Health Assessment Heart & Neck Vessels
Chapter 21 Assessing Heart and Neck Vessels
Structures & Function
Heart: helps blood flow through body; giving O2 to organs & tissues & removing wastes like CO2
Muscular organ with 4 chambers [left & right atria (upper chambers); left & right ventricles (lower chambers]
Right & Left side of heart is separated by SEPTUM
Right & Left atria (atrium) RECEIVE blood returning to the heart & pump into ventricles
Right & Left ventricle pump blood OUT the heart into body
Left ventricle is THICKER than right b/c it does more work
A one way valve controls blood flow in each ventricle
Atrioventricular (AV) valve - entrance at ventricles (lower chambers of heart)
Tricuspid valve - on the right between right atrium & right ventricle; has 3 flaps
Bicuspid (mitral) valve - on the left between left atrium & left ventricle; has 2 flaps
FLAPS are held in place by tough fibers called CHORDAE TENDINEAE these attach to muscles in ventricles called papillary muscles
Semilunar valves - exits of the ventricle (blood leave heart)
Pulmonic valve - right ventricle & pulmonary artery which carry blood to lungs
Aortic Valve - left ventricle & aorta which carries blood to rest of body
Heart Located between the lungs in area called MEDIASTINUM
Top of heart (Base of heart) start at 2nd intercostal space (ICS)
Apex (bottom of heart) located at 5th ICS & midclavicular line (MCL)
Area on chest that covers the heart is PRECORDIUM
Right side of heart pumps blood to lungs to RID of carbon dioxide (CO2) & get oxygen (O2) [aka PULMONARY CIRCULATION]
Left side of heart pumps O2-rich blood to BODY [aka SYSTEMIC CIRCULATION]
Great Vessels of the Heart
Superior & inferior vena cava - bring blood from upper AND lower parts of the body to right atrium (upper heart chamber)
Pulmonary Artery - carries blood from right ventricle (lower chamber of heart) to the lungs
Pulmonary Veins - RETURN oxygenated blood from lungs to left atrium (upper heart chamber)
Aorta - carries O2 rich blood from left ventricle to rest of body
Heart Covering & Walls
Pericardium - a fibrous sac that attaches to great vessels & surrounds the heart
Serous membrane lining (parietal pericardium) - secretes small amount of pericardial fluid allowing smooth, friction free movement of the heart
Serous membrane also covers the outer surface of the heart known as EPICARDIUM - PROTECTS the heart
Myocardium is the thickest layer of the heart - made up of contractile cardiac muscle cells - PUMPS the heart
Endocardium - thin layer of endothelial tissue; forms inner layer of the heart
Lining of the heart out to in: epicardium, myocardium, endocardium
Electrical Conduction of the Heart
Cardiac Cycle - filling & emptying of heart chambers composed of 2 phases
Diastole phase (RELAXATION OF VENTRICLES, AKA FILLING)
⅔ of cycle
AV values open, ventricles relaxed, blood rushes into heart, atria contract and empty blood into ventricles
The AV valves (Atrioventricular valves) are open, allowing blood to flow into the ventricles.
The ventricles are relaxed at this point.
As the blood flows into the ventricles, the atria (the upper chambers of the heart) contract, pushing the remaining blood into the ventricles to fill them up completely.
Systole phase (CONTRACTION OF VENTRICLES, AKA EMPTYING)
⅓ of cycle
Is heart’s contraction
Fills pulmonary & systemic arteries
As the ventricles contract, the pressure inside them rises, causing the mitral and tricuspid valves (the valves between the atria and ventricles) to close. This produces the first heart sound (the "lub" sound).
Once the valves close, the ventricles continue to contract, and the aortic and pulmonary valves (which lead to the body and lungs) open, allowing blood to be pumped out of the heart.
When the valves close again after blood is ejected, the second heart sound (the "dub" sound) is heard.
process of creating and passing electrical impulses is what keeps your heart beating in a regular pattern.
Cardiac muscle cells in your heart have a special ability to create electrical signals all by themselves. These signals travel through the heart, helping to control how the heart fills with blood and then pumps it out.
Pathways
SA node (Sinoatrial node):
Located in the upper right part of the heart.
It’s the heart's natural "pacemaker."
It sends electrical signals that make the top chambers (atria) contract and push blood into the lower chambers (ventricles).
AV node (Atrioventricular node):
Located in the middle of the heart.
It briefly delays the signal before passing it on.
AV bundle (Bundle of His):
Located between the ventricles.
It carries the electrical signal from the AV node.
