Heart & Neck Vessels
Assessment
Kousar Perveen
Assistant Professor
The University of
Lahore
Objectives
By the end of the unit, learners will be able to:
1.Describe the components of health history that should be
elicited during the assessment of cardiovascular system.
2. Identify the landmarks of the chest.
3. Describe the following:
Pulse rate, rhythm and pulsation characteristics
PMI
Heart sounds
Discuss systolic and diastolic murmurs
Fact
•
s
According to a recent study by the Registrar General of
India ( RGI) and the Indian Council of Medical Research
(ICMR), about 25 percent of deaths in the age group of 25-
69 years occur because of heart diseases.
• If all age groups are included, heart diseases account for
about 19 percent of all deaths.
3
Review of cardio vascular system
Route of blood from the heart:
–Arteries, arterioles, capillaries, venules, veins
Distribution of the Total Blood Volume
– Heart - Approx 9 % of blood volume at any
given time.
Arteries and veins act simply as conduits for
blood!
Only capillaries directly serve cells by exchanging
materials with them. 4
Cardiac tissues
• Connective tissues – form the fibrous skeleton
and valves.
• Cardiac muscle – produces the contractile
force of the heart.
• Epithelial tissue – lines the cardiac chambers
and covers the outer surfaces of the heart.
5
Arterial system
General Features
– Elastic Arteries
– Muscular
Arteries
– Arterioles
6
Exterior Anatomy of the Heart
7
Anatomy of the Heart
8
Valves of the Heart
• Tricuspid – Directs the flow of blood from the
right atrium to the left ventricle.
• Mitral Valve – Directs the flow of blood from
the left atrium to the left ventricle.
• Pulmonic (semilunar) – Lies between the
right ventricle and the pulmonary artery.
• Aortic Valve (semilunar) – Lies between the
left ventricle and the aortic artery.
9
Circulation in the Heart
1. Oxygen-poor blood (shown
in blue) flows from the body
into the right atrium.
2..Blood flows through the right
atrium into the right ventricle.
3. The right ventricle pumps
the blood to the lungs, where
the blood releases waste gases
and picks up oxygen.
10
Circulation in the Heart-contd
3.The newly oxygen-rich
blood (shown in red) returns
to the heart and enters the
left atrium.
4.Blood flows through the
left atrium into the left
ventricle.
5.The left ventricle pumps
the oxygen-rich blood to all
parts of the body.
11
Circulation in the Heart-contd
The
Circulatory
System
12
Coronary Circulation
13
Coronary Blood Flow
• Coronary Blood Flow is directly linked to
oxygen demand.
• Autoregulation helps to maintain normal
coronary blood flow whenever coronary
perfusion pressure changes due to changes in
aortic pressure.
14
Coronary Blood Flow
15
Physiology of Circulation (cont.)
Peripheral Resistance
– Opposition to flow
– A measure of the amount of friction blood encounters
as it passes through the vessels.
– Most friction is encountered in the peripheral
circulation (peripheral resistance (PR)).
– Sources of resistance…
16
Physiology of Circulation (cont.)
Blood Pressure
– Force per unit area exerted on the wall of a vessel by
its contained blood expressed in mm Hg.
– Usually means systemic arterial blood pressure in
the largest arteries near the heart.
– The differences in blood pressure within the vascular
system provided the driving force that keeps blood moving
through the body.
17
Physiology of Circulation
Blood Flow
• Actual volume of blood flowing through the entire
circulation or any part of it (a vessel, an organ, etc.) in a
given period of time (ml/min).
• Equals cardiac output (CO) when applied to the entire
circulation.
• Varies widely among individual body organs as
determined by their immediate needs.
18
The Cardiac Cycle
1. Iso volumetric
ventricular contraction
2. Ventricular ejection
3. Iso volumetric relaxation
4. Ventricular filling
5. Atrial systole
19
Ejection fraction (EF)
• The ejection fraction (EF) represents the
amount of blood pumped out of the heart (left
ventricle) with each beat. In the healthy
heart, it is around 70%.
• An EF below 55% is considered abnormal.
20
Risk factors of cardiac disease
– Non-modifiable
• Age
• Sex
• Family history
• Race
– Modifiable
• Cigarette smoking
• Hypertension
• Hyperlipidemia
• Physical inactivity
• Diabetes
• Stress
• Obesity
21
Subjective Data
Chest Pain and Palpitations
• Do you experience chest pain? When did it start? Describe the
type of pain, location, radiation, duration, and how often you
• experience the pain. Rate the pain on a scale of 0 to 10, with
10 being the worst possible pain. Does activity make the pain
• worse? Did you have perspiration (diaphoresis) with the chest
pain?
• Do you experience palpitations?
Other Symptoms
• Do you tire easily? Do you experience fatigue? Describe when
the fatigue started. Was it sudden or gradual? Do you notice it
at any particular time of day?
Subjective Data
• Do you have difficulty breathing or shortness of breath
(dyspnea)?
• Do you wake up at night with an urgent need to urinate
(nocturia)?
• How many times a night?
• Do you experience dizziness?
• Do you experience swelling (edema) in your feet,
ankles, or legs?
• Do you have frequent heart burn? When does it occur?
What relieves it? How often do you experience it?
Subjective Data
• Have you been diagnosed with a heart defect or a murmur?
• Have you ever had rheumatic fever?
• Have you ever had heart surgery or cardiac balloon interventions?
