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THE PAPER ENGLISH LANGUAGE III

ASSESSMENT ON THE CARDIOVASCULAR


SYSTEM

LECTURER:
Mrs Ns. Yelmi Reni Putri, S.Kep,MAN

CREATED BY:
Rosi Oktarida: 1814201054

UNIVERSITY FORT DE KOCK BUKITTINGI

SI NURSING SCIENCE

2020/2021
PREFACE

Praise the authors for the presence of God Almighty because of the abundance of
His grace, taufiq, and guidance, so that the author can complete a paper entitled
"ASSESSMENT ON THE CARDIOVASCULAR SYSTEM" on time.

The purpose and purpose of writing this paper is none other than to fulfill one of
the many obligations in the "ENGLISH III" course and is a form of the author's
direct responsibility for the given assignment. On this occasion, the author also
wishes to express his gratitude to all those who have helped in completing this
paper, either directly or indirectly.

Such is the introduction that the author can convey where the author is aware that
the author is only a human being who is not free from mistakes and shortcomings.
Therefore, constructive criticism and suggestions are expected from readers.
Finally, the author can only hope that behind the imperfections of writing and
composing this paper, something is found that can provide benefits or even
wisdom for the writer, reader, or the whole. Amiin ya Rabbal ‘alamin.

Wassalalam,
Bukittingi, 30 september 2020

Created By
TABLE OF CONTENTS

FOREWORD..........................................................................................................i
TABLE OF CONTENTS......................................................................................ii
CHAPTER I INTRODUCTION..........................................................................1
A. Background........................................................................................................1
B. Problem Formulation...........................................................................................2
C. Purpose...............................................................................................................2
CHAPTER II PURPOSE OF THEORY.............................................................3
A. Functional Anatomy of the Heart..................................................................3
B. Physical Examination of the Cardiovascular System..................................
1. General circumstances...................................................................................
2. Blood Pressure Check....................................................................................
3. Pulse Check...................................................................................................
4. Hands............................................................................................................
5. Jugular Vein Examination..............................................................................
6. Heart Examination.........................................................................................
7. Lungs.............................................................................................................
8. Abdomen......................................................................................................
9. Feet And Limbs............................................................................................
C. SOP of Cardiovascular System Assessment...............................................
1. Preparation Tools..........................................................................................
2. Client Preparation.........................................................................................
3. Physical Examination Procedure..................................................................
4. Inspection....................................................................................................
5. Palpation.....................................................................................................
6. Percussion...................................................................................................
7. Auscultation.................................................................................................
CHAPTER III CLOSING..............................................................................
A. Conclusion...................................................................................................
BIBLIOGRAPHY..........................................................................................
CAPTHER I

INTRODUCTION

A. Background of the paper


Cardiovascular consists of two syllables, namely cardiac and vascular. Cardiac
which means heart and vascular which means blood vessels. In this case includes
the circulatory system consisting of the heart and blood components of blood
vessels. This circulatory center or blood circulation begins in the heart, which is a
muscular pump that pulsates rhythmically and repeats 60-100x / minute. Each
beat causes blood to flow from the heart to the rest of the body in a closed
network of arteries, arterioles, and capillaries and then back to the heart through
the venules and veins.(Safri & ,Sofiana Nurchayati, 2018)

In the mechanism of maintaining the internal environment, blood circulation is


used as a transport system for oxygen, carbon dioxide, food, and hormones and
drugs throughout the tissues according to the metabolic needs of each cell in the
body. In this case, changes in the volume of body fluids and hormones can affect
the cardiovascular system either directly or indirectly.

In understanding the cardiac circulatory system, we need to understand the


physiological anatomy that is in the heart so that we are able to understand various
problems related to the cardivascular system without any mistakes that make us
neglicent (negligence). Therefore, it is very important to understand
cardiovascular physiological anatomy, which functions directly in circulating
drugs and oxygenation in the body in the process of life.

In carrying out the assessment properly, understanding, practice and skills to


recognize the signs and symptoms displayed by the patient are needed. This
process is carried out through the interaction of care from the client, observation,
and measurement. Nursing examination uses the same approach as the physical
medical assessment, namely the inspection, palpation, auscultation and percussion
approach. Medical physical assessment is carried out to establish a diagnosis in
the form of certainty about the client's illness. In principle, physical assessment of
nursing is developed based on a nursing model that is more focused on the
responses caused by the health problems experienced. Nursing physical
assessment must reflect the physical diagnosis that nurses can generally plan
actions to overcome. To obtain accurate data prior to physical examination, a
medical history, psychosocial history, social and social history is assessed, etc.
This allows a focused study and does not create bias in drawing conclusions about
the problems found.
Physical examination is an examination of the body to determine any
abnormalities in a system or an organ of a body part by seeing (inspection),
feeling (palpation), tapping (percussion) and listening (auscultation).

