Cardiovascular and Pulmonary Physical Therapy 173

↓ rate and ↓ force of myocardial contraction → ↓ decreased myocardial metabolism

●

➤ Decreased speed of conduction through the AV node

● Causes vasoconstriction of coronary arteries and dilation of peripheral blood vessels
■ Sympathetic stimulation (β-adrenergic)
● Control located in the medulla oblongata: cardioacceleratory center
● Via T1-T4 cord segments- innervates the SA node, AV node, conduction pathways, and
myocytes
➤ Sympathetic receptors located in the SA node and in the myocardium
● Releases epinephrine and norepinephrine
● ↑ rate and↑force of myocardial contraction → ↑ increased myocardial metabolism
● Causes vasodilation of the coronary arteries and vasoconstriction of the peripheral
blood vessels (increased peripheral vascular resistance)
➤ Drugs that mimic sympathetic function: sympathomimetics; include α- and β-agonists
‡ β-agonists: asthma
➤ Drugs that suppress sympathetic function: sympatholytics; include β-blockers
(antagonists)
■ Additional control mechanisms
● Baroreceptors (also called pressoreceptors): main mechanism for controlling HR
➤ Located in the walls of the internal carotid artery (above the carotid bifurcation)
and aortic arch; and carotid sinus
➤ Stimulated by stretching of the vessel wall from changes in blood pressure (BP)
‡ ↑ BP results in parasympathetic stimulation, sympathetic inhibition, ↓ HR and
force of contraction, and ↓ peripheral resistance
‡ ↓ BP results in sympathetic stimulation, ↑ HR, and vasoconstriction of periph-
eral blood vessels
■ Chemoreceptors
● Located in the carotid body and aortic body
● Respond to changes in blood chemicals, such as oxygen (O2), carbon dioxide (CO2),
lactic acid, and hydrogen ion (H+)
➤ ↑ CO2, ↓ O2, or ↓ pH (elevated lactic acid) → ↑ HR
➤ ↑ O2 → ↓ HR
■ Body temperature
● ↑ temperature → ↑ HR
● ↓ temperature → ↓ HR
● Ways to assess
➤ Rectal and tympanic membrane temperatures are 0.5°F to 0.9°F higher than oral
temperature
➤ Axillary temperature is approximately 1.1°F lower then oral temperature
➤ Normal healthy adult
‡ Oral temperature: 98.6°F
‡ Rectal and tympanic membrane temperatures: 99.5°F
‡ Axillary temperature: 97.6°F

Peripheral resistance
■ Influenced by arterial blood volume (viscosity of blood and diameters of arterioles and
capillaries)
● ↑ resistance → ↑ arterial blood volume and pressure
● ↓ resistance → ↓ arterial blood volume and pressure

Cardiovascular Exam: History, Systems Review, Tests, and Measures

Medical record review
■ Past medical history, medical problems, physician examination
■ Medications (dosage, schedule, type)

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 174 NPTE Final Frontier – Mastering the NPTE

■ Laboratory tests
● Example: Creatine kinase-myocardial band (CK-MB) and troponin tests indicate myo-
cardial infarction (MI)
■ Diagnostic studies (X-ray, electrocardiogram [ECG], exercise tolerance test [ETT], cardiac
catheterization)

Patient interview
■ History
● Clinical presentation: ask for onset, progression, nature of symptoms, any activity that
increases or decreases symptoms
● Chest pain, palpitations, shortness of breath (SOB)
➤ Palpitations: awareness by patient of abnormal HR
● General fatigue and weakness
● Dizziness, syncope: due to inadequate cerebral blood flow
● Edema: especially in dependent body parts and lower extremities
● Sudden weight gain
■ Past medical and surgical history: other diagnoses, surgeries, comorbidities
■ Social history: current living arrangement, support system, cultural beliefs and behaviors,
education level, employment status, lifestyle, risk factors
■ Quality of life (QOL), cognition
■ Risk factors: smoking history, diet, activity level

Table 55. Cardiovascular Disease Risk Factors.

Nonmodifiable Modifiable
• Age • Cigarette smoking
◦ Males: >45 years • Hypertension
◦ Females: >55 years ◦ >140/90 mmHg → increased risk
• Family history of cardiac event • Hyperlipidemia
◦ First-degree male relative <55 ◦ Absence of CAD and fewer than 2 risk factors: LDL should be
years or first-degree female <160 mg/dL
relative <65 years increases ◦ Absence of CAD and more than 2 risk factors: LDL should be
relative risk by 1.5–2-fold <130 mg/dL
• Race ◦ Presence of CAD: LDL should be <100 mg/dL
◦ African American ◦ HDL should be
• Sex ▪ >40 mg/dL for males
◦ Male >female ▪ >50 mg/dL for females
◦ After menopause, ◦ Triglycerides should be <150 mg/dL
female = male • Sedentary lifestyle
◦ <30 min of exercise, 3 times/wk
• Obesity: increased risk if
◦ BMI >30
◦ Waist circumference
▪ >40 in (>102 cm) for males
▪ >35 in (>89 cm) for females
• Diabetes: increased risk if
◦ HbA1C >7%
Abbreviations: BMI, body mass index; CAD, coronary artery disease; HbA1C, hemoglobin A1C; HDL, high-density lipoprotein; LDL, low-
density lipoprotein.

