Assessment of the Cardiovascular System The Heart and Peripheral Vasculature

Cardiovascular System Health History Inspection Palpation Percussion Auscultation

Health History Chest pain Dyspnea, Orthopnea, Cough, Fatigue Edema, Swollen joints, Nocturia HTN, DM, CAD, CHD, Hyperlipidemia, Bleeding disorders Cardiac surgery or related hospitalization within last 5 years Personal and Social Hx. Family History CHD – once a defect occurs in a family, the likelihood of recurrence is 3-5 times the general population, especially with left sided lesions Sudden death in young and middle-aged relatives Cardiac History/Race-related considerations

Cardiac History/Race-Related Considerations Rheumatic fever (5-15yrs.) Mitral valve prolapse (20-50yrs.) HTN (20-70yrs.) Valve stenosis or regurgitation (30-50yrs.) Coronary artery dx. (40-60yrs.) MI (40-60 yrs.) Arteriosclerosis (50-70 yrs.) CVA (50-70 yrs.) Abdominal aortic aneurysm (60-70 yrs.) Race-related Considerations: African American (CVA, CAD, HTN, Diabetes) Hispanic and Filipino (HTN) American Indian (CVA, CAD)

Age-related Considerations Children Prenatal Hx. Cyanosis with feedings Growth and activity FTT Developmental milestones Elderly Current medications Environment ADL’s

Inspection Note chest configuration Color of nailbeds, M/M Capillary refill, < 3 seconds Respiratory pattern and effort – any dyspnea, etc. Lifts or heaves Inspect for any pulsations Neck Jugular Vein Distention Anterior Chest – eye should be at chest level Mild pulsation – normal Strong pulsation - abnormal

Palpation Use palmar surface of fingers Check circulation – warmth of extremities Carotid arteries – gently, one at a time Apical pulse – PMI Greatest vibrations of heart contraction, a short gentle tap, short duration, ½ of systole Found at 5th ICS, left MCL, if deviated can give you an indication of heart size Use two fingers to palpate. If difficult have patient lean forward or lie on left side leaning over toward the right. Thrill Palpation of murmur. Feels like a purring cat.

Percussion Generally a poor indicator, rarely used Used to outline heart’s borders, dullness Difficult to perform with breast tissue CXR

Auscultation Valves for auscultation – Anterior chest Aortic – 2nd RICS, RSB Pulmonic – 2nd LICS, LSB Erbs – 3rd LICS, LSB Tricuspid – 4th LICS, LSB Mitral – 5th LICS, MCL

Auscultation – Heart Sounds Auscultate the heart in the sitting and lying down positions. Use both the diaphragm and the bell. Diaphragm – high pitched Bell – low pitched Note rate and rhythm 60-100 BPM Sinus arrhythmia Irregularities (apical), Count one full minute Identify heart sounds S1 S2

S1 Closure of the mitral and tricuspid valves, AV valves First heart sound – LUB Louder at the apex, heard best with diaphragm Heard at the beginning of systole It is the R wave on EKG and the carotid artery pulse Split S1 (normal) Hear closure of mitral and tricuspid valves separately

S2 Closure of the aortic and pulmonic valves, semilunar valves Second heart sound – DUB Louder at the base, heard best with diaphragm Heard at the end of systole, beginning of diastole Physiologic split of S2 (normal in children) Two sounds heard – A2, P2 Pressures in the R heart are lower than the L, producing two heart sound. The L side first A2, then the R side, P2. Split heard best in pulmonic area

Auscultate for Extra Heart Sounds Auscultate with diaphragm, then bell Heard during diastole Ventricular filling Lower pitch, heard at apex Extra heart sounds S3 S4

S3 Heard at the beginning of diastole, after S2 Heard best with bell Lub-dubba Ken/tuck/(Y) S1 – S2 – S3 Heard best with bell Sound is produced by blood hitting a non-pliable ventricle wall during diastole. Normal in infants and young children d/t firm heart muscle In adults can be d/t increased blood volume or indicative of heart dx. CHF Regurgitation

S4 Also known as an Atrial Gallup Heard at the end of diastole, before S1 daLub-Dub (Ten)/ness/ee S4 – S1 –S2 Heard best with bell It is caused by a turbulence of flow against pressure. (Resistance of flow). Heard with: Pulmonary hypertension Aortic and pulmonic stenosis Cardiomyopathy, valve dx. MI’s Always abnormal

Adventitious Heart Sounds Clicks Murmurs

Clicks Heard early in systole. More pronounced with pt. sitting up Associated with valve dx. Aortic click Most common D/T coarcation, aortic stenosis, anuerysm Sound does not change with respiration Mitral click D/T prolapsed mitral valve Pulmonic click Associated with pulmonic valve stenosis and pulmonary hypertension Heard throughout respiratory cycle, more intense in expiration

Murmurs Extra sound superimposed on normal heart sounds caused by a disruption of flow into, through, or out of heart Causes of Murmurs Anatomic valve disorder Diseased valves Hi output demands that increase speed of flow Anemia, pregnancy Diminished strength of myocardial contraction Altered blood flow in vessels near heart Newborn - PDA 7 Assessments Grading of Murmur

Murmurs – 7 Assessments Pitch Pattern Quality Location Radiation High, medium, low Pattern Crescendo Decrescendo Crescendo-Decrescendo Diamond shaped Quality Describe, generally a blowing, rubbing sound Location Where is it loudest Radiation Does it transmit to other areas Posture Does it change with position change Timing in cardiac cycle

Grading of Murmurs (Loudness) Grade 1 Barely audible Grade 2 Readily heard Grade 3 Moderately loud Grade 4 Loud with associated thrill – fine, palpable, rushing sensation Grade 5 Very loud with thrill Grade 6 Loudest with thrill, may be audible with diaphragm off the chest

Physiologic Murmur Normal in children Heard as a systolic flow murmur that varies with position change Generally a G1 or G2 Pregnant women