assessments heart & neck vessel
TRANSCRIPT
![Page 1: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/1.jpg)
Assessment of the Heart and
Peripheral vessels
Maria Carmela L. Domocmat, MSN, RN
Associate Professor, College of Nursing
Manila Adventist College
![Page 2: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/2.jpg)
Anatomy
Heart
8/14/2017 2 Maria Carmela L. Domocmat, RN, MSN
![Page 3: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/3.jpg)
Heart
extends vertically
L, 2nd to 5th
horizontally
R edge sternum to L MCL
inverted cone
o base – upper portion – near L 2nd ICS
o apex – lower portion – near L 5th ICs and L MCL
8/14/2017 3 Maria Carmela L. Domocmat, RN, MSN
![Page 4: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/4.jpg)
precordium
anterior chest that overlies the heart and great
vessels
great vessels
large veins and arteries leading directly to and away
from heart
8/14/2017 4 Maria Carmela L. Domocmat, RN, MSN
![Page 5: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/5.jpg)
great vessels includes:
o sup and inf vena cava
o pulmo artery, pulmo veins (2 from each lung)
o Aorta
septum – separates the R and L sides of heart
8/14/2017 5 Maria Carmela L. Domocmat, RN, MSN
![Page 6: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/6.jpg)
Valves
o AV
o at entrance into ventricles
tricuspid – R; bet R atrium and R ventricle
bicuspid (mitral) – L ; bet L atrium and ventricle
chordae tendinae- anchor AV valve flaps to papillary
muscles within ventricles; prevent reverse open of
AV valves
8/14/2017 6 Maria Carmela L. Domocmat, RN, MSN
![Page 7: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/7.jpg)
Valves
o semilunar valves – at exit of each
ventricle at beginning of great vessels
has 3 cusps or flaps that looks like half-
moons
open - during ventricular contraction
close – from pressure of ventricle when
ventricles relax
prevent blood from flowing
backward into relaxed ventricles
8/14/2017 7 Maria Carmela L. Domocmat, RN, MSN
![Page 8: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/8.jpg)
Valves
o semilunar valves – at exit of each ventricle at
beginning of great vessels
pulmonic valve – at entrance of pulmo artery as it
exits the R ventricle
aortic valve - at beginning of ascending aorta as it
exists L ventricle
8/14/2017 8 Maria Carmela L. Domocmat, RN, MSN
![Page 9: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/9.jpg)
Covering and Walls
pericardium – tough, inextensible, loose-fitting,
fibroserous sac that attaches to great vessels and
surrounds heart
parietal pericardium – serous membrane lining
o secretes small amount of pericardial fluid that allows
for smooth, friction-free movement of heart
8/14/2017 9 Maria Carmela L. Domocmat, RN, MSN
![Page 10: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/10.jpg)
Covering and Walls
epicardium – covers outer surface; also has
serous membrane lining
myocardium – thickest layer; made up of
contractile cardiac muscle cells
endocardium – thin layer of endothelial tissue;
forms innermost layer; continuous with
endothelial lining of blood vessels
8/14/2017 10 Maria Carmela L. Domocmat, RN, MSN
![Page 11: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/11.jpg)
Electrical Conduction
8/14/2017 11 Maria Carmela L. Domocmat, RN, MSN
![Page 12: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/12.jpg)
The Cardiac Cycle
refers to filling and emptying of heart’s
chambers
two phases: diastole & systole
o diastole – filling; relaxation of ventricles
2/3 of cardiac cycle
o systole – emptying; contraction of ventricles
1/3 of cardiac cycle
8/14/2017 12 Maria Carmela L. Domocmat, RN, MSN
![Page 13: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/13.jpg)
The Cardiac Cycle
Diastole
Systole
8/14/2017 13 Maria Carmela L. Domocmat, RN, MSN
![Page 14: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/14.jpg)
Diastole
early or protodiastolic filling
presystole or atrial systole
8/14/2017 14 Maria Carmela L. Domocmat, RN, MSN
![Page 15: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/15.jpg)
Diastole
o early or protodiastolic filling – early, rapid.