Bundle branches and Purkinje fibers:
These spread the signal to both ventricles, making them contract together.
Backup Pacemaker:
If the SA node isn’t working, the AV bundle can take over, but it beats slower (40–60 beats per minute).
Electrical signals created by the SA node travel through the heart and can be picked up from the skin’s surface. These signals can be measured using an ECG (electrocardiogram), which records how the heart’s muscles contract (depolarization) and relax (repolarization). The ECG shows these events in different phases called P, Q, R, S, and T.
P wave: This represents the contraction of the atria (the upper chambers of the heart). It shows the electrical activity as the impulse travels through the atria.
PR interval: This is the time between when the atria contract and the ventricles start to contract. It’s the period from the start of the P wave to the start of the QRS complex.
QRS complex: This shows the contraction of the ventricles (the lower chambers of the heart). It also includes the electrical activity of the atria relaxing, though that’s not seen clearly on the ECG. It starts at the beginning of the Q wave and ends at the end of the S wave.
ST segment: This is the time between when the ventricles contract and when they start to relax. It’s the flat line between the QRS complex and the T wave.
T wave: This represents the relaxation (or repolarization) of the ventricles, when they return to their resting state.
QT interval: This shows the total time it takes for the ventricles to contract and then relax. It’s the period from the start of the Q wave to the end of the T wave. This interval can change depending on the heart rate.
U wave: This wave is not always seen, but if it appears, it comes after the T wave and represents the last phase of the ventricles relaxing.
Heart Sounds
First Heart Sound (S1) – "Lub"
Cause: The closure of the AV valves (mitral and tricuspid valves).
Timing: S1 marks the beginning of systole (when the heart is contracting).
Sound: Usually heard as one sound, but it can sometimes be split into two sounds:
M1: The sound from the mitral valve closing (heard first).
T1: The sound from the tricuspid valve closing (heard second).
Best heard: Over the apex of the heart (left side, 5th intercostal space).
Second Heart Sound (S2) – "Dub"
Cause: The closure of the semilunar valves (aortic and pulmonic valves).
Timing: S2 marks the beginning of diastole (when the heart is relaxing).
Sound: Normally heard as one sound, but can also split into two sounds:
A2: The sound from the aortic valve closing (heard first).
P2: The sound from the pulmonic valve closing (heard second).
Best heard: Over the base of the heart (top of the chest).
Types of Variations in Heart Sounds:
Accentuated S1/S2: Louder than usual heart sounds, can happen in conditions like fever, anemia, or high blood pressure.
Diminished S1/S2: Softer heart sounds, can happen in conditions like heart block or valve issues.
Split S1/S2: When the sounds split due to different timing of valve closures (can happen in conditions like bundle branch block or right ventricular issues).
Normal Split S2: A natural split that happens during inspiration and closes during expiration.
Wide Split S2: A larger-than-normal split that occurs during the whole breathing cycle, often due to right bundle branch block.
Extra Heart Sounds:
S3 (Ventricular Gallop): Happens early in diastole, can indicate heart failure or volume overload.
S4 (Atrial Gallop): Happens late in diastole, can indicate stiffness of the ventricles (noncompliance), such as in hypertension.
Murmurs:
Cause: Turbulent blood flow through the heart, often due to valve problems, fast blood flow, or abnormal openings.
Sound: A swooshing or blowing sound.
Cardiac Output:
Definition: The amount of blood the heart pumps per minute.
Formula: Cardiac Output (CO) = Stroke Volume (SV) × Heart Rate (HR).
Normal range: 5 to 6 liters per minute in a healthy adult.
Stroke Volume (SV) is the amount of blood the heart pumps out with each beat. For example, the left ventricle typically pumps about 70 mL of blood per contraction.
Several factors affect SV:
Preload:
This is how much the heart muscle is stretched before it contracts.
The more the heart muscle stretches (up to a certain point), the stronger it contracts, leading to a higher SV.
However, if the heart stretches too much, it can't contract properly, and SV may decrease.
Afterload:
This is the pressure the heart has to work against to pump blood out.
If the pressure is higher (e.g., high blood pressure), the heart has to work harder to push blood out, which can decrease SV.
Synergy of Contraction:
This refers to how well the heart muscle contracts in a synchronized, uniform way.
If the heart muscle contracts in an uneven or uncoordinated way, like in certain heart conditions, SV can decrease.
Compliance (Distensibility):
This is the ability of the ventricles to stretch and fill with blood.
If the ventricles become stiff and can't stretch well, it can lead to a lower SV.
