1. The Cardiovascular System

2. The Cardiovascular System: Examining the Heart and Blood Vessels
Overview
Anatomy of the heart and great vessels
The heart as a pump, blood pressure
Beginning the examination — The vital signs: blood pressure and heart rate
Jugular venous pressure (JVP) and pulsations; carotid pulse
Chest wall and apical impulse/PMI
Auscultation: S1 and S2; S3 and S4
Auscultation: describing cardiac murmurs

3. The Heart and Great Vessels: Anatomy

4. Know Your Surface Landmarks
Can you count interspaces?
identify your own ...
the midsternal line
the midclavicular line
the anterior axillary line
the midaxillary line

5. Visualize the Chambers of the Heart and Important Great Vessels
Test yourself
Can you visualize the circulation through:
the superior and inferior vena cavas
the right atrium and the right ventricle ventricle
the pulmonary arteries
the left atrium and left ventricle
the aorta and the aortic arch

6. The Cardiovascular System: Anatomy

7. Pulmonic Valve
Aortic Valve
Mitral Valve
Tricuspid Valve

8. The Heart as a Pump: Key Points for Examining the Heart
Remember the heart chambers and valves and the forward flow of blood from right side of the heart through the pulmonary arteries and veins to the left side of the heart
Combine this knowledge with careful examination and systematic clinical reasoning
This will lead you to correct identification of valvular and congestive heart disease

9. The Heart as a Pump: The Cardiac Cycle of Systole and Diastole
Systole — The ventricles contract
The right ventricle pumps blood into the pulmonary arteries (pulmonic valve is open)
The left ventricle pumps blood into the aorta (aortic valve is open)
Diastole — The ventricles relax
Blood flows from the right atrium → right ventricle (tricuspid valve is open)
Blood flows from the left atrium → left ventricle (mitral valve is open)

10. S3 S4 S1 S2

11. Extra Heart Sounds S3 (Ventricular gallop): S4 (Atrial Gallop)
S3 & S4 occur
during Diastolic
Phase
Extra Heart Sounds
S3 (Ventricular gallop):
A ventricular filling sound
In early diastole after S2
Best heard at Apex in left lateral decubitus position
Best heard with bell
Low pitch
Indicates decrease ventricular compliance
Normal in children and young adults up to 40 yrs., then considered abnormal
Occur in patients with HF, aortic, mitral, or tricuspid regurgitation
Right sided S3 heard in the lower left sternal border or below the xiphoid in supine position and higher during inspiration
S4 (Atrial Gallop)
A ventricular filling sound
In late diastole immediately before S1
Best heard at the apex in left lateral position
Best heard with the bell
Soft low pitch
Indicates decrease compliance of ventricle
Could be normal in adults > 40 with NO evidence of cardiac disease
Pathologic S4 occur with patients who have CAD, HTN, and aortic stenosis
Right sided S4 heard in the lower left sternal border or below the xiphoid in supine position and higher during inspiration

12. Mitral Valve closes (S1) S1 S2 Ej Aortic Valve closes (S2)
Aortic Valve opens
Mitral Valve Opens; Opening snap (OS) OS S3 S4
After mitral valve opens, a period of rapid ventricular filling may create a third sound (S3/ S3 gallop). Normal in children and young adults; Pathologic in older adults; indicated pathologic changes in vent. Compliance.
S4 immediately precedes S1. marks atrial contraction; also reflects pathologic changes in ventricular compliance

13. Extra Heart Sounds Ejection Click (Ej): Murmurs:
Occur early in systole at the start of ejection
As a result of opening of the semilunar valves (aortic or pulmonic stenosis)
Short, high pitch with click quality
Aortic Ej heard at the 2nd right ICS, loudest at the apex; does not change with respiration
Pulmonic Ej heard in the 2nd left ICS, loudest with expiration
Murmurs:
longer than normal heart sounds
As a result of turbulent blood flow and may be innocent as in young adults or pathologic such in valve stenosis or regurgitation.

