Download Sound "1"

Islamic University of Gaza
Faculty of Nursing
• Chapter (8)
• Assessment of Cardiovascular System
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Assessment of Cardiovascular System
• Subjective data:
1. Assessment of chief complaints:
- Chest pain: location, quality, duration &
associated symptoms.
- Irregular heart beat: pound, too fast, jump.. Etc.
2. Assessment of risk factors:- Ask about history of hypertension, diabetes,
rheumatic fever?
- Ask about family history of heart attack,
hypertension, stroke, and diabetes?
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- Describe your nutritional intake: have you ever
been told you have high cholesterol, triglyceride
level.
-Do you smoke? How much? And for how long?
- How do you view yourself? What do you do to
relax?
- How many hours a day do you work? How do cope
with stress.
- Exercise: what do you do for exercise? How often?
- Pain in calves, feet, buttocks or legs? What
aggravates the pain (walking, sitting long periods,
standing long periods, sleep) what relieves the pain
“elevating legs, rest, lying down”.
- Is there fitting shoes? Does client wear constricting
garments or hosiery?
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In what type of chair does client usually sit?
- Does he/she cross legs frequently?
- assessment the client must be is in supine or sitting positing
according to his health
Inspection &palpation:
* By inspection and palpation you may detect ventricular
hypertrophy.
* Use source of light to inspect subtle movements in chest e.g.:
pulsation, retraction… Etc.
* Apical pulse in left fifth intercostal space, if deviation in site
observed may indicate cardiac enlargement 6th intercostal
space.
* Retractions may be seen around site of apical pulse, marked
retraction may indicate pericardial disease.
* Heaves or lifts: when right Ventricle work increase.
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• Palpation (supine position).
• Palpate from apex, moving to external
border to base:
• * Detect abnormalities in site of palpation
and abnormal sounds especially for thrill
“abnormal flow of blood”
• * It is important to describe pulsations in
relation to there timing in the cardiac cycle.
• * Describe in terms: locations of pulsation
in relation to mid-sternal, mid-clavicular or
axillary lines.
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• * Palpation of apical pulse, strength differs
from thin person to obese.
• * Conditions such as anxiety, anemia, fever,
and hyperthyroidism may increase in force
and duration of apical pulse. (you feel
lifting sensation under your fingers).
• * Palpation of pulse at base of the heart
(putting your hand at second left and right
intercostal spaces at sternal borders).
• ** Percussion: “not used in cardiac
assessment”
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•
Auscultation: All heart sounds are generally low
pitched “low frequency” and difficult for the
human ear to hear.
* You may start auscultation from base to apex or
from apex to the base.
• Assess:
1. Rate and rhythm of the beat.
2. Concentrates initially on sound "1", noting its
intensity and variations, possible duplication and
effects of respiration.
3. Then listen to Sound "2" for same characteristics.
4. Finally listen for extra sounds and for murmurs
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• Sound "1": caused by the closing of the tricuspid and mitral
valves. “Systole begins with Sound "1" &extends to Sound "2"
• Sound "2": results from closing of the aortic & pulmonary
valves.
“Diastole begins with Sound "2" and extends to next Sound "1"
• Sound "2" louder than Sound "1" at the base of heart, and is
quieter than Sound "1" at the apex.
• Sound "3": During diastole, rapid distention of ventricles occur
causes vibrations of ventricular walls ," and this known as
sound "3" ".
• Sound "3" best heard at the apex with bell of stethoscope.
• Sound "4": occur after Sound "3" (late diastolic filling), occur
from vibrations of ventricular wall or vibrations of the valves.
• * Summation gallop: three cardiac sounds heard S1, S2 and
summation of S3 and S4.
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Neck vessels:
- Jugular veins assessed for venous pulse
waves and pressure.
- Assess for distention, may result from
right Sided heart failure.
- The client must be in supine position or
in fowler position "45" degree.
- Assess jugular pulse “venous" which is
wave of blood retrograde after ejecting
blood into the right ventricle
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• Assess carotid arteries: inspection, then palpate
below and just medial to the angle of the jaw, then
Auscultate by the bell of the stethoscope.
• Assess carotid arteries for pulsation noting is it
strong or weak, rise or collapse, rapid or slow,
double or single.
• Listen for heart murmurs ( abnormal sounds
produced by vibrations within the heart or in the
walls of large vessels “during systole or diastole”.
• Murmurs occurrence result from valve defects,
changes in the blood vessels or by defects in the
myocardium.
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• Special maneuvers for vascular assessment
– Check for deep phlebitis by quickly squeezing calf
muscles against tibia (normally no pain)
– Check Homan's sign by extending leg and dorsiflexing foot (normally no pain).
– check for competency of valves (Trendelen-burg
test) if client has varicose veins: feel dilated veins
with one hand while using the other hand to
compress veins firmly above level of the first
hand, then palpate for impulse of blood flow
which is normally no pulsation palpated.
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Arterial and Venous insufficiency of lower extremities
Item
Arterial insufficiency
Venous
insufficiency
Pulses
Decreased or absent
Present
Color
Pale on elevation and cold
Pink to cyanotic, brown pigment
at ankles
Temperature
Cool, cold
Warm
Edema
Non
Present
Skin
Shiny skin, thick nails, absent of
hair, ulcers on toes, gangrene
may develop
Ulcers on ankles discolored, scaly
Sensation
Leg pain aggravated by standing
& relieved with rest.
Pressure on buttocks or calves or
cramps during walking,
parasthesia
Leg pain aggravated by standing
or sitting & relieved by
elevation of legs, lying down,
or walking. Also relieved with
use of support hose.
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The end
Thank you
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