Heart & Neck and Peripheral Vascular

ABNORMAL FINDINGS : Ventricular Impulses: THRILL

Felt by palpation in 2nd & 3rd ICS RIGHT = aortic stenosis, systemic hypertension LEFT = pulmonic stenosis, pulmonic hypertension

Why do we check the carotid pulse?

Gives useful information of cardiac function especially detecting aortic valve stenosis/insufficiency.

S4

- Pt in supine (or left lateral, listen with bell at the apical impulse - sounds like "TEN-ness-ee " as it occurs LATE in diastole (during the ACTIVE part of ventricular filling) - it's pathological almost always; e.g. coronary artery disease, myocardial infarction, aortic/pulmonary stenosis, hypertension

How to Auscultate

- Stand at pt R side. - Pt supine, with the upper trunk elevated 30 degrees - Use the dia- phragm to auscultate all areas of the precordium for high-pitched sounds. - Use the bell to detect (differentiate) low-pitched sounds or gallops. - 1st listen to rate and rhythm. - 2nd identify the first and second heart sounds, listen for extra heart sounds, listen for murmurs, and finally listen with the client in different positions.

ABNORMAL FINDINGS: Ventricular Impulses: LIFT/HEAVE

- associated with right ventricular hypertrophy - caused by pulmonic valve discase, pulmonic hypertension, and chronic lung disease - can be seen, palpated (both)

How to Auscultate

-Position yourself on the client's right side. -The client should be supine, with the upper trunk elevated 30 degrees. *Use the diaphragm of the stethoscope to auscultate all areas of the precordium for high-pitched sounds. *Use the bell of the stethoscope to detect (differentiate) low-pitched sounds or gallops. -Apply the diaphragm firmly to the chest, but apply the bell lightly. *Focus on one sound at a time as you auscultate each area of the precordium. -Start by listening to the heart's rate and rhythm. - Then identify the first and second heart sounds, concentrate on each heart sound individually, listen for extra heart sounds, listen for murmurs, and finally listen with the client in different positions.

ABNORMAL FINDINGS: ACCENTUATED APICAL IMPULSE

A sign of pressure overload, the accentuated apical impulse has increased force and duration but is not usually dis- placed in left ventricular hypertrophy without dilatation associated with aortic stenosis or systemic hypertension.

ABNORMAL FINDINGS: LATERALLY DISPLACED APICAL IMPULSE

A sign of volume overload, an apical impulse displaced laterally and found over a wider area is the result of ventricular hypertrophy and dilatation associated with mitral regurgitation, aortic regurgitation, or left-to-right shunts.

Pathways The AV node

AV node slightly delays incoming electrical impulses from the atria and then relays the impulse to the AV bundle (bundle of His) in the upper interventricular septum. The electrical impulse then travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles, causing them to contract almost simultaneously. Although SA node functions as the "pacemaker of the heart," this activity shifts to other areas of the conduction system, such as the Bundle of His (with inherent discharge of 40 to 60 per minute), if the SA node cannot function.

Dorsalis Pedis Artery

Anterior branch of the popliteal artery descends down the top of the foot to form this artery. Can be palpated on the great toe side of the foot

Auscultation positions:

Aortic - 2nd ICS RSB Pulmonic - 2nd ICS LSB Erb's point- 3rd ICS LSB Tricuspid - 4-5 ICS LSB Mitral (Apex) - 5th ICS MCL

The sternal angle at the right 2nd rib space is also known as what?

Aortic area

When a patient is obese or has a thick chest wall, what is difficult to palpate?

Apical Impulse

Things to remember when checking the carotid pulse.

Avoid pressing on carotid sinus (top of thyroid cartilage) -Reflex drop in HR/BP Never press both carotids at same time Decrease blood flow to brain & induces syncope

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

Bruits

Cardiac Assessment (video)

Drape patient for privacy; bed = 30-45° Step 1: Precordium Inspection Visible Pulsations Heaves/Lifts (could indicate LVH) Chest wall: general movement, scars, deformatiies Step 2: Palpate pulses 1) Use the palmar surface of hand to touch the apical-mitral area to find the pulse 2) Once pulse is found, use 1-2 finger pads for an accurate palpation 3) Then separately palpate: the apex, L sternal border, and base (top) of the heart for any abnormal pulsations Step 3: Auscultate over the Apex for the Apical Impulse 1) "What are you assessing?" : HR & Rhythm **if irregular HR & rhythm, auscultate for pulse deficit 2) Auscultate: aortic area, pulmonic area (S2, Dub), Erbs pt (murmurs), Tricuspid area & Mitral area (S1, Lub) "APE To Man" Drape patient for privacy, Left lateral recumbent Step 4: Check for S3 & S4 (extra sounds) 1) Listen to apex w/ bell

Diastole

During ventricular diastole, the AV valves are open and the ventricles are relaxed. This causes higher pressure in the atria than in the ventricles. Therefore, blood rushes through the atria into the ventricles. This early, rapid, passive filling is called early or protodiastolic filling. This is followed by a period of slow passive filling. Finally, near the end of ventricular diastole, the atria contract and complete the emptying of blood out of the upper chambers by propelling it into the ventricles. This final active filling phase is called presystole, atrial systole, or sometimes the "atrial kick." This action raises left ventricular pressure.