passive filling
AV valves open
ventricles relaxed
this causes higher pressure in atria than in ventricles
therefore – blood rushes thru atria into ventricles
8/14/2017 15 Maria Carmela L. Domocmat, RN, MSN
![Page 16: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/16.jpg)
Diastole
o followed by period of slow passive filling
o presystole or atrial systole – ―atrial kick‖ – final
active filing phase
atria contract— near the end of ventricular diastole
this complete emptying of blood out of upper
chambers by propelling into ventricles
this raises L ventricular pressure
8/14/2017 16 Maria Carmela L. Domocmat, RN, MSN
![Page 17: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/17.jpg)
Systole
o filling phases during diastole –result in large amt
of blood in ventricles
this causes the pressure in ventricles to be higher
than in atria
this causes the valves (mitral & tricuspid) to shut
8/14/2017 17 Maria Carmela L. Domocmat, RN, MSN
![Page 18: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/18.jpg)
Systole
o closure of AV valves
produces 1st heart sound (S1); beginning of systole
prevents blood from flowing backward
(regurgitation) into atria during ventricular
contraction
8/14/2017 18 Maria Carmela L. Domocmat, RN, MSN
![Page 19: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/19.jpg)
o isometric contraction
at this point – all 4 valves are closed and ventricles
contract
there is now high pressure inside ventricles
causing (1) aortic valve to open on L side of heart;
(2) pulmonic valve to open on R side
blood is ejected rapidly thru these valves
8/14/2017 19 Maria Carmela L. Domocmat, RN, MSN
![Page 20: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/20.jpg)
o with ventricular emptying – the ventricular
pressure falls and semilunar valves close
this closure produces the 2nd heart sound (S2); end of systole
o after closure semilunar valves – ventricles relax
o atrial pressure is now higher than ventricular
pressure
causing AV valves to open and diastolic filing to
being again
8/14/2017 20 Maria Carmela L. Domocmat, RN, MSN
![Page 21: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/21.jpg)
HEART SOUNDS
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 21
![Page 22: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/22.jpg)
Heart Sounds
produced by valve closure
opening of valve is silent
normal heart sounds
o ―lub dubb‖
o occasionally – extra heart sounds and murmurs are
auscultated
8/14/2017 22 Maria Carmela L. Domocmat, RN, MSN
![Page 23: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/23.jpg)
Heart Sounds
Heart Valves
Act as one-way doors, making sure that blood flows
in the correct direction through the heart.
Tricuspid valve
Mitral valve
Pulmonary valve
Aortic valve
8/14/2017 23 Maria Carmela L. Domocmat, RN, MSN
![Page 24: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/24.jpg)
atrio-ventricular valves (A-V valves)
openings leading to the right and left ventricles
first heart sound that we hear on the chest wall
occurs when these A-V valves close;
this heart sound is called S1.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 24
![Page 25: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/25.jpg)
Heart Valves
Tricuspid Valve
• right A-V valve
• between right atrium
& right ventricle
Bicuspid Valve
• left A-V valve
• between left atrium &
left ventricle
Pulmonary Valve
• semilunar valve
• between right
ventricle & pulmonary
trunk
Aortic Valve
• semilunar valve
• between left
ventricle & aorta
15-7
![Page 26: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/26.jpg)
Skeleton of Heart
• fibrous rings to which the heart valves are attached
15-10
![Page 27: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/27.jpg)
Heart Valves
Pulmonary and Aortic Valve
![Page 28: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/28.jpg)
semilunar valves
openings leading to the pulmonary trunk and aorta
pulmonic valve and the aortic valve
second heart sound occurs when these semilunar
valves close:
these heart sounds is called S2.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 28
![Page 29: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/29.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 29
![Page 30: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/30.jpg)
S1 – ―lub‖
o result of closure of AV valves (mitral and tricuspid)
o correlates with beginning of systole
o heard over entire precordium – heard best at apex (L
