ASSESSMENT OF THE adult females

HEART AND NECK • Pumps blood throughout

VESSELS circulatory system
Salient Points Of The Heart Chambers, Valves and
Cardiovascular System Circulatory Flow
• The cardiovascular system The Chambers of the HEART
plays an important role in the 1. RIGHT ATRIUM receives
body DEOXYGENATED blood from
o It delivers oxygenated the body via the superior and
blood inferior vena cavae
o Removes waste products 2. RIGHT VENTRICLE
• The autonomic nervous receives blood from the right
system controls how the heart atrium and pumps it to the
pumps lungs via the
• The vascular network the pulmonary artery
arteries, veins, capillaries 3. LEFT ATRIUM receives
carries blood throughout the OXYGENATED blood from
body, the lungs via four pulmonary
keeps the heart filled with veins
blood and maintains blood 4. LEFT VENTRICLE receives
pressure OXYGENATED blood from
The Heart the lungs via the left atrium
• The heart and major blood pumps
vessels lie centrally in the blood into the systemic
chest behind the protective circulation via the aorta - the
sternum largest and most muscular
• A cone-shaped muscle with chamber
four chambers The Valves of the HEART
Atrioventricular Valves
• A double pump about the 1. TRICUSPID VALVE
size of a clenched fist (12 cm located on the right side of the
long and 9 cm wide) 250–390 heart, has three leaflets and
g prevents
(8.8 13.8 oz) in adult males backflow of blood from the
200–275 g (7.0–9.7 oz) in right ventricle to the right
atrium ▪ “lub”
2. BICUSPID (MITRAL) ▪ the result of closure of the
VALVE located on the left atrioventricular (AV) valves
side of the heart, has two • the TRICUSPID VALVE
leaflets and • the MITRAL VALVE
prevents backflow of blood ▪ correlates with the beginning
from left ventricle to the left of systole
atrium ▪ heard at the base and apex
Semilunar Valves of the heart
1. PULMONIC SEMILUNAR • softer at the base
VALVE lies between the right • louder at the apex (best
ventricle and the pulmonary heard)
artery o left MCL, 5th ICS
and prevents backflow of o S2
blood from pulmonary trunk to ▪ the second heart sound
the right ventricle ▪ “dubb”
2. AORTIC SEMILUNAR ▪ results from closure of the
VALVE lies between the left semilunar valves
ventricle and the Aorta • the AORTIC VALVE
prevents • the PULMONIC VALVE
backflow of blood from the ▪ correlates with the beginning
aorta into the left ventricle of DIASTOLE
Heart Sounds ▪ best heard at the base of the
• produced by valve closure, heart
therefore, opening of valve is • Extra Heart Sounds
silent o S3 & S4
o S1 – “lub” ▪ diastolic filling sounds
o S2 – “dubb” ▪ result from ventricular
vibration secondary to rapid
• Extra heart sounds
ventricular filling
o S3 and S4
▪ S3
o Murmurs
• ventricular gallop
• Normal Heart Sounds • can be heard early in
o S1 diastole, after S2
▪ the first heart sound
• when the mitral valve opens ▪ flow of blood into a dilated
▪ S4 blood vessel from one of
• atrial gallop normal size
• results from ventricular Cycles of Heart Sounds
vibrations secondary to Auscultating Heart Sounds
ventricular resistance • The Traditional 5 Areas
during atrial contraction o Aortic Area
• can be heard late in diastole,
just before S1 ▪ 2nd ICS at the right sternal
o Murmurs border
▪ base of the heart
▪ Blood NORMALLY flows
o Pulmonic Area
silently through the heart
▪ 2nd or 3rd ICS at the left
▪ In conditions of an audible sternal border
and prolonged sounds, ▪ base of the heart
murmurs are auscultated o Erb’s point
over the precordium, a ▪ 3rd to 5th ICS at the left
swooshing or blowing sound sternal border
resulting from turbulence o Mitral (Apical)
created within the vascular ▪ 5th ICS near the left MCL
system ▪ apex of the heart
▪ Conditions that contributes o Tricuspid Area
to turbulent blood flow ▪ 4th or 5th ICS at the left
includes lower sternal border
• increased blood velocity; • Take Note!
• structural valve defects; o the 4 valve areas do not
• valve malfunction; and reflect the anatomical position
• abnormal chamber opening of the valves
(septal defect) o sounds always travel in the
▪ increased flow through
direction of the blood flow
normal blood vessels,
o the areas described in the
creating frictional, audible
traditional auscultation
sounds flow through
overlaps extensively and
constricted blood vessels
sounds
(e.g., aortic stenosis).
