Assessment of Cardiovascular System

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Anatomy of the heart

- Is a hollow, muscular organ about the size of a closed fist. It is located between the lungs in the mediastinum, behind and to the left of the sternum. The heart spans the area from the second to the fifth intercostal space. Its right border aligns with the right border of the sternum. The left border aligns with the midclavicular line.
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Pericardium

Is a thin sac with an inner, or visceral layer that forms the epicardium and an outer, or parietal, layer that protects the heart. The space between the two layers (the pericardial space) contains 10 to 30 ml of serous fluid, which prevents friction between the layers as the heart pumps.

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The Atria and ventricles

Four Chambers:

Right atrium Left atrium Right ventricle Left ventricle

Four Valves: Two atrioventricular (AV) 1. tricuspid 2. mitral

Two semilunar (SL) 1. pulmonic 2. aortic
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The vessels

Leading in and out of the heart are the great vessels: the inferior vena cava, the superior vena cava, the aorta, the pulmonary artery, and the four veins.

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Blood Flow through Blood Flow the Heart

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Physiology of the heart

Contractions of the heart occurs in a rhythm called the cardiac cycle and are regulated by impulses that normally begin at the sinoatrial (SA) node.

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Cardiac Cycle
It has two phases:
(A) Diastole ventricles relax & fill with blood (This is 2/3 of the cardiac cycle.) (B) Systolic heart contracts & pushes blood out of the ventricles to: (i) the lungs (ii) systemic arteries

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Preparation for Assessment

Room that is warm & quiet Examining table positioned so you can stand on the patients right side Patient Gown A watch with a second hand Stethoscope with diaphragm & bell Tape measure
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The Heart ( Precordium)

INSPECTION - Inspect the chest. Note landmarks you can use to describe your findings as well as the structures underlying the chest wall. - Look for the apical pulse (PMI)- located at the 5th intercostal space or just medial to the left midclavicular line ( may notice easily in children and in patient with thin chest wall)For women with large breast, displace the breast during examination.

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PALPATION

Maintain a gentle touch when you palpate so that you wont obscure pulsations or similar findings. Follow the systemic palpation sequence covering the sternoclavicular, aortic, pulmonic, tricuspid, and epigastric area.

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Palpating the apical impulse

- To find the apical impulse, use the ball of your hand, then with your fingertips, to palpate over the precordium. Note heaves or thrill, fine vibrations that feel like the purring of a cat.

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PERCUSSION

- percuss

at the anterior axillary line and continue toward the sternum along the fifth intercostal space. The sound changes from resonance to dullness over the left border of the heart, normally at the midclavicular line. The right border of the heart is usually aligned with the sternum and cant be percussed.
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AUSCULTATION

- use a zigzag pattern over the precordium. Be sure to listen over the entire precordium, not just over the valves. Note the heart rate and rhythm. Identify the first and second heart sound (S1 and S2) then listen for adventitious sounds such as third and fourth heart sounds (S3 and S4), murmurs, and pericardial friction rubs (scratchy, rubbing sounds).

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Positioning for auscultation

1. lying in a supine position with the head of the bed raised to 30 to 45 degrees 2. left lateral recumbent 3. sitting up/leaning forward.

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Left lateral recumbent

- is best suited for hearing low-pitched sounds, such as mitral valve murmurs and extra heart sounds. To hear this sound, place the bell of the stetoscope over the apical area.

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Leaning forward position

To auscultate for high pitched heart sounds related to semilunar valve problems, such as aortic and pulmonic valve murmurs. Lean the patient forward. Place the diaphragm of the stetoscope over the aortic and pulmonic areas in the right and left second intercostal spaces.

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Auscultating the heart sounds

1. begin auscultating over the aortic area, placing the stetoscope over the second intercostal space, along the right sternal border. 2. then move to the pulmonic area, located at the second intercostal space, at the left sternal border. 3. next, assess the tricuspid area, which lies over the 4th and 5th ICS, along the left sternal border.
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4. finally, listen over the mitral area, located at the 5th ICS, near the midclavicular line.

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concentrate as you listen for each sounds. Avoid auscultating through clothing or wound dressings because these items can block sound.

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Avoid picking up extraneous sounds by keeping the stetoscope tubing off the patients body and other surfaces. Until you become proficient at auscultation, explain to the patient that listening to his chest for a long period doesnt mean that anything is wrong.

