PHYSICAL ASSESSMENT- CARDIOVASCULAR

Physical assessment: Cardiovascular

Subjective data:

•             Chest pain
•             Dyspnea
•             Orthopnea
•             Cough
•             Fatigue
•             Cyanosis or pallor
•             Edema
•             Nocturia
•             Past cardiac history
•             Family cardiac history
•             Patient-centered care (cardiac risk factors)

Objective data:

When performing a regional cv assessment, use this order:

•             Pulse and bp

•             Extremities

•             Neck vessels

•             Precordium

The neck vessels

Normal /abnormal range of findings

Palpate the carotid artery

(Normal)                        

• Located central to the heart, the carotid artery yields important information on cardiac function.  

• Palpate each carotid artery medial to the sternomastoid muscle in the neck .avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults. Take care to palpate gently. Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain. 

• Feel the contour and amplitude of the pulse. Normally the contour is smooth with a brisk upstroke and slower downstroke, and the normal strength is moderate. Your findings should be the same bilaterally.     

(Abnormal)

• Carotid sinus hypersensitivity is the condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased bp, and cerebral ischemia with syncope. This may occur in older adults with hypertension or occlusion of the carotid artery.

• Diminished pulse feels small and weak (decreased stroke volume as in cardiogenic shock).Increased pulse feels full and strong in hyperkinetic states

 Auscultate the carotid artery  

(Normal)   

• For people middle-age or older or who show symptoms or signs of cvd, auscultate each carotid artery for the presence of a bruit (pronounced brú-ee). This is a blowing, swishing sound indicating blood flow turbulence; normally none is present.

• Keep the neck in a neutral position. Lightly apply the bell of the stethoscope over the carotid artery at three levels:

•  (1) the angle of the jaw, 
•  (2) the midcervical area, and
•  (3) the base of the neck . 

• Avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Ask the person to take a breath, exhale, and hold it briefly while you listen so tracheal breath sounds do not mask or mimic a carotid artery bruit. (holding the breath on inhalation also tenses the elevator scapulae muscles, which makes it hard to hear the carotids.) Sometimes you can hear normal heart sounds transmitted to the neck; do not confuse these with a bruit.    

(Abnormal)

• A bruit indicates turbulence from a local vascular cause and is a marker for atherosclerotic disease. This increases the risk of transient ischemic attack (tia) and ischemic stroke. However, a bruit also occurs in 5% of those age 45 to 80 years who have no significant carotid disease.

• A carotid bruit is audible when the lumen is occluded by ½ to ⅔. Bruit loudness increases as atherosclerosis worsen until the lumen is occluded by ⅔. After that, bruit loudness decreases. When the lumen is completely occluded, the bruit disappears. Thus the absence of a bruit does not ensure the absence of a carotid lesion.

• A murmur sounds much the same but is caused by a cardiac disorder. Some aortic valve murmurs (aortic stenosis) radiate to the neck and must be distinguished from a local bruit.

Inspect the jugular venous pulse

Normal                          

• From the jugular veins you can assess the central venous pressure (CVP) and thus judge the heart's efficiency as a pump and the intravascular volume status. Stand on the person's right side because the veins there have a direct route to the heart. You may use either the external or the internal jugular veins because Measurements in both are similar. You can see the top of the external jugular vein distention overlying the sternomastoid muscle or the pulsation of the internal jugular vein in the sternal notch. The latter is harder to see because of its deep position.   

• Position the person supine anywhere from a 30- to a 45-degree angle, wherever you can best see the top of the vein or pulsations. In general, the higher the venous pressure is, the higher the position you need. Remove the pillow to avoid flexing the neck; the head should be in the same plane as the trunk. Turn the person's head slightly away from the examined side and direct a strong light tangentially onto the neck to highlight pulsations and shadows.  

• Note the external jugular veins overlying the sternomastoid muscle. In some people the veins are not visible at all, whereas in others they are full in the supine position. As the person is raised to a sitting position, these external jugulars flatten and disappear, usually at 45 degrees. 

• Now look for pulsations of the internal jugular veins in the area of the suprasternal notch or around the origin of the sternomastoid muscle around the clavicle. You must be able to distinguish internal jugular vein pulsation from that of the carotid artery. It is easy to confuse them because they lie close together.      

   (Abnormal)          

•     Unilateral distention of external jugular veins is caused by local cause (kinking or aneurysm).

• Full distended external jugular veins above 45 degrees signify increased CVP as with heart failure.

