What do you call the anterior chest area that overlies the heart and great vessels?

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Nursing Assessment of the Heart and Neck vessels

Nursing Assessment of the Heart and Neck vessels

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1. 1. Assessment of the Heart and Peripheral vessels Maria Carmela L. Domocmat, MSN, RN Associate Professor, College of Nursing Manila Adventist College
2. 2. Anatomy Heart 8/14/2017 2Maria Carmela L. Domocmat, RN, MSN
3. 3. Heart  extends vertically  L, 2nd to 5th  horizontally  R edge sternum to L MCL  inverted cone o base – upper portion – near L 2nd ICS o apex – lower portion – near L 5th ICs and L MCL 8/14/2017 3Maria Carmela L. Domocmat, RN, MSN
4. 4.  precordium  anterior chest that overlies the heart and great vessels  great vessels  large veins and arteries leading directly to and away from heart 8/14/2017 4Maria Carmela L. Domocmat, RN, MSN
5. 5.  great vessels includes: o sup and inf vena cava o pulmo artery, pulmo veins (2 from each lung) o Aorta  septum – separates the R and L sides of heart 8/14/2017 5Maria Carmela L. Domocmat, RN, MSN
6. 6. Valves o AV o at entrance into ventricles  tricuspid – R; bet R atrium and R ventricle  bicuspid (mitral) – L ; bet L atrium and ventricle  chordae tendinae- anchor AV valve flaps to papillary muscles within ventricles; prevent reverse open of AV valves 8/14/2017 6Maria Carmela L. Domocmat, RN, MSN
7. 7. Valves o semilunar valves – at exit of each ventricle at beginning of great vessels  has 3 cusps or flaps that looks like half- moons  open - during ventricular contraction  close – from pressure of ventricle when ventricles relax  prevent blood from flowing backward into relaxed ventricles 8/14/2017 7Maria Carmela L. Domocmat, RN, MSN
8. 8. Valves o semilunar valves – at exit of each ventricle at beginning of great vessels  pulmonic valve – at entrance of pulmo artery as it exits the R ventricle  aortic valve - at beginning of ascending aorta as it exists L ventricle 8/14/2017 8Maria Carmela L. Domocmat, RN, MSN
9. 9. Covering and Walls  pericardium – tough, inextensible, loose-fitting, fibroserous sac that attaches to great vessels and surrounds heart  parietal pericardium – serous membrane lining o secretes small amount of pericardial fluid that allows for smooth, friction-free movement of heart 8/14/2017 9Maria Carmela L. Domocmat, RN, MSN
10. 10. Covering and Walls  epicardium – covers outer surface; also has serous membrane lining  myocardium – thickest layer; made up of contractile cardiac muscle cells  endocardium – thin layer of endothelial tissue; forms innermost layer; continuous with endothelial lining of blood vessels 8/14/2017 10Maria Carmela L. Domocmat, RN, MSN
11. 11. Electrical Conduction 8/14/2017 11Maria Carmela L. Domocmat, RN, MSN
12. 12. The Cardiac Cycle  refers to filling and emptying of heart’s chambers  two phases: diastole & systole o diastole – filling; relaxation of ventricles  2/3 of cardiac cycle o systole – emptying; contraction of ventricles  1/3 of cardiac cycle 8/14/2017 12Maria Carmela L. Domocmat, RN, MSN
13. 13. The Cardiac Cycle Diastole Systole 8/14/2017 13Maria Carmela L. Domocmat, RN, MSN
14. 14. Diastole early or protodiastolic filling presystole or atrial systole 8/14/2017 14Maria Carmela L. Domocmat, RN, MSN
15. 15. Diastole o early or protodiastolic filling – early, rapid. passive filling  AV valves open  ventricles relaxed  this causes higher pressure in atria than in ventricles  therefore – blood rushes thru atria into ventricles 8/14/2017 15Maria Carmela L. Domocmat, RN, MSN
16. 16. Diastole o followed by period of slow passive filling o presystole or atrial systole – ―atrial kick‖ – final active filing phase  atria contract— near the end of ventricular diastole  this complete emptying of blood out of upper chambers by propelling into ventricles  this raises L ventricular pressure 8/14/2017 16Maria Carmela L. Domocmat, RN, MSN
17. 17. Systole o filling phases during diastole –result in large amt of blood in ventricles  this causes the pressure in ventricles to be higher than in atria  this causes the valves (mitral & tricuspid) to shut 8/14/2017 17Maria Carmela L. Domocmat, RN, MSN
18. 18. Systole o closure of AV valves  produces 1st heart sound (S1); beginning of systole  prevents blood from flowing backward (regurgitation) into atria during ventricular contraction 8/14/2017 18Maria Carmela L. Domocmat, RN, MSN
19. 19. o isometric contraction  at this point – all 4 valves are closed and ventricles contract  there is now high pressure inside ventricles  causing (1) aortic valve to open on L side of heart; (2) pulmonic valve to open on R side  blood is ejected rapidly thru these valves 8/14/2017 19Maria Carmela L. Domocmat, RN, MSN
20. 20. o with ventricular emptying – the ventricular pressure falls and semilunar valves close  this closure produces the 2nd heart sound (S2); end of systole o after closure semilunar valves – ventricles relax o atrial pressure is now higher than ventricular pressure  causing AV valves to open and diastolic filing to being again 8/14/2017 20Maria Carmela L. Domocmat, RN, MSN
21. 21. HEART SOUNDS 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 21
22. 22. Heart Sounds  produced by valve closure  opening of valve is silent  normal heart sounds o ―lub dubb‖ o occasionally – extra heart sounds and murmurs are auscultated 8/14/2017 22Maria Carmela L. Domocmat, RN, MSN
