NUR314 Week 3: Heart
and Neck Vessels
Saturday, June 3, 2023
6:24 PM
Cardiovascular System
Highly complex
Heart and closed system of blood vessels
Heart and Great Vessels
Heart
Hollow, muscular, four chambered organ (atria/ventricles)
Middle of thoracic cavity in the mediastinum
Inverted cone or triangle from left 2nd-5th ICS
Great Vessels
Large veins and arteries leading directly TO and AWAY
Superior and Inferior Vena Cava
- return blood to the right atrium from the upper and lower body
Pulmonary Artery
- leaves RV and carries to Lungs
Pulmonary Veins (2 from each lung)
- returns O2 blood to LA
Aorta
- transports O2 blood from LV to the body
Heart Wall
Heart wall has numerous layers:
Pericardium: tough, fibrous, double-walled sac that surrounds and protects hear
Myocardium: muscular wall of heart
Endocardium: thin layer of endothelial tissue that lines inner surface of heart
chambers and valves
Heart Chambers
Four chambers:
→ Right Atrium (RA)
→ Left Atrium (LA)
→ Right Ventricle (RV)
→ Left Ventricle (LV)
Separated by the Septum
2 Pumps:
Right side pumps blood into the lungs
Left side pumps blood into the body
Valves
There are 4 Heart valves. They allow for unidirectional flow of blood. They only
one way. Prevents backflow of blood.
Two Atrioventricular (AV) VALVES
located at the ENTRANCE of the ventricles
▪ Tricuspid – between RA and RV
rt
y open
one way. Prevents backflow of blood.
Two Atrioventricular (AV) VALVES
located at the ENTRANCE of the ventricles
▪ Tricuspid – between RA and RV
▪ Mitral/Bicuspid – Between LA and LV
→ Allows blood flow from atria to ventricles, snap shut when ventricles b
to contract
Two Semilunar (SL) VALVES
located at the EXIT of each ventricle at the great vessel
▪ Pulmonic – exit RV and entrance to pulmonary artery
▪ Aortic – exit LV and entrance to aorta
→ Open during ventricular contraction, close when ventricles relax
Heart Wall, Chambers and Valves
Electrical Conduction of the Heart
• Cardiac muscle cells – unique, automatic ability
► Generate electrical impulse and conduct it through the heart
begin
•
•
•
•
•
•
•
Electrical Conduction of the Heart
Cardiac muscle cells – unique, automatic ability
► Generate electrical impulse and conduct it through the heart
Special sections of the myocardium – regulates the filling and emptying of the he
chambers
Sinoatrial (SA) node – posterior wall of the RA, near the junction of the vena ca
(SVC, IVC - Superior/ Inferior Vena Cava)
SA NODE IS THE PACEMAKER - Generates impulses at 60-100 per minute
Current travels through the atria – to the AV node to the AV bundle in the
interventricular septum
Then to bundle branches to the myocardium of both ventricles
RESULT: CONTRACTION of the Muscles
◊ Can be measured through an EKG
Cardiac Cycle
Refers to filling and emptying of the heart’s chambers
Diastole (RELAXATION of the ventricles) – filling
Lasts 2/3 of the cycle
AV valves open, ventricles relax, blood rushes in
Rapid early filling (PROTODIASTOLIC)
Atria contracts (ATRIAL KICK) – last kick by the atria
Systole (CONTRACTION of the ventricles) – emptying
Lasts 1/3 of the cycle
Pressure in Vent > Atria
AV Valves close (S1)
Beginning of systole & all four valves are closed and ventricles contract
Higher pressure in ventricles and Aortic and Pulmonic valves open – Blood eject
Pressure falls and valves close (S2), Ventricle relaxes
eart
avas
ted
Heart Sounds
First heart sound (S1) – LUB SOUND
Closure of AV valve—signals beginning of systole
S1 Loudest at apex
Correlates with pulse, with carotid
Second heart sound (S2) – DUB SOUND
Closure of semilunar valve—signals end of systole, beginning of Diastole
S2 loudest at base
Splitting of S2 – normal, occurs toward the end of inspiration in some people, he
only in the pulmonic valve area
Extra Heart Sounds: S3
Third heart sound (S3): Volume Overload
S3: Ventricular Gallop (fluid causes extra sound)
→ use BELL over APEX
▪ Physiologic: Children, Young adults (<40 men. <50 women), Athletes,
Pregnancy (3rd trimester). Disappears when patient sits up.