Ask the patient to breathe normally and to hold his breath periodically to enhance sounds that may be difficult to hear.
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Heart Sounds

S1 when closure of the AtrioVentricular valves (tricuspid & mitral) & ventricles contract
S2 when closure of the semilunar valves ( pulmonic & aortic) & the ventricles relax

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Extra Heart Sounds

S3 This occurs immediately after S2 Why? Resistance to filling of ventricles
Note: also called a ventricular gallop

*It is caused by overload. * use diaphragm (it is a high sound) S4 - This occurs at the end of diastole, just before the next S1. Why? The atrium contract & push blood into a non-compliant ventricles. Note: also called an atrial gallop *caused by Hypertension,Aortic stenosis, cardiomyopathy * Use bell to listen as it is a low sound.

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1. ACCENTUATED S1

TIMING - beginning of systole Possible cause: MITRAL STENOSIS OR FEVER

DIMINISHED S1 TIMING - beginning of systole Possible Cause: MITRAL INSUFFICIENCY, HEART BLOCK, SEVERE MITRAL STENOSIS WITH CALCIFIED, IMMOBILE VALVE.

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3. Split S1 (mitral and tricuspid components to the S1 sound) TIMING beginning of systole. Possible Causes: RIGHT BUNDLE-BRANCH BLOCK (BBB) OR PREMATURE VENTRICULAR CONTRACTIONS 4. ACCENTUATED S2 TIMING end of systole Possible Cause: PULMONARY OR SYSTEMIC HYPERTENSION

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5. Diminished S1 TIMING - end of systole Possible cause: AORTIC OR PULMONIC STENOSIS 6. Persistent S2 split (aortic and pulmonic components to the S2 sound) TIMING end of systole Possible cause: DELAYED CLOSURE OF THE PULMONIC VALVE USUALLY FROM OVERFILLING OF THE RIGHT VENTRICLE, CAUSING PROLONGED SYSTOLIC EJECTION TIME.

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Murmurs
Caused by turbulence Therefore we hear a gentle blowing, swooshing sound. Why? 1. Velocity of blood increases (eg. exercise) 2. Velocity of blood decreases (eg. anemia) 3. Structural defect in the valves or an unusual opening occurs in the chambers

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Murmurs Characterisctics:

Quality (blowing, musical harsh, or rumbling). Pitch ( medium, high or low). Location (where the murmurs sounds the loudest) - Use a standard, six level grading scale to describe the intensity (loudness) of the murmur.

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Timing

Quality Location Possible and pitch causes

pulmonic Pulmonic stenosis
Aortic and suprastern al notch AORTIC STENOSIS

midsystoli Harsh, c(systolic rough with ejection) medium to

high pitch Harsh, rough with medium to high pitch

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Holosystolic Harsh with (Pansystolic high pitch ) Blowing with high pitch Blowing with high pitch

Tricuspid

Ventricular septal defect MITRAL INSUFFICI ENCY TRICUSPID INSUFFICI ENCY

Mitral, lower left sternal border tricuspid

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Early diastolic

Blowing with high pitch

Midleft AORTIC sternal INSUFFICI edge (not ENCY aortic area)

Blowing with high pitch

pulmonic

PULMONIC INSUFFICI ENCY

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Middiastolic to late diastolic

Rumbling with low pitch

apex

MITRAL STENOSIS

Rumbling with low pitch

Tricuspid, lower right sternal border

TRICUSPID STENOSIS

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Grading of Murmurs
Use VI point grading scale & record as a fraction (ie. I/VI or II/VI) Grades: Grade I barely audible, heard only in a quiet room & then with difficulty Grade II clearly audible, but faint Grade III moderately loud, easy to hear Grade IV loud, associated with a thrill palpable on the chest wall Grade V very loud, heard with one corner of the stethoscope lifted off the chest wall Grade VI loudest, still heard with the entire stethoscope lifted off the chest

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Murmurs configurations (patterns) - refers to changes in murmur intensity.

1. 2.

3.

4.

Crescendo murmur becomes progressively louder. Decrescendo murmur becomes progressively softer. Crescendo-decrescendo also called DIAMOND-SHAPED HAIR; peaks in intensity and then decreases again. Plateau-shaped murmur remains equal in intensity.

