Transcript Cardiac Presentation

Cardiovascular Assessment
Cardiac Portion of
Complete Physical Assessment
Prime Suspect:
The Heart and the Vascular
System
 Cardiovascular system
 Continuous, fluid-filled elastic circuit with a
pump which connects all systems to each other
– communication / transportation of :
respiratory - oxygen and carbon dioxide
 endocrine - hormones, buffers and enzymes
 Gastrointestinal - nutrients, water, vitamins and
minerals

– Consist of the heart and vascular system
Cardiac Assessment:
begins at Introduction


Beginning with Vital Signs
 Blood Pressure
 Heart Rate
 Temperature
When confronted with multiple clients;
quick assessment can help prioritize
and help in doing complete assessment.

Introduce yourself (LOC)
– assess that they know who, where, and why
– How do they feel
– Is it neurologic, endocrine problem, or could
it be that they are not getting blood to brain
 Could be:
–Low Blood pressure
–Low hemoglobin
–Vascular Problems
• Carotid disease
Interview

Chief Complaint
– Chest Pain
 may be identified as:
–Indigestion
–burning
–discomfort
–tightness
–pressure in mid-chest
–left arm
–jaw pain
– Description of chest Pain (PQRST)
 P - rovication - What provokes or makes
worse
–Palliation - what relieves or does not
 Q-uality - what does it feel like
 R -egion - where is the pain and does it
radiate
 S-everity - scale 0-10
 T-iming - continuous or intermittent.
Relationship to other activities.
– Dyspnea
SOB
 Exertional
 Orthopnea - unable to lie flat
 Paroxysmal nocturnal
–wake up ^ 2 hrs after sleep SOB, if
accompanied by wheeze called Cardiac asthma
– Cardiac cough - occurs at night in supine
position, exertion, or turning to one side
– Headache
 Hypertension

– Syncope
 Effort synocope - after heavy activity is
started
–Aortic or subaortic stenosis.
 Stokes-Adams attack
–related to HB or rhythm disturbance
 Pacemaker syncope
–Malfunction or failure of artificial
pacemaker
 Hypersensitive Carotid sinus syncope
–caused by pressure applied to carotid
sinus body
– Abdominal pain
 related to RVF (Right Ventricular
Failure)
– Fatigue or weakness
 related to RVF
– Edema or weight gain
 related to RVF
Korotkoff’s Sounds



Sounds heard during auscultation of blood
pressure.
Produced by vibratory motion of the
arterial wall as the artery suddenly distends
when compressed by a pneumatic BP cuff.
Origin of sound may be within the blood
passing through the vessel wall or within
the wall itself.

5 distinct Korotkoff sounds heard during
auscultation of BP
–
–
–
–
–


1st - beat or tapping sound
2nd - murmur or swish sound
3rd - crisp tapping sound
4th - soft, muffled tone
5th - the last sound heard
Systolic - The first beat or tapping heard
Diastolic - The fourth sound heard
Blood Pressure Measurement


Materials needed:
– Stethoscope
– Sphygmomanometer
– Alcohol sponge
Choose cuff of appropriate size
– Too narrow may cause falsely high
pressure
– Excessive wide a falsely low pressure

Patients arm should be extended at heart
level.
– Artery above or below heart level, blood
pressure may be elevated or decreased
consecutively.

Wrap deflated cuff snugly around upper
arm
– Above antecubital area inner aspect of elbow.
– Center of bladder should rest directly over
medial aspect of arm. (Most cuffs have an
arrow for you to position over brachial artery
at where you feel strongest pulse)




Place Bell of stethoscope on brachial
artery at point of strongest pulse
Locate brachial artery by palpation.
Center the bell over the artery and hold it
in place with one hand. The bell of the
stethoscope transmits low pitched arterial
blood sounds more effectively than the
diaphragm.
Pump air into cuff while auscultating the
sound over brachial artery - until gauge
registers 160mm HG or at least 30 mm Hg
above last audible sound.





