Download Cardiovascular Assessment

Cardiovascular Assessment
Yuriy Slyvka MD, Ph.D.
Cardiovascular Assessment
The Heart
•Extends from the 2ed to the 5th intercostal space
•Between the R boarder of the sternum to the L
midclavicular
•Beats against chest wall to produce apical
impulse
•Palpate 5th intercostal space 7-9cm form the mid
sternal line
• Heart Chambers
– Right atrium (RA)
– Right ventricle (RV)
– Left atrium (LA)
– Left ventricle (LV)
• Valves
– Aortic valve
– Mitral valve
– Tricuspid valve
– Pulmonic valve
Directions of blood flow
Blood Flow
1. From liver to right atrium (RA) via inferior vena
cava: Superior vena cava drains venous blood
from the head and upper extremities
From RV, venous blood travels through
tricuspid valve to right ventricle (RV)
2. From RV, venous blood flows through
pulmonic valve to pulmonary artery
Pulmonary artery delivers unoxygenated
blood to lungs
3.Lungs oxygenate blood
Pulmonary veins return fresh blood to LA
4. From LA, arterial blood travels through mitral
valve to LV. LV ejects blood through aortic
valve into aorta
5. Aortic delivers oxygenated blood to body
Diastole
– Ventricles relax and fill with blood and AV
valves (tricuspid, mitral) open
– Bottom number of the B/P
– Occurs when AV valves are open to allow
filling of the ventricles
Systole
– Heart contract and blood pumped in ventricles
and fills pulmonary & systemic arteries
– Closure of AV valves contributes to first heart
sound and signals beginning of systole
– Top number of B/P
Percussion: outline of the heart’s boarder;
limited with the female breast tissue or in an
obese person or person with muscular chest
wall.
• Place stationary finger in person’s fifth
intercostal space over on L side of chest
near anterior axillary line. Slide hand
toward yourself note change in sound from
resonance over the lung to dull( over the
heart)
• Left border of cardiac dullness is at the
midclavicular line in 5th interspace
and slopes toward sternum
• At the second interspace the border os
dullness coincides with left sternal border
• Right border of dullness matches the
sternal border
• Palpate apical impulse
– Using 1 finger locate the apical impulse
– Ask client to “exhale and hold”=aids in
locating pulsation
– May need to turn client to left to find it.
–Note: Location, size, amplitude and
Duration
–Apical impulse palpable in ½ adults, and
not in obese or thick wall clients.
–Apical impulse increases in amplitude
and duration in client with anxiety, fever,
hyperthyroidism and anemia
• Auscultation: listen for the pitch, rate, regularity,
-low pitched, short duration of sound,
regularity
-deep breathing will temporarily slow heart
rate
-identify S1 and S 2, assess S 1and S 2
separately, listen for extra heat sounds
and listen for murmurs
-with stethoscope use Z pattern from base
of the heart across and down, then
over
apex or start at apex and work
way up.
-note rate and rhythm
-if notice irregularity, check for pulse deficit
(check radial and apical pulse
simultanously)
When listening
Start at base of heart and use Z pattern.
Note:
-rate & rhythm
-Identify S1 and S2
-Assess S1and S2 separately
-Listen for extra heart sounds
-Listen for murmurs
Landmarks
-second R interspace= aortic valve area
-second L interspace= pulmonic valve area
-L lower sternal border= triscupid valve area
-fifth interspace at around L midclavicular
line= mitral valve area
Heart Sounds
• S1
– Closure of the AV valve
– Beginning of systole
– “lup” of the “lup-dup” sound
-louder at apex
-coincides with carotid artery pulse
S2
– closure of semilunar valves
– end of systole
– “dup” of the “lup-dup” sound
– louder at base
Abnormal Heart Sounds
• Split S
-benign condition occurring in some patients
upon inspiration
-”lup-t-dup” sound
-crisper than a murmur
-occurs at end of inspiration
-occurs about every fourth beat, fading in with
inhalation and out with exhalation
– Murmurs
• Vibrations within the hearts chambers or
major arteries from the back and forth
blood flow; swishing sound
–Innocent- no anatomic or physiologic
abnormality exists
–Functional- no anatomic cardiac defect
exists but physiologic abnormality
such as anemia, fever, pregnancy,
hyperthyroidism)
• Murmur
– Blowing, swooshing sound that occurs with
turbulent blood flow in the heart or great
vessels.
