1. Heart and Peripheral Vascular System

2. Learning Outcomes
At the end of the session , the learner should be able to:
1- Review the anatomy and physiology of the heart and blood vessels.
Identify the landmarks of the chest.
Identify anatomic landmarks of the cardiovascular system used for auscultation sites.
2- Apply the techniques employed in performing physical examination of the cardiovascular and peripheral system.
3. Describe the normal heart sounds.
4- Differentiate between normal and abnormal findings.
5- Conduct cardiovascular system assessment including health history and physical examination following designated procedural guideline.
6- Document the cardiovascular system assessment findings following designated format

4. The Cardiovascular system
The cardiovascular system consists of the heart and the blood vessels.
The heart and the great vessels are located between the lungs in the (mediastinum).
The heart extends from 2nd to the 5th intercostal space and from right border of the sternum to the left midclavicular line,
the heart as an upside –down triangle in the chest .

5. The heart valves
Four valves regulate blood flow through your heart:
Two AV valves between atria and ventricles (tricuspid on right and mitral on left)
Two semilunar valves (pulmonic and mitral)  

6. Cardiovascular Landmarks

7. Aortic area- 2nd ICS to right of sternum (closure of the aortic valve).
Pulmonic area- 2nd ICS to left of sternum (closure of the pulmonic valve).
Tricuspid- 5th ICS left of sternal border (closure of tricuspid valve).
Mitral- 5th ICS left of the sternum Midclavicular line. (close to mitral valve)

8. I- Health history: Heart history
Chief complain: fatigue, chest pain, palpitation
Orthopnea (how many pillows the client uses when sleeping or lying down?),
Edema (does the client note any swelling in the feet or the shoes feel tight at the end of the day & how much swelling is estimated?)
Presence of symptoms in extremities: pain, cramping, enlarged or crooked leg veins
effectiveness of rest in relieving them
Client's past history of heart problems:
Family history: heart disease, high cholesterol level, high blood pressure, stroke, obesity, congenital heart disease, sudden death as young age.
Life style habits
Medication :antihypertensive, diuretics, anticoagulants (aspirin)

9. General guidelines for examining the cardiovascular system
vital signs Stand at the patient right side Note the anatomic location of sounds . Survey Carotid artery and jugular vein (neck vesseles) Note the general appearance of the client Color& Weight

10. Techniques of examination :
I- Inspection:
1.1. Inspect the anterior chest for pulsation,
1.2. Look for Apical impulse
1.3.No other pulsation should be present.
Abnormal findings:
INTERPRETATION
Warm skin
Fever
Absence of Body hair on the arms or legs
Diminished arterial blood flow to these areas
Cyanosis, pallor
Poor perfusion
nails thick and ridged
edema
Chronic venous insufficiency

11. Abnormal findings
INTERPRETATION
swelling of extremity
Heart failure, thrombophlebitis
bounding pulse
Hypertension
Weak; Decreased/ absent pulse
Arterial insufficiency
Thrill
Valvular dysfunction

12. 2- Palpation :
Palpate the anterior chest for pulsation Using finger pads, to feel the pulsation
Palpate the point of maximum impulse (PMI), and note its location, size, duration and amplitude .

13. 3- Auscultation of Heart Sounds
There are 2 basic normal heart sounds
S1 (produced by closure of the atrioventricular valves, mitral and tricuspid) best heard at the apex of the heart. The sound is “lub.”
S2 (produced by closure of aortic and pulmonic valve) is the “dub” sound. best at the aortic and pulmonic areas

14. In aortic and pulmonic areas S2 is louder than S1
In the mitral area and the tricuspid area , S 1 is louder than S2.

15. Abnormal heart sounds (extra sounds)
(S3) (Ventricular gallop)
The heart sound that occurs following S2 “Lub-Dub-By”.
Can be normal in young adults and children; pathologic in elderly.
(S4) Pre-systolic Gallop precedes S1 of the next cardiac cycle.  “Le-Lub- Dub”
clicks are associated with valves: aortic and mitral stenosis, prosthetic valves
A rub is a characterized as inflammation of the pericardium surrounding the heart and usually indicates pericarditis. 
Murmur: turbulent blood flow within the heart due to valve defects or abnormal openings between the compartments of the heart mostly commonly heard in aortic and pulmonic stenosis and regurgitation

16. Assessment of the peripheral vascular system (Peripheral circulation)
Arms and legs
Inspect , Palpate and compare for: Skin and nail bed color ,capillary refill; temperature, texture, skin turgor, the presence of any lesion, swelling, clubbing, hair distribution and venous return.
Palpate peripheral pulses (bilaterally), Comparing symmetrical the pulse rate,

18. Grading pulse volume Absent No pulse (no perfusion)
AMPLITUDE
CHARACTER OF PULSE
Grade 0 :
Absent
No pulse (no perfusion)
Grade 1:
Weak
Thready and difficult to palpate
Grade 2:
Normal
Easily palpable, full
Grade 3:
Increased
Easily palpable and stronger than the normal pulse.'
Grade 4
Bounding
Very strong, easily palpable, it may indicate a disease in some cases.

19. Inspect both legs for size & Palpate for edema:
Measure the lower legs calf circumference
Palpate for edema: Firmly press the skin over the tibia for 5 seconds and release
Run pads of fingers over the area pressed and note indentation .
If indentation is noted, repeat the procedure, moving up extremity and note the point at which no more swelling is present

20. Grade +1: Mild pitting , slight indentation Grade +2: less than 5mm
Grading of edema
Grade +1: Mild pitting , slight indentation
Grade +2: less than 5mm
Grade +3: 5-10mm
Grade +4 : more than 10 mm

21. Peripheral perfusion
Buerger's test - Assess the adequacy of arterial flow; the limb is raised by 90 degrees for 30 to 60 seconds
Normal: toes and sole of the foot stay pink,
Abnormal: Elevation to 15 or 30 degrees for 30 to 60 seconds may cause pallor ( ischaemic leg)
2. Capillary refill Test: Squeezing the client fingernail between your fingers sufficiently to cause blanching. Normal nail color to return within 3 seconds.