Cardiovascular Assessment

1
Cardiovascular Assessment

• The Heart
• Extends from the 2ed to the 5th intercostal
  space
  
• Between the R boarder of the sternum to the L
  midclavicular
  
• Beats against chest wall to produce apical
  impulse
  
• Palpate 5th intercostal space 7-9cm form the mid
  sternal line
  

2

• Heart Chambers
• Right atrium (RA)
• Right ventricle (RV)
• Left atrium (LA)
• Left ventricle (LV)
• Valves
• Aortic valve
• Mitral valve
• Tricuspid valve
• Pulmonic valve

3

• Directions of blood flow
• Blood Flow
• From liver to right atrium (RA) via inferior vena
  cava Superior vena cava drains venous blood from
  the head and upper extremities
  
• From RV, venous blood travels through tricuspid
  valve to right ventricle (RV)
  
• From RV, venous blood flows through pulmonic
  valve to pulmonary artery
  
• Pulmonary artery delivers unoxygenated
• blood to lungs
• 3.Lungs oxygenate blood

4

• Pulmonary veins return fresh blood to LA
• 4. From LA, arterial blood travels through mitral
  valve to LV. LV ejects blood through aortic
  valve into aorta
  
• Aortic delivers oxygenated blood to body
• Diastole
• Ventricles relax and fill with blood and AV
  valves (tricuspid, mitral) open
  
• Bottom number of the B/P
• Occurs when AV valves are open to allow filling
  of the ventricles
  

5

• Systole
• Heart contract and blood pumped in ventricles and
  fills pulmonary systemic arteries
  
• Closure of AV valves contributes to first heart
  sound and signals beginning of systole
  
• Top number of B/P

6

• Percussion outline of the hearts boarder
  limited with the female breast tissue or in an
  obese person or person with muscular chest wall.
  
• Place stationary finger in persons fifth
• intercostal space over on L side of chest near
  anterior axillary line. Slide hand toward
  yourself note change in sound from resonance over
  the lung to dull( over the heart)
• Left border of cardiac dullness is at the
  midclavicular line in 5th interspace
  

7

• and slopes toward sternum
• At the second interspace the border os dullness
  coincides with left sternal border
  
• Right border of dullness matches the sternal
  border
  
• Palpate apical impulse
• Using 1 finger locate the apical impulse
• Ask client to exhale and holdaids in locating
  pulsation
  
• May need to turn client to left to find it.
• Note Location, size, amplitude and Duration

8

• Apical impulse palpable in ½ adults, and not in
  obese or thick wall clients.
  
• Apical impulse increases in amplitude and
  duration in client with anxiety, fever,
  hyperthyroidism and anemia
  
• Auscultation listen for the pitch, rate,
  regularity,
  
• -low pitched, short duration of sound,
  regularity
  
• -deep breathing will temporarily slow heart rate

9

• -identify S1 and S 2, assess S 1and S 2
  separately, listen for extra heat sounds and
  listen for murmurs
  
• -with stethoscope use Z pattern from base
  of the heart across and down, then over apex
  or start at apex and work way up.
  
• -note rate and rhythm
• -if notice irregularity, check for pulse
  deficit
  
• (check radial and apical pulse
  simultanously)
  

10

• When listening
• Start at base of heart and use Z pattern.
• Note
• -rate rhythm
• -Identify S1 and S2
• -Assess S1and S2 separately
• -Listen for extra heart sounds
• -Listen for murmurs
• Landmarks
• -second R interspace aortic valve area

11

• -second L interspace pulmonic valve area
• -L lower sternal border triscupid valve area
• -fifth interspace at around L midclavicular
  line mitral valve area
  
• Heart Sounds
• S1
• Closure of the AV valve
• Beginning of systole
• lup of the lup-dup sound
• -louder at apex
• -coincides with carotid artery pulse

12

• S2
• closure of semilunar valves
• end of systole
• dup of the lup-dup sound
• louder at base
• Abnormal Heart Sounds
• Split S
• -benign condition occurring in some patients
  upon inspiration
  
• -lup-t-dup sound
• -crisper than a murmur
• -occurs at end of inspiration
• -occurs about every fourth beat, fading in
  with
  
• inhalation and out with exhalation

13

• Murmurs
• Vibrations within the hearts chambers or major
  arteries from the back and forth blood flow
  swishing sound
  
• Innocent- no anatomic or physiologic abnormality
  exists
  
• Functional- no anatomic cardiac defect exists but
  physiologic abnormality such as anemia, fever,
  pregnancy, hyperthyroidism)
  

14

• Murmur
• Blowing, swooshing sound that occurs with
  turbulent blood flow in the heart or great
  vessels.
  
