Ppt09 1

Chapter 9
The Cardiovascular System
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Cardiovascular System:
Examining the Heart and Blood Vessels
• Overview
– Anatomy of the heart and great vessels
– The heart as a pump; blood pressure
– Beginning the examination with the vital signs: blood
pressure and heart rate
– Jugular venous pressure (JVP) and pulsations;
carotid pulse
– Chest wall and apical impulse/PMI
– Auscultation: S1 and S2; S3 and S4
– Auscultation: describing cardiac murmurs

The Heart and Great Vessels: Anatomy

Know Your Surface Landmarks
• Count interspaces
– Identify your ...
o Midsternal line
o Midclavicular line
o Anterior axillary line
o Midaxillary line

Visualize the Chambers of the Heart and
Important Great Vessels
• Visualize the circulation through the:
– Superior and inferior vena cavas
– Right atrium and the right ventricle
– Pulmonary arteries
– Left atrium and left ventricle
– Aorta and the aortic arch

The Heart as a Pump:
Key Points for Examining the Heart
• Note the heart chambers and valves and the
forward flow of blood from the right side of the
heart through the pulmonary arteries and veins to
the left side of the heart
• Combine this knowledge with careful examination
and systematic clinical reasoning
– This will lead you to correct identification of
valvular and congestive heart disease

The Heart as a Pump:
The Cardiac Cycle of Systole and Diastole
• Systole: the ventricles contract
– The right ventricle pumps blood into the pulmonary
arteries (pulmonic valve is open)
– The left ventricle pumps blood into the aorta
(aortic valve is open)
• Diastole: the ventricles relax
– Blood flows from the right atrium → right ventricle
(tricuspid valve is open)
– Blood flows from the left atrium → left ventricle
(mitral valve is open)

The Heart as a Pump: Important Concepts
• Preload volume overload
• Contractility: ventricles contract during systole
• Afterload pressure overload
• Cardiac output: stroke volume x heart rate
• Blood pressure: cardiac output x systemic
vascular resistance

Blood Pressure
• Systolic blood pressure
– Pressure generated by the left ventricle (LV)
during systole, when the LV ejects blood into the
aorta and the arterial tree
o Pressure waves in the arteries create pulses
• Diastolic blood pressure
– Pressure generated by blood remaining in the
arterial tree during diastole, when the ventricles
are relaxed

Beginning the Examination:
The Vital Signs
• First, observe the patient, then begin assessing
the vital signs
– Blood pressure
o Select the proper size cuff
o Position the patient properly
o Make sure there is a brachial pulse
o Apply the cuff correctly
o Assess blood pressure for hypertension
– Heart rate: radial vs. apical

Jugular Venous Pressure (JVP)
and Pulsations
• Recall that jugular veins reflect right atrial 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

Assessing the Carotid Pulse
• 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
• Never palpate right and left carotid arteries
simultaneously
• The upstroke may be:
– Brisk – normal
– Delayed – suggests aortic stenosis
– Bounding – suggests aortic insufficiency
• Listen with the stethoscope for any bruits

Palpating the Chest Wall
• Using the finger pads, palpate for heaves or lifts from
abnormal ventricular movements
• Using the ball of the hand,
palpate for thrills, or
turbulence transmitted to
the chest wall surface by
a damaged heart valve
– Palpate the chest
wall in the aortic,
pulmonic, left
parasternal, and
apical areas

Assessing the Point of Maximal Impulse
(PMI)
• Inspect the left anterior chest for a visible PMI
• Using your finger pads, palpate at the apex for the PMI
• The PMI may be:
– Tapping — normal
– Sustained — suggests LV hypertrophy from
hypertension or aortic stenosis
– Diffuse — suggests a dilated ventricle from
congestive heart failure or cardiomyopathy
• Locate the PMI by interspace and distance in centimeters
from the midsternal line
• Assess location, amplitude, duration, and diameter

Question
When examining a patient for the apical impulse
(PMI), which of the following is LEAST important
to assess?
a. Location
b. Amplitude
c. Rhythm
d. Diameter

Answer
c. Rhythm
• Assess location, amplitude, duration, and
diameter

Listening to the Heart — Auscultation
• Listen in all 6 listening areas for S1 and S2 using
the diaphragm of the stethoscope
• Then listen at the apex with the bell
• The diaphragm and the bell ...
– The diaphragm is best for detecting high-pitched
sounds like S1, S2, and also S4 and
most murmurs
– The bell is best for detecting low-pitched
sounds like S3 and the rumble of mitral
stenosis

Question
The bell of the stethoscope is most useful for
auscultating:
a. Diastolic murmurs
b. High-pitched heart sounds
c. Low-pitched heart sounds
d. Systolic clicks
e. Systolic murmurs

Answer
c. Low-pitched heart sounds
• The bell is best for detecting low-pitched
sounds like S3 and the rumble of mitral
stenosis

Describing Heart Murmurs:
Timing and Duration
• Identify and describe any murmurs
• Timing: are the murmurs systolic or diastolic?
– Tip: palpate the carotid upstroke (occurs in
systole) as you listen
– If the murmur coincides with the carotid
upstroke, it is systolic
• Duration
– Early / mid / or late systolic
– Early / mid / or late diastolic

Shape and Intensity
• Shape
– Crescendo, decrescendo,
or both (sometimes called
diamond-shaped)
o Example, crescendo-decrescendo
systolic
murmur of aortic
stenosis
Crescendo
Decrescendo
Both

Shape and Intensity (cont.)
• Shape
– Plateau ... machinery
o Example, holosystolic
murmur of mitral
regurgitation
• Intensity: grade the murmur
on a scale of 1 to 6
– Grades 4 through 6 must
have accompanying thrill
Plateau Machinery

Quality, Pitch, and Location
• Quality
– Apply terms like harsh, musical, soft, blowing,
or rumbling
• Pitch
– Apply terms like high-, medium-, or low-pitched
• Examples
– Harsh 2/6 medium-pitched holosystolic murmur best
heard at the apex describes mitral regurgitation
– Soft, blowing 3/6 decrescendo diastolic murmur best
heard at the lower left sternal border describes aortic
regurgitation

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