Cardiovascular SYSTEM Examination Present by : Dr.Amira Yahia Health Assessment Cardiovascular SYSTEM Examination Introduction: Pericardium: The heart is surrounded by a thin sac (2 layers) composed of a fibro serous material called the pericardium. Fluid between the 2 layers lubricates the layers and allow for a gliding motion between them with each heart beat. Heart: Lies behind the sternum and extends from the second rib to the fifth intercostal space. The right side of the heart is more forward than the left. The upper posterior edge of the heart is known as the base. The lower edge, or apex, is downward, forward, and to the left. Hearts position in thorax 4 In mediastinum behind sternum and pointing left, lying on the diaphragm It weighs gm (about 1 pound) Heart: The heart beat is most easily palpated over the apex; thus, this point is refereed to as the point of maximal intensity (PMI). The heart wall is composed of three layers: epicardium, myocardium, and endocardium. The heart is composed of 4 chambers; 2 smaller, superior chambers called atria, and 2 larger, inferior chambers called ventricles. Introduction: Heart: The atrioventricular valves: (separate atria from ventricles|) Tricuspid valve is located between right atrium and right ventricle. Mitral (bicuspid) valve is located between left atrium and left ventricle. HEART VALVES 8 Function of AV valves Heart: The semilunar valves: (separate the ventricles from the vascular system) The pulmonary valve: separates the right ventricle from the trunk of pulmonary arteries. The aortic valve: separates the left ventricle from the aorta. HEART VALVES 10 Function of semilunar valves (Aortic and pulmonic valves) Normal Heart Sounds (S 1 & S 2 ): Closing of atrioventricular valves cause S 1 sound lub best heard at the apex. Closing of the semilunar valves causes S 2 sound dub best heard at the base. The time between S 1 and S 2 is ventricular systole, and the time between S 2 and S 1 is ventricular diastole. Extra Heart Sounds (S 3 & S 4 ): S 3 & S 4 are referred as diastolic filling sounds or extra heart sounds, which result from ventricular vibration secondary to rapid ventricular filling. S 3 is termed as ventricular gallop & S 4 is called atrial gallop. If present, S 3 can be heard early in diastole after S 2. If present, S 4 can be heard early in diastole after S 1. HEART SOUNDS MURMURS: These can be heard when there is turbulence in blood flow (due to valve malfunction or defects, increased blood velocity) in which swooshing or blowing sounds may be auscultated. CENTRAL VESSELS: Assessment of the carotid artery and the jugular veins reflects the integrity of the heart muscle. Assessment: Subjective Personal and family history Diet history: 24 hr. sample diet Opportunity for teaching food selection and preparation Socioeconomic status ability to purchase proper foods, medicines. Employment and its effects on health? Cigarette smoking : packs /day and also years smoked PACK YEARS Assessment: Subjective Physical Activity/Inactivity 30 minutes daily of moderate exercise recommended on most days ( Healthy People 2010 ) Obesity associated with HTN, hyperlipidemia, and diabetes and all contribute to CV disease. Type A personality not conclusive proof Current Health Problems describe health concerns. Assessment: Subjective Chest pain: or discomfort, a symptom of cardiac disease, can result from ischemic heart disease, pericarditis and aortic dissection. Chest pain: can also be due to non- cardiac causes; pleurisy, pulmonary embolus, hiatal hernia and anxiety musculoskeletal strain, Assessment- Chest Pain Onset Duration Frequency Precipitating factors / Relieving factors Location Radiation Quality Intensity Assessment: Subjective Paroxysmal Nocturnal Dyspnea client has been recumbent for several hours, increase in venous return leads to pulmonary congestion. Fatigue- resulting from decreased cardiac output is usually worse in evening. Ask pt. if can they perform same activities as a year ago Assessment: Subjective Palpitations- fluttering or unpleasant awareness of heartbeat. Non- cardiac- causes- fatigue, caffeine, nicotine, alcohol Weight gain- a sudden increase in wt. of 2.2 pounds (1 kg) can be result of accumulation of fluid (1L) in interstitial spaces, known as edema. Syncope- transient loss of consciousness, decrease in perfusion to brain. Gathering the Data: Client's current level of wellness: Can you perform all activities of daily livings? Do you exercise? Do you monitor your pulse and BP? Describe your diet, Weight, Personality, Work. Client's risk factors for developing cardiovascular diseases: Have you or any of your family ever had any of cardiovascular diseases? Have