NURS 1145 Cardiovascular & Peripheral Vascular Assessment

Precordium (Heart Anatomy)

The front of the chest over the heart

Mediastinum (Heart Anatomy)

The space between the lungs where the heart sits

Apex (Heart Anatomy)

Bottom tip of the heart = where you hear the loudest sounds

Base (Heart Anatomy)

Top of the heart = NOT the bottom (don't get this confused)

Pericardium (Heart Layers)

Protective sac around the heart (small amount of fluid inside is NORMAL)

Myocardium (Heart Layers)

The heart muscle = the LEFT side is thicker (pumps to the whole body)

Endocardium (Heart Layers)

Inner lining (includes the valves)

Tricuspid (The 4 Valves)

Right side, between right atrium and ventricle

Mitral (The 4 Valves)

Left side, between left atrium and ventricle

Pulmonic (The 4 Valves)

Semilunar, right side going to lungs

Aortic (The 4 Valves)

Semilunar, left side going to body

Chordae tendineae

'Heartstrings' = they attach valves to the myocardium

If a patient has an MI and develops a NEW murmur

Chordae may be involved = this is an emergency.

S1 (LUB) = Heart Sounds

1.Caused By = Mitral & tricuspid close 2.Normal 3.Louder at APEX

S2 (DUB) = Heart Sounds

1.Caused By = Pulmonic & aortic close 2.Normal 3.Louder at BASE

S3 (Heart Sounds)

1.Caused By = Rapid ventricular filling 2.Normal <40; otherwise = HF, fluid overload 3.Kentucky sound (lub-du-BUB)

S4 (Heart Sounds)

1.Caused By = Stiff ventricle (hypertension) 2.Usually ABNORMAL 3.Tennessee sound (BE-lub-dub)

Murmur (Heart Sounds)

1.Caused By = Valve not opening/closing properly 2.Abnormal 3.Whooshing/swishing sound

Pericardial Friction Rub (Heart Sounds)

1.Caused By = Inflamed pericardium layers rubbing 2.Abnormal = pericarditis 3.Scratchy rubbing sound; ask pt to hold breath

Use this mnemonic to remember where to place your stethoscope

Auscultation Areas = Apartment M (2245)

A = Aortic

Right 2nd intercostal space

P = Pulmonic

Left 2nd intercostal space

E = Erb's point

In between pulmonic and tricuspid, less critical

T = Tricuspid

Left 4th intercostal space (lower left sternal border)

M = Mitral

Left 5th intercostal space, midclavicular line (APEX)

S1 is louder at the ____; S2 is louder at the ____

APEX; BASE

S1 coincides with the

Carotid pulse and the R wave on ECG

Use BELL for

Low-pitched sounds (S3, S4, murmurs)

Use DIAPHRAGM for

Higher-pitched sounds (S1, S2)

Key Rules for Listening

1.Apply stethoscope directly to skin with firm pressure 2.For large breasts: have patient lift themselves, or use back of hand (TSA technique) 3.To hear extra sounds better: lay patient flat or turn them to left side 4.If unclear if it's pericardial or pleural: have patient hold their breath and listen to heart

Preload

How much the heart stretches before pumping (like filling a water balloon)

Starling's law (Preload)

More volume in → heart stretches more → pumps harder

Too much stretching over time (Preload)

Cardiac output eventually DROPS

Afterload

Resistance the heart pumps against (blood pressure related)

High afterload (high BP)

Heart works harder → left ventricle hypertrophy → eventual heart failure

A patient on dialysis who doesn't follow fluid restrictions will have

high sodium → water retention → high preload → may hear S3. Left ventricular hypertrophy from HTN = S4.

