Date post: | 27-Dec-2015 |
Category: |
Documents |
Upload: | evangeline-glenn |
View: | 214 times |
Download: | 0 times |
Nursing 69: Nursing 69: Health AssessmentHealth Assessment
The Cardiovascular System
Bill Powell, MSN, FNP
Cardiovascular (CV) System:Cardiovascular (CV) System:Anatomy and PhysiologyAnatomy and Physiology
Landmarks of the chest/precordium suprasternal notch angle of Louis Anterior Axillary Line (AAL) Midaxillary Line (MAL) Posterior Axillary Line (PAL) Midsternal Line (MSL) Sternal Border (SB) Midclavicular Line (MCL) Intercostal spaces (ICS) 2 - 5
Cardiovascular (CV) System:Cardiovascular (CV) System:Anatomy and PhysiologyAnatomy and Physiology
The Base - the top of the heart (atria)
The Apex - the bottom tip (LV)
The Precordium - the surface of the chest wall overlying the heart (2nd to 5th ICS from RSB to LMCL)
Cardiovascular System: Cardiovascular System: Anatomy and Physiology Anatomy and Physiology (cont)(cont)
What parts are where? right ventricle - anterior, behind and along LSB left ventricle - behind and to the left of RV, forms left border
and creates apical impulse (PMI) right atrium - lies above and slightly to right of RV, forms
right border of heart, not usually identifiable left atrium - above LV, mostly posterior, cannot be examined
directly Aorta - up from LV to sternal angle, then back, down Pulmonary artery - up from RV, 3rd ICS,
bifurcates into R & L branches Venae Cavae - empty into RA
What else is in there???
Chambers, Valves and Circulation
Atrioventricular Valves - between atria and ventricles
tricuspid - between RA and RV mitral - between LA and LV
Semilunar Valves - between the
ventricles and great arteries aortic - between LV and the aorta pulmonic - between RV and pulmonary artery
Closure of these valves creates the normal heart sounds...valve opening is normally silent.
Valvular Control of Blood Flow
Systole - period of ventricular contraction. The mitral and tricuspid valves close (S1) preventing backflow, and aortic and pulmonic valves open permitting forward flow. Blood is ejected into aorta by LV and pulmonary artery by RV.
Diastole - period of ventricular relaxation. The aortic and pulmonic valves close (S2) preventing backflow, and mitral and tricuspid valves open permitting forward flow. The atria contract forcing blood into the ventricles.
Events of the Cardiac Cycle Systole
ventricles contract... ventricular pressure > atrial pressure mitral and tricuspid valves close = S1 (“lubb”)
S1 signifies the beginning of systole ventricular pressure continues to rise ventricular pressure > arterial pressure aortic and pulmonic valves open blood flows forward through aorta to systemic circulation and
pulmonary artery to the lungs ventricles become almost empty -> ventricular pressure drops
ventricular pressure drops below arterial pressure. . .
Events of the Cardiac Cycle (cont)
Diastole ...ventricular pressure drops below arterial pressure
aortic and pulmonic valves close = S2 (“dubb”)S2 signifies the beginning of diastole
atrial pressure > ventricular pressure mitral and tricuspid valves open blood flows from atria to ventricles atria contract to eject remaining blood and increase ventricular
end-diastolic pressure ventricular pressure > atrial pressure
mitral and tricuspid valves close (S1) beginning another systole . . .
Blood flow during SystoleBlood flow during Systole
Blood flow during DiastoleBlood flow during Diastole
Heart Sounds and Heart Sounds and The Cardiac CycleThe Cardiac Cycle
S1 S2 S1
Systole Diastole
The The SplittingSplitting of Heart Sounds of Heart Sounds The events are occurring on both sides of the heart Right-sided events usually occur slightly later than
left-sided events Therefore, may hear 2 sounds for:
S1 (“split S1”), the mitral component > tricuspid S2 (“split S2”), the aortic component > pulmonic
Split sounds may be normal (physiologic) or abnormal (pathologic)
Extra Heart SoundsExtra Heart Sounds
S3 occurs just after S2 during the period of rapid
ventricular filling called “ventricular gallup” “SLOSH-ing-in” normal in children and
young adults almost always pathologic
in adults >40 (heart failure, etc)
S4 immediately before S1 marks atrial contraction called “atrial gallup” “a-STIFF-wall” may be normal in older
persons or trained athletes more commonly associated
with resistance to ventricular filling (hypertension, coronary artery disease, aortic stenosis)
Extra Heart Sounds Extra Heart Sounds (cont) (cont)
Ejection Sounds - heard shortly after S1, i.e. early systolic, coinciding with the opening of the aortic or pulmonic valves...indicates cardiovascular disease
Systolic Clicks - usually mid or late systolic, caused by an abnormal ballooning of part of the mitral valve into the LA...indicates mitral valve prolapse
Opening Snaps - a very early diastolic sound caused by the opening of a stenotic mitral valve...almost always from rheumatic heart disease
MurmursMurmurs Murmurs are vibratory sounds caused by
turbulent blood flow 4 causes of murmurs:
stenosis - forward blood flow through a constricted area
regurgitation - backward blood flow through an incompetent valve
structural defect - blood flow through an abnormal passage
physiologic - increased blood flow (high output) through a normal valve
Murmurs Murmurs (cont)(cont)
Murmurs may be: Systolic
occur between S1 & S2 Diastolic
occur between S2 & S1 Continuous
heard throughout the cardiac cycle
Electrical Activity of the HeartElectrical Activity of the Heart An electrical conduction system stimulates and
coordinates the sequence of muscle contraction during the cardiac cycle sinus node - in RA, serves as pacemaker automatically sending
impulses 60 -100 times/minute through both atria to the... atrioventricular (AV) node - located low in atrial septum,
delays impulse slightly before sending it to the... bundle of His - starts in intraventricular septum, then divides
into right and left bundle branches which carry the electrical impulse to the...
