1. Heart and Neck Vessels
By InnaKorda

2. Surface Anatomy

3. Cardiac Anatomy

4. Direction of Blood Flow

5. Cardiac Cycle Diastole Systole
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 Arrhythmias ECG 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 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?
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 Cough Fatigue Cyanosis or pallor
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) Nocturia Past cardiac history
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 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
Coronary Heart Disease
Risk Factors
Pharmacology – table 48.3 p 509
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 Skin LOC
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 Postural blood pressure (orthostatic)
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 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.
Internal jugular vein pulsation significance??????

22. Assessing Neck Vessels
Jugular Venous Pressure Estimate
Used to assess heart failure
Position 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 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
P 503 fig 19-18

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
Dilatation?
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 Percussion
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. Move stethoscope in a Z pattern, Aortic  Pulmonic  Right  Left
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
P 506 pic
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. Apical rate – Radial rate = Pulse deficit
Rate and Rhythm
Normal 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 hours, but may take up to 48 hours.
Cyanosis signals oxygen desaturation and congenital heart disease
Heart rate may range from bpm after birth, then stabilize 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 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. Auscultation Assistant
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

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 Physiologic S3 Pathologic S3 (ventricular gallop) 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. S4 Physiologic S4 Pathologic S4 (atrial gallop) TEN - NES - SEE‘
A - STIFF Heart
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. Murmurs Diastolic Systolic
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.
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).

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

51. Diastolic Rumbles of AV Valves
Filling murmurs at low pressures, best heard with bell lightly touching skin

52. Diastolic Rumbles of AV Valves

53. Early Diastolic Murmurs
Due to semilunar valve incompetence

54. Early Diastolic Murmurs