objective 14 Flashcards
area on the anterior chest overlying the heart and great vessels
precordium
area where the heart and great vessels are located; between the
lungs in the middle third of the thoracic cage
mediastinum
bottom of the heart
apex
top of the heart
base
Superior and inferior venae cavae, pulmonary artery,
pulmonary veins, and aorta
great vessels
Right side is anterior, left side is mostly
posterior
right and left cardiac boarders
Double-walled sac that surrounds and protects the heart
* 2 layers that contain pericardial fluid in-between
* Adherent to the great vessels, esophagus, sternum, and pleura
* Anchored to the diaphragm
pericardium
Muscular wall of the heart
* Responsible for “pumping”
myocardium
Thin layer of endothelial tissue that lines the inner surface of the
heart chambers and valves
endocardium
thin walled reservoir for holding blood
atrium
muscular pumping chamber
ventricle
separate the atria and ventricles
atrioventricular valves
right AV valve
tricuspid valve
left AV valve
mitral valve
located between the ventricles and the
pulmonary arteries
semilunar valves
right side of the heart
pulmonic valve
left side of the heart
aortic valve
Takes 2/3 of the cardiac cycle
* Ventricles relax and fill with blood
* AV valves are open
* Pressure is higher in atria then ventricles, blood pours rapidly into the
ventricles
diastole
takes 1/3 of the cardiac cycle
* Volume raise ventricular pressure higher than in atria, AV valves shut to
prevent backflow
* The heart contracts
* Blood is pumped from the ventricles and fills the pulmonary and systemic
arteries
systole
Specialized cells in the SA node near the superior venae cava initiate
an electrical impulse
SA (sinoatrial) Node
Current flows across the atria to the AV node low in the atrial septum
AV (atrioventricular) node
collection of heart muscle cells specialized for
electrical conduction
Current slightly delayed in AV node, then the impulse travels to the
Bundle of His
bundle of his
Bundle of His to right/left bundle branches to the ventricles
bundle branches
In a resting adult, the heart pumps normally between 4-6L of
blood per minute throughout the body
pumping ability
CO = Stroke volume X rate (number of beats per minute)
Cardiac output
Venous return that builds during diastole
* The length to which the ventricular muscle is stretched just before
contraction
preload
Opposing pressure that the ventricle must generate to open
the aortic valve against the higher aortic pressure
* Resistance against which the ventricle must pump its blood
* To overcome the difference in the ventricular end-diastolic
pressure and that in the aorta, the ventricular muscle tenses
(isovolumic contraction) and after the valve opens rapid
ejection occurs
afterload
S1 and S2
normal heart sounds
sometimes also heard, S3, S4
extra heart sounds
Occurs with
closure of the
AV valves
* Signals the
beginning of
systole
* Although the
mitral valve
closure slightly
precedes the
tricuspid, they
usually sound
like one sound
when
auscultating
* Louder at the
apex
S1
Occurs with
closure of the
semilunar
valves
*Signals the
end of systole
*The aortic
component of
the second
sounds
slightly
precedes the
pulmonic
component
*Louder at the base
S2
Normally
diastole is
silent, however
in some
conditions
ventricular
filling creates
vibrations (S3
sound) that
can be heard
over the chest
*Heard when
the ventricles
are resistant to
filling during
S3
Occurs at the
end of diastole
when the
ventricle is
resistant to
filling
*Atria contract
and push blood
into a
noncompliant
ventricle
*Vibrations are
created that are
heard (S4
sound)
S4
Some conditions create turbulence in blood flow and collision
currents
murmurs
in exercise, thyrotoxicosis
increases in velocity of blood flow
anemia
decreases in velocity of blood
narrowed valve, incompetent valve
structural defects in the valves
dilated chamber or wall defect
unusual openings in the chambers
what are the characteristics of all heart sounds?
Frequency (pitch) - high or low pitched
* Intensity (loudness) - loud or soft
* Duration
* Timing
the pulse of the carotid artery closely
coincides with ventricular systole.
carotid artery
empty unoxygenated blood directly
into the superior vena cava” (Jarvis, 2024, p. 510). They
provide information about activity on the right side of
the heart (filling pressure and volume changes)
jugular veins
lies deep and medial to the sternomastoid muscle.