Purkinje fibers - in the ventricular myocardium where ventricular contraction is stimulated
The Electrocardiogram (ECG)The Electrocardiogram (ECG)
Each electrical impulse produces a series of waves depolarization - the spread of the stimulus through the
heart muscle repolarization - the return of the stimulated heart
muscle to a resting state P wave - atrial depolarization PR interval - time from initial stimulation of the atria to
initial stimulation of the ventricles QRS complex - ventricular depolarization ST segment and T wave - ventricular repolarization U wave - sometimes seen after the T wave, represents final
phase of ventricular repolarization
ECG sampleECG sample
To Learn more about ECGs...To Learn more about ECGs...
Dubin, D. (1996). Rapid Interpretation of EKG’s. Fifth Edition. Tampa: COVER Publishing Company.
A fun, simple, rapid programmed approach to learning about ECG’s.
Peripheral Vascular SystemPeripheral Vascular SystemMade up of 2 systems:Made up of 2 systems:
Pulmonic Unoxygenated blood
leaves RV through Pulmonary artery
blood travels through numerous arteries, arterioles, and capillaries of the lungs
gas exchange occurs at alveoli
oxygenated blood returns to heart through pulmonary veins into LA
Systemic Oxygenated blood leaves
LV through aorta blood travels through
numerous arteries, arterioles and capillaries delivering oxygen and nutrients to body’s cells
deoxygenated blood passes into venous system
deoxygenated blood returns to heart through veins, entering RA through venae cavae
Peripheral Vascular SystemPeripheral Vascular SystemCharacteristics of the vessels:Characteristics of the vessels:
Arteries Tough, more tensile,
less expandable Able to withstand high
pressures
Veins Less sturdy, more
expandable Subjected to much
lower pressures Contain valves to
prevent backflow Able to expand and
hold excess blood (pooling) decreasing workload of the heart (preload)
Arterial PulsesArterial Pulses Ventricular constriction
forcing blood into the arteries, produces the characteristic pulse in peripheral arteries
Pulses normally felt or seen as synchronous with the heart beat...<0.3 second to reach most distal artery; however, carotid best for evaluation of cardiac function
Variables: Volume of blood Elasticity of the
arteries Viscosity of the blood Heart rate Arterial resistance
(afterload)_
Arterial PulsesArterial Pulses
Carotid Brachial Radial Ulnar Femoral Popliteal Dorsalies pedis Posterior tibial
The Jugular VeinsThe Jugular Veins Empty directly into the superior vena cava Reflect the activity of the right side of the heart
offering clues to its competency External Jugulars
more superficial and more visible easily visible bilaterally above clavicles near insertion of
sternocleidomastoid muscle less reliable than the internal jugulars
Internal Jugulars larger, are deep and less visible to inspection run deep to the sternocleidomastoids near the carotids,
will not see veins, only pulsations more accurate than external jugulars
Cardiovascular SystemCardiovascular SystemHistory and Symptom ReviewHistory and Symptom Review
Symptoms chest pain palpitations fatigue dyspnea/shortness of
breath syncope/dizziness edema cyanosis
cough orthopnea/paroxysmal
nocturnal dyspnea leg pain or cramps tingling, numbness,
burning in extremities skin changes in
extremities sores on legs or feet
Cardiovascular SystemCardiovascular SystemHistory and Symptom ReviewHistory and Symptom Review
Client’s Health History Heart disease (congenital and acquired) Cardiac procedures/surgery Chronic illness (associated with secondary heart
disease) Past medications which may have affected the heart Bleeding disorders Past medications which may have affected the
circulation
Cardiovascular SystemCardiovascular SystemHistory and Symptom ReviewHistory and Symptom Review
Client’s Current Health Diet Exercise Stress Occupation Current medications Alcohol/nicotine/recreational drugs
Cardiovascular SystemCardiovascular SystemHistory and Symptom ReviewHistory and Symptom Review
Family History Heart disease (including congenital) Sudden unexpected death Chronic illness associated with heart disease Circulatory diseases
Cardiovascular SystemCardiovascular SystemPhysical ExamPhysical Exam
The Basics: Good lighting, including tangential source Quiet room Appropriate draping Stand at patient’s right Use variety of positions Follow correct sequence
Inspection (first!) Palpation Percussion (optional) Auscultation (last!)
