Download Heart and Neck Vessels

Heart and Neck
Vessels
By InnaKorda
Surface Anatomy
Cardiac Anatomy
Direction of Blood Flow
Cardiac Cycle

Diastole




Ventricles are relaxed, AV valves are open
Pressure in atria are higher than in ventricles  causing blood to
pour into the ventricles
Atria contract casing more blood to enter the ventricles “atrial kick”
Systole



Pressure in ventricles is higher than in atria  causing AV valves
(mitral and tricuspid) valves to close. First heart sound.
Pressure of ventricle begins to become greater than pressure of aorta
and pulmonary artery  blood is ejected from the ventricles
When the ventricles’ pressure falls below the pressure of the aorta
(or pulmonary artery), some blood flows backwards toward the
ventricles, causing the semilunar (aortic, pulmonic) valves to close.
Second heart sound.
Neck Vessels
Neck Muscles
Developmental Considerations
Ageing Adult

Hemodynamic changes



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Arrhythmias


Systolic pressure tends to increase 20 mm Hg due to
arteriosclerosis
Decreased cardiac output with exercise
Blacks, Mexicans, and Native Americans have higher
incidence of hypertension
Increase with age
ECG changes

Prolonged P-R interval and prolonged Q-T interval
Health History

Chest pain





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Onset – When did it start? How long have you had it? Have you ever had
this pain before?
Location – Where did it start? Where does it radiate?
Character
Associative and alleviating factors – What brought on the pain? What
relieves it? (nitroglycerin
Associative symptoms – sweating, pale skin, SOB, N&V, tachycardia?
Dyspnea (shortness of breath)

What type of activity brought it on?




DOE – Dyspnea on exertion. Ex: walking
Onset
Duration
Positional


Nocturnal dyspnea occurs with heart failure.
Does it awaken you at night?
Question 1

A client with no history of cardiovascular disease
presents to the ambulatory clinic with flulike
symptoms. The client suddenly complains of chest
pain. Which of the following questions would best
help a nurse to discriminate pain caused by a
noncardiac problem?
1.
2.
3.
4.
“Have you ever had this pain before?”
“Can you describe the pain to me?”
“Does the pain get worse when you breathe in?”
“Can you rate the pain on a scale of 1 to 10, with 10 being
the worst?”
Health History

Orthopnea


Cough






Do you need to assume an upright position when sleeping? How many
pillows are used?
Duration
Frequency
Type – dry, hacking, congested?
Mucus? Color, odor, blood?
Associative and alleviative factors
Fatigue

Do you tire easily?



Fatigue due to decreased cardiac output (CO) is worse in evening
Onset – When did fatigue start? Was it sudden or gradual?
Cyanosis or pallor

Occurs with myocardial infarction (MI) or low CO  decreased tissue
perfusion
Health History

Edema (swelling)


Onset
Frequency




Amount - How much swelling occurs normally? Equal on both sides?
Associative and alleviative factors – SOB? Before or after leg swelling
Nocturia

Do you awaken at night with an urgent need to urinate?


More fluid reabsorption and excretion in pt with heart failure
Past cardiac history



Cardiac edema is worse at evening and better in morning
HTN, cholesterol, murmur, congenital heart disease, rheumatic fever
How was it treated?
Family history
Health History

Personal habits

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Nutrition – Usual diet? Usual
weight? Changes in weight?
Smoking – Cigarettes or
tobacco? Onset? Packs per
day?
Alcohol – Drinks per
week/day?
Exercise – Type, duration
Drugs – Medication, street
drugs
Pack Years =
Packs per day X Years smoked
Coronary Heart Disease
Risk Factors
4 cig per day = 2x risk for cardio disease
20 cig per day = 4x risk for cardio disease
Preparation for Physical
Examination

Environment


Privacy


Should be warm. Shivering might interfere with heart sounds
Make sure the female’s breasts remain draped. When auscultating
the heart, gently displace the breast or ask the woman to hold it out
of the way
Order of exam

Begin with observations peripherally and move toward the heart.
1.
2.
3.
4.
Pulse and blood pressure
Extremities – peripheral vascular assessment
Neck vessels
Precordium – (portion of body over heart and thorax)
General Appearance

