THE CARDIOVASCULAR SYSTEM

(PART 1)

Odielon C. Filomeno, RN, MPH

Learning Targets:
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At the end of the module, students will be able to:
1. Describe the structure and functions of the heart and
great vessels;
2. Identify the landmarks and key auscultation sites of the
precordium;
3. Describe the electrical conduction system of the heart;
4. Inspect, palpate, and auscultate the jugular veins, carotid
arteries, and the precordium to evaluate cardiovascular
status; and,
5. Obtain an accurate history of the cardiovascular system.
THE CARDIOVASCULAR SYSTEM
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• This is made up of the heart and blood vessels.
• The main functions of this system are delivering oxygen and
nutrients to the cells of the body, removing waste
products, and maintaining perfusion to the organs and tissues.
• The heart is the pump that drives circulation of the blood and
blood vessels are pathways to and from the tissues.
• To assess a patient’s cardiovascular health the nurse gathers a
thorough focused health history and uses this information to
perform an appropriate physical examination of the patient’s
heart and blood vessels.
 Location of the Heart and Great Vessels
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• The heart is a hollow muscular organ a little larger than the patient’s fist.
• It lies in the pericardial cavity in the mediastinum under the sternum and between 2nd and 5th
intercostal spaces.
• About 2/3 of the heart lies to the left of the midline of the sternum.
• The area of the exterior chest that overlays the heart and great vessels is called the precordium.
• It is helpful to visualize the underlying structures of the heart as you examine the precordium.
• Note that the heart is rotated so that the right ventricle occupies most of the anterior cardiac
surface.
• This chamber and the pulmonary artery form a wedge-shaped structure behind and to the left of
the sternum, outlined in black.
• The inferior border of the right ventricle lies at the junction of the sternum and the xiphoid process.
• The right ventricle narrows as it rises to meet the pulmonary artery just below the sternal angle.
This is called the “base of the heart” and is located at the right and left 2nd intercostal spaces next to
the sternum.
• The left ventricle, behind the right ventricle and to the left, outlined below in black, forms the left
margin of the heart.
 Location of the Heart and Great Vessels
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• Its tapered inferior tip is often termed the cardiac “apex.” It is clinically important
because it produces the apical impulse, identified during palpation of the precordium as
the point of maximal impulse, or PMI.
This impulse locates the left border of the heart and is normally found in the 5th
intercostal space 7 cm to 9 cm lateral to the midsternal line, at or just medial to the left
midclavicular line.
• In supine patients the diameter of the PMI may be as large as a quarter, approximately
1 cm to 2.5 cm. A PMI 2.5 cm is evidence of left ventricular hypertrophy (LVH), or
enlargement.
• Similarly, displacement of the PMI lateral to the midclavicular line or 10 cm lateral to
the midsternal line also suggests LVH, or enlargement.
Location of the Heart and Great Vessels
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The Conduction System

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• An electrical conduction
contraction of cardiac muscle. Each electrical impulse is initiated in the
sinus node, a group of specialized cardiac cells located in the right atrium
near the junction of the vena cava.
• The sinus node acts as the cardiac pacemaker and automatically
discharges an impulse about 60 to 100 times a minute.
• This impulse travels through both atria to the atrioventricular node, a
specialized group of cells located low in the atrial septum.
• Here the impulse is delayed before passing down the bundle of His and
its branches to the ventricular myocardium. Muscular contraction
follows: first the atria, then the ventricles.
 The Heart as a Pump

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• The left and right ventricles pump blood into the systemic and pulmonary
arterial trees, respectively.
• Cardiac output, the volume of blood ejected from each ventricle during 1
minute, is the product of heart rate and
stroke volume.
• Stroke volume (the volume of blood ejected with each heartbeat) depends in
turn on preload, myocardial
contractility, and afterload.
Preload
• This refers to the load that stretches the cardiac muscle before contraction.
The volume of blood in the right
ventricle at the end of diastole, then, constitutes its preload for the next beat.
 The Heart as a Pump

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Myocardial Contractility
• Refers to the ability of the cardiac muscle, when given a load, to contract or
shorten. Contractility increases when stimulated by the sympathetic nervous
system and decreases when blood flow or oxygen delivery to the
myocardium is impaired.
Afterload
• Refers to the degree of vascular resistance to ventricular contraction.
• Sources of resistance to left ventricular contraction include the tone in the
walls of the aorta, the large arteries, and the peripheral vascular tree (primarily
the small arteries and arterioles), as well as the volume of blood
already in the aorta.
• Increased arterial blood pressure causes increased afterload.
 The Heart as a Pump

