1. Heart & Neck Vessels
Chapter 19 - Jarvis

2. Overview Neck Precordium Carotid pulse – observe and palpate
Observe jugular venous pulse
Estimate jugular venous pressure
Precordium
Inspection and palpation
Describe location of apical pulse
Note any heave (lift) or thrill
Auscultation
Identify anatomic areas noting rate and rhythm
Listen in systole and diastole for murmurs
Repeat with bell
Listen at apex and base

3. Cardiovascular System
Consists of the Heart and Blood Vessels

4. Position & Surface Landmarks
Precordium: area on anterior chest directly overlying the heart and great vessels
Mediastinum: area between the lungs in the middle third of the thoracic cage
Heart: top is the broader base & bottom is the apex
Apical Impulse: 5th intercostal space, 7-9cm from midsternal line
Great Vessels: superior & inferior vena cava; pulmonary artery; pulmonary veins; aorta

5. Position & Surface Landmarks

6. Heart Wall, Chambers, & Valves
Heart Wall: Pericardium, Myocardium, & Endocardium
Chambers: Atria & Ventricles; right & left
Valves
Atrioventricular
Semi lunar

7. Blood Flow
Blood flow animation

9. Heart Sounds

10. Conduction P wave: depolarization of aorta PR interval: beginning
of P wave to beginning of
QRS (atrial depolarization
& impulse through AV node)
QRS complex: depolarization
of ventricles
T wave: repolarization of
ventricles
Conduction You tube

11. Pumping Ability
Cardiac Output: normally 4-6 Liters of blood per minute
Cardiac Output = Stroke Volume x Rate
Preload: venous return that builds during diastole; ventricular muscle is stretched before contraction
Afterload: opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure; resistance against which ventricle must pump its blood

12. Neck Vessels
Carotid Arteries
Jugular Veins:
Internal and external

13. History: Subjective Data
Chest pain
Dyspnea
Orthopnea
Cough
Fatigue
Cyanosis or pallor
Edema
Nocturia
Past cardiac history
Family cardiac history
Personal habits (cardiac risk factors)

14. Objective Data

15. Neck Vessels

16. Neck Vessels
Inspect Jugular Venous Pulse – assessing central venous pressure
Stand on patient’s right side
Position patient supine from degree angle; Pulsation may be seen the sternal notch
At 45 degree angle, jugulars should disappear
Inspect carotid pulsations
Neck Vessel Exam

17. Neck Vessels Palpate Carotid Artery Auscultate Carotid Artery
One at a time
Avoid excessive pressure
Normal: smooth with 2+ strength
Auscultate Carotid Artery
Listen for presence of bruit (blowing or swishing sound)
Apply bell of the stethoscope at angle of jaw, midcervical area, and base of the neck
Person can take breath, exhale, and hold while you listen so no sound is masked

18. Neck Vessels Jugular Venous Pressure
Use angle of Louis as arbitrary reference point, and compare it with highest level of venous pulsation
Hold a vertical ruler on sternal angle
Align a straight edge on ruler like a T-square, and adjust level of horizontal straight edge to level of pulsation
Read level of intersection on vertical ruler; normal jugular venous pulsation is 2 cm or less above sternal angle
State person’s position, e.g., “internal jugular vein pulsations 3 cm above sternal angle when elevated 30 degrees”

19. Chest Inspect Anterior Chest Palpate the Apical Impulse
Pulsations: may or may not see apical impulse at 4th intercostal space at or inside the midclavicular line
Palpate the Apical Impulse
Ask the person to exhale and hold
Use 1 finger pad
Note: location (4th or 5th intercostal space), size (1 x 2 cm), amplitude (short, gentle tap), duration (short)
May not be palpable in all adults

20. Chest Palpate Across Precordium Percussion
Use palmar aspects of 4 fingers, or ulnar surface of hand and gently palpate
Normally no findings
Percussion
Used to outline the heart’s border
Not done as much because of availability of chest x-ray and/or echocardiography

21. Chest Auscultation 4 traditional valve “areas”
2nd right interspace – aortic valve area
2nd left interspace – pulmonic valve area
Left lower sternal border – tricuspid valve area
5th interspace, left midclavicular line – mitral valve area
Auscultate in Z pattern from base of heart, across and down, then over to apex
Traditionally
Aortic area, pulmonic area, Erb’s point, tricuspid area, mitral area “ APE –To-Man”

22. Chest

23. Chest Rate: 50-90 bpm Rhythm: regular Identify S1 & S2: lub-dup
S1 louder at apex = closure of AV valves, beginning of systole
S2 louder at base = closure of semilunar valves
Focus on systole, then diastole, then listen for extra heart sounds
Listen for murmurs
Describe by timing, loudness, pitch, pattern, quality, location, radiation, posture
Heart Sounds

24. Variation in S1
Factors: Position of AV valve at start of systole, change in valve structure, & pressure in the ventricles
Loud S1
Faint S1
Varying Intensity of S1
Split S1

25. Variations in S2 Accentuated S2 Diminished S2 Split S2
Normal: occurs during inspiration
Fixed Split: unaffected by respiration
Paradoxical Split: occurs during expiration
Wide Split: wide on inspiration and still present with expiration

