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Jarvis 19
heart and neck vessels
Undergraduate 4

Additional Nursing Flashcards




Heart extends from the 2nd to 5th intercostal space and from the right border of the sternum to the left midclavicular line. Heart and great vessels are located between the lungs in the middle third of the thoracic cage in the mediastinum.
-top of the heart is the base, bottom is the apex.
-apex beats against chest wall producing apical pulse.
-apical pulse is palpable in most people normally at the 5th intercostal space, 7-9 cm from midsternal line.
-heart is rotated so the right side is anterior and its left side is mostly posterior.
-right ventricle forms the greatest area of anterior cardiac surface. left ventricle lies behind the right ventricle and forms the apex and slender area of the left border.
Great vessels
great vessels lie bunched above the base of the heart.
-superior and inferior vena cava return unoxygenated venous blood to the right side of the heart.
-pulmonary artery leaves right ventricle, bifurcates, and carries the venous blood to the lungs.
-pulmonary veins return the freshly oxygenated blood tot he left side of the heart and the aorta carries blood out to the body.
Heart anatomy
pericardium is a tough fibrous, double walled sac that surrounds and protects the heart. it has two layers that contain a few milliliters of serous pericardial fluid. this ensures friction free movement of the heart muscle. the pericardium is adherent to the great vessels, esophagus, sternum and pleurae and is anchored to the diaphragm.
-myocardium- is the muscular wall of the heart, it does the pumping
-endocardium is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves.
valves- main purpose is to prevent backflow of blood. valves are unidirectional, they can open only one way, the valves open and close passive in response to pressure gradients in teh moving blood.
Atrioventricular (AV) valves
AV valves (2) separate the atria and the ventricles.
tricuspid- right AV valve
Mitral- (bicuspid) left AV valve

Av valves open during hearts filling phase, or diastole, to allow the ventricles to fill with blood. during the pumping phase or systole, the AV valves close to prevent regurgitation of blood back up into the atria. the papillary muscles contract at this time, so that the valve leaflets meet and unite to form a perfect seal without turning themselves inside out
Semilunar Valves
Sl valves are set between the ventricle and the arteries. Each valve has three cusps that look like half moons. SL valves are
Pulmonic valve- right side of the heart
Aortic valve in the left side of the chart.
they open during pumping, or systole, to allow blood to be ejected from the heart
NO vena cava or pulmonary vein valves
there are no valvs between the vena cava and the right atrium nor between the pulmonary veins and the left atrium. for this reason, abnormally high pressure in the left side of the heart gives a person symptoms of pulmonary congestion, and abnormally high pressure in the right side of the heart shows in the neck veins and abdomen.
Cardiac cycle
Cardiac cycle has two phases- diastole and systole. during diastole the ventricles relax and fill with blood. it takes up to 2.3 of the cardiac cycle. the heart;s contraction is systole. during systole blood is pumped from the ventricles and fills the pulmonary and systemic arteries. 1/3 of cardiac cycle
Diastole: the ventricles are relaxed and AV valves (tricuspid and mitral) are open (opening of the normal valve is acoustically silent).
-the pressure in the atria is higher than that in the ventricles, so blood pours rapidly into the ventricles. this first passive filling is called early or protodiastolic filling
-toward the end of diastole, the atria contract and push the last amount of blood (25% of stroke volume) into the ventricles. this active filling phase is called presystole or atrial systole. atria aystole happened during ventricular diastole
Systole: ventricular pressure is finally higher than that in the atria, so the mitral an tricuspid valves swing shut. closure of the AV valves contributes to the first heart sound (S1) and signals the beginning of systole. the AV valves close to prevent any regurgitation of blood back up into the atria during contraction.
-for a brief moment, all four valves are closed. the ventricular walls contract. this contraction against a closed system works to build pressure inside the ventricle to a high level (isometric contraction). one the left side, ventricle pressure finally exceeds aortic pressure, the aortic valve opens and blood is ejected rapidly.
after the ventricles contents are ejected its pressure falls. when pressure falls below pressure in the aorta, some blood flows backwards toward the ventricle, causing the aortic valve to swing shut. this closure of the SL valves causes the second heart sound (S2) and signals the end of systole.