MCL, 5th ICS)
8/14/2017 30 Maria Carmela L. Domocmat, RN, MSN
![Page 31: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/31.jpg)
S2 – ―dub‖
o result from closure of semilunar valves (aortic and
pulmonic)
o correlates with beginning of diastole
o heard over base
o splitting of S2 – may be exaggerated during
inspiration and disappear during expiration
8/14/2017 31 Maria Carmela L. Domocmat, RN, MSN
![Page 32: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/32.jpg)
Extra heart sounds
o S3 and S4 - referred as diastolic filing sounds or extra
heart sounds
8/14/2017 32 Maria Carmela L. Domocmat, RN, MSN
![Page 33: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/33.jpg)
Extra heart sounds
o S3
can be heard early in diastole, after S2
often termed ventricular gallop
results from ventricular vibration secondary to rapid
ventricular filling
8/14/2017 33 Maria Carmela L. Domocmat, RN, MSN
![Page 34: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/34.jpg)
Extra heart sounds
o S4 -
heard late in diastole, just before S1
often termed atrial gallop
results from ventricular vibration secondary to rapid
ventricular resistance (noncompliance) during atrial
contraction
8/14/2017 34 Maria Carmela L. Domocmat, RN, MSN
![Page 35: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/35.jpg)
Murmurs
8/14/2017 35 Maria Carmela L. Domocmat, RN, MSN
![Page 36: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/36.jpg)
Murmurs
o blood normally flows silently through heart
o there are conditions that can create turbulent
blood flow in which swooshing or blowing
sound may be auscultated over precordium
8/14/2017 36 Maria Carmela L. Domocmat, RN, MSN
![Page 37: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/37.jpg)
Murmurs
o conditions that contribute to turbulent blood
flow include
increased blood velocity
structural valve defects
valve malfunction
abnormal chamber openings (e.g., septal defect)
8/14/2017 37 Maria Carmela L. Domocmat, RN, MSN
![Page 38: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/38.jpg)
Cardiac Output (CO)
8/14/2017 38 Maria Carmela L. Domocmat, RN, MSN
![Page 39: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/39.jpg)
Cardiac Output (CO)
the amount of blood pumped by ventricles
during a given period of time (usually 1 min)
determined by stroke volume (SV) multiplied by
heart rate (HR): SV x HR = CO
normal adult CO is 5 to 6 L/min
8/14/2017 39 Maria Carmela L. Domocmat, RN, MSN
![Page 40: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/40.jpg)
SV
o amount of blood pumped from heart with each
contraction
o SV from L ventricle is usually 70 ml
8/14/2017 40 Maria Carmela L. Domocmat, RN, MSN
![Page 41: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/41.jpg)
Factors that influence SV
degree of stretch of the heart muscle up to a
critical length before contraction (preload)
the greater the preload – the greater the SV
unless heart muscle is stretched so much that is
cannot contract effectively
8/14/2017 41 Maria Carmela L. Domocmat, RN, MSN
![Page 42: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/42.jpg)
Factors that influence SV
pressure against which heart muscle has to eject
blood during contraction (afterload)
increased afterload results in decreased SV
synergy of contraction
i.e, uniform, synchronized contraction of
myocardium
conditions that cause an asynchronous contraction
decrease SV
8/14/2017 42 Maria Carmela L. Domocmat, RN, MSN
![Page 43: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/43.jpg)
Factors that influence SV
compliance or distensibility of ventricles
decreased compliance decreased SV
contractility or force of contraction of
myocardium under loading conditions
8/14/2017 43 Maria Carmela L. Domocmat, RN, MSN
![Page 44: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/44.jpg)
8/14/2017 44 Maria Carmela L. Domocmat, RN, MSN
![Page 45: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/45.jpg)
HEALTH HISTORY
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 45
![Page 46: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/46.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 46
![Page 47: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/47.jpg)
Present Health History
Q: Do you experience chest pain?
When did it start?
Describe the type of pain, location,
radiation, duration, and how
often you experience the pain.
Rate the pain on a scale 0 to 10,
with being the worst possible
pain.
