Cardiovascular and Peripheral Vascular Assessment Flashcards
1
Q
What does the peripheral vascular system consist of
A
- Arteries
- Veins
- Lymphatic vessels
2
Q
Arteries
A
- Carry oxygenated blood away from heart
- High pressure system
- Vessel wall thicker and more tough; elastic and muscle fibres
- Mediate BP
- Have a ‘pump’ to keep blood moving; the heart, created pulse
3
Q
Veins
A
- Carry deoxygenated blood back to the heart
- Low pressure system; moves slower
- Have less number than arteries present in the body
4
Q
What mechanisms do veins rely on to keep blood moving?
A
1) Contracting skeletal muscles
2) Pressure gradients; thoracic pressure decreases when you breathe in, abdominal pressure increases
3) Intraluminal valves; prevent back flow
5
Q
Arteries accessible during examination
A
- temporal
- carotid
- brachial
- radial
- ulnar
- femoral
- popliteal
- dorsalis pedis
- posterior tibial
6
Q
Veins accessible during examination
A
- external jugular
- internal jugular
- superficial arm
- deep arm
- femoral
- popliteal
- great saphenous
- small saphenous
- perforators
7
Q
Venous pooling
A
Back up of blood on the venous side
8
Q
Important arteries in the arms
A
- Ulnar; located along pinky side running up arm
- Radial; located on thumb side running up arm
- Brachial; middle of upper arm
- Pulse sites; either side or wrist, elbow pit
- In children and infants you can palpate in between bicep and tricep
9
Q
Important arteries in the legs
A
- Femoral artery; major artery that supplies leg, runs alongside femur
- Popliteal artery; located behind knee
- Posterior tibial artery; along calf
- Dorsalis pedis artery; on top of foot
- Pulse sites; inner upper thigh, behind knee, top of foot on big toe side
10
Q
Important veins in the legs
A
- Great saphenous vein; runs all along the back of the leg
- Small saphenous vein; along the lower back of leg, smaller
11
Q
Functions of the lymphatic system
A
- Returns fluid back to the venous system
- Forms a major part of the immune system
- Absorbs lipids from the intestinal tract – helps with the transport of the fat soluble vitamins
12
Q
What trunks do lymph vessels drain into?
A
- Right lymphatic duct; upper right side of body
* Thoracic duct; upper left side of body and whole lower body
13
Q
What is lymph flow propelled by
A
- Contracting skeletal muscles
- Pressure changes during breathing
- Contraction of the vessels themselves
14
Q
What lymph nodes are possibly palpable during examinations
A
- Cervical nodes – can be palpated, the rest shouldn’t be
- Axillary nodes
- Epitrochlear node
- Inguinal nodes
15
Q
What are we looking for when assessing lymph nodes
A
- Tender (likely infection)
* Palpable and fixed – may be cancerous
16
Q
Infant and children considerations when assessing vascular system
A
- Larger lymph nodes; they grow faster than the rest of the body
17
Q
Pregnant persons considerations when peripheral assessing vascular system
A
- Drop in BP – changes in the body result in vasodilation, starts in the second trimester
- Edema in the lower extremities, varicose veins, hemorrhoids – due to the growing fetus
18
Q
Older persons considerations when assessing peripheral vascular system
A
- Arteriosclerosis – happens naturally as we age (regardless of lifestyle factors), blood vessels become more rigid, less compliant blood vessels; greater pressure from the heart is needed to push that blood out through them; increase in BP
- Enlargement of the calf veins – more at risk of venous pooling
- Loss of lymphatic tissue – atrophy
19
Q
Subjective assessment of peripheral vascular system
A
- Leg pain or cramps
- Skin changes on arms or legs
- Swelling in the arms or legs
- Bilateral may indicate systemic issue
- Unilateral may be a result of local issue
- Lymph node enlargement
- Medications
- History of vascular problems?
