Heart & Neck Vessel Assessment

Cardiac Disease/Definitions
most common cause of death in women and men CAD- coronary artery disease- leads to increased B/P, heart failure, angina, and MI (heart attack) atherosclerosis- lipid accumulation arteriosclerosis- decreased elasticity of arterial walls
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Heart functions
function of heart is to pump blood right side of heart pumps blood to the lungs for gas exchange (pulmonary circulation) left side of heart pumps blood to all other parts of the body (systemic circulation) heart consists of four chambers:right/left atria and right/left ventricles
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Heart Chambers
Atria have thin walls and serve to receive blood returning from the heart and to pump blood into the ventricles Ventricles have thicker walls and pump blood out of the heart Left ventricle is thicker than the right due to the greater workload on the left side of the heart
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Pericardium
A tough, double-walled sac that surrounds and protects the heart. The two layers contain a few milliliters of serous pericardial fluid. Provides friction-free movement of the heart muscle.

Myocardium
The muscular wall of the heart that does the pumping.

Endocardium
The thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves.

Heart Sounds
produced by valve closure can be auscultated by a stethoscope S1(lub) correlates with the beginning of systole, best heard at the apex( left MCL, 5th ICS) S2 (dub) correlates with the beginning of diastole, best heard at the base of the heart
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Heart Sounds contd

S3 and S4- extra heart sounds heard due to rapid ventricular filling murmurs- a swooshing or blowing sound may be auscultated over the precordium. May be due to increased blood velocity, structural valve defects, valve malfunction, and abnormal chamber openings
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Neck Vessels
Assessment of these vessels reflects the integrity of the heart Carotid artery pulse- centrally located arterial pulse Jugular venous pulse- determines the hemodynamics of the right side of the heart
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Heart and Neck Vessel Assessment

At every exam pt. should be screened for cardiac risk factors in personal/family history Cardiac risk factors include life style and health practices. Can you name some of them?

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Major Risk Factors

Hypertension Smoking High cholesterol

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Other Risk Factors

Minimal exercise Obesity Diabetes Diet high in fat Alcohol consumption Stress Family history Personality type
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Developmental Changes Average Pulses

Infant: 120 150 2 y.o.: 100 120 8 10 yr: 80 84 Adult: 60 - 100

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Developmental Changes Average Blood Pressure

Infant to 4 yr. : School age: Adolescents: Adults: 85/60 100/65 115/72 120/80

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Vascular Assessment
involves inspection, palpation, and auscultation of the neck and anterior chest explain the need to expose neck and anterior chest, usually the pt. is in supine position or sitting up. history- ask pt. if any S&S of peripheral vascular disease-coldness or loss of hair on extremities, edema, cyanosis, inflammation, open ulcers
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Vascular Assessment
Review peripheral pulses, comparing side to side Inspection color, size of extremities, ulcers, lesions, hair distribution, venous pattern, edema, redness, clubbing look for jugular venous pulsations- pt. should be laying down with HOB up 45 degreeshead turned away from examiner
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Jugular Venous Pulsations

Normal if seen when patient is flat / supine Abnormal if patients head is elevated more than 30 degrees and pulsations are seen higher than 2 cm above the Angle of Louis (sternal angle)(where the manubrium meets the sternum) This abnormal sign indicates increased jugular venous distension (JVD) and right sided CHF. Can estimate central venous pressure (CVP)
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Clubbing
View finger from the side and note the angle of the nail base. Angle should be about 160 degrees. Clubbing: Angle flattens to 180 degrees. Occurs with congenital chronic cyanotic heart disease and with emphysema, chronic bronchitis, and cystic fibrosis.
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Epitrochlear Node
In the antecubital fossa, in the depression above and behind the medial condyle of the humerus. Hold the patients hand and reach other hand under the persons elbow to the groove between the biceps and triceps muscles, above the medial epicondyle. Usually not palpable. Drains the hand and lower arm.
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Allen Test
Determines patency of ulnar artery. Hold forearm up. Firmly compress radial and ulnar artery. Have patient open and close hand and then keep hand open. Palm should be pale. Release ulnar artery only. Palm should turn pink promptly. Positive Allen Test = patent artery.
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Vascular Assessment contd.