Open valve and slowly deflate the cuff - 5
mm Hg / second. While releasing air watch the column and auscultate the sound
over the artery.
When you hear the first beat or clear
tapping note pressure on column. This is
the SYSTOLIC pressure.
Continue to release air gradually.
Note the fourth Korotkoff sound (a soft,
muffled tone) This is the DIASTOLIC
pressure.
Deflate the cuff quickly.

Problem and Possible Cause for:
– False-high reading





Cuff too small - (bladder must be approximately
20% wider than the circumference o f arm).
Cuff wrapped too loosely, reducing effectiveness
(tighten cuff)
Slow cuff deflation, causing venous congestion in
arm ( Never deflate the cuff more slowly than 2 mm
Hg/ heartbeat)
Tilted mercury column (Read pressure column
vertically)
Poorly timed measurement -after eating, ambulated,
appeared anxious, or flexed arm muscles.
– False-low reading
Incorrect position of arm (make sure the
arm is level with patient’s heart)
 Mercury column below eye level (Read
the mercury column at eye level)
 Failure to notice auscultatory gap (sound
fades out for 10 - 15 mm Hg, then
returns (estimate systolic pressure by
palpation before actually measuring it)
 Inaudible low-volume sound (Chart as
the palpated systolic pressure)

Heart Rate



Gently press your index, middle, and ring
finger on the radial artery, inside the
patient’s wrist.
Count the beats for 60 seconds, or for 30
seconds and multiply by 2. (60 second
count more efficient.)
Assess rhythm and volume by noting the
pattern and strength. If you detect an
irregular beat, repeat the count.
IRREGULARITIES ARE IMPORTANT
SIGNS
Skin and Appendages

Color
– The range of expected skin color varies from
dark brown to light tan with pink or yellow
overtones.
– Pallor may be indicator of:
 anemia
 SNS
 Sympathomimetics
–Dopamine

Cyanosis (Peripheral vs. Central Cyanosis)
– Peripheral (cold) cyanosis
 Fingertips
 Toes
 Associated with peripheral
hypoperfusion or vasoconstriction
Cyanosis (Central)

Central (warm) cyanosis
– Seen on lips, tongue, mucous membranes;
associated with deoxygenated hemoglobin: note in
dark-skinned persons - appear as ashen color
 May be late sign of hypoxemia in anemic clients
 May be early sign of hypoxemia in Chronic
Bronchitis (Blue Bloaters)
– Blue because of chronic hypoxemia
– Bloaters because of Chronic Right Ventricular
failure

Moisture
– Diaphoretic
– Dryness

Temperature
– Cold skin may be related to hypoperfusion

Turgor
– Decrease in skin turgor (tenting) related to
interstitial dehydration

Edema
– Indicates increase in interstitial fluid
Edema

Note location
– Facial
 allergies -anaphylaxis
 Steroids
– exogenous
• prednisone
– endogenous - Cushing’s syndrome
– Renal disease - Nephrotic syndrome
 Dependent: RVF

Degree of Pitting
– Grade 1+ - 0 to 1/4 in.
– Grade 2+ -1 /4 to 1/2 in
– Grade 3+ - 1/2 to 1 in.
– Grade 4+ - > 1 in.
Lesions


Arterial disease
– may cause ulcers at the toes or
points of trauma
Venous disease
– may cause ulcers at sides of ankles
Arterial Disease








Excruciating pain in acute occlusions
Intermittent claudication in chronic occlusions
Pulses are diminished or absent
Color is pale
Temperature cool or cold
Edema is absent
Skin changes
– Thin, shiny, atrophic skin
– Loss of hair
– thickened toenails
Ulcerations
– At toes or points of trauma
Venous Disease







Crampy pain
– Homan’s sign in thrombophlebitis
Normal pulses (may be difficult to palpate due to
severe edema)
Normal to ruddy color
Warm to touch
Edema - may be severe
Skin Changes
– Brown pigmentation at ankles
Ulcerations
– At sides of ankles
Fingertips and nail-beds


Color
– bluish nail-beds with peripheral disease
– Capillary refill <3 sec
 >3 - hypoperfusion
Clubbing
– Loss of normal angle between base of
nail and skin
– indicates chronic hypoxia


Splinter hemorrhages
– Red to black linear streaks running from
base to tip of nail
– bacterial endocarditis
Osler’s nodes
– Painful red subcutaneous nodules on
fingertips
– indicate embolization of bacterial
endocarditis