23. 23. Heart Sounds Heart Valves Act as one-way doors, making sure that blood flows in the correct direction through the heart. Tricuspid valve Mitral valve Pulmonary valve Aortic valve 8/14/2017 23Maria Carmela L. Domocmat, RN, MSN
24. 24. atrio-ventricular valves (A-V valves) openings leading to the right and left ventricles first heart sound that we hear on the chest wall occurs when these A-V valves close; this heart sound is called S1. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 24
25. 25. Heart Valves Tricuspid Valve • right A-V valve • between right atrium & right ventricle Bicuspid Valve • left A-V valve • between left atrium & left ventricle Pulmonary Valve • semilunar valve • between right ventricle & pulmonary trunk Aortic Valve • semilunar valve • between left ventricle & aorta 15-7
26. 26. Skeleton of Heart • fibrous rings to which the heart valves are attached 15-10
27. 27. Heart Valves Pulmonary and Aortic Valve
28. 28. semilunar valves openings leading to the pulmonary trunk and aorta pulmonic valve and the aortic valve second heart sound occurs when these semilunar valves close: these heart sounds is called S2. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 28
29. 29. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 29
30. 30.  S1 – ―lub‖ o result of closure of AV valves (mitral and tricuspid) o correlates with beginning of systole o heard over entire precordium – heard best at apex (L MCL, 5th ICS) 8/14/2017 30Maria Carmela L. Domocmat, RN, MSN
31. 31.  S2 – ―dub‖ o result from closure of semilunar valves (aortic and pulmonic) o correlates with beginning of diastole o heard over base o splitting of S2 – may be exaggerated during inspiration and disappear during expiration 8/14/2017 31Maria Carmela L. Domocmat, RN, MSN
32. 32.  Extra heart sounds o S3 and S4 - referred as diastolic filing sounds or extra heart sounds 8/14/2017 32Maria Carmela L. Domocmat, RN, MSN
33. 33. Extra heart sounds o S3  can be heard early in diastole, after S2  often termed ventricular gallop  results from ventricular vibration secondary to rapid ventricular filling 8/14/2017 33Maria Carmela L. Domocmat, RN, MSN
34. 34. Extra heart sounds o S4 -  heard late in diastole, just before S1  often termed atrial gallop  results from ventricular vibration secondary to rapid ventricular resistance (noncompliance) during atrial contraction 8/14/2017 34Maria Carmela L. Domocmat, RN, MSN
35. 35. Murmurs 8/14/2017 35Maria Carmela L. Domocmat, RN, MSN
36. 36. Murmurs o blood normally flows silently through heart o there are conditions that can create turbulent blood flow in which swooshing or blowing sound may be auscultated over precordium 8/14/2017 36Maria Carmela L. Domocmat, RN, MSN
37. 37. Murmurs o conditions that contribute to turbulent blood flow include  increased blood velocity  structural valve defects  valve malfunction  abnormal chamber openings (e.g., septal defect) 8/14/2017 37Maria Carmela L. Domocmat, RN, MSN
38. 38. Cardiac Output (CO) 8/14/2017 38Maria Carmela L. Domocmat, RN, MSN
39. 39. Cardiac Output (CO)  the amount of blood pumped by ventricles during a given period of time (usually 1 min)  determined by stroke volume (SV) multiplied by heart rate (HR): SV x HR = CO  normal adult CO is 5 to 6 L/min 8/14/2017 39Maria Carmela L. Domocmat, RN, MSN
40. 40.  SV o amount of blood pumped from heart with each contraction o SV from L ventricle is usually 70 ml 8/14/2017 40Maria Carmela L. Domocmat, RN, MSN
41. 41. Factors that influence SV  degree of stretch of the heart muscle up to a critical length before contraction (preload)  the greater the preload – the greater the SV  unless heart muscle is stretched so much that is cannot contract effectively 8/14/2017 41Maria Carmela L. Domocmat, RN, MSN
42. 42. Factors that influence SV  pressure against which heart muscle has to eject blood during contraction (afterload)  increased afterload results in decreased SV  synergy of contraction  i.e, uniform, synchronized contraction of myocardium  conditions that cause an asynchronous contraction decrease SV 8/14/2017 42Maria Carmela L. Domocmat, RN, MSN
43. 43. Factors that influence SV  compliance or distensibility of ventricles  decreased compliance decreased SV  contractility or force of contraction of myocardium under loading conditions 8/14/2017 43Maria Carmela L. Domocmat, RN, MSN
44. 44. 8/14/2017 44Maria Carmela L. Domocmat, RN, MSN
45. 45. HEALTH HISTORY 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 45
46. 46. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 46
47. 47. Present Health History Q: Do you experience chest pain? When did it start? Describe the type of pain, location, radiation, duration, and how often you experience the pain. Rate the pain on a scale 0 to 10, with being the worst possible pain. Does activity make the pain worse? Did you have perspiration (diaphoresis) with the chest pain? 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 47
48. 48. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 48
49. 49. Present Health History R: Chest pain can be cardiac, pulmonary, muscular, or GIT in origin. Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Diaphoresis and pain worsened by activity are usually related to cardiac chest pain. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 49
