heart and neck

Assessing the Heart and Neck Vessels

Fall 2023

Objectives

  • Describe the structure and function of heart and neck vessels.
  • Discuss risk factors for Coronary Artery Disease (CAD).
  • Perform a nursing history of the cardiac system.
  • Perform a physical assessment of the cardiac system.
  • Identify normal versus abnormal findings in heart health.
  • Describe findings associated with older adults.
  • Analyze case study scenarios concerning heart health.

Cardiovascular Disease Statistics

  • Cardiovascular disease is the leading cause of death in the United States.
  • Before procedures for intervention, blockages are common. After procedures, like the placement of a stent, normalized blood flow is typically achieved.

Anatomy of the Heart

  • The heart functions as a pump with an elaborate electrical system.
  • Functions of the heart:
    • The ventricles are responsible for pumping blood to the lungs and the rest of the body.
    • There are four chambers in the heart:
    • Two upper chambers called the left atrium and the right atrium.
    • Two lower chambers called the left ventricle and the right ventricle.
  • The Sinoatrial (SA) node, located in the right atrium, serves as the heart's natural "pacemaker," sending electrical impulses which trigger the contraction of the atria and ventricles.
  • The heart lies in the mediastinum between the lungs, located in the left chest within the thoracic cavity, spanning from the 2nd to the 5th intercostal space (ICS). The upper part is the base and the lower part is the apex, which points opposite to the lungs.
  • The size of the heart is approximately that of a fist.

Heart's Pump and Electrical System

  • The heart has an electric conduction system that initiates and regulates heartbeats. The flow of electricity travels through the heart, from the SA node to the Atrioventricular (AV) node, then through the Bundle of His, and into the right and left bundle branches that extend into the ventricles.
  • The electrical signal generated at the SA node is represented on an electrocardiogram (ECG) with distinct waves, namely the P wave representing atrial depolarization, the QRS complex for ventricular depolarization, and the T wave indicating ventricular repolarization.

Cardiac Output and Influencing Factors

  • Cardiac output (CO) is defined by the equation: CO=SVimesHRCO = SV imes HR Where:
    • CO is the cardiac output in liters per minute (normal range: 5-6 L/min).
    • SV stands for stroke volume, which is the amount of blood pumped by the left ventricle with each contraction (approximately 70 mL per contraction).
  • Factors influencing stroke volume include:
    • Preload: Refers to how much the heart stretches before contraction. An increase in preload corresponds to an increase in stroke volume.
    • Afterload: The amount of pressure that the ventricles have to work against during contraction. An increased afterload leads to a decrease in stroke volume.

Functionality of Heart: Right Side vs. Left Side

  • Left Heart:
    • Pumps oxygenated blood from the left ventricle via the aorta into systemic circulation.
    • Receives oxygenated blood from the lungs through the pulmonary veins into the left atrium.
  • Right Heart:
    • Pumps deoxygenated blood through the pulmonary artery to the lungs for gas exchange.
    • Returns blood to the right atrium through the superior and inferior vena cavas from the upper and lower body, respectively.

Structure of the Heart

  • Three Layers:
    1. Epicardium / Pericardium: The outer layer providing protection against infection, contains a fluid-filled sac.
    2. Myocardium: The muscular middle layer, considerably thickest, composed of cardiac muscle that enables pumping action. Damage here can lead to a myocardial infarction.
    3. Endocardium: The innermost layer that lines the chambers of the heart.

Cardiac Cycle and Heart Sounds

  • The cardiac cycle consists of:
    • Systole: The phase when the AV valves (tricuspid and mitral) close, creating the first heart sound (S1 or "lub") as the ventricles contract. Blood is ejected from the ventricles leading to the opening of the aortic and pulmonic valves.
    • Diastole: The phase when the semilunar valves (aortic and pulmonic) close, marking the second heart sound (S2 or "dub") when the ventricles are relaxed and filling with blood again.
  • Normal heart sounds are comprised of S1 and S2. S1 is best heard at the apex (5th ICS at the midclavicular line) and S2 is best at the base (second ICS at the left and right sternal border).

Abnormal & Extra Heart Sounds

  • S3 and S4 Heart Sounds:
    • These are termed "gallops" and may indicate rapid ventricular filling into a noncompliant ventricle, often associated with conditions like cardiomyopathy. S3 may be normal in children/adolescents; however, its presence in adults can suggest heart failure.
    • S4 is commonly seen in athletes and indicates a potential for coronary artery disease (CAD).
  • Murmurs:
    • Abnormal heart sounds that reflect turbulent blood flow through the heart, characterized by a "swooshing" or "blowing" sound. Causes can include valve defects, increased blood velocity, or septal defects.

Auscultation Areas on Chest for Heart Sounds

  • Auscultation locations include:
    • Aortic (2nd ICS, right sternal border) - Base Area
    • Pulmonic (2nd ICS, left sternal border) - Base Area
    • Erb’s Point (3rd-5th ICS, left sternal border)
    • Tricuspid (4th ICS, left sternal border)
    • Mitral (5th ICS, midclavicular line) - apex region

Carotid Artery and Neck/Jugular Veins Assessment

  • The carotid arteries supply oxygenated blood to the neck, head, and brain. Auscultation must be performed with the bell of the stethoscope to listen for bruit, which suggests potential blockages and increased risk for cerebrovascular accidents (strokes).
  • The neck contains two sets of jugular veins (internal and external), which function to return blood to the right side of the heart via the vena cava and right atrium. Distention in the jugular veins may indicate right-sided heart failure.

