Cardiovascular and Peripheral Vascular Systems Assessment

Chapter 30 Page 619 - 627

Dyana M. M. Saplan, RN, MAN

Heart
Nurses assess the heart thru (IPA):
Inspection Palpation Auscultation more meaningful when other data are obtained 1st

Usually assessed during an initial physical assessment Usually done while client is in a semi-reclined position Upper portion (both atria)= BASE Lower portion (ventricles) = APEX
Dyana M. M. Saplan, RN, MAN

Apex of the Heart

Apex of the left ventricle actually touches the chest wall @ or medial to the left MCL and @ or near the 5th left intercostal space (LICS)
Point of maximal impulse (PMI)

Dyana M. M. Saplan, RN, MAN

Precordium
Area of the chest overlying the heart Inspected and palpated for presence of abnormal pulsations or lifts or heaves Lifts rising along the sternal border w/ each heartbeat
occurs when cardiac action is very forceful Shd be confirmed by palpation w/ palm of hand

Anatomic sites of the precordium

Dyana M. M. Saplan, RN, MAN

Heart Sounds
Normal 1st 2 heart sounds are produced by closure of the valves of the heart S1 (LUB)
Occurs when atrioventricular (A-V) valves close A-V valves close when ventricles have been sufficiently filled Dull, low-pitched sound

S2 (DUB)
Higher pitched than S1; shorter duration

lub-dub occur w/in 1 sec. or less, depending on the heart rate

Dyana M. M. Saplan, RN, MAN

Heart sounds
Audible anywhere on the precordial area, but Best heard over the aortic, pulmonic, tricuspid, and apical areas

Dyana M. M. Saplan, RN, MAN

Systole and Diastole

Systole
Period in which ventricles contract Begins w/ S1 and ends at S2 Normally shorter than diastole

Diastole
Period in w/c ventricles relax Starts w/ S2 and ends @ the subsequent S1 Dyana M. M. Saplan, RN, MAN

Extra sounds (S3 and S4)

Both are low pitched and heard best @ the apex w/ bell of the stethoscope, w/ the client lying on the left side S3
Occurs early in diastole, right after S2 Sounds like lub dub ee (S1, S2, S3) or Kentuc ky Disappears when client sits-up Normal in children and young adults Older adults = failure
Dyana M. M. Saplan, RN, MAN

Central Vessels
Carotid arteries
Supply oxygenated blood to the head and neck Only source of blood to the brain = Prolonged occlusion result in serious brain damage

Jugular veins
Drain blood from the head and neck directly into the superior vena cava and right side of the heart External jugular vein superficial; visible above the clavicle

Dyana M. M. Saplan, RN, MAN

Extra sounds (S3 and S4)

S4
Occurs near @ the very end of diastole, just before S1 dee lub dub (S4, S1, S2) or Ten nessee Rarely heard in healthy young adults Heard in may elderly clients may be a sign of hypertension

Nurse may also hear other abnormal sounds such as clicks, rubs, murmurs
Caused by valve disorders or impaired blood flow w/in the and require advanced training to diagnose Dyana M. M. Saplan, RN, MAN

Carotid arteries
Carotid is auscultated for bruit Bruit (a blowing or swishing sound) is created by turbulence of blood flow due either to narrowed arterial lumen (common devt in older people) or to a condition such as:
Anemia Hyperthyroidism w/c elevates cardiac output

Also palpated for thrill

Frequently accompanies a bruit A vibrating sensation like the purring of a cat or water running thru a hose Also indicates turbulent blood flow due to arterial obstruction Dyana M. M. Saplan, RN, MAN

External neck veins

Nly distended and visible when a person lies down
Flat and not as visible when a person stands up gravity encourages venous drainage By inspecting jugular veins for pulsations and distention The nurse can assess the adequacy of fxn of the right side of the and venous pressure Bilateral jugular vein distension (JVD) = right-sided failure

Dyana M. M. Saplan, RN, MAN

Assessing the highest point of distention of the jugular vein

Measure the vertical height of the highest visible point of the internal jugular vein in centimeters from the sternal angle, the point @ w/c the clavicle meet
Normal bilateral measurement: 3 4 cm 3 4 cm = elevated; right-sided heart failure

Dyana M. M. Saplan, RN, MAN

Assessing precordium
Simultaneously inspect and palpate the precordium for the presence of abnormal pulsations, lifts or heaves. Locate the valve areas of the heart:
Locate the angle of Louis felt as a prominence on the sternum

Dyana M. M. Saplan, RN, MAN

Locate the valve areas of the heart

Dyana M. M. Saplan, RN, MAN

Location of the apical pulse for a child under 4 years, a child 4 to 6 years, and an adult.

Dyana M. M. Saplan, RN, MAN

Lifespan Considerations

Dyana M. M. Saplan, RN, MAN

Infants
Physiologic splitting of the second heart sound (S2) may be heard when the child takes a deep breath and the aortic valve closes a split second before the pulmonic valve. If splitting of S2 is heard during normal respirations
abnormal and may indicate an atrial-septal defect, pulmonary stenosis or another heart problem

May normally have sinus arrhythmia rel. to respiration

rate slows during expiration and increases when child breathes in

Dyana M. M. Saplan, RN, MAN

sinus arrhythmia
normal increase in heart rate that occurs during inspiration This is a natural response and is more accentuated in children than adults. "sinus" refers to the natural pacemaker of the heart which is called the sinoatrial (or sinus) node located in the wall of the right atrium (the right upper chamber of the heart) Normal cardiac impulses start there and are transmitted to the atria and down to the ventricles (the lower chambers of the heart)

Dyana M. M. Saplan, RN, MAN

Children
sounds louder thinner chest wall S3 caused as the ventricles fill; best heard @ the apex; present in about 1/3 of all children The PMI is higher and more medial in children under 8 years old

Dyana M. M. Saplan, RN, MAN

Elders
If no disease is present heart size remains the same throughout life Cardiac output and strength of contraction es lessening the older persons activity tolerance rate returns to its resting rate more slowly after exertion than it did when the individual was younger S4 heart sound considered normal in older adults Extra systole commonly occur
10 or more systoles/minute are considered abnormal

Sudden emotional and physical stresses may result in cardiac arrythmias and heart failure.

Dyana M. M. Saplan, RN, MAN

Peripheral vascular system

Assessing peripheral vascular system includes:
Measuring the blood pressure Palpating peripheral pulses, and Inspecting the skin and tissues to determine perfusion (blood supply to an area) to the extremities

Dyana M. M. Saplan, RN, MAN

Homans test
Done to assess deep vein thrombosis Firmly dorsiflex the clients foot while supporting the entire leg in extension or have client stand or walk (+) Homans test pain in calf muscles w/ forceful dorsiflexion of the foot

Dyana M. M. Saplan, RN, MAN

Other Tests:
Buergers Test (Arterial Adequacy Test)
Normal: original color returns in 10 sec.; veins in feet or hands fill in about 15 sec. Deviation: delayed color return or mottled appearance; delayed venous filling; marked redness of arms or legs (indicates arterial insufficiency)

Capillary Refill Test

Dyana M. M. Saplan, RN, MAN

Video Presentation

Dyana M. M. Saplan, RN, MAN