UNIT 8: Heart & Peripheral Vasculature Assessment

enlarged ventricle from an overload of work

(abnormal finding; pulsations)

• heave or lift may occur as the result of an..

  • (heaves/lifts are pulsations other than the apical pulsation)

1. detected by placing the heel of the hand over the left parasternal region.

2. in the presence of a heave the heel of the hand is lifted off the chest wall with each systole.

how to inspect for heaves

parasternal heave, lift, or thrust

• precordial impulse that may be felt (palpated) in patients with cardiac or respiratory disease

• visible or palpable pulsations of the chest wall, which originate on the heart or great vessels.

pulmonary hypertension

(heaves)

• heel of the hand is lifted off the chest wall with each systole.

• palpation with the fingers over the pulmonary area may reveal the palpable tap of pulmonary valve closure (palpable P2) in cases of..

1. right ventricular enlargement, or

2. rarely, severe left atrial enlargement which pushes the right ventricle forwards

parasternal heave is caused by:

1. client in supine position with the head of the bed

2. elevated between 30 and 45 degrees,

3. stand on the client’s right side

4. look for the apical impulse and any abnormal pulsations.

how to inspect pulsations

1. apical impulse may or may not be visible

normal findings for inspection of pulsations:

mitral area

• (left MCL, fourth or fifth ICS)

if apical pulse is apparent it would be in the..

left ventricle moving outward during systole

apical impulse is a result of the…

1. stay on client’s right side and ask the client to remain supine

2. use one or two finger pads to palpate the apical impulse in the mitral area (fourth or fifth ICS at the MCL)

3. you may ask the client to roll to the left side to better feel the impulse using your finger pads

4. If this apical pulsation cannot be palpated, have the client assume a left lateral position.

   • this displaces the heart toward the left chest wall and relocates the apical impulse farther to the left.

how to palpate the apical pulse:

1. apical impulse is palpated in the mitral area

2. may be the size of a nickel (1–2 cm)

3. amplitude is usually small—like a gentle tap

4. duration is brief

   • lasting through the first two thirds of systole and often less.

5. in clients who are obese or in clients with large breasts, the apical impulse may not be palpable

normal findings for palpation of apical impulse:

accentuated apical impulse

(ventricular impulses)

• sign of pressure overload

• has increased force and duration but is not usually displaced in left ventricular hypertrophy without dilatation associated with aortic stenosis or systemic hypertension

laterally displaced apical impulse

(ventricular impulses)

• sign of volume overload

• found over a wider area is the result of ventricular hypertrophy and dilatation associated with mitral regurgitation, aortic regurgitation, or left-to-right shunts.

pulmonary emphysema

(abnormal finding; apical impulse)

• apical impulse may be impossible to palpate in clients with..

cardiac enlargement

(abnormal finding; apical impuse)

• if the apical impulse is larger than 1–2 cm, displaced, more forceful, or of longer duration, suspect…

1. Use your palmar surfaces to palpate the apex

   • left sternal border, and base

how to palpate for abnormal pulsations

1. No pulsations or vibrations are palpated in the areas of the apex

   • left sternal border, or base

normal findings for palpation of abnormal pulsations:

grade 4 or higher murmur

(abnormal finding; abnormal pulsations)

• A thrill or a pulsation is usually associated with a..

right ventricular hypertrophy caused by:

1. pulmonic valve disease

2. pulmonic hypertension,

3. chronic lung disease.

the oversized right ventricle

(abnormal pulsations)

• lift:

  • diffuse lifting left during systole at the left lower sternal border, a lift or heave is associated with..

  • you may also see retraction at the apex, from the posterior rotation of the left ventricle caused by..

1. severe aortic stenosis

2. systemic hypertension

(abnormal pulsations)

• thrill:

  • is palpated over the second and third intercostal space;

  • a thrill may indicate..

1. pulmonic stenosis

2. pulmonic hypertension

(abnormal pulsations)

• thrill:

  • thrill palpated over the second and third left intercostal spaces may indicate..

