Assessment Of Cardiovascular System
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Assessment of Cardiovascular System Reymond Bicariato,RN
03/17/09
1
Objectives 1. describe the structure and function of the cardiovascular system, including the peripheral vascular system 2. explain developmental variations a nurse considers when assessing the heart & neck vessels & peripheral vascular system 3. state the specific areas considered essential in gathering subjective data pertaining to the cardiovascular system & the peripheral vascular system 4. demonstrate assessment of the heart, neck vessels & the PV system
03/17/09
2
Anatomy of the Heart
Four Chambers:
Right atrium Left atrium Right ventricle Left ventricle
03/17/09
Four Valves: Two atrioventricular (AV) 1. tricuspid 2. mitral Two semilunar (SL) 1. pulmonic 2. aortic 3
Blood FlowFlow through the Blood Heart
03/17/09
4
Cardiac Cycle It has two phases: (A) Diastole – ventricles relax & fill with blood (This is 2/3 of the cardiac cycle.) (B) Systolic – heart contracts & pushes blood out of the ventricles to: (i) the lungs (ii) systemic arteries
03/17/09
5
03/17/09
6
Heart Sounds
S1 – when closure of the AtrioVentricular valves (tricuspid & mitral) & ventricles contract
S2 – when closure of the semilunar valves ( pulmonic & aortic) & the ventricles relax
03/17/09
7
Extra Heart Sounds S3 – This occurs immediately after S2 Why? Resistance to filling of ventricles Note: also called a ventricular gallop
*It is caused by overload. * use diaphragm (it is a high sound) S4 - This occurs at the end of diastole, just before the next S1. Why? The atrium contract & push blood into a non-compliant ventricles. Note: also called an atrial gallop *caused by Hypertension,Aortic stenosis, cardiomyopathy * Use bell to listen as it is a low sound.
03/17/09
8
Murmurs Caused by “turbulence” Therefore we hear a gentle blowing, swooshing sound. Why? 1. Velocity of blood increases (eg. exercise) 2. Velocity of blood decreases (eg. anemia) 3. Structural defect in the valves or an unusual opening occurs in the chambers
03/17/09
9
Grading of Murmurs Use VI point grading scale & record as a fraction (ie. I/VI or II/VI) Grades: Grade I – barely audible, heard only in a quiet room & then with difficulty Grade II – clearly audible, but faint Grade III – moderately loud, easy to hear Grade IV – loud, associated with a thrill palpable on the chest wall Grade V – very loud, heard with one corner of the stethoscope lifted off the chest wall Grade VI – loudest, still heard with the entire stethoscope lifted off the chest
03/17/09
10
The Neck Vessels
The Carotid Artery
The Jugular Venous Pulse & Pressures 2 components: (a) internal jugular (b) external jugular
03/17/09
11
Subjective Data 1. chest pain 2. dyspnea 3. Orthopnea 4. Cough 5. Fatique 6. cyanosis or pallor 7. edema 8. nocturia 9. past cardiac history 10. family cardiac history 11. personal habits 12. environment
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23
Preparation for Assessment
Room that is warm & “quiet” Examining table positioned so you can stand on the patient’s right side Patient Gown A watch with a second hand Stethoscope with diaphragm & bell Tape measure
03/17/09
24
Recommended Sequence for assessing cardiovascular system 1. Pulses & BP 2. Extremities 3. Neck Vessels 4. Precordium
03/17/09
25
The Neck Vessels Carotid Arteries
A.
03/17/09
Palpate low in neck to avoid the sinus Be gentle Palpate only one side at a time to avoid compromising blood flow to the head Auscultate using the bell Listen in 3 places: angle of jaw midcervical area base of neck 26
Assessment of the Jugular Vein
Purpose: To measure the “central venous pressure” Method: Position patient @ 45 degree angle at the hip Turn head slightly away Use a strong light tangentially Observe the external jugular over the sternomastoid muscle
03/17/09
27
Specific Process for Central Venous Pressure Measurement Locate the internal jugular pulsation Mark the highest point of pulsation Locate the “angle of Louis” Make a “T square” with 2 index cards Read the level of intersection Note: The normal jugular venous pressure is 2 cm or less above the sternal angle.
