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
• MSL, MCL
• ICS
• located 2-5 ICS L of MSL to LMCL
• chest area called precordium

Anatomy & Physiology

• Location- to L of midline, behind sternum
• Inverted triangle Base- upper portion

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

Anatomy & Physiology

Structure -Cardiac Muscles

• epicardium
• myocardium
• endocardium

Anatomy & Physiology - Heart

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

   

• Valves separate atria from ventricles and great vessels

• Function of valves
  • Open to allow blood to flow
  • Close to prevent backflow
• Closure produces NL heart sounds

A & P

• 4 valves

• atrioventricular

tricuspid
mitral

• semilunar

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

• Aortic and Pulmonic valves
  • work in near synchrony
  • 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

• 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

• Semilunar valves are open
• Blood into pulmonary artery and aorta
• P decreases , pulmonic/aortic valves close S₂

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
  • "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
  • 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
  • Location substernal?
  • Radiate precordial?
  • Quality crushing?
  • Associated N/V

    • symptoms diaphoresis

  • Related to activity?

• Any medications?
  • type
  • dose
  • side effects
  • 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?
  • Type
  • battery check
• Presence of AID
  • 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

Erb’s 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 patient’s RIGHT side

Inspect

• Precordium
  • R side
  • tangential light - subtle movements
  • inspect 5 sites for

Palpate

• Precordium
  • palpate 5 sites for

Palpation

• Thrills - indicative of obstructed flow
  • fine palpable rushing sensation
  • R or L 2nd ICS - Aortic or pulmonic stenosis
• When palpate precordium
  • 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

• S₁ is loudest at tricuspid and mitral sites

• S₂ is loudest at pulmonic and aortic sites

Auscultate

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

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

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
  • e.g. HTN, pulmonary HTN

Auscultation

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

Auscultation

• Murmur
  • sound superimposed on S₁ and S₂
  • blowing, whooshing hum
  • describe as during systole or diastole
  • continuous sound caused by turbulent blood flow

• termed functional - usually systolic

PERIPHERAL VASCULAR ASSESSMENT

Factors Affecting Pulse

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

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

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

• Femoral arterial studies
• Popliteal
• Dorsalis Pedis
• Posterior Tibial

PERIPHERAL VASCULAR EXAM

History

• intermittent claudication

• 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
  • Radial
  • Brachial
  • Ulnar

CHARACTERISTICS OF PULSES
palpate along LENGTH of artery with finger pads

• Rate
• Rhythm
• Contour/elasticity
• Strength (Amplitude)
  • +4 = bounding
  • +3 = full, increased
  • +2 = normal
  • +1 = diminished, weak
  • 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
  • Dorsalis Pedis
  • Posterior Tibial

PALPATION of Lower Extremities Compare Side to Side

• Pulses
  • Dorsalis Pedis
  • Posterior Tibial
  • Femoral
  • Popliteal
• Temperature
• Edema

+1- +4 pitting

• Sensation

Arterial Insufficiency of Lower Extremities

Venous Insufficiency of Lower Extremities

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