Transcript Sound "1"

Chapter 10
Assessment of Cardiovascular System
1
• Subjective data:
1. Assessment of chief complaints:
- Chest pain: location, quality, duration & associated
symptoms.
- Irregular heart beat: pound, too fast, jump.. Etc.
2. Assessment of risk factors:
- Ask about history of hypertension, diabetes,
rheumatic fever?
- Ask about family history of heart attack,
hypertension, stroke, and diabetes?
2
- Describe your nutritional intake: have you ever
been told you have high cholesterol, triglyceride
level.
-Do you smoke? How much? And for how long?
- How do you view yourself? What do you do to
relax?
- How many hours a day do you work? How do you
cope with stress.
- Exercise: what do you do for exercise? How often?
- Pain in calves, feet, buttocks or legs? What
aggravates the pain (walking, sitting long periods,
standing long periods, sleep)? What relieves the
pain “elevating legs, rest, lying down”?
- Is there fitting shoes? Does client wear constricting
garments or hosiery?
3
-In what type of chair does client usually sit?
- Does he/she cross legs frequently?
- Assessment of the client must be in supine or
sitting positing according to his/her health.
*Inspection & palpation:
* By inspection and palpation you may detect
ventricular hypertrophy (thickening of the
ventricular walls in the heart).
* Use source of light to inspect subtle movement
in chest e.g.: pulsation, retraction, etc….
4
• Apical pulse in left fifth intercostal space, if
deviation in site observed may indicate cardiac
enlargement 6th intercostal space.
• Retractions (when some of the tissue is pulled
into the chest on the precordium) may be seen
around site of apical pulse. Marked retraction
may indicate pericardial disease.
• Heaves or lifts (precordial movements when
right ventricle work increases). Heaves are best
felt with the heel of the hand at the sternal
border).
5
Apical pulse
6
Apical pulse
7
Palpation (sitting position).
8
Palpation (supine position).
9
• Palpate from apex, moving to external
border to base.
• Detect abnormalities in site of palpation and
abnormal sounds especially for thrill
“abnormal flow of blood”
• Thrill: a fine vibration, felt by an examiner's
hand on a patient's body over the site of an
aneurysm or on the precordium, resulting
from turmoil (disturbance) in the flow of
blood and indicating the presence of an
organic murmur of grade 4 or greater
intensity.
10
• It is important to describe pulsations in
relation to their timing in the cardiac cycle.
• Describe in terms: locations of pulsation in
relation to mid-sternal, midclavicular or
axillary lines.
11
Midclavicular and axillary lines
12
• Strength of palpation of apical pulse
differs from thin person to obese.
• Conditions such as stress, anxiety, anemia,
fever, and hyperthyroidism may increase
the amplitude and duration of apical pulse
(you feel lifting sensation under your
fingers).
• Palpation of pulse at base of the heart
(putting your hand at second left and right
intercostal spaces at sternal borders).
**Percussion is not used in cardiac assessment**
13
*Auscultation:
-All heart sounds are generally low pitched and
difficult for the human ear to hear.
-You may start auscultation from base to apex or
from apex to the base.
*Assess:
1. Rate and rhythm of the beat.
2. Concentrate initially on sound "1", noting its
intensity and variations, possible duplication and
effects of respiration.
3. Then listen to sound "2" for same characteristics.
4. Finally listen for extra sounds and for murmurs.
14
• Sound "1": caused by the closing of the
tricuspid and mitral valves. “Systole begins
with Sound "1" & extends to Sound "2“.
• Sound "2": results from closing of the aortic &
pulmonary valves.
“Diastole begins with Sound "2" and extends to
next Sound "1"
• Sound "2" louder than Sound "1" at the base of
heart, and is quieter than Sound "1" at the apex.
15
• Sound "3": During diastole, rapid distention
of ventricles occurs causes vibrations of
ventricular walls, and this known as sound
"3".
• Sound "3" best heard at the apex with bell
of stethoscope.
• Sound "4": occurs after sound "3" (late
diastolic filling), occurs from vibrations of
ventricular wall or vibrations of the valves.
** Summation gallop: three cardiac sounds
heard S1, S2 and summation of S3 and S4.
16
*Neck vessels:
- Jugular veins assessed for venous pulse
waves and pressure.
- Assess for distention, may result from
right-sided heart failure.
- The client must be in supine position or
in fowler position "45" degree.
- Assess jugular pulse “venous" which is
wave of blood retrograde after ejecting
blood into the right ventricle
17
• Assess carotid arteries: inspection, then palpate
below and just medial to the angle of the jaw, then
auscultate by the bell of the stethoscope.
• Assess carotid arteries for pulsation noting is it
strong or weak, rise or collapse, rapid or slow,
double or single.
• Listen for heart murmurs ( abnormal sounds
produced by vibrations within the heart or in the
walls of large vessels “during systole or diastole”.
• Murmurs occurrence result from valve defects,
changes in the blood vessels or by defects in the
myocardium.
18
• Special maneuvers for vascular assessment
– Check for deep phlebitis by quickly squeezing calf
muscles against tibia (normally no pain).
– Check Homan's sign by extending leg and dorsiflexing foot (normally no pain).
– Check for competency of valves (Trendelenburg
test) if client has varicose veins: feel dilated veins
with one hand while using the other hand to
compress veins firmly above level of the first
hand, then palpate for impulse of blood flow
which is normally no pulsation palpated.
19
*Trendelenburg test (Tourniquet test)
• With the patient in a supine position, the lower
limb is elevated to empty the superficial
venous system. The tourniquet is applied just
below level of sapheno-femoral junction (SFJ).
• The patient is then asked to stand. Rapid filling
of the varicosities with the tourniquet still on
suggests incompetent perforators below the
level of the SFJ. If no filling is seen at this
point, the tourniquet is released.
20
Arterial and venous insufficiency of lower extremities
Item
Arterial insufficiency
Venous insufficiency
Pulses
Decreased or absent
Present
Color
Pale on elevation and cold
Pink to cyanotic, brown pigment at
ankles
Temperature
Cool, cold
Warm
Edema
Non
Present
Skin
Shiny skin, thick nails, absent of
hair, ulcers on toes, gangrene
may develop
Ulcers on ankles discolored, scaly
Sensation
Leg pain aggravated by standing
& relieved with rest.
Pressure on buttocks or calves or
cramps during walking,
parasthesia
Leg pain aggravated by standing or
sitting & relieved by elevation
of legs, lying down, or walking.
Also relieved with use of
support hose.
21
The end
Thank you
22