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Study Guide for Cardiac Assessment
 Anatomy and Physiology
 Base
 Apex
 Pericardium
 Parietal
 Visceral
 Precordium, Apex, and Base
 Anatomy and Physiology
 Chambers of the heart
 Right and left atria
 Right and left ventricles
 Heart Valves
 Semilunar valves
 Pulmonic
 Aortic
 Atrioventricular valves (A-V)
 Tricuspid
 Mitral
 Conduction
 Heart has unique ability: automaticity
 SA node has intrinsic rhythm, it is called the pacemaker
 Current flows in orderly sequence, SA to AV to bundle of His, right and left bundle branches, and then
through ventricles
 Electrical impulse stimulates heart to do its work, which is to contract
 Small amount of electricity spreads to body surface, and can be measured and recorded on
electrocardiograph (ECG)
 ECG
 ECG waves arbitrarily labeled PQRST, which stand for
 P wave: depolarization of atria
 P-R interval: from beginning of P wave to beginning of
 QRS complex (time necessary for atrial depolarization plus time for impulse to travel through AV
node to ventricles)
 QRS complex: depolarization of ventricles
 T wave: repolarization of ventricles
 Electrical events slightly precede mechanical events in heart
 Conditions Related to Coronary Circulation
 Ischemia
 Infarction
 Angina
 Cardiac Output
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 CO = SV x HR
 CO = Cardiac Output
 Stroke Volume (SV)
 Volume of blood ejected by the ventricles in one cardiac cycle
 Heart Rate (HR)
 Number of cardiac cycles in one minute
 Problems Associated with Decreased Cardiac Output
 Loss of blood volume
 _______________________
 Hemorrhagic
 Burns, Emesis, etc.
 Heart Rate
 Tachycardia
 Bradycardia
 Pump Issues
 Coronary Circulation
 Angina Pectoris
 __________________________
 Congestive Heart Failure (CHF)
 Trauma
 Direct
 Indirect
 Peripheral Vasculature
 Arterial system
 Arteries
 Arterioles
 Capillaries
 Venous system
 Veins
 Venules
 Subjective Data
 Chest pain
 Palpitations
 Syncope
 Dyspnea
 Orthopnea
 Cough
 Fatigue
 Cyanosis or pallor
 Edema
 Vascular
 Claudication
 DVT
 Past cardiac history
 Family cardiac history
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 Personal habits (cardiac risk factors)
 Chest Pain…Cardiac? Something Else?
 Chest Pain - Cardiac
 Angina, MI, pericarditis
 Other concerns
 Differentiate between cardiac, respiratory, musculoskeletal, gastrointestinal or psychosomatic
 Past Health History
 Medical
 Cardiac specific: AAA, angina, CAD, CHF, HTN, MI, PVD, hyperlipidemia
 Noncardiac specific: bleeding or blood disorder, DM, gout, renal artery disease, CVA, or thyroid
disease
 Surgical
 Prior cardiovascular procedures: aneurysm repair, coronary bypass graft surgery (CABG), heart
transplant, valve replacement, implantable or internal cardioverter or defibrillator (ICD)
 Common medications
 Antianginals or vasodilators
 Antidysrhythmics
 Anticoagulants
 Antihypertensives
 Antilipemics
 Diuretics
 Inotropics
 Thrombolytics
 Communicable diseases
 Childhood illnesses
 Allergies
 Aspirin
 ____________________
 Seafood
 Betadine
 Latex
 Family Health History
 Assess for the following diseases
 Aneurysm – AAA (abdominal aortic aneurysm)
 CAD (coronary artery disease)
 CVA (stroke)
