Health Assessment Exam 2: Heart & Neck

Basic Techniques

>Inspect the jugular veins: helps determine jugular venous pressure >Palpate the carotid arteries: helps indicate the strength of the puls >Auscultate the carotid artery: enables the hearing of bruits >Inspect the precordium: identifies abnormalities >Palpate the PMI (point of maximal impulse (apical pulse)): assesses for cardiac enlargement >Palpate the precordium: assesses for masses and tenderness >Auscultate the pulse: determines rate, rhythm >Auscultate extra heart sounds S3 and S4 >Auscultate systolic and diastolic murmurs: identifies presence of sounds through valves

Carotid Sinus

A dilation of a common carotid artery; involved in regulation of systemic blood pressure. Avoid compressing the carotid sinus. Stimulation of the sinus causes parasympathetic stimulation, which may lead to reduced pulse rate and bradycardia. Older adults and patients sensitive to this stimulation may develop periods of life-threatening asystole.

Auscultation of chest

A ortic P ulmonic E rb's point T ricuspid M itral Isolate the lub-dub rhythm, listening for a regular rhythmic cadence. Listen first to S1 and then to S2 for a single sound or split sound. Identify if S1 or S2 is louder or softer. Listen for extra heart sounds and identify if the sounds occur before or after S1 or S2. Listen for murmurs and identify if the murmur occurs during systole or diastole

Locations for auscultating heart sounds

A- aortic P- pulmonic E- erb point T- tricuspid valve M- Mitral valve

Systolic Ejection Click

Can occur early or in the middle of systole. The early syst sound occurs quickly after S1. Causes are either a sudden bulging of an abnormal aortic or pulmonic valve or the sudden distension of the associated great artery. Aortic stenosis, pulmonic stenosis, and a bicuspid aortic valve(when the aortic valve only has two "leaflets" instead of 3) can all produce a systolic ejection click sound, with or without a murmur. The midsystolic click is associated with mitral valve prolapse. There may or may not be an associated late systolic murmur, which is caused by mitral regurgitation. The click is produced by systolic prolapse of the mitral valve leaflets into the left atrium. If present, the Valsalva or squatting-to-standing maneuver should be performed to assess for increases in the click or murmur

Cardiac Electrophysiology

Cardiac electrophysiology studies are used in the diagnostic investigation of arrhythmias and syncope. Flexible catheters with multiple electrodes are placed within the heart to stimulate arrhythmias. The patient fasts for several hours before the study; usually, he or she is sedated during the procedure. Complications include the inability to induce arrhythmias, cardiac perforation and pericardial effusion, venous thrombosis or infection from the catheter site, and intractable ventricular fibrillation and death. Patients are monitored closely following this procedure.

Neck Vessels

Carotid artery, jugular veins (internal and external) -Carotid arteries: transport blood from the heart to the head. Located in the depression between the trachea and sternomastoid muscle in the anterior neck and run parallel to the trachea from the clavicle to the jaw bilaterally. -Internal jugular vein is usually not visible, because it is a vein it is not palpable. -The external jugular vein is visible above the clavicle and close to the insertion of the sternomastoid muscle and travels up to the jaw line.

Control of heart rate

Chemoreceptors- change in acidity/CO2/ pH Baroreceptors- change in pressure Mechano/Proprio receptors- detect movement (muscles/joints) Cardiac Control Centre/Medulla Oblongata Sympathetic- increases HR Parasympathetic- decreases HR Vagus nerve- is triggered by the parasympathetic division and since it innervates the SA node it can slow the natural pacemaker. It also slows the conduction through the AV junction, which in turn slows the heart rate. Both go to the SA Node

Common Symptoms

Chest pain Dyspnea, orthopnea (difficulty breathing when lying down), and cough Diaphoresis Fatigue Edema Nocturia Palpitations

Common Nursing Diagnoses Associated with Cardiovascular

Decreased Cardiac Output Risk for decreased cardiac tissue perfusion Excess fluid volume

Cultural Considerations

Women and men present with heart disease differently. Women with Diabetes II have a signif higher cardiovas mortality rate than men with DII. In addition women with AFib are at greater risk for stroke than men. Women have been underrepresented in trials studying heart disease so there are assumptions about women without evidence. Heart disease is the leading cause of death for most racial groups in the US

Conduction System

a group of specialized cardiac muscle cells in the walls of the heart that send signals to the heart muscle causing it to contract The impulse generated by the SA node moves through the "wiring" through the left and right atria (intraatrial pathways) and causes the atrial muscle cells to contract. The impulse pauses at the AV (atrioventricular valves) to allow the atria to finish contracting and then travels through the bundle of HIS and bundle branches in the left and right ventricles and finally moves to the purkinje fibers of the ventricles and then causes the ventricular muscle cells to contract.

