Cardiovascular Assessment

Cardiovascular Assessment Yuriy Slyvka MD, Ph.D.

Cardiovascular Assessment The Heart Extends from the 2ed to the 5th intercostal space Between the R boarder of the sternum to the L midclavicular Beats against chest wall to produce apical impulse Palpate 5th intercostal space 7-9cm form the mid sternal line

Heart Chambers • Right atrium (RA) • Right ventricle (RV) • Left atrium (LA) • Left ventricle (LV) • Valves • Aortic valve • Mitral valve • Tricuspid valve • Pulmonic valve

Directions of blood flow Blood Flow • From liver to right atrium (RA) via inferior vena cava: Superior vena cava drains venous blood from the head and upper extremities From RV, venous blood travels through tricuspid valve to right ventricle (RV) • From RV, venous blood flows through pulmonic valve to pulmonary artery Pulmonary artery delivers unoxygenated blood to lungs 3.Lungs oxygenate blood

Pulmonary veins return fresh blood to LA 4. From LA, arterial blood travels through mitral valve to LV. LV ejects blood through aortic valve into aorta • Aortic delivers oxygenated blood to body Diastole • Ventricles relax and fill with blood and AV valves (tricuspid, mitral) open • Bottom number of the B/P • Occurs when AV valves are open to allow filling of the ventricles

Systole • Heart contract and blood pumped in ventricles and fills pulmonary & systemic arteries • Closure of AV valves contributes to first heart sound and signals beginning of systole • Top number of B/P

Percussion: outline of the heart’s boarder; limited with the female breast tissue or in an obese person or person with muscular chest wall. • Place stationary finger in person’s fifth intercostal space over on L side of chest near anterior axillary line. Slide hand toward yourself note change in sound from resonance over the lung to dull( over the heart) • Left border of cardiac dullness is at the midclavicular line in 5th interspace

and slopes toward sternum • At the second interspace the border os dullness coincides with left sternal border • Right border of dullness matches the sternal border • Palpate apical impulse • Using 1 finger locate the apical impulse • Ask client to “exhale and hold”=aids in locating pulsation • May need to turn client to left to find it. • Note: Location, size, amplitude and Duration

Apical impulse palpable in ½ adults, and not in obese or thick wall clients. • Apical impulse increases in amplitude and duration in client with anxiety, fever, hyperthyroidism and anemia • Auscultation: listen for the pitch, rate, regularity, -low pitched, short duration of sound, regularity -deep breathing will temporarily slow heart rate

-identify S1 and S 2, assess S 1and S 2 separately, listen for extra heat sounds and listen for murmurs -with stethoscope use Z pattern from base of the heart across and down, then over apex or start at apex and work way up. -note rate and rhythm -if notice irregularity, check for pulse deficit (check radial and apical pulse simultanously)

When listening Start at base of heart and use Z pattern. Note: -rate & rhythm -Identify S1 and S2 -Assess S1and S2 separately -Listen for extra heart sounds -Listen for murmurs Landmarks -second R interspace= aortic valve area

-second L interspace= pulmonic valve area -L lower sternal border= triscupid valve area -fifth interspace at around L midclavicular line= mitral valve area Heart Sounds • S1 • Closure of the AV valve • Beginning of systole • “lup” of the “lup-dup” sound -louder at apex -coincides with carotid artery pulse

S2 • closure of semilunar valves • end of systole • “dup” of the “lup-dup” sound • louder at base Abnormal Heart Sounds • Split S -benign condition occurring in some patients upon inspiration -”lup-t-dup” sound -crisper than a murmur -occurs at end of inspiration -occurs about every fourth beat, fading in with inhalation and out with exhalation

Murmurs • Vibrations within the hearts chambers or major arteries from the back and forth blood flow; swishing sound • Innocent- no anatomic or physiologic abnormality exists • Functional- no anatomic cardiac defect exists but physiologic abnormality such as anemia, fever, pregnancy, hyperthyroidism)

