Cardiovascular.330.Ss.09

Cardio Vascular System

Nursing 330

Shirley Comer

Pertinent History

Chest Pain Edema Known disease Dyspnea Nocturia Family Hx Orthopnea Diet Smoking Cough Obesity Diabetes Mellitus Fatigue ETOH use Exercise Cyanosis or pallor Past Hx ie Rheumatic fever, recent dental work

Neck Vessels

Keep neck in a neutral position

Locate and Palpate Carotid Arteries– One at a time– Rate amplitude 1+ to 4 +

5 p of circulation

Neck Vessels cont

Auscultate the Carotid-normally no sound– Bruit- blowing or swishing sound indicating turbulent

blood flow Use bell of stethoscope Auscultate at 3 positions

– Thrill – Palpable vibration accompanying bruit

A loud aortic heart murmur may radiate to neck

Jugular Venous Assessment

Position client supine at 30 to 45 degree angle– Always be aware of client comfort– Turn client’s head slightly away

Note the external and internal Jugular vein distention (if any) and record the level in relation to the clavicle(normal less than 2 cm)– Observe for pulsations (if any)– Unilateral distension=kinking or aneurysm– Bilateral distension=increased CVP

Jugular Vein Drawing

The Precordium (chest wall)

Inspect– Heave(lift)=sustained forceful thrust of ventricle against chest

wall=ventricular hypertrophy– Apical pulse may be visible in thin adults and children

Palpate the Apical Pulse– Sometimes called PMI (point of maximum impulse)– Note

Location– should be at or near 5th intercostals space– LV dilatation (fluid overload) displaces down and to the left and

increases size

Apical Pulse cont

Size Amplitude- 1+ to 4+

– Increased in LV hypertrophy (pressure overload) Rate and Rhythm

– Regular irregularity or irregular irregularity– Compare irregular apical pulse to radial– Sinus arrhythmia common in children and young adults related to the

respiratory cycle– Premature Beat- more common in elderly

Palpate the Precordium– Use palm– Normally thrill or mass not felt

5 areas for listening to the heart

Auscultate Heart Sounds

Auscultation sites– 2nd right intercostal space (aortic value)– 2nd left intercostal space (Pulmonic Value)– Left lower sternal border (Tricuspid Valve)– Apex (Mitral Valve)

Continue auscultation in Z pattern

Blood Flow through Cardiac Valves

The Stethoscope

Auscultation Heart sounds

Auscultation cont

Use Diaphragm of Stethoscope Identify S1 and S2

– S1 is loudest at apex closure of AV valves Beginning of systole

– S2 is loudest at base Closure of semilumar valves Beginning of diastole

– S1 coincides /c carotid pulse and R wave on ECG

S1, S2

Extra Heart Sounds

Split S2– Normal phenomenon– Occurs at end of inspiration– Semilumar valves don’t close at the same time– Heard best at left 2nd ICS– Can be fixed or paradoxical

Extra Heart sounds cont

S3 – Ventricular Gallop– Early in diastole during rapid filling– Heard best at apex using bell of stethoscope– Doesn’t vary /c resp like Split S2– Indicates decreased ventricular compliance– In children and young adult may be innocent and

disappear when pt sits– May be earliest sign of heart failure– Heard /c increased CO ie hyperthyroidism,

Extra Heart Sounds cont

S4- Atrial Gallop– Ventricular filling sound– Occurs late in diastole immediately before S1– Heard when atria contract– Very soft, low pitched sound– Heard best at apex /c pt in left lateral position /c bell– Can occur /p exercise at 40 yr old– Occurs /c systolic overload, hypertension and aortic

stenosis

Extra Heart Sounds cont

Friction Rub– Occurs r/t inflammation of the pericardial

membranes– Occur in both systole and diastole– Hear best at apex – Common in 1st week following Myocardial Infarction

and pericarditis

Heart Murmurs

Murmurs

Blowing, swooshing sound Indicates abnormal turbulent blood flow A murmur outside the heart is called a bruit Are either systolic or diastolic Systolic murmur may occur innocently in

children and young adults r/t increased force of contraction

Assessment of Murmurs

Timing- systolic or diastolic Loudness-Grade I thru VI Pitch- high or low Pattern- Crescendo, decrescendo, plateau, diamond Quality- Musical, blowing, harsh or rumbling Location- Where is it loudest? Radiation- Is it audible in other parts of precordium Posture- Is it present or louder only in certain position

