MR.

SUDHIR KHUNTIA
INTRODUCTION:-
Assessment of the cardiovascular system is one of the
most important areas of the nurse’s daily patient assessment. Report
your findings as clearly as possible. Charting your results clearly is
essential for others to be able to assess the problem, and good
documentation is also essential for the treatment of the patient as
well as for the nursing care.
PHYSICAL EXAMINATION

General:-

 Build (obesity or wasting); shortness of breath; difficulty in talking; note

whether they look ill.

 Look for pallor, jaundice, sweatiness and clamminess, and for xanthelasma
around the eyes.

Cyanosis

 This is seen below the fingernails and toenails but also in the lips, cheeks,
ears and nose.

 It may increase in the cold and on exertion.

Face
 Malar flush - redness around the cheeks (mitral stenosis).
 Xanthomata - yellowish deposits of lipid around the eyes, palms, or tendons
(hyperlipidaemia).
 Corneal arcus - a ring around the cornea (normal ageing or
hyperlipidaemia).
 Proptosis - forward projection or displacement of the eyeball (Graves'
disease)

Hands
 Finger clubbing.
 Janeway lesions - macules on the back of the hands (infective endocarditis).
 Osler's nodes - tender nodules in the fingertips (infective endocarditis).
Pulse

 Rate: average 72/minute in adults, faster in children and may

slow in old age. Also slower in athletes. Compare with apex rate.

Rhythm:
Respiratory variations are common in healthy individuals (if
there is noticeable quickening in inspiration and slowing in
expiration, this is termed sinus arrhythmia).
•Peripheral pulses:
 Femoral pulses (radial femoral delay in coarctation) and foot
and ankle pulses.
 Listen over the renal and femoral artery for murmurs.
Check blood pressure
 This should be measured in the brachial artery, using a cuff
around the upper arm.
 A large cuff must be used in obese people, because a small cuff
will result in the blood pressure being overestimated.
 Systolic pressure is at the level when first heard (Korotkoff I)
and the diastolic pressure is when silence begins (Korotkoff V).
 In patients with chest pain, or if ever the radial pulses appear
asymmetrical, the pressure should be measured in both arms
because a difference between the two may indicate aortic dissection.
Chest examination
 Check the level of the jugular venous pressure.
 Chest examination:
 Look to see if the chest wall is deformed (eg, funnel chest)
and moves equally (inequality of expansion is usually due to
respiratory disease).
Note the respiratory rate; it is related to the pulse rate in the
ratio of about 1:4 and remains constant in the same individual.
  Ask the patient to breathe out and, using both hands resting lightly on
the side walls of the chest with thumbs meeting in the middle, ask them to
breathe in to assess the expansion of the chest on full inspiration by noting
how far the examiner's thumbs move apart.

 Feel over the anterior chest wall for any thrills associated with cardiac
murmurs.

 Auscultation of the heart -

Examination of other areas
Abdomen - see also separate Abdominal Examination
Palpate the abdomen for hepatomegaly and splenomegaly
(congestive cardiac failure), or spleen alone (infective
endocarditis).
Feel for enlargement of the aorta (aneurysm); feel with the
hands flat either side of the aorta - feel for pulsation and
tenderness.
Investigations
•These may include:
 Blood tests (for fasting glucose and/or haemoglobin, renal function, LFTs,
TFTs, lipid profile, cardiac enzymes, ESR or CRP).

 12-lead ECG and ambulatory ECG monitoring, exercise ECG testing.

 Ambulatory blood pressure monitoring
 chest x-ray
 Spirometry.
 Echocardiogram.
 Cardiac catheterization.
 Angiography.
Electrocardiography (ECG or EKG*) is the process of
recording the electrical activity of the heart over a period of
time using electrodes placed on the skin. These electrodes
detect the tiny electrical changes on the skin that arise from
the heart muscle's electro physiologic pattern
of depolarizing during each heart beat. It is a very
commonly performed cardiology test.
MAIN PATTERN

The 12 lead ECG is used to classify MI patients into one of three groups:

 those with ST segment elevation or new bundle branch block (suspicious

for acute injury and a possible candidate for acute reperfusion therapy
with thrombolytics or primary PCI),

 those with ST segment depression or T wave inversion (suspicious for

ischemia), and

 those with a so-called non-diagnostic or normal ECG. However, a normal

ECG does not rule out acute myocardial infarction.
 CARDIAC ASSESSMENT

GUIDE BY: PRESENTED BY:

MRS. SHEFALI CHARAN LECTURER MR. JEEVAN LAL
M.Sc. NURSING M. Sc. NURSING FINAL YEAR
(MEDICAL SURGICAL NURSING)
Health History:-
1. Current Health Status

-chest pain
- shortness of breath
- swelling of ankles or feet
- heart palpitations
- fatigue
2. Past Health History

-Congenital heart disease

- Rheumatic fever

- Heart murmur

- High blood pressure, high cholesterol, diabetes mellitus

- Confusion

- Fatigue
3. Family History

4. Personal Habits
Techniques of Examination

 The patient should be supine with upper body elevated

at a 15-30E angle.

