Download CardioVascular Assessment Lab

CardioVascular
Assessment Lab
C Ruckdeschel RN, BSN
Objectives
Review Anatomy of Heart
Review Vascular System
Review Physiologic basics for
Cardiovascular System
Objectives:
Identify Skills to assess cardiovascular
System:
Pulse
Peripheral vascular assessment
Heart Sounds
Blood Pressure
Anatomy of Heart
Right side of heart - receives
deoxygenated blood from systemic
circulation - LOW PRESSURE
Left Side of the heart - receives
oxygenated blood from pulmonary
circulation and pumps it into systemic
circulation - HIGH PRESSURE
Chambers and Valves
Rt Atrium
RT AV Valve (Tricuspid)
Rt Ventricle
Rt semilunar (Pulmonic)
Left Atrium
Lft AV Valve (bicuspid, Mitral)
Left Ventricle
Left semilunar (Aortic)
Great Vessels of the Heart
Vena Cava - deoxygenated blood brought to heart
IVC (inferior vena Cava)
SVC (superior Vena Cava)
Pulmonary Artery - deoxygenated blood from rt ventricle to pulmonary
capillaries
Pulmonary Veins - oxygenated blood from pulmonary capillaries to lft atrium
Aorta Ascending
Arch
Descending
Thoracic
Abdominal
http://www.youtube.com/wat
ch?v=PgI80Ue-AMo
Coronary Arteries
Arteries that arise from base of aorta and
supply myocardium with richly oxygenated blood
LCA
LAD
Circumflex
RCA
Cardiac Conduction System
•
Heart is innervated by Autonomic nervous system
Sympathetic : stimulates
Parasympathetic: slows
SA Node (Sinoatrial node): located in right atria,
generates impulses that travel through the
conduction system & produce cardiac muscle
contraction.
AV Node (atrioventricular node): located in the
atrial septum
Bundle of His: right and left bundle branches
Purkinjie fibers: located in ventricular myocardium,
where ventricular contraction takes place
12 Lead EKG
•
Chest X-ray
Common Cardiovascular Problems
CAD (Coronary Artery Disease)
HTN (Hyypertension) > 80% of US population
RHD (Rheumatic Heart Disease) - Sequelae of beta
hemolytic strep infections resulting in valvular damage, more
likely seen In older adults
BE (Bacterial Endocarditis) - bacteremia causes valvular
damage
CHD (Congenital Heart Disease) – greatest portion
diagnosed early in life
Peripheral Vascular Anatomy
Aorta
Arteries
Arterioles
Capillaries
Venules
Veins
Vena Cava
Important Vessels
Accessible arteries:
Temporal, Carotid, Aorta,
Brachial, Ulnar, Radial, Femoral,
Popliteal, Doraslis pedis,
Posterior Tibial
Accessible veins:
Jugular, Superficial & deep arm
veins, Femoral vein (deep),
Popliteal vein (deep),
saphenous (superficial)
Physiologic Basics
Myocardium - muscle layer of the heart
that allows it to act as pump
Cardiac Output = HR x SV
Heart Rate (pulse) = beats per minute
Blood Pressure = SVR x CO
Electrical conduction of the heart
Assessing: Heart Sounds
Heart Sound Review
Location
Aortic: 2nd ICS, RSB (s2 is loudest)
Pulmonic: 2nd ICS, LSB (s2 is loudest)
Erbs Point: 3rd ICS, LSB
Tricuspid: 4th ICS, LSB (s1 is loudest)
Mitral (Apex): 5th ICS, MCL (s1 is loudest)
S1: represents ventricular contraction & ejection: S1 sound is
produced by closing of AV valves (tricuspid and Mitral valves)
S2: represents ventricular relaxation & filling: S2 sound is
produced by closing of semilunar valves: Aortic and Pulmonic valves
http://www.youtube.com/
watch?v=Ge12P7u0aQo
Assessing: Heart Sounds
Assessing: Heart Sounds
Obtain History
Risk factors/lifestyle
diet, exercise
smoking
cholesterol
stress, palpitations
dyspnea/orthopnea
edema
fatigue - relationship to
exercise
chest pain
Location
substernal?
Radiate precordial?
