Cardiovascular AssessmentCardiovascular AssessmentCardiac Portion of Complete Physical Assessment

Prime Suspect:Prime Suspect:The Heart and the Vascular The Heart and the Vascular SystemSystem

Cardiovascular system Continuous, fluid-filled elastic circuit with a

pump which connects all systems to each other

– communication / transportation of : respiratory - oxygen and carbon dioxide endocrine - hormones, buffers and enzymes Gastrointestinal - nutrients, water, vitamins and

minerals

– Consist of the heart and vascular system

Cardiac Assessment:Cardiac Assessment:begins at begins at IntroductionIntroduction

Beginning with Vital Signs Blood Pressure Heart Rate Temperature

When confronted with multiple clients; quick assessment can help prioritize and help in doing complete assessment.

Introduce yourself (LOC)

– assess that they know who, where, and why

– How do they feel

– Is it neurologic, endocrine problem, or could it be that they are not getting blood to brain

Could be:

–Low Blood pressure

–Low hemoglobin

–Vascular Problems

• Carotid disease

InterviewInterview Chief Complaint

– Chest Pain may be identified as:

–Indigestion–burning–discomfort–tightness–pressure in mid-chest–left arm–jaw pain

– Description of chest Pain (PQRST) P - rovication - What provokes or makes

worse

–Palliation - what relieves or does not Q-uality - what does it feel like R -egion - where is the pain and does it

radiate S-everity - scale 0-10 T-iming - continuous or intermittent.

Relationship to other activities.

– Dyspnea SOB Exertional Orthopnea - unable to lie flat Paroxysmal nocturnal

–wake up ^ 2 hrs after sleep SOB, if accompanied by wheeze called - Cardiac asthma

– Cardiac cough - occurs at night in supine position, exertion, or turning to one side

– Headache Hypertension

– Syncope Effort synocope - after heavy activity is

started –Aortic or subaortic stenosis.

Stokes-Adams attack–related to HB or rhythm disturbance

Pacemaker syncope–Malfunction or failure of artificial

pacemaker Hypersensitive Carotid sinus syncope

–caused by pressure applied to carotid sinus body

– Abdominal pain related to RVF (Right Ventricular

Failure)

– Fatigue or weakness related to RVF

– Edema or weight gain related to RVF

Korotkoff’s SoundsKorotkoff’s Sounds

Sounds heard during auscultation of blood pressure.

Produced by vibratory motion of the arterial wall as the artery suddenly distends when compressed by a pneumatic BP cuff.

Origin of sound may be within the blood passing through the vessel wall or within the wall itself.

5 distinct Korotkoff sounds heard during auscultation of BP– 1st - beat or tapping sound– 2nd - murmur or swish sound– 3rd - crisp tapping sound– 4th - soft, muffled tone– 5th - the last sound heard

Systolic - The first beat or tapping heard Diastolic - The fourth sound heard

Blood Pressure MeasurementBlood Pressure Measurement

Materials needed:

– Stethoscope

– Sphygmomanometer

– Alcohol sponge Choose cuff of appropriate size

– Too narrow may cause falsely high pressure

– Excessive wide a falsely low pressure

Patients arm should be extended at heart level.– Artery above or below heart level, blood

pressure may be elevated or decreased consecutively.

Wrap deflated cuff snugly around upper arm– Above antecubital area inner aspect of elbow.– Center of bladder should rest directly over

medial aspect of arm. (Most cuffs have an arrow for you to position over brachial artery at where you feel strongest pulse)

Place Bell of stethoscope on brachial artery at point of strongest pulse

Locate brachial artery by palpation. Center the bell over the artery and hold it

in place with one hand. The bell of the stethoscope transmits low pitched arterial blood sounds more effectively than the diaphragm.

Pump air into cuff while auscultating the sound over brachial artery - until gauge registers 160mm HG or at least 30 mm Hg above last audible sound.

Open valve and slowly deflate the cuff - 5 mm Hg / second. While releasing air - watch the column and auscultate the sound over the artery.

When you hear the first beat or clear tapping note pressure on column. This is the SYSTOLIC pressure.

