Assessing Heart and Peripheral Vascular System

What is the green structure?

Apex of the heart.

What intercostal space is the base of the heart found in and which is the apex found in?

Base: Left 2nd intercostal space

Apex: Left 5th intercostal space

Identify each valve

1= Tricuspid valve

2 = Pulmonary valve

3 = Mitral valve

4 = Aortic valve

Path of electrical conduction

SA node → AV node → Bundle of His → Purkinje fibers

Role of SA node

Pace maker of the heart. Generates impulses of 60-100 BPM. Tells both atria to contract simultaneously.

Role of AV node

Backup pacemaker that will take over of AV node isn’t working. Generates impulses at 40-60 BPM, so pt will have this HR if AV node not working.

Role of bundle of his and purkinje fibers

Stimulates ventricular contraction/cardiac muscle. Generates 20-40 BPM, so pt will have very low HR if SA and AV node not working and body has to rely on these.

P-wave

Atrial depolarization (contraction). Accounts for 5-10% of cardiac output.

QRS complex

Ventricular depolarization (contraction)

T-wave

Ventricular repolarization (relaxation)

What happens during systole?

Contraction. Large amounts of blood in ventricles causes AV vales to close and semilunar valves to open as ventricles contract and send blood out.

What happens during diastole?

Relaxation and filling. AV valves are open as increased pressure in atria makes them open and blood from atria goes into ventricles. “Atrial kick” is when atria contract.

S1 heart sound

Produced by closing of the AV valves. “lub” sound. Signals beginning of systole. Loudest at apex.

S2 heart sound

Closure of semi-lunar valves. “dub” sound. From end of ventricle contraction + beginning of ventricle relaxation. Loudest at base.

S3 heart sound

Extra “dub” sound: “lub dub-dub”. Caused by blood hitting ventricle wall d/t rapid filling of ventricles. Best heard with the bell in the left lateral position. Considered an abnormal heart sound.

S4 heart sound

Extra “lub” sound: “lub-lub dub”. Caused by blood flowing rapidly into stiff ventricles after atria contract. Best heard with bell over apical area in supine/left lateral position. Considered an abnormal heart sound.

Pericardial friction rub

High-pitched, scratchy sound caused by inflammation of the pericardial sac. Best heard with diaphragm and pt leaning forward.

Description of murmurs

• Intensity - levels I-VI with I being faint and VI being very loud

• Timing - systolic or diastolic

• Pitch - high, med, low

• Pattern - increasing or decreasing volume

• Quality

• Location heard

• Radiation of sound

• Position of pt

Systolic vs diastolic murmurs

Systolic: heard when heart contracts (between S1 and S2)

Diastolic: heard when heart relaxes

SIgns and symptoms of murmurs

Client may have no signs or symptoms if murmur isn’t severe. Cyanosis (late sign), edema, JVD, chest pain, shortness of breath, dizziness, fainting.

Carotid artery

Located between the trachea and the R/L sternocleidomastoid muscle. Supplies blood to the brain (internal carotid) and superficial structures of head and neck (external carotid)

Carotid artery pulse

Since carotid artery is close to heart, it is good for assessing amplitude and contour. Its absence is very concerning.

Jugular veins

Internal and external. Are not routinely assessed for pulse/pressure but can be used for IV access (by provider).

History of present health concern for cardiac exam

Chest pain, tachycardia, heart skipping beats, tire easily, dyspnea, coughing mucous, dizziness, nocturia (frequent urination at night), swelling in lower extremities, frequent heartburn?

How do you know if heartburn is a GL problem or a cardiac problem?

GI = can be resolved by an antacid

Cardiac = can’t be resolved by antacid

Personal health history for cardiac exam

History of: heart murmur, rheumatic fever, heart surgery, ECG, blood pressure, lipid profile, medications.

Family history for cardiac exam

Hypertension, myocardial infarction, coronary artery disease, hyperlipidemia, diabetes

Lifestyle questions for cardiac exam

Smoking, alcohol, physical activity, stress, diet, ADLs, sexual activity (can reveal non adherence to meds), pillows used when sleeping (issues with laying flat), nocturia.

