Download Decreased cardiac output due to the heart pump failing

Heart & Neck Vessels
CHAPTER 19 - JARVIS
Overview
 Neck
 Carotid pulse – observe and palpate
 Observe jugular venous pulse
 Estimate jugular venous pressure
 Precordium
 Inspection and palpation
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Describe location of apical pulse
Note any heave (lift) or thrill
Auscultation
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Identify anatomic areas noting rate and rhythm
Listen in systole and diastole for murmurs
Repeat with bell
Listen at apex and base
Cardiovascular System
 Consists of the Heart and
Blood Vessels
Position & Surface Landmarks
 Precordium: area on anterior chest directly overlying
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the heart and great vessels
Mediastinum: area between the lungs in the middle
third of the thoracic cage
Heart: top is the broader base & bottom is the apex
Apical Impulse: 5th intercostal space, 7-9cm from
midsternal line
Great Vessels: superior & inferior vena cava;
pulmonary artery; pulmonary veins; aorta
Position & Surface Landmarks
Heart Wall, Chambers, & Valves
 Heart Wall: Pericardium,
Myocardium, &
Endocardium
 Chambers: Atria &
Ventricles; right & left
 Valves
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Atrioventricular
Semi lunar
Blood Flow
 Blood flow animation
Heart Sounds
Conduction
 P wave: depolarization
of aorta
 PR interval: beginning
of P wave to beginning of
QRS (atrial depolarization
& impulse through AV node)
 QRS complex: depolarization
of ventricles
 T wave: repolarization of
ventricles
Conduction You tube
Pumping Ability
 Cardiac Output: normally 4-6 Liters of blood per
minute
 Cardiac Output = Stroke Volume x Rate
 Preload: venous return that builds during diastole;
ventricular muscle is stretched before contraction
 Afterload: opposing pressure the ventricle must
generate to open the aortic valve against the higher
aortic pressure; resistance against which ventricle
must pump its blood
Neck Vessels
 Carotid Arteries
 Jugular Veins:
Internal and external
History: Subjective Data
 Chest pain
 Nocturia
 Dyspnea
 Past cardiac history
 Orthopnea
 Family cardiac history
 Cough
 Personal habits (cardiac
 Fatigue
 Cyanosis or pallor
 Edema
risk factors)
Objective Data
Neck Vessels
Neck Vessels
 Inspect Jugular Venous Pulse – assessing central
venous pressure
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Stand on patient’s right side
Position patient supine from 30-45 degree angle; Pulsation
may be seen the sternal notch
At 45 degree angle, jugulars should disappear
 Inspect carotid pulsations
 Neck Vessel Exam
Neck Vessels
 Palpate Carotid Artery
 One at a time
 Avoid excessive pressure
 Normal: smooth with 2+ strength
 Auscultate Carotid Artery
 Listen for presence of bruit (blowing or swishing sound)
 Apply bell of the stethoscope at angle of jaw, midcervical area,
and base of the neck
 Person can take breath, exhale, and hold while you listen so no
sound is masked
Neck Vessels
 Jugular Venous Pressure
 Use angle of Louis as arbitrary
reference point, and compare it
with highest level of venous
pulsation
 Hold a vertical ruler on sternal
angle
 Align a straight edge on ruler
like a T-square, and adjust level
of horizontal straight edge to
level of pulsation
 Read level of intersection on
vertical ruler; normal jugular
venous pulsation is 2 cm or less
above sternal angle
 State person’s position, e.g.,
“internal jugular vein
pulsations 3 cm above sternal
angle when elevated 30
degrees”
Chest
 Inspect Anterior Chest
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Pulsations: may or may not see apical impulse at 4th intercostal
space at or inside the midclavicular line
 Palpate the Apical Impulse
Ask the person to exhale and hold
 Use 1 finger pad
 Note: location (4th or 5th intercostal space), size (1 x 2 cm),
amplitude (short, gentle tap), duration (short)
 May not be palpable in all adults
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Chest
 Palpate Across
Precordium
Use palmar aspects of 4
fingers, or ulnar surface of
hand and gently palpate
 Normally no findings
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 Percussion
Used to outline the heart’s
border
 Not done as much because
of availability of chest xray and/or
echocardiography
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Chest
 Auscultation
 4 traditional valve “areas”
 2nd right interspace – aortic
valve area
 2nd left interspace –
pulmonic valve area
 Left lower sternal border –
tricuspid valve area
 5th interspace, left
midclavicular line – mitral
valve area
 Auscultate in Z pattern from
base of heart, across and down,
then over to apex
 Traditionally
 Aortic area, pulmonic area,
Erb’s point, tricuspid area,
mitral area “ APE –To-Man”
Chest
Chest
 Rate: 50-90 bpm
 Rhythm: regular
Heart Sounds
http://www.wilkes.med.ucla.edu/i
nex.htm
 Identify S1 & S2: lub-dup
 S1 louder at apex = closure of AV valves, beginning of systole
 S2 louder at base = closure of semilunar valves
 Focus on systole, then diastole, then listen for extra
heart sounds
 Listen for murmurs
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Describe by timing, loudness, pitch, pattern, quality, location,
radiation, posture
Variation in S1
 Factors: Position of AV valve at start of systole,
change in valve structure, & pressure in the
ventricles
1. Loud S1
2. Faint S1
3. Varying Intensity of S1
4. Split S1
Variations in S2
 Accentuated S2
 Diminished S2
