cardiovascular assessment

NURS 347Towson Universitycardiovascular assessment

structure and functioncardiovascular system

Blood flow through the Heart

Systole & DiastoleDiastole: ventricles relax and fill with blood; this takes up two thirds of cardiac cycleSystole: hearts contraction, blood pumped from ventricles fills pulmonary and systemic arteries; this is one third of cardiac cycle

SystoleVentricular pressure becomes higher than that in atria, so mitral and tricuspid valves close

Closure of AV valves contributes to first heart sound (S1) and signals beginning of systole

AV valves close to prevent any regurgitation of blood back up into atria during contraction

For a very brief moment, all four valves are closed and ventricular walls contract

DiastoleVentricles relaxed, and AV valves, tricuspid and mitral, are open; opening of normal valve is silentPressure in atria higher than that in ventricles, so blood pours rapidly into ventriclesToward end of diastole, atria contract and push last amount of blood into ventricles, known as pre-systole, or atrial systole

Electrical Conduction System

Cardiac ConductionHeart has unique ability: automaticityCan contract by itself, independent of any signals or stimulation from bodySpecialized cells in sinoatrial (SA) node, near superior vena cava initiate an electrical impulseBecause SA node has intrinsic rhythm, it is called the pacemaker

PQRSTP wave: depolarization of atriaP-R interval: from beginning of P wave to beginning of QRS complex (time necessary for atrial depolarization plus time for impulse to travel through AV node to ventricles)QRS complex: depolarization of ventriclesT wave: repolarization of ventricles

Blood CirculationIn resting adult, heart normally pumps between 4 and 6 L of blood per minute throughout body

Cardiac Cycle: Complete

The Cardiovascular AssessmentPeripheral AssessmentSubjective AssessmentChest pain?Dyspnea?Orthopnea?Cough?Fatigue?Cyanosis or pallor?Edema?Nocturia?Leg pain or cramps?Skin changes on arms or legs?Swelling?Lymph node enlargement?Personal habits and self-carePast cardiac history of self and family?Medications

InspectionBegin with the hands, noting:Color of skin and nail bedsTemperatureTextureSkin turgorLesions & ScarsEdemaHair growthClubbingSymmetry of extremities

PalpationCapillary refill:Depress and blanch the nail beds; release and note the time for color returnColor should return in less than 1-2 secondsPulses: Note rate, rhythm, elasticity of vessel wall, equality, and force:4+ Bounding3+ Increased2+ Normal1+ Weak0 Absent

PulsesTemporalCarotidRadialUlnarBrachialFemoralPoplitealPosterior tibialDorsalis pedal

carotid artery: palpationPalpate each separately medial to the sternomastoid muscle of the neckAvoid excessive pressure, may slow heart rateAssess contour and amplitude of pulse; Generally:smooth contour rapid upstrokeslower downstrokestrength 2+carotid artery: auscultationMiddle-aged, older, or demonstrate signs and symptoms of cardiovascular diseaseListen with the bell to each side separately for a bruitBruit: Blowing, swishing sound

Auscultation Locations:Angle of the jawMidcervical areaBase of neck

Homans SignAssesses for DVTSigns and Symptoms of DVT:Pain & crampsUnilateral edemaWeakened pulseBring leg up, allow fluid to drain.Dorsiflex foot while squeezing the calf.If pain is felt, positive test.

Has fallen out of favor in comparison to diagnostic imaging tests: ultrasound

cardiac examStraight to the HeartInspection: precordiumInspect for lifts, heaves, or visual pulsations:Apical impulseContinue to assess the integument

palpationPalpate for lifts, heaves, thrills, or pulsations

Apical pulse (point of maximal impulse or PMI)Use one fingerpad4th or 5th intercostal space, midclavicular lineNormally 1cm x 2cm and feels like a short, gentle tapDuration is short, generally occupies only the first half of systole

palpationGeneral appraisal of precordium for additional pulsations:Use the carotid artery pulsation as a guideUse palmar aspect of four fingers and palpate:ApexLeft sternal borderBase

auscultateRate & rhythmIdentify S1 & S2Assess each separatelyListen for extra heart soundsListen for murmursDiaphragm: High pitched soundsBell: Low pitched soundsUse a Z-pattern from base of the heart, right and left, and over the apex.

