1. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Lecture 5 Cardiovascular System

2. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Cardiovascular System

3. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Chambers in the Heart Left and right atria Left and right ventricles

4. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito

5. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Valves of the heart.

6. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Figure 17.6 Vessels of the heart. A. Anterior. A

7. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito THE HEART AS A PUMP: THE CARDIAC CYCLE OF SYSTOLE AND DIASTOLE Systole: the ventricles contract The phase of ventricular contraction in which the ventricles have been filled, then contract to expel blood into the aorta and pulmonary arteries. -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 The phase of ventricular relaxation in which the ventricles relax and are filled as the atria contract -Blood flows from the right atrium → right ventricle (tricuspid valve is open) -Blood flows from the left atrium → left ventricle (mitral valve is open)

8. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Heart Sounds S 1: (lub) – Heard when the AV valve close S 2 (dub) – occurs wen the aortic and pulmonic valves closed

9. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Table 17.1 Characteris tics of Heart Sounds

10. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito THIRD & FOURTH HEART SOUNDS 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

11. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito 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.

12. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito FOURTH HEART SOUND S4 Seen in patients with stiffened left ventricles, resulting from conditions such as hypertension, aortic stenosis, ischemic or hypertrophic cardiomyopathy.

13. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito MURMURS Murmurs are extra heart sounds that are produced as a result of turbulent blood flow that is sufficient to produce audible noise. Murmurs may also be the result of various problems, such as narrowing or leaking of valves.

14. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Table 17.3 Distinguis hing Heart Murmurs

15. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Cardiac Function Stroke volume –Amount of blood that is ejected with each heartbeat Cardiac output –Amount of blood ejected from the left ventricle over 1 minute –Cardiac output: stroke volume x heart rate

16. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Landmarks for Cardiac Assessment Sternum Clavicles Ribs Second through fifth intercostal spaces

17. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito

18. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito

19. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Physical Assessment of the Cardiovascular System Techniques –Inspection –Palpation –Percussion –Auscultation

20. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Specific Areas of the Cardiovascular Assessment Inspection of the face and lips Inspection of the jugular veins Inspection of the carotid arteries Inspection of the hands and fingers Inspection of the chest and legs

21. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito INSPECTION OF THE FACE AND LIPS Skin color changes may indicate cardiovascular disease. For example, pallor and cyanosis of lips or extremities are associated with decreased perfusion.

22. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Jugular Venous Pressure (JVP) and Pulsations Recall that 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 3- to 4-centimeter elevation is normal

23. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Assessment of central venous pressure.

24. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Top line – level of the higest visible point of distention Bottom line – level of the sternal angle Measure: the vertical distance between the sternal angle and the highest level of jugular distention

25. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito

26. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Assessing the Carotid Pulse Keep the patient’s head elevated to 30° Place your index and middle fingers on the right then the left carotid arteries, and palpate the carotid upstroke Never palpate right and left carotid arteries simultaneously Listen with the stethoscope for any bruits

27. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Palpation of the chest Using the ball of the hand, palpate for thrills Palpation of the chest, including the following –Precordium at the right and left second intercostal spaces –Left third intercostal space –Left fourth intercostal space –Left fifth intercostal space at the midclavicular line –(Palpate the chest wall in the aortic, pulmonic, left parasternal, and apical areas)

28. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Landmarks in precordial assessments.

29. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Landmarks for palpation of the chest.

30. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Percussion of the chest Percussion of the chest for cardiac border

31. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito AUSCULTATION Blood pressure measurement oSelect the proper size cuff oPosition the patient properly oMake sure there is a brachial pulse oApply the cuff correctly oAssess blood pressure for hypertension

32. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Auscultation of the chest Auscultation of the chest using the diaphragm and bell in various positions to include the following locations –Aortic area at the right second intercostal space–S 2 is louder than S 1 –Pulmonic area at the left second intercostal space–S 2 is louder than S 1 –Erb’s point at the left third intercostal space– S 1 and S 2 are heard equally

33. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Auscultation of the chest –Tricuspid area at the left fourth intercostal space–S 1 is louder than S 2 –Apex at the left fifth intercostal space at the midclavicular line–S 1 is louder than S 2

34. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Figure 17.22 Auscultating the chest over five key landmarks.

35. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Figure 17.24 Positions for auscultation of the heart. A. Supine.

36. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Figure 17.24 (continued) Positions for auscultation of the heart. B. Lateral.

37. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Figure 17.24 (continued) Positions for auscultation of the heart. C. Sitting.

38. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Health & Physical Assessment in Nursing, Second Edition Donita D’Amico Colleen Barbarito Auscultation of the carotid arteries Auscultation of the carotid arteries (using the diaphragm and bell) for any bruits