Cardiovascular assessment

1. 1
CARDIOVASCULAR
ASSESSMENT
D. Safaa eid
J. Borrero 9/10

2. 2
LECTURE OBJECTIVES
1.Review anatomy & physiology of the
cardiovascular system.
2.Describe physical assessment of
cardiovascular status.
3.Review diagnostic procedures

3. CARDIOVASCULAR EXAMINATION
Part I: Assessment of cardiovascular function
Health history
Physical assessment
Inspection
Palpation
Percussion
Auscultation
Laboratory test
Cardiac enzyme
Lipid profile
Coagulation studies

4. •Part II: Assessment of cardiovascular
structure
•Diagnostic studies
•ECG
•Echocardiography
•X- ray
•The exercise stress
•Cardiac catheterization

5. 5
Anatomy & Physiology
Functions of the heart & CV
system
•Pumps blood to tissues to
supply O
2
& nutrients
•Remove CO2 & metabolic
wastes

6. Circulation in the Heart
1. Oxygen-poor blood
(shown in blue) flows from
the body into the right atrium.
2..Blood flows through the
right atrium into the right
ventricle.
3. The right ventricle pumps
the blood to the lungs, where
the blood releases waste
gases and picks up oxygen.

7. 3. The newly oxygen-rich
blood (shown in red)
returns to the heart and
enters the left atrium.
4. Blood flows through
the left atrium into the left
ventricle.
5. The left ventricle
pumps the oxygen-rich
blood to all parts of the
body.

8. Coronary Circulation

9. Coronary Blood Flow

10. Valves of the Heart
•Tricuspid – Directs the flow of blood from
the right atrium to the left ventricle.
•Mitral Valve – Directs the flow of blood
from the left atrium to the left ventricle.
•Pulmonic (semilunar) – Lies between the
right ventricle and the pulmonary artery.
•Aortic Valve (semilunar) – Lies between
the left ventricle and the aortic artery.

11. Part I: Assessment of cardiovascular
function
physical assessment

12. 1. Health history
•a- Socio - cultural history: -
•Age, sex, occupation, educational level,
marital status
•b- Patient history:-
•Past medical history , Past surgical
history
•C-Family History
•d- Psychosocial Profile

13. - Symptom Analysis
•1- Chest Pain
•- Location: - Substernal, pericardial diffuse, localized
•- Radiation: -Radiates to jaw, arm, neck
•- Character: - Dull, aching, pressure, burning tightness,
crushing
•- Intensity: - Mild, moderate, severe
•- Onset: - Sudden, gradual
•- Duration: - 1 -10, more than 15 min, or continuous
•- Precipitating factors: - exercise, motion, eating
•- Relieving factors: - rest, walking, warmth, drugs
•- Accompanying symptoms : -dyspnea, restlessness,
sweating, vomiting, cough, syncope, fatigue

14. Pain Assessment Techniques
•The patient's self-reported pain is often
measured by using pain scales
•Numeric Pain Intensity Scale uses a 0-10
scale to assess the degree of pain.
Simple Description Intensity Scale, uses
such words as "mild", "moderate", and
"severe" to describe the patient's pain
intensity.

15. •Visual Analog Scale (VAS) requires
patients to mark a point on a 10 cm
horizontal or vertical line to indicate their
pain intensity, with
•0 indicating "no pain“
• and 10 indicating "the worst possible
pain".

17. Angina Pectoris
Substernal or
retrosternal pain
spreading across
chest; may radiate to
inside of arm, neck,
or jaw
5-15minUsually related
to exertion,
emotion, eating,
cold
Rest,
nitroglycerin,
oxygen

18. Angina Pectoris
Myocardial Infarction
MI Substernal pain or pain
over precordium; may
spread widely
throughout chest. Pain
in shoulders and hands
may be present.
>15
min
Occurs
spontaneo
usly but
may be
sequela to
unstable
angina
Morphine
sulfate,
successful
reperfusion
of blocked
coronary
artery

19. Esophageal Pain
Angina Pectoris
Substernal pain;
may be projected
around chest to
shoulders.
5–60
min
Recumbency,
cold liquids,
exercise.
May occur
Spontaneously
.
Food, antacid.
Nitro-glycerin
relieves Spasm.