50. 50. Q: Do you experience palpitations? R: Palpitations may occur with an abnormality of the heart’s conduction system or during the heart’s attempt to increase cardiac output by increasing the heart rate. Palpitations may cause the client to feel anxious. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 50
51. 51. Q: DO you tire easily? Do you experience fatigue? Describe when the fatigue started. Was it sudden or gradual? Do you notice it at any particular time day? R: Fatigue may result from compromised cardiac output. Fatigue related to decrease cardiac output is worse than the evening or as the day progresses. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 51
52. 52. Q: Do you have difficulty breathing or shortness of breath (dyspnea)? R: Dyspnea may result from congestive heart failure pulmonary disorders, coronary artery disease, myocardial ischemia, and myocardial infarction. Dyspnea may occur at rest, during sleep, or with mild, moderate or extreme exertion. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 52
53. 53. Q: Do you wake up at night with an urgent need to urinate (nocturia)? How many times a night? R: Increase renal perfusion during periods at rest or recumbency may cause nocturia. Decreased frequency may be related to decrease cardiac output. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 53
54. 54. Q: Do you experience dizziness? R: Dizziness may indicate decreased blood flow to the brain due to myocardial damage; however, there are several other causes for dizziness such as inner ear syndromes, decreased cerebral circulation and hypotension. Dizziness may put the client at risk for falls. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 54
55. 55. Q: Do you experience swelling (edema) in your feet, ankles or legs? R: Edema of the lower extremities may occur as a result of heart failure. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 55
56. 56. Q: Do you have frequent heart burn? When does it occur? What relieves it? How often do you experience it? R: Cardiac pain may be overlooked or misinterpreted as GIT problems. GIT pain may occur after meals, and is relieved with antacids, whereas cardiac pain may occur anytime, is not relieved with antacids and worsens with activity 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 56
57. 57. Family health History Q: Is there a history of hypertension, myocardial infarction, coronary heart disease, elevated cholesterol levels, or diabetes mellitus in your family? R: A genetic predispositions to these risk factors increases a client’s chance for development of heart disease. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 57
58. 58. Lifestyle and Health Practices Q: Do you smoke? How many packs of cigarettes per day and how many years? R: Cigarette smoking greatly increases the risk of heart disease. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 58
59. 59. Q: What type of stress do you have in your life? How do you cope with it? R: Stress has been identified as a possible risk factor for heart disease. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 59
60. 60. Q: Describe what you usually eat in a 24-hour period. R: An elevated cholesterol level increases the chance of fatty plaque formation in the coronary vessels. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 60
61. 61. Q: How much alcohol do you consume each day/week? R: Excessive intake of alcohol has been linked to hypertension. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 61
62. 62. Q: Do you exercise? What type of exercise and how often? R: A sedentary lifestyle is known modifiable risk factor contributing to heart disease. Aerobic exercise three times per week for 30 minutes is more beneficial than anaerobic exercise or sporadic exercise in preventing heart disease. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 62
63. 63. Q: Describe your daily activities. How are they different from your routine 5 or 10 years ago? Does fatigue, chest pain, or shortness of breath limit your ability to perform daily activities? Describe. Are you able to care for yourself? R: Heart disease may impede the ability to perform daily activities. Exertional dyspnea or fatigue may indicate heart failure. An inability to complete activities of daily living may necessitate a referral for home care. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 63
64. 64. Q: Has your heart disease had any effect on your sexual activity? R: Many clients with heart disease are afraid that sexual activity will precipitate chest pain. If the client can walk one block or climb two flights of stairs without experiencing symptoms, it is generally acceptable client to engage in sexual intercourse. Nitroglycerin can be taken before intercourse as prophylactic for chest pain. In addition, the side- lying position for sexual intercourse may reduce the workload on the heart. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 64
65. 65. Q: How many pillows do you use to sleep at night? Do you get up to urinate during the night? Do you feel rested in the morning? R: If heart function is compromised, cardiac output to the kidneys is reduced during episodes of activity. At rest, cardiac output increases, as does glomerular filtration and urinary output. Orthopnea (the inability to breathe while supine) and nocturia may indicate heart failure. In addition, these two conditions may also impede the ability to get adequate rest.8/14/2017 65