Age Specific Considerations

Infants– Use appropriate size stethoscope– May be irregular– Murmurs may be present r/t congenital fetal

circulation remnants Children

– May have visible apical pulses r/t thin chest wall– May have innocent murmurs-always note presence

of murmur

Age Specific Consideration cont

Pregnancy– Increased pulse rate– Exaggerated S2 splitting– Easily heard S3– Systolic murmur may be present-should

disappear /p delivery Elderly

– S4 even /s Hx of CAD– Irregular pulse more common

Practice Exam Question

You are assessing a 7 year old child upon admission to the pediatric unit. The child has a soft systolic murmur. His Mother states he has always had this murmur and the doctor is aware of it. How should you document your finding?

– A. No need to document it as it is an innocent murmur.– B. Describe murmur location, pitch and loudness in the

nurses notes but no need to mention it to the Doctor.– C. Document your finding in the nurses notes and

mention your finding to the Doctor.– D. Document you findings on the graphic sheet.

Rationale

C is the correct answer as the murmur is an abnormal finding

A is incorrect because you always document an abnormal finding

B is incorrect because the Physician should be aware of all abnormal findings

D is the wrong form

Peripheral Vascular system and Lymphatics

Nursing 330

Governors State University

Shirley Comer

Anatomy in Peripheral Vascular

Arteries- carry oxygenated blood to tissues– Thick muscular walled

Veins- carry deoxygenated blood to tissues– Thin walled

Lymphatics- separate vessel system which retrieves excess fluid and plasma proteins and returns them to blood stream

– Major player in immune system– Contains nodes that drain body areas

Assess Arms

Note color of skin and nails, temperature, texture, turgor, hair distrubuiton

Note lesions, edema or clubbing Assess capillary refill Assess radial and antecubital pulse (0 to 4+) Palpate antecubital and axillary lymph nodes All finding should be bilateral Edema indicates lymphatic obstruction

(lymphedema)

Pulse Assessment

Pulses are rated 0 to 4+ 3+ is normal Note rate, amplitude and rhythm Documenting in the physical assessment

Pulse Radial Carotid Brachial Apical Femoral Pop Post Tib Dorsal Ped

Left 3+ 3+ 3+ n/a 2+ 2+ 1+ 1+Right 3+ #+ 3+ n/a 2+ 2+ 1+ 0

Assess the legs

Inspect skin – Note: color, hair distribution, venous pattern, size,

edema, lesions, temperature, turgor, texture– Should be symmetrical

Venous pattern– Normally flat and barely visible– Vericose vein-enlarged surface vein, tortuous, prone

to clots– Note angiomas, petichia, purpuras, brusing ect

Assess the Legs cont

Palpate Inguinal lymph nodes Palpate Peripheral pedal pulses- use doppler if

unable to find– Femoral pulse– Popliteal pulse-can be difficult to locate– Posterior Tibial pulse- behind medial malleolus– Dorsal pedis pulse- lateral to extensor tendon of

great toe- use light touch

Edema

Pretibial- – Firmly press over skin of tibia or medial

malleolus for 5 seconds and release. – If indentations are left pt has pitting edema. – Scale 0 to 4+

Unilateral edema may indicate venous thrombosis, lymph obstruction, injury or dependant positioning

Practice Exam Question

Your patient has a history of a mastectomy on the right side. You note her right arm is twice the size of the left. What nursing intervention would you use to decrease the size of this arm?

A. elevate arm on pillow B. encourage ROM exercises C. discouarage constricting clothing D. all of the above

Rationale

D is the correct answer. The pt is experiencing lymphedema as a result of her mastectomy and all the interventions listed are appropriate.