03/17/09
28
Hepatojugular Reflux
This is measured if the CVP is elevated or CHF is suspected. Patient is supine Instruct patient to breathe quietly with mouth open With rt. hand on the patient’s RUQ of abdomen, just below the rib cage, exert firm consistent pressure for 30 seconds Watch the level of the jugular pressure Note: Normally the jugular rises but recedes back. Abnormally, the pressure elevates & stays.
03/17/09
29
The Heart ( Precordium) Inspection: Check pulsations, heaves, lifts (You may see the apical pulse.) Note: The apical is located in the 4th or 5th Intercostal space @ the left Midclavicle level. Palpate: Feel the apical impulse . Use 1 finger pad. Use palmar side of 4 fingers to feel for other pulsations on the chest. (eg. “thrills”
03/17/09
30
Heart Assessment (continued) Percussion: To check for heart enlargement (Note:often done by chest X-ray) Auscultation: Start at the base of the heart. “APE to Man” Aortic - 2nd Rt. ICS Pulmonic – 2nd left ICS Erb’s Point Tricuspid – left sternal border Mitral – 5th ICS @ left Midclavicle level.
03/17/09
31
Sequence for Auscultating A. Begin with the diaphragm. Note at each area: 1. rate & rhythm 2. identify S1 and S2 3. assess S1 and S2 separately 4. listen for extra heart sounds (ie. S3,S4) 5. listen for murmurs B. Repeat above using the bell. 03/17/09
32
What do you hear?
S1 and S2 sound like “lub-dup” S1 is louder than S2 at the apex S2 is louder than S1 at the base S1 coincides with the carotid pulsation
03/17/09
33
Assessment of the Peripheral Vascular System
Arteries assessed in cephalocaudal direction:
Head – temporal carotid Arms – brachial ulnar radial Legs – femoral poplitial Feet - dorsalis pedis posterior tibialis
03/17/09
34
Assessment of Veins
Neck – Jugular veins Arms – Superficial Deep Legs - Deep veins – femoral, popliteal Superficial veins:great saphenous (inside of leg) small saphenous (outside of leg) Perforators – join the above 2 sets Note: The veins have valves that keep blood moving toward the heart. However, you need exercise too.
03/17/09
35
Lymph Nodes Superficial nodes available for palpation: 1. Cervical nodes 2. Axillary nodes 3. Epitrochlear Nodes 4. Inguinal nodes Also organs – Spleen - assessed in abdomenal exam Tonsils – assessed with head & neck Thymus (behind sternum)
03/17/09
36
Subjective Data for Peripheral Vascular System
Leg pain Skin changes Swelling in arms & legs Lymph node enlargement Medications Smoking
03/17/09
37
Techniques used to assess the Peripheral Vascular System Arms: Inspection Palpation – radial, ulnar, brachial, epitrochlear lymph nodes * perform the Allen Test The Allen Test 1) The hand is elevated and the patient/person is asked to make a fist for about 30 seconds. 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails). 4) Ulnar pressure is released and the color should return in 7 seconds. Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate/prick the radial If color does not return or returns after 7 seconds, then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely pricked/cannulated.
03/17/09
38
Techniques used to assess the Peripheral Vascular System( Cont.) Legs: Inspection * If calf pain, check the Homan’s sign Palpation – femoral, poplitial, dorsalis pedis, posterior tibialis * If pretibial edema, press over tibia or medial malleolas for 5 seconds * Use rating scale 03/17/09
39
An Additional Test If there is a color change in the lower extremities… Elevate the legs 30 cms (12 inches) Have patient wag feet to drain blood Sit patient up with legs over side of table Note the time it takes for color to return. Normally, the color returns in 10 seconds. 03/17/09
40
Thank You…..
