4.CVS Assessment.pptx

cardio vascular system

1. SALALE UNIVERSITY COLLEGAE OF HEALTH SCIENCE DEPARTMENT OF ADULT HEALTH NURSING Presentation on : Assessment Of Cardiovascular System Presented To : Mr. Tadele K & Mr. Bikila T (Ass’t Professor) Presented by: Dereje A & Worku D (Bsc)   June,2023 Fiche Ethiopia

2. Outline 6/14/2023 2 Introduction Anatomy and Physiology of Cardiovascular Symptom of Cardiac Disease Assessment of Cardiovascular Cardiovascular Examination Normal and Abnormal Cardiac Sound

3. Objectives 6/14/2023 3 At the end of this lesson the students will be able to: Understanding and explaining Anatomy and Physiology of Cardiovascular Explain symptoms of cardiac disease Use a step -wise approach in cardiovascular examination Perform a complete cardiovascular assessment Differentiate between normal and abnormal cardiac findings Interpret cardiac findings

4. Introduction To Cardiovascular System 6/14/2023 4 Cardiovascular system consists of heart(a muscular pump) and blood vessels. • Blood vessels are arranged in two continuous loops – Systemic circulation – Pulmonary circulation • When the heart contracts, it pumps blood simultaneously into both loops

5. Overview Of Anatomy And Physiology Of Cardiovascular 6/14/2023 5 Understanding cardiac anatomy and physiology is particularly important in the examination of the cardiovascular system. Heart is shaped like “Cone” Top of the heart is the base Bottom ” is the apex Heart size = clenched fist Precordium - area on anterior chest that covers heart and great vessels

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7. Cont… 6/14/2023 7 Chambers and valves of the Heart The heart has four chambers and valves: Chambers Vs Valves -Right atrium -Tricuspid valve -Left atrium -Mitral valve -Right ventricle -Aortic valve -Left ventricle -Pulmonic valve

8. Cont… 6/14/2023 8 Atria are tilted slightly toward the back and ventricles extend to left and toward anterior chest wall . Note that the right ventricle occupies most of the anterior cardiac surface. This chamber and the pulmonary artery form a wedge like structure behind and to the left of the sternum. The left ventricle, behind the right ventricle and to the left, forms the left lateral margin of the heart.

9. Cont … 6/14/2023 9 Its tapered inferior tip is often termed the cardiac “ apex. ” It is clinically important because it produces the apical impulse, sometimes called the point of maximal impulse, or PMI. This impulse locates the left border of the heart and is usually found in the 5th interspace 7 cm to 9 cm lateral to the midsternal line. The right heart border is formed by the right atrium, a chamber not usually identifiable on physical examination.

10. Cont… 6/14/2023 10 The left atrium is mostly posterior and cannot be examined directly Because of their positions, the tricuspid and mitral valves are often called atrioventricular valves. The aortic and pulmonic valves are called semilunar valves because each of their leaflets is shaped like a half moon. Although this diagram shows all valves in an open position, they are not all open simultaneously in the living heart.

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12. Cardiovascular : Cardiac Cycle 6/14/2023 12 Tow phases: DIASTOLE : ventricles relax and fill with blood SYSTOLE : ventricles contract pump blood into pulmonary and systemic arteries

13. Cardiovascular :Pumping Ability 6/14/2023 13 Cardiac Output (C.O.) = volume of blood in liters ejected by the heart each minute. Adult = 4-7 liters/minute ( CO = HR x SV). Heart Rate (HR) = number of times ventricles contract each minute. Stroke Volume (SV) = The amount of blood ejected by the left ventricle during each systole. Preload = degree of stretch of myocardial fibers at end of Diastole . Afterload = pressure or resistance the ventricles must overcome to pump out blood.

14. Symptoms Of Heart Disease 6/14/2023 14 Dyspnea : This is a state of shortness of breath on exertion. But it may occur at rest as the heart failure progresses. The degree of dyspnea is graded based on the New York Heart Association Class (NHAC): Class I: No limitation of physical activity No symptoms with ordinary exertion Class II: Slight limitation of physical activity Ordinary activity causes symptoms

15. Symptoms Of Heart Disease cont… 6/14/2023 15 Class III: Marked limitation of physical activity -Less than ordinary activity causes symptoms -Asymptomatic at rest Class IV: Inability to carry out any physical activity without discomfort. -Symptoms at rest Paroxysmal Nocturnal Dyspnea : Is shortness of breath that occurs during sleep.