SYMPATHETIC NERVOUS SYSTEM (Fight or Flight)

1.Heart rate INCREASES 2.Vasoconstriction 3.Holds onto sodium and water 4.Triggered by: anxiety, exercise, heart failure, pain 5.Releases norepinephrine 6.Protects body in shock

PARASYMPATHETIC NERVOUS SYSTEM (Rest & Digest)

1.Heart rate DECREASES 2.Vasodilation 3.Cardiac output decreases 4.Triggered by: rectal exams, enemas, coughing, vomiting, bowel movements 5.Releases acetylcholine 6."Vasovagal" response = can cause fainting (syncope)

Giving enemas or rectal temps to elderly patients

→ vagal stimulation → heart rate drops. Never give enemas casually to elderly cardiac patients.

Cardiac Subjective Data

1.Chest pain = with activity or rest? Does it go away with rest? 2.Dyspnea (shortness of breath) = with activity or at rest? 3.Fatigue = the #1 most common symptom of CAD 4.Cough = can be from heart failure, pulmonary edema, or arrhythmia 5.Cyanosis = blue lips = CENTRAL cyanosis = ACUTE problem 6.Pallor = check: subconjunctival space, mucous membranes, nail beds, finger pads, gums 7.Edema = palpate, don't just look 8.Nocturia = peeing at night (SNS decreases at rest → better kidney perfusion)

Cardiac Risk Factors to Document

1.High blood pressure 2.Smoking (packs per day) 3.High cholesterol / LDL 4.Obesity 5.Diabetes = independent risk factor EQUAL to having already had an MI 6.Excessive alcohol = no amount is safe, it's poison to every cell 7.Family history = first-degree relative with sudden cardiac death before age 40 (or even 30) 8.Hard drugs (cocaine, etc.) 9.Sedentary lifestyle

Atrial Fibrillation (AFib) is responsible for

20% of all strokes. 2.7 million Americans live with AFib.

AFib

Atria quiver instead of beating → clots form in atria → travel to BRAIN → STROKE

How to detect AFib

Feel pulse or listen to heart for a FULL MINUTE if irregular

Electronic monitors (for vitals) do NOT tell you

If rhythm is irregular = you MUST auscultate or palpate

AFib Causes

Old age, hypertension, heart irritation, bad luck

AFib Treatment

Anticoagulant (blood thinner) + antiarrhythmic drug

BFAST Stroke Signs

1.B = Balance 2.F = Face (uneven smile) 3.A = Arms (one drops or is weak) 4.S = Speech (slurred) 5.T = Time (call code stroke or 911 immediately)

Palpate ONE side at a time (Carotid Arteries)

NEVER both simultaneously (cuts off blood to brain)

Auscultate with BELL for bruits (Carotid Arteries)

Whooshing sound = narrowed vessel = abnormal

Bruit is NEVER normal in the neck (Carotid Arteries)

Diagnosed with carotid Doppler ultrasound

Jugular vein distension (JVD)

Right-sided heart failure or CHF

Hepatojugular reflux (JVD)

Pressing the liver causes vein to fill further = confirms JVD

Inspect (Chest / Precordium)

Heaves (visible pulsation = valve dysfunction — rare)

Palpate (Chest / Precordium)

Apical impulse, vibrations (thrills), crepitus (bubblewrap feeling)

Percuss (Chest / Precordium)

Heart sounds DULL (not done routinely)

Auscultate (Chest / Precordium)

Listen at all 4 APTM areas, concentrate on S1 then S2 separately

0 (Pulse Grading Scale)

Absent = NEVER chart as absent; get a Doppler and chart as 'positive per Doppler'

1+ (Pulse Grading Scale)

Weak / thready

2+ (Pulse Grading Scale)

Normal

3+ (Pulse Grading Scale)

Bounding / full

4+ (Pulse Grading Scale)

Hyper-dynamic (too strong)

Upper extremity (Peripheral Vascular System Pulse Locations)

Radial, Ulnar, Brachial

Lower extremity (Peripheral Vascular System Pulse Locations)

Femoral (groin, deep), Popliteal (behind knee = not always palpable), Posterior tibial (behind medial malleolus), Dorsalis pedis (top of foot, between big toe tendons)

Shift Assessment

Check ONE upper pulse (radial) and ONE lower pulse (pedal or posterior tibial) every shift. Compare bilateral equality.

