Chapter 17: Heart and Neck Vessels Assessment

Epicardium

: thin; muscle, exterior layer

Dyspnea

(Shortness of breath);

Pericardial friction rub

-a high-pitched, scratching, and grating sound at the left lower sternal border

Cardiac : Chest pain of a cardiac origin is typically described as a sensation of squeezing around the heart, a steady, severe pain, and a sense of pressure.

A client presents with chest pain described as a pressure and squeezing sensation that is steady and severe. The nurse would suspect which system as the most likely source?

Flat neck veins A client with dehydration or volume depletion have barely visible neck veins, even when lying flat. These are described as flat neck veins. Distended neck veins are used to describe engorged neck veins found in clients with fluid volume overload. Round and invisible neck veins are distracters to the question.

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?

the S2 is softer than the S1.

A diminished S2 means that

the aortic or pulmonic valves have decreased mobility.

A diminished S2 occurs in conditions in which

Inflammation of the pericardial sac A high pitched, scratchy, scraping sound that increases with exhalation and when the client leans forward is called a pericardial friction rub. This is caused by inflammation of the pericardial sac. Increased pressure within the ventricles may cause a decrease in cardiac output. Inability of the atria to contract can be caused by any problem that causes the sinoatrial node not to fire. An incompetent mitral valve would cause a systolic murmur.

A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

Ask the client to assume the left lateral position If unable to locate the apical impulse, ask the client to turn to the left lateral position. This displaces the heart towards the left chest wall and relocates the apical impulse father to the left. Using one finger is appropriate after locating the pulse for a more accurate palpation. Coughing will not assist in location of the apical impulse. The nurse should locate the apical impulse by palpation be fore auscultating heart sounds.

A nurse experiences difficulty with palpation of the apical impulse on the precordium. What is an appropriate action by the nurse? Try using one finger of the dominant hand to locate the pulse Ask the client to assume the left lateral position Instruct the client to cough and attempt again Use the stethoscope to auscultate

Client has an increased chest diameter : The apical impulse may not be palpable in clients with increased anteroposterior diameters. Irregular heart rate should not interfere with the ability to palpate an apical impulse. Respiratory rate does not impact the apical impulse. Heart enlargement would displace the apical impulse but not cause it to be nonpalpable.

A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding? Heart enlargement is present Respiratory rate is too fast Heart rate is irregular Client has an increased chest diameter

Walk briskly 30 minutes per day. Use a low sodium seasoning to flavor food. Choose foods like bananas and sweet potatoes. Encouraging physical activity, decreasing dietary intake of sodium, and increasing dietary intake of potassium, such as in bananas and sweet potato, are lifestyle modifications that can promote sustaining a healthy blood pressure. Excess alcohol consumption is a modifiable lifestyle factor that can promote hypertension. Depending on gender, alcoholic beverages should be limited from one to two per day. Dairy products tend to be high in cholesterol. Clients at risk for hypertension should avoid increasing consumption of these foods.

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply.

Cardiac cycle The continuous rhythmic movement of blood during contraction and relaxation of the heart is the cardiac cycle.

A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following?

B. Heart rate × stroke volume Rationale: Cardiac output = heart rate × stroke volume.

A student is learning to compute the cardiac output of his or her patients. What is the formula for computing cardiac output? A. Pulse pressure × stroke volume B. Heart rate × stroke volume C. Pulse pressure × heart rate D. Stroke volume × diastolic BP

Patient C Cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection.

A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority?

the aortic or pulmonic valve has a higher closing pressure

An accentuated S2 occurs in conditions in which

early systole at the second right intercostal space and apex.

An aortic ejection click is heard during

Arterial great vessels

Carotids (neck, also)-located in the depression between the trachea and sternomastoid muscle

aortic,, pulmonic, , tricuspid ara, mitral area,

Common Auscultation Areas of heart

the end of S2 to the beginning of the next S1, when the mitral and tricuspid valves are open and the aortic and pulmonic valves are closed

Diastolic murmurs occur during filling from

Common cardiovascular symptoms Chest pain (CP)-

Differential Diagnosis-Musculoskeletal-palpation of the costochondral junction

P wave-depolarization in the atria PR interval-ventricular depolarization QRS complex-ventricular contraction T wave-repolarization

ECG records cardiac electrical changes as specific waves, intervals

Have the client hold his or her breath; if the rub persists, it is pericardial Pericardial friction rubs can be differentiated from pleural friction rubs by having the client hold the breath. If present without breathing, the rub is pericardial. Turning the client to the right side and auscultating either the base of the heart or the upper back do not differentiate between pericardial and pleural friction rubs.

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?

Murmur Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium.

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following?

left midclavicular line at the fifth intercostal space The apical pulse is the point of maximal impulse and is located in the fifth intercostal space at the left midclavicular line when the client is placed in a sitting position. The apical impulse is palpated in the mitral area and therefore cannot be palpated at the left midclavicular line at the third intercostal space, at right of the midclavicular line at the third intercostal space and at right of the midclavicular line at the fifth intercostal space.

