Physical Assessment- Cardiovascular

What is the function of the heart?

The main pump of our body

What are the 2 chambers on either side of the heart? 

Atrium and ventricle 

What does the cardiac cycle do?

Transports blood through the lungs and to all the peripheral tissues of the body

Where does blood transport oxygen and nutrients too? 

The tissues 

Where does blood transport metabolic waste too? 

The kidneys and lungs for elimination 

What is the shape of the heart?

Cone-shaped, hollow, muscular organ about the size of a fist

What is the upper (wide) portion of the heart known as? 

Base 

What is the lower (narrow) portion of the heart known as? 

Apex 

Where is the location of the heart?

lies behind the sternum and above the diaphragm in the mediastinum

What are the 4 layers of the heart that are supplied by the coronary arteries? 

Endocardium, Myocardium, Epicardium, Pericardium 

Endocardium

Thin, inner layer 

(infections of the heart) 

Myocardium

Thick, middle layer

(Responsible for ventricles to squeeze, contract and relax) 

Epicardium

Thin, outer layer

(Visceral fluid around) 

Pericardium

Fluid filled sac surrounding the heart

(Protects other organs from heart)

What is cardiac myopathy?

When the heart becomes inflamed and large-lead to a thick myocardium 

The right atrium receives blood from where? 

The superior and inferior venae cava. 

Where does the right ventricle pump blood through? 

Pumps through the pulmonary artery as deoxygenated blood which then leads it to pulmonary circulation to be oxygenated blood

The left atrium receives blood from where?

From the pulmonary veins

Where does the left ventricle pump blood through? 

Pumps through the aorta into systemic circulation 

Atrioventricular (AV) valves separate this? 

Atria from the ventricles 

Tricuspid valve separates this?

Right atrium and the right ventricle

Mitral valve separates this?

Left atrium and the left ventricle

The semilunar valves separate this?

The ventricles from circulation

Pulmonic valves separate this?

The right ventricle from the pulmonary artery

The aortic valve separates this?

The left ventricle from the aorta or from the whole body 

What is a cardiac cycle?

The start of one heartbeat to the start of the next heartbeat

What is diastole?

Time of heart relaxation, ventricles fill with blood

During diastole what is happening with the valves? 

AV valves are open and Semilunar valves are closed 

What is systole?

Ventricular contraction, blood is pushed out into circulation 

During systole what is happening with the valves? 

AV valves are closed and Semilunar valves are open 

What is cardiac output?

The amount of blood the heart pumps out in one minute 

What does it mean if the diastole number is higher than the systole number? 

Means that the heart is not pumping enough blood and there is no rest for the heart. 

What is the Sinoatrial (SA) node?

The pacemaker of the heart

• top of heart near atrium 

What does the SA node do?

• Initiates electrical impulses of the heart in the right atrium 

• Normally discharges 60-100 times per minute

When does that Atrioventricular (AV) node kick in? 

If the SA node is unable to kick in 

What happens if the SA node fails?

The AV node will contract at a slower rate of 40-60 bpm

What can the left and right bundle branches do? 

Can stimulate contractions if SA and V node fail at a rate of 20-40 bpm

How do the electrical impulses travel from the SA node? 

To the AV node, Bundle of His, Bundle branches, Purkinje fibers

• Overall results in ventricular contraction 

What may patients experience if the conduction system is not functioning properly? 

Tachycardia, bradycardia or arrhythmia (dysrhythmias) 

Even if the slightest delay of the heart occurs is that a major issue? 

Yes 

How are normal heart sounds caused? 

By the closure of the AV semilunar valves 

The 2 normal heart sounds are?

Lub and Dub

What is the Lub or S1 sound?

Closure of AV valves

• Heard best at apex 

What is the Dub or S2 sounds?

Closure of Semilunar valve

• Heard best at base 

What is the ventricular gap or s3 sounds?

Faint, low pitched sound heard directly after S2 

• Can sound like a horses gallop

Who is it typically normal for to have the S3 sounds?