• Have you ever had an electrocardiogram (ECG)? When was the
• last one performed? Do you know the results?
• Have you ever had a blood test called a lipid profile? Based on
• your last test, do you know what your cholesterol levels were?
• Do you take medications or use other treatments for heart disease?
• How often do you take them? Why do you take them?
• Do you monitor your own heart rate or blood pressure?
History
• Chest Pain
• Palpitation
• Fatigue
• Dyspnea
• Urination
• Dizziness
• Swelling
• Heart burn
History
• Congenital Problems
• Rheumatic Fever
• Cardiac Ballon Intervention
• ECG
• Lipid profile
• Medical Treatments
• Regular monitoring of BP
Additional history
• For infants: mother’s health during pregnancy, feeding
habits, growth, activity.
• For children: growth, activity, any joint pains or unexplained
fever, frequent headaches or nose bleedings, streptococcal
infection (tonsillitis).
• For pregnant female: any high BP during this or
previous pregnancies, associated signs (weight gain,
proteinuria), dizziness.
• For aging adult: any symptoms of heart diseases (HTN,
CAD) or COPD, any recent changes, medications (digitalis),
side effects; environment.
27
Traditional Areas of Auscultation
Aortic area: Second intercostal space at the right
sternal border—the base of the heart
Pulmonic area: Second or third intercostal space
at the left sternal border—the base of the heart
Erb’s point: Third to fifth intercostal space at the
left sternal border
Mitral (apical): Fifth intercostal space near the
left midclavicular line—the apex of the heart
Tricuspid area: Fourth or fifth intercostal space at
the left lower sternal border
Inspection
# Technique Normal Abnormal
1 Observe The jugular Fully distended jugular
the jugular venous pulse is veins with 45 degrees
venous not normally indicates
pulse visible • rt ventricular failure
•Pulmonary
hypertension
•Pulmonary emboli or
cardiac tamponade
Inspection
2- Evaluate Should not be Distended at 45, 60 or
jugular distended, 90 degrees indicate rt
venous bulging or sided heart failure
pressure protruding at 45 Client with obstructive
degrees or greater pulmonary disease have the
elevated venous pressure
only during expiration
An inspiratory increase in
venous pressure is called
kussmaul’s sign, may occur
in clients with severe
constrictive pericarditis
Inspection
Evaluating jugular vein distention
■ Elevate the head of the bed 30 to 45 degrees.
■ Locate the angle of Louis (sternal notch). To do so,
palpate the clavicles where they join the sternum (the
suprasternal notch). Place your first two fingers on
the suprasternal notch. Then, without lifting them
from the skin, slide them down the sternum until you
feel a bony protuberance—this is the angle of Louis.
■ Find the internal jugular vein. (It indicates venous
pressure more reliably than the external jugular vein.)
Cont…….
■ Shine a flashlight across the patient’s neck to create
shadows that highlight his venous pulse. Be sure to
distinguish jugular vein pulsations from carotid
artery pulsations. You can do this by palpating the
vessel: Arterial pulsations continue, whereas venous
pulsations disappear with light finger pressure.
Also, venous pulsations increase or decrease with
changes in body position; arterial pulsations remain
constant.
■ Locate the highest point along the vein where you
can see pulsations.
Cont……
■ Using a centimeter ruler, measure the distance
between the high point and the sternal notch.
Record this finding as well as the angle at
which the patient was lying. A finding greater
than 3 to 4 cm above the sternal notch, with
the head of the bed at a 45-degree angle,
indicates jugular vein distention.
Auscultation
1 Auscultate the carotid No blowing or Bruits are
artery swishing or other indicative of
occlusive
arterial
disease.
If the artery is
more than 2/3
occlusive
than no
bruits may be
heard.
Auscultation
Palpation
1 Place your fingers You shouldn’t Weak Pulse:
just medial to the be able to hypovolemi
trachea and below detect any a
the angle of the jaw. palpable
The pulse should be vibrations, Bounding pulse:
regular in known as hypervolemia
rhythm and have thrills.
equal strength Irregular pulse:
in the right and Pulse Amplitude Paradoxical Pulse
left carotid Scale
0 = Absent Bisferiens Pulse
arteries 1+ = Weak
2+ = Normal
3+ = Increased *A delayed upstroke
4+ = Bounding may indicated
aortic stenosis
Palpation
• *If you detect occlusion during
auscultation, palpate very lightly to avoid
blocking circulation or triggering vagal
stimulation and bradycardia, hypotension or
even cardiac arrest.
• * Palpate the arteries individually
because bilateral palpation could result in
reduce cerebral blood flow
Inspection (Pericordium)
1 With the client The apical impulse may Heaves or
in supine or may not be visible. lifts may be
position with the present
head of the bed If visible in the (enlarged
elevated midclavicular line , 4th to ventricle).
between 30 and 5th intercostal space
45 degrees, stand
on the client’s rt
side and look for
the apical
impulse and any
abnormal
pulsation
References
Bicklay, L. S. (2012). Bates’ guide to physical examination and
history taking (10th ed). Wolters Kluwer/Lippincott Williams
& Wilkins Health.
Carol, L.Cox (2010). Physical Assessment for Nurses (2nd. Ed)
Blackwell Publishing Ltd.
Chiocca, E. M. (2011). Advanced pediatric assessment.
Phildelphia, U.S: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Weber, J., & Kelley, J. H. (2015). Health Assessment in
Nursing
(5th ed). Phildelphia: Lippioncot.