14. Conduction System in the Heart
SA node (Sinus node)
Located in the RA
Acts as the cardiac pacemaker
Automatically discharge times/min
AV node (atrioventricular)
Located at the atrial septum
Delay the impulse fired by the SA node before the impulse passes to the bundle of His
P-wave: atrial depolarization
QRS complex: ventricular depolarization
T-wave ventricular repolarization
SA node
AV node
Bundle of His

15. The Heart As A Pump: Important Concepts
Preload Volume Overload
Contractility (ventricles contract during systole)
Afterload Pressure Overload
Cardiac output = stroke volume x heart rate
Blood pressure = cardiac output x systemic vascular resistance

16. Definitions
Preload: the load that stretches the cardiac muscle prior to contraction; it is the volume of blood in the right ventricle at the end of diastole.
Afterload: the vascular resistant against which the ventricle must contract.
Cardiac output: the volume of blood ejected from each ventricle during 1 minute.
Stroke volume: the volume of blood ejected with each heart beat.
Stenosis: abnormally narrow valvular orifice that obstruct blood flow
Regurgitation: insufficiency of valvular orifice that allow blood to leak backward and produce a regurgitate murmur.

17. Blood Pressure Systolic Blood Pressure Diastolic Blood Pressure
Pressure generated by left ventricle (LV) during systole, when the LV ejects blood into the aorta and the arterial tree. Pressure waves in the arteries create pulses
Diastolic Blood Pressure
Pressure generated by blood remaining in arterial tree during diastole, when the ventricles are relaxed

18. Subjective Data Chest pain Dyspnea, orthopnea, PND Palpitation Fatigue
Cyanosis or pallor
Edema/swelling
Past cardiac surgery
Family cardiac History
Personal habits (risk factors)

19. Health History Chest Pain
Your basic question: do you have pain or discomfort in your chest?
Is the pain related to exertion?
What kinds of activities bring on the pain?
How intense is the pain?
Does it radiate to the neck, shoulder, back, arm?
Associated symptoms like SOB, sweating, palpitation, nausea?
Does it wake up at night? what makes it better or worse
Like what this pain?

20. Occur in atrial fibrillation
Palpitations:
Unpleasant awareness of the heart beat
Result from irregular heart beat, from rapid acceleration or slowing of the heart, or from increased forcefulness of cardiac contractility
Occur in atrial fibrillation
Ask questions like: Are you ever aware of your heart beat? What it is like? Was it fast or slow?
Like racing, pounding, stopping
Did they stop suddenly or gradually?

21. SOB, dyspnea; uncomfortable awareness of breathing that is inappropriate to a given level of exertion.
( distance, position)
Orthopnea ; dyspnea that occurs when patient is lying down and improves when patient is sitting up.
( no. of pillows)
Paroxysmal noctural dyspnea, PND; episodic of sudden dyspnea and orthopnea that awaken the patient from sleep, mainly after 1-2 hours after going to bed. Can be associated with cough and wheezes.
Swelling or Edema
Dependent edema appears in the lowest body parts (feet & lower legs) when sitting; or the sacrum when bedridden
Occur in CHF, hypoalbuminemia

22. Health promotion and counselling
Preventing hypertension
Preventing cardiovascular disease and stroke
Lowering cholesterol and low density lipoprotein (LDL)
Lifestyle modification and risk intervention, including healthily eating and counselling about weight and exercise.
SEE text book( )

23. Preventing hypertension
Screening of adults 18 years and older for high blood pressure
Normal 120/80 mmHg
Pre-hypertension S: and D: are pre-hypertension.
Screening of risk factors:
Physical inactivity
Family history
Excessive intake of Na, insufficient intake of K
Alcohol consumption.

