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Assessment of the Heart, Great vesselsAssessment of the Heart, Great vessels
of the neck, and Peripheral Vascularof the neck, and Peripheral Vascular
systemsystem
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Great vessels of the neckGreat vessels of the neck
Jugular veinsJugular veins
Carotid arteriesCarotid arteries
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JUGULAR VENOUS DISTENTION
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JVDJVD
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AssessmentAssessment
Position clientPosition client supinesu
pine
ThenThenhead elevated at ! degreeshead elevated at ! degrees
"#$P%CT"'"#$P%CT"'
(ifts, heaves(ifts, heaves
P)" *assess location+P)" *assess location+
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"nspection"nspection
Chest for visile cardiac motionChest for visile cardiac motion
%stimate Jugular venous pressure%stimate Jugular venous pressure
Patient supine and head elevated toPatient supine and head elevated to
-!./0 degrees1-!./0 degrees1
JVP is the distance 23 highest pointJVP is the distance 23 highest point
at 3hich pulsation can e seen andat 3hich pulsation can e seen and
the sternal anglethe sternal angle
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Jugular venous pressureJugular venous pressure
An indirect measure of right atrial pressure.An indirect measure of right atrial pressure.
Measured in centimeters from the sternal angleMeasured in centimeters from the sternal angle
and is best visualized with the patient's headand is best visualized with the patient's head
rotated to the left.rotated to the left.
Described for its quality and character, effectsDescribed for its quality and character, effects
of respiration, and patient position-inducedof respiration, and patient position-induced
changes.changes.
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PalpationPalpation
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Physical (andmarksPhysical (andmarks
$uprasternal$uprasternal
notchnotch
$ternum$ternum
)anuriosternal)anuriosternalangle 4 Angle ofangle 4 Angle of
(ouis(ouis
"ntercostals"ntercostals$paces$paces
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palpationspalpations
Palpate for P)"5 easiest if patient sitsPalpate for P)"5 easiest if patient sitsup and leans for3ardup and leans for3ard
has a diameter ofhas a diameter of 6cm and located6cm and located
3ith -0 cm of the midsternal line3ith -0 cm of the midsternal line Palpate for general cardiac motion 3ithPalpate for general cardiac motion 3ith
7ngertips and patient in supine position7ngertips and patient in supine position
Palpate for radial, carotid, rachial,Palpate for radial, carotid, rachial,femoral, popliteal, posterior tiial Andfemoral, popliteal, posterior tiial And
dorsalis pedis peripheral pulsesdorsalis pedis peripheral pulses
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palpationspalpations
$ee 7gure .-6$ee 7gure .-6 8ate strength of the pulse normal,8ate strength of the pulse normal,
diminished, or asent on a scale of 0diminished, or asent on a scale of 0
to 9, 3here 69 is normal1 $ee taleto 9, 3here 69 is normal1 $ee tale.:.:
l
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Auscultation:Auscultation:Auscultatory SitesAuscultatory Sites
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AuscultationAuscultation
;ith a stethoscope;ith a stethoscope
uiet area or to close eyes
to reduce con?icting stimulito reduce con?icting stimuli
$ee also 7gure .-0 for auscultatory$ee also 7gure .-0 for auscultatory
$ites$ites
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Auscultatory ites! "ont.Auscultatory ites! "ont.
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Auscultatory itesAuscultatory ites
#he auscultatory ites are close to but not the#he auscultatory ites are close to but not thesame as the anatomic locations of the valves.same as the anatomic locations of the valves.
Aortic areaAortic area$$ndnd%" at the right sternal border%" at the right sternal border
&ulmonic&ulmonic $$ndnd%" at the left sternal border%" at the left sternal border
#ricuspid#ricuspid lt lower sternal borderlt lower sternal border
MitralMitral cardiac apecardiac ape
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(eart ounds(eart ounds
(eart sounds are characterized by location,(eart sounds are characterized by location,
pitch, intensity, duration, and timing within thepitch, intensity, duration, and timing within the
cardiac cyclecardiac cycle
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(eart ounds(eart ounds
(igh-pitched sounds such as (igh-pitched sounds such as ))and and $$,,
murmurs of aortic and mitral regurgitation, andmurmurs of aortic and mitral regurgitation, and
pericardial friction rubs are best heard with thepericardial friction rubs are best heard with the
diaphragm.diaphragm.
#he bell is preferred for low-pitched sounds#he bell is preferred for low-pitched sounds
such as such as **and and ++..
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(eart ounds )/ub0(eart ounds )/ub0
)! "losure of A1 valves)! "losure of A1 valves
mitral and tricuspidmitral and tricuspid
valves! M) before #)0valves! M) before #)0
"orrelates with the"orrelates with thecarotid pulsecarotid pulse
/oudest at the cardiac/oudest at the cardiac
apeape
"an be split but not"an be split but not
oftenoften
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(eart ounds $Dub0(eart ounds $Dub0
$! "losure of$! "losure of
emilunar valves aorticemilunar valves aortic
2 pulmonic02 pulmonic0
/oudest at the base of/oudest at the base ofthe heartthe heart
May have a split soundMay have a split sound
A$ before &$0A$ before &$0
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(eart ounds $Dub0(eart ounds $Dub0
)) and and $$assessed in all four sites in uprightassessed in all four sites in upright
and supine positionand supine position
))
precedes and the precedes and the $$
follows the carotidfollows the carotidpulsepulse
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(eart ounds "ont.(eart ounds "ont.