Systole

contraction phase of the heartbeat. Ejecting the blood.

ECG

electrocardiogram Monitor changes in heart rate

Stress Test

exercise tolerance test (ETT) determines the heart's response to physical exertion (stress) using ecg while exercising to monitor for signs of ischemia or arrhythmia.

myocardial infarction (MI)

heart attack; death of myocardial tissue (infarction) caused by ischemia (loss of blood flow) as a result of an occlusion (plugging) of a coronary artery; usually caused by atherosclerosis; symptoms include pain in the chest or upper body (shoulders, neck, and jaw), shortness of breath, diaphoresis, and nausea Nurses are normally the first to identify these systolic murmurs related to papillary muscle dysfunction (muscles located in the ventricles of the heart)

Cardiac output

heart rate x stroke volume volume in the right atrium at the end of diastole is called preload, an indicator of how much blood will be forwarded to and ejected from the ventricles. With increased blood in the right ventricle, force of contraction (contractility) will be stronger. The hearts has to pump against the high BP's in the arteries and arterioles. This pressure in the great vessels is termed as afterload.

Arrhythmias

irregular heart rhythms; uncoordinated atrial and ventricular contractions -An irregular rhythm common in older adults is called atrial fibrillation which is caused by many sites in the atria sending signals to the ventricles so the ventricles contract very irregularly, causing an irregular heart rhythm. -Cardiac arrhythmias are diagnosed by the location of impulse, rate, and regularity.

Sinotrial (SA) Node

pacemaker of the heart

Diastole

relaxation phase of the heartbeat takes twice as long as systole unless the heart rate is elevated, then the time can be around equal. This is when the heart is filling with blood.

Health History

-Biographical information (age, gender, ethnic background etc) -Past medical history -Lifestyle and personal habits (weight, smoking, exercise patterns etc) -Current medications (including over the counter and vitamins/supplements) -Family history

Carotid Arteries

(the major arteries that carry blood upward to the head) Inspect the carotid artery for a double stroke seen with S1 and S2. Grading of pulses scale 0-4+ (from nonpalpable or absent to weak and thready, normal expected, full-increased, and bounding) "contour is smooth with a rapid upstroke and slower downstroke. Strength is 2+ or normal. Pulses are equal bilaterally" Carotid pulse may be bounding and prominent with hypertension, hypermetabolic states, and disorders with a rapid rise and fall of pressure (ex. patent ductus arteriosus) The carotid pulse may be low in amplitude and volume and have a delayed peak in aortic stenosis (from decreased cardiac output). If the pulse is diminished unilaterally or bilaterally (often associated with a systolic bruit), the cause may be carotid stenosis from atherosclerosis.

Precordium Palpation

-Palpate apical impulse using one finger pad (ask person to exhale and hold it) - Feel it best at end of expiration when heart is closest to chest wall -Note location, size, amplitude and duration -Apical impulse is palpable in about half of adults; not palpable in obese persons or in ppl with thick chest walls -Palpate across the precordium w/ palmar aspects of 4 fingers: apex, left sternal border and base searching for thrills "PMI 5th left ICS at the MCL. The PMI may or may not be palpable in adults. No pulsations are palpated in other areas"

Valves

-The atrioventricular (AV) valves separate the atria from the ventricles. The tricuspid is for the right side and the bicuspid or mitral valve is for the left side. The left side of the heart has more muscle as it pumps to the body and the right side is leaner and pumps the pulmonary system's blood. -The AV valves are open during the ventricular filling period, or diastole. and close during ventricular contraction or systole to prevent regurgitation or backflow of blood. The two semilunar valves separate the ventricles from the great vessels. The pulmonic valve lies between the right ventricle and pulmonary artery. The aortic valve lies between the left ventricle and aorta. The valves are named after the vessel that they fill. The semilunar valves open during ventricular contraction or systole to allow blood to go to great vessels and then closes during diastole.

Echocardiogram

An echocardiogram uses high-frequency sound waves and the Doppler effect to evaluate the size, shape, and motion of cardiac structures and the direction and velocity of blood flow through the heart. A gel (often cold) is placed on the patient's chest wall and the transducer is moved around the anterior chest wall. The echocardiogram may also be done with the transducer inserted through the mouth into the esophagus (transesophageal echocardiogram [TEE]). This invasive procedure provides superior images when compared with traditional transthoracic echocardiography but requires fasting and sedation, with potential complications such as a perforated esophagus or impaired swallowing.