Generally these examinations are carried out sequentially (inspection,


palpation, percussion and auscultation).

B. Problem Formulation
1. What is the anatomy of the cardiac system?
2. How is the blood circulation of the heart?
3. What is the pathophysiology of the cardiovascular system?
4. What are some physical examinations performed on the cardiovascular system?
5. What are the diagnostic tests of the cardiovascular system?
C. Purpose
1. Knowing about the anatomy of the heart system.
2. Knowing the heart blood circulation.
3. Knowing the pathophysiology of the cardiovascular system.
4. Knowing the physical examination performed on the cardiovascular system.
5. Knowing the diagnostic tests on the cardiovascular system.
CHAPTER II

REVIEW OF THEORY

A. Functional Anatomy of the Heart


a. The basic principles of the cardiovascular system

The cardiovascular system principally consists of the heart, blood vessels


and lymph channels. This system functions to transport oxygen, nutrients
and other substances to be distributed throughout the body and carry the
end products of metabolism to be excreted from the body.

The heart is located in the mediatinum, which is the compartment in the


middle of the thoracic cavity between the two lung cavities. The
mediastinum is a dynamic, soft structure that is moved by the structures
contained in it (the heart) and surrounding it (the diaphragm and other
movements of the breath) as well as gravity and body position.

b. Heart Structure
The heart measures slightly larger than a head of a hand and weighs in the
range of 7-15 ounces (200-425 grams). In each day the heart is able to
pump up to 100,000 times and can pump blood up to 7,571 liters. The
position of the heart is behind the sternum in the mediastinal cavity,
between the second and sixth ribs. The right heart receives non-
oxygenated blood from the superior vena cava and inferior vena cava and
then flows to the pulmonary for oxygenation. While the left side of the
heart receives oxygenation from the lungs through the pulmonary veins to
then be circulated throughout the body through the aorta.

c. pericardium
The pricardium is the covering layer of the heart which is composed of
fibroserosa membrane and the surface of the large blood vessels. The
pericardium is composed of two layers, namely the fibrous pericardium
which is the hard outer layer and the pericardium serosa which is the inner
layer. The serous pericardium also has two layers, namely the parietal
pericardium and the visceral pericardium. Pariental pericardium is the
inner surface of the fibrous pericardium. Meanwhile, the visceral
pericardium is attached to the surface of the heart. The space between the
pariental pericardium and the visceral pericardium is called the
pericardium space. Under normal conditions, this space is filled with fluid
which makes it easier for the heart to move and pulsate without any
obstacles.

d. Heart walls and chambers

The heart wall is composed of three layers, namely the outer layer called
the epicardium, the middle layer called the myocardium and the inner
layer called the endocardium. The epicardium is the outer layer formed
from the visceral layer of the pericardium serosa. Myocardium is a layer
that consists of heart muscle.
The endocardium is a thin inner layer composed of subendothelial
connective tissue that also covers the heart valve.
While the heart chamber consists of two parts, namely the right and the
left. Each part has one atrium and one ventricle so that in the heart there
are four chambers, namely the right antrium, left antrium, right ventricle
and left ventricle. Between the antrium and the ventricle there is an
atrioventricular opening and in each hole there is a valve.
The antrium is a receiving cavity that pumps blood into the ventricles. The
right antrium gets blood from the superior vena cava and inferior vena
cava, the left antrium gets blood from the pulmonary vein. The ventricle is
the blood receiving cavity from the right antrium to be pumped into the
lungs through the pulmonary artery. While the left ventricle gets blood
from the left antrium, it gets blood from the left antrium to pump blood
around the body through the aortic valve. The heart muscle (myocardium)
in the ventricle is thicker than the antrium and the left ventricular muscle
is thicker than that of the right ventricle. This is because the ventricular
muscle has a duty to produce more pressure than the other muscles. The
left ventricle is responsible for memopa blood throughout the body.
Conducted by the atria and ventricles there are valves that separate them.
This valve is called the atriovebtrikular valve, which functions to keep
blood flow from the atria to the ventricles in a unidirectional way and
prevent back blood flow from the ventricles to the atria. The
antroventricular valve is divided into two, namely the tricuspid valve and
the bicuspid valve (mital valve). The tricuspid valve is a valve that has
three leaves that separate the right antrium from the right ventricle.
Meanwhile, the bicuspid valve (mitral valve) is a valve with two leaves
that separates the left antrium from the left ventricle. In addition to the
atrioventricular valve, there is a semilunar valve which consists of two
valves, namely the pulmonary valve and the aortic valve. The pulmonary
valve prevents backflow from the pulmonary artery to the right ventricle.
The aortic valve prevents backflow from the aorta to the left ventricle.
Within the walls of the ventricles are also thick bundles of muscles called
the papillary muscles. Below the papillary muscles there are thin tendon
threads called the cord tendinea and functions to prevent the valve lid from
being pushed into the atria when the ventricles contract.
There are also blood vessels that are directly connected to the heart. On the
right side of the heart there is the superior vena cava and the inferior vena
cava, which drain blood into the right atrium. Next there is also the
pulmonary artery. This artery serves to carry blood out of the right
ventricle to enter the lungs. Meanwhile, what brings blood flow from the
lungs to the heart again, namely into the left atrium, is called the
pulmonary vein. The next blood vessel is the aorta, which carries blood
out of the left ventricle.