16. Cont … 6/14/2023 16 Orthopnea : Shortness of breath that occurs during recumbent position. postural (orthostatic) hypotension: a sudden drop in blood pressure when they rise to a sitting or standing position/sudden change of position. Pain: Angina pectoris is a cardiac pain. It arises in the precordial area usually on the retrosternal region and radiates to the left neck, shoulder and left upper arm.

17. Cont … 6/14/2023 17 Body swelling : Usually which starts from the leg Palpitation : Is subjective unpleasant perception of one’s own heart beat. Cough : Which usually occurs at night (nocturnal) Syncope : Sudden episode of fainting related to hemodynamic derangement

18. Symptoms of Peripheral Vascular Disease 6/14/2023 18 Symptoms of Arterial occlusion : Acute : pain, loss of function, altered cutaneous sensation, gangrene . Chronic : Intermittent claudication (pain around calf muscle on walking) which gets relieved with rest Symptoms of Venous insufficiency : Swelling and pain of the affected limb

19. Assessment Of The Cardiovascular System 6/14/2023 19 Subjective Assessment Personal and family history Socioeconomic status Cigarette smoking : # packs /day and also # years smoked. Physical Activity/Inactivity: 30 minutes daily of light to moderate exercise recommended.

20. Cont … 6/14/2023 20 Obesity: associated with HTN, hyperlipidemia, diabetes and all contribute to CV disease. Current Health Problems: describe health concerns. Chest pain: discomfort, a symptom of cardiac disease, can result from ischemic heart disease, pericarditis and aortic dissection. Chest pain can also be due to non cardiac causes; pleurisy, pulmonary embolus, hiatal hernia and anxiety.

21. 6/14/2023 21 Assessment- Chest Pain Onset & Duration Frequency Precipitating factors Location Radiation Intensity

22. Cont … 6/14/2023 22 Paroxysmal Nocturnal Dyspnea – client has been recumbent for several hours, increase in venous return leads to pulmonary congestion. Fatigue - resulting from decreased cardiac output is usually worse in evening. Ask the patient if can they perform same activities as a year ago

23. Cont… 6/14/2023 23 Palpitations- fluttering or unpleasant awareness of heartbeat. Non cardiac causes- fatigue, caffeine, nicotine, alcohol Weight gain- a sudden increase in wt. of 2.2 pounds (1 kg) can be result of accumulation of fluid (1L) in interstitial spaces known as edema. Syncope- transient loss of consciousness, decrease in perfusion to brain.

24. Physical Examination 6/14/2023 24 General Considerations The patient must be properly undressed above the waist. The examination room must be quiet to perform adequate auscultation. Observe the patient for general signs of cardiovascular disease - Breathing pattern -Finger clubbing - Cyanosis -Edema

25. Cont… 6/14/2023 25 Objective Assessment BP: supine -change position 1-2 minutes, check again. Normally, systolic drops slightly or remains unchanged and diastolic increases slightly. Peripheral pulses are assessed for: -Presence -Rhythm -Equality -Amplitude -Rate

26. Cont … 6/14/2023 26 Precordium Assessment- area over heart is done by: -Inspection (I) -Palpation (P) -Percussion (P) -Auscultation (A)

27. Inspection 6/14/2023 27 Lips for (cyanosis) Clubbing of fingers may be seen Pallor of the conjunctiva indicates anemia Edema DVT and JVD Arm/leg skin changes, varicose veins visible pulsation on the neck, pericardium, epigastric area for pulsation of the abdominal aorta.

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30. Palpation 6/14/2023 30 Palpable Pulses ( heart sounds) at each valvular sites. PMI: which usually is located at the same area to the apical impulse. It is normally located in the 5th intercostals space Normally no pulsation palpable over the aortic and pulmonic areas but at the PMI. Also You may feel: Thrills (a palpable murmur) -Parasternal heave (lifting the palm or a pen when put on the Parasternal area)

31. Cont …. 6/14/2023 31 Arterial Pulses Components of arterial examination include -Rate -Character -Rhythm -Volume (amplitude) Major Arteries : Radial, Brachial, Carotid, Femoral, Popliteal, Posterior Tibial & Dorsalis pedis. NB . All arteries should be palpated symmetrically at the same time except carotid arteries, as this could cut off the blood supply to the brain and cause syncope.