eard
S1 and S2
S3
S4
Descrip1on
of Heart…
Third heart sound (S3): Volume Overload
S3: Ventricular Gallop (fluid causes extra sound)
→ use BELL over APEX
▪ Physiologic: Children, Young adults (<40 men. <50 women), Athletes,
Pregnancy (3rd trimester). Disappears when patient sits up.
▪ Pathologic: Fluid overload. CHF, Hyperthyroidism, Anemia, Pregnancy (1s
2nd Trimester)
○ Occurs immediately after S2, when AV valves open and atrial blood first pours in
ventricles.
Extra Heart Sounds: S4
S4: Atrial Gallop (hardening of ventricle (pressure) causes sound)
→ use BELL over APEX
• Physiologic: (hardly ever) 40-50 y/o after exercise.
• Pathologic: HTN, CAD, Cardiomyopathy, obstruction of blood (aortic steno
and ventricular hypertrophy)
• S4 occurs just before S1
17
Extra Heart Sounds: Murmurs
Gentle, blowing, swooshing sound that can be heard on chest wall
Conditions that create turbulent blood flow and collision currents
Conditions that can result in murmurs:
• Velocity of blood increases
• Viscosity of blood decreases
• Structural defects in valves
Murmurs
Systolic murmur – may occur with healthy heart OR with heart disease, Usually
with S1
Diastolic murmur – always heart disease
Innocent – no pathological cause
Functional – increased blood flow through the heart (pregnancy, anemia, fever, a
children)
of Heart…
st &
nto
osis
heard
PQRSTU
Questions Related t
• What makes
Provocati
ve
and in
• What makes
Palliative
Quality
• What does th
Note: If the client str
such as “aching,” “sta
to Pain
s your pain worse?
s your pain feel better?
he pain feel like?
ruggles to answer this question, you can provide suggestions
abbing,” “burning.”
children)
▪
▪
▪
▪
Characteristics of Sound
All heart sounds are described by:
Frequency or pitch: high or low
Intensity or loudness: loud or soft
Duration: very short for heart sounds; silent periods are longer
Timing: systole or diastole
20 Developmental Competence uPregnant woman
Developmental Competence
Pregnant woman
Blood volume increases by 30% to 40% during pregnancy.
Despite increased cardiac output, arterial blood pressure decreases in pregnancy a
result of peripheral vasodilation.
Infants and children
Fetal heart begins to beat after 3 weeks’ gestation.
Inflation and aeration of lungs at birth produces circulatory changes.
Aging adult
Closely interrelated with lifestyle, habits, and diseases
Lifestyle, smoking, diet, alcohol use, exercise patterns, and stress have an influen
• What makes
Palliative
Quality
• How bad is y
Quantity
Region
• Where do yo
• Point to whe
Radiation
• Does the pai
• Do you feel t
Severity
(severity
scale)
Timing
Treatmen
t
as a
nce on
• What does th
Note: If the client str
such as “aching,” “sta
• How would y
and 10 being
Note: The severity sc
provide evaluation o
provide some sort of
was effective.
•
•
•
•
•
•
When did the
What were y
Where were
Is the pain co
If the pain is
How long do
• Have you tak
• Have you trie
• What do you
Understa
nding
s your pain feel better?
he pain feel like?
ruggles to answer this question, you can provide suggestions
abbing,” “burning.”
your pain?
ou feel the pain?
ere you feel the pain.
in move around?
the pain elsewhere?
you rate your pain on a scale of 0 to 10, with 0 being no pain
g the worst pain you’ve ever experienced?
cale is an important assessment of pain and when used can
of a treatment’s effectiveness. After eliciting a baseline, you may
f pain control intervention and then reassess the pain to see if it
e pain start?
you doing when the pain started?
you when the pain started?
onstant or does it come and go?
intermittent, when did it last occur?
oes the pain last?
ken anything to help relieve the pain?
ed any treatments at home for the pain?
u think is causing the pain?
