Assessment of the Cardiovascular System

The Heart and Peripheral Vasculature

Cardiovascular System

Health HistoryInspectionPalpationPercussionAuscultation

Health History Chest pain Dyspnea, Orthopnea, Cough, Fatigue Edema, Swollen joints, Nocturia HTN, DM, CAD, CHD, Hyperlipidemia, Bleeding

disorders Cardiac surgery or related hospitalization within last 5

years Personal and Social Hx. Family History

CHD – once a defect occurs in a family, the likelihood of recurrence is 3-5 times the general population, especially with left sided lesions

Sudden death in young and middle-aged relatives Cardiac History/Race-related considerations

Cardiac History/Race-Related Considerations Rheumatic fever (5-15yrs.) Mitral valve prolapse (20-50yrs.) HTN (20-70yrs.) Valve stenosis or regurgitation (30-50yrs.) Coronary artery dx. (40-60yrs.) MI (40-60 yrs.) Arteriosclerosis (50-70 yrs.) CVA (50-70 yrs.) Abdominal aortic aneurysm (60-70 yrs.)

Race-related Considerations: African American (CVA, CAD, HTN, Diabetes) Hispanic and Filipino (HTN) American Indian (CVA, CAD)

Age-related Considerations Children

Prenatal Hx. Cyanosis with feedings Growth and activity FTT Developmental milestones

Elderly Current medications Environment ADL’s

Inspection Note chest configuration Color of nailbeds, M/M Capillary refill, < 3 seconds Respiratory pattern and effort – any

dyspnea, etc. Lifts or heaves Inspect for any pulsations

Neck Jugular Vein Distention

Anterior Chest – eye should be at chest level Mild pulsation – normal Strong pulsation - abnormal

Palpation Use palmar surface of fingers Check circulation – warmth of extremities Carotid arteries – gently, one at a time Apical pulse – PMI

Greatest vibrations of heart contraction, a short gentle tap, short duration, ½ of systole

Found at 5th ICS, left MCL, if deviated can give you an indication of heart size

Use two fingers to palpate. If difficult have patient lean forward or lie on left side leaning over toward the right.

Thrill Palpation of murmur. Feels like a purring cat.

Percussion

Generally a poor indicator, rarely used

Used to outline heart’s borders, dullness

Difficult to perform with breast tissue CXR

Auscultation

Valves for auscultation – Anterior chestAortic – 2nd RICS, RSBPulmonic – 2nd LICS, LSBErbs – 3rd LICS, LSBTricuspid – 4th LICS, LSBMitral – 5th LICS, MCL

Auscultation – Heart Sounds Auscultate the heart in the sitting and lying

down positions. Use both the diaphragm and the bell. Diaphragm – high pitched Bell – low pitched

Note rate and rhythm 60-100 BPM Sinus arrhythmia Irregularities (apical), Count one full minute

Identify heart sounds S1 S2

S1 Closure of the mitral and tricuspid valves,

AV valves First heart sound – LUB Louder at the apex, heard best with

diaphragm Heard at the beginning of systole It is the R wave on EKG and the carotid

artery pulse Split S1 (normal)

Hear closure of mitral and tricuspid valves separately

S2 Closure of the aortic and pulmonic valves,

semilunar valves Second heart sound – DUB Louder at the base, heard best with

diaphragm Heard at the end of systole, beginning of

diastole Physiologic split of S2 (normal in children)

Two sounds heard – A2, P2 Pressures in the R heart are lower than the L,

producing two heart sound. The L side first A2, then the R side, P2.

Split heard best in pulmonic area

Auscultate for Extra Heart Sounds

Auscultate with diaphragm, then bell Heard during diastole

Ventricular filling

Lower pitch, heard at apex Extra heart sounds

S3 S4

S3 Heard at the beginning of diastole, after S2

Lub-dubba Ken/tuck/(Y) S1 – S2 – S3

Heard best with bell Sound is produced by blood hitting a non-

pliable ventricle wall during diastole. Normal in infants and young children d/t firm

heart muscle In adults can be d/t increased blood volume or

indicative of heart dx.CHFRegurgitation

S4 Also known as an Atrial Gallup Heard at the end of diastole, before S1

daLub-Dub (Ten)/ness/ee S4 – S1 –S2

Heard best with bell It is caused by a turbulence of flow against pressure.

(Resistance of flow). Heard with: Pulmonary hypertension Aortic and pulmonic stenosis Cardiomyopathy, valve dx. MI’s

Always abnormal

Adventitious Heart Sounds

Clicks Murmurs

Clicks Heard early in systole. More pronounced with pt.

sitting up Associated with valve dx. Aortic click

Most common D/T coarcation, aortic stenosis, anuerysm Sound does not change with respiration

Mitral click D/T prolapsed mitral valve

Pulmonic click Associated with pulmonic valve stenosis and

pulmonary hypertension Heard throughout respiratory cycle, more intense in

expiration

Murmurs Extra sound superimposed on normal heart sounds

caused by a disruption of flow into, through, or out of heart

Causes of Murmurs Anatomic valve disorder Diseased valves Hi output demands that increase speed of flow

Anemia, pregnancy Diminished strength of myocardial contraction Altered blood flow in vessels near heart

Newborn - PDA 7 Assessments Grading of Murmur

Murmurs – 7 Assessments Pitch

High, medium, low Pattern

Crescendo Decrescendo Crescendo-Decrescendo Diamond shaped

Quality Describe, generally a blowing, rubbing sound

Location Where is it loudest

Radiation Does it transmit to other areas

Posture Does it change with position change

Timing in cardiac cycle

Grading of Murmurs (Loudness) Grade 1

Barely audible Grade 2

Readily heard Grade 3

Moderately loud Grade 4

Loud with associated thrill – fine, palpable, rushing sensation

Grade 5 Very loud with thrill

Grade 6 Loudest with thrill, may be audible with diaphragm

off the chest

Physiologic Murmur

Normal in children Heard as a systolic flow murmur that

varies with position change Generally a G1 or G2 Pregnant women