Cardiovascular Assessment

Heart Peripheral Vascular

Heart

Review of Relevant History

Personal habits

Smoking Diet Exercise Alcohol intake Diabetes Hypertension CAD Hyperlipidemia

Personal and family history

Review of Relevant History

Chest Pain Fatigue Dizziness Syncope

Fainting; transient loss of consciousness Profuse sweating

Diaphoresis

Palpitations

Possible Causes of Chest Pain

Cardiac Aortic Musculoskeletal Pleural Gastrointestinal Pulmonary Psychoneurotic NOTE: Chest pain in children and adolescents is seldom due to a cardiac problem.

Review of Relevant History

Dyspnea
Interference with ADL Orthopnea

# of pillows

Cough Edema Numbness or pain in the extremities

Review of Anatomy

Four chambers

Right atria Right ventricle Left atria Left ventricle Two atrioventricular
Tricuspid Mitral

Four valves

Two semiluunar
Pulmonic Aortic

Circulation

Circulation
Superior and Inferior vena cava Right atrium Tricuspid valve Right ventricle Pulmonic valve Pulmonary arteries Lungs Pulmonary veins Left atrium Mitral valve Left ventricle Aortic valve Aorta Head and Body

Cardiac Cycle

Systole

Ventricles contract and atria relax Pressure in the ventricles rises

Mitral and tricuspid valves are forced closed to prevent backflow into the atria This closure produces the first heart sound: S1: lubb When the pressure in the ventricles is > than that in the aorta and pulmonary arteries the aortic and pulmonic valves open

Blood is ejected
Right ventricle to lungs Left ventricle to aorta

Cardiac Cycle

Systole

When ventricles are almost empty

Pressure in ventricles becomes < than that in the aorta and pulmonary arteries Aortic and pulmonic valves close producing the second heart sound: S2: dubb

Cardiac Cycle

Diastole

Atria contract and ventricles relax As ventricular pressure falls below atrial pressure
Mitral and tricuspid valves open to allow the blood collected in the atria to refill the relaxed ventricles

Blood flows in a relatively passive manner

Right atria to right ventricle Left atria to left ventricle This passive filling sometimes produces a third heart sound: S3

Cardiac Cycle

Diastole

Then the atria contract to eject the remaining blood

This can sometimes be heard as a fourth heart sound :S4

Equipment and Techniques

Equipment

Marking pencil Centimeter ruler Stethoscope with bell and diaphragm Sphygmomanometer Inspection Palpation Percussion Auscultation

Techniques

General Assessment
Color Ease of respirations Signs of distress Blood Pressure

Both upper extremities in at least two positions

Inspection of the Extremities

Color Temperature Hair distribution Capillary refill Skin turgor Skin integrity Venous pattern Nails

Inspection of the Extremities

Edema

1+ 2+ 3+ 4+

slight pitting (2 mm), disappears rapidly a little deeper (4 mm), disappears within 10-15 seconds noticeable deep (6 mm), may last more than a minute very deep (8 mm), lasts as long as 2-5 minutes

Inspection of the Extremities

Varicose Veins
Dilated and swollen Evaluate venous incompetence

Trendelenburg test
person is supine Lift the leg above the level of the heart until the veins empty Then lower the leg quickly An incompetent system will allow rapid filling of the veins

Inspection of the Extremities

Jugular Venous Pressure

Place person in supine position Gradually raise the head of the bed until jugular venous pulsations are noted
To ensure they are not carotid pulsations, palpate the carotid pulse on the opposite side while you observe the pulsations

Place your cm ruler with its zero point at the sternal angle Extend the level of the JVP horizontally until it intersects with the cm ruler Record the cm height of the the JVP
Should not be > 2 cm.

Chest Landmarks

Manubrium Manubrial junction Angle of Louis

Costal angle

Palpation of the Extremities

Lymph Nodes
Epitrochlear Inguinal

Homans sign
Dorsiflexion of the foot with the knee slightly bent Positive sign is calf pain

This is usually an abnormal sign indicating thrombosis (blood clot)

Palpation of the Extremities

Peripheral Pulses

Palpate simultaneously so you can compare the right with the left
EXCEPTION: Carotids!

