Heart & Neck Vessels

Assessment
Kousar Perveen
Assistant Professor
The University of
Lahore
 Objectives
By the end of the unit, learners will be able to:
1. Describe the following:
Pulse rate, rhythm and pulsation characteristics
PMI
Heart sounds
Discuss systolic and diastolic murmurs
4. Assess the cardiovascular system systematically.
5. Document findings.
6.List the changes in cardiovascular system that is
characteristics of aging process.
 Palpation
2 Palpate the apical The pulse is It is not
impulse palpated in palpated in
the mitral the patients
•*If this pulse is not area and the of
palpated then ask the size of 1- pulmonary
client to assume the 2cm emphysema
left lateral position duration is
•* In older clients it is 2/3 of the If it is more
difficult b/c of the systole than 1-2cm ;
increase in the AP cardiac
diameter * Often it is enlargement
not palpated
 Palpation
2 Palpate for abnormal No Trills or
pulsation pulsations pulsation
or vibrations are usually
are associated
palpated in with grade
the areas of IV or higher
the apex , murmers
left sternal
border or
base
 Palpation
Lift/
Heave
A diffuse lifting left during systole at
the left lower sternal border
associated with
Pulmonic valve disease, pulmonic
hypertension, chronic lung disease
 Palpation
Thrill
A thrills over the 2nd and 3rd
intercostal space it is associated
with
Aortic stenosis, systematic
hypertension
 Palpation
Accentuated Apical Impulse:
Apical impulse has increased force and
duration ventricular hypertrophy,
aortic stenosis, systematic
hypertension
 Palpation
Laterally Displaced Apical
Impulse
A sign of volume overload an apical
impulse displaced laterally and found
over a wider area is the result of
ventricular hypertrophy
Auscultation
 Areas of Heart
1- Aortic Area (second interspace to the right of
the sternum).
• a pulsation could indicate an aortic aneurysm.
a thrill could indicate aortic stenosis.
 Areas of Heart
2. Pulmonic Area (second interspace to the left
of the sternum).
• a pulsation could indicate pulmonary
hypertension.
a thrill could indicate pulmonic
stenosis.
 Areas of Heart
3. ERB's Point (third interspace to the left of the
sternum).
• findings similar to that of aortic and pulmonic
areas.
 Areas of Heart
4. Tricuspid Area (Right Ventricular Area) (4-5th
interspace; lower half of the sternum).
• a sustained systolic lift could indicate right
ventricular enlargement.a systolic thrill could
indicate a ventricular septal defect.
• in patients with anemia, anxiety,
hyperthyroidism, fever, pregnancy, or
increased cardiac output, a brief pulsation
may be felt.
 Areas of Heart
5. Mitral Area (Left Ventricular Area) (5th intercostal space at
the midclavicular line). This is where you can find the Apical
Pulse and usually can find the Point of Maximum Intensity
(PMI).
• identify the PMI by location, diameter, amplitude, duration,
and rate. To help identify it, have patient exhale completely
and hold breath or have the patient lean forward. Normal is
a light tap, 1-2 cm in diameter at the 5th interspace at the
left midclavicular line. PMI could be displaced down and to
the left with ventricular hypertrophy, pregnancy, and
CHF.normally seen in less than half the population.
• Increased pulsation could indicate increased cardiac output,
anemia, anxiety, fever, or pregnancy.
• A thrill could indicate mitral regurgitation, or mitral
stenosis.
 Areas of Heart
6. Epigastric Area (below xyphoid process).
• increased aortic pulsation could indicate
Aortic Aneurysm, and aortic regurgitation or
right ventricular pulsation of right ventricular
enlargement.
 Areas of Heart
7. Ectopic Area (2-3rd interspace at the LMCL)
• increased pulsations in this area seen in
patients with MI's or coronary heart disease.
 Areas of Heart
8. Sternoclavicular Area (top of sternum at
junction of clavicles
• pulsation of aortic arch may be felt in a thin
client.
 Auscultation
1 Auscultat Rate should be •Bradycardia <
e heart 60 -100/min with 60 beats /min
rate and regular rhythm •*premature
rhythm atrial
contraction
•Premature
ventricular

contraction
•Atrial
fibrilation
•Atrial
flutter
 Premature Atrial or Junctional
Contractions
• These beats occur earlier than the next
expected beat and are followed by a pause.
