Cardiac and Vascular Assessment Quiz

Learning Objectives

• Identify pertinent cardiovascular and peripheral-vascular history questions
• Obtain a cardiovascular and peripheral-vascular history
• Perform a cardiovascular and peripheral-vascular physical assessment
• Document cardiovascular and peripheral-vascular findings
• Differentiate between normal and abnormal findings

Heart

• Cardiovascular system consists of the heart (muscular pump) and blood vessels (arteries and veins)
• Precordium: area on the anterior chest that overlays the heart and great vessels
• Heart and great vessels are located between the lungs in the middle third of the thoracic cage (mediastinum)
• Heart extends from the 2nd to 5th intercostal space and from the right border of the sternum to the left midclavicular line
• Base (top): widest point
• Apex (bottom): narrow point

Vessels

• Great vessels: superior and inferior vena cava, pulmonary artery, pulmonary veins, and aorta
• Blood vessels are arranged in two continuous loops: pulmonary circulation and systemic circulation

Heart Wall

• Heart wall has numerous layers:
  • Pericardium: tough, fibrous, double-walled sac that surrounds and protects the heart.
  • Myocardium: muscular wall of the heart; it pumps blood.
  • Endocardium: thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves.

Heart Chambers and Valves

• Four chambers: left atrium, right atrium, left ventricle, and right ventricle
• Valves are unidirectional (can only open one way) to prevent backflow of blood.
• Valves open and close passively in response to pressure gradients in moving blood
• Two atrioventricular (AV) valves (tricuspid and mitral)
• Two semilunar (SL) valves (pulmonic and aortic)

Heart Sounds

• Cardiac cycle generates heart sounds (heard through a stethoscope)
• Include:
  • Normal heart sounds (S1 and S2)
  • Extra heart sounds (S3 and S4)
  • Murmurs
• First heart sound (S1, “lub”): occurs with closure of AV valves and signals the beginning of systole. Heard over all precordium, loudest at apex
• Second heart sound (S2, “dub”): occurs with closure of SL valves and signals the end of systole. Heard over all precordium, loudest at base

2) Extra heart sounds

• Third heart sound (S3): occurs when ventricles are resistant to filling during early rapid filling phase. Occurs immediately after S2
• Fourth heart sound (S4): occurs at end of diastole, at presystole when ventricle is resistant to filling. Occurs just before S1

3) Murmurs

• Blood circulating through normal chambers and valves makes no noise
• Some conditions create turbulent blood flow, producing a murmur (blowing, swooshing sound).
• Associated with:
  • Increased blood flow velocity (exercise)
  • Decreased blood viscosity (anemia)
  • Structural defects in valves or unusual openings in the chambers

Neck Vessels

• Carotid artery (central): located in the groove between the trachea and sternomastoid muscle, medial to and alongside that muscle
• Jugular veins (JV): empty un-oxygenated blood directly into the superior vena cava
  • Internal JV: deep, not visible, lies deep and medial to sternomastoid muscle
  • External JV: more superficial, lies lateral to sternomastoid muscle, above clavicle

Peripheral Vascular System

• Primary function is to deliver blood to all areas of the body
• Vascular system consists of vessels for transporting fluid
• Any disease in the vascular system leads to:
  • Impairs delivery of oxygen and nutrients to target cells
  • Retards elimination of carbon dioxide and waste products from cellular metabolism
• Arteries: common carotid, subclavian, axillary, brachial, radial, deep palmar arch, ulnar, arteries in the arm and leg
• Veins: cephalic, accessory cephalic, intermediate (median), basilic, veins in the arms and legs

