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
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Four Chambers:
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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 8/31/2012 7 .

8/31/2012 8 .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.

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 8/31/2012 9 .

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Preparation for Assessment       Room that is warm & “quiet” Examining table positioned so you can stand on the patient’s right side Patient Gown A watch with a second hand Stethoscope with diaphragm & bell Tape measure 24 8/31/2012 .

.The Heart ( Precordium) INSPECTION . 8/31/2012 25 .Look for the apical pulse (PMI). displace the breast during examination.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. Note landmarks you can use to describe your findings as well as the structures underlying the chest wall.Inspect the chest.

pulmonic. Follow the systemic palpation sequence covering the sternoclavicular. aortic. 8/31/2012 26 .PALPATION  Maintain a gentle touch when you palpate so that you won’t obscure pulsations or similar findings. and epigastric area. tricuspid.

To find the apical impulse. Note heaves or thrill. fine vibrations that feel like the purring of a cat. then with your fingertips. use the ball of your hand. 8/31/2012 27 .Palpating the apical impulse  . to palpate over the precordium.

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. 28 8/31/2012 . The right border of the heart is usually aligned with the sternum and can’t be percussed. normally at the midclavicular line.

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). rubbing sounds). and pericardial friction rubs (scratchy. 8/31/2012 29 .use a zigzag pattern over the precordium.AUSCULTATION  . murmurs. Be sure to listen over the entire precordium. not just over the valves. Note the heart rate and rhythm.

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sitting up/leaning forward. 8/31/2012 31 . lying in a supine position with the head of the bed raised to 30 to 45 degrees 2.Positioning for auscultation    1. left lateral recumbent 3.

To hear this sound. such as mitral valve murmurs and extra heart sounds. 8/31/2012 32 . place the bell of the stetoscope over the apical area.Left lateral recumbent   .is best suited for hearing low-pitched sounds.

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. 8/31/2012 33 . Place the diaphragm of the stetoscope over the aortic and pulmonic areas in the right and left second intercostal spaces.

34 8/31/2012 . along the left sternal border.Auscultating the heart sounds    1. which lies over the 4th and 5th ICS. 3. next. located at the second intercostal space. at the left sternal border. along the right sternal border. assess the tricuspid area. 2. then move to the pulmonic area. begin auscultating over the aortic area. placing the stetoscope over the second intercostal space.

listen over the mitral area. 8/31/2012 35 .4. located at the 5th ICS. finally. near the midclavicular line.

•Avoid auscultating through clothing or wound dressings because these items can block sound.•concentrate as you listen for each sounds. 8/31/2012 36 .

explain to the patient that listening to his chest for a long period doesn’t 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. •Until you become proficient at auscultation. 8/31/2012 37 .•Avoid picking up extraneous sounds by keeping the stetoscope tubing off the patient’s body and other surfaces.

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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  8/31/2012 39 .

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8/31/2012 41 . cardiomyopathy * Use bell to listen as it is a low sound.This occurs at the end of diastole.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 . just before the next S1. Note: also called an atrial gallop *caused by Hypertension.Aortic stenosis. Why? The atrium contract & push blood into a non-compliant ventricles.

8/31/2012 42 .beginning of systole Possible cause: MITRAL STENOSIS OR FEVER DIMINISHED S1  TIMING . HEART BLOCK. SEVERE MITRAL STENOSIS WITH CALCIFIED.1. ACCENTUATED S1   TIMING .beginning of systole  Possible Cause: MITRAL INSUFFICIENCY. IMMOBILE VALVE.

Possible Causes: RIGHT BUNDLE-BRANCH BLOCK (BBB) OR PREMATURE VENTRICULAR CONTRACTIONS 4. ACCENTUATED S2 TIMING – end of systole Possible Cause: PULMONARY OR SYSTEMIC HYPERTENSION 8/31/2012 43 . Split S1 (mitral and tricuspid components to the S1 sound) TIMING – beginning of systole.3.

CAUSING PROLONGED SYSTOLIC EJECTION TIME. 8/31/2012 44 .5.end of systole Possible cause: AORTIC OR PULMONIC STENOSIS 6. Diminished S1 TIMING . 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.

Velocity of blood increases (eg. Velocity of blood decreases (eg. exercise) 2. anemia) 3.  Why? 1. Structural defect in the valves or an unusual opening occurs in the chambers  8/31/2012 45 .Murmurs Caused by “turbulence” Therefore we hear a gentle blowing. swooshing sound.

Murmurs Characterisctics:     Quality (blowing. 8/31/2012 46 . Pitch ( medium. musical harsh.Use a standard. high or low). six level grading scale to describe the intensity (loudness) of the murmur. or rumbling). Location (where the murmurs sounds the loudest) .

c(systolic rough with ejection) medium to high pitch Harsh.Timing  Quality Location Possible and pitch causes pulmonic Pulmonic stenosis Aortic and suprastern al notch AORTIC STENOSIS midsystoli Harsh. rough with medium to high pitch 8/31/2012 47 .

lower left sternal border tricuspid 8/31/2012 48 .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.