Palpation- temperature-assess bilaterally
edema-press 5 sec firmly over tibia or medial malleolus- if leaves depression, then pitting edema
+1 -slight pitting (2mm or less) +2 -deeper pit than +1 (4mm) +3 -deep pit, extremity looks full and swollen,up to 6mm +4 - very deep pit that lasts awhile, extremity is grossly distorted, 8 mm or more
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Palpation contd.
Homans sign- pain on forceful dorsiflexion of foot- positive is indicative of a blood clot pulses- assess all peripheral pulses for:
condition of wall, rate and rhythm, equality, and quality (volume or amplitude on a 0-4 scale)
0 = not palpable or pulse absent 1 = weak, thready, easily obliterated with pressure, fades in and out, diminished 2 = easily palpable- normal 3 = increased 4 = strong ,bounding 23

Capillary Refill
Depress the nail edge to blanch and then release. Color should return to pink in < 3 seconds. >3 second refill = cardiovascular or respiratory dysfunction.

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Pulses
Weak thready pulse (1+)
Shock Peripheral arterial disease

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Pulses
Full, bounding pulses (3+ or 4+)
Hyperkinetic states
Exercise Anxiety Fever

Anemia Hyperthyroidism

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Pulses
If you cannot palpate a pulse:
Is the extremity warm or cool distal to the pulse Is the distal extremity pink or pale Is it painful distal to the pulse

Warm, pink, no pain = blood flow Cool, pale, painful = decreased blood flow Chart: Cannot palpate ___ pulse, but extremity is warm, pink, and nonpainful.
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Doppler
If you cannot palpate a pulse, check it with a doppler. It magnifies the pulsatile sounds. Place untrasound gel on the transducer. Place the transducer over a pulse. Depress button on doppler. You will hear a swishing, whooshing sound.
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Peripheral Pulses - Palpation

Temporal anterior to ear Carotid on side of neck between trachea and sternomastoid muscle Brachial groove between biceps & triceps Radial flexor side of lateral wrist (thumb side) Ulnar medial side of wrist (pinky side)
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Peripheral Pulses cont.

Femoral inside groin area halfway between the pubis and anterior superior iliac spines Popliteal behind the knee (bend knee, thumbs on top of knee, fingers into popliteal fossa)) Posterior tibial Behind medial malleous, between the malleous and Achilles tendon Dorsalis pedis Dorsum of foot just lateral to and parallel with the extensor tendon of the big toe
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Pulsus Bigeminus
Every other beat comes early irrregular rhythm. Premature ventricular contraction PVC Premature atrial contraction PAC Force of premature beat is decreased due to shortened cardiac filling time.

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Pulsus Alternans
Rhythm is regular, but force varies with alternating beats of large and small amplitude. Indicative of heart failure.

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Pulsus Paradoxus
Pulse is weaker on inspiration and stronger on expiration. When taking a blood pressure, the mercury increases > 10 mmHg during expiration. Indicates blocked venous return to the right side of the heart, or blocks left ventricular filling. Cardiac tamponade, constrictive pericarditis, pulmonary embolism: all life threatening
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Allen Test for patent Ulnar artery

Done before ABGs Firmly occlude both the ulnar and radial arteries with hand in a fist until the hand blanches Open the hand and release pressure on the ulnar artery only Hand should return to normal color in 3 5 seconds
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Signs & Symptoms of Weak or absent pulses

Pale extremity Cool extremity Painful extremity Skin ulcerations

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Auscultation of Neck Vessels

auscultate with the bell over carotids or any artery for bruits (sounds like murmurs). A bruit signifies turbulent blood flow through blockages always auscultate before palpating normal assessment- no bruits heard
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Jugular Venous Pressure

Hold a vertical ruler on the sternal angle (Angle of Louis) with HOB 30 45 degrees up Hold a horizontal ruler along the jugular vein The rulers form a T square Read the level of intersection on the vertical ruler. Normal is 2 cm or less above the sternal angle. The reading + 5 = estimated CVP
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 Note patients position. Chart: Internal jugular vein pulsations 3 cm above sternal angle with HOB elevated 30 degrees.

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Cardiac Exam- heart anatomy

heart examined through anterior chest wall upper portion is base and lower tip is apex part of heart most accessible to exam is right ventricle
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Cardiac Exam contd.

Left ventricle presents small tip that rests at the apex. It forms the apical impulse or PMI. Cardiac palpatory and auscultatory areas are not where areas are anatomically, but sound is heard along the trajectory of the ejected blood
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History
Ask pt. about cardiac S&S- dyspnea, orthopnea, edema, cough, chest pain, wheezing, syncope, fatigue, palpitations Hx of high cholesterol, HTN, murmurs, rheumatic fever, heart failure, heart attack, thrombophlebitis Family history, lifestyle, medications
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Inspection
Inspect chest for color, respirations, deformities, distress Pt. should be sitting with HOB up 30-45 degrees or supine Look for visible heaves or lifts, and apical impulses
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Inspection
Apical Impulse
When visible, it occupies the 4th or 5th ICS, at the MCL