1. aortic area:

   • second ICS at the right sternal border—the base of the heart

2. pulmonic area:

   • second or third ICS at the left sternal border—the base of the heart

3. erb point:

   • third ICS at the left sternal border

4. mitral (apical):

   • fifth ICS near the left MCL—the apex of the heart

5. tricuspid area:

   • fourth or fifth ICS at the left lower sternal border

traditional areas for auscultating the heart

1. rate should be 60–100 beats/min, with regular rhythm.

2. regularly irregular rhythm, such as sinus arrhythmia when the HR increases with inspiration and decreases with expiration, may be normal in young adults.

3. resting pulse rate (RPR) varies with age, gender, and ethnic/racial factors (Hart, 2015).

4. adult female RPRs are a few beats faster than male RPRs.

normal findings for auscultating HR & rhythm

• bradycardia

• tachycardia

• decreased CO

(abnormal finding; HR & rhythm)

• less than 60 beats/min..

• more than 100 beats/min..

• may result in..

auscultate for a pulse rate deficit

if you detect an irregular rhythm then…

1. palpating the radial pulse while you auscultate the apical pulse

2. count for a full minute.

how to auscultate for a pulse rate deficit

1. radial and apical pulse rates should be identical

normal findings for auscultating pulse rate deficit:

pulse deficit

difference between the apical and peripheral/radial pulses

1. atrial fibrillation

2. atrial flutter

3. premature ventricular contractions

4. varying degrees of heart block

(abnormal finding; irregular rhythm)

• a pulse deficit may indicate..

1. auscultate the first heart sound (S1 or “lub”)

2. and second heart sound (S2 or “dub”)

   • remember these two sounds make up the cardiac cycle of systole and diastole

   • S1 starts systole

   • S2 starts diastole

3. the space, or systolic pause, between S1 and S2 is of short duration (thus S1 and S2 occur very close together);

4. the space, or diastolic pause, between S2 and the start of another S1 is of longer duration.

how to auscultate to identify S1 and S2

1. S1 corresponds with each carotid pulsation and is loudest at the apex of the heart

2. S2 immediately follows after S1 and is loudest at the base of the heart.

normal finding for auscultating to identify S1 and S2

palpate the carotid pulse:

• the harsh sound that you hear from the carotid pulse is S1

If you are experiencing difficulty differentiating S1 from S2 then..

1. use the diaphragm of the stethoscope to best hear S1

how to listen to S1

1. distinct sound is heard in each area but loudest at the apex

2. may become softer with inspiration

3. split S1 may be heard normally in young adults at the left lateral sternal border.

normal finding for listening to S1

1. accentuated, diminished, varying, or split S1

(abnormal finding; S1)

• abnormal findings for S1

1. use the diaphragm of the stethoscope

2. ask the client to breathe regularly

3. do not ask the client to hold their breath

   • breath holding will cause any normal or abnormal split to subside.

how to listen to S2

1. distinct sound is heard in each area but is loudest at the base / aortic area

2. split S2 (into two distinct sounds of its components—A2 and P2 ) is normal and termed physiologic splitting.

   • A2 – left sided aortic valve closure

   • P2 – right-sided pulmonic valve closure

3. it is usually heard late in inspiration at the second or third left interspaces

normal finding for listening to S2

1. any split S2 heard in expiration

(abnormal finding; S2)

• abnormal findings for S2

1. wide

2. fixed

3. reversed

abnormal split can be one of three types:

wide

(abnormal split)

• increase in the usual splitting that persists throughout the entire respiratory cycle and widens on expiration.

• occurs when there is delayed electrical activation of the right ventricle

fixed

(abnormal split)

• wide splitting that does not vary with respiration

• occurs when there is delayed closure of one of the valves.

reversed

(abnormal split)

• split S2 that appears on expiration and disappears on inspiration

• also known as paradoxical split.

• occurs when closure of the aortic valve is abnormally delayed

  • causing A2 to follow P2 in expiration

  • normal inspiratory delay of P2 makes the split disappear during inspiration

1. use the diaphragm first, then the bell to auscultate over the entire heart area.

2. note the characteristics (e.g., location, timing) of any extra sound heard.

3. auscultate during the systolic pause

   • (space heard between S1 and S2 ).

4. auscultate during the diastolic pause

   • (space heard between end of S2 and the next S1 ).

how to auscultate for extra heart sounds

1. normally no sounds are heard.

