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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.
2
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.)