Heart and Neck Vessels: Regional Examinations

• Regional Examinations: The Heart and Neck Vessels

Structure and Function of the Heart

• The heart pumps blood and distributes oxygen and nutrients throughout the body.
• Key structures include the right atrium, right ventricle, left ventricle, left atrium, the superior and inferior vena cava, pulmonary artery, pulmonary vein, and aorta.
• The right side pumps blood to the lungs, and the left side pumps blood to the body.
• The heart has four valves: the tricuspid (right atrioventricular), mitral (left atrioventricular), aortic (left semilunar), and pulmonary (right semilunar) valves.
• Valves can be best heard in certain positions: aortic valve at the 2nd intercostal space, pulmonary valve at the 2nd intercostal space, tricuspid valve near the 5th rib, and mitral valve at the 5th intercostal space.

Nursing Health History

• Important to note a History of Present Health Concern with pain, tachycardia, palpitations, fatigue, difficulty breathing, cough, dizziness, nocturia, swelling, and heartburn.
• Important to note Personal Health History, including heart defects, rheumatic fever, surgery, ECG, medications, and monitoring of heart rate and blood pressure.
• Also important to note Family History, which includes hypertension, myocardial infarction, coronary heart disease, elevated cholesterol, and diabetes.
• Lifestyle and Health Practices includes smoking, type of stress, diet, alcohol, exercise, daily activities, the effect of heart disease on sexual activity, sleeping patterns, and perceptions of a healthy heart.

Physical Assessment: General Routine Screening

• Examine the jugular venous pulse.
• Auscultate, then palpate the carotid arteries.
• Check for pulsations and palpate the apical impulse and abnormal pulsations.
• Auscultate to identify S1 and S2 sounds, extra heart sounds, and murmurs.

Physical Assessment: Focus Specialty Assessment

• Evaluate jugular venous pressure and identify the source of auscultated murmurs.
• Differentiate between split sounds, rubs, snaps, and clicks.

Physical Assessment: Neck Vessels - Normal Findings

• Jugular venous pulse is not normally visible when the client is sitting upright
• Jugular veins are visible when client is in supine position
• Jugular vein should not be distended, bulging or protruding at 45 degrees or greater elevation of torso
• No blowing or swishing sounds are heard when auscultating carotid artery
• Carotid pulses are equally strong (Scale: 0 =if absent, 1+ if weak., 2+ normal, 3+ bounding)
• Contour is smooth
• Arteries are elastic and no thrills are noted

Physical Assessment: Neck Vessels - Abnormal Findings

• Fully distended jugular veins with the client's torso elevated more than 45 degrees may indicate increased central venous pressure due to right ventricular failure, pulmonary hypertension, pulmonary emboli, or cardiac tamponade.
• Distention, bulging or protrusion at 45, 60, or 90 degrees may indicate right sided heart failure or obstructive pulmonary disease.
• A bruit, blowing or swishing sound, is indicative of occlusive arterial disease.
• There may be no bruit if more than 2/3 of the artery is occluded.
• Pulse inequality may indicate arterial constriction.
• A bounding pulse indicates hypervolemia or increased cardiac output.
• Losing elasticity indicates arteriosclerosis, and thrills indicate narrowing of the artery.

Physical Assessment: Heart (Precordium) Anterior Chest - Normal Findings

• Apical impulse (result of the LV moving outward during systole: left MCL, 4th or 5th ICS) may or may not be visible
• Apical impulse is palpated in the mitral area (left MCL, 4th or 5th ICS). Not palpable in obese client
• Heart rate should be 60-100 beats/minute; with regular rhythm
• S1 corresponds with each carotid pulsation and is loudest at the apex of the heart
• S2 immediately follows S1 and is loudest at the base of the heart
• No extra sound should be heard. (except for physiologic S3 and S4 -in the case of athletes or over 40 y.o. with no evidence of heart disease)
• No murmurs should be heard
• No pulsations or vibrations in the areas of the apex, left sternal border or base

Physical Assessment: Heart (Precordium) Anterior Chest - Abnormal Findings

• Pulsations(heaves or lifts) may be a result of an enlarged ventricle from an overload of work
• Not palpable in clients with pulmonary emphysema - if apical impulse is larger than 1-2 cm displaced, more forceful or of longer duration, suspect cardiac enlargement
• A thrill or pulsation is usually associated with a higher grade of murmur
• Bradycardia is less than 60 bpm
• Tachycardia – more than 100 bpm
• Irregularities may predispose the client to decrease cardiac output, heart failure or emboli
• Should auscultate for a pulse rate deficit for irregularities and palpate the radial pulse while auscultating the apical pulse for a full minute
• Valvular problems for heart murmurs
• Extra heart sounds In older individuals it indicates the presence of congestive heart failure