Assessment of Cardiovascular System PDF

Assessment of Cardiovascular System Assessment of Cardiovascular System Prepared by Assistant Prof : Naglaa Fawzy Medical-Surgical Nursing Faculty of Nursing Cairo University  OBJECTIVES By the end of this lecturer, the student...

Assessment of Cardiovascular System Assessment of Cardiovascular System Prepared by Assistant Prof : Naglaa Fawzy Medical-Surgical Nursing Faculty of Nursing Cairo University  OBJECTIVES By the end of this lecturer, the student will be able to: - Recall the anatomy and physiology of the heart. - Relate the relevant subjective information in an assessment of the heart. - Identify equipment appropriate to the examination of the heart. - Describe appropriate inspection, palpation, auscultation, percussion and positioning techniques used in the examination of the heart. - Discuss the characteristics of normal heart sounds. - Describe abnormal heart sounds. - Recognize normal and abnormal findings in a cardiac assessment. - Compare cardiac disease assessment findings. - Discuss the significance of jugular vein assessment.  OUTLINE - Structure and function. - Subjective data - Health history. - Objective data - Physical examination. - Abnormal findings. - Documentation. - Interpretation.  INTRODUCTION - Cardiovascular System – circulates blood continuously thought the body to deliver oxygen and nutrients to the body’s organs, tissues and to dispose of waste. - The cardiovascular system is a highly complex system made up of the heart (pump) and a closed system of blood vessels (plumbing).  Cardiovascular System  Heart (pump) and vasculature (plumbing).  The heart is composed of:  Cardiac muscle.  Atria.  Ventricles.  Valves.  Cardiac arteries and veins.  Electrical conduction system.  Cardiac Nerves.  Problems or failure of any of these system can lead to serious health concerns.  Landmarks for Cardiac Assessment - Sternum. - Clavicles. - Ribs. - Second through fifth intercostal spaces.  Heart - The heart is a hollow, muscular, four-chambered organ located in the middle region of the thoracic cavity between the lungs in the space called the mediastinum. - It is about the size of a clenched fist and weighs approximately 255g in women and 310g in men.  Heart - The heart extends vertically from the second to the fifth intercostal space (ICS) and horizontally from the right edge of the sternum to the left midclavicular line (MCL). - The heart can be thought of as an inverted cone. - The upper portion, near the second ICS, is the base, and the lower portion, near the 5th ICS and the left MCL, is the apex. Landmarks for Cardiac Assessment  Heart Covering and Walls The pericardium, which literally translates as “around the heart,” consists of two distinct sub layers: (1) The fibrous pericardium (outer layer) protects the heart and maintains its position in the thorax. (2) The more delicate serous pericardium (inner layer) consists of two layers: (a) The parietal pericardium, which is fused to the fibrous pericardium. (b) An inner visceral pericardium, or epicardium, which is fused to the heart and is part of the heart wall. The pericardial cavity, filled with lubricating serous fluid, lies between the epicardium and the pericardium.  Heart Covering and Walls The wall of the heart is composed of three distinct layers: (1)The outermost layer, the epicardium. (2)The myocardium is the thickest layer of the heart and is made up of contractile cardiac muscle cells. (3)The endocardium.  THE HEART AS A PUMP: THE CARDIAC CYCLE OF SYSTOLE AND DIASTOLE The cardiac cycle is concerned with those events associated with the filling and emptying of the chambers of the heart. The cardiac cycle consists of two phases: - Systole: refers to ventricular contraction and begins with closure of the AV valves (S1) and ends with the closure of the aortic and pulmonic valve (S2). - Diastole: refers to ventricular relaxation and begins with closure of the aortic and pulmonic valve (S2) and ends with closure of AV valves (S1).  Production of Heart Sounds - The first sound—the “lub”—is made by the mitral and tricuspid valves closing at the beginning of systole. - S1: may be heard over the entire precordium; but is heard best at the apex (left MCL, 5th ICS). - The second sound—the “dub”—is made by the aortic and pulmonary valves closing at beginning of diastole. - S2: is heard best at the base of the heart; 2nd ICS at right side (Aortic valve) and left side (Pulmonic valve) Production of Heart Sounds Production of Heart Sounds Heart sounds in systole and diastole  THIRD and FOURTH HEART SOUNDS Description S3: Extra heart sound, low pitched, ending in early diastole, best heard with the bell of the stethoscope. Location: It is best heard at the cardiac apex with the patient in the left lateral decubitus position and holding his breath.  