Transcript Chapter 19
Jarvis Chapter 19 ATI Skills Module on Physical Assessment (Adult) - Cardiac The Circulatory System http://www.youtube.com/watch?v=D3ZDJgFDdk0& feature=related Learning Outcomes 1. List the significant anatomic features of the heart and their location. 2. Describe the heart sounds & relate the name of the heart sound to the physiologic cause. 3. Describe the structures of conduction and the spread of the cardiac impulse through the heart. 4. Relate the circulation of blood through the heart and great vessels. 5. Discuss the significance of jugular vein assessment. Learning Outcomes (cont’d) 6. Cite the risk factors associated with heart disease and stroke. 7. List the hemodynamic changes that occur with aging. 8. Perform an accurate objective heart and neck vessels assessment on a client and document findings. 9. Discuss cultural/ethnic differences related to heart disease. Key Terms Automaticity Preload Orthostatic hypotension Afterload Paroxysmal nocturnal dyspnea (PND) Apical impulse Orthopnea Arrhythmia Pulse deficit Bruit Pulse pressure Cardiac output Sinus rhythm Systole Sinus arrhythmia Diastole Murmur Dyspnea on exertion (DOE) Atrial kick Cardiovascular (CV) System Precordium, Apex and Base © Pat Thomas, 2006. Slide 19-6 Cardiovascular (CV) System CV system: heart, blood vessels & blood • Heart & great vessels lie between lungs in the thoracic cavity (mediastinum) • Apex = bottom of heart; Base = top of heart • Great vessels • Superior vena cava • Inferior vena cava • Pulmonary artery deoxygenated blood from heart to lungs • Pulmonary veins fresh oxygen to heart from lungs • Aorta Structure and Function Heart wall Valves • Pericardium surrounds & protects the heart • Atrioventricular (AV) • Tricuspid • Mitral • Myocardium • Endocardium Chambers • Atria—right and left • Ventricles—right and left • Semilunar • Pulmonic • Aortic Chambers and Valves © Pat Thomas, 2006. Slide 19-12 Cardiac Blood Flow Deoxygenated blood from body enters superior & inferior vena cava (1) enters right atrium (2) enters right ventricle (3) through tricuspid valve pumped into pulmonary arteries (4) through pulmonic valve goes to lungs where CO2 removed & replaced with fresh O2 re-oxygenated blood returns through pulmonary veins (5) to the left atria (6) enters left ventricle (7) through mitral valve pumped through aortic valve to the aorta (8) fresh oxygenated blood to entire body R&L Common Carotid Arteries Superior Vena Cava Left Subclavian Artery Lungs Lungs LUNGS Direction of Blood Flow Cardiac Cycle Composed of 1 heart beat has 2 phases: 1. Diastole resting phase of the heart both ventricles relax & fill with blood takes up 2/3 of cardiac cycle time (Remember MAP?) 2. Systole contraction of both ventricles right ventricle pumps blood into the pulmonary arteries to take to the lungs for re-oxygenation and left ventricle pumps reoxygenated blood into aorta for delivery to the body tissues takes up 1/3 of cardiac cycle time Conduction Automaticity Electrical Conduction • Sinoatrial (SA) node pacemaker • Atrioventricular (AV) node • Bundle of his • Left & right bundle branches • Purkinje Fibers ECG ECG: PQRST • P wave: atrial contraction (depolarization) (“atrial kick”) • PR interval • QRS complex: ventricular contraction (depolarization) • T wave: ventricular repolarization • Go to: http://skillstat.com/learn.htm Cardiac Conduction System Right & left bundle branches Purkenjie fibers THE CARDIAC CYCLE Heart Sounds 1. First heart sound (S1) closure of atrioventricular (AV) valves (tricuspid & mitral valves); signals beginning of systole 2. Second heart sound (S2) closure of semilunar valves (pulmonic & aortic valves); signals end of systole 3. Split S2 normal with inspiration 4. Extra heart sounds • Third heart sound (S3) • Fourth heart sound (S4) 5. Murmurs sound of blood circulating through heart chambers or valves usually d/t defects in valves Go to: http://www.med.ucla.edu/wilkes/Physiology.htm Cardiac cycle Diastole Systole Events in the right and left sides Cardiac Output (CO) SV (stroke volume) X R (rate) = CO Example: 100ml X 60 HR = 6L/min CO Preload = amount of blood in ventricles before systole (contraction of