9/17/2014

Assessment of the
Cardiovascular
System

Jeremiah 17:10
I, the Lord search the
heart, I try the reins, even
to give every man
according to his ways,
and according to the fruit
of his doings.

Devotional

Risk Factors
NON-MODIFIABLE RISK FACTORS
Gender (male)
Race (African-American)
Age (>45yo men; >55yo women
(+) Family history

Risk Factors
MODIFIABLE RISK FACTORS
STRESS
Hyperlipidemia/HPN
Obesity
Physical inactivity
DM
Estrogen (lack in women)
Cigarette Smoking

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Assessment of the Signs

and Symptoms

Assessment of the Signs

and Symptoms

1. Chest Pain
Angina pectoris is the true
symptom of CAD.

1. Chest Pain

ASSESSMENT QUESTIONS

Where is your pain?

What does the pain feel like?

How severe is it on a scale of 0 to 10?

What causes the pain?

Does anything relieve it?
Does it spread to your arms, neck, jaw,
shoulders, or back?
How long does the pain last?
Do you have additional symptoms?

Assessment of the Signs

and Symptoms

Assessment of the Signs

and Symptoms

1. Chest Pain

1. Chest Pain

QUALITY
Tight, squeezing, constricting or
heavy sensation
Burning, aching,choking, dull or
constant
QUANTITY
pain scale

REGION & RADIATION

substernal or precordial

Assessment of the Signs

and Symptoms

Assessment of the Signs

and Symptoms

1. Chest Pain

2. Dyspnea / SOB
When did you first notice feeling
short of breath?
What makes you short of breath?
Is there anything that can ease
your breathing?
What activities are you no longer
able to do because of dyspnea?

TIMING & RESPONSE TO TREATMENT

Angina
usually relieved w/in 5-15 mins
by rest, w/ or w/o use of vasodilators
MI
lasts longer than 20 mins.
sudden onset, constant
not relieved by nitrates or rest, relief with
narcotics

may radiate to neck, arms,

shoulders, or jaw
ASSOCIATED MANIFESTATION
Dyspnea, pallor, tachycardia,
anxiety, and fear.

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Assessment of the Signs

and Symptoms

Assessment of the Signs

and Symptoms

2. Dyspnea / SOB
Do you you ever wake up at night
feeling short of breath?

2. Dyspnea / SOB
Do you get up at night to urinate?

Do you have a cough? If yes, what

do you cough up?

What is your normal weight? Have

On how many pillows do you

sleep?
Do you sleep in the bed or do you

breathe easier sleeping in a chair?

you had a recent weight gain?

Any swelling in your feet, ankles?

Assessment of the Signs

and Symptoms

Assessment of the Signs

and Symptoms

2. Dyspnea / SOB

2. Dyspnea / SOB

Check also for presence of:

Orthopnea - shortness of breath
which occurs when lying flat, causing
the person to have to sleep propped
up in bed or sitting in a chair.

Check also for presence of:

Paroxysmal Nocturnal Dyspnea
(PND) - dyspnea during sleep that

Assessment of the Signs

and Symptoms

Assessment of the Signs

and Symptoms

3. Palpitations

3. Palpitations

- sensation of a rapid or
irregular heartbeat.

Do you ever feel your heart racing,

awakens the sleeper with a

terrifying breathing attack.

skipping beats or pounding?

Do you ever feel lightheaded or

dizzy?
Are there any other symptoms at

the same time?

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Assessment of the Signs

and Symptoms

Assessment of the Signs

and Symptoms

3. Palpitations

4. Fatigue

How much caffeine do you

an overwhelming sustained
sense of exhaustion
decreased capacity for physical
& mental work at usual level

consume?
Do you smoke?
Do you use any stimulants,

nutritional supplements or herbs?

Assessment of the Signs

and Symptoms

Physical Assessment
Parameters

5. Syncope

1. General appearance & cognition

2. Skin
3. BP
4. Arterial pulses
5. JVP
6. Heart
7. Extremities
8. Lungs
9. Abdomen

Do you ever feel dizzy or

lightheaded?
Do you ever pass out or have

fainting spells?
Does this happen upon arising

from lying to sitting/standing?