-now all four valves are closed and ventricles relax (isometric or isovolumetric relaxation) meanwhile the atria have been filling with blood delivered from the lungs. atrial pressure is now higher than the relaxed ventricular blood pressure. the mitral valve drifts open, and diastolic filling begins again
First heart sound
second heart sound
third heart sound
fourth heart sound
S1: first heart sound occurs with closure of Av valves and thus signals the beginning of systole. s1 is heart loudest at the apex.

S2: second heart sound occurs with closure of the semilunar valves and signals end of systole. S2 is loudest at the base

S3: third heart sound with some conditions, ventriucular filling creates vibrations that can ebe heard over teh chest. these vibrations are S3. S3 occurs when the ventricles are resistant to filling during the early rapid filling phase (protodiastole). this occurs immediately after S2, when the AV valves open and atrial blood first pours into the ventricles

S4 fourth heart sound: S4 occurs at the end of diastole at presystole, when the ventricle is resistant o filling. the atria contract and push blood into a noncompliant ventricle. this creates vibrations that are heard as S4.S4 occurs just before S1.
Murmurs: some conditions crate turbulent blood flo and collision currents- resulting in murmur. a murmur is a gentle blowing, swooshing sound that can be heard on the chest wall. conditions resulting in a murmur are:
1. velocity of blood increases (flow murmur) ex: exercise, thyrotoxicosis
2. viscosity of blood decreases ex: anemia
3. structural defects in the valves (narrowed valve, incompetent valve) or unusual openings occur in the chambers (dilates chamber, wall defect)
Characteristics of heart sounds
characteristics of heart sounds:
1. frequency (pitch)- can be high or low pitched.
2. intensity (loudness)- loud or soft
3. duration- very short for heart sounds; silent periods are longer
4. timing-systole or diastole
Automaticity- the heart can contract by itself, independent of any signals or stimulation from the body. heart contracts in response to an electrical current conveyed by a conductions system
-specialized cells in the sinoatrial node (SA) near the superior vena cava initiate and electrical impulse.
-Sa node has an intrinsic rhythm, its is the "pacemaker"

Current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. there it is delayed slightly so that the atria had tie to contract before the ventricles are stimulated. then the impulse travels to the bundle of his, the right and left bundle branches, and then through the ventricles.

electric events slightly precede mechanical ones
Cardiac output
Pumping ability: in the resting adult, the heart normally pumps between 4 and 6 L of blood per minute throughout the body. this cardiac output equals the volume of blood in each systole (called stroke volume) times the number of beats per minute

once the ventricle if filled with blood, the ventricular end diastolic pressure is 5-10 mmHg whereas that in the aorta is 70-80 mmHg
Jugular veins
Jugular veins- give information about activity on the right side of the heart. they reflect filling pressure and volume changes. bc volume and pressure increase when the right side of the heart fails to pump efficiently, the jugular veins expose this.
Hypertension is a systolic blood pressure (SBP) of >/= 140 mmHg or diastolic blood pressure (DBP) of >/= 90 mmHg or currently taking antihypertensive medicine.
Serum cholesterol
Serum Cholesterol: current cut points for cholesterol risk in adults are the following:
total cholesterol levels of >/= 240 mg/dl are high risk
borderline high risk: 200-239 mg/dl
Overweight: bmi of >/=25 kg/m2
obese: >/= 30
Subjective data
Subjective data:
1.chest pain
2. dyspnea
3. orthopnea
4. cough
5. fatigue
6. cyanosis or pallor
7. edema
8. nocturia
9. past cardiac history
10. family cardiac history
11. personal habits (cardiac risk factors)
Chest pain
onset: angina an important cardiac symptom occurs when hearts own blood supply cannot keep up with metabolic demand.
- squeezing "clenched fist' sign is characteristic of angina, but the symptoms below may be anginal equivalents in teh absence of pain


character: crushing stabbing burning viselike

pain brought on by
associated symptoms: diaphoresis, cold sweats, pallor, grayness, palpitations, dyspnea, nausea, tachcardia, fatigue.