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Myocardial Contractility
• Refers to the ability of the cardiac muscle, when given a load, to contract or
shorten. Contractility increases when stimulated by the sympathetic nervous
system and decreases when blood flow or oxygen delivery to the
myocardium is impaired.
Afterload
• Refers to the degree of vascular resistance to ventricular contraction.
• Sources of resistance to left ventricular contraction include the tone in the
walls of the aorta, the large arteries, and the peripheral vascular tree (primarily
the small arteries and arterioles), as well as the volume of blood
already in the aorta.
• Increased arterial blood pressure causes increased afterload.
 The Heart as a Pump

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Jugular Venous Pressure (JVP)
• Reflects right atrial pressure, which in turn equals central venous pressure (CVP) and right
ventricular end diastolic pressure.
• The JVP is best estimated from the right internal jugular vein, which has a more direct
anatomic channel into the right atrium.
• Contrary to widely held views, a recent study has reaffirmed inspection of the right
external jugular vein as a useful and accurate method for estimating CVP.
Ask for the patient’s past history and family history on any cardiovascular disease and ask
about their lifestyle habits as well such as:
Nutrition
Smoking
Alcohol
Exercise: describe their daily or weekly exercise and type and amount
Medications/drugs
 THE CARDIOVASCULAR SYSTEM
(PART 2)

Odielon C. Filomeno, RN, MPH

 Preparation of the Patient:

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• The patient shouldStyle
be comfortable and calm as anxiety may
elevate the blood pressure or change the heart rate or rhythm.
• Review the examination procedure with the patient before putting
on the examination gown. Explain why visualization of the anterior
chest is important for data gathering.
• The examination gown has the opening in the front, which enables
the nurse to open the gown only as necessary during the
examination.
• Assist the patient onto the examination table, if necessary, and
immediately drape with a sheet. Perform the examination from the
patient’s right side.
 Preparation of the Patient:

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Equipment Needed forStyle
Examination:
• Stethoscope with a bell and diaphragm
• Sphygmomanometer
• Two 15-cm rulers
• Watch with second hand
• Examination light for tangential lighting
 Components of the Cardiovascular Examination:

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Face
As you are taking the patient’s history inspect the face, noting its
color and the presence of any orbital edema.
Look for signs of anxiety. Pallor or cyanosis may indicate poor
perfusion of oxygen and orbital edema may
indicate heart failure. Anxiety occurs during heart attacks.
Infants may exhibit circumoral cyanosis with feeding.
Great Vessels of the Neck
The carotid artery pulse provides valuable information about
cardiac function and is especially useful for detecting
stenosis or insufficiency of the aortic valve
 Components of the Cardiovascular Examination:

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The Amplitude and Contour
To assess amplitude and contour of the carotid pulse, the patient should be lying down with the head of the
bed elevated to about 30°.
First inspect the neck for carotid pulsations. These may be visible just medial to the sternocleidomastoid
muscles.
Then place your index and middle fingers on the right carotid artery in the lower third of the neck, press
posteriorly, and feel for pulsations.
A tortuous and kinked carotid artery may produce a unilateral pulsatile bulge.
Causes of decreased pulsations include decreased stroke volume and local factors in the artery such as
atherosclerotic narrowing or occlusion.
Press just inside the medial border of a well-relaxed sternocleidomastoid muscle, roughly at the level of the
cricoid cartilage.
Avoid pressing on the carotid sinus, which lies at the level of the top of the thyroid cartilage.
For the left carotid artery, use your right fingers. Never press both carotids at the same time.
This may decrease blood flow to the brain and induce syncope.
Slowly increase pressure until the maximal pulsation is felt, and then slowly decrease pressure until you best
sense the arterial pressure and contour.
 Components of the Cardiovascular Examination:

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The Amplitude of the Pulse
This correlates reasonably well with the pulse pressure.
Small, thready, or weak pulse in cardiogenic shock; bounding pulse in aortic
insufficiency
Contour of the Pulse Wave
The contour of the pulse wave, namely, the speed of the upstroke, the
duration of its summit, and the speed of
the downstroke.
The normal upstroke is brisk. It is smooth and rapid and follows S1 almost
immediately.
The summit is smooth, rounded, and roughly midsystolic.
The downstroke is less abrupt than the upstroke.
 Components of the Cardiovascular Examination:

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Variations in Amplitude
Refers to any variations in amplitude, either from beat to beat or with respiration.
The timing of the carotid upstroke in relation to S1 and S2.
Note that the normal carotid upstroke follows S1 and precedes S2.
This relationship is very helpful in correctly identifying S1 and S2, especially when
the heart rate is increased and the duration of diastole, normally shorter than systole,
is shortened and approaches the duration of systole.
Thrills and Bruits
During palpation of the carotid artery, humming vibrations, or thrills, that feel like
the throat of a purring cat may be detected.
Routinely, but especially in the presence of a thrill, listen over both carotid arteries
with the bell of the stethoscope for a bruit, a murmur-like sound of vascular rather
than cardiac origin.
Components of the Cardiovascular Examination:

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Components of the Cardiovascular Examination:

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Components of the Cardiovascular Examination:

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Components of the Cardiovascular Examination:

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