2-Assessment Cardiovascular system .pptx

Assessment of cardiovascular system

1. Nursing H ealth Assessment of CVS 1

2. Outline 2

3. Purpose of cardiovascular examination To assess the patient appearance To assess effectiveness of the heart as a pump To assess filling volume and pressure To assess the cardiac out put To identify the presence of compensatory mechanism that help to maintain cardiac out put 3

4. Subjective data Ask for any Chest pain, dyspnea , orthopnea , Cough, fatigue, Cyanosis or pallor, edema, nocturia , Past history, family history, personal habit,(nutrition, smoking, alcohol, exercise) 4

5. Objective data The neck vessels 1. The carotid arteries palpate each carotid arteries medial to the sternomastiod muscle in the lower third of the neck. 5

6. Palpate only one carotid at a time Feel the contour and amplitude of the pulse. Normally the contour is smooth and the normal stroke is 2+ or moderate. Diminished pulse fells small and weak occurs with decreased stroke volume. 6

7. Auscultate the carotid artery For persons who show signs of cardiovascular disease, auscultate each carotid artery for the presence of bruits. This is blowing, swishing sound indicating blood flow turbulence; normally there is none. Ask the person to hold his or her breath while you listen? 7

8. 2. The jugular vein From the jugular vein you can asses CVP and thus the heart efficiency as pump. You can not see the internal jugular vein it self but you can see its pulsation. 8

9. Position the person any where from a 30-45 degree angle, where ever you can best see the pulsations. Turn the person’s head slightly away from the examined side. Note the external jugular vein overlying the sternomastoid muscle. 9

10. Full distention of external jugular veins above 45 degree signify increased CVP. 10

11. Now look for pulsation’s of the internal jugular vein in the area of the supra sternal notch or around the origin of the sternomastoid muscle around the clavicle. You must be able to distinguish internal jugular vein pulsation from that of the carotid artery. 11

12. The pericardium Inspect the anterior chest. You may or may not see the apical impulse (pulsation of left ventricle,) when visible it occupies the fourth or fifith intercostals space at the mid- clavicular line. Easier to see in children or those with thinner chest walls. 12

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14. Assessment Position client supine Then head elevated at 45 degrees INSPECTION : Lifts, heaves PMI (assess location) 14

15. Inspection Chest for visible cardiac motion Estimate Jugular venous pressure Patient supine and head elevated to 15-30 degrees. JVP is the distance b/w highest point at which pulsation can be seen and the sternal angle 15

16. Jugular Venous Pressure An indirect measure of right atrial pressure. Measured in centimeters from the sternal angle and is best visualized with the patient's head rotated to the left. Described for its quality and character, effects of respiration, and patient position-induced changes. 16

17. Palpation 17

18. Physical Landmarks Suprasternal notch Sternum Manubriosternal angle – Angle of Louis Intercostals Spaces 18

19. Palpations Palpate for PMI; easiest if patient sits up and leans forward has a diameter of  2cm and located with 10 cm of the midsternal line Palpate for general cardiac motion with fingertips and patient in supine position Palpate for radial, carotid, brachial, femoral, popliteal, posterior tibial And dorsalis pedis peripheral pulses 19

20. 20 radial pulse Brachial pulse popliteal pulse

21. 21 Dorsalis pedis pulse Posterior tibial pulse

22. Palpations… Rate strength of the pulse normal, diminished, or absent on a scale of 0 to +4, where 2+ is normal. 22

23. Auscultation: Auscultatory Sites 23

24. Auscultation With a stethoscope Use diaphragm to assess higher pitched sounds Needs a lot of practice and experience Listen in a quiet area or to close eyes to reduce conflicting stimuli See also figure 4-10 for auscultatory Sites 24

25. Auscultatory Sites: Cont. 25

26. Auscultatory Sites The auscultatory Sites are close to but not the same as the anatomic locations of the valves. Aortic area 2 nd ICS at the right sternal border Pulmonic  2 nd ICS at the left sternal border Tricuspid  lt lower sternal border Mitral cardiac apex 26

27. Heart Sounds Heart sounds are characterized by location, pitch, intensity, duration, and timing within the cardiac cycle 27

28. Heart Sounds High-pitched sounds such as S 1 and S 2 , murmurs of aortic and mitral regurgitation, and pericardial friction rubs are best heard with the diaphragm. The bell is preferred for low-pitched sounds such as S 3 and S 4 . 28

