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Assessment of

Cardiovascular System
Professor Kneeshaw

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Objectives
1. describe the structure and function of the cardiovascular
system, including the peripheral vascular system
2. explain developmental variations a nurse considers when
assessing the heart & neck vessels & peripheral vascular
system
3. state the specific areas considered essential in gathering
subjective data pertaining to the cardiovascular system & the
peripheral vascular system
4. demonstrate assessment of the heart, neck vessels & the PV
system

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Anatomy of the Heart
 Four Valves:
 Four Chambers:  Two atrioventricular
 Right atrium (AV)
 Left atrium
1. tricuspid
 Right ventricle
 Left ventricle
2. mitral

 Two semilunar (SL)


1. pulmonic
2. aortic

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Blood
Blood FlowFlow
through the
Heart

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Cardiac Cycle

It has two phases:

(A) Diastole – ventricles relax & fill with


blood (This is 2/3 of the
cardiac cycle.)
(B) Systolic – heart contracts & pushes
blood out of the ventricles to:
(i) the lungs
(ii) systemic arteries

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Heart Sounds
 S1 – when closure of the AV valves
(tricuspid & mitral) & ventricles
contract

 S2 – when closure of the semilunar


valves ( pulmonic & aortic) &
the ventricles relax

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Extra Heart Sounds
S3 – This occurs immediately after S2
Why? Resistance to filling of ventricles
Note: also called a ventricular gallop
*It is caused by overload.
* use diaphragm (it is a high sound)
S4 - This occurs at the end of diastole, just
before the next S1.
Why? The atrium contract & push blood into
a non-compliant ventricles.
Note: also called an atrial gallop
*caused by HTN, CAD, Aortic stenosis, cardiomyopathy
* Use bell to listen as it is a low sound.

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Murmurs
 Caused by “turbulence”
Therefore we hear a gentle blowing, swooshing
sound.
 Why?
1. Velocity of blood increases
(eg. exercise, thyrotoxicosis)
2. Velocity of blood decreases (eg. anemia)
3. Structural defect in the valves or an unusual
opening occurs in the chambers

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Grading of Murmurs
Use VI point grading scale & record as a fraction
(ie. I/VI or II/VI)

Grades:
Grade I – barely audible, heard only in a quiet room & then with
difficulty
Grade II – clearly audible, but faint
Grade III – moderately loud, easy to hear
Grade IV – loud, associated with a thrill palpable on the chest wall
Grade V – very loud, heard with one corner of the stethoscope lifted
off the chest wall
Grade VI – loudest, still heard with the entire stethoscope lifted off
the chest

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The Neck Vessels
 The Carotid Artery

 The Jugular Venous Pulse & Pressures


2 components: (a) internal jugular
(b) external jugular

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Subjective Data
1. chest pain
2. dyspnea ( DOE, PND)
3. Orthopnea
4. Cough
5. Fatique
6. cyanosis or pallor
7. edema
8. nocturia
9. past cardiac history
10. family cardiac history
11. personal habits
12. environment

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Preparation for Assessment
 Room that is warm & “quiet”
 Examining table positioned so you can
stand on the patient’s right side
 Patient Gown
 A watch with a second hand
 Stethoscope with diaphragm & bell
 Tape measure

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Recommended Sequence
for assessing cardiovascular system
1. Pulses & BP
2. Extremities
3. Neck Vessels
4. Precordium

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The Neck Vessels
A. Carotid Arteries
 Palpate low in neck to avoid the sinus
 Be gentle
 Palpate only one side at a time to avoid
compromising blood flow to the head
 Auscultate using the bell
 Listen in 3 places: angle of jaw
midcervical area
base of neck

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Assessment of the Jugular Vein
 Purpose: To measure the
“central venous pressure”
 Method: Position patient @ 45 degree
angle at the hip
Turn head slightly away
Use a strong light tangentially
Observe the external jugular over the
sternomastoid muscle

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Specific Process for CVP
Measurement
 Locate the internal jugular pulsation
 Mark the highest point of pulsation
 Locate the “angle of Louis”
 Make a “T square” with 2 index cards
 Read the level of intersection
Note: The normal jugular venous pressure is
2 cm or less above the sternal angle.

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Hepatojugular Reflux
 This is measured if the CVP is elevated or CHF is
suspected.
 Patient is supine
 Instruct patient to breathe quietly with mouth open
 With rt. hand on the patient’s RUQ of abdomen,
just below the rib cage, exert firm consistent
pressure for 30 seconds
 Watch the level of the jugular pressure
 Note: Normally the jugular rises but recedes back.
 Abnormally, the pressure elevates & stays.

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The Heart ( Precordium)
 Inspection: Check pulsations, heaves, lifts
(You may see the apical pulse.)
Note: The apical is located in the 4th or 5th
ICS @ the left MCL .
 Palpate: Feel the apical impulse (also
called the PMI). * Use 1 finger
pad.
Use palmar side of 4 fingers to feel for
other pulsations on the chest.
(eg. “thrills”

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Heart Assessment (continued)
Percussion: To check for heart
enlargement
(Note:often done by chest Xray)
Auscultation: Start at the base of the heart.
“APE to Man”
Aortic - 2nd Rt. ICS
Pulmonic – 2nd left ICS
Erb’s Point
Tricuspid – left sternal border
Mitral – 5th ICS @ left MCL

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Sequence for Auscultating
A. Begin with the diaphragm.
 Note at each area:
1. rate & rhythm
2. identify S1 and S2
3. assess S1 and S2 separately
4. listen for extra heart sounds (ie. S3,S4)
5. listen for murmurs
B. Repeat above using the bell.

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What do you hear?
 S1 and S2 sound like “lub-dup”
 S1 is louder than S2 at the apex
 S2 is louder than S1 at the base
 S1 coincides with the carotid pulsation

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Assessment of the
Peripheral Vascular System
 Arteries assessed in cephalocaudal direction:

 Head – temporal
carotid
 Arms – brachial
ulnar
radial
 Legs – femoral
poplitial
 Feet - dorsalis pedis
posterior tibialis

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Assessment of Veins
 Neck – Jugular veins
 Arms – Superficial
Deep
 Legs - Deep veins – femoral, popliteal
Superficial veins:-
great saphenous (inside of leg)
small saphenous (outside of leg)
Perforators – join the above 2 sets
 Note: The veins have valves that keep blood moving toward
the heart. However, you need exercise too.

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Lymph Nodes
Superficial nodes available for palpation:
1. Cervical nodes
2. Axillary nodes
3. Epitrochlear Nodes
4. Inguinal nodes

Also organs –
 Spleen - assessed in abdomenal exam
 Tonsils – assessed with head & neck
 Thymus (behind sternum)

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Subjective Data for Peripheral
Vascular System
 Leg pain
 Skin changes
 Swelling in arms & legs
 Lymph node enlargement
 Medications
 Smoking

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Techniques used to assess the
Peripheral Vascular System
Arms: Inspection
Palpation – radial, ulnar, brachial,
epitrochlear lymph nodes
* perform the Allen Test
Legs: Inspection
* If calf pain, check the Honan’s sign
Palpation – femoral, poplitial, dorsalis
pedis, posterior tibialis
* If pretibial edema, press over tibia or
medial malleolas for 5 seconds
* Use rating scale

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An Additional Test
If there is a color change in the lower
extremities…
 Elevate the legs 30 cms (12 inches)
 Have patient wag feet to drain blood
 Sit patient up with legs over side of table
 Note the time it takes for color to return.
 Normally, the color returns in 10 seconds.

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The end

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