- Diabetes, cardiac issues, history of obesity; both in the client and family history
20
Q
Inspecting and palpating the arms
A
- Colour, temperature, texture, turgor, lesions, scars, edema, clubbing
- Capillary refill – colour should return <2secs; can do fingers and toes
- Symmetry – swelling and edema
- Pulses – with cardiac patient want to assess in all 4 places; ensure proper circulation
- Radial
- Ulnar
- Brachial
- Epitrochlear lymph node
21
Q
Grading a Pulse on a 4-point scale
A
3+= increased, bounding 2+= normal 1+= weak, thread (see in someone going into shock) 0= absent
22
Q
Inspecting and palpating the legs
A
- Skin colour, hair distribution, venous pattern, size (both lying down and standing), symmetry, skin lesions, ulcers
- Palpate for temperature
- Palpate inguinal lymph nodes
- Pulses
- Femoral
- Popliteal
- Dorsalis pedis
- Posterior tibial
- Asses for edema – if present we want to grade it
23
Q
Deep Vein Thrombosis (DVT)
A
- Clot in a vein, usually in the leg
- Swelling and inflammation below the blockage site
- Swollen, red, feels really hot
- Anyone who has prolonged immobility is at risk of DVT; older age, anyone who has altered blood coagulation, prone to clots, or any damage to the main clot itself (post-surgery)
24
Q
Peripheral Arterial Disease (PAD)
A
- Build-up of fatty substances on the walls of the artery
- Blockage in a peripheral artery
- Buildup of plaque in the artery wall itself; blood is trying to come down but can’t
- Paler, cooler, difficult to find pulse, capillary refill >2secs
- Decreased circulation leads to non-healing injuries on the foots; especially in areas of pressure (i.e. on the ties)
- If untreated can lead to gangrene and needs to be amputates; tissue not getting oxygen
25
Where is the heart located
* Heart located on the chest from the 2-5th intercostal space
* Does extend over to the right sternal boarder over to the left midclavicular line
* The top of the heart called the base, bottom of the heart called the apex
* Apex lies at the 5th intercostal space at the midclavicular line; at that point we can feel the PMI
26
Precordium
• Area on the chest where the heart would sit is called the precordium
27
Pulmonary vs Systemic Circulation
Pulmonary
- Right ventricle into pulmonary arteries (deoxygenated blood)
- Blood gets oxygenated in lungs
- Pulmonary veins carry oxygenated blood back to heart into left ventricle
Systemic
- Left ventricle pumps oxygenated blood into systemic arteries
- Lose oxygen in systemic circulation
- Systemic veins carry deoxygenated blood back to heart into right ventricle
28
Pericardium
Sac that holds the heart
29
Myocardium
Muscles surrounding the heart
30
Endocardium
Tissue that surrounds the inner structure of the heart
31
Valves of the heart
Aortic valve
Pulmonic valve
Mitral (AV) valve
Tricuspid (AV) valve
32
The cardiac cycle
Diastole
• Protodiastolic filling (passive filling)
• Presystole/Atrial systole/Atrial kick (active filling)
Systole
• Av vales close; creates the first heart sound
• For a moment, all 4 valves in the heart is closed and pressure is building
• The pressure gets to a certain point, then the semi-lunar valves
• When the semi-lunar valves close it is the second heart sound
Diastole Again
33
Expected heart sounds
S1 (“Lup”)
• Occurs with closure of the AV valves
• Loudest at the apex
S2 (“Dup”)
• Occurs with closure of the SL valves
• Loudest at the base
Split S2 (“Lup-T-Dup”) – the aortic valve closes just before the pulmonic valve
34
Extra heart sounds: S3
* Heard during diastole (protodiastole) – normally a silent phase; the ventricles are resistant to filling, results in vibrations or turbulence in blood which results in an extra beat
* Occurs just after S2
* Physiologic – children and pregnant people; but will go away when they sit up
* Pathologic (ventricular gallop) – gallop you hear when a horse is galloping; early sign of heart failure
35
Extra heart sounds: S4
* Heard at the end of diastole during presystole – ventricles that are resistant to filling; create extra vibration that is heard as a beat
* Occurs just before S1
* Physiologic – older person after exercise; not heard at rest
* Pathologic (atrial gallop) – present all the time; cardiomyopathy, issues with the heart muscles
36
Extra heart sounds: murmurs
* A blowing or swooshing sound
* Signals turbulent blood flow
* Conditions that may result in a murmur:
* Increased velocity of the blood – i.e. flow murmur in exercise
* Decreased viscosity of the blood – i.e. anemic person
* Structural defects in the valves or unusual openings in the chambers
* Turbulent blood flow in a great vessel = a bruit (usually from an artheroslortic plaque)
37
Conduction of the heart
• Automaticity – contract by itself independent of other signals
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Route:
• SA node (internal pacemaker)
• AV node
• Bundle of His
• Right and Left Bundle Branches
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38
Cardiac Output
The amount of blood being pumped by the heart per minute
| • CO= SV x rate
39
Stroke Volume
The amount of blood ejected from the heart (in one cycle)
40
Preload vs Afterload
* Preload = the length the ventricle must stretch just before contraction
* Afterload = the pressure the ventricles must generate in order to open the valves and eject the blood
* Exercise we increase the amount of blood returned to the heart; preload is slightly greater
* If an individual has a cardiomyopathy muscles, ,ay not generate enough afterload to eject blood to the system
* Medications that affect pre and afterload
41
Infant and children considerations for CV assessment
• Foramen ovale – blood reroutes in utero; hole between the two atriums; shunted through that hole into the systemic circulation. Closes first hour in life
• Ductus arteriosus – blood shunted into pulmonary artery into aorta into
pulmonary circulation; takes 10-15 hours of life to close.