Quality crushing?
Associated N/V
Related to activity?
Obtain History
Any
medications?ty
pe
doseside
effectsexpected
effectstake as
prescribed?
Pacemaker
Typebattery checkPresence
of AICDautomated
internal defibrillator
Assessing: Heart Sounds
Obtain History
Past Health History
Diabetes
Dependent edema
congenital heart
defect
CAD
Rheumatic fever
Most recent EKG,
stress EKG
Other diagnostics
Obtain History
Past Family
History
Angina
Heartdisease
MI,StrokeDM,
Hyperlipidemia
Sudden death age?
Assessing:
Heart Sounds
Inspection
Bare chest
Quiet room, Privacy
Note: symmetry of chest, any pulsatile areas, discolorations
Palpate
Precordium
palpate 5 sites for:
Heave (with palmer surface), thrust
Thrill (with base of finger of heel of hand (bony part))
palpable murmur » cat purring
Thrills - indicative of obstructed flow
fine palpable rushing sensation
R or L 2nd ICS - Aortic or pulmonic stenosis
When palpate precordium use other hand to palpate carotid artery
S1 should coincide with carotid impulse
Assessing:
Heart Sounds
Auscultate
Use diaphragm and bell of stethoscope
start with diaphragm, (S1 and S2 relatively high pitched)
use bell to listen for S3 and S4
heart sounds - S1 and S2
rate
rhythm - regular (NSR), irregular (warrants investigation)
extra sounds? Murmurs?
Auscultation: want to hear crisp, distinct S1 and S2
S1 > at apex
S2 > at base
Assessing:
Heart Sounds
BE Systematic!! APE TO MAN
Listening for S1 and S2
interval between S1 and S2 should be silent
heart sounds not heard best directly over valve
which produces it, but in direction of blood flow
there are specific sites where each valve sound is
best heard
http://www.youtube.
com/watch?v=2aO0
HKIP3vI
After Auscultating Heart
Sounds.....
Perfect time to auscultate Apical Pulse.
Count for one full minute, each cardiac
cycle.
Note rate & rhythm
What is a Pulse?
•
The ventricles pump blood into the
arteries at about 72 bpm. The blood
causes an alternating expansion and recoil
creates a pressure wave which travels
through all of the arteries.
Pulse
Adult (60-100) bpm
Child (80-120) bpm
Infant ( 140 bpm)
Palpated on superficial arteries (pulse
points)
Auscultated on Apex of the heart
Pulse Variations:
Tachycardia - >100 bpm
Bradycardia - < 60 bpm
Palpitations - Unpleasant sensations of awareness of
the heartbeat: described as skipped beats, racing,
fluttering, pounding or irregularity: may result from
rapid acceleration or slowing of heart, increased
forcefulness of cardiac contraction: not necessarily
associated with heart disease.
Factors Assessing Pulse
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•
•
•
•
•
•
Cardiac output
Age
Gender
Exercise
Fever
Stress
Position
Factors Assessing Pulse
Cardiac Output
Amount of blood ejected from the heart
in one minute
Measured by SV x HR
Normal HR = 60 - 100 beats per minute
Factors Assessing Pulse
Age
Adult (60-100) bpm
Child (80-120) bpm
Infant ( 140 bpm)
Gender - after puberty female > male
Exercise
increased HR with activity
increased metabolism causes vasodilatation
causes O2 demand
Factors Assessing Pulse
Fever
body compensates for increased temp by
vasodilatation, decreased BP causes body
to compensate by > HR
increased 10-20 beats/min/ degree above
norm
especially in children
Factors Assessing Pulse
Stress
sympathetic response, increases
HR & BP
Position
sitting, standing causes pooling
results in transient - BP
rate compensates by increasing
Assessing : Pulse
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•
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Please note:
Assessing a heart rate is determining
beats per minute, noting rate, rhythm and
strength.
Assessing peripheral pulses is to assess
arterial blood flow to peripheral arteries.
Assessment: Pulse
Auscultating at Apex
Using the diaphragm of your stethoscope, place it on the 5th
intercostal space, MCL
For one full minute, count each LUB, DUB as one!!
