CardioVascular Assessment Lab
C Ruckdeschel RN, BSN
Objectives
Review Anatomy of Heart
Review Vascular System
Review Physiologic basics for Cardiovascular System
Objectives:
Identify Skills to assess cardiovascular System:
Pulse
Peripheral vascular assessment
Heart Sounds
Blood Pressure
Anatomy of HeartRight side of heart - receives deoxygenated blood from systemic circulation - LOW PRESSURE
Left Side of the heart - receives oxygenated blood from pulmonary circulation and pumps it into systemic circulation - HIGH PRESSURE
Chambers and ValvesRt Atrium
RT AV Valve (Tricuspid)
Rt Ventricle
Rt semilunar (Pulmonic)
Left Atrium
Lft AV Valve (bicuspid, Mitral)
Left Ventricle
Left semilunar (Aortic)
Great Vessels of the HeartVena Cava - deoxygenated blood brought to heart
IVC (inferior vena Cava)
SVC (superior Vena Cava)
Pulmonary Artery - deoxygenated blood from rt ventricle to pulmonary capillaries
Pulmonary Veins - oxygenated blood from pulmonary capillaries to lft atrium
Aorta -
Ascending
Arch
Descending
Thoracic
Abdominalhttp://www.youtube.com/watch?v=PgI80Ue-AMo
Coronary ArteriesArteries that arise from base of aorta and supply myocardium with richly oxygenated blood
LCA
LAD
Circumflex
RCA
Cardiac Conduction System
• Heart is innervated by Autonomic nervous system
Sympathetic : stimulates
Parasympathetic: slows
SA Node (Sinoatrial node): located in right atria, generates impulses that travel through the conduction system & produce cardiac muscle contraction.
AV Node (atrioventricular node): located in the atrial septum
Bundle of His: right and left bundle branches
Purkinjie fibers: located in ventricular myocardium, where ventricular contraction takes place
12 Lead EKG
• Chest X-ray
Common Cardiovascular Problems
CAD (Coronary Artery Disease)
HTN (Hyypertension) > 80% of US population
RHD (Rheumatic Heart Disease) - Sequelae of beta hemolytic strep infections resulting in valvular damage, more likely seen In older adults
BE (Bacterial Endocarditis) - bacteremia causes valvular damage
CHD (Congenital Heart Disease) – greatest portion diagnosed early in life
Peripheral Vascular Anatomy
Aorta
Arteries
Arterioles
Capillaries
Venules
Veins
Vena Cava
Important VesselsAccessible arteries:
Temporal, Carotid, Aorta, Brachial, Ulnar, Radial, Femoral, Popliteal, Doraslis pedis, Posterior Tibial
Accessible veins:
Jugular, Superficial & deep arm veins, Femoral vein (deep), Popliteal vein (deep), saphenous (superficial)
Physiologic BasicsMyocardium - muscle layer of the heart that allows it to act as pump
Cardiac Output = HR x SV
Heart Rate (pulse) = beats per minute
Blood Pressure = SVR x CO
Electrical conduction of the heart
Assessing: Heart SoundsHeart Sound Review
Location
Aortic: 2nd ICS, RSB (s2 is loudest)
Pulmonic: 2nd ICS, LSB (s2 is loudest)
Erbs Point: 3rd ICS, LSB
Tricuspid: 4th ICS, LSB (s1 is loudest)
Mitral (Apex): 5th ICS, MCL (s1 is loudest)
S1: represents ventricular contraction & ejection: S1 sound is produced by closing of AV valves (tricuspid and Mitral valves)
S2: represents ventricular relaxation & filling: S2 sound is produced by closing of semilunar valves: Aortic and Pulmonic valves
http://www.youtube.com/watch?v=Ge12P7u0aQo
Assessing: Heart Sounds
Assessing: Heart SoundsObtain History
Risk factors/lifestylediet, exercisesmokingcholesterolstress, palpitationsdyspnea/orthopneaedemafatigue - relationship to exercisechest pain
Location substernal?Radiate precordial?Quality crushing?Associated N/VRelated to activity?
