Decreased cardiac output due to the heart pump failing
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Transcript Decreased cardiac output due to the heart pump failing
Heart & Neck Vessels
CHAPTER 19 - JARVIS
Overview
Neck
Carotid pulse – observe and palpate
Observe jugular venous pulse
Estimate jugular venous pressure
Precordium
Inspection and palpation
Describe location of apical pulse
Note any heave (lift) or thrill
Auscultation
Identify anatomic areas noting rate and rhythm
Listen in systole and diastole for murmurs
Repeat with bell
Listen at apex and base
Cardiovascular System
Consists of the Heart and
Blood Vessels
Position & Surface Landmarks
Precordium: area on anterior chest directly overlying
the heart and great vessels
Mediastinum: area between the lungs in the middle
third of the thoracic cage
Heart: top is the broader base & bottom is the apex
Apical Impulse: 5th intercostal space, 7-9cm from
midsternal line
Great Vessels: superior & inferior vena cava;
pulmonary artery; pulmonary veins; aorta
Position & Surface Landmarks
Heart Wall, Chambers, & Valves
Heart Wall: Pericardium,
Myocardium, &
Endocardium
Chambers: Atria &
Ventricles; right & left
Valves
Atrioventricular
Semi lunar
Blood Flow
Blood flow animation
Heart Sounds
Conduction
P wave: depolarization
of aorta
PR interval: beginning
of P wave to beginning of
QRS (atrial depolarization
& impulse through AV node)
QRS complex: depolarization
of ventricles
T wave: repolarization of
ventricles
Conduction You tube
Pumping Ability
Cardiac Output: normally 4-6 Liters of blood per
minute
Cardiac Output = Stroke Volume x Rate
Preload: venous return that builds during diastole;
ventricular muscle is stretched before contraction
Afterload: opposing pressure the ventricle must
generate to open the aortic valve against the higher
aortic pressure; resistance against which ventricle
must pump its blood
Neck Vessels
Carotid Arteries
Jugular Veins:
Internal and external
History: Subjective Data
Chest pain
Nocturia
Dyspnea
Past cardiac history
Orthopnea
Family cardiac history
Cough
Personal habits (cardiac
Fatigue
Cyanosis or pallor
Edema
risk factors)
Objective Data
Neck Vessels
Neck Vessels
Inspect Jugular Venous Pulse – assessing central
venous pressure
Stand on patient’s right side
Position patient supine from 30-45 degree angle; Pulsation
may be seen the sternal notch
At 45 degree angle, jugulars should disappear
Inspect carotid pulsations
Neck Vessel Exam
Neck Vessels
Palpate Carotid Artery
One at a time
Avoid excessive pressure
Normal: smooth with 2+ strength
Auscultate Carotid Artery
Listen for presence of bruit (blowing or swishing sound)
Apply bell of the stethoscope at angle of jaw, midcervical area,
and base of the neck
Person can take breath, exhale, and hold while you listen so no
sound is masked
Neck Vessels
Jugular Venous Pressure
Use angle of Louis as arbitrary
reference point, and compare it
with highest level of venous
pulsation
Hold a vertical ruler on sternal
angle
Align a straight edge on ruler
like a T-square, and adjust level
of horizontal straight edge to
level of pulsation
Read level of intersection on
vertical ruler; normal jugular
venous pulsation is 2 cm or less
above sternal angle
State person’s position, e.g.,
“internal jugular vein
pulsations 3 cm above sternal
angle when elevated 30
degrees”
Chest
Inspect Anterior Chest
Pulsations: may or may not see apical impulse at 4th intercostal
space at or inside the midclavicular line
Palpate the Apical Impulse
Ask the person to exhale and hold
Use 1 finger pad
Note: location (4th or 5th intercostal space), size (1 x 2 cm),
amplitude (short, gentle tap), duration (short)
May not be palpable in all adults
Chest
Palpate Across
Precordium
Use palmar aspects of 4
fingers, or ulnar surface of
hand and gently palpate
Normally no findings
Percussion
Used to outline the heart’s
border
Not done as much because
of availability of chest xray and/or
echocardiography
Chest
Auscultation
4 traditional valve “areas”
2nd right interspace – aortic
valve area
2nd left interspace –
pulmonic valve area
Left lower sternal border –
tricuspid valve area
5th interspace, left
midclavicular line – mitral
valve area
Auscultate in Z pattern from
base of heart, across and down,
then over to apex
Traditionally
Aortic area, pulmonic area,
Erb’s point, tricuspid area,
mitral area “ APE –To-Man”
Chest
Chest
Rate: 50-90 bpm
Rhythm: regular
Heart Sounds
http://www.wilkes.med.ucla.edu/i
nex.htm
Identify S1 & S2: lub-dup
S1 louder at apex = closure of AV valves, beginning of systole
S2 louder at base = closure of semilunar valves
Focus on systole, then diastole, then listen for extra
heart sounds
Listen for murmurs
Describe by timing, loudness, pitch, pattern, quality, location,
radiation, posture
Variation in S1
Factors: Position of AV valve at start of systole,
change in valve structure, & pressure in the
ventricles
1. Loud S1
2. Faint S1
3. Varying Intensity of S1
4. Split S1
Variations in S2
Accentuated S2
Diminished S2
Split S2
Normal: occurs during inspiration
Fixed Split: unaffected by respiration