Does activity make the pain worse?
Did you have perspiration
(diaphoresis) with the chest
pain?
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 47
![Page 48: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/48.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 48
![Page 49: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/49.jpg)
Present Health History
R: Chest pain can be cardiac, pulmonary,
muscular, or GIT in origin. Angina (cardiac
chest pain) is usually described as a sensation of
squeezing around the heart; a steady, severe
pain; and a sense of pressure. It may radiate to
the left shoulder and down the left arm or to the
jaw. Diaphoresis and pain worsened by activity
are usually related to cardiac chest pain.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 49
![Page 50: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/50.jpg)
Q: Do you experience
palpitations?
R: Palpitations may occur
with an abnormality of
the heart’s conduction
system or during the
heart’s attempt to
increase cardiac output
by increasing the heart
rate. Palpitations may
cause the client to feel
anxious.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 50
![Page 51: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/51.jpg)
Q: DO you tire easily? Do you
experience fatigue? Describe
when the fatigue started. Was
it sudden or gradual? Do you
notice it at any particular
time day?
R: Fatigue may result from
compromised cardiac
output. Fatigue related to
decrease cardiac output
is worse than the evening
or as the day progresses.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 51
![Page 52: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/52.jpg)
Q: Do you have difficulty
breathing or shortness of
breath (dyspnea)?
R: Dyspnea may result
from congestive heart
failure pulmonary
disorders, coronary
artery disease, myocardial
ischemia, and myocardial
infarction. Dyspnea may
occur at rest, during
sleep, or with mild,
moderate or extreme
exertion. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 52
![Page 53: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/53.jpg)
Q: Do you wake up at night
with an urgent need to
urinate (nocturia)? How
many times a night?
R: Increase renal perfusion
during periods at rest or
recumbency may cause
nocturia. Decreased
frequency may be related
to decrease cardiac
output.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 53
![Page 54: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/54.jpg)
Q: Do you experience
dizziness? R: Dizziness may indicate
decreased blood flow to
the brain due to
myocardial damage;
however, there are
several other causes for
dizziness such as inner
ear syndromes, decreased
cerebral circulation and
hypotension. Dizziness
may put the client at risk
for falls.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 54
![Page 55: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/55.jpg)
Q: Do you experience swelling
(edema) in your feet, ankles
or legs?
R: Edema of the lower
extremities may occur as
a result of heart failure.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 55
![Page 56: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/56.jpg)
Q: Do you have frequent heart
burn? When does it occur?
What relieves it? How often
do you experience it?
R: Cardiac pain may be
overlooked or
misinterpreted as GIT
problems. GIT pain may
occur after meals, and is
relieved with antacids,
whereas cardiac pain may
occur anytime, is not
relieved with antacids
and worsens with activity
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 56
![Page 57: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/57.jpg)
Family health History
Q: Is there a history of
hypertension, myocardial
infarction, coronary heart
disease, elevated cholesterol
levels, or diabetes mellitus in
your family?
R: A genetic
predispositions to these
risk factors increases a
client’s chance for
development of heart
disease.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 57
![Page 58: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/58.jpg)
Lifestyle and Health Practices
Q: Do you smoke? How many
packs of cigarettes per day
and how many years?
R: Cigarette smoking
greatly increases the risk
of heart disease.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 58
![Page 59: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/59.jpg)
Q: What type of stress do you
have in your life? How do
you cope with it?
R: Stress has been
identified as a possible
risk factor for heart
disease.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 59
![Page 60: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/60.jpg)
Q: Describe what you usually
eat in a 24-hour period.
R: An elevated cholesterol
level increases the chance
of fatty plaque formation
in the coronary vessels.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 60
![Page 61: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/61.jpg)
Q: How much alcohol do you
consume each day/week?
R: Excessive intake of
alcohol has been linked
to hypertension.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 61
![Page 62: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/62.jpg)
Q: Do you exercise? What type
of exercise and how often?
