Download Heart and Peripheral Vasculature

Heart and Peripheral
Vasculature
N1037
Anatomy and Physiology: Heart
• Base @ top
• Apex @ bottom
• Pericardium
– Parietal layer
– Visceral layer
Anatomy and Physiology: Heart
• 4 Chambers of the heart
– Right and left atria
– Right and left ventricles
• Heart valves
– Atrioventricular (AV) valves
• Tricuspid
• Mitral (bicuspid)
– Semilunar valves
• Pulmonic
• Aortic
Direction of Blood Flow
• Inferior & Superior Vena Cava to
Right Atrium (RA), then into Right
Ventricle (RV)
• Venous blood flows to Pulmonic
Valve to Pulmonary Artery
(unoxygenated) to the lungs.
• Lungs oxygenate blood. Pulmonary
veins (oxygenated) to Left Atrium
(LA).
• Into LA through Mitral Valve to Left
Ventricle (LV) and ejected through
Aortic Valve into Aorta.
• Aorta delivers oxygenated blood to
body.
Neck Vessels
Coronary Circulation
• Left main coronary artery
– Left circumflex artery
– Left anterior descending
artery
• Right coronary artery
Cardiac Cycle
• Systole
– Isovolumic contraction
– Early systole
– Late systole
• Diastole
– Isovolumic relaxation phase
– Early and mid-diastolic
filling periods
– Atrial systole (atrial kick)
Cardiac Cycle
Diastole
•
•
•
•
Ventricles relax and fill with blood
The AV valves(tricuspid & mitral) are open
During the first rapid filling phase, blood pours rapidly
from the atria into the ventricles (early diastolic
filling).
At the end, the atria contract & push the last amount of
blood into the ventricles (presystole = atrial kick).
Systole
•
•
•
•
After this, the AV valves close and we hear the first
heart sound “S1”. This is the beginning of Systole.
AV valves close to prevent regurgitation into the atria
during contraction.
Then, the aortic and pulmonic valves (semilunar
valves) open & blood is ejected rapidly into the
arteries.
After all the contents are ejected, the semilunar valves
close. This causes the second heart sound, “S2”. This
is the end of systole.
Excitation of the Heart
•
•
•
•
Sinoatrial (SA) node
Atrioventricular node
Bundle of His
Right and left bundle
branches
• Purkinje fibers
Conduction Pathway and EKG
• Sinoatrial node (SA Node)
initiates an electrical
impulse
• It is the “pacemaker” of
the heart.
• Travels to the
Atrioventricular node (AV
Node)
• Then it travels to the
“Bundle of His”
• Through the left and right
bundle branches.
• And lastly, through the
ventricles.
Electrocardiogram (EKG)
•
•
•
•
•
•
P
Q
R
S
T
Isoelectric line
Peripheral Vasculature
• Arterial system
– Three layers of arterial walls:
tunica intima, media, externa
– Arteries
– Arterioles
– Capillaries
– pulsating flow, no valves
• Venous system
– Veins
– Venules
– steady flow, 1 way
valves,thinner walls , less
elastic
Peripheral Vasculature
Health History
• Age
– Childhood onset: rheumatic fever
– Adult onset: HTN, CAD, MI, CVA, AAA
• Gender
– Female
– Male
• Race
– May predispose to higher risk for CVA, CAD,
HTN, diabetes mellitus
Common Chief Complaints
•
•
•
•
•
Chest pain
Syncope
Palpitations
Peripheral edema
Extremity pain
Characteristics of Chief Complaints
–
–
–
–
–
–
Quality
Associated manifestations
Aggravating factors
Alleviating factors
Setting
Timing
Past Health History
• Medical
– Cardiac specific: AAA, angina, cardiogenic shock, chest trauma
– Noncardiac specific
• Surgical
– Previous cardiovascular procedures
• Common medications
–
–
–
–
–
–
–
–
Antianginals or vasodilators
Antidysrhythmics
Anticoagulants
Antihypertensives
Antilipemics
Diuretics
Inotropics
Thrombolytics
Past Health History
• Communicable diseases
• Childhood illnesses
• Allergies
– Aspirin
– IVP dye
– Seafood
• Injuries and accidents
Family Health History
• Assess for
–
–
–
–
–
–
Aneurysm
CVA
CAD
HTN
MI or sudden cardiac death
MVP
Social History
•
•
•
•
•
•
Alcohol, drug, or tobacco use
Sexual practices
Travel history
Work and home environment
Hobbies and leisure activities
Stress
Health Maintenance Activities
•
•
•
•
•
•
Sleep
Diet
Exercise
Stress management
Use of safety devices
Health check-ups
Risk Factors
• Fixed
– Age, gender, race, family history
• Modifiable
