1. Cardiovascular Assessment
Dr. Zyad Saleh

2. Subjective Data specific heart problems: Chest pain
cardiac, pulmonary, muscular, or gastrointestinal
Sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure.
radiate to the left shoulder and down the left arm or to the jaw.
Diaphoresis and pain worsened by activity
dyspnea, diaphoresis, pallor, nausea, palpitations, or tachycardia.

3. Tachycardia and Palpitations (beat faster)
Tachycardia  increase cardiac output.
Palpitations  abnormality of the heart’s conduction (arrhythmia) or increase cardiac output by Tachycardia

4. Fatigue
Fatigue may result from compromised cardiac output.
Fatigue related to decreased cardiac output is worse in the evening or as the day progresses,

5. Difficulty of breathing (dyspnea) or shortness of breathing
Dyspnea  cardiac or pulmonary disorders
Dyspnea may occur at rest, during sleep, or with exertion.
Orthopnea is the need to sit more upright to breath easily
paroxysmal nocturnal dyspnea (wake up from dyspnea)  heart failure due to redistribution of fluid from the ankles to the lungs when one lies down at night.

6. Cough up with mucous
Fluid accumulation in the lungs from heart failure  white to pink-tinged sputum.
Dizziness
Dizziness  decreased blood flow to the brain

7. Wake up with an urgent need to urinate (nocturia)
Increased renal perfusion
Swelling edema in feet, ankles, and legs
Edema in both lower extremities at night
dependent areas of the body.

8. Heartburn
Gastrointestinal pain may occur after meals and is relieved with antacids.
Cardiac pain may occur anytime, is not relieved with antacids, and worsens with activity.

9. Personal Health History
a heart defect or a murmur
rheumatic fever
Rheumatic carditis results in inflammation of all layers of the heart, impairing contraction and valvular function.
heart surgery or cardiac balloon interventions
Electrocardiogram (ECG)

10. lipid profile
take medications or use other treatments for heart disease
monitor heart rate or blood pressure

11. Family History Hypertension Dyslipidemia Coronary artery disease
Diabetes mellitus

12. Lifestyle and Health Practices
Smoke
Stress
Usual diet
Alcohol
Exercise
daily activities
Number of pillows used to sleep at night

13. COLLECTING OBJECTIVE DATA

14. INSPECTION: Neck Vessels
Observe the jugular venous pulse
The jugular venous pulse is not normally visible with the client sitting upright. (position fully distends the vein)
pulsations may or may not be discernible.
increased central venous pressure

15. Evaluate jugular venous pressure
The jugular vein should not be distended, bulging, or protruding at 45 degrees or greater
Right side heart failure

16. Auscultation and Palpation
Auscultate the carotid arteries if you suspect cardiovascular disease.
No blowing or swishing or other sounds are heard.
Pulses are equally strong; a 2+, with no variation in strength
Contour is smooth and rapid on upstroke and slower on downstroke.
Pulse Amplitude Scale
0 = Absent
1+ = weak
2+ = Normal
3+ = Increased
4+ = Bounding

17. occlusive arterial disease  A bruit, a blowing or swishing sound  by turbulent blood flow through a narrowed vessel
Pulse inequality  arterial constriction or occlusion in one carotid.
Weak pulses  hypovolemia, shock, or decreased cardiac output.
A bounding, firm pulse may indicate hypervolemia or increased cardiac output.
Variations in strength from beat to beat or with respiration  abnormal
A delayed upstroke  aortic stenosis.

18. Palpate the carotid arteries.
Arteries are elastic and no thrills
Loss of elasticity  atherosclerosis
Thrills  a narrowing of the artery.

19. INSPECTION: Heart (Precordium)
is the portion of the body over the heart and lower chest
Inspect pulsations.

20. Aortic area at the right second intercostal space–S2 is louder than S1
Pulmonic area :at the left second intercostal space–S2 is louder than S1
Erb’s point: at the left third intercostal space–S1 and S2 are heard equally
Tricuspid area at the left fourth intercostal space–S1 is louder than S2
Apex: the left fifth intercostal space at the midclavicular line–S1 is louder than S2

21. INSPECTION: Heart (Precordium)
Inspect pulsations.
The apical impulse may or may not be visible.
it would be in the mitral area (left mid-clavicular line, fifth or fourth intercostal space)
Apical impulses  result of the left ventricle moving outward during systole.

22. PALPATION Palpate the apical impulse.
The apical impulse is palpated in the mitral area
Size 1-2 cm
Amplitude  small like a gentle tap.
The duration is brief, lasting through the first 2/3 of systole or less
obese clients may not be palpable.

23. The apical impulse may be impossible to palpate in clients with pulmonary emphysema.
Cardiac enlargement  large size displaced, more forceful, or of longer duration.

