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Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system

Rachel S. Natividad, RN,MSN

Position in the Chest


Beneath

precordiumarea on anterior chest overlying the heart and great vessels Located in mediastinummiddle third of chestbetween the lungs

Heart

is an upside down triangle in the chest Top of heart is Base, bottom is Apex

Extends

from 2nd to 5th ICS and from Rt sternal border to Lt MCL Great vessels above base of heart

Great vessels of the neck

Jugular veins

Carotid arteries

JUGULAR VENOUS DISTENTION

JVD

Anatomy of the Heart

Assessment
Position client supine Then head elevated at 45 degrees

INSPECTION: Lifts, heaves PMI (assess location)

Palpation

Physical Landmarks
Suprasternal notch Sternum Manubriosternal angle Angle of Louis Intercostal Spaces

Auscultation: Auscultatory Sites

Auscultatory Sites: Cont.

Heart Sounds S1(Lub)


S1: Closure of AV valves (mitral and tricuspid valves: M1 before T1) Correlates with the carotid pulse Can be split but not often

Heart Sounds S2(Dub)

S2: Closure of Semilunar valves (aortic & pulmonic) May have a split sound (A2 before P2)

Heart Sounds Cont.


Base (R/L 2nd ICS)


S2 louder than S1

Apex
S1 louder than S2

Normal physiologic S2 Split


Best heard at pulmonic area during inspiration

Fixed split (no variation with inspiration)

Extra Heart Sounds


S3

S4

Due to Rapid ventricular filling: ventricular gallop S1 -- S2-S3 (Ken--tuc-ky)

Due to slow ventricular contraction: atrial gallop S4-S1 S2 (Ten-nessee)

Murmurs

turbulent blood flow within the heart

Listen for murmurs in the same auscultatory sites APETM

and soft Gr III : moderated loud, without thrust or thrill Gr IV : loud, with thrill Gr V : louder with thrill, steth on chest wall Gr VI : loud enough to be heard before steth on chest

Grade I :barely audible Gr II : audible but quiet

Peripheral Vascular Assessment

Skin temp Color Pulses Cap refill edema

Peripheral Pulses

Documentation of Pulses

Capillary Refill

Edema

Pitting edema

Assessing for Edema


Depress pretibial area & medial malleolus for 5 seconds Grade pitting edema

1+ to 4+

Deep Vein Thrombosis (DVT)

Assessment Guide: Gas Transportation Blood Pressure: 128/64, 132/72 Apical Heart Rate: 80, 74 Peripheral Pulse: Radial rate: 78, 74 Rhythm: regular, irregular Strength: strong, weak, thready, bounding,0-+4 Rt. Pedal pulse: 2+ Lt. Pedal pulse: 2+
Edema: present, none Degree: 1+, 2+ Location: LLE, RUE

Cap refill Upper extremities: 2 sec Lower extremities: 2 sec Skin/Mucous Membranes: Other (bleeding, infection) Skin /mucous membranes pink note vascular lesions (purpura, ecchymoses, petechiae) redness and inflammation Interventions in use Venodyne/leg compression machine; elevated LEs on pillow; thigh high tedhose in use Med List: Digoxin, Atenolol, Zestril, etc.

Peripheral Vascular Assessment


Arms Inspection 1. Observe arm size & venous pattern; also look for edema

NORMAL FINDINGS Arms are bilaterally symmetric with minimal variation in size and shape. No edema or prominent venous patterning

DEVIATION FROM NORMAL Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery Lymphedema affects 1 extremity, causing induration and nonpitting edema. Prominent venous patterning with edema venous obstruction

Peripheral Vascular Assessment


Arms Inspection 2. Observe coloration of the hands and arms.

NORMAL FINDINGS Color varies depending on the clients skin tone, although color should be the same bilaterally.

DEVIATION FROM NORMAL Raynauds disease Vascular disorder caused by vasoconstriction of the fingers or toes Caused by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, & coldness. Occurs bilaterally; symptoms last minutes to hours

Peripheral Vascular Assessment


Arms Palpation 1. Palpate the clients fingers, hands, and arms, and note the temperature..

NORMAL FINDINGS Skin is warm to touch bilaterally

DEVIATION FROM NORMAL Cool extremity sign of arterial insufficiency. Cold fingers and hands common in Raynauds disease.

