Cardiovascular System: Disorders
Physical Assessment
A thorough physical assessment is the foundation for the nursing
database and the formation of nursing diagnoses and collaborative problems. Any
changes noted during the course of illness can be compared with this initial
database. The nurse evaluates the client's vital signs on admission to the hospital or during the initial visit to the clinic or
health care provider's office.
GENERAL APPEARANCE
Physical assessment begins with the client's general
appearance. The nurse assesses the following areas: general build and
appearance, skin color, distress level, level of consciousness, shortness of
breath, position, and verbal responses.
Clients with chronic heart failure
may appear malnourished, thin, and cachectic. Latent signs of severe heart
failure are ascites, jaundice, and anasarca (generalized edema) as a result of
prolonged congestion of the liver. Heart failure may cause fluid retention, and
clients may have engorged neck veins and generalized dependent edema.
Coronary artery disease is suspected
in clients with yellow, lipid-filled plaques on the upper eyelids (xanthelasma)
or ear-lobe creases. Clients with poor cardiac output and decreased cerebral
perfusion may experience mental confusion, memory loss, and slowed verbal
responses.
INTEGUMENTARY
SYSTEM
Assessment and evaluation of the integumentary system
are determined primarily by the color and temperature of the skin. The best areas
in which to assess circulation include the nail beds, mucous membranes, and
conjunctival mucosa because small blood vessels are located near the surface of
the skin.
Skin Color
If there is normal blood flow or adequate
perfusion to a given area in light-colored skin, it appears pink, perhaps rosy
in color, and it is warm to the touch. Decreased flow is depicted as cool,
pale, and moist skin. Pallor is characteristic of anemia and can be seen in
areas such as the nail beds, palms, and con-junctival mucous membranes.
A bluish or darkened discoloration of
the skin and mucous membranes in Caucasians is referred to as cyanosis. This
condition results from an increased amount of deoxygenated hemoglobin.
Dark-skinned individuals may express cyanosis as a graying of the same tissues.
Central cyanosis involves decreased
oxygenation of the arterial blood in the lungs and appears as a bluish tinge
of the conjunctivae and the mucous membranes of the mouth and tongue. Central
cyanosis may indicate impaired lung function or a right-to-left shunt found in
congenital heart conditions. Because of impaired circulation, there is a marked
desatura-tion of hemoglobin in the peripheral tissues, which produces a bluish
or darkened discoloration of the nail beds, earlobes, lips, and toes.
Peripheral cyanosis occurs when blood
flow to the peripheral vessels is decreased by peripheral vasoconstriction.
The clamping down of the peripheral blood vessels results from a low cardiac
output or an increased extraction of oxygen from the peripheral tissues.
Peripheral cyanosis localized in an extremity is usually a result of arterial
or venous obstruction.
Skin Temperature
Skin temperature can be assessed for symmetry by
touching different areas of the client's body (e.g., arms, hands, legs, and
feet) with the dorsal surface of the hand or fingers. Decreased blood flow
results in decreased skin temperature. Skin temperature is lowered in several
clinical conditions, including heart failure, peripheral vascular disease, and
shock.
EXTREMITIES
The nurse assesses the client's hands,
arms, feet, and legs for skin changes, vascular changes, clubbing, capillary
filling, and edema. Skin mobility and turgor are affected by the fluid status
of the client. Dehydration and aging reduce skin turgor, and edema decreases
skin mobility. Vascular changes in an affected extremity may include
paresthesia, muscle fatigue and discomfort, numbness, pain, coolness, and loss
of hair distribution from a reduced blood supply.
Clubbing of the fingers and toes results from
chronic oxygen deprivation in these tissue beds. Clubbing is characteristic in clients with advanced chronic pulmonary
disease, congenital heart defects, and cor pulmonale. Clubbing can be identified
by assessing the angle of the nail bed. The angle of the normal nail bed is 160
degrees. With clubbing, this angle increases to greater than 180
degrees, and the base of the nail becomes spongy.
Capillary filling of the fingers and the
toes is an indicator of peripheral circulation. Pressing or blanching the nail
bed of a finger or a toe produces a whitening effect; when pressure is
released, a brisk return of color should occur. If color returns within 3
seconds, peripheral circulation is considered intact. If the capillary refill
time exceeds 3 seconds, the lack of circulation may be due to arterial
insufficiency from atherosclerosis or spasm. Older adults typically have a
prolonged capillary refill. Rubor (dusky redness) that replaces pallor in a
dependent foot suggests arterial insufficiency.
Peripheral
edema is a common finding in clients with cardiovascular
problems. The location of edema helps the nurse to determine its potential
cause. Bilateral edema of the legs may be seen in clients with heart failure or
chronic venous insufficiency. Abdominal and leg edema can be seen in clients
with heart disease and cirrhosis of the liver. Localized edema in one extremity
may be the result of venous obstruction (thrombosis) or lymphatic blockage of
the extremity (lymph-edema). Edema may also be noted in dependent areas, such
as the sacrum, when a client is confined to bed.
The nurse documents the location of edema as
precisely as possible (e.g., midtibial or sacral) and the number of centimeters
from an anatomic landmark. Although some health care severe (or 1 + , 2+, 3 + , or 4+), there is no universal scale. In
addition, these values are not precise and are subjective. Instead of using a
grading scale, the nurse determines whether the edema is pitting (the skin can
be indented) or nonpitting, the depth of the pit (in millimeters), and the
amount of time the pit lasts (in seconds).
BLOOD PRESSURE
Arterial blood pressure is measured indirectly by sphygmomanometry.
Normal blood pressure in adults older than 45 years of age ranges from
90 to
A blood pressure less than 90/60 mm Hg may be
inadequate for providing proper and sufficient nutrition to body cells. In
certain circumstances, such as shock and hypotension, the Korotkoff sounds are
less audible or are absent. In these cases the nurse might palpate the blood
pressure, use an ultrasonic device (Doppler device), or obtain a direct measurement
by arterial catheter. When blood pressure is palpated, the diastolic pressure
is usually not obtainable.
Postural Blood Pressure
Clients may report dizziness or lightheadedness when
they move from a flat, supine position to a sitting or a standing position at
the edge of the bed. Normally these symptoms are transient and pass quickly;
pronounced symptoms may be due to orthostatic (postural) hypotension. Postural
hypotension occurs when blood pressure is not adequately maintained while
moving from a lying to a sitting or standing position. It is defined as a
decrease of more than
To detect orthostatic changes in blood pressure,
the nurse first measures the blood pressure when the client is supine. After
remaining supine for at least 3 minutes, the client changes position to sitting
or standing. Normally systolic pressure drops slightly or remains unchanged as
the client rises, whereas diastolic pressure rises slightly. After the position
change, a time delay of 1 to 5 minutes should be permitted before auscultating
blood pressure and palpating the radial pulse. The cuff should remain in the
proper position on the client's arm. The nurse observes and records any signs
or symptoms of distress. If the client is unable to tolerate the position
change, he or she is returned to the previous position of comfort.
Paradoxical Blood
Pressure
Paradoxical blood pressure is defined as an exaggerated decrease in systolic pressure by more than
decrease slightly. However, the decreased fluid volume in the ventricles
resulting from these pathologic conditions produces an exaggerated or marked
reduction in cardiac output.
Hepatojugular
reflux is determined by locating the internal jugular
vein after positioning the client with the head of the bed elevated to 45
degrees. The nurse compresses the right upper abdomen for 30 to 40 seconds.
Sudden distention of the neck veins after abdominal compression is usually
indicative of right-sided heart failure.
Pulse Pressure
The difference between the systolic and
diastolic values is referred to as pulse pressure. A normal pulse pressure for
an adult is 30 to
Proportional pulse
pressure = (Systolic blood pressure - Diastolic blood pressure)/ Systolic blood
pressure
A proportional pulse pressure less than
25% usually indicates a cardiac index of less than 2.2, as well as a
critically low cardiac output (Stevenson & Braunwald, 1998). Narrowed
pulse pressure is rarely normal and results from increased peripheral vascular
resistance or decreased stroke volume in clients with heart failure,
hypovolemia, or shock. Narrowed pulse pressure can also be seen in clients who
have mitral stenosis or regurgitation. An increased pulse pressure may be seen
in clients with slow heart rates, aortic regurgitation, atherosclerosis,
hypertension, and aging.