 Split S2
 Normal: occurs during inspiration
 Fixed Split: unaffected by respiration
 Paradoxical Split: occurs during expiration
 Wide Split: wide on inspiration and still present with
expiration
Extra Systolic Sounds
 Ejection Click: sound of the SL valves opening; best
heard with diaphragm; aortic at 2nd right
interspace and apex; pulmonic at 2nd left
interspace
 Aortic Prosthetic Valve Sounds: early systolic
sound
 Midsystolic Click: associated with mitral valve
prolapse; sound is short and high pitched; best
heard with the diaphragm at the apex;
Extra Diastolic Sounds
 Early Diastole
 Opening Snap: opening of AV valves
 Mitral Prosthetic Valve Sound: opening click just after S2
 Mid-diastole
 Third Heart Sound: S3 – ventricular filling sound, low
pitched, like “distant thunder”; heard at the apex or left
lower sternal border with the bell
Physiologic: frequently heard in children and young adults;
disappears when sitting up
 Pathologic: Ventricular Gallop – indicates decreased
compliance of the ventricles (heart failure)
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Discuss how you differentiate an S3 from a Split S2
Extra Diastolic Sounds
 Late Diastole
 Fourth Heart Sound: S4 – ventricular filling sound, soft and
low pitched; heard at the apex with person in left lateral
position with the bell
Physiologic: found in adults older than 40
 Pathologic: Atrial Gallop – decreased compliance of the ventricles
(CAD, cardiomyopathy, systemic HTN)
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Summation Sound: S3 & S4 present
Extra Cardiac Sounds
 Pericardial Friction Rub: inflammation of the
pericardium; high pitched and scratchy best heard
with the diaphragm
Murmurs
 Identified by
 Where they are heard on the chest
 Where they occur in the cardiac cycle- Systolic/Diastolic
 Loudness- graded I-VI
 Pitch- low to high
 Variation in loudness- Crescendo/Decrescendo, pan
Systolic Murmurs
 Aortic Stenosis: loud, harsh, midsystolic; loudest at
2nd right interspace
 Pulmonic Stenosis: medium, coarse, systolic;
loudest at 2nd left interspace
 Mitral Regurgitation: pansystolic, loud, blowing;
loudest at apex
 Triscupid Regurgitation: pansystolic, soft, blowing;
loudest at left lower sternal boarder
Diastolic Murmurs
 Mitral Stenosis: low-pitched, diastolic; best heard at
the apex with person in left lateral position
 Tricuspid Stenosis: rumbling, diastolic; best heart at
left lower sternal boarder, louder on inspiration
 Aortic Regurgitation: soft, high-pitched, blowing,
diastolic; best heard at 3rd left interspace at the base
 Pulmonic Regurgitation: same as aortic regurgitation
Developmental Considerations
Infants
 Subjective
 Mother’s health during pregnancy
 Any cyanosis
 Growth
 Activity
 Objective
 Fetal shunts close between 10-15 hours but may take up to 48
hours (may have murmurs until shunts close)
 Apical impulse: palpate at the 4th intercostal space, lateral to
the midclavicular line
 Heart rate: 120-140 bpm
 Sinus arrhythmia with respirations
 S2 higher pitched and sharper than S1
Children: Subjective
 Growth
 Activity
 Unexplained joint pain or fevers (strep throat,
rheumatic fever)
 Frequent headaches or nosebleeds
 Frequent respiratory infections
 Family History
Children: Objective
 Signs of heart disease: poor weight gain, developmental
delay, persistent tachycardia, tachypnea, dyspnea on
exertion, cyanosis, clubbing
 Apical impulse may be visible
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4th intercostal space left of the midclavicular line until age 4;
4th intercostal space at midclavicular line age 4-6;
5th intercostal space right of midclavicular line at age 7;
 Heart rate slows down
 Sinus arrhythmia common; Physiologic S3 is common
 Venous hum is common
 Heart murmurs may occur and are functional
Pregnant Woman: Subjective
 Blood pressure
 Usual blood pressure before pregnancy
 Blood pressure during pregnancy
 Treatments
 Associated symptoms
 Fainting or Dizziness
Pregnant Woman: Objective
 Resting pulse rate increase of 10-15 bpm
 Blood pressure  2nd trimester,  3rd trimester
 Apical impulse higher and lateral than normal
 Increased blood volume causes:
 Exaggerated splitting of S1, increased loudness of S1
 Loud S3
 Heart murmurs
Aging Adult: Subjective
 Heart or lung disease
 Treatment
 Symptoms
 Medications for any illness
 Environment
Aging Adult: Objective
 Gradual rise in systolic blood pressure is common
 Orthostatic hypotension
 AP chest diameter increases
 Carotid artery stenosis
 S4 may occur with no known cardiac disease
 S3 indicates heart failure
 Systolic murmurs are common
ABNORMAL FINDINGS
Heart Failure
Decreased cardiac output due to the heart pump failing
 Dilated pupils
 Gray, pale, or cyanotic
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skin; cool skin
Anxiety or confusion
Decreased O2 saturation
Dyspnea
Orthopnea
Jugular vein distention
Crackles/Wheezes in the
lungs
Cough
 Weak pulse
 Decreased blood
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pressure
S3 gallop/ tachycardia
Nausea and vomiting
Ascites
Edema
Fatigue
Enlarged spleen and liver
Decreased urine output
Congenital Heart Defects
 Atrial Septal Defect (ASD): abnormal opening in
the atrial septum, results in left-to-right shunting
 Ventricular Septal Defect (VSD): abnormal
opening in the septum between ventricles
 Tetralogy of Fallot: shunts venous blood into the
aorta, blood is not being oxygenated; severe
cyanosis
 Coarctation of the Aorta: severe narrowing of the
aorta