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Bruits

A murmur like sound of vascular (rather than cardiac) origin. CAUSES: occlusive arterial disease or an arteriovenous fistula (heard during arterial auscultation);carotid artery stenosis (Carotid bruit);anemia; hyperthyroidism;pheochromocytoma

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Hearing the pericardial friction rubs

have the patient lean forward because this position will bring the heart closer to the chest wall. If the patient cant tolerate leaning forward, position him sitting upright.
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 ask the patient to exhale, then listen with the diaphragm of the stetoscope over the 3rd ICS on the left side of the chest. if you suspect a rub but have trouble hearing one, ask the patient to hold his breath. A friction rub may be heard during atrial systole, ventricular systole,or ventricular diastole. As a result, the sounds produced by the rub may coincide with the 1st and 2nd heart sound.
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To differentiate a pericardial friction run from a pleural friction rub, ask the patient to hold his breath. The sound from a pericardial friction rub persists, but the sound from a pleural friction rub ceases.

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Vascular system

- delivers oxygen, nutrients, and other substances to the body cells and removes the waste product of cellular metabolism. The peripheral vascular system consist of a network of about 60,000 miles of arteries, arterioles, capillaries, venules and veins that constantly filled with about 5 L of blood, which circulates to and from every functioning cell in the body.
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The Arteries

- carry blood away from the heart. All arteries carry oxygen rich blood from the heart throughout the rest of the body. The only exception is the pulmonary artery which carries oxygen depleted blood from the right ventricle to the lungs. Arteries are thick-walled because they transport blood under high pressure.
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Capillaries

- the exchange of fluid, nutrients and metabolic wastes between blood and cells occurs in the capillaries. This exchange can occur because capillaries are thin-walled and highly permeable. Arterioles constrict and dilate to control blood flow to the capillaries. Venules gather blood from the capillaries.
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Veins

- carry blood toward the heart. Most carry oxygendepleted blood, with the exception of the pulmonary veins which carry oxygenated blood from the lungs to the left atrium. Veins serve as a large reservoir for circulating blood. The wall of a vein is thinner and more pliable than the wall of an artery. Vein contain valves at periodic intervals to prevent the blood from flowing backward

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Assess patients appearance. Is he overly thin? Obese? Alert? Anxious? Note skin color, temperature, turgor and texture. Are his fingers clubbed? (clubbing is a sign of hypoxia caused by lengthy cardiovascular or respiratory disorder). If the patient is dark-skinned, inspect his mucous membrane for pallor.

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The Carotid Artery

The Jugular Venous Pulse & Pressures 2 components: (a) internal jugular (b) external jugular
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INSPECTION
the carotid artery should appear brisk, localized pulsation

The internal jugular vein has a softer, undulating pulsation. Pulsation changes in response to position and breathing. The vein normally protrudes when the patient is lying down and lies flat when he stands.
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PALPATION

Palpate the carotid artery , lightly place your fingers just medial to the trachea and below the angle of the jaw The pulse should be regular in rhythm and have equal strength in the right and left carotid arteries. You shouldnt be able to detect any palpable vibrations, known as thrills.

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dont palpate both carotid arteries at the same time or press too firmly. if you do, the patient may FAINT or become BRADYCARDIC.

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AUSCULTATION

Normally, you should hear no vascular sounds over the carotid arteries upon auscultation. If you detect a blowing, swishing sound, this is a bruit that results from turbulent blood flow. A bruit can occur in patients with arteriosclerotic plaque formation.

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Subjective Data for Peripheral Vascular System

Leg pain Skin changes Swelling in arms & legs Lymph node enlargement Medications Smoking

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INSPECTION

Start by making general observation. Are the arms equal in size? Are the legs symmetrical? Then note the skin color, body hair distribution and lesions, scars, clubbing, and edema of the extremities. If the patient is confined in bed, check the sacrum for swelling. Examine the fingernails and toenails for abnormalities.

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Techniques used to assess the Peripheral Vascular System

Arms: Inspection Palpation radial, ulnar, brachial, epitrochlear lymph nodes * perform the Allen Test
The Allen Test
1) The hand is elevated and the patient/person is asked to make a fist for about 30 seconds. 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails). 4) Ulnar pressure is released and the color should return in 7 seconds. Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate/prick the radial If color does not return or returns after 7 seconds, then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely pricked/cannulated.

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Techniques used to assess the Peripheral Vascular System( Cont.)

Legs: Inspection * If calf pain, check the Homans sign Palpation femoral, poplitial, dorsalis pedis, posterior tibialis * If pretibial edema, press over tibia or medial malleolas for 5 seconds * Use rating scale
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PALPATION

Assess skin temperature, texture and turgor. Assess capillary refill in the nail beds of the fingers and toes. Refill time should not be more than 3 seconds,or long enough to say capillary refill. Palpate the patients arms and legs for temperature and edema. Palpate arterial pulses.

