Cardiac and Peripheral Vascular Systems

Heart Location

• Located in the chest (thorax).
• Specifically, the precordium area.
• Approximately from the second to the fifth intercostal space.

Anatomical Terminology

• Lungs: Apices (top), Base (bottom).
• Heart: Base (top), Apex (bottom) - switched from lung nomenclature.

Layers of the Heart

• Pericardium: The outer fibrous sac.
• Myocardium: The muscular layer responsible for contraction.
• Endocardium: The inner lining in contact with blood.
• Adding "itis" indicates infection/inflammation of the specific layer.

Heart Valves

• Tricuspid Valve: Between the right atrium and right ventricle (AV valve).
• Pulmonary Valve: From the right ventricle to the pulmonary artery.
• Mitral Valve: Between the left atrium and left ventricle (AV valve).
• Aortic Valve: From the left ventricle to the aorta.
• Tricuspid and Mitral are AV valves; Pulmonic and Aortic are semilunar valves.

Direction of Blood Flow

• Deoxygenated blood enters the right atrium, passes through the tricuspid valve to the right ventricle, through the pulmonary valve to the lungs. Oxygenated blood returns to the left atrium, passes through the mitral valve to the left ventricle, and through the aortic valve to the aorta for systemic circulation.
• The heart has blood on both sides simultaneously
  • Patient's Right and Left Side.

Cardiac Cycle

• Systole: Ventricular contraction, moving blood forward.
  • Smallest part of the cycle.
  • Occurs at the apex of the heart
  • Semilunar valves (pulmonic and aortic) open; AV valves (tricuspid and mitral) close.
• Diastole: Ventricular relaxation, passive filling from the atrium.
  • Two-thirds of the cardiac cycle.
  • Occurs at the base of the heart
  • AV valves (tricuspid and mitral) open; semilunar valves (aortic and pulmonic) close.

Heart Sounds

• S1: AV valves closing (tricuspid and mitral). Heard best at the apex.
• S2: Semilunar valves closing (aortic and pulmonic). Heard best at the base.

Lymphatic System

• Runs parallel to the circulatory system.
• Brachial/Axillary Nodes: Armpits, drains the upper chest and arm.
• Epitrochial Nodes: Elbow, drains the lower arm and hand.
• Inguinal Nodes: Groin, drains the leg and genitals.
• Popliteal Node: Knee, drains the lower leg.
• Normal Lymph Nodes: Soft, mobile, nontender.
• Inflamed Lymph Nodes: Tender, enlarged, may indicate inflammation.

Health History

• Inquire about cardiovascular symptoms, family history, and previous procedures.
• Risk factors: Smoking, claudication (pain with walking in legs).

Neck Assessment

• Carotid Arteries: Palpate (one at a time) for strength (2+ or 3+ is normal).
  • Do not palpate simultaneously.
  • Auscultate for bruit (blowing, whooshing sound), indicating turbulent blood flow.
• Jugular Veins: Assess for distension, especially at 30-45 degree elevation, indicates problems like right-sided heart failure.
  • Veins should not pulse

Precordium

• Inspect: Check for lifts or heaves (abnormal).
• Palpate: Feel for a thrill (vibration), which indicates turbulent blood flow.
• Apical Impulse/Point of Maximal Impulse: Fifth intercostal space, left midclavicular line.

Percussion

• Not typically used; heart sounds dull.

Auscultation

• Identify rate and rhythm; use the apical pulse for irregular rhythms.
• Auscultation Landmarks: Aortic, Pulmonic, Erb's Point, Tricuspid, Mitral (Use diaphragm for each location)
  • Aortic: Second intercostal space, right sternal border.
  • Pulmonic: Second intercostal space, left sternal border.
  • Erb's Point: Third intercostal space, left sternal border (all valves heard equally).
  • Tricuspid: Fourth intercostal space, left sternal border.
  • Mitral: Fifth intercostal space, left midclavicular line.
  • Then, repeat all locations with the bell.

Extra Heart Sounds

• S3 and S4: Heard with the bell, low-pitched, may indicate heart failure.
  • S3 appears after S2
  • S4 appears before S1

Murmurs

• Blowing or whooshing sounds; indicates turbulent blood flow.
• Functional, Innocent, and Pathologic.
  • Functional murmurs don't have other symptoms.
  • Innocent murmurs do not affect the cardiac output.
  • Pathologic murmur causes valvular heart disease/damage
• Grading: 1 (faint) to 6 (loud, can be heard without a stethoscope).
• Thrill: Humming or vibration over the heart, associated with loud murmurs.

Splitting

• S1 is the tricuspid/mitral valves
  • Split S1 occurs at the tricuspid
• S2 is the aortic/pulmonic valves
  • Split S2 occurs at the pulmonic.
• Splitting: Heard with the diaphragm, valves close at slightly different times.

EKGs/ECGs

• Measure electrical conduction through the heart.
• SA node: Pacemaker, 60-100 bpm.

Peripheral Vascular System

• Assess symmetry, skin integrity, color, temperature, cap refill, clubbing, and lymph nodes.
• Upper Extremities Pulses.
  • Brachial Pulse: Arm.
  • Radial Pulse: Thumb side of the wrist.
  • Ulnar Pulse: Pinky side of the wrist.
  • Modified Allen's Test: Assess collateral circulation.
• Lower Extremities.
  • hair distribution, temperature, edema, symmetry, skin integrity, skin color.
• Lower Extremities Pulses.
  • Femoral Pulse: Groin.
  • Popliteal Pulse: Behind the knee.
  • Posterior Tibialis Pulse: Ankle bone.
  • Dorsalis Pedis Pulse: Top of the foot.
• Use a Doppler to find a pulse
• Pulse Deficit: Apical rate significantly exceeds the radial rate, indicating peripheral vascular issues; apical rate minus radial rate.
• Edema: Assess for pitting (indentation after pressure).

Ejection Fraction

• Normal is 50-70%; the amount of blood that ejection with each heartbeat.
• Systolic Problem: Ventricle pump problem, ejection fraction drops.
• Diastolic Issue: Relaxation issue, ejection fraction doesn't tell