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anatomy of the heart- flow of blood
- blood comes in from the body through the sup and inf vena cava into the right atrium past the tricuspid valve into the right ventricle, through the pulmonic valve out the pulmonary artery to the lungs
- oxygenated blood comes back in through the pulmonary vein into the left atrium through the mitral (bicuspid valve) into the left ventricle out the aortic vavle out the aorta to the body
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S1
- Systolic
- mitral and tricuspid valves close, aortic and pulmonary valves open
- as ventricles empty, ventricular pressure decreases and then pulmonary and aoritc valves will close after this
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S2
- Diastole
- aortic and pulmonic valves close while mitral and valves open
- atrial contraction to fill ventricles
- coronary arteries also fill to perfuse the heart here
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rhythm of valves closing
- s1: mitral and tricuspid
- s2: aortic and pulmonnic
events on the left happen slightly before the right
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arteries large to small
- major large arteries
- arteries
- arterioles
- capillaries
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where does gas exchange happen
- at the capillary level
- arteries bring oxygenated blood to tissues while veins bring waste away
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starling's law
- 2 atria and 2 ventricles
- as the myocardium stretches, the strength of the subsequent contraction increases
- until it reaches a point where it cant stretch anymore
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myocardial pump
- effectiveness of CO is determined by how well the pump functions
- starlings law
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coronary artery circulation
coronary arteries supply the myocardium with nutrients and remove wastes
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systemic circulation
- arteries and veins deliver nutrients and oxygen and remove waste products
- important for peripheral vascular exam
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blood flow regulation
cardiac output= stroke volume x heart rate
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cardiac output
- amount of blood ejected from the left ventricle each minute
- 4-6L/min normally
- increased heart rate will cause decreased CO bc chambers dont have time to fill adequately and pump blood
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stroke volume
- amount of blood ejected from the left ventricle with each contraction
- affected by patient's blood volume
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preload
- end-diastolic pressure
- pressure in the ventricles at the end of diastole when theyre filled
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afterload
resistance to left ventricluar ejection that the heart has to overcome
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alterations in cardiac functioning
- disturbances in conduction: dysrhythmias
- altered CO: heart failure (L&R)
- Impaired valvular function: stenosis or regurgitation (can be congenital or acquired)
- Myocardial Ischemia: angina pectoris or myocaridal infarction
- illness: anything that affects heart rhythm and strength
- anything in the peripheral body that increases resistance to blood flow
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difference between angina and MI
- angina: temporary imbalance between O2 demand and availability
- MI: ischemia with irreversable damage
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nursing history for cardiac assessment
- smoking, alcohol, caffeine, recreational drug intake
- meds
- diet/exercise patterns
- life and occupational stressors
- family history
- past history of hear trouble
- comorbidities
- cardiac chest pain, pressure or discomfort, dyspnea, orthopnea, paoxysmal dyspnea
- excessive fatigue, cough, leg pain or cramps, lower extremety edema, cyanosis, dizziness, fainting, diaphoresis
- tests theyve had
- stress anxiety
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angina pain
substernal chest pain that can radiate to neck back and shoulders
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parts of the cardiovascular system affected by aging
- muscle contraction
- blood flow
- conduction system
- arterial vessel compliance
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muscle contraction in aging
- thickening of the ventricular wall, which causes lower CO and low cardiac reserve
- increased collagen and decreased elastin in the heart muscle
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blood flow in aging
- heart valves become thicker and stiffer, more often in the mitral and aortic valves
- mitric/aortic stenosis
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conduction system in aging
- sa node becomes fibrotic from calcification which can affect conduction
- decrease in number of pacemaker cells in SA node
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arterial vessel compliance in aging
- calcified vessels
- loss of arterial distensibility
- decreased elastin in vessel walls
- more tortuous vessels
- systolic bp will be higher
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tips for the cardiac exam
- stand on PT right side
- examine PT in recumbent position- laying down
- PT should be relaxed and comfortable
- quiet and well lit room
- inspect, palpate auscultate
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orientation of the heart
- dextrorotated
- behind the sternum and to the left