Murmur • Blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels. • Need to ID if it occurs in systole or diastole • Extra “humming” sound between S1 and S2 sounds • Listen to pitch (high, medium, or low) • Listen to pattern (crescendo, decrescendo, crescendo-decrescendo or diamond shaped) -Listen to loudness (grades i to vi= barely audible to loudness)

-Quality (musical, blowing, harsh, rumbling) -Location ( where best heard) -Radiation-transmitted downstream direction of blood flow -Posture- disappear or enhanced by change of position Causes: • structural- weakened valve or wall defect secondary to streptococcal infection or congenital defect • flow murmur • change in blood viscosity secondary to anemia • change in blood velocity secondary to exercise

-structural- weakened valve or wall defect secondary to streptococcal infection or congenital defect -flow murmur • change in blood viscosity secondary to anemia • change in blood velocity secondary to exercise

Loudness --Grades i-vi(adults) • i = barely audible, quiet room • ii= clearly audible but faint • iii= moderately loud • iv=loud, associated with a thrill palpable on chest wall • v= very loud, heard with one corner of steth. lifter off chest wall • vi=loudest, still heard with entire steth. lifted just off the chest wall

Thrill: • Palpable vibration felt over the heart as blood moves from chamber to chamber • ALWAYS ABNORMAL • Pericardial Friction Rub: • Grating sound upon inspiration, stops when breath is held • ALWAYS ABNORMAL

Assessment of Peripheral Pulses Strength • 0=absent • +1=weak • +2=diminished • +3=strong • +4=bounding and full Assessment of Pulses • Regularity/ Rate • Bilateral Equality • Should be the same on both sides of the body L or R

Head to Toe Equality • Should not be greatly different head to toe • Use additional assessments: • Check against apical pulse • Check other measures of circulation if pulse heard to find

Laeral to Cardiac Assessment in Children • Inspection: notice color of skin and mucous membranes, observe child in semi-fowler position, check for edema, warmth of extremities • Palpation: locate apical impulse (AI) -Lateral to the L midclavicular (LMCL) and fourth ICS in children < 7 yr. old -At LMCL and fifth ICS in children > 7 yrs. old • Point of maximum intensity (PMI)- area of most intense pulsation [Ai and PMI not used interchangeably but they are at the same place] • Thrills- palpable vibrations best felt with -

ball of hand and during expiration; produced by flow of blood from one chamber of heart to another through narrow or abnormal opening • Pericardial friction rubs-scratchy, high pitched grating sound; not affected by changes in respirations • Capillary refill time-brisk-less than 2 seconds; blanch nail beds with pressure for a few seconds and then release; prolonged associated with poor systemic perfusion

Auscultation: (Children) • S1 and S2 correspond to “lub-dub” • S1 caused by closure of tricuspid and mitral valves • S2 caused by closure of pulmonic and aortic valves • Distinguish between S1 and S2 simultaneously palpate carotid pulse with index & middle finger as listen to heart sounds

Alterations Through the Lifespan (Children) • Infants and Children • Change from fetal to neonatal circulation in first 24 hours • Foramen ovale closes in1st hours • ductus arterious closes by the first weeks of life • Heart is placed more laterally in children • Apex is at 4th intercostal space before 3 yrs • Apex is at the 5th intercostal space at 7 yrs. age • CAROTID ARTERY IN NOT PALPATED IN PATIENTS UNDER ONE YEAR OFAGE

Abnormal findings in Pediatric patients • Murmurs common and usually outgrow • Remain aware of strep effects on the heart valve • Innocent (no valvular or pathologic cause it is just a noise • Functional (due to increase blood flow) need to have diagnosis test as EKG or echocardiogram Rheumatic fever- • Causes weakening of heart valve