Contractility:
This is how forcefully the heart muscle contracts.
If the heart has a stronger contraction (higher contractility), it will pump more blood, increasing SV.
In summary, SV is determined by how much the heart is stretched, the pressure it faces, how well the heart muscle contracts, how well the ventricles can stretch, and the strength of the heart's contractions. All these factors work together to control the amount of blood pumped with each heartbeat.
Challenges in Palpation
Palpating the apical impulse (feeling the heartbeat at the chest's surface) can be challenging in clients who are obese or have a barrel chest because it increases the distance between the heart and the chest wall.
Where to Auscultate
Heart sounds can be heard in specific areas of the chest, known as the precordium. These areas are based on where heart sounds are likely to radiate, not the exact anatomical locations of the valves.
Traditional Areas of Auscultation:
Aortic area: Right second intercostal space (ICS) at the right sternal border.
Pulmonic area: Second or third ICS at the left sternal border.
Erb point: Third ICS at the left sternal border.
Mitral (apical) area: Fifth ICS near the left midclavicular line (MCL), near the apex of the heart.
Tricuspid area: Fourth or fifth ICS at the left lower sternal border.
Alternative Areas of Auscultation:
Since heart sounds can be heard all over the chest, it's important to listen to areas beyond just the traditional five.
These areas overlap, so you may use more general terms like left atrial area or right ventricular area instead of the traditional names.
Alternative Areas:Aortic area: Right second ICS to the apex of the heart.
Pulmonic area: Second and third left ICSs near the sternum.
Left atrial area: Second to fourth ICS at the left sternal border.
Right atrial area: Third to fifth ICS at the right sternal border.
Left ventricular area: Second to fifth ICS from the left sternal border to the left MCL.
Right ventricular area: Second to fifth ICS, centered over the sternum.
How to Auscultate
Positioning: Stand on the right side of the patient. The patient should be lying down with their upper body raised at a 30-degree angle.
Use the diaphragm of the stethoscope for high-pitched sounds, like normal heartbeats, and the bell for low-pitched sounds or abnormal ones (like murmurs or gallops).
Applying the Stethoscope:
Diaphragm: Apply firmly to the chest.
Bell: Apply lightly to the chest.
Systematic Listening: Focus on each sound individually. Start by listening for the rate and rhythm of the heart. Then, listen for the first and second heart sounds (S1 and S2), any extra heart sounds (S3 or S4), and check for any murmurs.
The heart has a natural ability to beat, but it can also adjust its speed based on the body's needs. The autonomic nervous system helps with this by sending signals to the heart.
Sympathetic impulses (which are part of the nervous system's "fight or flight" response) speed up the heart rate (HR), making the heart pump more blood (this increases cardiac output or CO).
Parasympathetic impulses (which are part of the "rest and digest" system) slow down the heart rate, reducing the amount of blood pumped by the heart (decreasing cardiac output).
When doctors assess the cardiovascular system, they often check the neck vessels, like the carotid artery (a main artery in the neck) and the jugular veins (veins that return blood to the heart). By feeling or examining these vessels, they can get an idea of how well the heart is working.
Carotid Artery Pulse:
The carotid arteries are big blood vessels in your neck that carry blood to your brain and head. You can feel the carotid pulse by gently pressing on the side of your neck. This pulse shows how well your heart is pumping blood.
Jugular Venous Pulse and Pressure:
The jugular veins are blood vessels in your neck that bring blood back to your heart. There are two types:
Internal jugular veins are deeper in your neck.
External jugular veins are closer to the surface, near your collarbone.
Doctors check the jugular venous pulse to understand the pressure in the right side of your heart. If the right side of the heart isn't working well, the pressure in the jugular veins goes up. If there’s a problem with the left side of the heart, the pressure goes down.
The jugular venous pulse has different waves that reflect heart activity:
A wave: pressure rise when the atrium contracts.
X descent: pressure drop as the atrium relaxes.
V wave: pressure rise when the atrium fills with blood.
Y descent: pressure drop as blood moves into the right ventricle.
Although checking jugular veins isn't always routine for nurses, it can provide useful information about heart function when done correctly.
Biologic and Cultural Behavior Variations:
Heart Disease is the leading cause of death in all groups, especially in the southern U.S.
Hispanics and Blacks tend to have stiffer carotid arteries as they age, compared to Whites.
Hispanics also have larger carotid arteries with age, a trend not seen in Whites or Blacks.
Non-Hispanic Blacks have the highest rates of hypertension (high blood pressure) and obesity.
