Cardiovascular Assessment Unit 7

Cardiovascular Assessment
Assess heart peripheral vessels arteries veins carotid arteries jugular veins "Pump" and "Pipes" cardiac output peripheral perfusion

A&P Path of blood flow Cardiac Cycle History IPPA Assessment of Peripheral Pulses Factors Affecting Pulse Rate

Location of heart

Use anterior chest wall landmarks o MSL, MCL o ICS o located 2-5 ICS L of MSL to LMCL o chest area called precordium

Anatomy & Physiology

Location- to L of midline, behind sternum Inverted triangle Base- upper portion Apex - at the bottom

Apex - where L ventricle almost touches chest wall (heart tipped forward) L ventricle contracts forms apical impulse (PMI) 5 ICS LMCL

Anatomy & Physiology

Structure -Cardiac Muscles

epicardium myocardium endocardium

Anatomy & Physiology - Heart

Four chambers: 2 atria, 2 ventricles Atria o act as a reservoir o receives blood returning via veins from lungs & body Ventricles o larger, thicker o pumps blood to lungs & body

Valves separate atria from ventricles and great vessels WHY ?

Function of valves o Open to allow blood to flow o Close to prevent backflow Closure produces NL heart sounds S1 "lub" S 2 "dub"

A&P

4 valves
o

atrioventricular tricuspid mitral

semilunar pulmonic aortic

Tricuspid and mitral valves o work almost in synchrony o when atria contract- valves open o when ventricles contract, valves snap shut

Aortic and Pulmonic valves o work in near synchrony o Pulmonic separates RV from pulmonary artery o Aortic separates LV from aortic artery o when ventricles contract- valves open o when ventricles relax, valves snap shut

A&P

Path of blood flow through heart

Cardiac Cycle

automatic result of electrical impulses, pressure changes

Cardiac Cycle

SA node begins the electrical impulse Through AV node Bundle of HIS To ventricles EKG is an electrical representation of activity

Heart sounds/cardiac cycle

Blood into R atrium L atrium P increases, valves open, atria contract Blood into ventricles P increases, tricuspid and mitral valves close S1 Ventricular contraction. Systole

Semilunar valves are open

Blood into pulmonary artery and aorta P decreases , pulmonic/aortic valves close S2 Ventricles relax . Diastole

Heart sounds/cardiac cycle

Systole

ventricular pressure rises Increase in pressure causes mitral and tricuspid valves to close ventricles contract LV ejects blood to body RV ejects blood to lungs Known as S1 o "lub"

Cardiac Cycle
Diastole- resting phase

ventricles relax while atria contract pressure in ventricles is less than in aorta and pulmonary artery causes the aortic and pulmonic valves to close Known as S2 o "dub" Sometimes hear a third sound while ventricles fill - S3

A&P

Pressure in L side of heart is greater than R Sometimes can hear aortic valves close before pulmonic o referred to as a split S2

History
Risk factors/Lifestyle

diet exercise cholesterol hypertension diabetes gender stress "heart trouble"

HTN heart murmur palpitations dyspnea/PND orthopnea edema fatigue - relationship to exercise chest pain o Location substernal? o Radiate precordial? o Quality crushing? o Associated N/V symptoms diaphoresis o Related to activity? Any medications? o type o dose o side effects o expected effects o take as prescribed?

History - child

Congenital heart defect cyanosis, dyspnea decreased exercise tolerance squat ?

Delayed development

History

Does the client have a pacemaker? o Type o battery check Presence of AID o automated internal defibrillator

Past Health History

Diabetes Dependent edema congenital heart defect CAD

Rheumatic fever Most recent EKG, stress EKG Other diagnostics

Family History

Angina Heart disease MI Stroke DM Hyperlipidemia Sudden death age?

Physical exam
3 techniques, 3 positions, 5 sites

Use IPA sitting, then supine, then L lateral recumbent (prn) IPA sites (more on this later) Aortic 2 R ICS RSB Pulmonic 2 L ICS LSB Tricuspid 5 L ICS LSB Mitral 5 L ICS MCL Erbs point 3 L ICS LSB be systematic: APTM or MTPA

Inspection

I and P give visual and tactile cues before auscultation Bare chest Quiet room Privacy Stand on patients RIGHT side

Inspect

Precordium o R side

o o

tangential light - subtle movements inspect 5 sites for Lifts indicates enlargement or increased cardiac workload Pulsations apical impulse 5 ICS LMCL NL size of nickel What if its larger or in a different place?? Visible @ other sites?

