1. Health & Physical Assessment in Nursing
Cardiovascular System

2. Cardiovascular System
Heart
Vasculature

3. Heart Pericardium Cardiac muscle Chambers Valves Cardiac vessels
Conduction system
Nerves

4. Figure 17.1 Layers of the heart.4

5. Structural components of the heart.5

6. Valves of the heart. 6

7. Pericardium
Thin Sac Composed of Fibroserous Material That Surrounds the Heart
Outer layer
Inner layer
Fluid between the layers

8. Heart Muscle
Base
Apex
Epicardium
Myocardium
Endocardium

9. Chambers in the Heart
Left and right atria
Left and right ventricles

10. Valves
Permit the Flow of Blood Between Chambers and Into Blood Vessels
Atrioventricular (AV)
Tricuspid
Mitral
Semilunar
Pulmonary
Aortic

11. Heart Sounds S1 S2

12. Heart sounds in systole and diastole.12

13. Table 17.1 Characteristics of Heart Sounds13

14. Table 17.3 Distinguishing Heart Murmurs14

15. Contraction and Relaxation Phases of the Heart
Systole
Diastole

16. Pulmonary and systemic circulation
Pulmonary and systemic circulation. The left side of the heart pumps oxygenated blood (indicated in red) into the arteries of the systemic circulation, which provides oxygen and nutrients to the cells. Deoxygenated blood (indicated in blue) returns via the venous system into the right side of the heart, where it is transported to the pulmonary arterial system to be reoxygenated. 16

17. Circulation of the Heart
Coronary arteries
Left main
Right coronary
Left anterior descending
Circumflex

18. Vessels of the heart. A. Anterior.18

19. (continued) Vessels of the heart. B. Posterior.19

20. Conduction System of the Heart
Sinoatrial (SA) node
Intra-atrial pathways
AV node
Bundle of His
Right and left bundle branches
Purkinje fibers

21. Conduction system of the heart.21

22. Cardiac Cycle
Contraction and Relaxation of the Chambers

23. The cardiac cycle. 23

24. Cardiac Cycle Ventricular filling Ventricular systole
Isovolumetric relaxation

25. Electrocardiogram (ECG)
Paper Recording of Deflections That Represent the Cardiac Cycle
Electrical deflections
P wave
PR interval
QRS interval
T wave

26. Electrocardiogram wave.26

27. Cardiac Function Stroke volume Cardiac output Cardiac index
Amount of blood that is ejected with each heartbeat
Cardiac output
Amount of blood ejected from the left ventricle over 1 minute
Cardiac index
Measurement accounting for an individual’s weight when evaluating the pumping action of the heart

28. Pumping Action of the Heart
Preload volume overload
Afterload pressure overload
Cardiac output: stroke volume x heart rate
Blood pressure: cardiac output x systemic vascular resistance

29. A. Preload is related to the amount of blood and stretching of the ventricular myocardial fibers.29

30. (continued) B. Afterload is the pressure that the ventricles must overcome in order to open the aortic and pulmonic valvular cusps. B 30

31. Landmarks for Cardiac Assessment
Sternum
Clavicles
Ribs
Second through fifth intercostal spaces

32. Landmarks for cardiovascular assessment.32

33. Focused Interview
General questions

34. Focused Interview Specific questions Illness Symptoms Behaviors
Infants and children
Pregnant female
Older adult
Environment

35. Equipment
Examination gown
Stethoscope
Metric rulers
Doppler

36. Other Considerations
Age
Gender
Language
Culture

37. Physical Assessment of the Cardiovascular System
Techniques
Inspection
Palpation
Percussion
Auscultation

38. Specific Areas of the Cardiovascular Assessment
Inspection of the face, lips, ears, and scalp
Inspection of the jugular veins
Inspection of the carotid arteries
Inspection of the hands and fingers
Inspection of the chest, abdomen, legs, and skeletal structure