Healthy young adults, typically those who do sports since it means there heart is working extra good

Who is it typically abnormal for to have S3 sounds? 

Patients who are older than 40 and is associated with heart failure due to fluid overload 

What are S4 sounds?

Soft, thud like sound occurring at end of diastole 

• Typically heard directly before the S1 heart sound 

Where is it best to hear the S4 sounds?

Over the apex of the heart with patient in left lateral position

Why might someone experience S4 sounds?

Caused by the atria working hard to contract against a poorly compliant left ventricle- trying to get that extra blood out 

• Could be due to scar tissue or normal loss of compliance with age

What are heart murmurs?

Are a swishing or unusually prolonged sounds indicative of turbulent blood flow in the vascular system

What are the types of heart murmurs someone can experience?

• Innocent or physiological

• Abnormal or pathological

Innocent or physiological heart murmurs? 

Not associated with a heart problem, patient is asymptomatic

Abnormal or pathological heart murmurs?

Associated with age related changes or disease, patient may have palpitations or SOB 

What is Pericardial Friction Rub?

High-pitched, muffled, grating sound heard with each heartbeat 

Why might someone experience pericardial friction rub? 

Due to the friction of the visceral and parietal layers of the pericardium

What can Pericardial Friction Rub indicate? 

Indicates pericardial inflammation caused by pericarditis or pericardial effusion

• Can feel sick and be in pain due to the friction and rubbing experienced

A lipid profile? 

Abnormal cholesterol levels are risk a risk factor for CAD

• want high HDL levels and low LDL so under 200

A troponin test? 

Measures the levels of protein released when damage to heart occurs and this can be elevated a ffew hours to 7 days following a cardiac event

A Electrocardiogram (EKG)?

Records the electrical activity of the heart to help diagnose abnormal rhythms 

What is the gold standard EKG?

A 12 lead

A echocardiography?

Ultrasound used to help diagnose structural abnormalities of the heart 

• See how heart is functioning and operating 

A holter monitor?

Ambulatory test of electrical activity worn for 24 hrs to several days

• To catch abnormal rhythms and figure out when those symptoms arise 

Doing an exercise stress test? 

Measures heart function and rhythm while the patient walks on a treadmill 

• This rapidly increases the heart to see what it does

• Alternative options is to give medication

When looking through a family history what should you document about? 

• Heart disease

• Rheumatic fever (affects vessels in heart during early childhood)

• High blood pressure

• Heart attacks- have members of family passed from this

What medication history should be documented? 

Medications like: beta blockers, calcium channel blockers, nitrates, angiotensin enzyme, statins 

Non-modifiable risk factors for heart disease?

• Age 

• Sex 

• Family history 

• Race 

Modifiable risk factors for heart disease?

• Smoking 

• Abnormal cholesterol

• High BP 

• Physical inactivity 

• Obesity 

• Stress 

• Diabetes 

Health promotion history for heart disease?

• Heart healthy diet

• Smoker or alcohol intake (How often and how much)

• Exercise

• Cardiologist (Why, last visit) 

• ECG or cardiac diagnostic tests (Results)

In the cardiac system what is the most commonly reported symptom? 

Chest pain (angina pectoris) 

How is angina pectoris described? 

Sudden pain beneath the sternum, often radiating to the left shoulder and arm 

When a patient states they have chest pain why is it important to do an in depth assessment? 

Patient could be experiencing a myocardial infarction (heart attack)

• Use OLDCARTS or OPQRST for assessment  

Overall health assessment for those with heart disease? 

• Heart palpitations are an increased awareness of the heart beating 

  • Can be described as “fluttering”, skipping beats, or heart racing

  • Related to irregular heart rate, fast heart rate, cardiac abnormality, fear, stress or anxiety 

• Skin color changes (cyanosis)

• Shortness of breath 

• Edema 

• Nocturia- due to fluid overload and possible heart failure 

• Fainting 

Risk factors and consideration for those with heart disease? 

