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Heart & Neck Vessel & Peripheral Vascular Assessment
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Assessment of the Heart, Great vessels Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular of the neck, and Peripheral Vascular
systemsystem
Rachel S. Natividad, RN,MSN
Position in the ChestPosition in the Chest
Beneath precordium—area on Beneath precordium—area on anterior chest overlying the anterior chest overlying the heart and great vesselsheart and great vessels
Located in mediastinum—Located in mediastinum—middle third of chest—middle third of chest—between the lungsbetween the lungs
Heart is an Heart is an upside down upside down triangle in the triangle in the chestchest
Top of heart isTop of heart is BaseBase, bottom , bottom is is ApexApex
Extends from Extends from 2nd to 5th ICS 2nd to 5th ICS and from Rt and from Rt sternal border sternal border to Lt MCLto Lt MCL
Great vessels Great vessels above base of above base of heartheart
Great vessels of the neckGreat vessels of the neck Jugular veinsJugular veins
Carotid arteriesCarotid arteries
JUGULAR VENOUS DISTENTION
JVDJVD
Anatomy of the HeartAnatomy of the Heart
AssessmentAssessment
Position client Position client supinesupine ThenThen head elevated at 45 degrees head elevated at 45 degrees
INSPECTION:INSPECTION: Lifts, heavesLifts, heaves PMI (assess location)PMI (assess location)
PalpationPalpation
Physical LandmarksPhysical Landmarks
Suprasternal Suprasternal notchnotch
SternumSternum Manubriosternal Manubriosternal
angle – Angle of angle – Angle of LouisLouis
Intercostal Intercostal SpacesSpaces
Auscultation: Auscultation: Auscultatory SitesAuscultatory Sites
Auscultatory Sites: Cont.Auscultatory Sites: Cont.
Heart Sounds – S1…(Lub)…Heart Sounds – S1…(Lub)…
S1: Closure of AV S1: Closure of AV valves (mitral and valves (mitral and tricuspid valves: tricuspid valves: M1 before T1)M1 before T1)
Correlates with the Correlates with the carotid pulsecarotid pulse
Can be split but not Can be split but not oftenoften
Heart Sounds – S2…(Dub)…Heart Sounds – S2…(Dub)…
S2: Closure of S2: Closure of Semilunar valves Semilunar valves (aortic & pulmonic) (aortic & pulmonic)
May have a split May have a split sound (A2 before sound (A2 before P2)P2)
Heart Sounds – Cont.Heart Sounds – Cont.
Base (R/L 2nd ICS)Base (R/L 2nd ICS)– S2 louder than S1S2 louder than S1
Apex Apex – S1 louder than S2S1 louder than S2
Normal physiologic S2 Normal physiologic S2 SplitSplit– Best heard at pulmonic Best heard at pulmonic
area area during inspirationduring inspiration
Fixed split (no variation Fixed split (no variation with inspiration)with inspiration)
Extra Heart SoundsExtra Heart SoundsS3…S3… Due to Rapid Due to Rapid
ventricularventricular filling: filling: ventricular gallopventricular gallop
S1 -- S2-S3 (Ken--tuc-S1 -- S2-S3 (Ken--tuc-ky) ky)
S4…S4… Due to slow ventricular Due to slow ventricular
contraction: atrial contraction: atrial gallopgallop
S4-S1 — S2 (Ten-nes—S4-S1 — S2 (Ten-nes—see)see)
MurmursMurmurs
Grade IGrade I :barely audible :barely audible Gr II :Gr II : audible but audible but
quiet and softquiet and soft Gr IIIGr III : moderated : moderated
loud, without thrust or loud, without thrust or thrillthrill
Gr IVGr IV : loud, with thrill : loud, with thrill Gr VGr V : louder with thrill, : louder with thrill,
steth on chest wallsteth on chest wall Gr VIGr VI : loud enough to : loud enough to
be heard before steth be heard before steth on cheston chest
turbulent blood flow turbulent blood flow within the heartwithin the heart
Listen for murmurs in Listen for murmurs in the same auscultatory the same auscultatory sites APETMsites APETM
Peripheral Vascular Peripheral Vascular AssessmentAssessment
Skin tempSkin temp ColorColor PulsesPulses Cap refillCap refill edemaedema
Peripheral PulsesPeripheral Pulses
Documentation of PulsesDocumentation of Pulses
Capillary RefillCapillary Refill
EdemaEdema
Pitting edemaPitting edema
Assessing for EdemaAssessing for Edema
Depress Depress
pretibial area pretibial area & medial & medial malleolusmalleolus for for 5 5 secondsseconds
Grade pitting Grade pitting edemaedema1+ to 4+1+ to 4+
Deep Vein Thrombosis Deep Vein Thrombosis (DVT)(DVT)
Assessment Guide: Gas Assessment Guide: Gas TransportationTransportation
Blood Pressure: 128/64, 132/72Apical Heart Rate: 80, 74Peripheral Pulse:
Radial rate: 78, 74Rhythm: regular, irregularStrength: strong, weak, thready, bounding,0-+4Rt. Pedal pulse: 2+Lt. Pedal pulse: 2+Edema: present, noneEdema: present, none
Degree: 1+, 2+Degree: 1+, 2+Location: LLE, RUELocation: LLE, RUE
Cap refillCap refill– Upper extremities: 2 secUpper extremities: 2 sec– Lower extremities: 2 secLower extremities: 2 sec
Skin/Mucous Membranes: Other Skin/Mucous Membranes: Other (bleeding, infection)(bleeding, infection)– Skin /mucous membranes pinkSkin /mucous membranes pink– note vascular lesions (purpura, note vascular lesions (purpura,
ecchymoses, petechiae)ecchymoses, petechiae)– redness and inflammationredness and inflammation– Interventions in useInterventions in use
Venodyne/leg compression machine; Venodyne/leg compression machine; elevated LEs on pillow; thigh high elevated LEs on pillow; thigh high tedhose in usetedhose in use
Med List: Digoxin, Atenolol, Zestril, etc.Med List: Digoxin, Atenolol, Zestril, etc.