e. Heart sound
In the heart there are two kinds of sounds. This sound comes from the
valves closing passively. The first sound is caused by closing the
atrioventricular valve and contracting the ventricles. While the second
sound is the sound due to closing the semilunar valve after ventricular
contraction.

f. Blood vessels and cardiac investment


In carrying out its function, the heart muscle requires blood flow that
supplies oxygen and nutrients and other substances needed for the life of
the heart muscle. The blood vessels that play a role in the heart are the
coronary arteries and coronary veins. Blood flows to and from the
myocardial muscles, mostly from these arteries and veins. These heart
blood vessels are affected by the work of the sympathetic nerves and
parasympathetic nerves.
The coronary arteries are the first branches of the aorta to supply blood to
the epicardium and myocardium. In addition, these arteries supply blood to
the aterium and ventricles. The coronary artery branches are the right
coronary artery and the left coronary artery. It is this coronary artery
branch that leaves the aorta first and then branches again to become
smaller arteries. Arteries - small arteries around the heart and deliver blood
to all other organs. Furthermore, blood returning from the heart collects
into the coronary sinus and will enter the right artrium.

The right coronary artery supplies blood to the right atrium, most of the
right ventricle, part of the left ventricle, part of the intraventricular septum,
sino atrial nodes (SA Nodes) and atryo ventricular nodes (AV Nodes).
Meanwhile, the left coronary artery supplies blood to the left atrium, most
of the left ventricle, most of the right ventricle and SA nodes (in about
40% of people). Meanwhile, the heart veins are located superficial to the
arteries. The coronary sinus is the largest vein, opening into the right
arterium. Most of the main heart veins drain into the coronary sinus except
for the anterior veins of the heart which drain into the right atrium.

The heart is innervated by autonomic nerve fibers from the plexus


cardiacus, this cardiac plexus is formed from parasympathetic and
sympathetic fibers on their way to the heart. The fibers are scattered along
and to the coronary arteries as well as the conducting components,
especially SA Nodes. Although the motion of the heart is rhythmic, the
rate of contraction is influenced by stimuli that reach the heart through
these nerves.

The stimulation of the sympathetic nerves causes increased pulse, implant


conduction, strength of contraction and causes increased blood flow
through the coronary arteries. SA Nodes adrenergic stimulation and
conductant tissue increases the rate of depolarization of pacemaker cells
while increasing atrioventricular conduction. Meanwhile, parasympathetic
nerve stimulation will slow the pulse, reduce the force of contraction and
constrict the coronary arteries, blocking energy between periods of
increased demand. Post-synaptic parasympathetic stimulation slows the
rate of depolarization of pacemaker cells and atrioventricular conduction
and reduces atrial contractility.

g. Cardiac conduction system

cardiac conduction system is a system that coordinates the cycle in the


heart by coordinating the contraction of the four chambers in the heart. In
carrying out its function as a blood pump, the atria and ventricles work
together. In this cardiac conduction system involves the SA Nodes, AV
Nodes, the bundle of his and purkinje fibers.

Pacemaker cells have the following characteristics:


1. Automation
Is the ability to start implants automatically.
2. Conductivity
Is the ability to deliver the implus from one cell to the next.
3. Contractility
Is the ability to shorten the heart fibers when receiving an implant.
SA Nodes is the center of the pacemaker that initiates and regulates the
implant to contract with a frequency of 60-100 beats / minute. This
contraction signal from the SA Nodes will cause contraction in the two
atria, namely the right atrium and the left atrium. Then the implus will
spread to AVNodes. From the AV Nodes, the implus will travel to the
bundle of his and then to the purkinje fibers. This flow of implants will
eventually cause contraction of the ventricles. If SA Nodes has trouble
starting the implant, it will be taken over by AV Nodes. However, the
contraction produced by these AV Nodes will cause contractions with a
frequency of 40 - 60 times / minute. Furthermore, if both SA Nodes and
AV nodes experience interference in producing implants, the ventricles
will start implants with a frequency of 20 - 40 times / minute.
The cardiac surplus generated from SA Nodes can be recorded using an
electrocardiogram (EKG) and produces an EKG image.