2. physiologic S3 heart sound is a benign finding

   • commonly heard at the beginning of the diastolic pause in children, adolescents, and young adults; rare after age 40.

3. physiologic S3 usually subsides upon standing or sitting up.

4. physiologic S4 heart sound may be heard near the end of diastole

   • well-conditioned athletes and in adults older than age 40 or 50 with no evidence of heart disease, especially after exercise.

normal findings for auscultating for extra heart sounds

1. midsystolic click associated with mitral valve prolapse are heard

2. friction rub may also be heard during the systolic pause

abnormal finding for extra heart sounds

heart failure

while auscultating, keep in mind that development of a pathologic S3 may be the earliest sign of..

pathologic S3 (ventricular gallop)

(abnormal finding for S3 & S4)

• may be heard with:

  1. ischemic heart disease

  2. hyperkinetic states (e.g., anemia)

  3. restrictive myocardial disease

pathologic S4 (atrial gallop)

(abnormal finding for S3 & S4)

• toward the left side of the precordium may be heard with:

  1. coronary artery disease

  2. hypertensive heart disease

  3. cardiomyopathy

  4. aortic stenosis

1. pulmonary hypertension

2. pulmonic stenosis

(abnormal finding for S3 & S4)

• pathologic S4 toward the right side of the precordium may be heard with…

summation gallop

(abnormal finding for S3 & S4)

• S3 and S4 pathologic sounds together create a quadruple rhythm, which is called a ___________

opening snaps (OSs)

(abnormal finding for S3 & S4)

• occur early in diastole and indicate mitral valve stenosis

• friction rub may also be heard during the diastolic pause

opening snap

(extra heart sounds)

• the increased left atrial opening pressures cause this to occur when the mitral valve leaflets suddenly tense and dome into the LV in early diastole.

• this high-frequency sound is best heard at the apex.

systolic ejection click

(extra heart sounds)

• frequently indicates a bicuspid aortic valve.

  • this sound is heard just after the S1 heart sound.

  • usually, the opening of the aortic valve is not audible; however, with a bicuspid aortic valve, the leaflets dome suddenly prior to opening and create a ___________.

• The click may be difficult to hear in the presence of significant AS.

mitral valve prolapse click

• mitral valve prolapse produces a ___________, usually followed by a uniform, high-pitched murmur.

• the murmur is actually due to MR that accompanies the MVP; thus, it is heard best at the cardiac apex.

• MVP responds to dynamic auscultation.

• after sudden standing, preload is decreased, and the click moves earlier in systole.

• with sudden squatting, preload increases, and the click moves later in systole.

tumor plop

• early diastolic low-pitched sound just after the S2 heart sound.

• this is in contrast to the opening snap of rheumatic mitral valve stenosis, which is high pitched.

• may be followed by a low-pitched diastolic murmur.

• if the mitral valve inflow obstruction is significant enough, physical exam findings of congestive HF will be present

(extra heart sounds)

• can be present in patients with constrictive pericarditis, as the early filling of the LV is limited from the constrictive process.

• the knock occurs earlier than a S3 heart sound.

• which is the distinguishing factor; this is because the S3 heart sound occurs from a stretch of a very compliant LV, which takes a short time longer.

murmur

is a swishing sound caused by turbulent blood flow through the heart valves or great vessels

1. auscultate for murmurs across the entire heart area

2. use the diaphragm and the bell of the stethoscope in all areas of auscultation because murmurs have a variety of pitches

3. also auscultate with the client in different positions as described in the next section because some murmurs occur or subside according to the client’s position

how to auscultate for murmurs

1. normally, no murmurs are heard.

2. innocent and physiologic midsystolic murmurs may be present in a healthy heart.

normal finding for auscultating for murmurs

1. pathologic midsystolic, pansystolic, and diastolic murmurs

abnormal findings for auscultating for murmurs

midsystolic murmurs

(abnormal findings for auscultating for murmurs)

• most common type of heart murmurs

• occur during ventricular ejection

• can be physiologic, innocent, or pathologic.