Peripheral Vascular Assessment


Arms Palpation 2. Palpate to assess capillary refill time (CRT). Compress the nailbed until it blanches. Release the pressure and calculate the time it takes for color to return. Indicates peripheral perfusion and reflects cardiac output CLINICAL TIP: X findings rm temp is cool, pt has edema, anemia, or recently smoked a cigar NORMAL FINDINGS Capillary bed refill (and therefore color returns) in 1-2 sec. DEVIATION FROM NORMAL

CRT greater than 2 seconds: (1) vasoconstriction (2) decreased CO (3) shock (4) arterial occlusion (5) hypothermia

Peripheral Vascular Assessment


Arms Palpation 3. Palpate the radial pulse. Gently press the radial artery against the radius. CLINICAL TIP: For difficult-to-palpate pulses, use a Doppler ultrasound device. NORMAL FINDINGS Radial pulses have equal strength bilaterally (2+). Artery walls have a resilient quality (bounce) DEVIATION FROM NORMAL Increased radial pulse (1) hyperkinetic state Diminished or absent radial pulse (1) Partial or complete arterial occlusion (more common in legs than in the arms) (2) Buergers disease (3) Scleroderma *Obliteration of the pulse may result from compression by external sources, as in compartment syndrome

Buergers Disease

The initial symptoms of Buergers Disease often include claudication (pain induced by insufficient blood flow during exercise) in the feet and/or hands, or pain in these areas at rest. The pain typically begins in the extremities but may radiate to other (more central) parts of the body. Other signs and symptoms of this disease may include numbness and/or tingling in the limbs and Raynauds phenomenon (a condition in which the distal extremities fingers, toes, hands, feet turn white upon exposure to cold). Skin ulcerations and gangrene (pictured below) of the digits (fingers and toes) are common in Buergers disease. Pain may be very intense in the affected regions.

Peripheral Vascular Assessment


Arms Palpation 4. Palpate the ulnar pulse. Not routinely assessed bec. they are located than radial pulses and are difficult to dectect. Done if you suspect arterial insufficiency NORMAL FINDINGS Ulnar pulses may not be detected. DEVIATION FROM NORMAL

Lack of resilience or inelasticity of the artery arteriosclerosis

Peripheral Vascular Assessment


Arms Palpation 5. Palpate the epithrochlear lymph nodes. Take the clients left hand in your right hand as if you were shaking hands. Flex the clients elbow about 90 degrees. Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles. If nodes are detected, evaluate for size, tenderness, and consistency

NORMAL FINDINGS Normally not palpable.

DEVIATION FROM NORMAL

Enlarged nodes (1) infection in the hand or forearm (2) may occur w/ generalized lymphadenopathy (3) lesion in the area

Peripheral Vascular Assessment


Arms Palpation 7. Perform the Allen Test. Evaluates patency of the radial or ulnar arteries. Done when patency is questionable or before procedures such as a radial artery puncture. Begins by assessing the ulnar patency. Have pt rest hand palm side up on the exam table and make a fist. NORMAL FINDINGS Pink coloration returns to the palms within 3-5 seconds if the ulnar artery is patent. Pink coloration returns within 3-5 seconds if the radial artery is patent. DEVIATION FROM NORMAL

Arterial insufficiency or occlusion of the ulnar & radial artery pallor persists,

Peripheral Vascular Assessment


Arms Palpation 7. Perform the Allen Test. To assess radial patency, repeat the procedure as before, but at the last test, release pressure on the radial artery. NORMAL FINDINGS DEVIATION FROM NORMAL

Peripheral Vascular Assessment


Arms Palpation 7. Perform the Allen Test. Evaluates patency of the radial or ulnar arteries. Done when patency is questionable or before procedures such as a radial artery puncture. Begins by assessing the ulnar patency. Have pt rest hand palm side up on the exam table and make a fist. NORMAL FINDINGS DEVIATION FROM NORMAL

Peripheral Vascular Assessment


Legs Palpation 1. Palpate the superficial inguinal lymph nodes.

NORMAL FINDINGS Nontender movable lymph nodes up to 1 or even 2 cm are commonly palpated.

DEVIATION FROM NORMAL Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy) (1) local infection (2) generalized lymphadenopathy Fixed nodes malignancy