NSG6020 Week 4 Cardiovascular System

NSG6020 Week 4 Cardiovascular SystemWeek 4 Lectures
The Cardiovascular System
Let’s start with some interesting facts about the heart.
Did you know that your blood vessel system, comprised of arteries, veins, and capillaries, is over 60,000
miles long? The adult heart pumps approximately five liters of blood each minute, whereas the infant’s
heart pumps approximately 0.5 to 1.5 liters per minute. The average heart beats approximately 100,000
times per day. By the age of 70, the average heart will have beat more than 2.5 billion times! There is a
difference between the sexes: an adult female heart weighs about eight ounces whereas the average
male adult heart weighs about ten ounces. The adult heart size can be estimated by putting two
clenched fists together; the child’s heart is approximately one clenched fist. It takes blood approximately
20 seconds to make one full circuit of the vascular system. Blood is approximately 78 percent water. A
French anatomy professor, Raymond de Viessens, first described the structure of the heart in 1706. The
electrocardiograph was invented in 1902 by Willem Einthoven, a Dutch physiologist. The aftermath of
World War I saw the first heart specialists.

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The heart and blood vessels constitute the cardiovascular system. The heart is the pump (a large muscle)
that pushes blood into the systemic and pulmonary circulation. The systemic and pulmonary circulations
are continuous loops that carry the blood through the body. Review the anatomy and physiology
covered in your textbook.
View the following videos:
Anatomy Review—Vascular Structures of the Neck
Click here to view a transcript for the video.
[Video can be viewed here within the course]
Estimating Jugular Venous Pressure
Click here to view a transcript for the video.
[Video can be viewed here within the course]
Assessing the Carotid Pulse
Click here to view a transcript for the video.
[Video can be viewed here within the course]
Anatomy Review—Heart
Click here to view a transcript for the video
[Video can be viewed here within the course]
Developmental Notes – The Heart:
Fetal heart function begins at the end of the third week of gestation. The lungs do not function in utero.
Oxygenation is conducted at the placenta and then the blood is taken to the right side of the heart
where it is moved through the foramen ovale or through the pulmonary artery to the ductus arteriosus.
The foramen ovale is the opening in the atrial septum and carries more than two-thirds of the
oxygenated blood to the fetal body. The pulmonary system is nonfunctional; therefore, the ductus
arteriosus moves the blood from the pulmonary artery to the aorta. The lungs become functional at
birth and assume the oxygenation of the blood. The foramen ovale should close immediately (within the
first hour after birth), and the ductus arteriosus closes within 10 to 15 hours after birth. The heart is
more horizontal than vertical in the infant, gradually shifting to reach the adult position by age 7 years.
The pregnant female’s blood volume is increased by 30 to 40 percent. The majority of the blood volume
is produced in the second trimester. The result of increased blood volume is an increase in stroke
volume and heart rate, which in turn means an increase in cardiac output. Inversely, the mother’s blood
pressure is actually lowest in the second trimester. A gradual increase in blood pressure occurs after this
point in the pregnancy.
The older adult’s cardiovascular system is greatly influenced by the adult’s history: lifestyle, habits, and
previous medical problems. Stress certainly plays a factor as well. The activity level of the adult can
improve his or her outcomes. The following facts are considered to be part of the “aging process”: (1) A
systolic blood pressure increase of approximately 20 mm Hg occurs between ages 20 and 60 years with
another 20-point increase between ages 60 and 80 years. (2) There is usually left ventricular
enlargement that is a response to stiffening of the arteries due to calcification, therefore increasing the
workload on the heart. (3) There is not an age-related increase in diastolic pressure. (4) The heart rate at
rest does not change with advancing years. (5) The heart becomes unable to boost cardiac output with
exercise. This may be multifactorial as the older person becomes less capable of exercise. (6) The risk of
arrhythmia increases with age, including ectopic beats as well as other supraventricular and ventricular
arrhythmias. (7) Electrocardiograph (EKG) changes may occur including first degree A-V block, prolonged
Q-T intervals, left axis deviation secondary to left ventricular hypertrophy, and bundle branch blocks. (8)
Last but not least, remember that coronary artery disease risk increases with each year.
