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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
vessels
– Blood
  vessels:
  arterial and
  venous
Blood flow
Overview of the Anatomy & Physiology
    of the Cardiovascular System
 The conduction system
Two phases (“lub-dub” on auscultation: normal heart
sounds)
 – Ventricular systole (S1: “lub”) – closing of MV and TV
 – Ventricular diastole (S2: “dub”) – closing of the AV and
   PV
Abnormal heart sounds:
 – Murmurs
              Murmurs
Causes of Murmurs
– Regurgitation- occurs when valve should
  be closed but doesn’t, resulting in
  backflow of blood causing murmur
  sound
– Stenosis- occurs when valve is open and
  blood flow is forced through a stiff
  noncompliant valve causing murmur
  sound
– Turbulent blood flow- related to excess
  blood volume
                Murmurs
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
Murmurs
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
                              night?
         Subjective Data
Orthopnea
– How pillows do you sleep with?
Cough
– Duration
– Frequency
– Associated with activity?
– Productive?
Cyanosis
– 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
Nocturia
– Awaken at night?
– How frequently?
– Recent changes?
Past Hx
– Hx of any cardiac diseases?
– Ever been tx for heart problems or had
  surgery?
– Last ekg, stress test, serum cholesterol,
  echo?
         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,
  Auscultation
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
   (CVP)
 – Integrate this when assessing person’s
   neck
Equipment
 – 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
       Distention
       Height of venous pulsation
Note: Palpate and auscultate carotid arteries
  (previously discussed)
Assessment of the Heart and
       Precordium

      PROCEDURE
              Procedure
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
                     Procedure
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
      impulse
    – 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
                 Procedure
3. Auscultate the major precordial
    landmarks
   – 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
                    Procedure
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
      sounds
                               –   Pericardial friction
                                   rubs
                               – 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
  “Ten-nes-see”)
  S4 occurs after atrial contraction, caused by
  vibrations when blood flows rapidly into the
  ventricles
  Vibrations result from the flow of a high blood
  volume or if ventricle wall has low compliance
  Clinical significance: CAD, cardiomyopathy
Murmurs
            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
             stethoscope

Documentation example: III/VI murmur heard best
    @ LLSB
           Abnormal Heart Sounds
Murmurs
   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
                   Procedure
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
                      Procedure
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
      wall
  –   Left-lateral decubitus
      position, brings the apex of
      the heart closer to chest wall
   Assessment of Neck Veins: Procedure
Observe jugular venous
    pressure
(JVP), commonly know as
    JVD
  –   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
      left
  –   Provide tangential lighting
      to neck area
   Assessment of Neck Veins: Procedure
Estimate jugular venous
    distention
(JVD) by measuring the
    height of
pulsation in the internal
    jugular
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
   reflux
   Indicated if a right sided
   heart failure is suspected
   Procedure:
  –   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
                        stethescope
  What is the Nurse’s Role?
Identify abnormalities in rate and
rhythm
Report new or changes in abnormal
heart sounds


     The Auscultation Assistant
     http://www.med.ucla.edu/wilkes/inex.htm

				
DOCUMENT INFO
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.