20. anxiety
Pain over chest; may
be variable. Does not
radiate. Patient may
complain of
numbness and
tingling of hands and
mouth.
2–3 min Stress,
emotional
tachypnea
Removal of
stimulus,
relaxation

21. •2- Palpitations
•3- Syncope
•Syncopal attacks (dizziness) are another
symptom that may signal cardiovascular
problems.
•4- Edema
•Edema may be seen with right-sided CHF
and vascular disease.

22. •Pitting edema is a depression in the skin
from pressure.
•To demonstrate the presence of pitting
edema, the nurse presses firmly with his
or her thumb over a bony surface
•The severity of edema is described on a
five-point scale, from none (0) to very
marked (4).

23. •1+ Mild pitting, slight indentation, no
perceptible swelling of the leg
•2+ Moderate pitting, indentation subsides
rapidly
•3+ Deep pitting, indentation remains for a
short time, leg looks swollen
•4+ Very deep pitting, indentation lasts a
long time, leg is very swollen

24. •5- Fatigue
•fatigue is associated with cardiovascular
disease.
•6- Extremity Changes
•Changes in the extremities may provide
clues about underlying cardiovascular
disease. Symptoms such as Paresthesia
(numbness, tingling), coolness, and
intermittent claudication (pain in calves
during ambulation) may be associated
with vascular disease, coronary heart
disease, or cerebral vascular disease.

25. •7- Dyspnea and Cough
•Dyspnea may also occur with cardiac
disease such as left-sided CHF.

26. B- Physical assessment
•General Appearance
•Vital Signs
•Height and Weight

27. Inspection and palpation
1-Skin
•Color
•Turgor
•Temperature and moisture:-

28. •2- Nails
•Nails should be assessed for color, shape,
thickness, symmetry, and adherence.
•Normal nail color is some variation of pink
• Nail thickness generally is 0.3 to 0.65
mm, but it may be thicker in men

29. •Nail abnormalities:-
•-Peripheral vascular disease can produce
nail depression,
•Clubbing

30. •-Clubbing of the fingers is associated with
decreased oxygen.
•In clubbing, the distal tips of the fingers
become bulbous, the nails are thickened
hard, and curved at the tip, and the nail
bed feels boggy when squeezed.
•- Separation from the nail bed produces a
white, yellowish, or greenish color on the
non-adherent portion of the nail.

31. •Capillary refill time:
• is a quickly test to assess the adequacy
of circulation in an individual with poor
cardiac output. An area of skin is pressed
firmly by (say) a fingertip until it becomes
white; the number of seconds for the area
to turn pink again indicates capillary refill
time. Normal capillary refill takes around 2
seconds.

32. 2- Inspection and palpation
•1- Inspection of neck

33. •Inspecting the carotid artery and jugular
venous system
• With the patient in a supine position,
inspect the carotid and jugular venous
systems in the neck for pulsations.
•To visualize external venous pulsations,
look for pulsations in the supraclavicular
area.

34. •To visualize internal venous pulsations,
look for pulsations at the suprasternal
notch.
• Using a penlight to cast a shadow on the
neck vessels may help you visualize the
pulsations
•Carotids have visible pulsation, jugulars
have undulated wave.

35. •Carotids not affected by respirations,
jugulars are.
•Carotids not affected by position,
jugulars normally only visible when
client is supine.
•Large, bounding visible pulsation in
neck of at suprasternal notch: HTN,
aortic stenosis,.

36. Measuring Jugular Venous Pressure
•-Position patient with the head of bed at
30 to 45-degree angle.
•- Place a ruler vertically, perpendicular to
the chest at the angle of Louis (sternal
angle).

