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  1. 1. Cardio Vascular System Nursing 330 Shirley Comer
  2. 2. Pertinent History <ul><li>Chest Pain Edema Known disease </li></ul><ul><li>Dyspnea Nocturia Family Hx </li></ul><ul><li>Orthopnea Diet Smoking </li></ul><ul><li>Cough Obesity Diabetes Mellitus </li></ul><ul><li>Fatigue ETOH use Exercise </li></ul><ul><li>Cyanosis or pallor </li></ul><ul><li>Past Hx ie Rheumatic fever, recent dental work </li></ul>
  3. 3. Neck Vessels <ul><li>Keep neck in a neutral position </li></ul><ul><li>Locate and Palpate Carotid Arteries </li></ul><ul><ul><li>One at a time </li></ul></ul><ul><ul><li>Rate amplitude 1+ to 4 + </li></ul></ul>
  4. 4. 5 p of circulation
  5. 5. Neck Vessels cont <ul><li>Auscultate the Carotid-normally no sound </li></ul><ul><ul><li>Bruit - blowing or swishing sound indicating turbulent blood flow </li></ul></ul><ul><ul><ul><li>Use bell of stethoscope </li></ul></ul></ul><ul><ul><ul><li>Auscultate at 3 positions </li></ul></ul></ul><ul><ul><li>Thrill – Palpable vibration accompanying bruit </li></ul></ul><ul><li>A loud aortic heart murmur may radiate to neck </li></ul>
  6. 6. Jugular Venous Assessment <ul><li>Position client supine at 30 to 45 degree angle </li></ul><ul><ul><li>Always be aware of client comfort </li></ul></ul><ul><ul><li>Turn client’s head slightly away </li></ul></ul><ul><li>Note the external and internal Jugular vein distention (if any) and record the level in relation to the clavicle(normal less than 2 cm) </li></ul><ul><ul><li>Observe for pulsations (if any) </li></ul></ul><ul><ul><li>Unilateral distension=kinking or aneurysm </li></ul></ul><ul><ul><li>Bilateral distension=increased CVP </li></ul></ul>
  7. 7. Jugular Vein Drawing
  8. 8. The Precordium (chest wall) <ul><li>Inspect </li></ul><ul><ul><li>Heave(lift)=sustained forceful thrust of ventricle against chest wall=ventricular hypertrophy </li></ul></ul><ul><ul><li>Apical pulse may be visible in thin adults and children </li></ul></ul><ul><li>Palpate the Apical Pulse </li></ul><ul><ul><li>Sometimes called PMI (point of maximum impulse) </li></ul></ul><ul><ul><li>Note </li></ul></ul><ul><ul><ul><li>Location </li></ul></ul></ul><ul><ul><ul><ul><li>should be at or near 5 th intercostals space </li></ul></ul></ul></ul><ul><ul><ul><ul><li>LV dilatation (fluid overload) displaces down and to the left and increases size </li></ul></ul></ul></ul>
  9. 9. Apical Pulse cont <ul><ul><ul><li>Size </li></ul></ul></ul><ul><ul><ul><li>Amplitude- 1+ to 4+ </li></ul></ul></ul><ul><ul><ul><ul><li>Increased in LV hypertrophy (pressure overload) </li></ul></ul></ul></ul><ul><ul><ul><li>Rate and Rhythm </li></ul></ul></ul><ul><ul><ul><ul><li>Regular irregularity or irregular irregularity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Compare irregular apical pulse to radial </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sinus arrhythmia common in children and young adults related to the respiratory cycle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Premature Beat- more common in elderly </li></ul></ul></ul></ul><ul><li>Palpate the Precordium </li></ul><ul><ul><li>Use palm </li></ul></ul><ul><ul><li>Normally thrill or mass not felt </li></ul></ul>
  10. 10. 5 areas for listening to the heart
  11. 11. Auscultate Heart Sounds <ul><li>Auscultation sites </li></ul><ul><ul><li>2 nd right intercostal space (aortic value) </li></ul></ul><ul><ul><li>2 nd left intercostal space (Pulmonic Value) </li></ul></ul><ul><ul><li>Left lower sternal border (Tricuspid Valve) </li></ul></ul><ul><ul><li>Apex (Mitral Valve) </li></ul></ul><ul><ul><li>Continue auscultation in Z pattern </li></ul></ul>
  12. 12. Blood Flow through Cardiac Valves
  13. 13. The Stethoscope
  14. 14. Auscultation Heart sounds