• #1 cause of death in both men and women 

• 1 out of 4 women die from heart disease 

• No ethnic group os spared the risk of CHD 

Steps that should be taken before the assessment begins? 

• Good lighting is very important to closely inspect the precordium

• Room temperature should be comfortable 

• Patient should be supine with HOB at 30 degrees 

• Environment should be quiet to clearly hear the heart sounds 

• Patient should be properly gowned so that only chest area is exposed 

The precordium landmarks on the body?

Aortic area, Pulmonic area, Erb’s point, Tricuspid area, Mitral area or Apex 

Where is the precordium?

In front of the chest wall

Where is the aortic area?

2nd intercostal space, right sternal border

Where is the pulmonic area?

2nd intercostal space, left sternal border

Where is Erb’s point?

3rd intercostal space, left sternal border

What is the best location to hear heart sounds? 

Erb’s point 

Where is the tricuspid point?

4th intercostal space, left sternal border

Where is the mitral area or Apex?

5th intercostal space, left midclavicular line (bottom of the heart)

What is the purpose of inspecting the anterior chest? 

Assess for pulsations, symmetry and heaves, surgical scars

What is a heave or lift?

A sustained forceful outward, thrusting of the ventricle secondary to increased workload 

How should you prepare the room for the patient when assessing the anterior chest? 

Adjust head of examination table so patient is playing supine with head and chest elevated 30 degrees 

Normal findings when inspecting the anterior chest? 

• An apical pulsation may or may not be visible at the left 5th midclavicular line 

• No heaves or lefts 

• Chest symmetrical 

Abnormal findings when inspecting the anterior chest? 

• A right ventricular heave is visualized at the sternal border

• A left ventricle heave is seen at the apex 

What is the purpose of palpating the precordium and apical pulse? 

Asses for vibrations and the apical pulse 

How should you palpate the precordium?

Using the palmar surface of your right hand, gently palpate the five landmarks feeling for pulsations or vibrations 

How should you palpate the apical pulse?

Using your 2nd and 3rd finger pads of your dominant hand, palpate the apical pulse at the 5th intercostal space at the midclavicular line noting the location and amplitude 

Normal findings when palpating the precordium and apical pulse? 

• No pulsations are felt at the 5 landmarks 

• Amplitude: Regular rhythmic tap 

Abnormal findings when palpating the precordium and apical pulse? 

• Visible pulsations 

• Heaves or lifts

• Thrill

What is the purpose of ausculating heart sounds? 

To assess for normal, extra or abnormal heart sounds 

What are some helpful tips when auscultating for heart sounds? 

• Use a stethoscope to listen

• Listen to and concentrate on one sound at a time 

• Use a sequence for auscultation, establish a pattern 

What positions are acceptable for the patient to be in to listen to heart sounds? 

Supine, Semi-Fowlers, Fowlers, Left side lying position

How should you auscultate the heart sounds?

• Warm the stethoscope before placing on the precordium

• Instruct patient to breathe normally while you listen to the heart 

• Using your 2nd and 3rd finger pads of your right or left hand, landmark each auscultatory site prior to placing the stethoscope on the skin 

• Using the diaphragm of the stethoscope auscultate the heart sounds (s1 and s2) at the 5 landmark sites  

What do want to listen for when auscultating heart sounds? 

• S1 and S2 heart sounds 

• Rhythm of the heart sounds 

• Abnormal or extra heart sounds 

Why should we instruct the patient to lean forward to listen to the aortic and pulmonic valves? 

To listen for murmurs or extra heart sounds 

How should you listen to the aortic and pulmonic valve areas for heart sounds?

• Using the bell of the stethoscope, auscultate for low pitched heart sounds at the 5 landmark sites

• Assist the patient to lie on their left lateral side

• Using bell of stethoscope, auscultate apical area listening for

  • Heart murmurs

  • Extra heart sounds