Weber Ch 20 Cardiac

• •CV system: transports O2 & nutrients to tissues; carries waste to kidneys & lungs
• •Heart: size of fist, 60 to 100 beats/min (adult)
• –Responds to internal and external stimuli: exercise, temp changes, stress
• –Endocrine and nervous systems communicate stimuli
• –CV system adjusts: alters diameter of vessels, cardiac output, blood distribution

• •Heart: right or left side (two chambers each): atrium, ventricle
• •Right side: blood from venae cavae, through pulmonary arteries into lungs
• •Left side: blood from pulmonary veins, through aorta
• into systemic circulation
• •Upper part, base (2nd ICS)InterCostal Space
• •Lower part, apex (5th ICS)
• Test: what are you hearing here (by location)?

• Location: Behind sternum, above diaphragm, in
• mediastinum
• –Lies at angle: R ventricle (anterior surface),
• –L ventricle (posterior surface)
• –R atrium: R border of heart, L atrium posterior

• •Aorta: curves upward out of L ventricle, bends posterior/down above sternal angle
• •Pulmonary arteries: out of superior aspect R
• ventricle near third ICS

• •3 Layers of Heart –
• –Epicardium = outside
• –Myocardium = middle, muscular - most heart attacks occur here (MI)
• –Endocardium = inner & valves
• •Pericardial sac/space –
• –Visceral layer next to epicardium
• –Parietal layer next to chest wall (fibrous)
• –Pericardial space between - shouldn't have too much fluid in it

• Blood flow through chambers controlled by four valves
• –AV valves: tricuspid(right), mitral (left); separate atria from ventricles
• –Semilunar valves: pulmonic (right ventricle from pulmonary artery), aortic (left ventricle from aorta)
• half moon - three leaflets
• dont always close completely - due to vegitation (relaspe or regurgitation)
• Cordae Tendinae - attach valves

• •(ventricles relaxed; fill with blood)
• –80% flow into relaxed ventricle
• –20%: atrial contraction (kick)
• •(ventricles contracting)
• –AV valve closure (prevent backflow of blood)
• –Semilunar valves open, allowing blood to flow into great vessels

• •Systole (ventricles contract): tricuspid/mitral valves close
• –First heart sound: S1 (lubb)

• •Diastole (ventricles almost empty): pulmonic/aortic
• valves close
• –Second heart sound: S2 (dubb)

• •Ventricular contraction: increased pressure – aortic pressure increases as blood flows into aorta
• •S1-S2 heard during normal cardiac cycle;
• •S3-S4 abnormal adult heart sounds
• not always abnormal in children
• S3 is usually fluid overload
• S4 usually stiff left ventricle from hypertrophy

• •Electrical stimulation from SA node (R atrium); 60 to 100 per minute - normal sinus rhythem
• SinalAtrial node - pacemaker of the heart
• •Internodal tracts (atrial contraction) to AV node
• is SA node doent work then control drops to AV note - 40 to 60 beats per minute
• •Travels through bundle of His,
• Purkinje fibers of myocardium, causing contraction

•AV node prevents excessive atrial impulses

SA node fails; impulses generated in AV node (slower 40-60)

SA/AV node failure: bundle branches take over (20-40/min) - not effective - needs pacemaker- not compadable with life

• QRS - junctional rhythems - ventrical related
• P - atria
• T - recovery process

•Works together with the peripheral vascular system.

•Removes fluid from interstitial spaces.

•Excess fluid left in interstitial spaces absorbed by lymph system & carried to lymph nodes.

•Lymph nodes located in groups along blood vessels.

Ducts from the lymph nodes empty into subclavian veins.

• •Carotid Arteries
• •Normally have smooth, rapid upstroke early in systole and gradual downstroke
• - should hear NOTHING if you put your stethoscope on the carotid arteries
• - if you hear something its a brewie - swishing sound
• -DO NOT occlude (obliterate) both carotid arteries at the same time

• •Jugular Veins (2 sets; internal and external)
• •Pulses important for determining hemodynamics
• of R heart functioning
• •A wave = Atrial contraction
• •X descent = RA relaxation
• •V wave = RA filling
• •Y descent = RA emptying into RV

• •Arteries – higher pressure
• –arterioles

• •Capillaries – exchange O2 & nutrients for waste
• products

• •Veins – lower pressure but expandable
• –venules
• veins have valves - arteries do not - when starting IV you can run into valves

Women with MI get pain between shoulder blades - middle of the back - Cardiac is now #1 killer of women becuase they dont seek care when they have pain

• •Carry oxygenated, nutrient-rich blood to capillaries
• –High pressure system with thick walls
• –Pulse = force of blood against arterial walls felt with heart beat

• •Major arteries of the arm:
• –Brachial, radial, ulnar

• •Major arteries of the leg:
• –Femoral, popliteal, dorsalis pedis, posterior tibial

