cardio vascular system

1. SALALE UNIVERSITY
COLLEGAE OF HEALTH SCIENCE
DEPARTMENT OF ADULT HEALTH NURSING
Presentation on : Assessment Of Cardiovascular System
Presented To : Mr. Tadele K & Mr. Bikila T (Ass’t Professor)
Presented by: Dereje A & Worku D (Bsc)
June,2023
Fiche Ethiopia

2. Outline
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 Introduction
 Anatomy and Physiology of Cardiovascular
 Symptom of Cardiac Disease
 Assessment of Cardiovascular
 Cardiovascular Examination
 Normal and Abnormal Cardiac Sound

3. Objectives
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At the end of this lesson the students will be able to:
 Understanding and explaining Anatomy and Physiology of
Cardiovascular
 Explain symptoms of cardiac disease
 Use a step -wise approach in cardiovascular examination
 Perform a complete cardiovascular assessment
 Differentiate between normal and abnormal cardiac findings
 Interpret cardiac findings

4. Introduction To Cardiovascular System
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 Cardiovascular system consists of heart(a muscular pump) and
blood vessels.
• Blood vessels are arranged in two continuous loops
– Systemic circulation
– Pulmonary circulation
• When the heart contracts, it pumps blood simultaneously into
both loops

5. Overview Of Anatomy And Physiology Of Cardiovascular
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 Understanding cardiac anatomy and physiology is particularly
important in the examination of the cardiovascular system.
 Heart is shaped like “Cone”
 Top of the heart is the base
 Bottom” is the apex
 Heart size = clenched fist
 Precordium - area on anterior chest that covers heart and great
vessels

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7. Cont…
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 Chambers and valves of the Heart
The heart has four chambers and valves:
Chambers Vs Valves
-Right atrium -Tricuspid valve
-Left atrium -Mitral valve
-Right ventricle -Aortic valve
-Left ventricle -Pulmonic valve

8. Cont…
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 Atria are tilted slightly toward the back and ventricles extend to left
and toward anterior chest wall.
 Note that the right ventricle occupies most of the anterior cardiac
surface.
 This chamber and the pulmonary artery form a wedge like
structure behind and to the left of the sternum.
 The left ventricle, behind the right ventricle and to the left, forms
the left lateral margin of the heart.

9. Cont…
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 Its tapered inferior tip is often termed the cardiac “apex.”
 It is clinically important because it produces the apical impulse,
sometimes called the point of maximal impulse, or PMI.
 This impulse locates the left border of the heart and is usually
found in the 5th interspace 7 cm to 9 cm lateral to the midsternal
line.
 The right heart border is formed by the right atrium, a chamber not
usually identifiable on physical examination.

10. Cont…
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 The left atrium is mostly posterior and cannot be examined
directly
 Because of their positions, the tricuspid and mitral valves are
often called atrioventricular valves.
 The aortic and pulmonic valves are called semilunar valves
because each of their leaflets is shaped like a half moon.
 Although this diagram shows all valves in an open position, they
are not all open simultaneously in the living heart.

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12. Cardiovascular: Cardiac Cycle
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Tow phases:
 DIASTOLE: ventricles relax and fill with blood
 SYSTOLE : ventricles contract pump blood into pulmonary and
systemic arteries

13. Cardiovascular :Pumping Ability
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 Cardiac Output (C.O.) = volume of blood in liters ejected by the heart
each minute. Adult = 4-7 liters/minute (CO = HR x SV).
 Heart Rate (HR) = number of times ventricles contract each minute.
 Stroke Volume (SV) = The amount of blood ejected by the left
ventricle during each systole.
 Preload = degree of stretch of myocardial fibers at end of Diastole.
 Afterload = pressure or resistance the ventricles must overcome to
pump out blood.

14. Symptoms Of Heart Disease
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 Dyspnea: This is a state of shortness of breath on exertion. But it
may occur at rest as the heart failure progresses.
 The degree of dyspnea is graded based on the New York Heart
Association Class (NHAC):
Class I: No limitation of physical activity
No symptoms with ordinary exertion
Class II: Slight limitation of physical activity
Ordinary activity causes symptoms

15. Symptoms Of Heart Disease cont…
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Class III: Marked limitation of physical activity
-Less than ordinary activity causes symptoms
-Asymptomatic at rest
Class IV: Inability to carry out any physical activity without discomfort.
-Symptoms at rest
 Paroxysmal Nocturnal Dyspnea: Is shortness of breath that
occurs during sleep.