General InspectionGeneral Inspection
Observe the patient for general signs of cardiovascular disease: cyanosis peripheral edema finger clubbing labored respiration
Inspection of the PrecordiumInspection of the Precordium Visualize lines of reference and underlying
structures (chambers, valves, vessels) Look for pulsations, lifts, heaves in the
following locations: Aortic area Pulmonic area Right ventricular area Apical area (PMI) Epigastric area
PalpationPalpation
Palpate the same areas for: abnormal pulsations vibrations/thrills
Assess the apical impulse (PMI) location diameter amplitude duration
PercussionPercussion
Of limited value in determining the borders of the heart
Left ventricular size better judged by the location of the apical impulse
Heart size is best determined by chest films
AuscultationAuscultation Auscultatory areas
Names may be misleading since murmurs of more than one origin may occur in a given area
aortic - R 2nd ICS pulmonic - L 2nd ICS Erb’s point (also called 2nd
pulmonic or tricuspid) 3rd ICS @ LSB
tricuspid - 4th &/or 5th ICS @LSB
mitral - 5th ICS @ LMCL
AuscultationAuscultation Pointers
Be consistent Listen at each area with diaphragm and bell
Press firmly with the diaphragm Apply the bell lightly
Take time to “tune in,” don’t rush Inch the stethescope along the route, don’t jump Listen in any area where you have observed an
abnormality
AuscultationAuscultation
Suggested Routine of Patient Positioning Upright and leaning slightly forward Supine Left lateral recumbent
What to listen for:What to listen for:
Identify cardiac rate and rhythm Identify S1 Identify S2 Listen to the quiet period between S1 and S2 =
Systole Listen to the quiet period between S2 and S1 =
Diastole Listen for split heart sounds
Next, listen for:Next, listen for: Extra Systolic Sounds
Ejection sounds Clicks
Extra Diastolic Sounds S3 S4 Opening snap
Finally, listen for:Finally, listen for:
MurmursDescribe murmurs in terms of these characteristics:
timing and duration pitch intensity pattern quality location and radiation respiratory variations
More about MurmursMore about MurmursMurmur Grades
Grade Volume Thrill1/6 very faint, only heard with optimal
conditionsnone
2/6 quiet, but clearly audible none3/6 moderately loud none4/6 loud yes5/6 very loud, may be heard with
stethescope partially off chestyes, easilypalpable
6/6 very loud, may be heard withstethescope completely off chest
yes,palpableand visible
Systolic MurmursSystolic MurmursS1S1 S2S2 S1S1
Mid-systolic Innocent Physiologic Pathologic
Aortic Stenosis Pulmonic Stenosis
Pansystolic (regurgitant) All are Pathologic
Mitral regurgitation Tricuspid regurgitation Ventricular septal defect
Diastolic MurmursDiastolic MurmursS1S1 S2S2 S1S1
AlwaysAlways indicate heart disease.. indicate heart disease.... Early Diastolic
Aortic regurgitation Pulmonic regurgitation
Mid or Late Diastolic Mitral stenosis Tricuspid stenosis
Sounds with Both Systolic and Sounds with Both Systolic and Diastolic ComponentsDiastolic ComponentsS1S1 S2S2 S1S1
Pericardial Friction Rub Patent Ductus Arteriosus Venous Hum
Peripheral Vascular SystemPeripheral Vascular SystemInspectionInspection
Inspect skin, nails, lips for signs of decreased circulation or cyanosis
Inspect nails for clubbing Inspect lower extremities for signs of arterial
insufficiency thin shiny skin decreased hair ridged/thickened nails ulceration
Peripheral Vascular SystemPeripheral Vascular SystemInspection Inspection (cont)(cont)
Inspect lower extremities for signs of venous insufficiency edema varicose veins thrombosis thickened/ulcerated skin
PalpationPalpation Note the temperature of the extremeties Check for pitting edema
If present, record by depth of indentation Palpate pulses, evaluate for:
rate rhythm contour (wave form) symmetry amplitude (strength)
Pulses Pulses (cont)(cont)
Note any variations in strength from beat to beat with respiration
Grade pulse strength 0 = absent 1 = weak/diminished 2 = normal/expected 3 = strong/increased 4 = bounding
AuscultationAuscultation
Auscultate over the major arteries for bruits carotid, aorta, renal, femoral
Use the bell of the stethescope Bruits are always abnormal
Jugular Vein AssessmentJugular Vein Assessment Provides insight into Right heart function May be performed when suspect heart failure
Hepatojugular reflux Patient supine with head of bed @ 30-60 degrees Gently press liver while watching external jugular vein May see wave level rise with right heart congestion
Jugular venous distension Patient supine with head of bed at 30-45 degrees Observe for venous pulsations in the neck (tangential light) Identify highest point of pulsation Using horizontal line from this point, measure vertically to
sternal angle...should be less than 3-4 cm in healthy adult
Physical Assessment Physical Assessment resources on the Internetresources on the Internet
To hear various heart and breath sounds http://www.med.ucla.edu/wilkes/intro.html
History and Physical Study Guides http://www.medinfo.ufl.edu/year1/bcs/clist/index.html