Class 7: Head and Neck Vessels

Precordium

The area on the anterior chest overlying the heart and great vessels

Mediastinum

Area between the lungs in the middle third of the thoracic cage. Cavity that houses the heart

Base

“top” broader part of the heart

Apex

“bottom” of the heart points down and to the left

1. superior and inferior vena cava

2. pulmonary artery

3. pulmonary veins

4. aorta

The great vessels [4]

Superior and inferior vena cava

Returns deoxygenated venous blood to the right side of the heart

Pulmonary artery

;eaves the right ventricle, bifurcates, and carries venous blood to the lungs

Pulmonary veins

Returns freshly oxygenated blood to the left side of the heart

Aorta

Carries blood out to the body

1. Pericardium

2. Myocardium

3. Endocardium

Layers of the heart wall [3]

Myocardium

Muscular wall of the heart, does the pumping

Endocardium

Thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

Pericardium

Tough, fibrous, double-walled sack that surrounds and protects the heart

Atria

Thin-walled reservoir for holding blood

Ventricles

Muscular pumping chambers

Atrioventricular valves

Valves separating atria and ventricles

Tricuspid valve

Right AV valve

Bicuspid/Mitral valve

Left AV valve

Diastole

Ventricles relax and fill with blood

Systole

Heart’s contraction, blood is pumped from the ventricles and fills the pulmonary and systemic arteries

Cardiac cycle

Rhythmic movement of blood through the heart

First heart sound (S1)

Sound occurs with the closure of the AV valves and thus signals the beginning of systole.

Second heart sound (S2)

Sound occurs with closure of the semilunar valves and signals the end of systole.

Third heart sound (S3)

Vibrations heard over the chest during diastole. Sound occurs immediately after S2, when AV valves open and atrial blood first pours into the ventricles.

Fourth heart sound (S4)

Sound occurs at the end of diastole, when the ventricle is resistant to filling. The atria contract and push blood into noncompliant ventricle. Creates vibrations just before S1.

Murmur

Turbulence in blood flow and collision currents. Noise as blood circulates through normal cardiac chambers and valves, gentle swooshing can be heard on the chest wall

1. Increases in velocity of blood flow (flow murmur; e.g., in exercise, thyrotoxicosis)

2. Decreases in viscosity of blood (e.g., in anemia)

3. Structural defects in the valves (narrowed valve, incompetent valve) or unusual openings in the chambers (dilated chamber, septal defect)

Conditions that result in a heart murmur: [3]

1. frequency (pitch)

2. intensity (loudness)

3. Duration

4. Timing (diastole or systole)

How heart sounds are described: [4]

Depolarization of atria

What happens during P wave?

the interval from the beginning of the P wave to the beginning of the QRS complex (the time necessary for atrial depolarization plus time for the impulse to travel

What happens during P-R interval

Depolarization of ventricals

wat happens during QRS complex?

Repolarization of ventricles

What happens during T wave?

cardiac output

Volume of blood in each systole times beats per minute

Preload

Venous return that builds during diastole. Length to which ventricular muscle is stretched a the end of diastole just before contraction

Afterload

Opposing pressure that the ventricle must generate to open the aortic valve against the higher aortic pressure. Resistance against which the ventricle pumps blood.

1. Carotid artery

2. Jugular veins

Vascular structures in the neck that reflect the efficiency of cardiac function: [2]

Carotid artery

Central artery located in the groove between the trachea and the sternomastoid muscle, medial to and alongside the muscle.

Jugular veins

Empties deoxygenated blood directly into the superior vena cava

1. Internal jugular

2. External jugular

Two jugular veins present in each side of the neck:

Internal jugular vein

Larger vein that lies deep and medial to the sternomastoid muscle. Usually not visible, although its diffuse pulsations may be seen in the sternal notch when the person is supine.

External jugular vein

More superficial vein, lies lateral to the sternomastoid muscle, above the clavicle.

Foramen ovale

Opening in the atrial septum, normally closes within the first hour after birth

Ductus arteriosus

Oxygenated blood in fetal circulation is pumped through the pulmonary artery but is detoured through this to the aorta. Closes within 10-15 hours after birth

1. Increased blood volume (30-40%)

2. Increased stroke volume and cardiac output

3. Increased pulse rate by 10-15 bpm

Pregnancy considerations for cardiovascular system: [3]

1. smoking

2. diet

3. alcohol

4. exercise patterns

5. stress

Older adult lifestyle considerations for cardiovascular system: [5]

1. Increase systolic BP

2. increase supraventricular and ventricular arrythmias

3. Decreased tolerance for tachyarrhythmias

4. Decreased ability of heart to augment CO with exercise

Older adult developmental considerations for cardiovascular system:

Lower income households

What households in Canada are more likely to report living with cardiovascular disease?

Incidence of high BP has increased with no significant diferences based on sex. Atlantic provinces have the highest rate, western provinces have the lowest

Influence of socioeconomic factors on high BP

Overweight

BMI of 25 - 29.9

Obesity

BMI of 30 or greater

• High blood pressure
  – Smoking
  – Alcohol
  – Serum cholesterol
  – Obesity
  – Diabetes
  – Stress
  
  

Social and cultural considerations for cardiovascular system [7]

1. Chest pain

2. Dyspnea

3. Orthopnea

4. Cough

5. Fatigue

6. Cyanosis or ashen or pallor

7. Edema

8. Nocturia

9. Past cardiac history

10. Family cardiac history

11. Personal habits (risk factors

Subjective data to collect during cardiovascular health history? [11]

Angina

When heart’s vascular supply cannot keep up with metabolic demand. (chest pain)

Dyspnea

“Shortness of breath” on exertion, constant, or intermittent

Orthopnea

Shortness of breath when lying down, goes away when standing. Needing to assume a more upright posture to breathe (note number of pillows)

Nocturia

Feeling of needing to pee at night

Cyanosis or pallor

Skin tint with myocardial infarction or low cardiac output states as a result of decreased perfusion:

elevated cholesterol level,

elevated blood pressure,

random plasma glucose level value in excess of 11.1mmol/L or

known diabetes mellitus,

obesity,

cigarette smoking,

low activity level,

and, for postmenopausal females, length of any hormone replacement therapy for postmenopausal females.