The rhythm resumes with the next beat.
• Auscultation Tip: The early beat has an S1 of
different intensity and a diminished S2. S1 and
S2 are otherwise similar to normal beats.
 Premature Ventricular Contractions
• These beats occur earlier than the next
expected beat and are followed by a pulse.
The rhythm resumes with the next beat.
• Auscultation Tip: The early beat has an S1 of
different intensity and a diminished S2. Both
sounds are usually split.
 Sinus Arrhythmia
• With this dysrhythmia, the heart rate speeds
up and slows down in a cycle, usually
becoming faster with inhalation and slower
with expiration.
• Auscultation Tip: S1 and S2 sounds are usually
normal. The S1 may vary with the heart rate.
 Atrial Fibrillation and Atrial Flutter
with Varying Ventricular
Response
With this dysrhythmia, ventricular contraction
occurs irregularly. At times, short runs of the
irregular rhythm may appear regularly.
• Auscultation Tip: S1 varies in intensity.
 Auscultation
2 If you detect an The radial The difference
irregular and between
rhythm, apical these 2 will
auscultate for a pulse rate indicate atrial
pulse rate should fibrillation,
deficit be atrial flutter,
identical premature
ventricular
contractions
 Auscultation
3 Auscultate to Identify S1 S1
and S2 corresponds
with each
Auscultate S1 “ Lub”, carotid
systole and the S2 pulsation and
“dubb”, diastole. is loudest at
the apex of
the heart. S2
immediately
follows after
S1 and is
loudest at the
base of heart
 Accentuated S1
An accentuated S1 sound is louder
than an S2. This occurs when the
mitral valve is wide open and closes
quickly. Examples include
•Hyperkinetic states in which
blood velocity increases such as
fever, anemia, and hyperthyroidism
•Mitral stenosis in which the
leaflets are still mobile but
increased ventricular pressure is
needed to close the valve
 Diminished S1
Sometimes the S1 sound is softer than the S2
sound. This occurs when the mitral valve is not
fully open at the time of ventricular contraction
and valve closing. Examples include
•Delayed conduction from the atria to the
ventricles as in first-degree heart block, which
allows the mitral valve to drift closed before
ventricular contraction closes it
•Mitral insufficiency in which extreme
calcification of the valve limits mobility
•Delayed or diminished ventricular contraction
arising from forceful atrial contraction into a
noncompliant ventricle as in severe pulmonary
or systemic hypertension.
 Split S1
As named, a split S1 occurs as a split sound.
This occurs when the left and right
ventricles contract at different times
(asynchronous ventricular contraction).
Examples include
•Conduction delaying the cardiac impulse
to one of the ventricles as in bundle branch
block
•Ventricular ectopy in which the impulse
starts in one ventricle, contracting it first,
and then spreading to the second ventricle
 Varying S1
• This occurs when the mitral
valve is in different positions
when contraction occurs.
Examples include
•Rhythms in which the atria
and ventricles are beating
independently of each other
•Totally irregular rhythm such
as atrial fibrillation
 Auscultation
5 Listen to Sound is heard every Any split
S2 where but will be S2 heard in
loudest at the base expiration
is
abnormal
 Accentuated S2
This occurs in conditions in which the aortic
or pulmonic valve has a higher closing
pressure. Examples include
•Increased pressure in the aorta from
exercise, excitement, or systemic
hypertension (a booming S2 is heard with
systemic hypertension)
•Increased pressure in the pulmonary
vasculature, which may occur with mitral
stenosis or congestive heart failure
•Calcification of the semilunar valve in
which the valve is still mobile as in pulmonic
or aortic stenosis
 Diminished S2
A diminished S2 means that S2 is softer
than S1. This occurs in conditions in
which the aortic or pulmonic valves have
decreased mobility. Examples include
•Decreased systemic blood pressure,
which weakens the valves, as in shock
•Aortic or pulmonic stenosis in which
the valves are thickened and calcified,
with decreased mobility
 Normal (Physiologic) Split S2
A normal split S2 can be heard over the
second or third left intercostal space. It is
usually heard best during inspiration and
disappears during expiration. Over the aortic
area and apex, the pulmonic component of
S2 is usually too faint to be heard and S2 is a
single sound resulting from aortic valve
closure. In some patients, S2 may not
become single on expiration unless the
patient sits up. Splitting that does not
disappear during expiration is suggestive of
heart disease.