General routine screening in cardiac exam

Inspect jugular veins, auscultate/palpate carotid arteries, inspect pulsations on anterior chest, palpate apical pulse, palpate for abnormal pulsations, auscultate S1/S2 and for abnormal sounds and murmurs.

Observing jugular venous pulse

Stand on pts right side with pt in suping 30-45 degrees. Have pts turn head to left. Shine light on neck. Look for distension of the vein (JVD).

Note: Can be done on left side as well.

When do we assess the carotid artery?

In older adults and/or suspected cardiovascular disease

Auscultating the carotid artery

Auscultate BEFORE palpating. Place the bell over the artery and have client hold breath. Press lightly. Abnormal = bruit sounds, indicates atherosclerotic disease

Palpating the carotid artery

Alternates sides, never do both at once. Note amplitude, contour, trills, and elasticity. Normal: 2+ equal bilaterally w/ no trills

Anterior heart inspection

Pt in supine. Pt should have no visible lifts/heaves in chest. These would be pulsations if present.

Palpating apical pulse

Left anterior 5th intercostal at the midclavicular line. Should feel like a gentle tap and is small in amplitude.

Name the 5 traditional areas for heart palaption/ausltation

1 = aortic - 2nd intercostal on right sternal boarder

2 = pulmonic - 2nd intercostal on left sternal boarder

3 = Erb point - 3rd intercostal on left sternal boarder

4 = tricuspid - 4th intercostal on left sternal boarder

5 = mitral - 5th intercostal on the left midclavicular line

Auscultation of heart

Use diaphragm. Should be 60-100 BPM and regular. Irregular is when there is different timing in between sounds.

What to do if rhythm is irregular upon auscultation

Palpate radial pulse while auscultating apical pulse. Assess for a full min. If regular, pulses will go at the same time. If they don’t assess for the pulse rate deficit.

Auscultating for extra heart sounds/murmurs

Start with diaphragm and bell. Auscultate all 5 traditional areas. Auscultate in various positions like left lateral.

Considerations when assessing heart of newborns

Formen ovale (allows flow b/t atria) should close within 1 hr after birth. Ductus arteriosus (shunts blood from pulmonary artery to aorta) should close within 10-15 hrs. May have systolic murmur that will resolve in 1-2 days. HR is 120-160. Listen at 4th intercostal margin.

Considerations when assessing heart of children/adolescents

Apical pulse at 4th intercostal. Heart rate will decrease by age 8. Some children will have a physiologic murmur. S3 may be heard at the apex of some children but should eventually dissipate with age.

Physiologic heart murmur

Complexly harmless heart murmur. Common in infants and children. May come and go depending on mood, exercise, etc.

Considerations when assessing heart of childbearing population

Increase in HR (10-15 BPM) expected. Increase in blood volume expected.

Considerations when assessing heart of older adults

Assess for orthostatic hypertension. Apical pulse may be difficult to palpate as chest diameter changes with age.

What is coronary heart disease

Includes coronary artery disease, heart rhythm abnormalities, and congenital defects.

Managing risk factors of coronary heart disease

BP monitoring, body weight, lipid management, smoking, diet, exercise, stress. Educate pts on preventative measures and lifestyle changes.

Function of arteries

Carry oxygenated blood away from heart and to tissues.

Name the indicated (green) vessel

Brachial artery

Name the indicated (green) vessel

Radial artery

Name the indicated (green) vessel

Ulnar artery

Name the indicated (green) vessel

Femoral arteries

Name the indicated (green) vessel

Popliteal artery

Name the indicated (green) vessel

Dorsalis pedis artery

Name the indicated (green) vessel

Posterior tibial artery

Vein function

Carry deoxygenated blood back to the heart.

The 3 types of veins + their examples

Deep - femoral and popliteal

Superficial - small and great saphenous

Perforator - connect superficial to deep

Function(s) of lymphatic system

Drain excess fluid back to venous system. Carries immune cells + helps with immune response. Absorbs fat from SI for the body.

Lymph nodes

Healthy = small/can’t feel

Infection = large/inflamed/swollen upon inspection or palpation

History of present health concern in peripheral vascular assessment

Any color, temp, or texture changes in skin? Any pain or cramping in legs? Pain with walking or stairs? Any varicose veins? Wounds or sores? Swelling? Swollen glands or lymph nodes? Sexual dysfunction?

