UWE Bristol Cardiovascular system examination

1. UWE BristolCardiovascular system examination Anna Neary

2. Cardiovascular system examination Introduction Prior to undertaking this learning activity you should have completed the learning activities: An introduction to Consultation models and History taking. This activity looks at examination and assessment of the cardiovascular system as a crucial component of a systematic patient assessment. In this activity, you will: • Explore the anatomy of the heart • Consider a systematic approach to cardio-vascular examination • Explore the elements of a general survey • Consider peripheral pulses • Determine the skills required to perform an examination i.e. inspection, palpation and auscultation

3. Cardiovascular system examination The Heart The heart has four chambers and four valves that pump blood to the pulmonary and systemic circulation. The left side of the heart comprising of the left atrium and ventricle, receives blood from the lungs and pumps blood to the tissues (high pressure). The right side comprising of the right atrium and ventricle receives blood from systemic veins and pumps blood to the pulmonary system (low pressure).

4. Cardiovascular system examination The valves of the heart and their function The heart has four valves: • TheAtrioventricular valves, the tricuspid valve on the right and the mitral on the left. • ThePulmonary valve between the right ventricle and pulmonary artery, this is a semi-lunar valve. • TheAortic valve between the left ventricle and the aorta, this is a semi lunar valve. All of the valves, when functioning normally, act as one-way valves, allowing blood to flow either from one chamber to another, or allowing blood to flow out of the heart, in only one direction. The valves control the flow of blood through the heart by opening and closing during the contractions of the heart. All of the valves open and close passively as a result of pressure changes within the four chambers and the great vessels.

5. Cardiovascular system examination The heart as a pump Systole: the ventriclescontract: • The right ventricle pumps blood into the pulmonary arteries, the pulmonic valve is open. • The left ventricle pumps blood into the aorta, theaortic valve is open. Diastole: the ventricles relax: • Blood flows from the right atrium → right ventricle, the tricuspid valve is open. • Blood flows from the left atrium → left ventricle, the mitral valve is open.

6. Cardiovascular system examination The vascular system The vascular system is made up of many arteries, arterioles, veins, venules and capillaries, their function is to deliver oxygen, nutrients and substances to the body’s cells and remove waste products. An adults circulating blood volume at any one given time is between 4 to 6 litres of blood. The pulse A pulse is an arterial pressure wave, generated from the pumping action of the heart. These can be felt at a variety of locations throughout the body. When feeling for the pulsation in a number of locations you are pressing the artery against bone, and this will require firm pressure. The exception is the carotid artery.

7. Cardiovascular system examination Systematic examination There are three aspects to consider when carrying out a systematic examination: LOOK: inspect FEEL: palpate and percuss LISTEN: auscultate

8. Cardiovascular system examination General Survey First you need to take time to look at your patients overall appearance, remembering the importance of basic assessment i.e. airway, breathing, circulation, disability and exposure and move on only when there is no immediate intervention in these areas. Also consider whether your patient appears to be alert or confused or aggressive. You will need to check their blood pressure in both arms, heart rate, respiratory rate and pulse. Look at hands, check for signs of cyanosis and any nail deformities. Does you patient look pale, sweaty are there any signs of cyanosis, are there signs of any shortness of breath? Think about other factors, is your patient thin or obese are they anxious are there any abnormal facial features e.g. Down’s syndrome are linked with congenital heart disease. Check for peripheral oedema. This survey will then become your opening words for the examination section in your documentation.

9. Cardiovascular system examination Below are some of the hand abnormalities that you may find with patients who have cardio-vascular disease. • Clubbing – swelling of the soft tissue at the nail base, can be due to hypoxia and congenital heart disease, lung disease, inflammatory bowel disease and malignancies. • Terry’s nails – transverse bands of white that cover the nail, pink at the distal aspect, this commonly associated with liver disease. • Koilonychia – this is thin spooned shaped nails with edges turning upwards, this is associated with anaemia, chronic infections, Raynaud’s disease and malnutrition. • Cool skin - can indicate poor cardiac output and tissue perfusion. • Splinter haemorrhages - fine vertical lines in the nail can be associated with bacterial endocarditis.

10. Cardiovascular system examination Inspection You need to look at the chest wall anterior and posterior. This will require that you undress your patient. Look at the shape of the chest, also their work of breathing, are there any scars, bruising or pacemaker sites, can you see any visible pulsations? Does your patient appear pale and/or central cyanosed? When looking at the movement of the chest you need to check symmetry and pulling in of the chest. Think about the underlying structure within the chest, look for any strong outward thrust of the chest wall that occurs during systole, this is called a heave.