Dyspnea: on exertion DOE-quantify exactly (blocks)
-constant or intermitent
Paroxysmal nocturnal dyspnea (PND)
Paroxysmal nocturnal dyspnea (PND)
occurs with heart failure. lying down increases volume of intrathoracic blood and the weakened heart cannot accommodate the increased load.
orthopnea: is the need to assume a more upright position to breathe note the exact number of pillows
cough: frequency duration type sputum production
fatigue- onset- related to time of day
fatigue form decreased cardiac output is worse in the evening, whereas fatigue from anxiety or depression occurs all day or is worse in the morning
cyanosis or pallor
cyanosis or pallor: occurs with myocardial infarction or low cardiac output states as a result of decreased tissue perfusion
edema: onset, recent changes, time of day, bilateral? associated symptoms?

is dependent when caused by heart failure. cardiac adema is worse at evening and better in morning after elevating legs all night.
cardiac edema is bilateral; unilateral swelling has a local vein cause
Nocturia- recumbency at night promotes fluid reabsorption at night and excretion; this occurs with heart failure in the person who is ambulatory during the day.
cardiac history
Past history: of hypertension, elevated cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever or unexplained joint pain, heart disease, medication surgery
family cardiac history
family history: of hypertension, obesity, diabetes, coronary artery disease, sudden death at young age
Personal habits
risk factors for coronary artery disease
Personal habits (cardiac risk factors):

Risk factors for CAD: collect data regarding elevated blood pressure, blood sugar levels above 130 mg/dl or known DM obesity, cigarette smoking, low activity level, and length of any hormone replacement therapy for post menopausal women.
to evaluate the carotid arteries, the person can be sitting up. to assess the jugular veins and the precordium, the person should be supine with the head and chest slightly elevated. stand on the person's right side.
when performing a regional cardiovascular assessment use this order:
1. pulse and blod pressure
2. extremities
3. neck vessels
4. precordium
observations peripherally and move in toward the heart.
Palpate the carotid artery

carotid sinus
palpate the carotid artery: located central to the heart the carotid artery yields important information on cardiac function.
-palpate each carotid artery medial to the sternomastoid muscle in the neck. avoid excessive pressure on the carotid sinus area, palpate gently, one at a time.
Abnormal: carotid sinus: hypersensitivity is the condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased bp, and cerebral ischemia with syncope. this may occur in older adults with hypertension or occlusion of the carotid artery

- feel the contour and amplitude of the pulse. normally the contour is smooth with a rapid upstroke and slower downstroke, and the normal strength is 2+ or moderate. findings should be same bilaterally
Abnormal: diminished pulse feels small and weak (decreased stroke volume). increased pulse feels full and strong in hyperkinetic states
Auscultate the carotid artery:
Auscultate the carotid: auscultate each one for a bruit
Bruit: is a blowing, swishing sound indicating blood flow turbulence; normally none is resent.
Abnormal: a bruit indicates turbulence due to a local vascular cause, such as atherosclerotic narrowing

-keep the neck in a neutral position. lightly apply bell over the carotid artery at three levels:
1. angle fo jaw
2. midcervical area
3. base of the neck
avoid compressing the artery to create and artificial bruit. ask the person to take a breath, exhale and hold it briefly while you listen so that tracheal sounds do not mask or mimic a carotid artery bruit.
Abnormal: a carotid bruit is audible when the lumen is occluded 1/2-2/3. bruit loudness icnreases as the atherosclerosis worsens until the lumen is occluded by 2/3 after that, bruit loudness is decreases. when the lumen is completely occluded, the bruit disappears. thus absence of a bruit does not ensure absence of a carotid lesion.
Inspect Jugular venous Pulse:
central venous pressure
Central venous pressure: form jugular veins u can assess CVp and hu judge the charts efficiency as a pump. position the person supine anywhere from 30-45 degree angle. see the top of the vein or pulsations. the higher the venous pressure is the higher the position you need. the head should be in the same plane as the trunk. turn the persons head slightly away from the examined side, and direct a strong light tangenitially onto the neck to highlight pulsations and shadows. note the external jugular veins overlying the sternocleomastoid muscle. as the person is raised to a siting position, these external jugulars flatten and disappear usually at 45 degrees
Abnormal: unilateral distention fo external jugular vein si due to local cause (kinking or aneurysm).
full distended external jugular veins above 45 degree signify increased CVP as with heart failure.

