1. Assessment of Heart and Great Vessels Christine M. Wilson Viterbo University

2. Objectives Landmarks Landmarks Structures Structures Cardiac cycle Cardiac cycle Developmental/transcultural Developmental/transcultural Risk factors Risk factors Subjective data Subjective data Objective data Objective data

3. Position in the Chest Beneath precordium—area on anterior chest overlying the heart and great vessels Beneath precordium—area on anterior chest overlying the heart and great vessels Located in mediastinum—middle third of chest—between the lungs Located in mediastinum—middle third of chest—between the lungs

4. Heart is an upside down triangle in the chest Heart is an upside down triangle in the chest Top of heart is Base, bottom is Apex Top of heart is Base, bottom is Apex

5. Extends from 2nd to 5th ICS and from Rt sternal border to Lt MCL Extends from 2nd to 5th ICS and from Rt sternal border to Lt MCL Great vessels above base of heart Great vessels above base of heart

6. Blood Flow Inferior vena cava Inferior vena cava Right atrium Right atrium Right ventricle Right ventricle Pulmonary artery Pulmonary artery Pulmonary vein Pulmonary vein Left atrium Left atrium Left ventricle Left ventricle Aorta Aorta

7. Valves of the Heart Tricuspid valve: right AV Tricuspid valve: right AV Mitral valve: left AV Mitral valve: left AV Pulmonic Valve: right Pulmonic Valve: right Aortic Valve: left Aortic Valve: left It is the closure of the heart valves that we hear as heart sounds. It is the closure of the heart valves that we hear as heart sounds.

8. Cardiac Cycle Diastole Tricuspid/mitral valves open Tricuspid/mitral valves open Ventricles relax and fill with blood Ventricles relax and fill with blood Ventricular pressures increases Ventricular pressures increases Tricuspid/mitral valves close causing first heart sound S1 Tricuspid/mitral valves close causing first heart sound S1 LUB dub LUB dubSystole Ventricular contraction increases pressure Ventricular contraction increases pressure Pulmonic/aortic valves open; blood ejects Pulmonic/aortic valves open; blood ejects Ventricular pressure drops Ventricular pressure drops Pulmonic/aortic valves close causing second heart sound S2 Pulmonic/aortic valves close causing second heart sound S2 lub DUB lub DUB

9. More heart sounds Events of right heart occur slightly later –S–S–S–S1 Mitral valve closes then tricuspid –S–S–S–S2 Aortic valve closes then pulmonic Sound radiates with direction of blood flow –S–S–S–S1 heard loudest at apex –S–S–S–S2 heard loudest at base Murmurs—turbulent flow through chambers and valves –S–S–S–Swooshing, blowing sound

10. Pumping ability Right side pumps blood to lungs Right side pumps blood to lungs Left side pumps blood to body Left side pumps blood to body Cardiac output—volume of blood pumped per minute Cardiac output—volume of blood pumped per minute –dependent upon volume ejected per stroke and heart rate (CO=SV x rate) –Normal cardiac output 4-6 L per minute

11. Great Vessels—Neck Carotid arteries –C–C–C–Central arteries branching from aorta Jugular veins –I–Internal and external –E–Empty into superior vena cava

12. Developmental Considerations Fetal Fetal heart begins to beat at 3 weeks Fetal heart begins to beat at 3 weeks Oxygenation takes place through the placenta Oxygenation takes place through the placenta Blood returned to the Right side of the heart and bypasses lungs Blood returned to the Right side of the heart and bypasses lungs –Foramen ovale-opening between atrium –Ductus arteriosus-opening b/tw PA and Aorta

13. Fetal Circulation

14. Changes take place at birth! Blood is oxygenated through lungs Blood is oxygenated through lungs Foramen ovale closes in one hour Foramen ovale closes in one hour Ductus Arteriosus closes in 10-15 hours Ductus Arteriosus closes in 10-15 hours Left ventricle pumps blood to entire body; by one year, left ventricle twice as large as the right Left ventricle pumps blood to entire body; by one year, left ventricle twice as large as the right

15. Pregnant Female Blood volume increases by 30-40%, mostly during the 2nd trimester Blood volume increases by 30-40%, mostly during the 2nd trimester Increases Stroke Volume and CO Increases Stroke Volume and CO Rate increases by 10-15 BPM Rate increases by 10-15 BPM