The P wave indicates the depolarizing phase of atrial contraction taking


place. The P wave is a record of the spread of depolarization through the
atrial myocardium from beginning to end. Because the SA Nodes are in
the right atrium, the right atrium begins to depolarize before the left atrium
and also finishes earlier.
The QRS complex shows depolarization of the ventricular myocardium
which results in ventricular contraction. QRS waves are characterized by a
large deflection on the EKG. The amplitude of the QRS complex is much
greater than that of the atrial P wave because the muscle mass of the
ventricles is much greater than that of the atria
The T wave represents the ventricular repolarization wave.
After depolarization, myocardial cells experience a short refractory period.
Myocardial cells undergo repolarization, that is, they restore
electonegativity in themselves so that they can be stimulated again.
There are actually atrial repolarization waves as well, but because these
waves coincide with ventricular depolarization they are obscured by the
much more prominent QRS complex.
The process of ventricular repolarization is much slower than ventricular
depolarization. So the T wave appears wider than the QRS complex.
Cardiac cycle

The main task of the heart is to pump blood around the body. In the heart
there are various activities related to blood circulation, this is called the
cardiac cycle. Heart movement is the result of atrial and ventricular
contractions. This heart movement consists of two types, namely systole
and diastole. Systole is the simultaneous contraction of both atria or both
ventricles. Meanwhile, diastole is the relaxation phase of the atria and
ventricles. Through the systolic and diastolic phases, the heart will
continue to beat throughout its life.
The contraction of the atria takes a shorter time than the contraction of the
two ventricles. In the ventricles, apart from the contraction lasting longer,
the force generated is also higher than that of the main atrium in the left
ventricle. The left ventricle is responsible for pushing blood throughout
the body and maintaining systemic arterial blood pressure. Whereas the
right ventricle also pumps the same velome of blood, but the pressure is
much lower than the left ventricle because it only pushes blood into the
lungs.

Blood vessel
In the vascular system, there are five different types of blood vessels that
will play a role, namely arteries, veins, arterioles, venules and capillaries.
The lining of the blood vessel walls except for the capillaries has three
layers, namely:
1. Tunica intima
Is the inner layer of blood vessels.
2. Media tunica
Is a layer of blood vessels in the middle.
3. Tunica adventisia
Is the outer layer of blood vessels.
Arteries have a thicker muscular wall structure than veins. This
aims to accommodate the function of the arteries to drain blood at
high speeds and pressures. In contrast, the veins have a thinner
muscular wall structure. However, veins have a larger diameter
than arteries because the blood pressure that flows back from the
veins to the heart is lower. In addition, the veins have a valve that
aims to prevent back blood flow.
Arteriols have walls that are thinner than arteries, which functions
to regulate blood flow to the capillaries by construction and
dilation. Whereas venules have walls that are thinner than
arterioles, function to collect blood from the heart, veins are
responsible for carrying blood to the heart, while capillaries act as
a link between arteries and veins which are the traffic route for
distribution of substances needed by the body and substances
which must be removed by the body. In addition, it is in these
capillaries that gas exchange occurs in the extracellular or
interstitial fluid.
The pulse is a wave that is felt in the arteries as a result of blood
being pumped out of the heart. Arterial pulsations are easily felt
and felt in a place that crosses a bone that is located close to the
surface, the minuses of the radial artery, temporalis artery and
dorsalis pedis artery. In addition, there are also large arteries that
are easy to feel, namely the carotid, brachial artery and femoral
artery.
Lymph channels are also part of the cardivascular system,
functioning to collect, filter and channel back into the lymph blood
which is excreted through the walls of the delicate capillaries to
clean the tissue.
Blood circulation
the heart is the main organ of blood circulation. There are two
kinds of circulation that occur, namely the systemic circulation and
the pulmonary circulation.
1. Systemic circulation
Systemic circulation starts from the flow of blood from the left
ventricle through the arteries, arterioles, and capillaries back to the
right atrium through the veins.
2. Pulmonary circulation.
Pulmonary circulation starts from the flow of blood from the right
ventricle into the lungs then from the lungs into the left atrium.

B. Physical Examination of the Cardiovascular System

Physical examination is an examination of the body to determine the presence


of abnormalities in a system or an organ of a body part by seeing (inspection),
feeling (palpation), tapping (percussion) and listening (auscultation). The
sequence of examinations runs logically from head to toe, and once trained can be
done in as little as 10 minutes:

1. general condition,

2.blood pressure,

3. pulse,

4.hand,

5.head and neck,

6. heart,

7. lungs,

8. abdomen and legs and feet

In the next examination of the heart, in addition to finding normal examination


results, we can also find abnormalities of physical examination results which
include: widened heart borders, various abnormal variations in heart sounds and
additional sounds in the form of noise (murmurs).