Risk factors for CAD: [8]

Patient suping with head and chest elevated 30 to 40 degrees

patient position for jugular vein assessment:

Patient sitting up

Patient position for carotid artery assessment:

Warm and quiet (so pt is comfortable and you can hear)

Room prep for physical cardio exam:

1. Pulse and blood pressure

2. extremities

3. neck vessels

4. Precordium

Order for regional cardiovascular assessment:

1. Marking pen

2. Small centimetre ruler

3. Stethoscope with diaphragm and bell endpieces

4. Alcohol wipe

Equipment needed for cardio assessment:

Bruit

Noise indicates turbulence with a local vascular cause, such as atherosclerotic narrowing. Blowing, whooshing sound indicating blood flow turbulence

Avoid vagal stimulation

Why palpate carotid arteries one at a time?

1. inspect the anterior chest

2. Palpate the apical pulse

3. palpate across the precordium

How to assess precordium:

4th or 5th intercostal space

Where is apical pulse located?

Supine position or midway of left side

How should patient be positioned to feel apical pulse:

Palpate with palmar aspect of four fingers, over apex, left sternal border, and base for palpations

How to palpate precordium:

Thrill

Palpable vibration, feels like the throat of a purring cat. Signifies turbulent blood flow and accompanies loud murmrs.

1. aortic area

2. pulmonic area

3. tricuspid area

4. erb’s point

5. mitral area

Auscultatory areas: [5]

Apex

where is s1 louder than s2:

1. extra heart sounds

2. murmurs

3. s1 and s2 separately

4. Note rate and rhythm

Things to listen for when ausciltating the heart:

S1 is louder than S2 at the apex; S2 is louder than S1 at the base.

S1 coincides with the carotid artery pulse. Feel the carotid pulse gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1

How to distinguish S1 from S2: [2]

S1 split

Hearing the mitral and tricuspid components separately. Audible in the tricuspid area. Is very rapid, with the two components only 0.03 seconds apart. Rare but normal findinig

Base

Where is S2 loudest?

S2 split

Occurs near the end of inspiration in some people. Inspiration separates the timing of closure of the semilunar valves (pulmonic closes 0.06 seconds after aortic). Only heart in pulmonic valve area.

may be caused by congenital defects and acquired valvular defects.

Systolic murmur may occur with a normal heart or with heart disease

Diastolic murmur always indicates heart disease

Causes of heart murmurs: [3]

120-140

Normal infant heart rate:

Because of fetal shunt closure.

Why are murmurs normal within few days of birth?

Apical impulse is sometimes visible in children with thin chest walls.

Describe child position of the apical pulse:

Venous hum

Common in healthy children and no pathological significance. Represents turbulence of blood flow in the jugular system.

increase 10-15 bpm

Change in pulse rate for pregnancy

Lower than normal. Lowest during second trimester and slowly rises during third.

Blood pressure difference in pregancy:

1. usually lowest in left lateral recumbent position

2. a bit higher in supine

3. highest in sitting

How does pregnant woman’s BP vary with position:

Systolic pressure rises gradually, diastolic stays fairly constant. Some experience orthostatic hypotension

Age-related change in BP:

Orthostatic hypotension

A sudden drop in blood pressure when rising to sit or stand

Could cause a reflex slowing of the heart rate. Also, could compromise circulation if the artery is already narrowed by atherosclerosis

Reason to avoid pressure on carotid artery of older adult:

1. dilated pupils

2. pallor, cyanosis

3. Dysnpea

4. Orthopnea

5. Crackles, wheezy breath sounds

6. Decreased BP

7. N&V

8. Ascites (fluid in peritoneal cavity)

9. Dependent, pitting edema

10. Weak pulse

11. cool, moist skin

12. decreased urine output

13. enlarged spleen and liver

14. S2 gallop, tachycardia

15. Fatigue

16. Infarct, may be cause of decreased CO

17. Jugular vein distension

18. Falling O2 sat.

19. Anxiety

Signs and symptoms of CHF and heart failure: [19]

Patent Ductus Arteriosus

Persistence of the channel joining left pulmonary artery to aorta. This is normal in the fetus and usually closes spontaneously within hours of birth.

Arterial septal defect

Abnormal opening in the atrial septum, resulting usually in left-to-right shunting of blood and causing a large increase in pulmonary blood flow

Ventricular Septal Defect (VSD)

Abnormal opening in septum between the ventricles, usually in subaortic area. The size and exact position vary considerably.

Tetralogy of Fallot

Four components: (a) right ventricular outflow stenosis, (b) VSD, (c) right ventricular hypertrophy, and (d) overriding aorta. The result is a large amount of venous blood shunted directly into aorta away from pulmonary system, so that blood is never oxygenated.

• Aortic stenosis
• Pulmonic stenosis
• Mitral stenosis
• Tricuspid stenosis
• Aortic regurgitation
• Pulmonic regurgitation
• Mitral regurgitation
• Tricuspid regurgitation
Abnormal Findings – Murmurs

Murmurs caused by valvular defects: [8]