Lecture 2: Cardiovascular and Peripheral Vascular Flashcards
CV: Heart Valves: Atrioventricular
Between the atria and the ventricles
- Tricuspid opens from RA to RV
- Mitral opens from LA to LV
CV: Heart Valves: Semilunar
- Pulmonic valve and aortic valve
CV: 2 Neck Vessels
- Carotid Artery
- Jugular Artery
- Internal
- External
- Venous pulse and pressure
Cardiovascular Assessment Subjective Data: Health History
- Chest pain
- Dyspnea
- Orthopnea
- Cough
- Fatigue
- Cyanosis or pallor
- Edema
- Nocturia
- Past cardiac history
- Family cardiac history
- Personal habits (cardiac risk factors)
Cardiovascular Assessment Subjective Data: Cultural and Social Considerations
- Increase incidence of cardiovascular disease (CVD) in Canada among men and women
- Influence of socioeconomic factors
- High blood pressure
- Smoking
- Serum Cholesterol
- Obesity
- Diabetes
CV: Nonmodifiable Risk Factors
- Age
- Gender
- Genetic Factors
- Race and Ethnicity
CV: Modifiable Risk Factors
- High BP
- Smoking
- Diabetes mellitus
- Physical inactivity
- Obesity
- High blood cholesterol
CV: Additional Health History Questions: Infants
- Maternal Health
- Feeding without tiring
- Growth
- Activity, milestones
CV: Additional Health History Questions: Children
- Growth
- Activity
- Joint pain and fever
- Headache and nosebleed
- Resp disease
- Family history
CV: Additional Health History Questions: Pregnant women
- Hypotension
- Hypertension
CV: Additional Health History Questions: Older Adults
- Disease
- Medication
- Environment
CV: Women and Heart Attacks
- Symptoms easily attributed as something else
- Often ignored
- Women minimize significance of symptoms
- Heart disease is the leading cause of death in women older than 55 yrs of age
- Ovaries decrease production of estrogen = increased low-density lipoprotein (LDL), blood pressure (BP), and body fat above the waist, decreased high-density lipoprotein (HDL), metabolism of sugar affected
- Hormone replacement therapy (HRT) or no HRT?
CV Physical exam: Palpate and auscultate carotid artery while pt. sitting #1
- Inspection
- Palpation
- Percussion
- Auscultation
1. Palpate carotid arteries while cient sitting, and auscultate for bruit
2. Assist client to supine position: - Inspect the anterior chest - deformities, pulsations, skin
- Palpate the apical impulse
- Palpate for thrills
- Repeat in L lateral position
3. Precordium - Inspect the anterior chest
- Palpate the apical impulse
- Palpate across the precordium
- (Precuss to outline the cardiac borders)
CV: Landmarking the chest
- Intercostal spaces
- Midclavicular lines
- Sternal border
- Axillary lines
CV: Auscultation of CV and PV
- Identity auscultatory areas. Use the diaphragm of stethoscope
- Note rhythm and rate
- Identify S1 and S2 (S1 is louder than S2 at the apex, S1 coincides with carotid artery pulse)
- Listen to S1 and S2 separately. Closure of valves produces sound
- Listen for extra heart sounds, murmurs
Where?
- 2nd ICS, RSB (aortic)
- 2nd ICS, LSB (pulmonic)
- 5th ICS, LSB (tricuspid)
- 5th ICS, LMCL (mitral)
Auscultatory Areas: APe To Man
CV: What is S1?
1. What valves are closing?
2. Location
3. Cardiac cycle
4. Sound
- Tricuspid and mitral
- Apex
- Beginning of Systole
- LUB-dup
CV: What is S2?
1. What valves are closing?
2. Location
3. Cardiac cycle
4. Sound
- Pulmonic and aortic
- Base
- End of Systole
- Lub-DUP
CV: Split S2
- Normal occurrence at end of inspiration
- Inspiration -> aortic closes before pulmonic
- DUP becomes T-DUP
- Expiration -> aortic and pulmonic valves close together
- Usually heard in pulmonic valve areas
CV: What are murmurs?
