Cardiovascular Assessment Flashcards
Precordium
area of the anterior chest containing the heart and great vessels
Base of the Heart
Top - located at the 3rd intercostal space
Apex of the Heart
Bottom - located at the 5th intercostal space
Layers of the Heart (3)
- Pericardium
- Myocardium
- Endocardium
Pericardium
a tough, fibrous, double-walled sac that surrounds and protects the heart
- filled with serous pericardial fluid that ensures smooth, friction-free movement of the heart muscle
Myocardium
the muscular wall of the heart
Endocardium
thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves
Apical Impulse
with each period of diastole and systole, the left ventricle of the heart pushes against the chest wall, creating a palpable pulsation = apical impulse
Carotid Artery
located in the groove between the trachea and the sternomastoid muscle
Jugular Veins
empty unoxygenated blood directly into the superior vena cava –> no cardiac valve separates the vena cava and the right atrium, so the jugular veins can give information on the activity of the right side of the heart
Internal Jugular Vein
lies deep and medial to the sternomastoid muscle
- not visible
- pulsations can be measured
to calculate JVP
External Jugular Vein
lies superficial and lateral to the sternomastoid muscle above the clavicle
- more visible
The Cardiac Cycle
- Diastole - the period of ventricular filling, two phases:
a. protodiastole - passive
filling of the ventricles
(75% CO)
b. presystole - atria contract
to push remaining 25%
of CO into ventricles - Systole - contraction of the ventricles
ECG
P Wave - depolarization of the atria (presystole)
P-Q Interval - atrial depolarization + electrical impulse moving from AV node to ventricles
QRS Complex - depolarization of ventricles (systole)
T Wave - repolarization of repolarization
Health History Points
- Chest Pain
- Dyspnea
- Orthopnea
- Cough
- Fatigue
- Cyanosis or Pallor
- Edema
- Nocturia
- Cardiac History
- Personal Habits
Auscultation of the Carotid Artery
keeping the neck in a neutral position, auscultate 3 points:
1. angle of the jaw
2. midcervical area
3. base of the neck
ask the patient to take a breath, breathe out, and hold briefly for best results
—> ALWAYS done prior to palpating to look for the presence of a bruit
Palpation of the Carotid Artery
palpate each carotid artery medial to the sternomastoid muscle in the neck
- note the contour, amplitude
of the pulse and presence
bilaterally
–> NEVER palpate both at the same time
Central Venous Pressure (CVP)
Jugular Venous Pressure can be used to assess central venous pressure (indicates the heart’s efficiency)
- the internal (right) jugular
vein is best (not visible but
pulse is palpable
Calculation of JVP
- patient suprine, HOB 45 degrees and head turned away
- place ruler 1 perpendicular to angle of louis
- place ruler 2 at the highest point of jugular pulsation
- JVP = intersection point
JVP of <2cm
normal
JVP of >2 cm
elevated, requires additional testing
Abdominojugular Test
performed when JVP calculation indicates an elevated pressure (>2) to confirm
- patient supine
- push RUQ in (on liver) for 30 sec –> fluid from the liver will cause the jugular vein to rise
- if the vein rises and falls
when pressure is released
= normal - if the vein rises, but it does
not fall immediately when
pressure is released =
elevated JVP confirmed
- if the vein rises and falls
Inspection of the Anterior Chest
inspect for visible pulsations of the apical impulse at the level of the 4th or 5th intercostal space (inside the midclavicular line)
Palpation of the Apical Impulse
position the patient supine and locate the apical impulse using one finger pad –> ask the patient to exhale and hold
- if the impulse cannot be felt
when supine, rotate the
patient midway to the left
–> this will displace the
impulse further left
Note:
- location of the impulse
- the size of the impulse
- amplitude
- duration
Palpation Across the Precordium
with the patient lying supine, use the palmar aspects of the four fingers to gently palpate over the apex, left sternal border, and the base
–> intended to identify the
presence of (if any)