16. Cont…
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 Orthopnea: Shortness of breath that occurs during recumbent
position.
 postural (orthostatic) hypotension: a sudden drop in blood
pressure when they rise to a sitting or standing position/sudden
change of position.
 Pain: Angina pectoris is a cardiac pain. It arises in the precordial
area usually on the retrosternal region and radiates to the left
neck, shoulder and left upper arm.

17. Cont…
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 Body swelling: Usually which starts from the leg
 Palpitation: Is subjective unpleasant perception of one’s own
heart beat.
 Cough: Which usually occurs at night (nocturnal)
 Syncope: Sudden episode of fainting related to hemodynamic
derangement

18. Symptoms of Peripheral Vascular Disease
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Symptoms of Arterial occlusion:
 Acute: pain, loss of function, altered cutaneous sensation,
gangrene .
 Chronic: Intermittent claudication (pain around calf muscle
on walking) which gets relieved with rest
Symptoms of Venous insufficiency: Swelling and pain of
the affected limb

19. Assessment Of The Cardiovascular System
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 Subjective Assessment
 Personal and family history
 Socioeconomic status
 Cigarette smoking : # packs /day and also # years smoked.
 Physical Activity/Inactivity: 30 minutes daily of light to
moderate exercise recommended.

20. Cont…
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 Obesity: associated with HTN, hyperlipidemia, diabetes and all
contribute to CV disease.
 Current Health Problems: describe health concerns.
 Chest pain: discomfort, a symptom of cardiac disease, can result
from ischemic heart disease, pericarditis and aortic dissection.
 Chest pain can also be due to non cardiac causes; pleurisy,
pulmonary embolus, hiatal hernia and anxiety.

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Assessment- Chest Pain
 Onset & Duration
 Frequency
 Precipitating factors
 Location
 Radiation
 Intensity

22. Cont…
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 Paroxysmal Nocturnal Dyspnea – client has been recumbent
for several hours, increase in venous return leads to pulmonary
congestion.
 Fatigue- resulting from decreased cardiac output is usually worse
in evening. Ask the patient if can they perform same activities as
a year ago

23. Cont…
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 Palpitations- fluttering or unpleasant awareness of heartbeat.
Non cardiac causes- fatigue, caffeine, nicotine, alcohol
 Weight gain- a sudden increase in wt. of 2.2 pounds (1 kg) can
be result of accumulation of fluid (1L) in interstitial spaces known
as edema.
 Syncope- transient loss of consciousness, decrease in perfusion
to brain.

24. Physical Examination
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General Considerations
 The patient must be properly undressed above the waist.
 The examination room must be quiet to perform adequate
auscultation.
 Observe the patient for general signs of cardiovascular disease
- Breathing pattern -Finger clubbing
- Cyanosis -Edema

25. Cont…
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 Objective Assessment
 BP: supine -change position 1-2 minutes, check again.
 Normally, systolic drops slightly or remains unchanged and
diastolic increases slightly.
 Peripheral pulses are assessed for:
-Presence -Rhythm -Equality
-Amplitude -Rate

26. Cont…
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 Precordium Assessment- area over heart is done by:
-Inspection (I)
-Palpation (P)
-Percussion (P)
-Auscultation (A)

27. Inspection
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 Lips for (cyanosis)
 Clubbing of fingers may be seen
 Pallor of the conjunctiva indicates anemia
 Edema
 DVT and JVD
 Arm/leg skin changes, varicose veins
 visible pulsation on the neck, pericardium, epigastric area
for pulsation of the abdominal aorta.

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30. Palpation
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 Palpable Pulses (heart sounds) at each valvular sites.
 PMI: which usually is located at the same area to the apical impulse.
 It is normally located in the 5th intercostals space
 Normally no pulsation palpable over the aortic and pulmonic areas
but at the PMI.
Also You may feel: Thrills (a palpable murmur)
-Parasternal heave (lifting the palm or a pen when put on the
Parasternal area)

31. Cont….
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Arterial Pulses
Components of arterial examination include
-Rate -Character
-Rhythm -Volume (amplitude)
Major Arteries: Radial, Brachial, Carotid, Femoral, Popliteal,
Posterior Tibial & Dorsalis pedis.
NB. All arteries should be palpated symmetrically at the same time
except carotid arteries, as this could cut off the blood supply to the
brain and cause syncope.