ventricles) Afterload = resistance of filled aortic artery pressure against which the left ventricle must pump its blood. Slide 19-24 Neck Vessels Left & right carotid arteries Left & right jugular veins • Internal jugular • External jugular Increased jugular venous pressure & distention (JVD) signals right-sided heart failure Slide 19-26 The Aging Adult Incidence of CV disease increases with age. CAD increases sharply with age & accounts for about 50% of deaths in older people Hypertension & heart failure increase with age. Modifiable lifestyle habits: • Smoking • Diet • Alcohol (ETOH) use • Exercise patterns • Stress • Sedentary lifestyle The Aging Adult (cont’d) Non-modifiable hemodynamic changes • Systolic BP increases d/t arteriosclerosis (stiffening of arteries) increased workload on left ventricle leads to thickening of muscle fibers • Diastolic pressure does not increase but increased systolic pressure leads to increased pulse pressure (difference between diastolic & systolic BP) • No change in resting heart rate or cardiac output at rest • Decreased ability to increase cardiac output (CO) with exercise The Aging Adult (cont’d) Non-modifiable hemodynamic changes (cont’d) • Arrhythmias may decrease cardiac output and BP may experience syncope d/t decreased cerebral blood flow • Cardiac Arrhythmia: • http://www.learnerstv.com/animation/animatio n.php?ani=202&cat=BiologyAutomaticity • ECG changes d/t changes in conduction system: prolonged P-R interval (first-degree heart block) & increased incidence of bundle branch block Risk Factors for Heart Disease & Stroke Hypertension Smoking High cholesterol levels Obesity Physical inactivity Diabetes Cultural & Genetics Risk factors for stroke and heart disease High blood pressure (HTN) -- black adults #1 Smoking Cholesterol – black adults lower than white & Mexican-Americans Obesity (BMI >30) or overweight (BMI >25) – All in 70%: blacks; Mexican-Americans; whites. Asians 25% Physical inactivity Diabetes Type 2 – increasing across all age & ethnic groups; American Indians >2x the rate of U.S. adults overall. Subjective Data— Health History Questions Chest pain onset, location, radiation, character, exertional or at rest, other s/sx, NTG Dyspnea exertional or at rest, positional, constant or intermittent, awakens at night (paroxysmal nocturnal dyspnea occurs with heart failure) Orthopnea # of pillows used when supine Cough duration, frequency, productive Fatigue onset, related to time of day Cyanosis or pallor Health History Questions (cont’d) Edema swelling of hands or feet, severity, resolve at night, other s/sx Nocturia frequency, how long Cardiac history HTN, high cholesterol, heart disease, rheumatic fever, surgery Family cardiac history HTN, CAD, sudden death at early age Personal habits (cardiac risk factors) For Aging Adults: • Any known heart or lung disease • Medications • Environment Objective Data—The Physical Exam Equipment needed: Stethoscope Carotid arteries • Palpate • Auscultate for bruits Jugular veins Inspect for jugular vein distention (JVD) occurs with right-sided heart failure Precordium • Inspect the anterior chest • Palpate the apical impulse 4th or 5th interspace, midclavicular line Objective Data—The Physical Exam (cont.) Auscultate the heart sounds • First, identify S1 and S2 (S1 is louder than S2 at the apex & coincides with carotid artery pulse; S2 is louder at the base) • Note the rate and rhythm rhythm should be regular but sinus arrhythmia occurs normally in young adults & children increases with inspiration, slows with expiration • Listen for extra heart sounds • Listen for murmurs • http://solutions.3m.com/wps/portal/3M/en_US/Littman n/stethoscope/education/heart-lung-sounds Palpate radial pulse calculate pulse deficit if present (difference between apical pulse & radial pulse) Objective Data—The Physical Exam (cont.) Characteristics of normal heart sounds • First heart sound (S1) • Second heart sound (S2) • Split S2 normal splitting is associated with inspiration Extra heart sound • Third heart sound (S3) • Fourth heart sound (S4) Murmurs The aging adult Auscultatory Areas Clinical Portrait of Heart Failure Slide 19-38 Sample Charting Sample Charting (cont.)