Lecture 4 - Cardiac Assessment PDF

Faculty of Nursing Academic Year 2023/2024 Assessment of Heart and Neck Vessels Lecturers: Duaa Allan Outlines Anatomy and physiology of the heart and lung vessels. Subjective Data Objective Data Documentation References LEARNING OBJECTIVES OBJECTIVES...

Faculty of Nursing Academic Year 2023/2024 Assessment of Heart and Neck Vessels Lecturers: Duaa Allan Outlines Anatomy and physiology of the heart and lung vessels. Subjective Data Objective Data Documentation References LEARNING OBJECTIVES OBJECTIVES Code 1.Demonstrate competency in collecting subjective data about C.PH.I.1 functions of the heart and neck vessels 2.Use proper equipment for assessing patients with disturbed S.PH.I.1 functions of the heart and neck vessels S.H.P.M.2 3.Illustrate safe practices while assessing patients with disturbed S-S.E.E.1.2 functions of the heart and neck vessels 4. Perform thorough assessment of patients with disturbed S.H.P.M.1 functions of heart and neck vessels 5. Differentiate between normal and abnormal heart sounds C.PH.I.1 6.Document correctly the normal and abnormal findings related S. G.H.E.2.1 to the cardiac and neck vessels examination LEARNING OBJECTIVES/ CLINICAL COURSE: On completion of this chapter, the learner will be able to: 1. Demonstrate competency in collecting subjective data about functions of the heart and neck vessels (C.PH.I.1.1) 2. Use proper equipment for assessing patients with disturbed functions of the heart and neck vessels (S.PH.I.1.3) 3. Illustrate safe practices while assessing patients with disturbed functions of the heart and neck vessels (S-S.E.E.1.2) 4. Perform thorough assessment of patients with disturbed functions of heart and neck vessels (S.PH.I.3) 5. Differentiate between normal and abnormal heart sounds (S.PH.I.1.2) 6. Describe the characteristics of heart murmurs(K.H.P.M.1.1) 7. Conclude proper finding of the procedures and create appropriate documentation and nursing notes. (S. G.H.E.2.1) 4 POSITION AND SURFACE LANDMARKS The cardiovascular (CV) system consists of the heart (a muscular pump) and the blood vessels. The heart and great vessels are located between the lungs in the middle third of the thoracic cage (mediastinum). Location The heart extends from the 2nd to the 5th intercostal space and from the right border of the sternum to the left midclavicular line. Anatomy and physiology Inside the body the heart is rotated so its right side is anterior and its left side is mostly posterior. Heart valves are : 1. Atrioventricular valves(AVV) : Rt tricuspid and Lt bicuspid (mitral valves ). 2. Semilunar valves (SLV ): pulmonic in the Rt side and Aortic in the Left side. - The main purpose of the valves is to prevent backflow of blood. They open and close passively in response to pressure gradients in the moving blood. Structure and Function (cont.)  Great vessels The superior and inferior vena cava return unoxygenated venous blood to the right side of the heart. The pulmonary artery leaves the right ventricle, bifurcates, and carries the venous blood to the lungs. The pulmonary veins return the freshly oxygenated blood to the left side of the heart, and the aorta carries it out to the body. The aorta ascends from the left ventricle, arches back at the level of the sternal angle, and descends behind the heart.  Cardiac cycle It is the rhythmic movement of the blood through the heart. Its phases are : 1. Diastole : ventricles are relaxed and the AVV are open ( tricusped and mitral ). Pressure in the atruim > p in the ventricles so blood drain silently , passively , and rapidly (early diastole ). At the end of diastole atria contract and push the last 25 % of blood volume into the ventricles called atrial kick or atrial systole. Cardiac cycle 2. Systole :Ventricles filled of blood Pressure in v > p in atrium causing closure of AVV : producing the first heart sound s1 then Pressure in v > p in SLV causes opening of SLV then when Pressure in v decreases causes closure of SLV producing the second heart sound S2 Cardiac cycle The Heart as a Pump: The Cardiac Cycle Normal Heart Sounds (S1) S1 (Lub): Caused by closure of Atriventricular valves (mitral & tricuspid) The start of systole Louder than S2 at the