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CardioVascular Assessment Lab


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Title: CardioVascular Assessment Lab

CardioVascular Assessment Lab
  • C Ruckdeschel RN, BSN

  • Review Anatomy of Heart
  • Review Vascular System
  • Review Physiologic basics for Cardiovascular

  • Identify Skills to assess cardiovascular System
  • Pulse
  • Peripheral vascular assessment
  • Heart Sounds
  • Blood Pressure

Anatomy of Heart
  • Right side of heart - receives deoxygenated blood
    from systemic circulation - LOW PRESSURE
  • Left Side of the heart - receives oxygenated
    blood from pulmonary circulation and pumps it
    into systemic circulation - HIGH PRESSURE

Chambers and Valves
  • Rt Atrium
  • RT AV Valve (Tricuspid)
  • Rt Ventricle
  • Rt semilunar (Pulmonic)
  • Left Atrium
  • Lft AV Valve (bicuspid, Mitral)
  • Left Ventricle
  • Left semilunar (Aortic)

Great Vessels of the Heart
  • Vena Cava - deoxygenated blood brought to heart
  • IVC (inferior vena Cava)
  • SVC (superior Vena Cava)
  • Pulmonary Artery - deoxygenated blood from rt
    ventricle to pulmonary capillaries
  • Pulmonary Veins - oxygenated blood from pulmonary
    capillaries to lft atrium
  • Aorta -
  • Ascending
  • Arch
  • Descending
  • Thoracic
  • Abdominal

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Coronary Arteries
  • Arteries that arise from base of aorta and supply
    myocardium with richly oxygenated blood
  • LCA
  • LAD
  • Circumflex
  • RCA

Cardiac Conduction System
  • Heart is innervated by Autonomic nervous system
  • Sympathetic stimulates
  • Parasympathetic slows
  • SA Node (Sinoatrial node) located in right
    atria, generates impulses that travel through the
    conduction system produce cardiac muscle
  • AV Node (atrioventricular node) located in the
    atrial septum
  • Bundle of His right and left bundle branches
  • Purkinjie fibers located in ventricular
    myocardium, where ventricular contraction takes

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12 Lead EKG
  • Chest X-ray

Common Cardiovascular Problems
  • CAD (Coronary Artery Disease)
  • HTN (Hyypertension) gt 80 of US population
  • RHD (Rheumatic Heart Disease) - Sequelae of beta
    hemolytic strep infections resulting in valvular
    damage, more likely seen In older adults
  • BE (Bacterial Endocarditis) - bacteremia causes
    valvular damage
  • CHD (Congenital Heart Disease) greatest
    portion diagnosed early in life

Peripheral Vascular Anatomy
  • Aorta
  • Arteries
  • Arterioles
  • Capillaries
  • Venules
  • Veins
  • Vena Cava

Important Vessels
  • Accessible arteries
  • Temporal, Carotid, Aorta, Brachial, Ulnar,
    Radial, Femoral, Popliteal, Doraslis pedis,
    Posterior Tibial
  • Accessible veins
  • Jugular, Superficial deep arm veins, Femoral
    vein (deep), Popliteal vein (deep),

    saphenous (superficial)

Physiologic Basics
  • Myocardium - muscle layer of the heart that
    allows it to act as pump
  • Cardiac Output HR x SV
  • Heart Rate (pulse) beats per minute
  • Blood Pressure SVR x CO
  • Electrical conduction of the heart

Assessing Heart Sounds
  • Heart Sound Review
  • Location
  • Aortic 2nd ICS, RSB (s2 is loudest)
  • Pulmonic 2nd ICS, LSB (s2 is loudest)
  • Erbs Point 3rd ICS, LSB
  • Tricuspid 4th ICS, LSB (s1 is loudest)
  • Mitral (Apex) 5th ICS, MCL (s1 is loudest)
  • S1 represents ventricular contraction
    ejection S1 sound is produced by closing of AV
    valves (tricuspid and Mitral valves)
  • S2 represents ventricular relaxation filling
    S2 sound is produced by closing of semilunar
    valves Aortic and Pulmonic valves

