Nursing 69: Nursing 69: Health AssessmentHealth Assessment

The Cardiovascular System

Bill Powell, MSN, FNP

Cardiovascular (CV) System:Cardiovascular (CV) System:Anatomy and PhysiologyAnatomy and Physiology

Landmarks of the chest/precordium suprasternal notch angle of Louis Anterior Axillary Line (AAL) Midaxillary Line (MAL) Posterior Axillary Line (PAL) Midsternal Line (MSL) Sternal Border (SB) Midclavicular Line (MCL) Intercostal spaces (ICS) 2 - 5

Cardiovascular (CV) System:Cardiovascular (CV) System:Anatomy and PhysiologyAnatomy and Physiology

The Base - the top of the heart (atria)

The Apex - the bottom tip (LV)

The Precordium - the surface of the chest wall overlying the heart (2nd to 5th ICS from RSB to LMCL)

Cardiovascular System: Cardiovascular System: Anatomy and Physiology Anatomy and Physiology (cont)(cont)

What parts are where? right ventricle - anterior, behind and along LSB left ventricle - behind and to the left of RV, forms left border

and creates apical impulse (PMI) right atrium - lies above and slightly to right of RV, forms

right border of heart, not usually identifiable left atrium - above LV, mostly posterior, cannot be examined

directly Aorta - up from LV to sternal angle, then back, down Pulmonary artery - up from RV, 3rd ICS,

bifurcates into R & L branches Venae Cavae - empty into RA

What else is in there???

Chambers, Valves and Circulation

Atrioventricular Valves - between atria and ventricles

tricuspid - between RA and RV mitral - between LA and LV

Semilunar Valves - between the

ventricles and great arteries aortic - between LV and the aorta pulmonic - between RV and pulmonary artery

Closure of these valves creates the normal heart sounds...valve opening is normally silent.

Valvular Control of Blood Flow

Systole - period of ventricular contraction. The mitral and tricuspid valves close (S1) preventing backflow, and aortic and pulmonic valves open permitting forward flow. Blood is ejected into aorta by LV and pulmonary artery by RV.

Diastole - period of ventricular relaxation. The aortic and pulmonic valves close (S2) preventing backflow, and mitral and tricuspid valves open permitting forward flow. The atria contract forcing blood into the ventricles.

Events of the Cardiac Cycle Systole

ventricles contract... ventricular pressure > atrial pressure mitral and tricuspid valves close = S1 (“lubb”)

S1 signifies the beginning of systole ventricular pressure continues to rise ventricular pressure > arterial pressure aortic and pulmonic valves open blood flows forward through aorta to systemic circulation and

pulmonary artery to the lungs ventricles become almost empty -> ventricular pressure drops

ventricular pressure drops below arterial pressure. . .

Events of the Cardiac Cycle (cont)

Diastole ...ventricular pressure drops below arterial pressure

aortic and pulmonic valves close = S2 (“dubb”)S2 signifies the beginning of diastole

atrial pressure > ventricular pressure mitral and tricuspid valves open blood flows from atria to ventricles atria contract to eject remaining blood and increase ventricular

end-diastolic pressure ventricular pressure > atrial pressure

mitral and tricuspid valves close (S1) beginning another systole . . .

Blood flow during SystoleBlood flow during Systole

Blood flow during DiastoleBlood flow during Diastole

Heart Sounds and Heart Sounds and The Cardiac CycleThe Cardiac Cycle

S1 S2 S1

Systole Diastole

The The SplittingSplitting of Heart Sounds of Heart Sounds The events are occurring on both sides of the heart Right-sided events usually occur slightly later than

left-sided events Therefore, may hear 2 sounds for:

S1 (“split S1”), the mitral component > tricuspid S2 (“split S2”), the aortic component > pulmonic

Split sounds may be normal (physiologic) or abnormal (pathologic)

Extra Heart SoundsExtra Heart Sounds

S3 occurs just after S2 during the period of rapid

ventricular filling called “ventricular gallup” “SLOSH-ing-in” normal in children and

young adults almost always pathologic

in adults >40 (heart failure, etc)

S4 immediately before S1 marks atrial contraction called “atrial gallup” “a-STIFF-wall” may be normal in older

persons or trained athletes more commonly associated

with resistance to ventricular filling (hypertension, coronary artery disease, aortic stenosis)

Extra Heart Sounds Extra Heart Sounds (cont) (cont)

Ejection Sounds - heard shortly after S1, i.e. early systolic, coinciding with the opening of the aortic or pulmonic valves...indicates cardiovascular disease

Systolic Clicks - usually mid or late systolic, caused by an abnormal ballooning of part of the mitral valve into the LA...indicates mitral valve prolapse

Opening Snaps - a very early diastolic sound caused by the opening of a stenotic mitral valve...almost always from rheumatic heart disease

MurmursMurmurs Murmurs are vibratory sounds caused by

turbulent blood flow 4 causes of murmurs:

stenosis - forward blood flow through a constricted area

regurgitation - backward blood flow through an incompetent valve

structural defect - blood flow through an abnormal passage

physiologic - increased blood flow (high output) through a normal valve

Murmurs Murmurs (cont)(cont)

Murmurs may be: Systolic

occur between S1 & S2 Diastolic

occur between S2 & S1 Continuous

heard throughout the cardiac cycle

Electrical Activity of the HeartElectrical Activity of the Heart An electrical conduction system stimulates and

coordinates the sequence of muscle contraction during the cardiac cycle sinus node - in RA, serves as pacemaker automatically sending

impulses 60 -100 times/minute through both atria to the... atrioventricular (AV) node - located low in atrial septum,

delays impulse slightly before sending it to the... bundle of His - starts in intraventricular septum, then divides

into right and left bundle branches which carry the electrical impulse to the...