 Wide Split S2
This is an increase in the usual splitting that
persists throughout the entire respiratory cycle
and widens on expiration. It occurs when there
is delayed electrical activation of the right
ventricle. Example includes
•Right bundle branch block, which delays
pulmonic valve closing
 Auscultation
6 Auscultate for extra heart Normally no Ejection
sounds.Use the diaphragm sounds are sounds or
first and then the bell to heard clicks (e.g a
auscultate over the entire mid systolic
heart area. Note the click
characteristic of any extra associated
sound heard. Auscultate with mitral
during the systolic pause valve prolapse.
(space heart between S1 See the table
and S2) below.
 Auscultation
7 Auscultat S3 sound in S3 sound ( ventricular
e during children, gallop) is in ischemic
the after 40 yearsheart disease,
diastolic of age. It hyperkinetic state or
pause subsides by restrictive myocardial
standing. disease.
S4 with CAD,
S4 is common cardiomyopathy, aortic
sound in stenosis.
athletes or S4 in right percordium
above 50 represents pulmonary
years of age. hypertension, pulmonary
stenosis
 Aortic Ejection Click
Heard during early systole at the second right
intercostal space and apex, the aortic ejection
click occurs with the opening of the aortic
valve and does not change with respiration.
 Pulmonic Ejection Click
Best heard at the second left intercostal space
during early systole, the pulmonic ejection
click often becomes softer with inspiration.
 Midsystolic Click
Heard in middle or late systole, a midsystolic click
can be heard over the mitral or apical area and is
the result of mitral valve leaflet prolapse during left
ventricular emptying. A late systolic murmur
typically follows, indicating mild mitral
regurgitation.
 Heart Auscultation
8 Auscultate for murmurs: A Normally Pathologic
murmur is a swishing sound no midsystolic :
caused by turbulent blood flow murmurs pansystolic
through the heart valves or great are heard. and diastolic
vessels. Auscultate for murmurs However, murmurs.
across the entire heart area. Use innocent
the diaphragm and the bell of and
the stethoscope in all areas of physiologic
auscultation because murmurs midsystolic
have a variety of pitches. Also murmurs
auscultate with the client in may be
different positions as described present in a
below because some murmurs healthy
occur or subside according to heart.
the client’s position
 Heart Auscultation
Levine scale
1.The murmur is only audible on listening carefully for some
time.
2.The murmur is faint but immediately audible on placing the
stethoscope on the chest.
3. A loud murmur readily audible but with no palpable thrill.
4. A loud murmur with a palpable thrill.
5.A loud murmur with a palpable thrill. The murmur is so loud
that it is audible with only the rim of the stethoscope touching
the chest.
6.A loud murmur with a palpable thrill. The murmur is audible
with the stethoscope not touching the chest but lifted just off it.
 Heart Auscultation
9 Auscultate the client S1 and S2 An S1 and S4
assuming other positions: heart heart sound or a
Ask the client to assume a sounds are murmur of mitral
left lateral position. Use normally stenosis that was
the bell of the stethoscope present. not detected
and listen at the apex of with the client
the heart. in the supine
position may be
revealed when
the client
assumes the left
lateral position
 Heart Auscultation
10 Ask the client to sit up, S1 and S2 Murmurs of
lean forward and exhale. heart sounds aortic
Use the diaphragm if are regurgitation
the stethoscope and normally may be
listen over the apex and present. detected when
along the left sternal the client
border assumes this
position
 References
Bicklay, L. S. (2012). Bates’ guide to physical examination and
history taking (10th ed). Wolters Kluwer/Lippincott Williams
& Wilkins Health.
Carol, L.Cox (2010). Physical Assessment for Nurses (2nd. Ed)
Blackwell Publishing Ltd.
Chiocca, E. M. (2011). Advanced pediatric assessment.
Phildelphia, U.S: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Weber, J., & Kelley, J. H. (2015). Health Assessment in
Nursing
(5th ed). Phildelphia: Lippioncot.