Ankle Brachial Index
The ankle brachial index (ABI) can be used to
assess the vascular status of the lower extremities. The nurse applies a blood
pressure cuff to the lower extremities just above the malleoli and measures the
systolic pressure by Doppler ultrasound at both the dorsalis pedis and
posterior tibial pulses. The higher of these two pressures is then divided by
the higher of the two brachial pulses to obtain the ankle brachial index:
Normal values for ABI are 1 or
higher, because blood pressure in the legs is usually higher than blood
pressure in the arms. ABI values less than 0.80 usually indicate moderate
vascular disease, whereas values less than 0.50 indicate severe vascular compromise.
VENOUS AND ARTERIAL
PULSATIONS
Venous Pulsations
The nurse observes the venous pulsations
in the neck to assess the adequacy of blood volume and central venous pressure
(CVP). The nurse can assess jugular venous pressure (JVP) to estimate
the filling volume and pressure on the right side of the heart . The right
internal jugular vein is usually used to estimate JVP.
JVP is normally 3 to
Arterial Pulsations
Assessment of arterial pulsations gives
the nurse information about
vascular integrity and circulation.
For clients with suspected or actual
vascular disease, all major peripheral pulses, including the temporal, carotid,
brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis
pedis pulses, need to be assessed for presence or absence, amplitude, contour,
rhythm, rate, and equality. The nurse examines the peripheral arteries in a
head-to-toe approach with a side-to-side comparison.
A hypokinetic pulse is a weak
pulsation indicative of a narrow pulse pressure. It is seen in clients with
hypovolemia, aortic stenosis, and decreased cardiac output.
A hyperkinetic pulse is a large,
"bounding" pulse caused by an increased ejection of blood. It is seen
in clients with a high cardiac output (with exercise or thyrotoxicosis) and in
those with increased sympathetic system activity (with pain, fever, or
anxiety).
In pulsus alternans, a weak
pulse alternates with a strong pulse despite a regular heart rhythm. It is seen
in clients with severely depressed cardiac function. Clients may be asked to
hold their breath to exclude any false readings. The nurse may palpate the
brachial or radial arteries to assess this condition, but it is more accurately
assessed by auscultation of blood pressure.
Auscultation of the major arteries
(e.g., carotid and aorta) is necessary to assess for bruits. Bruits are
swishing sounds that may develop in narrowed arteries and are usually
associated with atherosclerotic disease. The nurse can assess for the absence
or presence of bruits by placing the bell of the stethoscope over the skin of
the carotid artery while the client holds his or her breath. Normally there are
no sounds if the artery has uninterrupted blood flow. A bruit may develop when
the internal diameter of the vessel is narrowed by 50% or more, but this does
not indicate the severity of disease in the arteries. Severity is determined
by Doppler flow studies and arteriography.
PRECORDIUM
Assessment of the precordium (the area over the heart)
involves inspection, palpation, percussion, and auscultation. In most settings
the medical-surgical nurse seldom performs precordial palpation and percussion.
However, the critical care nurse should perform a complete assessment (McGrath
& Cox, 1998). The nurse places the client in a supine position, with the
head of the bed slightly elevated for comfort. Some clients may require
elevation of the head of the bed to 45 degrees for ease and comfort in
breathing.
Inspection
A cardiac examination is usually performed
in a systematic order, beginning with inspection. The nurse inspects the chest
from the side, at a right angle, and downward over areas of the precordium
where vibrations are visible. Cardiac motion is of low amplitude, and sometimes
the inward movements are more easily detected by the naked eye.
The nurse examines the entire
precordium, focusing on the seven precordial areas and noting any prominent
precordial pulsations.
Movement over the aortic, pulmonic, and
tricuspid areas is abnormal. Pulsations in the mitral area (the apex of the
heart) are considered normal and are referred to as the apical impulse, or the point
of maximal impulse (PMI). The PMI should be located at the left fifth intercostal
space (ICS) in the midclavicular line. If the apical impulse appears in more
than one intercostal space and has shifted lateral to the midclavicular line,
it may indicate left ventricular hypertrophy.
Palpation
The nurse palpates with the fingers and the most sensitive part of the
palm of the hand to detect precordial motion and thrills, respectively. The
nurse palpates by inching his or her hand in a Z pattern along the chest,
starting with the aortic area and passing through all seven areas. Turning the
client on his or her left side brings the heart closer to the surface of the
chest. This may be helpful in achieving maximum tactile sensitivity.
An abnormal forceful thrust accompanied by a
sustaining outward movement over the left anterior side of the chest usually
indicates left ventricular enlargement. An outward systolic lift along the
left sternal border that extends from the fourth to the fifth intercostal space
represents right ventricular enlargement.
Heaves and lifts are
terms found with pulsations associated with valvular diseases or pulmonary
hypertension. Thrills are vibrations associated with abnormal heart valve
function (mitral regurgitation, tricuspid regurgitation, and pulmonic stenosis).
When palpating for heaves or thrills, the nurse should consider several
factors, including location, amplitude, duration, distribution, and timing in
relation to the cardiac cycle.
Percussion
Cardiac size is determined most
accurately by chest x-ray examination; percussion is now rarely used to
determine the size of the heart. However, the size of the left ventricle can be
estimated by locating the apical impulse by inspection and palpation.
Auscultation
Auscultation evaluates heart rate and rhythm,
cardiac cycle (systole and diastole), and valvular function. The technique of
auscultation requires a good-quality stethoscope and extensive clinical
practice. The medical-surgical nurse needs to be familiar with normal heart
sounds. The critical care nurse, telemetry nurse, and
advance practice nurse should be able to identify common abnormal heart sounds.
The nurse evaluates heart sounds in a systematic
order. Examination usually begins at the aortic outflow tract area and
progresses slowly to the apex of the heart. The diaphragm of the stethoscope is
pressed tightly against the chest to listen for high-frequency sounds and is
useful in listening to the first and second heart sounds and high-frequency
murmurs. The nurse then repeats the progression from the base to the apex of
the heart using the bell of the stethoscope, which is held lightly against the
chest. The bell is able to screen out high-frequency sounds and is useful in
listening for low-frequency gallops (diastolic filling sounds) and murmurs.
The nurse auscultates by inching a stethoscope in
a Zpattern across the base of the heart, down the left sternal border, then
over to the apex. Auscultation checks
for heart rate and rhythm, murmurs, extrasystolic sounds, and rubs in the
presence of a current or suspected cardiac problem.
NORMAL
HEART SOUNDS
The first heart sound (S,) is created by the closure of the mitral and
tricuspid valves (atrioventricular valves). When auscultated, the first heart
sound is softer and longer; it is of a low pitch and is best heard at the lower
left sternal border or the apex of the heart. It may be identified by palpating
the carotid pulse while listening. S, marks the beginning of ventricular
systole and occurs right after the QRS complex on the electrocardiogram (ECG).
The first heart sound can be accentuated or
intensified in conditions such as exercise, hyperthyroidism, and mitral
stenosis. A decrease in sound intensity occurs in clients with mitral
regurgitation and heart failure.
The second heart sound (S2) is caused
mainly by the closing of the aortic and pulmonic valves (semilunar valves). S2
is characteristically shorter. It is higher pitched and is heard best at the
base of the heart at the end of ventricular systole.
The splitting of heart sounds is often difficult
to differentiate from diastolic filling sounds (gallops). A splitting of S1
(closure of the mitral valve followed by closure of the tricuspid valve) occurs
physiologically because left ventricular contraction occurs slightly before
right ventricular contraction. However, closure of the mitral valve is louder
than closure of the tricuspid valve, so splitting is often not heard. Normal
splitting of S2 occurs because of the longer systolic phase of the
right ventricle. Splitting of S, and S2 can be accentuated by
inspiration (increased venous return), and it narrows during expiration.
