James 1:5-6
Philippians 4:13
HEART AND NECK VESSELS
• Cardiovascular disease is the every
State’s leading killer for both men
and women among all racial and
ethnic groups.
• A thorough cardiovascular
assessment will help to identify
significant factors that can influence
cardiovascular health such as high
blood cholesterol, cigarette use,
diabetes, or hypertension.
CENTRAL VENOUS PRESSURE (CVP)
- It is the venous pressure as
measured at the right atrium, done
by means of a catheter introduced
through the median cubital vein to
the superior vena cava.
BLOOD PRESSURE
• It is the amount of force (pressure)
that blood exerts on the walls of the
blood vessels as it passes through
them.
• ARTERIES RECEIVE MORE PRESSURE,
HUS, THE TUNICA MEDIA IS
GREATER THAN
SYSTOLIC PRESSURE
• The blood pressure measured during
the period of ventricular
contraction (systole). In blood
pressure readings, it is the higher of
the two measurements
DIASTOLE
• The period between contractions of
the atria or the ventricles during
which blood enters the relaxed
chambers from the systemic
circulation and the lungs.
• The blood pressure (as measured by
a sphygmomanometer) after the
contraction of the heart while the
chambers of the heart refill with
blood.
HEAD TO SHOULDER – Superior Vena Cava
SHOULDER GOING DOWN – inferior vena
cava
Sinoatrial node – natural pacemaker of the
heart
Atrioventricular Node –
*should be fast, if slow, pt. is bradycardic
HISTORY:
• The purpose of the cardiovascular
health history is to provide
information about your patient’s
cardiovascular symptoms and how
they developed. A complete
cardiovascular history will give you
indications to potential or
underlying cardiovascular illnesses
or disease states.
PAST HEALTH HISTORY:
- hypertension,
- elevated blood cholesterol or
triglycerides,
- heart murmurs,
- congenital heart disease,
- rheumatic fever or unexplained joint
pains
LIFESTYLE AND PSYCHOSOCIAL STATUS
• Nutrition (usual food intake) – more
detrimental than smoking and
alcohol
• Smoking (how many packs / day;
how long)
• Alcohol
• Exercise
• Drugs
• Family History
ASSESSMENT ARTICLES:
• A Double-Headed, Double-Lumen
Stethoscope
• A Blood Pressure Cuff
• A Moveable Light Source or Pen
Light
• Sphygmomanometer
• Measure tap
• Wrist watch and pen
GENERAL INSPECTION
EYES:
• The presence of yellowish plaques
on the eyelids (xanthelasma) could
indicate hyperlipoproteinemia, a risk
factor for hypertension as well as
arteriolosclerosis.
CHEST:
• Observe the chest for overall torso
contour.
• Do you see pectus excavatum
(caved-in chest)?
• Do you see pectus carinatum
(pigeon chest)?
SKIN:
• Clubbing - The presence of clubbing
(broadening of the extremities of
the digits, accompanied by nails
James 1:5-6
Philippians 4:13
which are abnormally curved and
shiny) indicates chronic poor oxygen
perfusion to the distal tissues of the
hand and feet.
• Cyanosis - The presence of cyanosis
(bluish colour) also denotes chronic
poor oxygen delivery to the
peripheral tissues of the hands and
feet.
• Xanthomas - The presence of
yellowish plaques under the skin
(non-eruptive) excoriated through
the skin (eruptive) could indicate
hyperlipoproteinemia, a risk factor
for hypertension as well as
arteriolosclerosis.
• Edema – (Bipedal E. – both feet) -
The presence of edema (tissue
swelling) can be caused by several
factors, although most commonly is
associated with decreased cardiac
function leading to decreased
capillary flow.  branch block
• Palpation
- Use the palm of your hand to feel
the chest wall for the "Point of
Maximal Impulse" (PMI), which is
usually found at the apex of the
heart. This apical pulse is generally
located in the 5th intercostal space,
about 7-9 cm (the width of your
palm) to the left of the midline.
Rate, rhythm, elasticity – should be noted
in the pulses
*brachial, radial, femoral, popliteal,
dorsalis pedis, and posterior tibial. Note
the contour and amplitude of each
pulsation. These should feel similar
bilaterally.
