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CARDIOVASCULAR ASSESSMENT

D. Safaa eid

J. Borrero 9/10

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LECTURE OBJECTIVES

1. Review anatomy & physiology of the cardiovascular system.

2. Describe physical assessment of cardiovascular status.

3. Review diagnostic procedures

CARDIOVASCULAR EXAMINATION

Part I: Assessment of cardiovascular functionHealth history Physical assessment Inspection PalpationPercussion Auscultation Laboratory testCardiac enzymeLipid profileCoagulation studies

• Part II: Assessment of cardiovascular structure

• Diagnostic studies

• ECG

• Echocardiography

• X- ray

• The exercise stress

• Cardiac catheterization

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Anatomy & Physiology

Functions of the heart & CV system

• Pumps blood to tissues to supply O2 & nutrients

• Remove CO2 & metabolic wastes

Circulation in the Heart

1. Oxygen-poor blood (shown in blue) flows from the body into the right atrium.

2..Blood flows through the right atrium into the right ventricle.

3. The right ventricle pumps the blood to the lungs, where the blood releases waste gases and picks up oxygen.

3. The newly oxygen-rich blood (shown in red) returns to the heart and enters the left atrium.

4. Blood flows through the left atrium into the left ventricle.

5. The left ventricle pumps the oxygen-rich blood to all parts of the body.

Coronary Circulation

Coronary Blood Flow

Valves of the Heart

• Tricuspid – Directs the flow of blood from the right atrium to the left ventricle.

• Mitral Valve – Directs the flow of blood from the left atrium to the left ventricle.

• Pulmonic (semilunar) – Lies between the right ventricle and the pulmonary artery.

• Aortic Valve (semilunar) – Lies between the left ventricle and the aortic artery.

Part I: Assessment of cardiovascular function

physical assessment

1. Health history

• a- Socio - cultural history: -

• Age, sex, occupation, educational level, marital status

• b- Patient history:-

• Past medical history , Past surgical history

• C-Family History

• d- Psychosocial Profile

- Symptom Analysis• 1- Chest Pain• - Location: - Substernal, pericardial diffuse, localized• - Radiation: -Radiates to jaw, arm, neck • - Character: - Dull, aching, pressure, burning tightness,

crushing • - Intensity: - Mild, moderate, severe• - Onset: - Sudden, gradual • - Duration: - 1 -10, more than 15 min, or continuous• - Precipitating factors: - exercise, motion, eating• - Relieving factors: - rest, walking, warmth, drugs • - Accompanying symptoms : -dyspnea, restlessness,

sweating, vomiting, cough, syncope, fatigue

Pain Assessment Techniques

• The patient's self-reported pain is often measured by using pain scales

• Numeric Pain Intensity Scale uses a 0-10 scale to assess the degree of pain. Simple Description Intensity Scale, uses such words as "mild", "moderate", and "severe" to describe the patient's pain intensity.

• Visual Analog Scale (VAS) requires patients to mark a point on a 10 cm horizontal or vertical line to indicate their pain intensity, with

• 0 indicating "no pain“

• and 10 indicating "the worst possible pain".

Angina Pectoris

Substernal or retrosternal pain spreading across chest; may radiate to inside of arm, neck, or jaw

5-15min Usually related to exertion, emotion, eating, cold

Rest, nitroglycerin,oxygen

Angina PectorisMyocardial Infarction

MI Substernal pain or pain over precordium; may spread widely throughout chest. Pain in shoulders and hands may be present.

>15 min

Occurs spontaneously but may be sequela to unstable angina

Morphine sulfate,successful reperfusion of blockedcoronary artery

Esophageal Pain

Angina Pectoris

Substernal pain;may be projected

around chest to shoulders.

5–60 min

Recumbency, cold liquids,

exercise.May occur

Spontaneously.

Food, antacid. Nitro-glycerin

relieves Spasm.

anxiety

Pain over chest; may be variable. Does not

radiate. Patient may complain of

numbness and tingling of hands and

mouth.

2–3 min Stress, emotionaltachypnea

Removal of stimulus,

relaxation

• 2- Palpitations• 3- Syncope• Syncopal attacks (dizziness) are another

symptom that may signal cardiovascular problems.

