1. Nursing 69: Health Assessment The Cardiovascular System Bill Powell, MSN, FNP

2. Cardiovascular (CV) System: Anatomy and Physiology l Landmarks of the chest/precordium l suprasternal notch l angle of Louis l Anterior Axillary Line (AAL) l Midaxillary Line (MAL) l Posterior Axillary Line (PAL) l Midsternal Line (MSL) l Sternal Border (SB) l Midclavicular Line (MCL) l Intercostal spaces (ICS) 2 - 5

3. Cardiovascular (CV) System: Anatomy and Physiology l The Base - the top of the heart (atria) l The Apex - the bottom tip (LV) l The Precordium - the surface of the chest wall overlying the heart (2nd to 5th ICS from RSB to LMCL)

4. Cardiovascular System: Anatomy and Physiology (cont) l What parts are where? l right ventricle - anterior, behind and along LSB l left ventricle - behind and to the left of RV, forms left border and creates apical impulse (PMI) l right atrium - lies above and slightly to right of RV, forms right border of heart, not usually identifiable l left atrium - above LV, mostly posterior, cannot be examined directly l Aorta - up from LV to sternal angle, then back, down l Pulmonary artery - up from RV, 3rd ICS, bifurcates into R & L branches l Venae Cavae - empty into RA l What else is in there???

5. Chambers, Valves and Circulation l Atrioventricular Valves - between atria and ventricles l tricuspid - between RA and RV l mitral - between LA and LV l Semilunar Valves - between the ventricles and great arteries l aortic - between LV and the aorta l pulmonic - between RV and pulmonary artery J Closure of these valves creates the normal heart sounds...valve opening is normally silent.

6. Valvular Control of Blood Flow l 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. l 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.

7. Events of the Cardiac Cycle l Systole l ventricles contract... l ventricular pressure > atrial pressure l mitral and tricuspid valves close = S1 (“lubb”) l S1 signifies the beginning of systole l ventricular pressure continues to rise l ventricular pressure > arterial pressure l aortic and pulmonic valves open l blood flows forward through aorta to systemic circulation and pulmonary artery to the lungs l ventricles become almost empty -> ventricular pressure drops l ventricular pressure drops below arterial pressure...

8. Events of the Cardiac Cycle (cont) l Diastole l...ventricular pressure drops below arterial pressure l aortic and pulmonic valves close = S2 (“dubb”) l S2 signifies the beginning of diastole l atrial pressure > ventricular pressure l mitral and tricuspid valves open l blood flows from atria to ventricles l atria contract to eject remaining blood and increase ventricular end-diastolic pressure l ventricular pressure > atrial pressure è mitral and tricuspid valves close (S1) beginning another systole...

9. Blood flow during Systole

10. Blood flow during Diastole

11. Heart Sounds and The Cardiac Cycle S1S2S1 Systole Diastole

12. The Splitting of Heart Sounds l The events are occurring on both sides of the heart l Right-sided events usually occur slightly later than left-sided events l Therefore, may hear 2 sounds for: l S1 (“split S1”), the mitral component > tricuspid l S2 (“split S2”), the aortic component > pulmonic l Split sounds may be normal (physiologic) or abnormal (pathologic)

13. Extra Heart Sounds l S3 l occurs just after S2 l during the period of rapid ventricular filling l called “ventricular gallup” l “SLOSH-ing-in” l normal in children and young adults l almost always pathologic in adults >40 (heart failure, etc) l S4 l immediately before S1 l marks atrial contraction l called “atrial gallup” l “a-STIFF-wall” l may be normal in older persons or trained athletes l more commonly associated with resistance to ventricular filling (hypertension, coronary artery disease, aortic stenosis)

14. Extra Heart Sounds (cont) l Ejection Sounds - heard shortly after S1, i.e. early systolic, coinciding with the opening of the aortic or pulmonic valves...indicates cardiovascular disease l 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 l Opening Snaps - a very early diastolic sound caused by the opening of a stenotic mitral valve...almost always from rheumatic heart disease

15. Murmurs l Murmurs are vibratory sounds caused by turbulent blood flow l 4 causes of murmurs: l stenosis - forward blood flow through a constricted area l regurgitation - backward blood flow through an incompetent valve l structural defect - blood flow through an abnormal passage l physiologic - increased blood flow (high output) through a normal valve

16. Murmurs (cont) Murmurs may be: l Systolic l occur between S1 & S2 l Diastolic l occur between S2 & S1 l Continuous l heard throughout the cardiac cycle