Inflation and aeration of lungs at birth produces circulatory changes.
Aging adult
Closely interrelated with lifestyle, habits, and diseases
Lifestyle, smoking, diet, alcohol use, exercise patterns, and stress have an influen
coronary artery disease.
Pumping Ability
Cardiac output: In resting adult, heart normally pumps between 4 and 6 L of bloo
minute throughout body
CO= HR x SV
Heart can alter its cardiac output to adapt to metabolic needs of body.
Preload and afterload affect heart's ability to increase cardiac output.
Preload: venous return that builds during diastole
According to Frank-Starling law, greater the stretch, the stronger the heart's
contraction.
• This increased contractility results in an increased volume of blood ejected,
increased stroke volume.
Afterload: opposing pressure ventricle must generate to open aortic valve against
higher aortic pressure
• Resistance against which ventricle must pump its blood
Neck Vessels
nce on
od per
t
Hemodynamic Changes with Aging
Pressure/pulse changes
uPressure/pulse changes
Isolated systolic HTN: Increase in systolic BP due to thickening and stiffening o
arteries
Left ventricular wall becomes thicker but the overall size of the heart does not ch
Pulse pressure increases.
No change in resting heart rate or cardiac output at rest
Ability of heart to augment cardiac output with exercise is decreased.
Dysrhythmias
Presence of supraventricular and ventricular dysrhythmias increases with age.
Ectopic beats common in aging people; usually asymptomatic in healthy older pe
may compromise cardiac output and blood pressure when disease present
Tachyarrhythmias may not be tolerated as well in older people.
Electrocardiogram changes:
Occur as result of histologic changes in conduction system; these changes includ
□ Prolonged P-R interval (first-degree AV block)
□ Prolonged Q-T interval
□ QRS interval unchanged
□ Increased incidence of bundle branch block
Cardiac Disease and Aging Adult
Incidence of coronary artery disease increases sharply with advancing age and
accounts for about half of deaths of older people.
▪ Hypertension and heart failure also increase with age
▪ Lifestyle habits play a significant role in the acquisition of heart disease.
Increasing the physical activity of older adults associated with a reduced risk for
of the
hange.
eople,
de:
death
Incidence of coronary artery disease increases sharply with advancing age and
accounts for about half of deaths of older people.
▪ Hypertension and heart failure also increase with age
▪ Lifestyle habits play a significant role in the acquisition of heart disease.
Increasing the physical activity of older adults associated with a reduced risk for
from cardiovascular diseases and respiratory illnesses
- Both points underscore need for health teaching as an important treatment
parameter.
○
○
○
○
○
Culture and Genetics
CVD: most common underlying cause of death globally
Risk increased with race, ethnicity, gender, socioeconomic status, and educationa
- Recommend favorable lifestyle: no current smoking, no obesity, physical ac
at least once a week and a healthy diet
- Consider access to care
Risk factors - Identification, early treatment, and health promotion:
uConsider access to care
HTN
Smoking
Serum cholesterol
Physical activity
Sex and gender differences- leading cause of death in women
Subjective Data – Review of Systems - CV
Chest pain
► PQRSTU
Dyspnea
27 Subjective Data – Review of Systems - CV uChest pain
Exertional or at rest, constant or intermittent
► PND (Paroxysmal nocturnal dyspnea ) – occurs with heart failure, affects ADLs
Orthopnea
# of pillows used when supine
Cough
death
al
ctivity
s
Orthopnea
# of pillows used when supine
Cough
u# of pillows used when supine uCough
Duration, frequency, productive
Fatigue
Onset, time of day
Edema
Any swelling of hands or feet, does it resolve at night
Nocturia
Get up at night, how long? frequency
Past Cardiac History
HTN, high cholesterol, heart disease, rheumatic fever, surgery
Family Cardiac History
HTN, CAD, sudden death at an early age
Cardiac risk factors
Nutrition, smoking, alcohol, exercise, medication
Infants, Children and Pregnant Women
Infants
Maternal health: How was mother’s health during pregnancy?
Feeding pattern: Any cyanotic changes during nursing or crying?
Growth and activity: Meeting developmental outcomes?