The room must be quiet, warm, and have good lighting.

You should stand to the right of the patient being

examined. Inspection and Palpation of the Heart

The finger pads are more sensitive in detecting pulsations.

Inspect and Palpate for:

Pulsations- these are more visible when patients are thin. A

thick chest wall or increased AP diameter can obscure them.
Pulsations may indicate increased blood volume or
pressure.

Lift or heaves- these are forceful cardiac contractions that

cause a slight to vigorous movement of sternum and ribs.

Thrills- these are the vibrations of loud cardiac murmurs.

They feel like the throat of a purring cat. Thrills occur with
turbulent blood flow.
You should inspect and palpate at the following areas:
AREA FINDINGS
Aortic (2nd inter A pulsation could indicate an aortic aneurysm
coastal space to A thrill could indicate aortic stenosis
the right of the
sternum)
Pulmonary A pulsation could indicate pulmonary
(2nd inter hypertension
coastal space A thrill could indicate pulmonic stenosis
to the left of
the sternum)
Tricuspid (4- A sustained systolic lift could indicate right ventricular enlargement.
5th inter A systolic thrill could indicate a ventricular septal defect.
coastal
space,
lower half
of the
sternum)
Mitral (5th Increased pulsation could indicate increased output, anxiety,
intercoastal fever, or pregnancy.
space at A thrill could indicate mitral regurgitation, or mitral stenosis.
mid
clavicular
line)
-

Epigastric Increased aortic pulsation could indicate right

(below ventricular pulsation of right ventricular
xiphoid enlargement and aortic regurgitation.
process)
Sternoclavicular Pulsation of aortic arch may be felt in a thin client.
(top of sternum
at junction of
clavicles)
Auscultation of the Heart
2nd right interspace close to the
1. Aortic Area
sternum.

2. Pulmonic Area 2nd left interspace.

3. ERB's Point 3rd left interspace.

5th left interspace close to the

4. Tricuspid Area
sternum.
5. Mitral Area
5th left interspace medial to the MCL
(Apical)
AUSCULATION OF HEART WITH STETHOSCOPE

1. With your stethoscope, identify the first and second heart

sounds (S1 and S2) at the aortic and pulmonic areas (base).
S2 is normally louder than S1. S2 is considered the dub of
'lub-DUB.' S2 is caused by the closure of the aortic and
pulmonic valves.
Contd…….

2. Identify the heart rate.

tachycardia
bradycardia

3. Identify the rhythm.

if it is irregular, try to identify the pattern.
Do early beats appear on a regular rhythm?
Does the irregularity vary consistently with respiration?
Is rhythm totally irregular?
Contd……

4. Listen to S1 first, then S2 at the previously mentioned

areas using the diaphragm and then the bell.
note its intensity.
are there any splitting sounds check during inspiration
where S2 usually splits at pulmonic and ERB's point.
A thick chest wall or increased AP diameter may make S2
inaudible.
ALTERATION IN S1, S2, S3, S4, and murmur
sound
 S.N ALTERATION ALTERATION LISTEN FOR LISTEN FOR LISTEN FOR MURMUR
O IN S1 IN S2 S3 S4
1. S1 is Normal A physiologic It occurs Heart murmur are heart sound
accentuated in physiological S3 is before S1 produced when blood flows across
exercise, splitting of S2 is frequently one of the heart valves that is loud
It is low
anemia, best heard at heard in enough to be heard with a
pitched and
hyperthyroidis pulmonic area. children and stethoscope.
best heard
m and mitral It occurs on in pregnant
with the bell
stenosis inspiration. women.
2. S1 is diminished in Splitting of S2 can It occurs early in It may be
first degree heart indicate pulmonic diastole during caused by
block stenosis, atrial rapid ventricular coronary
septal defect, filling. It is heard artery disease,
right ventricular best at the apex hypertension,
failure. in the left lateral myocardiopat
decubitus hy, or aortic
position. stenosis.
3. S1 split is most A pathologic S3 Sounds like
audible in occurs in people dee-lub-dub(or
tricuspid area over the age of Tennessee)
40. Cause is
usually
myocardial
failure
Assessment of Extra Heart Sounds:
S.NO ASSESSMENT OF EXTRA FEATURES OF SOUNDS
HEART SOUND
1. Ejection click High pitched sounds that occur at the
moment of maximal opening of the
aortic or pulmonary valves.

2. Opening snap High pitched additional sound may be

herd after the A2 (aortic) component of
the second heart sound (S2), which
correlates to the forceful opening of the
mitral valve.

3. Mid systolic click High frequency sound in mid systole.