Cultural Diversity:
If you read through the American Heart Association website, you will see that Native Americans
under the age of 35 years are twice as likely to have a fatal heart attack than all other Americans
of the same age. African American males have twice the risk of stroke than Caucasian males.
African American males are twice as likely to die from a stroke as other males. 3.8 percent of
non-Hispanic black males, age 20 and older, have had a stroke, whereas 4.3 percent of nonHispanic black females, age 20 and older, have had a stroke. The website has fascinating
information and is an excellent resource for you.
Other considerations are hypertension, smoking, cholesterol, obesity, and diabetes. African
Americans and Hispanic populations have higher rates of hypertension. Smoking is in general an
issue across the cultural divide. Hypercholesterolemia is influenced by diet with Asians
appearing to have slightly lower cholesterol levels than other groups. Obesity is present in all
cultures. Diabetes is prevalent in Native American tribes, African Americans, Asian Americans,
and Hispanics as well as Caucasians. The non-Hispanic white population seems to have a lower
prevalence of diabetes than others.
History of Present Illness –The Heart
Subjective Data
Here are some questions to ask when taking a patient’s cardiovascular history:
Chest pain: When did it start? Is this the first time you have experienced this chest pain? Have you had
other types of chest pain? How frequently does your chest pain occur? How long does it last? Where is
the pain located? Does it spread? Are there other associated symptoms such as pain elsewhere in the
body? Describe the pain: sharp, dull, aching, stabbing, pressure like, or squeezing? Crushing? Do not
suggest any type of description to the patient. Ask the patient to describe the pain then wait for the
answer. Is the pain precipitated by anything? Activity, stress, food, or no triggers? Does it occur at rest?
Are there other associated symptoms such as shortness of breath, diaphoresis, pallor, cyanosis,
restlessness, nausea and/or vomiting, or increased heart rate or palpitations? What makes the pain
better? Rest, aspirin, nitroglycerin, movement, deep breaths, meditation, food? If nitroglycerin is used,
inquire about the total number of tablets taken to relieve pain and how often the pills were taken. Does
moving the head, shoulders, arms, or neck make the pain worse? Does a position change affect the
symptoms?
Dyspnea or shortness of breath: Does this occur with or without activity? What type of activity? How
does this compare to three or six months ago? What is the onset? Abrupt or gradual? Does position
change affect the dyspnea? Does the shortness of breath awaken you at night? Do you associate the
dyspnea with any chest discomfort? How about with stress? Does this shortness of breath interfere with
your daily activities? Specific questions for orthopnea: Do you have difficulty lying supine? How many
pillows do you sleep on? Do you have to sleep in a chair to improve your discomfort?
Cough: Do you have a cough? If yes, how long have you had the cough? Is it better or worse any time of
the day? What type of cough is it? Dry, hacking, congested, wheezing, hoarse, or barking? Is the cough
productive? If yes, ask the patient to describe the sputum. Be sure to question about blood-tinged
sputum or frothy pink sputum. Is the cough associated with activity such as exercise, position change,
talking, or anxiety? Does anything make the cough better? This should include rest, prescription, or
over-the-counter (OTC) medications as well as home remedies.
Fatigue: Does the patient complain of becoming tired easily? Has this caused a change in daily activities?
When did the fatigue begin? Was the onset abrupt/sudden or gradual in nature? How does this compare
to your energy level three and six months ago? Has there been any recent (within the past 14 to 30
days) change in your energy level? Can the fatigue be associated with any particular time of day or
activity?
Cyanosis: Has the patient noted a change in skin color or pallor? Does the facial skin turn blue or ashen?
If so, when does this occur, how long does it last, is it triggered or relieved by any factors, and are there
any associated symptoms?