Peripheral Pulses
– Carotid - palpate only lower half and
never palpate both carotids
simultaneously
– Brachial
– Radial and Ulnar
– Femoral
– Popliteal
– Posterior tibialis
– Dorsalis Pedis

Pulse contour
– Pulsus Magnus
 readily palpable - not easily obliterated
 Characteristic of:
– Hypertension
– Aortic Insufficiency
– Pulsus Parvus
 Pulse difficult to feel, easily obliterated
 small weak pulse
 Characteristic of:
– Aortic and/or mitral Stenosis
– Cardiac Tamponade
– Constrictive Pericarditis
– Pulsus Alternans


Pulses have large amplitude beats followed by pulses
of small amplitude
– Every other beat weaker than the preceding one
Characteristic of Left Ventricular Failure
– Pulsus Paradoxus


Exaggeration of normal response to inspiration
Normal decrease in BP during inspiration is 10
mmHg or less
– BP drop more than 10 mmHg during inspiration
– Characteristic in:
• Pericardial effusion
• Cardiac tamponade
• Advanced HF
• Severe Lung disease
– Pulsus Bisferiens


Two pulses palpated during systole with
second slightly weaker than the first
Characteristic of:
– Hypertrophic Cardiomyopathy
– Aortic stenosis or regurgitation
– Water-hammer (Corrigan’s) pulse


Increased pulse pressure with a rapid upstroke
and downstroke and shortened peak
Characteristic of Aortic Regurgitation
Head and Neck

Head
– Head bobbing up and down with heartbeat
– Called de Musset’s sign
– Indicates aortic aneurysm or regurgitation

Eyes
– Exophthalmos - abnormal protrusion of the eye
– Usually due to hyperthyroidism
– May be seen in advanced HF with Pulmonary
hypertension

Ears
– Diagonal bilateral earlobe creases (McCarty’s
sign)
– May indicate coronary artery disease if seen in
individuals < 45 years of age.
Neck

Neck vein distention of greater than 2 cm
above the sternal angle is indicative of any
of the following:
– Right Ventricular Failure
– Hypervolemia
– Tension Pneumothorax
– Cardiac Tamponade

To Evaluate
– Place patient at 45 degree angle
– Identify sternal angle
 raised notch that is created where the
manubrium and the body of the
sternum join - (Angle of Lewis)
– Measure height of neck distention above
level of sternal angle
Estimate Central Venous
Pressure

Add 5 cm to height of neck vein distention
– Normal CVP is 3 to 8 cm

Evaluate hepatojugular or abdominojugular
reflux
– Apply pressure over right upper quadrant
– Evaluate increase in neck vein distention
– Increase > 3 cm:

Hepatojugular reflux and Right ventricular
failure
Landmarks

Anatomic
– Clavicle
– Sternum
– Ribs
– Intercostal spaces
– Angle of Louis
– Xiphoid process
– Costal margin and angle
Imaginary Landmarks







Mid-sternal line (MSL)
Mid-clavicular Line (MCL)
Anterior Axillary Line (AAL)
Midaxillary Line (MAL)
Posterior Axillary line (PAL)
Scapular Line (SL)
Midspinal line
Location of Heart



Between the sternum and spinal column
Lies between second intercostal space and
Fifth intercostal space (5 ICS)
Apex normally at fifth LICS and MCL
Precordium
Inspect and Palpate

Point Of Maximum Impulse (PMI)
– Frequently visible and usually palpable
– Location



Fifth LICS and MCL
Lateral displacement
– Left ventricular dilation (aortic or mitral
insufficiency)
– Upward displacement (pregnancy, ascites)
Right to left mediastinal shift
– Tension Pneumothorax
– Left ventricular hypertrophy or failure

Medial Displacement
– Downward displacement of the diaphragm

COPD
– Left to right mediastinal shift



Left Pleural Effusion
Tension Pneumothorax
Intensity
– normally light tap
– HF may increase (cause heave)