Diabetes rates are highest in Hispanics, but not much higher than in non-Hispanic Blacks.
LDL cholesterol (bad cholesterol) levels are highest in Hispanic men, followed by non-Hispanic White women.
Asians tend to have lower rates of hypertension, obesity, diabetes, and high cholesterol compared to other groups.
Older Adult Considerations:
When checking the neck vessels in older adults, be careful, as atherosclerosis (hardening of the arteries) can make the vessels blocked, and pressing too hard might reduce blood flow.
The apical impulse (heartbeat felt on the chest) may be harder to feel in older adults because their chest shape can change with age.
History of present health concern
Chest Pain Assessment (COLDSPA Method)
Question: Do you experience chest pain?
Rationale: Chest pain can come from different causes like heart problems (cardiac), lung issues (pulmonary), stomach or digestive problems (gastrointestinal), muscle pain (musculoskeletal), or even stress (psychogenic). A thorough assessment is needed to figure out the exact cause.
COLDSPA Method:
C (Character): Describe the chest pain. Is it stabbing, burning, crushing, squeezing, or tightness?
Rationale: Different types of pain can point to different causes. For example, cardiac pain is often described as squeezing or pressure.
O (Onset): When did the pain start?
Rationale: Chest pain may have many causes: heart issues like angina (heart pain) may start with exertion, while pulmonary or gastrointestinal issues may happen differently.
L (Location): Where is the pain? Does it radiate to other areas, like the shoulder, arm, or jaw?
Clinical Tip: Always consider that chest pain might be caused by cardiac ischemia (lack of oxygen to the heart) until proven otherwise, as this can be life-threatening. This condition can damage heart muscle.
D (Duration): How long does the pain last? How often do you feel it?
Rationale: Angina pain usually lasts a few minutes and happens with activity, while more serious heart pain may last longer and not go away with rest.
S (Severity): Rate the pain on a scale of 0–10, with 10 being the worst pain.
Rationale: Severity helps assess the seriousness of the pain. Severe pain may be a sign of a heart attack or other serious conditions.
P (Patterns): What brings on the pain (e.g., activity, stress, eating, temperature changes)? What relieves it (e.g., nitroglycerin, rest)?
Rationale: Identifying triggers and relief factors helps to pinpoint the cause. Cardiac pain often worsens with activity and improves with rest.
A (Associated Factors): Do you have other symptoms with the pain, like shortness of breath, sweating, nausea, or a fast/irregular heartbeat?
Rationale: Symptoms like shortness of breath, sweating, or nausea along with chest pain are commonly seen in heart problems such as angina or a heart attack. Some people may have these symptoms without chest pain.
Clinical Considerations:
Cardiac pain often occurs with exertion and is relieved by rest. Other symptoms that may accompany this include:
Dyspnea (shortness of breath)
Diaphoresis (sweating)
Pallor (pale skin)
Nausea
Palpitations or tachycardia (fast heart rate)
Table 21-1: Description of Various Types of Cardiovascular Pain Using COLDSPA
1. Angina (Myocardial Ischemia)
C (Character): Tight, pressing, heavy
O (Onset): Often occurs with exertion
L (Location): Across the chest; may radiate to shoulders, jaws, neck, or upper abdomen
D (Duration): Lasts up to 20 minutes
S (Severity): Mild to moderate pain
P (Pattern): May be relieved with nitroglycerin
A (Associated Factors): May occur with difficulty breathing, nausea, or sweating
2. Myocardial Infarction (Heart Attack)
C (Character): Heavy, tight, pressing
O (Onset): Can occur with or without exertion
L (Location): Across the chest; may radiate to shoulders, jaws, neck, or upper abdomen
D (Duration): Lasts 20 minutes to several hours
S (Severity): Often moderate to severe pain
P (Pattern): Rest does not relieve pain
A (Associated Factors): May include nausea, vomiting, weakness, and sweating
3. Aortic Dissecting Aneurysm (Tear in the Aorta Wall)
C (Character): Tearing, ripping sensation
O (Onset): Abrupt onset
L (Location): In the chest; may radiate to neck, back, or abdomen
D (Duration): Lasts for hours
S (Severity): Severe pain
P (Pattern): Aggravated by hypertension; relieved only with treatment
A (Associated Factors): May also cause difficulty swallowing, hoarseness, leg pain, and fainting (syncope)
4. Pericarditis (Inflammation of the Pericardium)
C (Character): Sharp, stabbing, pounding feeling when the heart beats
O (Onset): Ongoing pain
L (Location): Pericardial pain, radiating to shoulders or neck
D (Duration): Ongoing
S (Severity): Severe pain
P (Pattern): Aggravated by changes in breathing or position, coughing, and may be relieved by sitting forward
A (Associated Factors): May also involve fever, weakness, tiredness, coughing, trouble breathing, or pain when swallowing
Health Assessment: Cardiovascular Focus
Tachycardia and Palpitations
Questions to Ask:
Does your heart ever beat faster? Skip beats? Have extra beats? When does it occur? How long does it last? What makes it better or worse?