38. •-identify the highest level of the jugular
vein pulsation; if unable to see pulsations,
use the highest level of jugular vein
distension.
•- Place another ruler horizontally at the
point of the highest level of the venous
pulsation.

39. •- Measure the distance up from the
chest wall.
•The normal JVP is less than 3 cm. A
central venous pressure can be estimated
by adding 5 cm to the JVP

41. • Elevated JVP: Right-sided CHF,
constrictive pericarditis, tricuspid
stenosis, or superior vena cava
obstruction.
•Low JVP: Hypovolemia.

42. Palpation
•Palpating the Carotid

43. •-Lightly palpate each carotid
separately.
•- Note rate, rhythm, amplitude,
contour, symmetry, elasticity, thrills.

44. Palpating the Jugulars
• Palpate jugular veins and check direction of fill.
• Occluding under the jaw, the jugular should
flatten, but the wave form become more prominent.
•Occluding above the clavicle, the jugular normally
distends

45. •Palpating the Precordium
•- Identify and palpate each cardiac site for
pulsations, and thrills:
•- Apex (left ventricular area), or mitral
area fifth intercostals space, midclavicular
line.

46. •- Base right (aortic area), second
intercostals space right sternal border.

47. •- LLSB (tricuspid area), fourth to fifth
intercostal space at left sternal border.

48. •- Base left (pulmonic area), second
intercostal space left sternal border.
- Listen at each site with both the bell and the diaphragm.

49. - Listen at each site with both the bell
and the diaphragm.

50. PALPATION
• Impulses - finger pads
•Thrills (vibrations palpated secondary to
a murmur—turbulent blood flow through
a heart valve) - Bony part of hand, ball
of hand

51. •Thrills are palpable vibrations created by
turbulent blood flow.
•Lifts or heaves are diffuse, lifting impulses.
•A thrust is a rocking movement.

52. AUSCULTATION
•Diaphragm – medium and high frequency
sounds
•Bell – low frequency sounds
•Normally hear closure of valve Sounds from
left side of heart louder than equivalent
sounds from right side of heart

53. •S1 – closure of mitral and tricuspid
valves
•S2 – closure of aortic and pulmonic
valves
•Low pitched sounds S3, S4, mitral
stenosis

54. •Right 2
nd
intercostal space Aortic Area
•Left 2
nd
intercostal space Pulmonic Area
•Left lower sternal border Tricuspid area
•Apex – over apical impulse Mitral area

55. Landmarks

56. •the aortic and pulmonic areas are
correlated anatomically with the base of
the heart.

57. •S3 (also called a ventricular gallop) may
be heard in the tricuspid and mitral areas
during the early to mid-diastole following
the S2 sound.
•S3 is heard well when the client is in the
left lateral recumbent position,

58. •S4 (also called atrial diastolic gallop) may
be heard in the tricuspid and mitral areas
during the late phase of diastole, before
S1 of the next cardiac cycle.
• S4 is heard well when the client is in the
supine position

59. Auscultating the Precordium
•Auscultate at apex.
•- Note rate, rhythm, extra sounds, or
murmurs.
•- Note S1, S2, extra sounds, or murmurs.
•- Listen at each site with both the bell and
the diaphragm.

60. Murmurs and Stenosis…
•A valve that does not close efficiently, results in
the backflow of blood (i.e., insufficiency or
regurgitation).
•A valve that does not open wide enough
may cause turbulent backflow secondary
to obstruction or narrowing (i.e., stenosis).

61. Abnormal finding
•Irregular rhythm: Arrhythmia.
•Accentuated S1: High-output states, mitral or
tricuspid stenosis.
• Diminished S1: First-degree heart block, CHF,
CAD.
•-Variable S1: Atrial fibrillation.
•S3, low-pitched, early diastolic sound: CHF.
•S4, low-pitched late-diastolic sound: CAD, HTN,
MI.