• 4- Edema• Edema may be seen with right-sided CHF

and vascular disease.

• Pitting edema is a depression in the skin from pressure.

• To demonstrate the presence of pitting edema, the nurse presses firmly with his or her thumb over a bony surface

• The severity of edema is described on a five-point scale, from none (0) to very marked (4).

• 1+ Mild pitting, slight indentation, no perceptible swelling of the leg

• 2+ Moderate pitting, indentation subsides rapidly

• 3+ Deep pitting, indentation remains for a short time, leg looks swollen

• 4+ Very deep pitting, indentation lasts a long time, leg is very swollen

• 5- Fatigue• fatigue is associated with cardiovascular

disease. • 6- Extremity Changes• Changes in the extremities may provide

clues about underlying cardiovascular disease. Symptoms such as Paresthesia (numbness, tingling), coolness, and intermittent claudication (pain in calves during ambulation) may be associated with vascular disease, coronary heart disease, or cerebral vascular disease.

• 7- Dyspnea and Cough

• Dyspnea may also occur with cardiac disease such as left-sided CHF.

B- Physical assessment

• General Appearance

• Vital Signs

• Height and Weight

Inspection and palpation

1-Skin

• Color

• Turgor

• Temperature and moisture:-

• 2- Nails

• Nails should be assessed for color, shape, thickness, symmetry, and adherence.

• Normal nail color is some variation of pink

• Nail thickness generally is 0.3 to 0.65 mm, but it may be thicker in men

• Nail abnormalities:-

• -Peripheral vascular disease can produce nail depression,

• Clubbing

• -Clubbing of the fingers is associated with decreased oxygen.

• In clubbing, the distal tips of the fingers become bulbous, the nails are thickened hard, and curved at the tip, and the nail bed feels boggy when squeezed.

• - Separation from the nail bed produces a white, yellowish, or greenish color on the non-adherent portion of the nail.

• Capillary refill time:• is a quickly test to assess the adequacy of

circulation in an individual with poor cardiac output. An area of skin is pressed firmly by (say) a fingertip until it becomes white; the number of seconds for the area to turn pink again indicates capillary refill time. Normal capillary refill takes around 2 seconds.

2- Inspection and palpation

• 1- Inspection of neck

• Inspecting the carotid artery and jugular venous system

• With the patient in a supine position, inspect the carotid and jugular venous systems in the neck for pulsations.

• To visualize external venous pulsations, look for pulsations in the supraclavicular area.

• To visualize internal venous pulsations, look for pulsations at the suprasternal notch.

• Using a penlight to cast a shadow on the neck vessels may help you visualize the pulsations

• Carotids have visible pulsation, jugulars have undulated wave.

• Carotids not affected by respirations, jugulars are.

• Carotids not affected by position, jugulars normally only visible when client is supine.

• Large, bounding visible pulsation in neck of at suprasternal notch: HTN, aortic stenosis,.

Measuring Jugular Venous Pressure

• -Position patient with the head of bed at 30 to 45-degree angle.

• - Place a ruler vertically, perpendicular to the chest at the angle of Louis (sternal angle).

• -identify the highest level of the jugular vein pulsation; if unable to see pulsations, use the highest level of jugular vein distension.

• - Place another ruler horizontally at the point of the highest level of the venous pulsation.

• - Measure the distance up from the chest wall.

• The normal JVP is less than 3 cm. A central venous pressure can be estimated by adding 5 cm to the JVP

• Elevated JVP: Right-sided CHF, constrictive pericarditis, tricuspid stenosis, or superior vena cava obstruction.

• Low JVP: Hypovolemia.

Palpation

• Palpating the Carotid

• -Lightly palpate each carotid separately.

• - Note rate, rhythm, amplitude, contour, symmetry, elasticity, thrills.

Palpating the Jugulars

• Palpate jugular veins and check direction of fill.• Occluding under the jaw, the jugular should

flatten, but the wave form become more prominent.• Occluding above the clavicle, the jugular normally

distends

• Palpating the Precordium

• - Identify and palpate each cardiac site for pulsations, and thrills:

• - Apex (left ventricular area), or mitral area fifth intercostals space, midclavicular line.

• - Base right (aortic area), second intercostals space right sternal border.

