Cardiovascular Assessment

Dr. Zyad Saleh

Subjective Data specific heart problems: Chest pain - cardiac, pulmonary, muscular, or gastrointestinal- Sensation of squeezing around the heart; a steady, severe

pain; and a sense of pressure.- radiate to the left shoulder and down the left arm or to the jaw.- Diaphoresis and pain worsened by activity- dyspnea, diaphoresis, pallor, nausea, palpitations, or

tachycardia.

Tachycardia and Palpitations (beat faster)- Tachycardia increase cardiac output.- Palpitations abnormality of the heart’s

conduction (arrhythmia) or increase cardiac output by Tachycardia

Fatigue- Fatigue may result from compromised

cardiac output. - Fatigue related to decreased cardiac

output is worse in the evening or as the day progresses,

Difficulty of breathing (dyspnea) or shortness of breathing

- Dyspnea cardiac or pulmonary disorders- Dyspnea may occur at rest, during sleep, or with

exertion. - Orthopnea is the need to sit more upright to breath easily- paroxysmal nocturnal dyspnea (wake up from dyspnea)

heart failure due to redistribution of fluid from the ankles to the lungs when one lies down at night.

Cough up with mucous- Fluid accumulation in the lungs from heart

failure white to pink-tinged sputum.

Dizziness- Dizziness decreased blood flow to the

brain

Wake up with an urgent need to urinate (nocturia)

- Increased renal perfusion

Swelling edema in feet, ankles, and legs- Edema in both lower extremities at night- dependent areas of the body.

Heartburn - Gastrointestinal pain may occur after

meals and is relieved with antacids. - Cardiac pain may occur anytime, is not

relieved with antacids, and worsens with activity.

Personal Health History

a heart defect or a murmur rheumatic fever- Rheumatic carditis results in inflammation of

all layers of the heart, impairing contraction and valvular function.

heart surgery or cardiac balloon interventions Electrocardiogram (ECG)

lipid profile take medications or use other treatments

for heart disease monitor heart rate or blood pressure

Family History

Hypertension Dyslipidemia Coronary artery disease Diabetes mellitus

Lifestyle and Health Practices Smoke Stress Usual diet Alcohol Exercise daily activities Number of pillows used to sleep at night

COLLECTING OBJECTIVE DATA

INSPECTION: Neck Vessels

Observe the jugular venous pulse- The jugular venous pulse is not normally

visible with the client sitting upright. (position fully distends the vein)

- pulsations may or may not be discernible.- increased central venous pressure

Evaluate jugular venous pressure- The jugular vein should not be distended,

bulging, or protruding at 45 degrees or greater

- Right side heart failure

Auscultation and Palpation Auscultate the carotid arteries if you suspect

cardiovascular disease.- No blowing or swishing or other sounds are heard.- Pulses are equally strong; a 2+, with no variation in strength- Contour is smooth and rapid on upstroke and slower on downstroke. - Pulse Amplitude Scale

0 = Absent

1+ = weak

2+ = Normal

3+ = Increased

4+ = Bounding

occlusive arterial disease A bruit, a blowing or swishing sound by turbulent blood flow through a narrowed vessel

Pulse inequality arterial constriction or occlusion in one carotid.

Weak pulses hypovolemia, shock, or decreased cardiac output.

A bounding, firm pulse may indicate hypervolemia or increased cardiac output.

Variations in strength from beat to beat or with respiration abnormal

A delayed upstroke aortic stenosis.

Palpate the carotid arteries.- Arteries are elastic and no thrills- Loss of elasticity atherosclerosis - Thrills a narrowing of the artery.

INSPECTION: Heart (Precordium) is the portion of the body over the heart

and lower chest Inspect pulsations.

Aortic area at the right second intercostal space–S2 is louder than S1

Pulmonic area :at the left second intercostal space–S2 is louder than S1

Erb’s point: at the left third intercostal space–S1 and S2 are heard equally

Tricuspid area at the left fourth intercostal space–S1 is louder than S2

Apex: the left fifth intercostal space at the midclavicular line–S1 is louder than S2

INSPECTION: Heart (Precordium) Inspect pulsations.- The apical impulse may or may not be visible. - it would be in the mitral area (left mid-

clavicular line, fifth or fourth intercostal space)- Apical impulses result of the left ventricle

moving outward during systole.

PALPATION

Palpate the apical impulse.- The apical impulse is palpated in the mitral area- Size 1-2 cm - Amplitude small like a gentle tap. - The duration is brief, lasting through the first 2/3

of systole or less- obese clients may not be palpable.

The apical impulse may be impossible to palpate in clients with pulmonary emphysema.

Cardiac enlargement large size displaced, more forceful, or of longer duration.