additional or abnormal
pulsations (ex. thrills)
Thrill
a palpable vibration signifying the presence of turbulent blood flow, accompanies a loud murmur
Note:
- if a thrill is present
- location
- timing during the cardiac cycle
Auscultation Points
the regions in which sounds produced by the valves are best heard
Note:
- rate and rhythm, irregularities
- Identify S1 and S2 seperately
- extra heart sounds
- murmurs
Normal Heart Sounds
S1 and S2
S1
occurs with the closure of the AV valves (tricuspid and mitral)
- occurs when the pressure
within the ventricles
exceeds that of the atria,
closing the AV valves
- signals the beginning of
systole
S2
occurs with the closure of the semilunar valves (aortic and pulmonary)
- occurs when the pressure
inside the atria and
pulmonary arteries exceed
that of the ventricles,
forcing the valves shut
- signals the end of systole
Abnormal Heart Sounds
S3, S4, and murmurs
S3
occurs when the ventricles are resistant to filling during protodiastole (passive filing)
- present immediately after
S2
ventricles have just contracted (S2) and are ready to passively fill (protodiastole)
S4
occur when the ventricles are resistant to filling during prediastole (active filling, atrial contraction)
- present just before S1
ventricles have contracted (S2) and have passively filled, and are ready for presystole to occur to finish filling (just prior to S1)
Murmurs
conditions resulting in turbulence of blood flow –> creates a gentle, blowing, swooshing type sound that can be heard all over the chest wall
Conditions resulting in murmurs (3)
- increases in velocity of blood (blood flows faster)
- Decreases in viscosity of blood (blood is thinner, thus can move faster)
- Structural defects in the vales or unusual openings in the chambers (causes blood to circulate inefficiently)
Heart Failure
occurs when the heart cannot pump blood efficiently, cannot meet the body’s metabolic needs
Aortic Stenosis
Calcification of the aortic valve does not allow it to open properly, restricting the forward flow of blood during systole
- results in hypertrophy of the
LV (needs more muscle to
overcome stenosis)
- S2 split if valve is thicker
- apical pulse displaced left
(LV hypertrophy pushes it)
- thrill present
Mitral Stenosis
calcified mitral valve does not open properly, restricting the forward flow of blood during diastole
- results in the enlargement
of LA (accommodate
increased blood volume
and pressure)
- pulmonary congestion +
edema, orthopnea, SOBE
(fluid backflow into lungs
- thrill present
Aortic Regurgitation
incompetent aortic valve doesn’t close, blood flows back into LV during diastole
- results in hypertrophy of the
LV (needs more muscle to
overcome stenosis)
- results in the dilation of LV
(to accommodate inc blood
volume)
- angina
- displaced apical impulse
- BP increased (increased
resistance, blood volume)
- murmur during S2 (doesn’t
fully close when systole
finishes, some turbulence
present)
Mitral Regurgitation
incompetent mitral valve doesn’t close, blood flows back into LA during systole
- results in hypertrophy of the
LV (needs more muscle to
overcome stenosis)
- results in the dilation of LV
(to accommodate inc blood
volume)
- angina
- displaced apical impulse
- murmur during S1 (doesn’t
fulling close for systole,
some turbulence present)
Older Adult Considerations: Anatomical Changes
- systolic BP increases
- diastolic BP decreases
- LV thickens (compensation
mechanism for stiffening
vessels and increased
resistance) - inability to meet CO needs
during exercise (SOBOE) - increase in ectopic beats
- ECG changes (prolonged P-R
interval and Q-T intervals) - presence of supraventricular/
ventricular arrythmias
Older Adult Considerations: Health History
- history of pulmonary OR heart disease
- taking medications
- home environment assessment (could anything exacerbate symptoms? affect AODL?)
Older Adult Considerations: Physical Exam
- gradual rise in systole BP with age
- sensitive carotid artery
- chest dize increases in anterio-posterior diameter
= harder to palpate apical
impulse
= difficult to hear S2 split - S4 increasingly common
- systolic murmurs common
-ectopic beats common