Psychosocial Assessment
To many people, their heart is a symbol of their ability to exist,
survive, and love. A client with a heart-related illness, whether acute or
chronic, usually perceives it as a major life crisis. The client and families
and significant others confront not only the possibility of death but also
fears about pain, disability, lack of self-esteem, physical dependence, and
changes in family dynamics. The nurse may assess the meaning of the illness to
the client and family members by asking, "What do you understand about
what happened to you (or the client)?" and "What does that mean to
you?" When the client or family members perceive the stressor as
overwhelming, formerly adequate support systems may no longer be effective. In
these circumstances, the client and family members attempt to cope to regain a
sense or feeling of control.
Coping behaviors vary among clients. Those who
feel helpless to meet the demands of the situation may exhibit behaviors such
as disorganization, fear, and anxiety. The
nurse may ask the client or family members, "Have you ever encountered
such a situation before?", "How did you manage that situation?",
and "To whom can you turn for help?" The answers to these
questions often reassure the client that he or she has encountered difficult
situations in the past and has the ability and resources to cope with them.
A common and normal response is denial, which
is a defense mechanism that enables the client to cope with threatening
circumstances. The client may deny that he or she has the current
cardiovascular condition, may state that it was present but is now absent, or
may be excessively cheerful. Denying the seriousness of the illness while
following the treatment regimen is a protective response. Denial becomes
maladaptive when the client is noncompliant with significant portions of
medical and nursing care.
Family members and significant others may be more
anxious than the client. Often they recall all events of the illness, are
unprotected by denial, and are afraid of recurrence. Disagreements often occur
between the client and family members over compliance with appropriate
follow-up care.
CURRENT
HEALTH PROBLEMS
Inquiring about major concerns helps the nurse to
establish priorities in nursing care and management. The client is asked to
describe his or her health concerns. The nurse expands on the description of
these concerns by obtaining information about their onset, duration,
chronology, frequency, location, quality, intensity, associated symptoms, and
precipitating, aggravating, and relieving factors. Major symptoms identified
by clients with cardiovascular disease include chest pain or discomfort,
dyspnea, fatigue, palpitations, weight gain, syncope, and extremity pain.
Chest Pain
Chest pain or
discomfort, a cardinal symptom of heart disease,
can result from ischemic heart disease, pericarditis, and aortic dissection.
Chest pain can also be due to noncardiac conditions such as pleurisy, pulmonary
embolus, hiatal hernia, and anxiety. Nurses must thoroughly evaluate the
nature and characteristics of the chest pain. Because chest pain resulting
from myocardial ischemia is life threatening and can lead to serious
complications, its cause should be considered ischemic (reduced or obstructed
blood flow to the myocardium) until proven otherwise.
When assessing for chest pain, the
nurse uses alternative terms such as "discomfort," "heaviness,"
and "indigestion." Clients often do not experience pain in the chest
but instead feel discomfort or indigestion. The client may also describe the
sensation as aching, choking, strangling, tingling, squeezing, constricting,
or vise-like.
The nurse asks the client to identify
when the pain was first noticed (onset). Did the pain begin suddenly or develop
gradually (manner of onset)? How long did it last (duration)? If the client
has repeated chest pain episodes, the nurse assesses how often the pain occurs
(frequency). The nurse asks whether this pain is different from any other
episodes of pain. The nurse asks the client to describe what activities he or
she was doing when it first occurred, such as sleeping, arguing, or running
(precipitating factors). The client can be asked to point to the area where the
chest pain occurred (location) and to describe how the pain spread (radiation).
In addition, the client describes how
the pain feels and whether it is sharp or dull (quality). To understand the
severity of the pain, the nurse asks the client to grade it from 0 to 10, with
0 indicating an absence of pain and 10 indicating severe pain (intensity). The
client may also report other signs and symptoms that occur at the same time
(associated symptoms), such as dyspnea, diaphoresis, nausea, and vomiting.
Other factors that need to be addressed are those that may have made the chest
pain worse (aggravating factors) or less intense (relieving factors). Chest
pain may arise from a variety of sources. By obtaining the appropriate information,
the nurse may assist in identifying the source of the chest discomfort.
Dyspnea
Dyspnea can occur as a result of both cardiac and
pulmonary disease. Dyspnea is objectively described as difficult or labored breathing
and is subjectively experienced as uncomfortable breathing or shortness of
breath. When obtaining the client's history, the nurse ascertains what factors
precipitate and relieve dyspnea, what level of activity produces dyspnea, and
the client's body position when dyspnea occurred.
There are several types of dyspnea.
Dyspnea that is associated with activity, such as climbing stairs, is referred
to as dyspnea on exertion (DOE). This is usually an early symptom of heart
failure.
The client with advanced heart
disease may experience or-thopnea, or dyspnea that appears when the client lies
flat. The client may use several pillows at night to elevate the head and chest
or may sleep in a recliner to prevent nighttime breath-lessness. The severity
of orthopnea is measured by the number of pillows or the amount of head
elevation needed to provide restful sleep. Orthopnea is usually relieved
within a matter of minutes by sitting up or standing.
Paroxysmal nocturnal dyspnea develops after the client has been lying down for several hours. In this
position, blood from the lower extremities is redistributed to the venous system,
which increases venous return to the heart. A diseased heart is unable to
compensate for the increased volume and is ineffective in pumping the
additional fluid into the circulatory system. Pulmonary congestion results. The
client awakens abruptly, often with a feeling of suffocation and panic. The
client usually sits upright with the legs dangled over the bedside to relieve
the dyspnea. This sensation may last for 20 minutes before disappearing.
Fatigue
Fatigue may be described as a feeling of
tiredness or weariness resulting from activity. The client may complain that a
certain activity takes longer to complete or that he or she tires easily after
activity. Although fatigue in itself is not diagnostic of heart disease, many
people with heart failure are limited by leg fatigue during exercise. Fatigue
that occurs after mild activity and exertion usually indicates inadequate
cardiac output (low stroke volume) and anaerobic metabolism in skeletal muscle.
The nurse questions the client to determine the time of day he or she
experiences fatigue as well as the activities that he or she can perform.
Fatigue resulting from decreased cardiac output is often worse in the evening.
The nurse asks whether the client can perform the same activities as a year ago
or the same activities as others of the same age. Often the client limits
activities in response to fatigue and unless questioned is unaware how much
less active he or she has become.
Palpitations
A feeling of fluttering in the chest or an unpleasant
awareness of the heartbeat is referred to as palpitations. Palpitations
may result from a change in heart rate or rhythm or from an increase in the
force of heart contractions. Rhythm disturbances that may cause palpitations
include paroxysmal supraventricular tachycardia, premature contractions, and sinus
tachycardia. Those that occur during or after strenuous physical activity, such
as running and swimming, may indicate overexertion or possibly heart disease.
Noncardiac factors that may precipitate palpitations include anxiety, stress,
fatigue, insomnia, hyperthyroidism, and the ingestion of caffeine, nicotine,
or alcohol.
Weight Gain
A sudden weight increase of
Syncope
Syncope refers
to a transient loss of consciousness. The most common cause is decreased
perfusion to the brain. Any condition that suddenly reduces cardiac output,
resulting in decreased cerebral blood flow, can potentiate a syncopal episode.
Conditions such as cardiac rhythm disturbances (ventricular dysrhythmia or
Stokes-Adams attack) and valvular disorders (aortic stenosis) may potentiate
this symptom.
Near-syncope refers to dizziness with
an inability to remain in an upright position. The nurse explores the circumstances
that lead to dizziness or syncope.
Extremity Pain
Extremity pain may be caused by two conditions:
ischemia from atherosclerosis and venous
insufficiency of the peripheral blood vessels. Clients who report a moderate
to severe cramping sensation in their legs or buttocks associated with an
activity such as walking have intermittent claudication related to reduced
arterial tissue perfusion. Claudication pain is usually relieved by resting or
lowering the affected extremity to decrease tissue demands or to enhance
arterial blood flow. Leg pain that results from prolonged standing or sitting
is related to venous insufficiency from either incompetent valves or venous
obstruction. This pain may be relieved by elevating the extremity.