General Appearance and

Cognition
LOC
Conscious, coherent?
Irritable?
Q: What would you ask to
assess LOC?
A: orientation to time,
place, person

Skin
PALLOR
a decrease in the
color of the skin.
Q: Where is it best
observed?
A: Around the
fingernails, lips,
oral mucosa,
palms of hands &
soles of feet.

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Skin

Skin

PERIPHERAL
CYANOSIS

Xanthelasma
A yellowish,
slightly raised
plaques in the
skin of eyelids

a bluish
discoloration of
the nails & skin of
nose, lips,
earlobes &
extremities.
Poor capillary refill

Skin
POOR SKIN
TURGOR
lift a fold of skin
over the sternum
or lower arms, then
release it.
skin with
decreased turgor
stays pinched for
up to 30 secs

Placing the BP Cuff

Blood Pressure
Systemic arterial BP

the pressure exerted on

the walls of arteries
during v. systole &
diastole
NORMAL BP:
systolic <120; diastolic <80

Palpating the Brachial

Pulse

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Proper placement of the

diaphragm

Blood Pressure
Pulse Pressure
Q: 120/80 What is the PP?
= 40
Normal PP:
= 30-40 mmHg or 1/3 of SBP

Blood Pressure

Blood Pressure

NARROWED PULSE PRESSURE

1. Reflects reduced stroke volume &
ejection velocity.
cardiac tamponade
HF, shock, hypovolemia, MR,
pulmonary embolus
2. Obstruction to blood flow during
systole
mitral stenosis, aortic stenosis

WIDENED PULSE PRESSURE

Blood Pressure

Blood Pressure

Postural / Orthostatic
hypotension
occurs when there is decrease in
SBP 15mmHg & DBP over 10 mmHg
usually asso w/ dizziness,
lightheadedness or syncope.

How to Assess Postural/Orthostatic

Hypotension

(>50mmHg)
1. Reflects conditions that increased stroke
volume

Anxiety, exercise, bradycardia

2. Reduced systemic vascular
resistance

Fever
3. Reduce distensibility of the arteries
Atherosclerosis, HPN, aging

1. Position supine in 10 minutes

before taking the initial BP & HR.
2. The BP should not be removed
between position changes.
3. Assist the patient to sit on the
edge of the bed w/ feet dangling.
4. Check the BP & HR

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Blood Pressure

Blood Pressure

How to Assess Postural/Orthostatic

Hypotension
5. 1-3 minutes should elapse after each
postural change before measuring BP &
HR.
6. If the patient exhibits any signs or
symptoms of distress, return to supine
position.
7. Record the BP & HR, and the s/sx that
accompany the postural changes.

NORMAL POSTURAL CHANGE

RESPONSES
HR increases 5-20bpm above the
resting rate.
An unchanged systolic BP, or slight
decrease of up to 10 mmHg

Blood Pressure

Blood Pressure

Pulsus paradoxus
abnormal fall in systolic BP >10
mmHg during inspiration.
palpate carotid or femoral artery,
the pulse is diminished or absent
during inspiration.
Found in clients with:
1. pericardial tamponade
2. pulmonary HPN

MEAN ARTERIAL PRESSURE

(MAP)
NR: 70-110mmHg
- the force that propels the blood
through the arteries

Blood Pressure

Arterial Pulses

MEAN ARTERIAL PRESSURE

(MAP)
How to compute MAP? 120/80
MAP=DBP + Pulse Pressure/3
80 + 40/3
=93mmHg

PULSE RATE
60-100 bpm
PULSE RHYTHM
Check if initial cardiac exam
or if HR is irregular.

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Arterial Pulses

Arterial Pulses

Apical Pulse & Pulse Deficit

Apical Pulse & Pulse Deficit

Q: HOW TO ASSESS PULSE

DEFICIT?
count the HR by auscultating the
apical pulse for 1 minute while
simultaneously palpating the radial
pulse.

Q: HOW TO ASSESS PULSE

DEFICIT?
IF the radial pulse falls behind the
apical rate, the client has a pulse
deficit,

Arterial Pulses

Arterial Pulses

Pulse quality or amplitude

0 - absent, not palpable
+1 - diminished
+2 - normal, easy to palpate
+3 increased
+4 - bounding

Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsalis pedis
Posterior tibial

Palpating the Femoral Artery

indicates ineffective LV contraction.