now loo for pulsations of the internal jugular veins int eh area of the suprasternal notch or around the origin of the sternomastoid muscle around the clavicle. you must be able to distinguish internal jugular vein pulsation from that of the carotid artery
The precordium:
Inspect the anterior chest:
Apical pulse
Apical pulse: pulsation created as the left ventricle rotates agains the chest wall during systole. when visible, it occupies the 4th or 5th intercostal space at or inside the midclavicular line.
Heave- or lift is a sustained forceful thrusting of the ventricular hypertrophy as a result of increased workload. a right ventricular heave is seen at the sternal border, a left ventricular heave is seen at the apex.

location- the apical pulse should occupy only one interspace, the 4th or 5th and be at or medial to the midclavicular line
size- normally 1x2 cm
amplitude- normally a short, gentle tap
duration- short, normally occupies only first half of systole
Abnormal: cardiac enlargement
-left ventricular dilation (volume overload) displaces impulse down and to left and increases size more than one space
- a sustained impulse with increased force and duration but no change in location occurs with left ventricular hypertrophy and no dilation (pressure overload)

the apical impulse is palpable in about half of adults. nor palapable in obese pl or in ppl with thick chest walls. with high cardiac output states (anxiety, fever, hyperthyroidism, anemia), the apical impulse increases in amplitude and duration.
Abnormal: not palpable with pulmonary edema due to overriding lungs
Palpating the precordium:
Thrill: is a palpable vibration. it feels like the throat of a purring cat. the thrill signifies tubulent blood flow and accompanies loud murmurs. absence of a thrill, however, does not necessarily rule out the presence of a murmur. accentuated first and second heart sounds and extra heart sounds also may cause abnormal pulsations.
Percussion: is used to outline the heart's borders (more commonly done with xrays and echocardiograms). cardiac enlargement is due to increased ventricular volume or wall thickness. it occurs with hypertension, CAD, heart failure and cardiomyopathy
Auscultation: the valve areas are not over the actual anatomic locations of the valves but are the sites on the chest wall where sounds produced by the valves are best heard. the sound radiates with the direction of blood flow.
the valve areas are:
Second right interspace- aortic valve area
Second left interspace: pulmonic valve area
Left lower sternal border- tricuspid valve area
Fifth interspace at around left midclavicular line-Mitral valve area
Auscultating Heart sounds
Auscultating heart sounds: diaphragm is for higher pitched sounds, bell is for lower pitched sounds.
concentrate and listen to one sounds at a time
1. note the rate an rhythm
2. identify S1 and S2
3. assess S1 and S2 separately
4. listen for extra heart sounds
5. listen for murmurs
rate and rhythm
rate and rhythm: the rate ranges normally from 50-90 beats per minute
-rhythm should be regular although sinus arrhythmia ocurs normally in young adults and kids. sinus arrhythmia varies with the person;s breathing, increasing at the peak of inspiration and slowing with expiration. note any irregular rhythm.
Abnormal: premature beat- an isolates eat is early, or a pattern occurs in which every third or fourth beat sounds early.
irregularly irregular- no patter to the sounds; beat comes rapidly and at random intervals

-when u notice an irregularity check for pulse deficit. normally every beat you hear at the apex should perfuse to the periphery and be palpable. the two counts should be identical. when different, subtract the radial rate from the apical rate and record the remainder as the pulse deficit
Abnormal: pulse deficit- signals weak contraction of ventricle; it occurs with atrial fibrillation, premature beats, and heart failure.
Identify S1 and S2
S1 is the start of systole and serves as the reference point for timing of all other cardiac sounds. Lup-dub, S1 is LUB.
guidelines for distinguishing S1 from S2:
-S1 is louder than S2 at apex; S2 is louder than S1 at base
-S1 coincides with the carotid artery pulse. feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1

Abnormal: both sounds are diminished with conditions that place an increased amount of tissue between the heart and you stethoscope; emphysema (hyper inflated lungs) obesity, pericardial fluid
Focus on systole, the diastole, and listen for any extra heart sounds
Listen with diaphragm, then switch to bell, covering all auscultatory area, usuall these are silent periods. when you detect an extra heart sounds listen carefully to note its timing, and characteristics.
during systole, the midsystolic click (which is associated with mitral valve prolapse) is the most ocmmon extra sound. the third and 4th heart sounds occur in diastole, either may be normal or abnormal.
Abnormal: pathologic S3 (ventricular gallop) occurs with heart failure and volume overload; a pathologic S4 (atrial gallop) occurs with CAD
Listening for murmurs

loudness grades
Murmurs- a murmus is a blowing swooshing sound that occurs with turbulent blood flow in the heart of great blood vessels. murmurs are abnormal. if you hear a murmur, describe it by indicating characteristics- timing, loudness, pitch, pattern, quality, location, radiation and posture.

timing: is crucial to define the murmur by its occurrence in systole or diastole. furhter describe the murmur as being in early, mid or late systole or diastole, throughout the cardiac event (pan systolic) and whether it obscures or muffles the heart sounds.

