ASSESSING HEART AND NECK VESSEL HEART CHAMBERS
4 chambers
HEART Thin-walled atria - receiving chamber
Thick-walled ventricle - pumping chamber
Left ventricle - thicker; greater workload
Septum - partition between left & right side of
the heart.
HEART VALVES - unidirectional blood flow
Atrioventricular (AV) valves are located
Hollow, muscular, four- chambered organ at the entrance into the ventricles
located in the mediastinum (tricuspid & bicuspid)
Extends vertically from the left 2nd the left 5th Chordae tendinae - anchor AV valve flaps to
ICS; horizontally from the right edge of the papillary muscles within the ventricles
sternum to the left MCL Semilunar valves are located at the exit of each
Precordium - anterior chest area that overlies ventricle at the beginning of the great vessels
the heart and great vessels. (pulmonic & aortic)
HEART COVERING & WALLS
Pericardium - tough, inextensible, loose-fitting,
fibro-serous sac that attaches to the great
vessels & surrounds the heart
Right side - Pulmonary Circulation Parietal pericardium - secretes pericardial fluid
Left side - Systemic Circulation HEART LAYERS - epicardium; myocardium;
endocardium.
GREAT VESSELS
PERICARDIAL FRICTION RUB
Superior & Inferior vena cava return blood to High pitched, scratchy, leathery sound that is
the right atrium generated when the inflamed parietal & visceral
Pulmonary artery - exits right ventricle; carries pericardial layers rub together.
deoxygenated blood to the lungs Pericarditis, pericardial effusion & acute MI
Pulmonary veins - return oxygenated blood to Sharp, knife like pain may accompany the rub
the left atrium
Aorta -oxygenated blood from left ventricle to
the body.
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ELECTRICAL CONDUCTION OF THE HEART CARDIAC CYCLE
The generation & conduction of electrical
impulses by specialized sections of the
myocardium regulate the events associated
with the filling and emptying of the cardiac
chambers.
Refers to the filling & emptying of the heart’s
chambers
2 phases:
Diastole - relaxation of the ventricles
(filling)
Systole - contraction of the ventricles
(emptying)
Sinoatrial (SA) node - posterior wall of the R
atrium near the junction of the SVC & IVC.
“Pacemaker of the heart” HEART SOUNDS
Generates impulses at 60-100 rpm
Atrioventricular (AV) node - lower interatrial
septum.
Slightly delays incoming electrical
impulses from atria & relays impulse to
AV bundle.
AV bundle (bundle of His) - upper inter
ventricular septum
Purkinje fibers - myocardium of both ventricles
ELECTRICAL ACTIVITY
Produced by valve closure
S1 “lub” - AV valve closure
S2 “dubb” - Semilunar valve closure
EXTRA HEART SOUNDS
S3 & S4 - Diastolic filling sounds; result from
ventricular vibration secondary to rapid
ventricular filling
Electrical impulses, which are generated by the S3 (Ventricular gallop) - can be heard early in
SA node & travel throughout the cardiac diastole, after S2; normally in children & young
conduction circuit, can be detected on skin adult; CHF
surface. S4 (Atrial gallop)- secondary to ventricular
Electrocardiography (ECG/ EKG) resistance during atrial contraction; heard late
records the depolarization & repolarization of in diastole, just before S1; HTN, CAD, MI.
the cardiac muscles.
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MURMURS
Turbulent blood flow in which swooshing or NECK VESSELS
blowing sound is heard upon auscultation over
the precordium
Conditions that contribute turbulent blood
flow:
1. Increased blood velocity
2. Structural valve defects
3. Valve malfunction
4. Abnormal chamber openings
GRADING OF MURMURS (LEVINE GRADE SCALING)
Is a numeric scoring system to characterized the
intensity or loudness of heart murmur.
Grade I - barely audible, heard only in a CAROTID ARTERY
quiet room & then with difficulty Supply the neck and head, including
Grade II – clearly audible, but faint the brain with oxygenated blood
Grade III – moderately loud, easy to Centrally located arterial pulse
hear Pressure waves pulsation coincides
Grade IV – loud, associated with a thrill closely with ventricular systole
palpable on the chest wall
Grade V – very loud, heard with one
corner of the stethoscope liftedoff the JUGULAR VENOUS PULSE & PRESSURE
chest
Grade VI – loudest, still heard with the
entire stethoscope lifted off the chest.