Location of left ventricular apex & PMI (point of maximum
impulse)
Adult: 5th ICS, MCL
Infants: 4th ICS, left of MCL
Pregancy: PMI moves 1-2 cm left of MCL & up to 4th ICS
Assessment:Pulses
Peripheral Pulses
Obtain History
Intermittent claudication
pain on walking disappears with rest
leg cramps, leg ulcers
varicose veins
edema of feet or legs
blood clots
pallor of fingertips
Assessment:Pulses
Peripheral Pulses
Inspection of Extremities Compare Left to Right
Size
Symmetry
Skin/color
Nail Beds
Nails
Hair Growth
Assessment:Pulses
Peripheral Pulses
Palpation - Compare Right to Left
Temperature
Capillary refill
Pulses
UE:Radial,Brachial
LE: Dorsalis Pedis, Posterior tibial, popliteal, Femoral
Edema
+1- +4 pitting
Sensation
Assessment: Pulses
Characteristics of Pulses
Rate
Rhythm - regular, irregular
Contour/elasticity
Strength (Amplitude)
+4 = bounding
+3 = full, increased
+2 = normal
+1 = diminished, weak
0 = absent
Arterial Insufficiency of Lower Extremities
Pulses - Decreased/Absent
Color - Pale on elevation : Dusky Rubor on
dependency
Temperature - Cool/Cold
Edema - None
Skin - Shiny, thick nails, no hair, Ulcers on Toes
Sensation - Pain, more with exercise, Paresthesias
Venous Insufficiency of Lower Extremities
Pulses - Present
Color- Pink to cyanotic, Brown
pigment at ankles
Temperature - Warm
Edema - Present
Skin - Discolored, scaly, ulcers on ankles
Sensation - Pain, More with standing or sitting.
Relieved with elevation/support hose
Peripheral Vascular Disease
Nursing interventions to promote venous return
ankle circles, flex ankles, frequent ambulation, avoid dependent
position for prolonged periods of time
apply TED stockings or ace bandages (if no arterial problem)
Nursing Diagnosis
Altered cardiac output: decreased
Altered tissue perfusion:peripheral
Fluid volume deficit: actual
Irregular Rhythm
ALL irregular rhythms demand an APICAL RADIAL
assessment
Assessment: Blood Pressure
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Obtain History:
Obtain History:
** Non-modifiable Risk factors **
** Modifiable Risk factors**
Age, sex, personality type
SmokingEmployment: physical vs
Family History – sudden
emotional demands, environmental hazard,
death, HTN, stroke, MI prior
stress managementNutritional Status:
to 50, severe hyperlipidemis,
body fat & type of dietAnaerobic
DM
exerciseEstrogen replacement (if postmenopausal)Drug use – alcohol,, cocaine,
PMH – arrythmias, murmurs,
prescription & OTCEssential
CHF, Rheumatic disease
HTNHypercholesterolemia, DM,
DM, CAD,Congenital
CAD
Heart Defects
Taking a Blood Pressure
Blood Pressure: Key Facts
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Korotkoff sounds: Turbulent sounds of
partial obstruction of arterial flow
Phase I: sharp tapping sound (systolic)
Phase II: change to soft swishing sound
Phase III: sounds more crisp & intense
Phase IV: muffled tapping
Phase V: cessastion of sound (diastolic)
Blood Pressure: Key Facts
Arm Blood Pressure: May be 5-10 mmHg higher in right arm than left arm:
greater differences between right & left arm may be associated with
congenital aortic stenosis or acquired conditions such as aortic dissection
or obstruction of arteries to upper arm.
Leg Blood Pressure: Arm & leg blood pressures are about equal during
first year of life & after that time the leg blood pressure is 15-20 mmHg
higher than the arm BP.
Pulse Pressure: difference between systolic and diastolic blood pressures:
Usual pulse pressure is between 30-40 mmHg
Orhtostatic Hypotension: Decrease in SBP of 20-30 mmHg or more
when changing from supine to standing position, & increase in pulse of 1020 bpm: sudden drops may result in fainting. Dizziness & faintness from
orthostatic hypotension may occur when taking anti-hypertensive
medications, hypovolemia, confined to bed for prolonged periods of time, or
the elderly.