Heart, Neck, and Peripheral Vascular System Lecture PDF

Learning Objectives After you have successfully completed this lecture, you should be able to: ❑Identify pertinent cardiovascular and peripheral-vascular history questions ❑Obtain a cardiovascular and peripheral-vascular history ❑Perform a cardiovascular and peripheral-vascular physical assess...

Learning Objectives After you have successfully completed this lecture, you should be able to: ❑Identify pertinent cardiovascular and peripheral-vascular history questions ❑Obtain a cardiovascular and peripheral-vascular history ❑Perform a cardiovascular and peripheral-vascular physical assessment ❑Document cardiovascular and peripheral-vascular findings ❑Differentiate between normal and abnormal findings  Heart ❑ Cardiovascular system consists of heart (muscular pump) and blood vessels (arteries & veins) ❑Precordium Area on anterior chest overlays heart & great vessels Heart & great vessels are located between lungs in middle third of thoracic cage (mediastinum)  Heart (Cont….) Heart extends from 2nd to 5th intercostal space and from right border of sternum to left midclavicular line Base (top): widest point Apex (bottom): narrow point  Vessels ❑ Great vessels: i. Superior and inferior vena cava ii. Pulmonary artery iii. Pulmonary veins iv. Aorta ❑ Blood vessels are arranged in two continuous loops: 1) pulmonary circulation and 2) systemic circulation Let's discuss cardiac circulation  Heart Wall ❑ Heart wall has numerous layers: 1) Pericardium Tough, fibrous, double walled sac (surrounds & protects the heart) 2) Myocardium Muscular wall of heart; it does the pumping 3) Endocardium Thin layer of endothelial tissue that lines inner surface of heart chambers & valves  Heart Chambers and Valves ❑ Four chambers: 1) left atrium, 2) right atrium, 3) left ventricle 4) and right ventricle ) separated by valves to prevent backflow of blood ❑Valves are unidirectional (can only open one way) ❑Valves open and close passively in response to pressure gradients in moving blood Two atrioventricular (AV) valves (Tricuspid & mitral) Two semilunar (SL) valves (Pulmonic & aortic) 7  Heart Sounds ❑ Cardiac cycle generates heart sounds (heard through a stethoscope) ❑Include: 1) normal heart sounds, 2) extra heart sounds and 3) murmurs 1) Normal heart sound First heart sound- S1 (lub) Second heart sound- S2 (dub) ▪ Occurs with closure of AV valves and signals the beginning ▪ Occurs with closure of SL of systole valves and signals the end of systole ▪ Heard over all precordium, S1 loudest at apex ▪ Heard over all precordium, S2 loudest at base  Heart Sounds (Cont….) 2) Extra heart sounds Third heart sound- S3 Forth heart sound- S4 ▪ Occurs when ventricles are ▪ Occurs at end of diastole, at resistant to filling during early presystole when ventricle is rapid filling phase resistant to filling ▪ Occurs immediately after S2 ▪ Occurs just before S1  Heart Sounds (Cont….) 3) Murmurs ❑Blood circulating through normal cardiac champers & valves makes no noise ❑ Some conditions create Turbulent blood flow produces murmur sound (blowing, swooshing sound like a sharp turn in a stream creates a noisy water flow) ❑Associated with: i. Increase in blood flow velocity (exercise) ii. Decrease in blood viscosity (anemia) iii. Structural defects in valves or unusual openings occur in the chambers  Neck Vessels 1) Carotid artery (central) ❑ Located in the groove between trachea & sternomastoid muscle, medial to and alongside that muscle 2) Jugular Veins (JV) ❑Empty un-oxygenated blood directly into superior vena cava Internal JV: deep, not visible, lies deep and medial to sternomastoid muscle External JV: more superficial, lies lateral to sternomastoid muscle, above clavicle  Peripheral Vascular System 12 ❑Primary function is to deliver blood to all areas of body ❑Vascular system consists of vessels for transporting fluid ❑ Any disease in vascular system leads to: i. Impairs delivery of oxygen & nutrients to target cells ii. Retards elimination of carbon dioxide & waste products from cellular metabolism  Peripheral Vascular System (Cont….) 