Objective Data Collection

BP, peripheral vascular system, neck vessels, and heart sounds are all indicators of adequate circulation and tissue perfusion.

Hemodynamic Monitoring

Bedside hemodynamic monitoring includes measurement of central venous pressure, pulmonary artery pressures, and systemic interarterial pressures using a catheter placed in the heart. Systemic intraarterial pressure monitoring provides access to direct and continuous BP s in critically ill patients. The catheter is usually placed in the radial artery. Hemodynamic monitoring requires the advanced training and skill of nurses in critical care areas

Congestion

Blood backing up causes congestion. If the blood is backing up on the left side of the heart it will go into the lungs. If it is backing up on the right side it will go into the body especially the legs and feet. Signs and symptoms of heart failure are shortness of breath, weight gain, swollen ankles, and decreased cardiac output.

Cardiovascular System

Blood vessels transport blood, which carries oxygen, carbon dioxide, nutrients, wastes, etc. The heart pumps blood. heart and blood vessels-> great and peripheral vessels

Risk Reduction and Health Promotion

Complete risk assessment helps identify possible conditions. Primary prevention is necessary to help those without evidence of cardiovascular disease to prevent them from having it and secondary preventions are there to detect any cardiac issues in order to treat and hopefully reverse the issue if it is detected early on. Screenings are a priority for public health. Smoking and high BP etc are focus areas for teaching as are high fat diet and consequences from being overweight. Healthy People 2020's overall goals include improved hypertension and cholesterol control and increased patient education regarding s/sx and early treatment.

Lipid Profile

Elevated levels of blood lipids are a risk factor for cardiovascular disease. A lipid profile includes total cholesterol, high density lipoprotein (HDL), LDL, and triglyceride levels. For the general population, the guidelines designate a desirable total cholesterol level less than 200 mg/dl, a moderate LDL-C level less than 100 mg/dl, a triglyceride level less than 150 mg/dl, and apolipoprotein B less than 90. HDL-C should be greater than 40 mg/dl and as high as possible through lifestyle interventions—e.g., weight loss, physical activity, and tobacco cessation

Palpation of Carotid Artery

Gently palpate only 1 artery at a time 2 avoid compromising arterial blood 2 brain. Feel contour & amplitude of pulse. Normally contour is smooth with brisk upstroke & slower downstroke, & normal strength is moderate & equal bilaterally. Palpate the carotid artery medial to the sternomastoid muscle in the neck between the jaw and clavicle Note: a diminished or thready pulse may accompany decreased stroke volume, found with reduced fluid volume. If the heart's ability to pump is decreased and cardiac output is low, as in heart failure, pulse strength may be reduced. Another cause of decreased pulse strength is a narrowed carotid artery from atherosclerosis. Pulse strength may increase during exercise or stress. Strength of pulse is on a 2+/4+ scale bilaterally.

Cultural Considerations

Heart disease is the leading cause of death in the world. Cardiovascular disease is accounted for one in 3 deaths in the united states in 2013. -1 in 3 adults have hypertension in the U.S. with 20% of the population being unaware. -POC are 40% more likely to have high BP than white people and are less likely to be in treatment for their BP. -Hispanic people have higher overweight and obese statistics than other groups and premature death is higher. -Premature deaths from heart disease <65yrs is seen the most in native american or alaskan native groups.

Chest X-Ray

Help determine size, shape, contour and position of heart, alterations in pulmonary circulation and acute or chronic lung disease.

Additional Techniques

Hepatojugular Reflux. Pressing gently on the liver increases venous return (Fig. 17.18). Apply gentle pressure (30-40 mm Hg) over the right upper quadrant or middle abdomen for at least 10 seconds (some studies suggest up to 1 minute) A positive result is when the highest level of pulsation stays above 3 cm for more than 15 seconds. The pulsation remains elevated in disorders that cause a dilated and poorly compliant right ventricle or in obstruction of the right ventricular filling by tricuspid stenosis (Grossman & Porth, 2014). A positive result of the hepatojugular reflux test is highly sensitive and specific for right ventricular fluid overload "hepatojugular reflux negative" Percussion of the Precordium. Chest x-ray has largely replaced chest percussion. Detecting percussion sounds over an obese or muscular chest or female breast tissue can be difficult. If x-ray is not available, percussion may be useful in identifying the left border if the heart is enlarged (as in cases of suspected heart failure). Identification of the right border is rarely useful. If heart failure or cardiomegaly is suspected, cardiac dullness may be percussed in the ICSs. Beginning at the anterior axillary line in the 4th ICS, percuss medially toward the sternum. Repeat the procedure in the 5th and 6th ICSs. "Dullness noted in 4thto 5th left ICS at MCL. Note the point at which the note changes from resonant (lung tissue) to dull (cardiac tissue)."