• Pulsations. you may or may not see the apical impulse, the pulsation created as the left ventricle rotates against the chest wall during systole. When visible, it occupies the 4th or 5th intercostal space, at or inside the midclavicular line. It is easier to see in children and in those with thinner chest walls.

 Auscultation  
    

Identify the auscultatory areas where you will listen. These include the four traditional valve “areas”             

The valve areas are:

• second right interspace—aortic valve area

• second left interspace—pulmonic valve area

• left lower sternal border—tricuspid valve area

• fifth interspace at around left midclavicular line—mitral valve area

• Do not limit your auscultation to only four locations. Sounds produced by the valves may be heard all over the precordium. (for this reason, many experts even discourage the naming of the valve areas.) Thus learn to inch your stethoscope in a rough z pattern, from the base of the heart across and down and over to the apex. Or start at the apex and work your way up.

• Recall the characteristics of a good stethoscope clean the earpieces with an alcohol wipe; you will use both earpieces. Although all heart sounds are low frequency, the diaphragm detects relatively higher-pitched sounds, and the bell detects relatively lower-pitched ones. Make sure that your earpieces fit snugly and are aimed forward, toward your nose, to avoid air leak. These heart sounds are soft; enhance your success with a completely quiet room—no television, no radio, no talking, please.

• Before you begin, alert the person: “i always listen to the heart in a number of places on the chest. Just because i'm listening for a long time, it does not necessarily mean that something is wrong.”

• After you place the stethoscope, try closing your eyes briefly to tune out any distractions. 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. You cannot process everything at once. Begin with the diaphragm earpiece and use the following routine: 

(1) note the rate and rhythm, 
(2) identify s1 and s2, 
(3) assess s1 and s2 separately, 
(4) listen for extra heart sounds, and 
(5) listen for murmurs.

Rate and Rhythm  

(Normal)

• Note the rate and rhythm. the rate ranges normally from 50 to 95 beats/min. The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration and slowing with expiration. Note any other irregular rhythm. If one occurs, check if it has any pattern or if it is totally irregular.

• When you notice any irregularity, check for a pulse deficit by auscultating the apical beat while simultaneously palpating the radial pulse. Count a serial measurement (one after the other) of apical beat and radial pulse. Normally every beat you hear at the apex should perfuse to the periphery and be palpable. The two counts should be identical. When different, subtract the radial rate from the apical, and record the remainder as the pulse deficit.   

(Abnormal)

• Premature beat—an isolated beat is early, or a pattern occurs in which every third or fourth beat sounds early.
• Irregularly irregular—no pattern to the sounds; beats come rapidly and at random intervals as in atrial fibrillation.

• Atrial fibrillation exemplar (A pulse deficit signals a weak contraction of the ventricles; it occurs with atrial fibrillation, premature beats, and heart failure)

Identify s1 and s2

Identify s1 and s2.  this is important because s1 is the start of systole and thus serves as the reference point for the timing of all other cardiac sounds. You must learn to distinguish systole from diastole before you can attach meaning to all other sounds. Usually you can identify s1 instantly because you hear a pair of sounds close together (lub-dup) and s1 is the first of the pairs. This guideline works, except in the cases of the tachydysrhythmias (rates >100 beats/min). Then the diastolic filling time is shortened, and the beats are too close together to distinguish.

            

Other guidelines to distinguish S1 from S2 are:• S1 is louder than S2 at the apex; S2 is louder than s1 at the base.

• S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1.

• S1 coincides with the r wave (the upstroke of the qrs complex) if the person is on an ecg monitor.  
           

Listen to S1 and S2 separately. note whether each heart sound is normal, accentuated, diminished, or split. Inch your diaphragm across the chest as you do this.  

First heart sound (S1)

(Normal)

First heart sound (S1) caused by closure of the av valves, s1 signals the beginning of systole. You can hear it over the entire precordium, although it is loudest at the apex (sometimes the two sounds are equally loud at the apex because s1 is lower pitched than S2.)  

You can hear s1 with the diaphragm with the person in any position and equally well in inspiration and expiration. A split s1 is normal, but it occurs rarely. A split s1 means that you are hearing the mitral and tricuspid components separately. It is audible in the tricuspid valve area, the left lower sternal border. The split is very rapid, with the two components only 0.03 seconds apart. 

(Abnormal)

Causes of accentuated or diminished s1.

Both heart sounds are diminished with conditions that place an increased amount of tissue between the heart and your stethoscope: emphysema (hyperinflated lungs), obesity, pericardial fluid.