• Position of the heart in infants is higher and more horizontal until age 7 (at 4th intercostal space as opposed to 5th)
42
Pregnant persons considerations for CV assessment
* Blood volume increases – 30-40%, to support both pregnant person and fetus
* Pulse rate increases – by about 10-15bpm
* BP drops slightly
43
Older persons considerations for CV assessment
* Systolic BP increases – harder to push blood out against less elastic vessels
* Left ventricle wall thickens – because the muscle grows bigger as it starts to work harder
* Increased prevalence of arrhythmias – irregular heart rhythms
* Increased incidence of cardiovascular disease, hypertension and heart failure – lifestyle habits as well as genetics
44
Subjective assessment of the CV system
* Chest pain – or tightness; not necessarily a presenting sign, especially in women
* Dyspnea – shortness of breath
* Orthopnea – need to assume a more upright position in order to feel like you can breathe
* Cough
* Fatigue
* Cyanosis/pallor – ask the patient about colour changes
* Edema
* Nocturia – urgent need to get up and go pee in the night; can develop in person with congestive heart failure
* Current/past cardiac history
* Family cardiac history
* Personal habits – nutrition smoking/alcohol/substances, stress, sleep, etc.
45
Assessing neck vessels: CV system
* Palpate the carotid artery – one side at a time
* Pulse strength – ideally around a 2+
* Equal bilaterally
* Auscultate the carotid artery – pick 3 spots down the artery and listen; we should hear nothing
* Bruit? – hearing the turbulent blood blow; breath sounds can interfere, tell them to hold breath for 5 seconds while you assess
46
Inspecting the precordium
Anterior chest
• Apical impulse – may not see in an adult
• 5th intercostal space at the midclavicular line; lighting can help
47
Palpating the precordium
* Apical impulse – helpful to tell them to take a breath in, exhale, then hold it (no chest rising and falling) – may not be palpable in all people
* Palpate across the precordium
* Thrill – someone who has a very loud murmur – palpable vibration that is not at the apical impulse
48
Percussion of the precordium
* Place finger on the 5th intercostal space on the left chest at the axillary line, percuss inwards
* Hollow sounds of lungs; midclavicular line you get dull thud of heart
* Hollow sound vs. full sound
* To detect heart enlargement; difficult to do – usually sent for tests instead
49
Auscultation of the precordium
* Note the rate and rhythm – consistency
* Identify S1 and S2 – identify them separately (S1 louder at apex and at same time as the Cartoid pulse), S2 louder at the base)
* Assess S1 and S2 separately
* Listen for extra heart sounds
* Listen for murmurs
* Listen in a ‘Z’ pattern – point on the precordium where you can hear the valves best
* Use diaphragm and bell – bell will pick up S3, S4 and murmur best
50
'Z' Pattern
- 5 spots on the precordium where you can hear the valves the best
1) Mitral valve; S1 loudest
2) Tricuspid valve
3) Erb's point; S1 and S2 equal volume
4) Pulmonic valve
5) Aortic area; S2 loudest
51
Cardiac Murmurs
* Timing – between S1 and S2 or outside of them
* Loudness
* Pitch
* Pattern
* Quality – musical murmur
* Location – hear it best in one specific area
* Radiation – can we hear it in other places on the chest, up into the neck
* Posture – can sometimes disappear when a person sits up, or our ability to hear a murmur can be enhances in certain postural changes
52
Rating loudness of murmurs
* Grade 1 = barely audible, only in a faint room and then with difficulty
* Grade 2 = clearly audible, but faint
* Grade 3 = moderately loud, easy to hear
* Grade 4 = loud, associated with a thrill
* Grade 5 = very loud, heard with one corner of stethoscope lifted off chest wall
* Grade 6 = loudest, heard with entire stethoscope lifted just off the chest wall
