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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 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
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
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.