  15. 15. Auscultation cont <ul><li>Use Diaphragm of Stethoscope </li></ul><ul><li>Identify S1 and S2 </li></ul><ul><ul><li>S1 is loudest at apex </li></ul></ul><ul><ul><ul><li>closure of AV valves </li></ul></ul></ul><ul><ul><ul><li>Beginning of systole </li></ul></ul></ul><ul><ul><li>S2 is loudest at base </li></ul></ul><ul><ul><ul><li>Closure of semilumar valves </li></ul></ul></ul><ul><ul><ul><li>Beginning of diastole </li></ul></ul></ul><ul><ul><li>S1 coincides /c carotid pulse and R wave on ECG </li></ul></ul>
  16. 16. S1, S2
  17. 17. Extra Heart Sounds <ul><li>Split S2 </li></ul><ul><ul><li>Normal phenomenon </li></ul></ul><ul><ul><li>Occurs at end of inspiration </li></ul></ul><ul><ul><li>Semilumar valves don’t close at the same time </li></ul></ul><ul><ul><li>Heard best at left 2 nd ICS </li></ul></ul><ul><ul><li>Can be fixed or paradoxical </li></ul></ul>
  18. 18. Extra Heart sounds cont <ul><li>S3 – Ventricular Gallop </li></ul><ul><ul><li>Early in diastole during rapid filling </li></ul></ul><ul><ul><li>Heard best at apex using bell of stethoscope </li></ul></ul><ul><ul><li>Doesn’t vary /c resp like Split S2 </li></ul></ul><ul><ul><li>Indicates decreased ventricular compliance </li></ul></ul><ul><ul><li>In children and young adult may be innocent and disappear when pt sits </li></ul></ul><ul><ul><li>May be earliest sign of heart failure </li></ul></ul><ul><ul><li>Heard /c increased CO ie hyperthyroidism, </li></ul></ul>
  19. 19. Extra Heart Sounds cont <ul><li>S4- Atrial Gallop </li></ul><ul><ul><li>Ventricular filling sound </li></ul></ul><ul><ul><li>Occurs late in diastole immediately before S1 </li></ul></ul><ul><ul><li>Heard when atria contract </li></ul></ul><ul><ul><li>Very soft, low pitched sound </li></ul></ul><ul><ul><li>Heard best at apex /c pt in left lateral position /c bell </li></ul></ul><ul><ul><li>Can occur /p exercise at 40 yr old </li></ul></ul><ul><ul><li>Occurs /c systolic overload, hypertension and aortic stenosis </li></ul></ul>
  20. 20. Extra Heart Sounds cont <ul><li>Friction Rub </li></ul><ul><ul><li>Occurs r/t inflammation of the pericardial membranes </li></ul></ul><ul><ul><li>Occur in both systole and diastole </li></ul></ul><ul><ul><li>Hear best at apex </li></ul></ul><ul><ul><li>Common in 1 st week following Myocardial Infarction and pericarditis </li></ul></ul>
  21. 22. Heart Murmurs
  22. 23. Murmurs <ul><li>Blowing, swooshing sound </li></ul><ul><li>Indicates abnormal turbulent blood flow </li></ul><ul><li>A murmur outside the heart is called a bruit </li></ul><ul><li>Are either systolic or diastolic </li></ul><ul><li>Systolic murmur may occur innocently in children and young adults r/t increased force of contraction </li></ul>
  23. 24. Assessment of Murmurs <ul><li>Timing - systolic or diastolic </li></ul><ul><li>Loudness -Grade I thru VI </li></ul><ul><li>Pitch- high or low </li></ul><ul><li>Pattern- Crescendo, decrescendo, plateau, diamond </li></ul><ul><li>Quality- Musical, blowing, harsh or rumbling </li></ul><ul><li>Location- Where is it loudest? </li></ul><ul><li>Radiation- Is it audible in other parts of precordium </li></ul><ul><li>Posture- Is it present or louder only in certain position </li></ul>
  24. 26. Age Specific Considerations <ul><li>Infants </li></ul><ul><ul><li>Use appropriate size stethoscope </li></ul></ul><ul><ul><li>May be irregular </li></ul></ul><ul><ul><li>Murmurs may be present r/t congenital fetal circulation remnants </li></ul></ul><ul><li>Children </li></ul><ul><ul><li>May have visible apical pulses r/t thin chest wall </li></ul></ul><ul><ul><li>May have innocent murmurs-always note presence of murmur </li></ul></ul>
  25. 27. Age Specific Consideration cont <ul><li>Pregnancy </li></ul><ul><ul><li>Increased pulse rate </li></ul></ul><ul><ul><li>Exaggerated S2 splitting </li></ul></ul><ul><ul><li>Easily heard S3 </li></ul></ul><ul><ul><li>Systolic murmur may be present-should disappear /p delivery </li></ul></ul><ul><li>Elderly </li></ul><ul><ul><li>S4 even /s Hx of CAD </li></ul></ul><ul><ul><li>Irregular pulse more common </li></ul></ul>