• •Carry deoxygenated, nutrient-depleted waste blood from tissues back to the heart
• –No force that propels blood flow
• –Low pressure system

• •3 mechanisms that propel blood back to heart: valves, muscular contraction, & pressure gradient
• •Failure to propel blood back to heart result in: impeded venous return/venous stasis

• Types of veins
• •Deep:
• –Femoral
• –Popliteal

• •Superficial:
• –Great & small saphenous veins

coolateral ciriculation - if vein is removed (heart surgury) smaller veins will take over

• •Chronic illnesses such as DM, renal failure, chronic hypoxia, HTN.
• •Medications
• •Exercise
• •Life style-personality type, stress, relax, sports.
• •Alcohol consumption
• •Eating habits.
• •Smoking habits.- makes vessels harder & stiffer & increases viscocity of blood

DM - diabetics have microvascular changes - neuropathic - do not process cholesterol properly - tend to have more arteriosclorosis

• –Chronic illnesses? (describe)
• –Taking medications (what/when), side effects; OTC drugs (aspirin, herbs, cocaine, street drugs; how often)? cocaine blows out back side of heart - causes heart to wear out very early - MI or stroke
• –Past tests on heart (EKG, stress test, angiogram)?
• –Past surgery on heart or great vessels?
• –Circulatory problems in arms or legs (ulcers, cold, reduced hair, numbness, poor healing)

• Prednizone increases blood sugar - causes fluid retention (edema of arms & lower extremity)
• Theofolin - another steroid - causes heart problems
• Cardiac meds open
• Respiratory meds close - if person has both cardiac & respiratory probles must be very careful

• –Family history (HT, DM, CAD, hyperlipidemia, sudden death syndrome)
• •Age of family members at death
• •Gender of family members
• –Race - back males (hypertension & heart disease)
• –Childhood: Congenital heart disease/defect, “growing pains,” joint pains, recurrent tonsillitis, rheumatic
• fever, murmur?

• Chest pain/ angina
• Cough
• Swelling/ edema of leg & feet
• Nocturia - getting up to go to bathroom more than once during the night
• Fainting/ Syncope - in need of pacemaker - older people on cardiac medication
• CV risk factors
• Shortness of breath
• Fatigue
• Leg cramps - electrolite imbalance - potassium

• •Smoking
• •Diet, low fat & Na
• •Inactivity/Exercise
• •Obesity, weight loss
• •Hypertension
• •Diabetes Mellitus
• •Hyperlipidemia
• •Alcohol
• •Stress

• •Leading cause of death & disability in US. Include CAD, MI, CVA, HTN, PVD, & hyperlipidemia.
• •Goals of Healthy People 2010
• •1. Improve CV health
• •2. Improve quality of life.

• •Smoking Cessation.
• •Diet limit high-cholesterol, saturated fats, increase fruits, vegetables, grains.
• •Limit alcohol, limit salt intake.
• •Maintain optimal wt., BMI 18.-24.9.
• •Exercise – 30 minutes most days.
• •Low-dose ASA if at risk.

• •BP screening
• •Lipid-level screening-routine for men > 35, women > 45.
• •Lipid level for younger adults if risk
• factors.

• •General appearance
• –Evaluate general condition; lying supine at 45 degrees for skin color, breathing, posture
• –Approach from right side (gives you better position to listen to left side- heart)
• •Peripheral vascular: measure blood pressure
• –Orthostatic/postural hypotension
• change position laying to sitting/ sitting to standing - more than 20 mm Hg difference is orthostatic hypotension

• •Palpate temporal pulses bilaterally
• •Palpate carotid pulses one at a time
• •Check if pulse regular, irregular, or pattern
• •Grade pulse amplitude
• –0 = absent
• –1+ = diminished, barely palpable
• –2+ = normal
• –3+ = full volume
• –4+ = bounding, hyperkinetic

• •Auscultate carotid artery for bruits
• •Use bell of stethoscope as bruits are low pitched & blowing during systole
• •Client holds breath while you listen
• •Normal is no sound

• •Upper Extremities
• –Inspect and palpate for skin turgor/integrity:
• •Tenting
• •Pitting edema:
• –1+ = 2mm deep, barely perceptible
• –2+ = 4 mm deep but rebounds after a few seconds
• –3+ = 6 mm deep & rebounds within 10 – 20 seconds
• –4+ = 8 mm deep & rebounds > 30 seconds
• –Inspect and palpate for appearance, color temperature, & capillary refill
• –Palpate brachial & radial pulses for rate, amplitude & if regular, irregular or pattern

• –Inspect and palpate for appearance, color, temperature, capillary refill, and clubbing
• –Allen Test (occlude radial & ulnar til pale then release ulnar with return of color < 5 –10 sec.)

