Cardiac Assessment

pericardium

tough, fibrous, double-walled sac that surrounds and protects heart

myocardium

muscular wall of heart; it does the pumping

endocardium

thin layer of endothelial tissue that lines inner surface of heart chambers and valves

atrium

thin-walled reservoir for holding blood

ventricle

thick-walled, muscular pumping chamber

precordium

area on anterior chest overlying

heart and great vessels

apical impulse

apex beats against chest wall

pulmonary veins

return freshly oxygenated

blood to left side of heart, and aorta carries it

out to body

valves

prevent backflow of blood; undirectional (only open one way)

cardiac assessment

inspection, palpation, auscultation

chest landmarks

• suprasternal notch

• sternal angle

• midclavicular line

• anterior axillary line

• xiphoid process

AV valves

tricuspid, bicuspid (mitral)

tricuspid valve

right AV valve

bicuspid (mitral) valve

left AV valve

diastole

filling phase; allows ventricles to fill with blood (open); 2/3 of cardiac cycle

systole

pumping phase; close to prevent regurgitation of blood back up into atria; 1/3 of cardiac cycle

SL valves

pulmonic and aortic valve

pulmonic valve

SL valve (right side)

aortic valve

SL valve (left side)

abnormally high pressure in left side of heart

pulmonary congestion symptoms appear

abnormally high pressure in right side of heart

shows in neck veins and abdomen

S1

closure of AV valves (1st heart sound)

• heard louder at apex

S2

SL valves close (2nd heart sound)

• heard louder at base

pericardial friction rub

inflammation due to pericarditis

murmurs

• turbulent blood flow (heard on chest wall)

• graded on scale (I-VI)

audible murmurs

• S1 or S2

  • pitch, pattern, quality, location, radiation, variations

health history common or concerning symptoms

• chest pain, pain in neck, left shoulder, arm, back, arrhythmias, dyspnea, cough, edema, nocturia, fatigue, cyanosis, pallor

chest pain

Angina pectoris, coronary artery disease, myocardial

infarction, acute coronary syndrome

palpitations

Skipping, racing, fluttering, pounding, stopping

shortness of breath

Dyspnea, orthopnea, paroxysmal nocturnal dyspnea

cough

Heart failure, fine crackles, and rales

edema

Dependent edema, congestive heart disease,

hypoalbuminemia

nocturia

Dependent edema, clears at night when patient is

supine

fatigue

Signals heart is not adequately supplying oxygen

cyanosis/ pallor

Poor oxygenation of body

cardiovascular examination

• heart, neck vessels, peripheral vascular system

inspection of precordium

• Pulsations: You may/may not see apical pulse  created as L

ventricle rotates against chest wall during systole

• Heaves/lifts: Can occur with ventricular hypertrophy as a result

of increased workload

• Vascularities: Any venous abnormalities

palpation of precordium

• Supine position

• Palpate apical impulse (PMI)

• Localize apical impulse precisely by

using one finger pad

• Note the location, size, amplitude

and duration

• 5 ICS Midclavicular line

• Palpable in about half of adults; is

not palpable in obese persons or in

persons with thick chest walls

• Compare carotid pulse to the apical pulse

how to palpate precordium

Using palmar aspects of your four

fingers, gently palpate the 4 valve areas

searching for any other pulsations

 Normally none occur

 With the dorsal part of the hand, palpate

for a thrill  palpable vibration that

signifies turbulent blood flow

thrill

palpable vibration that signifies turbulent blood flow

precordium auscultation

 Identify valve “areas” where you will

listen

 Valve areas are not over actual

anatomic locations of valves but sites

on chest wall where sounds produced

by valves are best heard

 Sound radiates with blood flow

direction; valve areas are

 Aortic valve area – 2nd right

intercostal space sternal border

 Pulmonic valve area – 2nd left

intercostal space sternal border

 Tricuspid valve area –4th

intercostal space, left sternal

border

 Mitral valve area – 5th intercostal

space, mid-clavicular line

aortic valve area

2nd right

intercostal space sternal border

pulmonic valve area

2nd left

intercostal space sternal border

tricuspid valve area

4th

intercostal space, left sternal

border

mitral valve area

5th intercostal

space, mid-clavicular line

valve location and auscultation

• All valve areas using diaphragm

then bell

• Move stethoscope to each valve

area

• S1 vs. S2

• S1 (lub) louder at

apex/beginning of systole

• S2 (dub) louder at

base/beginning of diastole

• Presence of abnormal sounds?