Urgent Assessment

If patient is experiencing chest pain, dyspnea, cyanosis, diaphroesis(sweating), dizziness. Gather information while assessing the interventions are the most important things to do, you can always ask more questions once the patient is stable or when family arrives etc.

Older Adults

In the older adult, changes in the heart and BP are primarily due to age-related stiffening of the vasculature and decreased responsiveness to stress hormones. Blood and pulse pressures increase as a result of the stiffened blood vessels. Additionally, body mass index increases, causing the heart to work harder. Elevated late diastolic filling increases the volume of atrial contraction, which may be associated with the S4 gallop of late diastolic filling

Precordium Inspection

Inspect the anterior chest for any lesions, masses, or areas of tenderness. Observe for the PMI in the apex at the 4-5th ICS at the left MCL. *cardiomegaly displaces the PMI(point of maximal impulse) laterally and inferiorly. "impulses are absent or located in the 4-5th ICS and MCL with no lifts or heaves."

Heart Sounds

Lub-dub. 1st- a-v valves close. 2nd- aortic and pulmonary valves close

Electrocardiogram Continued

P wave represents the spread of depolarization in the atria that causes atrial contraction (note that atrial repolarization is not seen because it is hidden when the ventricles contract in the QRS complex); PR interval represents the time from the firing of the SA node to the beginning of ventricular depolarization (includes a slight pause at the AV junction); QRS complex represents the spread of depolarization and sodium release in the ventricles that causes ventricular contraction; T wave represents cellular repolarization, or the restoration of the ventricular resting state, caused by the return of intracellular sodium.

Auscultation of Carotid Arteries

Performed in cases of suspected narrowing of the arteries. Using the bell to hear the low pitched sound of bruit or the swooshing sound (similar to the sound the BP makes). Auscultate over 3 areas of the neck 1) base of the neck 2) mid-cervical area 3) angle of the jaw Have patient hold breath to prevent interference in sound Avoid compressing because that can actually make a bruit Murmurs and bruits sound similar. Murmurs originate in the heart or great vessels and are louder over the upper precordium and quieter near the neck. Bruits are loudest over the carotid artery and do not radiate to the precordium. "bruit or no bruit"

Pericardial Friction Rub

Pericardial Friction Rub. The pericardial friction rub is an important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating. It can best be heard with the diaphragm of the stethoscope at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration and increases when the patient is upright and leaning forward. The examiner may need to ask the patient to hold his or her breath briefly to determine whether the rub is pleural or cardiac in origin.

Pulmonary and Systemic Circulation

Pulmonary circulation - for oxygenation of the blood. Right ventricle to pulmonary artery to lungs to pulmonary vein to left atrium. Systemic circulation - to supply cells with oxygenated blood and remove waste. Left ventricle to aorta to body to vena cave to right atrium.

Older Adults

Risk for Hypertension and cardiac disease rises Cardiac reserves decline and the left ventricular wall becomes thicker and stiffer in normal aging causing the mitral valve to close more slowly. -due to fibrotic changes and fat deposits on the SA node, older adults have less heart rate variability than younger adults. a 20-year old can increase their heart rate to 180 beats/min where as an 80-year old person has a max heart rate of 140-150 -receptors for stress hormones also may become less sensitive in older adults making them less able to respond to stressors

Assessment of Risk Factors

Smoking High BP Physical Inactivity Diabetes

Snap

Snap. The opening snap is an early diastolic sound associated with mitral stenosis. It is audible shortly after S2 and may or may not be associated with a late diastolic murmur. It results from the rapid opening of the anterior mitral valve leaflet during diastole with high left atrial pressures. The opening snap is challenging to differentiate from either S3 or split S2

Stroke Volume

The amount of blood ejected from the heart in one contraction.

Electrocardiogram

The conduction system is a pathway similar to an electrical cord, by which signals travel quickly and efficiently to muscle cells. After the signal has been delivered, the muscle cells depolarize, causing muscle fibers to slide over one another and contract. Depolarization occurs when there is an exchange of electrolytes, including sodium, potassium, and calcium. The shift in electrolytes causes electrical changes that can be detected by electrocardiography and recorded on an electrocardiogram (ECG).