13 ❑Arteries Arteries in the arm Arteries in the leg  Peripheral Vascular System (Cont….) ❑Veins Veins in the arm Veins in the leg Subjective Data: Heart & Neck Vessels 1- Chest Pain PQRSTU ❑Provocation: pain made worse by, relieved by ❑Quality: characteristics ❑Region/Location ❑Severity ❑Timing: onset ❑Understanding ❑Associated symptoms: Sweating (diaphoresis), ashen grey or pale skin, palpitations, shortness of breath (SOB) nausea/ vomiting, fatigue and tachycardia Subjective Data: Heart & Neck Vessels (Cont….) 2- Dyspnea (difficulty breathing) ❑ Any shortness of breath (SOB)? ❑ Onset/When: Does the SOB come on unexpectedly? After activity? Which type of activity? ❑ Duration: Constant or does it come and go? ❑ Affected by position: lying down? ❑ Awaken you from sleep at night? ❑ Does the SOB interfere with activity of daily living? Subjective Data: Heart & Neck Vessels (Cont….) 3-Orthopnea (SOB when lying flat) ❑ How many pillows do you use to when sleeping or lying down? 4-Cough Orthopnea is the need to assume a ❑ Do you have a cough? more upright position to breathe ❑ Duration: How long have you had it? ❑ Frequency: Is it related to time of day? ❑ Type: Dry, hacking, barky, or congested? ❑ Do you cough up mucus? Color? Any odor? Blood stained? ❑ Does the activity make it better or worse? ❑ Is it relieved by rest or medication? Subjective Data: Heart & Neck Vessels (Cont….) 5-Fatigue (being tired) ❑ Do you seem to tire easily? ❑ Able to keep up with your family and co-workers? ❑ Onset: When did the fatigue start? Sudden or gradual? Has any recent change occurred in energy level? ❑ Fatigue related to time of day: all day, morning, evening (cardiac failure)? 6-Cyanosis or Pallor (decreased tissue perfusion- low cardiac output or myocardial infarction) Subjective Data: Heart & Neck Vessels (Cont….) 7-Edema ❑ Any swelling of your feet or legs? ❑ Onset: What time of day does the swelling occur? Are both legs equally swollen? ❑ Does the swelling go away with: rest, elevation, sleep? 8-Nocturia (urinating at night) ❑ Do you awaken at night with an urgent need to urinate? ❑ How long has this been occurring? Any recent changes? Subjective Data: Heart & Neck Vessels (Cont….) 9-Cardiac History ❑Any past history of: Hypertension, elevated cholesterol or triglycerides, congenital heart disease, rheumatic fever or unexplained joint pains as child or youth, recurrent tonsillitis? ❑Ever had heart disease? When was this? Treated by medications or heart surgery? ❑Last ECG, serum cholesterol measurement, other heart tests? Subjective Data: Heart & Neck Vessels (Cont….) 10-Family Cardiac History Any family history of: ▪ Hypertension ▪ Obesity ▪ Diabetes ▪ Coronary artery disease (CAD) 11-Cardiac Risk Factors ▪ Nutrition ▪ Smoking ▪ Alcohol ▪ Exercise  Subjective Data: Peripheral Vascular System 1- Leg pain or cramps ❑ Any leg pain (PQRST)? 2- Skin changes on arms or legs ❑ Any skin changes on arms or legs? What color: redness, pallor, brown, blueness discoloration? ❑ Any change in temperature – excess warmth or coolness? ❑ Do your leg veins look bulging? Have you treated these? ❑ Do you have any leg sores or ulcers? Subjective Data: Peripheral Vascular System (Cont....) 3- Swelling in the arms or legs: ❑Do you have swelling in one or both legs? When did swelling start? In one or both legs? What time of day is swelling at its worst: morning or evening? Is swelling constant or not? ❑ What seems to bring it on: sitting, standing all day, trauma? What relieves swelling: elevation, rest? Is swelling associated with pain, heat, redness? 4- Smoking history: ❑ Do you smoke cigarettes? How many packs per day would you say? At what age did you start? ❑ How many years have you smoked? Have you tried to quit? What helped for you? What did not help?  Objective Data: Neck Vessels 1) Palpate the carotid artery Palpate each carotid artery medial to sternomastoid muscle in the neck Avoid excessive pressure on the carotid area (Why??) Palpate gently & only one carotid artery at a time (Why??) Feel contour and amplitude of pulse. Normally, smooth and moderate Findings should be the same bilaterally Objective Data: Neck Vessels (Cont….) 