Edema: Has the patient noted any fluid retention, in particular edema of the legs? Have they had a
sudden change in weight? When did this begin, and has it changed in the past 14 to 30 days? How does
it compare to three and six months ago? Is it worse at certain times of the day or better at certain
times? Is it worse at the end of the day? If the patient is not sure, ask about his or her shoes—are the
shoes tight at the end of the day; do the socks or shoes leave indentations or marks when removed? Is
the edema equal bilaterally? Is the edema made better by rest, elevation of legs, dietary changes (less
salt intake), or after a good night’s sleep? Does the patient associate any other symptoms with the
edema such as dyspnea? If yes, is the dyspnea noted before, during, or after the edema? Any
medications to relieve the edema? If yes, please make note. Patient presenting with edema and any of
the following serious symptoms requires immediate medical attention. The serious symptoms include
fever, skin sensitivity, shortness of breath, difficulty breathing, swollen feet, heart palpitations,
sweating, changes in vision, or rapid weight gain.
Nocturia: Is the patient awakened at night with a strong urge to void? If yes, how many times per night?
Any triggers such as increased fluid intake or caffeine at night? How long has this been happening and
are there any recent changes?
Past cardiac history: Is there any past history of hypertension, known coronary artery disease (CAD),
hypercholesterolemia, heart murmur, congenital heart disease, rheumatic fever (or unexplained joint
pains as a child or adolescent), anemia, or recurrent tonsillitis? Is there any previous history of transient
ischemic attack (TIA) or cerebral vascular accident (CVA)? If yes to CAD, when was it diagnosed, how was
it diagnosed (EKG, diagnostic testing to include laboratory tests, stress test, heart catheterization, etc.)?
Was medication prescribed and/or other intervention? When was the patient’s last EKG, stress test, lipid
panel, echo, etc. done?
Family history: Is there a family history of CAD? Include hypertension, diabetes, obesity, sudden death
under age 65 years, and hyperlipidemia. Ask age of death for parents and siblings. If grandparent history
is known, add if pertinent. For example, if all the males in the family died before age 65 due to sudden
death or perhaps everyone had an acute myocardial infarct before age 70, document this as it would be
pertinent to the patient’s history.
Personal habits: The habits should be assessed for cardiac risk factors. Ask for an overview of the
patient’s current diet: a 24-hour recall can be very useful. Be sure to note caffeine and salt intake.
Inquire about changes in weight recently. Are these changes intentional or unintentional? Does the
patient smoke or use any type of tobacco products? When did the use start (at what age)? How much
(how many packs) do they use per day? Calculate pack year history for tobacco use. For how long have
they smoked? Have they ever attempted to quit, if yes, was it successful and how did they quit? If not
successful, make note of the means used to quit. If the attempt was unsuccessful, what triggered the
resumption of tobacco use and when?
Ask specifically about alcohol intake. Quantitative intake is important as is type. Note by day, week, or
month. When was the last drink? Be mindful of delirium tremens (DTs) risk. Has the patient ever been
told they have a drinking problem? If yes, has the patient cut back or tried to quit drinking? Was the
attempt successful? Does the patient have a specific exercise program? If yes, what type of exercise,
how many minutes, and how often? Make note of current prescription and OTC medications. Ask about
street drugs. Use evidence-based screening tools for the risk of alchoholism or drug use.
When taking the history, you will also want to ask developmental specific questions.
Infant:
Start the history with inquiring about prenatal history. Was the mother diagnosed with any health
conditions during her pregnancy, such as hypertension, rubella in the first trimester, unexplained fever,
or other infections? What medications did the mother take during her pregnancy? Were there any
abnormalities in the prenatal ultrasounds?
Next inquire about any abnormalities that the mother may have observed in the infant. Ask the mother
if she has seen any facial color change of the baby while nursing or crying. Does the baby sweat while
drinking? Is the baby able to finish feeding without resting? Does the baby play without tiring quickly?
How much sleep does the baby seem to require daily? How many naps and for how long? Is this pattern
consistent? Is the baby meeting its motor-skill milestones as anticipated? Has the baby grown as
expected when compared to siblings or developmental growth charts?