11. Cardiovascular system examination Signs and symptoms of cardiovascular conditions Thesigns and symptoms you may observe in a patient with a cardiovascular condition are: • Shortness of breath • Pallor • Confusion • Cyanosis of lips and peripheral cyanosis • Chest pain • Clubbing of finger nails • Anxiety and distress • Tremor • Sweating • Malar flush • Corneal arcus • Xanthomata and/or xanthelasma • Petechial haemorrhages

12. Cardiovascular system examination Palpate Palpate the anterior and posterior chest wall. This requires gentle touch so that any pulsations or other findings are not missed. The ball of the hand and the finger tips are placed over the precordium to find a apical beat and the flat of the hand is placed over the chest to feel for any heaves or thrills. This will feel like a purring cat. Check for tenderness while you are palpating. It is important to note that the apical beat can be difficult to locate in an obese patient or a patient with a thick chest wall. Asking the patient to roll slightly over onto their left side or lean forward can move the heart slightly anteriorly making it easier to feel.

13. Cardiovascular system examination Capillary refill Assess capillary refill, centrally or peripherally. Apply pressure for 5 seconds, then observe the blood flow back into the finger or chest wall it should return within 2 seconds, this is a normal capillary refill time. It should be recorded as CRT < (less than) 2 seconds or CPT > (greater than) 2 seconds.

14. Cardiovascular system examination Palpate pulses • Palpate pulses • Count beats per minute • Assess quality and regularity of pulse. • Never check the both carotid arteries together, check one at a time, pressing too firmly will cause you patient to faint. • Click on thumbnails for site name Bilateral radial pulses Bilateral brachial pulse Bilateral carotid pulses

15. Cardiovascular system examination Auscultation • Listen at 5 points with the patient at 45 degrees. • Aortic (2nd Intercostal space, Right Sternal Boarder) • Pulmonary x 2 (2nd ICS, LSB and 3rd ICS LSB) • Tricuspid (4th ICS, LSB) • Mitral (5th ICS, LSB) You will here “lub” “dub” throughout all 5 points however, the first heart sound is “lub” and is caused by the closure of the mitral and tricuspid valves and is heard loudest at the apex of the heart (M). The second heart sound is “dub” and is caused by the closure of the pulmonary and aortic valves and is heard loudest on the right (aortic) and left (pulmonary) sternal edge (A and P). There are many heart sounds that can indicate abnormalities within the heart. Click on the link and then listen to both recordings of Heart Sounds.

16. Cardiovascular system examination Summary You have now reached the end of this activity. Here is a summary of the key points: • It is important to know the anatomy of the heart prior to any examination of the cardio-vascular system. • It is essential to examine the cardio-vascular system using a systematic approach i.e. general survey, inspection, palpation and auscultation. • It is important to have heard normal heart sounds on auscultation so that abnormal heart sounds can be differentiated.

17. Cardiovascular system examination References • Douglas, G, Nicol, F and Robertson, C (2009) Macleod’s Clinical Examination. Churchill Livingstone • Hogan-Quigley, B, Louise Palm, M, Bickley, L (2012)Bates’ Nursing Guide to Physical Examination and History Taking. First Edition. Lippincott, Williams and Wilkins. • Rushforth, H (2009) Assessment made incredibly easy.First UK Edition. Lippincott, Williams and Wilkins. • Tortora, G and Derrickson, B (2010) Essentials of anatomy and physiology. Wiley Plus

18. Cardiovascular system examination Guided learning (Duration: 2 hours) As part of your guided study throughout these activities you are required to keep a record of the patient’s documentation (anonymous) and also reflect on your own consultation style. • Identify a patient in practice and under the supervision of an Advanced Nurse Practitioner or doctor, watch a cardio-vascular examination and then perform a cardio-vascular examination. Use the templates provided as an aid memoir. • Discuss your findings with the ANP or doctor. • Research common cardio-vascular conditions, Write a reflective piece of work about a patient you have seen and the guidelines you have learnt. The websites cardiovascular disease and prevention of cardiovascular disease will help your research. • You will also be able to attend a day long face to face skills workshop to complement this learning activity.

19. Cardiovascular system examination Introduction Prior to undertaking this learning activity you should have completed the learning activities: An introduction to Consultation models and History taking. This activity looks at examination and assessment of the cardiovascular system as a crucial component of a systematic patient assessment. In this activity, you will: • Explore the anatomy of the heart • Consider a systematic approach to cardio-vascular examination • Explore the elements of a general survey • Consider peripheral pulses • Determine the skills required to perform an examination i.e. inspection, palpation and auscultation

20. Cardiovascular system examination Introduction Prior to undertaking this learning activity you should have completed the learning activities: An introduction to Consultation models and History taking. This activity looks at examination and assessment of the cardiovascular system as a crucial component of a systematic patient assessment. In this activity, you will: • Explore the anatomy of the heart • Consider a systematic approach to cardio-vascular examination • Explore the elements of a general survey • Consider peripheral pulses • Determine the skills required to perform an examination i.e. inspection, palpation and auscultation

21. Cardiovascular system examination Introduction Prior to undertaking this learning activity you should have completed the learning activities: An introduction to Consultation models and History taking. This activity looks at examination and assessment of the cardiovascular system as a crucial component of a systematic patient assessment. In this activity, you will: • Explore the anatomy of the heart • Consider a systematic approach to cardio-vascular examination • Explore the elements of a general survey • Consider peripheral pulses • Determine the skills required to perform an examination i.e. inspection, palpation and auscultation