Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system

1. Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system

2. Great vessels of the neck Jugular veins Carotid arteries Jvd Carotid artery pulse – correlates with first heart sound Jugular veins Empty unoxugenated blood directly into the superior vena cava, which empties into the right side of the heart Carotid arteries Reflects cardiac systole and is timed with S1, Palpate only one at a time Jvd Carotid artery pulse – correlates with first heart sound Jugular veins Empty unoxugenated blood directly into the superior vena cava, which empties into the right side of the heart Carotid arteries Reflects cardiac systole and is timed with S1, Palpate only one at a time

3. JVD

4. Assessment Position client supine Then head elevated at 45 degrees INSPECTION: Lifts, heaves, pulsations PMI (assess location) Stand on the patient’s right side if you’re right handed and left if left handed Look for pulsations, symmetry of movement, retractions, or heaves (a lifting in the cardiac area; a strong outward thrust of the chest wall and occurs during systole) Use your landmarks when you note any lifting or other pulsations (sternal line, midclavicular lne, axillary line) The PMI or apical impulse gives an indication of how well the left ventricle is working because it corresponds to the apex of the heart. The impulse can be visualized in about 50% adults. It is more visible in children and patients with thin chest walls. Displace the breast in women with large breasts.Stand on the patient’s right side if you’re right handed and left if left handed Look for pulsations, symmetry of movement, retractions, or heaves (a lifting in the cardiac area; a strong outward thrust of the chest wall and occurs during systole) Use your landmarks when you note any lifting or other pulsations (sternal line, midclavicular lne, axillary line) The PMI or apical impulse gives an indication of how well the left ventricle is working because it corresponds to the apex of the heart. The impulse can be visualized in about 50% adults. It is more visible in children and patients with thin chest walls. Displace the breast in women with large breasts.

5. Palpation Maintain a gentle touch when you palpate so you won’t obscure pulsations. Palpate with the palmar aspects of your four fingers to note for any thrills (fine vibrations that feel like a purring cat) Palpate over the precordium to find the apical impulse Also palpate the pulmonic, tricuspid, aortic and tricuspid areas for abnormal pulsations. May be difficult to palpate in obese patients and pts with thick chest walls. If its difficult to palpate the apical impulse with the pt lying on his back, have him lie on his left side or sit upright Normally you won’t feel pulsations in those areas. An aortic arch pulsation in the sernoclavicular area, and an epigastric pulsation in the epigastic area may be a normal finding in a thin pt.Maintain a gentle touch when you palpate so you won’t obscure pulsations. Palpate with the palmar aspects of your four fingers to note for any thrills (fine vibrations that feel like a purring cat) Palpate over the precordium to find the apical impulse Also palpate the pulmonic, tricuspid, aortic and tricuspid areas for abnormal pulsations. May be difficult to palpate in obese patients and pts with thick chest walls. If its difficult to palpate the apical impulse with the pt lying on his back, have him lie on his left side or sit upright Normally you won’t feel pulsations in those areas. An aortic arch pulsation in the sernoclavicular area, and an epigastric pulsation in the epigastic area may be a normal finding in a thin pt.

6. Physical Landmarks Suprasternal notch Sternum Manubriosternal angle – Angle of Louis Intercostal Spaces Suprasternal Notch – notch above the sternum Sternum – breastbone – can feel in between breasts Manubriosternal angle- The protuberance felt where the manubrium joins the sternum. It is located at the level of the second ribs. Intercostal spaces – spaces between the ribs. The number of ICS corresponds to the number of the ribs above it.Suprasternal Notch – notch above the sternum Sternum – breastbone – can feel in between breasts Manubriosternal angle- The protuberance felt where the manubrium joins the sternum. It is located at the level of the second ribs. Intercostal spaces – spaces between the ribs. The number of ICS corresponds to the number of the ribs above it.