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where is the base of the heart
where the right ventricle joins the pulmonary artery
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cardiac apex
- behind the right ventricle and to the left
- most anterior tip of the LV
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inspection
- inspect the anterior chest wall over the heart (precordium) for any visible pulsations or heaving
- inspect neck for jugular vein distension
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precordium
center of the anterior chest wall
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heaves
- unexpected elevation of the chest
- often present in heart failure or enlarged chamber (usually ventricle)
- heaves or lifts are unexpected, visual elevations of the chest wall
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jugular veins
- both drain the head and neck
- external jugular vein: more superficial, lies along the clavicle
- internal jugular vein: more deep, lines the coronary artery
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how to assess jugular veins
- head of bed 30-45 degrees (semifowlers)
- turn patients head slightly away from the side you are inspecting to expose the neck and thorax
- tangenital lighting
- examine both sides of neck for distention
- looking at supra clavicular area just above the clavicle posterior to the sternomastoid muscle
- avoid the PT hyperextending neck- can kink vein
- loking for a biphasic soft undulating wave- seen better after exercise- dont confuse it with carotid pulse
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when does jugular vein distension happen
- when pressure in right atrium is high
- ie in r sided heart failure
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palpation
- palpate precordium for any abnormal pulsations, heaves, arrhythmical tapping or thrills
- palpate the apical impulse at PMI- can be displaced if heart problems or different positioning
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pmi
- point of maximal impulse
- place where apical pulse is palpated as strongest
- identify its location- 5th IC space at L mid clav line
- note the diameter and amplitude
- lay tips of fingers over chest
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how far left of the midsternal line is the pmi
7-9cm
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palpating the PMI
- not always palpable even in healthy patients
- if you cant find with them supine, have them move to left laterul decubitus position to move their heart closer to the chest wall- this will displace it a bit more to the left and a wider diameter
- have PT fully exhale and hold breath for a few seconds
- palpate diameter- usually 1-2cm
- amplitude feels like small brisk tapping
- once located, make finer assessments with your fingertips and then one finger- should feel like tapping
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diameter of more than 2.5
could be ventricular hypertrophy
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carotid arteries
- supply oxygenated blood to the head and neck
- inspect and palpate- but dont palpate both at once
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inspecting carotid arteries
- have patient turn head slightly away from the artery
- pulse may or may not be visible
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palpating carotid
- never both at once
- have pt turn head towards the artery- opposite of inspecting. this is to relax the sternomastoid muscle
- dont massage artery
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ascultating carotid
- for bruit
- narrowed blood vessel creates turbulence, causes blowing/swishing sound
- place steth. bell over where you palpated and have them hold breath
- normal to hear nothing
- if you hear a bruit, always palpate for a thrill
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auscultating the heart
- listen with diaphragm of stethoscope
- follow a systematic patterm, inching stethescope across each of the anatomical sites
- repeat sequence with bell
- note rate and rhythm
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auscultatory sites of the heart
- aortic: right 2nd ICS
- pulmonic: left 2nd ICS
- erb's point: left 3rd ICS
- tricuspid: left 4th ICS
- apical: left MCL at 5th ICS
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abnormal heart sounds
- extra sounds: gallops, clicks, rubs
- murmers: note grade, pitch and quality
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what does pericardial friction rub sound like
scratchy- high pitched sound
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murmers
- turbulent blood flow in heart
- if you hear it ask if they have a history of one
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what causes clicks
- caused by degeneration of valve leaflets
- ie mitral prolapse
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S3
- caused by premature rush of blood into a stiff or dilated ventricle
- low pitched
- heart early in diastole, closely after s2
- known as ventricular gallop
- sounds like kenTUCKy
- abnormal in adults over 31
- can be benign or pathogenic
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S4
- caused by the atria trying really hard to contract pushing against a ventricle that wont fill bc of heart failure or some other problem
- low pitched
- heard in diastole, precedes S1
- known as atrial gallop
- sounds like TENnes see
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what are murmurs and types
- turbulent blood flow through the heart and across the affected valves
- sustained swishing or blowing sound
- can be benign or a sign of heart disease
