Jarvis
Chapter 19
ATI Skills Module on Physical Assessment (Adult) - Cardiac
The Circulatory System
http://www.youtube.com/watch?v=D3ZDJgFDdk0&
feature=related
Learning Outcomes
1. List the significant anatomic features of the heart and
their location.
2. Describe the heart sounds & relate the name of the
heart sound to the physiologic cause.
3. Describe the structures of conduction and the spread
of the cardiac impulse through the heart.
4. Relate the circulation of blood through the heart and
great vessels.
5. Discuss the significance of jugular vein assessment.
Learning Outcomes (cont’d)
6. Cite the risk factors associated with heart disease and
stroke.
7. List the hemodynamic changes that occur with aging.
8. Perform an accurate objective heart and neck vessels
assessment on a client and document findings.
9. Discuss cultural/ethnic differences related to heart
disease.
Key Terms
Automaticity
Preload
Orthostatic hypotension
Afterload
Paroxysmal nocturnal dyspnea (PND)
Apical impulse
Orthopnea
Arrhythmia
Pulse deficit
Bruit
Pulse pressure
Cardiac output
Sinus rhythm
Systole
Sinus arrhythmia
Diastole
Murmur
Dyspnea on exertion (DOE)
Atrial kick
Cardiovascular (CV) System
Precordium, Apex and Base
© Pat Thomas, 2006.
Slide 19-6
Cardiovascular (CV) System
CV system: heart, blood vessels & blood
• Heart & great vessels lie between lungs in the thoracic
cavity (mediastinum)
• Apex = bottom of heart; Base = top of heart
• Great vessels
• Superior vena cava
• Inferior vena cava
• Pulmonary artery  deoxygenated blood from heart
to lungs
• Pulmonary veins  fresh oxygen to heart from lungs
• Aorta
Structure and Function
Heart wall
Valves
• Pericardium 
surrounds & protects
the heart
• Atrioventricular (AV)
• Tricuspid
• Mitral
• Myocardium
• Endocardium
Chambers
• Atria—right and left
• Ventricles—right and
left
• Semilunar
• Pulmonic
• Aortic
Chambers and Valves
© Pat Thomas, 2006.
Slide 19-12
Cardiac Blood Flow
Deoxygenated blood from body
enters superior & inferior vena cava
(1)  enters right atrium (2) 
enters right ventricle (3) through
tricuspid valve  pumped into
pulmonary arteries (4) through
pulmonic valve goes to lungs
where CO2 removed & replaced with
fresh O2 re-oxygenated blood
returns through pulmonary veins (5)
to the left atria (6) enters left
ventricle (7) through mitral valve 
pumped through aortic valve to the
aorta (8)  fresh oxygenated blood
to entire body
R&L
Common
Carotid
Arteries
Superior
Vena
Cava
Left
Subclavian
Artery
Lungs
Lungs
LUNGS
Direction of Blood Flow
Cardiac Cycle
Composed of 1 heart beat  has 2 phases:
1. Diastole  resting phase of the heart 
both ventricles relax & fill with blood 
takes up 2/3 of cardiac cycle time (Remember
MAP?)
2. Systole  contraction of both ventricles 
right ventricle pumps blood into the
pulmonary arteries to take to the lungs for
re-oxygenation and left ventricle pumps reoxygenated blood into aorta for delivery to
the body tissues  takes up 1/3 of cardiac
cycle time
Conduction
Automaticity
Electrical Conduction
• Sinoatrial (SA) node  pacemaker
• Atrioventricular (AV) node
• Bundle of his
• Left & right bundle branches
• Purkinje Fibers
ECG
ECG: PQRST
• P wave: atrial contraction (depolarization)
(“atrial kick”)
• PR interval
• QRS complex: ventricular contraction
(depolarization)
• T wave: ventricular repolarization
• Go to: http://skillstat.com/learn.htm
Cardiac Conduction System
Right & left bundle branches
Purkenjie fibers
THE CARDIAC CYCLE
Heart Sounds
1. First heart sound (S1)  closure of atrioventricular (AV) valves (tricuspid & mitral
valves); signals beginning of systole
2. Second heart sound (S2)  closure of semilunar valves (pulmonic & aortic
valves); signals end of systole
3. Split S2 normal with inspiration
4. Extra heart sounds
• Third heart sound (S3)
• Fourth heart sound (S4)
5. Murmurs  sound of blood circulating through heart chambers or valves 
usually d/t defects in valves
Go to: http://www.med.ucla.edu/wilkes/Physiology.htm
Cardiac cycle
Diastole
Systole
Events in the right and left sides
Cardiac Output (CO)
SV (stroke volume) X R (rate) = CO
Example: 100ml X 60 HR =
6L/min CO
Preload = amount of blood in ventricles
before systole (contraction of ventricles)
Afterload = resistance of filled aortic artery
pressure against which the left ventricle
must pump its blood.