Obtain History
Any medications?type
doseside effectsexpected effectstake as prescribed?
Pacemaker
Typebattery checkPresence of AICDautomated internal defibrillator
Assessing: Heart Sounds
Obtain HistoryPast Health History
DiabetesDependent edemacongenital heart defectCADRheumatic feverMost recent EKG, stress EKGOther diagnostics
Obtain History
Past Family History
Angina
Heartdisease
MI,StrokeDM,
Hyperlipidemia
Sudden death age?
Assessing: Heart Sounds
Inspection
Bare chest
Quiet room, Privacy
Note: symmetry of chest, any pulsatile areas, discolorations
Palpate
Precordium
palpate 5 sites for:
Heave (with palmer surface), thrust
Thrill (with base of finger of heel of hand (bony part))
palpable murmur » cat purring
Thrills - indicative of obstructed flow
fine palpable rushing sensation
R or L 2nd ICS - Aortic or pulmonic stenosis
When palpate precordium use other hand to palpate carotid artery
S1 should coincide with carotid impulse
Assessing: Heart SoundsAuscultate
Use diaphragm and bell of stethoscopestart with diaphragm, (S1 and S2 relatively high pitched)use bell to listen for S3 and S4
heart sounds - S1 and S2raterhythm - regular (NSR), irregular (warrants investigation)extra sounds? Murmurs?Auscultation: want to hear crisp, distinct S1 and S2S1 > at apexS2 > at base
Assessing: Heart Sounds
BE Systematic!! APE TO MAN
Listening for S1 and S2
interval between S1 and S2 should be silent
heart sounds not heard best directly over valve which produces it, but in direction of blood flow
there are specific sites where each valve sound is best heard
http://www.youtube.com/watch?v=2aO0HKIP3vI
After Auscultating Heart Sounds.....
Perfect time to auscultate Apical Pulse.
Count for one full minute, each cardiac cycle.
Note rate & rhythm
What is a Pulse?• The ventricles pump blood into the
arteries at about 72 bpm. The blood causes an alternating expansion and recoil creates a pressure wave which travels through all of the arteries.
PulseAdult (60-100) bpm
Child (80-120) bpm
Infant ( 140 bpm)
Palpated on superficial arteries (pulse points)
Auscultated on Apex of the heart
Pulse Variations:Tachycardia - >100 bpm
Bradycardia - < 60 bpm
Palpitations - Unpleasant sensations of awareness of the heartbeat: described as skipped beats, racing, fluttering, pounding or irregularity: may result from rapid acceleration or slowing of heart, increased forcefulness of cardiac contraction: not necessarily associated with heart disease.
Factors Assessing Pulse
• Cardiac output• Age• Gender• Exercise• Fever• Stress• Position
Factors Assessing Pulse
Cardiac Output
Amount of blood ejected from the heart in one minute
Measured by SV x HR
Normal HR = 60 - 100 beats per minute
Factors Assessing PulseAge
Adult (60-100) bpm
Child (80-120) bpm
Infant ( 140 bpm)
Gender - after puberty female > male
Exercise
increased HR with activity
increased metabolism causes vasodilatation
causes O2 demand
Factors Assessing PulseFever
body compensates for increased temp by vasodilatation, decreased BP causes body to compensate by > HR
increased 10-20 beats/min/ degree above norm
especially in children
Factors Assessing Pulse
Stress
sympathetic response, increases HR & BP
Position
sitting, standing causes pooling
results in transient - BP
rate compensates by increasing
Assessing : Pulse• Please note:• Assessing a heart rate is
determining beats per minute, noting rate, rhythm and strength.
• Assessing peripheral pulses is to assess arterial blood flow to peripheral arteries.
Assessment: PulseAuscultating at Apex
Using the diaphragm of your stethoscope, place it on the 5th intercostal space, MCL
For one full minute, count each LUB, DUB as one!!
