Title: Assessment of Cardiovascular System
1Assessment of Cardiovascular System
2Lecture Objectives
- Anatomy and physiology of cardiovascular system.
- Developmental considerations
- Transcultural considerations
- History taking and physical examination
- Main disorders of cardiovascular system
- Congenital heart defects.
- Valvular defects.
- Heart failure.
3Structure of the Cardiovascular system
4Anatomical Structure of the Heart
5Common abbreviations used to refer to chambers
- RA right atrium
- RV right ventricle
- LA left atrium
- LV left ventricle
- AV atrioventricular valve
- Left AV left atrioventricular valve
- Right AV - right atrioventricular valve
- SL semilunar valve
NB No valves are present between major veins and
atria. Hyperpressure leads to signs of congestion.
6Topographical Landmarks of the Heart
7Topographical Landmarks of the Heart
- Precordium the part of the ventral surface of
the body overlying the heart and stomach and
comprising the epigastrium and the lower median
part of the thorax
8Topographical Landmarks
- Each area corresponds to one of the hearts 4
valves. - Aortic area - 2nd ICS to right of sternum
(closure of the aortic valve loudest here). - Pulmonic area - 2nd ICS to left of sternum
(closure of the pulmonic valve loudest here). - Tricuspid - 5th ICS left of sternal border
(closure of tricuspid valve). - Mitral - 5th ICS left of the sternum just medial
to MCL (closure of mitral valve). When cardiac
output is increased as in anemia, anxiety, HTN,
fever, the impulse may have greater force -
inspect for lift or heave.
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10Normal Heart Sounds
- The first heart sound - systolic S1
- Signals the closure of AV valves and the
beginning of systole. - Consists of mitral M1 and tricuspid T1
components. - Is loudest at the apex
11- The second heart sound - diastolic S2
- Signals the closure of semilunar valves and the
end of systole. - Consists of aortic A2 and pulmonic P2 components.
- Is loudest at the base.
- S1 S2 correspond respectively to the familiar
"lub dub" often used to describe the sounds.
12Effect of respiration
- MoRe to the Right heart
- Less to the Left
- A split S2 when the aortic valve closes
significantly earlier than the pulmonic valve,
you can hear the two components separately.
13Other Heart Sounds
- Extra Heart Sounds
- S3
- is the result of vibrations produced during
ventricular filling. - is normally heard only in some children and young
adults, but it is considered abnormal in older
individuals. - S4
- is caused by the recoil of vibrations between the
atria and ventricles following atrial
contraction, at the end of diastole. - is rarely heard as a normal heart sound usually
it is considered indicative of further cardiac
evaluation.
14Other Heart Sounds
- Murmurs
- are produced by vibrations within the heart
chambers or in the major arteries from the back
and forth flow of blood. - are classified as
- 1. Innocent, occurring in individuals with no
anatomic or physiologic abnormality. - 2. Functional, occurring in individuals with no
anatomic cardiac defect but with a physiologic
abnormality such as anemia. - 3. Organic, occurring in individuals with a
cardiac defect with or without a physiologic
abnormality.
15The conduction system of the heart consists of
four structures
- 1. The sinoatrial (SA) node, located within the
rig atrial wall near the opening of the superior
vena cava - 2. The atrioventricular (AV) node, also located
within the right atrium but near the lower end of
the septum - 3. The atrioventricular bundle (bundle of His),
which extends from the atrioventricular node
along each side of the interventricular septum - 4. Purkinje fibers, which extend from the
atrioventricular bundle into the walls of the
ventricles. The electric impulses from this
conduction system can be recorded on an
electrocardiogram.
16Conduction System
17Electrocardiography (ECG)
- records the electrical impulses generated from
the heart muscle and provides a graphic
illustration of the summation of these impulses
and their sequence and magnitude.
