Lecture 2-Cardiovascular Assessment

7/24/2019 Lecture 2-Cardiovascular Assessment

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Assessment of the Heart, Great vesselsAssessment of the Heart, Great vessels

of the neck, and Peripheral Vascularof the neck, and Peripheral Vascular

systemsystem


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Great vessels of the neckGreat vessels of the neck

Jugular veinsJugular veins

Carotid arteriesCarotid arteries


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JUGULAR VENOUS DISTENTION


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JVDJVD


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AssessmentAssessment

Position clientPosition client supinesu

pine

ThenThenhead elevated at ! degreeshead elevated at ! degrees

"#$P%CT"'"#$P%CT"'

(ifts, heaves(ifts, heaves

P)" *assess location+P)" *assess location+


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"nspection"nspection

Chest for visile cardiac motionChest for visile cardiac motion

%stimate Jugular venous pressure%stimate Jugular venous pressure

Patient supine and head elevated toPatient supine and head elevated to

-!./0 degrees1-!./0 degrees1

JVP is the distance 23 highest pointJVP is the distance 23 highest point

at 3hich pulsation can e seen andat 3hich pulsation can e seen and

the sternal anglethe sternal angle


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Jugular venous pressureJugular venous pressure

An indirect measure of right atrial pressure.An indirect measure of right atrial pressure.

Measured in centimeters from the sternal angleMeasured in centimeters from the sternal angle

and is best visualized with the patient's headand is best visualized with the patient's head

rotated to the left.rotated to the left.

Described for its quality and character, effectsDescribed for its quality and character, effects

of respiration, and patient position-inducedof respiration, and patient position-induced

changes.changes.


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PalpationPalpation


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Physical (andmarksPhysical (andmarks

$uprasternal$uprasternal

notchnotch

$ternum$ternum

)anuriosternal)anuriosternalangle 4 Angle ofangle 4 Angle of

(ouis(ouis

"ntercostals"ntercostals$paces$paces


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palpationspalpations

Palpate for P)"5 easiest if patient sitsPalpate for P)"5 easiest if patient sitsup and leans for3ardup and leans for3ard

has a diameter ofhas a diameter of 6cm and located6cm and located

3ith -0 cm of the midsternal line3ith -0 cm of the midsternal line Palpate for general cardiac motion 3ithPalpate for general cardiac motion 3ith

7ngertips and patient in supine position7ngertips and patient in supine position

Palpate for radial, carotid, rachial,Palpate for radial, carotid, rachial,femoral, popliteal, posterior tiial Andfemoral, popliteal, posterior tiial And

dorsalis pedis peripheral pulsesdorsalis pedis peripheral pulses


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palpationspalpations

$ee 7gure .-6$ee 7gure .-6 8ate strength of the pulse normal,8ate strength of the pulse normal,

diminished, or asent on a scale of 0diminished, or asent on a scale of 0

to 9, 3here 69 is normal1 $ee taleto 9, 3here 69 is normal1 $ee tale.:.:

l


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Auscultation:Auscultation:Auscultatory SitesAuscultatory Sites


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AuscultationAuscultation

;ith a stethoscope;ith a stethoscope

uiet area or to close eyes

to reduce con?icting stimulito reduce con?icting stimuli

$ee also 7gure .-0 for auscultatory$ee also 7gure .-0 for auscultatory

$ites$ites


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Auscultatory ites! "ont.Auscultatory ites! "ont.


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Auscultatory itesAuscultatory ites

#he auscultatory ites are close to but not the#he auscultatory ites are close to but not thesame as the anatomic locations of the valves.same as the anatomic locations of the valves.

Aortic areaAortic area$$ndnd%" at the right sternal border%" at the right sternal border

&ulmonic&ulmonic $$ndnd%" at the left sternal border%" at the left sternal border

#ricuspid#ricuspid lt lower sternal borderlt lower sternal border

MitralMitral cardiac apecardiac ape


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(eart ounds(eart ounds

(eart sounds are characterized by location,(eart sounds are characterized by location,

pitch, intensity, duration, and timing within thepitch, intensity, duration, and timing within the

cardiac cyclecardiac cycle


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(eart ounds(eart ounds

(igh-pitched sounds such as (igh-pitched sounds such as ))and and $$,,

murmurs of aortic and mitral regurgitation, andmurmurs of aortic and mitral regurgitation, and

pericardial friction rubs are best heard with thepericardial friction rubs are best heard with the

diaphragm.diaphragm.

#he bell is preferred for low-pitched sounds#he bell is preferred for low-pitched sounds

such as such as **and and ++..


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(eart ounds )/ub0(eart ounds )/ub0

)! "losure of A1 valves)! "losure of A1 valves

mitral and tricuspidmitral and tricuspid

valves! M) before #)0valves! M) before #)0

"orrelates with the"orrelates with thecarotid pulsecarotid pulse

/oudest at the cardiac/oudest at the cardiac

apeape

"an be split but not"an be split but not

oftenoften


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(eart ounds $Dub0(eart ounds $Dub0

$! "losure of$! "losure of

emilunar valves aorticemilunar valves aortic

2 pulmonic02 pulmonic0

/oudest at the base of/oudest at the base ofthe heartthe heart

May have a split soundMay have a split sound

A$ before &$0A$ before &$0


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(eart ounds $Dub0(eart ounds $Dub0

)) and and $$assessed in all four sites in uprightassessed in all four sites in upright

and supine positionand supine position

))

precedes and the precedes and the $$

follows the carotidfollows the carotidpulsepulse


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(eart ounds "ont.(eart ounds "ont.

