HA: cardiovascular

Palpation

(gentle, unilateral - yet checking for symmetry, quality - strength, absence of thrill)

Subjective Data: Risk factors for Cardiovascular (and Cerebrovascular) Disease

(includes carotid, aortic, femoral, and all smaller vessels) Gender Age Genetics - family member with heart attack before age 50 Abnormal lipid status, known atherosclerosis Hypertension Smoking Diabetes Excessive alcohol intake (>2/d) Sedentary lifestyle (accustomed to sitting or little exercise) Blood thinners

Inspection

- skin color, temperature, moisture (looking for hypoxia, presyncope). No inspection of neck.

Measuring jugular venous pressure

- to assess for volume overload (usually in patients with congestive heart failure), but generally considered unreliable

Physical Assessment of the Neck Vessels and Heart

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Subjective Assessment of the Neck Vessels and Heart

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what are S1 and S2 due to?

...So heart sounds S1 and S2 are the sounds of valves closing under pressure (not by the movement of blood or the contraction of the heart muscle (myocardium) - Think of slamming doors.

Electrical System of the Heart: list

1 Sinoatrial node (Pacemaker)2 Atrioventricular node3 Atrioventricular Bundle (Bundle of His)4 Left & Right Bundle branches (which fire separately)5 Purkinje Fibers

Ten leading causes of death in the US in all ages

1. Heart disease 2. Cancers 3. Cerebrovascular diseases (strokes) 4. Chronic lower respiratory diseases (smoking-related) 5. Unintentional injuries 6. Alzheimer's disease 7. Diabetes mellitus 8. Influenza 9. Kidney disease (from HTN, DM) 10. Septicemia (A systemic disease caused by pathogenic organisms or their toxins in the bloodstream. Also called blood poisoning)

coronary arteries originate at

2. The coronary arteries are clearly shown to originate at the base of the aorta.

Ten leading causes of death in the US in all ages: stats for the majority

616,067 people died in 2007 from an acute myocardial infarction (AMI) - (CDC) (1,687 people every day)

Auscultation

:Use the bell, gentle, hold breath on exhalation Listen for bruits, usually unilateral (check for cardiac murmur to make sure it is not radiating into carotids - more likely bilateral)

Changes in viscosity

Anemia decreases H&H, decreases viscosity so produces hyperdynamic state

S4 -

Atrial Gallop Pathologic - Decreased ventricular compliance, failure, overload, aortic stenosis, hypertension

does blood circulating make noise?

Blood circulating through normal cardiac chambers and valves usually makes no noise

Heart Murmurs: def

Blood circulating through normal cardiac chambers and valves usually makes no noise However, some conditions create turbulent blood flow and collision currents A murmur is an abnormal sound heard during S1 or S2 and can be gentle, blowing, swooshing or harsh. It can be heard over precordium with or without a stethoscope and can radiate into the carotid arteries.

Blood vessels are arranged

Blood vessels are arranged in two continuous loops Pulmonary circulation Systemic circulation

Carotid Arteries

Central arteries; timing of pulse closely coincides with ventricular systole

Conditions resulting in murmur: list

Changes in velocity (flow murmur) Changes in viscosity Structural defects

flow murmur

Changes in velocity (flow murmur) From hyperdynamic state (exercise, pregnancy, thyrotoxicosis)

Subjective Data: Cardiac Symptoms & History

Chest pain Dyspnea Orthopnea Cough Fatigue Cyanosis or pallor Edema Nocturia Past cardiac history Family cardiac history Personal habits (cardiac risk factors) We will cover symptoms carotid artery disease in the lecture on assessment of the neurologic system, but basically partial or complete carotid artery occlusion symptoms are the symptoms of interrupted blood supply to the brain (transient ischemic attack or stroke).(A decrease in the blood supply to a bodily organ, tissue, or part caused by constriction or obstruction of the blood vessels.)

Men's symptoms:

Chest pressure/pain Dyspnea Diaphoresis (Perspiration, especially when copious and medically induced.) Pallor Dizziness (presyncope) Denial Study Jarvis pages 467 - 470 well

Symptoms of Angina (A subset of cardiac symptoms)

Chest/back/jaw/L shoulder/L arm pain/pressure Dyspnea Pallor Diaphoresis Fatigue Palpitations/tachycardia Anxiety/denial or sleep disturbances Nausea/vomiting Dizziness Exertional pattern Silent MIs

Pathway of Blood Through the Heart

Direction of Blood Flow Unoxygenated red blood drains into vena cava then to right atrium From right atrium through tricuspid valve to right ventricle From right ventricle, venous blood flows through pulmonic valve to pulmonary artery Lungs oxygenate blood Blood returns from lungs via pulmonary vein to left atrium From left atrium, arterial blood travels through mitral valve to left ventricle Blood travels through aortic valve to aorta Aorta delivers oxygenated blood to body

apical impulse: how it is created

During contraction, the apex beats against the chest wall, producing an apical impulse

Jugular Veins Internal & External

Empty unoxygenated blood directly into the superior vena cava

Anatomy and Physiology

Everything in this section is pulled from the A&P at the beginning of the chapter and is what you are responsible for knowing.