CHARACTERISTICS OF SOUNDS
N: 60-100bpm
Rate: brady-/tachycardia
Rhythm: regular, irregular, regularly irregular
Pitch: high, medium, low Intensity: soft to loud, 1 to 6
Duration: short, long
Timing: systolic, diastolic or both JUGULAR VEINS
Quality: blowing, rumbling, sharp, snappy Return blood to the heart from the
Location: site where heard best & radiates. head & neck by way of superior vena
cava
Right IJV - most directly connected to
CARDIAC OUTPUT the right atrium; provides best
assessment of pressure changes.
Amount of blood pumped by the ventricles The level of the jugular venous pressure
during a given period of time (1 minute) reflects right atrial (central venous)
Determined by the Stroke Volume multiplied pressure
by the Heart Rate Right sided heart failure raises pressure
CO = SV x HR & volume, thus, raising jugular venous
pressure.
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DEVELOPMENTAL VARIATIONS CULTURAL VARIATIONS
Japanese have a lower incidence of HTN & high
INFANTS cholesterol
Hispanics have a lower mortality rate from
heart disease than, non-Hispanics
Middle – aged Caucasians have the highest
incidence of CAD
African American have an earlier onset &
greater severity of CAD than other groups
Native Americans under age 35 have twice the
mortality rate from heart disease as other
groups.
Foramen ovale
Connected right & left atria closes after SYMPTOMS (CARDIOVASCULAR PROBLEM)
birth
Ductus arteriosus CHEST PAIN
Shunt between the pulmonary trunk & Most common
aorta Cardiac, respiratory, gi, ms, or psychogenic
Systolic murmurs may result until adults chest pain always treated as cardiac in
closure occurs within 48 hours origin.
120-160 BPM – normal HR.
PALPITATION
CHILDREN Sense that heart is racing or skipping beats
Apical pulse is on the 4th ICS until age 7 (more
horizontal)
Thin chest wall – louder heart sounds, SYNCOPE/ SYNCOPAL ATTACKS (DIZZINESS)
physiologic S3 Result from decreased cerebral blood flow (may
Innocent murmurs are common 60-100 BPM be non cardiac or side effect of medications)
PREGNANT WOMEN
Increase in cardiac workload often results in EDEMA
development of systolic murmur Seen with right-sided CHF & vascular disease
A mammary souffle is a murmur that develops Increased capillary hydrostatic pressure that
from increased blood flow through mammary shifts fluid from capillaries to the tissue
artery
Apical impulse displaced – as pregnancy
progresses, the diaphragm rises, the heart rises
& rotates
BP – lower during 1st & 2nd trimesters
HR – slightly higher
OLDER ADULTS
Changes in BP
Auscultatory gaps also frequently occur
(inaccurate BP readings) FATIGUE
Postural (orthostatic) hypotension results Feeling tired & having no energy subtle
from: symptom
Decrease baroreceptor response Investigate changes in ADL, rest & sleep
Increase incidence of CV disease patterns
Medications
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EXTREMITY CHANGES B. VASCULAR ULCERS
May provide clues about underlying 1. Venous Ulcers
cardiovascular disease Due to venous HPN that are seen in the lower
Paresthesia Coolness legs, and ankles.
Intermittent claudication
2. Lymphatic Ulcers
DYSPNEA & COUGH Due to lymphedema in which capillaries are
Results from pulmonary congestion or compressed by thickened blood flow to the
increased pulmonary venous & capillary skin.
pressure. 3. Arterial Ulcers
Due to occlusive arterial disease secondary to
arterial insufficiency. Common sites include tips
ABNORMAL PULSATIONS of the toes, nail beds corners, over bony
A weak arterial pulse - indicate decreased prominences.
