N209 - Heart & Neck Vessels

• Diastole

• 2/3

What is occurring when the ventricles are relaxed & the AV valves are open? How much of the cardiac cycle does this make up?

Protodiastolic (early) filling

What is the passive filling phase (blood going down its gradient & into ventricles) of diastole?

Presystole/atrial systole/ atrial kick

What is the active filling phase (atria contracts and pushes the last amount of blood into ventricles after pressure equalizes) of diastole called?

• Systole

• 1/3

What is occurring when blood is pumped from the ventricles & fills the pulmonary & systemic arteries? How much of the cardiac cycle does this make up?

ventricular diastole

What is occurring at the same time as atrial systole?

Isometric contraction

= ventricles contract but blood is not ejected bc all valves are closed (inc. pressure in ventricles)

Isometric relaxation

= all valves are closed & ventricles are relaxed

• right side

• requires less energy to pump to the pulmonary circuit than the left to systemic circuit

Which side of the heart has less pressure? Why?

S1

• Sound of AV valves being forced closed (beginning of systole

• Heard loudest @ the apex

S2

• Sound from closure of the semilunar valves (end of systole & beginning of diastole)

• Heard loudest @ the base

s3

• Occurs when ventricles are resistant to filling during protodiastole immediately after S₂

  • when AV valves open and atrial blood first pours into ventricles

• = a dull, soft sound

• Can be found in Pregnancy, fever; isn’t pathologic (goes away after)

s4

• Occurs at end of diastole, at presystole, when ventricle resistant to filling

• Atria contracts and pushed blood into the noncompliant ventricle

• occurs just before S₁

s4

daLUB-dub

s3

LUB-duppa

murmurs

= Gentle, blowing, swooshing sound that can be heard on chest wall

• Occurs with Conditions that create turbulent blood flow & collision currents

• Velocity of blood increases (flow murmur)

• Viscosity of blood decreases (e.g., anemia)

• Structural defects in valves (narrowed valves, regurgitant valves)

What conditions can result in murmurs?

Diastolic

What murmurs always indicate heart disease?

pulse

= a pressure wave generated by each systole pumping blood into the aorta

a smooth rapid upstroke, followed by a rounded and smooth summit, followed by a gradual downstroke.

How would you describe this pulse?

Carotid Artery

Where would you find this pulse?

Jugular veins

Which vein empties unoxygenated blood directly into superior vena cava?

Carotid

What vein in the neck are you evaluating if the pt. is sitting up?

Jugular Veins

What vein in the neck are you evaluating if the pt. is supine & slightly elevated?

Precordium

= the area directly overlying the heart and great vessels.

1. Pulse & BP

2. Extremities

3. Neck Vessels

4. Precordium

In what order would you do a regional cardiovascular assessment?

• central venous pressure (CVP)

• it’s efficiency as a pump

What does assessing the jugular vein tell you about the heart?

1-2 cm above the clavicle

Where should the jugular vein be visible normally?

• Jugular Vein Distension (JVD)

• fluid overload

What is visible in the image? Why might this have occurred?

Jugular Vein

Location = lower, more lateral, under or behind the sternomastoid muscle

Quality - undulant (wavelike), w 2 visible waves per cycle

Respiration - descends during inspiration (intrathoracic pressure)

Palpable - no

Pressure - light pressure @ the base of the neck

Position of the person - drops/disappears when sitting up

Carotid Artery

Location - higher & medial to sternomastoid muscle

Quality - brisk & localized; 1 wave per cycle

Respiration - does not vary

Palpable - yes

Pressure - no change

Position of the person - unaffected

doing both can compromise blood flow to the brain

Why shouldn’t you palpate both carotids at the same time?

doing this could slow down the HR & cause syncope.

Why should you avoid excessive pressure on the carotid sinus area?

+2 (moderate)

What should the strength of the carotid be?

bruit

= blowing, swishing sound heard in blood vessels that indicates blood flow turbulence

• can be artificially created if an artery is compressed

atherosclerosis

What is a bruit when auscultating the carotid a marker for?

• otherwise, you’ll hear tracheal breaths.

• hold your breath w the pt. so you are conscious of how long they’ve held it.

Why should you ask a pt to hold their breath when auscultating the carotid? What practice should you yourself do during this?

1. angle of the jaw

2. midcervical area

3. base of the neck

At what 3 places should you auscultate the carotid artery?

arrange tangential lighting to accentuate flickers of movement

How should you inspect for any pulsations on the anterior chest?

apical pulse

What is the ONLY pulse that you should visibly see on the anterior chest normally?

left midclavicular, 4th or 5th intercostal space

Where is the apical pulse located?

• the base, the left sternal border and the apex

• you should only feel a pulsation the apical pulse

What should you palpate on the anterior chest and what should you feel?

Retractions

= pulling of tissue with heart beats (abnormal)

Lifts

= strong, sustained outward thrusts

Heaves

= excessive thrust of larger area of the chest

NO! the sound radiates with the direction of blood flow

Should you hear the valve sounds over their anatomical position? Why or why not?

• Aortic Valve Area

• right 2nd interspace

#1? How would you describe this location?

• pulmonic valve area

• left 2nd interspace

#2? How would you describe this location?

• Erb’s Point

• left 3rd interspace

#3? How would you describe this location?

• Tricuspid Valve Area

• left sternal border

#4? How would you describe this location?

• Mitral Valve Area

• 5th interspace, midclavicular

#5? How would you describe this location?

auscultate the apical beat while palpating the radial pulse

How would you check for pulse deficit?

left lateral recumbent

(Brings the heart closer to the chest wall)

what position is best for auscultating the heart?

Split S1

= a normal variation of asynchronous valves (hearing the mitral and tricuspid components separately)

Loud (accentuated) S1

= variation in S1 from increased velocity of blood flow

• due to exercise, fever, anemia & pulmonary stenosis

Split S2

= normal variation heard @ the end of inspiration in some people

• inspiration separates the timing of the semilunar valves closing.

Fixed split

= abnormal S2 split that is unaffected by respirations & always present

Midsystolic click

= extra systolic sound from mitral valve prolapse; tensing of valve leaflets and chordae tendinea create the click

Aortic prosthetic valve sounds

= extra systolic sound from mechanical aortic ball-in-cage prosthetics

Ejection Click

= extra systolic sound that is a result of the SL valves opening at the start of ejection in the presence of aortic & pulmonary stenosis

Pericardial Friction Rub

= Extra diastolic sound from inflammation of the pericardium; high-pitched and scratchy

Summation Sound

= Extra diastolic sound when both s3 and s4 are present (quadruple rhythm)

Mitral Prosthetic Valve Sound

= Extra diastolic sound from the opening of the ball-in-cage mitral prosthetic

newborns transition from fetal to pulmonic circulation (can take time for shunts from fetal circulation to close)

Why don’t murmurs in the immediate newborn period necessarily indicate congenital heart disease?

• Poor weight gain

• developmental delay

• persistent tachycardia

• tachypnea

• dyspnea on exertion (DOE)

• cyanosis

• clubbing

What are signs that may indicate heart disease in children?

sinus arrythmia

What characterizes rhythm of a child’s HR?

because their SBP gradually rises with age

Why does the pulse pressure (diff. b/t diastolic and systolic) widen in OA?

Orthostatic hypotension

= drop in BP when rising to sit or stand