- One day the heart beats 100,000 times , Heart pumps about 2,000 gallons
- In 70 years the heart beats more than 2.5 billion times
- Extends from the 2nd to the 5th intercostal space
- Between the right boarder of the sternum to the lift midclavicular
- Beats against chest wall to produce apical impulse
Anatomy of the Heart
- Right Ventricle
- Left Ventricle
- Right Atrium
- Left Atrium
- Superior and Inferior Vena Cava
- Pulmonary Artery
- Pulmonary Vein
- Right side pumps blood to lungs
- Left side pumps blood to body
- Two Atrioventricular Valve (AV)
1.Tricuspid Valve (right atrioventricular valve)
2. Mitral (left atrioventricular valve)
- Two Semilunar Valve (SL)
1. Aortic valve (left semilunar valve)
2. Pulmonary valve (right semilunar valve)
1. Carotid Artery
2. Jugular Veins
- – Internal
- – External
What is the order of the flow of blood from the Superior/Inferior Vena Cava to Aorta?
• Superior/Inferior Vena Cava
• Right Atrium
• Tricuspid Valve (right atrioventricular valve)
• Right Ventricle
• Pulmonary Valve (right semilunar valve)
• Pulmonary Artery delivers un oxygenated blood to lungs
• Lungs oxygenate blood
• Pulmonary Vein
• Left Atrium
• Mitral Valve (left atrioventricular valve)
• Left Ventricle ejects blood through aortic valve into aorta
• Aortic Valve (left semilunar valve)
• Aorta delivers oxygenated blood to body
Diastole & Systole
- Ventricles are relaxed, AV valves (tricuspid, mitral) open
- Blood pours rapidly into ventricles
- Atria contract to push last amount of blood-(pre systole)
- Bottom number of the B/P
- Mitral and tricuspid valves close, S1 beginning of systole
- Left ventricular pressure > aortic pressure → aortic valve opens, blood ejected
- Semilunar valves close (pulmonic and aortic) → S2, end of systole
- Top number of B/P
– Sinoatrial node (SA node) – “pacemaker” begin electrical impulse → Atrioventcular node (AV node) → Bundle of His → Bundle branches → ventricles
– ECG- measures electrical impulses
- P wave : atrial depolarization
- PR interval: the time from beginning of atrial depolarization to the beginning of ventricular depolarization
- QRS complex : ventricular depolarization
- lT wave : ventricular repolarization
- QT interval : total time for ventricular depolarization and repolarization
- U wave: may or may not be present ; it follow the T wave , respresnt the final phase of ventricular repolarization
Taking a Health History
– Lifestyle factors:
- Smoking habits- stimulant for CV system
- Serum cholesterol- causes blockages
- Obesity and fats
- Stress life
– Past health history:
- Diabetes- stresses body, effects heart
- HTN- wear& tear in aorta and LV
- Family history heart disease or Peripheral Vascular Disease
- Large genetic correlation
History – past health history
- Problems during pregnancy
- History of childhood disease “e.g. rheumatic heart disease (RHD)” Are children meeting developmental and expected growth parameters
- Any history of chest pain (PQRST)
- When? Where?
- What precipitated it?
- What gave relief?
- Qualities (Stabbing, crushing, shooting, radiating)
- All indicate possible poor cardiac output
Assessment of chest pain
Cardiac cause : myocardial infarction
- Provocative factors : same angina
- Palliative action : nitroglycerin , morphine
- Qualitative or Quantity: crushing or squeezing sensation; feeling of heaviness, pressure or tightness
- Region and radiation :substantial region: radiation to left shoulder, jaw, neck, arm, elbow or wrist or figures.
- Severity : asymptomatic to sever
- Timing : gradual or sudden onset constant duration during episode
Cardiac causes : angina
- Provocative factors : emotional stress, heavy meal, physical exertion , extreme whether, sexual intercourse.
- Palliative action : nitroglycerin , rest, high fowler’s position
- Quality or quantity : crushing sensation; feeling heaviness, pressure or tightness.
- Region and radiation: substantial region: radiation to left shoulder, jaw, neck, arm, elbow or wrist
- Severity : mild to sever
- Timing : 5-10 minute gradual or sudden onset.
Cardiac causes : pericarditis
- Provocative factors : cough , deep breathing , laughing , lying down , movement.