FUNCTIONAL HISTORY
After the history of the client's cardiovascular status is obtained, he
or she may be classified according to the New York Heart Association's
Functional Classification (Table 33-2). The four classifications (I, II, III,
and IV) depend on the degree to which ordinary physical activities (routine
activities of daily living [ADLs]) are affected by heart disease.
ABNORMAL HEART SOUNDS
PARADOXICAL SPLITTING. Abnormal
splitting of S2 is referred to as paradoxical splitting and is characteristic
of a wider split heard on expiration. Paradoxical splitting of S2 is
heard in clients with severe myocardial depression that causes early closure of
the pulmonic valve or a delay in aortic valve closure. Such conditions include
myocardial infarction, left bundle branch block, aortic stenosis, aortic
regurgitation, and right ventricular pacing.
GALLOPS AND MURMURS. Gallops
and murmurs are common abnormal heart sounds that may occur with heart disease.
GALLOPS. Diastolic
filling sounds (S3) and (S4) are produced when blood
enters a noncompliant chamber during rapid ventricular filling. The third heart
sound (S3) is produced during the rapid passive filling phase of
ventricular diastole when blood flows from the atrium to a noncompliant ventricle.
The sound arises from vibrations of the valves and supporting structures. The
fourth heart sound (S4) occurs as blood enters the ventricles during
the active filling phase at the end of ventricular diastole.
S3 is termed ventricular gallop, and S4
is referred to as atrial gallop. These sounds can be caused by decreased compliance
of either or both ventricles. The nurse can best hear left ventricular
diastolic filling sounds with the client on his or her left side. The bell of
the stethoscope is placed at the apex and at the left lower sternal border
during expiration.
An S3 heart sound is probably a normal
finding in children or young adults up to 30 years of age. An S3
gallop in clients older than 40 years of age is considered abnormal and represents
a decrease in left ventricular compliance. S3 can be detected as an
early sign of heart failure or as a ventricular sep-tal defect.
An atrial gallop (S4) may be heard in clients
with hypertension, anemia, ventricular hypertrophy, myocardial infarction,
aortic or pulmonic stenosis, and pulmonary emboli. It may also be heard with
advancing age because of a stiffened ventricle.
The auscultation of both S3 and S4,
called a summation or a quadruple gallop, is an indication of
severe heart failure. If the quadruple rhythm is present and the client has
tachycardia (a shortened diastole), the two sounds may actually fuse to produce
a rhythm that sounds like a horse galloping.
MURMURS. Murmurs
reflect turbulent blood flow through normal or abnormal valves. They are
classified according to their timing in the cardiac cycle: systolic murmurs
(e.g., aortic stenosis and mitral regurgitation) occur between S, and S2,
whereas diastolic murmurs (e.g., mitral stenosis and aortic regurgitation)
occur between S2 and S,. Murmurs can occur during presystole,
midsystole, or late systole or diastole or can last throughout both phases of
the cardiac cycle. They are also graded according to their intensity, depending
on their level of loudness.
The nurse describes the location of a murmur by
where it is best heard on auscultation. Some murmurs transmit or radiate from
their loudest point to other areas, including the neck, the back, and the
axilla. The configuration is described as crescendo (increases in intensity)
or decrescendo (decreases in intensity). The quality of murmurs can be further
characterized as harsh, blowing, whistling, rumbling, or squeaking. They are
also described by pitch, usually high or low.
PERICARDIAL FRICTION RUB. A
pericardial friction rub originates from the pericardial sac and occurs with
the movements of the heart during the cardiac cycle. Rubs are usually transient
and are a sign of inflammation, infection, or infiltration. Pericardial
friction rubs may be heard in clients with pericarditis resulting from
myocardial infarction and cardiac tamponade.
The three phases of cardiac movement—atrial
systole, ventricular diastole, and ventricular systole—can produce three components
of a rub. Usually only one or two components can be heard. A short,
high-pitched scratchy sound is produced with each movement; the loudest
component is heard in systole. The nurse may be most able to auscultate the
rubs when the client sits, leans forward, and exhales. A pericardial friction
rub is better heard with the diaphragm of the stethoscope.
An Overview of the
Cardiovascular System
The evaluation of the
cardiovascular system includes a thorough medical history, a detailed examination
of the heart and the peripheral arterial and venous circulations, and
appropriate laboratory studies. In addition to the electrocardiogram and chest
x-ray, the availability of sophisticated noninvasive techniques (e.g.,
echocardiography and nuclear cardiology) and the continued improvement of
cardiac catheterization and angiography have significantly enhanced the
clinical work-up of the patient with a cardiovascular problem. A careful
assessment will enable the clinician to identify the etiologic, anatomic, and
physiologic components of a specific cardiovascular disorder, as well as to
determine overall cardiac function.
History
The medical history in a patient with a
cardiac problem is usually centered on symptoms due to myocardial ischemia, dysrhythmias,
and reduction in ventricular function. The majority of these individuals will
consult a physician because of chest pain, dyspnea, palpitations, ankle edema,
or syncope. Any or all of these symptoms may also have extra-cardiac causes.
Because symptoms of heart disease may be absent at rest and appear only during
stress, the medical history has unique diagnostic importance. The patient's
daily activities should be assessed for their role in precipitating the
symptoms and in identifying these symptoms as cardiac in origin. A purely
symptom-based classification of heart disease has major limitations, however,
since functional abnormalities are often more extensive than those represented
by symptoms alone. In addition, the anatomic and physiologic disturbances may
develop to advanced stages before symptoms appear. Examples of the manner in
which the principal symptoms of heart disease may serve as a guide to diagnosis
will be highlighted.
Chest pain or discomfort has numerous
cardiac causes (e.g., myocardial ischemia, pericarditis, pulmonary embolism,
aortic dissection) as well as noncardiac etiologies (e.g., anxiety,
cholecystitis, pneumonia). The pain of myocardial ischemia, characterized by a
squeezing, strangling, or burning sensation, must be differentiated from
pleuritic pain, which is sharp, stabbing, intensified by inspiration, and
relieved by sitting up. Among the causes of myocardial ischemia are angina
pectoris and myocardial infarction. Pleuritic pain usually accompanies
pericarditis and pulmonary embolism.
Dyspnea (shortness of breath) of cardiac origin
must be distinguished from dyspnea due to pulmonary disease. Cardiac dyspnea,
including paroxysmal nocturnal dyspnea (breathlessness at night) and orthopnea
(dyspnea precipitated by assuming the recumbent position), is
characteristically related to effort until the advanced stages of heart disease
when it may become present at rest. Rapid progression of an episode of
respiratory distress may result in a very severe form of dyspnea, acute pulmonary
edema, i.e., "asthmatic" wheezes and a pink, frothy sputum.
Palpitations describe an
awareness of the heartbeat. Although the underlying disturbance usually
requires electrocardiographic confirmation, occasionally the cadence of the
palpitations may be ascertained at the bedside. Palpitations may often be of no
consequence.
Syncope of cardiac origin may be due either
to an inability of the heart to maintain adequate cardiac output for a given
level of activity or to a dysrhythmia that results in sudden loss of cardiac
output. Left ventricular outflow tract obstruction (e.g., aortic stenosis or
hypertrophic cardiomyopathy) commonly causes effort syncope, whereas syncopal
episodes due to dysrhythmias can occur either at rest or during activity.
Edema a detectable excess of fluid in the
interstitial spaces, is most commonly located in the ankles and feet and is
referred to as peripheral or ankle edema. When due to cardiac disease, it is
usually a late sign of congestive heart failure, specifically, right heart
failure.
Additional symptoms that may herald a
cardiovascular problem include claudication (extertional
cramping of the muscles) most often of the lower extremities, fatigue, and
hemoptysis (Table 7.1).
Symptoms
of Cardiovascular Diseases.