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Inspection1. Observe arm size & venous pattern; also look for edema
Arms are bilaterally symmetric with minimal variation in size and shape.
No edema or prominent venous patterning
Lymphedema – results from blocked lymphatic circulation, which may be caused by breast surgery
Lymphedema – affects 1 extremity, causing induration and nonpitting edema.
Prominent venous patterning with edema – venous obstruction
Peripheral Vascular AssessmentPeripheral Vascular Assessment
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Inspection2. Observe coloration of the hands and arms.
Color varies depending on the client’s skin tone, although color should be the same bilaterally.
Raynaud’s disease Vascular disorder caused by vasoconstriction of the fingers or toesCaused by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, & coldness.Occurs bilaterally; symptoms last minutes to hours
Peripheral Vascular AssessmentPeripheral Vascular Assessment
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Palpation1. Palpate the client’s fingers, hands, and arms, and note the temperature..
Skin is warm to touch bilaterally
Cool extremity – sign of arterial insufficiency.
Cold fingers and hands – common in Raynaud’s disease.
Peripheral Vascular AssessmentPeripheral Vascular Assessment
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Palpation2. Palpate to assess capillary refill time (CRT). Compress the nailbed until it blanches.Release the pressure and calculate the time it takes for color to return.Indicates peripheral perfusion and reflects cardiac outputCLINICAL TIP: X findings – rm temp is cool, pt has edema, anemia, or recently smoked a cigar
Capillary bed refill (and therefore color returns) in 1-2 sec.
CRT greater than 2 seconds: (1) vasoconstriction (2) decreased CO (3) shock (4) arterial occlusion (5) hypothermia
Peripheral Vascular AssessmentPeripheral Vascular Assessment
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Palpation3. Palpate the radial pulse.Gently press the radial artery against the radius.CLINICAL TIP: For difficult-to-palpate pulses, use a Doppler ultrasound device.
Radial pulses have equal strength bilaterally (2+). Artery walls have a resilient quality (bounce)
Increased radial pulse (1) hyperkinetic stateDiminished or absent radial pulse (1) Partial or complete arterial occlusion (more common in legs than in the arms) (2) Buerger’s disease (3) Scleroderma*Obliteration of the pulse may result from compression by external sources, as in compartment syndrome
Peripheral Vascular AssessmentPeripheral Vascular Assessment
Buerger’s Disease
The initial symptoms of Buerger’s Disease often include claudication (pain induced by insufficient blood flow during exercise) in the feet and/or hands, or pain in these areas at rest. The pain typically begins in the extremities but may radiate to other (more central) parts of the body. Other signs and symptoms of this disease may include numbness and/or tingling in the limbs and Raynaud’s phenomenon (a condition in which the distal extremities — fingers, toes, hands, feet — turn white upon exposure to cold). Skin ulcerations and gangrene (pictured below) of the digits (fingers and toes) are common in Buerger’s disease. Pain may be very intense in the affected regions.
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Palpation4. Palpate the ulnar pulse.Not routinely assessed bec. they are located than radial pulses and are difficult to dectect.Done if you suspect arterial insufficiency
Ulnar pulses may not be detected.
Lack of resilience or inelasticity of the artery - arteriosclerosis
Peripheral Vascular AssessmentPeripheral Vascular Assessment
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Palpation5. Palpate the epithrochlear lymph nodes.Take the client’s left hand in your right hand as if you were shaking hands.Flex the client’s elbow about 90 degrees.Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles.If nodes are detected, evaluate for size, tenderness, and consistency
Normally not palpable. Enlarged nodes (1) infection in the hand or forearm (2) may occur w/ generalized lymphadeno- pathy (3) lesion in the area
Peripheral Vascular AssessmentPeripheral Vascular Assessment
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Palpation7. Perform the Allen Test.Evaluates patency of the radial or ulnar arteries.Done when patency is questionable or before procedures such as a radial artery puncture.Begins by assessing the ulnar patency.Have pt rest hand palm side up on the exam table and make a fist.
Pink coloration returns to the palms within 3-5 seconds if the ulnar artery is patent.Pink coloration returns within 3-5 seconds if the radial artery is patent.
Arterial insufficiency or occlusion of the ulnar & radial artery – pallor persists,
Peripheral Vascular AssessmentPeripheral Vascular Assessment
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Palpation7. Perform the Allen Test.To assess radial patency, repeat the procedure as before, but at the last test, release pressure on the radial artery.
Peripheral Vascular AssessmentPeripheral Vascular Assessment
ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Palpation7. Perform the Allen Test.Evaluates patency of the radial or ulnar arteries.Done when patency is questionable or before procedures such as a radial artery puncture.Begins by assessing the ulnar patency.Have pt rest hand palm side up on the exam table and make a fist.
Peripheral Vascular AssessmentPeripheral Vascular Assessment
LegsLegs NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL
Palpation1. Palpate the superficial inguinal lymph nodes.
Nontender movable lymph nodes up to 1 or even 2 cm are commonly palpated.
Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy)
(1) local infection (2) generalized lymphadenopathy Fixed nodes -
malignancy
Peripheral Vascular AssessmentPeripheral Vascular Assessment