• Need to ID if it occurs in systole or diastole
• Extra humming sound between S1 and S2 sounds
• Listen to pitch (high, medium, or low)
• Listen to pattern (crescendo, decrescendo,
• crescendo-decrescendo or diamond shaped)
• -Listen to loudness (grades i to vi barely
  audible to loudness)

15

• -Quality (musical, blowing, harsh, rumbling)
• -Location ( where best heard)
• -Radiation-transmitted downstream direction of
  blood flow
  
• -Posture- disappear or enhanced by change of
  position
  
• Causes
• structural- weakened valve or wall defect
  secondary to streptococcal infection or
  congenital defect
  
• flow murmur
• change in blood viscosity secondary to anemia
• change in blood velocity secondary to exercise

16

• -structural- weakened valve or wall defect
  secondary to streptococcal infection or
  congenital defect
  
• -flow murmur
• change in blood viscosity secondary to anemia
• change in blood velocity secondary to exercise

17

• Loudness
• --Grades i-vi(adults)
• i barely audible, quiet room
• ii clearly audible but faint
• iii moderately loud
• ivloud, associated with a thrill palpable on
  chest wall
  
• v very loud, heard with one corner of
• steth. lifter off chest wall
• viloudest, still heard with entire steth.
  lifted
  
• just off the chest wall

18

• Thrill
• Palpable vibration felt over the heart as blood
  moves from chamber to chamber
  
• ALWAYS ABNORMAL
• Pericardial Friction Rub
• Grating sound upon inspiration, stops when breath
  is held
  
• ALWAYS ABNORMAL

19

• Assessment of Peripheral Pulses Strength
• 0absent
• 1weak
• 2diminished
• 3strong
• 4bounding and full
• Assessment of Pulses
• Regularity/ Rate
• Bilateral Equality
• Should be the same on both sides of the body L or
  R
  

20

• Head to Toe Equality
• Should not be greatly different head to toe
• Use additional assessments
• Check against apical pulse
• Check other measures of circulation if pulse
  heard to find

21
Laeral to

• Cardiac Assessment in Children
• Inspection notice color of skin and mucous
  membranes, observe child in semi-fowler position,
  
  
• check for edema, warmth of extremities
• Palpation locate apical impulse (AI)
• -Lateral to the L midclavicular (LMCL) and
  fourth ICS in children
  
• -At LMCL and fifth ICS in children 7 yrs. old
• Point of maximum intensity (PMI)- area of most
  intense pulsation Ai and PMI not used
  interchangeably but they are at the same place
  
• Thrills- palpable vibrations best felt with

-
22

• ball of hand and during expiration
• produced by flow of blood from one
• chamber of heart to another through
• narrow or abnormal opening
• Pericardial friction rubs-scratchy, high pitched
  grating sound not affected by changes in
  respirations
  
• Capillary refill time-brisk-less than 2 seconds
  blanch nail beds with pressure for a few seconds
  and then release prolonged associated with poor
  systemic perfusion

23

• Auscultation (Children)
• S1 and S2 correspond to lub-dub
• S1 caused by closure of tricuspid and mitral
  valves
  
• S2 caused by closure of pulmonic and aortic
  valves
  
• Distinguish between S1 and S2 simultaneously
  palpate carotid pulse with index middle finger
  as listen to heart sounds
  

24

• Alterations Through the Lifespan (Children)
• Infants and Children
• Change from fetal to neonatal circulation in
  first 24 hours
  
• Foramen ovale closes in1st hours
• ductus arterious closes by the first weeks of
  life
  
• Heart is placed more laterally in children
• Apex is at 4th intercostal space before 3 yrs
• Apex is at the 5th intercostal space at 7 yrs.
  age
  
• CAROTID ARTERY IN NOT PALPATED IN PATIENTS UNDER
  ONE YEAR OF AGE

25

• Abnormal findings in Pediatric patients
• Murmurs common and usually outgrow
• Remain aware of strep effects on the heart
• valve
• Innocent (no valvular or pathologic cause it
  is just a noise
  
• Functional (due to increase blood flow) need to
  have diagnosis test as EKG or echocardiogram
  
• Rheumatic fever-
• Causes weakening of heart valve

26

• Physiological Changes in Pregnancy
• Growing uterus pushes heart up. Left and forward
• Blood volume rises to 40-45 greater than pre
  pregnancy vol.
  
