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.