apex Heard with diaphragm Coincide with carotid artery pulse 14 Normal Heart Sounds (S2) S2 (Dup) Closure of semilunar valves (aortic & pulmonic) The start of diastole Heard with diaphragm Loudest at the base Normal splitting of S2 may occur with Inspiration (aortic & pulmonic valves closes separately). Heard over pulmonic area (2nd left ICS) or 3rd ICS 15  Extra Heart Sounds (S3) S3 occurs when the ventricles are resistant to filling during the early rapid filling phase (prediastole). This occurs immediately after S2, when the AV valves open and atrial blood first pours into the ventricles It is heard best in a quiet room, at the apex, with the bell held lightly and with the person in the left lateral position. The S3 may be normal (physiologic) or abnormal (pathologic). The physiologic S3 is heard frequently in children and young adults; it occasionally may persist after 40 years, especially in women. The normal S3 usually disappears when the person sits up In adults the S3 is usually abnormal. Extra Heart Sounds (S3) The pathologic S3 is also called a ventricular gallop or an S3 gallop, and it persists when sitting up. The S3 indicates decreased compliance of the ventricles, as in heart failure. The S3 also occurs with conditions of volume overload such as mitral regurgitation and aortic or tricuspid regurgitation. The S3 is also found in high cardiac output states in the absence of heart disease such as hyperthyroidism, anemia, and pregnancy. https://www.easyauscultation.com/cases?coursecaseorder=1&courseid=25 Extra Heart Sounds (S4) S4 occurs at the end of diastole, at pre-systole, when the ventricle is resistant to filling. The atria contract and push blood into a noncompliant ventricle. This creates vibrations that are heard as S4. S4 occurs just before S1. This is a very soft sound, of very low pitch. You need a good bell, It is heard best at the apex, with the person in left lateral position. A physiologic S4 may occur in adults older than 40 or 50 years with no evidence of cardiovascular disease, especially after exercise. Extra Heart Sounds (S4) A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle (e.g., coronary artery disease, cardiomyopathy) and systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension.. https://www.easyauscultation.com/cases?courseca seorder=2&courseid=25 Murmurs Murmur is a gentle, blowing, swooshing sound that can be heard on the chest wall, results from turbulent blood flow and collision currents. Conditions resulting in a murmur are: exercise, thyrotoxicosis, anemia). - Structural defects in the valves (a stenotic or narrowed valve, an incompetent or regurgitate valve) or unusual openings occur in the chambers (dilated chamber, septal defect) Structure and Function (cont.) Neck vessels –Carotid artery –Jugular veins Internal External 21Slide 19- Subjective Data: Health History Chest Pain (PQRSTU) Your basic question: do you have pain or discomfort in your chest? Is the pain related to exertion? What kinds of activities bring on the pain? How intense is the pain? Does it radiate to the neck, shoulder, back, arm? Associated symptoms like SOB, sweating, palpitation, nausea? Does it wake up at night? what makes it better or worse Like what this pain? 22 Subjective Data: Health History Palpitations: Unpleasant awareness of the heart beat Result from irregular heart beat, from rapid acceleration or slowing of the heart, or from increased forcefulness of cardiac contractility Occur in atrial fibrillation Ask questions like: Are you ever aware of your heart beat? What it is like? Was it fast or slow? Like racing, pounding, stopping Did they stop suddenly or gradually?  SOB, dyspnea; uncomfortable awareness of breathing that is inappropriate to a given level of exertion. ( distance, position) Orthopnea ; dyspnea that occurs when patient is lying down and improves when patient is sitting up. ( no. of pillows) Paroxysmal noctural dyspnea, PND; episodic of sudden dyspnea and orthopnea that awaken the patient from sleep, mainly after 1-2 hours after going to bed. Can be associated with cough and wheezes. 