Palpate

Precordium o palpate 5 sites for Heave (with palmer surface) thrust Thrill (with base of finger of heel of hand (bony part)) palpable murmur cat purring

Palpation

Thrills - indicative of obstructed flow o fine palpable rushing sensation o R or L 2nd ICS - Aortic or pulmonic stenosis When palpate precordium o use other hand to palpate carotid artery o S1 should coincide with carotid impulse

Auscultate

Systematic S1 and S2 interval between S1 and S2 should be silent heart sounds not heard best directly over valve which produces it, but in direction of blood flow there are specific sites where each valve sound is best heard Auscultation sites Aortic 2 R ICS RSB Pulmonic 2 L ICS LSB Tricuspid 5 L ICS LSB

Mitral 5 L ICS MCL Erbs point 3 L ICS LSB

S1 is loudest at tricuspid and mitral sites LUB-dub

S2 is loudest at pulmonic and aortic sites lub-DUB

Auscultate

To accentuate sound ask client to exhale and hold breath o hold yours at same time

Use diaphragm and bell o start with diaphragm (S1 and S2 relatively high pitched) o use bell to listen for S3 and S4 Assess o heart sounds - S1 and S2 o rate o rhythm - regular (NSR, NRR) o (irregularly irregular warrants investigation) extra sounds

Auscultation

want to hear crisp, distinct S1 and S2 S1 > at apex S2 > at base

Extra Heart Sounds Split S2

can be physiologic, pronounced during inspiration, should disappear during exhalation

S3

best heard at apex with bell during L ventricular filling physiologic in children and young adults, pregnancy after age 40 suggests ventricular or valve problem

S4

best heard L lateral recumbent position with bell seldom heard in young adults unless well conditioned in older people can be OK or indicate heart disease indicates resistance to ventricular filling o e.g. HTN, pulmonary HTN

Auscultation

Describe findings in terms of o location (ICS, MCL, etc) o timing (systole, diastole)

Auscultation

Murmur o sound superimposed on S1 and S2 o blowing, whooshing hum o describe as during systole or diastole o continuous sound caused by turbulent blood flow ~ bruit 20 increased blood flow incompetent valve congenital heart defect

termed functional - usually systolic 30-50% of young pregnancy, fever abnormal - all diastolic #9;

PERIPHERAL VASCULAR ASSESSMENT

Factors Affecting Pulse

Cardiac output Age Gender Exercise Fever Stress Position Cardiac output o amount of blood ejected from the heart in one minute o measured by SV x HR o Normal HR = 60 - 100 beats per minute Gender o after puberty female > male Exercise o increased HR with activity o increased metabolism causes vasodilatation o causes O2 demand Fever o body compensates for increased temp by vasodilatation o increased 10-20 beats/min/ degree above norm especially in children o increased BP causes body to compensate by > HR

Stress sympathetic response increased BP Position o sitting, standing causes pooling o results in transient BP o rate compensates by increasing
o o

Check for Symmetry

Compare R to L Compare UE to LE

Palpable Pulses

Carotid - Assess one at a time!!! Accessible for CPR

Temporal infants and children

Upper Extremities:

Brachial BP, CPR in infant Radial pulse Ulnar

Palpable Pulses
Lower Extremities:

Femoral arterial studies Popliteal Dorsalis Pedis Posterior Tibial

PERIPHERAL VASCULAR EXAM

History

intermittent claudication pain on walking disappears with rest

leg cramps leg ulcers varicose veins edema of feet or legs blood clots pallor of fingertips

INSPECTION of Upper Extremities (UEs) Compare Side to Side

Size Symmetry Skin/color Nail Beds / Capillary Refill Nails Venous Pattern Hair Growth

PALPATION of Upper Extremities (UEs) Compare Side to Side

Temperature

Capillary refill
Pulses
o o o

Radial Brachial Ulnar

CHARACTERISTICS OF PULSES palpate along LENGTH of artery with finger pads

Rate Rhythm Contour/elasticity Strength (Amplitude) o +4 = bounding o +3 = full, increased o +2 = normal o +1 = diminished, weak o 0 = absent

Rhythm/Pattern regular

irregular (dysrhythmia) if irregular - take apical apical/radial pulse

Should they be the same ? If difference - pulse deficit 20 inefficient vent. contraction inadequate peripheral perfusion INSPECTION of Lower Extremities (LEs) Compare Side to Side