18The ECG waves
- P wave represents the electric activity
associated with the sinoatrial node and the
spread of the impulse over the atria. It is a
wave of depolarization. - QRS complex (wave) is composed of three separate
waves the Q wave, the R wave, and the S wave.
They are all caused by currents generated when
the ventricles depolarize before their
contraction. Because ventricular depolarization
requires septal and right and left ventricular
depolarization, the electrical wave depicting
these events is more complex than the smooth P
wave. - P-R interval is measured from the beginning of
the P wave to the beginning of the QRS complex.
It is termed P-R instead of PQ because frequently
the Q wave is absent. This interval represents
the time that elapses from the begin Q-T
intervalning of atrial depolarization to the
beginning of ventricular depolarization.
19The ECG waves
- The T wave represents repolarization of the
ventricles. The Q-T interval begins with the QRS
complex and ends with the completion of the T
wave. It represents ventricular j depolarization
and repolarization. This interval varies with j
the heart rate. The faster the rate, the shorter
the Q-T interval. Therefore in children this
interval is normally shorter than in adults. - The S-T segment is normally an isoelectric (flat)
line that I connects the end of the S wave to the
beginning of the T wave. - The T-P interval represents atrial and
ventricular polarization in anticipation of the
next cardiac cycle.
20Pumping Ability
- 4 to 6 L of blood per min throughout the body
- Preload venous return
- Afterload the opposing pressure the ventricles
must generate to open aortic valve.
21Developmental Considerations
- Infants
- Transition from fetal circulation to postnatal
circulation. By 9 months anatomical closure of
foramen ovale occurs. - S1 and S2 sounds similarly on auscultation. Pulse
rate 120/min. - Horizontal position of the heart (till
7-years-old).
22Developmental Considerations
- Infants
- Apex impulse is located at the 4th intercostal
space 1 to 2 cm outward from left midclavicular
line.
23Developmental Considerations
- The pregnant female
- By the end of pregnancy blood volume increases by
30 to 40 . - Stroke volume and cardiac output are increased.
- BP decreases due to vasodilation.
- Pulse rate increases of 10 to 15 beats/min.
24Developmental Considerations
25Developmental Considerations
- An aging adult
- The incidence of CV diseases increases with age
coronary artery disease, HBP, heart failure.
26Transcultural considerations
- Smoking widely spread in some societies.
- HBP Afro-Americans, Mexican-Americans and Native
Americans have higher risk of hypertension. - Serum cholesterol during childhood (4-19 yrs)
Afro-American children have higher total
cholesterol than Euro- and Mexican-Am. Children.
This difference reverse during adulthood. - Obesity more than 50 of Am. population are
overweight. - Diabetes the prevalence of diabetes increases in
all groups in USA.
27Physical Examination
- Objectives
- Subjective data.
- Health history data.
- Preparation.
- Inspection general appearance, precordium.
- Palpation peripheral pulses, apical impulse.
- Percussion.
- Auscultation heart sounds, murmurs.
- Summary checklist.
28Subjective data
29Chest pain
Angina an important cardiac symptom. Clenched
fist sign is characteristic of angina.
- Onset, location, character, aggravating and/or
relieving factors - Character crashing, stabbing, burning,
vise-like. - Associated symptoms sweating, ashen gray or pale
skin, shortness of breath, nausea or vomiting,
racing of heart, heart skips beat.
30Subjective data
Paroxysmal nocturnal dyspnea (PND) occurs with
heart failure. Classically, the person awakens
after 2 hrs. of sleep, arises, and flings open
the window with the perception of needing fresh
air.
- Dyspnea
- Cause, onset, duration, affection by position,
- Does shortness of breath interfere with
activities of daily living? - Orthopnea
- Is the need to assume a more upright position to
breathe. - Note the exact number of pillows used.
31Subjective data
Hemoptysis is often a pulmonary problem, but
also occurs with mitral stenosis
- Cough duration, frequency, type, coughing up
sputum (color, odor, blood tinged, aggravating
and/or relieving factors. - Fatigue onset, relation to time of day?