- Palliative action: high fowler’s position , leaning forward
- Quality or Quantity
- Knifelike, sharp or stabbing sensation
- Region and radiation : substantial region: radiation to left shoulder, back , neck, arm.
- Severity : mild to sever
- Timing : sudden onset; constant duration
Cardiac causes : dissecting aortic aneurysm
- Provocative factors: lifting heavy weight spontaneous
- Palliative action : narcotic , surgery
- Quality or quantity :Ripping or tearing sensation, throbbing of chest with heart beat
- Region and radiation : upper back or upper anterior chest radiation neck , left shoulder. Abdomen or thigh
- Severity : sever specially at on-set
- Timing : sudden onset; intermittent , nocturnal or constant duration
Pulmonary causes: pneumothorax
- Provocative factors: coughing , exertion , valsalva maneuver
- Palliative action: chest tube insertion
- Quality and quantity : described as sharp tearing sensation
- Region and radiation : lateral thorax ; radiation to lateral shoulder
- Severity : mild to sever
- Timing sudden onset. Few hours duration
Pulmonary causes : pulmonary embolism
- Provocative factor : coughing , deep breathing, immobility
- Palliative action : high fowler’s position , splinting of chest , position change
- Quality and quantity : gripping or stabbing sensation that worse with deep breathing or sensation of inability to take a breath
- Region and radiation : affect region ; may radiate to neck or shoulder
- Severity : mild to sever
- Timing : sudden onset; few hours duration
Risk Factors of Cardiac Disease
Unalterable Risk Factors
Alterable Risk Factors
2.left ventricular hypertrophy
Assessment of Body structure
- Skin color for cyanosis ,flushing or pallor
- Tongue , mucosa, conjunctiva for central cyanosis .
- Lips- tip of nose and nail for peripheral cyanosis
- Skin temperature , moist ,turger , and edema
- Eyelid –xanthelasmas
- Retina – for nicking of vessels seen with HTN.
- Ensure the patient is comfortable. Ideally the patient should be sitting at a 45-degree angle with their chest, arms and legs exposed.
- Cover the breasts of female patients with a towel or loose piece of clothing.
- Lighting should allow the assessment of skin color and the contour of the neck.
- Quiet environment
- Small pillow
- Gown and drape
- Client supine with head of table slightly elevated (stand at R side of client)
- Inspect for pericardial movement/visible
- Pulsations (tangential lighting) apical impulse/point of maximal impulse ( PMI)
- Note symmetry of chest, distortions
- Inspect for jugular vein
- Note abnormal posture or chest configuration
- Note skin color, edema
- Note nail beds (clubbing, capillary refill, color…)
- Look for neck veins and note any distension.
- Client supine with head slightly elevated
- Use 4 fingers or whole hand and touch lightly
- Palpate the
- Radial, Ulnar
- Posterior Tibial
- Dorsalis Pedis
The location of pulse sites on the body
The carotid pulse is located on the anterior (front) right and left sides of the neck
- A carotid pulse is normally taken when performing CPR on an adult or child victim.
Radial Pulse and Ulnar Pulse
The radial pulse is the most common site for taking pulse measurements on adult patients.
The radial pulse can be easily palpated on the thumb side of the wrist.
The brachial pulse is located on the inside aspect of the upper arm.
•The brachial pulse is used for taking an infant’s pulse during CPR.
•The brachial pulse is also palpated when performing blood pressure on patients.
The femoral pulse is located in the front between the upper leg and the lower hip, where the hip bends.
It is often used to check circulation of the leg
The dorsalis pedis pulse is found on the anterior (front) side of the foot.
•The dorsalis pedis pulse is often used to check circulation of the foot.
The posterior tibial pulse is located on the inner ankle area.
The posterior tibial pulse is often used to assess circulation of the lower leg and foot.
The popliteal pulse is located behind the knee
- The popliteal pulse may be used to check circulation of a patient’s leg or extremity.
A pulse assessment is based on three factors:
- The Rate of the pulse.
1. Adults : 60 – 100 beat/minute
2. Children 90 – 120 beat/minute
3. Newborns 70 – 170 beat/minute
4. < normal = bradycardia
5. > normal = tachycardia
- The Rhythm of the pulse: ( regular or irregular)
- The Force (Strength) of the pulse.
1. force measures the volume of blood flow.
2. weak indicate reduced volume of blood flow as in the condition of shock )
Systolic maximum pressure exerted on arterial wall during ventricular contraction.