Paradoxical Split: occurs during expiration
Wide Split: wide on inspiration and still present with
expiration
Extra Systolic Sounds
Ejection Click: sound of the SL valves opening; best
heard with diaphragm; aortic at 2nd right
interspace and apex; pulmonic at 2nd left
interspace
Aortic Prosthetic Valve Sounds: early systolic
sound
Midsystolic Click: associated with mitral valve
prolapse; sound is short and high pitched; best
heard with the diaphragm at the apex;
Extra Diastolic Sounds
Early Diastole
Opening Snap: opening of AV valves
Mitral Prosthetic Valve Sound: opening click just after S2
Mid-diastole
Third Heart Sound: S3 – ventricular filling sound, low
pitched, like “distant thunder”; heard at the apex or left
lower sternal border with the bell
Physiologic: frequently heard in children and young adults;
disappears when sitting up
Pathologic: Ventricular Gallop – indicates decreased
compliance of the ventricles (heart failure)
Discuss how you differentiate an S3 from a Split S2
Extra Diastolic Sounds
Late Diastole
Fourth Heart Sound: S4 – ventricular filling sound, soft and
low pitched; heard at the apex with person in left lateral
position with the bell
Physiologic: found in adults older than 40
Pathologic: Atrial Gallop – decreased compliance of the ventricles
(CAD, cardiomyopathy, systemic HTN)
Summation Sound: S3 & S4 present
Extra Cardiac Sounds
Pericardial Friction Rub: inflammation of the
pericardium; high pitched and scratchy best heard
with the diaphragm
Murmurs
Identified by
Where they are heard on the chest
Where they occur in the cardiac cycle- Systolic/Diastolic
Loudness- graded I-VI
Pitch- low to high
Variation in loudness- Crescendo/Decrescendo, pan
Systolic Murmurs
Aortic Stenosis: loud, harsh, midsystolic; loudest at
2nd right interspace
Pulmonic Stenosis: medium, coarse, systolic;
loudest at 2nd left interspace
Mitral Regurgitation: pansystolic, loud, blowing;
loudest at apex
Triscupid Regurgitation: pansystolic, soft, blowing;
loudest at left lower sternal boarder
Diastolic Murmurs
Mitral Stenosis: low-pitched, diastolic; best heard at
the apex with person in left lateral position
Tricuspid Stenosis: rumbling, diastolic; best heart at
left lower sternal boarder, louder on inspiration
Aortic Regurgitation: soft, high-pitched, blowing,
diastolic; best heard at 3rd left interspace at the base
Pulmonic Regurgitation: same as aortic regurgitation
Developmental Considerations
Infants
Subjective
Mother’s health during pregnancy
Any cyanosis
Growth
Activity
Objective
Fetal shunts close between 10-15 hours but may take up to 48
hours (may have murmurs until shunts close)
Apical impulse: palpate at the 4th intercostal space, lateral to
the midclavicular line
Heart rate: 120-140 bpm
Sinus arrhythmia with respirations
S2 higher pitched and sharper than S1
Children: Subjective
Growth
Activity
Unexplained joint pain or fevers (strep throat,
rheumatic fever)
Frequent headaches or nosebleeds
Frequent respiratory infections
Family History
Children: Objective
Signs of heart disease: poor weight gain, developmental
delay, persistent tachycardia, tachypnea, dyspnea on
exertion, cyanosis, clubbing
Apical impulse may be visible
4th intercostal space left of the midclavicular line until age 4;
4th intercostal space at midclavicular line age 4-6;
5th intercostal space right of midclavicular line at age 7;
Heart rate slows down
Sinus arrhythmia common; Physiologic S3 is common
Venous hum is common
Heart murmurs may occur and are functional
Pregnant Woman: Subjective
Blood pressure
Usual blood pressure before pregnancy
Blood pressure during pregnancy
Treatments
Associated symptoms
Fainting or Dizziness
Pregnant Woman: Objective
Resting pulse rate increase of 10-15 bpm
Blood pressure 2nd trimester, 3rd trimester
Apical impulse higher and lateral than normal
Increased blood volume causes:
Exaggerated splitting of S1, increased loudness of S1
Loud S3
Heart murmurs
Aging Adult: Subjective
Heart or lung disease
Treatment
Symptoms
Medications for any illness
Environment
Aging Adult: Objective
Gradual rise in systolic blood pressure is common
Orthostatic hypotension
AP chest diameter increases
Carotid artery stenosis
S4 may occur with no known cardiac disease
S3 indicates heart failure
Systolic murmurs are common
ABNORMAL FINDINGS
Heart Failure
Decreased cardiac output due to the heart pump failing
Dilated pupils
Gray, pale, or cyanotic
skin; cool skin
Anxiety or confusion
Decreased O2 saturation
Dyspnea
Orthopnea
Jugular vein distention
Crackles/Wheezes in the
lungs
Cough
Weak pulse
Decreased blood
pressure
S3 gallop/ tachycardia
Nausea and vomiting
Ascites
Edema
Fatigue
Enlarged spleen and liver
Decreased urine output
Congenital Heart Defects
Atrial Septal Defect (ASD): abnormal opening in
the atrial septum, results in left-to-right shunting
Ventricular Septal Defect (VSD): abnormal
opening in the septum between ventricles
Tetralogy of Fallot: shunts venous blood into the
aorta, blood is not being oxygenated; severe
cyanosis
Coarctation of the Aorta: severe narrowing of the
aorta