Grading and Recording Murmurs

Grade i - barely audible in quiet room Grade ii - clearly audible, but faint (most common) Grade iii - moderately loud, easy to hear Grade iv - loud, asso. w/ palpable thrill Grade v - very loud, heard w/ one edge of stethoscope lifted off chest Grade vi - loudest, heard w/ entire stethoscope lifted just off chest Record whether it was a systolic or diastolic murmur, grade and location. Note: there is no such thing as an S1 or S2 murmur as these imply normal heart sounds.

Electrical System of the Heart: how

Heart has unique ability: automaticity Can contract by itself, independent of any signals or stimulation from body Contracts in response to an electrical current conveyed by a conduction system Specialized cells in sinoatrial (SA) node initiate an electrical impulse. It is called the pacemaker. Current flows in orderly sequence, first across atria to AV node low in atrial septum There, it is delayed slightly so that atria have time to contract before ventricles are stimulated. Then, impulse travels to bundle of His, right and left bundle branches, and then through ventricles via the Purkinje fibers. Electrical impulse stimulates heart to do its work, which is to contract.

Cardiac Changes in The Older Adult: list

Hemodynamic Changes Increase in systolic BP, unchanged diastolic pressure, dehydration, anemia of chronic disease or poor nutritional intake Decreased maximum heart rate, slower increase and decrease during exercise and recovery Dysrhythmias (irregular heart beats) increase with age Greater incidence of atherosclerosis

some conditions create

However, some conditions create turbulent blood flow and collision currents

For carotids:

Include history of carotid artery disease, carotid surgery

Objective Data: Neck Vessels

Inspection Palpation Auscultation (Percussion never used)

Objective Data: Cardiac

Inspection Palpation Percussion (rarely used) Auscultation

Jugular pulse

Jugular pulse results from a backwash from the contraction of the right atrium, producing a waveform moving backward.

Ausculatory Areas

Landmarks in an adult with a normal heart RSB, 2nd ICS - Aortic valve LSB, 2nd ICS - Pulmonic valve LSB, 3rd ICS - Erb's Point (S2) - You may hear the closing of the aortic and pulmonic valves better here LSB, 5th ICS - Tricuspid valve - very difficult to hear 5th ICS, MCL - Mitral valve "Z pattern"

Objectives

List the significant anatomic features of the heart. Relate anatomic structures to the correct landmark or anatomic location. Describe the pathway of blood through the heart. List common cardiac changes that occur with aging. Describe the assessment of the carotid artery pulse. Cite the risk factors for CVD and stroke. Describe the steps of physical assessment of the heart. Describe the characteristics of heart sounds. Relate the name of the heart sound to the physiologic event. Chart findings of a carotid and cardiac assessment.

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Listent to S1, S2, S3, S4: http://depts.washington.edu/physdx/heart/tech2.html or on Evolve, Ch.19 Student Resources

Palpation

Locate apical impulse using base of fingers Palpate across precordium for other pulsations (which would be abnormal)

Structural defects

Narrowed or incompetent valves, wall defects (patent ductus arteriosis, patent foramen ovale)

percussion

No percussion.

Cross-Section of an Artery: types

Normal healthy artery Plaque build up along the wall of artery Blockage and narrowing of lumen from plaque

S2

Normal heart sounds: second heart sound (S2) Occurs with closure of semilunar valves (pulmonic and aortic) and signals end of systole

S1

Occurs with closure of AV valves (tricuspid and mitral) and thus signals beginning of systole

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PMI can also be located by turning patient onto L side

Inspection

Patient is lying supine, chest well lit Look for pulsations at apex (L MCL, 5th ICS) Abnormal in adults, indicates ventricular hypertrophy or hyperdynamic state/fluid overload Referred to as a heave or life when abnormal

Atherosclerosis occurance in the body

Please also remember... Atherosclerosis does not occur in isolated areas of the body If it is in the coronary arteries, it is in all the arteries (cerebral, ophthalmologic, carotid, renal, peripheral) Disease generally shows up in the smallest arteries first

Position and surface landmarks Position and surface landmarks: list

Precordium, Apex, and Base

Cardiac Cycle: def, list

Rhythmic flow of blood through heart is cardiac cycle Has two phases, diastole and systole