Physical
Examination
Instruments needed for the cardiovascular
examination are listed in Table 7.2. The examination
involves inspection, palpation, and auscultation of the heart, arteries, and
veins. The cardiac examination consists of evaluation of (1)
the carotid arterial pulse and auscultation for carotid bruits; (2) the jugular
venous pulse and auscultation for cervical venous hums; (3) the precordial
impulses and palpation for heart sounds and murmurs; and (4) auscultation of
the heart. The evaluation of the peripheral arteries, the
aortic pulsation, elicitation of pulsus alternans, and a search for thrombophlebitis completes
the cardiovascular examination (Table 7.3).
Instruments
Needed for Cardiovascular Examination.
Most
Frequently Used Examination Sequence of the Cardiovascular System.
Special attention should be given to the
patient's general appearance, since it can reflect the state
of the circulation as well as noncardiac diseases that may involve the heart.
The patient's color (pale, flushed, or cyanotic), facial features, body build,
and obvious pulsations should be noted. The blood pressure and heart rate and
rhythm are obtained with the vital signs, but must be integrated with the
findings of the cardiovascular examination to arrive at the proper diagnosis.
Examination of the
Heart
Carotid Arteries
Begin the cardiovascular examination by
assessing the carotid arterial pulses . They are ordinarily
examined while the patient is breathing normally and reclining with the trunk
of the body elevated about 15 to 30 degrees (Figure 7.1). In order to
examine the carotid arteries, the sternocleidomastoid (SCM) muscle should be relaxed
and the head rotated slightly toward the examiner. The examiner places the
forefinger or thumb, depending on individual preference, slightly over the
artery in the groove just lateral to the trachea. Care should be taken always
to palpate in the lower half of the neck in order to avoid the area of the
carotid bulb, lest a hypersensitive carotid sinus reflex be evoked with
resultant bradycardia and hypotension. It is important that the carotid pulses
be palpated using light pressure, one side at a time, since bilateral carotid
compression may produce cerebral ischemia and syncope; extreme caution should
be exercised in patients who have a history of syncope or transient neurologic
symptoms.
Examination
of the carotid arterial pulse. Place the patient in the supine position with
the trunk elevated approximately 30 degrees, the head turned slightly toward
the side being examined and the chin elevated. Palpate the carotid artery by
gently pressing
Listen to the heart with the stethoscope
in order to identify the first (S1) and second (S2) heart
sounds while simultaneously palpating the carotid artery. The heart sounds are
used as reference points for the cardiac examination in order to determine
which events occur in systole (between S1 and S2)
and which in diastole (between S2 and S1). While
listening to the heart sounds, the examiner carefully and slowly applies more
and more pressure to the carotid artery until the maximum pulse is felt;
palpation should be continued for 5 to 8 seconds. The examiner should then
slowly release the pressure on the artery while attempting to form a mental
image of the pulse wave. It may be possible to detect an anacrotic notch (halt
on the upstroke) or a bisferiens pulse (bifid or double peak) more easily with
light pressure than with heavy pressure. In patients with evidence of carotid
arterial disease, palpation of the vessels obviously should be gentle.
Divide the carotid pulse wave into three
parts: (1) ascending limb or upstroke; (2) peak; and (3) descending limb.
Initially concentrate on the amplitude (size) of the carotid
pulse and note whether it is normal, decreased, or increased. If necessary, use
your own carotid pulse as a control. Next, direct attention to analysis of the
pulse contour and note if there is a single or double peak, a
shudder or thrill, and the location of the peak within systole (i.e., early,
mid, or late). Then concentrate on the upstroke and note
whether it is normal, rapid, or slow. Finally, concentrate on the down-stroke
of the pulse, which is difficult to palpate reliably. If there is a rapid
fall-off, for instance, the majority of the clownstroke will be completed
during systole.
The normal carotid arterial pulse wave is
illustrated in Figure 7.2 together
with the heart sounds. The upstroke of the carotid tracing is moderately rapid
and smooth, and begins just after the initial component of the first heart
sound. The summit of the carotid pulse is smooth and dome shaped, and occurs
approximately in the middle of systole. The descending limb from the systolic
peak is usually less steep than the ascending limb. In most normal individuals,
the carotid incisura or dicrotic notch is not palpable; however, one can
usually sense a change to a less steep down-slope.
These
graphics represent the normal cardiac pulsations and heart sounds. The jugular
venous pulsation normally has 3 positive waves—the a, c, and v waves
and 2 negative troughs—x and y troughs. The "a" wave is approximately
synchronous
There are a variety of abnormal arterial
pulses including the hypokinetic pulse commonly seen with left ventricular
failure; the hyper kinetic pulse commonly seen with mitral or aortic
regurgitation; and the bisferiens pulse seen with aortic regurgitation or
hypertrophic cardiomyopathy. During routine palpation of the carotid pulse, pay
particular attention to the amplitude of the pulse following any premature
beat, A diminished pulse amplitude following a premature beat is suggestive of
hypertrophic cardiomyopathy.
Auscultation should be performed along the
course of the carotid artery in order to detect any bruits. The
location of maximum intensity of the bruit should be noted, as well as the
pitch and duration of the sound. It is necessary for the patient to stop
breathing during auscultation to eliminate the harsh sounds of tracheal
breathing that could mask a low-pitched carotid bruit.
Auscultation
of the carotid artery. Lightly apply the bell of the stethoscope over the
course of the carotid artery, from the base of the neck to angle of the jaw,
during full expiration.
Jugular Veins
The jugular venous pulse is
usually examined next. It includes observation of venous wave form, assessment
of the response of the venous pressure to abdominal compression, estimation of
the central venous pressure (CVP), and auscultation for cervical venous hums.
Venous pulsations are examined by inspection of either the external or internal
jugular veins, although the latter are generally more reliable because they
more directly reflect right atrial hemodynamics.
The position of the patient is extremely important
for the examination of the jugular veins (Figure 7.4). Relax the
neck muscles by placing a small pillow behind the neck. The head should not be
rotated more than a few degrees, since rotation may tense the SCM muscle and
obscure the transmission of venous pulsations. The trunk of the body should be
elevated until maximal venous pulsations are noted. The degree of trunk
elevation varies from subject to subject and must be established for each
person. In most normal individuals, the maximum pulsation of the internal
jugular vein is usually observed when the trunk is inclined to about 15 to 30
degrees. In patients with elevated venous pressure, it may be necessary to
elevate the trunk more than 45 degrees to visualize the maximum venous
pulsation. At times there is venous distention without visible waves and the
pulsations are only seen with the patient upright at 90 degrees.
Anatomy
of the blood vessels in the neck. Evaluation of the jugular venous pulse and
the carotid artery are best accomplished with the patient supine, the neck
muscles relaxed by placing a small pillow under the head and the trunk elevated
until the maximal
Look for pulsations of the
internal jugular vein by standing just behind the patient and looking
down alongside the SCM muscle or by bending over in front of the patient and looking
directly along the SCM muscles. Direct your study of the wave form to whichever
internal jugular pulse is easier to see. For most patients, the right internal
jugular vein is superior for accurate evaluation of the venous wave form. The
internal jugular venous pulsations may be highlighted by shining a beam of
light from a penlight tangentially across the skin overlying the left internal
jugular vein. This technique may amplify the wave form by casting a shadow of
its pulsations on the pillow or bed sheet behind the neck.
The normal jugular venous pulse consists
of intermittent increases in the volume of blood in the veins caused by slowing
or halting of blood flow in the right atrium. Because they are low-pressure
impulses, venous pulsations are not palpable and therefore are interpreted by
inspection rather than by palpation, in contrast to the carotid arterial pulse.
Generally, internal and external jugular venous pulsations may be eliminated by
applying gentle pressure below the point of observation. This procedure also
may produce increased distention of the vein by blocking the flow of blood to
the heart. The visible venous pulsations in the neck are slower and more
undulating than the brisk, forceful arterial pulse waves. Respiration may produce
marked changes in venous pulsations, whereas arterial pulses normally change
relatively little. Under normal circumstances, inspiration decreases
intrathoracic pressure and increases return of blood to the heart from the
peripheral veins. The result is to reduce the mean level of venous pulsation
and distention; the opposite occurs during expiration.