7. Auscultation: Auscultatory Sites Normal heart sounds indicate events in the cardiac cycle, such as the closing of the heart valves, and are reflected to specific areas of the chest wall. Diahragm of the stethoscpe – for highpitched sounds – heart sounds Bell- for low pitched sounds – bruits, murmurs When auscultating sounds, place the stethoscpe over the four different site All physicians take money- APTM The sites are identified by the names of heart valves… but they are not located directly over the valves. Rather, these sites are located along the pathway blood takes as it flows throught eh heart’s chambers and valves. Normal heart sounds indicate events in the cardiac cycle, such as the closing of the heart valves, and are reflected to specific areas of the chest wall. Diahragm of the stethoscpe – for highpitched sounds – heart sounds Bell- for low pitched sounds – bruits, murmurs When auscultating sounds, place the stethoscpe over the four different site All physicians take money- APTM The sites are identified by the names of heart valves… but they are not located directly over the valves. Rather, these sites are located along the pathway blood takes as it flows throught eh heart’s chambers and valves.

8. ? Sounds – S1(Lub)…& S2(Dub) When you auscutate a patient’s chest and hear the familiar lub-dub , you are hearing the first heart sound S1 ad the second heart sound S2. S1: Closure of AV valves: tricuspid & mitral valves (T,M) Correlates with carotid pulse Apex S1 louder than S2 S2: Closure of Semilunar valves: aortic & pulmonic (A,P) Base (R/L 2nd ICS) S2 louder than S1 May have a split sound (A2 before P2) When the valves close, the heart muscle can be heard through the chest wall. Contraction of the ventricles- ventricular pressure rises, closing the mitral and tricuspid valves (to prevent backflow) and causes vibrations heard as S1. Ventrcles relax- ventricular pressure falls and the aortic and pulmonic valves close, causing vibrations heard as S2 Identify S1 and S2 and ten listen for any extra heart sounds such as S3 and S4 or any murmurs S1: Closure of AV valves (mitral and tricuspid valves: M1 before T1) Increased blood flow to right heart and delays pulmonic valve closure will increase splitting When you auscutate a patient’s chest and hear the familiar lub-dub , you are hearing the first heart sound S1 ad the second heart sound S2. S1: Closure of AV valves: tricuspid & mitral valves (T,M) Correlates with carotid pulse Apex S1 louder than S2 S2: Closure of Semilunar valves: aortic & pulmonic (A,P) Base (R/L 2nd ICS) S2 louder than S1 May have a split sound (A2 before P2) When the valves close, the heart muscle can be heard through the chest wall. Contraction of the ventricles- ventricular pressure rises, closing the mitral and tricuspid valves (to prevent backflow) and causes vibrations heard as S1. Ventrcles relax- ventricular pressure falls and the aortic and pulmonic valves close, causing vibrations heard as S2 Identify S1 and S2 and ten listen for any extra heart sounds such as S3 and S4 or any murmurs S1: Closure of AV valves (mitral and tricuspid valves: M1 before T1) Increased blood flow to right heart and delays pulmonic valve closure will increase splitting

9. Heart Sounds – Cont. Normal physiologic S2 Split Best heard at pulmonic area during inspiration Fixed split (no variation with inspiration)-abnormal Draw a diagram S1 loudest at the apex (tricuspid), this sound corresponds to the closure of M1& T1 May be split. S2 loudest at the base (aortic), Physiologic S2 splitting- heard best at pulmonic area during peak inspiration S2 splitting – when the pulmonic valve closes later than the aortic valve – normal during inspiration Fixed split – ASHD – no variation with insp. Draw a diagram S1 loudest at the apex (tricuspid), this sound corresponds to the closure of M1& T1 May be split. S2 loudest at the base (aortic), Physiologic S2 splitting- heard best at pulmonic area during peak inspiration S2 splitting – when the pulmonic valve closes later than the aortic valve – normal during inspiration Fixed split – ASHD – no variation with insp.

