1. Heart and Neck Vessels Jarvis Chapter 19
ATI Skills Module on Physical Assessment (Adult) - - Cardiac
The Circulatory System
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2. Learning Outcomes
1. List the significant anatomic features of the heart and their location. 2. Describe the heart sounds & relate the name of the heart sound to the physiologic cause. 3. Describe the structures of conduction and the spread of the cardiac impulse through the heart. 4. Relate the circulation of blood through the heart and great vessels. 5. Discuss the significance of jugular vein assessment.

3. Learning Outcomes (cont’d)
6. Cite the risk factors associated with heart disease and stroke.
7. List the hemodynamic changes that occur with aging.
8. Perform an accurate objective heart and neck vessels assessment on a client and document findings.
9. Discuss cultural/ethnic differences related to heart disease.

4. Key Terms
Automaticity Preload Afterload Apical impulse Arrhythmia Bruit Cardiac output Systole Diastole Dyspnea on exertion (DOE)
Orthostatic hypotension Paroxysmal nocturnal dyspnea (PND) Orthopnea Pulse deficit Pulse pressure Sinus rhythm Sinus arrhythmia Murmur Atrial kick
Cardiac arrhythmia is any of a group of conditions in which the electrical activity of the heart is irregular or is faster or slower than normal. In adults the normal resting heart rate ranges from 60 beats per minute to 100 beats per minute. The normal heart beat is controlled by a small area in the upper chamber of the heart called the sinoatrial node or sinus node. The sinus node contains specialized cells that have spontaneous electrical activity that starts each normal heart beat. In an adult, a heart rate faster than 100 beats/minute is considered tachycardia. A slow rhythm, known as bradycardia (less than 60 beats/min), is usually not life threatening, but may cause symptoms.

5. Cardiovascular (CV) System

6. Precordium, Apex and Base
© Pat Thomas, 2006.

7. Cardiovascular (CV) System
CV system: heart, blood vessels & blood
Heart & great vessels lie between lungs in the thoracic cavity (mediastinum)
Apex = bottom of heart; Base = top of heart
Great vessels
Superior vena cava
Inferior vena cava
Pulmonary artery  deoxygenated blood from heart to lungs
Pulmonary veins  fresh oxygen to heart from lungs
Aorta

11. Structure and Function
Heart wall
Pericardium  surrounds & protects the heart
Myocardium
Endocardium
Chambers
Atria—right and left
Ventricles—right and left
Valves
Atrioventricular (AV)
Tricuspid
Mitral
Semilunar
Pulmonic
Aortic

12. Chambers and Valves
© Pat Thomas, 2006.

13. Cardiac Blood Flow
Deoxygenated blood from body enters superior & inferior vena cava (1)  enters right atrium (2)  enters right ventricle (3) through tricuspid valve  pumped into pulmonary arteries (4) through pulmonic valve goes to lungs where CO2 removed & replaced with fresh O2 re-oxygenated blood returns through pulmonary veins (5) to the left atria (6) enters left ventricle (7) through mitral valve  pumped through aortic valve to the aorta (8)  fresh oxygenated blood to entire body

14. Superior Vena Cava R & L Common Carotid Arteries Left Subclavian
Artery
Superior
Vena
Cava
Lungs
Lungs
LUNGS

15. Direction of Blood Flow

16. Cardiac Cycle
Composed of 1 heart beat  has 2 phases:
Diastole  resting phase of the heart  both ventricles relax & fill with blood  takes up 2/3 of cardiac cycle time (Remember MAP?)
Systole  contraction of both ventricles  right ventricle pumps blood into the pulmonary arteries to take to the lungs for re-oxygenation and left ventricle pumps re- oxygenated blood into aorta for delivery to the body tissues  takes up 1/3 of cardiac cycle time

17. Conduction Sinoatrial (SA) node  pacemaker Atrioventricular (AV) node
Automaticity
Electrical Conduction
Sinoatrial (SA) node  pacemaker
Atrioventricular (AV) node
Bundle of his
Left & right bundle branches
Purkinje Fibers

18. ECG P wave: atrial contraction (depolarization) (“atrial kick”)
ECG: PQRST
P wave: atrial contraction (depolarization) (“atrial kick”)
PR interval
QRS complex: ventricular contraction (depolarization)
T wave: ventricular repolarization
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19. Cardiac Conduction System
Right & left bundle branches
Purkenjie fibers

20. THE CARDIAC CYCLE

21. Heart Sounds Third heart sound (S3) Fourth heart sound (S4)
1. First heart sound (S1)  closure of atrioventricular (AV) valves (tricuspid & mitral valves); signals beginning of systole
2. Second heart sound (S2)  closure of semilunar valves (pulmonic & aortic valves); signals end of systole
Split S2 normal with inspiration
4. Extra heart sounds
Third heart sound (S3)
Fourth heart sound (S4)
5. Murmurs  sound of blood circulating through heart chambers or valves  usually d/t defects in valves
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22. Cardiac cycle
Diastole
Systole
Events in the right and left sides

23. Cardiac Output (CO)
SV (stroke volume) X R (rate) = CO Example: 100ml X 60 HR = 6L/min CO Preload = amount of blood in ventricles before systole (contraction of ventricles) Afterload = resistance of filled aortic artery pressure against which the left ventricle must pump its blood.