Continue to release air gradually. Note the fourth Korotkoff sound (a soft,

muffled tone) This is the DIASTOLIC pressure.

Deflate the cuff quickly.

Problem and Possible Cause for:

– False-high reading Cuff too small - (bladder must be approximately

20% wider than the circumference o f arm). Cuff wrapped too loosely, reducing effectiveness

(tighten cuff) Slow cuff deflation, causing venous congestion in

arm ( Never deflate the cuff more slowly than 2 mm Hg/ heartbeat)

Tilted mercury column (Read pressure column vertically)

Poorly timed measurement -after eating, ambulated, appeared anxious, or flexed arm muscles.

– False-low reading Incorrect position of arm (make sure the

arm is level with patient’s heart) Mercury column below eye level (Read

the mercury column at eye level) Failure to notice auscultatory gap (sound

fades out for 10 - 15 mm Hg, then returns (estimate systolic pressure by palpation before actually measuring it)

Inaudible low-volume sound (Chart as the palpated systolic pressure)

Heart RateHeart Rate Gently press your index, middle, and ring

finger on the radial artery, inside the patient’s wrist.

Count the beats for 60 seconds, or for 30 seconds and multiply by 2. (60 second count more efficient.)

Assess rhythm and volume by noting the pattern and strength. If you detect an irregular beat, repeat the count. IRREGULARITIES ARE IMPORTANT SIGNS

Skin and AppendagesSkin and Appendages Color

– The range of expected skin color varies from dark brown to light tan with pink or yellow overtones.

– Pallor may be indicator of: anemia SNS Sympathomimetics

–Dopamine

Cyanosis (Peripheral vs. Central Cyanosis)

– Peripheral (cold) cyanosis Fingertips Toes Associated with peripheral

hypoperfusion or vasoconstriction

Cyanosis (Central)Cyanosis (Central) Central (warm) cyanosis

– Seen on lips, tongue, mucous membranes; associated with deoxygenated hemoglobin: note in dark-skinned persons - appear as ashen color

May be late sign of hypoxemia in anemic clients May be early sign of hypoxemia in Chronic

Bronchitis (Blue Bloaters)– Blue because of chronic hypoxemia– Bloaters because of Chronic Right Ventricular

failure

Moisture– Diaphoretic– Dryness

Temperature– Cold skin may be related to hypoperfusion

Turgor– Decrease in skin turgor (tenting) related to

interstitial dehydration Edema

– Indicates increase in interstitial fluid

EdemaEdema Note location

– Facial allergies -anaphylaxis Steroids

– exogenous• prednisone

– endogenous - Cushing’s syndrome– Renal disease - Nephrotic syndrome

Dependent: RVF

Degree of Pitting

– Grade 1+ - 0 to 1/4 in.

– Grade 2+ -1 /4 to 1/2 in

– Grade 3+ - 1/2 to 1 in.

– Grade 4+ - > 1 in.

LesionsLesions Arterial disease

– may cause ulcers at the toes or points of trauma

Venous disease

– may cause ulcers at sides of ankles

Arterial DiseaseArterial Disease Excruciating pain in acute occlusions Intermittent claudication in chronic occlusions Pulses are diminished or absent Color is pale Temperature cool or cold Edema is absent Skin changes

– Thin, shiny, atrophic skin– Loss of hair– thickened toenails

Ulcerations– At toes or points of trauma

Venous DiseaseVenous Disease Crampy pain

– Homan’s sign in thrombophlebitis Normal pulses (may be difficult to palpate due to

severe edema) Normal to ruddy color Warm to touch Edema - may be severe Skin Changes

– Brown pigmentation at ankles Ulcerations

– At sides of ankles

Fingertips and nail-bedsFingertips and nail-beds Color

– bluish nail-beds with peripheral disease

– Capillary refill <3 sec >3 - hypoperfusion

Clubbing

– Loss of normal angle between base of nail and skin

– indicates chronic hypoxia

Splinter hemorrhages

– Red to black linear streaks running from base to tip of nail

– bacterial endocarditis Osler’s nodes

– Painful red subcutaneous nodules on fingertips

– indicate embolization of bacterial endocarditis

Peripheral Pulses– Carotid - palpate only lower half and

never palpate both carotids simultaneously

– Brachial– Radial and Ulnar– Femoral– Popliteal– Posterior tibialis– Dorsalis Pedis