Rationale: Tachycardia (rapid heart rate) may occur due to weak heart muscles, as the heart tries to compensate by increasing cardiac output (CO). Palpitations may be caused by arrhythmias or heart's attempt to increase CO.
Other Symptoms Related to Heart Health
Fatigue:
Do you tire easily? When did fatigue start? Was it sudden or gradual? Does it happen at any particular time of day?
Rationale: Fatigue due to decreased CO worsens in the evening, whereas fatigue due to depression is persistent throughout the day.
Dyspnea (Shortness of Breath):
Do you have difficulty breathing? When does this occur? Is it worse when lying down or after exertion? How many pillows do you use to sleep?
Rationale: Dyspnea can indicate conditions like heart failure or coronary artery disease. Waking up short of breath (paroxysmal nocturnal dyspnea) is common in heart failure due to fluid redistribution.
Cough:
Do you cough up mucous? When does it occur? What does it look like?
Rationale: Heart failure can cause white- or pink-tinged sputum due to fluid in the lungs.
Dizziness:
Do you experience dizziness? When does it occur?
Rationale: Dizziness may be due to decreased blood flow to the brain, which can result from myocardial damage or low blood pressure.
Nocturia (Frequent Urination at Night):
Do you wake up to urinate during the night? How many times?
Rationale: Nocturia is often linked to heart failure, as increased renal perfusion during rest may lead to urination at night.
Swelling (Edema):
Do you have swelling in your feet, ankles, or legs? Is it one leg or both? When does it occur?
Rationale: Swelling in both legs, especially at night, may indicate heart failure. Sudden swelling in one leg could point to a deep vein thrombosis (DVT).
Heartburn:
Do you experience heartburn? When does it happen? What relieves it?
Rationale: Cardiac pain is often confused with gastrointestinal pain. Heartburn occurs after meals and is relieved with antacids, while cardiac pain is not relieved by antacids and worsens with exertion.
Personal Health History
Heart Defects or Murmurs: Have you been diagnosed with a heart defect or murmur?
Rheumatic Fever: Have you ever had rheumatic fever?
Heart Surgery or Interventions: Have you had any heart surgeries or cardiac balloon interventions?
ECG History: Have you had an ECG? When was the last one? Do you know the results?
Self-Monitoring: Do you monitor your heart rate or blood pressure? When was your last checkup?
Lipid Profile: Have you had a lipid profile? Do you know your cholesterol levels?
Medications: Are you taking medications for heart disease? How often?
Family History
Genetic Risks: Is there a family history of hypertension, MI, elevated cholesterol, or diabetes?
Rationale: A family history of heart disease increases the risk of developing similar issues.
Lifestyle and Health Practices
Smoking:
Do you smoke? How much? Are you trying to quit?
Rationale: Smoking is a major risk factor for heart disease. Support can be provided to quit.
Stress:
What type of stress do you experience, and how do you cope with it?
Rationale: Stress is a potential risk factor for heart disease.
Diet:
What does your typical diet look like?
Rationale: A high-fat, low-fruit diet increases the risk of cardiovascular disease.
Alcohol Consumption:
How much alcohol do you drink? How often?
Rationale: Excessive alcohol can contribute to hypertension.
Exercise:
Do you exercise regularly? How often?
Rationale: A sedentary lifestyle increases the risk of heart disease.
Daily Activities and Limitations:
How do your daily activities compare to 5-10 years ago? Do you experience fatigue, chest pain, or shortness of breath during daily activities?
Rationale: Difficulty performing daily activities may indicate heart disease or heart failure.
Sexual Activity:
Has heart disease affected your sexual activity?
Rationale: Sexual activity may be limited by concerns about chest pain; understanding the risks and precautions can help guide the client.
Sleep and Rest:
How many pillows do you use at night? Do you get up to urinate during the night? Do you feel rested?
Rationale: Orthopnea and nocturia are signs of heart failure, which can affect rest.