Children
Growth and activity: Meeting developmental outcomes?
Evidence of any chest pain?
History of respiratory infections
Significant family history—genetic abnormalities
Growth and activity: Meeting developmental outcomes?
Evidence of any chest pain?
History of respiratory infections
Significant family history—genetic abnormalities
uHistory of respiratory infections
Pregnant women
HTN during pregnancy?
Associated clinical symptoms—proteinuria, weight gain, edema?
Experiencing faintness or dizziness?
Additional History for Aging Adult
Medical history
• Review presence of comorbidities.
Medication profile history
• Rx or OTC
• Aware of side effects
• Compliance with therapy
uAware of side effects uCompliance with therapy
Environment
• Impact on ADLs
Preparation and Equipment
Preparation
To evaluate carotid arteries, a person can be sitting.
To assess jugular veins and precordium, the person should be supine with head
chest slightly elevated.
Ensure woman’s privacy by keeping her breasts draped.
Equipment
Marking pen
Small centimeter ruler
Stethoscope with diaphragm and bell endpieces
Alcohol wipe to clean endpiece
uu
d and
Marking pen
Small centimeter ruler
Stethoscope with diaphragm and bell endpieces
Alcohol wipe to clean endpiece
uu
Physical Exam
Carotid Arteries
Inspect
Palpate
Auscultate for bruits
Jugular Veins
INSPECT
Pulsation
2 ruler test
Hepatojuguloreflux
- consists of a distention of the neck veins when pressure is applied over the l
- an indication that the right ventricle cannot accommodate an increased veno
return
Precordium
2 uPrecordium
Inspect anterior chest for heaves, lifts, & apical pulse
Palpate: heaves, lifts, thrills, apical pulse
Percussion: Deferred
Auscultation:
- Bell: murmurs, S3
- Diaphragm: S1, S2, S3, S4
- Apical Pulse
Neck Vessels:
Palpation and Auscultation
Palpate carotid artery
○ Palpate only one carotid artery at a time to avoid compromising arterial bloo
brain.
○ Feel contour and amplitude of pulse, normal strength 2+.
○ Findings should be same bilaterally
Auscultate carotid artery.
liver
ous
od to
brain.
○ Feel contour and amplitude of pulse, normal strength 2+.
○ Findings should be same bilaterally
Auscultate carotid artery.
○ Assess for presence of carotid bruit.
○ Avoid compressing the artery which can create an artificial bruit.
○ Keep neck in neutral position and lightly apply stethoscope at angle of jaw,
midcervical area, and base of neck
uAuscultate carotid artery.
uAuscultate carotid artery.
uAssess for presence of carotid bruit.
The Physical Exam: Great Vessels
Jugular veins
Inspect the jugular venous pulse
Estimate the jugular venous pressure
Palpate for hepatojugular reflux
Precordium
Inspect anterior chest:
○ Arrange tangential lighting to accentuate any flicker of movement.
○ Observe for any possible pulsations.
Palpate apical impulse:
○ Note location, size, amplitude and duration
○ Palpate across precordium to assess for any possible pulsations
Auscultation:
Identify auscultatory areas associated with valves.
Sound radiates with blood flow direction; valve areas are:
Second right interspace: aortic valve area
Second left interspace: pulmonic valve area
Left third to fourth lower interspace: tricuspid valve area
Fifth interspace at around left midclavicular line: mitral valve area
Note rate and rhythm: describe characteristics
Identify S1 and S2
Listen for extra heart sounds: describe characteristics.
Listen for murmurs: Timing, loudness, pitch, pattern, quality, location, radia
posture and change of position.
uSecond left interspace: pulmonic valve area
uLeft third to fourth lower interspace: tricuspid valve area
ation
Listen for extra heart sounds: describe characteristics.