Chest percussion:
• Normally only the left border of
heart can be detected by percussion.
It extends from the sternum to mid
clavicular line in the third to fifth
inter costal space.
• The right border lies under the right
margin of the sternum and is not
detectable. Enlargement of the
heart too either the left or right
usually can be noted.
HEART SOUNDS:
S1
• S1, the “lub” of the “lub-dub,” is
produced by the closure of tricuspid
and mitral valves.
• S1 is accentuated in exercise,
anemia, hyperthyroidism, and mitral
stenosis.
• S1 is diminished in first degree heart
block. (Arrythmia)
• S1 split is most audible in tricuspid
area (T-lub-dub)
S2
• S2, the “dub” of the “lub-dub,” is
produced by the closure of aortic &
pulmonic valves.
• Normal physiological splitting of S2
is best heard at pulmonic area. It
occurs on inspiration(“lub-T-dub,
lub-dub”).
• Splitting of S2 can indicate pulmonic
stenosis, atrial septal defect, right
ventricular failure, and left bundle
S3
• S3 is also known as a ventricular
gallop (“lub-DUB-ta”). S3 is heard in
early diastole.
• It is normal in pregnancy, children,
adults less than thirty years old,
during exercise, anxiety, or anemia.
• It is heard best at the apex in the
left lateral decubitus position, using
the bell. Pathologic S3 occurs in
people over the age of 40, usually
due to myocardial failure.
S4
• S4 is also known as an atrial gallop
(“ta-lub-DUB”). It is typically heard
in late diastole before S1. It results
when ventricular resistance to atrial
filling is increased from either
decreased ventricular compliance or
increased ventricular volume
• HEARD BEST IN PT. WITH
HYPERTENSION
Summation Gallop
• A summation gallop is produced
when S3 & S4 merge into one
sound. It often occurs at rates
greater than 100 beats per minute.
It may occur in heart failure and
pericarditis.
• Summation gallops occur in 15% of
all myocardial infractions
• ON TACHYCARDIC PATIENTS
James 1:5-6
Philippians 4:13
Opening Snap
• At the end of ventricular systole,
when the aortic and pulmonic valves
close, S2 is produced Immediately
after S2, the heart relaxes, and
ventricular pressure falls below that
of atrial pressure. This allows the
atrioventricular valves to open. This
is the start of diastole.
Ejection Click
• Similar to an opening snap, an
ejection click is caused by stenotic
valve leaflets. This sound is
produced when the aortic or
pulmonic valves open at the
beginning of systole.
• It is a brief high frequency sound
best heard with the diaphragm over
the aortic or pulmonary artery or
Erb’s point, or near the apex over
the mitral area
Mid-systolic Click
• A mid-systolic click occurs when the
mitral valve’s leaflets and cordae
tendenae (responsible for opening
of the valves) tense. The anterior or
posterior or both leaflets can
prolapse. Every once in a while
multiple clicks occur.
• They are heard in mid to late systole.
They are best heard over the
tricuspid area and towards the
mitral area.
Pericardial Friction Rub
• A pericardial friction rub is usually
heard best and is sometimes
palpable over the tricuspid and
xyphoid areas. It occurs when
inflamed pericardial surfaces rub
together.
