HEARTHEART ASSESSMENTASSESSMENT

ANATOMY & PHYSIOLOGYANATOMY & PHYSIOLOGY

HEART VALVESHEART VALVES

EQUIPMENT NEEDEDEQUIPMENT NEEDED

Dual head stethoscopeDual head stethoscope

A. SUBJECTIVE DATAA. SUBJECTIVE DATA

A.1. ASSESSMENT OF CHIEF COMPLAINTSA.1. ASSESSMENT OF CHIEF COMPLAINTS

1. Chest Pain1. Chest Painaa. . Location?Location?b.b. Does it radiate?Does it radiate? If yes, where? Neck, If yes, where? Neck,

face, back, abdominal area.face, back, abdominal area.c.c. Quality of pain?Quality of pain? Dull, sharp, crushing, Dull, sharp, crushing,

burningburningd.d. DurationDuration

e.e. What brings it on?What brings it on? Breathing, Breathing, swallowing, coughing, rapid walking, swallowing, coughing, rapid walking, emotional stress, exposure to coldemotional stress, exposure to coldf.f. What relieves it?What relieves it? Rest, change in Rest, change in position, medicationposition, medicationg.g. Are there any other associatedAre there any other associated symptoms?symptoms? Nausea, vomiting, sweating Nausea, vomiting, sweating

2. IRREGULAR HEART BEAT2. IRREGULAR HEART BEATa. Does your heart pound or beat too fast?a. Does your heart pound or beat too fast?b. Does your heart skip or jump?b. Does your heart skip or jump?

A.2. ASSESSMENT OF RISK FACTORSA.2. ASSESSMENT OF RISK FACTORS

1. Do you have a history of hypertension, 1. Do you have a history of hypertension, diabetes, rheumatic fever?diabetes, rheumatic fever?

2. Is there a history in your family of heart 2. Is there a history in your family of heart attack, hypertension, stroke, diabetes?attack, hypertension, stroke, diabetes?

3. Describe your nutritional intake. Have 3. Describe your nutritional intake. Have you ever been told you have high you ever been told you have high

cholesterol/ triglyceride level?cholesterol/ triglyceride level?4. Do you smoke? How much? For how 4. Do you smoke? How much? For how

long?long?5. How do you view yourself? What do you 5. How do you view yourself? What do you

do to relax? How many hours a day do do to relax? How many hours a day do you work? How do you cope with stress?you work? How do you cope with stress?

6. Exercise: What do you do for exercise? 6. Exercise: What do you do for exercise? How often?How often?

B. OBJECTIVE DATAB. OBJECTIVE DATA

ASSESSMENT TECNIQUES TO BE UTILIZED:ASSESSMENT TECNIQUES TO BE UTILIZED:

INSPECTIONINSPECTIONPALPATIONPALPATIONAUSCULTATIONAUSCULTATION

PERCUSSION- has limited usefulness PERCUSSION- has limited usefulness because x-rays & other diagnostic tests because x-rays & other diagnostic tests provide the same information in a much provide the same information in a much more accurate manner.more accurate manner.

INSPECTIONINSPECTIONInspect the chest to identify Inspect the chest to identify

landmarks which aid in landmarks which aid in assessment of the heart. assessment of the heart.

LANDMARK OF THE LANDMARK OF THE CHESTCHEST

1. Intercostal Space1. Intercostal Space (ICS)(ICS)

Find the sternal angle Find the sternal angle which is felt as ridge which is felt as ridge in the sternum in the sternum approximately 2 approximately 2 inches below the inches below the sternal notch.sternal notch.

2. Midsternal line2. Midsternal line (MSL)(MSL)

Imaginary line Imaginary line extending down the extending down the chest through the chest through the middle of the middle of the sternum. It divides sternum. It divides the anterior chest in the anterior chest in half.half.

3. Midclavicular line3. Midclavicular line (MCL)(MCL)

Imaginary line Imaginary line extending from extending from middle to clavicle middle to clavicle down the chest down the chest dividing the left or dividing the left or right anterior chest right anterior chest into 2 partsinto 2 parts

4. Anterior axillary line4. Anterior axillary line (AAL)(AAL)

Imaginary line Imaginary line extending along the extending along the lateral wall of the lateral wall of the anterior chest and anterior chest and even with the even with the anterior axillary fold.anterior axillary fold.