24. Health Promotion Behaviors for CVD
Desired goal for LDL level depends on # of risk factors:
<160 if 0-1 risk factors
<130 if 2+ or multiple risk factors
<100 if CHD
Cholesterol Level:
LDL <100 mg/dL
HDL mg/dL
Triglyceride < 200 mg/dL
Total Cholesterol <200 mg/dL
Risk factors (“risk equivalents”:
Smoking
HTN
HDL < 40
Family Hx.
Age (men >45, women > 55) DM
Atherosclerotic Diseases

25. Health Promotion Behaviors
Dietary management
Low saturated fat
Low cholesterol
High fiber
Weight reduction
Assess BMI
Overweight BMI > 25
Obese, BMI >30
Regular exercise
Aerobic exercise
Regular min x 3-5 times/week
Screening for HTN

26. Beginning the Examination: The Vital Signs
First Observe The Patient Then … Begin with the vital signs
Blood Pressure
Select the proper size cuff
Position the patient properly
Make sure there is a brachial pulse
Apply the cuff correctly!
Assess blood pressure for hypertension
Heart Rate: radial vs. apical

27. Objective data The Neck Vessels Carotid artery Palpation Auscultation
Jugular vein
Inspection
JVP

28. Jugular Venous Pressure (JVP) and Pulsations
Recall that the jugular veins reflect right atrial pressure
Steps for examination
Raise the head of the bed or examining table to 30°
Turn the patient’s head gently to the left
Identify the topmost point of the flickering venous pulsations
Place a centimeter ruler upright on the sternal angle
Place a card or tongue blade horizontally from the top of the JVP to the ruler, making a right angle
Measure the distance above the sternal angle in centimeters – a centimeter elevation is normal

30. Assessing the Carotid Pulse
Keep the patient’s head elevated to 30°
Place your index and middle fingers on the right then the right carotid arteries, and palpate the carotid upstroke
The upstroke may be:
Brisk, or normal
Delayed – suggests aortic stenosis, or
Bounding – suggests aortic insufficiency
Listen with the stethoscope for any bruits

31. Carotid Artery
Palpation
Auscultation

32. Distinguishing Jugular from Carotid artery Pulsation

33. Palpating the Chest Wall
Using the fingerpads, palpate for heaves or lifts from abnormal ventricular movements
Using the ball of the hand, palpate for thrills, or turbulence transmitted to the chest wall surface by a damaged heart valve
Palpate the chest wall in the aortic, pulmonic, left parasternal, and apical areas

34. Assessing the PMI, or point of maximal impulse
Inspect the left anterior chest for a visible PMI
Using you fingerpads, palpate at the apex for the PMI
The PMI may be:
Tapping, or normal
Sustained — suggests LV hypertrophy from hypertension or aortic stenosis, or
Diffuse — suggests a dilated ventricle from congestive heart failure or cardiomyopathy
Locate the PMI by interspace and distance in centimeters from the midsternal line

35. Palpation Areas Right 2nd ICS- aortic area Left 2nd ICS- pulmonic area
Apex Left Ventricular Area
Left sternal border right ventricular area
Left 2nd ICS- pulmonic area
Right 2nd ICS- aortic area
Epigastric (subxiphoid)

36. Palpation of Apical Impulse (PMI)
Left lateral decubitus
Left lateral decubitus-finger assessment
Abnormal finding may:
Sustained high-amplitude due to vent. Hypertrophy
Low amplitude may be due to dilated cardiomyopathy

37. Palpation of Ventricular Movement
3rd ICS
4th ICS
5th ICS
For the LV impulses, feel apical beats with one finger; pt. lie down on left side and breath out then briefly stop breathing
For the RV area, pt rest supine at 300, you place your fingers at the 3rd, 4th, & 5th ICSs and try to feel systolic impulses; pt. breath out and stop breathing
For RV area also, place your hand flat; press index finger under rib cage upward toward the left shoulder; try to feel pulsation.
Subxiphoid area

38. Listening to the Heart — Auscultation
Listen in all 6 listening areas for S1 and S2 using the diaphragm of the stethoscope
Then listen at the apex with the bell
The diaphragm and the bell ...
The diaphragm is best for detecting high-pitched sounds like S1, S2, and also S4 and most murmurs
The bell is best for detecting low-pitched sounds like S3 and rumble of mitral stenosis

39. Auscultation of Heart Sounds
Supine
Left lateral decubitus
Sit up, leaning forward

40. Describing Heart Murmurs: Timing and Duration
Identify and describe any murmurs
Timing — are they systolic or diastolic?
Tip — palpate the carotid upstroke (occurs in systole) as you listen
If the murmur coincides with the carotid upstroke, it is systolic
Duration
early / mid / or late systolic
early / mid / or late diastolic