Early diastolic Blowing with high pitch Midleft AORTIC sternal INSUFFICI edge (not ENCY aortic area) Blowing with high pitch pulmonic PULMONIC INSUFFICI ENCY 8/31/2012 49 .

Middiastolic to late diastolic Rumbling with low pitch apex MITRAL STENOSIS Rumbling with low pitch Tricuspid. lower right sternal border TRICUSPID STENOSIS 8/31/2012 50 .

heard with one corner of the stethoscope lifted off the chest wall Grade VI – loudest. I/VI or II/VI) Grades: Grade I – barely audible. associated with a thrill palpable on the chest wall Grade V – very loud. but faint Grade III – moderately loud. heard only in a quiet room & then with difficulty Grade II – clearly audible.Grading of Murmurs Use VI point grading scale & record as a fraction (ie. still heard with the entire stethoscope lifted off the chest 8/31/2012 51 . easy to hear Grade IV – loud.

8/31/2012 52 . Plateau-shaped – murmur remains equal in intensity. Crescendo-decrescendo – also called DIAMOND-SHAPED HAIR. 2. Crescendo – murmur becomes progressively louder.refers to changes in murmur intensity. 4. Decrescendo – murmur becomes progressively softer. peaks in intensity and then decreases again.Murmurs configurations (patterns) . 3. 1.

CAUSES: occlusive arterial disease or an arteriovenous fistula (heard during arterial auscultation). hyperthyroidism.carotid artery stenosis (Carotid bruit).pheochromocytoma  8/31/2012 53 .Bruits  A murmur like sound of vascular (rather than cardiac) origin.anemia.

position him sitting upright. 8/31/2012 54 . If the patient can’t tolerate leaning forward.Hearing the pericardial friction rubs • have the patient lean forward because this position will bring the heart closer to the chest wall.

the sounds produced by the rub may coincide with the 1st and 2nd heart sound.or ventricular diastole. ventricular systole. • if you suspect a rub but have trouble hearing one. then listen with the diaphragm of the stetoscope over the 3rd ICS on the left side of the chest. As a result. •A friction rub may be heard during atrial systole. ask the patient to hold his breath. 8/31/2012 55 .• ask the patient to exhale.

8/31/2012 56 . The sound from a pericardial friction rub persists. ask the patient to hold his breath. but the sound from a pleural friction rub ceases. To differentiate a pericardial friction run from a pleural friction rub.

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The peripheral vascular system consist of a network of about 60. and other substances to the body cells and removes the waste product of cellular metabolism. 58 8/31/2012 . arterioles.delivers oxygen.000 miles of arteries. nutrients. venules and veins that constantly filled with about 5 L of blood. which circulates to and from every functioning cell in the body. capillaries.Vascular system  .

The only exception is the pulmonary artery which carries oxygen depleted blood from the right ventricle to the lungs. All arteries carry oxygen rich blood from the heart throughout the rest of the body. 59 8/31/2012 . Arteries are thick-walled because they transport blood under high pressure.The Arteries  .carry blood away from the heart.

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. 60 8/31/2012 .Capillaries  .the exchange of fluid. Venules gather blood from the capillaries.

Vein contain valves at periodic intervals to prevent the blood from flowing backward 8/31/2012 61 . Veins serve as a large reservoir for circulating blood.carry blood toward the heart. with the exception of the pulmonary veins which carry oxygenated blood from the lungs to the left atrium. The wall of a vein is thinner and more pliable than the wall of an artery. Most carry oxygendepleted blood.Veins  .

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turgor and texture. temperature. If the patient is dark-skinned. 8/31/2012 63 .    Assess patient’s appearance. Is he overly thin? Obese? Alert? Anxious? Note skin color. Are his fingers clubbed? (clubbing is a sign of hypoxia caused by lengthy cardiovascular or respiratory disorder). inspect his mucous membrane for pallor.

The Carotid Artery The Jugular Venous Pulse & Pressures 2 components: (a) internal jugular (b) external jugular 8/31/2012 64 .

8/31/2012 65 . localized pulsation •The internal jugular vein has a softer. undulating pulsation. The vein normally protrudes when the patient is lying down and lies flat when he stands.INSPECTION •the carotid artery should appear brisk. Pulsation changes in response to position and breathing.

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8/31/2012 67 . known as thrills.PALPATION    Palpate the carotid artery . You shouldn’t be able to detect any palpable vibrations. 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.

8/31/2012 68 .•don’t palpate both carotid arteries at the same time or press too firmly. the patient may FAINT or become BRADYCARDIC. • if you do.

you should hear no vascular sounds over the carotid arteries upon auscultation. A bruit can occur in patients with arteriosclerotic plaque formation. If you detect a blowing. swishing sound. this is a bruit that results from turbulent blood flow. 8/31/2012 69 .AUSCULTATION    Normally.