PALPATIONPALPATIONAreas to palpate on Areas to palpate on the chest:the chest:

Cardiac landmarksCardiac landmarks

CARDIAC LANDMARKSCARDIAC LANDMARKS

THE CARDIAC LANDMARKSTHE CARDIAC LANDMARKS

CARDIAC CARDIAC LANDMARKSLANDMARKS

1. AORTIC AREA1. AORTIC AREA

2. PULMONIC AREA2. PULMONIC AREA

LOCATIONLOCATION

22NDND ICS to the right of ICS to the right of the sternumthe sternum

22NDND ICS to the left of the ICS to the left of the sternumsternum

3.3. ERB’S POINTERB’S POINT

4.4. TRICUSPID AREATRICUSPID AREA

5.5. MITRAL AREAMITRAL AREA

33RDRD ICS to the left of the ICS to the left of the sternumsternum

55THTH ICS to the left of the ICS to the left of the sternumsternum

55THTH ICS at the left ICS at the left midclavicular linemidclavicular line

PALPATE THE CARDIAC LANDMARKS PALPATE THE CARDIAC LANDMARKS FOR:FOR:

1.1. PULSATIONS PULSATIONS: using the : using the finger padsfinger pads2. 2. THRILLSTHRILLS: using the : using the palmar surfacepalmar surface of of

the handthe handThrillThrill- vibrations that feel similar to what - vibrations that feel similar to what

one feels when a hand is placed on a one feels when a hand is placed on a purring catpurring cat

3. 3. HEAVESHEAVES: using the : using the palmar surfacepalmar surface of of the handthe hand

Heaves- lifting of the cardiac area Heaves- lifting of the cardiac area secondary to an increased workload & secondary to an increased workload & force of left ventricular contraction; also force of left ventricular contraction; also referred to as referred to as lift.lift.

EXAMINATION: PALPATE THE AREAS FOR PULSATION, EXAMINATION: PALPATE THE AREAS FOR PULSATION, THRILLS, AND HEAVES.THRILLS, AND HEAVES.

AORTIC AREAAORTIC AREAPULMONIC AREAPULMONIC AREAERB’S POINTERB’S POINTTRICUSPID AREATRICUSPID AREA

Normal findings:Normal findings:

No pulsation,No pulsation,Thrills,Thrills,

OrOrHeaves Heaves

should be felt at these should be felt at these areas.areas.

EXAMINATION: PALPATE THE AREA FOR PULSATIO, EXAMINATION: PALPATE THE AREA FOR PULSATIO, THRILLS, & HEAVES.THRILLS, & HEAVES.

MITRAL AREAMITRAL AREA

Normal Findings:Normal Findings:

The APICAL IMPULSE The APICAL IMPULSE is palpable in is palpable in

approximately half of approximately half of the adult population.the adult population.No thrills or heavesNo thrills or heaves

Should be felt.Should be felt.

AUSCULTATIONAUSCULTATIONa. Auscultate to identify the first heart a. Auscultate to identify the first heart

sound sound (S1)(S1) or “lub” and the second or “lub” and the second heart sound heart sound (S2)(S2) or “dub” or “dub”

S1- caused by the closure of the mitral & S1- caused by the closure of the mitral & tricuspid valvestricuspid valves

S2- caused by the closure of the semi lunar S2- caused by the closure of the semi lunar valvesvalves

b. Auscultate for rate & rhythm.b. Auscultate for rate & rhythm.

60-100 beats/min- normal heart rate for an 60-100 beats/min- normal heart rate for an adultadult

Bradycardia- heart rate below 60Bradycardia- heart rate below 60Tachycardia- heart rate above 60Tachycardia- heart rate above 60

c. Auscultate & focus on each sound & pause c. Auscultate & focus on each sound & pause individuallyindividually

c.1. c.1. Auscultate S1Auscultate S1 -heard at -heard at tricuspid areatricuspid area (softer) (softer) & & mitral areamitral area (loudest) (loudest)ABNORMAL FINDINGS:ABNORMAL FINDINGS:

Tricuspid areaTricuspid area-- A split S1 with an abnormally A split S1 with an abnormally wide split is pathological.wide split is pathological.Mitral areaMitral area-- An abnormally loud S1 occurs An abnormally loud S1 occurs when the mitral valve is wide open when when the mitral valve is wide open when systolic contraction occurs, then slams shut.systolic contraction occurs, then slams shut.

c.2.c.2. Auscultate S2 Auscultate S2 -- heard at aortic area (louder) & heard at aortic area (louder) &

pulmonic area (softer)pulmonic area (softer)ABNORMAL FINDINGSABNORMAL FINDINGS::

An split S2 that is abnormally wide. ( the An split S2 that is abnormally wide. ( the aortic valve closes early & the pulmonic aortic valve closes early & the pulmonic valve closes late)valve closes late)

c.3. c.3. Auscultate Auscultate systolic pause-spacesystolic pause-space: heard : heard between S1 & S2between S1 & S2

-silent pause: should hear distinct end -silent pause: should hear distinct end of S1 & beginning of S2 with nothing in of S1 & beginning of S2 with nothing in betweenbetween

c.4. c.4. Auscultate diastolic pause: space Auscultate diastolic pause: space heard between S2 & the next S1heard between S2 & the next S1

- silent pause: should hear distinct end - silent pause: should hear distinct end of S2 & distinct beginning of next S1.of S2 & distinct beginning of next S1.