Extra heart sounds: list

S3 S4

Sample charting

S: 65 yo male presents with 24 hrs of intermittent squeezing midsternal chest pressure, 4/10, brought on by exertion, lasting 10 minutes, relieved by rest. Associated diaphoresis, nausea. PMH positive for MI last year, smoking with 25 pk yr hx. O: Well nourished, well groomed, pale, no circumoral cyanosis. Agitated, restless. VS: 98.6 - 99 - 20, 110/70 O2 Sat 92%. Carotids: pulses symmetric, no bruits heard Cor: No visible pulsations, no heaves on palpation of precordium. Apical rate 84 bpm, regular rhythm. Normal S1, S2. Systolic murmur gr ii/vi heard best 5th ICS, MCL. Pul: Lungs CTA&P. Cap fill 2 sec., early clubbing.

Women's symptoms:

Study Jarvis pages 467 - 470 well Nausea/vomiting Fatigue Dyspnea Shoulder pain Back pain Sleep disturbances (insomnia, restlessness)

Auscultation, con't.

Technique 1. Inform pt. of long, repetitious exam. 2. RSB, 2nd ICS Rate, rhythm S2 should be louder (closing of aortic valve) Check for aortic murmur 3. LSB, 2nd ICS Check for pulmonic murmur 4. RSB, 3rd ICS Check for aortic or pulmonic murmur RSB, 5th ICS Check for tricuspid murmur (very hard to hear) 5th ICS, MCL Evaluate rate and rhythm Check for pulse deficit S1 louder than S2 (tricuspid, mitral) Check for mitral murmur Check for extra heart sounds S3 and S4 Switch to bell and go back through all areas with patient supine, then in left lateral position Heard best 5th ICS MCL (over apex) Place bell lightly on chest

PMI def

The point of maximum impact (PMI) is located on the chest by palpation.

heart Murmurs: reason

The valve (door) does not open all the way or does not close all the way. Or there is a problem with the speed or viscosity of the blood passing through it. Murmurs can be heard in either systole or diastole, depending on the valve and the problem with it.

S3 and S4 are made by

Third & fourth heart sounds (S3 & S4) are made by ventricular vibrations, not the closing of valves.

how is heart lied?

This diagram shows anatomy as well as two key points: 1. The heart lies at an angle in the adult, and even more so in children.

Percussion

Used to determine borders of the heart Only when xray or ECHO unavailable "moderately" reliable Less so in females with extensive breast tissue

S3 -

Ventricular Gallop Pathologic - Decreased ventricular compliance, failure, overload, high output states

What i need to know

What you will be responsible for knowing: everything on the slides in this lecture. Use the book to learn/review it, but you do not need to learn the rest of the material in Chapter 19.

how blood travels

When the heart contracts, it pumps blood simultaneously into both loops Blood is kept moving by continually shifting pressure gradients - Blood flows from area of higher pressure to area of lower pressure

Important points to remember:

Women have slightly more heart attacks than men Women under 50 are twice as likely to die from an AMI as a man under 50 Men and women differ in presentation Diabetes can affect presentation (altered transmission and perception of pain) Silent MIs do occur and can go unrecognized Arterial spasms can mimic an AMI or aggravate a clot

Precordium: def

area on anterior chest overlying heart and great vessels

Heart Sounds: Normal heart sounds: list

first heart sound (S1) second heart sound (S2)

Cardiovascular system consists of

heart (a muscular pump) and blood vessels

Systole:

heart's contraction, blood pumped from ventricles fills pulmonary and systemic arteries; this is one third of cardiac cycle

Coronary Arteries: list

pic Aorta Right coronary artery Left anterior descending coronary artery Circumflex coronary artery Left main coronary artery

summary the above

pic Cardiovascular system consists of heart (a muscular pump) and blood vessels Blood vessels are arranged in two continuous loops Pulmonary circulation Systemic circulation When the heart contracts, it pumps blood simultaneously into both loops Blood is kept moving by continually shifting pressure gradients - Blood flows from area of higher pressure to area of lower pressure

The Neck Vessels: list

pic Carotid Arteries: Jugular Veins: Internal & External

Chambers and Valves

pic Four Chambers: Atria and ventricles Great vessels lie bunched above the base of the heart Pulmonary veins return freshly oxygenated blood to left side of heart, and aorta carries it out to body

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pic Localize point of maximum impact, note location

artery: usage of stent

pic Stent usage Compressed plaque: Widened artery, compressed plaque, blood flow Narrowed artery: restenosis:Restonosis in and around stent, stent, decreased blood flow

Cardiac Cycle and Heart Sounds

slide 16

Diastole:

ventricles relax and fill with blood; this takes up two thirds of cardiac cycle

Additional Subjective History

● Older Adults Ask about known heart or lung conditions & their interference with ADLs Lung disease can cause or worsen cardiac disease.