Developmental Specific History:
 Toddler/Children:
Start by obtaining a history. Is there a family history of heart defects—in particular, a sibling? Is there a
family history of chromosomal abnormalities such as Down syndrome? Does the child keep up with
playmates in activity endurance? Can the child climb, ride a bike, walk, run, or play without having to
rest after a brief time? Does the child assume a squatting position to rest during play or a knee-to-chest
position during sleep? Are there any facial skin color changes or “blue spells” during playtime or activity?
Does the child complain of unexplained joint pain or fevers, or suffer from frequent headaches or nose
bleeds? Does the child have recurrent respiratory infections? How many per year and how are they
treated? Is there any documentation of streptococcal infections? Has growth been maintained?
 Pregnancy:
Inquire about pregnancy-induced hypertension (PIH) in the current or previous pregnancies. What was
the typical blood pressure reading before pregnancy? How often has the patient had her blood pressure
checked during the pregnancy? Any treatment initiated? Are there other associated symptoms such as
unusual weight gain, proteinuria, or edema of the face, legs, or feet? Any syncope or near-syncope
episodes in this pregnancy? Remember that dizziness is common in the first trimester.
 Geriatric:
Inquire about CAD and hypertension as with other patients, but include lung diseases such as COPD, or
chronic bronchitis. Has the patient received treatment for these problems? Is there any recent change in
symptoms? Do any of the illnesses interfere with normal activities?
Physical Exam of Cardiovascular System
Begin with the patient sitting in an upright position with you to his or her right side. Standing on the
patient’s right side will allow for hand position to auscultate the precordium. The jugular veins must be
assessed with the patient in a supine position, head and chest slightly elevated. Begin with pulse and
blood pressure check followed by extremities (covered in the Peripheral Vascular section—a
demonstration of measuring the jugular vein pulsation is shown in the video “Estimate JVP” presented in
the lecture “The Heart” at the beginning of the this week’s information), neck vessels, and then
precordium. This allows you to begin on the periphery and work in towards the center of the body.
The adult exam is covered in the textbook; please read carefully. Remember to follow the process of
general assessment, which includes blood pressure readings and pulse, inspection, auscultation,
palpation, and occasionally percussion. Evaluate cardiac enzymes as deemed necessary.
View the following videos:
Inspection and Palpation of the Heart
Click here to view a transcript for the video.
[Video can be viewed here within the course]
Heart Sounds
Click here to view a transcript for the video.
[Video can be viewed here within the course]
Auscultation of Heart Sounds
Click here to view a transcript for the video
[Video can be viewed here within the course]
An EKG is very useful in the patient who presents with chest pain, fullness, palpitations, hypertension,
irregular heart beat, and sometimes shortness of breath. Also consider EKG in a patient with pedal
edema. The history alone may prompt the decision for an EKG but you should also take into account the
physical findings on assessment. An irregular heart beat, pedal edema, chest x-ray findings, or abnormal
laboratory findings may indicate the need for the EKG.
The EKG with an ST segment elevation would be strongly suggestive of an acute myocardial infarction
(AMI). Please keep in mind that up to 20 percent of patients may have a normal EKG but still have
coronary artery disease with an acute event (McPhee & Papadakis, 2010). If you are suspicious, further
work up is warranted. NSG6020 Week 4 Cardiovascular System.
Panic or anxiety attacks are responsible for up to 25 percent of chest pain patients in an emergency
department setting. This number is significantly higher in a primary care setting. Panic disorder is not
limited to a specific age, sex, culture, or socioeconomic group but is more often found in younger female
patients who present with atypical chest pain symptoms and who have described themselves as being
anxious (McPhee & Papadakis, 2010).
Additional cardiac testing is available including: a 24-hour event monitor, a 4-30–day event monitor,
implantable monitors that last up to 18 months, cardiac catherizations, cardiac cat scans, and stress
tests.
Cardiovascular Exam for Different Ages:
 Infants: See the previous notes regarding the closure of the foramen ovale and ductus
arteriosus. Full closure may take up to 48 hours; therefore, reassess the infant’s cardiovascular
system during the first 24 hours of life and again in 48 to 72 hours. Assess the infant’s skin: is
there any pallor or cyanosis present? NSG6020 Week 4 Cardiovascular System Liver enlargement, persistent tachycardia, and tachypnea
are warning signs of heart failure (HF) in an infant. Palpate the apical impulse to locate the heart
and determine size. The infant heart should be more horizontal. It is best to auscultate the
infant’s heart rate as radial pulses may be hard to locate, this must be counted for a full minute.