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Assessment of the Peripheral Vascular System(Palpate)

Arteries assessed in cephalocaudal direction:

Head temporal carotid Arms brachial ulnar radial Legs femoral poplitial Feet - dorsalis pedis posterior tibialis

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Grading of pulses:

4+ 3+ 2+ 1+ 0

bounding increased normal weak absent

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Cyanosis and pallor

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Arterial and Venous Insufficiency

Arterial Insufficiency
- in patients, pulses may be decreased pr absent. -skin is cool, pale, and shiny, hair loss occurs in the area, and the patient may have pain in the legs and feet.

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-Ulcerations typically occur in the area around the toes, and the foot usually turns deep red when dependent. Nails may be thick and ridged.

CHRONIC VENOUS INSUFFICIENCY

- In patient, ulcerations develop around the
ankle. Pulses are present but may be difficult to find because of edema. The foot may become cyanotic when dependent.

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Vascular ulcers

Venous ulcer result from venous hypertension.occur mostly at the lower leg.typically found at the ankle.

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Lymphatic ulcers

- Usually results from lymphedema, in w/c the capillaries are compressed by thickened tissue, w/c occludes blood flow to the skin.
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Lymphatic ulcers are extremely difficult to treat because of the reduced blood flow.

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Arterial Ulcers

- Result from arterial

occlusive disease caused by insufficient blood flow to tissue due to arterial insuffieciency. Commonly found at the distal ends of the arterial branches, esp at the tip of the toe, the corners of nail bed or over the bony prominences

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An Additional Test
If there is a color change in the lower extremities Elevate the legs 30 cms (12 inches) Have patient wag feet to drain blood Sit patient up with legs over side of table Note the time it takes for color to return. Normally, the color returns in 10 seconds.
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Edema

May indicate heart failure or venous insufficiency. Right sided heart failure may cause swelling in the lower legs. Edema may also results from varicosities or thrombophlebitis

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2 types of edema:

PITTING EDEMApressure forces fluid in the underlying tissues, causing an indentation that slowly fills. To determine the severity of pitting edema, estimate the indentations depth in centimeters: 1+, 2+, 3+, or 4+
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NONPITTING EDEMA

Pressure leaves no indentation because fluid has coagulated in the tissues. Typically, the skin feels unusually tight and firm

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Weak arterial pulse may indicate decreased cardiac output or increased peripheral vascular resistance; both point to atherosclerotic disease. Strong or bounding pulseoccur in a patient with a condition that causes increased cardiac output, such as hypertension, anemia, or anxiety. A thrill usually suggest a valvular dysfunction.

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Abnormal Pulsation
1. displaced apical impulse Cause: heart failure and hypertension 2. forced apical impulse Cause: increased cardiac output 3. aortic, pulmonic,or tricuspid pulsation Causes: Valvular disease, heart chamber enlargement, aortic aneurysm

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4. epigastric pulsation Causes: heart failure; aortic aneurysm 5. sternoclavicular pulsation Cause: aortic aneurysm 6. slight left and right sternal pulsation Causes: anemia; anxiety; increased cardiac output; thin chest wall 7. sternal border heave Causes: right ventricular hypertrophy; ventricular aneurysm

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Weak pulse - has decreased amplitude with a slower upper stroke and downstroke Possible Causes: increased peripheral vascular resistance; severe heart failure; decreased stroke volume(as occurs in hypovolemia and aortic aneurysm)

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Pulsus Alternans

Has regular, alternating pattern of a weak and strong pulse Possible Cause: left sided heart failure

Pulsus bigeminus - similar to pulsus alternans but occurs at irregular interval Possible Cause: premature atrial/vrentricular beats
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Pulsus Paradoxus

Has increases and decreases in amplitude associated with the respiratory cycle Possible Causes: pericardial tamponade, advanced heart failure and constrictive pericarditis

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Pulsus Biferiens

Shows an initial upstroke, a subsequent downstroke, then another upstroke during systole. Caused: aortic stenosis; aortic insufficiency

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Bounding pulse

Has a sharp upstroke and downstroke with a pointed peak. The amplitude is elevated Possible Causes: increased stroke volume(aortic insufficiency); stiffness of arterial walls (as with aging).

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Thank You..

The end
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