 HTN (hypertension)
 CHF (congestive heart failure)
 MI or sudden cardiac death
 MVP (mitral valve prolapse)
 Rheumatic fever
 Social History
 Alcohol, drug, or tobacco use
 Sexual practices
 Work and home environment
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





Stress
Health Maintenance Activities
Sleep
Diet
Exercise
Health checkups
 Patient Education
 Risk factor modification
 Heart Smart diet
 Exercise
 Sexual activity
 Risk Factors
 _______________________
 HTN, hyperlipidemia, tobacco use, physical inactivity, diet, glucose intolerance, stress, sedentary
lifestyle, obesity
 Nonmodifiable
 Age, gender, race, family history
 Assessment Equipment
 Stethoscope
 Sphygmomanometer
 Watch with second hand
 Assessment tips
 Explain procedure
 Ensure room is quiet and well lit
 Expose patient’s chest only
 Position patient in a supine or sitting position
 Stand to the patient’s _______________
 Assessment of the Precordium and Peripheral vasculature
 Inspection
 Palpation
 Auscultation
 Inspection
 Assess the following areas: aortic , pulmonic, midprecordial, tricuspid, and mitral
 Normal findings: no visible ______________except for the PMI in the mitral area
 Palpation
 Assess for pulsations, thrills, _________________
 Assess the following areas: aortic , pulmonic, midprecordial, tricuspid, and mitral
 Normal findings
 No pulsations, thrills, or heaves palpated, except in the mitral area where the apical impulse may be
palpated
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 Landmarks – APE To Man
 A=Aortic 2nd ICS RSB
 P=Pulmonic 2nd ICS LSB
 E= Erb’s point 3rd ICS LSB
 T= Tricuspid 4th ICS LSB
 M= Mitral 5th ICS MCL
 Auscultation
 Warm stethoscope
 Listen to all ______cardiac landmarks
 Listen for at least a few cardiac cycles in each area
 Listen first for S1 and S2, then for possible S3 and S4.
Finally listen for murmurs, clicks and friction rubs
 Normal Systolic Sound: S1
 S1 – blood heaves against the closed mitral and tricuspid
valves in the heart
 High pitched – heard with diaphragm
 Heard best at Apex –____________area
 LUB – dub
 Normal Diastolic Sound: S2
 Represents closure of aortic and pulmonic valves
 Heard best at Base –____________area
 lub – DUB
 Auscultation: Normal Findings
 Aortic: S2 is louder than S1
Pulmonic: S2 is louder than S1

Midprecordial (______________) both aortic and pulmonic murmurs by be heard

 Tricuspid: S1 is louder than S2
 Mitral: S1 is louder than S2
 Mitral and tricuspid: S3 (gallop) may be heard in children, young adults, and pregnant women. S4 may
indicate cardiac decompensation
 Evaluating Cardiac Sounds
 Rate
 Bradycardia
 Tachycardia
 Rhythm
 Murmurs, Gallops Clicks or Rubs
 Abnormal Finding - Murmur
 Blowing, whooshing, or rasping sounds
 The result of vibrations caused by abnormal blood flow patterns
 valve does not close tightly (such as with mitral regurgitation)
 an irregularity in the shape of a heart chamber or one of the great vessels (such as an aortic
aneurysm)
 Blood is flowing through a narrowed opening or a stiff valve (such as with aortic stenosis).
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 Does not necessarily indicate a disease or disorder, and all heart disorders do not cause murmurs.