1. General Conditions

Observe the patient's distress level. The level of consciousness must be noted
and explained. Evaluation of the patient's ability to think logically is very
important because it is a way to determine whether oxygen is able to reach the
brain (brain perfusion). Client awareness needs to be assessed in general, namely
compos mentis, apathy, somnolence, sopor, soporokomatous, or coma.

2. Blood Pressure Check

Blood pressure is the pressure exerted on the artery walls. This pressure is
influenced by several factors such as cardiac output, arterial tension, and blood
volume, rate and viscosity (viscosity). Blood pressure is usually described as the
ratio of systolic pressure to diastolic pressure, with normal adult values ranging
from 100/60 to 140/90. Blood pressure measurement techniques include:

1. The spignomanometer cuff is tied to the upper arm, the stethoscope is


placed in the brachial artery on the ventral surface of the elbow slightly below the
spigmomanometer cuff.

2. The pressure in the spigmomanometer is increased by pumping air into the


cuff until the radial and brachial pulses disappear. The cuff is extended again by
20 to 30 mmHg above the point of loss of the radial pulse then the pressure inside
the spigmomanometer is gradually lowered.

3. When the pulse starts to sound again, read the pressure listed on the
spigmomanometer scale, this pressure is systolic pressure.

4. The sound of the next pulse is a bit loud and still sounds that loud until one
day the pulse weakens or disappears completely. The last pulsating sound is the
diastolic pressure.

3. Pulse Check

Palpation

Palpation assessment includes frequency, rhythm, quality, wave configuration,


and the state of blood vessels. Normal heart rate

Age Heart rate (beats / minute)


Baby 120-160/mnt

Todler 90-140/mnt

Preschol 80-110/mnt

Schol age 75-100/mnt

Youth 60-90/mnt

adults 60-100/mnt
a. Rhythm
Normally the rhythm is the regular interval that occurs between each pulse or
heart. If the pulse is irregular, then the heart rate should be calculated by
auscultating the apical pulse for one full minute while feeling the pulse.
Any difference between audible contraction and palpable pulse should be
noted. Rhythmia (dysrhythmias) often results in pulse deficits, a difference
between the apex frequency (the frequency of the heart heard at the apex
of the heart) and the pulse rate. Pulse deficits usually occur with atrial
fibrillation, atrial flutter, premature ventricular contractions and varying
degrees of heart block.
a. Pulse strength
The strength or amplitude of the pulse indicates the volume of blood injected
into the artery wall with each contraction of the heart and the state of the
arterial system leading to the pulse. Normally, the pulse strength remains
the same with each heart beat.
0 does not exist, cannot be palpable
1+ pulse missing, very difficult to palpate, easy to lose
2+ easy to palpate, normal pulse
3+ full pulse, increasing
4+ strong, pulse ricochet, irreversible

1. Hands
In cardiac patients, the following are the most important findings to pay
attention to when examining the upper limb:
1. Peripheral cyanosis, in which the skin appears bluish, indicates a decreased
rate of blood flow to the periphery, so it takes longer for hemoglobin to
desaturate. Normal occurs with peripheral vasoconstriction due to cold air,
or in pathological decreased blood flow, for example, cardiac shock.
2. Pale, can indicate anemia or increased systemic vascular resistance.
3. Capillary refill time (CRT = Capillary Refill Time), is the basis for
estimating peripheral blood flow velocity. To test capillary refill, press
firmly on the tip of your finger and then release quickly. Normally,
reperfusion occurs almost immediately with the return of color to the
fingers. Slow reperfusion indicates a slower rate of peripheral blood flow,
as occurs in heart failure.
4. Temperature and humidity of the hands are controlled by the autonomic
nervous system. Normally hands feel warm and dry. In a state of stress, it
will feel cold and damp. In cardiac shock, hands are very cold and wet due
to stimulation of the sympathetic nervous system and result in
vasoconstriction.
5. Edema stretches the skin and makes it difficult to fold.
6. Decreased skin turgor occurs with dehydration and aging.
7. Clubbing of the fingers and toes indicates chronic desaturation of
hemoglobin, as in congenital heart disease.