Personal history in peripheral vascular assessment

Previous circulatory issues? Heart or blood vessel surgury/treatment?

Family history in peripheral vascular assessment

Varicose veins, hypertension, coronary artery disease, elevated cholesterol/triglycerides?

Lifestyle in peripheral vascular assessment

Smoking, exercise, oral contraceptive use in females (clot risk), stress, ADLs, medications, compression sock/support hose use?

General routine screening in peripheral vascular assessment

Inspect arm size, color, edema. Palpate fingers, hands, arms for temp. Capillary refill. Upper and lower extremity pulses. Inspect legs for distribution of hair, temp, ulcers, edema. Inspect for varicosities and thrombophlebitis.

When do you use a doppler

Unpalpable pulses, determining patency of bypass graft, assessing tissue perfusion

Doppler sounds

We use to assess artery pulses. On an artery = whooshing sound with pulsing. On a vein = non-pulsating rush.

How to use a doppler

Apply lukewarm gel over the vessel. Lightly place the probe on gel. Listen to sound. Clean off skin. Mark site for easy reassessment. Document findings.

Assessing lymph nodes in extremities

Only assessed if there is a concern. Epitrochlear nodes found in groove between bicep and tricep. Inguinal lymph nodes found in crease between thigh and hip.

Considerations for peripheral vascular assessment in newborns

Should be pink and well perfused. Assess radial, brachial, and femoral pulses. Weak pulse indicates that something in system didn’t form/close properly.

Considerations for peripheral vascular assessment in childbearing population

Dependent edema expected, varicose veins due to extra pressure expected, watch for thrombophlebitis as clotting risk increases with pregnancy.

Considerations for peripheral vascular assessment in older adults

Evaluate for arterial and venous sufficiency. Be aware that symptoms may not be typical. Lymph nodes naturally smaller.

Peripheral artery disease (PAD)

Arteries slowly become narrowed or blocked for build up of plaque

PAD risk factors

Smoking, diabetes, and history of coronary arty disease or stroke are the biggest ones. Others are obesity, uncontrolled hypertension, high cholesterol, age (>50), and family history.

PAD symptoms

Intermittent claudication relived with rest (most common in calf), painful cramping, leg weakness/numbness, coldness in lower leg/foot, sores that don’t heal, hair loss, shiny skin, no pulse/weak pulse.

Late PAD symptoms

Severe ischemic rest pain that disrupts sleep and ADLs.

PAD education

Smoking cessation, blood sugar control, exercise, diet, healthy weight, cholesterol levels, BP.

What is arterial insufficiency?

Impeded blood flow in arterial system. Causes sharp, constant pain and diminished or absent pulses. Skin becomes dry and shiny, cool or cold, and has loss of hair.

Ulcers in arterial insufficiency

Seen on tips of toes, heels, or other pressure areas. Very painful and deep. Circular in shape. Minimal edema. Black to gangrene as tissues becomes necrotic.

Acute limb ischemia

Impeded blood flow to limb that can be due to exacerbation of arterial insufficiency. Classic presentation of six Ps: Pallor, Pain, Pulseless, Paralysis, Paresthesia, Poikilothermic (inability to regulate temp).

What to do when tissue becomes necrotic

Note line of demarcation to track growth so that we don’t amputate too early.

Venous insufficiency signs/symptoms

Aching and cramping pain as blood pools. Pulses are present but may need a doppler as edema blocks palpation. Skin becomes thick, tough, and reddish-blue-brown (hemosiderin).

Ulcers in venous insufficiency

Seen in medial malleolus or anterior tibial area. Minimal to severe pain depending on deepness. Superficial. Irregular boarder. Moderate to severe edema, may have leakage. Granulation tissue (beefy red to yellow in color).

Lymphedema vs edema

Lymphedema fluid is rich in protein and typically unilateral. Edema fluid contains very little protein and is usually bilateral.

Lyphedema

Caused by abnormal or blocked lymph vessels preventing proper drainage. Assessment shows non-pitting edema, usually unilateral, no skin ulceration or pigmentation.

Peripheral edema

Accumulation of fluid causing swelling due to fluid imbalance. Assessment shows usually bilateral but can be unilateral, skin ulceration and pigmentation may be present.