3ase 45/ $nd %"03ase 45/ $nd %"0 $ louder than )$ louder than )
ApeApe ) louder than $) louder than $
6ormal physiologic $ plit6ormal physiologic $ plit 3est heard at pulmonic area3est heard at pulmonic area
during inspirationduring inspiration
7ied split no variation7ied split no variationwith inspirationwith inspiration++
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8tra (eart ounds8tra (eart ounds
**
Due to volume overloadDue to volume overload
Due to 4apidDue to 4apid ventricularventricular
filling! ventricular gallopfilling! ventricular gallop
) -- $-* 9en--tuc-:y) -- $-* 9en--tuc-:y++
++
Due to pressure overloadDue to pressure overload
Due to slow ventricularDue to slow ventricular
contraction! atrial gallopcontraction! atrial gallop
+-) ; $ #en-nes;see0+-) ; $ #en-nes;see0
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8tra (eart ounds8tra (eart ounds
**
low-pitched soundlow-pitched sound
usually heard at the ape ofusually heard at the ape of
the heart.the heart.
caused by rapid filling andcaused by rapid filling and
stretching of the leftstretching of the left
ventricle when the leftventricle when the left
ventricle is somewhatventricle is somewhat
noncompliant.noncompliant.
characteristic of volumecharacteristic of volumeoverloading, such as in "(7overloading, such as in "(7
especially left-sided heartespecially left-sided heart
failure0, tricuspid or mitralfailure0, tricuspid or mitral
valve insufficiencyvalve insufficiency11
++
a dull, low-pitched postsystolica dull, low-pitched postsystolicatrial gallopatrial gallop
usually caused by reducedusually caused by reduced
ventricular compliance.ventricular compliance.
best heard at the ape in thebest heard at the ape in theleft lateral position.left lateral position.
occurs with reduced ventricularoccurs with reduced ventricular
compliance and is present incompliance and is present in
conditions such as aorticconditions such as aorticstenosis, hypertension,stenosis, hypertension,
hypertrophic cardiomyopathies,hypertrophic cardiomyopathies,
and coronary artery disease.and coronary artery disease.
less specific for "(7 than less specific for "(7 than **..
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MurmursMurmurs
#urbulent blood flow across a valve or a disease such#urbulent blood flow across a valve or a disease such
as anemia or hyperthyroidismas anemia or hyperthyroidism
/isten for murmurs in the same auscultatory sites/isten for murmurs in the same auscultatory sites
A&8#MA&8#M
ystolic b5w ) 2 $ystolic b5w ) 2 $
Diastolic b5w $ 2 )Diastolic b5w $ 2 )
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Characteristics of Heart Sounds
Type of
Murmur Examples Location Pitch Radiation Quality
Midsystolic
Aorticstenosis 2nd RICS Medium
Neck, leftsternal border Harsh
Pulmonicstenosis
2nd and 3rdICS Medium
eft shoulderand neck Harsh
Hy!ertro!hiccardiomyo!athy
3rd and "thICS Medium eft sternalborder toa!e#Harsh
Pansystolic
Mitralre$ur$itation A!e#
Medium tohi$h eft a#illa %lo&in$
'ricus!id
re$ur$itation
o&er left
sternal border
MediumRi$htsternum,
#i!hoid
%lo&in$
(entricularse!tal defect
3rd, "th, and)th ICS Hi$h *ften harsh
+iastolic
Aorticre$ur$itation
2nd to "thICS Hi$h A!e# %lo&in$
Mitral stenosis A!e# o& ittle or none
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MurmursMurmurs
#hey are classified by#hey are classified by
timing and duration within the cardiac cycle systolic,timing and duration within the cardiac cycle systolic,
diastolic, and continuous0,diastolic, and continuous0,
location,location,
intensity,intensity,
shape configuration or pattern0,shape configuration or pattern0,
pitch frequency0,pitch frequency0,
quality, and radiationquality, and radiation
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MurmursMurmurs
Grade IGrade I!barely audible!barely audible
Gr II :Gr II :audible but quiet and softaudible but quiet and soft
Gr IIIGr III! moderated loud, without thrust or thrill! moderated loud, without thrust or thrill
Gr IVGr IV! loud, with thrill! loud, with thrill Gr VGr V! louder with thrill, steth on chest wall! louder with thrill, steth on chest wall
Gr VIGr VI! loud enough to be heard before steth on chest! loud enough to be heard before steth on chest
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MurmursMurmurs
#hrill!#hrill! a palpable murmura palpable murmur
3ruits!3ruits!
1ascular murmur1ascular murmur
sounds made by turbulent blood flowsounds made by turbulent blood flow
(eard over blood vessels with constricted lumens.(eard over blood vessels with constricted lumens.
"arotid and femoral are routinely assessed for bruits"arotid and femoral are routinely assessed for bruits
ometimes found over the vertebral, subclavian and abdominal arteriesometimes found over the vertebral, subclavian and abdominal arteries