session 4 cv boot camp part 1 - ccrn certification and ... 4 cv boot camp part 1.pdfedema •...

Cardiovascular Boot Camp April 2009

www.cardionursing.com 1

CNEA 2009 1

Cardiovascular

Assessment

Presented By:

Karen Marzlin, BSN, RN, CCRN-CMC

2

Auscultatory Areas



3

The Cardiac Cycle

Systole and Diastole

4

Cardiac Diastole

(Atrial and Ventricular):

Early Passive Filling



5

Atrial Systole & Ventricular Diastole: Late Active Filling

Atrial Kick

6

Beginning Ventricular Systole:Isovolumic Contraction



7

Ventricular Systole:

Ejection

8

FIRST HEART SOUND



9

Basic Heart Sounds

S1

• Closure of the Mitral (M1) valve and the Tricuspid (T1)valve

• Beginning of Ventricular Systole and Atrial Diastole

• Isovolumic contraction

10

Basic Heart Sounds

S1

• Location: Mitral area – at the hearts apex

• Intensity: Directly related to force of contraction

• Duration: Short

• Quality: Dull

• Pitch: High



11

SECOND HEART

SOUND

12

Basic Heart Sounds

S2

• Closure of Aortic (A2) Valve and Pulmonic (P2) Valve

• End of Ventricular Systole Beginning of Ventricular Diastole



13

Basic Heart Sounds

S2• Location: Pulmonic area

• Intensity: Directly related

to closing pressure in

the aorta and pulmonary

artery

• Duration: Shorter than

S1

• Quality: Booming

• Pitch: High

14

Third and Fourth Heart Sounds

S3 and S4

• Ventricular diastolic filling sounds

• Low frequency sounds

• Produced by ventricular filling rather than valve closure

• Normal in children and young adults



15

THIRD HEART SOUND

16

S3

Ventricular Gallop

• Ventricular Gallop

• Early diastole

• Caused by increased diastolic pressure



17

Left or Right Sided S3

• Left lateral position

• Location: – Left Sided Mitral area

– Right Sided Tricuspid area

• Intensity:– Left Sided Heard Best

during expiration

– Right Sided Heard Best during inspiration

• Duration: Short

• Quality: dull, thudlike

• Pitch: Low

18

S4

Atrial Gallop



19

S4

Atrial Gallop

• Late diastole

• Caused by atrial contraction and the propulsion of blood into a noncompliant ventricle

20

Left or Right Sided S4

• Left Lateral position

• Location: – Left Sided Mitral Area

– Right Sided Tricuspid area

• Intensity: – Left Sided Louder on

expiration

– Right Sided Louder on inspiration

• Duration: Short

• Quality: Thudlike

• Pitch: Low



21

Summation Gallop

Combination of S3 and S4

22

MURMURS



23

Murmur Fundamentals

Turbulence

• Murmur: If turbulence is intracardiac

• Bruit: If turbulence is extracardiac

24

Murmur Fundamentals

Causes of Turbulence

Forward flow through a stenotic valve

Backward flow through an incompetent

valve



25

Murmur Fundamentals

Causes of Turbulence

• Flow through a septal

defect or an AV fistula

• Flow into a dilated chamber or a portion

of a vessel

26

Murmur Fundamentals

• Stenotic Murmurs

– Valve does not open appropriately

– Heard during the part of the cardiac cycle when the valve is open

• Regurgitant Murmurs

– Valve does not close appropriately

– Heard during the part of the cardiac cycle when the valve is to be closed



27

Murmur Fundamentals

• Timing

– Systolic

• Holosystolic

• Ejection (midsystolic)

• Late

– Diastolic

• Early

• Middiastolic

• Late

• Location

– Place heard the

loudest

• Radiation

– Direction in which

murmur radiates

28

Murmur Fundamentals

• Configuration– Crescendo

• Gets louder

– Decrescendo• Gets softer

– Crescendo –Decrescendo

• Louder then softer

– Plateau• Even intensity

throughout

• Pitch– High Pitched - diaphragm

– Low Pitched – bell

• Quality– Soft

– Harsh

– Blowing

– Musical

– Rumbling

– Rough



29

Systolic Murmurs

• Tricuspid and Mitral Valve Closed

– Tricuspid

Regurgitation

– Mitral Regurgitation

• Pulmonic and Aortic Valve Open

– Pulmonic Stenosis

– Aortic Stenosis

30

Aortic Stenosis

Systolic Ejection Murmur• Timing: Midsystolic

• Location: Best heard

over aortic area

• Radiation: Toward right

side of neck

• Configuration:

Crescendo-decrescendo

• Pitch: Medium to high

• Quality: Harsh



31

Pulmonic StenosisSystolic Ejection Murmur

• Timing: Midsystolic

• Location: Best heard over pulmonic area

• Radiation: Left neck of left shoulder

• Configuration:

Crescendo-decrescendo

• Pitch: Medium

• Quality: Harsh

32

Systolic Murmurs

Mitral Regurgitation• Timing: Holosystolic

• Location: Mitral area

• Radiation: To the left axilla

• Configuration:Plateau

• Pitch: High

• Quality: Blowing, harsh or musical



33

Systolic Murmurs

Tricuspid Regurgitation• Timing: Holosystolic

• Location: Tricuspid area

• Radiation: To the right of

sternum

• Configuration: Plateau

• Pitch: High

• Quality: Scratchy or

blowing

34

Diastolic Murmurs

• Diastolic regurgitant murmurs

– Retrograde flow across an incompetent semilunar valve

• Diastolic filling murmurs

– Forward flow across stenotic or obstructed AV valves



35

Diastolic Murmurs

• Tricuspid and Mitral Valves Open

– Tricuspid Stenosis

– Mitral Stenosis

• Pulmonic and Aortic Valves Close

– Pulmonic

Regurgitation

– Aortic Regurgitation

36

Diastolic Murmurs

Aortic Regurgitation• Timing: Early diastole

• Location: Aortic area

• Radiation: Toward apex

• Configuration:Decrescendo

• Pitch: High

• Quality: Blowing



37

Diastolic Murmurs

Pulmonic Regurgitation• Timing: Early diastole

• Location: Pulmonic area Erb’s Point

• Radiation: Toward apex


• Pitch: High

• Quality: Blowing

38

Diastolic Murmurs

Mitral Stenosis• Timing: Mid to Late

diastole

• Location: Mitral area

• Radiation: None

• Configuration:Crescendo

• Pitch: Low

• Quality: Rumbling



39

Diastolic Murmur

Tricuspid Stenosis

• Timing: Mid to Late diastole

• Location: Tricuspid area

• Radiation: None


• Pitch: Low

• Quality: Rumbling

• Increases during inspiration and decreases during expiration

40

Other Sounds

Pericardial Friction Rub

• Timing: Systolic, Early diastolic and late diastolic

• Location: Tricuspid area and Xyphoid area

• Radiation: None


• May get louder during inspiration

• Pitch: High

• Quality: Grating, scratching



41

Other SoundsVentricular Septal Defect or

Rupture• Timing: Continuous

• Location: 3-4 LSB

• Radiation: Widely throughout the precordium


• Pitch: High

• Quality: Harsh

42

Other Sounds

• Papillary Muscle Rupture

– Same as Mitral Regurgitation



43

REMEMBER:

The most important part of

the stethoscope is the part

between the ear pieces.

44

Other Assessment Tools



45

Blood Pressure

• Definitions:– BP = CO X SVR

– Systolic: Maximum pressure when blood is expelled from the left ventricle

– Diastolic:Measures rate of flow of ejected blood and vessel elasticity

– Pulse Pressure: Difference between systolic and diastolic pressure

46

Cardiac Assessment

• Blood Pressure

– Variation of up to 15mm Hg between arms is

normal

– BP in legs - 10 mm Hg higher than arms

– Narrowed pulse pressure – vasoconstriction

• Innervation of sympathetic nervous system – Hypovolemic shock

– Widened pulse pressure – vasodilation

• Excessive vasodilatory mediator release– Septic shock



47

JVP (Jugular Venous Pressure)

• Reflects volume and pressure in right side

of heart

• Visual inspection

• HOB 30 -45 degree angle

– 45 degree angle will cause venous pulsation to rise 1 to 3 cm above the manubrium

48

Measuring JVD

• Raise HOB until pulsation in internal jugular seen (usually 30 – 45 degrees)

