Cardiovascular assessment lab
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CardioVascular Assessment Lab. C Ruckdeschel RN, BSN. Objectives. Review Anatomy of Heart Review Vascular System Review Physiologic basics for Cardiovascular System. Objectives:. Identify Skills to assess cardiovascular System: Pulse Peripheral vascular assessment Heart Sounds

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Cardiovascular assessment lab

CardioVascular Assessment Lab

  • C Ruckdeschel RN, BSN


Objectives

Objectives

  • Review Anatomy of Heart

  • Review Vascular System

  • Review Physiologic basics for Cardiovascular System


Objectives1

Objectives:

  • Identify Skills to assess cardiovascular System:

    • Pulse

    • Peripheral vascular assessment

    • Heart Sounds

    • Blood Pressure


Anatomy of heart

Anatomy of Heart

  • Right side of heart - receives deoxygenated blood from systemic circulation - LOW PRESSURE

  • Left Side of the heart - receives oxygenated blood from pulmonary circulation and pumps it into systemic circulation - HIGH PRESSURE


Chambers and valves

Chambers and Valves

  • Rt Atrium

    • RT AV Valve (Tricuspid)

  • Rt Ventricle

    • Rt semilunar (Pulmonic)

  • Left Atrium

    • Lft AV Valve (bicuspid, Mitral)

  • Left Ventricle

    • Left semilunar (Aortic)


Great vessels of the heart

Great Vessels of the Heart

  • Vena Cava - deoxygenated blood brought to heart

    • IVC (inferior vena Cava)

    • SVC (superior Vena Cava)

  • Pulmonary Artery - deoxygenated blood from rt ventricle to pulmonary capillaries

  • Pulmonary Veins - oxygenated blood from pulmonary capillaries to lft atrium

  • Aorta -

    • Ascending

    • Arch

    • Descending

      • Thoracic

      • Abdominal

http://www.youtube.com/watch?v=PgI80Ue-AMo


Coronary arteries

Coronary Arteries

  • Arteries that arise from base of aorta and supply myocardium with richly oxygenated blood

  • LCA

    • LAD

    • Circumflex

  • RCA


Cardiac conduction system

Cardiac Conduction System

  • Heart is innervated by Autonomic nervous system

    • Sympathetic : stimulates

    • Parasympathetic: slows

    • SA Node (Sinoatrial node): located in right atria, generates impulses that travel through the conduction system & produce cardiac muscle contraction.

    • AV Node (atrioventricular node): located in the atrial septum

    • Bundle of His: right and left bundle branches

    • Purkinjie fibers: located in ventricular myocardium, where ventricular contraction takes place


12 lead ekg

12 Lead EKG

  • Chest X-ray


Common cardiovascular problems

CommonCardiovascular Problems

  • CAD (Coronary Artery Disease)

  • HTN (Hyypertension) > 80% of US population

  • RHD (Rheumatic Heart Disease) - Sequelae of beta hemolytic strep infections resulting in valvular damage, more likely seen In older adults

  • BE (Bacterial Endocarditis) - bacteremia causes valvular damage

  • CHD (Congenital Heart Disease) – greatest portion diagnosed early in life


Peripheral vascular anatomy

Peripheral Vascular Anatomy

  • Aorta

  • Arteries

    • Arterioles

    • Capillaries

    • Venules

  • Veins

  • Vena Cava


Important vessels

Important Vessels

  • Accessible arteries:

    • Temporal, Carotid, Aorta, Brachial, Ulnar, Radial, Femoral, Popliteal, Doraslis pedis, Posterior Tibial

  • Accessible veins:

    • Jugular, Superficial & deep arm veins, Femoral vein (deep), Popliteal vein (deep), saphenous (superficial)


Physiologic basics

Physiologic Basics

  • Myocardium - muscle layer of the heart that allows it to act as pump

  • Cardiac Output = HR x SV

  • Heart Rate (pulse) = beats per minute

  • Blood Pressure = SVR x CO

  • Electrical conduction of the heart


Assessing heart sounds

Assessing: Heart Sounds

  • Heart Sound Review

    • Location

      • Aortic: 2nd ICS, RSB (s2 is loudest)

      • Pulmonic: 2nd ICS, LSB (s2 is loudest)

      • Erbs Point: 3rd ICS, LSB

      • Tricuspid: 4th ICS, LSB (s1 is loudest)

      • Mitral (Apex): 5th ICS, MCL (s1 is loudest)

    • S1: represents ventricular contraction & ejection: S1 sound is produced by closing of AV valves (tricuspid and Mitral valves)

    • S2: represents ventricular relaxation & filling: S2 sound is produced by closing of semilunar valves: Aortic and Pulmonic valves

http://www.youtube.com/watch?v=Ge12P7u0aQo


Assessing heart sounds1

Assessing: Heart Sounds


Assessing heart sounds2

Assessing: Heart Sounds

  • Obtain History

    • Any medications?type

  • doseside effectsexpected effectstake as prescribed?