- Diastolic pressure in vasculature during ventricular relaxation .
- Children vary with age
Blood Pressure Classification in Adults
1.Secondary means cause is known may be a side-effect of medication
2.Primary Hypertension means cause is unknown
- Late sign of hypovolemia, cardiac failure, shock
- 90 / 60 common in young females
- Hypotension Lead to inadequate perfusion in vital organs such as heart, brain and kidney
Two factors determine blood pressure
- Cardiac output = stroke volume x heart rate
- Systemic vascular resistance (SVR)
Stroke Volume determine by
1. Preload = filling volume of ventricles
2. Contractility = force of muscle contraction
3. Afterload = resistance ventricles contract against
- Systolic – Diastolic
- Normal 35 – 40 mmHg
- < 30 mmHg pulse hard to detect
- Decreasing pulse pressure early sign of inadequate circulating blood volume
- Pericardium palpation: When palpation the pericardium used the pads of figures because especially sensitivity to vibration and can affect in large pulse site.
- Place the palm of your hand over the left 4th, 5th, and 6th ICS along the midclavicular line to locate the apical impulse.
- Systemic palpation that cover the sternoclavicular , aorta , pulomonic,
- right ventricular , left ventricular (apical) and epigastric area, Apical pulse area.
- Palpate apical impulse
- Using 1 finger locate the apical impulse
- Ask client to “exhale and hold”=aids in locating pulsation
- May need to turn client to left to find it.
- – Note: Location, size, amplitude and Duration
- Apical impulse palpable in ½ adults, and not in obese or thick wall clients.
- Apical impulse increases in amplitude and duration in client with anxiety, fever, hyperthyroidism and anemia
- Percussion: outline of the heart’s boarder; limited with the female breast tissue or in an obese person or person with muscular chest wall.
- Used to detect the approximate location of the left cardiac border.
- Place the pleximeter finger of your nondominant hand parallel to the third left intercostal space just medial to the midclavicular line.
- Percuss lightly from lateral resonance to medial dullness.
- Note the precise location at which the percussion note changes to dullness.
- Repeat the examination at the 4th and 5th left intercostal spaces.
- Note the distance between the percussion note change and the midsternal line to provide a rough estimate of cardiac size.
- Notes : Chest X ray more exact information about heart size ( some pt have lung disease which reduce the accuracy of percussion).
- Sound is transmitted in direction of blood flow, so specific sounds are best heard over areas where blood flows after it passes through a valve
- Client supine with head slightly elevated, stand at right side in a quiet room (concentrated listening)
- Begin by identifying S1 & S2
- Palpate carotid while auscultating the heart
- Carotid pulsation & S1 are synonymous
- Rate, rhythm, and heart sounds
- The diaphragm is used for listening to higher-pitched sounds, such as normal heart sounds as it is applied tightly against the chest wall.
- The bell is used to listen to lower-pitched sounds such as additional heart sounds and some murmurs. It should be applied lightly to the chest wall.
- Auscultating the apical pulse with the diaphragm to evaluate cardiac rate and rhythm.
- Count the number of beats that occur in 15 seconds, if the rhythm is regular. If the rhythm is irregular, listen for a full 60 seconds to count heart rate.
- Also note if the rhythm pattern is regularly irregular, or if there is no distinguishable pattern.
- Listen with the diaphragm at the right 2nd intercostal space near the sternum (aortic area).
- Listen with the diaphragm at the left 2nd i intercostal space near the sternum (pulmonic area).
- Listen with the diaphragm at the left 3rd, 4th, and 5th intercostal space near the sternum (tricuspid area).
- Listen with the diaphragm at the apex (mitral area).
Heart Sounds – S1…(Lub)…
- S1: Closure of mitral and tricuspid valves:
- Correlates with the carotid pulse
Heart Sounds – S2…(Dub)…
- S2: Closure of Semilunar valves (aortic & pulmonic)
- Base (R/L 2nd ICS)
- S2 louder than S1
- S1 louder than S2
- Best heard at pulmonic area during inspiration
- Normally silent (at apex & at beginning of expiration, best Left side lying with bell)
- May be normal/physiological third heart sound
- Occurs with patients with heart failure, mitral regurgitation, and constrictive pericarditis.
- Heard best at apex with bell
Note : Gallop the abnormal third or fourth heart sound which, when added to the first and second sounds, produces the triple cadence of gallop rhythm.