General build


Skin


Chronic HF may appear malnourished, thin,
cachectic
Jaundice and generalized edema in late HF
LOC

Poor cardiac output and decreased cerebral
perfusion may cause mental confusion, memory loss,
slowed verbal responses
Blood Pressure

Normal for adults

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Postural blood pressure (orthostatic)

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90 to 140 mm Hg systolic
60 to 90 mm Hg diastolic
Pressure greater than 140/90 is considered hypertension
Pressure less than 90/60 is considered hypotension and may be
inadequate to provide oxygenation to cells
Moving from lying to sitting or standing position
↑ in mm Hg by 10 and/or ↑ in pulse by 10 after a minute
May be caused by cardiac drugs or loss of autonomic NS
compensatory ability, generally in older adults
Paradoxical blood pressure

Decrease in systolic BP more than 10 mm Hg during inspiration
Question 2

A client is admitted to an emergency room with chest
pain and is being ruled out for myocardial infarction
(MI). Vital signs are as follows: at 11:00 a.m., pulse (P)
92, respiratory rate (RR) 24, blood pressure (BP)
140/88 mm Hg; 11:15 a.m., P 96, RR 26, BP 128/82
mm Hg; 11:30 a.m., P 104, RR 28, BP 104/68 mm Hg;
11:45 a.m., P 118, RR 32, BP 88/58 mm Hg. A nurse
alerts the physician because these changes are most
consistent with:
1.
2.
3.
4.
Cardiogenic shock
Cardiac tamponade
Pulmonary embolism
Dissecting thoracic aortic aneurysm
Question 3

A nurse is assessing the blood pressure of a client
diagnosed with primary hypertension. The nurse
ensures accurate measurement by avoiding which of
the following?
1.
2.
3.
4.
Seating the client with arm bared, supported, and at heart
level
Measuring the blood pressure after the client has been
seated quietly for 5 minutes
Using a cuff with a rubber bladder that encircles at elast
80% of the limb
Taking the blood pressure within 30 minutes after nicotine
or caffeine ingestion
Assessing Neck Vessels

Carotid Artery

Palpate the carotid artery


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Avoid excessive pressure.
Excessive vagal stimulation
could slow down heart rate.
Carotid arteries should be
same bilaterally
Auscultation

Listen for bruits – blowing,
swishing sounds indicating
blood flow turbulence.
Caused by atherosclerotic
narrowing (one half or two
thirds of artery).
Assessing Neck Vessels

Jugular Veins

Can be used to assess central venous pressure (CVP) and cardiac
efficiency


Position the patient at 30-45 degree angle, wherever pulsations can
be seen best. Remove pillow to avoid flexion of head.


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Distended external jugular veins signify increased CVP, as with heart failure
The higher the CVP, the higher the position you will need
Turn the pt’s head away from examiner’s side
Distinguish from carotid artery pulsations. Internal jugular pulse
is lower, varies with respiration, not palpable, and disappears as
person is sitting.
Assessing Neck Vessels

Jugular Venous Pressure Estimate
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
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Used to assess heart failure
Position the patient at 30-45 degree angle. Place one ruler vertically
at the manubriosternal angle. Place a second ruler perpendicular to
the first and record the height of pulsation of the internal jugular
vein.
Normal pulsation is 2 cm or less above sternal angle


Pulsations 3 or more cm above sternal angle while at 45 degrees occur with
heart failure
Record height of pulsations and degrees of elevation
Question 4

The examiner has estimated the jugular venous
pressure. Identify the finding that is abnormal.
1.
2.
3.
4.
Patient elevated to 30 degrees, internal jugular vein
pulsation at 1 cm above sternal angle.
Patient elevated to 30 degrees, internal jugular vein
pulsation at 2 cm above sternal angle
Patient elevated to 40 degrees, internal jugular vein
pulsation at 1 cm above sternal angle
Patient elevated to 45 degrees, internal jugular vein
pulsation at 4 cm above sternal angle
Assessing the Heart

Apical Impulse

Apical impulse may or may not be seen
against the chest wall. (Seen more in
children)

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A heave or lift is a sustained forceful
thrusting of ventricle during systole.
Occurs with ventricular hypertrophy.
Seen in 4th or 5th intercostal space,
midclavicular line.
Palpate the apical impulse. May need to
ask pt to exhale or to roll to the left.