– Use targeted light

– Use centimeter ruler

• Measure distance from angle of Louis (Manubriosternal joint)

to top column of blood

• Draw imaginary horizontal line from column to sternal angle



49

JVD (Jugular Venous

Distension)• Normal JVD level is 3 cm above the

sternal angle

• Sternal angle is 5cm above right atrium

• JVD of 3 cm + 5cm = estimated CVP of 8cm

• Estimated CVP> 8 cm– Increased blood volume

– Usually RV failure• Tricuspid valve regurgitation

• Pulmonary hypertension

50

Tips to Take Away for JVD Assessment

• If unable to accurately assess

– Lie patient flat to visualize and then raise HOB

– If venous congestion is expected may need to sit or stand patient to see top of column



51

Profiles of Perfusion and Congestion

YesNo

Warm and Dry

No congestion

No hypoperfusion

Warm and Wet

Congestion

No hypoperfusion

Cold and WetCongestion

Hypoperfusion

Cold and DryNo congestionHypoperfusion

Congestion at Rest

Low Perfusion

at Rest

No

Yes

PWP 18

CI 2.2

52

Cardiac Assessment

Arterial vs. Venous Disease



53

Edema

• Evaluated on a 4-point scale.

• 0 = None present.

• 1+ = 0 to 1⁄4 inch Trace.

• 2+ = 1⁄4 to 1⁄2 inch Mild.

• 3+ = 1⁄2 to 1 inch Moderate.

• 4+ = > than 1 inch Severe.

• Described as pitting or non-pitting.

• Anasarca: generalized edema.

54

Pulses

• 4 point scale (0-3)

• 0 = absent

• 1+ = Palpable but thready and weak,

easily obliterated

• 2+ = Normal, easily identified, not easily

obliterated

• 3+ = Full, bounding, cannot obliterate



55

Central Cyanosis

• Occurs when more than 5 grams/dL of hemoglobin is deoxygenated

• Results in a bluish or steel-gray discoloration of the skin and mucous membranes– Bluish or steel-gray discoloration of the lips can be from central

or peripheral cyanosis

– Oral mucosa or the tongue may be better tools for assessment of central cyanosis

• Usually not seen until oxygen saturation drops to between 73% to 78%

• Absence of cyanosis does not exclude hypoxemia

56

Peripheral Cyanosis

• Caused by peripheral vasoconstriction

and decreased local blood flow

• May occur with or without central

cyanosis (i.e., with or without hypoxemia)

Usually observed in the nailbeds of the

hands or feet, the earlobes or nose

• Should improve with warming



57

Pulsus Paradoxus• To measure the pulsus paradoxus, patients are often

placed in a semirecumbent position; respirations should be normal. The blood pressure cuff is inflated to at least 20 mm Hg above the systolic pressure and slowly deflated until the first Korotkoff sounds are heard only during expiration. At this pressure reading, if the cuff is not further deflated and a pulsus paradoxus is present, the first Korotkoff sound is not audible during inspiration. As the cuff is further deflated, the point at which the first Korotkoff sound is audible during both inspiration and expiration is recorded. If the difference between the first and second measurement is greater than 12 mm Hg, an abnormal pulsus paradoxus is present.

(Yarlagadda, Chakri, 2005 Cardiac Tamponade. Retrieved 3-22-06 from www.emedicine.com)

Risk Assessment

58



59

Risk Assessment in UA / NSTEMI

• TIMI Risk Score

– Age > 65

– 3 or > risk factors for CAD

– Prior 50% or > stenosis

– ST deviation on ECG

– 2 or > anginal events in

previous 24 hours

– Use of ASA in prior 7 days

– Elevated cardiac biomarkers

• GRACE

– Older age

– Killip class

– Systolic BP

– Cardiac arrest during

presentation

– Serum creatinine

– Positive initial cardiac

markers

– HR

Stroke Risk Assessment

• Congestive Heart Failure

• Hypertension

• Age > 75

• Diabetes

• Stroke TIA

60



61

Assessment Integration For Cardiac Emergencies

62

Assessment Considerations for Emergencies

• Tamponade

– Beck’s triad

– Pulses Paradoxus

• Pulmonary Embolus

– Right axis deviation

– T wave inversion

– Respiratory Alkalosis

• Acute Aortic Dissection

– Diastolic murmur

– Bilateral BPs

– 4 extremity pulses

– Inferior MI

• Papillary Muscle Rupture

– Holosystolic murmur

– Acute pulmonary edema

• VSD

– Holosysytolic murmur



63

Thanks for Attending Cardiovascular Boot Camp

You may contact us at www.cardionursing.com

64

session 4 cv boot camp part 1 - ccrn certification and ... 4 cv boot camp part 1.pdfedema •...

Documents