66. 66. Q: How important is having a healthy heart to your ability to feel good about yourself and your appearance? What fears about heart disease do you have? R: A person’s feeling of self-worth may depend on his or her ability to perform usual daily activities and fulfill his or her usual roles. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 66
67. 67. PREPARING THE CLIENT 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 67
68. 68. • explain - need to expose the anterior chest • Female clients may keep their breast covered and may simply hold the left breast out of the way when necessary Explain need to assume several different positions for the examination. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 68
69. 69. • supine position with the head elevated to about 30 degrees.. • Auscultation and palpation of the neck vessels and • inspection, palpation and auscultation of the pericordium • left lateral position • palpation of the apical impulse • if the examiner is having trouble locating the pulse with the client in the supine position. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 69
70. 70. • left lateral and sitting-up and leaning-forward position • auscultate for the presence of any abnormal heart sounds. • These positions may bring out an abnormal sound not detected with the client in the supine position. • Make sure you explain to the client that you will be listening to a heart in a number of places and that this does not necessarily mean that any thing is wrong. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 70
71. 71. • Help ease any anxiety • Provide with such modesty as possible during the examination • describe the steps of the examination • and answer any questions the client may have. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 71
72. 72. EQUIPMENTS 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 72
73. 73. Steth with bell and diaphragm Sml pillow Penlight or movable exam light Watch with second hand Cm rulers (2) 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 73
74. 74. PHYSICAL ASSESSMENT 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 74
75. 75. ASSESSMENT OF THE HEART 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 75
76. 76. Overview 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 76
77. 77. Assessment of the Heart  Inspect pulsations  Palpate apical impulse  Palpate abnormal pulsations  Auscultate heart rate and rhythm  Auscultate heart sounds  Auscultate : pulse rate deficit 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 77
78. 78. Assessment of the Heart  Auscultate heart sounds  Auscultate heart rate and rhythm  If detect an irregular rhythm, auscultate for pulse rate deficit  Auscultate to identify S1 and S2  Auscultate for extra heart sounds  Auscultate for murmurs  Auscultate in with the client assuming other position 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 78
79. 79. Inspect pulsations Client supine position with the head of the bed elevated between 30 and 45 degrees  stand on client’s right side and look for the apical impulse and any abnormal pulsation 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 79
80. 80. Inspect pulsations o Note: apical pulse – originally called PMI (point of maximal impulse)  not used anymore – bcoz maximal impulse may occur in other areas of precordium as result of abnormalities 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 80
81. 81. Inspect pulsations o normal findings:  apical impulse – may or may not be visible  if visible – in mitral area (Left MCL, 4th or 5th ICS)  result of left ventricle moving outward during systole 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 81
82. 82. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 82
83. 83. Inspect pulsations o abnormal findings:  pulsations – or heaves or lifts –other than the apical pulsation  may occur as result of enlarged ventricle from an overload of work. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 83
84. 84. Abnormal ventricular impulses Lift Thrill Accentuated Apical Impulse Laterally displaced apical impulse 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 84
85. 85. PALPATION 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 85
86. 86. Palpate the apical impulse Remain on the client’s right side Client remain supine Use palmar surfaces of hand palpate the apical impulse in the mitral area (fourth or fifth intercostals space at the midclavicular line). After locating the pulse, use one finger pad for more accurate palpation. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 86
87. 87. Palpate the apical impulse If cannot be palpated  Have client assume left lateral position  This displaces heart toward left chest wall and relocates apical impulse farther to left Elderly  May be difficult to palpate  Bcoz of increased AP chest diameter 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 87
88. 88. Normal findings: Palpation apical impulse  apical impulse – palpated in mitral area; size – nickel (1-2 cm)  amplitude – small – like gentle tap  duration – brief; lasting thru first 2/3 of systole and often less  obese or large breasts – may not be palpable 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 88