Jugular Venous Pressure

The indirectly observed pressure over the venous system via visualization of the internal jugular vein Normal findings are JVP up to 3cm above the sternal angle, which is equivalent to a central venous pressure of 8mm Hg. If exact levels are not measured, document findings as "JVP normal", "JVP not elevated," "neck veins not distended" or "no JVD". Heart rate and rhythm regular. No gallops, murmurs, or rubs. JVP within normal limits. JVD is associated with heart failure, tricuspid regurgitation, and a fluid volume overload. The neck veins appear full, and the level of pulsation may have elevated JVP greater than 3cm (about 1/4in) above the sternal angle.

Cardiac Enzymes and Proteins

The myocardium releases cardiac enzymes and proteins in response to cell damage. These enzymes and proteins are measured in blood samples to diagnose or rule out MI. Creatine kinase-MB (CK-MB) and troponin I are intracellular proteins specific to the myocardium; their values are elevated with MI

Coronary arteries and veins

These are the vessels located on and in the actual myocardium or heart muscle. They supply and drain the myocardium of blood, respectively.

Auscultation Technique and normal findings

Using the diaphragm listen to the erb point to identify S1 & S2, heart rhythm, and heart rate as described. Rate increases at the peak of inspiration and slows at the peak of expiration known as sinus arrhythmia. *if rhythm is irregular find out if there is a pattern or if it is totally irregular. Ex: every third beat missed would be known as regular irregular rhythm. No pattern is characteristic of atrial fibrillation. If rhythm is irregular take the radial pulse while listening to the apical pulse at the same time. "Heart rate is 60-100 beats/min and regular in adults." Identify S1 and S2 (lub dub). Then listen to each sound separately. Normally you would hear one sound each but S1 signals the beginning of systole as the mitral and tricuspid valves close. Because the right side of the heart may contract slightly more slowly than the left the tricuspid valve may close slightly after mitral causing a split S1. A split S1 is heard in the tricuspid area. *The rare split S1 is constant, does not vary with respiration and so is referred to as a fixed split. Wide splitting occurs when a bundle branch block delays activation of the right ventricle or when stenosis of the pulmonic valve or pulmonary hypertension delays emptying of the right ventricle. A paradoxical split is the opposite of what is expected when closure of the aortic valve is delayed, the pulmonic valve closes before the aortic which occurs with a left bundle branch block, right ventricular pacing, aortic stenosis, or left ventricular failure heard during expiration and disappearing with inspiration. S2 signals the end of systole and the beginning of the diastole as the aortic and pulmonic valves close. A split S2 can occur from pulmonic valve closing after the aortic and would be heard in P area during inspiration in children but is very difficult to auscultate. S1 is louder than S2 in the mitral and tric areas because those are the valves closing at the beginning of systole. S2 is louder in the aortic and pulmonic areas for the same reason except those valves are for diastole. "S1 is greater than S2 in the mitral and tricuspid areas; S2 is greater than S1 at the aortic and pulmonic areas; S1 is equal to S2 at erb point. Heart rate and rhythm regular. No gallops, murmurs, or rubs. JVP within normal limits"

Cardiac Catheterization and Coronary Angiography

Visualize blockages (diagnostic) Open blockages (interventional) Percutaneous coronary intervention (PCI) Balloon angioplasty Stent Cardiac catheterization and coronary angiography are invasive diagnostic procedures that delineate coronary anatomy and CHD using fluoroscopy, usually in the radiology department. Right-sided heart catheterization is performed to measure right-sided heart pressures and structures. Left-sided heart catheterization involves placing a catheter through the femoral or radial artery to the coronary arteries where dye is used for visualization. Following the procedure, the patient is on bed rest (if a femoral approach is used), and the puncture site and distal circulation must be monitored frequently. Nursing staff also monitor BP and cardiac rhythm

Jugular Venous Pulses Inspection

a wave - atrial contraction c wave - ventricular contraction against a closed tricuspid valve (tricuspid valve bulging back into right atrium) x descent - atrial relaxation v wave - atrial filling (diastole) y descent - atrial emptying crest of "a" and "v" waves equal. There are usually two pulsations with a prominent descent in veins as compared with the carotid arterial pulse, which has one pulsation and a prominent ascent with systole. Note: position patient with the head of the bed at 30-45 degrees to promote visibility of the pulsation. Place a folded pillow under the patient's head but have shoulders touching the bed. Right side is easiest to see, can have patient turn head sideways and upwards slightly to help see. Observe the pulsations in the groove near the middle of the clavicle.

Murmur

abnormal swishing sound caused by improper closure of the heart valves which leads to S3 and S4 sounds or gallop sounds. These sounds typically mean the heart is failing due to things like aortic stenosis, mitral insufficiency and ventricular septal defects for systolic murmurs and insufficiency and mitral stenosis for diastolic murmurs. "no murmurs. no gallops, murmurs, or rubs"