Palpate for abnormal pulsations.- No pulsations or vibrations are palpated in

the areas of the apex, left sternal border, or base.

- A thrill or a pulsation is usually associated with murmur.

AUSCULTATION

Auscultate heart rate and rhythm.- Rate = regular 60 to 100- Bradycardia- Tachycardia- Arrhythmia - Cause Decrease cardiac output or emboli

If you detect an irregular rhythm, auscultate for a pulse rate deficit.

- The radial and apical pulse rates should be identical.

- pulse rate deficit (difference between apical pulse and peripheral pulse arrhythmia

Auscultate to identify S1 and S2.- The first heart sound (S1) is the result of closure of the

AV valves: the mitral and tricuspid valves.- S1 (“lub”) is usually heard as one sound but may be

heard as two sounds- two sounds, the first component represents mitral

valve closure (M1); the second component represents tricuspid closure (T1).

- heard best at the apex (left MCL, fifth ICS).

Auscultate to identify S1 and S2.- second heart sound (S2) results from closure

of the semilunar valves (aortic and pulmonic)- two sounds, the first component represents

aortic valve closure (A2) and the second component represents pulmonic valve closure (P2).

- heard best at the base of the heart.

Auscultate to identify S1 and S2.- First heart sound = S1 or lub- Second heart sound = S2 or dubb- two sounds make up the cardiac cycle of systole and

diastole. - S1 starts systole, and S2 starts diastole. The space

between S1 and S2 (systolic pause) is of short duration- The space between S2 and the start of another S1

(diastolic pause) is of longer duration.

S1 corresponds with each carotid pulsation and is loudest at the apex of the heart.

S2 immediately follows after S1 and is loudest at the base of the heart.

diminished, varying, or split

An accentuated S1 sound is louder than an S2. This occurs when the mitral valve is wide open and closes quickly.

Diminished S1: S1 sound is softer than the S2 sound. This occurs when the mitral valve is not fully open at the time of ventricular contraction and valve closing.

a split S1 occurs when the left and right ventricles contract at different times (asynchronous ventricular contraction).

Varying S1 occurs when the mitral valve is in different positions when contraction occurs.

An accentuated S2 means that S2 is louder than S1.

conditions in which the aortic or pulmonic valve has a higher closing pressure.

A diminished S2 means that S2 is softer than S1.

conditions in which the aortic or pulmonic valves have decreased mobility.

A normal split S2 can be heard over the second or third left intercostal space.

It is usually heard best during inspiration and disappears during expiration.

Wide Split S2 is an increase in the usual splitting that persists throughout the entire respiratory cycle and widens on expiration.

It occurs when there is delayed electrical activation of the right ventricle.

Fixed Split S2 This is a wide splitting that does not vary with respiration.

It occurs when there is delayed closure of one of the valves.

Reverse split S2 sound:

Auscultate for extra heart sounds.- Auscultate during the systolic and diastolic

pause- S3 heart sound heard at the beginning

of the diastolic pause- S4 heart sound heard at the end of the

diastole

Extra Heart SoundS3 and S4 are referred to as diastolic filling sounds, or extra

heart sounds, which result from ventricular vibration secondary to rapid ventricular filling.

Description:

Both sounds are low frequency and thus best heard with the bell of the stethoscope.

Location:

Usually best heard over

apex with patient in the left lateral position

THIRD HEART SOUND S3

• Results from increased atrial pressure leading to increased flow rates, as seen in congestive heart failure, which is the most common cause of a S3.

• May be normal physiological finding in patients less than age 40,pregnancy,athlatist or fever.

FOURTH HEART SOUND S4

Seen in patients with stiffened left ventricles, resulting from conditions such as

hypertension, aortic stenosis, ischemic or hypertrophic cardiomyopathy.

Auscultate for murmurs.- A murmur a swishing sound caused by turbulent

blood flow through the heart valves or great vessels.

- increased blood velocity, structural valve defects, valve malfunction, and abnormal chamber openings

- Thrills are superficial vibratory sensations felt on the skin overlying an area of turbulence

Systolic Murmurs

These are ejection murmurs

May be caused by turbulence across the aortic or pulmonic valves if they are stenosed

May be caused by turbulence across the mitral or tricuspid valves if they are incompetent (regurgitant)

The murmur falls between S1 and S2 Sounds like, LUB-shhh-dub

Diastolic Murmurs

Mitral and tricuspid stenosis can cause a diastolic murmur.

Aortic or pulmonic regurgitation can cause a diastolic murmur.

Sounds like this: Lub-dub-shhh

auscultate with the client in different positions because some murmurs occur or subside according to the client’s position.

Auscultate with the client assuming other positions.