Jarvis

Chapter 19

ATI Skills Module on Physical Assessment (Adult) -- Cardiac

The Circulatory System

http://www.youtube.com/watch?v=D3ZDJgFDdk0&feature=related

Heart and Neck Vessels

1. List the significant anatomic features of the heart and their location.

2. Describe the heart sounds & relate the name of the heart sound to the physiologic cause.

3. Describe the structures of conduction and the spread of the cardiac impulse through the heart.

4. Relate the circulation of blood through the heart and great vessels.

5. Discuss the significance of jugular vein assessment.

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Learning Outcomes

6. Cite the risk factors associated with heart disease and stroke.

7. List the hemodynamic changes that occur with aging.

8. Perform an accurate objective heart and neck vessels assessment on a client and document findings.

9. Discuss cultural/ethnic differences related to heart disease.

 

Learning Outcomes (cont’d)

Orthostatic hypotension

Paroxysmal nocturnal dyspnea (PND)

Orthopnea

Pulse deficit

Pulse pressure

Sinus rhythm

Sinus arrhythmia

Murmur

Atrial kick

Automaticity

Preload

Afterload

Apical impulse

Arrhythmia

Bruit

Cardiac output

Systole

Diastole

Dyspnea on exertion (DOE)

Key Terms

Cardiovascular (CV) System

Precordium, Apex and Base

Slide 19-6

© Pat Thomas, 2006.

CV system: heart, blood vessels & blood

• Heart & great vessels lie between lungs in the thoracic cavity (mediastinum)

• Apex = bottom of heart; Base = top of heart

• Great vessels

• Superior vena cava• Inferior vena cava• Pulmonary artery deoxygenated blood from heart to lungs

• Pulmonary veins fresh oxygen to heart from lungs

• Aorta

Cardiovascular (CV) System

Valves

•Atrioventricular (AV)•Tricuspid•Mitral

•Semilunar•Pulmonic•Aortic

Heart wall

•Pericardium surrounds & protects the heart

•Myocardium•Endocardium

Chambers

•Atria—right and left

•Ventricles—right and left

Structure and Function

Chambers and Valves

Slide 19-12

© Pat Thomas, 2006.

Cardiac Blood FlowDeoxygenated blood from body enters superior & inferior vena cava (1) enters right atrium (2) enters right ventricle (3) through tricuspid valve pumped into pulmonary arteries (4) through pulmonic valve goes to lungs where CO2 removed & replaced with fresh O2 re-oxygenated blood returns through pulmonary veins (5) to the left atria (6) enters left ventricle (7) through mitral valve pumped through aortic valve to the aorta (8) fresh oxygenated blood to entire body

LUNGS

Superior Vena Cava

R & L Common Carotid Arteries

Left SubclavianArtery

Lungs

Lungs

Direction of Blood Flow

Composed of 1 heart beat has 2 phases:

1. Diastole resting phase of the heart both ventricles relax & fill with blood takes up 2/3 of cardiac cycle time (Remember MAP?)

2. Systole contraction of both ventricles right ventricle pumps blood into the pulmonary arteries to take to the lungs for re-oxygenation and left ventricle pumps re-oxygenated blood into aorta for delivery to the body tissues takes up 1/3 of cardiac cycle time

Cardiac Cycle

Automaticity

Electrical Conduction

•Sinoatrial (SA) node pacemaker•Atrioventricular (AV) node•Bundle of his•Left & right bundle branches•Purkinje Fibers

Conduction

ECG: PQRST

•P wave: atrial contraction (depolarization) (“atrial kick”)

•PR interval•QRS complex: ventricular contraction (depolarization)

•T wave: ventricular repolarization•Go to: http://skillstat.com/learn.htm

ECG

Cardiac Conduction System

Right & left bundle branches

Purkenjie fibers

THE CARDIAC CYCLE

1. First heart sound (S1) closure of atrioventricular (AV) valves (tricuspid & mitral valves); signals beginning of systole

2. Second heart sound (S2) closure of semilunar valves (pulmonic & aortic valves); signals end of systole

3. Split S2 normal with inspiration

4. Extra heart sounds

• Third heart sound (S3)• Fourth heart sound (S4)5. Murmurs sound of blood circulating through heart chambers or valves usually d/t defects in valves Go to: http://www.med.ucla.edu/wilkes/Physiology.htm

Heart Sounds

Cardiac cycleDiastoleSystoleEvents in the right and left sides

SV (stroke volume) X R (rate) = CO

Example: 100ml X 60 HR = 6L/min CO

Preload = amount of blood in ventricles before systole (contraction of ventricles)

Afterload = resistance of filled aortic artery pressure against which the left ventricle must pump its blood.