  26. 28. Practice Exam Question <ul><li>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? </li></ul><ul><ul><li>A. No need to document it as it is an innocent murmur. </li></ul></ul><ul><ul><li>B. Describe murmur location, pitch and loudness in the nurses notes but no need to mention it to the Doctor. </li></ul></ul><ul><ul><li>C. Document your finding in the nurses notes and mention your finding to the Doctor. </li></ul></ul><ul><ul><li>D. Document you findings on the graphic sheet. </li></ul></ul>
  27. 29. Rationale <ul><li>C is the correct answer as the murmur is an abnormal finding </li></ul><ul><li>A is incorrect because you always document an abnormal finding </li></ul><ul><li>B is incorrect because the Physician should be aware of all abnormal findings </li></ul><ul><li>D is the wrong form </li></ul>
  28. 30. Peripheral Vascular system and Lymphatics Nursing 330 Governors State University Shirley Comer
  29. 31. Anatomy in Peripheral Vascular <ul><li>Arteries- carry oxygenated blood to tissues </li></ul><ul><ul><li>Thick muscular walled </li></ul></ul><ul><li>Veins - carry deoxygenated blood to tissues </li></ul><ul><ul><li>Thin walled </li></ul></ul><ul><li>Lymphatics- separate vessel system which retrieves excess fluid and plasma proteins and returns them to blood stream </li></ul><ul><ul><li>Major player in immune system </li></ul></ul><ul><ul><li>Contains nodes that drain body areas </li></ul></ul>
  30. 32. Assess Arms <ul><li>Note color of skin and nails, temperature, texture, turgor, hair distrubuiton </li></ul><ul><li>Note lesions, edema or clubbing </li></ul><ul><li>Assess capillary refill </li></ul><ul><li>Assess radial and antecubital pulse (0 to 4+) </li></ul><ul><li>Palpate antecubital and axillary lymph nodes </li></ul><ul><li>All finding should be bilateral </li></ul><ul><li>Edema indicates lymphatic obstruction (lymphedema) </li></ul>
  31. 33. Pulse Assessment <ul><li>Pulses are rated 0 to 4+ </li></ul><ul><li>3+ is normal </li></ul><ul><li>Note rate, amplitude and rhythm </li></ul><ul><li>Documenting in the physical assessment </li></ul>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
  32. 34. Assess the legs <ul><li>Inspect skin </li></ul><ul><ul><li>Note: color, hair distribution, venous pattern, size, edema, lesions, temperature, turgor, texture </li></ul></ul><ul><ul><li>Should be symmetrical </li></ul></ul><ul><li>Venous pattern </li></ul><ul><ul><li>Normally flat and barely visible </li></ul></ul><ul><ul><li>Vericose vein-enlarged surface vein, tortuous, prone to clots </li></ul></ul><ul><ul><li>Note angiomas, petichia, purpuras, brusing ect </li></ul></ul>
  33. 35. Assess the Legs cont <ul><li>Palpate Inguinal lymph nodes </li></ul><ul><li>Palpate Peripheral pedal pulses- use doppler if unable to find </li></ul><ul><ul><li>Femoral pulse </li></ul></ul><ul><ul><li>Popliteal pulse-can be difficult to locate </li></ul></ul><ul><ul><li>Posterior Tibial pulse- behind medial malleolus </li></ul></ul><ul><ul><li>Dorsal pedis pulse- lateral to extensor tendon of great toe- use light touch </li></ul></ul>
  34. 36. Edema <ul><li>Pretibial- </li></ul><ul><ul><li>Firmly press over skin of tibia or medial malleolus for 5 seconds and release. </li></ul></ul><ul><ul><li>If indentations are left pt has pitting edema. </li></ul></ul><ul><ul><li>Scale 0 to 4+ </li></ul></ul><ul><li>Unilateral edema may indicate venous thrombosis, lymph obstruction, injury or dependant positioning </li></ul>
  35. 37. Practice Exam Question <ul><li>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? </li></ul><ul><li>A. elevate arm on pillow </li></ul><ul><li>B. encourage ROM exercises </li></ul><ul><li>C. discouarage constricting clothing </li></ul><ul><li>D. all of the above </li></ul>
  36. 38. Rationale <ul><li>D is the correct answer. The pt is experiencing lymphedema as a result of her mastectomy and all the interventions listed are appropriate. </li></ul>