Location of left ventricular apex & PMI (point of maximum impulse)
Adult: 5th ICS, MCL
Infants: 4th ICS, left of MCL
Pregancy: PMI moves 1-2 cm left of MCL & up to 4th ICS
Assessment:Pulses Peripheral Pulses
Obtain History
Intermittent claudication
pain on walking disappears with rest
leg cramps, leg ulcers
varicose veins
edema of feet or legs
blood clots
pallor of fingertips
Assessment:Pulses Peripheral Pulses
Inspection of Extremities Compare Left to Right
Size
Symmetry
Skin/color
Nail Beds
Nails
Hair Growth
Assessment:Pulses Peripheral Pulses
Palpation - Compare Right to Left
Temperature
Capillary refill
Pulses
UE:Radial,Brachial
LE: Dorsalis Pedis, Posterior tibial, popliteal, Femoral
Edema
+1- +4 pitting
Sensation
Assessment: PulsesCharacteristics of Pulses
Rate
Rhythm - regular, irregular
Contour/elasticity
Strength (Amplitude)
+4 = bounding
+3 = full, increased
+2 = normal
+1 = diminished, weak
0 = absent
Arterial Insufficiency of Lower Extremities
Pulses - Decreased/Absent
Color - Pale on elevation : Dusky Rubor on dependency
Temperature - Cool/Cold
Edema - None
Skin - Shiny, thick nails, no hair, Ulcers on Toes
Sensation - Pain, more with exercise, Paresthesias
Venous Insufficiency of Lower Extremities
Pulses - Present
Color- Pink to cyanotic, Brown pigment at ankles
Temperature - Warm
Edema - Present
Skin - Discolored, scaly, ulcers on ankles
Sensation - Pain, More with standing or sitting. Relieved with elevation/support hose
Peripheral Vascular Disease
Nursing interventions to promote venous return
ankle circles, flex ankles, frequent ambulation, avoid dependent position for prolonged periods of time
apply TED stockings or ace bandages (if no arterial problem)
Nursing Diagnosis
Altered cardiac output: decreased
Altered tissue perfusion:peripheral
Fluid volume deficit: actual
Irregular Rhythm
ALL irregular rhythms demand an APICAL RADIAL assessment
Assessment: Blood Pressure
Obtain History: • ** Non-modifiable Risk factors
**
Age, sex, personality type
Family History – sudden death, HTN, stroke, MI prior to 50, severe hyperlipidemis, DM
PMH – arrythmias, murmurs, CHF, Rheumatic disease
DM, CAD,Congenital Heart Defects
Obtain History:
** Modifiable Risk factors**
SmokingEmployment: physical vs emotional demands, environmental hazard, stress managementNutritional Status: body fat & type of dietAnaerobic exerciseEstrogen replacement (if post-menopausal)Drug use – alcohol,, cocaine, prescription & OTCEssential HTNHypercholesterolemia, DM, CAD
Taking a Blood Pressure
Blood Pressure: Key Facts
• Korotkoff sounds: Turbulent sounds of partial obstruction of arterial flowPhase I: sharp tapping sound (systolic)Phase II: change to soft swishing soundPhase III: sounds more crisp & intensePhase IV: muffled tapping Phase V: cessastion of sound (diastolic)
Blood Pressure: Key FactsArm Blood Pressure: May be 5-10 mmHg higher in right arm than left arm: greater differences between right & left arm may be associated with congenital aortic stenosis or acquired conditions such as aortic dissection or obstruction of arteries to upper arm.
Leg Blood Pressure: Arm & leg blood pressures are about equal during first year of life & after that time the leg blood pressure is 15-20 mmHg higher than the arm BP.
Pulse Pressure: difference between systolic and diastolic blood pressures:
Usual pulse pressure is between 30-40 mmHg
Orhtostatic Hypotension: Decrease in SBP of 20-30 mmHg or more when changing from supine to standing position, & increase in pulse of 10-20 bpm: sudden drops may result in fainting. Dizziness & faintness from orthostatic hypotension may occur when taking anti-hypertensive medications, hypovolemia, confined to bed for prolonged periods of time, or the elderly.