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Cardiovascular Boot Camp
April 2009
Cardiovascular
Assessment
Presented By:
Karen Marzlin, BSN, RN, CCRN-CMC
CNEA
2009
1
Auscultatory Areas
2
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1
Cardiovascular Boot Camp
April 2009
The Cardiac Cycle
Systole and Diastole
3
Cardiac Diastole
(Atrial and Ventricular):
Early Passive Filling
4
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Cardiovascular Boot Camp
April 2009
Atrial Systole & Ventricular Diastole:
Late Active Filling
Atrial Kick
5
Beginning Ventricular Systole:
Isovolumic Contraction
6
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Cardiovascular Boot Camp
April 2009
Ventricular Systole:
Ejection
7
FIRST HEART SOUND
8
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Cardiovascular Boot Camp
April 2009
Basic Heart Sounds
S1
• Closure of the Mitral
(M1) valve and the
Tricuspid (T1)valve
• Beginning of
Ventricular Systole and
Atrial Diastole
• Isovolumic contraction
9
Basic Heart Sounds
S1
• Location: Mitral area
– at the hearts apex
• Intensity: Directly
related to force of
contraction
• Duration: Short
• Quality: Dull
• Pitch: High
10
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Cardiovascular Boot Camp
April 2009
SECOND HEART
SOUND
11
Basic Heart Sounds
S2
• Closure of Aortic (A2)
Valve and Pulmonic
(P2) Valve
• End of Ventricular
Systole Beginning of
Ventricular Diastole
12
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Cardiovascular Boot Camp
April 2009
Basic Heart Sounds
S2
• Location: Pulmonic area
• Intensity: Directly related
to closing pressure in
the aorta and pulmonary
artery
• Duration: Shorter than
S1
• Quality: Booming
• Pitch: High
13
Third and Fourth Heart Sounds
S3 and S4
• Ventricular diastolic filling sounds
• Low frequency sounds
• Produced by ventricular filling rather than valve
closure
• Normal in children and young adults
14
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Cardiovascular Boot Camp
April 2009
THIRD HEART SOUND
15
S3
Ventricular Gallop
• Ventricular Gallop
• Early diastole
• Caused by
increased
diastolic pressure
16
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Cardiovascular Boot Camp
April 2009
Left or Right Sided S3
• Left lateral position
• Location:
– Left Sided Mitral area
– Right Sided Tricuspid area
• Intensity:
– Left Sided Heard Best
during expiration
– Right Sided Heard Best
during inspiration
• Duration: Short
• Quality: dull, thudlike
• Pitch: Low
17
S4
Atrial Gallop
18
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Cardiovascular Boot Camp
April 2009
S4
Atrial Gallop
• Late diastole
• Caused by
atrial
contraction and
the propulsion
of blood into a
noncompliant
ventricle
19
Left or Right Sided S4
• Left Lateral position
• Location:
– Left Sided Mitral Area
– Right Sided Tricuspid area
• Intensity:
– Left Sided Louder on
expiration
– Right Sided Louder on
inspiration
• Duration: Short
• Quality: Thudlike
• Pitch: Low
20
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Cardiovascular Boot Camp
April 2009
Summation Gallop
Combination of S3 and S4
21
MURMURS
22
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Cardiovascular Boot Camp
April 2009
Murmur Fundamentals
Turbulence
• Murmur: If turbulence is intracardiac
• Bruit: If turbulence is extracardiac
23
Murmur Fundamentals
Causes of Turbulence
Forward flow through a stenotic valve
Backward flow through an incompetent
valve
24
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Cardiovascular Boot Camp
April 2009
Murmur Fundamentals
Causes of Turbulence
• Flow through a septal
defect or an AV fistula
• Flow into a dilated chamber or a portion
of a vessel
25
Murmur Fundamentals
• Stenotic Murmurs
– Valve does not open appropriately
– Heard during the part of the cardiac cycle
when the valve is open
• Regurgitant Murmurs
– Valve does not close appropriately
– Heard during the part of the cardiac cycle
when the valve is to be closed
26
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Cardiovascular Boot Camp
April 2009
Murmur Fundamentals
• Timing
– Systolic
• Location
• Holosystolic
• Ejection (midsystolic)
• Late
– Place heard the
loudest
– Diastolic
• Early
• Middiastolic
• Late
• Radiation
– Direction in which
murmur radiates
27
Murmur Fundamentals
• Configuration
– Crescendo
• Gets louder
– Decrescendo
• Gets softer
– Crescendo –
Decrescendo
• Louder then softer
– Plateau
• Even intensity
throughout
• Pitch
– High Pitched - diaphragm
– Low Pitched – bell
• Quality
–
–
–
–
–
–
Soft
Harsh
Blowing
Musical
Rumbling
Rough
28
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Cardiovascular Boot Camp
April 2009
Systolic Murmurs
• Tricuspid and Mitral
Valve Closed
– Tricuspid
Regurgitation
– Mitral Regurgitation
• Pulmonic and Aortic
Valve Open
– Pulmonic Stenosis
– Aortic Stenosis
29
Aortic Stenosis
Systolic Ejection Murmur
• Timing: Midsystolic
• Location: Best heard
over aortic area
• Radiation: Toward right
side of neck
• Configuration:
Crescendo-decrescendo
• Pitch: Medium to high
• Quality: Harsh
30
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Cardiovascular Boot Camp
April 2009
Pulmonic Stenosis
Systolic Ejection Murmur
• Timing: Midsystolic
• Location: Best heard over
pulmonic area