10. Extra Heart Sounds S3… Due to Rapid ventricular filling: ventricular gallop S1 -- S2-S3 (Ken--tuc-ky) S4… Due to slow ventricular contraction: atrial gallop S4-S1 — S2 (Ten-nes—see) a low-pitch vibration in early diastole immediately after S2 S3- rapid ventricualr filling; called a ventricular gallop in adults. May be a cardinal sign of CHF in adults. Frequently heard in children and in pts with high cardiac output. Ken-tuc-ky May be normal in children, and patients with high cardiac output (athletes) Pathological in adults: CHF, HTN, CAD S4 Soft, low-pitched sound in late diastole immediately before S1 May be physiological in infants and small children a low-pitch vibration in early diastole immediately after S2 S3- rapid ventricualr filling; called a ventricular gallop in adults. May be a cardinal sign of CHF in adults. Frequently heard in children and in pts with high cardiac output. Ken-tuc-ky May be normal in children, and patients with high cardiac output (athletes) Pathological in adults: CHF, HTN, CAD S4 Soft, low-pitched sound in late diastole immediately before S1 May be physiological in infants and small children

11. Murmurs turbulent blood flow within the heart Listen for murmurs in the same auscultatory sites APETM Grading of murmurs (I/VI -VI/VI) Murmurs occur when structural defects in the heart’s chambers or valves cause turbulent blood flow. Turbulence may also be caused by changes in the viscosity of blood or the speed of blood flow (too fast –compensatory like in anemia). Listen for murmurs in the same auscultatory sites APTM Heart Murmurs What is a heart murmur? A heart murmur, also called a cardiac murmur, is an abnormal sound made as blood moves through the valves during beating of the heart. A murmur can be described as blowing, wooshing or rasping noises and are rated on a scale according to occurrence, intensity and sound (Mosby). What is the cause of a heart murmur? The murmur is a result of altered blood flow as it passes through the heart chambers and valves. The noises are caused by irregularities on the inside of the walls of the heart. The vessels are not perfectly smooth and valves, which keep blood flowing in one direction, may not seal each heart chamber perfectly, making a “swooshing” sound or irregular noises. A murmur can be created or increased in intensity during exercise, when a person gets nervous, or at times when the heart simply needs to beat harder than normal. In addition, murmurs may be caused by pregnancy, fever, thyrotoxicosis (overactive thyroid gland), or anemia (American). A heart murmur may be caused by a previous heart condition or strain to the heart from a previous illness. One example is Rheumatic fever which can damage valves of the heart, leading to a possible murmur. (Donohue) Murmurs occur when structural defects in the heart’s chambers or valves cause turbulent blood flow. Turbulence may also be caused by changes in the viscosity of blood or the speed of blood flow (too fast –compensatory like in anemia). Listen for murmurs in the same auscultatory sites APTM Heart Murmurs What is a heart murmur? A heart murmur, also called a cardiac murmur, is an abnormal sound made as blood moves through the valves during beating of the heart. A murmur can be described as blowing, wooshing or rasping noises and are rated on a scale according to occurrence, intensity and sound (Mosby).

12. Peripheral Vascular Assessment Skin temp Color Pulses Cap refill edema Peripheral vascular system= assesment of the vascular system is an important part of the cardiovascular system Assess skin temp and color, cap refill, pulses, edema Cyanosis, pallor, or cool skin may indicate poor cardiac output and tissue perfusion Palpate pulse on each side comparing pulse volume and symmetry. Cap refill should be less than 3 sec Swelling or edema may indicate CHF or venous insufficiency. They may also be caused by varicosities or thrombophlebitis Chronicrigtventricular failure may cause ascites and generalized edema. Localized swelling may be caused by compression of a vein in a specific area Do not palpate the carotid arteries at the same time or press too firmly – pt may faint or become bradycardic. (vagal stim) Can reveal arterial or venous disorders. Does not have to be a totally separate assessment. Examine the pts arms when taking vital signs; check legs later during physical exam whe the pt is lying on his back., evaluate leg veins when the pt stands upPeripheral vascular system= assesment of the vascular system is an important part of the cardiovascular system Assess skin temp and color, cap refill, pulses, edema Cyanosis, pallor, or cool skin may indicate poor cardiac output and tissue perfusion Palpate pulse on each side comparing pulse volume and symmetry. Cap refill should be less than 3 sec Swelling or edema may indicate CHF or venous insufficiency. They may also be caused by varicosities or thrombophlebitis Chronicrigtventricular failure may cause ascites and generalized edema. Localized swelling may be caused by compression of a vein in a specific area Do not palpate the carotid arteries at the same time or press too firmly – pt may faint or become bradycardic. (vagal stim) Can reveal arterial or venous disorders. Does not have to be a totally separate assessment. Examine the pts arms when taking vital signs; check legs later during physical exam whe the pt is lying on his back., evaluate leg veins when the pt stands up