Assessing Heart Sounds
Assessing Heart Sounds
  • Obtain History
  • Risk factors/lifestyle
  • diet, exercise
  • smoking
  • cholesterol
  • stress, palpitations
  • dyspnea/orthopnea
  • edema
  • fatigue - relationship to exercise
  • chest pain
  • Location substernal?
  • Radiate precordial?
  • Quality crushing?
  • Associated N/V
  • Related to activity?
  • Obtain History
  • Any medications?type
  • doseside effectsexpected effectstake as
  • Pacemaker
  • Typebattery checkPresence of AICDautomated
    internal defibrillator

Assessing Heart Sounds
  • Obtain History
  • Past Health History
  • Diabetes
  • Dependent edema
  • congenital heart defect
  • CAD
  • Rheumatic fever
  • Most recent EKG, stress EKG
  • Other diagnostics
  • Obtain History
  • Past Family History
  • Angina
  • Heartdisease
  • MI,StrokeDM,
  • Hyperlipidemia
  • Sudden death age?

Assessing Heart Sounds
  • Inspection
  • Bare chest
  • Quiet room, Privacy
  • Note symmetry of chest, any pulsatile areas,
  • Palpate
  • Precordium
  • palpate 5 sites for
  • Heave (with palmer surface), thrust
  • Thrill (with base of finger of heel of hand (bony
  • palpable murmur cat purring
  • 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

Assessing Heart Sounds
  • Auscultate
  • Use diaphragm and bell of stethoscope
  • start with diaphragm, (S1 and S2 relatively high
  • use bell to listen for S3 and S4
  • heart sounds - S1 and S2
  • rate
  • rhythm - regular (NSR), irregular (warrants
  • extra sounds? Murmurs?
  • Auscultation want to hear crisp, distinct S1 and
  • S1 gt at apex
  • S2 gt at base

Assessing Heart Sounds
  • BE Systematic!! APE TO MAN
  • Listening for 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

After Auscultating Heart Sounds.....
  • Perfect time to auscultate Apical Pulse.
  • Count for one full minute, each cardiac cycle.
  • Note rate rhythm

What is a Pulse?
  • The ventricles pump blood into the arteries at
    about 72 bpm. The blood causes an alternating
    expansion and recoil creates a pressure wave
    which travels through all of the arteries.

  • Adult (60-100) bpm
  • Child (80-120) bpm
  • Infant ( 140 bpm)
  • Palpated on superficial arteries (pulse points)
  • Auscultated on Apex of the heart

Pulse Variations
  • Tachycardia - gt100 bpm
  • Bradycardia - lt 60 bpm
  • Palpitations - Unpleasant sensations of
    awareness of the heartbeat described as skipped
    beats, racing, fluttering, pounding or
    irregularity may result from rapid acceleration
    or slowing of heart, increased forcefulness of
    cardiac contraction not necessarily associated
    with heart disease.

Factors Assessing Pulse
  • Cardiac output
  • Age
  • Gender
  • Exercise
  • Fever
  • Stress
  • Position

Factors Assessing Pulse
  • Cardiac Output
  • Amount of blood ejected from the heart in one
  • Measured by SV x HR
  • Normal HR 60 - 100 beats per minute

Factors Assessing Pulse
  • Age
  • Adult (60-100) bpm
  • Child (80-120) bpm
  • Infant ( 140 bpm)
  • Gender - after puberty female gt male
  • Exercise
  • increased HR with activity
  • increased metabolism causes vasodilatation
  • causes O2 demand

Factors Assessing Pulse
  • Fever
  • body compensates for increased temp by
    vasodilatation, decreased BP causes body to
    compensate by gt HR
  • increased 10-20 beats/min/ degree above norm
  • especially in children

Factors Assessing Pulse
  • Stress
  • sympathetic response, increases HR BP
  • Position
  • sitting, standing causes pooling
  • results in transient - BP
  • rate compensates by increasing

Assessing Pulse
  • Please note
  • Assessing a heart rate is determining beats per
    minute, noting rate, rhythm and strength.
  • Assessing peripheral pulses is to assess arterial
    blood flow to peripheral arteries.