62. Ejection fraction (EF)
•The ejection fraction (EF) represents the
amount of blood pumped out of the heart
(left ventricle) with each beat. In the
healthy heart, it is around 70%.
•An EF below 55% is considered abnormal.

64. 64
CARDIAC CYCLE
EKG – A 12
lead EKG is
a graphic
record of
the
electrical
forces
produced
by the heart

66. Acute Anteroseptal MI

67. 67
ELECTRODE POSITIONS
“LEADS”
•Leads measure electrical activity
between 2 points
•Movement toward Å electrode causes
positive deflection
•Movement away from Å electrode
causes negative deflection

68. 68
ELECTRODE POSITIONS
A 12 Lead EKG shows electrical activity
from 12 different positions in the heart,
concentrating on (L) ventricle
A 14 Lead EKG includes (R) ventricle
activity

69. Cardiac output
•SV-
•CO-
•Preload-
•Afterload-
•Ejection fraction
•GOAL is to maintain adequate MAP so
perfusion of oxygenated blood to vital
organs occurs
69

70. 70
Stroke Volume (Sv) & Cardiac
Output (Co)
•SV – amount of blood ejected by 1
ventricle in 1 beat
•CO – volume ejected in 1 min
Control of SV and HR = SV&HR are
continually adjusted by the body, and
are affected by the return of blood from
the tissues (think of exercise)
CO = SVxHR

71. 71

72. 11-09 NR 47
Decreased S1:
©Slowed ventricular ejection rate/volume
©Mitral insufficiency
©Increased chest wall thickness
©Pericardial effusion
©Hypothyroidism

73. Decreased S1 (cont.):
©Cardiomyopathy
©LBBB
©Shock
©Aortic insufficiency
©First degree AV block

74. Other Abnormal S1 (cont.):
©Increased S1:
-Increased cardiac output
-Increased A-V valve flow velocity (acquired
mitral stenosis, but not congenital MS)
©Wide splitting of S1:
-RBBB (at tricuspid area)
-PVC’s
-VT

75. 11-09 NR 47
S2:
©From closure vibrations of aortic and
pulmonary valves
©Often ignored, but it can tell much
©Divided into A2 and P2 (aortic and
pulmonary closure sounds)
©Best heard at LMSB/2LICS
©Higher pitched than S1--better heard with
diaphragm

76. 11-09 NR 47
S2 splitting (normal):
©Normally split due to different impedance
of systemic and pulmonary vascular beds
©Audible split with > 20 msec difference
©Split in 2/3 of newborns by 16 hrs. of age,
80% by 48 hours
©Harder to discern in heart rates > 100 bpm

77. 11-09 NR 47
S2 splitting (normal, cont.):
©Respiratory variation causes ­ splitting on
inspiration: ¯ pulmonary vascular
resistance
©When supine, slight splitting can occur in
expiration
©When upright, S2 usually becomes single
with expiration

78. 11-09 NR 47
S2 splitting (abnormal):
©Persistent expiratory splitting
-ASD
-RBBB
-Mild valvar PS
-Idiopathic dilation of the PA
-WPW

79. S2 splitting (abnormal, cont.):
©Widely fixed splitting
-ASD
-RBBB

80. S2 splitting (abnormal, cont.):
©Wide /mobile splitting
-Mild PS
-RVOTO
-Large VSD or PDA
-Idiopathic PA dilation
-Severe MR
-RBBB
-PVC’s

81. S2 splitting (abnormal, cont.):
©Reversed splitting
-LBBB
-WPW
-Paced beats
-PVC’s
-AS
-PDA
-LV failure

82. 11-09 NR 47
Single S2:
©Single S2 occurs with greater impedance
to pulmonary flow, P2 closer to A2
©Single and loud (A2): TGA, extreme ToF,
truncus arteriosus
©Single and loud (P2): pulmonary HTN!!
©Single and soft: typical ToF
©Loud (not single) A2: CoA or AI