The end 03/17/09
41
03/17/09
1
Objectives 1. describe the structure and function of the cardiovascular system, including the peripheral vascular system 2. explain developmental variations a nurse considers when assessing the heart & neck vessels & peripheral vascular system 3. state the specific areas considered essential in gathering subjective data pertaining to the cardiovascular system & the peripheral vascular system 4. demonstrate assessment of the heart, neck vessels & the PV system
03/17/09
2
Anatomy of the Heart
Four Chambers:
Right atrium Left atrium Right ventricle Left ventricle
03/17/09
Four Valves: Two atrioventricular (AV) 1. tricuspid 2. mitral Two semilunar (SL) 1. pulmonic 2. aortic 3
Blood FlowFlow through the Blood Heart
03/17/09
4
Cardiac Cycle It has two phases: (A) Diastole – ventricles relax & fill with blood (This is 2/3 of the cardiac cycle.) (B) Systolic – heart contracts & pushes blood out of the ventricles to: (i) the lungs (ii) systemic arteries
03/17/09
5
03/17/09
6
Heart Sounds
S1 – when closure of the AtrioVentricular valves (tricuspid & mitral) & ventricles contract
S2 – when closure of the semilunar valves ( pulmonic & aortic) & the ventricles relax
03/17/09
7
Extra Heart Sounds S3 – This occurs immediately after S2 Why? Resistance to filling of ventricles Note: also called a ventricular gallop
*It is caused by overload. * use diaphragm (it is a high sound) S4 - This occurs at the end of diastole, just before the next S1. Why? The atrium contract & push blood into a non-compliant ventricles. Note: also called an atrial gallop *caused by Hypertension,Aortic stenosis, cardiomyopathy * Use bell to listen as it is a low sound.
03/17/09
8
Murmurs Caused by “turbulence” Therefore we hear a gentle blowing, swooshing sound. Why? 1. Velocity of blood increases (eg. exercise) 2. Velocity of blood decreases (eg. anemia) 3. Structural defect in the valves or an unusual opening occurs in the chambers
03/17/09
9
Grading of Murmurs Use VI point grading scale & record as a fraction (ie. I/VI or II/VI) Grades: Grade I – barely audible, heard only in a quiet room & then with difficulty Grade II – clearly audible, but faint Grade III – moderately loud, easy to hear Grade IV – loud, associated with a thrill palpable on the chest wall Grade V – very loud, heard with one corner of the stethoscope lifted off the chest wall Grade VI – loudest, still heard with the entire stethoscope lifted off the chest
03/17/09
10
The Neck Vessels
The Carotid Artery
The Jugular Venous Pulse & Pressures 2 components: (a) internal jugular (b) external jugular
03/17/09
11
Subjective Data 1. chest pain 2. dyspnea 3. Orthopnea 4. Cough 5. Fatique 6. cyanosis or pallor 7. edema 8. nocturia 9. past cardiac history 10. family cardiac history 11. personal habits 12. environment
03/17/09
12
03/17/09
13
03/17/09
14
03/17/09
15
03/17/09
16
03/17/09
17
03/17/09
18
03/17/09
19
03/17/09
20
03/17/09
21
03/17/09
22
03/17/09
23
Preparation for Assessment
Room that is warm & “quiet” Examining table positioned so you can stand on the patient’s right side Patient Gown A watch with a second hand Stethoscope with diaphragm & bell Tape measure
03/17/09
24
Recommended Sequence for assessing cardiovascular system 1. Pulses & BP 2. Extremities 3. Neck Vessels 4. Precordium
03/17/09
25
The Neck Vessels Carotid Arteries
A.
03/17/09
Palpate low in neck to avoid the sinus Be gentle Palpate only one side at a time to avoid compromising blood flow to the head Auscultate using the bell Listen in 3 places: angle of jaw midcervical area base of neck 26
Assessment of the Jugular Vein
Purpose: To measure the “central venous pressure” Method: Position patient @ 45 degree angle at the hip Turn head slightly away Use a strong light tangentially Observe the external jugular over the sternomastoid muscle
03/17/09
27
Specific Process for Central Venous Pressure Measurement Locate the internal jugular pulsation Mark the highest point of pulsation Locate the “angle of Louis” Make a “T square” with 2 index cards Read the level of intersection Note: The normal jugular venous pressure is 2 cm or less above the sternal angle.
