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 o o o

Pulmonic separates RV from pulmonary artery Aortic separates LV from aortic artery when ventricles contract- valves open 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

"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

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 tangential light - subtle movements o 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

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 Radial o Brachial o 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 Sensation

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

(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