you a history of medical conditions (DM, thyroid )? Other risk factors: age, smoking, elevated cholesterol Client's ability to modify risk factors: Do you know risk factors, modifiable, TECHNIQUES OFPHYSICAL EXAMINATION FOR HEART Inspection Palpation Auscultation Palpation & auscultation of carotid arteries Inspection of jugular veins Physical Assessment Inspection- side to side, at right angle and downward over precordium where vibrations are visible. Point of Maximal Impulse (PMI) Apical Impulse located at 5 th intercostal (IC) space at midclavicular line (MCL) mitral area Right Ventricular (RV area) Epigastric area Pulmonic area Inspect the client chest (Precordial Movement): Inspect for precordial movement. In particular, observe for pulsations over the five key landmarks. Right sternal border (RSB), second intercostal space (2 nd ICS). Left sternal border (LSB), 2 nd ICS. LSB, 3ed to 5 th ICS. The apex: 5 th ICS, MCL. Finish with the epigastric area, below the xiphoid process. Landmarks for the precordial exam: A=Aortic, P=Pulmonary, T=tricuspid, M=mitral Palpate the chest in the five key landmarks: Palpation: fingers and most sensitive part of palm of hand to detect any precordial motion or thrills. Palpate apical impulse Palpate for pulsations over the five key landmarks. You should not feel any pulsation, heave, or vibratory sensation, except over the apex of heart you feel soft vibration less than 1 cm in diameter or for then people. Landmarks for the precordial exam: A=Aortic, P=Pulmonary, T=tricuspid, M=mitral Auscultation: Listen with the diaphragm: Over the RSB, 2 nd ICS: (aortic area). S2 should be louder than S1. Over the LSB, 2 nd ICS: (pulmonic area). S2 should be louder than S1. Over the LSB, 3 rd to 5 th ICS: (tricuspid area). S1 should be louder than S2. Over the apex of the heart -5 th ICS, MCL- (PMI) (mitral area). S1 should be louder than S2. Listen with the bell: Low pitched sounds are best auscultated with light application of the bell. Sounds like S3, S4 murmurs (originating from stenotic valves) and gallops are best heard with the bell). Place the bell of the stethoscope lightly on each of the five key landmarks positions mentioned above. Auscultation: Arterial Pulses Rate and Rhythm: Compress the radial artery with your index and middle fingers. Note whether the pulse is regular or irregular. Record the rate and rhythm. Amplitude and Contour: Observe for carotid pulsations. (the carotid artery is located in the groove between the trachea and sternocleidomastoid muscle). Avoid compressing both sides at the same time. This could cut off the blood supply to the brain and cause syncope. Avoid compressing the carotid sinus higher up in the neck. This could lead to bradycardia and depressed blood pressure. Carotid artery Auscultation for Bruits: If the patient is late middle aged or older, you should auscultate for bruits. A bruit is often, but not always, a sign of arterial narrowing and risk of a stroke. Use the bell of the stethoscope Carotid Artery Inspect the jugular veins: Examination of jugular veins can provide essential information about the client's central venous pressure and the heart's pumping efficiency. Peripheral Circulation Assessment : Subjective Leg Pain: Hx: DVT? Arm/leg skin changes, varicose veins Edema Medications Assessment : Objective Inspection: skin including color & hair distribution skin ulcers? symmetry in extremity size? jugular vein distention varicosities? Palpation: pulses, tenderness, temperature, edema, capillary refill Assessment:Objective Pulses- carotid, brachial, radial, femoral, popliteal, posterior tibialis and dorsalis pedis. 0= nonpalpable 1+ = easily obliterated 2+ = weak, but cannot be obliterated 3+ = easy to palpate; full; cannot be obliterated. 4+ = strong, bounding; may be abnormal Assessment : Objective Edema- Check for pretibial edema. How high up does it go? 1+- Mild pitting, slight indentation. 2+- Moderate pitting- indentation subsides rapidly. 3+- Deep pitting, indentation remains short time, leg looks swollen. 4+- Very deep pitting, very swollen. Assessment : Objective Allen test- occlude radial & ulnar arteries, pt. opens and closed fist, hand should blanch. Then let go of ulnar artery quickly while you are occluding radial artery; if hand turns pink, ulnar is intact. Doppler Assessment Position client supine Externally rotate leg Apply conducting gel Place transducer over pulse site 45 degree angle with light pressure Listen for whooshing sound Cardiovascular diseases Hypertension Stroke / cardiovascular accident Heart failure Coronary artery disease :Myocardial infarction, artherosclerosis Valvular, rheumatic heart disease Peripheral vascular disease