5Cardiac Cycle Diastole Systole Ventricles are relaxed, AV valves are openPressure in atria are higher than in ventricles causing blood to pour into the ventriclesAtria contract casing more blood to enter the ventricles “atrial kick”SystolePressure 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 ventriclesWhen 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.
9Ageing Adult Hemodynamic changes Arrhythmias ECG changes Systolic pressure tends to increase 20 mm Hg due to arteriosclerosisDecreased cardiac output with exerciseBlacks, Mexicans, and Native Americans have higher incidence of hypertensionArrhythmiasIncrease with ageECG changesProlonged P-R interval and prolonged Q-T interval
10Health History Chest pain Dyspnea (shortness of breath) 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?CharacterAssociative and alleviating factors – What brought on the pain? What relieves it? (nitroglycerinAssociative symptoms – sweating, pale skin, SOB, N&V, tachycardia?Dyspnea (shortness of breath)What type of activity brought it on?DOE – Dyspnea on exertion. Ex: walkingOnsetDurationPositionalNocturnal dyspnea occurs with heart failure.Does it awaken you at night?
11Question 1A 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?”
12Health History Orthopnea Cough Fatigue Cyanosis or pallor Do you need to assume an upright position when sleeping? How many pillows are used?CoughDurationFrequencyType – dry, hacking, congested?Mucus? Color, odor, blood?Associative and alleviative factorsFatigueDo you tire easily?Fatigue due to decreased cardiac output (CO) is worse in eveningOnset – When did fatigue start? Was it sudden or gradual?Cyanosis or pallorOccurs with myocardial infarction (MI) or low CO decreased tissue perfusion
13Health History Edema (swelling) Nocturia Past cardiac history OnsetFrequencyCardiac edema is worse at evening and better in morningAmount - How much swelling occurs normally? Equal on both sides?Associative and alleviative factors – SOB? Before or after leg swellingNocturiaDo you awaken at night with an urgent need to urinate?More fluid reabsorption and excretion in pt with heart failurePast cardiac historyHTN, cholesterol, murmur, congenital heart disease, rheumatic feverHow was it treated?Family history
14Health History 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, durationDrugs – Medication, street drugsCoronary Heart DiseaseRisk FactorsPharmacology – table 48.3 p 5094 cig per day = 2x risk for cardio disease20 cig per day = 4x risk for cardio diseasePack Years =Packs per day X Years smoked
15Preparation for Physical Examination EnvironmentShould be warm. Shivering might interfere with heart soundsPrivacyMake 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 wayOrder of examBegin with observations peripherally and move toward the heart.Pulse and blood pressureExtremities – peripheral vascular assessmentNeck vesselsPrecordium – (portion of body over heart and thorax)
16General Appearance General build Skin LOC Chronic HF may appear malnourished, thin, cachecticSkinJaundice and generalized edema in late HFLOCPoor cardiac output and decreased cerebral perfusion may cause mental confusion, memory loss, slowed verbal responses
17Blood Pressure Normal for adults Postural blood pressure (orthostatic) 90 to 140 mm Hg systolic60 to 90 mm Hg diastolicPressure greater than 140/90 is considered hypertensionPressure less than 90/60 is considered hypotension and may be inadequate to provide oxygenation to cellsPostural blood pressure (orthostatic)Moving from lying to sitting or standing position↑ in mm Hg by 10 and/or ↑ in pulse by 10 after a minuteMay be caused by cardiac drugs or loss of autonomic NS compensatory ability, generally in older adultsParadoxical blood pressureDecrease in systolic BP more than 10 mm Hg during inspiration
18Question 2A 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 shockCardiac tamponadePulmonary embolismDissecting thoracic aortic aneurysm
19Question 3A 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 levelMeasuring the blood pressure after the client has been seated quietly for 5 minutesUsing a cuff with a rubber bladder that encircles at elast 80% of the limbTaking the blood pressure within 30 minutes after nicotine or caffeine ingestion
20Assessing Neck Vessels Carotid ArteryPalpate the carotid arteryAvoid excessive pressure. Excessive vagal stimulation could slow down heart rate.Carotid arteries should be same bilaterallyAuscultationListen for bruits – blowing, swishing sounds indicating blood flow turbulence. Caused by atherosclerotic narrowing (one half or two thirds of artery).
21Assessing Neck Vessels Jugular VeinsCan be used to assess central venous pressure (CVP) and cardiac efficiencyDistended external jugular veins signify increased CVP, as with heart failurePosition the patient at 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 needTurn the pt’s head away from examiner’s sideDistinguish from carotid artery pulsations. Internal jugular pulse is lower, varies with respiration, not palpable, and disappears as person is sitting.Internal jugular vein pulsation significance??????