 If difficult to hear
 Place in lateral recumbent position – low pitched, mitral – use bell
 Lean patient forward – high pitched, aortic or pulmonic – use diaphragm
 Murmurs – Seven Descriptive Characteristics
 Location (where it is loudest)
 Radiation (from valves to adjacent anatomic areas)
 Timing (systolic, diastolic)
 Loudness/Intensity
 Quality (description)
 ________________ (high, low)
 Pattern (crescendo, decrescendo)
 Grading Intensity of Murmurs
 The intensity of murmurs range from grade 1/6 to 6/6. A
murmur is said to be at least Grade 4/6 if associated with a ____________
 Abnormal Finding
 Click
 _________________Heart valves – mitral and aortic most common
 Click noted especially with mechanical valves, human tissue valves produce sounds similar to
human valves – but may produce a murmur
 Pericardial friction rub
 Caused by rubbing together of the inflamed visceral and parietal layers of the pericardium
 Noted in ____________________
 Characterize based on location, radiation, timing, quality and pitch
 Does not change with respiration
 Bruits
 For persons middle-aged or older, or who show symptoms or signs of cardiovascular disease, auscultate
each carotid artery for presence of a bruit
 This is a blowing, swishing sound indicating blood flow turbulence; normally none is present
 Lightly apply bell of stethoscope over carotid artery
 Avoid compressing artery
 artificial bruit and could compromise circulation
 Ask person to hold an exhaled breath so that tracheal breath sounds do not mask
 Sometimes you can hear normal heart sounds transmitted to neck; do not confuse these with a bruit
 Assessment of Arterial Pulses
 Evaluate carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
 Patient position
 Characteristics: rate, rhythm, amplitude, symmetry
 Other CV assessments
 Carotid and Popliteal pulses
 Dorsalis Pedis and Post-Tibial pulses
 Capillary Refill
 Peripheral Edema
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 CMS Check
 C (_______________)
 M (Motor function) – neuro function
 S (Sensation)- neuro function
 Homan’s Sign
 Sharply dorsiflex foot toward tibia
 Should be no pain in calf muscle
 Tenderness could indicate DVT
 If DVT suspected, measure calf circumference with nonstretchable tape measure
 Notify _______________________
 Not routine assessment; used in OB
 Cardiovascular assistive devices
 Artificial pacemakers, ICD
 Hemodynamic monitoring
 Antiembolic stockings
 Chest tubes
 EKG monitoring
 IV Catheters
 Infants
 Heart rate best auscultated because radial pulses are hard to count accurately; use small (pediatric size)
diaphragm and bell
 170 bpm or more with crying or being active to 70 to 90 bpm with sleeping
 Expect heart sounds to be louder in infants than in adults because of infant’s thinner chest wall.
 Murmurs are relatively common in first 2 to 3 days because of fetal shunt closure
 Children
 Physiologic _______________ is common in children
 Heart murmurs that are innocent (or functional) in origin are very common through childhood
 Most innocent murmurs have these characteristics
 Soft, relatively short systolic ejection murmur
 Medium pitch; vibratory
 Best heard at left lower sternal or midsternal border, with no radiation to apex, base, or back
 Pregnancy
 Enlarging uterus elevates diaphragm and displaces heart up and to left and rotates it on its long axis
 Heart sounds
 Exaggerated splitting of S1 and increased loudness of S1
 A loud, easily heard ____________________
 Heart murmurs
 Systolic murmur in 90% which disappears soon after delivery
 Aging Adults
 Chest often increases in anteroposterior diameter with aging
 More difficult to palpate apical impulse
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 S4 often occurs in older people with no known cardiac disease
 Systolic murmurs common, occurring in over 50% of aging people
 Peripheral blood vessels grow more rigid with age, resulting in a condition called arteriosclerosis
 Documentation
Chest symmetrical with no visible pulsations, masses, heaves, or scars. No tenderness from palpation of
anterior and posterior thorax. No thrills. The abdominal aorta is not enlarged to palpation and there are no
bruits. Apical pulse 2+, regular, 64 B/M. Positive S1 and S2. No murmurs, rubs, gallops, or S3 and S4
sounds. No jugular vein distension or carotid bruits. Carotid, brachial, radial, femoral pulses equal and
present at a 1+ bilaterally equal. Popliteal, posterior tibial, dorsalis pedis present at a 1+ in left leg. Edema
present at +1 in lower left leg. No edema in right leg. Capillary refill <2 seconds in fingers bilaterally and
in toes. Negative Homan’s sign. No assistive devices present. ----------------------Carl Smith, ADNS CVTC
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