Heave or Lift
A sustained forceful thrusting of the ventricle during systole Occurs with ventricular hypertrophy and increased workload of the heart Seen at the sternal border or the apex
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Palpation
place pt. in supine position palpate using palmar surfaces of handsmore sensitive to vibrations palpate for thrills, lifts, heaves at 5 cardiac areas, epigastric area palpate PMI or apical impulsepresence,location, size- 5th L ICS at the MCL (only present in about 50% of people)
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Thrill
A palpable vibration Feels like the throat of a purring cat Signifies turbulent blood flow Accompanies loud murmurs

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PMI picture

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Percussion
Used to outline the hearts borders. Cardiac enlargement:
Increased ventricular volume Increased wall thickness Hypertension Coronary Artery Disease Heart Failure Cardiomyopathy

We will not do
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Cardiac Auscultation
Position self on right side, pt. in supine position. Use diaphragm of the stethoscope to detect high-pitched sounds, then bell for low-pitched sounds Listen for heart rate, rhythm Examine all 5 areas, be systematic from base to apex (top to bottom)
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Patient position
Supine Sitting up Abnormal sounds at the base place patient in left lateral position Abnormal sounds at the apex have patient lean forward

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Auscultate with both diaphragm and bell of the stethoscope

DIAPHRAGM Best for high-pitched sounds I.e. normal heart sounds Press firmly against the skin BELL Best for low-pitched sounds I.e. extra heart sounds, murmurs, and carotid bruits Press lightly against the skin (just enough to make a seal)
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Cardiac Exam- APE to MAN

Aortic- 2nd IC space along right sternum Pulmonic- 2nd ICS along left sternum Erbs point- where S1=S2, left 3rd ICS along sternum Triscuspid-right ventricular sounds- left 5th ICS along sternum Mitral or apex- left ventricular sounds- left 5th ICS at MCL
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APE To Man

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Heart Rate & Rhythm

Rate usually 5 10 beats per minute faster in females than males. Normal 60 100 bpm. If pulse is irregular, auscultate for pulse deficit. Auscultate apical while simultaneously palpating the radial pulse. Count each one after another. The two counts should be identical. When different subtract the radial rate from the apical rate.
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Cardiac Auscultation- Heart Sounds

Listen and evaluate S1 (lub)- S1 starts systole- heart sound that occurs with carotid pulse- is loudest at apex- slower and longer than S2- same timing as closure of triscupid and mitral valve S2 (dub)- S2 starts diastole- loudest at base of heart-same timing as closure of aortic and pulmonic valves
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Split S1
Normal but uncommon Hearing the mitral and tricuspid components separately. Audible in tricuspid valve area

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Split S2
Fixed split atrial septal defect or R CHF Paradoxical split on inspiration the aortic valve closes slower than pulmonic valve

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Heart Sounds picture

S1= Tricuspid + Mitral S2= Aortic + Pulmonic

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Heart Sounds
S3- heard best at apex with bell in laying down position- signifies rapid filling of left ventricle (called ventricular gallop)- WNL for children and young adults- in older adults may signify heart failure S4 heard best at apex- signifies sound of forceful atrial ejection (called atrial gallop)-is produced by cardiac pathology58

OS, S3 and S4 Picture

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Midsystolic Click
Heard during systole Indicates a mitral valve prolapse Listen at the apex or left lower sternal border with the diaphragm

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Murmurs
Whooshing or blowing sounds during cardiac cycle- caused by increased rate of blood flow through heart valves auscultate for murmurs across the entire heart areas, using the diaphragm and bell auscultate the client in different positions
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Characteristics of Murmurs
Timing-when in cardiac cycle- systole or diastole Pitch- high, medium, or low Intensity loudness Quality- musical, blowing, harsh, rumbling Location- point where it is the loudest, use heart landmarks for description Radiation- where murmur radiates to Effects of position
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Murmurs contd.
Intensity-loudness on scale I-VI
grade I- very faint, barely audible grade II- quiet but heard immediately when placing stethoscope on chest grade III- moderately loud grade IV- loud grade V- very loud, may be heard with stethoscope partly off the chest grade VI- may be heard with stethoscope entirely off the chest
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Evaluation of Murmurs
all diastolic murmurs are pathologic most murmurs of grade IV and above are pathologic in nature functional murmurs of children and young adults are systolic, short duration, grade IIII, change in position and respiration are heard at base with bell
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Evaluation of Murmurs contd.

Systolic murmurs- common with elderly and s&s cardiac disease

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Pericardial Friction Rub

Signifies inflammation of the pericardium or pericardial sac. Sounds scratchy, grating. Is a high pitched sound that does not vary much with respiration. Best heard at the apex. Sounds like 2 balloons rubbing together.

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