39. Jugular Venous Pressure (JVP) and Pulsations
Recall that jugular veins reflect right atrial pressure
Steps for examination
Raise the head of the bed or examining table to 30°
Turn the patient’s head gently to the left
Identify the topmost point of the flickering venous pulsations
Place a centimeter ruler upright on the sternal angle
Place a card or tongue blade horizontally from the top of the JVP to the ruler, making a right angle
Measure the distance above the sternal angle in centimeters: a 3- to 4-centimeter elevation is normal

40. Assessment of central venous pressure.40

41. Top line – level of the higest visible point of distention
Bottom line – level of the sternal angle
Measure: the vertical distance between the sternal angle and the highest level of jugular distention

42. Splinter hemorrhage. 42

43. Landmarks in precordial assessments.43

44. Specific Areas of the Cardiovascular Assessment
Palpation of the chest, including the following
Precordium at the right and left second intercostal spaces
Left third intercostal space
Left fourth intercostal space
Left fifth intercostal space at the midclavicular line

45. Landmarks for palpation of the chest.45

46. Specific Areas of the Cardiovascular Assessment
Palpation of the carotid pulses (sequentially)
Percussion of the chest for cardiac border

47. Palpating the carotid artery.47

48. Assessing the Carotid Pulse
Keep the patient’s head elevated to 30°
Place your index and middle fingers on the right then the left carotid arteries, and palpate the carotid upstroke
Never palpate right and left carotid arteries simultaneously
The upstroke may be:
Brisk – normal
Delayed – suggests aortic stenosis
Bounding – suggests aortic insufficiency
Listen with the stethoscope for any bruits

49. Percussing the chest. 49

50. Specific Areas of the Cardiovascular Assessment
Auscultation of the chest using the diaphragm and bell in various positions to include the following locations
Aortic area at the right second intercostal space–S2 is louder than S1
Pulmonic area at the left second intercostal space–S2 is louder than S1
Erb’s point at the left third intercostal space–S1 and S2 are heard equally

51. Specific Areas of the Cardiovascular Assessment
Auscultation of the chest using the diaphragm and bell in various positions to include the following locations
Tricuspid area at the left fourth intercostal space–S1 is louder than S2
Apex at the left fifth intercostal space at the midclavicular line–S1 is louder than S2

52. Listen in all 5 listening areas for S1 and S2 using the diaphragm of the stethoscope
Then listen at the apex with the bell
The diaphragm and the bell ...
The diaphragm is best for detecting high-pitched sounds like S1, S2, and also S4 and most murmurs
The bell is best for detecting low-pitched sounds like S3 and the rumble of mitral stenosis

53. Auscultating the chest over five key landmarks.53

55. Positions for auscultation of the heart. A. Supine.55

56. (continued) Positions for auscultation of the heart. B. Lateral.56

57. (continued) Positions for auscultation of the heart. C. Sitting.57

58. Specific Areas of the Cardiovascular Assessment
Auscultation of the carotid arteries using the diaphragm and bell
Comparison of the apical pulse to a carotid pulse

59. Comparing the carotid and apical pulses.59

60. Abnormal Findings in the Cardiovascular System
Myocardial and pump disorders
Valvular disease
Septal defects
Congenital heart disease
Electrical rhythm disturbances

61. Myocardial and Pump Disorders
Myocardial ischemia
Myocardial infarction
Congestive heart disease
Ventricular hypertrophy

62. Valvular Diseases Mitral, aortic, tricuspid, and pulmonic stenosis
Mitral and aortic regurgitation
Mitral valve prolapse

