Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system

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Assessment of the Heart, Great vessels of the
neck, and Peripheral Vascular system
Rachel S. Natividad, RN,MSN
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Great vessels of the neck

• Jugular veins
• Carotid arteries

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JUGULAR VENOUS DISTENTION
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JVD
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Anatomy of the Heart
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Assessment

• Position client supine
• Then head elevated at 45 degrees
• INSPECTION
• Lifts, heaves
• PMI (assess location)

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Palpation
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Physical Landmarks

• Suprasternal notch
• Sternum
• Manubriosternal angle Angle of Louis
• Intercostal Spaces

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Auscultation Auscultatory Sites
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Auscultatory Sites Cont.
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Heart Sounds S1(Lub)

• S1 Closure of AV valves (mitral and tricuspid
  valves M1 before T1)
• Correlates with the carotid pulse
• Can be split but not often

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Heart Sounds S2(Dub)

• S2 Closure of Semilunar valves (aortic
  pulmonic)
• May have a split sound (A2 before P2)

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Heart Sounds Cont.

• Base (R/L 2nd ICS)
• S2 louder than S1
• Apex
• S1 louder than S2
• Normal physiologic S2 Split
• Best heard at pulmonic area during inspiration
• Fixed split (no variation with inspiration)

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Extra Heart Sounds

• S3
• Due to Rapid ventricular filling ventricular
  gallop
• S1 -- S2-S3 (Ken--tuc-ky)

• S4
• Due to slow ventricular contraction atrial
  gallop
• S4-S1 S2 (Ten-nessee)

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Murmurs

• turbulent blood flow within the heart
• Listen for murmurs in the same auscultatory sites
  APETM

• Grade I barely audible
• Gr II audible but quiet and soft
• Gr III moderated loud, without thrust or thrill
• Gr IV loud, with thrill
• Gr V louder with thrill, steth on chest wall
• Gr VI loud enough to be heard before steth on
  chest

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Peripheral Vascular Assessment

• Skin temp
• Color
• Pulses
• Cap refill
• edema

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Peripheral Pulses
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Documentation of Pulses
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Capillary Refill
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Edema
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Pitting edema
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Assessing for Edema

• Depress
• pretibial area medial malleolus for 5 seconds
• Grade pitting edema
• 1 to 4

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Deep Vein Thrombosis (DVT)
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Assessment Guide Gas Transportation
Blood Pressure 128/64, 132/72 Apical Heart Rate
80, 74 Peripheral Pulse Radial rate 78,
74 Rhythm regular, irregular Strength strong,
weak, thready, bounding,0-4 Rt. Pedal pulse
2 Lt. Pedal pulse 2 Edema present,
none Degree 1, 2 Location LLE, RUE
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• Cap refill
• Upper extremities 2 sec
• Lower extremities 2 sec
• Skin/Mucous Membranes Other (bleeding,
  infection)
• Skin /mucous membranes pink
• note vascular lesions (purpura, ecchymoses,
  petechiae)
• redness and inflammation
• Interventions in use
• Venodyne/leg compression machine elevated LEs on
  pillow thigh high tedhose in use
• Med List Digoxin, Atenolol, Zestril, etc.