1. Assessment of the Cardiovascular System
The Heart and
Peripheral Vasculature

2. Cardiovascular System
Health History
Inspection
Palpation
Percussion
Auscultation

3. 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

4. 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)

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

6. 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

9. 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.

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

11. 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

13. 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
BPM
Sinus arrhythmia
Irregularities (apical), Count one full minute
Identify heart sounds S1 S2

14. 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

15. 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

17. 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

18. 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

19. 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

20. Adventitious Heart Sounds
Clicks
Murmurs

21. 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

22. 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

23. 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

24. 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

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