Cardiac Output (CO)

Slide 19-24

Neck Vessels

Left & right carotid arteries

Left & right jugular veins

• Internal jugular•External jugular

Increased jugular venous pressure & distention (JVD) signals right-sided heart failure

Slide 19-26

Incidence of CV disease increases with age.

CAD increases sharply with age & accounts for about 50% of deaths in older people

Hypertension & heart failure increase with age.

Modifiable lifestyle habits:

•Smoking•Diet •Alcohol (ETOH) use•Exercise patterns•Stress•Sedentary lifestyle

The Aging Adult

Non-modifiable hemodynamic changes

•Systolic BP increases d/t arteriosclerosis (stiffening of arteries) increased workload on left ventricle leads to thickening of muscle fibers

•Diastolic pressure does not increase but increased systolic pressure leads to increased pulse pressure (difference between diastolic & systolic BP)

•No change in resting heart rate or cardiac output at rest

•Decreased ability to increase cardiac output (CO) with exercise

The Aging Adult (cont’d)

Non-modifiable hemodynamic changes (cont’d)

•Arrhythmias may decrease cardiac output and BP may experience syncope d/t decreased cerebral blood flow

•Cardiac Arrhythmia:•http://www.learnerstv.com/animation/animation.php?ani=202&cat=BiologyAutomaticity

•ECG changes d/t changes in conduction system: prolonged P-R interval (first-degree heart block) & increased incidence of bundle branch block

The Aging Adult (cont’d)

Hypertension

Smoking

High cholesterol levels

Obesity

Physical inactivity

Diabetes

Slide 19-30

Risk Factors for Heart Disease & Stroke

Risk factors for stroke and heart disease

High blood pressure (HTN) -- black adults #1

Smoking

Cholesterol – black adults lower than white & Mexican-Americans

Obesity (BMI >30) or overweight (BMI >25) – All in 70%: blacks; Mexican-Americans; whites. Asians 25%

Physical inactivity

Diabetes Type 2 – increasing across all age & ethnic groups; American Indians >2x the rate of U.S. adults overall.

Cultural & Genetics

Chest pain onset, location, radiation, character, exertional or at rest, other s/sx, NTG

Dyspnea exertional or at rest, positional, constant or intermittent, awakens at night (paroxysmal nocturnal dyspnea occurs with heart failure)

Orthopnea # of pillows used when supine

Cough duration, frequency, productive

Fatigue onset, related to time of day

Cyanosis or pallor

Subjective Data—Health History Questions

Edema swelling of hands or feet, severity, resolve at night, other s/sx

Nocturia frequency, how long

Cardiac history HTN, high cholesterol, heart disease, rheumatic fever, surgery

Family cardiac history HTN, CAD, sudden death at early age

Personal habits (cardiac risk factors)

For Aging Adults:

•Any known heart or lung disease•Medications•Environment

Health History Questions (cont’d)

Equipment needed: Stethoscope

Carotid arteries

•Palpate•Auscultate for bruitsJugular veins Inspect for jugular vein distention (JVD) occurs with right-sided heart failure

Precordium

• Inspect the anterior chest•Palpate the apical impulse 4th or 5th interspace, midclavicular line

Objective Data—The Physical Exam

Auscultate the heart sounds

•First, identify S1 and S2 (S1 is louder than S2 at the apex & coincides with carotid artery pulse; S2 is louder at the base)

•Note the rate and rhythm rhythm should be regular but sinus arrhythmia occurs normally in young adults & children increases with inspiration, slows with expiration

•Listen for extra heart sounds•Listen for murmurs•http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds

Palpate radial pulse calculate pulse deficit if present (difference between apical pulse & radial pulse) Slide 19-35

Objective Data—The Physical Exam (cont.)

Characteristics of normal heart sounds

•First heart sound (S1)•Second heart sound (S2)•Split S2 normal splitting is associated with inspiration

Extra heart sound

•Third heart sound (S3)•Fourth heart sound (S4)Murmurs

The aging adult

Slide 19-36

Objective Data—The Physical Exam (cont.)

Auscultatory Areas

Slide 19-38

Clinical Portrait of Heart Failure

Slide 19-39

Sample Charting

Slide 19-40

Sample Charting (cont.)