Palpation of the Extremities

Peripheral Pulses

Assess
Rate (NOT at all sites!) Rhythm
Regular Irregular Regularly irregular

Contour
Smooth

Palpation of the Extremities

Peripheral Pulses

Assess
Amplitude (strength)
0 Absent +1 Thready or weak +2 Easily felt (normal) +3 Bounding

Symmetry with opposite side

Palpation of the Extremities

Peripheral Pulses

Locations:
Carotid Brachial Radial Femoral Popliteal Dorsalis pedis Posterior tibial

Popliteal Pulse Location

Posterior Tibial Location

Dorsalis Pedis Location

Auscultation of the Extremities

Peripheral Vessels

Carotid arteries
Listen for bruits
Bruit: Low-pitched bowing sound over a peripheral vessel Usually indicates a narrowed vessel

Jugular veins
Listen for a venous hum
Venous hum: low to medium-pitched soft hum heard throughout the cycle Common in normal children and has no pathological significance

Auscultation of the Extremities

Peripheral Vessels

Others will be done with the abdominal examination

Abdominal aorta: bruits Renal and ileac arteries: bruits Umbilicus: venous hum
Indicates portal hypertension

Arterial vs. Venous Disorders

PAIN
Arterial After exercise Sharp, stabbing Worse w activity Lowering feet reduces pain Venous With prolonged sitting/standing Aching, heavy Helped by activity Raising feet and legs reduces pain

Arterial vs. Venous Disorders

SKIN
Arterial Cool; cold Hairless Shiny Pallor on elevation Rubor on dangling Venous Warm Thickened Mottled Brown pigmented areas

Arterial vs. Venous Disorders

PULSES
Arterial Often absent Venous Usually present

EDEMA
Infrequent Frequent

Evaluation of the Heart

Inspection of the Chest

Contour Heaves or lifts Pulsations

Chest Landmarks

Chest Landmarks

Evaluation of the Heart

Palpation of the Chest

Palpate for

Areas

Thrills Pulsations PMI (Point of Maximal Impulse) Aortic

Pulmonic

2nd RICS @ SB 2nd LICS @ SB 3rd-5th LICS @ SB 5th LICS @ MCL Normal location of PMI in an adult

Right ventricle
Apical

Chest Landmarks

Aortic Pulmonic Right Ventricle Mitral/PMI

Evaluation of the Heart

Palpation of the Chest

Simultaneously palpating the carotid artery will allow you to describe the chest palpation in relation to the cardiac cycle
Carotid pulsation and S1 are practically synchronous

Evaluation of the Heart

Percussion of the Chest

Limited value Not done with regularity If you do it

Percuss in anterior axillary line across the intercostal spaces toward the sternum
Change from resonance to dullness marks the cardiac border

Evaluation of the Heart

Auscultation of the Chest

Make sure room is warm Make sure stethoscope is warm Take time to isolate each sound and each pause in the cycle Avoid jumping the stethoscope from one site to another

Inch the end piece along the route

Heart Sounds
Sound is transmitted in the direction of blood flow Specific sounds are heard best over areas where the blood flows after it passes through a valve Auscultation should be performed in at least the five cardiac areas

With the diaphragm Then with the bell

Cardiac Auscultatory Areas

Named for the locations where the valves are best heard Assessment should proceed in an systematic order

From the base of the heart to the apex OR From the apex of the heart to the base
Aortic area Pulmonic area Mitral area

Base of the heart

Apex of the heart

Cardiac Areas

Aortic

2nd RICS @ RSB 2nd LICS @ LSB 3rd LICS @ LSB

Pulmonic

Erbs point (second pulmonic)

Tricuspid

4th or 5th LICS @ LSB

5th LICS in LMCL

Mitral

Cardiac Areas

Aortic Pulmonic Erbs Point Tricuspid Mitral

Cardiac Areas
All People Enjoy Their Meals

Aortic Pulmonic Erbs point (2nd pulmonic) Tricuspid Mitral (Apical)