- Cyanosis or pallor occurs with myocardial
infarction or low cardiac output.
32Subjective data
- Edema
- Swelling of legs or dependent body part due to
increased interstitial fluid. - Onset, recent change, relation to time of day,
relieving factors, associated symptoms. - Nocturia
- Occurs with heart failure in the person who is
ambulatory during the day.
33History taking.
- Past cardiac history
- ! Last ECG, stress ECG, serum chilesterol
measurements, other heart tests? - Family cardiac history
- Family history of hypertension, diabetes, heart
problems, coronary artery disease (CAD), sudden
death at younger age? - Personal habits (cardiac risk factors)
nutrition, smoking, alcohol, exercise, drugs.
34Additional history
- For infants mothers health during pregnancy,
feeding habits, growth, activity. - For children growth, activity, any joint pains
or unexplained fever, frequent headaches or
nosebleedings, streptococcal infection
(tonsillitis). - For pregnant female any high PB during this or
previous pregnancies, associated signs (weight
gain, proteinuria), dizziness. - For aging adult any symptoms of heart diseases
(HTN, CAD) or COPD, any recent changes,
medications (digitalis), side effects
environment.
35Preparation
- Bring to lab
- Watch with second hand,
- Stethoscope,
- Marking pen and small centimeter ruler,
- Alcohol swab (to clean endpiece).
- Wear
- loose T-shirt or some other garment that allows
for practice of physical assessment
36Inspection
- Skin colour (cyanosis, pallor) and condition
- Any obvious bulging on anterior thorax at the
left - Edema
- Orhtopnea
37Palpation
- Palpate the apical impulse (the point of maximal
impulse, or PMI) - Location one intercostal space (usually 5th ICS)
at left MCL, - Size normally 1 cm ? 2 cm,
- Amplitude normally a shot, gentle tap,
- Duration short, normally occupies only first
half of systole. - Ask the client to exhale then hold it or turn
him to the left side.
38Palpation
39Palpation
- Palpate across the precordium for
- Other pulsations,
- Thrill palpable vibration due to strong heart
murmur (like a purring cat), - Pericardial friction rubs are scratchy,
high-pitched grating sounds, similar to pleural
friction rubs, except that they are not affected
by changes in respiration. - Accentuated S1 and S2.
- A diffuse impulse (lift, heave).
40Palpation
41Percussion
- Is used to estimate approximately heart borders
and configuration. - Recently is displaced by the chest x-ray or
EchoCG. - Helps to detect heart enlargement
Heart (cardiac) enlargement is due to increased
ventricular volume or thickening of heart
wall. Occurs with HTN, CAD, heart failure,
cardiomyopathy
42Auscultation
43Auscultation
- A Z-pattern is recommended.
- Before beginning alert the person for long
duration of procedure. - Begin with diaphragm endpiece and use the
following routing - Note the rate
- the rhythm
- Identify S1 and S2
- Listen for extra heart sounds
- Listen for murmurs
44Auscultation (cont.)
- Rhythm
- Regular
- Irregular
- Synus arrythmia common variation. Rate ? on
inspiration and ? on expiration. - Regularly irregular
- Irregularly irregular no pattern to the sounds,
beats come rapidly and at random intervals. - Pulse deficit occurs with atrial fibrillation,
heart failure, detects weak heart contractions.
45Auscultation (cont.)
- Identify S1 and S2
- Location and amplitude,
- Correlation with peripheral pulses, PMI
- Correlation with ECG waves
- Lub or dup
- Give description of origin.
- Listen to sounds separately accentuation, split
(fixed, paradoxical).
46Auscultation (cont.)