The heart rate will fluctuate from 100–180 beats per minute (bpm) immediately after birth to
70–90 bpm while asleep. Crying, feeding, or other activity will influence the heart rate. The
infant heart rhythm should be sinus arrhythmia, changing with respiration. A few hours after
birth, a split S2 is common. Murmurs are common in the first week of life; usually very soft,
systolic in nature, and disappear spontaneously. A patent ductus arteriosus (PDA) murmur
sounds like a machine: continuous and murmuring. The absence of murmurs does not mean
that there are not problems. Auscultate often and document any changes.
 Children: Look for any symptoms that indicate heart disease such as failure to thrive (poor
weight gain of < 5% that is significantly below that of other children of similar age and gender.),
developmental delays, persistent tachycardia, tachypnea or dyspnea on exertion, clubbing of
the fingers and toes, or cyanosis. Clubbing does not usually appear until late in the first 12
months even in the presence of severe cyanosis. Any obvious bulge or heaves of the chest wall
are abnormal although apical impulse may be seen. Heart murmurs are common in childhood
with many being functional but not malignant. These murmurs are often soft, with short systolic
ejection, with medium pitch and vibration, heard at the left lower sternal or midsternal border.
If in doubt, refer for further evaluation. NSG6020 Week 4 Cardiovascular System
 The pregnant female: An increase in resting pulse rate of 10 to 15 bpm is a normal response.
The blood pressure reaches its lowest levels during the second trimester. An exaggerated
splitting of S1 and increased S2 are noted; a loud S3 is possible. A systolic murmur may be heard
in up to 90 percent of pregnant females. This should disappear shortly after delivery. A soft
diastolic murmur may be heard intermittently in up to 19 percent of pregnant females while a
continuous murmur whose source is the breast vasculature is found in 10 percent. This is a
mammary soufflé which begins close to delivery or during lactation. The murmur is produced by
the blood flow in the internal mammary artery.
 The older adult: Orthostasis is common in addition to the blood pressure changes noted earlier
in the lecture content. Be cautious with assessment of the carotid artery: older patients may be
more sensitive to pressure on the carotid artery causing syncope or an arrhythmia. The chest
often increases in the anteroposterior diameter which may create some difficulties in
auscultation of the heart sounds. Although EKGs have been used as a good diagnostic tool when
concerns arise in the past, recommended updated guidelines for EKG diagnostic testing from the
U.S. Preventive Services Task Force suggest that routine EKGs should not be done. Patients with
no chest pain and that are at low risk for heart disease do not need routine EKGs. The task force
also said that for those patients at intermediate or high risk with no symptoms, there is no
evidence to say if an EKG will help predict heart disease (WebMD, [n.d.]) Do remember that the
EKG is simply a snapshot in time; there may be problems occurring at other times. Twenty-fourhour and 30-day event monitors are available if needed NSG6020 Week 4 Cardiovascular System.
Overview of Murmurs
This information is to be used in conjunction with your textbook. It is important that you understand
how to grade the murmurs in order to fully interpret your findings.