17. Electrical Activity of the Heart l An electrical conduction system stimulates and coordinates the sequence of muscle contraction during the cardiac cycle l sinus node - in RA, serves as pacemaker automatically sending impulses 60 -100 times/minute through both atria to the... l atrioventricular (AV) node - located low in atrial septum, delays impulse slightly before sending it to the... l bundle of His - starts in intraventricular septum, then divides into right and left bundle branches which carry the electrical impulse to the... l Purkinje fibers - in the ventricular myocardium where ventricular contraction is stimulated

18. The Electrocardiogram (ECG) l Each electrical impulse produces a series of waves l depolarization - the spread of the stimulus through the heart muscle l repolarization - the return of the stimulated heart muscle to a resting state l P wave - atrial depolarization l PR interval - time from initial stimulation of the atria to initial stimulation of the ventricles l QRS complex - ventricular depolarization l ST segment and T wave - ventricular repolarization l U wave - sometimes seen after the T wave, represents final phase of ventricular repolarization

19. ECG sample

20. To Learn more about ECGs... Dubin, D. (1996). Rapid Interpretation of EKG’s. Fifth Edition. Tampa: COVER Publishing Company. l A fun, simple, rapid programmed approach to learning about ECG’s.

21. Peripheral Vascular System Made up of 2 systems: l Pulmonic l Unoxygenated blood leaves RV through Pulmonary artery l blood travels through numerous arteries, arterioles, and capillaries of the lungs l gas exchange occurs at alveoli l oxygenated blood returns to heart through pulmonary veins into LA l Systemic l Oxygenated blood leaves LV through aorta l blood travels through numerous arteries, arterioles and capillaries delivering oxygen and nutrients to body’s cells l deoxygenated blood passes into venous system l deoxygenated blood returns to heart through veins, entering RA through venae cavae

22. Peripheral Vascular System Characteristics of the vessels: l Arteries l Tough, more tensile, less expandable l Able to withstand high pressures l Veins l Less sturdy, more expandable l Subjected to much lower pressures l Contain valves to prevent backflow l Able to expand and hold excess blood (pooling) decreasing workload of the heart (preload)

23. Arterial Pulses l Ventricular constriction forcing blood into the arteries, produces the characteristic pulse in peripheral arteries l 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 l Variables: l Volume of blood l Elasticity of the arteries l Viscosity of the blood l Heart rate l Arterial resistance (afterload)_

24. Arterial Pulses l Carotid l Brachial l Radial l Ulnar l Femoral l Popliteal l Dorsalies pedis l Posterior tibial

25. The Jugular Veins l Empty directly into the superior vena cava l Reflect the activity of the right side of the heart offering clues to its competency l External Jugulars l more superficial and more visible l easily visible bilaterally above clavicles near insertion of sternocleidomastoid muscle l less reliable than the internal jugulars l Internal Jugulars l larger, are deep and less visible to inspection l run deep to the sternocleidomastoids near the carotids, will not see veins, only pulsations l more accurate than external jugulars

26. Cardiovascular System History and Symptom Review l Symptoms l chest pain l palpitations l fatigue l dyspnea/shortness of breath l syncope/dizziness l edema l cyanosis l cough l orthopnea/paroxysmal nocturnal dyspnea l leg pain or cramps l tingling, numbness, burning in extremities l skin changes in extremities l sores on legs or feet

27. Cardiovascular System History and Symptom Review l Client’s Health History l Heart disease (congenital and acquired) l Cardiac procedures/surgery l Chronic illness (associated with secondary heart disease) l Past medications which may have affected the heart l Bleeding disorders l Past medications which may have affected the circulation

28. Cardiovascular System History and Symptom Review l Client’s Current Health l Diet l Exercise l Stress l Occupation l Current medications l Alcohol/nicotine/recreational drugs

29. Cardiovascular System History and Symptom Review l Family History l Heart disease (including congenital) l Sudden unexpected death l Chronic illness associated with heart disease l Circulatory diseases

30. Cardiovascular System Physical Exam l The Basics: l Good lighting, including tangential source l Quiet room l Appropriate draping l Stand at patient’s right l Use variety of positions l Follow correct sequence l Inspection (first!) l Palpation l Percussion (optional) l Auscultation (last!)