THIRD and FOURTH HEART SOUNDS Description S4: Extra heart sound, low pitched, ending in late diastole, and best heard with the bell of the stethoscope. Location: It is best heard at the cardiac apex with the patient in the left lateral decubitus position and holding his breath  Neck Vessels Carotid Artery Pulse: the right and left common carotid arteries. It is located in the groove between the trachea and the right and left sternocleidomastoid muscles. Slightly below the mandible. They supply the neck and head, including the brain, with oxygenated blood.  Neck Vessels Carotid Artery Pulse:  Neck Vessels Jugular venous pulse and pressure: There are two sets of jugular veins, internal and external. The internal jugular veins lie deep and medial to the sternomastoid muscle. The external jugular veins are more superficial; they lie lateral to the sternomastoid muscle and above the clavicle. The jugular veins return blood by way of the superior vena cava to the heart from the head and neck.  Subjective Data and Health history  Chest pain  Past history (hypertension, elevated  Dyspnea cholesterol, heart murmur, rheumatic  Orthopnea fever, anemia, heart disease)  Cough  Family history (hypertension, obesity,  Fatigue diabetes, coronary artery disease)  Cyanosis or pallor Lifestyle (diet high in cholesterol,  Edema calories, or salt; smoking; alcohol use; drugs; amount of exercise)  Clubbing  Respiratory problems with heart disorder Tachypnea: Rapid, shallow breathing. Cheyne-Stokes respirations: a pattern of rapid respirations alternating with apnea. Hemoptysis. Cough. Crackles and Wheezes:  Physical Assessment of the Cardiovascular System 25  Physical Assessment Techniques: Inspection- side to side, at right angle and downward Palpation: to detect any precordial motion or thrills. Palpate apical impulse Percussion: estimate heart size, most accurately done by chest x- ray Auscultation:– evaluates heart rate, rhythm, cardiac cycle and valvular function.  Patient preparation Explain the procedure and expose the anterior chest. Supine position with head elevated to about 30 degrees or left lateral position and sitting –up and leaning forward position. Answer any questions the patient may have (psychological preparation).  Equipment Examination gown. Examination drape. Stethoscope. Two centimeter rulers. Small pillow. Penlight or movable examination light. Watch with second hand. Inspection: Specific Areas of the Cardiovascular Assessment  Inspection of the face, lips, ears, and scalp:  Skin color.  Movement.  Earlobe creases.  Inspection of the jugular veins:  Pulsations.  Distention.  Inspection of the carotid arteries:  Pulse characteristics.  Inspection of the hands and fingers:  Color.  Shape of fingers.  Inspection: Specific Areas of the Cardiovascular Assessment Inspection of the chest, abdomen, legs, and skeletal structure: – Pulsations, which may also be called heaves or lifts, other than the apical pulsation are considered abnormal and should be evaluated  INSPECTION -Skin color changes may indicate cardiovascular disease. -For example, pallor and cyanosis of lips or extremities are associated with decreased perfusion. - Example: Splinter hemorrhage: INSPECTION Xanthelasma  Inspect Jugular Venous Pressure (JVP) and Pulsations Inspect the jugular venous pulse by standing on the right side of the patient. The patient should be in a supine position with the torse elevated 30 to 45 degrees. Make sure that the head and torse are on the same plane. Ask the patient to turn the head slightly to the left. Shine a tangential light source onto the neck to increase visualization of pulsations as well as shadows. Next, inspect the suprasternal notch or the area around the clavicles for pulsations of the internal jugular veins. The jugular venous pulse is not normally visible with the patient sitting upright.  Measures Jugular Venous Pressure (JVP) Recall that jugular veins reflect right atrial pressure. Steps for examination: – Position the patient supine with the head of the table elevated to 30° degrees. – Use tangential, side lighting to observe for venous pulsations in the neck. – Turn the patient’s head gently to the left. – Look for a rapid, double sometimes triple wave with sternal end of the clavicle to eliminate the pulsations and rule out a carotid origin.  Measures Jugular Venous Pressure (JVP) Steps for examination: – Identify the topmost point of the flickering venous pulsations. – Place a centimeter ruler upright on the sternal angle (angle of louis). – Place a card or tongue blade horizontally from the top of the JVP to the ruler, making a right angle. – Measure the distance above the sternal angle in centimeters: a 3- to 4-centimeter elevation is normal.  INSPECTION Jugular Venous Pressure (JVP) and Pulsations Assessment of central venous pressure.  