Abdominal pressure may also be used to
distinguish venous from arterial neck pulsations. This test is best performed
with the patient lying comfortably in bed at the optimal angle for observing
the internal jugular venous pulsations. The patient is instructed to continue
normal breathing in order to avoid performance of a Valsalva maneuver.
Moderately firm pressure is then slowly applied for about 30 seconds with the
palm of the hand pressing on the abdomen, usually on the right side (over the
liver). Normally this maneuver produces no visible change in the arterial
pulse, but a slight increase in the prominence of the jugular venous
pulsations. In the presence of heart failure the jugular venous pulsations may
be markedly increased. The response of jugular venous pulse to abdominal
compression is known as the hepato-jugular reflux test. It is useful not only
for distinguishing venous from arterial pulsations but also in unmasking occult
abnormalities of circulatory function.
The normally visible jugular venous
pulsations consist of two outward pulsations or positive waves ("a"
and "v") and two descents or collapses or negative waves
("x" and "y") as shown in Figure 7.2. The
"c" wave, a positive wave that follows the "a" wave, may be
recorded, but is seldom seen at the bedside. The carotid pulse may be used to
time venous pulsations, but the heart sounds generally are preferable at the
bedside. The "a" wave, the larger of the two visible positive waves,
begins before S1 and precedes the upstroke of the carotid
pulse. The negative "x" and "y" waves occupy systole and diastole,
respectively. The "v" wave occurs in late systole virtually
synchronous with S2. Frequently, it is easier to visualize jugular
descents because they are the largest and fastest movements.
The internal jugular veins are also used
to estimate central venous pressure. The technique is similar
to that for evaluation of the internal jugular venous wave form (Figure 7.5). The patient
is examined at the optimum degree of trunk elevation for inspection of the
venous pulse. While the patient is breathing gently or preferably at the end of
a normal expiration, the highest point of visible pulsation of the internal
jugular vein is determined (Figure 7.5). The CVP can
then be estimated by measuring the vertical distance between the midright
atrium and the top of the column of venous blood in relation to a fixed reference
point, the sternal angle (of Louis). The vertical distance between the top of
the column of venous blood and the level of the sternal angle is normally 2 cm.
For convenience at the bedside, the sternal angle is chosen as a reference
point because it has a relatively constant relationship, in all positions, to
the midpoint of the right atrium (i.e., 5 cm above the mid-right atrium).
Estimation
of the central venous pressure (CVP). Place the patient in the supine position
with the head slightly elevated on a pillow to relax the sternocleidomastoid
muscle. Elevate the trunk by adjusting the head of the bed so as to maximize
the internal
The normal CVP is less than or equal to 7
cm H2O (i.e., 5 + 2 cm). The most common cause of an elevated CVP is
failure of the right ventricle secondary to failure of the left ventricle.
Earlobe and rarely eyeball pulsations are evidence of markedly elevated venous
pressure.
Central venous pressure may also be
estimated by examining the veins of the dorsum of the hand. To perform this
determination, the patient should be in either a sitting or lying position at a
30-degree elevation or greater, and the hand should be kept below the level of
the heart long enough for the veins of the dorsum of the hand to become
distended. The arm is then slowly and passively raised while the physician
observes the veins. Care should be taken that the arm is not flexed excessively
at either the shoulder or the elbow and that the upper arm is not constricted
by-clothing. Normally, the veins will be seen to collapse when the level of the
dorsum of the hand reaches the sternal angle or the level of the suprasternal
notch. The vertical distance above the sternal angle at which the veins
collapse should be recorded as well as the position of the patient during the
test.
Auscultation at the base of the neck, just
above the clavicle and lateral to the clavicular attachment of the SCM muscle,
with the patient sitting, enables one to determine if a cervical venous
hum is present. The cervical venous hum is a continuous whining or
roaring noise throughout systole and diastole produced by the flow of blood
through the internal jugular veins. It occurs more frequently on the right than
on the left, but may be present bilaterally. It is loudest with the patient
sitting, during inspiration, and in diastole. It may be increased by turning
the head away from the side being auscultated. It is obliterated by applying
light pressure directly above the point of auscultation, the Valsalva maneuver,
compression of the internal jugular vein, or lying down. An arterial bruit, in
contrast, is loudest in systole, unaffected by light pressure, the Valsalva
maneuver, and the patient's changing position. The venous hum is a frequent finding
in normal individuals, but may also be a clue to high-output states (e.g.,
thyrotoxicosis).
Precordial Movements
and Thrills
The precordial examination, performed
next, consists of inspection and palpation of the anterior chest wall. Precordial
movements should be evaluated at the apex (left ventricle), lower left
parasternal edge (right ventricle), upper left (pulmonary artery) and upper
right (aorta) parasternal edges, and epigastric and sternoclavicular areas (Figure 7.6). It is best to
examine the precordium with the patient supine because if the patient is turned
on the left side, the apical region of the heart is displaced against the
lateral chest wall, distorting the chest movements. Inspect the chest wall by
positioning yourself on the patient's right side and looking tangentially
across the fourth, fifth, and sixth intercostal spaces. Ask the patient to take
a deep breath and then to exhale slowly as you look for a discrete area of
apical movement. The following are the factors to be considered about any
precordial movement that can be seen or felt: (1) location; (2) amplitude; (3)
duration; (4) time of the impulse in the cardiac cycle; and (5) contour.
Anteroposterior
view of the chest indicating the major precordial areas to be examined. Try to
detect by both inspection and palpation any abnormal pulsations that the
underlying cardiac chambers and great vessels may produce. Auscultation is
routinely
Locate the apex impulse by
placing the palm and fingers of your right hand over the left precordium in the
fourth, fifth, and sixth intercostal spaces near the midclavicular line (Figure 7.7). If unable to
palpate an impulse, move your hand laterally to the anterior axillary line. If
still unable to locate the impulse, ask the patient to roll onto the left side
and attempt to palpate the apex as just described (Figure 7.8). Always state
in which patient position the apex impulse was identified because the left
lateral decubitus position distorts a normal apex and makes it appear or feel
unduly sustained. If still unable to locate the apex impulse, inspect the right
precordium in a manner similar to that used for the left precordium. On rare
occasions the impulse may be visible in the right chest, providing the initial
clue to the presence of dextrocardia.
Examination
of the apex impulse in the supine position. Place the patient in the supine
position elevating the trunk approximately 30–45 degrees. Position yourself on
the patient's right side and place the flat part of your right hand over
the
Examination
of the apex impulse with the patient in the left lateral decubitus position. If
the apex impulse cannot be located with the patient supine, ask the patient to
roll to his left side and attempt to palpate the apex with the fingers of your
right
Record the location of the apex impulse by
noting its distance from either the midsternal or midclavicular line and the
intercostal space in which it is felt. Also record the approximate diameter
(cm) of the apex. The amplitude and duration of the apical pulsation may be
more important than its location and size; therefore, state whether the impulse
is of normal, increased, or diminished force and whether it occupies half or
more than half of systole. If necessary, palpate your own apex impulse for
comparison. In addition, if a single pulsation is palpated, determine whether
its force is uniform throughout systole or whether there is a late systolic
accentuation or bulge.
In a normal individual the apex impulse is
a tapping, early systolic outward thrust that occurs in the fifth intercostal
space in the midclavicular line. It is localized to a small area not more than
1 to 2 cm (dime-sized) in diameter. The outward thrust is brief, lasting about
one-half of systole, and is of minimal amplitude. Normally, diastolic
pulsations are not palpable. Left ventricular hypertrophy, for instance,
results in exaggeration of the normal left ventricular thrust both in amplitude
and duration. It is nondisplaced, sustained (occupying more than one-half of systole),
and 2 to3 cm (quarter-sized). Left ventricular dilation, in contrast, results
in downward and lateral displacement of the apex below the fifth interspace.
The lower left parasternal region of
the chest is best evaluated by looking at the chest from the side and by
placing the heel of the hand over or just to the left of the sternum (Figure 7.9). If a left
parasternal impulse or lift is appreciated, determine if the impulse is
sustained throughout systole, vigorous or slight, and begins with or after the
onset of the apex impulse. Determine its onset by placing your right hand over
the apex impulse and your left palm over the left parasternal impulse. The
right ventricle is really an anterior structure, and when enlarged, it may lift
the anterior portion of the chest including the sternum. In normal individuals
the parasternal region usually retracts (moves inward) during ejection and is
not palpable.