03/17/09
28
Hepatojugular Reflux
This is measured if the CVP is elevated or CHF is suspected. Patient is supine Instruct patient to breathe quietly with mouth open With rt. hand on the patient’s RUQ of abdomen, just below the rib cage, exert firm consistent pressure for 30 seconds Watch the level of the jugular pressure Note: Normally the jugular rises but recedes back. Abnormally, the pressure elevates & stays.
03/17/09
29
The Heart ( Precordium) Inspection: Check pulsations, heaves, lifts (You may see the apical pulse.) Note: The apical is located in the 4th or 5th Intercostal space @ the left Midclavicle level. Palpate: Feel the apical impulse . Use 1 finger pad. Use palmar side of 4 fingers to feel for other pulsations on the chest. (eg. “thrills”
03/17/09
30
Heart Assessment (continued) Percussion: To check for heart enlargement (Note:often done by chest X-ray) Auscultation: Start at the base of the heart. “APE to Man” Aortic - 2nd Rt. ICS Pulmonic – 2nd left ICS Erb’s Point Tricuspid – left sternal border Mitral – 5th ICS @ left Midclavicle level.
03/17/09
31
Sequence for Auscultating A. Begin with the diaphragm. Note at each area: 1. rate & rhythm 2. identify S1 and S2 3. assess S1 and S2 separately 4. listen for extra heart sounds (ie. S3,S4) 5. listen for murmurs B. Repeat above using the bell. 03/17/09
32
What do you hear?
S1 and S2 sound like “lub-dup” S1 is louder than S2 at the apex S2 is louder than S1 at the base S1 coincides with the carotid pulsation
03/17/09
33
Assessment of the Peripheral Vascular System
Arteries assessed in cephalocaudal direction:
Head – temporal carotid Arms – brachial ulnar radial Legs – femoral poplitial Feet - dorsalis pedis posterior tibialis
03/17/09
34
Assessment of Veins
Neck – Jugular veins Arms – Superficial Deep Legs - Deep veins – femoral, popliteal Superficial veins:great saphenous (inside of leg) small saphenous (outside of leg) Perforators – join the above 2 sets Note: The veins have valves that keep blood moving toward the heart. However, you need exercise too.
03/17/09
35
Lymph Nodes Superficial nodes available for palpation: 1. Cervical nodes 2. Axillary nodes 3. Epitrochlear Nodes 4. Inguinal nodes Also organs – Spleen - assessed in abdomenal exam Tonsils – assessed with head & neck Thymus (behind sternum)
03/17/09
36
Subjective Data for Peripheral Vascular System
Leg pain Skin changes Swelling in arms & legs Lymph node enlargement Medications Smoking
03/17/09
37
Techniques used to assess the Peripheral Vascular System Arms: Inspection Palpation – radial, ulnar, brachial, epitrochlear lymph nodes * perform the Allen Test The Allen Test 1) The hand is elevated and the patient/person is asked to make a fist for about 30 seconds. 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails). 4) Ulnar pressure is released and the color should return in 7 seconds. Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate/prick the radial If color does not return or returns after 7 seconds, then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely pricked/cannulated.
03/17/09
38
Techniques used to assess the Peripheral Vascular System( Cont.) Legs: Inspection * If calf pain, check the Homan’s sign Palpation – femoral, poplitial, dorsalis pedis, posterior tibialis * If pretibial edema, press over tibia or medial malleolas for 5 seconds * Use rating scale 03/17/09
39
An Additional Test If there is a color change in the lower extremities… Elevate the legs 30 cms (12 inches) Have patient wag feet to drain blood Sit patient up with legs over side of table Note the time it takes for color to return. Normally, the color returns in 10 seconds. 03/17/09
40
Thank You…..
The end 03/17/09
41
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