Purkinje fibers - in the ventricular myocardium where ventricular contraction is stimulated

The Electrocardiogram (ECG)The Electrocardiogram (ECG)

Each electrical impulse produces a series of waves depolarization - the spread of the stimulus through the

heart muscle repolarization - the return of the stimulated heart

muscle to a resting state P wave - atrial depolarization PR interval - time from initial stimulation of the atria to

initial stimulation of the ventricles QRS complex - ventricular depolarization ST segment and T wave - ventricular repolarization U wave - sometimes seen after the T wave, represents final

phase of ventricular repolarization

ECG sampleECG sample

To Learn more about ECGs...To Learn more about ECGs...

Dubin, D. (1996). Rapid Interpretation of EKG’s. Fifth Edition. Tampa: COVER Publishing Company.

A fun, simple, rapid programmed approach to learning about ECG’s.

Peripheral Vascular SystemPeripheral Vascular SystemMade up of 2 systems:Made up of 2 systems:

Pulmonic Unoxygenated blood

leaves RV through Pulmonary artery

blood travels through numerous arteries, arterioles, and capillaries of the lungs

gas exchange occurs at alveoli

oxygenated blood returns to heart through pulmonary veins into LA

Systemic Oxygenated blood leaves

LV through aorta blood travels through

numerous arteries, arterioles and capillaries delivering oxygen and nutrients to body’s cells

deoxygenated blood passes into venous system

deoxygenated blood returns to heart through veins, entering RA through venae cavae

Peripheral Vascular SystemPeripheral Vascular SystemCharacteristics of the vessels:Characteristics of the vessels:

Arteries Tough, more tensile,

less expandable Able to withstand high

pressures

Veins Less sturdy, more

expandable Subjected to much

lower pressures Contain valves to

prevent backflow Able to expand and

hold excess blood (pooling) decreasing workload of the heart (preload)

Arterial PulsesArterial Pulses Ventricular constriction

forcing blood into the arteries, produces the characteristic pulse in peripheral arteries

Pulses normally felt or seen as synchronous with the heart beat...<0.3 second to reach most distal artery; however, carotid best for evaluation of cardiac function

Variables: Volume of blood Elasticity of the

arteries Viscosity of the blood Heart rate Arterial resistance

(afterload)_

Arterial PulsesArterial Pulses

Carotid Brachial Radial Ulnar Femoral Popliteal Dorsalies pedis Posterior tibial

The Jugular VeinsThe Jugular Veins Empty directly into the superior vena cava Reflect the activity of the right side of the heart

offering clues to its competency External Jugulars

more superficial and more visible easily visible bilaterally above clavicles near insertion of

sternocleidomastoid muscle less reliable than the internal jugulars

Internal Jugulars larger, are deep and less visible to inspection run deep to the sternocleidomastoids near the carotids,

will not see veins, only pulsations more accurate than external jugulars

Cardiovascular SystemCardiovascular SystemHistory and Symptom ReviewHistory and Symptom Review

Symptoms chest pain palpitations fatigue dyspnea/shortness of

breath syncope/dizziness edema cyanosis

cough orthopnea/paroxysmal

nocturnal dyspnea leg pain or cramps tingling, numbness,

burning in extremities skin changes in

extremities sores on legs or feet

Cardiovascular SystemCardiovascular SystemHistory and Symptom ReviewHistory and Symptom Review

Client’s Health History Heart disease (congenital and acquired) Cardiac procedures/surgery Chronic illness (associated with secondary heart

disease) Past medications which may have affected the heart Bleeding disorders Past medications which may have affected the

circulation

Cardiovascular SystemCardiovascular SystemHistory and Symptom ReviewHistory and Symptom Review

Client’s Current Health Diet Exercise Stress Occupation Current medications Alcohol/nicotine/recreational drugs

Cardiovascular SystemCardiovascular SystemHistory and Symptom ReviewHistory and Symptom Review

Family History Heart disease (including congenital) Sudden unexpected death Chronic illness associated with heart disease Circulatory diseases

Cardiovascular SystemCardiovascular SystemPhysical ExamPhysical Exam

The Basics: Good lighting, including tangential source Quiet room Appropriate draping Stand at patient’s right Use variety of positions Follow correct sequence

Inspection (first!) Palpation Percussion (optional) Auscultation (last!)