• - LLSB (tricuspid area), fourth to fifth intercostal space at left sternal border.

• - Base left (pulmonic area), second intercostal space left sternal border.

- Listen at each site with both the bell and the diaphragm.

- Listen at each site with both the bell and the diaphragm.

PALPATION

• Impulses - finger pads

• Thrills (vibrations palpated secondary to a murmur—turbulent blood flow through a heart valve) - Bony part of hand, ball of hand

• Thrills are palpable vibrations created by turbulent blood flow.

• Lifts or heaves are diffuse, lifting impulses.

• A thrust is a rocking movement.

AUSCULTATION

• Diaphragm – medium and high frequency sounds

• Bell – low frequency sounds

• Normally hear closure of valve Sounds from left side of heart louder than equivalent sounds from right side of heart

• S1 – closure of mitral and tricuspid valves

• S2 – closure of aortic and pulmonic valves

• Low pitched sounds S3, S4, mitral stenosis

• Right 2nd intercostal space Aortic Area

• Left 2nd intercostal space Pulmonic Area

• Left lower sternal border Tricuspid area• Apex – over apical impulse Mitral area

Landmarks

• the aortic and pulmonic areas are correlated anatomically with the base of the heart.

• S3 (also called a ventricular gallop) may be heard in the tricuspid and mitral areas during the early to mid-diastole following the S2 sound.

• S3 is heard well when the client is in the left lateral recumbent position,

• S4 (also called atrial diastolic gallop) may be heard in the tricuspid and mitral areas during the late phase of diastole, before S1 of the next cardiac cycle.

• S4 is heard well when the client is in the supine position

Auscultating the Precordium

• Auscultate at apex.

• - Note rate, rhythm, extra sounds, or murmurs.

• - Note S1, S2, extra sounds, or murmurs.

• - Listen at each site with both the bell and the diaphragm.

Murmurs and Stenosis…

• A valve that does not close efficiently, results in the backflow of blood (i.e., insufficiency or regurgitation).

• A valve that does not open wide enough may cause turbulent backflow secondary to obstruction or narrowing (i.e., stenosis).

Abnormal finding

• Irregular rhythm: Arrhythmia.• Accentuated S1: High-output states, mitral or

tricuspid stenosis.• Diminished S1: First-degree heart block, CHF,

CAD.• -Variable S1: Atrial fibrillation.• S3, low-pitched, early diastolic sound: CHF.• S4, low-pitched late-diastolic sound: CAD, HTN,

MI.

Ejection fraction (EF)

• The ejection fraction (EF) represents the amount of blood pumped out of the heart (left ventricle) with each beat. In the healthy heart, it is around 70%.

• An EF below 55% is considered abnormal.

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CARDIAC CYCLE

EKG – A 12 lead EKG is a graphic record of the electrical forces produced by the heart

Acute Anteroseptal MI

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ELECTRODE POSITIONS

“LEADS”

• Leads measure electrical activity between 2 points

• Movement toward electrode causes positive deflection

• Movement away from electrode causes negative deflection

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ELECTRODE POSITIONS

A 12 Lead EKG shows electrical activity from 12 different positions in the heart, concentrating on (L) ventricle

A 14 Lead EKG includes (R) ventricle activity

Cardiac output

• SV-

• CO-

• Preload-

• Afterload-

• Ejection fraction

• GOAL is to maintain adequate MAP so perfusion of oxygenated blood to vital organs occurs

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Stroke Volume (Sv) & Cardiac Output (Co)

• SV – amount of blood ejected by 1 ventricle in 1 beat

• CO – volume ejected in 1 min

Control of SV and HR = SV&HR are continually adjusted by the body, and are affected by the return of blood from the tissues (think of exercise)

CO = SVxHR

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Decreased S1:

Slowed ventricular ejection rate/volume Mitral insufficiency Increased chest wall thickness Pericardial effusion Hypothyroidism

Decreased S1 (cont.):

Cardiomyopathy LBBB Shock Aortic insufficiency First degree AV block

Other Abnormal S1 (cont.):

Increased S1: Increased cardiac output Increased A-V valve flow velocity (acquired

mitral stenosis, but not congenital MS) Wide splitting of S1:

RBBB (at tricuspid area) PVC’s VT

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S2:

From closure vibrations of aortic and pulmonary valves

Often ignored, but it can tell much Divided into A2 and P2 (aortic and

pulmonary closure sounds) Best heard at LMSB/2LICS Higher pitched than S1--better heard with

diaphragm

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S2 splitting (normal):

Normally split due to different impedance of systemic and pulmonary vascular beds

Audible split with > 20 msec difference Split in 2/3 of newborns by 16 hrs. of age,

80% by 48 hours Harder to discern in heart rates > 100 bpm

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S2 splitting (normal, cont.):

Respiratory variation causes splitting on inspiration: pulmonary vascular resistance

When supine, slight splitting can occur in expiration

When upright, S2 usually becomes single with expiration

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S2 splitting (abnormal):

Persistent expiratory splitting ASD RBBB Mild valvar PS Idiopathic dilation of the PA WPW

S2 splitting (abnormal, cont.):

Widely fixed splitting ASD RBBB

S2 splitting (abnormal, cont.):

Wide /mobile splitting Mild PS RVOTO Large VSD or PDA Idiopathic PA dilation Severe MR RBBB PVC’s

S2 splitting (abnormal, cont.):

Reversed splitting LBBB WPW Paced beats PVC’s AS PDA LV failure

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Single S2:

Single S2 occurs with greater impedance to pulmonary flow, P2 closer to A2

Single and loud (A2): TGA, extreme ToF, truncus arteriosus

Single and loud (P2): pulmonary HTN!! Single and soft: typical ToF Loud (not single) A2: CoA or AI

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Extra heart sounds

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S3 (gallop):

Usually physiologic Low pitched sound, occurs with rapid filling

of ventricles in early diastole Due to sudden intrinsic limitation of

longitudinal expansion of ventricular wall Makes Ken-tuck-y rhythm on auscultation

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S3 (cont.):

Best heard with patient supine or in left lateral decubitus

Increased by exercise, abdominal pressure, or lifting legs

LV S3 heard at apex and RV S3 heard at LLSB

S3 (abnormal):

Seen with Kawasaki’s disease--disappears after treatment

If prolonged/high pitched/louder: can be a diastolic flow rumble indicating

increased flow volume from atrium to ventricle

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S4 (gallop):

Nearly always pathologic Can be normal in elderly or athletes Low pitched sound in late diastole Due to elevated LVEDP (poor compliance)

causing vibrations in stiff ventricular myocardium as it fills

Makes “Ten-nes-see” rhythm

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S4 (cont.):

Better heard at the apex or LLSB in the supine or left lateral decubitus position

Occurs separate from S3 or as summation gallop (single intense diastolic sound) with S3

S4 Associations:

CHF!!! HCM severe systemic HTN pulmonary HTN Ebstein’s anomaly myocarditis

S4 Associations (cont.):

Tricuspid atresia CHB TAPVR CoA AS w/ severe LV disease Kawasaki’s disease

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Click:

Usually pathologic Snappy, high pitched sound usually in

early systole Due to vibrations in the artery distal to a

stenotic valve

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Can be associated with:

Valvar aortic stenosis or pulmonary stenosis

Truncus arteriosus Pulmonary atresia/VSD Bicuspid aortic valve Mitral valve prolapse (mid-systolic click) Ebstein’s anomaly (can have multiple

clicks)

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Does NOT occur w/ supravalvar or subvalvar AS,

or calcific valvar AS.

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Whoop (sometimes called a honk):

Loud, variable intensity, musical sound heard at the apex in late systole

Classically associated w/ MVP and MR Seen w/ VSD’s closing w/ an aneurysm,

subAS, rarely TR Some whoops evolve to become systolic

murmurs

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Friction rub:

Creaking sound heard with pericardial inflammation

Classically has 3 components; can have fewer than 3 components

Changes with position, louder with inspiration

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Murmur:

Sounds made by turbulence in the heart or blood stream

Can be benign (innocent, flow, functional) or pathologic

Murmurs are the leading cause for referral for further evaluation

Don’t let murmurs distract you from the rest of the exam!!

Laboratory tests

• Creatine kinase (CK) and its isoenzyme CK-MB

• Lactic dehydrogenase

• Troponin I

• as low-density lipoproteins (LDL) and high-density lipoproteins (HDL).