Slide 19-24
Neck Vessels
Left & right carotid arteries
Left & right jugular veins
• Internal jugular
• External jugular
Increased jugular venous pressure & distention (JVD) signals right-sided
heart failure
Slide 19-26
The Aging Adult
Incidence of CV disease increases with age.
CAD increases sharply with age & accounts for about 50% of deaths in older
people
Hypertension & heart failure increase with age.
Modifiable lifestyle habits:
• Smoking
• Diet
• Alcohol (ETOH) use
• Exercise patterns
• Stress
• Sedentary lifestyle
The Aging Adult (cont’d)
Non-modifiable hemodynamic changes
• Systolic BP increases d/t arteriosclerosis (stiffening
of arteries)  increased workload on left ventricle
leads to thickening of muscle fibers
• Diastolic pressure does not increase but increased
systolic pressure leads to increased pulse pressure
(difference between diastolic & systolic BP)
• No change in resting heart rate or cardiac output at
rest
• Decreased ability to increase cardiac output (CO)
with exercise
The Aging Adult (cont’d)
Non-modifiable hemodynamic changes (cont’d)
• Arrhythmias  may decrease cardiac output
and BP  may experience syncope d/t
decreased cerebral blood flow
• Cardiac Arrhythmia:
• http://www.learnerstv.com/animation/animatio
n.php?ani=202&cat=BiologyAutomaticity
• ECG changes d/t changes in conduction system:
prolonged P-R interval (first-degree heart block)
& increased incidence of bundle branch block
Risk Factors for Heart Disease & Stroke
Hypertension
Smoking
High cholesterol levels
Obesity
Physical inactivity
Diabetes
Cultural & Genetics
Risk factors for stroke and heart disease
High blood pressure (HTN) -- black adults #1
Smoking
Cholesterol – black adults lower than white & Mexican-Americans
Obesity (BMI >30) or overweight (BMI >25) – All in 70%: blacks; Mexican-Americans;
whites. Asians 25%
Physical inactivity
Diabetes Type 2 – increasing across all age & ethnic groups; American Indians >2x the
rate of U.S. adults overall.
Subjective Data—
Health History Questions
Chest pain  onset, location, radiation, character, exertional or at rest,
other s/sx, NTG
Dyspnea  exertional or at rest, positional, constant or intermittent,
awakens at night (paroxysmal nocturnal dyspnea  occurs with heart
failure)
Orthopnea  # of pillows used when supine
Cough  duration, frequency, productive
Fatigue  onset, related to time of day
Cyanosis or pallor
Health History Questions (cont’d)
Edema  swelling of hands or feet, severity, resolve at night, other s/sx
Nocturia  frequency, how long
Cardiac history  HTN, high cholesterol, heart disease, rheumatic fever, surgery
Family cardiac history  HTN, CAD, sudden death at early age
Personal habits (cardiac risk factors)
For Aging Adults:
• Any known heart or lung disease
• Medications
• Environment
Objective Data—The Physical Exam
Equipment needed: Stethoscope
Carotid arteries
• Palpate
• Auscultate for bruits
Jugular veins  Inspect for jugular vein distention (JVD)  occurs with
right-sided heart failure
Precordium
• Inspect the anterior chest
• Palpate the apical impulse  4th or 5th
interspace, midclavicular line
Objective Data—The Physical Exam (cont.)
Auscultate the heart sounds
• First, identify S1 and S2 (S1 is louder than S2 at the apex
& coincides with carotid artery pulse; S2 is louder at the
base)
• Note the rate and rhythm  rhythm should be regular
but sinus arrhythmia occurs normally in young adults &
children  increases with inspiration, slows with
expiration
• Listen for extra heart sounds
• Listen for murmurs
• http://solutions.3m.com/wps/portal/3M/en_US/Littman
n/stethoscope/education/heart-lung-sounds
Palpate radial pulse  calculate pulse deficit if present (difference between apical
pulse & radial pulse)
Objective Data—The Physical Exam (cont.)
Characteristics of normal heart sounds
• First heart sound (S1)
• Second heart sound (S2)
• Split S2  normal splitting is associated with
inspiration
Extra heart sound
• Third heart sound (S3)
• Fourth heart sound (S4)
Murmurs
The aging adult
Auscultatory Areas
Clinical Portrait of Heart Failure
Slide 19-38
Sample Charting
Sample Charting (cont.)