Size Symmetry Skin -color, lesions Nail Beds / Capillary Refill Nails

Venous Pattern Hair Growth

PALPATION of Lower Extremities Compare Side to Side

Pulses Femoral Popliteal

PALPATION of Lower Extremities (LEs) Compare Side to Side

Pulses
o o

Dorsalis Pedis Posterior Tibial

PALPATION of Lower Extremities Compare Side to Side

Pulses Dorsalis Pedis Posterior Tibial Femoral Popliteal Temperature Edema +1- +4 pitting
o o o o

Sensation

Arterial Insufficiency of Lower Extremities

Pulses Color Temperature Edema Skin

Decreased/Absent Pale on elevation Dusky Rubor on dependency Cool/Cold None Shiny, thick nails, no hair Ulcers on Toes

Sensation

Pain, more with exercise Paresthesias

Venous Insufficiency of Lower Extremities

Pulses Color Temperature Edema Skin Sensation

Present Pink to cyanotic Brown pigment at ankles Warm Present Discolored, scaly ulcers on ankles Pain, More with standing or sitting. Relieved with elevation/support hose

Nursing interventions to promote venous return

ankle circles flex ankles apply TED stockings or ace bandages o (if no arterial problem)

Jugular venous pressure

Reflects R atrial pressure (central venous P) estimated by observing int. (or ext. prn) jugular veins at level appear full NL Heart fx- not evident until supine measure vertical distance from sternal angle pressures > 3-4 cm considered elevated may indicate some R heart problem

Nursing Diagnosis

Altered cardiac output: decreased Altered tissue perfusion:peripheral Fluid volume deficit: actual

Irregular Rhythm

ALL irregular rhythms demand an APICAL RADIAL assessment

Teaching Possibilities

Hypertension Medications Risk Factors Prevention of heart disease

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CARDIAC ASSESSMENT

Health History
1. Current Health Status
- chest pain angina pericarditis pneumothorax esophageal reflux myocardial infarction dissecting aortic aneurysm pneumonia esophageal spasm post-myocardial syndrome pulmonary artery hypertension rib fracture esophageal rupture

- shortness of breath - syncope - swelling of ankles or feet - heart palpitations - fatigue

2. Past Health History

- congenital heart disease - rheumatic fever - heart murmur - high blood pressure, high cholesterol, diabetes mellitus - confusion - fatigue

- dental work

3. Family History 4. Personal Habits

- smoking - alcohol - sleep & rest - exercise - nutrition - stress & coping

Techniques of Examination
The patient should be supine with upper body elevated at a 15-30E angle. The room must be quiet, warm, and have good lighting. You should stand to the right of the patient being examined. Inspection and Palpation of the Heart Inspection and palpation reinforce each other and are time saving when done together. Tangential lighting helps you detect pulsations. The ball of the hand (at the base of the fingers) is the most sensitive at detecting thrills. The finger pads are more sensitive in detecting pulsations. Inspect and Palpate for: Pulsations- these are more visible when patients are thin. A thick chest wall or increased AP diameter can obscure them. Pulsations may indicate increased blood volume or pressure. Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. Thrills- these are the vibrations of loud cardiac murmurs. They feel like the throat of a purring cat. Thrills occur with turbulent blood flow. You should inspect and palpate at the following areas:

1. Aortic Area (second interspace to the right of the sternum). a pulsation could indicate an aortic aneurysm. a thrill could indicate aortic stenosis. 2. Pulmonic Area (second interspace to the left of the sternum). a pulsation could indicate pulmonary hypertension. a thrill could indicate pulmonic stenosis. 3. ERB's Point (third interspace to the left of the sternum). findings similar to that of aortic and pulmonic areas. 4. Tricuspid Area (Right Ventricular Area) (4-5th interspace; lower half of the sternum). a sustained systolic lift could indicate right ventricular enlargement. a systolic thrill could indicate a ventricular septal defect. in patients with anemia, anxiety, hyperthyroidism, fever, pregnancy, or increased cardiac output, a brief pulsation may be felt. 5. Mitral Area (Left Ventricular Area) (5th intercostal space at the midclavicular line). This is where you can find the Apical Pulse and usually can find the Point of Maximum Intensity (PMI). identify the PMI by location, diameter, amplitude, duration, and rate. To help identify it, have patient exhale completely and hold breath or have the patient lean forward. Normal is a light tap, 1-2 cm in diameter at the 5th interspace at the left midclavicular line. PMI could be displaced down and to the left with ventricular hypertrophy, pregnancy, and CHF. normally seen in less than half the population. increased pulsation could indicate increased cardiac output, anemia, anxiety, fever, or pregnancy. a thrill could indicate mitral regurgitation, or mitral stenosis. 6. Epigastric Area (below xyphoid process). increased aortic pulsation could indicate AAA, and aortic regurgitation or right ventricular pulsation of right ventricular enlargement. 7. Ectopic Area (2-3rd interspace at the LMCL) increased pulsations in this area seen in patients with MI's or