– HTN, hyperlipidemia, tobacco use, glucose
intolerance, physical inactivity, diet, stress,
sedentary lifestyle, obesity
Assessment Equipment
• Equipment
–
–
–
–
Stethoscope
Sphygmomanometer
Watch with second hand
Tape measure
Inspection
Ape To Man
• Aortic 2ICS
• Pulmonic 2ICS
• Midprecordial 3ICS
• Tricuspid 5ICS
• Mitral 5ICS
N = no visible pulsations except for the PMI in the
mitral area
Palpation
• Assess for pulsations, thrills, heaves
• Assess the following areas: aortic,
pulmonic, midprecordial, tricuspid, and
mitral
N = No pulsations, thrills, or heaves palpated,
except in the mitral area, where the apical
impulse may be palpated
Auscultation
Use diaphragm and bell of
stethoscope
• N= Aortic: S2 is louder than S1
• N= Pulmonic: S2 is louder than S1
• N= Tricuspid: S1 is louder than S2
• N=Mitral: S1 is louder than S2
•
Remember S1 = Apex, S2 = Base
Auscultation: Normal Findings
• Aortic and Pulmonic
– N= physiologoical split of S2
• Mitral and tricuspid:
– N= S3 (gallop) may be heard in
children, young adults, and pregnant
women
– N= S4 may indicate cardiac
decompensation
Auscultation
Abnormal
• Murmurs
– Use stethoscope diaphragm over aortic,
pulmonic, mitral, and tricuspid areas
– Use stethoscope bell over mitral and
tricuspid areas
• Possible causes
• Characteristics: location, radiation, timing,
intensity, quality, pitch, configuration
• Pericardial friction rub
– Characteristics: location, radiation,
timing, quality, pitch
• Possible cause
Assessment of Peripheral Vasculature
• Inspection of jugular venous
pressure
– Place pt at 45°angle
– measure vertical distance from
sternum to top of distended neck
vein
– N= <4cm
Abnormal
> 4 cm indicates R ventricular
pressure,  bld vol, or obstruction
Inspection of Hepatojugular Reflux
• Position pt at 30 ° in bed, press firmly on RUQ, observe neck for
elevation of JVP
N = no change in jugular veins
Abnormal
• A rise of more than 1 cm = right-sided CHF or fluid overload
Assessment of Arterial Pulses
• Palpate temporal, carotid, brachial,
radial, femoral, popliteal, posterior
tibial, dorsalis pedis for rate, rhythm,
amplitude, symmetry
• auscultate with bell carotids, temporal
& femoral pulses
N= equal bilaterally, no bruits
auscultated at carotids, temporal
& femoral
• Abnormal
– Presence of bruits = obstruction
due to atherosclerotic plaques,
high-output states such as anemia
or thyrotoxicosis
Special Techniques
• Assessing for Pulsus paradoxus
– take BP while pt supine, note 1st systolic sound heard, note
point where all systolic sounds are not heard
N= paradox should be < or = 10 mmHg
• Abnormal
– cardiac tamponade, pericardial effusion, cardiomyopathy,
obstructive lung disease dt blood return to the L ventricle
Assessment of Peripheral Perfusion
• Overall …..Evaluate peripheral
pulses, color, clubbing, capillary
refill, skin temperature, edema,
ulcerations, hair distribution
• Assess Venous system
– Inspect fingers, legs, feet & toes
– bend pts knee slightly and
dorsiflex each foot - monitor for
Homan sign
N= no c/o calf pain
Abnormal
+ VE Homan sign indicates DVT
or thrombophlebitis
Assessment of Peripheral Perfusion
• Assess Arterial system
• Pallor test
– Instruct pt to raise extremities
– note the time it takes for pallor or lack of color to devlop
N= no pallor develops within 60 secs
• Allen test
– ask pt to make fist ,
– occlude ulnar and radial artery
– open hand and release one artery while compressing the
other, repeat with opposite artery
N= + ve Allen test = good blood flow
both arteries in palm of hand
Abnormal
– no blood flow dt thrombus or
atherosclerosis
Palpation of Epitrochlear Node
• Place pt in supine position
• support pt hand in your hand
• plappate behind elbow in btwn biceps & triceps
for epitrochlear node for size, shape, consistency ,
tenderness, & mobility
N= node not palpable
• Abnormal
– enlarged lymph node
Gerontological Variations
• Decreased size of heart muscle
• Atria and ventricles become fibrotic and
sclerotic
• Decreased cardiac output
• Change in heart position
• Obesity
• Vessels become fibrotic and rigid