  • have a crescendo-decrescendo shape

• usually peak midsystole and near stop before S2

pansystolic murmurs

(abnormal findings for auscultating for murmurs)

• occurring when blood flows from a chamber with high pressure to a chamber of low pressure through an orifice that should be closed

• also called holosystolic murmur

• begin with S1 and continue through systole to S2

diastolic murmurs

(abnormal findings for auscultating for murmurs)

• usually indicative of heart disease

• occur in two types

• early decrescendo diastolic murmurs indicate flow through an incompetent semilunar valve, commonly the aortic valve

• rumbling diastolic murmurs in mid- or late diastole indicate:

  1. valve stenosis, usually of the mitral valve

grade 1

(grading murmur intensity)

• very faint, heard only after the listener has “tuned in;” may not be heard in all positions

grade 2

(grading murmur intensity)

• quiet, but heard immediately on placing the stethoscope on the chest

grade 3

(grading murmur intensity)

• moderately loud

grade 4

(grading murmur intensity)

• loud

grade 5

(grading murmur intensity)

• very loud, may be heard with a stethoscope partly off the chest

grade 6

(grading murmur intensity)

• may be heard with the stethoscope entirely off the chest

1. client to assume a left lateral position.

   • use the bell of the stethoscope and listen at the apex of the heart.

2. client to sit up, lean forward, and exhale.

   • use the diaphragm of the stethoscope and listen over the apex and along the left sternal border

ways to auscultate with the client assuming other positions:

S1 and S2 heart sounds are normally present

normal findings to auscultate with the client assuming other positions:

1. left lateral position.

   • S3 or S4 heart sound or a murmur of mitral stenosis that was not detected with the client in the supine position may be revealed when the client assumes the left lateral position.

2. sit up, lean forward, and exhale.

   • murmur of aortic regurgitation may be detected when the client assumes this position.

abnormal findings to auscultate with the client assuming other positions:

1. standing on the right side of the client

2. client should be in a supine position

3. torso elevated 30–45 degrees

4. make sure the head and torso are on the same plane.

5. ask the client to turn the head slightly to the left.

6. shine a tangential light source onto the neck to increase visualization of pulsations as well as shadows

7. next, inspect the suprasternal notch or the area around the clavicles for pulsations of the internal jugular veins.

   • be careful not to confuse pulsations of the carotid arteries with pulsations of the internal jugular veins.

how to inspect the jugular venous pulse

1. not normally visible with the client sitting upright.

2. this position fully distends the vein, and pulsations may or may not be discernible.

normal finding for inspecting the jugular venous pulse

1. fully distended jugular veins with the client’s torso elevated more than 45 degrees indicate increased central venous pressure that may be the result of:

   1. right ventricular failure

   2. pulmonary hypertension

   3. pulmonary emboli

   4. cardiac tamponade

2. distention of jugular vein on one side may be caused by:

   1. a kink or aneurysm

abnormal finding for inspecting the jugular venous pulse

1. watching for distention of the jugular vein.

2. normal for the jugular veins to be visible when the client is supine

3. to evaluate jugular vein distention,

   • position the client in a supine position with the head of the bed elevated 30, 45, 60, and 90 degrees

   • at each increase of the elevation, have the client’s head turned slightly away from the side being evaluated

   • using tangential lighting, observe for distention, protrusion, or bulging.

how to evaluate jugular venous pressure

1. jugular vein should not be distended, bulging, or protruding at 45 degrees or greater.

normal findings for evaluating jugular venous pressure

right-sided heart failure

(abnormal findings for evaluating jugular venous pressure)

• distention, bulging, or protrusion at 45, 60, or 90 degrees may indicate..

  • document at which positions (45, 60, and/or 90 degrees) you observe distention.

obstructive pulmonary disease

(abnormal findings for evaluating jugular venous pressure)

• clients with this may have elevated venous pressure only during expiration.

• kussmaul sign

• severe constrictive pericarditis.

(abnormal findings for evaluating jugular venous pressure)

• inspiratory increase in venous pressure, called __________, may occur in clients with ____________

1. client in a supine or semi-Fowler's position with the neck slightly extended to allow access to the carotid arteries or other areas where bruits are being assessed

   • such as the abdominal aorta, renal arteries, or femoral arteries

2. locate the artery by palpation.