ABNORMAL FINDINGS:ABNORMAL FINDINGS:

MurmursMurmurs-swishing sound heard at -swishing sound heard at beginning, middle, or end of systolic beginning, middle, or end of systolic pause or diatolic pause; produced by pause or diatolic pause; produced by turbulent blood flow.turbulent blood flow.

CLASSIFICATION OF MURMURS.CLASSIFICATION OF MURMURS.

a.a. INNOCENT- always systolic & are not INNOCENT- always systolic & are not associate with any other abnormalitiesassociate with any other abnormalities

b.b. FUNCTIONAL- associated with high FUNCTIONAL- associated with high output statesoutput states

c.c. PATHOLOGICAL- related to structural PATHOLOGICAL- related to structural abnormalitiesabnormalities

Configuration of murmurConfiguration of murmur

1.1. CRESCENDO- soft to loudCRESCENDO- soft to loud2.2. DECRESCENDO- loud to softDECRESCENDO- loud to soft3.3. CRESCENDO-DECRESCENDO- soft CRESCENDO-DECRESCENDO- soft

to loud to softto loud to soft4.4. PLATEAU-sound is sustainedPLATEAU-sound is sustained

GRADING HEART MURMURSGRADING HEART MURMURS

GRADEGRADE CHARACTERISTICSCHARACTERISTICS II very faint; heard only after a period very faint; heard only after a period

of concentrationof concentration II II faint; heard immediatelyfaint; heard immediately IIIIII moderate intensitymoderate intensity IV IV loud; may be associated with a thrillloud; may be associated with a thrill VV loud; stethoscope must remain in loud; stethoscope must remain in

contact the chest wall in order to hearcontact the chest wall in order to hearthrill palpablethrill palpable

VIVI very loud; heard with stethoscope off very loud; heard with stethoscope off of of

chest wall; thrill palpablechest wall; thrill palpable

c.5. c.5. Auscultate for Auscultate for S3 S3 (also known as (also known as ventricularventricular diastolicdiastolic gallop)gallop)

-heard best at the apex of the heart -heard best at the apex of the heart -characterized by low-pitched sounds-characterized by low-pitched sounds -a right-sided S3 (tricuspid area) is heard -a right-sided S3 (tricuspid area) is heard

longer during inspirationlonger during inspiration -S3 occurs just after an S2-S3 occurs just after an S2NORMAL FINDINGS:NORMAL FINDINGS:An S3 heart sound can be a normal An S3 heart sound can be a normal

physiological sound in children & in young physiological sound in children & in young adults.adults.

After the age 30, a physiological S3 is very After the age 30, a physiological S3 is very infrequent. An S3 can also be normal in infrequent. An S3 can also be normal in high-output states such as the third high-output states such as the third trimester of pregnancy.trimester of pregnancy.

ABNORMAL FINDINGABNORMAL FINDINGIn an adult, an S3 heart sound may be one In an adult, an S3 heart sound may be one

of the earliest findings of cardiac of the earliest findings of cardiac dysfunction. A loud, persistent S3 can be dysfunction. A loud, persistent S3 can be an ominous sound.an ominous sound.

c.6. c.6. Auscultate for S4 ( also known as Auscultate for S4 ( also known as atrial atrial diastolic gallopdiastolic gallop))- a late diastolic filling sound associated - a late diastolic filling sound associated with atrial contraction.with atrial contraction.- can be either left or right sided & is best - can be either left or right sided & is best heard in mitral & tricuspid areas.heard in mitral & tricuspid areas.- occurs just before S1.- occurs just before S1.

NORMAL FINDINGS:NORMAL FINDINGS:An S4 heart sound may occur with or An S4 heart sound may occur with or without any evidence of cardiac without any evidence of cardiac decompensation.decompensation.

ABNORMAL FINDINGS:ABNORMAL FINDINGS:- the presence of an S4 can be indicative - the presence of an S4 can be indicative of cardiac decompensation.of cardiac decompensation.