart sound, signifies closure of

atrioventricular valves and corresponds to onset of ventricular systole.

52 (normal)

All areas

Second heart sound, signifies closure of

semilunar valves and corresponds

with onset of ventricular diastole.

53 (abnormal) Best appreciated

Immediately following S2, occurs early

at apex

in diastole and represents filling of

the ventricle. In young healthy individuals, it is considered normal and

called a physiologic third sound. In

the presence of heart disease, it

results from decreased ventricular

compliance (a classic sign of congestive heart failure).

54 (abnormal) Best appreciated

Immediately preceding S l , occurs late

at apex

in ventricular diastole, associated

with increased resistance to ventricular filling; common in patients with

hypertensive heart disease, coronary

heart disease, pulmonary disease, or

myocardial infarction, or following

coronary artery bypass grafts.

Murmur

Over respective

Indicates regurgitation of blood

(abnormal)

valves

through valves; can also be classified

as sysrolic or diastolic ll1llfmurs.

Common pathologies resulting in

murmurs include mitral regurgitation and aortic stenosis.

Pericardia I

TIlird or fourth

Sign of pericardial innammation (perifriction rub

inrercostal

carditis), associated with each beat of

(abnormal)

space, anrerior

the hearr, sounds like a creak or

axillary line

leather being rubbed together.

Source: Data from LS Bickley. Bate's Guide to Physical Examination and Hisfory

Taking 17th cd). Philadelphia: Lippincott, 1999.

24 AClITE CARE HAND nOOK FOR I)I·IYSICAL THERAPISTS

Pulmonic Area

Aortic Area

Figure 1-8. Areas for heart sound auscultation. (Drawn by Barbara Cocanour.

Ph.D., University of Massac/msetts, Loweff. Departmel1l of Physical Therapy.)

Figure 1-8. Abnormal sounds should be noted with a description of

the conditions in which they were heard (e.g., after exercise or during exercise).

Clinical Tip

• Always ensure proper function of stethoscope by tapping

the diaphragm before applying the stethoscope to the patient.

• Rubbing the stethoscope on extraneous objects can add

noise and detract from true examination.

• Auscultation of heart sounds over clothing should be

avoided, because it muffles the intensity of both normal

and abnormal sounds.

• If the patient has an irregular cardiac rhythm, HR

should be determined through auscultation (apical HR).

To save time, this can be done during a routine auscultatOry examination with the stethoscope's bell or diaphragm

in any location.

CARDIAC SYSTEM

25

Diagnostic and Laboratory Measures

The diagnostic and laboratory measures discussed in this section provide information that is used to determine medical diagnosis, guide interventions, and assist with determining prognosis. The clinical relevance of each test in serving this purpose varies according to the pathology. This section is organized across a spectrum of least invasive to most invasive measures. When appropriate, the test results mOst pertinent to the physical therapist are highlighted. Information

that bears a direct impact on physical therapy clinical decision making usually includes that which helps the therapist identify indications for intervention, relative or absolute contraindications for intervention, possible complications during activity progression, and indicators of performance.

Oximetry

Oximetry (Sa02) is used to indirectly evaluate the oxygenation of a

patient and can be used to titrate supplemental oxygen. Refer to

Chapter 2 for a further description of oximetry.

Electrocardiogram

ECC provides a graphic analysis of the heart's electrical activity.

The ECC is commonly used to detect arrhythmias, heart blocks,

and myocardial perfusion. It can also detect atrial or ventricular

enlargement. ECC used for continuous monitoring of patients in

the hospital typically involves a two- or three-lead system. A lead

represents a particular portion or "view" of the heart. The

patient'S rhythm is usually displayed in his or her room, in the hall,

and at the nurses' station. Diagnostic ECC involves a 1 2-lead analysis, the description of which is beyond the scope of this book. For a review of basic ECC rate and rhythm analysis, refer to Table 1-10

and Figure 1-3.

Holter Monitoring

Holter monitoring is 24- or 48-hour ECC analysis. This is performed to detect cardiac arrhythmias and corresponding symptoms during a patient'S daily activity.12 Holter monitoring is different than telemetric monitoring because the ECC signal is