NURS 347 Towson University cardiovascular assessment

structure and function cardiovascular system

Blood flow through the Heart

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

Systole Ventricular pressure becomes higher than that in atria, so mitral and tricuspid valves close Closure of AV valves contributes to first heart sound (S 1 ) 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

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

Electrical Conduction System

Cardiac Conduction Heart has unique ability: automaticity Can contract by itself, independent of any signals or stimulation from body Specialized cells in sinoatrial (SA) node, near superior vena cava initiate an electrical impulse Because SA node has intrinsic rhythm, it is called the pacemaker

PQRST P wave: depolarization of atria P-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 ventricles T wave: repolarization of ventricles

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

Cardiac Cycle: Complete

The Cardiovascular Assessment Peripheral Assessment

Subjective Assessment Chest 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-care Past cardiac history of self and family? Medications

Inspection Begin with the hands, noting: Color of skin and nail beds Temperature Texture Skin turgor Lesions & Scars Edema Hair growth Clubbing Symmetry of extremities

Palpation Capillary refill: Depress and blanch the nail beds; release and note the time for color return Color should return in less than 1-2 seconds Pulses: Note rate, rhythm, elasticity of vessel wall, equality, and force: 4+ Bounding 3+ Increased 2+ Normal 1+ Weak 0 Absent

Pulses 1. Temporal 2. Carotid 3. Radial 4. Ulnar 5. Brachial 6. Femoral 7. Popliteal 8. Posterior tibial 9. Dorsalis pedal

carotid artery: palpation Palpate each separately medial to the sternomastoid muscle of the neck Avoid excessive pressure, may slow heart rate Assess contour and amplitude of pulse; Generally: smooth contour rapid upstroke slower downstroke strength 2+

carotid artery: auscultation Middle-aged, older, or demonstrate signs and symptoms of cardiovascular disease Listen with the bell to each side separately for a bruit Bruit: Blowing, swishing sound Auscultation Locations: Angle of the jaw Midcervical area Base of neck

Homan’s Sign Assesses for DVT Signs and Symptoms of DVT: Pain & cramps Unilateral edema Weakened pulse 1. Bring leg up, allow fluid to drain. 2. Dorsiflex foot while squeezing the calf. 3. If pain is felt, positive test. Has fallen out of favor in comparison to diagnostic imaging tests: ultrasound

cardiac exam Straight to the Heart

Inspection: precordium Inspect for lifts, heaves, or visual pulsations: Apical impulse Continue to assess the integument

palpation Palpate for lifts, heaves, thrills, or pulsations Apical pulse (point of maximal impulse or PMI) Use one fingerpad 4 th or 5 th intercostal space, midclavicular line Normally 1cm x 2cm and feels like a short, gentle tap Duration is short, generally occupies only the first half of systole

palpation General appraisal of precordium for additional pulsations: Use the carotid artery pulsation as a guide Use palmar aspect of four fingers and palpate: Apex Left sternal border Base

auscultate Rate & rhythm Identify S1 & S2 Assess each separately Listen for extra heart sounds Listen for murmurs Diaphragm: High pitched sounds’ Bell: Low pitched sounds Use a “Z-pattern” from base of the heart, right and left, and over the apex.

Aortic: 2 nd right interspace Pulmonic: 2 nd left interspace Tricuspid: Left lower sternal border Mitral: 5 th interspace near midclavicular line Erb’s point: 3 rd interspace, left sternal border

auscultate Heart Rate: bpm Rhythm: Regular (normal sinus rhythm) Arrhythmia: varies with person’s breathing, increasing at the peak of inspiration and slowing with expiration Pulse deficit: Auscultating apical beat and simultaneously palpating radial pulse

heart sounds: “lub-dub” S1: “lub” Start of systole, caused by the close of AV valves Louder at apex Use diaphragm Carotid artery pulse Electrical conduction: R- wave S2: “dub” Closure of the semilunar valves Louder at the base Can auscultate with diaphragm

extra heart sounds Listen with the diaphragm, then the bell Cover all auscultatory areas Generally silent Most common extra sound is a mid-systolic click in systole S3: During diastole Ventricular gallop S4: During diastole Atrial gallop

murmurs Murmur: A blowing, swooshing sound related to turbulent blood flow in the heart or great vessels Aside 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 cycle Muffles heart sounds?

murmur grading Loudness: Describe intensity with the following scale: Grade i: Barely audible, heard only in a quiet room and then with difficulty Grade ii: Clearly audible, but faint Grade iii: Moderately loud, easy to hear Grade iv: Loud, associated with a thrill palpable on the chest wall Grade v: Very loud, heard with one corner of the stethoscope lifted off the chest wall Grade vi: Loudest, still heard with entire stethoscope lifted just off the chest wall

murmurs Pitch: Describe as “high, medium, or low” Depends on the pressure and rate of blood flow producing the murmur Pattern: Does it follow a pattern through the cardiac phase? Crescendo: Grows louder Decrescendo: Tapers off Crescendo-decrescendo: Increases to a peak and then decreases Quality: Musical Blowing Harsh Rumbling Location: Describe the area where the murmur is best heard: Valve area Intercostal spaces

murmurs Radiation: May be transmitted in the direction of blood-flow: Another precordial area Neck Back Axilla Posture: Some murmurs disappear or are enhanced by a change in position. Innocent: No valvular or other pathologic cause Generally soft, grade ii, midsystolic, short Crescendo-decrescendo, musical quality 2 nd or 3 rd intercostal space, disappears with sitting No history of cardiac dysfunction Functional: Due to increased blood flow of the heart

physiologic splitting A split S1 means you are hearing the mitral and tricuspid components separately, it is “normal” Very rapid; 0.03 seconds apart Auscultate over the tricuspid valve area A split S2 occurs toward the end of inspiration, is normal. “T-DUB” Auscultate over the pulmonic valve area, 2 nd interspace Fixed split: Unaffected by respiration, always there Paradoxical split: Sounds fuse on inspiration; split on expiration

Jugular Venous Distention (JVD) A technique used to assess central venous pressure (CVP) Judges the heart’s efficiency as a pump Position patient supine at a 30-45’ angle Remove pillow to decrease flexing the neck Turn head slightly from area being assessed Look 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

variations Infants Fetal shunt closure may take up to 48 hours Apical pulse may be palpable at 4 th intercostal space, lateral to midclavicular line. HR bmp after birth; bmp average Sinus arrhythmias with respirations Children Apical pulse palpation changes bmp Venous hum Innocent murmurs

variations Pregnant female: Increased resting heart rate Mild hyperemia (increased cutaneous blood flow to eliminate excess heat) Increased volume of S1, exaggerated S1 split Heart murmurs Aging Adult: Gradual rise in blood pressure Orthostatic hypotension Avoid pressure on carotid artery Decreased visibility of JVD Ectopic beats

sample charting Subjective: 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 5 th ics at left midclavicular line, no thrill Auscultation: 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.