– Need to ID if it occurs in systole or diastole
– Extra “humming” sound between S1 and S2
sounds
– Listen to pitch (high, medium, or low)
– Listen to pattern (crescendo, decrescendo,
crescendo-decrescendo or diamond shaped)
-Listen to loudness (grades i to vi= barely
audible to loudness)
-Quality (musical, blowing, harsh, rumbling)
-Location ( where best heard)
-Radiation-transmitted downstream direction of
blood flow
-Posture- disappear or enhanced by change of
position
Causes:
– structural- weakened valve or wall defect
secondary to streptococcal infection or
congenital defect
– flow murmur
• change in blood viscosity secondary to
anemia
• change in blood velocity secondary to
-structural- weakened valve or wall defect
secondary to streptococcal infection or
congenital defect
-flow murmur
• change in blood viscosity secondary to
anemia
• change in blood velocity secondary to
exercise
– Loudness
--Grades i-vi(adults)
• i = barely audible, quiet room
• ii= clearly audible but faint
• iii= moderately loud
• iv=loud, associated with a thrill palpable on
chest wall
• v= very loud, heard with one corner of
steth. lifter off chest wall
• vi=loudest, still heard with entire steth. lifted
just off the chest wall
• Thrill:
– Palpable vibration felt over the heart as
blood moves from chamber to chamber
– ALWAYS ABNORMAL
• Pericardial Friction Rub:
- Grating sound upon inspiration, stops when
breath is held
- ALWAYS ABNORMAL
Assessment of Peripheral Pulses Strength
– 0=absent
– +1=weak
– +2=diminished
– +3=strong
– +4=bounding and full
Assessment of Pulses
• Regularity/ Rate
• Bilateral Equality
– Should be the same on both sides of the body
L or R
• Head to Toe Equality
• Should not be greatly different head to toe
• Use additional assessments:
• Check against apical pulse
• Check other measures of circulation if pulse heard
to find
Cardiac Assessment in Children
• Inspection: notice color of skin and mucous
membranes, observe child in semi-fowler position,
check for edema, warmth of extremities
• Palpation: locate apical impulse (AI)
-Lateral to the L midclavicular (LMCL) and fourth
- ICS in children < 7 yr. old
-At LMCL and fifth ICS in children > 7 yrs. old
• Point of maximum intensity (PMI)- area of
most intense pulsation [Ai and PMI not used
interchangeably but they are at the same
place]
• Thrills- palpable vibrations best felt with
ball of hand and during expiration;
produced by flow of blood from one
chamber of heart to another through
narrow or abnormal opening
• Pericardial friction rubs-scratchy, high
pitched grating sound; not affected by
changes in respirations
• Capillary refill time-brisk-less than 2
seconds; blanch nail beds with pressure for
a few seconds and then release; prolonged
associated with poor systemic perfusion
• Auscultation: (Children)
– S1 and S2 correspond to “lub-dub”
– S1 caused by closure of tricuspid and mitral
valves
– S2 caused by closure of pulmonic and aortic
valves
• Distinguish between S1 and S2
simultaneously palpate carotid pulse with
index & middle finger as listen to heart
sounds
• Alterations Through the Lifespan
(Children)
• Infants and Children
– Change from fetal to neonatal circulation in first 24
hours
– Foramen ovale closes in1st hours
– ductus arterious closes by the first weeks of
life
– Heart is placed more laterally in children
• Apex is at 4th intercostal space before 3 yrs
• Apex is at the 5th intercostal space at 7 yrs. age
• CAROTID ARTERY IN NOT PALPATED IN
PATIENTS UNDER ONE YEAR OF AGE
– Abnormal findings in Pediatric patients
– Murmurs common and usually outgrow
• Remain aware of strep effects on the heart
valve
• Innocent (no valvular or pathologic cause
it is just a noise
• Functional (due to increase blood flow)
need to have diagnosis test as EKG or
echocardiogram
Rheumatic fever• Causes weakening of heart valve
– Physiological Changes in Pregnancy:
– Growing uterus pushes heart up. Left and
forward
– Blood volume rises to 40-45% greater than
pre pregnancy vol.
