Heart and Neck Vessels

1. Heart and Neck Vessels By InnaKorda

2. Surface Anatomy

3. Cardiac Anatomy

4. Direction of Blood Flow

5. 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.

6. Neck Vessels

7. Neck Muscles

8. Developmental Considerations

9. Ageing Adult • Hemodynamic changes • 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 • Arrhythmias • Increase with age • ECG changes • Prolonged P-R interval and prolonged Q-T interval

10. Health History • Chest pain • 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?

11. 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? • “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?”

12. Health History • Orthopnea • Do you need to assume an upright position when sleeping? How many pillows are used? • Cough • 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

13. Health History • Edema (swelling) • Onset • Frequency • Cardiac edema is worse at evening and better in morning • 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 • HTN, cholesterol, murmur, congenital heart disease, rheumatic fever • How was it treated? • Family history

14. Health History Coronary Heart Disease Risk Factors • Personal habits • 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 4 cig per day = 2x risk for cardio disease 20 cig per day = 4x risk for cardio disease Pack Years = Packs per day X Years smoked

15. Preparation for Physical Examination • Environment • Should be warm. Shivering might interfere with heart sounds • Privacy • 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. • Pulse and blood pressure • Extremities – peripheral vascular assessment • Neck vessels • Precordium – (portion of body over heart and thorax)

16. General Appearance • General build • Chronic HF may appear malnourished, thin, cachectic • Skin • Jaundice and generalized edema in late HF • LOC • Poor cardiac output and decreased cerebral perfusion may cause mental confusion, memory loss, slowed verbal responses

17. Blood Pressure • Normal for adults • 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 • Postural blood pressure (orthostatic) • 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

18. 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: • Cardiogenic shock • Cardiac tamponade • Pulmonary embolism • Dissecting thoracic aortic aneurysm

19. 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? • 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

20. Assessing Neck Vessels • Carotid Artery • Palpate the carotid artery • 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).

21. Assessing Neck Vessels • Jugular Veins • Can be used to assess central venous pressure (CVP) and cardiac efficiency • Distended external jugular veins signify increased CVP, as with heart failure • Position the patient at 30-45 degree angle, wherever pulsations can be seen best. Remove pillow to avoid flexion of head. • 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.

22. Assessing Neck Vessels • Jugular Venous Pressure Estimate • 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

23. Question 4 • The examiner has estimated the jugular venous pressure. Identify the finding that is abnormal. • 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

24. Assessing the Heart • Apical Impulse • Apical impulse may or may not be seen against the chest wall. (Seen more in children) • 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. • 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

25. Assessing the Heart • Palpation • Use the palms of your fingers to palpate across chest to search for any other pulsations • A thrill is a palpable vibration. Signifies turbulent blood flow and accompanies loud murmurs • Percussion • Used to outline cardiac borders • Not as accurate as X-ray or echocardiogram • Hypertrophy may be due to hypertension, CAD, heart failure, cardiomyopathy

26. Auscultation • 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 Erb’s point Move stethoscope in a Z pattern, Aortic  Pulmonic  Right  Left

27. Auscultation • Tune out any distractions • Listen to one sound at a time • Note rate and rhythm • Identify S1 and S2 • Assess S1 and S2 separately • Listen for extra heart sounds • Listen for murmurs

28. 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

29. Developmental Considerations in Assessment - Infants • 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 • 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

30. Developmental Considerations in Assessment - Children • 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

31. Developmental Considerations in Assessment - Pregnancy • 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

32. Developmental Considerations in Assessment - Aging • 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!

33. 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 • 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

34. S1 • Caused by closure of the AV valves • Abnormalities • Accentuated (loud) S1 • Hyperkinetic states such as exercise, fever, anemia, hyperthyroidism • Calcification of AV valves - requires increasing ventricular pressure to close valves against increased atrial pressure • Diminished S1 • 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 • Mitral and tricuspid components are heard separately • Normal but uncommon

35. S2 • Caused by closure of semilunar valves (aortic and pulmonic) • Abnormalities • Accentuated S2 • Higher closing pressure due to systemic hypertension • Pulmonary hypertension • Aortic or pulmonic stenosis – calcification, still mobile • Diminished S2 • 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

36. S3 • KEN - TUCK - Y • SHLOSH - ING IN • Physiologic S3 • 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

37. TEN - NES - SEE‘ • A - STIFF Heart S4 • Physiologic S4 • 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: • Decreased compliance of ventricles (coronary artery disease, cardiomyopathy) • Systolic overload (afterload) • Aortic stenosis • Systemic hypertension

38. Extracardiac Sounds • Pericardial friction rub • 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

39. Question 5 • The examiner wishes to listen for a pericardial friction rub. Select the best method for listening: • 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

40. Congenital Heart Defects

41. Congenital Heart Defects

42. Congenital Heart Defects

43. Congenital Heart Defects

44. Congenital Heart Defects

45. Listening for Murmurs • Loudness • 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

46. 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. Murmurs

47. Midsystolic Ejection Murmurs Due to forward flow through semilunar valves

48. Midsystolic Ejection Murmurs

49. Pansystolic Regurgitant Murmurs Due to backward flow of blood from area of higher pressure to one of lower pressure

50. Pansystolic Regurgitation Murmurs