Heart Sounds

Heart sounds are produced by valve closure, as just described. The opening of valves is silent. Normal heart sounds, characterized as "lubdubb" (S, and S,), and occasionally extra heart sounds and murmurs can be auscultated with a stethoscope over the precordium, the area of the anterior chest overlying the heart and great vessels.

Cardiac Assessment: Collecting Subjective Data

History of heart problems? (rheumatic fever, hypertension, heart murmurs) Any test results? (EKG) Any symptoms? (chest pain, palpitations, SOB, DOE: dyspnea on exertion, Orthopnea or PND aka Paroxysmal Nocturnal Dyspnea) Edema? Any other questions?

Name the proper sequence of these 3 during your physical exam. palpation auscultation inspection

Inspection Palpation Auscultation *If your physical looks good, you can celebrate w/ an IPA :) *

Closure of the mitral valve produces the first heart sound, S1. The closure of the atrial valve begins a cycle of diastole. During systole, the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial pressure, shutting the mitral valve. Aortic valve closure produces the second heart sound, S2.

Mitral Valve Closure & "1st Sound" Explained

aortic stenosis

Narrowing of of aortic valve cusps that restricts forward flow of blood during systole

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?

Orthopnea

S3

Pt in Left Lateral Decubitus position , listen at Apex "Ken-TUCK-y" sound as it occurs EARLY in diastole (passive time of ventricular filling) caused by fluid overload, e.g. pulmonary congestion Due to conditions, like LVF and MR

Pathways The sinoatrial (SA) node

The SA node, with inherent rhythmicity, generates impulses minute) that are conducted over both atria, causing them to contract simultaneously and send blood into the ventricles. The current, initiated by the SA node, is conducted across the atria to the AV node located in the lower interatrial septum

Systole

The filling phases during diastole result in a large amount of blood in the ventricles, causing the pressure in the ventricles to be higher than in the atria. This causes the AV valves (mitral and tricuspid) to shut. Closure of the AV valves produces the first heart sound (S), which is the beginning of systole. This valve closure also prevents blood from flowing backward (a process known as regurgitation) into the atria during ventricular contraction. At this point in systole, all four valves are closed and the ventricles contract (isometric contraction). There is now high pressure inside the ventricles, causing the aortic valve to open on the left side of the heart and the pulmonie valve to open on the right side of the heart. Blood is ejected rapidly through these valves. With ventricular emptying, the ventricular pressure falls and the semilunar valves close. This closure produces the second heart sound (S), which signals the end of systole. After closure of the semilunar valves, the ventricles relax. Atrial pressure is now higher than the ventricular pressure, causing the AV valves to open and diastolic filling to begin again.

The nurse assesses the client's pulses to be normal. These would be documented how?

The nurse assesses the client's pulses to be normal. These would be documented how? O 1+ 2+ 3+ Normal pulses are 2+. Absent pulses are 0. Weak pules are 1+. Increased pulses are are 3+. P448

atrioventricular (AV) valves

There are two AV valves: the tricuspid valve and the bicuspid (mitral) valve. The tricuspid valve is composed of three cusps, or flaps, and is located between the right atrium and the right ventricle; the bicuspid (mitral) valve is composed of two cusps and is located between the left atrium and the left ventricle. Open AV valves allow blood to flow from the atria into the ventricles. as the ventricles begin to contract, the AV valves snap shut, preventing the regurgitation of blood into the atria.

semilunar valves

There are two semilunar valves: the pulmonic valve is located at the entrance of the pulmonary artery as it exits the right ventricle and the aortic valve is located at the beginning of the ascending aorta as it exits the left ventricle. These valves are open during ventricular contraction and close from the pressure of blood when the ventricles relax. Blood is thus prevented from flowing backward into the relaxed ventricles

Describe the 2 main types of valvular pathology (murmurs)

Types of valvular pathology Stenotic (Narrowing) -Narrowing of valvular orifice -Example: aortic stenosis Regurgitant/insufficency ("leaky" backflow) -Fails to close fully allows blood to leak back -Example: aortic regurgitation

capillary refill

after blanching nail bed, color should return to normal within <3 secs

atrioventricular (AV) node

atrioventricular (AV) node: node of specialized heart muscle located in the septal wall of the right atrium; receives impulses from the sinoatrial node and transmits them to the atrioventricular bundle

S1 *S1S

first heart sound, is produced by the tricuspid, mitral valves closing while aortic, pulmonic opening S1 (the "lub" portion of "lubdubb") correlates with the beginning of systole

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?

he hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest

Cardiovascular:

relating to the heart and blood vessels

Cardiopulmenary:

relating to the heart and the lungs

Auscultations best heard along the left lower sternal border at the fourth or fifth intercostal space?

sounds that originate in the tricuspid valve

The nurse hears a distinctive first heart sound while auscultating a client's heart rate. What does this heart sound represent?

the beginning of systole closure of the mitral valve the ending of diastole closure of the aortic valve

Precordium

the region or the thorax immediately in front of the heart

Pericardium

tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart. A serous membrane lining, the parietal pericardium, secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart.

Traditional Areas of Auscultation

• Aortic area: Second ICS at the right sternal border-the base of the heart • Pulmonic area: Second or third ICS at the left sternal border-the base of the heart • Erb point: Third ICS at the left sternal border • Mitral (apical): Fifth ICS near the left MCL-the apex of the heart • Tricuspid area: Fourth or fifth ICS at the left lower sternal border