5. Jugular Vein Examination


An estimate of the function of the right heart can be made by observing the
jugular vein pulsation in the neck. This is a way of estimating central
venous pressure, which reflects the end-diastolic pressure of the right
atrium or right ventricle (the pressure just before right ventricular
contraction). The jugular vein is inspected to measure venous pressure
which is affected by blood volume, the capacity of the right atrium to
receive blood and deliver it to the right ventricle, and the ability of the
right ventricle to contract and push blood into the pulmonary artery.
Technique :
Have the client lie on his back with his head elevated 30 to 45 degrees (semi-
Fowler position)
• Ensure that the neck and upper thorax are exposed. Use a pillow to straighten
your head.
• Avoid hyperextension or neck flexion to ensure that veins are not stretched
or curled.
• Usually the pulse is not seen when the client is seated. When the client
returns to the supine position slowly, the venous pulse height begins to
increase above the manubrium height, which is 1 or 2 cm when the client
reaches a 45 degree angle. Measure venous pressure by measuring the
vertical distance between the Louis angle and the highest point of visible
internal jugular vein pulsation.
• Use two rulers. Draw a line from the bottom edge of the regular ruler with
the end of the pulsating area of the jugular vein. Then take a centimeter
ruler and make it perpendicular to the first ruler at the level of the corner
of the sternum. Measure in centimeters the distance between the second
ruler and the sternal angle.
• Repeat the same measurement on the other side. Bilateral pressure greater
than 2.5 cm is considered elevated and is a sign of right heart failure.
Increased pressure on one side can be caused by obstruction.
1. Heart examination
Inspection
a. Thorax / chest
The patient lies on a flat base. In the form of the chest "Veussure Cardiac"
there is a wide local protrusion in the precordium, between the sternum
and apex codis. Sometimes shows a heart pulsation. The presence of
Voussure Cardiaque, indicates the presence of organic heart defects, heart
defects that have been long / occurring before complete retention,
hypertrophy or ventricular dilatation. This lump can be confirmed by
touch.
a. Ictus Cordis
In normal adults who are somewhat thin, there is often an easy pulsation
called ictus cordis in the V intercostal, left medioclavicularis line. This
pulse is located in accordance with the apex of the heart. The pulsation
diameter is approximately 2 cm, with the maximum punctum in the center
of the area. Pulses occur at the time of the ventricular system. If the ictus
kordis is shifted to the left and widens, there may be left ventricular
enlargement. In adhesive pericarditis, ictus out occurs during diastolis, and
at the time of systemic retraction occurs. This situation is called negative
ictus kordis. The strong pulse in the left third rib is caused by dilation of
the pulmonary artery. The supra sternal pulse may be the result of a strong
aortic pulse. In right ventricular hypertrophy, pulsations appear in the IV
ribs in the sternal line or epigastric region. Look for visible intercostal
artery pulsations on the back. This situation is found in mitral stenosis.
Pulses in the lower neck near the scapula are found at the coarctatio aorta.

1. Palpation
Apical impulses can also sometimes be palpated. Normally felt as a light
pulsation, 1 to 2 cm in diameter. The palms were first used to determine
their size and quality. When the apical impulse is wide and strong, it is
called the heave or lift of the left ventricle. It is so named because it seems
to "lift" the hand off the chest wall during palpation. PMI is abnormal. If
the PMI is located below the V intercostal space or lateral to the
medioclavicular line, the cause is left ventricular enlargement due to left
heart failure. Normally, PMI is only felt in one intercostal space. If the
PMI is palpable in two separate areas and the pulsation is paradoxical (not
concurrent), a ventricular aneurysm should be suspected. In addition to the
pulsation, pay attention to the vibration of "thrill" that is felt in the palms,
due to abnormal heart valves. These vibrations correspond to a strong
heart sound (murmur) on auscultation so that they can be palpated. Thrill
can also be palpated over the blood vessel if there is significant obstruction
of blood flow, and will occur over the carotid artery if there is narrowing
(stenosis) of the aortic valve. Determine at what phase the vibration is felt,
as well as its location.

2. Percussion
The use of percussion is to define the boundaries of the heart. In patients with
pulmonary emphysema there is difficulty percussion of the boundaries of the
heart. In addition to percussion of the boundaries of the heart, large blood vessels
in the basal part of the heart must also be percussed. In normal circumstances
between the left and right sternal lines in the manubrium sterni there is a deaf
which is the aortic area. If this area is widened, possibly due to aortic aneurysm.
To determine the left border of the heart perform percussion from the lateral to the
medial direction. The left heart border extends from the medioclavicular line in
the intercostal spaces III to V. The change between sonor sounds from the lungs
to the relative dimness is defined as the left heart border.

The right border lies below the right border of the sternum and cannot be
detected. An enlarged heart either to the left or right will usually be seen. In some
people whose chest is very thick or obese or has emphysema, the heart is located
so far below the surface of the chest that even the left border is not clear unless it
is enlarged.

1. Heart auscultation

Cardiac auscultation studies include examination of heart sounds, heart sounds


and pericardial scraping.

a. Heart Sounds

To hear heart sounds, pay attention to the localization and origin of heart
sounds, determine S1 and S2 heart sounds, sound intensity and quality, presence
or absence of S3 heart sounds and S4 heart sounds, heart sound rhythm and
frequency, and other accompanying heart sounds.