• S3, S4, Splitting

• May need to reposition patient

(turn, lean forward)

precordium auscultation

 Concentrate, and listen selectively to one sound at a time

 Consider that at least 2, and perhaps 3 or 4 sounds may be happening in

less than 1 second

• The diaphragm detects relatively higher-pitched sounds, and the bell

detects relatively lower-pitched ones

• Begin with diaphragm and follow this routine and then the bell

• Note rate and rhythm

• Identify S1 and S2

• Assess S1 and S2 separately

• Listen for extra heart sounds

• Listen for murmurs

congenital heart defects

• Patent ductus arteriosus

• Atrial septal defect

• Ventricular septal defect

• Tetralogy of Fallot

• Co-arctation of the aorta

mid-systolic ejection murmurs

• Aortic stenosis

• Pulmonic

stenosis

pan-systolic regurgitation murmurs

• Mitral

regurgitation

• Tricuspid

regurgitation

diastolic rumbles of AV valves

 Mitral stenosis

 Tricuspid stenosis

early diastolic murmurs

 Aortic regurgitation

 Pulmonic regurgitation

carotid arteries

• Close to heart; timing closely coincides

with ventricular systole

• Located in groove between trachea and

sterno-mastoid muscle, medial to and

along-side that muscle

• Palpate only one carotid at a time to avoid

compromising arterial blood to the brain

• Feel the contour and amplitude of the

pulse; normally the contour is smooth and

the strength is moderate and equal

bilaterally

jugular veins

empty un-oxygenated

blood directly into superior vena cava

 Because no cardiac valve exists to

separate superior vena cava from right

atrium, jugular veins give information

about activity on right side of heart

 Specifically reflect filling pressure and

volume changes

 Expose this because

volume and pressure increase when

right side of heart fails to pump

efficiently

palpation of carotid artery

 Yields important information on cardiac function

 Palpate each carotid artery medial to sterno-mastoid muscle in neck;

palpate gently

 Palpate only one carotid artery at a time to avoid compromising

arterial blood to brain

 Feel contour and amplitude of pulse

 Normally contour is smooth with a rapid upstroke and slower down

stroke, and the normal strength is 2+ or moderate

 Findings should be same bilaterally

 Palpation of all other pulses: temporal, brachio-radialis, radial, femoral,

patellar, posterior tibialis, dorsalis pedis will be discussed in a separate

recording

carotid artery pulse

• Great vessels of the neck

• Amplitude and contour

• Thrills and bruits

carotid artery auscultation

• For persons middle-aged or older, or who show symptoms or signs

of cardiovascular disease, auscultate each carotid artery for

presence of a bruit

• This is a blowing, swishing sound indicating blood flow turbulence; normally

none is present

• Have patient hold their breath; breathing can mimic a blowing sound

• Lightly apply bell of stethoscope over carotid artery at three levels:

• Angle of jaw

• Mid-cervical area

• Base of neck

pregnant women

• Blood volume increases by 30% to

40% during pregnancy

• Most rapid expansion occurs during

second trimester

• Creates an increase in stroke volume

and cardiac output and an increased

pulse rate of 10 to 15 beats per

minute

• Despite increased cardiac output,

arterial blood pressure decreases in

pregnancy due to peripheral

vasodilation

• Blood pressure drops to lowest point

during second trimester, then rises

after that

• Blood pressure varies with person’s

position

aging adult

 Gradual rise in systolic blood pressure due to thickening of arteries

 Some older adults experience orthostatic hypotension: a sudden

drop in BP when rising to stand or sitting

 Pulse pressure increases

 No change in resting HR or cardiac output at rest

 Cardiac output with exercise is decreased

 Presence of supraventricular and ventricular dysrhythmias increases

with age

 Age-related ECG changes occur as a result of histologic changes in

the conduction system

• Left ventricular wall thickens but the overall size of the heart

doesn’t change

• Incidence of coronary artery disease increases sharply with

advancing age and accounts for about 1/2 of deaths of older

people

• Hypertension and heart failure also increase with age

• Lifestyle habits play a significant role in the acquisition of heart

disease (smoking, chronic alcohol use, obesity, lack of exercise,

diet)