Palpation
of the left parasternal impulse. Place the patient in the supine position with
the trunk elevated 30–45 degrees. Place the heel of your right hand, with the
hand slightly cocked up, together with downward pressure (arrow) of your
left
Right ventricular hypertrophy and/or
dilation results in a sustained systolic lift of the lower parasternal region
of the chest. This lift is present in patients with high right ventricular
pressure (pulmonary arterial hypertension or pulmonic stenosis) or volume
overload (tricuspid regurgitation or atrial septal defect), but is infrequently
seen in chronic lung disease if right-sided heart failure is not present. The
pulsations of the main pulmonary artery are also often visible and palpable,
especially in patients with parasternal pulsations.
Patients with acute myocardial infarction
or with angina pectoris may have an outward paradoxical precordial movement
that often can be seen or palpated at the apex, the anterior precordium, or in
an "ectopic" area. The impulse is usually sustained throughout
systole, frequently with a second systolic bulge, and is often difficult to
distinguish from that of left ventricular hypertrophy by palpation alone if the
bulge occurs in the region of the apex. In order to time systolic and diastolic
cardiac movements accurately, it is essential to inspect and palpate the
precordium while actually listening to the heart sounds.
The early diastolic and late diastolic
(presystolic) precordial movements are the visible and palpable counterparts of
the third (S3) and fourth (S4) heart sounds,
respectively. They may be felt at the cardiac apex with the patient in the left
lateral decubitus position. Careful inspection of the precordium with the naked
eye or observing the motions of a wooden stick taped over the cardiac apex best
demonstrates any precordial impulses that correlate with audible S3 and
S4 sounds. The right-sided S4, seen and felt at the
lower left sternal edge, occurs slightly earlier in diastole than the
left-sided S4. It often correlates with a very prominent jugular
"a" wave and a sustained outward movement (lift) in the lower left
parasternal area.
Heart murmurs that can be palpated are
referred to as thrills . The diastolic rumble of mitral
stenosis and the systolic murmur of mitral regurgitation may be palpated at the
cardiac apex. The harsh systolic murmur of aortic stenosis may cut across the
palm of the hand toward the right side of the neck, while the thrill of
pulmonic stenosis cuts across the palm of the hand to the left side of the
neck. The thrill due to ventricular septal defect is usually located in the
third and fourth intercostal spaces near the left sternal border. Heart sounds
may also be palpable. For instance, the loud S1 of mitral
stenosis may be palpated at the apex.
Heart Sounds and
Murmurs
Auscultation of the heart is
performed after examining the jugular venous pulse, carotid pulse, and
precordial movements because acoustic events can best be interpreted after the
other components of the cardiac examination have been evaluated. Auscultation
of the heart should, therefore, not be performed as an isolated event because
heart sounds, murmurs and pulse tracings must all be integrated in order to
understand normal and altered cardiac physiology and anatomy. Attempt to study
two and occasionally three aspects of the cardiac examination simultaneously.
Then pictorially display the heart sounds and correlate them, by use of a
diagram, with any murmurs heard, the jugular venous wave form, the carotid
pulse, and the apex impulse to best understand the patient's cardiac problem (Figure 7.2).
Proper use of a quality stethoscope is
essential for an accurate auscultatory examination. The important parts of the
stethoscope are the ear pieces, the tubing, and the chest pieces. The ear
pieces must fit the ear canal snugly without going to an uncomfortable depth.
The tubing should be as short as possible, but long enough to be comfortable
and convenient for the user; 10 to 12 inches is an ideal length. The chest
pieces, the bell, and the diaphragm should be combined into one housing. A
diaphragm pressed firmly on the chest filters out low-frequency vibrations and
amplifies high-frequency vibrations. It is routinely used to hear the first and
second heart sounds, systolic murmurs, and the diastolic murmur of aortic
regurgitation. The bell should be applied to the chest with very light
pressure, barely creating an air seal, so low-frequency sounds and murmurs are
appreciated. It is used to hear the third and fourth heart sounds and the
diastolic murmur (rumble) of mitral stenosis. A trumpet-shaped bell is much
better than a shallow one.
Auscultation usually begins at the aortic
area (upper right sternal edge). The stethoscope is then moved sequentially to
the pulmonary (upper left sternal edge), tricuspid (lower left sternal edge),
and mitral (apex) areas. It is helpful to palpate the carotid pulse or apex
impulse simultaneously to time the acoustic events as systolic or diastolic. A
finger on the carotid artery will sense the systolic thrust that is virtually
coincident with S1. Use of a more distant artery for this purpose
leads to error because of the time it takes the pulse wave to reach the
periphery.
The heart sounds are usually the first
auscultatory events identified. They are brief, discrete, auditory vibrations
of varying intensity (loudness) and frequency (pitch). The first heart
sound identifies the onset of systole. It is normally split into
mitral (M1) and tricuspid (T1) components that are
temporally related to closure of the respective atrioventricular (A-V) valves.
The second heart sound identifies the end of systole and the
onset of diastole. It is normally split into aortic (A2) and
pulmonic (P2) components that are temporally related to closure of the
respective semilunar valves. The second sound is louder than S1 in
the aortic listening area; S1 is louder at the apex.
In the aortic area, listen for the first
and second heart sounds, the aortic ejection sound, and the murmurs of aortic stenosis
and aortic regurgitation with the stethoscope diaphragm. Then move the
diaphragm to the second and third left intercostal spaces in order to
appreciate the aortic and pulmonic components of S2, the pulmonary
ejection sound, and the murmurs of pulmonic stenosis and pulmonary and aortic
regurgitation. Continue to the fourth and fifth intercostal spaces along the
left sternal border and listen for the murmurs of tricuspid regurgitation and
tricuspid stenosis and the murmur produced by ventricular septal defect. Right
ventricular S3 and S4 sounds (gallops) can best
be heard in this area with the stethoscope bell. The diaphragm should be moved
to the third and fourth intercostal spaces to the right of the sternum to judge
whether a murmur of aortic regurgitation is louder along the left or right
sternal border.
The diaphragm should then be positioned at
the cardiac apex where S1 and S2 should again
be studied. An aortic ejection sound, a mid to late systolic click, the opening
snap of mitral stenosis, the systolic murmur of mitral regurgitation, and
occasionally the high-pitched murmur of aortic regurgitation are also heard in
this area with the diaphragm.
The bell of the stethoscope should then be
positioned over the apical impulse with the patient turned to the left lateral
position to listen for low-frequency diastolic sounds and murmurs.
Have the patient exercise (5 to 10
sit-ups), or cough if myocardial infarction is suspected, to "bring
out" the murmur of mitral stenosis and the S3 and S4 gallop
sounds. The third and fourth heart sounds
are low pitched and may be audible as well as palpable. They are best
heard at the cardiac apex when generated from the left ventricle and at the
lower left sternal edge when generated from the right ventricle.
The technique known as inching may help
determine whether extra cardiac sounds are systolic or diastolic. The examiner
moves the stethoscope inch by inch from the aortic area to the apex while
focusing attention on S2. Determine whether the extra sound precedes
(systolic) or follows (diastolic) S2. The acoustic events can best
be appreciated by a careful review of the hemodynamic curves of the cardiac
cycle.
Several additional areas should be
ausculted (Figure 7.10), including
(1) the inferior edge of the sternum and epigastrium, especially in patients
with chronic obstructive lung disease, in whom heart sounds and murmurs are
difficult to hear in the more conventional listening areas; (2) the first and
second intercostal spaces below the left midclavicular area for the continuous
(systolic and diastolic) murmur of patent ductus arteriosus; (3) the
interscapular area of the back for the systolic murmur of coarctation of the
aorta; (4) over the lung areas; (5) over the head, eyes, liver, sacrum,
abdomen, as well as over tumors or bony overgrowths; and (6) over all scars to
identify the continuous murmur of a peripheral A-V Fistula.
