1. Heart and Peripheral Vasculature

2. Anatomy and Physiology: Heart
top
bottom
Pericardium
Parietal layer
Visceral layer

3. Anatomy and Physiology: Heart
4 Chambers of the heart
Right and left atria
Right and left ventricles
Heart valves
Atrioventricular (AV) valves
Tricuspid
Mitral (bicuspid)
Semilunar valves
Pulmonic
Aortic

4. Direction of Blood Flow
Inferior & Superior Vena Cava to Right Atrium (RA), then into Right Ventricle (RV)
Venous blood flows to Pulmonic Valve to Pulmonary Artery (unoxygenated) to the lungs.
Lungs oxygenate blood. Pulmonary veins (oxygenated) to Left Atrium (LA).
Into LA through Mitral Valve to Left Ventricle (LV) and ejected through Aortic Valve into Aorta.
Aorta delivers oxygenated blood to body.

5. Neck Vessels

6. Coronary Circulation Left main coronary artery Right coronary artery
Left circumflex artery
Left anterior descending artery
Right coronary artery

7. Cardiac Cycle Systole Isovolumic contraction Early systole
Late systole
Diastole
Isovolumic relaxation phase
Early and mid-diastolic filling periods
Atrial systole (atrial kick)

8. Cardiac Cycle Diastole Systole Ventricles relax and fill with blood
The AV valves(tricuspid & mitral) are open
During the first rapid filling phase, blood pours rapidly from the atria into the ventricles (early diastolic filling).
At the end, the atria contract & push the last amount of blood into the ventricles (presystole = atrial kick).
Systole
After this, the AV valves close and we hear the first heart sound “S1”. This is the beginning of Systole.
AV valves close to prevent regurgitation into the atria during contraction.
Then, the aortic and pulmonic valves (semilunar valves) open & blood is ejected rapidly into the arteries.
After all the contents are ejected, the semilunar valves close. This causes the second heart sound, “S2”. This is the end of systole.

9. Excitation of the Heart
Sinoatrial (SA) node
Atrioventricular node
Bundle of His
Right and left bundle branches
Purkinje fibers

10. Conduction Pathway and EKG
Sinoatrial node (SA Node) initiates an electrical impulse
It is the “pacemaker” of the heart.
Travels to the Atrioventricular node (AV Node)
Then it travels to the “Bundle of His”
Through the left and right bundle branches.
And lastly, through the ventricles.

11. Electrocardiogram (EKG)P Q R S T
Isoelectric line

12. Peripheral Vasculature
Arterial system
Three layers of arterial walls: tunica intima, media, externa
Arteries
Arterioles
Capillaries
pulsating flow, no valves
Venous system
Veins
Venules
steady flow, 1 way valves,thinner walls , less elastic

13. Peripheral Vasculature

14. Health History Race Age Gender Childhood onset: rheumatic fever
Adult onset: HTN, CAD, MI, CVA, AAA
Gender
Female
Male
Race
May predispose to higher risk for CVA, CAD, HTN, diabetes mellitus

15. Common Chief Complaints
Chest pain
Syncope
Palpitations
Peripheral edema
Extremity pain
Characteristics of Chief Complaints
Quality
Associated manifestations
Aggravating factors
Alleviating factors
Setting
Timing

16. Past Health History Medical Surgical Common medications
Cardiac specific: AAA, angina, cardiogenic shock, chest trauma
Noncardiac specific
Surgical
Previous cardiovascular procedures
Common medications
Antianginals or vasodilators
Antidysrhythmics
Anticoagulants
Antihypertensives
Antilipemics
Diuretics
Inotropics
Thrombolytics

17. Past Health History Communicable diseases Childhood illnesses
Allergies
Aspirin
IVP dye
Seafood
Injuries and accidents

18. Family Health History Assess for Aneurysm CVA CAD HTN
MI or sudden cardiac death
MVP

19. Social History Alcohol, drug, or tobacco use Sexual practices
Travel history
Work and home environment
Hobbies and leisure activities
Stress

20. Health Maintenance Activities
Sleep
Diet
Exercise
Stress management
Use of safety devices
Health check-ups

21. Risk Factors Fixed Modifiable Age, gender, race, family history
HTN, hyperlipidemia, tobacco use, glucose intolerance, physical inactivity, diet, stress, sedentary lifestyle, obesity