Size of PMI
– 1 - 2 cm

Heave
– Lifting of chest wall (indicative of failure)
– Left ventricular heave felt at or near the apex
– Right ventricular heave (or lift) felt at or near
the sternum

Thrill
– Palpable vibration associated with a
murmur or bruit
– Felt where the murmur is heard the
loudest or a location of a bruit.
 Murmur - a periodic sound of short
duration intracardiac in origin.
 Bruit - a sound or murmur heard,
extracardiac.
Auscultation

Stethoscope
– snug fitting earplugs
– Tubing
 two tubings preferable for high
frequency sounds
 Not longer than 12 to 15 inches
– Chest Piece
 Diaphragm - held firmly against skin
–Used for high pitched sounds
• S1, S2 and splits, pericaridal
friction rubs, most murmurs
 Bell- held tightly enough against skin
to create seal
 Used for low pitched sounds: S3, S4

Auscultation Areas
– Aortic - 2nd RICS at Right sternal border
– Pulmonic - 2nd LICS at Left sternal
border
– Erb’s Point - 3rd LICS at Left sternal
border
– Tricuspid - 5th LICS at Left sternal
border
– Mitral - 5th LICS at mid-clavicular line

Auscultation should be performed in each of
the five cardiac areas
– use of the diaphragm first, then the bell of the
stethoscope. Using firm pressure with the
diaphragm and light pressure with the bell
– Assess the overall rate and rhythm of the heart noting the area being accessed.
– Breathing normally, then holding breath listen
for S1 while palpating the carotid pulse. S1
coincides with the rise of the carotid pulse.
(Systole)
– Note the intensity, any variations, the effect of
respiration and any splitting of S1
Basic Heart Sounds


There are four basic heart sounds: S1, S2,
S3 and S4. S1 and S2 are the most distinct
heart sounds.
S3 and S4 may or may not be present; their
absence is not an unusual finding, but their
presence does not necessarily indicate a
pathologic condition.
Rules to consider


Left sided heart events precede right side
(mitral component precedes tricuspid of
S1, Aortic event precedes pulmonic of S2)
Left sided heart events are normally
loudest during expiration, and right sided
events are normally loudest during
inspiration.

S1 is the result of the closure of the AV
valves
– indicate the beginning of systole and is best
heard toward the apex where it is usually
louder than S2

S2 is the result of closure of the semi-lunar
valves and indicates the end of systole
– indicates the end of systole and is best heard
in the aortic and pulmonic areas.
Heart sounds according to
Cardiac Area

Aortic area
– Loudness - S1< S2
– Duration - S1 > S2

Pulmonic area
– Loudness - S1 < S2
– Duration - S1 > S2

Erb’s Point
– Loudness - S1 < S2
– Duration - S1 > S2

Mitral area
– Loudness - S1 > S2
– Duration - S1 > S2

Tricuspid Area
– Loudness - S1 > S2
– Duration - S1 > S2
Splitting of S1 and S2

S1
– usually is not heard because the sound o the
tricuspid valve closing is too faint to hear.
– Heard best when audible in the tricuspid area

S2
– Expected due to the higher pressures and
depolarization occurs earlier on the left side of
the heart.
– Ejection times on the right are longer and
pulmonic valve closes a bit later than the
aortic valve.
S1 and S2 Split


S1 is the result of
closure of the AV
valves - indicating
the beginning of
systole. Mitral and
Tricuspid valves.
Heard best at
tricuspid area on
inspiration.


Although there is
some asynchrony
between closure of
the mitral and
tricuspid valves usually heard as one
sound.
Narrowly split may
be normal

A split S1 is more abnormal than normal
and is associated with any one of the
following:
– RBBB
– Left ventricular (epicardial) pacemaker
– Left ventricular ectopy

Split S2
– Both Aortic and Pulmonic components
can be heard
– Inspiratory only is normal
2
 Called physiologic split of S
 Split ONLY during inspiration
 Caused by intra-thoracic changes in
pressure; increased venous return to
right and decreased venous return to
left
Expiratory Split of S2

Increased splitting during inspiration (split on
expiration but split more on inspiration)
– RBBB (Right Bundle Branch Block)
– Left ventricular ectopy
– Severe mitral regurgitation
– Ventricular septal defect
S3