R: A sedentary lifestyle is
known modifiable risk
factor contributing to
heart disease. Aerobic
exercise three times per
week for 30 minutes is
more beneficial than
anaerobic exercise or
sporadic exercise in
preventing heart disease.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 62
![Page 63: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/63.jpg)
Q: Describe your daily
activities. How are they
different from your routine
5 or 10 years ago? Does
fatigue, chest pain, or
shortness of breath limit
your ability to perform daily
activities? Describe. Are you
able to care for yourself?
R: Heart disease may
impede the ability to
perform daily activities.
Exertional dyspnea or
fatigue may indicate
heart failure. An
inability to complete
activities of daily living
may necessitate a
referral for home care.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 63
![Page 64: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/64.jpg)
Q: Has your heart disease had
any effect on your sexual
activity?
R: Many clients with heart disease are
afraid that sexual activity will
precipitate chest pain. If the client
can walk one block or climb two
flights of stairs without
experiencing symptoms, it is
generally acceptable client to
engage in sexual intercourse.
Nitroglycerin can be taken before
intercourse as prophylactic for
chest pain. In addition, the side-
lying position for sexual
intercourse may reduce the
workload on the heart.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 64
![Page 65: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/65.jpg)
Q: How many pillows do you
use to sleep at night? Do
you get up to urinate during
the night? Do you feel
rested in the morning?
R: If heart function is
compromised, cardiac output
to the kidneys is reduced
during episodes of activity. At
rest, cardiac output increases,
as does glomerular filtration
and urinary output. Orthopnea
(the inability to breathe while
supine) and nocturia may
indicate heart failure. In
addition, these two conditions
may also impede the ability to
get adequate rest. 8/14/2017 65
![Page 66: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/66.jpg)
Q: How important is having a
healthy heart to your ability
to feel good about yourself
and your appearance? What
fears about heart disease do
you have?
R: A person’s feeling of
self-worth may depend
on his or her ability to
perform usual daily
activities and fulfill his or
her usual roles.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 66
![Page 67: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/67.jpg)
PREPARING THE CLIENT
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 67
![Page 68: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/68.jpg)
• explain - need to expose the
anterior chest
• Female clients may keep their
breast covered and may
simply hold the left breast
out of the way when
necessary
Explain need to assume
several different
positions for the
examination.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 68
![Page 69: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/69.jpg)
• supine position with the head
elevated to about 30 degrees..
• Auscultation and palpation of
the neck vessels and
• inspection, palpation and
auscultation of the pericordium
• left lateral position
• palpation of the apical
impulse
• if the examiner is having
trouble locating the pulse
with the client in the
supine position.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 69
![Page 70: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/70.jpg)
• left lateral and sitting-up and
leaning-forward position
• auscultate for the presence of
any abnormal heart sounds.
• These positions may bring
out an abnormal sound not
detected with the client in the
supine position.
• Make sure you explain to
the client that you will be
listening to a heart in a
number of places and that
this does not necessarily
mean that any thing is
wrong.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 70
![Page 71: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/71.jpg)
• Help ease any anxiety
• Provide with such modesty as
possible during the
examination
• describe the steps of the
examination
• and answer any questions the
client may have.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 71
![Page 72: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/72.jpg)
EQUIPMENTS
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 72
![Page 73: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/73.jpg)
Steth with bell and diaphragm
Sml pillow
Penlight or movable exam light
Watch with second hand
Cm rulers (2)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 73
![Page 74: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/74.jpg)
PHYSICAL ASSESSMENT
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 74
![Page 75: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/75.jpg)
ASSESSMENT OF THE HEART
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 75
![Page 76: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/76.jpg)
Overview
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 76
![Page 77: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/77.jpg)
Assessment of the Heart
Inspect pulsations
Palpate apical impulse
Palpate abnormal pulsations
Auscultate heart rate and rhythm
Auscultate heart sounds
Auscultate : pulse rate deficit
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 77
![Page 78: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/78.jpg)
Assessment of the Heart
Auscultate heart sounds
Auscultate heart rate and rhythm
If detect an irregular rhythm, auscultate for pulse
rate deficit
Auscultate to identify S1 and S2
Auscultate for extra heart sounds