coronary heart disease. 8. Sternoclavicular Area (top of sternum at junction of clavicles pulsation of aortic arch may be felt in a thin client.

Auscultation of the Heart

1. Aortic Area 2nd right interspace close to the sternum. 2. Pulmonic Area 2nd left interspace. 3. ERB's Point 3rd left interspace. 4. Tricuspid Area 5th left interspace close to the sternum. 5. Mitral Area (Apical) 5th left interspace medial to the MCL 1. With your stethoscope, identify the first and second heart sounds (S1 and S2). at the aortic and pulmonic areas (base). S2 is normally louder than S1. S2 is considered the dub of 'lub-DUB.' S2 is caused by the closure of the aortic and pulmonic valves. at the tricuspid and mitral area (apex) S1 is often, but not always louder than S2. S1 is considered the lub of 'LUB-dub.' S1 is caused by the closure of the mitral and tricuspid valves. S1 is synchronous with the onset of the apical impulse. 2. Identify the heart rate. tachycardia bradycardia 3. Identify the rhythm. if it is irregular, try to identify the pattern. Do early beats appear on a regular rhythm? Does the irregularity vary consistently with respiration? Is rhythm totally irregular? 4. Listen to S1 first, then S2 at the previously mentioned areas using the diaphragm and then the bell. note its intensity.

are there any splitting sounds check during inspiration where S2 usually splits at pulmonic and ERB's point. a thick chest wall or increased AP diameter may make S2 inaudible. Alterations in S1 a. S1 is accentuated in exercise, anemia, hyperthyroidism, and mitral stenosis. b. S1 is diminished in first degree heart block. c. S1 split is most audible in tricuspid area (T-lubdub). Alterations in S2 a. Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on inspiration (lub-T-dub, lub-dub). b. Splitting of S2 can indicate pulmonic stenosis, atrial septal defect, right ventricular failure, and left bundle branch block (lub-T-dub). 5. Listen for S3 (ventricular gallop). a physiologic S3 is frequently heard in children and in pregnant women. it occurs early in diastole during rapid ventricular filling. It is heard best at the apex in the left lateral decubitus position. it is heard best using the bell. a pathologic S3 occurs in people over the age of 40. Cause is usually myocardial failure. sounds like lub-dub-dee (or 'Kentucky'). 6. Listen for an S4 (atrial gallop). it occurs before S1 it is low pitched and best heard with the bell.

often normal in older adults. it is heard best at the apex in the left lateral decubitus position. it may be caused by coronary artery disease, hypertension, myocardiopathy, or aortic stenosis. sounds like dee-lub-dub (or 'Tennessee'). 7. Listen for murmurs. CHECK TIMING. Are they systolic or diastolic? (systolic murmurs may be benign. Diastolic murmurs are never benign). LOCATION OF MAXIMAL INTENSITY. Where is the murmur best heard? FREQUENCY (pitch). This varies from low-pitched, caused by slow velocity of blood flow, to high pitched, caused by a rapid velocity of blood flow. INTENSITY. the loudness of a murmur is described on a scale of 1 to 6: Grade Intensity/ Sounds 1 2 3 4 5 6 very faint, easily missed quiet, barely audible moderately loud but easily heard. Same intensity as S1 or S2. loud but usually no thrill present very loud- thrill present heard with stethoscope off of chest. Thrill present.

RADIATION. some murmurs radiate in the direction of the blood stream by which they are produced. Listen over neck, back, shoulders, and left axilla. - QUALITY. musical blowing harsh rumbling aortic murmurs are heard best in full expiration with patient

leaning forward. mitral murmurs are heard best after exercise in left side lying position. Assessment of Extra Heart Sounds - ejection click - opening snap - midsystolic click Home | Back