Health Assessment Chp. 20

In Assessing heart...

-Inspect pulsations -Palpate the apical impulse -Palpate for abnormal pulsations -Auscultate heart rate and rhythm -If you detect an irregular rhythm, auscultate for a pulse rate deficit -Auscultate to identify S1 and S2 -Listen to S1 and S2 -Auscultate for extra heart sounds -Auscultate for murmurs -Auscultate in with the client assuming other positions The apical pulse may or may not be visible. If apparent, it would be in the mitral area (left midclavicular line, fourth or fifth intercostal space). The apical impulse is the result of the left ventricle moving outward during systole. If the client's heartbeat is irregular, you should assess for a pulse deficit. To assess for a pulse deficit, you palpate the radial pulse while you auscultate the apical pulse. Count for a full minute. The radial and apical pulses should be identical. We say there is a pulse deficit when there is a difference between the apical and peripheral/radial pulse. A pulse deficit may indicate atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block.

Obtaining data from client's heart and neck vessels

Subjective data: -History of present health concern - chest pain, palpitations -Past health history -Family history -Lifestyle and health practices Objective data: -Briefing on physical examination -Preparing the client -Explain the procedures -Client would have to assume different positions -Equipment -Physical assessment

Conditions that can create turbulent blood flow (heart murmurs)

Turbulent blood flow with a swooshing or blowing sound when doing auscultation 1) increased blood velocity 2) structural valve defects 3) valve malfunction 4) abnormal chamber openings

Structure of Heart

-Located in mediastinum -Four chambers - left atrium and ventricle, right atrium and ventricle -Two atrioventricular valves, two semilunar valves -Three layers - epicardium, myocardium, endocardium -The two AV valves are located at the entrance into the ventricles. They are called the tricuspid valve and the bicuspid (mitral) valve. The tricuspid valve is located between the right atrium and the right ventricle; the bicuspid (mitral) valve is located between the left atrium and the left ventricle. -The semilunar valves are located at the exit of each ventricle at the beginning of the great vessels. They are known as the pulmonic valve and the aortic valve. The pulmonic valve is located at the entrance of the pulmonary artery as it exits the right ventricle. The aortic valve is located at the beginning of the ascending aorta as it exits the left ventricle.

U wave

-May or may not be present -If present, it follows the T wave and represents the final phase of ventricular repolarization

Coronary Heart Disease Risk Factors

-Overview of coronary heart disease -Risk factors -Risk reduction teaching tips -Cultural considerations Have a good look at the box on pages 362 and 363 that discusses Coronary Heart Disease. It is very detailed. Briefly, some of the risk factors include metabolic syndrome, increased body weight, high blood pressure, high cholesterol, diabetes, smoking, sedentary lifestyle, excessive alcohol consumption, and increased stress. Some risk reduction tips: stop smoking, lower high cholesterol, control high blood pressure, maintain tight control of diabetes, exercise regularly, achieve and maintain your ideal body weight, control stress and anger, and many more...(see the table). Ethnicity also plays a role. African Americans, Mexican Americans, American Indians, native Hawaiians, and some Asian Americans have a higher risk of heart disease. These rates are thought to be due to more severe hypertension, and higher rates of obesity and diabetes in these populations.

ST segment

-Period between ventricular depolarization and the beginning of ventricular repolarization

Second heart sound

-S2: results from closer of the semilunar valves (aortic and pulmonic) -marks the start of diastole ("dubb") -one or two sounds -from aortic valve closure and pulmonic

Equipment for Heart and Neck Vessels Assessment

-Stethoscope with a bell and diaphragm -Small pillow -Penlight or movable examination light -Watch with second hand -Centimeter rulers

QT interval

-Total time for ventricular depolarization and repolarization -from the beginning of Q wave to the end of T wave -Varies with heart rate

QRS complex

-Ventricular depolarization (also atrial repolarization) -Conduction of the impulse throughout the ventricles which triggers contraction of ventricles -measured from the beginning of Q wave to end of S wave

T wave

-Ventricular repolarization -Ventricles return to a resting state

Assessing Carotid Artery and Jugular Venous Pulse and Pressure

Carotid artery: Pulse Vessel elasticity Thrills Jugular venous pulse and pressure -Auscultate and palpate the carotid arteries for bruits, amplitude, regularity, and contour of the pulse, vessel elasticity, or presence of thrills. -Inspect the jugular for visibility of pulse, and measure jugular venous pressure

T/F: The Pulmonary Artery returns oxygenated blood to the left atrium

False. -The pulmonary artery carries blood to the lungs.

T/F: Physiologic murmur is not associated with any physical abnormality; it occurs when the ejection of blood into the aorta is turbulent.

False. Physiologic murmur is caused by a temporary increase in blood flow; it can occur with anemia, pregnancy, fever, and hyperthyroidism.

In Assessing Neck Vessels...