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? left midclavicular line at the third intercostal space right of the midclavicular line at the third intercostal space left midclavicular line at the fifth intercostal space right of midclavicular line at the fifth intercostal space

True Rationale: Semilunar valves include the pulmonic and aortic valves.

Is the following question true or false? The pulmonic valve is a semilunar valve.

Nocturia

Nocturia-a common symptom associated with redistribution of fluid from the legs to the core when lying. Do you need to get up at night to use the bathroom? pee at night

second or third left

Normal split S2 can be heard over the _____ or __________ intercostal space; it is usually heard best during inspiration and disappears during expiration

lub

S1, the first heart sound, sounds like

dub

S2, the second heart sound, sounds like

Precordium Auscultation: most important CV technique

Specific auscultation sites: rationale; 3rd left rib space; this is the third site for auscultation (Erb point) PMI in the apex at the 4th-5th ICS at the left MCL; The enlarged heart of cardiomegaly displaces the PMI laterally and inferiorly. Identify: rate/rhythm; S1, S2; extra sounds; murmurs; Diastolic murmurs occur during filling from the end of S2 to the beginning of the next S1, when the mitral and tricuspid valves are open and the aortic and pulmonic valves are closed

Angina Angina is temporary heart pain, resolving in less than 20 minutes. It can be aggravated by physical activity and stress, or there may be no triggers (unstable angina). This type of pain is not musculoskeletal, gastrointestinal, or crushing.

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what?

mitral area and therefore cannot be palpated at the left midclavicular line at the third intercostal space, at right of the midclavicular line at the third intercostal space and at right of the midclavicular line at the fifth intercostal space.

The apical impulse is palpated in the

Apical impulse The apical impulse is palpated in the mitral area and may be the size of a nickel (1-2 cm). Amplitude is usually small—like a gentle tap. The nurse is not palpating for gastritis, splenomegaly, or pulmonary fremitus.

The nurse assesses a client's chest as shown. What is the nurse assessing?

2nd intercostal space left sternal border Since the nurse started at the base of the heart, the next location to assess would be the 2nd intercostal space left sternal border. The 3rd left intercostal space would be assessed next and followed by the 4th intercostal space. The 5th left intercostal space midclavicular line would be assessed last.

The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next? 4th left intercostal space 3rd intercostal space left sternal border 2nd intercostal space left sternal border 5th left intercostal space midclavicular line

The client may be experiencing symptoms of heart failure. With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. This does not signal CAD, a conduction problem, or adequate compensation.

The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize what implication of this statement?

Inspect the suprasternal notch or around the clavicles. When assessing the jugular venous pulse, the client should be supine with the torso elevated 30 to 45 degrees, with the head and torso on the same plane. The client turns his or her head slightly to the left, and the nurse shines a tangential light source onto the neck to increase visualization of pulsations as well as shadows. The nurse inspects the sternal notch or area around the clavicles for pulsations.

The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse? Have the client look straight ahead with chin slightly lifted. Have the client sit up at a 90-degree angle. Perform the exam with the client in a supine position. Inspect the suprasternal notch or around the clavicles.

third to fifth intercostal space at the left sternal border. : Erb's point: Third to fifth intercostal space at the left sternal border.

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the

"Do you have any pain or discomfort in your chest?" The first question the nurse asks should be broad as this will encourage the client to share more detail regarding the source of the pain. Chest pain is one of the most serious and important symptoms often signaling coronary artery disease, potentially leading to myocardial infarction. All of the other options are more specific; these questions should only be asked when the nurse needs to narrow the focus of the cardiovascular examination.

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

"Your risk for heart disease will drop greatly if you're able to stop smoking." Smoking is among the most significant risk factors for heart disease. Screening does not need to be performed on a twice yearly basis. Stress reduction is beneficial, but smoking is a greater risk factor than stress. Dietary fat is a risk factor, but for most clients there is not a need to wholly eliminate red meat from the diet.

The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease?

Palpate each artery individually to compare. When assessing a client's carotid arteries, the nurse should palpate each artery individually because bilateral palpation could result in reduced cerebral blood flow. Auscultation should be done before palpation because palpation may increase or slow the heart rate, changing the strength of the carotid pulse heard. The nurse should use the bell of the stethoscope to auscultate the arteries and have the client hold the breath for a moment so breath sounds do not conceal any vascular sounds.

The nurse is preparing to assess a client's carotid arteries. Which nursing action would be most appropriate? Palpate each artery individually to compare. Palpate the arteries before auscultating them. Use the diaphragm of the stethoscope. Ask the client to breathe in and out deeply.

