Cardiovascular and Peripheral Vascular

Diastole

Atrioventricular (AV) valves are open

• Tricuspid valve

• Mitral valve

Semilunar valves closed

• Aortic and Pulmonary valves

Ventricles are relaxed

Ventricular filling

Atrial kick

Systole

Mitral and Tricuspid valves close

Semilunar valves open

• Aortic valve

• Pulmonic valve

Ventricular contraction

Ejection of blood

Subjective Data: Personal health history

Previous diagnoses

Rheumatic fever

Cardiac surgeries or procedures

ECG

Home monitoring of BP/ heart rate

Laboratory monitoring

Medications

Subjective Data: Family Health History

HTN (hypertension)

MI (myocardial infarction)

CHD (congenital heart defects)

HLD (hyperlipidemia)

DM (diabetes mellitus)

Subjective Data: Lifestyle and Health Practices

Smoking

Stressors and coping strategies

24-hour dietary recall

Alcohol consumption

Exercise habits

Toleration of daily activities

Sleep hygiene (How many pillows do you use? Do you feel rested in the morning? Do you wake up at night?)

Subjective Data: Problem-based questions

Chest pain 

Tachycardia  

Palpitations  

Fatigue  

Breathing  

Coughing  

Dizziness  

Nocturia  

Edema  

Heartburn

Inspect for jugular venous distension (JVD): Procedure

Evaluate jugular venous pressure by inspecting for distention of the

jugular vein while the patient is supine, 45 degrees, and finally sitting

upright at 90 degrees

Inspect for jugular venous distension (JVD): Normal

Jugular veins are flat and with no signs of distention, protrusion, or

bulging at 45 degrees

It is NORMAL for the jugular veins to be visible when the client is supine (flat)

Key Takeaways: You DO NOT want the jugular veins to be visible or

distended when the patient is elevated t45 degrees or higher. You D

want the jugular veins to be visible when the patient is supine (flat)

Inspect for jugular venous distension (JVD): Abnormal

Distention, bulging, or protrusion while the client is upright (positioned at 45 degrees or higher)

• Possible causes: right sided HF, COPD, cardia tamponade

Flat jugular veins while supine (flat)

• Possible causes: low volume, dehydration

Key Takeaways:

• Jugular veins that are visible/distended when the patient is at 45 degrees or higher are a sign of a problem.

• Jugular veins that are not visible/flat when the patient is supine (flat) are a sign of a problem.

Palpate Carotid arteries: procedure

Palpate each carotid artery independently by placing the pads of the index and middle fingers medial to the sternocleidomastoid muscle on the neck

• Note rate, amplitude, elasticity, and thrills (purring cat, vibrations)

• SAFETY TIP DO NOT palpate the carotid arteries simultaneously.

Palpate Carotid arteries: Normal

Carotid pulses are 2+ bilaterally. Arteries are elastic, no thrills noted

Palpate Carotid arteries: abnormal

Pulse inequality (arterial constriction or occlusion)

Weak pulses, amplitude of 1+ (hypovolemia, shock, decreased CO)

Bounding pulses, amplitude of 3+ or greater (hypervolemia, increased CO)

Loss of elasticity – may feel rope-like or rigid (arteriosclerosis)

Thrills (carotid artery stenosis)

Auscultate carotid arteries: procedure

Auscultate the carotid arteries by placing the bell of the stethoscope over the carotid artery

Ask the patient to hold their breath

Auscultate carotid arteries: normal

no blowing, swishing, or other sounds are heard

Auscultate carotid arteries: abnormal

Bruit, blowing, swishing sound (narrowed carotid artery, occlusive arterial disease)

Inspect precordium for pulsations: procedure

With the client supine and the head of the bed (HOB) at 30 to 45 degrees, inspect the chest and look for the apical impulse or any abnormal pulsations  

Inspect precordium for pulsations: normal

Apical impulse may or may not be visible

If visible, it will be in the location of the mitral valve/ apex (5th ICS, Left MCL)

Is the result of the left ventricle (LV) moving outward during systole

Inspect precordium for pulsations: abnormal

Any visible pulsations other than the apical pulsation are considered abnormal  

Heaves and lifts

Palpate Abnormal Pulsations: procedure

With the palmar surface of the hand, palpate the apex, left sternal border,

and base

Palpate Abnormal Pulsations: normal

No vibrations or thrills are palpated in the areas of the apex, left sternal  border, or base  

No heaves or lifts are palpated to the anterior chest wall  

There should be NO impulses felt at any location other than the apical region

Palpate Abnormal Pulsations: abnormal

Heave and lifts are palpable (and/or visible) lifting sensation under the  sternum and anterior chest 

• Possible causes:  

 Thrill or vibrations felt to gentle palpation of the left side of the chest 

• Possible causes: 