24 Subjective Data—Health History Questions Edema –Accumulation of excessive fluid in the interstitial tissue spaces and appears as swelling Location, timing, setting of swelling, associated symptoms, weight changes “Cardiac (better in the morning), nutritional, positional Dependent edema, bilateral-HF Subjective Data—Health History Questions Cyanosis or pallor: Ever noted your facial skin turning blue or ashen? - ( Central Vs Peripheral cyanosis) Fatigue: Do you seem to tire easily? Onset: When did fatigue start? Sudden or gradual? Fatigue related to time of day: all day, morning, evening? Fatigue from decreased cardiac output is worse in the evening, whereas fatigue from anxiety or depression occurs all day or is worse in the morning. Nocturia: Do you awaken at night with an urgent need to urinate? How long has this been occurring? Any recent change? Objective Data—The Physical Exam Preparation –Position (patient: supine, left lateral recumbent, sitting & leaning forward) –Room preparation ( warm, and private) Order of examination: (Pulse and BP, extremities, neck vessels, then precordium) Equipment needed –Marking pen –Small centimeter ruler –Stethoscope with diaphragm and bell endpieces –Alcohol swab Inspection Inspection begins when you first encounter the patient. Look for: - General appearance: body habitus (thin, obese), level of alertness (anxious, lethargic), skin color, turgor, texture, temperature, and diaphoresis. - Shortness of breath (@ rest or walking)? – Sitting upright? Able to speak? - Observe mucous membranes for pallor and extremities for clubbing of fingers or cyanosis Beginning the Examination: The Vital Signs First Observe The Patient Then … Begin with the vital signs Blood Pressure Heart Rate: radial vs. apical: (pulse deficit) Cardiac examination : neck vessels. Palpate carotid and listen for : 1. If there is thrill ( like a throat of cat ) or bruit. 2. Pulsation Palpate jugular for : 1. Pulsation. 2. Measure jugular venous pressure or venous pressure. Normal 2-3 cm above sternal angle which is 5 cm from right atrium.elevate the head of bed 30 -45.  Objective data/ jvp o Jugular venous pressure and pulsations: Reflects right atrial or central venous pressure oUse right side oElevate head of bed to 30-45 degrees oRemove pillows oTurn pt head slightly away from you oShine strong light onto neck to highlight pulsations oIdentify external jugular vein (overlying sternomastoid), then find internal jugular venous pulsation (suprasternal notch)- both could be used Objective data/ jvp  Note highest oscillation point, or meniscus  Extend card or ruler horizontally from highest pulsation point , cross with ruler placed on the sternal angle (Angle of Louis), (normal is less than 3 cm). Add 5 cm (to get to the center of the atrium) and then report the JVP as "the jugular venous pressure was 8 cm of water" (not mercury). Normal CVP 3 cm above the sternal angle while at 45 degrees This occurs with right-sided heart failure, tricuspid stenosis, superior vena cava obstruction  Physical Exam/ carotid artery Carotid Pulse – Pt lying at 30 degrees or sitting up. – Seen just inside sternocleidomastoid muscles – Use pads of left 2nd and 3rd digits to feel pulse – Never feel both sides at same time!!! – Feel the contour and amplitude of the pulse. Normally the contour is smooth with a brisk upstroke and slower downstroke, and the normal strength is moderate upstroke may be: Brisk, or normal Delayed – suggests aortic stenosis. Bounding – suggests aortic insufficiency Neck vessels auscultation Your findings should be the same bilaterally. Feel for thrills = humming vibrations (like a cat purr) Listen for bruits using bell of stethoscope (a murmur like sound) while the patient hold his breath at three levels: (1) the angle of the jaw. (2) the midcervical area. (3) the base of the neck  Comparism between carotid and jugular pulsation Internal jugular vein Carotid artery 1.Rarly palpable 1. palpable 2.Soft and rapid 2. More strong and thrust. 3.Pulsation eliminated by 3.Pulsation not eliminated light pressure by light pressure 4. Level of pulsation 4. Level of pulsation not changed with position changed with position 5. Pulsation change with 5. Not changed. respiration Physical Exam/ The Precordium Inspect the anterior chest Palpate the apical impulse Palpate across the precordium Percuss to outline the cardiac borders Auscultate the precordium Inspection of the heart The examiner should stand at the Rt side of patient note the following : 1. 