Pulse contour– Pulsus Magnus

readily palpable - not easily obliterated Characteristic of:

– Hypertension– Aortic Insufficiency

– Pulsus Parvus Pulse difficult to feel, easily obliterated small weak pulse Characteristic of:

– Aortic and/or mitral Stenosis– Cardiac Tamponade– Constrictive Pericarditis

– Pulsus Alternans Pulses have large amplitude beats followed by pulses

of small amplitude– Every other beat weaker than the preceding one

Characteristic of Left Ventricular Failure– Pulsus Paradoxus

Exaggeration of normal response to inspiration Normal decrease in BP during inspiration is 10

mmHg or less– BP drop more than 10 mmHg during inspiration – Characteristic in:

• Pericardial effusion• Cardiac tamponade• Advanced HF• Severe Lung disease

– Pulsus Bisferiens Two pulses palpated during systole with

second slightly weaker than the first Characteristic of:

– Hypertrophic Cardiomyopathy

– Aortic stenosis or regurgitation

– Water-hammer (Corrigan’s) pulse Increased pulse pressure with a rapid upstroke

and downstroke and shortened peak Characteristic of Aortic Regurgitation

Head and NeckHead and Neck Head

– Head bobbing up and down with heartbeat

– Called de Musset’s sign

– Indicates aortic aneurysm or regurgitation Eyes

– Exophthalmos - abnormal protrusion of the eye

– Usually due to hyperthyroidism

– May be seen in advanced HF with Pulmonary hypertension

Ears– Diagonal bilateral earlobe creases (McCarty’s

sign)– May indicate coronary artery disease if seen in

individuals < 45 years of age.

NeckNeck Neck vein distention of greater than 2 cm

above the sternal angle is indicative of any of the following:

– Right Ventricular Failure

– Hypervolemia

– Tension Pneumothorax

– Cardiac Tamponade

To Evaluate– Place patient at 45 degree angle– Identify sternal angle

raised notch that is created where the manubrium and the body of the sternum join - (Angle of Lewis)

– Measure height of neck distention above level of sternal angle

Estimate Central Venous Estimate Central Venous PressurePressure

Add 5 cm to height of neck vein distention– Normal CVP is 3 to 8 cm

Evaluate hepatojugular or abdominojugular reflux– Apply pressure over right upper quadrant– Evaluate increase in neck vein distention– Increase > 3 cm:

Hepatojugular reflux and Right ventricular failure

LandmarksLandmarks Anatomic

– Clavicle

– Sternum

– Ribs

– Intercostal spaces

– Angle of Louis

– Xiphoid process

– Costal margin and angle

Imaginary LandmarksImaginary Landmarks Mid-sternal line (MSL) Mid-clavicular Line (MCL) Anterior Axillary Line (AAL) Midaxillary Line (MAL) Posterior Axillary line (PAL) Scapular Line (SL) Midspinal line

Location of HeartLocation of Heart Between the sternum and spinal column Lies between second intercostal space and

Fifth intercostal space (5 ICS) Apex normally at fifth LICS and MCL

PrecordiumPrecordiumInspect and PalpateInspect and Palpate Point Of Maximum Impulse (PMI)

– Frequently visible and usually palpable– Location

Fifth LICS and MCL Lateral displacement

– Left ventricular dilation (aortic or mitral insufficiency)

– Upward displacement (pregnancy, ascites) Right to left mediastinal shift

– Tension Pneumothorax– Left ventricular hypertrophy or failure

Medial Displacement– Downward displacement of the diaphragm

COPD

– Left to right mediastinal shift Left Pleural Effusion Tension Pneumothorax

Intensity– normally light tap– HF may increase (cause heave)

Size of PMI– 1 - 2 cm

Heave– Lifting of chest wall (indicative of failure)– Left ventricular heave felt at or near the apex– Right ventricular heave (or lift) felt at or near

the sternum

Thrill

– Palpable vibration associated with a murmur or bruit

– Felt where the murmur is heard the loudest or a location of a bruit.