• –Inspect and palpate for skin turgor/integrity
• –Inspect and palpate for appearance, color, temperature, hair distribution, capillary refill, and
• superficial veins
• –Perform Trendelenburg test to evaluate competence of venous valves (varicose veins)
• –Check Homan’s sign or measure calf circumference
• –Calculate Ankle-Brachial Index < 0.9 art. occlusion
• –Palpate femoral, popliteal, posterior tibial, dorsalis
• pedis pulses for rate,amplitude & rhythm

• •Palpate all pulses for rhythm, strength and amplitude.
• •Temporal
• •Carotid
• •Brachial
• •Ulnar
• •Femoral
• •Popliteal
• •Dorsalis pedis
• •Posterior tibial

• •1+ barely perceptible pit 2 mm
• •2+ deeper bit rebounds in sec. 4 mm
• •3+ deep pit, rebounds 10-20 sec. 6 mm
• •4+ deeper pit, rebound > 30 sec. 8 mm

• •Inspect anterior chest wall for contour, pulsations, lifts heaves, retractions
• •Palpate apical pulse for location - apical pulse is sometimes called point of maximal impulse
• •Palpate precordium for pulsations, thrills, lifts, heaves
• •Percuss heart borders for heart size
• •Auscultate S1-S2 heart sounds for rate, rhythm, pitch, splitting
• •Interpret ECG/EKG conduction of heart

• Palpate apical pulse for location
• (PMI = point of maximal impulse < 2 cm)
• 4-5 intercostal spaces on Left Intercostal border
• Use 2 to 3 fingers

• All
• Physicians
• Take
• Money

or APT M

• A - Aortic - 2nd intercost palce right sternal border
• P - Pulmonic -2nd intercostal space left sternal border
• T - 4 ICS LB
• M - 5 ICS MCL

Erbs point - 3ICS LB

• •S3 (heart failure, mitral/tricuspid regurg)
• –S1, S2, S3 (me too)
• –Slosh-ing-in or Ken-tuck-y or me too

• •S4 (stiff, non-compliant ventricle, CAD)
• –S4, S1, S2 (middle)
• –a-Stiff-wall or Ten-ness-ee or middle

• •Murmurs
• –Systolic
• –Diastolic
• •Pericardial Friction Rub

• •I = barely audible in quiet room
• •II = quiet but clearly audible
• •III = moderately loud
• •IV = loud with associated thrill
• •V = very loud with easily palpable thrill
• •VI = very loud with palpable & visual thrill
• •Patterns (crescendo, decrescendo, plateau)

• Systolic Murmurs
• •Aortic/pulmonic stenosis
• •Tricuspid/mitral regurgitation
• •Anemia
• •Thyrotoxicosis
• •Ventricular-septal defect (holosystolic)

• Diastolic Murmurs
• -ALWAYS pathologic - never normal in any age group
• •Aortic/pulmonic regurgitation
• •Tricuspid/mitral stenosis

• •Aging heart unable to compensate if stress, blood loss, tachycardia, exertion, fever
• –Increased age; heart size decreased, output less than 30% to 40% (decreased heart rate/vagal, contractility)
• –Arterial walls or superficial vessels: decreased compliance (dilated, prominent, tortuous, calcified)
• •Increased BP (systolic/diastolic) from increased peripheral resistance (widened pulse pressure & + orthostatics)
• –Fibrosis or sclerosis of SA node or mitral and aortic valves causes altered cardiac function (heart blocks & systolic murmurs)
• –S4 common: decreased L ventricular compliance

• Left Heart Failure
• •Due to aortic stenosis, HT, or MI
• •Frothy pink sputum (color of my computer)
• •Bilat. Crackles
• •Apical pulse lateral
• •Systolic murmur
• •Palpable apical thrill

• Right Heart Failure
• •Due to pulmonary HT, MI, or cor pulmonale
• •+ JVD
• •Peripheral edema
• •Systolic murmur
• •S3 (lubb-dubb-me too)

• •Due to increased cardiac output (heart rate & stroke volume) & increased vasoconstriction or excess fluid
• •No specific symptoms so do screenings
• •2003Criteria –
• –< 120/80 = normal
• –120-139/80-89 Prehypertensive
• –140-159/90-99 Stage 1 hypertension
• –>160-179/100-109 Stage 2 hypertension
• –> 180/110 Stage 3 hypertension
• •Need to do health screenings

Cardiologist would like normal to be 110/ 70

• •Decreased cardiac output
• •Risk for imbalanced fluid volume
• •Risk for impaired skin integrity or infection RT poor circulation
• •Ineffective tissue perfusion: peripheral or cardiopulmonary
• •Activity intolerance RT leg pain
• •Knowledge deficit re CAD, HT, diet, meds
• •Fatigue RT decreased cardiac output
• •Acute pain RT angina, venous or arterial insufficiency
• •Ineffective therapeutic regime management RT diet, exercise or medications