- benign systolic murmurs
- murmur due to stenosis
- regurgitant murmur
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benign systolic murmer
increased blood flow through a normal valve
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murmur due to stenosis
forward flow through a stenotic valve or into a dilated vessel or heart chamber
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regurgitant murmur
backward flow through a valve that fails to close (regurgitation)
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what do you want to know when you hear a murmur
- timing in the cardiac cycle: systolic or diastolic, beginning middle or end of phase
- location best heard: not always best heard over the valve theyre happening in
- radiation to other areas
- pitch: low med high depending on velocity of blood flow
- quality: charcter of it
- intenisty: or loudness (grade)
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grades of murmurs
- 1: barely audible in a quiet room, you really have to listen for it
- 2: quiet but clearly audible
- 3: moderately loud
- 4: loud, with associated thrill
- 5: very loud, thrill easily palpable
- 6: Very loud, audible with stethescope not even touching skin, thrill palpable and visible
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positioning to hear murmurs
- normally recumbent
- aortic regurgitation murmurs best heart sitting up, leaning forward and holding breath
- stenosis best heard lying on left side
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peripheral vascular assessment
- when heart pumps it transmits arterial pulse throughout the body
- adequacy of blood flow to the extremities by measuring arterial pulses and inspecting the condition of the skin and nails (color temp, cap refill, cyanosis)
- integrity of the venous system
- look at veins for phlebitis, vericosity, etc
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main upper extremity arteries
- brachial
- radial
- ulnar
- deep palmar arch
- superficial palmar arch
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main lower extremity arteries
- femoral- along symphysis pubis inguinal ligament
- popliteal- back of knee- 2 handed approach here
- posterior tibial
- anterior tibial
- dorsalis pedis
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assessing peripheral pulses
- asses bilaterally except corotid
- assess for equality and strength
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grading pulses
- 0: absent, not palpable
- 1+: diminished, weaker than expected, barely palpable
- 2+: normal
- 3+: full, increased
- 4+: bounding
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where should you find the pulse to assess blood flow
- the pulse you find is to assess blood flow to that extremity
- ie dorsalis pedis is used to asses status of circulation to the foot
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doppler
- ultrasound stethoscope
- amplifies sounds when pulse is difficult to palpate
- angle it 45-90 degrees
- adjust volume
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inspecting the extremities
- skin and nail texture
- hair distribution
- venous pattern
- pigmentation
- temp
- cap refill
- edema
- pain
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signs and sx of vascular disease
- leg cramps, numbness or tingling in extremities
- sensation of cold hands/feet
- pain in legs
- swelling or cyanosis of feet, ankles or hand
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vascular vs musculoskeletal problems
- if pt has leg pain or cramping in lower extremities, ask if walking of standing for long time aggrivates or releives it
- pain caused by vascular condition tends to increase with activity while musculoskeletal does not get better when the activity ends
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what can impair venous return
- tight fitting garters, socks or hosiery
- crossing legs
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what predisposes patients to vascular disease
- smoking, exercise lack
- nutritional problems
- other risk factors ie hypertension
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color in venous vs arterial insufficiency
- venous: normal or cyanotic
- arterial: pale, worsened by elevation of extremity. dusky red when extremity is lowered
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temperature in venous vs arterial insufficiency
- venous: normal
- arterial: cool (blood flow is blocked to extremity)
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pulse in venous vs arterial insufficiency
- Venous: normal
- Arterial: decreased or absent
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Edema in venous vs arterial insufficiency
- venous: often marked
- arterial: absent or mild
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Skin changes in venous vs arterial insufficiency
- venous: brown pigmentation around ankles
- arterial: thin, shiny skin. decreased hair growth thickened nails
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what to assess the peripheral veins for
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peripheral edema
- accumulation of fluid in the tissues from impaired venous return or direct trauma
- evaluate for pitting edema by compressin the skin for at least 5 sec over a bony prominance (ie around ankle or shin)
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places to evaluate pitting edema
- over the skin
- behind the medial malleolus
- dorsum of foot
- ankle
- shin
depth of pitting reflects degree of pitting
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pitting edema scale
- 1+: 2mm
- 2+: 4mm
- 3+: 6mm
- 4+: 8mm
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