Characteristics
A. Identify the beginning of systole and diastole.
a. S1
b. S2
Timing
A. Determine the timing of the murmur.
a. Systolic
b. Distolic
B. Determine if the murmur is early, middle, or late in the interval.
Severity
A. Grade 1/6: barely audible
B. Grade 2/6: just audible, heard without straining
C. Grade 3/6
D. Grade 4/6
E. Grade 5/6: louder than previous levels, heard with a stethoscope
F. Grade 6/6: Heard without the stethoscope on the chest wall
Location
A. Identify which valve area is involved in the murmur.
Pattern
A. Uniform or constant
B. Crescendo or increasing
C. Decrescendo or decreasing; diminuendo
D. Crescendo-decrescendo: Diamond-shaped murmur
Pitch
A. Low pitched
a. Best auscultated with the bell of the stethoscope with only light pressure being applied
if any
B. High pitched
a. Best auscultated with the diaphragm of the stethoscope with firm pressure being
applied NSG6020 Week 4 Cardiovascular System
Dynamic maneuvers
A. Position
a. Supine
b. Erect
c. Left lateral decubitus position
B. Exercise
Interpretation
A. Benign murmurs
a. Murmur characteristics
i. Crescendo-decrescendo character
ii. Musical or vibratory murmur
iii. Quite murmur
iv. Timing: early systolic or midsystolic
v. Location: left sterna border or pulmonic area
b. Associated findings absent
i. Cardiopulmonary symptoms absent
ii. Family history absent
iii. Exam (blood pressure, pulse, auscultation otherwise normal)
iv. Normal physiologic split S2 without gallop or click
B. Pathologic Murmurs
a. Murmur characteristics
i. Timing: Diastolic, mid-to-late systolic, holosystolic
ii. Loud murmur: Grade 3 or higher
iii. Exacerbated by the Valsalva maneuver
iv. Radiation of the murmur to carotid artery or axilla
b. Associated findings present
i. Arrhythmia present
ii. Chest pain, palpitations, dyspnea, syncope present
iii. Sudden cardiac death family history
iv. Jugular venous pulsation abnormal
v. Arterial pulsation abnormal
1. Wide pulse pressure
2. Water-hammer pulse (rapidly rising bounding pulse)
3. Weak, slow-rising pulse
vi. Other abnormal precordial exam
1. Other heart sounds (e.g. loud S1, fixed split S2)
2. Left ventricular heave
View the following video:
Attributes and Grading of Murmurs
Click here to view a transcript for the video.
[Video can be viewed here within the course] NSG6020 Week 4 Cardiovascular System
Types of Murmurs:
When you suspect a murmur it is best to consider having another person listen in order to confirm or
validate what you are hearing.
Midsystolic Ejection Murmurs
 Aortic stenosis: Loud, harsh, midsystolic murmur with crescendo-decrescendo notes. It is
loudest at the second right intercostal space. This murmur radiates to the carotid arteries, and
down the left sternal border. Patients with sever aortic stenosis generally need surgery to
correct the issue. If left untreated serious heart conditions may occur due to the limited amount
of blood the heart can pump which may weaken the heart muscle.
 Pulmonic stenosis: A medium pitch, coarse, midsystolic murmur, with crescendo-decrescendo
notes. It is best heard at the left second intercostal space. This murmur radiates to the neck and
the left chest wall. People with mild pulmonic stenosis may not have symptoms but those with
severe pulmonic stenosis may present, along with the murmur, shortness of breath, chest pain,
fainting, fatigue, and palpitations. If an adult or child patient presents with shortness of breath,
chest pain, or fainting then prompt evaluation and treatment will reduce the risk of
complications.
 Mitral regurgitation: May be pansystolic, blowing murmur, best heard at the apex with
radiation to the left axilla possible. This murmur may be soft or loud. In some cases surgery is
required to repair the mitral valve. Treatment depends on severity of the patient’s condition.
 Tricuspid regurgitation: A soft, blowing, pansystolic murmur that increases upon inspiration.
This murmur is best auscultated at the left lower sterna border. Treatment may not be
necessary if there are few or no symptoms associated with the murmur. If symptoms are
present then treatment will depend on the presenting symptoms.
Diastolic murmurs
 Mitral stenosis: A low-pitched murmur best heard at the apex when patient is in the left lateral
side lying position. This murmur does not radiate. The primary cause of mitral stenosis is
rhuematic fever.
 Tricuspid stenosis: A rumble-like sound that increases with inspiration. This is best heard at the
left lower sterna border. This murmur usually does not require treatment.
 Aortic regurgitation: This soft, high pitched, blowing murmur begins with the S2 sound. It has a
decrescendo sound; being heard best at the left third intercostal space with the patient in an
upright, sitting position, leaning forward. This murmur should radiate down the chest wall.