Self-Image and Fears:
How important is having a healthy heart to your self-image? Do you have any fears about heart disease?
Rationale: Addressing emotional concerns related to heart disease can help with managing overall health and well-being.
Coronary Heart Disease (CHD) Overview
What is Coronary Heart Disease (CHD)?
Definition: CHD refers to the narrowing or blockage of the coronary arteries, which supply blood and oxygen to the heart. This can lead to serious complications such as:
Heart attack: Occurs when blood flow to the heart muscle is blocked.
Chest pain (angina): Due to reduced blood flow.
Stroke: If blood flow to the brain is interrupted.
Heart rhythm issues: Caused by changes in the heart’s electrical system.
Damage to heart muscles and valves: This can impair the heart's ability to pump blood efficiently.
Screening for Risk of Heart Disease
The American Heart Association (AHA) recommends routine screenings to identify risks for coronary heart disease:
Blood Pressure: Check at least once every two years starting at age 20.
Fasting Lipoprotein Profile (Cholesterol Test): Screen at age 20 and every 4–6 years after, depending on risk.
Body Weight: Screen for obesity or overweight at routine visits.
Blood Glucose: Screen starting at age 45 every 3 years.
C-reactive Protein (CRP): A test to assess inflammation that may increase the risk of heart disease.
Health History: Review for family history of heart disease, diabetes, or other related conditions.
Peripheral Artery Disease (PAD): Screen for reduced blood flow to the limbs as it often accompanies heart disease.
Risk Factors for Coronary Heart Disease
1. Inherited Risks
Increasing age: Risk increases with age.
Gender: Men have a higher risk at a younger age, though the risk for women increases post-menopause.
Heredity: Family history of heart disease, especially among close relatives (parents, siblings), significantly increases risk.
Race: Certain races, such as African Americans, have a higher risk of heart disease.
2. Modifiable Risk Factors
Smoking: Smoking damages blood vessels and accelerates atherosclerosis (narrowing of the arteries).
High cholesterol/triglycerides: High levels of LDL (bad cholesterol) and low levels of HDL (good cholesterol) increase plaque buildup in the arteries.
Hypertension (high blood pressure): Forces the heart to work harder and contributes to arterial damage.
Physical inactivity: Lack of exercise leads to obesity, poor circulation, and high blood pressure.
Obesity: Excess fat increases cholesterol levels and contributes to insulin resistance.
Diabetes Mellitus (type 2): Diabetes accelerates the development of atherosclerosis and other cardiovascular issues.
3. Contributing Factors
Stress: Chronic stress can increase blood pressure and lead to unhealthy behaviors such as poor diet and smoking.
Excessive alcohol consumption: Drinking too much can raise blood pressure and contribute to heart damage.
Diet and nutrition: A diet high in saturated fats, trans fats, and sodium can increase the risk of heart disease.
Diabetes Mellitus (type 1): Though less common, type 1 diabetes can also increase the risk of developing coronary heart disease over time.
Client Education on Prevention
The key to managing and preventing coronary heart disease lies in addressing both inherited and modifiable risk factors. Education should include:
Smoking cessation: Encourage clients to quit smoking, which is one of the most effective ways to reduce heart disease risk.
Physical activity: Aim for at least 30 minutes of moderate-intensity exercise on most days to improve cardiovascular health.
Weight management: Maintain a healthy body weight to reduce the burden on the heart and lower cholesterol levels.
Blood pressure management: Encourage regular monitoring and lifestyle changes to maintain normal blood pressure levels.
Cholesterol management: Promote a heart-healthy diet and, if necessary, cholesterol-lowering medications.
Alcohol consumption: Recommend moderation in alcohol intake to avoid increased risk of hypertension and other heart-related issues.
Stress management: Promote relaxation techniques such as meditation, yoga, or therapy to help reduce stress.
Nutrition: Focus on a balanced diet with plenty of fruits, vegetables, whole grains, and lean proteins, while limiting unhealthy fats and sodium.
Physical Assessment: Heart and Neck Vessels
Equipment Needed for Cardiovascular Assessment:
Stethoscope with a bell and diaphragm
Small pillow
Penlight or movable examination light
Watch with second hand
Two centimeter rulers
Key Points for Assessment:
Understanding the anatomy and function of the heart and major coronary vessels is crucial to interpret heart sounds and electrocardiograms accurately.
Recognize normal cardiovascular variations in older adults to avoid misinterpretation.
Routine Screening vs. Focused Specialty Assessment:
General Routine Screening: Involves basic inspection and auscultation of the heart and neck vessels.
