Cardiac physical assessment PDF

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Cardiac Examination • • • • • • •

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Review vital signs Look for signs of cardiovascular problems Inspect and palpate the neck for carotid pulses Auscultate the neck for bruits Inspect and palpate the precordium for pulsations Auscultate over the precordium at five auscultatory sites Review vital signs o Fever may explain increased heart rate o Heart failure: short of breath with rapid, shallow respirations o Weight is significant for cardiac assessment as well o Poor cardiac output: edema or fluid collection in tissues Look for cardiovascular problems o In pain o Trouble breathing o Shortness of breath o Alert and oriented o Skin condition o Clubbing of nailbeds: due to inadequate supply of oxygenation in the peripheral system o Retract lower eyelids to inspect the palpebral conjunctivae (poor cardiac perfusion may be pale) Inspect and palpate the neck for carotid pulses o Neck o Groove between the trachea and sternocleidomastoid muscle, palpate the carotid arteries o This and checking for jugulovenous distension are described in the neck portion of the physical examination o Avoid disrupting blood flow to brain: palpate one side at a time o Note rate and rhythm of carotid pulsations, are they equal, not elasticity of carotid arteries, do they feel soft and pliable or stiff due to atherosclerosis o Check for jugulovenous distention or JVD ▪ Most common with heart failure, especially right sided failure but it can occur with anything that increases pressure in either the superior vena cava or right atrium ▪ Measure clients venous pressure by using two rulers to measure the vertical distance between the angle of louis and the highest level of the visible point of the intercostal jugular vein pulsation ▪ Repeat measurement on the opposite side Auscultate the neck for bruits o Using bell of stethoscope and light pressure, listen over the carotid areries for bruits heard as blowing or swishing sounds that reflect turbulent blood flow o Patient has atherosclerosis: important o Depending on length of neck, listen at two or three places along the carotid artery

Breathing interferes with ability to listen, ask patient to hold his breath briefly for this part Inspect and palpate the precordium for pulsations o Turn attention to patients anterior chest wall or precordium o Have patient bare his chest o Inspect for apical pulsation ▪ This pulse is also called the point of maximal impulse PMI occurs as the apex of the heart bumps against the chest wall with each heartbeat ▪ Not always visible and more easily seen in patients who have thin chest walls or enlarged hearts or high cardiac output stages like exercise or fluid volume overload ▪ Having patient sit upright or lean forward is useful as it brings heart closer to the chest wall ▪ Breast tissue makes it difficult to see ▪ PMI visible: note location and size ▪ Normally, PMI located near the fourth or fifth intercostal space near the left midclavicular line and covers an area no larger than that of a nickel ▪ If left ventricle is enlarged as with left ventricular hypertrophy, the apical impulse may be visible ▪ Inspect for pulsations all over the precordium and upper abdomen for any abnormal findings ▪ Palpate the PMI ▪ Lift: so forceful it lifts fingers upward ▪ Heave: feels rolling under fingers ▪ Thrill or vibration: 4 fingers to palpate over PMI ▪ Paplate the rest of precordium using the same sequence as for listening to heart sounds ▪ If you choose to palpate the entire precordium, lay your fingertips lightly over each of the five precordial landmarks described in the sequence ▪ Firm pressure can obliterate pulsations ▪ Normally you will feel no pulsations in these areas ▪ Angle of Louis o

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• Second intercostal space

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• Fifth intercostal space

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Midclavicular line

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• Point of maximal impulse PMI

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Auscultate over the precordium at five auscultatory sites

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Listen for heart sounds by auscultating with your stethoscope at each of the five precordial landmarks Places on the chest wall where you can hear sounds the best Aortic and pulmonic: base of heart Aortic: lies in the second intercostal space at the right sternal border To find second intercostal space, feel for angle of louis, where the manubrium joins the body of the sternum an inch or two below the sternal notch