41. Describing Heart Murmurs: Shape and Intensity
Crescendo, decrescendo, or both (sometimes called diamond-shaped)
Example, crescendo-decrescendo systolic murmur of aortic stenosis
Crescendo
Decrescendo
Both

42. Describing Heart Murmurs: Shape and Intensity (cont.)
Plateau ... machinery
Example, holosystolic murmur of mitral regurgitation
Intensity — grade the murmur on a scale of 1 to 6
grades /6 must have accompanying thrill
Plateau Machinery

43. Describing Heart Murmurs: Quality,Pitch, and Location
Apply terms like harsh, musical, soft, blowing, or rumbling
Pitch
Apply terms like high, medium, or low-pitched
Examples
Harsh 2/6 medium-pitched holosystolic murmur best heard at the apex—describes mitral regurgitation
Soft blowing 3/6 decrescendo diastolic murmur best heard at the lower left sternal border – describes aortic regurgitation

44. Heart Murmurs 4. Radiation: from point of maximum intensity
Intensity: the grade on 6-point scale to describe the intensity of murmur
Pitch: high, medium, or low.
Quality: blowing, harsh, rumbling, or musical.

45. Splitting of S1 and S2
Splitting of S2 , the normal or physiologic heard at pulmonic area Lt 2nd ICS or 3rd Lt ICS and happen with inspiration. However if it happen with both inspiration and expiration in other words not affected by respiration, considered abnormal
Splitting of S1, normal but uncommon and its heard at Rt ventricle area Lt lower sternal border

46. Cardiac Diagnostic Studies

47. Non Invasive Procedures
ECG.
Holter Monitor.
Stress Test.
Echocardiography.
MRI.

48. Electrocardiogram (ECG or EKG)
A diagnostic tool that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage.
provide information about the Mechanical function and conduction of the heart – can not tell about structural or perfusion disorders.

49. What do you know about ECG PREPARATIONS?
Types:
Continuous Monitoring: provide continuous monitoring of cardiac activity in the cardiac unit.
Standard/12-lead: record electrical impulses as they travel through the heart.
What do you know about ECG PREPARATIONS?

50. Positions of chest electrodes

52. Holter Monitoring:
A small, portable, battery-powered ECG machine worn by a patient to record heartbeats on tape over a period of 24 to 48 hours - during normal activities. At the end of the time period, the monitor is returned to the physician's office so the tape can be read and evaluated.
ECG tracing recorded continuously for a day or longer to detect arrhythmias that may not appear in a routine ECG but when the pt. At work or moving.
a small portable ECG size of a transistor radio. The monitor is carried with shoulder strap (battery pack).

53. PROCEDURE:
Three electrodes are attached to the patient's chest and connected to a small portable ECG recorder by lead wires.
The patient goes about his/her usual daily activities (except for activities such as taking a shower, swimming, or any activity causing an excessive amount of sweating which would cause the electrodes to become loose or fall off) during this procedure.

54. Holter monitoring may be done when arrhythmia is suspected but not seen on a resting or signal-average ECG, since arrhythmias may be transient in nature and not seen during the shorter recording times of the resting or signal-average ECG.

55. Exercise Electrocardiogram (Stress Testing):

56. Exercise Electrocardiography (Stress Testing):
Identify client at risk and diagnosis Angina.
It is indicated for:
Cause of chest pain
Presence of CAD
Dysrhythmias that occur during physical activity
Determining functional capacity post MI & post open heart surgery
Evaluate pharmacological effect on angina

57. Stress testing
Non invasive procedure to evaluate cardiac response to stress
It Measure body reaction to increased exercise level. (changes in HR, RR, BP, ……)
Patient walk on treadmill and exercise intensity progress according to establish protocol( Bruce protocol)
In bruce protocol the speed and grade of treadmill increase Q 3 min till reach (target heart rate)
The later is % of maximum predicted HR based on age and gender