Focused Specialty Assessment: Involves a more detailed evaluation, such as jugular venous pressure (JVP) assessment and identification of murmurs and abnormal heart sounds.
General Routine Screening Includes:
Inspecting the Jugular Venous Pulse (JVP).
Auscultating and palpating the carotid arteries.
Inspecting pulsations on the anterior chest.
Palpating the apical impulse.
Palpating for abnormal pulsations.
Auscultating to identify S1 and S2 heart sounds.
Auscultating for extra heart sounds.
Auscultating for murmurs.
Focused Specialty Assessment Includes:
Evaluating jugular venous pressure (JVP).
Grading and identifying the source of murmurs.
Differentiating between specific split sounds, rubs, snaps, and clicks.
Assessment Procedure: Neck Vessels
Inspection of Jugular Venous Pulse (JVP):
Procedure:
Stand on the right side of the client.
Position the client supine with the torso elevated 30–45 degrees (head and torso on the same plane).
Ask the client to turn the head slightly to the left.
Shine a tangential light to improve visualization of the jugular venous pulsations and shadows.
Inspect the suprasternal notch or clavicle area for pulsations from the internal jugular veins.
Clinical Tip:
Do not confuse jugular venous pulsations with carotid artery pulsations. Jugular venous pulse should not be visible when the client is sitting upright.
Distention of the jugular veins when the client’s torso is elevated more than 45 degrees indicates increased central venous pressure (often due to right ventricular failure, pulmonary hypertension, pulmonary embolism, or cardiac tamponade).
One-sided distention may indicate a kink or aneurysm.
Evaluation of Jugular Venous Pressure:
To evaluate, observe for distention at various degrees of head elevation (30°, 45°, 60°, and 90°).
Normal Findings: Jugular veins should not be distended or protruding at 45° or greater.
Abnormal Findings:
Distention at 45°, 60°, or 90° may indicate right-sided heart failure.
Kussmaul sign (increased venous pressure on inspiration) may indicate severe constrictive pericarditis.
Auscultation and Palpation of Carotid Arteries:
Auscultation:
Listen for bruits (blowing or swishing sounds) over the carotid artery. Bruits indicate turbulent blood flow caused by narrowed vessels.
Always auscultate before palpating the carotid arteries as palpation can alter heart rate, which may affect the strength of the carotid pulse.
Normal Findings: No abnormal sounds (blowing, swishing).
Abnormal Findings: A bruit suggests occlusive arterial disease. However, if the artery is more than two-thirds occluded, a bruit may not be audible.
Palpation:
Palpate each carotid artery alternately by placing the pads of your fingers on the neck, medial to the sternocleidomastoid muscle.
Normal Findings: A smooth, rapid upstroke and slower downstroke, with no thrills or variations in pulse.
Abnormal Findings:
Weak pulse may indicate hypovolemia, shock, or decreased cardiac output (CO).
Bounding pulse may indicate hypervolemia or increased CO.
Thrills: A vibration or "purring cat" sensation indicates a narrowing artery.
Pulse Inequality: If one pulse is weaker or stronger than the other, it may suggest arterial constriction or occlusion.
Pulse Amplitude Scale (Used for Palpation of Carotid Arteries):
0 = Absent
1+ = Weak, diminished (easily obliterated)
2+ = Normal (obliterated with moderate pressure)
3+ = Strong (obliterated with firm pressure)
4+ = Bounding (unable to obliterate)
Older Adult Considerations:
Be cautious when palpating older adults due to arteriosclerosis (hardening of the arteries), which can lead to an increased risk of compression and blocked circulation.
Pulses should be checked for strength and equality. Weak pulses may indicate decreased blood flow, while a bounding pulse suggests excessive blood volume.
Key Clinical Tips:
Jugular venous distention may be the first sign of heart failure.
Bruits are an important sign of vascular disease and should be carefully auscultated.
Thrills and abnormal pulse findings (such as inequality or bounding pulses) suggest underlying cardiovascular problems, including arterial occlusion or hypervolemia.