Auscultating the Femoral

Artery

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Palpating & Auscultating the

Carotid Artery

Jugular Venous Pressure

ASSESSING FOR JVP
1. Elevate HOB 30-45 deg
2. Turn the clients head to opposite
side.
3. Shine light across the neck.
4. Locate the highest point of internal
jugular vein pulsation.
5. >3cm above the angle of Louis is
JVP

Assessing the Carotid

Artery and Jugular Vein

Assessing the Heart

Auscultating the Mitral

Area

Inspection
Palpation
Percussion
Auscultation

Cardiac Landmarks

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Assessment Landmarks

Assessment Landmarks

Auscultatory Landmarks

Auscultatory Landmarks

Aortic area 2nd ICS right sternal

border (RSB)
Pulmonic area 2nd ICS left sternal
border (LSB)
Erbs point 3rd ICS, LSB
Tricuspid area 4th & 5th ICS, LSB
Mitral area 5th ICS, left MCL

Auscultatory Landmarks

Auscultatory Landmarks

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9/17/2014

Auscultation of the Heart

Guidelines for Cardiac

Auscultation
1. Locate the auscultatory areas.
2. Listen with the ff positions:

a. sitting or supine position.

b. lie on left side, focus on
apex.
c. sit up and lean forward

Guidelines for Cardiac

Auscultation

Apical Impulse
Assessment

Carry out the ff steps when the client

assumes each of the positions:

Ask client to assume a left side lying

position.
Palpate the Point of Maximum
Impulse(PMI)
5th ICS, left MCL
Use palm of hand initially, then
fingerpads

1. Diaphragm - high-pitched sounds S, S,

murmurs, pericardial friction rub.
2. bell- low-pitched sounds S3, S4,
murmur
3. While the client is sitting and leaning
forward, ask the client to exhale & hold the
breath while you listen to heart sounds.

Palpating the Apical

Impulse

Palpating the Apical

Impulse
Normal:
light pulsation, 1-2 cm diameter
Abnormal:

LV heave or lift a broad &

forceful apical impulse

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Apical Impulse
Assessment
amplitude and duration in the LV:
1. LV afterload
HPN, aortic stenosis
2. preload
aortic or mitral regurgitation
3. anxiety, anemia,
hyperthyroidism

Thrills

Apical Impulse
Assessment
amplitude and duration may be
associated w/:
1. dilated cardiomyopathy
2. cardiac tamponade

Assessing Heart Sounds

a palpable vibration
palpated w/ palm of hand

d/t abnormal, turbulent

blood flow over the chest
or an artery
d/t stenosis

Heart Sounds
Q: S or lub is due to?
closure of mitral & tricuspid
valves

Q: it is best heard where?

at the apical area
5th ICS, left MCL

Heart Sounds
Q: S or dub is due to:
closure of aortic & pulmonic valves
Q: it is best heard where?
at aortic & pulmonic areas
2nd ICS, right & 2nd ICS, left

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Heart Sounds
SYSTOLE

DIASTOLE

0.28 sec

0.52 sec

Assessing S1 & S2 Sounds

S coincides with onset of ventricular systole.

S coincides with onset of ventricular diastole.

3rd & 4th Heart Sounds

A triple rhythm in diastole is called a gallop and results from
the presence of a S3, S4 or both.
Description:
Both sounds are low frequency and thus best heard with the
bell of the stethoscope.
Location:

If originating from LV

EXTRA HEART SOUNDS

Usually best heard over apex with patient in the left

lateral position
Softer during inspiration

If originating from RV
Usually best heard over left lower sternal border
Louder during inspiration

S3 Ventricular Gallop

heard during _______

diastole
Apex, left side lying

Normal in children, young & 3rd

trimester preg

blood filling the ventricle is

impeded during diastole.
come in triplets resembling
sound of a galloping horse.
HF, MR, TR, acute MI

S4 Atrial Gallop
atrial systole or atrial
contraction (LATE
DIASTOLE)
RESIST FILLING of
NONCOMPLIANT ventricles.
HPN, aortic stenosis, or hx
of MI

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9/17/2014

S4 Atrial Gallop
d/t forceful atrial ejection of
blood into ventricles that DO
NOT expand.
Best heard at the TRICUSPID
OR MITRAL area when pt is left
sidelying.
May be normal in older
adults