- Extra heart sounds
- Midsystolic click
- S3 normal, pathological (ventricular gallop)
- S4 atrial gallop
- Listen for murmurs
- Characteristics timing, loudness, pitch,
pattern, quality, location, radiation, posture
47Grading murmurs
- Grade I-VI
- Refers to the severity of a heart murmur
(blowing, whooshing, or rasping sound), which is
the result of vibrations caused by turbulent
blood flow patterns. - Murmurs are classified ("graded") depending on
their ability to be heard by the examiner. The
grading is on a scale with grade I being barely
detectable. - An example of a murmur description is a "grade
II/VI murmur." (This means the murmur is grade 2
on a scale of 1 to 6).
48Murmurs are classified according to their timing
within the cardiac cycle.
- Systolic Between S1and S2.
- Diastolic Between S2 and S1).
- Systolic ejection Begin after the first heart
sound, attain a peak during midsystole, and
terminate before the second heart sound. - Pansystolic or holosystolic During all of
systole. - Pandiastolic or holodiastolic During all of
diastole. - Prodiastolic Early diastolic.
- Presystolic Late diastolic.
- Continuous Continue through all of systole and
all or part of diastole.
49Timing of murmurs
50Conclusion
- Function can be assessed to a large degree by
findings in the history shortness of breath
(SOB), edema of ankles/legs, pain, pulse rate and
rhythm vital signs, signs and symptoms of oxygen
deficit. - Location Heart lies behind and to the left of
the sternum. The upper portion or atria (BASE)
lies to the back the ventricles (APEX) points
forward, the apex of the left ventricle actually
touches the anterior chest wall near the left
midclavicular line at or near the 5th left ICS.
Known as point of maximal impulse (PMI) and is
where apical beat is assessed. Impulse is a good
index of heart size. - Landmarks for assessment The precordium is the
area on the anterior chest overlying the heart.
Hearts sounds are heard throughout the
precordium, but there are 4 major areas for
examining heart sounds.
51Techniques of Assessment
- Inspection- look for lift at apex.
- Auscultation- Client should be assessed in supine
position with head up to 45 deg. examiner stands
at right side. Use diaphragm for basic sounds
bell for murmurs and extra sounds. - Identify the heart rate, rhythm bell for murmurs
aortic, pulmonic, mitral.
52Heart Sounds
- There are 2 basic normal heart sounds and several
abnormal ones. Normal - S1 (produced by closure of the atrioventricular
valves, mitral and tricuspid)- at mitral area and
tricuspid area S1 is louder than S2. The sound is
a dull, low pitched lub. - S2 (produced by closure of aortic and pulmonic
valve) is higher pitched, shorter and is the
dub sound. Heard best at the base (aortic and
pulmonic areas) where S2 is louder than S1 - Systole begins with the 1st sound. As ventricles
start to contract, pressure within exceeds the
atria, shutting the mitral and tricuspid valves.
Blood is forced into the great vessels. - When the ventricles have emptied themselves, the
pressure in the aorta and pulmonary arteries
force the semilunar valves shut
(aortic/pulmonic), which is the 2nd sound and
diastole (ventricular relaxation) begins.
53Other heart sounds
- S3 rapid filling of the ventricle with blood
heard following S2. Can be normal in young adults
and children pathologic in elderly. - S4 atrial contraction and thought to result
from stiffened left ventricle directly precedes
S1. Heard in elderly. - Extra sounds snaps and clicks are associated
with valves aortic and mitral stenosis,
prosthetic valves. - Murmurs S1 or S2 is a swishing or blowing sounds
caused by - Forward flow through a stenotic (narrowed) valve
- Increased flow through a normal valve
- Backward flow through a valve that fails to close
(insufficiency).
54- Murmurs should be identified as systolic (S1) or
diastolic (S2). Murmurs are common in children
and occur often in the elderly. - Try to identify grade of murmur Grade I (barely
audible) to Grade VI (loud and may be heard with
the stethoscope not quite on the chest or barely
touching the chest). - Documentation Normally, you should be able to
note that S1, S2 heard without extra sounds.
55Thanks for attention! Questions?