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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. Assessment of the Heart and Peripheral vessels Maria Carmela L. Domocmat, MSN, RN Associate Professor, College of Nursing Manila Adventist College
- 2. Anatomy Heart 8/14/2017 2Maria Carmela L. Domocmat, RN, MSN
- 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. 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. 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. 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. 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. 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. 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. 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. Electrical Conduction 8/14/2017 11Maria Carmela L. Domocmat, RN, MSN
- 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. The Cardiac Cycle Diastole Systole 8/14/2017 13Maria Carmela L. Domocmat, RN, MSN
- 14. Diastole early or protodiastolic filling presystole or atrial systole 8/14/2017 14Maria Carmela L. Domocmat, RN, MSN
- 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. 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. 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. 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. 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. 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. HEART SOUNDS 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 21
- 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. 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. 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. 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. Skeleton of Heart • fibrous rings to which the heart valves are attached 15-10
- 27. Heart Valves Pulmonary and Aortic Valve
- 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 29
- 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. 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. 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. 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. 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. Murmurs 8/14/2017 35Maria Carmela L. Domocmat, RN, MSN
- 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. 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. Cardiac Output (CO) 8/14/2017 38Maria Carmela L. Domocmat, RN, MSN
- 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. 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. 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. 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. 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. 8/14/2017 44Maria Carmela L. Domocmat, RN, MSN
- 45. HEALTH HISTORY 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 45
- 46. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 46
- 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 48
- 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. PREPARING THE CLIENT 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 67
- 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. • 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. • 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. • 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. EQUIPMENTS 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 72
- 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. PHYSICAL ASSESSMENT 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 74
- 75. ASSESSMENT OF THE HEART 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 75
- 76. Overview 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 76
- 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. 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. 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. 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. 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 82
- 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. Abnormal ventricular impulses Lift Thrill Accentuated Apical Impulse Laterally displaced apical impulse 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 84
- 85. PALPATION 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 85
- 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. 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. 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. 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. 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. 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 92
- 93. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 93
- 94. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 94
- 95. AUSCULTATION 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 95
- 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. 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. Heart Sounds
- 99. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 99 1. 2. 3. 4. 5.
- 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. Auscultation of heart sounds
- 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. 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. 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. 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. 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. 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. S1 AND S2 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 108
- 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. 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 111
- 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 113
- 114. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 114
- 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. 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. S1 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 117
- 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. 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. 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. S1 o abnormal finding Accentuated S1 Diminished S1 Varying S1 Split S1 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 121
- 122. S2 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 122
- 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. 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. 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. EXTRA HEART SOUNDS Snaps Clicks Friction rubs Murmurs 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 126
- 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. 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. 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. Normal findings: Auscultation systolic pause o systolic pause o no extra heart sounds 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 130
- 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. MURMURS 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 141
- 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. Heart Murmurs
- 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. 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. 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 147
- 148. AUSCULTATE : DIFFERENT POSITION 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 148
- 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. Auscultation: Other position o Normal findings: S1 and S2 heart sounds present 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 150
- 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. CLINICAL PEARLS 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 152
- 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. 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. 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. DOCUMENTATION 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 156
- 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. 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. NECK VESSEL ASSESSMENT 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 159
- 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. 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 162
- 163. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 163
- 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. 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. 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 167
- 168. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 168
- 169. AUSCULTATE & PALPATE CAROTID ARTERIES 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 169
- 170. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 170
- 171. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 171
- 172. Observing Jugular Venous Pulse & Evaluating Jugular venous pressure
- 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. 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. 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. 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. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 177
- 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. Pulse Amplitude Scale 0 = Absent 1+ = Weak 2+ = Normal 3+ = Increased 4+ = Bounding 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 179
- 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. NURSING DIAGNOSES
- 182. Wellness Readiness for enhanced cardiac output Health seeking behavior: Desired information on exercise and low fat diet
- 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. 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. 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?
The anterior chest area that overlies the heart and great vessels is called the precordium (Fig. 18-1).
What is the term that refers to the surface that overlies the heart?
Medical Definition of precordium
: the part of the ventral surface of the body overlying the heart and stomach and comprising the epigastrium and the lower median part of the thorax.
How do you assess heart and neck vessels?
Methods of assessment for the heart and neck vessels include inspection, palpation, and auscultation.
Which great vessels can be assessed during the inspection of neck?
The cardiovascular system assessment includes the survey of the vascular structures in the neck: carotid artery & jugular veins. These vessels reflect the efficiency of the cardiac function.