Identifying S3 & S4
Sounds
S3 Sounds

S4 Sounds

Diminished S1
1st degree AV block
Mitral regurgitation
CHF
CAD
Pulmonary or systemic HPN

SYSTOLE

S4

DIASTOLE

S3
S

S4
S

Accentuated S1

Tachycardia
Fever
Anxiety
Exercise
Anemia
Hyperthyroidism

Pericardial Friction Rub

scratchy, grating sound much
like a squeaky leather
use diaphragm at 3rd ICS,LSB
Ask the pt to sit up, lean
forward & hold breath

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Mitral Stenosis
(opening snap)

High-pitched sound very early

in diastole
Heard at LSB
Caused by high pressure in LA
d/t rigid mitral valve.

Aortic Stenosis
(click)

Short high-pitched sound

immediately after S1.
d/t high pressure w/in the
ventricle as it displaces a
rigid & calcified aortic
valve

Splitting of S1

Splitting of S2

Abnormal splitting may

be heard w/ right bundle
branch block (RBBB) &
premature contraction
ventricular PVCs.

Wide splitting is asso. w/

delayed emptying of the
RV.
Fixed splitting occurs when
RV output is > than LV
output.

Mid-systolic click

Murmur Assessment

Ejection sounds (or

clicks) result from the
opening of deformed
semilunar valves
MVP

Grade I barely audible

II audible but quiet & soft
III clearly heard
IV loud, with a thrill
V very loud, w/ thrust or thrill
VI loud enough to be heard
before steth touches the chest

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Murmur Assessment
Midsystolic murmurs are heard w/:
semilunar valve disease (ASV & PSV
stenosis)
hypertrophic cardiomyopathy
Pansystolic (holosystolic) murmurs
AV valve disease (MR, TR, & VSD)
Middiastolic murmur
Mitral stenosis, AR

Assessment of the
Extremities
Clubbing of
Fingers

Edema
An abnormal accumulation of
fluid in the interstitial spaces.
Dependent areas feet, ankles,
lower legs.
Bedridden/chair-ridden clients

Assessment of the
Extremities
Peripheral
edema/Pitting
edema

Assessment of the
Extremities
Lower
extremity
ulcers

Dependent Edema
When heart fails,
blood volume
expands, & fluid
accumulates.
Wt gain of 3 lbs
or more in 24
hrs results from
fluid

sacrum, abdomen or scapula.

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Grading of Edema
SCALE

DEPTH

+1

2mm depression

Slight pitting

+2

4mm depression

+3

6mm depression

+4

8mm depression

Pitting slightly
deeper
Leg visibly
swollen
Leg very
swollen

Clubbing of Fingers

Clubbing of Fingers

chronic tissue hypoxia in

the distal tips of fingers.
the angle bet the base of
the nail & the skin next to
the cuticle increases to >180

Allen Test
Arterial
insufficiency
The normal
ulnar artery
may or may
not have a
palpable
pulse.

Allen Test

Allen Test

1. Have the client make tight fist.

2. Compress both the radial & ulnar
arteries.

3. Have the client open the hand.

4. Observe for pallor & pain.

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Allen Test

5. Release the ulnar artery & observe for

return of pink color w/in 3-5 secs.
6. Repeat the procedure on radial artery.

Abdomen
HEPATOJUGULAR
REFLEX
Press firmly over
the RUQ of the
abdomen for 3060secs
Note an increase
of 1 cm or more in
jugular venous
pressure.

Abdomen

Abdomen

PALPATE
ABDOMINAL AORTA

Ascites,
hepatomegaly,
splenomegaly
Increased or
decreased
bowel tones

subxiphoid area

abdominal

aortic aneurysm
(AAA)
Bruit sound
w/ by palpable
abdominal
pulsation

Ausculating Bruits

Palpating the Spleen

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Palpating the Liver

Percussing the Liver

Lungs

Sequence for Percussing &

Auscultating the Anterior Thorax

Tachypnea
Cheyne-Stokes respiration:
rapid respiration alternating
w/ apnea (LV failure)
Hemoptysis: pink-frothy
sputum
Cough: dry, hacking cough

Sequence for Auscultating the

Posterior Thorax

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