Nursing Health Assessment of The Cardiovascular system or Heart

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					     Assessment of the
   Cardiovascular System

Health Assessment
NUR 304
Location of the Heart
Overview of the Anatomy & Physiology of the
          Cardiovascular System
The heart
and great
– Blood
  arterial and
Blood flow
Overview of the Anatomy & Physiology
    of the Cardiovascular System
 The conduction system
Two phases (“lub-dub” on auscultation: normal heart
 – Ventricular systole (S1: “lub”) – closing of MV and TV
 – Ventricular diastole (S2: “dub”) – closing of the AV and
Abnormal heart sounds:
 – Murmurs
Causes of Murmurs
– Regurgitation- occurs when valve should
  be closed but doesn’t, resulting in
  backflow of blood causing murmur
– Stenosis- occurs when valve is open and
  blood flow is forced through a stiff
  noncompliant valve causing murmur
– Turbulent blood flow- related to excess
  blood volume
Murmurs may occur anywhere
along the cardiac cycle
– Systole
   associated with S1 heart sound
   mitral and tricuspid valves closed
   aortic and pulmonic valves open
– Diastole
   associated with S2 heart sound
   mitral and tricuspid valves open
   aortic and pulmonic valves closed
Factors that Affect the Heart
             Subjective Data
Chest pain                  Dyspnea
–   Onset                   – Onset
–   Duration                – How much activity
–   Quality                   brings it on?
–   precipitating factors   – Duration
–   associated sx           – Affected by
–   tx                        position?
                            – Awakens you at
         Subjective Data
– How pillows do you sleep with?
– Duration
– Frequency
– Associated with activity?
– Productive?
– Skin color changes?
            Subjective Data
Fatigue                   Edema
–   Tire easily?          – Onset?
–   Onset?                – Recent changes?
–   When does it occur?   – How much swelling
–   Recent changes?         is there?
                          – Does it get better?
                          – Any associated sx?
           Subjective Data
– Awaken at night?
– How frequently?
– Recent changes?
Past Hx
– Hx of any cardiac diseases?
– Ever been tx for heart problems or had
– Last ekg, stress test, serum cholesterol,
         Subjective Data
Family Hx
– Family hx of any cardiac disease or
  sudden death at young age?
Personal Habits
– Smoking?
– Alcohol use?
– Exercise?
– Diet?
– Drugs (Rx, OTC, Herbal, Street)?
General Principles of Assessment of
   the Cardiovascular System
Precordial examination
– Focusing on the anterior chest wall and
  determine the status of underlying
  cardiovascular structures
– PE Technique: Inspection, Palpation,
Arterial pulse examination
Skin is inspected during
cardiovascular examination
General Principles of Assessment of
   the Cardiovascular System
Neck vein (venous pulse) examination
 – Determine the characteristic of venous
   pulsations and central venous pressure
 – Integrate this when assessing person’s
 – Stethoscope with bell and diaphragm
 – Ruler
 – Light source Doppler (optional)
General Principles of Assessment of
   the Cardiovascular System
Patient preparation
– Quiet room, privacy, positioning: sitting
  or lying on exam table or bed
Adequate lighting and exposure of
body parts
Precordial examination position:
examiner stands on right side
Precordial landmarks
Precordial Landmarks
                Aortic area
                 – 2nd RICS
                Pulmonic area
                 – 2nd LICS
                Erb’s Point
                 – 3rd – 4th LICS
                Tricuspid area
                 – LLSB
                Mitral area
                 – 5th ICS L of MCL
  General Principles of Assessment of
     the Cardiovascular System
  Examination and documentation focus
   – Precordium
       Inspection: pulsatile movements
       Palpation: pulsatile movements, vibrations
       Auscultation: heart rate and rhythm, heart sounds
       and murmurs
  – Arterial pulses (previously discussed)
  – Neck veins
       Pulse contour and amplitude
       Height of venous pulsation
Note: Palpate and auscultate carotid arteries
  (previously discussed)
Assessment of the Heart and