Anteroposterior
view of the chest showing some additional areas shaded for auscultation. The
first and second left intercostal spaces at the mid clavicular line (MCL). The
fifth intercostal space to the right of the sternum. The epigastric area just
below
Murmurs are prolonged series of auditory
vibrations that should be characterized according to (1) timing in the cardiac
cycle (systolic, diastolic, continuous); (2) intensity (loudness); (3) frequency
(pitch); (4) configuration (shape); (5) duration (long or short); (6) radiation
(to other auscultatory areas); and (7) variation, if any, with respiration or
other maneuvers (position change, Valsalva, etc.).
The classic way to time murmurs and heart
sounds is with a finger on the carotid arterial pulse. The heart sound
virtually coinciding with the carotid upstroke (pulse) is Sl and
the heart sound just after the carotid pulse is S2. The intensity of
a murmur is graded I to VI with I faint, III loud, IV palpable, and VI loud
enough to be heard with the stethoscope just off the chest. The frequency of a
murmur varies from low (rumbling) to mid (harsh) to high (blowing). The
configuration is described as crescendo (increases progressively in intensity),
decrescendo (decreases progressively in intensity), crescendo-decrescendo
(diamond-shaped), or plateau (even). Of all the parameters by which a murmur is
analyzed, its time of occurrence in the cardiac cycle and the precordial area
of maximal intensity are easiest to learn and thus are most reliable.
The influence of respiration on the second
sound is extremely important. The examiner will wish to note respiratory
variation both during quiet breathing and at times during exaggerated
breathing. The interval between the two audible components of S2 normally
increases on inspiration and virtually disappears on expiration. The Valsalva
maneuver may be used to exaggerate the effects of respiration. Variation in the
cardiac cycle, as with atrial fibrillation or heart block, may also exert
profound influences on S2 and on S1. When S2 is
split, determine the relative loudness of each component (A2 and
P2).
Examination of the
Peripheral Arteries
The evaluation of the peripheral
arterial pulses is an integral part of the cardiovascular examination.
Palpation of the peripheral arteries may yield the following information: (1)
frequency and regularity of the pulsations; (2) condition and patency of the
peripheral arteries; and (3) characteristics of the arterial pulse wave. All of
the following pulses should be examined thoroughly by palpation: temporals,
brachials, radials, aortic, femorals, popliteals, posterior tibials, and the
dorsalis pedii (Figure 7.11). When
applicable, pulses should be examined bilaterally and graded as to quality of
the impulse on a scale of 0 to 3 with 2 being normal, 0 absent, 1 decreased,
and 3 increased. In addition, hair distribution should be checked on the toes
and feet.
Location
of the arteries that are routinely examined. The temporalis artery is located
in front of the ear where it is very superficial and readily palpated. Pulses in
the upper extremities can be identified at the brachial artery, just medial to
the
To examine the brachial artery, palpate
along the course of the artery just medial to the biceps tendon and lateral to
the medial epicondyle of the humerus. To examine the radial artery, palpate
along the radial–volar aspect of the subject's forearm at the wrist.
The abdominal aorta is an upper abdominal,
retroperitoneal structure that is best palpated by applying firm pressure with
the flattened fingers of both hands to indent the epigastrium toward the
vertebral column. The normal aortic pulse should be less than 6 cm in diameter.
Auscultation should be performed over the aorta and along both iliac arteries
into the lower abdominal quadrants to detect bruits.
The femoral artery is best palpated with
the fingertips of the examining hand pressed firmly into the groin.
Auscultation should be performed in this area as well.
The popliteal artery passes vertically
through the deep portion of the popliteal space. It may be difficult or
impossible to palpate in obese or very muscular individuals. The pulse is
detected by pressing deeply into the popliteal space with the supporting
fingertips.
The posterior tibial artery lies just
posterior to the medial malleolus and is felt most readily by curling the
fingers of the examining hand around the ankle.
The dorsalis pedis artery usually lies
near the center of the long axis of the foot. Place the fingertips transversely
across the dorsum of the forefoot near the ankle. This pulse often requires
some searching and is congenitally absent in approximately 10% of normal
individuals.
Information should be obtained by
simultaneously palpating the radial and femoral arteries and noting the
relative time of onset of the pulse at the two locations. Normally, the pulse
wave arrives in these locations virtually simultaneously. In a patient with
coarctation of the aorta, both onset and peak of the weak femoral pulses are
delayed. Compared to the carotid pulse, the pulse wave in these more peripheral
vessels arrives later and is characterized by a steeper initial wave that
reaches a higher systolic peak, whereas the diastolic and the mean arterial
pressures are lower.
Palpating peripheral arteries is the most
important single maneuver in establishing whether or not chronic occlusive
arterial disease is present. One may obtain an impression of thickness and
hardness of the walls of the brachial, radial, and dorsalis pedis arteries by
"rolling" the compressed vessel against the underlying tissue.
Auscultation of the peripheral arteries is also very important. A systolic
bruit over the abdominal aorta, iliac, or femoral arteries when the patient has
been supine for more than 10 minutes usually signifies intimal disease, but not
necessarily significant occlusion.
Pulsus alternans refers to a
characteristic pulse pattern in which the beats occur at regular intervals, but
with an alternation of the height of the pulse. This valuable sign should be
searched for by palpating the femoral artery; less often, the radial artery may
disclose that alternate pulses vary in amplitude. Have the patient hold his or
her breath while you feel the pulse to make certain that the alternation of
pulse volume is independent of respiration. The pulse rhythm should be regular,
since alternation of the strength of cardiac beats commonly results from
bigeminal rhythm. Rarely, pulsus alternans may feel irregular because of a
slight delay in sensing the weaker beat.
When pulsus alternans is prominent, it may
be confirmed and quantified by use of a sphygmomanometer. As the pressure is
lowered in the sphygmomanometer, the examiner should routinely observe whether
every Korotkoff sound is heard with equal intensity. As the cuff pressure is
lowered further, the frequency of the sounds may suddenly double as the weaker
beats also become audible. In most instances, the weak pulses are only slightly
weaker than the strong beats. On rare occasions, a weak beat may be so small
that no palpable pulse is detected at the periphery, so-called total alternans.
Pulsus alternans is produced by an alternation in left ventricular contractile
force associated with an alternation of left ventricular fiber length; it is a
very valuable sign of left ventricular dysfunction. In most instances, it is found
in association with a third heart sound.
Examination for
Thrombophlebitis
The presence or absence of thrombophlebitis is
an integral part of the cardiovascular database. Thrombophlebitis refers to
venous inflammation with secondary thrombosis of the involved vein. It is most
commonly noted in the deep veins of the leg and superficial veins of the arm.
Superficial thrombophlebitis can be seen and felt, making the diagnosis easy in
most cases. Most deep vein thromboses are clinically silent and cannot be
detected by routine examination. When thrombophlebitis is confined to small
venous channels beneath the subcutaneous tissue or in the pelvis, the lesions
are neither visible nor palpable. Mild pain in the calf may be the only
symptom, and tenderness may be the only sign.
The examiner should also compare the skin
temperature in the two calves, since active phlebitis may create local warmth.
Calf circumference should also be determined in all suspected cases. Pain is a
prominent feature of muscular, synovial, or vascular leg diseases, and various
tests have been used to identify the specific etiology. Homans's test
(dorsiflexion sign) is used to detect irritability of the posterior leg muscles
through which inflamed or thrombosed veins course. The Lowenberg cuff test is
another helpful clinical maneuver for detection of calf vein thrombosis.
A summary of only the most common
conditions associated with an abnormality on the cardiovascular examination is
shown inTable 7.4.
Common
Conditions Associated with an Abnormality on the Cardiovascular Examination.
Conclusion
An orderly process of history
taking and physical examination together with selective application of modern
laboratory technology should enable the clinician to arrive at an
accurate diagnosis, estimate the degree of severity, formulate
a logical plan of treatment,and better understand the
pathophysiologic abnormalities in the patient with a cardiovascular problem.