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33. Percussion
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 Has little significance in pericardial examination.
 It is done when suspects dextrocardia or significant mediastinal
shift.
 In most cases, palpation has replaced percussion in the estimation
of cardiac size
 Starting well to the left on the chest, percuss from resonance
toward cardiac dullness in the 3rd, 4th, 5th, and possibly 6th
intercostal spaces.

34. Auscultation
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 listen to the heart with your stethoscope in the right 2nd
interspace close to the sternum, continue auscultation along the
left sternal border in each interspace from the 2nd through the 5th,
and at the apex.
 Recall that the upper margins of the heart are sometimes termed
the “base” of the heart. Some clinicians begin auscultation at the
apex, others at the base.

35. Cont…
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Areas of auscultation:
1. Aortic area : The right 2nd inter costal space near the sternum
2. Pulmonic area :The left 2nd inter costal space near the
sternum.
3. Tricuspid area : The left 4th and 5th inter costal spaces near the
sternum
4. Mitral (apical) area: 5th inter costal space just medial to the
midclavicular line.

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37. Auscultation Cont…
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Different maneuvers to emphasize cardiac auscultation
 Have the patient roll on their left side and auscultate at the apex.
This position emphasizes S3 and mitral murmurs.
 Have the patient sit up and lean forward. This position enhances
diastolic murmur of aortic regurgitation, and pericardial friction rub.

38. Auscultation Cont…
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Ask the patient to hold on breathing:
 If the patient holds on inspiration which makes sounds arising
from the right side of the heart louder.
 If the patient holds on expiration sound originating from the left
side of the heart are exaggerated.

39. Auscultation Cont…
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Heart Sounds
 Heart sounds- are caused by the closure of heart valves.
Heart sounds: LUB DUB
 SYSTOLE: lub= S1 (closing of Aterio Ventricular valves)
 DIASTOLE: dub = S2 (closing of semilunar valves)
 During the cardiac cycle, valves are opening and closing, causing different
heart sounds (S1 and S2).
 Sometimes abnormal heart sounds are heard due to improper opening or
closing of the valves (murmurs).

40. Auscultation Cont…
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Characteristics of Heart Sound
 Frequency (pitch): high or low
 Intensity (loudness): loud or soft
 Duration: very short hear sounds or longer periods of silence
 Timing: systole or diastole

41. Auscultation Cont…
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During auscultation focus heart sounds are:
 1st Heart Sound (S1): This signals the onset of systole and is
caused by the closure of the mitral and tricuspid valves.
NB: The 1st heart sound can be identified by palpating the carotid
pulse while auscultating.
 The upstroke of the carotid pulse closely follows the 1st heart
beat.

42. Auscultation Cont…
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S1 is loud in:
-mitral stenosis
-tachycardia
-hyperdynamic circulation like e.g. anemia
S1 is soft ( Muffled )in:-
-mitral regurgitation
-bradycardia and etc.

43. Auscultation Cont…
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 2nd Heart Sound (S2): This separates systole and diastole.
 The sound is made by the closure of aortic and pulmonary
valves.
 The aortic valve closes before the pulmonary valve and this
splitting of the second sound is heard.
 Particularly during inspiration, as more blood is drawn into the
right ventricle which is a normal phenomenon.

44. Auscultation Cont…
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 Normally S2 is louder than S1 at the base and often softer than
the first heart sound at the apex.
 The aortic component of the 2nd heart sound is increase intensity
by Systemic HTN because of increase pressure.
 The pulmonic component of the 2nd heart sound is increase
intensity by Pulmonary HTN.

45. Auscultation Cont…
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 3rd & 4th Heart Sounds
 These are low pitched sounds. If either S3 or S4 is very loud it is
often heard as gallop/triple rhythm.
 3rd Heart Sound (S3) or ventricular gallop
 This is produced by rapid ventricular filling and occurs in early-
mid diastole i.e. soon after S2 occurs normally in young fit adults
with bradycardia.

46. Auscultation Cont…
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 Physiologic 3rd heart sounds is frequently heard in children and
3rd trimester pregnancy.
It occurs abnormally in patients with heart failure:
 left heart failure - S3 heard best in mitral area
 right heart failure - S3 heard best in tricuspid area

47. Auscultation Cont…
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 4th Heart Sound (S4) or atrial gallop
 This is an atrial sound, occurring just before S1.
 It is always abnormal as it represents atrial contraction against a
stiffened ventricle.
 It may occur in heart failure, aortic stenosis or hypertensive
heart disease.