31. General Inspection l Observe the patient for general signs of cardiovascular disease: l cyanosis l peripheral edema l finger clubbing l labored respiration

32. Inspection of the Precordium l Visualize lines of reference and underlying structures (chambers, valves, vessels) l Look for pulsations, lifts, heaves in the following locations: l Aortic area l Pulmonic area l Right ventricular area l Apical area (PMI) l Epigastric area

33. Palpation l Palpate the same areas for: l abnormal pulsations l vibrations/thrills l Assess the apical impulse (PMI) l location l diameter l amplitude l duration

34. Percussion l Of limited value in determining the borders of the heart l Left ventricular size better judged by the location of the apical impulse l Heart size is best determined by chest films

35. Auscultation l Auscultatory areas l Names may be misleading since murmurs of more than one origin may occur in a given area l aortic - R 2nd ICS l pulmonic - L 2nd ICS l Erb’s point (also called 2nd pulmonic or tricuspid) 3rd ICS @ LSB l tricuspid - 4th &/or 5th ICS @LSB l mitral - 5th ICS @ LMCL

36. Auscultation l Pointers l Be consistent l Listen at each area with diaphragm and bell l Press firmly with the diaphragm l Apply the bell lightly l Take time to “tune in,” don’t rush l Inch the stethescope along the route, don’t jump l Listen in any area where you have observed an abnormality

37. Auscultation l Suggested Routine of Patient Positioning l Upright and leaning slightly forward l Supine l Left lateral recumbent

38. What to listen for: l Identify cardiac rate and rhythm l Identify S1 l Identify S2 l Listen to the quiet period between S1 and S2 = * Systole l Listen to the quiet period between S2 and S1 = * Diastole l Listen for split heart sounds

39. Next, listen for: l Extra Systolic Sounds l Ejection sounds l Clicks l Extra Diastolic Sounds l S3 l S4 l Opening snap

40. Finally, listen for: l Murmurs Describe murmurs in terms of these characteristics: l timing and duration l pitch l intensity l pattern l quality l location and radiation l respiratory variations

41. More about Murmurs

42. Systolic Murmurs S1S2S1 l Mid-systolic l Innocent l Physiologic l Pathologic l Aortic Stenosis l Pulmonic Stenosis l Pansystolic (regurgitant) l All are Pathologic l Mitral regurgitation l Tricuspid regurgitation l Ventricular septal defect

43. Diastolic Murmurs S1S2S1 Always indicate heart disease... l Early Diastolic l Aortic regurgitation l Pulmonic regurgitation l Mid or Late Diastolic l Mitral stenosis l Tricuspid stenosis

44. Sounds with Both Systolic and Diastolic Components S1S2S1 l Pericardial Friction Rub l Patent Ductus Arteriosus l Venous Hum

45. Peripheral Vascular System Inspection l Inspect skin, nails, lips for signs of decreased circulation or cyanosis l Inspect nails for clubbing l Inspect lower extremities for signs of arterial insufficiency l thin shiny skin l decreased hair l ridged/thickened nails l ulceration

46. Peripheral Vascular System Inspection (cont) l Inspect lower extremities for signs of venous insufficiency l edema l varicose veins l thrombosis l thickened/ulcerated skin

47. Palpation l Note the temperature of the extremeties l Check for pitting edema è If present, record by depth of indentation l Palpate pulses, evaluate for: l rate l rhythm l contour (wave form) l symmetry l amplitude (strength)

48. Pulses (cont) l Note any variations in strength l from beat to beat l with respiration l Grade pulse strength l 0 = absent l 1 = weak/diminished l 2 = normal/expected l 3 = strong/increased l 4 = bounding

49. Auscultation l Auscultate over the major arteries for bruits l carotid, aorta, renal, femoral l Use the bell of the stethescope l Bruits are always abnormal

50. Jugular Vein Assessment l Provides insight into Right heart function l May be performed when suspect heart failure l Hepatojugular reflux l Patient supine with head of bed @ 30-60 degrees l Gently press liver while watching external jugular vein l May see wave level rise with right heart congestion l Jugular venous distension l Patient supine with head of bed at 30-45 degrees l Observe for venous pulsations in the neck (tangential light) l Identify highest point of pulsation l Using horizontal line from this point, measure vertically to sternal angle...should be less than 3-4 cm in healthy adult

52. Physical Assessment resources on the Internet l To hear various heart and breath sounds l http://www.med.ucla.edu/wilkes/intro.html l History and Physical Study Guides l http://www.medinfo.ufl.edu/year1/bcs/clist/index.html