Palpate Apical Impulse: procedure

With the index and middle finger, palpate the apical impulse in the mitral  valve location (Apical impulse)  

LOCATION: 5^th intercostal space, LEFT midclavicular line 

If unable to feel, ask client to turn on their left side 

NOTE: in clients who are obese, those with increased AP chest diameter, or those with a large amount of breast tissue, it may be difficult to palpate the apical impulse

Palpate Apical Impulse: normal

Apical pulse is palpated over the apex/mitral valve and is about the size of

a nickel

You should feel a gentle tapping sensation

Palpate Apical Impulse: abnormal

Apical impulse area larger than 2cm, displaced, more forceful, or longer

duration (cardiac enlargement)

Traditional areas of auscultation - apical impulse

Aortic valve: 2nd ICS, RSB

Pulmonic valve: 2nd ICS, LSM

Erb’s point: 3rd ICS, LSM

Tricuspid valve: 4th ICS, LSM

Mitral valve: 5th ICS, MCL

Auscultate Apical Heart Rate and Rhythm: procedure

Place the diaphragm of the stethoscope at the apex and listen closely to the rate and rhythm of the apical impulse  

NOTE: when auscultating heart sounds on patients with breasts, it may be  necessary task them to hold up their breast tissue or use the back/side  of your hand to push the tissue aside

Auscultate Apical Heart Rate and Rhythm: normal

Apical pulse is 60-100 beats per minute with a regular rhythm  

Lifespan considerations A regularly irregular rhythm, such as sinus  arrhythmia when the HR increases with inspiration and decreases with expiration, may be normal in a young adult

Auscultate Apical Heart Rate and Rhythm: abnormal

Apical pulse <60 or >100

Irregular rhythm

Auscultate for pulse deficit: procedure

Indications: when you detect an irregular rhythm when auscultating the apical pulse

Use a partner to assess for a pulse deficit 

One nurse will palpate the radial pulse for 60 seconds, while the other nurse will auscultate the apical pulse for 60 seconds  

Compare pulse rates

Auscultate for pulse deficit: normal

Radial pulse and apical pulse are identical

Auscultate for pulse deficit: abnormal

The detection of any difference in apical pulse and radial pulse (this is referred to as a pulse deficit)

Pulse deficit may indicate: atrial fibrillation, atrial flutter, premature ventricular contractions (PVC), and varying degrees of heart blocks

Auscultate to identify S1 and S2: procedure

Place the diaphragm of the stethoscope in all five traditional areas of auscultation and listen for S1 and S2 sounds

Auscultate to identify S1 and S2: normal

S1 - LUB

• represents beginning of ventricular systole

• sound of the tricuspid and mitral valves closing

• heard loudest as APEX (5th ICS, LMCL)

S2 - DUB

• represents the end of systole and beginning of diastole

• sound of the aortic and pulmonic valves closing

• heard best at the BASE (2nd ICS, L or R sternal border)

Auscultate to identify S1 and S2: abnormal

When S1 is accentuated, diminished, split, or varied (may suggest a range of conditions: mitral stenosis, HTN, electrical dysfunction, etc.)

When S2 is accentuated, diminished, or split with expiration (may suggest a range of conditions: HTN, heart failure, aortic or pulmonic stenosis, etc.)

Auscultate for extra heart sounds: procedure

Place stethoscope in all five precordial heart areas first with the diaphragm and then with the bell

Listen for any sounds other than S1 and S2

Auscultate for extra heart sounds: normal

No extra heart sounds are heard

Lifespan considerations physiological S3 sounds may be heard at beginning of diastolic pause in children, adolescents, and young adults – test for this by asking the client to stand or sit up – if the S3 sound is physiologic, the sounds should disappear when standing/sitting up

Auscultate for extra heart sounds: abnormal - S3

Description of Sound: Heard early in diastole, Just before S2

Source of sound: rapid ventricular filling

Best heard: with bell over apical area, L lateral to accentuate

Pathological Causes: ischemic heart disease, FVO, anemia, hyperkinetic states, early S/S of HF

Innocent Causes: children & young adults, sometimes pregnancyCauses

Auscultate for extra heart sounds: abnormal - S4

Description of Sound: heard late in diastole, Just before S1

Source of sound: non-compliant ventricle during atrial contraction

Best heard: with bell over apical area, Supine/L latera to accentuate

Pathological Causes: CAD, HTN, acute MI, aortic/pulmonary stenosis

Innocent Causes: healthy athletes

Auscultate for extra heart sounds: abnormal - Pericardial friction rub

Description of Sound: scratchy/scraping

Source of sound:

Best heard: ask pt to lean forward and hold their breath to accentuate

Pathological Causes: pericarditis, post MI