- Blowing/Swooshing sound from turbulent blood flow
- Innocent
- Normal in healthy children and adolescents
- Functional
- From increased blood flow in the heart - Pathological
- Valvular defect -> stenosis or regurgitation - Frequently found with a thrill
- Repeat auscultation with pt. in L lateral position
CV Physical Exam - Murmurs
- Timing
- Loudness
- Pitch
- Pattern
- Quality
- Location
- Radiation
- Posture
CV Extra Heart Sounds
- After listening to S1, S2, and murmurs
- Bell at LLSB an apex in L lateral position
- Filling sounds -> extra heart sounds
- 3rd Heart sound, S3
- Soft, dull, low-pitched after S2
- Normal (physiological) children/young adults
- Pathological in older adults
- Ventricles resistant to filling - 4th Heart Sound, S4
- Very soft, low-pitched, just before S1
- Atria contract against resistant ventricles (CHF, MI)
- May be normal in adults after exercise
- R sided S4 LLSB; L sided S4 at apex - Summation Gallop S4, S1, S2, S3 together
- Pericardial friction rub
CV Developmental Considerations: Infants
- Diff. in apical, radial pulses
- Normal heart rates
- Murmurs more common in 1st days
CV Developmental Considerations: Children
- Position of apical impulse
- Venous hum
- Innocent heart murmurs
CV Developmental Considerations: Pregnant women
- Changes in BP (varies with position)
- Heart sound changes from increased blood volume and workload
- Mammary souffle
CV Developmental Considerations: Older adult
- Orthostatic hypotension
- Avoid pressure on carotid artery
- Premature ectopic beats more common
CV Physical Assessment: Assist to supine and… #2
a. Inspect anterior chest
b. Palpate apical pulse and precordium
c. Auscultation (APTM)
i. assess rate and rhythm (how long do you listen for?)
ii. identify S1 and S2 separately (S1 louder than S2 @ apex; at base S2 is louder)
iii. listen for murmurs in systole and diastole
iv. repeat with bell
CV Physical Assessment: Assist to L lateral position #3
- Auscultate APeToMan
- Assess S3 and S4 at apex and 5th ICS, LSB
PV: Veins
- Veins run parallel to arteries but more veins than arteries in body and lie closer to skin so easier to palpate/examine
- Jugular, arm, leg veins
- No pump
PV: Developmental Considerations; Infants and children
- Transient acrocyanosis and skin mottling
PV: Developmental Considerations; Pregnant women
- Diffuse bilateral pitting edema
- Varicose veins
PV: Developmental Considerations; Older adults
- Arteriosclerosis
- Atherosclerosis
- Increased risk of deep vein thrombosis (DVT)
- Dorsalis pedis, posterior tibial pulses more difficult to find
- Trophic changes associated with arterial insufficiency
PV: Subjective Data; Health History
- Leg pain or cramps
- Skin changes on arm or legs
- Swelling in arms or legs
- Medications
- Occupation
- Recent travel
- Recent surgery
PV: Objective Data
- Inspection
- Palpation
- Percussion (if relevant)
- Auscultation
PV Objective Data: Arms
Inspect and palpate
- Skin
- Profile sign
- Capillary refill
- Symmetry
- Radial pulses
- Ulnar pulses
- Brachial pulses
(3+, 2+ normal, 1+ weak, 0 absent)
PV: Pulses in Arms
- Radial
- Ulnar
- Brachial
PV Remember to think about…
- Cold room
- Smoking
- Decreased body temperature
- Edema
- Anemia
- Low BP
PB Objective Data: Legs
Inspect and palpate
- Skin and hair
- Symmetry
- Temperature
- Calf muscle
- Femoral pulse (near goin)
- Popliteal pulse (behind knee)
- Posterior tibial pulse (in foot)
- Dorsalis pedis pulse (in foot)
- Pretibial edema
- Measurement
- 1+ to 4+ grading scale for pitting edema
- Ankle circumference
- Colour
- Elevate and dangle
PV: Edema
Test: depress skin over bone, and release
Rate: 1+ mild with slight indentation 2mm depression, 2+ moderate 4mm depression, 3+ deep pitting and swollen 6mm depression, 4+ very deep and very swollen 8mm depression
Characteristics: pitting, dependent, bilateral/unilateral
PV Disease in Legs
- Chronic arterial insufficiency
- Chronic venous insufficiency
- Arterial (ischemic) ulcer
- Venous (stasis) ulcer
- Diabetic changes
- Chronic venous disease
- Superficial varicose veins
- Deep venous thrombophelebitis
PV: Foot care
- Often 1st sign of arthritis/diabetes/nerve or circulatory disorders
- Check feet every day, and keep blood flowing to the feet
- Wear comfortable-fitting shoes
- Fit shoes to larger foot
- Low-heeled shoes for women
- Keep skin soft and smooth
Abnormal Findings: PV disease in arms
- Raynauds phenomenon
- Lymphedema
Abnormal Findings: PV Pain
- Arterial Disease
- Causes signs and symptoms of O2 deficit - Venous Disease
- Causes signs and symptoms of metabolic waste buildup - Symptom analysis of pain for:
- Location, character, onset and duration, aggravating factors, relieving factors, associated symptoms, risk factors
- OPQRSTU
PV: Deep Vein Thrombosis
Risk Factors:
- Bedrest, immobility
- Surgery
Signs and symptoms:
- Redness, swelling, pain in calf
- +’ve Homan’s sign (not specific for DVT but requires further assessment)
Prevention
- Early mobilization
- Compression stockings
- Prophylactic anticoagulation