produced by the valves can heard as the vessel distends
be heard all over the with blood
precordium o Phase III:
• The Alternative Areas ▪ Sounds become more
o AORTIC AREA intense
▪ right 2nd ICS to apex of ▪ Vessel is open in systole but
heart not in diastole
o PULMONIC AREA o Phase IV:
▪ 2nd and 3rd left ICS close to ▪ Sounds begin to muffle, and
sternum but may be higher or pressure is closest to diastolic
lower arterial pressure
o LEFT ATRIAL AREA o Phase V:
▪ 2nd to 4th ICS at the left ▪ Sounds disappear because
sternal border vessel remains open
o RIGHT ATRIAL AREA ASSESSMENT PROPER
▪ 3rd to 5th ICS at the right • You will use all four
sternal border techniques of physical
o LEFT VENTRICULAR assessment to assess the
AREA cardiovascular
▪ 2nd to 5th ICS, extending system
from the left sternal border to o I
the left MCL o P
o RIGHT VENTRICULAR o P
AREA o A
▪ 2nd to 5th ICS, centered • Perform the assessment in 3
over the sternum positions
o sitting, supine, and left
• Korotkoff’s Sounds
o Phase I: lateral
• Inspection
▪ A faint, clear, rhythmic
o Neck
tapping noise that gradually
increases in intensity ▪ Differentiate carotid arteries
o Phase II: and jugular veins
▪ Normal
▪ A swishing sound that is
• Carotids have visible
pulsation over base in thin adults and
• Jugulars have undulated children
wave ▪ Deviations from normal
• Carotids have palpable • Pulsations may occur
pulsations o to right of sternum
• Jugulars are obliterated o epigastric area
• Carotids not affected by o sternoclavicular areas
respirations, jugulars are ▪ AORTIC ANEURYSM
• Carotids not affected by • Apical pulsation displaced
position toward axillary line
• Jugulars normally only o left ventricular hypertrophy
visible when client is supine • Palpation
▪ Deviations from normal o Carotid Artery
• Large, bounding visible ▪ Lightly palpate each carotid
pulsation in neck of separately
suprasternal notch: ▪ Note
o HTN, aortic stenosis, or • rate
aneurysm • rhythm
• Abnormal venous • amplitude
waveforms • contour
• Giant A waves • symmetry
• Tricuspid stenosis, right • elasticity
ventricular hypertrophy • thrills
o cor pulmonale o Jugular Veins
• Absent A wave ▪ Palpate jugular veins and
o atrial fibrillation check direction of fill.
o Precordium ▪ 3 ways
▪ Look for pulsations on the 1. Occluding under the jaw,
precordium, paying particular the jugular should flatten, but
attention to the apex the wave form
area. will become more prominent.
▪ Normal o Assessing Jugular Flow
• Positive pulsation at apex ▪ Compress jugular below jaw.
• May note slight pulsations ▪ Jugular vein collapses and
jugular wave is more o Sinus tachycardia
prominent at supraclavicular o Supraventricular
area tachycardia (SVT)
2. Occluding above the o Paroxsymal tachycardia
clavicle, the jugular normally (PAT)
distends while the o Uncontrolled atrial
jugular wave diminishes. fibrillation
o Checking Jugular Fill o Ventricular tachycardia
▪ Compress jugular above ▪ causes include CHF drugs,
clavicle. such as:
▪ Jugular distends and jugular ▪ atropine
wave disappears. ▪ nitrates
3. Testing Abdominojugular ▪ epinephrine
(Hepatojugular) Reflux ▪ isoproterenol
o Position patient at 45- ▪ nicotine and caffeine
degree angle, place hands ▪ HYPERCALCEMIA
over the • Cardiac Rate <60 bpm
midabdominal area and apply o Sinus bradycardia heart
20 to 30 mm Hg of pressure block
for o causes include MI drugs,
about 15 to 30 sec. such as:
o Estimate the pressure by ▪ digoxin
placing a partially inflated BP ▪ quinidine
cuff on ▪ procainamide, and
the abdomen under your ▪ beta-adrenergic inhibitors;
hand. ▪ HYPERKALEMIA
o Look at the jugular veins • Irregular rhythm
while applying pressure o arrhythmia
▪ note increase vein ▪ abnormal pulses
distension ▪ unequal pulses
▪ return to normal upon o obstruction or occlusion
release of pressure ▪ stiff, cordlike arteries
▪ Deviations from normal o Right – sided CHF
• Cardiac Rate >100 bpm o tricuspid regurgitation
o tricuspid stenosis o 2nd ICS, left sternal border
o constrictive pericarditis • Base right (aortic area)
o cardiac tamponade o 2nd ICS, right sternal
o inferior vena cava border
obstruction • Epigastric area
o HYPERVOLEMIA o Below the xyphoid process
o Precordium o Normal
▪ Apex (left ventricular area) ▪ Positive slight pulsation may
or mitral area be normal, no diffusion
▪ 5th ICS, MCL ▪ Palpations not palpable
▪ Normal • at base left, the pulmonic
• Apex (left ventricular area): area
o PMI is 1–2 cm • base right, the aortic area
o Negative thrills o except in thin patients
o Amplitude may normally be • Abnormal
increased in high-output o Enlargement and
states displacement of PMI to left
SUCH AS EXERCISE midaxillary line
o Apical pulsation may not o Cause:
always be palpable ▪ Ventricular hypertrophy with
o Left lateral displacement of dilation
PMI may occur during the last o Apical impulse located on
trimester of pregnancy right side of precordium:
• LLSB (tricuspid area) 4th to ▪ DEXTROCARDIA
5th ICS at left sternal border ▪ Cause:
• LLSB • a heart located on the right
o May not be palpable, side, often associated
although small, nonsustained, with congenital heart disease
systolic o Enlarged apical pulsation
impulse may be palpated, without displacement >2–2.5
especially in thin patients cm with
o Negative thrills patient supine or >3 cm with
• Base left (pulmonic area) patient in left lateral
recumbent • Percussion
position o Dullness at 3rd, 4th, and
▪ Cause: 5th ICS to left of sternum at
• Ventricular enlargement, MCL
HTN, aortic stenosis o Left sternal border extends
o Sustained pulsation to midaxillary lines in an
▪ Cause: enlarged, dilated heart
• Hypertrophy • Auscultation
• HTN o Neck
• Overload ▪ Have client hold breath.