Aortic: 2nd right interspacePulmonic: 2nd left interspaceTricuspid: Left lower sternal borderMitral: 5th interspace near midclavicular lineErbs point: 3rd interspace, left sternal border

auscultateHeart Rate: 60-100 bpm Rhythm: Regular (normal sinus rhythm)Arrhythmia: varies with persons breathing, increasing at the peak of inspiration and slowing with expiration

Pulse deficit: Auscultating apical beat and simultaneously palpating radial pulse

heart sounds: lub-dubS1: lubStart of systole, caused by the close of AV valvesLouder at apexUse diaphragmCarotid artery pulseElectrical conduction: R- waveS2: dubClosure of the semilunar valvesLouder at the baseCan auscultate with diaphragm

extra heart soundsListen with the diaphragm, then the bellCover all auscultatory areasGenerally silentMost common extra sound is a mid-systolic click in systoleS3:During diastoleVentricular gallopS4:During diastoleAtrial gallop

murmursMurmur: A blowing, swooshing sound related to turbulent blood flow in the heart or great vesselsAside from that innocent murmur; murmurs are abnormal

Document findings by:Timing: During what part of the cardiac cycle? Early, mid-, or late systole or diastole? Throughout cardiac cycleMuffles heart sounds?murmur gradingLoudness: Describe intensity with the following scale:Grade i: Barely audible, heard only in a quiet room and then with difficultyGrade ii: Clearly audible, but faintGrade iii: Moderately loud, easy to hearGrade iv: Loud, associated with a thrill palpable on the chest wallGrade v: Very loud, heard with one corner of the stethoscope lifted off the chest wallGrade vi: Loudest, still heard with entire stethoscope lifted just off the chest wall

murmursPitch: Describe as high, medium, or low Depends on the pressure and rate of blood flow producing the murmurPattern: Does it follow a pattern through the cardiac phase?Crescendo: Grows louderDecrescendo: Tapers offCrescendo-decrescendo: Increases to a peak and then decreasesQuality: MusicalBlowingHarshRumblingLocation: Describe the area where the murmur is best heard:Valve areaIntercostal spaces

murmursRadiation: May be transmitted in the direction of blood-flow:Another precordial areaNeckBackAxilla Posture: Some murmurs disappear or are enhanced by a change in position.Innocent: No valvular or other pathologic causeGenerally soft, grade ii, midsystolic, short Crescendo-decrescendo, musical quality2nd or 3rd intercostal space, disappears with sittingNo history of cardiac dysfunctionFunctional: Due to increased blood flow of the heart

physiologic splittingA split S1 means you are hearing the mitral and tricuspid components separately, it is normalVery rapid; 0.03 seconds apartAuscultate over the tricuspid valve areaA split S2 occurs toward the end of inspiration, is normal.T-DUBAuscultate over the pulmonic valve area, 2nd interspace

Fixed split: Unaffected by respiration, always thereParadoxical split: Sounds fuse on inspiration; split on expiration

Jugular Venous Distention (JVD)A technique used to assess central venous pressure (CVP)Judges the hearts efficiency as a pumpPosition patient supine at a 30-45 angleRemove pillow to decrease flexing the neckTurn head slightly from area being assessedLook for pulsating internal jugular veins near the suprasternal notch, or origin of the sternomastoid muscle near the clavicle Be careful not to confuse the carotid pulse with the internal jugular

variationsInfantsFetal shunt closure may take up to 48 hoursApical pulse may be palpable at 4th intercostal space, lateral to midclavicular line.HR 100-180 bmp after birth; 120-140 bmp averageSinus arrhythmias with respirationsChildrenApical pulse palpation changes70-100 bmpVenous humInnocent murmursvariationsPregnant female:Increased resting heart rateMild hyperemia (increased cutaneous blood flow to eliminate excess heat)Increased volume of S1, exaggerated S1 splitHeart murmursAging Adult:Gradual rise in blood pressureOrthostatic hypotensionAvoid pressure on carotid arteryDecreased visibility of JVDEctopic beatssample chartingSubjective:No chest pain, dyspnea, orthopnea, cough, or edema. No past history of hypertension, abnormal blood tests, heart murmur, or rheumatic fever in self. Last ECG 2 years. PTA, result normal. No stress ECG or other heart tests.

Objective:Neck: Carotids 2+ and = bilaterally, internal jugular vein pulsations present when supine, and disappear when elevated at a 45 position.Precordium: Inspection. No visible pulsations, no heave or lift.Palpation: Apical pulse in 5th ics at left midclavicular line, no thrillAuscultation: Rate 68 beats per minute, rhythm regular. S1-S2 present, not diminished or accentuated, no S3, no S4, no other extra heart sounds, no murmurs.