25. Neck Vessels Internal jugular External jugular
Left & right carotid arteries
Left & right jugular veins
Internal jugular
External jugular
Increased jugular venous pressure & distention (JVD) signals right-sided heart failure

27. The Aging Adult Smoking Diet Alcohol (ETOH) use Exercise patterns
Incidence of CV disease increases with age.
CAD increases sharply with age & accounts for about 50% of deaths in older people
Hypertension & heart failure increase with age.
Modifiable lifestyle habits:
Smoking
Diet
Alcohol (ETOH) use
Exercise patterns
Stress
Sedentary lifestyle

28. The Aging Adult (cont’d)
Non-modifiable hemodynamic changes
Systolic BP increases d/t arteriosclerosis (stiffening of arteries)  increased workload on left ventricle leads to thickening of muscle fibers
Diastolic pressure does not increase but increased systolic pressure leads to increased pulse pressure (difference between diastolic & systolic BP)
No change in resting heart rate or cardiac output at rest
Decreased ability to increase cardiac output (CO) with exercise

29. The Aging Adult (cont’d)
Non-modifiable hemodynamic changes (cont’d)
Arrhythmias  may decrease cardiac output and BP  may experience syncope d/t decreased cerebral blood flow
Cardiac Arrhythmia:
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ECG changes d/t changes in conduction system: prolonged P-R interval (first-degree heart block) & increased incidence of bundle branch block

30. Risk Factors for Heart Disease & Stroke
Hypertension Smoking High cholesterol levels Obesity Physical inactivity Diabetes

31. Cultural & Genetics
Risk factors for stroke and heart disease High blood pressure (HTN) -- black adults #1 Smoking Cholesterol – black adults lower than white & Mexican-Americans Obesity (BMI >30) or overweight (BMI >25) – All in 70%: blacks; Mexican-Americans; whites. Asians 25% Physical inactivity Diabetes Type 2 – increasing across all age & ethnic groups; American Indians >2x the rate of U.S. adults overall.

32. Subjective Data— Health History Questions
Chest pain  onset, location, radiation, character, exertional or at rest, other s/sx, NTG Dyspnea  exertional or at rest, positional, constant or intermittent, awakens at night (paroxysmal nocturnal dyspnea  occurs with heart failure) Orthopnea  # of pillows used when supine Cough  duration, frequency, productive Fatigue  onset, related to time of day Cyanosis or pallor
Chest pain: Any chest pain or tightness? Edition Change: diaphoresis, pallor, palpitations, dyspnea, nausea, tachycardia, or fatigue should be considered to be equivalent to angina.
Dyspnea: Any shortness of breath?
Orthopnea: How many pillows do you use when sleeping or lying down?
Cough: Do you have a cough?
Fatigue: Do you seem to tire easily? Able to keep up with your family and co-workers?
Cyanosis or pallor: Ever noted your facial skin to turn blue or ashen?

33. Health History Questions (cont’d)
Edema  swelling of hands or feet, severity, resolve at night, other s/sx
Nocturia  frequency, how long
Cardiac history  HTN, high cholesterol, heart disease, rheumatic fever, surgery
Family cardiac history  HTN, CAD, sudden death at early age
Personal habits (cardiac risk factors)
For Aging Adults:
Any known heart or lung disease
Medications
Environment
Edema: Any swelling of your feet and legs?
Nocturia: Do you awaken at night with an urgent need to urinate? How long has this been occurring? Any recent change?
Cardiac history: Any history of hypertension, elevated blood cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever or unexplained joint pains as child or youth, recurrent tonsillitis, anemia?
Family cardiac history: Any family history of hypertension, obesity, diabetes, coronary artery disease (CAD), sudden death at younger age?

34. Objective Data—The Physical Exam
Equipment needed: Stethoscope
Carotid arteries
Palpate
Auscultate for bruits
Jugular veins  Inspect for jugular vein distention (JVD)  occurs with right-sided heart failure
Precordium
Inspect the anterior chest
Palpate the apical impulse  4th or 5th interspace, midclavicular line

35. Objective Data—The Physical Exam (cont.)
Auscultate the heart sounds
First, identify S1 and S2 (S1 is louder than S2 at the apex & coincides with carotid artery pulse; S2 is louder at the base)
Note the rate and rhythm  rhythm should be regular but sinus arrhythmia occurs normally in young adults & children  increases with inspiration, slows with expiration
Listen for extra heart sounds
Listen for murmurs
Palpate radial pulse  calculate pulse deficit if present (difference between apical pulse & radial pulse)

36. Objective Data—The Physical Exam (cont.)
Characteristics of normal heart sounds
First heart sound (S1)
Second heart sound (S2)
Split S2  normal splitting is associated with inspiration
Extra heart sound
Third heart sound (S3)
Fourth heart sound (S4)
Murmurs
The aging adult

37. Auscultatory Areas

38. Clinical Portrait of Heart Failure

39. Sample Charting

40. Sample Charting (cont.)