Listen for murmurs: Timing, loudness, pitch, pattern, quality, location, radia
posture and change of position.
uSecond left interspace: pulmonic valve area
uLeft third to fourth lower interspace: tricuspid valve area
uSecond left interspace: pulmonic valve area
uLeft third to fourth lower interspace: tricuspid valve area
uNote rate and rhythm: describe characteristics
uIdentify S1 and S2.
uListen for extra heart sounds: describe characteristics.
uListen for murmurs: Timing, loudness, pitch, pattern, quality, location, radiation
posture and
Developmental Competence:
Infants
Transition from fetal to pulmonic circulation occurs in immediate newborn perio
• Heart rate may range from 100 to 180 beats per minute (bpm) immediately a
birth
Note any extracardiac signs that may reflect heart status
• Skin, liver size, and respiratory status
Murmurs in the immediate newborn period do not necessarily indicate congenita
disease seen due to shunt closure.
• Murmurs are usually grade 1 or 2, systolic, no other signs of heart disease a
disappear in 2 to 3 days.
• Absence of murmurs in the immediate newborn period does not ensure a he
heart.
• Best to listen frequently and to note and describe any murmur according to
ation
n
od after
l heart
and
ealthy
disease seen due to shunt closure.
• Murmurs are usually grade 1 or 2, systolic, no other signs of heart disease a
disappear in 2 to 3 days.
• Absence of murmurs in the immediate newborn period does not ensure a he
heart.
• Best to listen frequently and to note and describe any murmur according to
characteristics.
Children
Note any extracardiac or cardiac signs that may indicate heart disease.
▪ Poor weight gain, developmental delay, persistent tachycardia, tachypnea,
dyspnea on exertion, cyanosis, and clubbing
- Note that clubbing of fingers and toes usually does not appear until late
first year, even with severe cyanotic defects.
Palpate apical pulse
• Be aware of location by age.
• Rhythm remains characterized by sinus dysrhythmia
• Physiologic S3 is common in children.
Children Heart Murmurs
uNote that clubbing of fingers and toes usually does not appear until late in first y
even with severe cyanotic defects.
Innocent (or functional)
- Very common through childhood
- Some say they have 30% occurrence, and some say nearly all children may
demonstrate murmur.
Patient teaching:
○ Need to believe that this murmur is just a “noise” and has no pathologic significa
○ Knowledge through education to prevent overprotection and limit activity for chi
Pregnant Woman
Vital signs increase in resting pulse rate of 10 to 15 bpm and drop in BP from no
pre- pregnancy level.
Palpation of apical impulse is higher, and lateral compared with normal position.
Heart sounds: Changes due to increased volume and workload
Aging Adult
and
ealthy
e in
year,
ance
ild
ormal
.
pre- pregnancy level.
Palpation of apical impulse is higher, and lateral compared with normal position.
Heart sounds: Changes due to increased volume and workload
Aging Adult
Gradual rise in systolic blood pressure common with aging; widening of pulse
pressure—be alert for orthostatic hypotension
Left ventricular wall thickness increase.
Presence of supraventricular and ventricular dysrhythmias increases with age.
uAge-related ECG changes occur due to histologic changes in the conduction sys
u
Health Promotion and Patient Teaching
Appropriate aspirin therapy
Blood pressure control
Cholesterol control
Smoking cessation
Lifestyle changes :
- Diet
- Physical activity
- Weight control
Differential Diagnosis of Chest Pain
Cardiovascular
◊ Ischemic: Angina pectoris, Prinzmetal or variant angina, and acute coronary
syndrome (ACS)
◊ Non-ischemic: Pericarditis, mitral valve prolapse, aortic dissection, and
secondary pulmonary HTN
Pulmonary
◊ Pulmonary embolism, pneumonia, and pneumothorax
Gastrointestinal
◊ Gastroesophageal reflux, esophageal spasm, cholecystitis, and pancreatitis
Dermatologic
◊ Herpes Zoster
.
stem.
y
Gastrointestinal
◊ Gastroesophageal reflux, esophageal spasm, cholecystitis, and pancreatitis
Dermatologic
◊ Herpes Zoster
Musculoskeletal/neurologic
◊ Costochondritis and chest wall muscle strain
Psychogenic
◊ Depression and anxiety
Abnormal Findings:
Abnormal Pulsations: Precordium
Thrill at the base
Lift (heave) at the left sternal border
Volume overload at the apex
Pressure overload at the apex
Lift (heave) at the left sternal border
Volume overload at the apex
Pressure overload at the apex
Heart and Neck Vessels Examinatio
on