cardiovascular & peripheral assessment

PMI (Point of Maximal Impulse)

Normally found at the 5th intercostal space (ICS) at the midclavicular line (MCL).

PMI in children younger than 8

More medial and around the 4th ICS.

Abnormal displaced PMI

A pulsation displaced toward the axillary line may indicate left ventricular hypertrophy.

Pulsation right of sternum

May indicate an aortic aneurysm.

Carotid palpation safety rule

NEVER palpate both carotid arteries at the same time because bilateral pressure may impair cerebral blood flow.

Why avoid massaging the carotid artery?

Too much pressure can decrease heart rate and blood pressure and may lead to cardiac arrest.

Normal carotid pulse

Regular rhythm, +2 amplitude, equal bilaterally, smooth upstroke, and soft/pliable arteries.

Carotid thrill

Indicates turbulent blood flow.

Carotids in older adults

May become stiff and cordlike.

Precordium

The area over the heart that is inspected and palpated during a cardiovascular assessment.

Best position for precordium palpation

Have the patient sit up and lean forward, or turn onto the left side if lying down.

Why turn the patient to the left side?

It brings the apex of the heart closer to the chest wall.

Five areas of precordium palpation

Apex, left lateral sternal border, epigastric area, base left, and base right.

Normal PMI palpation

PMI is palpable at the apex over a 1-2 cm area.

Lift

A forceful pulsation that feels like it is lifting the examiner's fingers.

Heave

A pulsation that feels like it is rolling underneath the fingers.

Thrill

A vibration caused by turbulent blood flow.

Carotid auscultation

Use the bell of the stethoscope to listen for bruits.

Bruit

A low-pitched, whooshing sound caused by turbulent blood flow.

What should the patient do while carotids are auscultated?

Hold their breath so breath sounds do not interfere.

Normal carotid auscultation

No audible bruit.

What can an adult carotid bruit suggest?

Carotid stenosis, increased cardiac output from fluid overload, stimulant use, or hyperthyroidism.

Jugular vein auscultation

Use the bell and have the patient hold their breath.

Normal jugular vein auscultation

No audible bruit.

Venous hum in children

May be heard and can be a benign finding.

Precordium auscultation

Listen systematically for S1, S2, S3, S4, murmurs, clicks, and rubs.

Why use the same order for cardiac auscultation?

Being systematic helps prevent missing important findings.

Aortic valve location

2nd ICS at the right sternal border.

Pulmonic valve location

2nd ICS at the left sternal border.

Tricuspid valve location

4th ICS at the left lateral sternal border.

Mitral valve location

5th ICS at the midclavicular line.

Valve order memory trick

Aunt Polly Takes Meds = Aortic, Pulmonic, Tricuspid, Mitral.

S1

"Lub"; closure of the AV valves (mitral and tricuspid); begins systole.

S2

"Dub"; closure of the semilunar valves (aortic and pulmonic); begins diastole.

S3

Occurs after S2.

S4

Occurs before S1.

S3 in young children

Can be a normal finding in young children and adolescents when sitting or lying.

S3 during pregnancy

Can be a normal finding during the third trimester.

Abnormal S3 in adults

An S3 that does not disappear with position change may indicate heart failure or volume overload.

S4 in athletes and older adults

May be a normal finding according to the provided material.

Abnormal S4

May occur with coronary artery disease, hypertension, or pulmonic stenosis.

Split S2 in infants

May be heard when the child takes a deep breath.

Heart sounds in children

Often louder because the chest wall is thinner.

Murmur

An extra heart sound caused by turbulent blood flow.

What to assess if a murmur is heard

Location, quality, pitch, intensity, timing, duration, configuration, radiation, and respiratory variation.

Murmur grade 1/6

Very faint and comes and goes.

Murmur grade 2/6

Quiet but heard immediately.

Murmur grade 3/6

Moderately loud.

Murmur grade 4/6

Loud and associated with a thrill.

Murmur grade 5/6

Heard with the stethoscope half off the chest wall and a thrill is present.

Murmur grade 6/6

Heard with the stethoscope entirely off the chest wall and a thrill is present.

Which murmurs are never considered innocent?

A diastolic murmur or a murmur greater than 3/6.

Peripheral circulation inspection

Assess color, temperature, and edema.

Normal peripheral findings

Warm skin, no edema, and appropriate color.

Abnormal peripheral findings

Pallor, cyanosis, coolness, shininess, sparse hair growth, and clubbing.

Peripheral pulses to assess

Radial, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial.

What fingers should be used to palpate peripheral pulses?

Distal pads of the 2nd and 3rd fingers.

What should you avoid when palpating a pulse?

Pressing so hard that you occlude the artery.

What should be assessed about peripheral pulses?

Rate, rhythm, equality, amplitude, and elasticity.

Pulse amplitude 0

Absent; pulse cannot be felt.

Pulse amplitude 1+

Weak/thready; barely palpable and easily obliterated.

Pulse amplitude 2+

Normal quality.

Pulse amplitude 3+

Full; easily felt with little pressure and not easily obliterated.

Pulse amplitude 4+

Bounding/forceful; requires strong pressure to obliterate.

Normal peripheral pulse

Regular, strong, equal bilaterally, and usually 2+.

Weak, absent, or unequal pulses

May indicate partial or complete arterial occlusion.

Signs of arterial occlusion

Pain, pallor, cool temperature, paresthesia, and paralysis.

Varicosities

Ropelike, distended, tortuous, or painful veins.

Older adults and venous circulation

Peripheral edema may occur due to chronic venous insufficiency.

Manual compression test

Used to assess valve competence in varicose veins.

Competent venous valves

No backflow is felt when the vein is compressed.

Incompetent venous valves

A wave/pulsation is felt because of blood flowing backward.

Capillary refill test

Press the skin until it blanches, release, and observe how quickly color returns.

Normal capillary refill

Color returns in less than 3 seconds.

Allen test

Assesses arterial flow in the hand.

Allen test basic steps

Compress radial and ulnar arteries, have the patient open the hand, then release one artery and observe color return.

Normal Allen test

Skin color returns rapidly.

Normal pallor resolution during Allen test

About 3-5 seconds.

Abnormal Allen test

Failure of normal color to return indicates impaired flow through the open artery.

ABI

Ankle-Brachial Index; used to assess circulation to the feet.

ABI formula

Ankle systolic pressure ÷ brachial systolic pressure.

ABI normal

1.0 or greater.

ABI minimal disease

0.80-0.95.

ABI moderate disease

0.79-0.40.

ABI severe disease

0.39-0.

ABI example

Ankle 75 ÷ brachial 100 = 0.75, indicating moderate peripheral vascular disease according to the provided material.

Color change test

Used to assess arterial circulation in the legs.

Color change test steps

Elevate the legs while supine, then have the patient sit with feet dangling and observe color return.

Normal color return after color change test

Less than 10 seconds.

Pallor with legs elevated

Sign of arterial insufficiency.

Dependent rubor

Reddish-purple color when the legs are dependent; may indicate arterial insufficiency.

Big carotid safety rule

Never palpate both carotids at the same time.

Big PMI rule

5th ICS + MCL.

Big valve memory trick

Aunt Polly Takes Meds.

Big S1 rule

S1 = LUB = AV valves close.

Big S2 rule

S2 = DUB = semilunar valves close.

Big pulse rule

Normal peripheral pulse = 2+.

Big capillary refill rule

Less than 3 seconds is normal.

Big ABI rule

ABI = Ankle ÷ Brachial.

Big arterial occlusion rule

Think pain, pallor, coolness, paresthesia, and paralysis.