Nursing 314

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Nursing 314

• Heart Neck Vessels

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Position Surface Landmarks

• Precordium area on anterior chest overlying the
  heart great vessels
• Upside down triangle
• Base top of the heart
• Apex narrow bottom portion of the heart
• Position
• 2nd ICS 5th ICS
• Right sternal border to left midclavicular line
  (MCL)
• Right side of heart is mostly anterior

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Landmarks
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Layers of the heart

• Pericardium tough fibrous double-walled sac,
  filled with pericardial fluid which decreases
  friction (epicardium outermost layer)
• myocardium muscular wall, pumping
• Endocardium thin layer of epithelial tissue
  that lines inner surface of heart valves

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Anatomy of pumps

• Two pumps right and left
• Right pulmonary circulation
• Right atrium through tricuspid valve to right
  ventricle
• Right ventricle through pulmonic valve to lungs
• Left systemic circulation
• Left atrium through mitral valve to left
  ventricle
• Left ventricle through aortic valve to aorta

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Blood flow
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Valves

• Purpose to prevent backflow of blood
• Open close passively in response to pressure
  gradients
• Atrioventricular valves
• Tricuspid separates right atria from right
  ventricle
• Mitral separates left atria from left ventricle
• Semilunar valves separate ventricles and
  arteries
• Pulmonic valve right ventricle and pulmonary
  artery
• Aortic valve left ventricle and aorta
• No valves between right atria and vena cava or
  between left atria and pulmonary veins

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Heart Anatomy
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Cardiac Cycle

• Review bloodflow through heart
• 2 phases that occur in response to changes in
  pressure gradients
• Diastole ventricles relaxed
• AV valves open
• Pressure in atria higher than ventricles so blood
  pours into ventricles (early diastole)
• Presystole (atrial kick) atria contract to push
  last amount of blood into ventricles

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Cardiac Cycle cont.

• Systole
• Ventricular pressure higher than atrial
• Closure of AV valves (tricuspid mitral)
• Creates the first heart sound S1
• S1 signals the beginning of systole
• Ventricular walls contract increased pressure
  opens aortic and pulmonic valves and blood pumps
  out
• Pressure in aorta pulmonary artery increase,
  ventricular pressure decreases
• Semilunar valves close (aortic pulmonic)
  create S2, marks end of systole

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Cardiac Cycle
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Points to remember

• Pressure in right side of heart is lower than
  left side of heart
• Events occur slightly slower on right than left
  due to route of depolarization
• Therefore, valves on right close slightly later
  than on the left

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Conduction

• Heart contracts in response to an electrical
  current conveyed through a conduction system
• Special cells in SA node initiate electrical
  current
• Electrical current flows in an orderly sequence
• Small amount of electrical current flows to body
  surface where in can be measured and recorded
  (ECG wave)
• PQRST
• P depolarization of atria
• QRS depolarization of ventricles
• T repolarization of ventricles

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Pumping

• Cardiac output volume of blood in each systole
  (stroke volume) X beats per minute. Heart can
  adjust
• Preload passive stretching force applied to
  ventricles
• Afterload opposing pressure the ventricle must
  generate top open the aortic valve

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Neck Vessels

• Carotid artery pulse coincides with ventricular
  systole (S1)
• Jugular venous pulse jugular vein empties
  directly into superior vena cava so jugular
  venous pressure reflects activity in right side
  of heart

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Subjective History

• Chest pain
• Onset, location, character, with activity,
  relieving factors, associated factors
• Dyspnea, Orthopnea
• Cough
• Fatigue
• Cyanosis, pallor
• Nocturia
• Family cardiac history
• Risk factors

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Inspection

• Inspect precordium
• Heave or lift visible thrusting of ventricle
  (ventricular hypertrophy)
• Apical impulse may see at 4-5th intercostal
  space MCL
• Palpate Apical impulse
• 4-5th intercostal space left MCL
• Palpable in 50 of adults (roll to left)
• 1-2 cm in size, short gentle tap
• Palpate precordium
• Thrill palpable vibration which signifies
  turbulent flow, accompanies a loud murmur

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Auscultation

• Four traditional valve areas
• Aortic 2nd ICS right sternal border
• Pulmonic 2nd ICS left sternal border
• Tricuspid 4th ICS left sternal border
• Mitral 5th ICS left midclavicular line
• Use a Z pattern with both bell diaphragm
• Note rate rhythm

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Auscultatory areas
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Auscultation

• Identify S1
• Closure of AV valves
• Begins systole
• Loudest at apex
• Coincides with carotid puls
• May hear split
• Identify S2
• Signals end of systole
• Loudest at base
• May hear split with inspiration

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Auscultation extra sounds

• S3
• Ventricular filling sound
• Dull soft sound
• May hear normally in children or young adults
• Pathologic S3 (ventricular gallop) associated
  with heart failure
• May hear with increased cardiac output,
  hyperthyroidism, anemia, pregnancy

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Auscultation extra sounds

• S4
• Ventricular filling end of diastole
• May hear normally after exercise with no
  cardiovascular disease
• Pathologic S4 (atrial gallop) decreased
  compliance of ventricles with coronary artery
  disease, cardiomyopathy, hypertension

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Cardiac cycle
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Auscultation extra sounds

• Midsystolic click most common extra sound,
  associated with mitral valve prolapse
• Pericardial friction rub high pitched scratchy
  sound, usually heard best at apex, may occur
  throughout systole and diastole

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Murmurs

• Occurs with turbulent bloodflow in heart or great
  vessels
• Structural defects
• Increased velocity of blood
• Decreased viscosity (anemia)
• Timing in cardiac cycle
• Systole vs. diastole
• Loudness
• Grade I - VI

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Jugular venous pressure

• Internal jugular more accurate
• Measure of central venous pressure
• Jugular veins should disappear at 45 degree angle
  and above
• Hepatojugular reflux push upper right quadrant
  empties blood out of liver, jugular vein will
  stay full with additional blood flow

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Peripheral Vascular Lymphatic

• Arteries subjected to pressure, tough, strong
  walls
• Peripheral pulses
• Carotid
• Brachial
• Radial
• Femoral
• Dorsalis pedis
• Posterior tibial

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Arteries in legs
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Arteries in arm
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Arteries

• Supple oxygen nutrients to tissue
• Ischemia deficient supply of oxygent
• Assessment
• Rate
• Rhythm
• Amplitude
• 0absent
• 4bounding
• Bruits auscultate with bell, indicated narrowing
  or obstruction

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Arterial insufficiency

• Chronic
• Intermittent claudication
• Rest relieves
• Cool, pale skin
• Acute
• Throbbing pain
• Sudden onset
• Pain, pallor, pulselessness, paresthesia

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Veins

• Less sturdy, more passive, bloodflow less
  forceful
• Blood flows (prevents venous stasis)
• Contracting muscle
• Patent lumen
• Competent valves

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Veins

• Assessment
• Chronic insufficiency
• Aching, tired legs at end of day with standing
• Edema - 1 to 4
• Varicosities
• Weeping ulcers
• Brown discoloration (deposits of by-product of
  RBCs)
• Venous hum sound created by turbulent flow

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Veins

• Assessment
• Acute Deep vein thrombosis
• Red, warm, swollen
• Pain with dorsiflexion (Homans sign)
• Usual sudden onset

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Lymphatics

• Flow system throughout the body
• Purposes
• Conserve fluid plasma protein which leak out
• Immune system function
• Lymph nodes
• Filter fluid before returning to bloodstream
  (lymphocytes)
• Areas
• Cervical
• Axillary
• Epitrochlear
• inguidal