• Murmur in 90% pregnant patients
disappear at delivery ( non-functional
murmurs)
– Cardiac output rises to 50% above pre
pregnancy levels; pulse rate rises by 10-20
– In Vessels:
• Vena Cava syndrome
–Uterus puts pressure on vena cava
when patients is in supine position
–Lowers B/P
–Patient feels clammy, dizzy and shows
pallor
–Turn patient to L side to relieve pressure
of vena cava
Geriatrics
• Arteries stiffen with age and B/P rises
• Average rise is 20 mmHg between 20-60 and
between 60-80 another 20 mm HG
• LV wall thickens
• Loss of ability to augment exercise with
increased cardiac output
• Resting pulse rate remain in the lifetime range
between 60-100 and maybe irregular
• Vessels lose elasticity
–Varicose veins
–More susceptible to clots
–Loss of venous elasticity plus less
efficient cardiac output results in
decreased circulation
»Lower healing
»Body temperature, regulation is
changed
• Abnormal findings in Geriatric Patients
• At risk for dehydration and altered
nutritional status
–Dehydration impacts fluid volume and
B/P
–Electrolyte imbalance impact on
cardioelectricity
– Murmurs common in this age group
• Arryhthmias more common in this age
group
–Ectopic beats( extra beats)
• Lower cardiac output and B/P
• May deprive organs of needed
oxygenation
• Better tolerated in younger population
• Tachycardia
• Results in 40-70% drop in cerebral
blood volume
• Syncope
• Peripheral blood vessels grow more rigid with
age
»Tests and vocabulary
– Atherosclerosis = deposit of fatty plaques on
the intima of the arteries.
– Artheriosclerosis= arteries becoming more
rigid producing a rise in systolic B/P
Claudication- pain produced when walking, not
relieved by rest
– Bruit- occurs with turbulent blood flow,
indicating partial occlusion
– Modified Allen Test- evaluate collateral
circulation [firmly depress ulna & radial arties,
patient opens & closes fist; normal when open
fist, blood returns to normal
– Homans’ sign-pain in calf with dorsiflexion of
the foot, indicating thrombophlebitis or
thrombus
– Pitting Edema
• 1+= mild pitting, slightly indentation, no
perceptible swelling of legs; depth of pitting
is 1 cm
• 2+= moderate pitting, indentation subsides
rapidly; depth of pitting is 2 cm
• 3+= deep pitting, indentation remains for a
short time, leg looks swollen; depth of
pitting is 3 cm
• 4+= very deep pitting, indentation lasts a
long time, leg is very swollen; depth of
pitting is 4 cm
– Trendelenburg Test- varicosites present in
legs to determine valve competence; lying
supine elevate legs 90* until veins empty,
place tourniquet high on thigh, help patient to
– Stand, watch for venous filling; saphenous
veins should fill slowly from below in about 30
seconds
Taking a Health History
• Lifestyle factors:
• Smoking- stimulant for CV system
• Serum cholesterol- causes blockages
• Obesity- stresses heart with fat deposits
and constant state of exertion
• Past medical history:
• Diabetes- stresses body, effects heart
• HTN- wear& tear in aorta and LV
• Family history heart disease or PVD
–Large genetic correlation
• Problems during pregnancy
• Are children meeting developmental
milestones & expected growth parameters
• Any history of chest pain
– When
– What precipitated it
– What gave relief
– Qualities
• Stabbing, crushing, shooting, radiating
• Angina
• Constriction of small vessels surrounding the
heart
• Causes sharp chest pain
• Relief with nitroglycerine
• Assess for complains of fatigue, pallor,
edema and temperature; alterations in the
extremities
• All indicate possible poor cardiac output
Nursing Interventions:
• Take a careful history
• Provide patient teaching as to risk factors for
cardiovascular health
• When helping patients OOB allow them to move
•
•
•
•
to prevent hypotension
Encourage pregnant women to lay on their L
side to prevent vena cava syndrome
Educate pregnant women of S & S of pre
eclampsia and keep careful B/P records of
patients
Keep careful records of pediatric growth &
development parameters for each patient and
continually check progress
Watch oxygen status of patient with altered
cardiac output