Physiological Changes in Pregnancy: • Growing uterus pushes heart up. Left and forward • Blood volume rises to 40-45% greater than pre pregnancy vol. • Murmur in 90% pregnant patients disappear at delivery ( non-functional murmurs) • Cardiac output rises to 50% above pre pregnancy levels; pulse rate rises by 10-20 • In Vessels: • Vena Cava syndrome • Uterus puts pressure on vena cava when patients is in supine position

Lowers B/P • Patient feels clammy, dizzy and shows pallor • Turn patient to L side to relieve pressure of vena cava

Geriatrics • Arteries stiffen with age and B/P rises • Average rise is 20 mmHg between 20-60 and between 60-80 another 20 mm HG • LV wall thickens • Loss of ability to augment exercise with increased cardiac output • Resting pulse rate remain in the lifetime range between 60-100 and maybe irregular • Vessels lose elasticity • Varicose veins • More susceptible to clots

Loss of venous elasticity plus less efficient cardiac output results in decreased circulation • Lower healing • Body temperature, regulation is changed • Abnormal findings in Geriatric Patients • At risk for dehydration and altered nutritional status • Dehydration impacts fluid volume and B/P • Electrolyte imbalance impact on cardioelectricity

Murmurs common in this age group • Arryhthmias more common in this age group • Ectopic beats( extra beats) • Lower cardiac output and B/P • May deprive organs of needed oxygenation • Better tolerated in younger population • Tachycardia • Results in 40-70% drop in cerebral blood volume • Syncope

Peripheral blood vessels grow more rigid with age • Tests and vocabulary • Atherosclerosis = deposit of fatty plaques on the intima of the arteries. • Artheriosclerosis= arteries becoming more rigid producing a rise in systolic B/P Claudication- pain produced when walking, not relieved by rest • Bruit- occurs with turbulent blood flow, indicating partial occlusion

Modified Allen Test- evaluate collateral circulation [firmly depress ulna & radial arties, patient opens & closes fist; normal when open fist, blood returns to normal • Homans’ sign-pain in calf with dorsiflexion of the foot, indicating thrombophlebitis or thrombus • Pitting Edema • 1+= mild pitting, slightly indentation, no perceptible swelling of legs; depth of pitting is 1 cm • 2+= moderate pitting, indentation subsides rapidly; depth of pitting is 2 cm

3+= deep pitting, indentation remains for a short time, leg looks swollen; depth of pitting is 3 cm • 4+= very deep pitting, indentation lasts a long time, leg is very swollen; depth of pitting is 4 cm • Trendelenburg Test- varicosites present in legs to determine valve competence; lying supine elevate legs 90* until veins empty, place tourniquet high on thigh, help patient to • Stand, watch for venous filling; saphenous veins should fill slowly from below in about 30 seconds

Taking a Health History • Lifestyle factors: • Smoking- stimulant for CV system • Serum cholesterol- causes blockages • Obesity- stresses heart with fat deposits and constant state of exertion • Past medical history: • Diabetes- stresses body, effects heart • HTN- wear& tear in aorta and LV • Family history heart disease or PVD • Large genetic correlation

Problems during pregnancy • Are children meeting developmental milestones & expected growth parameters • Any history of chest pain • When • What precipitated it • What gave relief • Qualities • Stabbing, crushing, shooting, radiating • Angina • Constriction of small vessels surrounding the heart • Causes sharp chest pain

Relief with nitroglycerine • Assess for complains of fatigue, pallor, edema and temperature; alterations in the extremities • All indicate possible poor cardiac output Nursing Interventions: • Take a careful history • Provide patient teaching as to risk factors for cardiovascular health • When helping patients OOB allow them to move

to prevent hypotension • Encourage pregnant women to lay on their L side to prevent vena cava syndrome • Educate pregnant women of S & S of pre eclampsia and keep careful B/P records of patients • Keep careful records of pediatric growth & development parameters for each patient and continually check progress • Watch oxygen status of patient with altered cardiac output

Cardiovascular Assessment