Basic Head to Toe Assessment Part 3 Cardiac Assessment continued Perfusion Pulses Cap refill

Auscultation Auscultation (based on the Latin verb auscultare "to listen") is the term for listening to the internal sounds of the body, usually using a stethoscope. Auscultation is performed for the purposes of examining the circulatory system and respiratory system (heart sounds and breath sounds), as well as the gastrointestinal system (bowel sounds).stethoscopecirculatory systemrespiratory systemheart soundsbreath sounds gastrointestinal system

Perfusion Definition of PERFUSION = an act or instance of perfusing; specifically : the pumping of a fluid through an organ or tissue

Aortic valve The aortic valve lies between the left ventricle and the aorta.left ventricleaorta It has three cusps = folds or flaps of a cardiac valve. The closure of the aortic valve contributes the A2 component of the second heart sound (S2).heart sound

Pulmonary valve The pulmonary valve (sometimes referred to as the pulmonic valve) is the semilunar valve of the heart that lies between the right ventricle and the pulmonary artery, and has three cusps.pulmonary valve The closure of the pulmonary valve contributes the P2 component of the second heart sound (S2). The right heart is a low-pressure system, so the P2 component of the second heart sound is usually softer than the A2 component of the second heart sound.

Tricuspid valve The tricuspid valve is the three-flapped valve on the right side of the heart, between the right atrium and the right ventricle which stops the backflow of blood between the two.tricuspid valveright atriumright ventricle

Mitral valve The mitral valvemitral valve Also known as the "bicuspid valve" because it contains two flaps, the mitral valve gets its name from the resemblance to a bishop's mitre (look at the picture).bishopmitre It allows the blood to flow from the left atrium into the left ventricle. It is on the left side of the heart and has two cusps.left atriumleft ventricle

The apical pulse is located on the chest near the heart. To take an apical pulse a stethoscope and a stop-watch or a clock with a second hand are needed. To locate the apical pulsation anatomical landmarks are used. First locate the first intercostal space (the space between the first and second rib) on the left side of the chest. Count down to the fifth intercostal space (between the fifth and sixth rib). Draw a straight line from the left nipple to the fifth intercostal space to identify the area of the apical pulse. Place the diaphragm (flat part) of the stethoscope on this point and count the heart beat for 60 seconds. The heart beat consists of two distinct sounds, lub-dub. Each lub-dub counts as one heart beat.

Valve locations

S1 and S2 “lub” “dub” The two major sounds of the normal heart sound like "lub dub". The "lub" is the first heart sound, commonly termed S1, and is caused by turbulence caused by the closure of mitral and tricuspid valves at the start of systole. The second heart sound, "dub" or S2, is caused by the closure of the aortic and pulmonic valves, marking the end of systole. The time period elapsing between the first heart sound and the second sound defines systole (ventricular ejection) and the time between the second sound and the following first sound defines diastole (ventricular filling).

These are normal heart rate values Infants: 100 to 160 beats per minute Children 1 to 10 years: 70 to 120 beats per minute Children over 10 and adults: 60 to 100 beats per minute Athletes: 40 to 60 beats per minute A heart rate above the normal values is referred to as tachycardia, a heart rate below the normal values is referred to as bradycardia:

PERFUSION Definition = the pumping of a fluid through an organ or tissue. The capillary nail refill test (cap refill) is a quick test done on the nail beds. It is used to monitor dehydration and the amount of blood flow to tissue.dehydration

Cap refill test

Cap refill Normal Results – If there is good blood flow to the nail bed, a pink color should return in less than 2 seconds after pressure is removed. What Abnormal Results Mean – Blanch times that are greater than 2 seconds may indicate: Dehydration Shock Peripheral vascular disease (PVD) Peripheral vascular disease Hypothermia Alternative Names= – Nail blanch test; Capillary refill time

Locating pulses: The dorsalis pedis artery pulse pulse

Posterior Tibial Pulse

Now watch the video. Then answer the questions.

Auscultation 1.Which tones is the diaphragm of the stethoscope for? 2.Which tones is the bell or smaller concave part of the stethoscope for? 3.What should you do before using the stethoscope on a new patient? 4.What are the names of the valves? 5.Where is the aortic valve?

Auscultation Answers 1.The diaphragm is for the higher pitch tones. 2.The bell is to hear the lower pitch tones or the more vascular type tones. 3.You should wipe the stethoscope off between patients, otherwise it could carry bacteria from one patient to another. 4.Aortic, pulmonary, tricuspid and mitral valves. 5.The aortic valve is on the right sternal border.

More auscultation questions 1.What is the Apical pulse. 2.Which part of the stethoscope does the nurse use first? 3.After applying firm pressure with the stethoscope what does the nurse listen for? 4.What is another description of S1 and S2? 5.What should the nurse ask him/herself when listening? 6.For how long should the nurse count an apical pulse?

Answers( to more auscultation questions) 1.Apical pulse = auscultation over the chest wall of the patients heart rate. 2.The nurse starts the auscultation with the diaphragm. 3.The nurse listens for S1 and S2. 4.S1 and S2 are also called “lub and dub”. 5.“Is the heart rate regular or is it irregular?” 6.For a whole minute.

Perfusion questions 1.What do the patient’s nail beds look like? 2.What is the patient’s cap refill like? 3.What should the nurse do if a patient’s cap refill is over/more than 3 seconds? 4.Where else can the cap refill be checked for? 5.Which is the best place to check for cap refill on kids/children?

Perfusion answers 1.His nail beds look nice and pink. 2.He has a brisk cap refill, less than 3 seconds. 3.The nurse must specify on the patient’s chart if the cap refill is over 3 secs, indicating how many seconds it is, e.g. 7 seconds, so the next nurse can see what the patient’s cap refill was. 4.On the feet, ( but may be cold in a nervous patient) 5.On the chest wall or over the abdomen.

Locating pulses: Questions 1.How do you find the dorsalis pedis pulse? 2.On which type of patient is the dorsalis pedis usually marked? 3.What characteristics of the pulse are we looking for? 4.Where is the posterior tibial pulse? 5.Should the nurse feel the pulse on one leg only?

Pulses -answers 1.The dorsalis pedis is on the top of the foot follow the groove between the larger toe and the 2 nd toe until you find a bone. 2.On vascular patients( femural bypass patients). 3.Regularity and equality of the pulse. 4.The posterior tibial pulse is right behind the ankle. 5.No, the nurse should feel the pulse on the other side too.