• Radiation: Left neck of left
shoulder
• Configuration:
Crescendo-decrescendo
• Pitch: Medium
• Quality: Harsh
31
Systolic Murmurs
Mitral Regurgitation
• Timing: Holosystolic
• Location: Mitral area
• Radiation: To the left
axilla
• Configuration:
Plateau
• Pitch: High
• Quality: Blowing,
harsh or musical
32
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Cardiovascular Boot Camp
April 2009
Systolic Murmurs
Tricuspid Regurgitation
• Timing: Holosystolic
• Location: Tricuspid area
• Radiation: To the right of
sternum
• Configuration: Plateau
• Pitch: High
• Quality: Scratchy or
blowing
33
Diastolic Murmurs
• Diastolic regurgitant murmurs
– Retrograde flow across an incompetent
semilunar valve
• Diastolic filling murmurs
– Forward flow across stenotic or obstructed
AV valves
34
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Cardiovascular Boot Camp
April 2009
Diastolic Murmurs
• Tricuspid and Mitral
Valves Open
– Tricuspid Stenosis
– Mitral Stenosis
• Pulmonic and Aortic
Valves Close
– Pulmonic
Regurgitation
– Aortic Regurgitation
35
Diastolic Murmurs
Aortic Regurgitation
• Timing: Early diastole
• Location: Aortic area
• Radiation: Toward
apex
• Configuration:
Decrescendo
• Pitch: High
• Quality: Blowing
36
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Cardiovascular Boot Camp
April 2009
Diastolic Murmurs
Pulmonic Regurgitation
• Timing: Early diastole
• Location: Pulmonic
area Erb’s Point
• Radiation: Toward
apex
• Configuration:
Decrescendo
• Pitch: High
• Quality: Blowing
37
Diastolic Murmurs
Mitral Stenosis
• Timing: Mid to Late
diastole
• Location: Mitral area
• Radiation: None
• Configuration:
Crescendo
• Pitch: Low
• Quality: Rumbling
38
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Cardiovascular Boot Camp
April 2009
Diastolic Murmur
Tricuspid Stenosis
• Timing: Mid to Late
diastole
• Location: Tricuspid
area
• Radiation: None
• Configuration:
Decrescendo
• Pitch: Low
• Quality: Rumbling
• Increases during
inspiration and
decreases during
expiration
39
Other Sounds
Pericardial Friction Rub
•
•
•
•
•
•
•
Timing: Systolic, Early diastolic and late diastolic
Location: Tricuspid area and Xyphoid area
Radiation: None
Configuration: Plateau
May get louder during inspiration
Pitch: High
Quality: Grating, scratching
40
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Cardiovascular Boot Camp
April 2009
Other Sounds
Ventricular Septal Defect or
Rupture
• Timing: Continuous
• Location: 3-4 LSB
• Radiation: Widely
throughout the
precordium
• Configuration:
Plateau
• Pitch: High
• Quality: Harsh
41
Other Sounds
• Papillary Muscle Rupture
– Same as Mitral Regurgitation
42
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Cardiovascular Boot Camp
April 2009
REMEMBER:
The most important part of
the stethoscope is the part
between the ear pieces.
43
Other Assessment Tools
44
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Cardiovascular Boot Camp
April 2009
Blood Pressure
• Definitions:
– BP = CO X SVR
– Systolic: Maximum pressure when blood is
expelled from the left ventricle
– Diastolic:Measures rate of flow of ejected
blood and vessel elasticity
– Pulse Pressure: Difference between systolic
and diastolic pressure
45
Cardiac Assessment
• Blood Pressure
– Variation of up to 15mm Hg between arms is
normal
– BP in legs - 10 mm Hg higher than arms
– Narrowed pulse pressure – vasoconstriction
• Innervation of sympathetic nervous system
– Hypovolemic shock
– Widened pulse pressure – vasodilation
• Excessive vasodilatory mediator release
– Septic shock
46
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Cardiovascular Boot Camp
April 2009
JVP (Jugular Venous Pressure)
• Reflects volume and pressure in right side
of heart
• Visual inspection
• HOB 30 -45 degree angle
– 45 degree angle will cause venous pulsation
to rise 1 to 3 cm above the manubrium
47
Measuring JVD
• Raise HOB until pulsation in internal jugular
seen (usually 30 – 45 degrees)
– Use targeted light
– Use centimeter ruler
• Measure distance from angle of Louis (Manubriosternal joint)
to top column of blood
• Draw imaginary horizontal line from column to sternal angle
48
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Cardiovascular Boot Camp
April 2009
JVD (Jugular Venous
Distension)
• Normal JVD level is 3 cm above the
sternal angle
• Sternal angle is 5cm above right atrium
• JVD of 3 cm + 5cm = estimated CVP of
8cm
• Estimated CVP> 8 cm
– Increased blood volume
– Usually RV failure
• Tricuspid valve regurgitation
• Pulmonary hypertension
49
Tips to Take Away for JVD
Assessment
• If unable to accurately assess
– Lie patient flat to visualize and then raise
HOB
– If venous congestion is expected may need to
sit or stand patient to see top of column
50
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Cardiovascular Boot Camp
April 2009
Profiles of Perfusion and
Congestion
Congestion at Rest
No
No
Low
Perfusion
at Rest CI 2.2
Yes
Yes
Warm and Wet
Warm and Dry
Congestion
No congestion
No hypoperfusion No hypoperfusion
Cold and Dry
No congestion
Hypoperfusion
Cold and Wet
Congestion
Hypoperfusion
PWP 18
51
Cardiac Assessment
Arterial vs. Venous Disease
52
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Cardiovascular Boot Camp
April 2009
Edema
•
•
•
•
•
•
•
•
Evaluated on a 4-point scale.
