1. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Chapter 14
Heart
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

2. Heart
The main function of the heart is to circulate blood through the body and lungs.
Two separate circulations
Located in the mediastinum 2

3. Figure 14-02.   Heart within the Pericardium.3

4. Structure (Cont.) Chambers
Two upper chambers are the right and left atria
Thin-walled chambers that act primarily as reservoirs for blood returning to the heart from the veins throughout the body
Two bottom chambers are the right and left ventricles
Thick-walled chambers that pump blood to the lungs and throughout the body 4

5. Structure (Cont.)
Chambers
Septum: divides right and left heart 5

6. Structure (Cont.)
Valves: permit the flow of blood in only one direction
Atrioventricular
Tricuspid valve, which has three cusps (or leaflets), separates the right atrium from the right ventricle.
Mitral valve, which has two cusps, separates the left atrium from the left ventricle.
Semilunar
Two semilunar valves, each has three cusps.
Pulmonic valve separates the right ventricle from the pulmonary artery.
Aortic valve lies between the left ventricle and the aorta. 6

7. Cardiac Cycle
To help ensure proper circulation, the heart contracts and relaxes rhythmically, creating a two-phase cardiac cycle.
Systole
Diastole 7

8. Figure 14-06. Blood Flow through the Heart. A, Systole. B, Diastole
Figure    Blood Flow through the Heart. A, Systole. B, Diastole. (From Canobbio, 1990.) 8

9. Systole Ventricles contract.
Blood is ejected from the left ventricle into the aorta and from the right ventricle into the pulmonary artery.
Mitral and tricuspid valves close (first heart sound).
Pressure continues to rise.
Aortic and pulmonic valves open.
Blood ejected into arteries.
Pressure falls.
Aortic and pulmonic valves close (second heart sound). 9

10. Diastole Mitral and tricuspid valves open.
Blood moves from atria to ventricles (third heart sound).
Ventricles dilate, an energy-requiring effort that draws blood into the ventricles as the atria contract, thereby moving blood from the atria to the ventricles.
Atria contract as ventricles almost filled.
Causes complete emptying of atria (fourth heart sound). 10

11. Electrical Activity
Intrinsic electrical conduction system enables the heart to contract within itself
Coordinates the sequence of muscular contractions taking place during the cardiac cycle
Sinoatrial node (SA node)
Atrioventricular node (AV node)
Bundle of His
Purkinje fibers 11

12. Electrical Activity (Cont.)
An electrocardiogram (ECG) is a graphic recording of electrical activity during the cardiac cycle. 12

13. Figure 14-09. Usual Electrocardiogram Waveform
Figure    Usual Electrocardiogram Waveform. (From Berne and Levy, 1996.) 13

14. Electrocardiogram (ECG)
ECG waves
P wave: the spread of a stimulus through the atria
PR interval: the time from initial stimulation of the atria to initial stimulation of the ventricles
QRS complex: the spread of a stimulus through the ventricles
ST segment and T wave: the return of stimulated ventricular muscle to a resting state
U wave: a small deflection sometimes seen just after the T wave
Q-T interval: the time elapsed from the onset of ventricular depolarization until the completion of ventricular repolarization 14

15. Older Adults Heart size may decrease. Left ventricular wall thickens.
Valves fibrose and calcify.
Heart rate slows.
Stroke volume decreases.
Cardiac output during exercise declines by 30% to 40%.
Endocardium thickens.
Myocardium becomes less elastic.
Electrical irritability may be enhanced. 15

16. Older Adults (Cont.) ECG tracing changes
First-degree atrioventricular block
Bundle branch blocks
ST wave abnormalities
Premature systole (atrial and ventricular)
Left ventricular hypertrophy
Atrial fibrillation
TAKE HOME MESSAGE: THINGS CHANGE IN THE ADULT HEART 16

17. Review of Related History
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18. History of Present Illness
Chest pain
Onset and duration
Character
Location
Severity
Associated symptoms
Treatment
Medications: prophylactic penicillin 18

19. History of Present Illness (Cont.)
Fatigue
Unusual or persistent
Inability to keep up with peers
Associated symptoms
Medications (e.g Beta blockers)
Cough
Onset and duration
Character
Medications: ACE inhibitors 19

20. History of Present Illness (Cont.)
Difficulty breathing (dyspnea, orthopnea)
Aggravated by exertion
On level ground, climbing stairs
Worsening or remaining stable
Lying down or eased by resting on pillows
(How many? Or sleep in a recliner?)
Paroxysmal nocturnal dyspnea 20

21. History of Present Illness (Cont.)
Loss of consciousness (transient syncope) associated with:
Palpitation
Dysrhythmia
Unusual exertion
Sudden turning of neck (carotid sinus effect)
Looking upward (vertebral artery occlusion)
Change in posture 21