Assessment PulseAuscultating at Apex
  • Using the diaphragm of your stethoscope, place it
    on the 5th intercostal space, MCL
  • For one full minute, count each LUB, DUB as one!!
  • Location of left ventricular apex PMI (point of
    maximum impulse)
  • Adult 5th ICS, MCL
  • Infants 4th ICS, left of MCL
  • Pregancy PMI moves 1-2 cm left of MCL up to
    4th ICS

AssessmentPulses Peripheral Pulses
  • Obtain 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

AssessmentPulses Peripheral Pulses
  • Inspection of Extremities Compare Left to Right
  • Size
  • Symmetry
  • Skin/color
  • Nail Beds
  • Nails
  • Hair Growth

AssessmentPulses Peripheral Pulses
  • Palpation - Compare Right to Left
  • Temperature
  • Capillary refill
  • Pulses
  • UERadial,Brachial
  • LE Dorsalis Pedis, Posterior tibial, popliteal,
  • Edema
  • 1- 4 pitting
  • Sensation

Assessment PulsesCharacteristics of Pulses
  • Rate
  • Rhythm - regular, irregular
  • Contour/elasticity
  • Strength (Amplitude)
  • 4 bounding
  • 3 full, increased
  • 2 normal
  • 1 diminished, weak
  • 0 absent

Arterial Insufficiency of Lower Extremities
  • Pulses - Decreased/Absent
  • Color - Pale on elevation Dusky Rubor on
  • Temperature - Cool/Cold
  • Edema - None
  • Skin - Shiny, thick nails, no hair, Ulcers
    on Toes
  • Sensation - Pain, more with exercise,

Venous Insufficiency of Lower Extremities
  • Pulses - Present
  • Color- Pink to cyanotic, Brown
    pigment at ankles
  • Temperature - Warm
  • Edema - Present
  • Skin - Discolored, scaly, ulcers on ankles
  • Sensation - Pain, More with standing or
    sitting. Relieved with elevation/support hose

Peripheral Vascular Disease
  • Nursing interventions to promote venous return
  • ankle circles, flex ankles, frequent ambulation,
    avoid dependent position for prolonged periods of
  • apply TED stockings or ace bandages (if no
    arterial problem)
  • Nursing Diagnosis
  • Altered cardiac output decreased
  • Altered tissue perfusionperipheral
  • Fluid volume deficit actual
  • Irregular Rhythm
  • ALL irregular rhythms demand an APICAL RADIAL

Assessment Blood Pressure
  • Obtain History
  • Non-modifiable Risk factors
  • Age, sex, personality type
  • Family History sudden death, HTN, stroke, MI
    prior to 50, severe hyperlipidemis, DM
  • PMH arrythmias, murmurs, CHF, Rheumatic disease
  • DM, CAD,Congenital Heart Defects
  • Obtain History
  • Modifiable Risk factors
  • SmokingEmployment physical vs emotional demands,
    environmental hazard, stress managementNutritional
    Status body fat type of dietAnaerobic
    exerciseEstrogen replacement (if
    post-menopausal)Drug use alcohol,, cocaine,
    prescription OTCEssential HTNHypercholesterolemi
    a, DM, CAD

Taking a Blood Pressure
Blood Pressure Key Facts
  • Korotkoff sounds Turbulent sounds of partial
    obstruction of arterial flow
  • Phase I sharp tapping sound (systolic)
  • Phase II change to soft swishing sound
  • Phase III sounds more crisp intense
  • Phase IV muffled tapping
  • Phase V cessastion of sound (diastolic)

Blood Pressure Key Facts
  • Arm Blood Pressure May be 5-10 mmHg higher in
    right arm than left arm greater differences
    between right left arm may be associated with
    congenital aortic stenosis or acquired conditions
    such as aortic dissection or obstruction of
    arteries to upper arm.
  • Leg Blood Pressure Arm leg blood pressures
    are about equal during first year of life after
    that time the leg blood pressure is 15-20 mmHg
    higher than the arm BP.
  • Pulse Pressure difference between systolic and
    diastolic blood pressures
  • Usual pulse pressure is between 30-40 mmHg
  • Orhtostatic Hypotension Decrease in SBP of
    20-30 mmHg or more when changing from supine to
    standing position, increase in pulse of 10-20
    bpm sudden drops may result in fainting.
    Dizziness faintness from orthostatic
    hypotension may occur when taking
    anti-hypertensive medications, hypovolemia,
    confined to bed for prolonged periods of time, or
    the elderly.