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Location – should occupy only one
interspace (4th or 5th) and be at or medial
to midclavicular line
Size – normally 1cm x 2cm
Amplitude – normally a short gentle tap
Duration – short, first half of systole
Abnormalities:
•Left ventricular dilatation (volume
overload) displaces impulse down and left
•Left ventricular hypertrophy (pressure
overload) increases force and duration but
no change in location
Assessing the Heart

Palpation

Use the palms of your fingers to
palpate across chest to search for
any other pulsations

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A thrill is a palpable vibration.
Signifies turbulent blood flow and
accompanies loud murmurs
Percussion


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Used to outline cardiac borders
Not as accurate as X-ray or
echocardiogram
Hypertrophy may be due to
hypertension, CAD, heart failure,
cardiomyopathy
Auscultation

Erb’s
point


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2nd right interspace –
Aortic valve area
2nd left interspace –
Pulmonic valve area
Left lower sternal border
– Tricuspid valve area
5th interspace around
midclavicular line- Mitral
valve area
Move stethoscope in a Z pattern,
Aortic  Pulmonic  Right  Left
Auscultation


Tune out any distractions
Listen to one sound at a time
1.
2.
3.
4.
5.
Note rate and rhythm
Identify S1 and S2
Assess S1 and S2 separately
Listen for extra heart sounds
Listen for murmurs
Rate and Rhythm


Normal 60-100 beats per minute for adults.
Rhythm should be regular
Sinus arrhythmias occur normally in young adults and
children and varies with respiration. Rhythm increases
at peak of inspiration, slows with expiration.
 Premature beat – an early beat. May be isolated or
patterned – occurs every 3rd or 4th beat.
 Pulse deficit – the beats at the apex are not the same as
at a peripheral pulse. May occur with atrial fibrillation,
premature beats, heart failure.

Apical rate – Radial rate = Pulse deficit
Developmental Considerations in
Assessment - Infants

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Fetal shunts normally close within 10-15 hours, but may
take up to 48 hours.
Cyanosis signals oxygen desaturation and congenital
heart disease
Heart rate may range from 100-180 bpm after birth,
then stabilize 120-140 bpm


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Tachycardia – greater than 200 bpm in newborns and greater
than 150 bpm in infants
Bradycardia – less than 90 in newborns, less than 60 in older
infants and children
Expect sinus arrhythmia – varied heartbeat with
respiration
Developmental Considerations in
Assessment - Children
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Slowing of heart rate
Physiologic S3 is common
Innocent heart murmurs are common
Venous hum (turbulence of blood flow in
jugular venous system) is also common
Developmental Considerations in
Assessment - Pregnancy
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Increase in pulse rate of 10-15 bpm
Decrease of blood pressure in 2nd trimester, rise
again in 3rd trimester
Increase loudness of S1, S3 heard
Possible appearance of heart murmurs, which
disappear after pregnancy
Developmental Considerations in
Assessment - Aging

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Rise in systolic BP – arteriosclerosis and
atherosclerosis
Orthostatic hypotension
Increase in AP diameter of chest
Systolic murmurs become more common
Be careful when palpating carotid artery due to
the carotid autonomic reflex causing
bradycardia!
S1 and S2


S1 is the start of systole and is the reference point
for other cardiac sounds
Distinguishing S1 from S2


1st sound of the “LUB – dup” except in
tachyarrhythmias
S1 is louder than S2 at the apex. S2 is louder than S1 at
the base


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Erb’s point – S1 and S2 heard equally
S1 coincides with carotid artery pulse
S1 coincides with R wave on ECG monitor
Auscultation Assistant
http://www.med.ucla.edu/wilkes/intro.html
S1


Caused by closure of the AV valves
Abnormalities

Accentuated (loud) S1

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Diminished S1

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Hyperkinetic states such as exercise, fever, anemia, hyperthyroidism
Calcification of AV valves - requires increasing ventricular pressure to
close valves against increased atrial pressure
First degree heart block – prolonged PR interval on ECG due to
delayed conduction from atria to ventricles
Extreme calcification of valves, limiting their mobility
Split S1