58. During the test the following are monitored; 2 or more ECG leads, heart rate, rhythm, BP, perceived exertion, chest pain, dizziness, and other ischemic changes)
The test is terminated when the target heart rate achieved or when patient develop chest pain, extreme fatigue, decrease in BP or pulse, serious dysrhythmias or ST segment changes
The test is reporting positive, when significant ECG abnormalities occur during the test( ST- segment elevation or depression)

59. Stress testing Preparation;
Pt. Should not eat or drink for 4 hours before
no heavy exercise for the last 12 hours,
wear relaxed fit clothes and shoes,
Avoid taking stimulants; coffee and tobacco
can take prescribed meds with sips of water
Some cardiac drugs like B blockers could not be taken
The nurse explain the procedure, equipements found, and sensation that he might feel
After the test, patient monitored for 15 min.

60. Echocardiogram (echo)

61. Echocardiography (ultrasound):
A noninvasive test that uses sound waves to produce a study of the motion of the heart's chambers and valves. The echo sound waves create an image on the monitor as an ultrasound transducer is passed over the heart.
Is used to examine size, shape, motion of cardiac structures, cardiac wall motion, ejection fraction (EF), ventricle volumes.

62. Modes of Echocardiogram
M- mode, the unidimensional mode provide information about cardiac structures and their motion
2- dimensional or cross sectional, gives correct image of the heart
Doppler and color flow imaging, show the direction and velocity of blood flow

63. Preparation;
inform patient about the test
Explain its painless.
Gel applied to skin to help transmit of waves
Patient will have to turn to left side and hold breath
Patient Need to lie quietly 30 min to 1 hr.

64. Magnetic Resonance Imaging (MRI):
most expensive, provides best information on chamber size, wall motion, valve function, and large vessel blood flow quantification, wall thickness, and tissue characteristics.
The patient is placed in a tube for minutes (explain this to the patient so he/she will not be fearful), patient may be premedicated.
NPO for at least 4 hours before the procedure.
Contraindicated in patients who have implanted metal parts (pacemakers, wires, metal valves, pumps, …)

65. Angiography
It is an invasive technique in which a contrast agent is injected into the vascular system to outline the heart and blood vessels.
Immediately, then x-rays taken to visualize any abnormalities in the cardiac circulation under local anasthesia.
Common sites
Right sided heart angiography or catheterization; it involves the passage of catheter from antecubetal or femoral vein into the right atrium, right ventricle, pulmonary artery and arterioles.
Pressures and O2 saturation levels are obtained

66. Left sided angiography or catheterization
Perfomed to evaluate the patency of coronary arteries and the function of left ventricle, mitral and aortic valve.
The catheter is inserted into right brachial artery or femoral artery and advanced into aorta and left ventricle.
Coronary arteriography or angiograghy
the catheter is introduced into Rt or Lt brachial or femoral artery, then passes into ascending aorta and manipulated into Rt or Lt coronary arteries.
Used to detect degree of atherosclerosis and determine treatment

67. Test Results (results of Angiography):
Normal Values  :  Adequate blood supply to the heart is a normal finding with a coronary angiogram.
What abnormal results mean (Coronary angiography shows the following):
* How many coronary arteries are blocked
* Where are they blocked
* The degree of each blockage

68. Instruct patient & Family about procedure
Patient preparation (Pre-Procedure care):
Instruct patient & Family about procedure
Food and fluid are restricted 6 to 8 hours before the test.
health care provider should explain the procedure and its risks.
A witnessed, signed consent for the procedure is required.
Allergic history: to seafood, if the pt had a bad reaction to contrast material in the past

69. Nursing care( post coronary angiography)
assess pulses, B/P in arm not used for test
Assess temp, color and amplitude of pulses on extremities used Q 15 min 1st hr then 30 min 2nd hr then q1 to 2 hrs
force fluids - unless worried about fluid volume overload to facilitate elimination of contrast media
Pressure dressing over arterial site (usually groin) & complete bed rest for up to 12 hr & check site for bleeding.
Possible complications; Ventricular fibrillation, tachycardia, CVA, hypotension from contrast media that has diuretic effect
Instruct client to avoid bending the hips during the first hours.