INSPECTION Jugular Venous Pressure (JVP) and Pulsations Top line – level of the highest visible point of distention Bottom line – level of the sternal angle Measure: the vertical distance between the sternal angle and the highest level of jugular distention  INSPECTION Inspection of face, lips, hands and fingers. Precordial Bulge. Dilated veins on the chest wall. Scars of previous operations. Pulsations all over the chest and carotid pulse. Inspect the jugular venous pulse. Measure jugular venous pressure.  Palpation: (1)Carotid Pulse Keep the patient’s head elevated to 30°. Place the pads of the index and middle fingers on the right then the left carotid arteries to the sternocleidomastoid muscle on the neck. Palpate the carotid upstroke. Palpate the carotid arteries gently and individually because bilateral carotid palpation could result in vagal stimulation and bradycardia, hypotension, or even cardiac arrest. Bilateral palpitation could result in reduced cerebral blood flow. Listen with the stethoscope for any bruits.  Palpation: Carotid Pulse Be especially cautious with the older patient, who may already have obstruction due to atherosclerosis. Compression may easily occlude the circulation.  Palpation: (2) Chest Using the ball of the hand, palpate for thrills. Palpation of the chest, including the following – Aortic area: 2nd intercostal space at the right sternal border – the base of the heart. – Pulmonic area: 2nd or 3rd intercostal space at the left sternal border – the base of the heart. – Erb’s point: 3rd to 5th intercostsal space at the left sternal border. – Mitral (apical): 5th interspace near the left midclavicular line – the apex of the heart. – Tricuspid area: 4th or 5th intercostal space at the left lower sternal border.  Palpation Landmarks in precordial assessments.  Palpation (3) Apical Pulse Palpate for pulsation: – Remain on the patient’s right side and ask the patient remain supine. – Use the palmar surfaces of the hand to palpate the apical impulses in the mitral area. – Once you have located the pulse, use one finger pad for more accurate palpation. – If this pulsation cannot be palpated, it may be helpful to have the patient assume a left lateral position. – The apical impulse may not be felt in patients who are obese. – The apical impulse may be difficult to palpate in the older patient because of an increase in anterioposterior chest diameter.  Palpation Palpate the apical impulse. Palpate aortic and pulmonary area. Palpate Epigastric pulsation and its origin. Palpate left parasternal area at the 3rd and 4th intercostals left sternal border. Palpate right parasternal area at the 3rdand 4th intercostals right sternal border. Palpate lower end of sternum. Palpate infraclavicular area for thrill. Palpate carotids for thrill.  Percussion of the chest Percussion of the chest for cardiac border – bare area of the heart. Percussion of the chest: Bare Area of the Heart  AUSCULTATION Auscultation of the chest using the diaphragm and bell in various positions to include the following locations: – Aortic area at the right second intercostal space–S2 is louder than S1. – Pulmonic area at the left second intercostal space–S2 is louder than S1. – Erb’s point at the left third intercostal space–S1 and S2 are heard equally. – Tricuspid area at the left fourth intercostal space–S1 is louder than S2. – Apex at the left fifth intercostal space at the midclavicular line–S1 AUSCULTATION AUSCULTATION AUSCULTATION  AUSCULTATION Comparing the carotid and apical pulses: if the examiner are experiencing difficulty differentiating S1 from S2; palpate the carotid pulse: the heart bound that occurs with the carotid pulse is S1.  AUSCULTATION Positions for auscultation of the heart. A. Supine.  AUSCULTATION Positions for auscultation of the heart. B. Lateral “Mitral Valve disease”  AUSCULTATION Positions for auscultation of the heart. C. Sitting “Aortic Valve disease”.  Auscultation of the carotid arteries Auscultation of the carotid arteries (using the diaphragm and bell) for any bruits.  Auscultation of the carotid arteries - Place the bell of the stethoscope over the carotid artery. - Ask the patient to hold the breath for a moment so that breath sounds do not cover up any vascular sounds. - Always auscultate the carotid arteries before palpating. If occlusion is noted during auscultation, you would know to palpate very lightly so as not to occlude the patient’s circulation.  Auscultate: Carotid Pulse Listen with the stethoscope for any bruits. Bruit indicates turbulence due to a local vascular cause, such as atherosclerotic narrowing. - Lightly apply the bell of the stethoscope over the carotid artery in three levels: (1) The angle of the jaw. (2) The midcervical area. (3) The base of the neck.