- Define as turbulent blood flow ; may be due to a stenotic or regurgitate valve producing a high velocity jet.
- Listen for murmurs in the same auscultatory sites aorta , pulmonary, erb’s point, tricuspid and marital
- Grade I :barely audible
- Grade II : audible but quiet and soft
- Grade III : moderated loud, without thrust or thrill
- Grade IV : loud, with thrill
- Grade V : louder with thrill, stethoscope on chest wall
- Grade VI : loud enough to be heard before stethoscope on chest
- Frequency (pitch) – high or low pitched
- Intensity – loudness (Grades I-VI)
- Duration – very short for heart sounds
- Timing – during systole, diastole or continuous
- Position – Effect of client maneuvers (respirations, sitting, squatting, exercise, Valsalva maneuver)
- Location and radiation –Mitral area , radiates to the left axilla”
- Common in healthy infants, children and adolescents, athletes, fever, anemia, adults over 50 and pregnancy.
- Secondary to streptococcal infection or congenital defect
- Change in blood viscosity secondary to anemia
- Change in blood velocity secondary to exercise
- Aortic stenosis
- Pulmonic stenosis
- Mitral regurgitation (mitral valve prolapse)
- Tricuspid regurgitation (Insufficiency)
- Mitral stenosis
- Tricuspid stenosis
- Aortic regurgitation (Insufficiency)
- Pulmonic regurgitation (Insufficiency)
Extra Abnormal Heart Sounds
1. Ejection click
2. Opening snap
3. Friction rub
- Early in systole at start of ejection
- Results from the abnormal opening of the semilunar valves (aortic and pulmonic)
- With left semilunar valve stenosis their opening makes a sound
- Best heard at:
- 2nd RICS, apex – aortic
- 2nd LICS – pulmonic
- Sound produced by the opening of stenotic AV valves (tricuspid & mitral)
- Increased atrial pressure is required to open the valve (mitral stenosis c murmur)
- Sharp, high-pitched with a snapping quality
- Best heard with
- diaphragm at 3rd or 4th ICS at LSB/apex – after S2
- Due to inflammation of the pericardial sac
- High-pitched, scratchy (sandpaper rubbing together)
- Best heard:
- Client sitting and leaning forward
- Hold breath in expiration
- Apex and LLSB
- Systolic &/or diastolic
- Common in 1st week after MI
- A palpable vibration (like purring cat)
- Turbulent blood flow
- Accompanies a loud murmur
- Also follows an MI with pericordial inflammation
- Due to turbulent, vascular, blood flow (atherosclerotic narrowing, aortic valve disease)
- Auscultate at carotid and femoral (should be done with abdominal assessment)
- Best heard with bell – at three places
- Murmur-like sound
- May be able to palpate a slight thrill
Peripheral Vascular Assessment
- Skin abnormalities
- Arm size and Color
- Cap refill
- Venous Jugular distension
- Capillary refill
- Epitrochlear Lymph node located in the upper inside of the arm. Normally are not palpate
bruits : Carotid and femoral (may defer to abdominal assessment)
Other Peripheral Vascular Assessments
1. Allen Test
- The hand is elevated and the patient/person is asked to make a fist for about 30 seconds.
- Pressure is applied over the ulnar and the radial arteries so as to occlude both of them.
- Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails.
- Normally: Ulnar pressure is released and the color should return in 7 seconds.
- Abnormal If color does not return or returns after 7-10 seconds, then the ulnar artery supply to the hand is not sufficient .
- Risk for hand ischemia
- Radial vessel spasm
2. Venous Jugular Distension
Due to venous congestion (CHF)
3. Homan’s Sign
- Checks for deep vein thrombosis
- Move the foot toward tibia quickly, + sign produces pain
4. Capillary refill
Check both finger and toe pads bill
5. Pitting Edema
- 1+ mild pitting, slightly indentation of legs; depth of pitting is 1 cm
- 2+ moderate pitting, indentation subsides rapidly; depth of pitting is 2 cm
- 3+ deep pitting, indentation remains for a short time, depth of pitting is 3 cm
- 4+ very deep pitting, indentation lasts a long time, depth of pitting is 4 cm
6. Trendelenburg Test
lying supine elevate legs 90 degree until veins empty, place tourniquet high on thigh, help patient to
Stand, watch for venous filling; saphenous veins should fill slowly from below in about 30 seconds