89. 89. Normal findings: Palpation apical impulse o abnormal findings:  not palpable – pulmonary emphysema  suspect cardiac enlargement  If larger than 1 to 2cm,  displaced more forceful, or  of longer duration 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 89
90. 90. Palpate: abnormal pulsations Use palmar surfaces to palpate the apex, left sternal border, and base 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 90
91. 91. Palpate abnormal pulsations o normal findings: o No pulsations or vibrations in the areas of the apex, left sternal border, or base o abnormal findings:  thrill – feels similar to purring cat  is usually associated with Grave IV or higher murmur 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 91
92. 92. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 92
93. 93. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 93
94. 94. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 94
95. 95. AUSCULTATION 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 95
96. 96. Auscultate heart rate and rhythm Place the diaphragm of the stethoscope at the apex and listen closely to the rate and rhythm of the apical impulse. Concentrate on systematically moving the steth from left to right across entire heart area from base to apex (top to bottom) or from apex to base (bottom to top) 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 96
97. 97. Auscultate heart sounds o Traditional 5 areas  aortic area : 2nd ICS, R sternal border (base of heart)  pulmonic area : 2nd or 3rd ICS, L sternal border (base of heart)  Erb’s point : 3rd to 5th ICS, L sternal border  tricuspid area : 4th or 5th ICS, L lower sternal border  mitral or apical area : 5th ICS, L lower sternal border 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 97
98. 98. Heart Sounds
99. 99. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 99 1. 2. 3. 4. 5.
100. 100. Auscultate heart sounds o Alternative areas o (by chamber)  aortic area  pulmonic area  left atrial area  right atrial area  left ventricular area  right ventricular area 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 100
101. 101. Auscultation of heart sounds
102. 102. Auscultate heart rate and rhythm Traditional areas of auscultation  Aortic area  Pulmonic area  Erb’s point  Mitral (apical) area  Tricuspid area “Alternative” areas  Aortic area  Pulmonic area  Left atrial area  Right atrial area  Left ventricular area  Right ventricular area 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 102
103. 103. Systematically auscultate in each of the five areas while the patient is breathing regularly and holding breath for the following:  Rate, rhythm  S1 ,S2  Splitting  S3 and S4  Extra heart sound  snaps, clicks, friction rubs, or murmurs 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 103
104. 104. Normal findings: Heart rate and rhythm  60-100 bpm  regular rhythm  regularly irregular rhythm – sinus arrhythmia when HR increases with inspiration and decreased with expiration  female – 5 to 10 beats faster than male  do not differ by race or age in adults 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 104
105. 105. Abnormal findings: Heart rate and rhythm  bradycardia (‹60 bpm)  tachycardia (›100 bpm)  regular irregular rhythms (i.e., premature atrial contraction or PVC)  irregular rhythms (i.e., atrial fibrillation, atrial flutter) – may predispose client to decreased CO, heart failure, emboli 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 105
106. 106. If detect irregular rhythm, auscultate for a pulse rate deficit. Palpate radial pulse while auscultate apical pulse  Count for a full minute. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 106
107. 107. Auscultate : pulse rate deficit Normal findings  radial and apical pulse rates – identical Abnormal findings  pulse deficits  difference between apical and peripheral/radial pulse  indicate atrial fibrillation, atrial flutter, PVC, varying degrees of heart block 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 107
108. 108. S1 AND S2 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 108
109. 109. Auscultate to define S1 and S2 Auscultate the first heart sound (S1 or ―lub‖) and the second heart sound (S2 or ―dub‖). Remember these two sounds make up the cardiac cycle of systole and diastole. S1 starts systole S2 starts diastole. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 109
110. 110. Auscultate to identify S1 and S2 o S1- first heart sound  ―lub‖  the result of closure of AV valves – indicate start of systole  best heard – apex of heart; where S1 is louder than S2  lower in pitch and a bit longer than S2  occurs immediately after diastole 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 110
111. 111. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 111
112. 112. Auscultate to identify S1 and S2 o S2 – second heart sound  ―dubb‖  result of closure of semilunar valves- indicate end of systole, starts diastole  higher in pitch, shorter duration than S1 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 112
113. 113. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 113
114. 114. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 114