Inspection: -Observe the jugular venous pulse -Evaluate jugular venous pressure -Auscultation and palpation -Auscultate the carotid arteries -Palpate the carotid arteries

Types of Heart murmurs (abnormal findings)

Midsystolic Pansystolic Diastolic

characteristic of pulsus alternans?

Regular Rhythm

Heart Sounds

S1 is the first heart sound and it signals the beginning of systole. Closing of the AV valves produces the first heart sound. The closing of the semilunar valves produces the second heart sound known as S2. S2 signals the beginning of diastole. Sometimes there are extra heart sounds known as S3 and S4. If present, S3 can be heard early in diastole after S2. If present, S4 can be heard late in diastole, just before S1. S3 may be associated with ischemic heart disease, hyperkinetic states (e.g. anemia), or restrictive myocardial disease. S4 (atrial gallop) toward the left side of the precordium may be associated with coronary artery disease, hypertensive heart disease, cardiomyopathy and aortic stenosis. S4 toward the right side of the precordium may be heard with pulmonary hypertension and pulmonic stenosis.

Murmur

a swishing sound caused by turbulent blood flow through the heart valves or great vessels. Auscultate for murmurs across the entire heart area. Use the diaphragm and the bell of the stethoscope in all areas of auscultation because murmurs have a variety of pitches.

characteristic of bisferiens pulse

double systolic peak

Superior/Inferior Vena Cava

return blood to the right atrium from the upper and lower torso respectively

epicardium

serous membrane that covers the outer surface of the heart

characteristic of a weak pulse

slow upstroke

Pericardium

tough, inextensible, loose-fitting, fibroserous sac that attaches to great vessels and surrounds the heart

Structure of Neck Vessels

-Carotid artery, jugular veins -Carotid artery pulse - ventricular systole -Level of the jugular venous pressure reflects right atrial (central venous) pressure

Electrocardiogram (ECG, EKG)

-Electrical activity of heart measured by electrocardiography (ECG) -Phases of ECG - P, Q, R, S, T -Records depolarization and repolarization

Cardiac Cycle

-Filling and emptying of the heart's chamber -Two phases: diastole and systole Diastole - relaxation of the ventricles Systole - contraction of the ventricle

Cardiac Output (CO)

-Amount of blood pumped by the ventricles during a given period of time -SV × HR = CO -Stroke volume (SV) -Heart rate (HR) -Normal adult CO: 5 to 6 L/min

P wave

-Atrial Depolarization -conduction of the impulse throughout the atria

Electrical Conduction of the Heart

-Cardiac cycle: the events associated with the filling and emptying of the cardiac chambers. -Sinoatrial node: generates electrical impulses over both atria, causing them to contract. -AV node: slightly delays incoming electrical impulses from the atria, then relays the impulse to the AV bundle. -AV bundle (bundle of His): located in the upper interventricular septum, the AV bundle conveys the electrical impulse down the right and left bundle branches and the Purkinje fibers. -Purkinje fibers: in the myocardium of both ventricles cause them to contract almost simultaneously.

Procedure for checking neck vessels

-You should auscultate the carotid arteries for bruits if the client is middle aged or older or if you suspect cardiovascular disease - Place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath for a moment so breath sounds do not conceal any vascular sounds. -Palpate each carotid artery alternately (never palpate both at once) and note the amplitude and contour of the pulse, elasticity of the artery, and any thrills. -Pulses should be equally strong, 2+, with no variation in strength from beat to beat. -Contour is normally smooth and rapid on the upstroke and slower and less abrupt on the downstroke. -Arteries are elastic and no thrills are noted. -You should evaluate jugular venous pressure by watching for distention of the jugular veins. - It is normal for the jugular veins to be visible when the client is supine. -To evaluate for jugular vein distention, place the client in a supine position with the head of the bed elevated to 45-degrees. -Have the client's head turned slightly away from the side being evaluated. - Using tangential lighting, observe for distention, protrusion or bulging of the jugular vein. Note: in the acute care setting, there will be invasive cardiac monitors (pulmonary artery catheters) that can measure pressures.

endocardium

-a thin layer of endothelial tissue that forms the innermost layer of the heart -continuous with the endothelial lining of blood vessels

Extra heart sounds (S3-S4)

-diastolic filling sounds -result from ventricular vibration secondary to rapid ventricular filling -S3: ventricular gallop -S4: atrial gallop

First Heart Sound

-result of closure of the AV valves (mitral and tricuspid valves) -S1 ("lub") marks start of systole -usually heard as one sound but may be heard as 2 sounds -sounds when mitral valve and triscuspid valve closes

Systemic circulation

-the right side of the heart pumps blood to the lungs for gas exchange -the left side of the heart pumps blood to all other parts of the body

myocardium

-the thickest layer of the heart -made up of contractile cardiac muscle cells

PR interval

-time from beginning of atrial depolarization to the beginning of ventricular depolarization -from the beginning of P wave to the beginning of the QRS complex

characteristic of large, bounding pulse

increased pulse pressure