63. Mitral stenosis. 63

64. Aortic stenosis. 64

65. Mitral regurgitation. 65

66. Pulmonic stenosis. 66

67. Tricuspid stenosis. 67

68. Mitral valve prolapse. 68

69. Aortic regurgitation. 69

70. Septal Defects
Openings between the right and left atria or right and left ventricles

71. Ventricular septal defect.71

72. Atrial septal defect. 72

73. Congenital Heart Diseases
Coarctation of the aorta
Patent ductus arteriosus
Tetralogy of Fallot

74. Coarctation of the aorta.74

75. Patent ductus arteriosus.75

76. Tetralogy of Fallot. 76

77. (continued) Tetralogy of Fallot.77

78. Electrical Rhythm Disturbances
Ventricular tachycardia
Ventricular fibrillation

79. Ventricle tachycardia.79

80. Ventricular fibrillation.80

81. Objectives Outlined in Healthy People
Coronary heart disease
High blood cholesterol

82. Key Objectives for Coronary Heart Disease
Screening for risk factors
Individual, community, culturally linguistically appropriate education and counseling
Education about symptoms and emergency care
Weight reduction programs
Programs to increase physical activity

83. Key Objectives for High Total Blood Cholesterol
Education about risks
Education about diet and exercise
Education about screening

84. Glossary
Atrioventricular Valves   Valves that separate the atria from the ventricles.
Bruit   A loud blowing sound, an abnormal finding, most often associated with a narrowing or stricture of the carotid artery usually associated with atherosclerotic plaque.
Bundle Branches   Expressways of conducting fibers that spread the electrical current through the ventricular myocardial tissue.
Bundle of His Atrioventricular Node   Nodes that are intricately connected and function to receive the current that has finished spreading throughout the atria.
Cardiac Conduction System   The heart's conduction system which can initiate an electrical charge and transmit that charge via cardiac muscle fibers throughout the myocardial tissue.
Cardiac Cycle   The events of one complete heartbeat, the contraction and relaxation of the atria and ventricles.
Cardiac output   The amount of blood ejected from the left ventricle over 1 minute.
Diastole   The phase of ventricular relaxation in which the ventricles relax and are filled as the atria contract.

85. Glossary
Electrocardiogram (EKG)   Electrical representations of the cardiac cycle are documented by deflections on recording paper.
Endocardium   The innermost layer of the heart, a smooth layer that provides an inner lining for the chambers of the heart.
Heart   An intricately designed pump composed of a meticulous network of synchronized structures.
Infective Endocarditis   A condition caused by bacterial infiltration of the lining of the heart’s chambers.
Left Atrium   Forms the posterior aspect of the heart.
Left Ventricle   Egg shaped, most muscular chamber of the heart, located behind the right ventricle and forms the left border of the heart.
Marfan's Syndrome   A degenerative disease of the connective tissue, which over time may cause the ascending aorta to either dilate or dissect, leading to abrupt death.
Mediastinal space   The area where the heart sits obliquely within the thoracic cavity between the lungs and above the diaphragm.

86. Glossary
Myocardium   The second, thick, muscular layer of the heart, made up of bundles of cardiac muscle fibers reinforced by a branching network of connective tissue fibers called the fibrous skeleton of the heart.
Pericardium   A thin sac composed of a fibroserous material that surrounds the heart.
Purkinje Fibers   Fibers that fan out and penetrate into the myocardial tissue to spread the current into the tissues themselves.
Right Atrium   A thin-walled chamber located above and slightly to the right of the right ventricle that forms the right border of the heart.
Right Ventricle   Part of heart formed triangularly and comprises much of the anterior or sternocostal surface of the heart.
S1   The first heart sound (lub), is heard when the AV valves close. Closure of these valves occurs when ldrslt the ventricles have been filled.
S2   The second heart sound (dub), occurs when the aortic and pulmonic valves close, they close when the ventricles have emptied their blood into the aorta and pulmonary arteries.
Semilunar Valves   Valves that separate the ventricles from the vascular system.

87. Glossary
Sinoatrial Node   The node located at the junction of the superior vena cava and right attrium that initiates the electrical impulse.
Sternum   The flat, narrow center bone of the upper anterior chest.
Stroke Volume   The amount of blood that is ejected with every heartbeat.
Systole   The phase of ventricular contraction in which the ventricles have been filled, then contract to expel blood into the aorta and pulmonary arteries.
Visceral Layer   The inner layer, which lines the surface of the heart.
Xanthelasma   Yellowish cholesterol deposits seen on the eyelids and are indicative of premature atherosclerosis.