• Cholesterol (normal level, less than 200 mg/dL) • LDL (normal level, less than 130 mg/dL) \• HDL (normal range in men, 35 to 65 mg/dL; in

women, 35to 85 mg/dL) have a protective action • Triglycerides (normal range, 40 to 150 mg/dL),

composed of free fatty acids and glycerol, are stored in the adipose tissue and are a source of energy

• Coagulation Studies

• Partial thromboplastin time (PTT)

• Prothrombin time (PT)

• Chest x-ray and fluoroscopy

• Electrocardiography

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Diagnostic Procedures

1. EKG 12 Lead

continuous cardiac monitoring

holter monitor

2. Chest x-ray – detects enlargement of heart & pulmonary congestion

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Diagnostic procedures

3. Echocardiography – ultrasound that reveals size, shape and motion of cardiac structuresEvaluates heart wall thickness, valve structure, differentiates murmurs

4. TEE – transesophageal echocardiography provides a clearer image because less tissue for sound waves to pass through

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Diagnostic procedures

5. Angiography / cardiac catherization

determines coronary lesion size, location, evaluate (L) ventricular

function, measures heart pressures

6. Exercise tolerance test

7. Radionuclide Imaging

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Cardiac enzymes = enzymes are released when cells are damaged (MI). Enzymes are found in many tissues/muscles, and some are specific to cardiac tissue.

Lab Studies

Cardiac enzymes =

CPK – MB (CK-MB),myoglobin, Troponin

In general, the greater the rise in the serum level of an enzyme, the greater the degree or extent of damage to the muscle.

LDH

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LAB studies

2. Electrolytes

3. Lipid panel

4. CBC

5. C – Reactive Protein

6. BNP- Human B-Natriuretic Peptide

7. Blood coags-PT/PTT/INR

Cholesterol Level : AHA Recommendation

• Total Cholesterol– < 200 mg/dL

• best

– 200 – 239 • borderline high

– 240 mg/dL and above• 2X risk of CAD

Cholesterol Level : AHA Recommendation

• HDL Cholesterol– < 40 mg/dL (men)– < 50 mg/dL (women)– > 60 mg/dL

• cardioprotective

Cholesterol Level : AHA Recommendation

• LDL Cholesterol– < 100 mg/dL

• Optimal

– 100 – 129 mg/dL• Near or above optimal

– 130 – 159 mg/dL• Borderline

– 160 – 189 mg/dL• High

– 190 mg/dL• Very high

Cholesterol Level : AHA Recommendation

• Triglyceride– < 150 mg/dL

• Normal

– 150 – 199 mg/dL• Borderline high

– 200 – 499mg/dL• High

– 500 mg/dL and above• Very high

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NCLEX TIME

Mary is attending a sophomore level nursing class on anatomy and physiology. Which statement, if made by Mary, demonstrates a good understanding of the anatomy and physiology of the heart?

A."The heart is encapsulated by a protective coating called the endocardium.“

B."The SA node is considered the main regulator of heart rate.“

C."The left atrium receives deoxygenated venous blood from all peripheral tissues.“

D."Stroke volume is the amount of blood ejected by the right ventricle during each diastole

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NCLEX TIME

Kirsten is completing her graduate clinical rotation in a large urban teaching hospital in a medical coronary care unit (CCU). Which observation demonstrates a good understanding of completing a thorough cardiac examination?

• A. In an obese client, an adult cuff size of 12 to 14 cm is preferable.

• B.The carotid artery on the neck is auscultated to assess for the presence of a bruit.

• C.The apical impulse is auscultated over the fifth intercostal space in the midclavicular line.

• D.Palpation is used to determine cardiac size.

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NCLEX TIME

Edward is a 40-year-old white male. He is an accountant who works on average 11 hours per day. He reports feeling stressed each day, even with mundane things such as a traffic jam. His father had a massive myocardial infarction at the age of 48. His mother has a history of congestive heart failure. He seldom has time to exercise, but does eat balanced meals when possible, although he does not get to eat three meals a day. Select all factors that place Edward at risk for heart disease.

• A.Family history• B.Age• C.Coping-stress tolerance• D.Race• E.Occupation