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33. Percussion 6/14/2023 33 Has little significance in pericardial examination. It is done when suspects dextrocardia or significant mediastinal shift. In most cases, palpation has replaced percussion in the estimation of cardiac size Starting well to the left on the chest, percuss from resonance toward cardiac dullness in the 3rd, 4th, 5th, and possibly 6th intercostal spaces.

34. Auscultation 34 listen to the heart with your stethoscope in the right 2nd interspace close to the sternum, continue auscultation along the left sternal border in each interspace from the 2 nd through the 5 th , and at the apex . Recall that the upper margins of the heart are sometimes termed the “base” of the heart. Some clinicians begin auscultation at the apex , others at the base .

35. Cont … 6/14/2023 35 Areas of auscultation : 1. Aortic area : The right 2 nd inter costal space near the sternum 2. Pulmonic area : The left 2 nd inter costal space near the sternum. 3. Tricuspid area : The left 4 th and 5 th inter costal spaces near the sternum 4. Mitral (apical) area: 5 th inter costal space just medial to the midclavicular line.

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37. Auscultation Cont… 6/14/2023 37 Different maneuvers to emphasize cardiac auscultation Have the patient roll on their left side and auscultate at the apex. This position emphasizes S3 and mitral murmurs. Have the patient sit up and lean forward. This position enhances diastolic murmur of aortic regurgitation, and pericardial friction rub .

38. Auscultation Cont… 6/14/2023 38 Ask the patient to hold on breathing: If the patient holds on inspiration which makes sounds arising from the right side of the heart louder. If the patient holds on expiration sound originating from the left side of the heart are exaggerated.

39. Auscultation Cont… 6/14/2023 39 Heart Sounds Heart sounds- are caused by the closure of heart valves. Heart sounds : LUB DUB SYSTOLE: lub= S1 (closing of Aterio Ventricular valves) DIASTOLE : dub = S2 (closing of semilunar valves) During the cardiac cycle, valves are opening and closing, causing different heart sounds (S1 and S2). Sometimes abnormal heart sounds are heard due to improper opening or closing of the valves (murmurs).

40. Auscultation Cont… 6/14/2023 40 Characteristics of Heart Sound Frequency (pitch): high or low Intensity (loudness): loud or soft Duration: very short hear sounds or longer periods of silence Timing: systole or diastole

41. Auscultation Cont… 6/14/2023 41 During auscultation focus heart sounds are: 1st Heart Sound (S1) : This signals the onset of systole and is caused by the closure of the mitral and tricuspid valves. NB: The 1st heart sound can be identified by palpating the carotid pulse while auscultating. The upstroke of the carotid pulse closely follows the 1st heart beat.

42. Auscultation Cont… 6/14/2023 42 S1 is loud in: -mitral stenosis -tachycardia -hyperdynamic circulation like e.g. anemia S1 is soft ( Muffled )in:- -mitral regurgitation -bradycardia and etc.

43. Auscultation Cont… 6/14/2023 43 2nd Heart Sound (S2) : This separates systole and diastole. The sound is made by the closure of aortic and pulmonary valves. The aortic valve closes before the pulmonary valve and this splitting of the second sound is heard. Particularly during inspiration, as more blood is drawn into the right ventricle which is a normal phenomenon.

44. Auscultation Cont… 6/14/2023 44 Normally S2 is louder than S1 at the base and often softer than the first heart sound at the apex . The aortic component of the 2nd heart sound is increase intensity by Systemic HTN because of increase pressure. The pulmonic component of the 2nd heart sound is increase intensity by Pulmonary HTN .

45. Auscultation Cont… 6/14/2023 45 3rd & 4th Heart Sounds These are low pitched sounds. If either S3 or S4 is very loud it is often heard as gallop/triple rhythm. 3rd Heart Sound (S3) or ventricular gallop This is produced by rapid ventricular filling and occurs in early-mid diastole i.e. soon after S2 occurs normally in young fit adults with bradycardia.

46. Auscultation Cont… 6/14/2023 46 Physiologic 3 rd heart sounds is frequently heard in children and 3 rd trimester pregnancy. It occurs abnormally in patients with heart failure: left heart failure - S3 heard best in mitral area right heart failure - S3 heard best in tricuspid area

47. Auscultation Cont… 6/14/2023 47 4th Heart Sound (S4) or atrial gallop This is an atrial sound, occurring just before S1. It is always abnormal as it represents atrial contraction against a stiffened ventricle. It may occur in heart failure , aortic stenosis or hypertensive heart disease .