Subjective Data: Heart & Neck Vessels

• 1- Chest Pain: provocation, quality, region/location, severity, timing, understanding, associated symptoms (sweating, ashen skin, palpitations, SOB, nausea/vomiting, fatigue, tachycardia)
• 2- Dyspnea (difficulty breathing): any SOB, onset/when, type, duration, affected by position (lying down), awaken from sleep, interferes with daily activity
• 3- Orthopnea (SOB when lying flat): how many pillows used
• 4- Cough: do you have a cough, duration, frequency, type, cough up mucus, relieved by rest/medication
• 5- Fatigue: do you seem to tire easily, able to keep up with family/co-workers, onset, related to time of day
• 6- Cyanosis or Pallor: decreased tissue perfusion, low cardiac output, myocardial infarction
• 7- Edema: any swelling in feet or legs, onset, equally swollen, does swelling go away
• 8- Nocturia (urinating at night): awaken at night, how long has this been occurring
• 9- Cardiac History: any past history of hypertension, elevated cholesterol/triglycerides, congenital heart disease, rheumatic fever, unexplained joint pains, or recurrent tonsillitis. Ever had heart disease, treated by medications/surgery, past ECGs, serum cholesterol measurements, other heart tests
• 10- Family Cardiac History: any family history of hypertension, obesity, diabetes, coronary artery disease (CAD)
• 11- Cardiac Risk Factors: nutrition, smoking, alcohol, exercise
• Subjective Data: Peripheral Vascular System: leg pain/cramps, skin changes, temperature change, leg veins, leg sores/ulcers, swelling in the arms or legs, smoking history

Objective Data: Neck Vessels

• Palpate the carotid artery: palpate each carotid artery medial to sternomastoid muscle, avoid excessive pressure, palpate gently and only one carotid artery at a time. Feel contour and amplitude of pulse. Findings should be the same bilaterally
• Auscultate the carotid artery: performed for who shows symptom or signs of cardiovascular disease. Auscultate for presence of a bruit (blowing, swishing sound indicating blood flow disorder). Keep neck in neutral position, lightly apply bell of stethoscope on 3 levels: angle of jaw, midcervical area, base of neck.
• Inspect jugular venous pulse: stand on patient's right side, position patient supine from 30-45°, remove pillow to avoid flexing neck, turn head slightly away from examiner side, direct strong light onto the neck. Note external jugular vein overlying sternomastoid muscle. Observe bilaterally.

Objective Data: Heart

• 1. Inspection: Pulsations (You may or may not see apical impulse. If visible, it occupies the 4th-5th intercostal space. It is easier to see in children and those with thinner chest walls)
• 2. Palpate apical impulse: Locate apical impulse area by using one finger pad. Ask client to exhale and hold. Not palpable in obese persons or persons with thick chest wall. Note location, size, amplitude and duration.
• 2. Palpate across the precordium: Use palmar aspect of four fingers. Gently palpate apex, left sternal border, and base. Search for any other pulsations (thrills).
• 3. Percussion: Percussion to outline the heart's borders has been replaced by Chest X-ray image or echocardiogram. More accurate in detecting heart enlargement.
• 4. Auscultation: Use the diaphragm & a zigzag pattern. Four traditional valve “areas”. Note rate and rhythm. When you notice any irregularity check for a pulse deficit.

Objective Data: Peripheral Vascular System

• Inspect the arms: Lift both hands, inspect hands while turning them over. Note skin color, nail beds, temperature, texture, turgor of skin, presence of any lesions, edema, or clubbing. Check profile sign and capillary refill. Two arms should be symmetrical in size.
• Palpate the arms: Pulse and note the following: Rate (Beats/min), Tachycardia: above 95, Bradycardia: below 50, Rhythm (Regular/ irregular). Elasticity: elastic and smooth contour. Equal force: grade force on a 3-point scale. Modified allen test used to evaluate adequacy of collateral circulation before cannulating radial artery.
• Inspect the leg: Uncover legs while keeping genitalia draped. Inspect both legs together, noting the following: Skin color and discoloration, skin lesion or ulcers, Hair distribution, Venous pattern (flat, barely visible), Leg size (swelling or atrophy).
• Palpate the leg (Femoral, distal pulses and use graded scale for pulses equal bilaterally.)
• Palpate the legs; Assess venous system. Note any visible, dilated tortuous veins.
• Color changes: Raise legs 30 cm for 30 seconds; Now have client sit up with legs over side of table. Compare color of both feet. Note the time it takes for color to return to the feet.

Abnormalities : Heart & Neck Vessels & Peripheral Vascular System

• Edema
• Thrill
• Full distended external jugular vein