Murmur - a periodic sound of short duration intracardiac in origin.

Bruit - a sound or murmur heard, extracardiac.

AuscultationAuscultation Stethoscope

– snug fitting earplugs

– Tubing two tubings preferable for high

frequency sounds Not longer than 12 to 15 inches

– Chest Piece Diaphragm - held firmly against skin

–Used for high pitched sounds

• S1, S2 and splits, pericaridal friction rubs, most murmurs

Bell- held tightly enough against skin to create seal

Used for low pitched sounds: S3, S4

Auscultation Areas

– Aortic - 2nd RICS at Right sternal border

– Pulmonic - 2nd LICS at Left sternal border

– Erb’s Point - 3rd LICS at Left sternal border

– Tricuspid - 5th LICS at Left sternal border

– Mitral - 5th LICS at mid-clavicular line

Auscultation should be performed in each of the five cardiac areas– use of the diaphragm first, then the bell of the

stethoscope. Using firm pressure with the diaphragm and light pressure with the bell

– Assess the overall rate and rhythm of the heart -noting the area being accessed.

– Breathing normally, then holding breath listen for S1 while palpating the carotid pulse. S1 coincides with the rise of the carotid pulse. (Systole)

– Note the intensity, any variations, the effect of respiration and any splitting of S1

Basic Heart SoundsBasic Heart Sounds

There are four basic heart sounds: S1, S2, S3 and S4. S1 and S2 are the most distinct heart sounds.

S3 and S4 may or may not be present; their absence is not an unusual finding, but their presence does not necessarily indicate a pathologic condition.

Rules to considerRules to consider Left sided heart events precede right side

(mitral component precedes tricuspid of S1, Aortic event precedes pulmonic of S2)

Left sided heart events are normally loudest during expiration, and right sided events are normally loudest during inspiration.

S1 is the result of the closure of the AV valves– indicate the beginning of systole and is best

heard toward the apex where it is usually louder than S2

S2 is the result of closure of the semi-lunar valves and indicates the end of systole– indicates the end of systole and is best heard

in the aortic and pulmonic areas.

Heart sounds according to Heart sounds according to Cardiac AreaCardiac Area Aortic area

– Loudness - S1< S2

– Duration - S1 > S2

Pulmonic area – Loudness - S1 < S2

– Duration - S1 > S2

Erb’s Point– Loudness - S1 < S2

– Duration - S1 > S2

Mitral area– Loudness - S1 > S2

– Duration - S1 > S2

Tricuspid Area– Loudness - S1 > S2

– Duration - S1 > S2

Splitting of SSplitting of S11 and S and S22 S1

– usually is not heard because the sound o the tricuspid valve closing is too faint to hear.

– Heard best when audible in the tricuspid area S2

– Expected due to the higher pressures and depolarization occurs earlier on the left side of the heart.

– Ejection times on the right are longer and pulmonic valve closes a bit later than the aortic valve.

SS11 and S and S22 Split Split

S1 is the result of closure of the AV valves - indicating the beginning of systole. Mitral and Tricuspid valves.

Heard best at tricuspid area on inspiration.

Although there is some asynchrony between closure of the mitral and tricuspid valves - usually heard as one sound.