Murmurs
• A murmur is an abnormal heart
sound caused by turbulent blood
flow. The sound may indicate that
blood is flowing through a damaged
or overworked heart valve (usually
needs to have an open heart
operation), that there may be a hole
in one of the heart's walls, or that
there is a narrowing in one of the
heart's vessels
ASSESSMENT:
HISTORY:
NECK VESSELS:
 Keep neck in a neutral position
 Locate and Palpate Carotid Arteries
– One at a time
– Rate amplitude 0 to 3+
 Auscultate the Carotid-normally no
sound
– Bruit- blowing or swishing
sound indicating turbulent blood
flow
 Use bell of
stethoscope
 Auscultate at 3
positions (down, middle, up)
– Thrill – Palpable vibration
accompanying bruit
 A loud aortic heart murmur may
radiate to neck
Jugular Venous Assessment
 Position client supine at 30 to 45
degree angle (Semi-Fowler)
– Always be aware of client
comfort
– Turn client’s head slightly
away
 Note the external and internal
Jugular vein distention (if any) and
record the level in relation to the
clavicle (normal less than 2 cm)
– Observe for pulsations (if
any)
– Unilateral distension
(embossed) = kinking or
aneurysm (ballooning of the
blood vessel)
– Bilateral distension =
increased CVP
James 1:5-6
Philippians 4:13
The Precordium (chest wall)
 Inspect
– Heave(lift) = sustained
forceful thrust of ventricle
against chest wall =
ventricular hypertrophy
– Apical pulse (palm) may be
visible in thin adults and
children
 Palpate the Apical Pulse
– Sometimes called PMI (point
of maximum impulse)
Note:
 Location
– should be at
th
or near 5 intercostals space
– LV dilatation
(fluid overload) displaces down
and to the left and increases size
 Size
 Amplitude- 0 to 3+
– Increased in
LV hypertrophy (pressure
overload)
 Rate and Rhythm
– Regular
irregularity or irregular
irregularity
– Compare
irregular apical pulse to radial
– Sinus
arrhythmia common in children
and young adults related to the
respiratory cycle
– Premature
Beat - more common in elderly
 Palpate the Precordium
– Use palm
– Normally thrill or mass not
felt
AUSCULTATION
 Use Diaphragm of Stethoscope
 Identify S1 and S2
– S1 is loudest at apex
 closure of AV valves
 Beginning of systole
– S2 is loudest at base
 Closure of semilunar
valves
 Beginning of diastole
– S1 coincides /c carotid pulse
and R wave on ECG
EXTRA HEART SOUNDS:
 Split S2
– Normal phenomenon
– Occurs at end of inspiration
– Semilunar valves don’t close
at the same time
– Heard best at left 2nd ICS
– Can be fixed or paradoxical
 S3 – Ventricular Gallop
– Early in diastole during rapid
filling
– Heard best at apex using bell
of stethoscope
– Doesn’t vary /c resp like Split
S2
– Indicates decreased
ventricular compliance
– In children and young adult
may be innocent and
disappear when pt sits
– May be earliest sign of heart
failure
– Heard /c increased CO i.e .
hyperthyroidism
 S4- Atrial Gallop
– Ventricular filling sound
– Occurs late in diastole
immediately before S1
– Heard when atria contract
– Very soft, low pitched sound
– Heard best at apex /c pt in
left lateral position /c bell
– Can occur /p exercise at 40 yr
old
– Occurs /c systolic overload,
hypertension and aortic
stenosis
 Friction Rub
– Occurs r/t inflammation of
the pericardial membranes
– Occur in both systole and
diastole
– Hear best at apex
– Common in 1st week
following Myocardial
Infarction and pericarditis
James 1:5-6
Philippians 4:13

Murmurs
 Blowing, swooshing sound
 Indicates abnormal turbulent blood
flow
 A murmur outside the heart is called
a bruit
 Are either systolic or diastolic
 Systolic murmur may occur
innocently in children and young
adults r/t increased force of
contraction

Assessment of Murmurs
 Timing- systolic or diastolic
 Loudness-Grade I thru VI
 Pitch- high or low
 Pattern- Crescendo, decrescendo,
plateau, diamond
 Quality- Musical, blowing, harsh or
rumbling
 Location- Where is it loudest?
 Radiation- Is it audible in other parts
of precordium
 Posture- Is it present or louder only
in certain position

Age Specific Considerations

 Infants
– Use appropriate size
stethoscope
– May be irregular
– Murmurs may be present r/t
congenital fetal circulation
remnants
 Children
– May have visible apical
pulses r/t thin chest wall
– May have innocent
murmurs-always note
presence of murmur
 Pregnancy
– Increased pulse rate
– Exaggerated S2 splitting
– Easily heard S3 (normal)
– Systolic murmur may be
present-should disappear /p
delivery
 Elderly
– S4 even /s Hx of CAD
– Irregular pulse more
common