  • Pacemaker

  • Typebattery checkPresence of AICDautomated internal defibrillator

    • Obtain History

      • Risk factors/lifestyle

        • diet, exercise

        • smoking

        • cholesterol

        • stress, palpitations

        • dyspnea/orthopnea

        • edema

        • fatigue - relationship to exercise

        • chest pain

          • Location substernal?

          • Radiate precordial?

          • Quality crushing?

          • Associated N/V

          • Related to activity?


    Assessing heart sounds3

    Assessing: Heart Sounds

    • Obtain History

    • Past Family History

    • Angina

    • Heartdisease

    • MI,StrokeDM,

    • Hyperlipidemia

    • Sudden death age?

    • Obtain History

      • Past Health History

        • Diabetes

        • Dependent edema

        • congenital heart defect

        • CAD

        • Rheumatic fever

        • Most recent EKG, stress EKG

        • Other diagnostics


    Assessing heart sounds4

    Assessing: Heart Sounds

    • Inspection

      • Bare chest

      • Quiet room, Privacy

      • Note: symmetry of chest, any pulsatile areas, discolorations

    • Palpate

      • Precordium

      • palpate 5 sites for:

        • Heave (with palmer surface), thrust

        • Thrill (with base of finger of heel of hand (bony part))

        • palpable murmur » cat purring

    • Thrills - indicative of obstructed flow

      • fine palpable rushing sensation

      • R or L 2nd ICS - Aortic or pulmonic stenosis

    • When palpate precordium use other hand to palpate carotid artery

      • S1 should coincide with carotid impulse


    Assessing heart sounds5

    Assessing: Heart Sounds

    • Auscultate

      • Use diaphragm and bell of stethoscope

      • start with diaphragm, (S1 and S2 relatively high pitched)

      • use bell to listen for S3 and S4

    • heart sounds - S1 and S2

      • rate

      • rhythm - regular (NSR), irregular (warrants investigation)

      • extra sounds? Murmurs?

      • Auscultation: want to hear crisp, distinct S1 and S2

      • S1 > at apex

      • S2 > at base


    Assessing heart sounds6

    Assessing: Heart Sounds

    • BE Systematic!! APE TO MAN

    • Listening for S1 and S2

    • interval between S1 and S2 should be silent

    • heart sounds not heard best directly over valve which produces it, but in direction of blood flow

    • there are specific sites where each valve sound is best heard


    Cardiovascular assessment lab

    http://www.youtube.com/watch?v=2aO0HKIP3vI


    After auscultating heart sounds

    After Auscultating Heart Sounds.....

    • Perfect time to auscultate Apical Pulse.

    • Count for one full minute, each cardiac cycle.

      • Note rate & rhythm


    What is a pulse

    What is a Pulse?

    • The ventricles pump blood into the arteries at about 72 bpm. The blood causes an alternating expansion and recoil creates a pressure wave which travels through all of the arteries.


    Pulse

    Pulse

    • Adult (60-100) bpm

    • Child (80-120) bpm

    • Infant ( 140 bpm)

    • Palpated on superficial arteries (pulse points)

    • Auscultated on Apex of the heart


    Pulse variations

    Pulse Variations:

    • Tachycardia - >100 bpm

    • Bradycardia - < 60 bpm

    • Palpitations - Unpleasant sensations of awareness of the heartbeat: described as skipped beats, racing, fluttering, pounding or irregularity: may result from rapid acceleration or slowing of heart, increased forcefulness of cardiac contraction: not necessarily associated with heart disease.


    Factors assessing pulse

    Factors Assessing Pulse

    • Cardiac output

    • Age

    • Gender

    • Exercise

    • Fever

    • Stress

    • Position


    Factors assessing pulse1

    Factors Assessing Pulse

    • Cardiac Output

      • Amount of blood ejected from the heart in one minute

      • Measured by SV x HR

      • Normal HR = 60 - 100 beats per minute


    Factors assessing pulse2

    Factors Assessing Pulse

    • Age

      • Adult (60-100) bpm

      • Child (80-120) bpm

      • Infant ( 140 bpm)

    • Gender - after puberty female > male

    • Exercise

      • increased HR with activity

      • increased metabolism causes vasodilatation

      • causes ­ O2 demand


    Factors assessing pulse3

    Factors Assessing Pulse

    • Fever

      • body compensates for increased temp by vasodilatation, decreased BP causes body to compensate by > HR

      • increased 10-20 beats/min/ degree above norm

      • especially in children


    Factors assessing pulse4

    Factors Assessing Pulse

    • Stress

      • sympathetic response, increases HR & BP

    • Position

      • sitting, standing causes pooling

      • results in transient - BP

      • rate compensates by increasing


    Assessing pulse

    Assessing : Pulse

    • Please note:

    • Assessing a heart rate is determining beats per minute, noting rate, rhythm and strength.

    • Assessing peripheral pulses is to assess arterial blood flow to peripheral arteries.


    Assessment pulse auscultating at apex

    Assessment: PulseAuscultating at Apex

    • Using the diaphragm of your stethoscope, place it on the 5th intercostal space, MCL

    • For one full minute, count each LUB, DUB as one!!