0 = None present.
1+ = 0 to 1⁄4 inch Trace.
2+ = 1⁄4 to 1⁄2 inch Mild.
3+ = 1⁄2 to 1 inch Moderate.
4+ = > than 1 inch Severe.
Described as pitting or non-pitting.
Anasarca: generalized edema.
53
Pulses
• 4 point scale (0-3)
• 0 = absent
• 1+ = Palpable but thready and weak,
easily obliterated
• 2+ = Normal, easily identified, not easily
obliterated
• 3+ = Full, bounding, cannot obliterate
54
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Cardiovascular Boot Camp
April 2009
Central Cyanosis
•
Occurs when more than 5 grams/dL of hemoglobin is
deoxygenated
• Results in a bluish or steel-gray discoloration of the skin
and mucous membranes
– Bluish or steel-gray discoloration of the lips can be from central
or peripheral cyanosis
– Oral mucosa or the tongue may be better tools for assessment of
central cyanosis
•
Usually not seen until oxygen saturation drops to
between 73% to 78%
• Absence of cyanosis does not exclude hypoxemia
55
Peripheral Cyanosis
• Caused by peripheral vasoconstriction
and decreased local blood flow
• May occur with or without central
cyanosis (i.e., with or without hypoxemia)
Usually observed in the nailbeds of the
hands or feet, the earlobes or nose
• Should improve with warming
56
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Cardiovascular Boot Camp
April 2009
Pulsus Paradoxus
• To measure the pulsus paradoxus, patients are often
placed in a semirecumbent position; respirations
should be normal. The blood pressure cuff is
inflated to at least 20 mm Hg above the systolic
pressure and slowly deflated until the first Korotkoff
sounds are heard only during expiration. At this
pressure reading, if the cuff is not further deflated
and a pulsus paradoxus is present, the first
Korotkoff sound is not audible during inspiration. As
the cuff is further deflated, the point at which the
first Korotkoff sound is audible during both
inspiration and expiration is recorded. If the
difference between the first and second
measurement is greater than 12 mm Hg, an
abnormal pulsus paradoxus is present.
(Yarlagadda, Chakri, 2005 Cardiac Tamponade. Retrieved 3-22-06 from
www.emedicine.com)
57
Risk Assessment
58
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Cardiovascular Boot Camp
April 2009
Risk Assessment in UA / NSTEMI
• TIMI Risk Score
–
–
–
–
–
Age > 65
3 or > risk factors for CAD
Prior 50% or > stenosis
ST deviation on ECG
2 or > anginal events in
previous 24 hours
– Use of ASA in prior 7 days
– Elevated cardiac biomarkers
• GRACE
–
–
–
–
Older age
Killip class
Systolic BP
Cardiac arrest during
presentation
– Serum creatinine
– Positive initial cardiac
markers
– HR
59
Stroke Risk Assessment
•
•
•
•
•
Congestive Heart Failure
Hypertension
Age > 75
Diabetes
Stroke TIA
60
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Cardiovascular Boot Camp
April 2009
Assessment Integration For
Cardiac Emergencies
61
Assessment Considerations for
Emergencies
• Tamponade
– Beck’s triad
– Pulses Paradoxus
• Pulmonary Embolus
– Right axis deviation
– T wave inversion
– Respiratory Alkalosis
• Acute Aortic Dissection
–
–
–
–
Diastolic murmur
Bilateral BPs
4 extremity pulses
Inferior MI
• Papillary Muscle Rupture
– Holosystolic murmur
– Acute pulmonary edema
• VSD
– Holosysytolic murmur
62
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Cardiovascular Boot Camp
April 2009
Thanks for Attending
Cardiovascular Boot Camp
You may contact us at www.cardionursing.com
63
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