1.Chest shape: Symmetry :–– ? Visible impulse on chest wall from vigorously contracting ventricle (rare) localized bulge or retraction 2. Apical impulse : in 5th intercostals space at the MCL ( mid clavicular line ). 3. Lift or heave : forceful thrusting of the heart due to LT v hypertrophy. Inspection/ chest Palpation Using you finger pads, palpate at the apex for the PMI. Note: : Location—The apical impulse should occupy only one interspace, the 4th or 5th, and be at or medial to the midclavicular line Size—Normally 1 × 2 cm Amplitude—Normally a short, gentle tap Duration—Short; normally occupies only first half of systole Abnormal findings: Sustained — suggests LV hypertrophy from hypertension or aortic stenosis, or Diffuse — suggests a dilated ventricle from congestive heart failure or cardiomyopathy Palpation & Percussion Palpate apical impulse-PMI-5TH LICS- use one finger pad-exhale and hold Palpation of the apex of the heart, left sternal border, and base- look for heave (lift), and thrills (palpable humming vibrations)- turbulent blood flow. Palpation Abnormal findings: A thrill is a palpable vibration. It feels like the throat of a purring cat. The thrill signifies turbulent blood flow and directs you to locate the origin of loud murmurs. Cardiac percussion The major purpose is to detect the location : 1. LT border : in 4th ICS from anterior axillary's line to mid line. 2. Rt 1cm to the RT of sternum. Auscultation o Normal Heart Sounds o S1……S2 o Murmur: an abnormal sound produced by the blood passing through deformed cardiac valves o Gallops: Extra Heart Sounds o S4..S1…….S2 o S1……S2..S3 o Rubs: inflammation of the pericardial sac  Cardiac auscultation areas Area to auscultate : 1. Second Rt ICS : Aortic valve area. 2.2nd Lt ICS : pulmonic valve area. 3. "Erb's point" located in the third intercostal space close to the sternum. 3. 4th ICS Lt lower sternal border : tricuspid valve area. 4. 5th ICS Lt to MCL : Mitral valve area  Examine in seated and supine positions (APT. M = Aortic, Pulmonic, Tricuspid, and Mitral) Listening to the Heart — Auscultation Listen for S1 and S2 using the diaphragm of the stethoscope Then listen at the apex with the bell The diaphragm and the bell... The diaphragm is better for picking up the relatively high pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs. The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis. Apply the bell lightly, with just enough pressure to produce an air seal with its full rim.  Describing Heart Murmurs: Timing and Duration Identify and describe any murmurs Timing — are they systolic or diastolic? Tip — palpate the carotid upstroke (occurs in systole) as you listen If the murmur coincides with the carotid upstroke, it is systolic Duration early / mid / or late systolic early / mid / or late diastolic Quality Apply terms like harsh, musical, soft, blowing, or rumbling Pitch Apply terms like high, medium, or low-pitched  Describing Heart Murmurs: Shape and Intensity Shape Crescendo, decrescendo, Crescendo or both (sometimes called diamond-shaped) Example, crescendo-decrescendo Decrescendo systolic murmur of aortic stenosis Both Intensity — grade the murmur on a scale of 1 to 6 grades 4 - 5 - 6/6 must have accompanying thrill Documentation Objective data: Neck: Carotids’ upstrokes are brisk and = bilaterally. No bruit The JVP is 3 cm above the sternal angle with the head of bed elevated to 30°.. Precordium: Inspection. No visible pulsations; no heave or lift. Palpation: Apical impulse in 5th ICS at left midclavicular line; no thrill. Auscultation: Rate 68 bpm, rhythm regular, S1-S2 are crisp, not diminished or accentuated, no S3, no S4 or other extra sounds, no murmurs. References Jarvis Carolyn. (2020). Physical Examination & Health Assessment. (8th edition), Saunders, United State Bickley, L.S. (2018). Bates guide to physical examination and history taking. Philadelphia: Lippincott Williams Cox, C.L. (2019). Physical assessment for nurses. London: Blackwell Publisher Kozier & Erb's Fundamentals of Nursing (Fundamentals of Nursing. (2022). 10th Edition