115. 115. Normal findings: Auscultation : S1 and S2 o S1 corresponds with each carotid pulsation and is loudest at the apex of the heart o Note: if have difficulty differentiating S1 from S2 – palpate carotid pulse o S1 – harsh sound that occurs with carotid pulse . S2 immediately follows after S1 and is loudest at the base of the heart. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 115
116. 116. Auscultate to identify S1 and S2 • abnormal findings: – ventricular impulses • lift • thrills • accentuated apical impulse • laterally displaced apical impulse – abnormal heart rhythms • premature atrial or junctional contractions • premature ventricular contractions • sinus arrhythmia • atrial fibrillation and atrial flutter with varying ventricular response 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 116
117. 117. S1 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 117
118. 118. Listen to S1 Use the diaphragm of the stethoscope to best hear S1. Intensity of S1 depends on position of mitral valve at start of systole Structure of valve leaflets How quickly pressure rises in the ventricles All these factors influence speed and amount of closure of the valve 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 118
119. 119. S1 o Normal finding  distinct sound heard in each area  loudest – apex  may become softer with inspiration  split S1 – young adults; left lateral sternal border 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 119
120. 120. S1 Normal variations Softer at base and louder at apex of heart May be split along the lower left sternal border, where tricuspid component of sound, usually too faint to be heard, can be auscultated Split S1 heard over apex – may be an S4 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 120
121. 121. S1 o abnormal finding Accentuated S1 Diminished S1 Varying S1 Split S1 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 121
122. 122. S2 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 122
123. 123. Listen to S2 o use diaphragm of steth o breathe regularly o Note: do not ask to hold breath – breath holding may cause any normal or abnormal split to subside 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 123
124. 124. Listen to S2 o normal finding  distinct sound heard in each area  loudest – base  physiologic split  split S2 – two distinct sounds of its components – A2 and P2  heard at in late inspiration at 2nd or 3rd left ICS 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 124
125. 125. Listen to S2 o abnormal finding Any split S2 heard in expiration is abnormal. The abnormal split can be one of these three types: Wide Fixed Reversed 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 125
126. 126. EXTRA HEART SOUNDS Snaps Clicks Friction rubs Murmurs 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 126
127. 127. Auscultate for extra heart sounds o 1st - use diaphragm then bell of steth o to auscultate over entire heart area o (1) auscultate during systolic pause o (2) auscultate during diastolic pause 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 127
128. 128. Auscultate for extra heart sounds o systolic pause  space between S1 and S2  short duration  that’s why occur S1 and S2occur very close together o diastolic pause  space between end of S2 and next S1  longer duration 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 128
129. 129. Auscultate during the systolic pause Auscultate during the systolic pause  space between S1 and S2 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 129
130. 130. Normal findings: Auscultation systolic pause o systolic pause o no extra heart sounds 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 130
131. 131. Abnormal findings: Auscultation systolic pause  extra heart sounds  ejection sounds or clicks  e.g., midsystolic click associated with mitral valve prolapse  friction rub – heard during systolic pause 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 131
132. 132. Auscultate during the diastolic pause Auscultate during the diastolic pause space heard between end of S2 and S1 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 132
133. 133. Normal findings: Auscultation diastolic pause Normally no sounds are heard. Other normal findings Physiologic S3 heart sound Physiologic S4 heart sound 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 133
134. 134. Normal findings: Auscultation diastolic pause  Physiologic S3  benign finding  quiet sound heard during diastole - as ventricle fill form atria  resembles rhythm of ―Tenn-es-see‖  heard at beginning of diastolic pause  Normal among:  children, adolescence, young adults  rare after age 40  usually subsides upon standing or sitting up 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 134
135. 135. Normal findings: Auscultation diastolic pause  Physiologic S4 o quiet sound o sound like ―Ken-tuc-ky‖ o occur in second phase of ventricle filling from atria o heard near the end of diastole o Normally heard among: owell-conditioned athletes oadults older than 40 or 50 with no evidence of heart dse, esp after exercise 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 135
136. 136. Abnormal findings: Auscultation diastolic pause 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 136 pathologic S3 – (ventricular gallop) pathologic S4 – (atrial gallop) summation gallop snaps friction rub
137. 137. Abnormal findings: Auscultation diastolic pause 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 137  pathologic S3 – (ventricular gallop)  ischemic heart dse, hyperkinetic states (e.g., anemia), restrictive myocardial dse