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Subjective Data for Peripheral Vascular System       Leg pain Skin changes Swelling in arms & legs Lymph node enlargement Medications Smoking 8/31/2012 72 .

check the sacrum for swelling. clubbing. Examine the fingernails and toenails for abnormalities. Are the arms equal in size? Are the legs symmetrical? Then note the skin color. If the patient is confined in bed. and edema of the extremities. 8/31/2012 73 . body hair distribution and lesions.INSPECTION    Start by making general observation. scars.

3) Still elevated. then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely pricked/cannulated.Techniques used to assess the Peripheral Vascular System Arms: Inspection Palpation – radial. 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. ulnar. 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 4) Ulnar pressure is released and the color should return in 7 seconds. the hand is then opened. 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. brachial. It should appear blanched (pallor can be observed at the finger nails). 8/31/2012 74 .

) Legs: Inspection * If calf pain. press over tibia or medial malleolas for 5 seconds * Use rating scale 8/31/2012 75 . posterior tibialis * If pretibial edema. poplitial. dorsalis pedis. check the Homan’s sign Palpation – femoral.Techniques used to assess the Peripheral Vascular System( Cont.

8/31/2012 76 . Palpate arterial pulses.or long enough to say “capillary refill”. Refill time should not be more than 3 seconds. texture and turgor. Palpate the patient’s arms and legs for temperature and edema. Assess capillary refill in the nail beds of the fingers and toes.PALPATION     Assess skin temperature.

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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   8/31/2012 78 .

Grading of pulses:      4+ 3+ 2+ 1+ 0 bounding increased normal weak absent 8/31/2012 79 .

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Cyanosis and pallor 8/31/2012 81 .

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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85 8/31/2012 .Usually results from lymphedema.Lymphatic ulcers . w/c occludes blood flow to the skin. in w/c the capillaries are compressed by thickened tissue.

Lymphatic ulcers are extremely difficult to treat because of the reduced blood flow. 8/31/2012 86 .

esp at the tip of the toe.Result from arterial occlusive disease caused by insufficient blood flow to tissue due to arterial insuffieciency. the corners of nail bed or over the bony prominences 8/31/2012 87 .Arterial Ulcers . Commonly found at the distal ends of the arterial branches.

8/31/2012 88 . the color returns in 10 seconds.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.

Edema  May indicate heart failure or venous insufficiency. Edema may also results from varicosities or thrombophlebitis 8/31/2012 89 . Right –sided heart failure may cause swelling in the lower legs.

2 types of edema:   PITTING EDEMApressure forces fluid in the underlying tissues. 3+. estimate the indentation’s depth in centimeters: 1+. 2+. or 4+ 90 8/31/2012 . causing an indentation that slowly fills. To determine the severity of pitting edema.

NONPITTING EDEMA  Pressure leaves no indentation because fluid has coagulated in the tissues. Typically. the skin feels unusually tight and firm 8/31/2012 91 .

   Weak arterial pulse may indicate decreased cardiac output or increased peripheral vascular resistance. anemia. both point to atherosclerotic disease. Strong or bounding pulseoccur in a patient with a condition that causes increased cardiac output. 8/31/2012 92 . A thrill usually suggest a valvular dysfunction. such as hypertension. or anxiety.

heart chamber enlargement. aortic aneurysm  8/31/2012 93 . displaced apical impulse Cause: heart failure and hypertension 2.Abnormal Pulsation 1. pulmonic.or tricuspid pulsation Causes: Valvular disease. aortic. forced apical impulse Cause: increased cardiac output 3.

sternal border heave Causes: right ventricular hypertrophy. slight left and right sternal pulsation Causes: anemia. thin chest wall 7. epigastric pulsation Causes: heart failure. increased cardiac output. aortic aneurysm 5.4. ventricular aneurysm  8/31/2012 94 . sternoclavicular pulsation Cause: aortic aneurysm 6. anxiety.

Weak pulse . severe heart failure. decreased stroke volume(as occurs in hypovolemia and aortic aneurysm)  8/31/2012 95 .has decreased amplitude with a slower upper stroke and downstroke Possible Causes: increased peripheral vascular resistance.

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similar to pulsus alternans but occurs at irregular interval Possible Cause: premature atrial/vrentricular beats 8/31/2012 97 .Pulsus Alternans   Has regular. alternating pattern of a weak and strong pulse Possible Cause: left sided heart failure Pulsus bigeminus .

Pulsus Paradoxus   Has increases and decreases in amplitude associated with the respiratory cycle Possible Causes: pericardial tamponade. advanced heart failure and constrictive pericarditis 8/31/2012 98 .

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Caused: aortic stenosis.Pulsus Biferiens   Shows an initial upstroke. aortic insufficiency 8/31/2012 100 . a subsequent downstroke. then another upstroke during systole.

Bounding pulse   Has a sharp upstroke and downstroke with a pointed peak. stiffness of arterial walls (as with aging). 8/31/2012 101 . The amplitude is elevated Possible Causes: increased stroke volume(aortic insufficiency).

. The end 8/31/2012 102 .Thank You….