This document provides information on assessing the cardiovascular system. It begins with an introduction on the importance of cardiovascular assessment by nurses. It then covers anatomy and physiology of the heart, including the valves and blood circulation. Physical examination techniques are outlined, including inspection, palpation, percussion and auscultation. Common abnormalities that may be found on assessment are listed. Finally, additional investigation methods are mentioned, such as electrocardiograms, blood tests and cardiac imaging.

1. ASSESSMENT OF
CARDIOVASCULAR
SYSTEM
PRESENTED BY-
KIRTI PANDEY
MSC(N)1ST YEAR
AIIMS JODHPUR

2. INTRODUCTION
Assessment of the cardiovascular
system is one of the most
important areas of the nurse’s
daily patient assessment. Report y
findings as clearly as possible.
Charting results clearly is essential
for others to be able to assess the
problem, and good documentation
is also essential for the treatment
of the patient as well as for the
nursing care.

3. ANATOMY AND PHYSIOLOGY

4. VALVES OF
THE
HEART
Tricuspid –
Directs the
flow of blood
from the right
atrium to the
left ventricle.
Mitral Valve –
Directs the
flow of blood
from the left
atrium to the
left ventricle.
Pulmonic
(semilunar) –
Lies between
the right
ventricle and
the pulmonary
artery.
Aortic Valve
(semilunar) –
Lies between
the left
ventricle and
the aortic
artery.

5. CIRCULATION
IN THE HEART
1. Blood flows from the body into the right
atrium.Blood flows through the right atrium
into the right ventricle.
2. The right ventricle pumps the blood to the
lungs, where the blood releases waste gases
and picks up oxygen
3.The newly oxygen-rich blood returns to
the heart and enters the left atrium.
4.Blood flows through the left atrium into
the left ventricle.
5.The left ventricle pumps the oxygen-rich
blood to all parts of the body.

6. FUNCTIONS OF THE
HEART
•Pumps blood to tissues to supply O2 &
nutrients.
•Remove CO2 & metabolic wastes.
•Regulation of body temperature, fluid pH, and
water content of cells.
•Transport of nutrients, oxygen, and hormones
to cells throughout the body and removal of
metabolic wastes (carbon dioxide, nitrogenous
wastes).
•Protection of the body by white blood cells,
antibodies, and complement proteins that
circulate in the blood and defend the body
against foreign microbes and toxins.
•Clotting mechanisms are also present that
protect the body from blood loss after injuries.

7. ASSESSMENT OF
CARDIOVASCULAR SYSTEM
HEALTH HISTORY-The purpose of the
cardiovascular health history is to
provide information about patient’s
cardiovascular disease and how they
developed. A complete
cardiovascular history will give
indications to potential or underlying
cardiovascular illnesses or disease
states.

8. PAST
HEALTH
HISTORY
It is important to ask
questions about patient’s
past health history. The past
health history should elicit
information about the
following issues:
hypertension, elevated blood
cholesterol or triglycerides,
heart murmurs, congenital
heart disease, rheumatic
fever or unexplained joint
pains.

9. CURRENT
LIFESTYLE
Nutrition
Smoking
Alcohol
Exercise
Drugs

10. CARDIOVASCULAR
ASSESSMENT
Cardiovascular examination is a central
tool for assessing the cardiovascular
system. Examination includes assessment
of vital signs and jugular venous pulse,
chest inspection and palpation, and, most
importantly, auscultation of the heart. For
specific auscultatory findings in valvular
heart disease, see auscultation in valvular
defects. For specific auscultatory findings
of heart defects, see congenital heart
defects.

11. ARTICLES TO
BE USED
DURING
ASSESSMENT
A DOUBLE-
HEADED,
DOUBLE-
LUMEN
STETHOSCOPE
A BLOOD
PRESSURE
CUFF
A MOVEABLE
LIGHT SOURCE
OR PEN LIGHT
SPHYGMOMANO
METER
MEASURE TAP WRIST WATCH
AND PEN

12. PHYSICAL
EXAMINATION
INSPECTION

13. GENERAL
•Body Build (obesity or
wasting); shortness of
breath; difficulty in
talking; note whether
they look ill.
• Look for pallor,
jaundice, sweatiness and
clamminess, and for
xanthelasma around the
eyes.

14. EYES
The presence of yellowish
plaques on the eyelids
(xanthelasma) could Indicate
hyperlipoproteinemia, a
risk factor for hypertension as
well as
arteriolosclerosis

15. SKIN
Clubbing
The presence of clubbing
(broadening of
the extremities of the digits,
accompanied by nails which are
abnormally curved and
shiny) indicates chronic poor oxygen
perfusion to the distal tissues of the
hand and feet.

16. CYANOSIS
The presence of
cyanosis (bluish
colour) also
denotes
chronic poor
oxygen
delivery to the
peripheral tissues
of
the hands and
feet.