22. Family History Diabetes Heart disease Dyslipidemia Hypertension
Congenital heart defects
Family members with cardiac risk factors 22

23. Personal and Social History
Employment
Physical demands
Environmental hazards
Tobacco use
Nutritional status
Personality assessment
Relaxation activities
Use of alcohol and/or drugs 23

24. Older Adults Common symptoms of cardiovascular disorder
Confusion and syncope
Palpitations
Coughs and wheezes
Hemoptysis
Shortness of breath
Chest pain and tightness
Incontinence, impotence, and heat intolerance
Fatigue
Leg edema 24

25. Examination and Findings
The examination of the heart includes the following:
Auscultate
Palpate artery sites
Inspect Jugular distention
Rarely Percussing the chest 25

26. Equipment
Stethoscope with bell and diaphragm 26

27. Palpation
Pulse sites 27

28. Palpation (Cont.)
Apical impulse
Carotid artery palpation 28

29. Auscultation
There are five traditionally designated auscultatory areas, located as follows:
Aortic valve area
Second right intercostal space at the right sternal border
Pulmonic valve area
Second left intercostal space at the left sternal border
Second pulmonic area
Third left intercostal space at the left sternal border (ERBS Point) 29

30. Auscultation (Cont.) Five auscultatory areas Tricuspid area
Fourth left intercostal space along the lower left sternal border
Mitral (or apical) area
Apex of the heart in the fifth left intercostal space at the midclavicular line 30

31. Auscultation (Cont.) Assess overall rate and rhythm
Pathology such as 31

32. Heart Sounds Basic heart sounds Extra heart sounds
S1 or S2 most distinct
Extra heart sounds
Gallops
Murmurs
Mitral snaps
Ejection clicks
Friction rubs 32

33. Rhythm Disturbance
Determine the steadiness of the heart rhythm, which should be regular.
If it is irregular, determine whether there is a consistent pattern.
Irregular but occurring in a repeated pattern may indicate sinus dysrhythmia, a cyclic variation of the heart rate
Patternless, unpredictable, irregular rhythm may indicate heart disease or conduction system impairment 33

34. Older Adults
Slow down pace of examination; cardiac response may be slowed by demands of positional changes.
Heart rate is variable:
Slower if increased vagal tone
Range from low 40s to 100+ beats per minute NO – WE WILL DISCUSS THIS
Ectopic beats common
Apical impulse is harder to find with increased anteroposterior chest diameter. 34

35. Older Adults (Cont.)
Diaphragm is raised and heart is transverse in obese adults.
Exercise may delay age-related changes.
Physiologic murmurs are caused by:
Aortic lengthening
Sclerotic changes 35

36. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Abnormalities
Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 36

37. Heart Murmurs
Causes
What the sound like 37

38. Cardiac Disorders Bacterial endocarditis Congestive heart failure
Bacterial infection of the endothelial layer of the heart and valves
Congestive heart failure
Heart fails to propel blood forward with its usual force, resulting in congestion in the pulmonary or systemic circulation 38

39. Cardiac Disorders (Cont.)
Cardiac tamponade
Excessive accumulation of effused fluids or blood between the pericardium 39

40. Figure 14-23. Hemopericardium and Cardiac Tamponade
Figure    Hemopericardium and Cardiac Tamponade. (Modified from Canobbio, 1990.) 40

41. Cardiac Disorders (Cont.)
Pericarditis
Sudden inflammation of the pericardium
Cor pulmonale
Enlargement of the right ventricle secondary to pulmonary malfunction 41

42. Cardiac Disorders (Cont.)
Myocardial infarction
Ischemic myocardial necrosis caused by abrupt decrease in coronary blood flow to a segment of the myocardium
Myocarditis
Focal or diffuse inflammation of the myocardium 42

43. Abnormalities in Heart Rates and Rhythms
Conduction disturbances
Atrial flutter
Sinus bradycardia
Atrial fibrillation
Heart block
Sick sinus syndrome
Arrhythmias caused by a malfunction of the sinus node
Atrial tachycardia
Ventricular tachycardia
Ventricular fibrillation 43

44. Older Adults Atherosclerotic heart disease
Caused by deposition of cholesterol, other lipids, and by a complex inflammatory process
Mitral insufficiency/Regurgitation
Abnormal leaking of blood through the mitral valve, from left ventricle into left atrium
Angina
Pain caused by myocardial ischemia 44

45. Older Adults (Cont.) Senile cardiac amyloidosis Aortic sclerosis
Amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease, deposition in the heart
Aortic sclerosis
Thickening and calcification of aortic valves 45