    • Location of left ventricular apex & PMI (point of maximum impulse)

      • Adult: 5th ICS, MCL

      • Infants: 4th ICS, left of MCL

      • Pregancy: PMI moves 1-2 cm left of MCL & up to 4th ICS


    Assessment pulses peripheral pulses

    Assessment:PulsesPeripheral Pulses

    • Obtain History

      • Intermittent claudication

      • pain on walking disappears with rest

      • leg cramps, leg ulcers

      • varicose veins

      • edema of feet or legs

      • blood clots

      • pallor of fingertips


    Assessment pulses peripheral pulses1

    Assessment:PulsesPeripheral Pulses

    • Inspection of Extremities Compare Left to Right

      • Size

      • Symmetry

      • Skin/color

      • Nail Beds

      • Nails

      • Hair Growth


    Assessment pulses peripheral pulses2

    Assessment:PulsesPeripheral Pulses

    • Palpation - Compare Right to Left

      • Temperature

      • Capillary refill

      • Pulses

        • UE:Radial,Brachial

        • LE: Dorsalis Pedis, Posterior tibial, popliteal, Femoral

      • Edema

      • +1- +4 pitting

      • Sensation


    Assessment pulses characteristics of pulses

    Assessment: PulsesCharacteristics of Pulses

    • Rate

    • Rhythm - regular, irregular

    • Contour/elasticity

    • Strength (Amplitude)

      • +4 = bounding

      • +3 = full, increased

      • +2 = normal

      • +1 = diminished, weak

      • 0 = absent


    Arterial insufficiency of lower extremities

    Arterial Insufficiency of Lower Extremities

    • Pulses - Decreased/Absent

    • Color - Pale on elevation : Dusky Rubor on dependency

    • Temperature - Cool/Cold

    • Edema - None

    • Skin - Shiny, thick nails, no hair, Ulcers on Toes

    • Sensation - Pain, more with exercise, Paresthesias


    Venous insufficiency of lower extremities

    Venous Insufficiency of Lower Extremities

    • Pulses - Present

    • Color- Pink to cyanotic, Brown pigment at ankles

    • Temperature - Warm

    • Edema - Present

    • Skin - Discolored, scaly, ulcers on ankles

    • Sensation - Pain, More with standing or sitting. Relieved with elevation/support hose


    Peripheral vascular disease

    Peripheral Vascular Disease

    • Nursing interventions to promote venous return

      • ankle circles, flex ankles, frequent ambulation, avoid dependent position for prolonged periods of time

      • apply TED stockings or ace bandages (if no arterial problem)

    • Nursing Diagnosis

      • Altered cardiac output: decreased

      • Altered tissue perfusion:peripheral

      • Fluid volume deficit: actual

    • Irregular Rhythm

      • ALL irregular rhythms demand an APICAL RADIAL assessment


    Assessment blood pressure

    Assessment: Blood Pressure

    • Obtain History:

    • ** Modifiable Risk factors**

    • SmokingEmployment: physical vs emotional demands, environmental hazard, stress managementNutritional Status: body fat & type of dietAnaerobic exerciseEstrogen replacement (if post-menopausal)Drug use – alcohol,, cocaine, prescription & OTCEssential HTNHypercholesterolemia, DM, CAD

    • Obtain History:

    • ** Non-modifiable Risk factors **

      • Age, sex, personality type

      • Family History – sudden death, HTN, stroke, MI prior to 50, severe hyperlipidemis, DM

      • PMH – arrythmias, murmurs, CHF, Rheumatic disease

      • DM, CAD,Congenital Heart Defects


    Taking a blood pressure

    Taking a Blood Pressure


    Blood pressure key facts

    Blood Pressure: Key Facts

    • Korotkoff sounds: Turbulent sounds of partial obstruction of arterial flow

    • Phase I: sharp tapping sound (systolic)

    • Phase II: change to soft swishing sound

    • Phase III: sounds more crisp & intense

    • Phase IV: muffled tapping

    • Phase V: cessastion of sound (diastolic)


    Blood pressure key facts1

    Blood Pressure: KeyFacts

    • Arm Blood Pressure: May be 5-10 mmHg higher in right arm than left arm: greater differences between right & left arm may be associated with congenital aortic stenosis or acquired conditions such as aortic dissection or obstruction of arteries to upper arm.

    • Leg Blood Pressure: Arm & leg blood pressures are about equal during first year of life & after that time the leg blood pressure is 15-20 mmHg higher than the arm BP.

    • Pulse Pressure: difference between systolic and diastolic blood pressures:

      • Usual pulse pressure is between 30-40 mmHg

    • Orhtostatic Hypotension: Decrease in SBP of 20-30 mmHg or more when changing from supine to standing position, & increase in pulse of 10-20 bpm: sudden drops may result in fainting. Dizziness & faintness from orthostatic hypotension may occur when taking anti-hypertensive medications, hypovolemia, confined to bed for prolonged periods of time, or the elderly.


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