24. Palpate for abnormal pulsations.
No pulsations or vibrations are palpated in the areas of the apex, left sternal border, or base.
A thrill or a pulsation is usually associated with murmur.

25. AUSCULTATION Auscultate heart rate and rhythm.
Rate = regular 60 to 100
Bradycardia
Tachycardia
Arrhythmia
Cause Decrease cardiac output or emboli

26. If you detect an irregular rhythm, auscultate for a pulse rate deficit.
The radial and apical pulse rates should be identical.
pulse rate deficit (difference between apical pulse and peripheral pulse  arrhythmia

27. Auscultate to identify S1 and S2.
The first heart sound (S1) is the result of closure of the AV valves: the mitral and tricuspid valves.
S1 (“lub”) is usually heard as one sound but may be heard as two sounds
two sounds, the first component represents mitral valve closure (M1); the second component represents tricuspid closure (T1).
heard best at the apex (left MCL, fifth ICS).

28. Auscultate to identify S1 and S2.
second heart sound (S2) results from closure of the semilunar valves (aortic and pulmonic)
two sounds, the first component represents aortic valve closure (A2) and the second component represents pulmonic valve closure (P2).
heard best at the base of the heart.

29. Auscultate to identify S1 and S2.
First heart sound = S1 or lub
Second heart sound = S2 or dubb
two sounds make up the cardiac cycle of systole and diastole.
S1 starts systole, and S2 starts diastole. The space between S1 and S2 (systolic pause) is of short duration
The space between S2 and the start of another S1 (diastolic pause) is of longer duration.

30. S1 corresponds with each carotid pulsation and is loudest at the apex of the heart.
S2 immediately follows after S1 and is loudest at the base of the heart.
diminished, varying, or split

31. An accentuated S1 sound is louder than an S2
An accentuated S1 sound is louder than an S2. This occurs when the mitral valve is wide open and closes quickly.
Diminished S1: S1 sound is softer than the S2 sound. This occurs when the mitral valve is not fully open at the time of ventricular contraction and valve closing.

32. a split S1 occurs when the left and right ventricles contract at different times (asynchronous ventricular contraction).
Varying S1 occurs when the mitral valve is in different positions when contraction occurs.

33. An accentuated S2 means that S2 is louder than S1.
conditions in which the aortic or pulmonic valve has a higher closing pressure.
A diminished S2 means that S2 is softer than S1.
conditions in which the aortic or pulmonic valves have decreased mobility.

34. A normal split S2 can be heard over the second or third left intercostal space.
It is usually heard best during inspiration and disappears during expiration.
Wide Split S2 is an increase in the usual splitting that persists throughout the entire respiratory cycle and widens on expiration.
It occurs when there is delayed electrical activation of the right ventricle.

35. Fixed Split S2 This is a wide splitting that does not vary with respiration.
It occurs when there is delayed closure of one of the valves.

36. Reverse split S2 sound:

37. Auscultate for extra heart sounds.
Auscultate during the systolic and diastolic pause
S3 heart sound  heard at the beginning of the diastolic pause
S4 heart sound  heard at the end of the diastole

38. Extra Heart Sound Description:
S3 and S4 are referred to as diastolic filling sounds, or extra heart sounds, which result from ventricular vibration secondary to rapid ventricular filling.
Description:
Both sounds are low frequency and thus best heard with the bell of the stethoscope.
Location:
Usually best heard over
apex with patient in the left lateral position

39. THIRD HEART SOUND S3
Results from increased atrial pressure leading to increased flow rates, as seen in congestive heart failure, which is the most common cause of a S3.
May be normal physiological finding in patients less than age 40,pregnancy,athlatist or fever.

40. FOURTH HEART SOUND S4
Seen in patients with stiffened left ventricles, resulting from conditions such as
hypertension, aortic stenosis, ischemic or hypertrophic cardiomyopathy.

41. Auscultate for murmurs.
A murmur  a swishing sound caused by turbulent blood flow through the heart valves or great vessels.
increased blood velocity, structural valve defects, valve malfunction, and abnormal chamber openings
Thrills are superficial vibratory sensations felt on the skin overlying an area of turbulence

42. Systolic Murmurs These are ejection murmurs
May be caused by turbulence across the aortic or pulmonic valves if they are stenosed
May be caused by turbulence across the mitral or tricuspid valves if they are incompetent (regurgitant)
The murmur falls between S1 and S2
Sounds like, LUB-shhh-dub

43. Diastolic Murmurs
Mitral and tricuspid stenosis can cause a diastolic murmur.
Aortic or pulmonic regurgitation can cause a diastolic murmur.
Sounds like this: Lub-dub-shhh

44. auscultate with the client in different positions because some murmurs occur or subside according to the client’s position.

45. Auscultate with the client assuming other positions.