1. Inspect the precordium
  – Normal findings:
       Location of apical pulse or PMI
       (5th ICS, MCL)
       Pregnancy, obese, large breasts
  – Deviations from normal:
       Displaced PMI
       Heave or lift
2. Palpate major precordial landmarks
    – Aortic, pulmonic, Erb’s point, tricuspid, mitral (use
      ball of your hand)
    – Note any pulsations, thrills, or rubs: describe
      location, amplitude, duration, and direction of
    – Perform palpation in 3 different positions: supine,
      forward sitting or left lateral decubitus
   Findings on palpation of precordial landmarks:
    – Normal findings:
         Pulsatile movements (PMI area)
    – Deviations from normal:
         Vibrations or palpable thrills
3. Auscultate the major precordial
   – Sequence: aortic, pulmonic, Erb’s
      point, tricuspid, mitral
   – Listen several cardiac cycles at each
      landmark (one sound at a time)
   – Use diaphragm of stethoscope to
      detect higher-pitched sound (S1, S2)
   – Use bell of stethoscope to detect
      lower-pitched sound (S3, S4)
   – Clinical significance: eliciting heart rate
      and rhythm
4. Identify S1 and S2          Abnormal findings
    Normal finding:            – Splitting (S1 or S2)
  –   S1, loudest at the       – Third heart sound
      apex (mitral area)         (S3)
  –   S2, loudest at the       – Fourth heart sound
      base (pulmonic area)       (S4)
  –   Note intensity and       –   Opening Snap
      splitting (physiologic   –   Summation gallop
      split)                   –   Ejection click
  –   Note abnormal heart      –   Midsystolic click
                               –   Pericardial friction
                               – Murmurs
         Abnormal Heart Sounds
Third heart sound (S3)
   Also called, ventricular gallop, a low-frequency
   sound best heard using the bell of the
   stethoscope at either the left or lower right
   apical area
   Sound may be accentuated during inspiration
   (sounds like “Ken-tuc-ky”)
   Normal in young children or in people with high
   cardiac output
   The early diastolic represents rapid ventricular
   filling, vibrations caused by blood forcefully
   hitting the ventricular wall
   Clinical significance: CHF, fluid overload
          Abnormal)Heart Sounds
Fourth heart sound (S4
  Also known as atrial gallop, occurs near the end of
  diastole when the atria contract
  A low frequency sound (use bell of stethoscope)
  LV S4 loudest at the apical area: supine or left
  lateral decubitus position
  RV S4 loudest at the lower right ventricular area
  when person assumes a supine position
  May increase volume during inspiration (sounds like
  S4 occurs after atrial contraction, caused by
  vibrations when blood flows rapidly into the
  Vibrations result from the flow of a high blood
  volume or if ventricle wall has low compliance
  Clinical significance: CAD, cardiomyopathy
            Abnormal Heart Sounds
    Timing – which phase of the cardiac cycle?
       Does it occur during systole or diastole?
     Intensity – how loud is the murmur? Use
     murmur grading system
     I.     barely audible
     II.    audible but quiet
     III.   clearly heard
     IV.    Loud; may be associated with thrill
     V.     Very loud; palpable thrill; may hear with stethoscope
            partially off chest
     VI.    Very loud; palpable thrill; can hear without using a

Documentation example: III/VI murmur heard best
    @ LLSB
           Abnormal Heart Sounds
   Quality – what is the quality, pitch, and pattern
   of the murmur?
   –   Describe pitch as high or low, quality as blowing,
       harsh, or musical
   –   Patterns to changes in the murmur intensity, e.g.
       crescendo, decrescendo
    Location – over which precordial landmark is
    the murmur loudest?
    Radiation –is the sound of the murmur
    transmitted to other areas of precordium?
    Ventilation – is the murmur affected by
    inspiration, expiration or position changes?
              Abnormal Heart Sounds
Common Types of Murmurs
      Physiologic murmurs (detected during systole) – or
      known as functional or innocent murmurs, e.g.
      pregnancy, children, increased cardiac output states, etc.
      Systolic Murmurs
  –      Mitral Regurgitation
  –      Tricuspid Regurgitation
  –      Mitral Valve Prolapse
  –      Aortic Stenosis
  –      Pulmonic Stenosis
      Diastolic Murmurs
  –      Mitral Stenosis
  –      Tricuspid Stenosis
  –      Aortic Regurgitation
  –      Pulmonic Regurgitation
5. Identify normal splitting of the first and
    second heart sounds
  –   Split second sound (physiologic splitting of S2)
      most common, especially in young children
  –   S2 is made up of 2 components
  –   Mechanism:
        Inspiration, venous return
         increased (PV delayed closure, AV
         closes first)
        Expiration, sound occurs as one
        Ask patient to take a deep breath
         and hold
5. Identify extra heart sounds
    and murmurs (other than
    physiologic split)
6. Auscultate precordium with
    person assuming different
    position (optional)
  –   Forward sitting, brings base
      of the heart closer to chest
  –   Left-lateral decubitus
      position, brings the apex of
      the heart closer to chest wall
   Assessment of Neck Veins: Procedure
Observe jugular venous
(JVP), commonly know as
  –   Assess by inspection
  –   Venous pulse is not
      normally visible with person
      sitting fully upright
  –   Observe the person from
      the right side
  –   Positioning: HOB 30 to 45
      degrees head slightly to the
  –   Provide tangential lighting
      to neck area
   Assessment of Neck Veins: Procedure
Estimate jugular venous
(JVD) by measuring the
    height of
pulsation in the internal
vein (IJ)
    Select a reference point
    (sternal angle = 5 cm
    above the right atrium)
    Measure the distance (in
    cm) from the sternal
    angle to the top of
    distended jugular vein
    Pulsations visible at
    >3cm is abnormal
   Assessment of Neck Veins: Procedure
Check for hepatojugular
   Indicated if a right sided
   heart failure is suspected
  –   HOB: 30 to 60 degrees
  –   Compress right upper
      quadrant for 30 seconds
      with your palm
  –   (+) hepatojugular reflux; if
      JVP rises with this
      maneuver and stay
      elevated for as long as you
      perform maneuver
      Putting it All Together
Inspect and           Auscultate
palpate neck          – Rate and rhythm
– Check carotids      – S1/S2
– JVD                 – Listen for extra
Auscultate carotids     heart sounds
                      – Listen in systole
Inspect and             and diastole for
palpate                 murmurs
– PMI                 – Repeat sequence
– Heave or thrill       with the bell of
  What is the Nurse’s Role?
Identify abnormalities in rate and
Report new or changes in abnormal
heart sounds

     The Auscultation Assistant

Description: What the nursing student needs to know about how to assess a patients heart. Lecture note for health assessment of the heart in nursing.