Usually not visible
internal jugular
more superficial, lies lateral to the
sternomastoid muscle, above the clavicle
external jugular vein
opening in the atrial septum
foramen ovale
opening between right atrium and pulmonary artery
ductus arteriosus
what is the position of the heart as u grow?
In the infant, more horizontal in the chest than in adults
* Apex at 4th left intercostal space until age 7
* At age 7 reaches the adult position
what are the cultural considerations for pregnancy?
Increase in blood volume 30-40%
* Increase in stroke volume and cardiac output
* Increase in HR by 10-15 beats per minute
what are the cultural considerations for the older adult?
Influence of lifestyle, habits, and diseases
* Increases in systolic blood pressure (stiffening of large arteries)
* Increase in systolic blood pressure when the diastolic is relatively
stable occurs in the older adult –widening pulse pressure
* Some adults experience orthostatic hypotension – sudden drop in BP
when rising to sit or stand
* Decreased ability of the heart to augment CO with exercise
* Increased supraventricular and ventricular arrhythmias
* Changes in conduction system on ECG
how do we prep to examine the cardiovascular system?
Client should be sitting up to evaluate the carotid arteries
* Client should be lying supine with head and chest elevated 30-40
degrees to evaluate the jugular veins, precordium
* Stand on the client’s right side to facilitate hand placement , viewing
of neck veins, & auscultation of the precordium
* Room must be warm and quiet
* Ensure privacy
* Regional cardiac assessment order:
* HR and BP
* Extremities
* Neck vessels
* Precordium
what equipment do we need to examine the cardiovascular system?
Marking pen
* Small cm ruler
* Stethoscope
* Alcohol swab
blowing, swishing sound indicating blood flow
turbulence, normally none is present” (Jarvis, 2024, p.
519). Presence indicates a local vascular cause such as
atherosclerotic narrowing. audible when the
lumen of the artery is 1/2 - 2/3 occluded. Once 2/3 occluded,
loudness of the bruit increases. When the lumen is
completely occluded, the bruit disappears
bruit
how do we auscultate the carotid artery for presence of a bruit?
Keep neck in neutral position
* Lightly apply bell of stethoscope over the carotid artery at 3 levels
* Angle of the jaw
* Mid-cervical area
* Base of the neck
* Avoid compressing the artery
* Ask the client to take a breath, exhale, and hold still briefly without breathing
* Hold breath so tracheal sounds do not mask or mimic a carotid artery bruit
* Holding breath on inspiration will tense the levator scapula muscles which
makes it harder to hear the carotid arteries
* Findings
* Normal findings: no bruit
* Abnormal findings: presence of a bruit
how do we palpate the carotid artery?
Palpation of the Carotid Artery
* The carotid provides important information about cardiac function.
* Palpate each carotid artery medial to the mastoid muscle in the neck
* Avoid excessive pressure on the carotid sinus area
* Carotid sinus area - higher in the neck, excessive vagal stimulation will slow the
heart rate and can make the client pass out
* Hypersensitivity of the carotid sinus – pressure will cause syncope, occurs with
older adults with hypertension or occlusion of the carotid artery
* Palpate gently
* Palpate only one carotid artery at a time (to avoid compromising arterial blood flow
to the brain)
what are the normal and abnormal findings when palpating the carotid artery?
Normal contour: smooth with a rapid upstroke and slower down-stroke
* Normal strength – 2+ or moderate
* Findings should be the same bilaterally
can be used to “judge the heart’s
efficiency as a pump”
jugular veins
Despite being easier to see, the external jugular vein is
not as reliable as the internal jugular vein
external jugular vein
is attached more directly to the superior vena cava
* The internal jugular vein itself cannot be seen, however
the pulsation can be and this pulsation is used for the
assessment.
internal jugular vein
what is the position of the body when assessing the jugular venous pulse?
Supine at a 30-45 degree angle
* Neck should not be flexed (pillow under the head must be removed)
* Head should be in the same plane as the trunk and turned slightly away
from the side being examined\
* Shine a strong light tangentially onto the neck (to increase visibility of the
pulse)
* When inspecting the jugular venous pulse, there are different
considerations that the examiner should be aware of.
