Transcript Sound "1"
Islamic University of Gaza Faculty of Nursing • Chapter (8) • Assessment of Cardiovascular System 1 Assessment of Cardiovascular System • 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 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 the client must be is in supine or sitting positing according to his health Inspection &palpation: * By inspection and palpation you may detect ventricular hypertrophy. * Use source of light to inspect subtle movements in chest e.g.: pulsation, retraction… Etc. * Apical pulse in left fifth intercostal space, if deviation in site observed may indicate cardiac enlargement 6th intercostal space. * Retractions may be seen around site of apical pulse, marked retraction may indicate pericardial disease. * Heaves or lifts: when right Ventricle work increase. 4 • Palpation (supine position). • 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” • * It is important to describe pulsations in relation to there timing in the cardiac cycle. • * Describe in terms: locations of pulsation in relation to mid-sternal, mid-clavicular or axillary lines. 5 • * Palpation of apical pulse, strength differs from thin person to obese. • * Conditions such as anxiety, anemia, fever, and hyperthyroidism may increase in force 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: “not used in cardiac assessment” 6 • Auscultation: All heart sounds are generally low pitched “low frequency” 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. Concentrates 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 7 • 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. • Sound "3": During diastole, rapid distention of ventricles occur causes vibrations of ventricular walls ," and this known as sound "3" ". • Sound "3" best heard at the apex with bell of stethoscope. • Sound "4": occur after Sound "3" (late diastolic filling), occur from vibrations of ventricular wall or vibrations of the valves. • * Summation gallop: three cardiac sounds heard S1, S2 and summation of S3 and S4. 8 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 9 • 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. 10 • 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 (Trendelen-burg 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. 11 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. 12 The end Thank you 13