83. 11-09 NR 47
Extra heart sounds

84. 11-09 NR 47
S3 (gallop):
©Usually physiologic
©Low pitched sound, occurs with rapid
filling of ventricles in early diastole
©Due to sudden intrinsic limitation of
longitudinal expansion of ventricular wall
©Makes Ken-tuck-y rhythm on auscultation

85. 11-09 NR 47
S3 (cont.):
©Best heard with patient supine or in left
lateral decubitus
©Increased by exercise, abdominal
pressure, or lifting legs
©LV S3 heard at apex and RV S3 heard at
LLSB

86. S3 (abnormal):
©Seen with Kawasaki’s disease--
disappears after treatment
©If prolonged/high pitched/louder:
-can be a diastolic flow rumble indicating
increased flow volume from atrium to ventricle

87. 11-09 NR 47
S4 (gallop):
©Nearly always pathologic
©Can be normal in elderly or athletes
©Low pitched sound in late diastole
©Due to elevated LVEDP (poor compliance)
causing vibrations in stiff ventricular
myocardium as it fills
©Makes “Ten-nes-see” rhythm

88. 11-09 NR 47
S4 (cont.):
©Better heard at the apex or LLSB in the
supine or left lateral decubitus position
©Occurs separate from S3 or as summation
gallop (single intense diastolic sound) with
S3

89. S4 Associations:
©CHF!!!
©HCM
©severe systemic HTN
©pulmonary HTN
©Ebstein’s anomaly
©myocarditis

90. S4 Associations (cont.):
©Tricuspid atresia
©CHB
©TAPVR
©CoA
©AS w/ severe LV disease
©Kawasaki’s disease

91. 11-09 NR 47
Click:
©Usually pathologic
©Snappy, high pitched sound usually in
early systole
©Due to vibrations in the artery distal to a
stenotic valve

92. 11-09 NR 47
Can be associated with:
©Valvar aortic stenosis or pulmonary
stenosis
©Truncus arteriosus
©Pulmonary atresia/VSD
©Bicuspid aortic valve
©Mitral valve prolapse (mid-systolic click)
©Ebstein’s anomaly (can have multiple
clicks)

93. 11-09 NR 47
Does NOT occur w/
supravalvar or subvalvar AS,
or calcific valvar AS.

94. 11-09 NR 47
Whoop (sometimes called a
honk):
©Loud, variable intensity, musical sound
heard at the apex in late systole
©Classically associated w/ MVP and MR
©Seen w/ VSD’s closing w/ an aneurysm,
subAS, rarely TR
©Some whoops evolve to become systolic
murmurs

95. 11-09 NR 47
Friction rub:
©Creaking sound heard with pericardial
inflammation
©Classically has 3 components; can have
fewer than 3 components
©Changes with position, louder with
inspiration

96. 11-09 NR 47
Murmur:
©Sounds made by turbulence in the heart or
blood stream
©Can be benign (innocent, flow, functional)
or pathologic
©Murmurs are the leading cause for referral
for further evaluation
©Don’t let murmurs distract you from the
rest of the exam!!

97. Laboratory tests
•Creatine kinase (CK) and its isoenzyme
CK-MB
•Lactic dehydrogenase
•Troponin I
•as low-density lipoproteins (LDL) and
high-density lipoproteins (HDL).

