Health Assessment: Heart and Neck Vessels

Cardiovascular System Overview

  • The cardiovascular system is a highly complex system that includes the heart and a closed system of blood vessels.

Heart and Great Vessels

  • Heart: A hollow, muscular, four-chambered organ consisting of left and right atria, and left and right ventricles.
      - Located in the middle of the thoracic cavity between the lungs in the mediastinum.
      - Size of a clenched fist; weighs approximately 255 g (9 oz) in women and 310 g (10.9 oz) in men.
      - Extends vertically from the left second to the left fifth intercostal space (ICS) and horizontally from the right edge of the sternum to the left midclavicular line (MCL).
      - Shaped like an inverted cone:
        - The upper portion is near the left second ICS (base).
        - The lower portion is near the left fifth ICS and the left MCL (apex).

  • Precordium: The anterior chest area that overlies the heart and great vessels.

  • Heart Function:
      - The right side pumps blood to the lungs for gas exchange (pulmonary circulation).
      - The left side pumps blood to the rest of the body (systemic circulation).

  • Great Vessels:
      - Superior and Inferior Vena Cava: Return blood to the right atrium from the upper and lower body.
      - Pulmonary Artery: Exits the right ventricle; carries blood to the lungs.
      - Pulmonary Veins: Return oxygenated blood from the lungs to the left atrium.
      - Aorta: Transports oxygenated blood from the left ventricle to the body.

Heart Chambers and Valves

  • Chambers: Four chambers (right atrium, left atrium, right ventricle, left ventricle).

  • Septum: A partition separating the right and left sides of the heart.

  • Atrioventricular (AV) Valves: Located at the entrance to the ventricles.
      - Tricuspid Valve: Composed of three cusps; located between the right atrium and right ventricle.
      - Bicuspid (Mitral) Valve: Composed of two cusps; located between the left atrium and left ventricle.

  • Chordae Tendineae: Collagen fibers anchoring the AV valve flaps to papillary muscles.

  • Semilunar Valves: Located at the exit of each ventricle:
      - Pulmonic Valve: Entrance to the pulmonary artery from the right ventricle.
      - Aortic Valve: Beginning of the ascending aorta from the left ventricle.

  • Valves are open during ventricular contraction and close from the pressure of blood when ventricles relax.

Heart Coverings and Walls

  • Pericardium: Tough, fibrous sac surrounding the heart, attaching to the great vessels.

  • Parietal Pericardium: Serous membrane lining; secretes pericardial fluid for friction-free movement.

  • Epicardium: Serous membrane covering the outer surface of the heart.

  • Myocardium: Thickest layer made up of contractile cardiac muscle cells.

  • Endocardium: Thin endothelial tissue forming the innermost layer, continuous with the lining of blood vessels.

Electrical Conduction of the Heart

  • Cardiac muscle cells can spontaneously generate and conduct electrical impulses.

  • Cardiac Cycle: The generation and conduction of electrical impulses regulates filling and emptying of cardiac chambers.

Pathways of Electrical Conduction

  • Sinoatrial (SA) Node: Located on the right atrium; generates impulses at a rate of 60-100 per minute, causing atrial contraction.

  • Atrioventricular (AV) Node: Delays electrical impulses before relaying them to the AV bundle (Bundle of His).

  • The impulse travels down the right and left bundle branches and Purkinje fibers, causing ventricle contraction.

  • If the SA node fails, other areas (e.g., Bundle of His) can take over, discharging at a lower rate (40-60 per minute).

Electrical Activity Measurement

  • ECG (Electrocardiography): Records depolarization and repolarization phases of the cardiac muscle:
      - P Wave: Atrial depolarization.
      - PR Interval: Time from the beginning of atrial depolarization to the beginning of ventricular depolarization.
      - QRS Complex: Ventricular depolarization (atrial repolarization).
      - ST Segment: Period between ventricular depolarization and repolarization.
      - T Wave: Ventricular repolarization.
      - QT Interval: Total time for ventricular depolarization and repolarization.
      - U Wave: May represent the final phase of repolarization if present.

Cardiac Cycle

  • The cardiac cycle involves the phases of filling and emptying the heart’s chambers:

Phases

  • Diastole: Relaxation phase (filling).

  • Systole: Contraction phase (emptying).

  • Diastole lasts approximately two-thirds of the cycle; systole occupies one-third.

Diastole Details

  • During ventricular diastole, the AV valves open, allowing blood flow into the ventricles.
      - Protodiastolic Filling: Early rapid passive filling.
      - Atria contract near the end of diastole, completing ventricular filling.
      - Known as atrial kick.