Subjective Data for Cardiac History

  • Inquiry into chest pain is crucial, distinguishing between cardiac, pulmonary, muscle, or GI sources. Cardiac chest pain (angina) is typically:
    • Described as pressure-like, often indicated by a feeling of an "elephant sitting on the chest."
    • Commonly associated symptoms may include diaphoresis and radiation to the left arm or jaw.
  • Other vital symptoms to assess include:
    • Dyspnea: Can relate to congestive heart failure (CHF), myocardial ischemia, or myocardial infarction (MI).
    • Types of dyspnea include orthopnea (difficulty breathing while lying down) and paroxysmal nocturnal dyspnea (SOB upon waking due to fluid shifts).
    • Palpitations: May be indicative of an arrhythmia such as atrial fibrillation.
    • Symptoms of fatigue, dizziness, syncope, nocturia, leg edema, and cough should also be evaluated.

Personal and Family History

  • Personal Health History: Assess for:
    • Hypertension (HTN), self-monitoring status.
    • Lipid levels: total cholesterol, triglycerides, low-density lipoproteins (LDL), and high-density lipoproteins (HDL).
    • Comorbid conditions like diabetes; previous heart surgeries; history of murmurs or rheumatic fever.
  • Family History: Document incidence of heart-related illnesses such as hypertension, myocardial infarction (MI), coronary artery disease (CAD), cholesterol issues, and diabetes.

Modifiable Lifestyle Risk Factors for Heart Disease and Stroke

  • Smoking significantly increases risk factors for heart disease.
  • A sedentary lifestyle contributes to elevated risks.
  • Stress can act as a surrogate risk indicator.
  • Dietary factors including high fat intake correlate positively with coronary artery disease
  • Alcohol consumption must be moderated: 1-2 standard drinks are generally acceptable, while excess consumption can lead to hypertension.
  • DASH Diet: A dietary approach to stop hypertension and improve cardiovascular health.

Assessment Techniques

Neck and Heart Assessment Procedure
  • Conduct assessment following a thoracic examination, positioning clients in various ways:
    1. Supine with head of bed (HOB) elevated 30 degrees.
    2. Left lateral position for apical impulse and murmur assessment.
    3. Sitting up/leaning forward to enhance listening for murmurs.
  • Always explain the process to the client to ease anxiety regarding potential findings.
Jugular Venous Pressure Assessment
  • Perform inspection in a supine position with HOB elevated at different angles.
  • Jugular venous pressure assessments will help spot signs of right-sided heart failure when distended.
Carotid Arteries and Heart Assessment
  • Always auscultate the carotid arteries before palpation using the bell of the stethoscope to listen for any bruits caused by turbulent flow through narrowed arteries.
  • Assess the apical impulse and note any abnormal sensations or murmurs during palpation of the heart.
  • Heart sounds should be documented and analyzed, including any extra sounds detected using the diaphragm across all auscultation areas.
Murmur Assessment
  • Murmurs should be characterized by:
    • Timing (systolic/diastolic), intensity, and quality (blowing, rumbling).
    • Location where the murmur is best heard, and whether it radiates elsewhere during respiration or different positions.

Grading of Heart Murmurs

  • Heart murmurs are graded as follows:
    • Grade 1: Very faint
    • Grade 2: Quiet
    • Grade 3: Moderately loud
    • Grade 4: Loud
    • Grade 5: Very loud, may be heard with the stethoscope off the chest
    • Grade 6: Can be heard without a stethoscope.

Elderly Considerations in Cardiac Assessment

  • Assess for dizziness or orthostatic hypotension when a patient transitions from supine to standing.
  • Blood pressure may be higher due to decreased arterial elasticity in older adults.
  • In COPD patients, the apical impulse may be challenging to assess due to an enhanced antero-posterior diameter resembling a barrel chest.

Documentation Tips for Cardiac Assessments

  • Always capture details pertaining to heart rate and rhythm, live any irregularities observed.
  • Document physical findings such as the location and size of the PMI (point of maximal impulse), presence of lifts, heaves, thrills, and character of heart sounds, including all murmurs and extra sounds.
  • Record findings related to jugular venous distension and capillary refill, as well as peripheral edema and pulse characteristics.

Nursing Diagnoses Related to Cardiac Health

  • Readiness for Enhanced Self-Health Management regarding informed knowledge on exercise and dietary management.
  • Risk for Ineffective Denial: Related to smoking habits and obesity.
  • Fatigue: Related to decreased cardiac output (CO).
  • Activity Intolerance: Resulting from compromised oxygen transport associated with heart failure.

Risk for Complications

  • Consider potential complications such as:
    • Decreased cardiac output (CO)
    • Dysrhythmias
    • Hypertension (HTN)
    • Congestive heart failure (CHF)
    • Angina
    • Cerebrovascular accidents (CVA)
    • Cerebral hemorrhage
    • Renal failure.