98. •Cholesterol (normal level, less than 200 mg/dL)
• LDL (normal level, less than 130 mg/dL) \
•HDL (normal range in men, 35 to 65 mg/dL; in
women, 35to 85 mg/dL) have a protective action
•Triglycerides (normal range, 40 to 150 mg/dL),
composed of free fatty acids and glycerol, are
stored in the adipose tissue and are a source of
energy

99. •Coagulation Studies
•Partial thromboplastin time (PTT)
•Prothrombin time (PT)

100. •Chest x-ray and fluoroscopy
•Electrocardiography

101. 101
Diagnostic Procedures
1.EKG 12 Lead
continuous cardiac monitoring
holter monitor
2.Chest x-ray – detects
enlargement of heart & pulmonary
congestion

102. 102
Diagnostic procedures
3.Echocardiography – ultrasound that
reveals size, shape and motion of
cardiac structures
Evaluates heart wall thickness, valve
structure, differentiates murmurs
4.TEE – transesophageal
echocardiography provides a clearer
image because less tissue for sound
waves to pass through

103. 103
Diagnostic procedures
5.Angiography / cardiac catherization
determines coronary lesion size,
location, evaluate (L) ventricular
function, measures heart pressures
6.Exercise tolerance test
7.Radionuclide Imaging

104. 104
Cardiac enzymes = enzymes are released
when cells are damaged (MI). Enzymes
are found in many tissues/muscles, and
some are specific to cardiac tissue.
Lab Studies

105. Cardiac enzymes =
CPK – MB (CK-MB),myoglobin,
Troponin
In general, the greater the rise in the
serum level of an enzyme, the greater
the degree or extent of damage to the
muscle.
LDH

106. 106
LAB studies
2.Electrolytes
3.Lipid panel
4.CBC
5.C – Reactive Protein
6.BNP- Human B-Natriuretic
Peptide
7.Blood coags-PT/PTT/INR

107. Cholesterol Level :
AHA Recommendation
•Total Cholesterol
–< 200 mg/dL
• best
–200 – 239
•borderline high
–240 mg/dL and above
• 2X risk of CAD

108. Cholesterol Level :
AHA Recommendation
•HDL Cholesterol
–< 40 mg/dL (men)
–< 50 mg/dL (women)
–> 60 mg/dL
•cardioprotective

109. Cholesterol Level :
AHA Recommendation
•LDL Cholesterol
–< 100 mg/dL
•Optimal
–100 – 129 mg/dL
•Near or above optimal
–130 – 159 mg/dL
•Borderline
–160 – 189 mg/dL
•High
–190 mg/dL
•Very high

110. Cholesterol Level :
AHA Recommendation
•Triglyceride
–< 150 mg/dL
•Normal
–150 – 199 mg/dL
•Borderline high
–200 – 499mg/dL
•High
–500 mg/dL and above
•Very high

111. 111
NCLEX TIME
Mary is attending a sophomore level nursing class
on anatomy and physiology. Which statement, if
made by Mary, demonstrates a good
understanding of the anatomy and physiology of
the heart?
A."The heart is encapsulated by a protective coating
called the endocardium.“
B."The SA node is considered the main regulator of
heart rate.“
C."The left atrium receives deoxygenated venous
blood from all peripheral tissues.“
D."Stroke volume is the amount of blood ejected by
the right ventricle during each diastole

112. 112
NCLEX TIME
Kirsten is completing her graduate clinical rotation in
a large urban teaching hospital in a medical
coronary care unit (CCU). Which observation
demonstrates a good understanding of completing
a thorough cardiac examination?
•A. In an obese client, an adult cuff size of 12 to 14
cm is preferable.
•B.The carotid artery on the neck is auscultated to
assess for the presence of a bruit.
•C.The apical impulse is auscultated over the fifth
intercostal space in the midclavicular line.
•D.Palpation is used to determine cardiac size.

113. 113
NCLEX TIME
Edward is a 40-year-old white male. He is an accountant who
works on average 11 hours per day. He reports feeling
stressed each day, even with mundane things such as a
traffic jam. His father had a massive myocardial infarction
at the age of 48. His mother has a history of congestive
heart failure. He seldom has time to exercise, but does eat
balanced meals when possible, although he does not get
to eat three meals a day. Select all factors that place
Edward at risk for heart disease.
•A.Family history
•B.Age
•C.Coping-stress tolerance
•D.Race
•E.Occupation