2) Auscultate carotid artery (use bell of stethoscope) Performed for who shows symptom or signs of cardiovascular disease Auscultate for presence of a bruit (blowing, swishing sound indicating blood flow disorder) Keep neck in neutral position, lightly apply bell of stethoscope on 3 levels: 1) Angle of the jaw 2) Midcervical area 3) The base of the neck ▪ Normally none is present Objective Data: Neck Vessels (Cont….) 3) Inspect Jugular Venous Pulse Stand on patient’s right side Position patient supine from 30-45o, remove pillow to avoid flexing neck Turn head slightly away from examiner side & direct strong light onto the neck Note external jugular vein overlying sternomastoid muscle. Observe bilaterally Objective Data: Neck Vessels (Cont….) Table 1. Characteristics of carotid versus jugular pulsations Carotid artery pulse Jugular vein pulse Location Higher, medial to muscle Lower, lateral or under muscle Palpable Yes No Position of Unaffected by position Pulse disappear when patient patient is brought to a sitting position  Objective Data: Heart 1) Inspection ❑ Pulsations You may or may not see apical impulse If visible, it occupies 4th - 5th ICS It is easier to see in children and in those with thinner chest walls  Objective Data: Heart (Cont….) 2) Palpate apical impulse Localize apical impulse area by using one finger pad Asking client to exhale and hold you may need to roll client midway to the left to find it Not palpable in obese persons or persons with thick chest wall Note location, size, amplitude and duration  Objective Data: Heart (Cont….) 2) Palpate across the precordium i. Use palmar aspect of your four fingers ii. Gently palpate apex, left sternal border & base iii. Search for any other pulsations (thrills is a palpable vibration) Normally none occur  Objective Data: Heart (Cont….) 3) Percussion Percussion to outline the heart’s borders has been replaced by: ▪ Chest x-ray image or echocardiogram ❖ More accurate in detecting heart enlargement  Objective Data: Heart (Cont….) 4 ) Auscultation ❑ Use the diaphragm & a zigzag pattern) ❑Four traditional valve “areas” Name of Location the area Aortic 2nd right interspace valve Pulmonic 2nd left interspace valve Tricuspid Left lower sternal border valve Mitral 5th interspace at around left valve midclavicular line  Objective Data: Heart (Cont….) 4) Auscultation (Cont….) ❑ You cannot process everything at once, use the following routine: Rate and Heart sounds Extra heart sounds rhythm (S1 & S2) (S3, S4 & murmur)  Objective Data: Heart (Cont….) 4) Auscultation (Cont….) ❑ Rate and rhythm Rate ranges normally from 50 to 95 beats/min Rhythm should be regular (note any sinus arrhythmia) When you notice any irregularity check for a pulse deficit  Objective Data: Heart (Cont….) ❑Pulse deficit i. Auscultate apical beat while simultaneously palpating radial pulse ii. Normally, every beat you hear at apex should perfuse to periphery and be palpable iii. The two counts should be identical iv.When different, subtract radial rate from apical and record reminder as pulse deficit  Objective Data: Heart (Cont….) 4) Auscultation (Cont….) ❑ Heart sounds (S1 & S2) (lub-dub) S1 (lub): is louder than S2 at apex of heart S2 (dub): is louder than S1 at base of heart ❖ S1 coincides with carotid artery pulse ❖ Feel carotid gently as you auscultate at apex; sound you hear as you feel each pulse is “S1”  Objective Data: Heart (Cont….) 4) Auscultation (Cont….) ❑ Extra heart sound After auscultating in a supine position roll client towards left side listen by using bell at apex for presence of S3 & S4 S3 and S4 is usually abnormal heart sounds in adults  Objective Data: Heart (Cont….) 4) Auscultation (Cont….) ❑ Extra heart sound (Cont….) Ask client to sit up Lean forward slightly and exhale Listen with diaphragm firmly pressed at the base, right &left sides Check for early diastolic murmur of aortic or pulmonic regurgitation Objective Data: Peripheral Vascular System ❑ Inspect the arms Lift both hands in your hands Inspect while turning the client’s hands over ▪ Note color of skin, nail beds; temperature, texture, turgor of skin, presence of any lesions, edema, or clubbing ▪ Check profile sign and capillary refill Two arms should be symmetrical in size  Objective Data: Peripheral Vascular System (Cont….) ❑Palpate the arms Pulse and note the following: ▪ Rate (Beats/min) ❖Tachycardia: above 95 ❖Bradycardia: below 50 ▪ Rhythem ❖(Regular/ irregular) ▪ Elasticity: elastic and smooth contour ▪ Equal force: grade force on a 3-point scale: 3+ = increased, bounding 2+ = normal 1+ = weak 0 = absent Objective Data: Peripheral Vascular System (Cont….) ❑ Palpate the arms (Cont….) Modified allen test used to evaluate adequacy of collateral circulation before cannulating radial artery i. Firmly occlude both ulnar & radial arteries of one hand while client makes a fist several times ii. Ask client to open hand ; then release pressure on ulnar artery while maintaining pressure on radial artery ▪ Normally, return to normal color of hand in less than 7 seconds  42 Objective Data: Peripheral Vascular System (Cont….) ❑ Inspect the leg Uncover legs, while keeping genitalia draped Inspect both legs together, noting the following: ▪ Skin color and discoloration, skin lesion or ulcers ▪ Hair distribution ▪ Venous pattern (flat, barely visible) ▪ Leg size (swelling or atrophy) ▪ Normally, both legs should be symmetric in size without any swelling or atrophy Objective Data: Peripheral Vascular System (Cont….) 43 ❑ Palpate the leg Femoral pulse Posterior tibial pulse Popliteal pulse Dorsalis pedis pulse Check pretibial edema  44 Objective Data: Peripheral Vascular System (Cont….) ❑Palpate the legs (Cont….) 1) Assess venous system Ask client to stand up to assess venous system Note any visible, dilated tortuous veins (varicose veins)  45 Objective Data: Peripheral Vascular System (Cont….) ❑Palpate the legs (Cont….) 2) Color changes i. Raise legs 30 cm for 30 seconds ii. Now have client sit up with legs over side of table iii. Compare color of both feet (normally look little pale but still should be pink) iv. Note the time it takes for color to return to the feet (normal time is 10 seconds or less)  Abnormalities : Heart ❑ Edema Swelling may indicate heart failure or venous Cardiac edema is bilateral: it is worse at evening and better in morning after elevating legs all night Unilateral swelling: has a local vein cause  Abnormalities : Heart ❑ Thrill Abnormal pulsations on the precordium Base Apex Left Sternal Border  Abnormalities : Neck Vessels ❑Full distended external jugular vein above 45 degrees signify heart failure  49 Abnormalities : Peripheral Vascular System Varicose veins Arterial insufficiency Chronic venous insufficiency  In-Class Case Study ❑ S.R. is a 65- year-old woman who presents to emergency department complaining of shortness of breath, productive cough, and swelling in both legs. The patient has a past medical history of congestive heart failure (CHF) & hypertension. Vital signs are T 97.5, P 85, R 16, and BP 160/90. Physical exam reveals +2 edema bilateral lower extremities, heart rate and rhythm regular. An electrocardiogram has been ordered. 1. The nurse is assessing the patient’s pulses. Which locations should the nurse check? 2. The nurse needs to evaluate the adequacy of the collateral circulation before obtaining an arterial blood gas (ABG) sample. How should the nurse proceed? 3. What is the most likely cause of this patient’s shortness of breath, productive cough, and swelling in both legs?  Sample Charting: Subjective Data ❑No chest pain, dyspnea, orthopnea, cough, fatigue, or edema. No history of hypertension or heart murmur. Last ECG 2 yrs, result normal. ❑ Family history: Father with obesity, smoking, and hypertension, treated diuretic medication. No other family history significant for CV disease. ❑No leg pain, no skin changes. No history of heart or vascular problems, diabetes, or obesity. Does not smoke. On no medications.  Sample Charting: Objective Data ❑Neck: Carotids’ upstrokes are brisk and = bilaterally. No bruit. Internal jugular vein pulsations present when supine and disappear when elevated to a 45-degree position. ❑Precordium: No visible pulsations; no heave or lift. ❑Peripheral vascular system: Extremities have pink color without redness, cyanosis, or any skin lesions. Extremity size is symmetric without swelling or atrophy. ❑Palpation: Apical impulse in 5th ICS at left midclavicular line; no thrill. Temperature is warm and = bilaterally. All pulses present, 2+ and = bilaterally. ❑Auscultation: Rate 68 bpm, rhythm regular, not diminished or accentuated, no S3, no S4 or other extra sounds, no murmurs.