• CMP ▪ Auscultate the carotid with
DEVIATIONS FROM the bell portion of the
NORMAL stethoscope for bruits.
THRILLS ▪ Auscultate the jugulars with
o cause: murmur the bell portion of the
PALPABLE LIFTS OR stethoscope for venous
HEAVES hums.
o cause: right ventricular ▪ Normal
hypertrophy • Positive carotid bruit may be
PULSATIONS FELT ON THE normal in children and is
FINGERTIPS associated with
o cause: may come from the high-output states
right ventricle, indicating right • Negative venous hum
ventricular hypertrophy • Positive venous hum may be
LARGE DIFFUSE normal in children
EPIGASTRIC PULSATION ▪ Deviations from normal
o cause: abdominal aortic • Bruit suggests carotid
aneurysm stenosis
ACCENTUATED PULSATION • Murmurs can also radiate up
IN PULMONIC AREA to the neck from the heart, as
o cause: pulmonary HTN in aortic
ACCENTUATED PULSATION stenosis
IN AORTIC AREA o Precordium
o cause: HTN or aneurysm ▪ Auscultate at apex
▪ Note rate, rhythm, extra • Irregular rhythm: Arrhythmia
sounds, or murmurs. • Quadruple rhythm, S3 S4
▪ Auscultate at each site with fast rate is called a
(apex, LLSB, Erb’s point, summation gallop
base left and base right). COMMON ABNORMALITIES
▪ Note S1, S2, extra sounds, Angina Pectoris
or murmurs. • Chest pain resulting from
▪ Listen at each site with both myocardial ischemia
the bell and the diaphragm. o Anxiety, chest pain
▪ The diaphragm of the o Skin pale, diaphoretic, cool,
stethoscope is best for clammy
detecting high-pitched o Dyspnea, tachycardia,
sounds. pulsus alternans,
▪ The bell is best for detecting o arrhythmias, S4, S3
low-pitched sounds. o Nausea, belching
▪ Use firm pressure with the o Weakness, paresthesias
diaphragm and light pressure Congestive Heart Failure
with the bell. • Failure of the heart to pump
▪ Apex (Mitral) sufficiently to meet the
• Rate: • demands of the body
o depends on age • CHF can be right, left, or
• Rhythm: both.
o regular • Right-Sided Failure
o S1 S2; • Fatigue, weight gain,
o high-pitched systolic confusion
o short duration • Skin pale, cool
o No extra sounds • Neck vein distension
• Physiological S3 and S4 • Tachycardia, right ventricular
may be heard in children and heaves, murmurs, S3, right-
young adults sided pleural effusion
without heart disease • Anorexia, bloating, RUQ
▪ Deviations from normal tenderness, hepatomegaly,
• Bradycardia rates 60 BPM or ascites
tachycardia rates 100 BPM
• Edema, diminished hair urinary output
growth • Cool, pale, decreased pulses
Left - Sided Failure • Chest pain aggravated by
• Fatigue, confusion inspiration, coughing, or
• Skin pale, dusky, cyanotic, movement
cool • Fever
• Left ventricular heaves, • Friction rub at LLSB
pulsus alternans, increased Pericarditis
heart rate, displaced PMI, S3, • An inflammation of the
S4, visceral or parietal
dyspnea, crackles, orthopnea, pericardium, resulting in
dry, hacking cough, PND cardiac compression,
• Nocturia decreased ventricular filling
Coronary Artery Disease and emptying, and cardiac
• A progressive narrowing of failure
the coronary arteries • Often occurs 2 to 3 days
• Atherosclerosis is the major after MI
cause of CAD
• CAD can present as angina
pectoris, acute MI, or sudden
cardiac death
• MI is necrosis of myocardial
tissue from ischemia
• Anxiety, dizziness, chest
pain, fatigue
• Skin pale to ashen, cool,
diaphoretic, feverish
• Neck vein distension
• Dyspnea, tachypnea,
crackles, tachycardia or
bradycardia, arrhythmias,
elevated BP
initially, S3, S4, murmur, rubs,
and diminished heart sounds
• Nausea, vomiting, low