cardiac output or increased peripheral vascular
resistance
Strong or bounding pulse – occur in patients
with a condition that causes increased cardiac EXTREMITY CHANGES
output
Thrill – suggest valvular dysfunction ARTERIAL INSUFFICIENCY
ABNORMAL PULSES
Pulsus Alternans – regular alternating pattern
of a weak and strong pulse
Pulsus Bigeminus – similar to pulsus alternans
but occurs at irregular intervals
Pulsus Paradoxus – increases and decreases in o Absent/Decreased Pulses
amplitude associated with respiratory cycle, o Cool, pale, shiny skin
decreases when patient inhales. o Hair loss on legs
o Leg pain
o Ulcerations around toes
o Foot becomes deep red when
dependent
o Thick, ridged nails
VENOUS INSUFFICIENCY
o Ulcerations around the ankle
VASCULAR ABNORMALITIES o Pulses may be present but difficult to
A. BRUITS palpate
Murmur-like sound that is vascular in origin o Edema
Arterial bruit o Cyanotic when dependent
occlusive arterial disease, arterio-
venous fistula
anemia, hyperthyroidism,
pheochromocytoma
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HEALTH ASSESSMENT Do you experience swelling (edema) in your feet,
COLLECTING SUBJECTIVE DATA: The Nursing ankles, or legs? When did this begin? What time of
Health History the day do you have this swelling?
Is it in one or both legs?
HISTORY OF PRESENT HEALTH CONCERN (CHEST PAIN)
Do you experience chest pain? (COLDSPA) Do you have frequent heartburn? When does it
Character: Describe your chest pain (stabbing, burning, occur? What relieves it? How often do you experience
crushing, squeezing or tightness) it?
Onset: When did it start?
Location: Where is the pain? Does it radiate to any Have you been diagnosed with a heart defect or a
other area? murmur?
Duration: How long does the pain last? How often do
you experience the pain? Have you ever had heart surgery or cardiac balloon
Severity: Rate the pain on scale of 0-10, with 10 being interventions?
the worst possible pain.
Patterns: What brings on the pain? What relieves Have you ever had rheumatic fever?
the pain?
Associated Factors: Do you have any other Have you ever had an electrocardiogram (ECG)? When
symptoms with this pain (shortness of breath was the last one performed? Do you know the
(dyspnea), perspiration (diaphoresis), pale clammy skin, results?
nausea, vomiting, heart beat skips or speeds up)?
Have you ever had a blood test called a lipid profile?
TACHYCARDIA AND PALPITATIONS Based on your last test, do you know what your
Does your heart ever beat faster? cholesterol levels were?
Does your heart ever skip beats, or have extra beats?
When does this occur and how long does it last? What Have you ever had an electrocardiogram (ECG)? When
makes this better or worse? was the last one performed?Do you know the results?
OTHER SYMPTOMS Have you ever had a blood test called a lipid profile?
Do you tire easily? Do you experience fatigue? Based on your last test, do you know what your
Describe when the fatigue started. cholesterol levels were?
Was is sudden or gradual?
Do you notice it at any particular time of the day? Do you monitor your own heart rate or blood
pressure?
Do you have difficulty breathing (dyspnea) or shortness
of breath? FAMILY HISTORY
When does it occur? Is there a history of hypertension, myocardial
What activities cause you to be short of breath? Infarction (MI), coronary heart disease (CHD), elevated
Do you have difficulty breathing when you are lying cholesterol levels, or diabetes mellitus (DM) in your
down? How many pillows do you use to sleep? Does family?
the difficulty breathing wake you up at night?
LIFESTYLE AND HEALTH PRACTICES
Do you cough up mucous? When does it occur? Do you smoke? How many packs of cigarettes per day
Describe the appearance. and for how many years?
Do you experience dizziness? How much alcohol do you consume each day/ week?
Do you wake up at night with an urgent need to Describe what you usually eat in a 24-hour period.
urinate (nocturia)? If so, how man times each
night? Do you exercise? What type of exercise and how
often?
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What type of stress do you have in your life? How do
you cope with it?
Describe your daily activities. How are they different
from your routine 5 or 10 years ago? Does fatigue,
chest pain, or shortness of breath limit your ability to
perform daily activities? Describe. Are you able
to care for yourself?
Has your heart disease had any effect on your sexual
activity?
How many pillows do you use to sleep at night? Do you
get up to urinate during the night? Do you feel rested
in the morning?
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