Heart Sounds

S1
Closure of mitral and tricuspid valves at the beginning of systole Heard loudest at the apex

Mitral area

Almost synchronous with carotid pulsation May be split

Tricuspid area on inhalation

Heart Sounds

S2
Closure of aortic and pulmonic valves at the beginning of diastole Heard loudest at the base

Upper precordium

May have a physiologic split

Pulmonic area on inhalation

Extra Heart Sounds

S3

Variation during first rapid filling phase during diastole Heard best at apex Sound
Ken-tuc-ky S1 S2 S3

Normal
< 30 yoa Pregnancy

Abnormal
Fluid overload Mitral or tricuspid regurgitation

Extra Heart Sounds

S4

Variation during 2nd rapid filling phase Heard best at apex Sound
Ten-nes-see S4 S1 S2

Normal
< 30 yoa

Abnormal
Hypertension Mitral or tricuspid regurgitation

Extra Heart Sounds

Mitral valve opening snap

Valvular stenosis

Ejection clicks

Semilunar valves

Pericardial friction rub

Inflammation of the pericardium Grating sound

Heart Murmurs
Relatively prolonged extra sounds heard during systole or diastole Causes

Increased blood flow across normal valves Forward flow through a stenosed valve Backward flow through an incompetent valve

Heart Murmurs

Describe
Location Timing and duration

Systolic S1

Diastolic Pansystolic (both) S2

S1

Heart Murmurs

Describe

Pitch
High Medium Low

Character
Blowing Harsh Rumbling

Intensity

Heart Murmurs

Describe

Intensity: Grade
I II III IV V VI Very faint
Hardly heard

Faint
Clearly audible but quiet

Moderately loud Loud Very loud

Associated with thrill Thrill easily palpated

Very loud

Visible heave or lift Heard with stethoscope not in contact with chest

Developmental Variations

Newborns and Infants

HR very fast Skin and mucous membranes should be uniformly pink

Acrocyanosis is normal
Bluish coloration of hands and feet Disappears within a few days after birth

Apical impulse usually in 4th or 5th LICS just medial to the LMCL Murmurs are frequent in the newborn in the first 48 hours

Developmental Variations

Children

Sinus arrhythmia is a physiologic event in childhood

Heart rate varies in a cyclic pattern, usually faster on inhalation and slower on exhalation

Venous hum is common in children

Caused by turbulent blood flow in the internal jugular veins

Watch for squatting

Developmental Variations

Pregnancy

Pulse rate gradually increases throughout

At term is 10-15 bpm faster

BP gradually falls in the first 16-20 weeks then rise to pre-pregnant levels at term May hear an audible S4 Grade II systolic ejection murmurs are heard in 90% of pregnant women Dependent edema is the norm
Decreased venous return

Developmental Variations

Older Adults
S4 is more common in the elderly Soft murmurs are not uncommon Dorsalis pedis and posterior tibial pulses are more difficult to find Heart rate does not respond as readily to exercise Systolic blood pressure may increase

Questions?

What are the five cardiac areas for auscultation?

Aortic Pulmonic Erbs Point Tricuspid Mitral

Questions?

What valves closing constitute S1?

Mitral and Tricuspid

What valves closing constitute S2?

Pulmonic and Aortic

Questions?

What creates S3?

Rapid filling of the ventricles

What does it sound like?
Kentucky

What creates S4?

Rapid filling of the ventricles

What does it sound like?
Tennessee

Questions?

In what cases might an S3 or S4 be considered normal?

In persons < 30 yoa In pregnancy

An extra heart sound that may be heard as a soft blowing sound during systole is called a:

Murmur

Questions?

Is a bluish discoloration of the hands and feet in a newborn considered normal?

Yes
What is this called?
Acrocyanosis

Videos of Cardiovascular Exam

Copy these URLs into your Web browser

http://medinfo.ufl.edu/other/opeta/cardi o/CV_main.html OR http://www.conntutorials.com/video.html

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