Modified Allen's Test

Before ABG from radial artery = checks if ulnar provides adequate collateral flow

Homan's Sign

Dorsiflex foot with knee bent = calf pain may indicate DVT (not reliable, but still tested)

Manual Compression Test

For visible varicose veins = press top of vein, feel for wave at another point

AV Fistula/Shunt

Assess for BRUIT (sound) and THRILL (vibration) = both are NORMAL findings in dialysis patients

1 Preventable Cause of Death in Hospitalized Patients

Pulmonary Embolism from DVT.

DVT (Deep Vein Thrombosis) Signs & Symptoms

1.Unilateral leg swelling (one leg bigger than the other = key indicator) 2.Hot to touch / warmth 3.Pain / tenderness in calf 4.Some patients have NO symptoms until PE occurs

DVT Risk Factors

1.Immobility (long flights, post-surgical, bed rest) 2.Old age 3.Pregnancy (especially late-term and postpartum) 4.Major surgery: knee, hip, hysterectomy, GI 5.Varicose veins / venous insufficiency history 6.Refusing anticoagulation therapy

DVT → PE: The Dangerous Chain

DVT clot breaks off → travels through venous system → through heart → to LUNGS = (PE = respiratory emergency, potentially fatal)

AFib clots go to the

BRAIN

DVT clots go to the

LUNGS

VENOUS DISEASE

1.Blood BACKS UP in veins 2.Valves become bidirectional 3.Swelling (edema) = often bilateral but may be asymmetric 4.Pain WORSE when legs dangled / dependent 5.Pain IMPROVES with leg elevation 6.Brown/dark skin discoloration (heme staining = permanent) 7.Pulses PRESENT but hard to feel (due to swelling) 8.Ulcers near ankle (venous stasis ulcers, pink wound bed) 9.Skin temperature: normal (hot if DVT is active) 10.Hair: present (or minimally changed) 11.Nail appearance: may be thickened by other causes 12.Treat with: compression stockings, elevation, venous ablation

ARTERIAL DISEASE (PAD)

1.Blood CANNOT GET IN (blocked artery) 2.Plaque/atherosclerosis narrows lumen 3.Cold extremity (no warm blood getting through) 4.Pain with walking (claudication), relieved quickly by REST 5.Pain at REST in advanced disease 6.Pale or dependent rubor (flush when hanging down) 7.Pulses DECREASED or ABSENT 8.Ulcers at bony prominences: toes, pressure points (gray bed) 9.Skin temperature: cool/cold 10.Hair LOSS on extremity 11.Toenails: slow-growing, thickened (with arterial disease) 12.Treat with: revascularization, stenting, angioplasty, amputation if severe

VENOUS

= V for Volume stuck in legs. Signs: swollen, brown, achy, worse when down.

ARTERIAL

= A for Away (blood can't get away from heart to the limb). Signs: cold, pale, no hair, claudication.

1+ Edema Grading

2 mm pit, barely visible = patient already has ~30% extra fluid volume

2+ Edema Grading

4 mm pit

3+ Edema Grading

6 mm pit

4+ Edema Grading

8 mm pit, very deep, lasts a long time

Brawny edema

Won't pit at all (very severe, chronic)

Edema is a PALPATION finding → don't just look

Press fingertip and feel along the skin. Even non-pitting edema is edema.

Normal lymph nodes

< 1 cm, mobile, non-tender (may become tender with infection)

Nodes get smaller with age

Enlarged nodes in older adults are more concerning

Lymphedema

Fluid backup from lymph node removal (e.g., post-mastectomy) = arm/leg can enlarge massively

Predictable flow

Infection near hairline → swollen nodes in neck

Instructions to the patient are NOT your 15-step procedure.

Tell the patient what they will FEEL or EXPERIENCE, in simple language.

Patient Instruction Example

'I am going to listen to your lungs with my stethoscope. You will feel it move across your back.' NOT: 'I will place the diaphragm of the stethoscope at the right upper lobe…'