• Murmur in 90 pregnant patients disappear at
  delivery ( non-functional murmurs)
  
• Cardiac output rises to 50 above pre pregnancy
  levels pulse rate rises by 10-20
  
• In Vessels
• Vena Cava syndrome
• Uterus puts pressure on vena cava when patients
  is in supine position
  

27

• Lowers B/P
• Patient feels clammy, dizzy and shows pallor
• Turn patient to L side to relieve pressure of
  vena cava
  

28

• Geriatrics
• Arteries stiffen with age and B/P rises
• Average rise is 20 mmHg between 20-60 and between
  60-80 another 20 mm HG
  
• LV wall thickens
• Loss of ability to augment exercise with
  increased cardiac output
  
• Resting pulse rate remain in the lifetime range
  between 60-100 and maybe irregular
  
• Vessels lose elasticity
• Varicose veins
• More susceptible to clots

29

• Loss of venous elasticity plus less efficient
  cardiac output results in decreased circulation
  
• Lower healing
• Body temperature, regulation is changed
• Abnormal findings in Geriatric Patients
• At risk for dehydration and altered nutritional
  status
  
• Dehydration impacts fluid volume and B/P
• Electrolyte imbalance impact on
  cardioelectricity
  

30

• Murmurs common in this age group
• Arryhthmias more common in this age group
• Ectopic beats( extra beats)
• Lower cardiac output and B/P
• May deprive organs of needed oxygenation
• Better tolerated in younger population
• Tachycardia
• Results in 40-70 drop in cerebral blood volume
• Syncope

31

• Peripheral blood vessels grow more rigid with
  age
  
• Tests and vocabulary
• Atherosclerosis deposit of fatty plaques on the
  intima of the arteries.
  
• Artheriosclerosis arteries becoming more rigid
  producing a rise in systolic B/P
  
• Claudication- pain produced when walking, not
  relieved by rest
  
• Bruit- occurs with turbulent blood flow,
  indicating partial occlusion

32

• Modified Allen Test- evaluate collateral
  circulation firmly depress ulna radial arties,
  patient opens closes fist normal when open
  fist, blood returns to normal
• Homans sign-pain in calf with dorsiflexion of
  the foot, indicating thrombophlebitis or
  thrombus
  
• Pitting Edema
• 1 mild pitting, slightly indentation, no
  perceptible swelling of legs depth of pitting is
  1 cm
  
• 2 moderate pitting, indentation subsides
  rapidly depth of pitting is 2 cm

33

• 3 deep pitting, indentation remains for a short
  time, leg looks swollen depth of pitting is 3
  cm
  
• 4 very deep pitting, indentation lasts a long
  time, leg is very swollen depth of pitting is 4
  cm
  
• Trendelenburg Test- varicosites present in legs
  to determine valve competence lying supine
  elevate legs 90 until veins empty, place
  tourniquet high on thigh, help patient to
• Stand, watch for venous filling saphenous veins
  should fill slowly from below in about 30 seconds

34

• Taking a Health History
• Lifestyle factors
• Smoking- stimulant for CV system
• Serum cholesterol- causes blockages
• Obesity- stresses heart with fat deposits and
  constant state of exertion
  
• Past medical history
• Diabetes- stresses body, effects heart
• HTN- wear tear in aorta and LV
• Family history heart disease or PVD
• Large genetic correlation

35

• Problems during pregnancy
• Are children meeting developmental milestones
  expected growth parameters
  
• Any history of chest pain
• When
• What precipitated it
• What gave relief
• Qualities
• Stabbing, crushing, shooting, radiating
• Angina
• Constriction of small vessels surrounding the
  heart
  
• Causes sharp chest pain

36

• Relief with nitroglycerine
• Assess for complains of fatigue, pallor, edema
  and temperature alterations in the extremities
  
• All indicate possible poor cardiac output
• Nursing Interventions
• Take a careful history
• Provide patient teaching as to risk factors for
  cardiovascular health
  
• When helping patients OOB allow them to move

37

• to prevent hypotension
• Encourage pregnant women to lay on their L side
  to prevent vena cava syndrome
  
• Educate pregnant women of S S of pre eclampsia
  and keep careful B/P records of patients
  
• Keep careful records of pediatric growth
  development parameters for each patient and
  continually check progress
  
• Watch oxygen status of patient with altered
  cardiac output