Abnormal Arterial Pulse and Pressure Waves
A normal pulse has a smooth, rounded wave with a subtle notch on the descending slope. It is characterized by a strong and regular pulse, and the pulse pressure (the difference between systolic and diastolic pressure) typically ranges from 30 to 40 mmHg. Pulse pressure can be measured using waveforms produced by a pulmonary artery catheter to assess arterial pressure. The waveform consists of five parts:
Anacrotic limb (upstroke)
Systolic peak
Dicrotic limb
Dicrotic notch
End diastole (diastolic peak)
Pulse Variations
Here are some abnormal pulse types and their causes:
1. Small, Weak Pulse
Characteristics:
Diminished pulse pressure
Weak and small on palpation
Slow upstroke
Prolonged systolic peak
Causes:
Decreased stroke volume (SV): Heart failure, hypovolemia, severe aortic stenosis
Increased peripheral resistance: Hypothermia, severe congestive heart failure
2. Large, Bounding Pulse
Characteristics:
Increased pulse pressure
Strong and bounding on palpation
Rapid rise and fall with a brief systolic peak
Causes:
Increased SV or decreased peripheral resistance: Fever, anemia, hyperthyroidism, aortic regurgitation, patent ductus arteriosus
Increased SV due to decreased HR: Bradycardia, complete heart block
Decreased aortic wall compliance: Aging, atherosclerosis
3. Pulsus Bisferiens
Characteristics:
Double systolic peak
Causes:
Pure aortic regurgitation
Combined aortic stenosis and regurgitation
Hypertrophic cardiomyopathy
4. Pulsus Alternans
Characteristics:
Regular rhythm
Amplitude alternates (one strong pulse, followed by a weaker one)
Causes:
Left ventricular failure (typically accompanied by an S3 heart sound)
5. Bigeminal Pulse
Characteristics:
Regular, irregular rhythm (one normal beat followed by a premature contraction)
Alternates in amplitude (strong pulse, followed by weaker one)
Causes:
Premature ventricular contractions (PVCs)
6. Paradoxical Pulse
Characteristics:
Palpable decrease in pulse amplitude during quiet inspiration (pulse weakens during inspiration, strengthens with expiration)
May require a sphygmomanometer to detect the change (systolic pressure decreases by more than 10 mmHg during inspiration)
Causes:
Pericardial tamponade
Constrictive pericarditis
Obstructive lung disease
Ventricular Impulses
The ventricular impulse assessment identifies abnormalities or variations that may suggest hypertension, hypertrophy, volume overload, or pressure overload. Here are some examples:
1. Lift (Heave)
Characteristics: Diffuse lifting during systole at the left lower sternal border.
Cause: Right ventricular hypertrophy, often due to pulmonic valve disease, pulmonic hypertension, or chronic lung disease.
2. Thrill
Characteristics: A palpable vibration, often felt over the second and third intercostal spaces.
Cause:
Severe aortic stenosis
Systemic hypertension
Pulmonic stenosis
Pulmonic hypertension
3. Accentuated Apical Impulse
Characteristics: Increased force and duration, though not displaced.
Cause: Pressure overload, especially seen in left ventricular hypertrophy related to aortic stenosis or systemic hypertension.
4. Laterally Displaced Apical Impulse
Characteristics: Displacement of the apical impulse laterally, found over a wider area.
Cause: Volume overload, often associated with ventricular hypertrophy and dilatation related to mitral regurgitation, aortic regurgitation, or left-to-right shunts.
Abnormal Heart Rhythms
Changes in heart rhythm affect auscultation findings, and these changes are associated with various abnormal heart rhythms:
1. Premature Atrial or Junctional Contractions
Characteristics: Early beats followed by a pause.
Auscultation Tip:
The early beat has an S1 of different intensity and a diminished S2.
S1 and S2 are otherwise similar to normal beats.
2. Premature Ventricular Contractions (PVCs)
Characteristics: Early beats followed by a pause.
Auscultation Tip:
The early beat has an S1 of different intensity and a diminished S2. Both sounds may be split.
3. Sinus Arrhythmia
Characteristics: HR speeds up and slows down in a cycle (faster with inhalation, slower with exhalation).
Auscultation Tip: S1 and S2 are usually normal, though S1 may vary with the HR.
4. Atrial Fibrillation and Atrial Flutter with Varying Ventricular Response
Characteristics: Irregular ventricular contractions, often with short runs of irregular rhythms that may appear regular.
Auscultation Tip: S1 varies in intensity.
Extra Heart Sounds
Extra heart sounds are classified by their timing in the cardiac cycle, either during systole or diastole. Some sounds extend into both phases of the cardiac cycle.
Extra Heart Sounds During Systole:
Clicks: High-frequency sounds heard just after S1 (ejection clicks), produced by a functioning but diseased valve.
Aortic Ejection Click:
Heard early in systole at the second right ICS and apex.
Occurs with the opening of the aortic valve and does not change with respiration.