Physical Examination: Cardiovascular (CV) System

Examine skin
■ Check for signs and symptoms (S/S) of ↓ CO and ↓ O2 saturation
● Cyanosis: blue color of skin, nail beds, lips, and tongue

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 Cardiovascular and Pulmonary Physical Therapy 175

➤ Central cyanosis: O2 saturation < 80%

Pallor: washed-out, white appearance
●

➤ Anemia, internal hemorrhage

● Diaphoresis: excessive sweating and cool, clammy skin
■ Bilateral peripheral edema: congestive heart failure (CHF), RV failure
■ Unilateral peripheral edema: thrombophlebitis, lymphedema, deep vein thrombosis
(DVT)

Examine pulse
■ Influenced by age, sex, force of contraction, volume and viscosity of blood, diameter
and elasticity of vessels, emotions, stress, exercise, medications, blood temperature, and
hormones
■ Determine pulses
● Regular rhythm: palpate for 30 seconds
● Abnormal rhythm: palpate for 1 to 2 minutes
● Sites to take pulse: radial artery, carotid artery, temporal artery, brachial artery, femo-
ral artery, popliteal fossa, dorsalis pedis artery, posterior tibial artery, apical pulse
point (over the apex of the heart)
➤ Apical pulse: point of maximal impulse
‡ Patient supine, palpate at 5th intercostal space, midclavicular vertical line
‡ Most accurate
‡ Used when peripheral pulses are weak or imperceptible, or when other sites
are not accessible or are difficult to palpate
‡ Displaced upward with pregnancy or high diaphragm
‡ Displaced laterally with CHF, cardiomyopathy, or ischemic heart disease
➤ Radial pulse: most common site
‡ Palpate radial artery at distal radius at the base of the thumb
➤ Carotid pulse
‡ Palpate carotid artery on either side of the lower neck between the trachea and
sternocleidomastoid muscle
‡ Assess one side at a time to reduce the risk of reflex drop of pulse rate or blood
pressure due to stimulation of baroreceptors
➤ Temporal pulse: used by anesthesiologist for monitoring during surgery
‡ Palpate temporal artery superior and lateral to the eye (over the temporal
bone)
➤ Brachial pulse: typically used to measure BP
‡ Palpate brachial artery medial aspect of the antecubital fossa; elbow should be
slightly flexed and supported
➤ Femoral pulse: used to monitor lower-extremity circulation and during cardiac
arrest
‡ Typically examined with patient supine lying
‡ Palpate femoral artery inferior to inguinal ligament, midway between the
­anterior superior iliac spine and pubic symphysis
➤ Popliteal pulse: popliteal artery is deep and, therefore, difficult to palpate at
times
‡ Used to monitor lower-extremity circulation
‡ Typically examined with patient in prone position with knee flexed
‡ Palpate popliteal artery inferior aspect of popliteal fossa
➤ Pedal pulse (dorsalis pedis): used to monitor foot circulation
‡ Palpate dorsalis pedis artery, or dorsal, medial aspect of foot lateral to the
tendon of extensor hallucis longus; ankle is slightly dorsiflexed
➤ Posterior tibial pulse: used to monitor foot circulation; weak or absent pulse
indicative of arterial disease
‡ Palpate posterior tibial artery inferior to medial malleolus

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 176 NPTE Final Frontier – Mastering the NPTE

Table 56. Grading Scale for Peripheral Pulse.

Grade Description
0 Absent, not palpable
1+ Diminished, barely palpable
2+ Normal, easily palpable
3+ Full pulse, increased strength
4+ Bounding pulse

Determine heart rate (HR)

■ Normal
● Adults: 60 to 100 bpm (average is 80 bpm); 40 to 60 bpm in aerobically trained
individuals
● Newborns: 80 to 180 bpm (average is 130 bpm)
■ Tachycardia: >100 bpm
● Compensatory tachycardia: due to volume loss (surgery, dehydration)
● Postural tachycardia syndrome: sustained HR increase of ≥30 bpm within 10 minutes
of standing
■ Bradycardia: <60 bpm

Abnormalities of pulse
■ Irregular: variations in force or frequency; can be due to arrhythmias, myocarditis
■ Weak or thready: low SV, cardiogenic shock, increased peripheral resistance, severe CHF
■ Bounding, full pulse: increased SV, shortened ventricular systole, decreased peripheral
pressure, aortic insufficiency, anxiety, fever, hypertension (HTN), exercise

Figure 50. Cardiac Auscultation.