2. Localization and origin of heart sounds

Auscultation of heart sounds is carried out in the following places:

• Ictus cordis to hear heart sounds coming from the mitral valve

• Left intercostal II to hear heart sounds coming from the pulmonary valve.

• Right intercostal III to hear heart sounds coming from the aorta

• Intercostal IV and V on the right and left edges of the sternum or end of the
sternum to hear heart sounds coming from the tricuspidal valve.

The sites of auscultation above are incompatible with the anatomical location
and location of the valves in question. This is due to the delivery of heart sounds
to the chest wall.

3. Determine the heart sounds I and II


In a healthy person, two kinds of heart sounds can be heard:

Heart sound I (S1), caused by closing the mitral and tricuspidal valves. This
sound is a sign of the start of the ventricular systole phase. The I heart sound is
heard to coincide with the palpation of the pulse in the carotid artery.

Heart sound II (S2), caused by closure of the aortic and pulmonary valves and
signs the start of the ventricular diastolic phase.

4. Sound Intesity and Quality

The intensity of the heart sound is greatly influenced by the thickness of the
chest wall and the presence of fluid in the pericardial cavity.

The intensity of the heart sound must be determined according to how slow or
loud the sound is heard. The heart sound I is generally louder than the second
heart sound at the apex of the heart, while the basal sound of the II heart sound is
greater than the I heart sound.

5. Also pay attention to the quality of the heart sound

In a state of splitting (sound of a broken heart), namely the sound of the heart I
burst due to closing the mitral and tricuspid valves not simultaneously. This may
be found under normal circumstances. A second heart sound that is broken, is
normally found at the time of inspiration where P 2 is slower than A 2. In a
situation where the splitting of the heart sound does not disappear in respiration
(fixed splitting), this condition is usually pathological and is found in ASD and
Right Bundle branch Block (RBBB).

6. The presence or absence of heart sounds III and heart sounds IV

A low-intensity 3rd heart sound is occasionally heard at the end of the


ventricular rapid filling, low pitched, most clearly at the apex area of the heart.
Under normal circumstances found in children and young adults. In pathological
conditions found in severe heart defects such as heart trouble and myocarditis.
Heart sounds 1, 2 and 3 give a sound like galloping horses, known as gallop
protodiastolic.

The fourth heart sound occurs due to forced ventricular distension due to atrial
contraction, most clearly heard at the apex cordis, normal in children and in adults
found in pathological conditions, namely with A - V block and systemic
hypertension. The rhythm that occurs by the 4th heart is called the presystolic
gallop.
1. The rhythm and frequency of heart sounds

The rhythm and frequency of the heart sounds must be compared with the
pulse rate. The normal rhythm of the heart is regular and when it is irregular it is
called an arrhythmia cordis.

The frequency of the heart sounds should be determined in minutes, then


compared with the pulse rate. If the pulse rate and heart sound are more than 100
beats per minute each, it is called tachycardi and if the frequency is less than 60
beats per minute it is called bradycardia.

Sometimes the heart rhythm changes according to respiration. When


expiration is slower, this condition is called sinus arrhythmia. This is due to
changes in stimulation of the autonomic nervous system at the S - A node as a
pacemaker. If the heart rhythm is completely irregular it is called fibrillation.
Sometimes a normal heart rhythm is occasionally punctuated by a faster heart rate
called extrasystole, which is followed by a longer diastolic phase (compensatory
pause). Opening snap, caused by the opening of the mitral valve in the aortic
stenosa, or pulmonary stenosa.

1. Lungs

Findings that are often found in heart patients include:

• Tachypnea. Rapid, shallow breathing can be seen in patients who have heart
failure or are in pain, or who are very anxious.

• Chyne-stokes respiration. Patients with severe left ventricular failure may


exhibit chyne-stokes breathing, which is characterized by rapid breathing
alternating with periods of apnea.

• Hemoptitis. Pink frothy sputum indicates acute pulmonary edema.

• Cough. Dry and deep cough due to minor airway irritation is common in
patients with pulmonary congestion due to heart failure.

• Krekels. Heart failure or atelectasis associated with bed rest, splinting due to
ischemic pain, or the effects of painkillers and sedatives often result in cramps.

• Wheezing. Compression of the small airways due to edema of the pulmonary


interstitial tissue can result in wheezing.

2. Abdomen
In cardiac patients, there are two common components for abdominal
examinations

• Hepatojugular reflux. Swelling of the liver results from decreased venous


return caused by right ventricular failure. The liver becomes large, hard, non-
tender, and smooth. Hepatojugular reflux can be checked by pressing firmly on
the liver for 30 to 60 seconds and a 1 cm increase in jugular venous pressure will
be seen. This elevation indicates the inability of the right side of the heart to
respond to increased volume.