General InspectionGeneral Inspection

Observe the patient for general signs of cardiovascular disease: cyanosis peripheral edema finger clubbing labored respiration

Inspection of the PrecordiumInspection of the Precordium Visualize lines of reference and underlying

structures (chambers, valves, vessels) Look for pulsations, lifts, heaves in the

following locations: Aortic area Pulmonic area Right ventricular area Apical area (PMI) Epigastric area

PalpationPalpation

Palpate the same areas for: abnormal pulsations vibrations/thrills

Assess the apical impulse (PMI) location diameter amplitude duration

PercussionPercussion

Of limited value in determining the borders of the heart

Left ventricular size better judged by the location of the apical impulse

Heart size is best determined by chest films

AuscultationAuscultation Auscultatory areas

Names may be misleading since murmurs of more than one origin may occur in a given area

aortic - R 2nd ICS pulmonic - L 2nd ICS Erb’s point (also called 2nd

pulmonic or tricuspid) 3rd ICS @ LSB

tricuspid - 4th &/or 5th ICS @LSB

mitral - 5th ICS @ LMCL

AuscultationAuscultation Pointers

Be consistent Listen at each area with diaphragm and bell

Press firmly with the diaphragm Apply the bell lightly

Take time to “tune in,” don’t rush Inch the stethescope along the route, don’t jump Listen in any area where you have observed an

abnormality

AuscultationAuscultation

Suggested Routine of Patient Positioning Upright and leaning slightly forward Supine Left lateral recumbent

What to listen for:What to listen for:

Identify cardiac rate and rhythm Identify S1 Identify S2 Listen to the quiet period between S1 and S2 =

Systole Listen to the quiet period between S2 and S1 =

Diastole Listen for split heart sounds

Next, listen for:Next, listen for: Extra Systolic Sounds

Ejection sounds Clicks

Extra Diastolic Sounds S3 S4 Opening snap

Finally, listen for:Finally, listen for:

MurmursDescribe murmurs in terms of these characteristics:

timing and duration pitch intensity pattern quality location and radiation respiratory variations

More about MurmursMore about MurmursMurmur Grades

Grade Volume Thrill1/6 very faint, only heard with optimal

conditionsnone

2/6 quiet, but clearly audible none3/6 moderately loud none4/6 loud yes5/6 very loud, may be heard with

stethescope partially off chestyes, easilypalpable

6/6 very loud, may be heard withstethescope completely off chest

yes,palpableand visible

Systolic MurmursSystolic MurmursS1S1 S2S2 S1S1

Mid-systolic Innocent Physiologic Pathologic

Aortic Stenosis Pulmonic Stenosis

Pansystolic (regurgitant) All are Pathologic

Mitral regurgitation Tricuspid regurgitation Ventricular septal defect

Diastolic MurmursDiastolic MurmursS1S1 S2S2 S1S1

AlwaysAlways indicate heart disease.. indicate heart disease.... Early Diastolic

Aortic regurgitation Pulmonic regurgitation

Mid or Late Diastolic Mitral stenosis Tricuspid stenosis

Sounds with Both Systolic and Sounds with Both Systolic and Diastolic ComponentsDiastolic ComponentsS1S1 S2S2 S1S1

Pericardial Friction Rub Patent Ductus Arteriosus Venous Hum

Peripheral Vascular SystemPeripheral Vascular SystemInspectionInspection

Inspect skin, nails, lips for signs of decreased circulation or cyanosis

Inspect nails for clubbing Inspect lower extremities for signs of arterial

insufficiency thin shiny skin decreased hair ridged/thickened nails ulceration

Peripheral Vascular SystemPeripheral Vascular SystemInspection Inspection (cont)(cont)

Inspect lower extremities for signs of venous insufficiency edema varicose veins thrombosis thickened/ulcerated skin

PalpationPalpation Note the temperature of the extremeties Check for pitting edema

If present, record by depth of indentation Palpate pulses, evaluate for:

rate rhythm contour (wave form) symmetry amplitude (strength)

Pulses Pulses (cont)(cont)

Note any variations in strength from beat to beat with respiration

Grade pulse strength 0 = absent 1 = weak/diminished 2 = normal/expected 3 = strong/increased 4 = bounding

AuscultationAuscultation

Auscultate over the major arteries for bruits carotid, aorta, renal, femoral

Use the bell of the stethescope Bruits are always abnormal

Jugular Vein AssessmentJugular Vein Assessment Provides insight into Right heart function May be performed when suspect heart failure

Hepatojugular reflux Patient supine with head of bed @ 30-60 degrees Gently press liver while watching external jugular vein May see wave level rise with right heart congestion

Jugular venous distension Patient supine with head of bed at 30-45 degrees Observe for venous pulsations in the neck (tangential light) Identify highest point of pulsation Using horizontal line from this point, measure vertically to

sternal angle...should be less than 3-4 cm in healthy adult

Physical Assessment Physical Assessment resources on the Internetresources on the Internet

To hear various heart and breath sounds http://www.med.ucla.edu/wilkes/intro.html

History and Physical Study Guides http://www.medinfo.ufl.edu/year1/bcs/clist/index.html