16. Aging Adult Cardiac aging depends on lifestyle factors Cardiac aging depends on lifestyle factors Stiffening of large arteries due to calcification of vessel walls causes increased workload for heart Stiffening of large arteries due to calcification of vessel walls causes increased workload for heart –BP increases by 25-30% –LV wall thickness increases by 25%

17. Aging Adult (con’t) Arrhymias increase with age Arrhymias increase with age Conduction changes are common Conduction changes are common 50% of deaths in elderly due to cardiovascular disease 50% of deaths in elderly due to cardiovascular disease Hypertension increases with age Hypertension increases with age –Systolic greater than 140 and Diastolic greater than 90 Heart failure common Heart failure common

18. Transcultural Considerations Heart Disease and Stroke 1/3 of deaths from culturally diverse backgrounds 1/3 of deaths from culturally diverse backgrounds Prevalence higher in blacks, followed by whites, then Mexican Americans Prevalence higher in blacks, followed by whites, then Mexican Americans Native Americans (<35) CAD 2X greater than other groups Native Americans (<35) CAD 2X greater than other groups Black males 2X more likely to die from stroke as white males Black males 2X more likely to die from stroke as white males

19. Transcultural Considerations Heart Disease and Stroke (con’t) Blacks 20-40 years Blacks 20-40 years –Increased # of deaths from CVD compared to whites –Increased mortality in black females over black males Black and Mexican American females higher CVD risk factors Black and Mexican American females higher CVD risk factors

20. Risk Factors for Heart Disease, Stroke, and Hypertension Smoking Smoking Increased cholesterol levels (LDL) Increased cholesterol levels (LDL) Obesity Obesity Diabetes Diabetes Oral contraceptives Oral contraceptives Post-menopause Post-menopause

22. Subjective Data Chest Pain Chest Pain Dyspnea Dyspnea Orthopnea Orthopnea Cough Cough Fatigue Fatigue Cyanosis or pallor Cyanosis or pallor Edema Edema Nocturia Nocturia Past cardiac history Past cardiac history Family cardiac history Family cardiac history Cardiac risk factors Cardiac risk factors

23. Objective Assessment Order of the exam Pulse and blood pressure Pulse and blood pressure Extremities:Peripheral Vascular System Extremities:Peripheral Vascular System Neck Vessels Neck Vessels Precordium Precordium

24. The Neck Vessels Carotid arteries Palpate –I–I–I–Individually, with gentle touch Auscultate –A–A–A–Angle of jaw, mid-cervical, base of neck –P–P–P–Patient to exhale and hold breath

25. The Precordium The Precordium Inspect for pulsations Inspect for pulsations Palpate the apical pulse Palpate the apical pulse –5 th ICS MCL –“Bump” of the left ventricle against chest wall during systole Palpate apex, Lt sternal border, base Palpate apex, Lt sternal border, base Percussion not usually done Percussion not usually done

26. Auscultation Areas to listen Aortic valve area: 2 nd Rt. intercostal space Aortic valve area: 2 nd Rt. intercostal space Pulmonic area: 2 nd Lt. intercostal space Pulmonic area: 2 nd Lt. intercostal space Erb’s Point: 3rd Lt. intercostal space Erb’s Point: 3rd Lt. intercostal space Tricuspid area: 5 th Lt. intercostal space Tricuspid area: 5 th Lt. intercostal space Mitral area: 5th intercostal space at MCL Mitral area: 5th intercostal space at MCL

27. Heart Ascultation Areas

28. Ascultation tips Concentrate Concentrate Inch diaphragm in Z pattern, base to apex Inch diaphragm in Z pattern, base to apex –Aortic—pulmonic—Erb’s—tricuspid—mitral Listen to one sound at a time Listen to one sound at a time –Rate –Rhythm –Identify and assess S1 and S2 separately Listen for extra sounds Listen for extra sounds

29. REMEMBER REMEMBER S1 is louder than S2 at Apex. S1 is louder than S2 at Apex. S2 is louder than S1 at Base. S2 is louder than S1 at Base. S1 coincides with the Carotid artery pulse S1 coincides with the Carotid artery pulse Visualize what’s under the skin Visualize what’s under the skin