     

Second heart sound (S2)

Second heart sound (S2). the S2 is associated with closure of the semilunar valves. You can hear it with the diaphragm over the entire precordium, although s2 is loudest at the base.           

Listen for murmurs

(Normal)

• A murmur is a blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels. Except for the innocent murmurs described, murmurs are abnormal. If you hear a murmur, describe it by indicating these following characteristics:  

• Timing. it is crucial to define the murmur by its occurrence in systole or diastole. You must be able to identify s1 and s2 accurately to do this. Try to further describe the murmur as being in early, mid, or late systole or diastole; throughout the cardiac event (termed pan-systolic, holosystolic/pan-diastolic, or holodiastolic); and whether it obscures or muffles the heart sounds. 
• Loudness: describe the intensity in terms of six “grades.” For example, record a grade 2 murmur as “2/6.”             

Grade 1: barely audible; heard only in a quiet room and then with difficulty.

Grade 2: clearly audible but faint.

Grade 3: moderately loud; easy to hear.

Grade 4: loud; associated with a thrill palpable on the chest wall.

Grade 5: very loud; heard with one corner of the stethoscope lifted off the chest wall; associated thrill.

Grade 6: loudest; still heard with entire stethoscope lifted just off the chest wall; associated thrill.     

Pitch: describe the pitch as high, medium, or low. The pitch depends on the pressure and rate of blood. Flow producing the murmur.   
       

Pattern: the intensity may follow a pattern during the cardiac phase, growing louder (crescendo), tapering off (decrescendo) or increasing to a peak, and then decreasing (crescendo-decrescendo or diamond-shaped). Because the whole murmur is just milliseconds long, it takes practice to diagnose any pattern.    

Quality: describe the quality as musical, blowing, harsh, or rumbling.

The murmur of mitral stenosis is low-pitched and rumbling, whereas that of aortic stenosis is harsh.

Location: describe the area of maximum intensity of the murmur (where it is best heard) by noting the valve area or intercostal spaces.

Radiation: the murmur may be transmitted downstream in the direction of blood flow and may be heard in another place on the precordium, the neck, the back, or the axilla.

Posture: some murmurs disappear or are enhanced by a change in position.

Some murmurs are common in healthy children or adolescents and are termed innocent or functional. Innocent indicates having no valvular or other.

Pathologic cause: functional is caused by increased blood flow in the heart (e.g., in anemia, fever, pregnancy, hyperthyroidism). The contractile force of the heart is greater in children. This increases blood flow velocity. The increased velocity plus a smaller chest measurement makes an audible murmur.

The innocent murmur is generally soft (grade 2), mi systolic, short, crescendo-decrescendo, and with a vibratory or musical quality (“Vooot” sound like fiddle strings). It is heard at the 2nd or 3rd left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction. It is important to distinguish innocent murmurs from pathologic ones. Diagnostic tests such as ECG and echocardiogram will establish an accurate diagnosis.

(Abnormal)

• Murmurs may be caused by congenital and acquired valvular defects.

• A systolic murmur may occur with a healthy heart or with heart diseases; a diastolic murmur always indicates heart disease.

Heart, neck vessels, and peripheral vascular system

Behavior performance:

Assessment:

gather subjective data i.e. Chest pain, dyspnea, orthopnea, cough, fatigue, heart diseases, do you get tired easily while exercise.

Neck vessels:

• Palpate the carotid arteries (one side at a time), (inhale and exhale then hold the breath.)
• Auscultate the carotid arteries for bruits (use bell of stethoscope).
• Identifies a jugular vein.
• Inspect for external jugular venous distension (hob at 45-degree angle).

Precordium:

• Inspect anterior chest for:
• Apical pulsation (rate, rhythm, regular/irregular).
• Heaves/lifts

Auscultate: (With the diaphragm)

•  Aortic
• Pulmonic
• Erb’s point
• Tricuspid
• Mitral (PMI) (identify s1, s2 and any extra heart sound, rate, rhythm, regular/irregular).

 (With the bell over same area, note extra heart sounds)

Peripheral vascular system:

Assessment:
gather subjective data i.e. Leg pain or cramps, skin changes on arms, legs, swelling in leg, etc.

Inspect and palpate both hands/arms for:

• Color
• Edema
• Capillary refill
• Symmetry
• Lesions
• Texture

Palpate:

• Radial pulses
• Brachial pulses