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Second ribs attach to the sternum at this level and the second intercostal space is just below the second rib Auscultating at this sit useful for assessing aortic valve Next three points are along the left sternal border Pulmonic area which is where you can best hear the pulmonic valve is at the left base of the heart located in the second intercostal space along the left sternal border Erbs point can be found at the third intercostal space, one interspace below the pulmonic area ▪ Does not reflect sound from one particular heart valve, but is a common listening post lying halfway between the base and the apex of the heart Fourth intercostal space along the left sternal border, you will find tricuspid listening post, which is the best place to listen to the tricuspid valve Final listening post is the same site where you found the PMI- at the apex, normally located in the fifth intercostal space at the left midclavicular line Using diaphragm of your stethoscope listen to each posts Listen for first and second heart sounds ▪ First heart sound: lub called S1 occurs when the tricuspid and mitral valves snap shut at the beginning of systole. ▪ S1 is therefore loudest at the apex of the heart, over tricuspid and mitral valves. ▪ The second heart sound, which is the dub or S2 occurs when the aortic and pulmonic valves close at the beginning af diastole, and so S2 is best heard at the base of the heart, at the aortic and pulmonic listening posts. ▪ At the second pulmonic area, s1 and s2 are typically equal in sound volume. Helpful to inch your steth from one point to the next rather then picking it up and down ▪ Track sounds as you move over precordium ▪ Concentrate on S1 and S1 and try to identify each sound ▪ Differentiate the two • Rhythm o Heart rate slower then 100 bpm, systole is shorter then diastole so longer pause after s2 ▪ S2 louder at base while s1 louder at apex o Palpate carotid pulse while you listen over the precordium ▪ S1 occurs at beginning of systole, coincides with the carotid pulse o Each sound is generated by two valves closing one on each side of the heart, if they valves do not close simultaneously, heart sound may be split o S3 in patients with congestive heart failure o S4 associated with hypertension, coronary artery disease, and myocardial infarction Listen to the spaces between s1 and s2 as well ▪ Should be silent because the blood should be flowing smoothly through the heart valves

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Valve is stenotic: does not open widely, blood may flow through it in a turbulent fashion causing a whooshing or swishing sound • Called a murmur • Valve doesn’t close tightly, blood may leak backward also causing a murmur • Notice where on the precordium it sounds loudest and try to place the murmur in either systole or diastole • May here systolic murmur only in the aortic area • Graded 1-6 6 loudest • 4 and above accompanied by a palpable thrill • Repeat sequence for cardiac auscultation using bell sound of stethoscope • Use light pressure when using bell so you can identify low pitched murmurs • S3 and 4 are low pitches sounds so they are also heard better with the bell of the stethoscope Pericardial friction rub ▪ Occur when pericardium, the membrane surrounding the heart becomes inflamed ▪ Causes a high pitched, scratchy sound like sandpaper ▪ Can be heard throughout systole and diastole and loudest over apex of the heart ▪ More likely to hear with a diaphragm

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Review vital signs Note clients overall condition Note level of consciousness Consider overall skin condition Inspect and palpate skin, cool moist dry Look for clubbing, sign of long term oxygen deprivation o Look for capillary refill Inspect eyelids Palpate carotid arteries one side at a time o Note rate and rhythm or carotid pulsations ▪ Diminished, normal or forceful or stiff o Listen over carotid arteries with stethoscope for bruits ▪ Could be two or three places along artery 45 degrees, check jugular venous distension (CHF) Bear chest Apical pulsations Visual indications of pulse? Note size Palpate PMI

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Bony part palpate for thrill or vibration over pmi Listen heart sounds at 5 precordial landmarks Aortic site, feel for angle of lous, lies just to the right at second intercostal space o Assess aortic valve. Listen for s1 and s2. o Move over to left sternal border and second intercostal space to listen to pulmonic valve o Move to third intercostal space at lsb for second pulmonic area o Fourth intercostal space lsb for tricuspid valve o Apical/mitral area, fifth intercostal space, PMI, best place to listen o Use bell of steth with light pressure to go over each listening sites...