Transcript lecture 2-Cardiovascular Assessment

Assessment of the Heart, Great vessels of
the neck, and Peripheral Vascular system
Great vessels of the neck
Jugular veins
 Carotid arteries

JUGULAR VENOUS DISTENTION
JVD
Assessment
Position client supine
 Then head elevated at 45 degrees

INSPECTION:
 Lifts, heaves
 PMI (assess location)

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

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.
Palpation
Physical Landmarks
Suprasternal notch
 Sternum
 Manubriosternal
angle – Angle of
Louis
 Intercostals Spaces

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

palpations
See figure 4-12
 Rate strength of the pulse normal,
diminished, or absent on a scale of 0 to
+4, where 2+ is normal. See table 4-6

Auscultation:
Auscultatory Sites
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

Auscultatory Sites: Cont.
Auscultatory Sites

The auscultatory Sites are close to but not the
same as the anatomic locations of the valves.
 Aortic area2nd ICS at the right sternal border
 Pulmonic  2nd ICS at the left sternal border
 Tricuspid  lt lower sternal border
 Mitral cardiac apex
Heart Sounds

Heart sounds are characterized by location,
pitch, intensity, duration, and timing within the
cardiac cycle
Heart Sounds

High-pitched sounds such as S1 and S2,
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 S3 and S4.
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
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)
Heart Sounds – S2…(Dub)…

S1 and S2 assessed in all four sites in upright
and supine position
 S1 precedes and the S2 follows the carotid
pulse
Heart Sounds – Cont.

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)
Extra Heart Sounds
S3…
S4…


Due to volume overload
 Due to Rapid ventricular
filling: ventricular gallop
 S1 -- S2-S3 (Ken--tuc-ky)
Due to pressure overload
 Due to slow ventricular
contraction: atrial gallop
 S4-S1 — S2 (Ten-nes—see)
Extra Heart Sounds
S3…
S4…


low-pitched sound
 usually heard at the apex of
the heart.
 caused by rapid filling and
stretching of the left
ventricle when the left
ventricle is somewhat
noncompliant.
 characteristic of volume
overloading, such as in CHF
(especially left-sided heart
failure), tricuspid or mitral
valve insufficiency.



a dull, low-pitched
postsystolic atrial gallop
usually caused by reduced
ventricular compliance.
best heard at the apex in the
left lateral position.
occurs with reduced
ventricular compliance and is
present in conditions such as
aortic stenosis, hypertension,
hypertrophic
cardiomyopathies, and
coronary artery disease.
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/w S1 & S2

Diastolic b/w S2 & S1
Characteristics of Heart Sounds
Type of
Murmur
Midsystolic
Pansystolic
Diastolic
Examples
Location
Pitch
Radiation
Aortic
stenosis
2nd RICS
Medium
Neck, left
sternal border Harsh
Pulmonic
stenosis
2nd and 3rd
LICS
Medium
Left shoulder Harsh
and neck
Hypertrophic 3rd and 4th
cardiomyopat LICS
hy
Medium
Left sternal
border to
apex
Harsh
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 High
5th LICS
Aortic
regurgitation
2nd to 4th
LICS
Mitral stenosis Apex
Quality
Often harsh
High
Apex
Low
Little or none
Blowing
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
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
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