22Assessing Neck Vessels Jugular Venous Pressure EstimateUsed to assess heart failurePosition the patient at 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 anglePulsations 3 or more cm above sternal angle while at 45 degrees occur with heart failureRecord height of pulsations and degrees of elevationP 503 fig 19-18
23Question 4The 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 anglePatient elevated to 40 degrees, internal jugular vein pulsation at 1 cm above sternal anglePatient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal angle
24Assessing 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 lineSize – normally 1cm x 2cmAmplitude – normally a short gentle tapDuration – short, first half of systoleDilatation?Abnormalities:Left ventricular dilatation (volume overload) displaces impulse down and leftLeft ventricular hypertrophy (pressure overload) increases force and duration but no change in location
25Assessing the Heart Palpation Percussion Use the palms of your fingers to palpate across chest to search for any other pulsationsA thrill is a palpable vibration. Signifies turbulent blood flow and accompanies loud murmursPercussionUsed to outline cardiac bordersNot as accurate as X-ray or echocardiogramHypertrophy may be due to hypertension, CAD, heart failure, cardiomyopathy
26Move stethoscope in a Z pattern, Aortic Pulmonic Right Left Auscultation2nd right interspace – Aortic valve area2nd left interspace – Pulmonic valve areaLeft lower sternal border – Tricuspid valve area5th interspace around midclavicular line- Mitral valve areaErb’s pointP 506 picMove stethoscope in a Z pattern, Aortic Pulmonic Right Left
27Auscultation Tune out any distractions Listen to one sound at a time Note rate and rhythmIdentify S1 and S2Assess S1 and S2 separatelyListen for extra heart soundsListen for murmurs
28Apical rate – Radial rate = Pulse deficit Rate and RhythmNormal beats per minute for adults.Rhythm should be regularSinus 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
29Developmental Considerations in Assessment - Infants Fetal shunts normally close within hours, but may take up to 48 hours.Cyanosis signals oxygen desaturation and congenital heart diseaseHeart rate may range from bpm after birth, then stabilize bpmTachycardia – greater than 200 bpm in newborns and greater than 150 bpm in infantsBradycardia – less than 90 in newborns, less than 60 in older infants and childrenExpect sinus arrhythmia – varied heartbeat with respiration
30Developmental Considerations in Assessment - Children Slowing of heart ratePhysiologic S3 is commonInnocent heart murmurs are commonVenous hum (turbulence of blood flow in jugular venous system) is also common
31Developmental Considerations in Assessment - Pregnancy Increase in pulse rate of bpmDecrease of blood pressure in 2nd trimester, rise again in 3rd trimesterIncrease loudness of S1, S3 heardPossible appearance of heart murmurs, which disappear after pregnancy
32Developmental Considerations in Assessment - Aging Rise in systolic BP – arteriosclerosis and atherosclerosisOrthostatic hypotensionIncrease in AP diameter of chestSystolic murmurs become more commonBe careful when palpating carotid artery due to the carotid autonomic reflex causing bradycardia!
33Auscultation Assistant S1 and S2S1 is the start of systole and is the reference point for other cardiac soundsDistinguishing S1 from S21st sound of the “LUB – dup” except in tachyarrhythmiasS1 is louder than S2 at the apex. S2 is louder than S1 at the baseErb’s point – S1 and S2 heard equallyS1 coincides with carotid artery pulseS1 coincides with R wave on ECG monitorAuscultation Assistant
34S1 Caused by closure of the AV valves Abnormalities Accentuated (loud) S1Hyperkinetic states such as exercise, fever, anemia, hyperthyroidismCalcification of AV valves - requires increasing ventricular pressure to close valves against increased atrial pressureDiminished S1First degree heart block – prolonged PR interval on ECG due to delayed conduction from atria to ventriclesExtreme calcification of valves, limiting their mobilitySplit S1Mitral and tricuspid components are heard separatelyNormal but uncommon
35S2 Caused by closure of semilunar valves (aortic and pulmonic) AbnormalitiesAccentuated S2Higher closing pressure due to systemic hypertensionPulmonary hypertensionAortic or pulmonic stenosis – calcification, still mobileDiminished S2Fall in systemic BP – shockAortic and pulmonic stenosis – calcification, decreased mobilitySplit S2Normal. Due to the aortic valve closing 0.06 seconds before the pulmonic valve during inspirationHeard only in the pulmonic valve areaParadoxical split – opposite of what you’d expect. Split on expiration
36S3 Physiologic S3 Pathologic S3 (ventricular gallop) KEN - TUCK - Y SHLOSH - ING INPhysiologic S3Heard frequently in children and young adults, disappears when the person sits up.Pathologic S3 (ventricular gallop)Persists when sitting up and heard after age 40Occurs because the left ventricle is not very compliantAt the beginning of diastole the rush of blood into the left ventricle causes vibration of the valve leaflets and the chordae tendinaeOccurs with heart failure due to volume overload, such as mitral, aortic, or tricuspid regurgitation
37S4 Physiologic S4 Pathologic S4 (atrial gallop) TEN - NES - SEE‘ A - STIFF HeartPhysiologic S4May occur in older adults after exercisePathologic S4 (atrial gallop)Caused by the relatively rapid filling rate against a relatively stiff ventricleOccurs with:Decreased compliance of ventricles (coronary artery disease, cardiomyopathy)Systolic overload (afterload)Aortic stenosisSystemic hypertension
38Extracardiac Sounds Pericardial friction rub High pitched, scratchy sound as a result of inflammation of the pericardiumHeard best at apex and lower sternal borderThis 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
39Question 5The 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 expirationUsing the bell with the patient leaning forwardAt the base during normal respirationWith the diaphragm, patient turned to the left side
45Listening for Murmurs Loudness Grade i – barely audibleGrade ii – clearly audible, but faintGrade iii – moderately loud, but easy to hearGrade iv – loud, associated with a thrill palpable on the chest wallGrade v – very loud, heard with one corner of stethoscope lifted offGrade vi – loudest, heard with entire stethoscope lifted off the chest wallPitch – high, medium, low. Depends on pressure and rate of blood flowPatternQuality – musical, blowing, harsh, rumblingLocationRadiationPosture
46Murmurs Diastolic Systolic Occur in the filling phase of the cardiac cycleCaused by incompetent semilunar valves or stenotic AV valvesEarly 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.SystolicOccur during the ventricular ejection phase of the cardiac cycleMost caused by obstruction of the outflow of the semilunar valve (aortic, pulmonic) or by incompetent AV valves (mitral, tricuspid).
47Midsystolic Ejection Murmurs Due to forward flow through semilunar valves