Pulsation created as the left ventricle rotates
against the chest wall during systole
* may (or may not) be seen. If visible, it is located at the 4th-
5th intercostal space, mid-clavicular line
apical pulse
how do we palpate the apical pulse?
Localize the apical impulse by using one finger pad
(client in supine position)
* Ask the client to exhale and hold it
* The examiner may need to roll the client midway to left to
find it – this also displaces the apical impulse father to the left
what are the normal findings of the apical pulse?
Location: one interspace (4th or 5th ), at the mid-clavicular line or medial to it
* Size: normally 1x2 cm
* Amplitude: short, gentle tap
* Duration: short, only occupies first half of systole
what are the abnormal findings of the apical pulse?
Left ventricular dilatation-displaces the impulse down and to the left and
increases size > 1 space
* Left ventricular hypertrophy-increases force and duration but no change in
location and no dilatation
how do we palpate across the precordium?
Use the palmar aspect of the fingers
* Gently palpate over the: apex, left sternal border, and
base. Note any pulsations
what are the normal and abnormal findings when palpating across the precordium?
Normal finding: no pulsations
* Abnormal finding: palpable vibration (thrill)
* If a thrill is palpated, note the timing(use the carotid artery
pulsation or auscultate as you palpate)
* Thrill – signifies turbulent blood flow and accompanies loud
murmurs
how do we auscultate the precordium?
Identify the areas where you will listen. These include
the 4 traditional valve areas. The valve areas are not
over the actual anatomical 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.
what are the valve areas?
Aortic: 2nd right intercostal space
* Pulmonic: 2nd left intercostal space
* Tricuspid: 5th intercostal space at lower left sternal border
* Mitral: 5th intercostal space, left mid-clavicular line
Occurs normally in young adults and children
* Rhythm varies with the client’s breathing, increasing at the peak of inspiration and
slowing with expiration
sinus arrhythmia
Isolated beat which is early or a pattern occurs in which every 3rd – 4th beat sounds
early
premature beat
Sounds have no pattern
* Beats come rapidly and at random intervals
* When this is noted, check for a pulse deficit
irregularly irregular
associated with closure of the AV valves, beginning of systole
audible when client is in any position and equally well during
inspiration and expiration
* Split S1 normal but rare: means that the mitral and tricuspid
components are heard separately
S1 heart sound
associated with closure of the semilunar valves
* Split S2 is normal and usually heard towards the end of
inspiration in some people
* Split S2 only heard in the pulmonic valve area
S2 heart sound
what characteristics should you follow when describing a murmur?
Loudness – describe the intensity in terms of 6 grades (refer to p. 526
for a description of each grade)
* Pitch – high, medium, low. Pitch depends on the pressure and rate of
blood flow producing the murmur
* Pattern – may follow a pattern during the cardiac phase, i.e. growing
louder (crescendo), tapering off (decrescendo) etc.
* Quality – musical, blowing, harsh, or rumbling (harsh – aortic stenosis;
rumbling – mitral stenosis)
* Location – valve area of maximum intensity of the murmur
* Radiation – other places on the precordium, neck, back, or axilla
how do we position the pt for auscultation for a murmur?
Begin with the supine position
* Roll the client toward left side
* Listen with the bell at the apex for the presence of any diastolic
filling sounds
* S3 and S4 and the murmur of mitral stenosis sometimes can only
be heard when on the left side
* Ask the client to sit up, lean forward slightly, and exhale. Listen with
the diaphragm firmly pressed at the base, right, and left sides
* Assess for the soft, high-pitched early diastolic murmur of aortic
or pulmonic regurgitation
* Murmur of aortic regurgitation sometimes can only be heard when
the client is leaning forward in the sitting position
how do we check for a pulse deficit?
Auscultate the apical beat while palpating the radial pulse
* Count a serial measurement of apical beat and radial pulse
* The apical beat and radial pulse counts should be identical
(every beat heard should perfuse to the periphery and be
palpable)
* If the counts of the apical beat and radial pulse differ:
subtract the radial rate from the apical rate; record the
difference as the pulse deficit
* APICAL RATE - RADIAL RATE = PULSE DEFICIT
what does a pulse deficit signify?
It indicates a weak contraction of the ventricles. This
occurs with conditions such as: atrial fibrillation,
premature beats, and heart failure.