• Bladder distension. Urine output is an important indicator of heart function.


Thus, a decrease in urine output is a significant finding that should be investigated
to determine whether the reduction is due to decreased urine output (which occurs
when renal perfusion is decreased) or due to the patient's inability to urinate.

3. Feet and Legs

Most patients with heart disease also develop peripheral vascular disease, or
peripheral edema due to right ventricular failure. Therefore, in all cardiac patients
it is important to assess the peripheral arterial circulation and venous return.

C. SOP for the Assessment of the Cardiovascular System

1. Preparation of tools

• Stethoscope

• Spignomanometer

• Stationary

• Ruler

• Client records

• Blankets

• Sampiran

• Wristwatch

2. Client preparation

• Set the client's position (lying on his back) with the upper body slightly
raised

• Ask the client not to talk during the examination

• Make good lighting in the room


3. Physical examination procedures

• Washing hands

• Describe the procedure

4. Inspection

• See nail color, nail shape and palms

• Check skin color on the body, limbs and mucous membranes

• Inspection of the eye for xanthoma palpebra / soft yellow spot / eyelid plague

• Determine the jugular vein pressure (JVP), measure the height between the
angle of the strnum and the place of the highest palpation of the internal jugular
vein using a ruler.

• Check the precordium for: visible palpation, lift, 50% adult wave will show
in the PMI area, lower apical impulses suggest ventricular enlargement

• Inspect for edema in the area around the scapula, abdomen, sacrum, wrists
and feet.

5. Palpation

• Palpate the whole chest for: Apical impulses, vibrations, waves and
tenderness. Impulses can be palpated in the inter-costal area (AIK) to the mid-5
clavicle

• Palpation of the pulse: Compare one side to the other, note palpation of the
carotid, radial, femoral, polyeal, tibial posterior and dorsalis pedis areas.

 0 = Nothing
 + 1 = Decreasing, weak, smooth
 + 2 = Normal
 + 3 = Full, jumping
 • Palpation for peripheral edema, edema is graded on a scale of four:
 + 1 = 0 - ¼ inches
 + 2 = ¼ - ½ inch
 + 3 = ½ - 1 inch
 + 4 = more than an inch
6. Percussion
 • Percussion of the left heart border sequentially between the 5th, 4th and
3rd intercostal cavities, indicating where percussion shows a change in
sensitivity.
7. Auscultation
 • Eliminate room noise
 • If it takes a few seconds to hear heart sounds, explain to the client to
reduce anxiety
 • Raise the client's breasts to hear over the chest wall better
 • Auscultate for high notes. Take the time to listen to every sound
 • Start with the aortic area or PMI, then slowly move the stethoscope
systematically across 5 areas of the heart
 • Make sure to hear the heart sound clearly at each location
 • Repeat the series of assessments by placing the bell side of the
stethoscope to the chest
 • If necessary ask the client to do three different positions during the
assessment (sitting straight and body slightly forward, lying on his back,
left lateral recmben position)
 • Check heart rate:
 After the two sounds are clear like 'lupdup' count each combination of S1
and S2 as one heartbeat and count for one minute
 • If irregular, compare the apical and radial frequencies. Pulse deficit
occurs when the radial pulse is less than the apical
 • Use the bell side of the stethoscope to listen for extra low-pitched sounds
(S3 and S4) S3 (ventricular galop) occur after S2 and S4 (atrial gallops)
occur after S1
 • Auscultate for murmurs, note time, location and so on
 • Auscultate blood pressure
 • Record abnormalities and results in the client's nursing record
CHAPTER IV

CLOSING

A. Conclusion

The cardiovascular system consists of the heart and the vascular system including
the heart muscle, atria, ventricles, valves, coronary arteries, cardiac veins, electrical
conduction structures and cardiac breathing. While the blood vessel system (vascular)
is formed by the body's blood vessels including arteries, arterioles, veins, venules, and
capillaries. The main function of the cardiovascular system is the transportation of
nutrients and oxygen to the body, removing waste substances and carbon dioxide,
maintaining adequate perfusion of organs and tissues.
REFERENCES

Arif muttaqin.2009.buku pengantar asuhan keperawatan klie dengan gangguan sistem


kardiovaskuler.edisi 1.jakarta:selemba medika

riza fikriana.2018.buku sistem kardiovaskuler.edisi 1.yogyakarta:budi utama. (n.d.).

Safri, & ,Sofiana Nurchayati, S. R. (2018). Gambaran Asuhan Keperawatan. 9(1), 1–10.