17. XANTHOMAS
The presence of
yellowish plaques
under the skin
(noneruptive)
excoriated
through the skin
(eruptive) could
indicate
hyperlipoproteinemi
a, a risk factor for
hypertension as well
as arteriolosclerosis

18. EDEMA
The presence of edema
(tissue swelling) can be
caused by several
factors, although most
commonly is associated
with decreased cardiac
function leading to
decreased capillary
flow.

19. OSLER NODES
Osler's nodes are
painful, red, raised
lesions found on
the hands and feet.
They are associated
with a number of
conditions,
including infective
endocarditis, and
are caused by
immune complex
deposition.

20. PULSE
Rate: average
72/minute in
adults, faster in
children and may
slow in old age.
Also slower in
athletes.

21. BLOOD
PRESSURE

22. CHEST
EXAMINATION

23. INSPECTION
ABNORMALITY IN THE SHAPE OF
CHEST
PECTUS EXCAVATUM is a structural
deformity of the anterior thoracic
wall in which the sternum and rib
cage are shaped abnormally. This
produces a caved-in or sunken
appearance of the chest. It can either
be present at birth or develop after
puberty.

24. PECTUS
CRANIATUM
PECTUS CARINATUM is a
rare chest wall deformity
that causes the
breastbone to push
outward instead of being
flush against the chest. It
is also known as pigeon
chest or keel chest.

25. CHECK
THE LEVEL
OF THE
JUGULAR
VENOUS
PRESSURE
STEPS FOR EXAMINATION-
Raise the head of the bed or examining
table to 30°
Turn the patient’s head gently to the
left.
Identify the topmost point of the
flickering venous pulsations.
Place a centimeter ruler upright on the
sternal angle.
Place a card or tongue blade
horizontally from the top of the JVP to
the ruler, making a right angle.
Measure the distance above the
sternal angle in centimeters: a 3- to 4-
centimeter elevation is normal.

26. JUGULAR VEIN PRESSURE
MEASUREMENT
ELEVATED JVP-classical sign of venous hypertensiom
(rt. Sided heart failure)

27. PALPATION OF CHEST

28. LANDMARKS IN PRECORDIAL ASSESSMENTS

29. Palpate to the left of
the sternum to
ascertain whether
the hand visibly lifts
with each ventricular
contraction. Place the
heel of the right hand
with the fingers
pointing upwards
over the precordium
to the left of the
sternum . In normal
circumstances the
movement related to
respirations will be
felt.

30. PALPATION OF THE
CAROTID PULSES
Keep the
patient’s head
elevated to 30°.
Place your
index and
middle fingers
on the right
then the left
carotid arteries,
and palpate the
carotid
upstroke

31. CHEST PERCUSSION
Normally only the left
border of heart can be
detected by
percussion. It extends
from the sternum to
mid clavicular line in
the third to fifth inter
costal space. The right
border lies under the
right margin of the
sternum and is not
detectable.Enlargemen
t of the heart too
either the left or right
usually can be noted.

33. AUSCULTATION

34. POSITIONS FOR AUSCULTATION OF THE
HEART
SUPINE

35. LATERAL

36. SITTING

39. Abnormal
Findings in the
Cardiovascular
System
Myocardial and pump disorders
Valvular disease
Septal defects
Congenital heart disease
Electrical rhythm disturbances
Myocardial ischemia
Myocardial infarction
Congestive heart disease
Ventricular hypertrophy
Mitral, aortic, tricuspid, and pulmonic
stenosis
Mitral valve prolapse

40. INVESTIGATIONS

41. It includes
Blood tests-
Troponin-Contractile protein that
are released after an MI. Both
troponin T and troponin I are
highly specific to cardiac tissue.
below 0.04 ng/ml. Probable heart
attack: above 0.40 ng/ml.
CK-MB-Cardiospecific isoenzyme
is released in the presence of
myocardial tissue injury
.Concentration >4%-6% of total
creatine kinase (CK) are highly
indicative of MI.Serum levels
increase within 4-6hr after MI

42. Myoglobin-Low molecular-
weight protein that is 99%-
100% sensitive for myocardial
injury.Serum concentration
rises 30-60 min after MI.
Reference interval-
Male-15.2-91.2mcg/L
Female-11.1-57.5mcg/L

43. SERUM LIPIDS
It includes-
Cholesterol-A blood lipid.Elevated cholesterol is
considered a risk factor for cardiovascular heart
disease.
Reference level- <200mg/dl
Triglycerides-Mixtures of fatty acids.Elevations are
associated with cardiovascular disease and diabetes.
Reference level-<150mg/dl

44. Lipoprotein (HDL,LDL)-Electrophoresis is done to
separate lipoproteins into HDL and LDL.There are
marked day to day fluctuates in serum lipid levels.More
than one determination is needed for accurate
diagnosis and treatment.
Reference level-
HDL-Male>40mg/dl
Female>50mg/dl

45. LDL- cholesterol levels should be less than 100 mg/dL.
Levels of 100 to 129 mg/dL are acceptable for people
with no health issues but may be of more concern for
those with heart disease or heart disease risk factors. A
reading of 130 to 159 mg/dL is borderline high and 160
to 189 mg/dL is high

47. 12 Lead ECG

48. Electrical Rhythm
Disturbances

49. Atrial fibrillation-Atrial
fibrillation irregular
heartbeat (arrhythmia) that
can lead to blood clots,
stroke, heart failure and
other heart-related
complications.