Palpating carotid pulses simultaneously. Caroid pulse palpation should be conducted by feeling one side at a time; otherwise the client my become dizzy or lightheaded. All other assessment techniques are correct.

The nurse manager on a cardiac unit should immediately intervenen when observing which staff nurse's assessment technique? Auscultaing all heart sounds with the bell and diaphragm. Palpation of the point of maximum impluse on the chest. Palpating carotid pulses simultaneously. Inspecting bilateral jugular veins.

Increase heart rate Increase stroke volume Increase heart rate + stroke volume Epinephrine (adrenaline) and Norepinephrine (stress hormones) increase both heart rate and stroke volume during exercise, trauma, or anxiety

To increase circulating blood (cardiac output)

aortic pressure is greater than ventricular pressure mitral valve closes producing S1 the atrium is empty and pressures in the ventricles increase slightly S3 and S4 may be heard if pathologic ventricular compliance ventricular pressure increases and forces the opening of the aortic valve aortic valve closes producing S2

Understanding pressures in the left atrium, left ventricle, and aorta is fundamental to understanding heart sounds. Place the following in order of pressures and sounds through one cardiac cycle.

Pericardial friction rub A pericardial friction rub is the most 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. Acute pericarditis, elevated white cell count, and a murmur heard over the left sternal border would not be the primary physical sign of the condition.

What is the most important physical sign of acute pericarditis?

Apical impulse Obesity or a thick chest wall makes palpation of the apical impulse difficult.

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

Accentuated An accentuated S2 means that the S2 is louder than the S1. This occurs in conditions in which the aortic or pulmonic valve has a higher closing pressure. A diminished S2 means that the S2 is softer than the S1. This occurs in conditions in which the aortic or pulmonic valves have decreased mobility. Normal split S2 can be heard over the second or third left intercostal space; it is usually heard best during inspiration and disappears during expiration. Wide split S2 is an increase in the usual splitting that persists throughout the entire respiratory cycle, and widens on expiration.

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2? Accentuated Diminished Normal split Wide split

S1 The S1 heart sound is associated with systole, while the S2, S3, and S4 heart sounds are associated with diastole.

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?

The mediastinum, between the lungs above the diaphragm The heart and great vessels are located in the mediastinum between the lungs and above the diaphragm from the center to the left of the thorax.

Where are the heart and great vessels located in the human body?

Pericardial friction rub A pericardial friction rub is best heard in the third intercostal space at the left sternal border and is associated with a high-pitched, scratchy sound caused by inflammation of the pericardial sac. A midsystolic click is heard in middle or late systole over the mitral or apical area. A summation gallop is the simultaneous occurrence of S3 and S4 sounds. An aortic ejection click is heard during early systole at the second right intercostal space and apex.

While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. How would the nurse document the findings?

Cardiac output Preload-

amount of blood in the right atrium to be squeezed out; contractility

Afterload- cardiac output

amount of pressure the heart has to work against, similar to the resistance in the arterioles with the blood pressure

Arrhythmias

abnormal heart rhythms with premature, delayed, or irregular beats Atria; AV junction; ventricles

Auscultation landmarks

anterior thoracic wall Intercostal spaces (ICS); sternal lines Midclavicular line (MCL)

Apex:

bottom of the heart; found at 5th ICS Point of maximal impulse (PMI)

Cardiac output

heart rate × stroke volume

Jugular pulsations

hemodynamics of the right side of the heart

PMI Auscultation: most important CV technique

in the apex at the 4th-5th ICS at the left MCL; The enlarged heart of cardiomegaly displaces the PMI laterally and inferiorly.

Atrial fibrillation

irregularly irregular heart rhythm

SA node

pacemaker of the heart

Comprehensive physical assessment Jugular vein

pulses- hemodynamics of the right side of the heart

Atrioventricular (AV) valves

separate atria from ventricles Tricuspid; mitral

Semilunar valves:

separate ventricles from great vessels Pulmonic; aortic

true

t/f The nurse auscultates the apical pulse and then palpates the PMI (point of maximal impulse). To best palpate the PMI, the nurse places two fingers at the left border of the heart in the 5th intercostal space.

Myocardium time is muscle- 4hrs

thick; muscular for pumping

Endocardium

thin; lines interiors of chambers, valves

Base

top of the heart; found at 2nd ICS

Distended neck veins

what are used to describe engorged neck veins found in clients with fluid volume overload.

Epinephrine (adrenaline) and Norepinephrine (stress hormones)

what hormones increase both heart rate and stroke volume during exercise, trauma, or anxiety

Ventricular gallop

what is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium.

Wide split S2

what is an increase in the usual splitting that persists throughout the entire respiratory cycle, and widens on expiration.

A midsystolic click

what is heard in middle or late systole over the mitral or apical area.

Contractility

what is the ability of the heart to shorten its muscle fibers, producing a contraction during systole

A summation gallop

what is the simultaneous occurrence of S3 and S4 sounds.