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Cardiovascular System
Professor Kneeshaw
11/24/2018 1
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
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Blood
Blood FlowFlow
through the
Heart
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Cardiac Cycle
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Heart Sounds
S1 – when closure of the AV valves
(tricuspid & mitral) & ventricles
contract
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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
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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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