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49. Auscultation Cont…
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 Murmur
 Murmur is abnormal sound due to turbulence of blood flow.
 It may be innocent (Physiologic) e.g. hyperdynamic states like
anemia pregnancy etc.
 Pathologic e.g. valvular lesions

50. Classification of Murmurs
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 Murmurs are classified according to their timing and cardiac
cycle Systolic or diastolic
A. Systolic murmurs
1) Ejection systolic murmur
 This originates from the aortic outflow tract.
 It may be an innocent flow murmur which is common in
childhood, pregnancy and anemia.

51. Classification of Murmurs Cont..
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 pathological Ejection systolic murmur as in:
 Aortic stenosis
 Aortic sclerosis
 Atrial septal defect
 Hypertrophic obstructive cardio myopathy
 Pulmonary stenosis

52. Classification of Murmurs Cont..
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2) Pansystolic murmur: It is uniform intensity and merges with
S1 and S2, is often muffled.
It is found in:-
 Mitral or Tricuspid regurgitation
 Ventricular septal defect

53. Classification of Murmurs Cont..
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 Diastolic murmurs
1) Early diastolic murmur: This is high-pitched and blowing.
It occurs due to:-
Aortic or pulmonary regurgitation.-The aortic regurgitation
murmur is usually soft and is best heard with the patient leaning
forward and in expiration.

54. Classification of Murmurs Cont..
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2) Mid-diastolic murmur: This is low-pitched and rumbling,
It often starts after an opening snap/sudden.
It is caused by:-
 Mitral stenosis (common)
 Rheumatic fever
 Thickens mitral valve leaflets
 Aortic regurgitation

55. Cont…
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 Lung And Abdomen
 During any cardiac examination the lung should be assessed for
 Respiratory rate and pattern
 Hemoptysis
 Cough
 Crackle
 Wheezes

56. Cont…
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 Abdomen
Look for:
 Hepatomegaly and characterize it
 Splenomegaly may be found in endocarditis
 Ascites
 Hepato-jugular reflex-pressing 30-60 seconds on the liver rises
the jugular venous pressure by 2cm when the right heart fails to
accommodate increase volume.

57. Cont…
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 Hand and feet
 Hand and feet should be assessed for peripheral circulation –
edema, venous return, deep phlebitis thrombophlebitis,
peripheral cyanosis, capillary refill ,clubbing of finger and toes.
 Check deep phlebitis by quick squeezing calf muscle against
tibia.
 Normally patient feel no pain;pain full calf suggests deep
phlebitis.

58. Summary
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 A thorough cardiovascular assessment includes a health history and
physical examination and provides invaluable data about the patient’s overall
health status.
 Before you begin, visualize the underlying structures and review expected
normal findings. Understanding normal cardiovascular functioning is crucial
to interpreting your findings.
 As you work through the assessment, systematically look for cardiovascular
changes in every system.
 Let your patient’s current health status direct your assessment. If she or he
has an acute problem, perform a focused assessment.

59. Reference
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1) F. A. Davis. (2007). Nursing Health Assessment. (2nd Edi). Philadelphia,
Pennsylvania. Patricia M. Dillon, DNSc, RN. Chapter No.14 p.n 438-490.
2) Bickley, L. S., Szilagyi, P. G., & Bates, B. (2007). Bates' guide to physical
examination and history taking (11th Edi). Philadelphia: Lippincott Williams &
Wilkins. Chapter No.06 & 07 p.n 171-250.
3) Weber, Kelley's. (2007). Health Assessment in Nursing, 3rd Ed: North American
Edition. Lippincott Williams & Wilkins. Chapter No.14 &15 p.n 239-294.
4) Lippincott, Williams & Wilkins (2005). Heart Sounds Made Incredibly Easy. PA.

60. Acknowledgement
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 First and for most we would like to thanks our almighty of God.
Next to this we would like to forward our deepest appreciation and
thanks to our lecturer Mr.Tadele K & Mr. Bikila T [Ass’t Professor]
for giving us this opportunity to prepare individual presentation on
Advanced Nursing Health Assessment. At the Last but not Least we
would like to thanks Salale university for Library and WIFI Service.

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