Ventricular gallop
Occurs early in diastole
Caused by rapid rush of blood into a
dilated ventricle.
Heard best with bell
Associated primarily with Heart Failure

Associated with:
–
–
–
–
Fluid overload
Cardiomyopathy
Ventricular septal defect
Mitral or tricuspid regurgitation
– __S1____S2__S3
S4




Atrial Gallop
Dull, low pitched occurring late in diastole
before S1..
Caused by atrial contraction and
propulsion of blood into a non-compliant
ventricle
Heard best with bell

Associated with:
–
–
–
–
–

Myocardial ischemia or infarction
Hypertension
Ventricular ectopy
AV blocks
Severe aortic or pulmonic stenosis.
__S4__S1___S2__
Extra Heart Sounds:

Summation gallop
– All four heart sounds plus
tachycardia
– Merging of S3 and S4
causing a louder middiastolic sound

Pericardial friction rub
– scratchy sound - usually
triphasic; systolic, early
and late diastolic
– Caused by pericardial
inflammation

after MI or CABG

Snaps
– Opening snap
 Short, highpitched; early
diastole
 Caused by:
– Opening of
stenotic AV
valve
– Increased flow
– closing snap
1
 Really a loud S
 Caused by closure
of AV valve
Murmurs

Caused by turbulence
– Increased flow through a normal valve
– Forward flow through a stenotic valve
– Backward flow through a regurgitant valve
(insufficient or incompetent)
– Flow through a AV fistula or septal defect
– Flow into a dilated chamber or a portion of a
vessel

Description
– Timing

Systolic
– Holosystolic: AV regurgitation or VSD
– Midsystolic (Ejection) - Semilunar stenosis
– Late - papillary muscle dysfunction;
Hypertrophic cardiomyopathy (IHSS) Idiopathic
hypertrophic subaortic stenosis.
– Location

Place murmur is loudest
– Radiation

Direction murmur radiates
– Intensity

Levine scale

Levine scale
–
–
–
–
–
Grade I/VI: barely audible
Grade II/VI: clearly audible, but quiet
Grade III/VI: Moderately loud w/o a thrill
Grade IV/VI: Loud, w/ or w/o
Grade VI/V: Loud, thrill present, audible
w/stethoscope partially off chest
– Grade VI/VI- loud, w/thrill, stethoscope off
chest

Timing
– Synchronize S1 and S2 with Carotid pulse
– Listen for murmur


Lub - murmur - dub is systolic murmur
Lub - dub - murmur - is a diastolic murmur

Diastolic murmurs
– produced with a stenotic Mitral / Tricuspid
valve
– Produced with a incompetent Aortic/Pulmonic
valve

Systolic murmurs
– produced by a stenotic Aortic or Pulmonic
valve
– Produced by incompetent Mitral / Tricuspid
valve

Pitch
– High pitched (heard w/
diaphragm)


Mitral / Tricuspid
regurgitation
Aortic / Pulmonic
stenosis or regurgitation
– Low Pitched (heard
best w/bell


Mitral and Tricuspid
stenosis
Quality
– soft, harsh, blowing,
musical, rumbling, or
rough

Vascular Sound: bruit
– Turbulent sound
– may be heard over:





Carotid
Aorta
Renal
Iliac
Femoral
– Associated with plaque
or aneurysm

Common Murmurs
– Holosystolic

Mitral area
– toward L axilla
– Blowing, harsh
– Mitral regurgitation

Tricuspid
– Along right sternal border
– Blowing, harsh
– Tricuspid Regurgitation

3-4 ICS at lower sternal border
– Harsh
– Ventricular septal rupture or defect
– Midsystolic

Aortic area
– Toward right side of neck
– Harsh
– Aortic Stenosis

Pulmonic
– Toward Left side of neck
– Harsh
– Pulmonic Stenosis
– Early diastolic

Aortic or Erb’s point
– Blowing
– Aortic Regurgitation

Pulmonic
– Blowing
– Pulmonic Regurgitation
– Mid to late diastolic

Mitral area
– Rumbling
– Mitral Stenosis

Tricuspid
– Rumbling
– Tricuspid Stenosis1