Patients should seek medical attention if they have fatigue, shortness of breath, or swollen
ankles and feet.
 Pulmonic regurgitation: This murmur is very similar to aortic regurgitation and most likely
cannot be determined on physical exam alone. A 2-D echo is suggested for diagnosis. Treatment
is management of the cause of the pulmonic regurgitation.
Pediatric Murmur
 Still’s Murmur: This innocent murmur was first described by Dr. George Still in 1909. It is
commonly found in children ages two to eight years old and up to 30 percent of this population.
The Still’s murmur is a low to medium frequency, midsystolic murmur, Grade II-III of VI intensity.
The murmur can be best auscultated near the apex, described as a vibratory, harmonic, musical,
twanging, or groaning noise. The murmur is louder when the patient is in a supine position,
experiencing fever, or is anemic.
View the video on listening for murmurs:
Auscultation of Murmurs
Click here to view a transcript for the video.
[Video can be viewed here within the course] NSG6020 Week 4 Cardiovascular System
Cardiovascular Examination Summary:
Neck:
Observe, palpate, and auscultate the carotid pulse.
Observe the venous pulse and estimate jugular venous pressure.
Precordium:
Inspect and palpate: apical impulse noting any lift, or thrill.
Auscultation:
Identify the areas.
Note rate and rhythm.
Note S1 and S2: Are there any variations?
Are there any extra heart sounds in systole and diastole?
Are there any murmurs in systole and diastole?
Begin with the diaphragm, repeat with the bell.
Auscultate the apex when the patient is in the left lateral position.
Auscultate the base with the patient in a sitting position.
After the examination it is important to document your findings.
View the following video:
Describing Your Findings
Click here to view a transcript for the video.
[Video can be viewed here within the course]
Cardiovascular Differential Diagnoses:
In addition to the differential diagnoses listed in your textbook, consider the following options.
Congenital heart defects: PDA, atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of
Fallot, and coarctation of the aorta.
PDA: Failure of the ductus arteriosis to close after birth (see notes above). Symptoms vary with the size
of the defect and the gestational age of the infant at birth. If the PDA is small, there may be no signs or
symptoms and often goes undetected until adulthood. A large PDA may present with signs of HF soon
after birth. Symptoms that may present with a large PDA include poor eating, poor growth, sweating
with crying or eating, persistent fast breathing or breathlesssness, easy tiring, rapid heart rate, or a
bluish or dusky skin tone. If the infant or child has any of the above symptoms you should seek medical
attention.
ASD: Failure of the ASD to close after birth. An ASD is a hole in the wall between the two upper
chambers of the heart and is present from birth. Small ASDs may close on their own during infancy or
early childhood. Large ASD can damage the heart and lungs and potentially shorten the life span of an
adult due to HF and high blood pressure in the lungs. ASD symptoms include a heart murmur, shortness
of breath (especially when exercising), fatigue, swelling of legs, feet, or abdomen, heart palpitations,
frequent lung infections, stroke, and bluish skin color. If any of the symptoms is present, the patient
should seek medical attention. Surgery is often the treatment option to prevent complications.
VSD: An opening in the septum of the ventricles. This may vary in size and exact location. Infants may
have small defects and be completely asymptomatic whereas large defects may present with failure to
thrive, presence of pallor, and frail appearance. Feeding difficulty along with dyspnea with exertion,
respiratory infections, and even HF may be seen. NSG6020 Week 4 Cardiovascular System
Tetralogy of Fallot: This congenital heart defect has four distinct components: (a) right ventricular
outflow stenosis, (b) presence of a VSD, (c) right ventricular hypertrophy, and (d) overriding aorta.
Venous blood is shunted into the aorta and away from the pulmonary system where it would be
oxygenated.
Coarctation of the aorta: Severe narrowing of the descending aorta, most often found at the ductus
arteriosus and the aortic arch, just below the left subclavian artery. This creates an increased workload
on the left ventricle. Aortic valve defects, PDA, and VSD are often found with coarctation of the aorta. NSG6020 Week 4 Cardiovascular System