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 Cardiovascular and Pulmonary Physical Therapy 177

Examine heart sounds

■ Auscultation
● Aortic valve: 2nd intercostal space (ICS), right sternal border
● Pulmonic valve: 2nd ICS, left sternal border
● Tricuspid valve: 4th ICS, left sternal border
● Mitral valve: 5th ICS, left midclavicular line
➤ Where you will hear S3 if present
➤ Also called apical pulse; point of maximal impulse
● Erb point: auscultation location for heart sounds and heart murmurs located at the
3rd left ICS
● Mnemonic
➤ “APTM – 2245” = All Physical Therapists Make $2,245
■ Normal sounds
● Heart sounds are associated with valve closings
● S1 = “Lub”: mitral and tricuspid valves (AV valves) closing → onset of systole
➤ Decreased sound in first-degree heart block
● S2 = “Dub”: aortic and pulmonic valves (semilunar valves) closing → onset of
diastole
➤ Decreased sound in aortic stenosis
● Systole occurs between S1 and S2
● Diastole occurs between S2 and S1
■ Abnormal sounds: Gallops
● S3 = “kenTUCKy” (S1–S2–S3)
➤ Ventricular gallop
➤ Associated with ventricular filling after mitral and tricuspid valves open
‡ Low-frequency turbulence; heard during early diastole
➤ Hallmark sign of CHF
➤ May be normal in children and young athletes
● S4 = “TENNessee” (S4–S1–S2)
➤ Atrial gallop
➤ Associated with abnormal ventricular filling and atrial contraction
‡ Low-frequency turbulence; heard during late diastole
➤ Associated with MI, HTN, and LV hypertrophy
■ Abnormal sounds: Murmurs
● Abnormal heart sounds due to valvular disorders resulting from changes in the blood
flow through the altered valve
● Systolic murmur: turbulence between S1 and S2; valvular disease (mitral valve pro-
lapse), aortic stenosis, or may be normal
➤ Abnormal “swishing” sound is heard instead of “lub”; heard as “lush”
● Diastolic murmur: turbulence between S2 and S1; aortic and pulmonary regurgitation
or mitral stenosis
➤ Fairly uncommon
● Grades of murmurs: grade 1 (softest) to grade 6 (audible with stethoscope lifted off
chest)
● Thrill: abnormal tremor with vascular or cardiac murmur; felt with palpation
● Stenotic valve: impaired opening
● Regurgitant valve: impaired closing
■ Abnormal sounds: Bruit
● Adventitious sound or murmur (blowing sound) of arterial or venous origin
➤ Turbulent blood flow
● Common in carotid or femoral arteries
● Indicates atherosclerosis or partially blocked artery
■ Abnormal sounds: Pericardial friction rub
● Abnormal sound associated with each heartbeat; high-pitched; leathery, scratchy
quality

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 178 NPTE Final Frontier – Mastering the NPTE

● Due to inflammation of the pericardial sac (with or without excessive fluid)

● Post-MI pericarditis: Dressler syndrome

Examine blood pressure (BP)

■ Procedure
● Stethoscope and sphygmomanometer are needed
● Usually, right brachial artery is used to measure BP
● BP cuff bladder length must be sufficient to cover at least 80% of arm circumference
and width must be approximately 40% of arm circumference
➤ Incorrect size is most frequent cause of BP errors
‡ Cuff too narrow → high readings
‡ Cuff too wide → low readings
● Deflate at 2 to 3 mmHg per second
● At least 2 BP readings should be taken at 1-min intervals and values averaged
■ Hypertension (HTN)
● HTN crisis
➤ Requires prompt changes in medication if no other problems are identified
➤ Requires immediate hospitalization if there are signs of organ damage

Table 57. Blood Pressure Classification.

Stage SBP, mmHg AND/OR DBP, mmHg Treatment
Normal <120 AND <80 None
Elevated 120–129 AND <80 Treat with healthy lifestyle and diet
Stage 1 130–139 OR 80–89 Treat with healthy lifestyle and diet or medication in case
of high risk and/or comorbidities
Stage 2 >140 OR >90 Treat with medication
HTN crisis >180 AND/OR >120 Treat as medical emergency
Abbreviations: DBP, diastolic blood pressure; HTN, hypertension; SBP, systolic blood pressure.

■ Hypotension
● Decrease in BP below normal; SBP <90 mmHg or DBP <60 mmHg
● Decrease in BP resulting in inadequate blood flow to the heart, brain, and other vital organs
● Can be due to bed rest, drugs, arrhythmias, blood loss or shock, or MI
■ Orthostatic (postural) hypotension
● Sudden drop in BP due to change in position; usually, from supine to an upright
position
● Drop in SBP of >20 mmHg and/or drop in DBP of >10 mmHg
➤ Assess BP and HR when patient has been supine at rest for 5 minutes
➤ Then, have the patient move directly into standing position. Repeat assessment of
BP and HR after 3 minutes in standing position
● S/S: light-headedness, dizziness, pallor, diaphoresis, syncope, loss of balance, leg
weakness
➤ If patient experiences S/S, have them move from standing to a sitting position or
from sitting with legs elevated to a reclined position

Examine respiration

Table 58. Normal Respiration Rates.

Adult 12–20 br/min
Child 20–30 br/min
Newborn 30–40 br/min
Abbreviation: RR, respiration rate.

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