138. 138. Abnormal findings: Auscultation  pathologic S4 – (atrial gallop)  toward left side of precordium o coronary artery dse (CAD), hypertensive heart dse, cardiomyopathy , aortic stenosis  toward right side of precordium o pulmonary HTN, pulmo stenosis 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 138
139. 139. Abnormal findings: Auscultation  summation gallop  S3 and S4 pathologic sounds together - creates quadruple rhythm  friction rub  Harsh, grating sound that can be heard in both systole and diastole  caused by abrasion of inflamed pericardial surfaces (pericarditis)  Heard best with diaphragm of steth, patient sit and leaning forward 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 139
140. 140. Abnormal findings: Auscultation Note: normally no sound produced when valves open Opening snaps: abnormal diastolic sounds heard during opening of AV valve (mitral stenosis) Systolic click: result of opening of a rigid and calcified aortic or pulmonic valve during ventricular contraction 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 140
141. 141. MURMURS 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 141
142. 142. Murmur o swishing sound caused by turbulent blood flow thru heart valves or great vessels 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 142
143. 143. Heart Murmurs
144. 144. Auscultate for murmurs o use diaphragm and bell o bcoz murmurs have diff pitches o different positions & across entire heart area o bcoz murmurs occur or subside according to client’s position 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 144
145. 145. Auscultate for murmurs o normal findings:  no murmurs  innocent and physiologic midsystolic murmurs –may be present 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 145
146. 146. Auscultate for murmurs o abnormal findings:  pathologic midsystolic, pansystolic, diastolic murmurs (p.382)  types of murmur:  systolic: early, mid, late, pansystolic  diastolic: early, mid, late, pandiastolic 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 146
147. 147. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 147
148. 148. AUSCULTATE : DIFFERENT POSITION 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 148
149. 149. Auscultate in with the client assuming other position o (1) client assume left lateral position  use bell – apex of heart o (2) client sit up, lean forward, and exhale  use diaphragm – apex, along left sternal border 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 149
150. 150. Auscultation: Other position o Normal findings:  S1 and S2 heart sounds present 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 150
151. 151. Auscultate in with the client assuming other position o Abnormal findings:  heard when client assume left lateral position  S3 and S4 or murmur  not detected on supine – indicate mitral stenosis  murmur from aortic regurgitation  May be heard sit up, lean forward, and exhale 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 151
152. 152. CLINICAL PEARLS 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 152
153. 153. Heart sounds  It is a common to try to hear all of the sounds in the cardiac cycle at one time. Take the time to isolate each sound and each pause in the cardiac cycle, listening separately and selectively for as many beats as necessary to evaluate the sounds. It takes time to tune in, so you must not rush. Avoid jumping the stethoscope from one site to another; instead, inch the endpiece along the route. This maneuver prevents missing important sounds, particularly more widely transmitted abnormal sounds, and it allows tracking of a sound from its loudest point to its farthest reach (e.g. into the axilla or the back). 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 153
154. 154. The infant heart and liver If heart failure is suspected, note that the infants liver may enlarged before there is any of moisture in the lungs, and that the left lobe of the liver may be more distinctly enlarged than the right. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 154
155. 155. Chest wall thickness The heart of an infant or child, particularly a preschool child, is very close to the chest wall; thus it is much easier to hear the innocent sounds cause by the necessary rush of the cardiovascular system. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 155
156. 156. DOCUMENTATION 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 156
157. 157. Sample of subjective data: No chest pain, dyspnea, dizziness or palpitations. No previous history of cardiovascular diseases. Denies rheumatic fever, no current medications or treatment. Denies family history of hypertension, myocardial infarction, CAD, high cholesterol levels, or diabetes mellitus. Has never had an ECG, states he needs to exercise more and consume less fat. Client does not monitor own pulse or blood pressure. Denies the use of tobacco. Sleeps 6-8 hours per night. Feels rested after sleep. States that job can be somewhat stressful. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 157