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Mitral and tricuspid components are heard separately
Normal but uncommon
S2
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Caused by closure of semilunar valves (aortic and pulmonic)
Abnormalities

Accentuated S2
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Diminished S2
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Higher closing pressure due to systemic hypertension
Pulmonary hypertension
Aortic or pulmonic stenosis – calcification, still mobile
Fall in systemic BP – shock
Aortic and pulmonic stenosis – calcification, decreased mobility
Split S2



Normal. Due to the aortic valve closing 0.06 seconds before the pulmonic
valve during inspiration
Heard only in the pulmonic valve area
Paradoxical split – opposite of what you’d expect. Split on expiration
S3

Physiologic S3


KEN - TUCK - Y
SHLOSH - ING IN
Heard frequently in children and young adults, disappears
when the person sits up.
Pathologic S3 (ventricular gallop)


Persists when sitting up and heard after age 40
Occurs because the left ventricle is not very compliant


At the beginning of diastole the rush of blood into the left ventricle
causes vibration of the valve leaflets and the chordae tendinae
Occurs with heart failure due to volume overload, such as
mitral, aortic, or tricuspid regurgitation
S4

Physiologic S4


TEN - NES - SEE‘
A - STIFF Heart
May occur in older adults after exercise
Pathologic S4 (atrial gallop)


Caused by the relatively rapid filling rate against a relatively
stiff ventricle
Occurs with:

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Decreased compliance of ventricles (coronary artery disease,
cardiomyopathy)
Systolic overload (afterload)
Aortic stenosis
Systemic hypertension
Extracardiac Sounds

Pericardial friction rub

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High pitched, scratchy sound as a result of inflammation of
the pericardium
Heard best at apex and lower sternal border
This sound is usually continuous, and heard diffusely over the
chest.
If the rub completely disappears when the patient holds his
breath it is more likely due to pleural, not pericardial, origin.
Common during the 1st week following a myocardial
infarction
Question 5

The examiner wishes to listen for a pericardial
friction rub. Select the best method for
listening:
1.
2.
3.
4.
With the diaphragm, patient sitting up and leaning
forward, breath held in expiration
Using the bell with the patient leaning forward
At the base during normal respiration
With the diaphragm, patient turned to the left side
Congenital Heart Defects
Congenital Heart Defects
Congenital Heart Defects
Congenital Heart Defects
Congenital Heart Defects
Listening for Murmurs

Loudness


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Grade i – barely audible
Grade ii – clearly audible, but faint
Grade iii – moderately loud, but easy to hear
Grade iv – loud, associated with a thrill palpable on the chest wall
Grade v – very loud, heard with one corner of stethoscope lifted off
Grade vi – loudest, heard with entire stethoscope lifted off the chest wall
Pitch – high, medium, low. Depends on pressure and rate of
blood flow
Pattern
Quality – musical, blowing, harsh, rumbling
Location
Radiation
Posture
Murmurs

Systolic


Occur during the
ventricular ejection phase of
the cardiac cycle
Most caused by obstruction
of the outflow of the
semilunar valve (aortic,
pulmonic) or by incompetent
AV valves (mitral, tricuspid).

Diastolic




Occur in the filling phase of
the cardiac cycle
Caused by incompetent
semilunar valves or stenotic AV
valves
Early diastolic murmurs usually
result from insufficiency of a
semilunar valve or dilation of
the valvular ring.
Mid-and late diastolic murmurs
are generally caused by
narrowed, stenosed mitral and
tricuspid valves that obstruct
blood flow.
Midsystolic Ejection Murmurs
Due to forward flow
through semilunar valves
Midsystolic Ejection Murmurs
Pansystolic Regurgitant Murmurs
Due to backward flow of blood
from area of higher pressure to
one of lower pressure
Pansystolic Regurgitation Murmurs
Diastolic Rumbles of AV Valves
Filling murmurs at low
pressures, best heard with bell
lightly touching skin
Diastolic Rumbles of AV Valves
Early Diastolic Murmurs
Due to semilunar valve
incompetence
Early Diastolic Murmurs