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49. Auscultation Cont… 6/14/2023 49 Murmur Murmur is abnormal sound due to turbulence of blood flow. It may be innocent (Physiologic) e.g. hyperdynamic states like anemia pregnancy etc. Pathologic e.g. valvular lesions

50. Classification of Murmurs 6/14/2023 50 Murmurs are classified according to their timing and cardiac cycle Systolic or diastolic A. Systolic murmurs 1) Ejection systolic murmur This originates from the aortic outflow tract. It may be an innocent flow murmur which is common in childhood, pregnancy and anemia.

51. Classification of Murmurs Cont.. 6/14/2023 51 pathological Ejection systolic murmur as in : Aortic stenosis Aortic sclerosis Atrial septal defect Hypertrophic obstructive cardio myopathy Pulmonary stenosis

52. Classification of Murmurs Cont.. 6/14/2023 52 2) Pansystolic murmur : It is uniform intensity and merges with S1 and S2 , is often muffled. It is found in:- Mitral or Tricuspid regurgitation Ventricular septal defect

53. Classification of Murmurs Cont.. 6/14/2023 53 Diastolic murmurs 1) Early diastolic murmur : This is high-pitched and blowing . It occurs due to:- Aortic or pulmonary regurgitation .-The aortic regurgitation murmur is usually soft and is best heard with the patient leaning forward and in expiration.

54. Classification of Murmurs Cont.. 6/14/2023 54 2) Mid-diastolic murmur: This is low-pitched and rumbling , I t often starts after an opening snap/sudden. It is caused by:- Mitral stenosis (common) Rheumatic fever Thickens mitral valve leaflets Aortic regurgitation

55. Cont … 6/14/2023 55 Lung And Abdomen During any cardiac examination the lung should be assessed for Respiratory rate and pattern Hemoptysis Cough Crackle Wheezes

56. Cont … 6/14/2023 56 Abdomen Look for: H epatomegaly and characterize it S plenomegaly may be found in endocarditis Ascites H epato-jugular reflex-pressing 30-60 seconds on the liver rises the jugular venous pressure by 2cm when the right heart fails to accommodate increase volume.

57. Cont… 6/14/2023 57 Hand and feet Hand and feet should be assessed for peripheral circulation –edema, venous return, deep phlebitis thrombophlebitis, peripheral cyanosis, capillary refill ,clubbing of finger and toes. Check deep phlebitis by quick squeezing calf muscle against tibia. Normally patient feel no pain;pain full calf suggests deep phlebitis.

58. Summary 6/14/2023 58 A thorough cardiovascular assessment includes a health history and physical examination and provides invaluable data about the patient’s overall health status . Before you begin, visualize the underlying structures and review expected normal findings. Understanding normal cardiovascular functioning is crucial to interpreting your findings . As you work through the assessment, systematically look for cardiovascular changes in every system. Let your patient’s current health status direct your assessment . If she or he has an acute problem , perform a focused assessment.

59. Reference 6/14/2023 59 F . A. Davis. (2007). Nursing Health Assessment. (2 nd Edi). Philadelphia, Pennsylvania. Patricia M. Dillon, DNSc, RN. Chapter No.14 p.n 438-490. Bickley , L. S., Szilagyi, P. G., & Bates, B. (2007). Bates' guide to physical examination and history taking (11th Edi). Philadelphia: Lippincott Williams & Wilkins. Chapter No.06 & 07 p.n 171-250. Weber, Kelley's. (2007). Health Assessment in Nursing, 3rd Ed: North American Edition. Lippincott Williams & Wilkins. Chapter No.14 &15 p.n 239-294. Lippincott, Williams & Wilkins (2005). Heart Sounds Made Incredibly Easy. PA.

60. Acknowledgement 6/14/2023 60   First and for most we would like to thanks our almighty of God. Next to this we would like to forward our deepest appreciation and thanks to our lecturer Mr. Tadele K & Mr . Bikila T [Ass’t Professor] for giving us this opportunity to prepare individual presentation on Advanced Nursing Health Assessment . At the Last but not Least we would like to thanks Salale university for Library and WIFI Service.

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