1. Heart, neck, vasculature/peripheral, vascular, lymphatic system

Heart wall has numerous layers: pericardium

tough, fibrous, double-walled sac that surrounds and protects heart

Heart wall has numerous layers: myocardium

muscular wall of heart

Heart wall has numerous layers: endocardium

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

Heart is ___ pumps separated by septum

2

Each side of the heart has an ____ and a _____

atrium and ventricle

Atrium

thin-walled reservoir for holding blood

Ventricle

thick-walled, muscular pumping chamber

Left ventricle

workload of the heart

Tricuspid valve

right AV valve

Bicuspid, or mitral valve

left AV valve

Valves thin leaflets are anchored by collagenous fibers ____ to papillary muscles embedded in ventricle floor

chordae tendineae

Pulmonic valve

SL valve in right side of heart

Aortic valve

SL valve in left side of the heart

Systole ventricle

heart depolarization

• contraction

Diastole ventricle: 3 R’s

• repolarize

• refill with blood

• rest

Diastole

ventricles relax and fill with blood; 2/3 of cardiac cycle

Prodiastolic filling

early passive phase

Presystole or atrial systole

atrial kick

Systole

heart’s contraction

• blood pumped from ventricles fills pulmonary and systemic arteries; 1/3 of cardiac cycle

Cardiac cycle: note that atrial systole occurs during ventricular diastole:

for a very brief moment, all four valves are closed, and ventricular walls undergo:

• isometric contraction

• isometric (or isovolumic) relaxation

Isometric contraction

contraction against closed system works to build high level pressure in ventricles

Isometric (or isovolumic) relaxation

all four valves closed, and ventricles relax

Aortic valve

2nd right intercostal space

Pulmonic valve

2nd left intercostal space

Nursing cardiovascular assessment: areas of auscultation

apply so-called Z pattern

• aortic valve

• pulmonic valve

• erb’s point

• tricuspid valve

• mitral valve

Tricuspid valve

left lower sternal border

Mitral valve

5th intercostal space, mid-clavicular line

Areas of auscultation technique: S1

the so-called first heart sound

• due to atroventricular (AV) valve

• denotes start of systole

• heard loudest at the apex of the heart

• occurs simultaneously with a patients carotid artery pulse in a healthy adult

S1 stated another way..

• atria relaxation

• ventricle contraction

Where is the apex of the heart?

the inferior aspect or so-called bottom of the heart or base of the heart

Areas of auscultation technique: S2

the so-called second heart sound

• due to semilunar (SL) valve closure

  • valves included

    • aortic valve

    • pulmonic valve

• most audible at base of heart

What is occurring from a physiology standpoint during S2?

the ventricles are relaxing and filling with blood as the atria contract

• stated another way

  • atria contraction

  • ventricle relaxation

Heart sound abnormalities: bruit

turbulent blood flow, can occur within the carotid artery

Heart sound abnormalities: murmur

so-called swooshing and blowing sound of turbulent blood flow in the heart/great vessels

Heart sound abnormalities: murmur characteristics

• loudness

  • grading system of loudness

  • score grade (1-6)

• timing

• pitch

  • high, medium, low

• pattern

  • crescendo, decrescendo

• quality

• location

• radiation

Heart sound abnormalities: stenosis

refers to a narrowing of a blood vessel

Heart sound abnormalities: regurgitation

• backflow of blood, so-called “leaky valves”

• decreases cardiac output efficency

• higher risk of blood clots

• heart workload is increased to maintain homeostasis

Heart sound abnormalities: S3

so-called third heart sound

• sound of ventricular filling

• timing: early diastole

• dull, soft and low-pitch sound

• “distant thunder”

• may be physiologic in pediatric patients/young adults

Heart sound abnormalities: S4

so-called fourth heart sound

• vibrations that occur when blood pushed from atria into a ventricle that resists filling with blood

• timing: so-called presystole, i.e. end of diastole

• may be physiologic or pathologic

  • so-called atrial gallop, S4 gallop

Heart sound abnormalities: pericardial friction rub

• may occur as result of pericardial inflammation

• high pitched, scratchy, compared to sandpaper friction

Neck vessels palpation and auscultation: palpate carotid artery

palpate only ONE artery at a time

• to avoid compromising arterial blood to brain

• note contour and amplitude of pulse, normal strength 2+

• normal finding is the same bilaterally

• assess for bruit

Precordium abnormalities: thrill

abnormal pulsation palpated along the bilateral 2nd and 3rd intercostal spaces

• note anatomical location

Precordium abnormalities: right-sided thrill

associated with systemic hypertension and severe aortic stenosis

Precordium abnormalities: left-sided thrill

associated with pulmonic hypertension and stenosis

Precordium abnormalities: heave (lift)

abnormal left lower sternal border pulsation

• may occur which chronic lung disease, pulmonic hypertension, and valve disease

Pulse

a so-called pressure wave that occurs as the heart beats

What does generating a pulse accomplish for the human body?

• maintenance of cardiac output

• oxygen delivery

• tissue perfusion

• carbon dioxide venous return to the lungs

• oxygen - carbon dioxide gas exhange

Ischemia

insufficient amount of oxygenated blood in a tissue

What is the cause of ischemia?

blood vessel obstruction, commonly associated with atherosclerosis

Artery

carry oxygenated blood away from heart to distal tissues

• high pressure

Vein

return carbon dioxide-rich (deoxygenated) and waste product blood back → heart and lungs

• low pressure

Lymphatic system: hydrostatic pressure

vessel system managing fluid excess and plasma using a pressure gradient

Lymphatic system: lymph nodes

• tissue-dense areas found which filter fluid and pathogens

• superficial and may be inspected and palpated

Palpation of lower leg: femoral artery

palpate below inguinal ligament halfway between pubis and anterior superior iliac spines

Palpation of lower leg: popliteal pulse

with leg extended but relaxed, anchor your thumbs on knee, and curl your fingers around into popliteal fossa

Palpation of lower leg: posterial tibial

curve your fingers around medial malleolus and palpate groove between malleolus and achilles tendon

Palpation of lower leg: dorsalis pedis

typically lateral to and parallel with extensor tendon of big toe

Pretibial edema: check for this

firmly depress skin over tibia or medial malleolus for 5 seconds and release

• grading of pitting edema

• perform standing assessment

Pretibial edema: grading of pitting edema

• 1+ mild pitting, slight indentation, no perceptible swelling

• 2+ moderate pitting, indentation subsides rapidly

• 3+ deep pitting, indentation remains, leg looks swollen

• 4+ very deep pitting, indentation lasts long time, leg grossly swollen and distorted

Which health conditions are commonly associated with this figure?

heart failure (HF) and peripheral vascular disease (PVD)

Nursing assessment: evaluation of deep vein thrombosis (DVT)

• well’s score

• higher score = greater risk

  • score of 0 or less indicates low probability

  • score 1 or 2 indicates moderate probability

  • score 3 points or higher indicates high probability

What health conditions places a patient at risk of foot ulcers and neuropathy?

poorly controlled diabetes mellitus

• maintain quality foot hygiene

• assess for infection or pain of the fingers and toes

• perform range of motion exercises of your extremities

• periodic mobility as tolerated

• use appropriately fitting shoes

Peripheral vascular disease: raynaud phenomenon

progressive pathology

• finger pallor

• progression to cyanosis (blue) coloration

• advanced disease red (rubor) of hand heel area

Raynaud phenomenon: symptoms

pain, numbness, cold sensation