22. Assessment Equipment Equipment Stethoscope Sphygmomanometer
Watch with second hand
Tape measure

23. Inspection Ape To Man Aortic 2ICS Pulmonic 2ICS Midprecordial 3ICS
Tricuspid 5ICS
Mitral 5ICS
N = no visible pulsations except for the PMI in the mitral area

24. Palpation Assess for pulsations, thrills, heaves
Assess the following areas: aortic, pulmonic, midprecordial, tricuspid, and mitral
N = No pulsations, thrills, or heaves palpated, except in the mitral area, where the apical impulse may be palpated

26. Auscultation Use diaphragm and bell of stethoscope
N= Aortic: S2 is louder than S1
N= Pulmonic: S2 is louder than S1
N= Tricuspid: S1 is louder than S2
N=Mitral: S1 is louder than S2
Remember S1 = Apex, S2 = Base

27. Auscultation: Normal Findings
Aortic and Pulmonic
N= physiologoical split of S2
Mitral and tricuspid:
N= S3 (gallop) may be heard in children, young adults, and pregnant women
N= S4 may indicate cardiac decompensation

28. Auscultation Abnormal Murmurs Pericardial friction rub
Use stethoscope diaphragm over aortic, pulmonic, mitral, and tricuspid areas
Use stethoscope bell over mitral and tricuspid areas
Possible causes
Characteristics: location, radiation, timing, intensity, quality, pitch, configuration
Pericardial friction rub
Characteristics: location, radiation, timing, quality, pitch
Possible cause

29. Assessment of Peripheral Vasculature
Inspection of jugular venous pressure
Place pt at 45°angle
measure vertical distance from sternum to top of distended neck vein
N= <4cm
Abnormal
> 4 cm indicates R ventricular pressure,  bld vol, or obstruction

30. Inspection of Hepatojugular Reflux
Position pt at 30 ° in bed, press firmly on RUQ, observe neck for elevation of JVP
N = no change in jugular veins
Abnormal
A rise of more than 1 cm = right-sided CHF or fluid overload

31. Assessment of Arterial Pulses
Palpate temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis for rate, rhythm, amplitude, symmetry
auscultate with bell carotids, temporal & femoral pulses
N= equal bilaterally, no bruits auscultated at carotids, temporal & femoral
Abnormal
Presence of bruits = obstruction due to atherosclerotic plaques, high-output states such as anemia or thyrotoxicosis

33. Special Techniques Assessing for Pulsus paradoxus
take BP while pt supine, note 1st systolic sound heard, note point where all systolic sounds are not heard
N= paradox should be < or = 10 mmHg
Abnormal
cardiac tamponade, pericardial effusion, cardiomyopathy, obstructive lung disease dt blood return to the L ventricle

34. Assessment of Peripheral Perfusion
Overall …..Evaluate peripheral pulses, color, clubbing, capillary refill, skin temperature, edema, ulcerations, hair distribution
Assess Venous system
Inspect fingers, legs, feet & toes
bend pts knee slightly and dorsiflex each foot - monitor for Homan sign
N= no c/o calf pain
Abnormal
+ VE Homan sign indicates DVT or thrombophlebitis

35. Assessment of Peripheral Perfusion
Assess Arterial system
Pallor test
Instruct pt to raise extremities
note the time it takes for pallor or lack of color to devlop
N= no pallor develops within 60 secs
Allen test
ask pt to make fist ,
occlude ulnar and radial artery
open hand and release one artery while compressing the other, repeat with opposite artery
N= + ve Allen test = good blood flow
both arteries in palm of hand
Abnormal
no blood flow dt thrombus or
atherosclerosis

36. Palpation of Epitrochlear Node
Place pt in supine position
support pt hand in your hand
plappate behind elbow in btwn biceps & triceps for epitrochlear node for size, shape, consistency , tenderness, & mobility
N= node not palpable
Abnormal
enlarged lymph node

37. Gerontological Variations
Decreased size of heart muscle
Atria and ventricles become fibrotic and sclerotic
Decreased cardiac output
Change in heart position
Obesity
Vessels become fibrotic and rigid