Loudness: describe its intensity in six terms "grades
gade i: barely audible
grade ii: clearly audible, but faint
grade iii: moderately loud, easy to hear
grade iv: loud, associated wit thrill palpable on chest wall
grade v- very loud, heard with one corner of the stethoscope lifted off chest wall
grade vi: loudest, still heart with entire stethoscope lifted just off the chest wall

Pitch:describe the pitch as high,medium or low. the pitch depends on pressure and tehr ate of blood flow producing the murmur.

Pattern: the intensity may follow a pattern during the cardiac phase (cresendo), tapering off (decrescendo) or increased to a peak and then decrease (cresendo-decresendo or diamond shaped)

Quality: describe the quality as musical, blowing, harsh, or rumbling
Abnormal: the murmur of mitral stenosis is rumbling, whereas the aortic stenosis is harsh.

location: describe the area of maximum intensity of the murmur by noting the valve area or intercostal space

radiation: murmur may be transmitted downstream in direction of blood flow and may be heard in another place on the precordium, neck back or axilla

Posture: some murmurs dissapea or are enhanced by a change in position

change postion: after auscultating in the supine position, roll person toward his or her left side. listen with the bell at the apex for the presence of any diastolic filling sounds (ex: S3 or S4)
Abnormal: S3 and S4 and the murmur of mitral stenosis sometimes may be heard only when on left side.
Clinical Portrait of heart failure
Clinical Portrait of heart failure:
dilated pupils: sympathetic nervous system response
skin pale, gray or cyanotic
dyspnea- SOBOE early symptom from pulmonary congestion
orhtopnea- cannot breath unless sitting up
crackles, wheezes-adventitious lung sounds
cough- pink or frothy white
decreased BP- stimulates sympathetic nervous system, which acts on heat to increase rate and increase force of contraction
nausea and vomiting- as peristalsis slows and bile and fluids back up into stomach
ascites -fluid in peritoneal cavity
dependent pitting edema-sacrum and legs
anxiety-gasping form pulmonary congestion
falling O2 saturation
confusion- unconsciousness form decreased O2 to rbain
jugular vein distention- from venous congestion
infarct- may be cause of decreasedc ardiac output
fatigue- weakness from decreased cardiac output
s3, gallor tachycardia
enlarged spleen and liver-from venous congestion, which causes pressure on breathing
decreased urine output- as kidneys compensate for decreased cardiac output by retaining sodium and H2O
weak pulse cool, moist skin- as peripheral vasoconstriction shunts blood to vital organs

decreased cardiac output: occurs when the hear fails as a pump, and the circulation becomes backed up and congested
signs and symptoms: of heart faulure come from 2 basic mechanisms:
1. heart's inability to pump enough blood to meet the metabolic demands of the body
2. kidney's compensatory mechanism of abnormal retention of sodium and water to compensate for decreased cardiac output. this increases blood volume and venous return which causes further congestion
onset: of heart failute may be
1. acute- as following a myocardial infarction when direct damage to the hearts contracting ability has occurred
2. chronic: as with hypertension when the ventricles must pump against chronically increased pressure
Base: thrill
Thrill in the second and 3rd interspaces occurs with severe aortic stenosis and systemic hypertension
a thrill in 2nd and 3rd left interspaces occurs with pulmonic stenosis and pulmonic hypertension
Left sternal border:
lift (heave)
Lift (heave: occurs with right ventricular hypertrophy as found in pulmonic valve disease, pulmonic hypertnesion and chronic lung disease. you feel a diffuse lifting impulse during systole at the let lower sternal border. it may be associated with retraction at the apex bc the left ventricle is rotated posterior by the enlarged right ventricle
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