51. In atrial flutter, the atria
beat regularly, but faster
than usual and more often
than the ventricles, it may
have four atrial beats to
every one ventricular beat.

53. Ventricular tachycardia is a
very fast heart rhythm that
begins in the ventricles. ...
Ventricular tachycardia is a
pulse of more than 100 beats
per minute with at least three
irregular heartbeats in a row. It
is caused by a malfunction in
the heart's electrical system.

55. Ventricular fibrillation is a
heart rhythm problem that
occurs when the heart
beats with rapid, erratic
electrical impulses. This
causes pumping chambers
in heart (the ventricles) to
quiver uselessly, instead of
pumping blood.

57. Myocardial infarction: A heart
attack. Abbreviated MI. The
term "myocardial infarction"
focuses on the myocardium
(the heart muscle) and the
changes that occur in it due to
the sudden deprivation of
circulating blood. The main
change is necrosis (death) of
myocardial tissue.

58. ABNORMALITY
Summation Gallop
A summation gallop is produced when S3 & S4
merge into one sound. It often occurs at rates
greater than 100 beats per minute. It may occur
in heart failure and pericarditis.Summation
gallops occur in 15% of all myocardial infarctions.
Opening Snap
At the end of ventricular systole, when the aortic
and pulmonic valves close, S2 is produced
Immediately after S2, the heart relaxes, and
ventricular pressure falls below that of atrial
pressure. This allows the atrioventricular valves
to open. This is the start of diastole.

59. Ejection Click
Similar to an opening snap, an ejection click is caused by
stenotic valve leaflets.This sound is produced when the
aortic or pulmonic valves open at the beginning of systole. It
is a brief high frequency sound best heard with the
diaphragm over the aortic or pulmonary artery or Erb’s
point, or near the apex over the mitral area.
Mid-systolic Click
A mid-systolic click occurs when the mitral valve’s leaflets
and cordae tendenae tense. The anterior or posterior or
both leaflets can prolapse. Every once in a while multiple
clicks occur. They are heard in mid to late systole. They are
best heard over the tricuspid area and towards the mitral
area.

61. Pericardial Friction Rub
A pericardial friction rub is usually heard best and is
sometimes palpable over the tricuspid and xyphoid areas. It
occurs when inflamed pericardial surfaces rub together.
Murmurs
A murmur is an abnormal heart sound caused by turbulent
blood flow. The sound may indicate that blood is flowing
through a damaged or overworked heart valve, that there
may be a hole in one of the heart's walls, or that there is a
narrowing in one of the heart's vessels.
Some heart murmurs are a harmless type called innocent
heart murmurs which are common in children and usually
do not require treatment.

64. RESEARCH ARTICLE
A low-cost machine learning-based cardiovascular/stroke risk
assessment system: integration of conventional factors with
image phenotypes
Methods:
The ML-based algorithm consists of an offline and online system.
The offline system extracts 47 features which comprised of 13
CRF and 34 CUSIP. Principal component analysis (PCA) was used
to select the most significant features. These offline features
were then trained using the event-equivalent gold standard
(consisting of percentage stenosis) using a random forest (RF)
classifier framework to generate training coefficients. The online
system then transforms the PCA-based test features using offline
trained coefficients to predict the risk labels on test subjects. The
above ML system determines the area under the curve (AUC)
using a 10-fold cross-validation paradigm. The above system so-
called “AtheroRisk-Integrated” was compared against
“AtheroRisk-Conventional”, where only 13 CRF were considered
in a feature set

65. Conclusions: ML-based integrated model with the
event-equivalent gold standard as percentage
stenosis is powerful and offers low cost and high
performance CV/stroke risk assessment

66. Cardiovascular disease risk factors in relation to
smoking behaviour and history: a population-based
cohort study
Objective-
To investigate how individual risk factors for
cardiovascular disease (CVD) (blood pressure, lipid
levels, body mass index, waist and hip circumference,
use of antihypertensive or hypolipidemic medication,
and diagnosed diabetes) differ in people aged 46
years with different smoking behaviour and history

67. Conclusions-
The effect of past or present smoking on individual
CVD risk parameters such as blood pressure and
cholesterol seems to be of clinically minor
significance in people aged 46 years. In other words,
smoking seems to be above all an independent risk
factor for CVD in the working-age population.
Quitting smoking in working age may thus reduce
calculated CVD risk nearly to the same level with
people who have never smoked.