Narrowly split may be normal

A split S1 is more abnormal than normal and is associated with any one of the following:– RBBB– Left ventricular (epicardial) pacemaker– Left ventricular ectopy

Split S2

– Both Aortic and Pulmonic components can be heard

– Inspiratory only is normal Called physiologic split of S2

Split ONLY during inspiration Caused by intra-thoracic changes in

pressure; increased venous return to right and decreased venous return to left

Expiratory Split of SExpiratory Split of S22

Increased splitting during inspiration (split on expiration but split more on inspiration)

– RBBB (Right Bundle Branch Block)

– Left ventricular ectopy

– Severe mitral regurgitation

– Ventricular septal defect

SS33

Ventricular gallop Occurs early in diastole Caused by rapid rush of blood into a

dilated ventricle. Heard best with bell Associated primarily with Heart Failure

Associated with:– Fluid overload– Cardiomyopathy– Ventricular septal defect– Mitral or tricuspid regurgitation

– __S1____S2__S3

SS44

Atrial Gallop Dull, low pitched occurring late in diastole

before S1.. Caused by atrial contraction and

propulsion of blood into a non-compliant ventricle

Heard best with bell

Associated with:– Myocardial ischemia or infarction– Hypertension– Ventricular ectopy– AV blocks– Severe aortic or pulmonic stenosis.

__S4__S1___S2__

Extra Heart Sounds:Extra Heart Sounds: Summation gallop

– All four heart sounds plus tachycardia

– Merging of S3 and S4 causing a louder mid-diastolic sound

Pericardial friction rub– scratchy sound - usually

triphasic; systolic, early and late diastolic

– Caused by pericardial inflammation

after MI or CABG

Snaps– Opening snap

Short, high-pitched; early diastole

Caused by:– Opening of

stenotic AV valve

– Increased flow– closing snap

Really a loud S1

Caused by closure of AV valve

MurmursMurmurs Caused by turbulence

– Increased flow through a normal valve– Forward flow through a stenotic valve– Backward flow through a regurgitant valve

(insufficient or incompetent)– Flow through a AV fistula or septal defect– Flow into a dilated chamber or a portion of a

vessel

Description– Timing

Systolic– Holosystolic: AV regurgitation or VSD– Midsystolic (Ejection) - Semilunar stenosis– Late - papillary muscle dysfunction;

Hypertrophic cardiomyopathy (IHSS) Idiopathic hypertrophic subaortic stenosis.

– Location Place murmur is loudest

– Radiation Direction murmur radiates

– Intensity Levine scale

Levine scale– Grade I/VI: barely audible– Grade II/VI: clearly audible, but quiet– Grade III/VI: Moderately loud w/o a thrill– Grade IV/VI: Loud, w/ or w/o– Grade VI/V: Loud, thrill present, audible

w/stethoscope partially off chest– Grade VI/VI- loud, w/thrill, stethoscope off

chest

Timing – Synchronize S1 and S2 with Carotid pulse

– Listen for murmur Lub - murmur - dub is systolic murmur Lub - dub - murmur - is a diastolic murmur

Diastolic murmurs– produced with a stenotic Mitral / Tricuspid

valve– Produced with a incompetent Aortic/Pulmonic

valve

Systolic murmurs– produced by a stenotic Aortic or Pulmonic

valve– Produced by incompetent Mitral / Tricuspid

valve

Pitch– High pitched (heard w/

diaphragm) Mitral / Tricuspid

regurgitation Aortic / Pulmonic

stenosis or regurgitation

– Low Pitched (heard best w/bell

Mitral and Tricuspid stenosis

Quality– soft, harsh, blowing,

musical, rumbling, or rough

Vascular Sound: bruit– Turbulent sound

– may be heard over: Carotid Aorta Renal Iliac Femoral

– Associated with plaque or aneurysm

Common Murmurs– Holosystolic

Mitral area– toward L axilla

– Blowing, harsh

– Mitral regurgitation Tricuspid

– Along right sternal border

– Blowing, harsh

– Tricuspid Regurgitation 3-4 ICS at lower sternal border

– Harsh

– Ventricular septal rupture or defect

– Midsystolic Aortic area

– Toward right side of neck

– Harsh

– Aortic Stenosis Pulmonic

– Toward Left side of neck

– Harsh

– Pulmonic Stenosis

– Early diastolic Aortic or Erb’s point

– Blowing

– Aortic Regurgitation Pulmonic

– Blowing

– Pulmonic Regurgitation

– Mid to late diastolic Mitral area

– Rumbling

– Mitral Stenosis Tricuspid

– Rumbling

– Tricuspid Stenosis1