3ase 45/ $nd %"03ase 45/ $nd %"0 $ louder than )$ louder than )

ApeApe ) louder than $) louder than $

6ormal physiologic $ plit6ormal physiologic $ plit 3est heard at pulmonic area3est heard at pulmonic area

during inspirationduring inspiration

7ied split no variation7ied split no variationwith inspirationwith inspiration++


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8tra (eart ounds8tra (eart ounds

**

Due to volume overloadDue to volume overload

Due to 4apidDue to 4apid ventricularventricular

filling! ventricular gallopfilling! ventricular gallop

) -- $-* 9en--tuc-:y) -- $-* 9en--tuc-:y++

++

Due to pressure overloadDue to pressure overload

Due to slow ventricularDue to slow ventricular

contraction! atrial gallopcontraction! atrial gallop

+-) ; $ #en-nes;see0+-) ; $ #en-nes;see0


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8tra (eart ounds8tra (eart ounds

**

low-pitched soundlow-pitched sound

usually heard at the ape ofusually heard at the ape of

the heart.the heart.

caused by rapid filling andcaused by rapid filling and

stretching of the leftstretching of the left

ventricle when the leftventricle when the left

ventricle is somewhatventricle is somewhat

noncompliant.noncompliant.

characteristic of volumecharacteristic of volumeoverloading, such as in "(7overloading, such as in "(7

especially left-sided heartespecially left-sided heart

failure0, tricuspid or mitralfailure0, tricuspid or mitral

valve insufficiencyvalve insufficiency11

++

a dull, low-pitched postsystolica dull, low-pitched postsystolicatrial gallopatrial gallop

usually caused by reducedusually caused by reduced

ventricular compliance.ventricular compliance.

best heard at the ape in thebest heard at the ape in theleft lateral position.left lateral position.

occurs with reduced ventricularoccurs with reduced ventricular

compliance and is present incompliance and is present in

conditions such as aorticconditions such as aorticstenosis, hypertension,stenosis, hypertension,

hypertrophic cardiomyopathies,hypertrophic cardiomyopathies,

and coronary artery disease.and coronary artery disease.

less specific for "(7 than less specific for "(7 than **..


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MurmursMurmurs

#urbulent blood flow across a valve or a disease such#urbulent blood flow across a valve or a disease such

as anemia or hyperthyroidismas anemia or hyperthyroidism

/isten for murmurs in the same auscultatory sites/isten for murmurs in the same auscultatory sites

A&8#MA&8#M

ystolic b5w ) 2 $ystolic b5w ) 2 $

Diastolic b5w $ 2 )Diastolic b5w $ 2 )


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Characteristics of Heart Sounds

Type of

Murmur Examples Location Pitch Radiation Quality

Midsystolic

Aorticstenosis 2nd RICS Medium

Neck, leftsternal border Harsh

Pulmonicstenosis

2nd and 3rdICS Medium

eft shoulderand neck Harsh

Hy!ertro!hiccardiomyo!athy

3rd and "thICS Medium eft sternalborder toa!e#Harsh

Pansystolic

Mitralre$ur$itation A!e#

Medium tohi$h eft a#illa %lo&in$

'ricus!id

re$ur$itation

o&er left

sternal border

MediumRi$htsternum,

#i!hoid

%lo&in$

(entricularse!tal defect

3rd, "th, and)th ICS Hi$h *ften harsh

+iastolic

Aorticre$ur$itation

2nd to "thICS Hi$h A!e# %lo&in$

Mitral stenosis A!e# o& ittle or none


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MurmursMurmurs

#hey are classified by#hey are classified by

timing and duration within the cardiac cycle systolic,timing and duration within the cardiac cycle systolic,

diastolic, and continuous0,diastolic, and continuous0,

location,location,

intensity,intensity,

shape configuration or pattern0,shape configuration or pattern0,

pitch frequency0,pitch frequency0,

quality, and radiationquality, and radiation


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MurmursMurmurs

Grade IGrade I!barely audible!barely audible

Gr II :Gr II :audible but quiet and softaudible but quiet and soft

Gr IIIGr III! moderated loud, without thrust or thrill! moderated loud, without thrust or thrill

Gr IVGr IV! loud, with thrill! loud, with thrill Gr VGr V! louder with thrill, steth on chest wall! louder with thrill, steth on chest wall

Gr VIGr VI! loud enough to be heard before steth on chest! loud enough to be heard before steth on chest


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MurmursMurmurs

#hrill!#hrill! a palpable murmura palpable murmur

3ruits!3ruits!

1ascular murmur1ascular murmur

sounds made by turbulent blood flowsounds made by turbulent blood flow

(eard over blood vessels with constricted lumens.(eard over blood vessels with constricted lumens.

"arotid and femoral are routinely assessed for bruits"arotid and femoral are routinely assessed for bruits

ometimes found over the vertebral, subclavian and abdominal arteriesometimes found over the vertebral, subclavian and abdominal arteries

Documents

Lecture 2-Cardiovascular Assessment