   • for carotid bruits, lightly palpate one side of the neck to identify the carotid artery's location.

3. use a stethoscope with the diaphragm side initially to for listen high-pitched sounds, and the bell to detect low-pitched sounds (the bell is more often used for detecting bruits

4. place the stethoscope gently over the artery (e.g., carotid artery)

5. client to hold their breath momentarily while you listen for any abnormal sounds.

   • helps reduce background respiratory noise

6. listen carefully for a whooshing or blowing sound, which may indicate a bruit.

   • or carotid arteries, assess one side at a time to prevent occlusion of blood flow to the brain.

   • repeat the procedure on the other side, if applicable, or on other areas where bruits are suspected (e.g., abdominal or femoral arteries).

how to assess for bruits

• normally, no sound should be heard over arteries when auscultating.

  • absence of a bruit suggests unobstructed and smooth blood flow through the arteries.

normal finding for assessing bruits

turbulent blood flow through a partially obstructed or narrowed artery

abnormal finding for assessing bruits

bruits

abnormal whooshing or blowing sound caused by turbulent blood flow through a partially obstructed or narrowed artery

1. If there is an observable difference, measure bilaterally the circumference of the arms at the same locations with each remeasurement and record findings in centimeters.

2. mark locations on arms with a permanent marker to ensure the exact same locations are used with each reassessment

how to observe arm size and venous pattern; also look for edema

1. arms are bilaterally symmetric with minimal variation in size and shape

2. no edema or prominent venous patterning.

normal findings for observing arm size and venous pattern, edema

1. lymphedema

2. prominent venous patterning with edema

abnormal findings for observing arm size and venous pattern, edema

lymphedema

(abnormal findings for observing arm size and venous pattern, edema)

• results from damaged or blocked lymphatic circulation, which may be caused by cancer treatments

venous obstruction

(abnormal findings for observing arm size and venous pattern, edema)

• prominent venous patterning with edema may indicate..

raynaud disorder

(abnormal findings for coloration of the hands and arms)

• vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes

• characterized by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, and coldness.

• commonly occurs bilaterally; symptoms last minutes to hours.

• affects about 3%–5% of the population, more often in women than men, and more often in people living in colder climates

arterial insufficiency

cool extremity may be a sign of..

1. compress the nail bed until it blanches

2. release the pressure and calculate the time it takes for color to return.

3. inaccurate findings may result if the room is cool, if the client has edema, has anemia, or recently smoked a cigarette.

how to palpate for assessing capillary refill time

1. peripheral perfusion

2. reflects cardiac output

capillary refill time test indicates…

capillary beds refill (and, therefore, color returns) in 2 seconds or less.

normal findings for assessing capillary refill time

capillary refill time exceeding 2 seconds may indicate:

1. vasoconstriction

2. decreased cardiac output

3. shock

4. arterial occlusion

5. hypothermia

abnormal findings for assessing capillary refill time

allen test

• this test evaluates patency of the radial or ulnar arteries.

• is essential before arterial sampling (arterial blood gas) or arterial line insertion/placement.

• is implemented when patency is questionable or before such procedures as a radial artery puncture

1. assessing ulnar patency.

2. have the client rest the hand palm side up on the examination table and make a fist.

3. use your thumbs to occlude the radial and ulnar arteries

4. continue pressure to keep both arteries occluded and have the client release the fist

5. note that the palm remains pale.

6. release the pressure on the ulnar artery and watch for color to return to the hand.

7. to assess radial patency, repeat the procedure as before, but at the last step, release pressure on the radial artery

how to perform allen test

pink coloration returns to the palms within 3–5 seconds if the ulnar and radial artery is patent.

normal findings for allen test

1. arterial insufficiency

2. occlusion of the ulnar and radial artery, pallor persists.

abnormal findings for allen test

1. client to stand because varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting.

2. as the client is standing, inspect for superficial vein thrombophlebitis.

3. to fully assess for a suspected phlebitis, lightly palpate for tenderness.

4. if superficial vein thrombophlebitis is present, note redness or discoloration on the skin surface over the vein.

how to inspect for varicosities and thrombophlebitis