158. 158. Sample of objective data: Carotid pulse equal bilaterally, 2+, elastic. No bruits auscultated over carotids. Jugular venous pulsation disappears when upright. Jugular venous pressure x 2 cm. no visible pulsations, heaves or lifts on pericardium. Apical impulse palpated in the 5th ICS, at the left MCL, approximately the size of a nickel, with no thrill. Apical heart rate auscultated, 70 beats per min,, regular rhythm, S1 heard best at apex, S2 heard best at base. No S3 or S4 auscultated. No splitting of heart sound, snaps, clicks, or murmurs noted 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 158
159. 159. NECK VESSEL ASSESSMENT 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 159
160. 160. Neck vessel Observe for jugular venous pulse Evaluate jugular venous pressure Auscultate carotid arteries Palpate carotid arteries 8/14/2017 160Maria Carmela L. Domocmat, RN, MSN
161. 161. Observe for jugular venous pulse o normal findings: o jugular venous pulse – not visible when sitting upright; visible on supine 8/14/2017 161Maria Carmela L. Domocmat, RN, MSN
162. 162. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 162
163. 163. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 163
164. 164. Observe for jugular venous pulse o abnormal findings: o visible jugular venous pulse – right ventricular failure, pulmo htn, pulmo emboli, cardiac tamponade 8/14/2017 164Maria Carmela L. Domocmat, RN, MSN
165. 165. Evaluate jugular venous pressure o normal findings:  jugular vein – not distended, bulging, or protruding at 45 degrees or greater 8/14/2017 165Maria Carmela L. Domocmat, RN, MSN
166. 166. Evaluate jugular venous pressure o abnormal findings:  distended, bulging, or protruding at 45 degrees or greater – right sided heart failure  document at which positions you observe distention  elevated venous pressure on expiration – obstructive pulmonary disease  elevated venous pressure on inspiration – Kussmaul’s sign – severe constrivtive pericarditis 8/14/2017 166Maria Carmela L. Domocmat, RN, MSN
167. 167. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 167
168. 168. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 168
169. 169. AUSCULTATE & PALPATE CAROTID ARTERIES 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 169
170. 170. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 170
171. 171. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 171
172. 172. Observing Jugular Venous Pulse & Evaluating Jugular venous pressure
173. 173. Auscultate carotid arteries Note: always auscultate first before palpating – palpation may increase or slow the HR, therefore, changing strength of impulse 8/14/2017 173Maria Carmela L. Domocmat, RN, MSN
174. 174. Auscultate carotid arteries o normal findings:  no blowing or swishing sound or other sounds 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 174
175. 175. Auscultate carotid arteries o abnormal findings:  bruit  blowing or swishing sound; cause- turbulent blood flow thru narrowed vessel  occlusive arterial disease  no bruit heard – if more than 2/3 artery occluded 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 175
176. 176. Palpate carotid arteries o Note: if detect occlusion during auscultation – palpate very lightly  to avoid blocking circulation or triggering vagal stimulation and bradycardia, hypotension, or cardiac arrest 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 176
177. 177. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 177
178. 178. Palpate carotid arteries o normal findings:  pulses – equally strong; 2+; no variation in strength  contour  smooth and rapid on upstroke  slower and less abrupt on down stroke  arteries – elastic and no thrills noted 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 178
179. 179. Pulse Amplitude Scale 0 = Absent 1+ = Weak 2+ = Normal 3+ = Increased 4+ = Bounding 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 179
180. 180. Palpate carotid arteries o abnormal findings:  unequal pulse – arterial constriction or occlusion in 1 carotid  weak pulse – hypovolemia, shock, decreased CO  bounding, firm pulse – hypervolemia or increased CO  variations in strength from beat to beat  delayed upstroke – aortic stenosis  loss of elasticity – arteriosclerosis  thrills – narrowing of artery 1808/14/2017 Maria Carmela L. Domocmat, RN, MSN
181. 181. NURSING DIAGNOSES
182. 182. Wellness Readiness for enhanced cardiac output Health seeking behavior: Desired information on exercise and low fat diet
183. 183. Risk Diagnoses Risk for sexual dysfunction related to misinformation or lack of knowledge regarding sexual activity and heart disease Risk for ineffective denial related to smoking and obesity
184. 184. Actual Diagnoses Fatigue related to decreased cardiac output Activity intolerance related to compromised oxygen transport secondary to heart failure Acute pain: Cardiac related to an inequality between oxygen supply and demand Ineffective tissue perfusion related to impaired circulation.
185. 185. References Weber J; Kelly J. (2007). Health assessment in nursing (3rd ed.) Philadelphia: Lippincott Williams and Wilkins. National Institute of Health. (n.d.). Heart Diseases. Retrieved from www.nlm.nih.gov/medlineplus/heartdiseases.ht ml - Health Information-MedlinePlus 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 185

Which of the following pertains to the anterior chest area that overlies the heart and the great vessels?

What is the term that refers to the surface that overlies the heart?

How do you assess heart and neck vessels?

Which great vessels can be assessed during the inspection of neck?