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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 www.cardionursing.com 1 Cardiovascular Boot Camp April 2009 The Cardiac Cycle Systole and Diastole 3 Cardiac Diastole (Atrial and Ventricular): Early Passive Filling 4 www.cardionursing.com 2 Cardiovascular Boot Camp April 2009 Atrial Systole & Ventricular Diastole: Late Active Filling Atrial Kick 5 Beginning Ventricular Systole: Isovolumic Contraction 6 www.cardionursing.com 3 Cardiovascular Boot Camp April 2009 Ventricular Systole: Ejection 7 FIRST HEART SOUND 8 www.cardionursing.com 4 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 www.cardionursing.com 5 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 www.cardionursing.com 6 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 www.cardionursing.com 7 Cardiovascular Boot Camp April 2009 THIRD HEART SOUND 15 S3 Ventricular Gallop • Ventricular Gallop • Early diastole • Caused by increased diastolic pressure 16 www.cardionursing.com 8 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 www.cardionursing.com 9 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 www.cardionursing.com 10 Cardiovascular Boot Camp April 2009 Summation Gallop Combination of S3 and S4 21 MURMURS 22 www.cardionursing.com 11 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 www.cardionursing.com 12 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 www.cardionursing.com 13 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 www.cardionursing.com 14 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 www.cardionursing.com 15 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 www.cardionursing.com 16 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 www.cardionursing.com 17 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 www.cardionursing.com 18 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 www.cardionursing.com 19 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 www.cardionursing.com 20 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 www.cardionursing.com 21 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 www.cardionursing.com 22 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 www.cardionursing.com 23 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 www.cardionursing.com 24 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 www.cardionursing.com 25 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 www.cardionursing.com 26 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 www.cardionursing.com 27 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 www.cardionursing.com 28 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 www.cardionursing.com 29 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 www.cardionursing.com 30 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 www.cardionursing.com 31 Cardiovascular Boot Camp April 2009 Thanks for Attending Cardiovascular Boot Camp You may contact us at www.cardionursing.com 63 64 www.cardionursing.com 32