26. Extra Systolic Sounds
Ejection Click: sound of the SL valves opening; best heard with diaphragm; aortic at 2nd right interspace and apex; pulmonic at 2nd left interspace
Aortic Prosthetic Valve Sounds: early systolic sound
Midsystolic Click: associated with mitral valve prolapse; sound is short and high pitched; best heard with the diaphragm at the apex;

27. Extra Diastolic Sounds
Early Diastole
Opening Snap: opening of AV valves
Mitral Prosthetic Valve Sound: opening click just after S2
Mid-diastole
Third Heart Sound: S3 – ventricular filling sound, low pitched, like “distant thunder”; heard at the apex or left lower sternal border with the bell
Physiologic: frequently heard in children and young adults; disappears when sitting up
Pathologic: Ventricular Gallop – indicates decreased compliance of the ventricles (heart failure)
Discuss how you differentiate an S3 from a Split S2

28. Extra Diastolic Sounds
Late Diastole
Fourth Heart Sound: S4 – ventricular filling sound, soft and low pitched; heard at the apex with person in left lateral position with the bell
Physiologic: found in adults older than 40
Pathologic: Atrial Gallop – decreased compliance of the ventricles (CAD, cardiomyopathy, systemic HTN)
Summation Sound: S3 & S4 present

29. Extra Cardiac Sounds
Pericardial Friction Rub: inflammation of the pericardium; high pitched and scratchy best heard with the diaphragm

30. Murmurs Identified by Where they are heard on the chest
Where they occur in the cardiac cycle- Systolic/Diastolic
Loudness- graded I-VI
Pitch- low to high
Variation in loudness- Crescendo/Decrescendo, pan

31. Systolic Murmurs
Aortic Stenosis: loud, harsh, midsystolic; loudest at 2nd right interspace
Pulmonic Stenosis: medium, coarse, systolic; loudest at 2nd left interspace
Mitral Regurgitation: pansystolic, loud, blowing; loudest at apex
Triscupid Regurgitation: pansystolic, soft, blowing; loudest at left lower sternal boarder

32. Diastolic Murmurs
Mitral Stenosis: low-pitched, diastolic; best heard at the apex with person in left lateral position
Tricuspid Stenosis: rumbling, diastolic; best heart at left lower sternal boarder, louder on inspiration
Aortic Regurgitation: soft, high-pitched, blowing, diastolic; best heard at 3rd left interspace at the base
Pulmonic Regurgitation: same as aortic regurgitation

33. Developmental Considerations

34. Infants Subjective Objective Mother’s health during pregnancy
Any cyanosis
Growth
Activity
Objective
Fetal shunts close between hours but may take up to 48 hours (may have murmurs until shunts close)
Apical impulse: palpate at the 4th intercostal space, lateral to the midclavicular line
Heart rate: bpm
Sinus arrhythmia with respirations
S2 higher pitched and sharper than S1

35. Children: Subjective Growth Activity
Unexplained joint pain or fevers (strep throat, rheumatic fever)
Frequent headaches or nosebleeds
Frequent respiratory infections
Family History

36. Children: Objective
Signs of heart disease: poor weight gain, developmental delay, persistent tachycardia, tachypnea, dyspnea on exertion, cyanosis, clubbing
Apical impulse may be visible
4th intercostal space left of the midclavicular line until age 4;
4th intercostal space at midclavicular line age 4-6;
5th intercostal space right of midclavicular line at age 7;
Heart rate slows down
Sinus arrhythmia common; Physiologic S3 is common
Venous hum is common
Heart murmurs may occur and are functional

37. Pregnant Woman: Subjective
Blood pressure
Usual blood pressure before pregnancy
Blood pressure during pregnancy
Treatments
Associated symptoms
Fainting or Dizziness

38. Pregnant Woman: Objective
Resting pulse rate increase of bpm
Blood pressure  2nd trimester,  3rd trimester
Apical impulse higher and lateral than normal
Increased blood volume causes:
Exaggerated splitting of S1, increased loudness of S1
Loud S3
Heart murmurs

39. Aging Adult: Subjective
Heart or lung disease
Treatment
Symptoms
Medications for any illness
Environment

40. Aging Adult: Objective
Gradual rise in systolic blood pressure is common
Orthostatic hypotension
AP chest diameter increases
Carotid artery stenosis
S4 may occur with no known cardiac disease
S3 indicates heart failure
Systolic murmurs are common

41. ABNORMAL FINDINGS

42. Heart Failure Dilated pupils Gray, pale, or cyanotic skin; cool skin
Decreased cardiac output due to the heart pump failing
Dilated pupils
Gray, pale, or cyanotic skin; cool skin
Anxiety or confusion
Decreased O2 saturation
Dyspnea
Orthopnea
Jugular vein distention
Crackles/Wheezes in the lungs
Cough
Weak pulse
Decreased blood pressure
S3 gallop/ tachycardia
Nausea and vomiting
Ascites
Edema
Fatigue
Enlarged spleen and liver
Decreased urine output

44. Congenital Heart Defects
Atrial Septal Defect (ASD): abnormal opening in the atrial septum, results in left-to-right shunting
Ventricular Septal Defect (VSD): abnormal opening in the septum between ventricles
Tetralogy of Fallot: shunts venous blood into the aorta, blood is not being oxygenated; severe cyanosis
Coarctation of the Aorta: severe narrowing of the aorta