29. Heart Sounds – S1…(Lub)… S1: Closure of AV valves (mitral and tricuspid valves: M1 before T1) Correlates with the carotid pulse Loudest at the cardiac apex Can be split but not often 29

30. Heart Sounds – S2…(Dub)… S2: Closure of Semilunar valves (aortic & pulmonic) Loudest at the base of the heart May have a split sound (A2 before P2) 30

31. Heart Sounds – S2…(Dub)… S 1 and S 2 assessed in all four sites in upright and supine position S 1 precedes and the S 2 follows the carotid pulse 31

32. Heart Sounds… Base (R/L 2nd ICS) S2 louder than S1 Apex S1 louder than S2 Normal physiologic S2 Split Best heard at pulmonic area during inspiration Fixed split (no variation with inspiration ) 32

33. Slide 19- 33 Sample Charting

34. Slide 19- 34 Sample Charting (cont.)

35. Extra Heart Sounds S3… Due to volume overload Due to Rapid ventricular filling: ventricular gallop S1 -- S2-S3 (Ken--tuc-ky ) S4… Due to pressure overload Due to slow ventricular contraction: atrial gallop S4-S1 — S2 (Ten-nes—see) 35

36. Extra Heart Sounds S3… Low-pitched sound Usually heard at the apex of the heart. C aused by rapid filling and stretching of the left ventricle when the left ventricle is somewhat noncompliant. C haracteristic of volume overloading, such as in CHF (especially left-sided heart failure), tricuspid or mitral valve insufficiency . S4… A dull, low-pitched postsystolic atrial gallop U sually caused by reduced ventricular compliance. B est heard at the apex in the left lateral position. O ccurs with reduced ventricular compliance and is present in conditions such as aortic stenosis , hypertension, hypertrophic cardiomyopathies , and coronary artery disease. L ess specific for CHF than S 3 . 36

37. Murmurs Turbulent blood flow across a valve or a disease such as anemia or hyperthyroidism Listen for murmurs in the same auscultatory sites APETM Systolic b/n S1 & S2 Diastolic b/n S2 & S1 37

38. Characteristics of Heart Sounds Type of Murmur Examples Location Pitch Radiation Quality Midsystolic Aortic stenosis 2nd RICS Medium Neck, left sternal border Harsh Pulmonic stenosis 2nd and 3rd LICS Medium Left shoulder and neck Harsh Hypertrophic cardiomyopathy 3rd and 4th LICS Medium Left sternal border to apex Harsh Pansystolic Mitral regurgitation Apex Medium to high Left axilla Blowing Tricuspid regurgitation Lower left sternal border Medium Right sternum, xiphoid Blowing Ventricular septal defect 3rd, 4th, and 5th LICS High   Often harsh Diastolic Aortic regurgitation 2nd to 4th LICS High Apex Blowing Mitral stenosis Apex Low Little or none   38

39. Murmurs They are classified by timing and duration within the cardiac cycle (systolic, diastolic, and continuous), location, intensity, shape (configuration or pattern), pitch (frequency), quality, and radiation 39

40. Murmurs Grade I : barely audible Gr II: audible but quiet and soft Gr III : moderated loud, without thrust or thrill Gr IV : loud, with thrill Gr V : louder with thrill, steth on chest wall Gr VI : loud enough to be heard before steth on chest 40

41. Murmurs Thrill : a palpable murmur Bruits : Vascular murmur sounds made by turbulent blood flow Heard over blood vessels with constricted lumens. Carotid and femoral are routinely assessed for bruits Sometimes found over the vertebral, subclavian and abdominal arteries 41

42. Slide 19- 42 Abnormal Findings Murmurs Caused by Valvular Defects Midsystolic ejection murmurs Aortic stenosis Pulmonic stenosis Pansystolic regurgitant murmurs Mitral regurgitation Tricuspid regurgitation Diastolic rumbles of atrioventricular valves Mitral stenosis Tricuspid stenosis Early diastolic murmurs Aortic regurgitation Pulmonic regurgitation

43. Diagnostic Tests Cardiac Enzymes Troponin tests , if elevated -- myocardial injury Blood Chemistry; Cholesterol, LDL,HDL, VLDL Serum Electrolyte Levels ; Na, Ca, K, CBC Renal Function Test Serum glucose Chest X-ray Electrocardiography Echocardiography MRI 43

44. Risk Factors of Cardiovascular Diseases Non-modifiable risk factors Increasing age Gender Positive family history Modifiable risk factors Elevated blood cholesterol level Elevated blood pressure Cigarette smoking Physical inactivity Stress Obesity 44

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