Systole Details

  • Increased ventricular pressure results in the closure of AV valves, causing the first heart sound (S1).

  • This prevents retrograde flow into the atria during contraction.

Heart Sounds

  • Heart sounds are produced by valve closure.

Normal Heart Sounds

  • S1: Closure of AV valves; corresponds with systole; heard best at the apex.
      - If split, M1 (mitral closure) occurs before T1 (tricuspid closure).

  • S2: Closure of semilunar valves; corresponds with diastole; best heard at the base. If split, A2 (aortic closure) occurs before P2 (pulmonic closure).

  • Variations in S1 and S2 may occur with respiration (e.g., split S2).

Extra Heart Sounds

  • S3: Ventricular gallop heard in early diastole; may indicate volume overload.

  • S4: Atrial gallop occurring late in diastole; may indicate decreased compliance.

Heart Murmurs

  • Turbulent blood flow creates sounds; assessed for conditions like increased blood velocity or valve malfunction.

Cardiac Output

  • Cardiac Output (CO): Amount of blood pumped by the ventricles in one minute; calculated as:
    extCO=extSVimesextHRext{CO} = ext{SV} imes ext{HR}

  • Normal adult cardiac output is 5-6 L/min.

Stroke Volume

  • Stroke Volume (SV): Amount of blood pumped from the heart with each contraction (70 mL from the left ventricle).

  • Influenced by:
      - Preload: Degree of stretch of the heart muscle.
      - Afterload: Pressure needed for ejection of blood.
      - Contractility: Strength of myocardial contractions.

Neck Vessels

  • Assessment includes evaluation of the carotid artery and jugular veins; reflects heart muscle integrity.

Carotid Artery Pulse

  • Located between the trachea and sternocleidomastoid muscles; amplitude and contour assessment crucial.

Jugular Venous Pulse

  • Consists of internal and external jugular veins; examination reflects right heart function.

Areas of Auscultation for Heart Sounds

  • Aortic Area: 2nd intercostal space (right sternal border).

  • Pulmonic Area: 2nd or 3rd intercostal space (left sternal border).

  • Erb's Point: 3rd to 5th intercostal space (left sternal border).

  • Mitral (Apical): 5th intercostal space near the left mid-clavicular line.

  • Tricuspid Area: 4th or 5th intercostal space (left lower sternal border).

Collecting Subjective Data: Health History

History of Present Health Concern

  • Evaluate chest pain and palpitations using COLDSPA criteria (characteristics of pain).

  • Differentiate between cardiac and non-cardiac sources based on description.

Signs and Symptoms Inquiry

  • Fatigue: Timing, onset, degree, and relation to physical activity.

  • Dyspnea: Types, triggers, and relation to exertion.

  • Nocturia: Frequency and relation to fluid intake.

  • Edema: Evaluation of lower extremities.

  • Gastric symptoms: Distinguish between cardiac and gastrointestinal origins.

Past Health History

  • Inquire about congenital defects, rheumatic fever history, cardiac surgeries, previous ECGs, lipid profile results, and adherence to medications.

Family History

  • Assess genetic predispositions to hypertension, cardiovascular diseases, and diabetes.

Lifestyle Practices

  • Assess smoking habits, stress levels, nutrition, alcohol consumption, exercise frequency, and sexual activity impact.

Collecting Objective Data: Physical Examination

  • Examination prepares to identify signs of heart disease and initiate referral/treatment; cardiovascular disease is a major cause of mortality in the U.S. Set client position to facilitate inspection and palpation.

Equipment Needed

  • Stethoscope, pillow, penlight, and ruler for measurements.

Assessment Procedure for Neck Vessels

  • Inspect jugular venous pulse while the client is supine; evaluate for distention at various angles.

  • Auscultate carotid arteries and palpate both arteries separately.

  • Evaluate for bruits and thrills.

Assessment Procedure for Heart (Precordium)

  • Inspect for pulsations, palpate the apical impulse, and auscultate heart rate, rhythm, and sounds while noting the timing and characteristics of each.

Pulse Characteristics

  • Assess amplitude and duration of apical impulse; perform additional assessments based on abnormalities detected during inspection/palpation.

Detailed Auscultation Steps

  • Differentiate between S1 and S2 and assess for extra sounds or murmurs, noting structural defects or conditions affecting blood flow. Use both diaphragm and bell of the stethoscope for best results.

Midsystolic Click and Heart Murmurs

  • Midsystolic clicks may suggest mitral valve prolapse followed by mitral regurgitation if a murmur accompanies it.

(Continued with additional sections on assessment of abdomen, abnormal findings, abnormal arterial pulse and pressure waves, various heart sounds and murmurs).