13. Peripheral Pulses

14. Documentation of Pulses

15. Capillary Refill Should test fingers and toes Press down on end of nail to compress capillaries Color goes white, then release Color should return briskly; < 3 seconds Document “sluggish” if > 3 seconds Should test fingers and toes Press down on end of nail to compress capillaries Color goes white, then release Color should return briskly; < 3 seconds Document “sluggish” if > 3 seconds

16. Edema

17. Pitting edema

18. Assessing for Edema Depress pretibial area & medial malleolus for 5 seconds Nonpitting edema vs pitting edema Grade if pitting present (1+ to 4+) Depress pretibial for 5 seconds Depress pretibial for 5 seconds

19. Peripheral Vascular Assessment:Deep Vein Thrombosis (DVT) Skin temp Color Pulses Cap refill edema Skin temp Color Pulses Cap refill edema

20. A 92 year-old man went to the Doctor to get a physical. A few days later the Dr. saw the man walking down the street with a gorgeous young lady on his arm. A couple of days later the Dr. talked to the man and said, "You're really doing great, aren't you?" The man replied, "Just doing what you said Doctor, 'Get a hot mamma and be cheerful." The Doctor said, "I didn't say that. I said you got a heart murmur. Be careful."

21. Assessment Guide: Gas Transportation Blood Pressure: 128/64, 132/72 Apical Heart Rate: 80, 74 Peripheral Pulse: Radial rate: 78, 74 Rhythm: regular, irregular Strength: strong, weak, thready, bounding,0-+4 Rt. Pedal pulse: 2+ Lt. Pedal pulse: 2+ Edema: present, none Degree: 1+, 2+ Location: LLE, RUE Cap refill Upper extremities: 2 sec Lower extremities: 2 sec Skin/Mucous Membranes: Other (bleeding, infection) Skin /mucous membranes pink note vascular lesions (purpura, ecchymoses, petechiae) redness and inflammation Interventions in use Venodyne/leg compression machine; elevated LEs on pillow; thigh high tedhose in use Med List: Digoxin, Atenolol, Zestril, etc. Blood Pressure: 128/64, 132/72 Apical Heart Rate: 80, 74 Peripheral Pulse: Radial rate: 78, 74 Rhythm: regular, irregular Strength: strong, weak, thready, bounding,0-+4 Rt. Pedal pulse: 2+ Lt. Pedal pulse: 2+ Edema: present, none Degree: 1+, 2+ Location: LLE, RUE Cap refill Upper extremities: 2 sec Lower extremities: 2 sec Skin/Mucous Membranes: Other (bleeding, infection) Skin /mucous membranes pink note vascular lesions (purpura, ecchymoses, petechiae) redness and inflammation Interventions in use Venodyne/leg compression machine; elevated LEs on pillow; thigh high tedhose in use Med List: Digoxin, Atenolol, Zestril, etc.

22. Cap refill Upper extremities: 2 sec Lower extremities: 2 sec Skin/Mucous Membranes: Other (bleeding, infection) Skin /mucous membranes pink note vascular lesions (purpura, ecchymoses, petechiae) redness and inflammation Interventions in use Venodyne/leg compression machine; elevated LEs on pillow; thigh high tedhose in use Med List: Digoxin, Atenolol, Zestril, etc.