Auscultate for murmurs
Auscultate in with the client assuming other
position
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 78
![Page 79: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/79.jpg)
Inspect pulsations
Client supine position with the head of the bed
elevated between 30 and 45 degrees
stand on client’s right side and look for the
apical impulse and any abnormal pulsation
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 79
![Page 80: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/80.jpg)
Inspect pulsations
o Note: apical pulse – originally called PMI (point
of maximal impulse)
not used anymore – bcoz maximal impulse may
occur in other areas of precordium as result of
abnormalities
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 80
![Page 81: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/81.jpg)
Inspect pulsations
o normal findings:
apical impulse – may or may not be visible
if visible – in mitral area (Left MCL, 4th or 5th ICS)
result of left ventricle moving outward during systole
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 81
![Page 82: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/82.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 82
![Page 83: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/83.jpg)
Inspect pulsations
o abnormal findings:
pulsations – or heaves or lifts –other than the apical
pulsation
may occur as result of enlarged ventricle from an
overload of work.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 83
![Page 84: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/84.jpg)
Abnormal ventricular impulses
Lift
Thrill
Accentuated Apical Impulse
Laterally displaced apical impulse
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 84
![Page 85: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/85.jpg)
PALPATION
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 85
![Page 86: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/86.jpg)
Palpate the apical impulse
Remain on the client’s right side
Client remain supine
Use palmar surfaces of hand
palpate the apical impulse in the mitral area
(fourth or fifth intercostals space at the
midclavicular line).
After locating the pulse, use one finger pad for
more accurate palpation.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 86
![Page 87: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/87.jpg)
Palpate the apical impulse
If cannot be palpated
Have client assume left
lateral position
This displaces heart toward left
chest wall and relocates apical
impulse farther to left
Elderly
May be difficult to palpate
Bcoz of increased AP chest
diameter
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 87
![Page 88: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/88.jpg)
Normal findings:
Palpation apical impulse
apical impulse – palpated in mitral area; size –
nickel (1-2 cm)
amplitude – small – like gentle tap
duration – brief; lasting thru first 2/3 of systole
and often less
obese or large breasts – may not be palpable
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 88
![Page 89: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/89.jpg)
Normal findings:
Palpation apical impulse
o abnormal findings:
not palpable – pulmonary emphysema
suspect cardiac enlargement
If larger than 1 to 2cm,
displaced more forceful, or
of longer duration
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 89
![Page 90: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/90.jpg)
Palpate: abnormal pulsations
Use palmar surfaces to palpate the
apex,
left sternal border, and
base
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 90
![Page 91: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/91.jpg)
Palpate abnormal pulsations
o normal findings:
oNo pulsations or vibrations in the areas of the apex,
left sternal border, or base
o abnormal findings:
thrill – feels similar to purring cat
is usually associated with Grave IV or higher
murmur
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 91
![Page 92: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/92.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 92
![Page 93: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/93.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 93
![Page 94: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/94.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 94
![Page 95: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/95.jpg)
AUSCULTATION
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 95
![Page 96: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/96.jpg)
Auscultate heart rate and rhythm
Place the diaphragm of the stethoscope at the
apex and listen closely to the rate and rhythm of
the apical impulse.
Concentrate on systematically moving the steth
from left to right across entire heart area from
base to apex (top to bottom) or from apex to
base (bottom to top)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 96
![Page 97: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/97.jpg)
Auscultate heart sounds
o Traditional 5 areas
aortic area : 2nd ICS, R sternal border (base of heart)
pulmonic area : 2nd or 3rd ICS, L sternal border
(base of heart)
Erb’s point : 3rd to 5th ICS, L sternal border
tricuspid area : 4th or 5th ICS, L lower sternal border
mitral or apical area : 5th ICS, L lower sternal border
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 97
![Page 98: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/98.jpg)
Heart Sounds
![Page 99: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/99.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 99
1. 2.
3.
4.
5.
![Page 100: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/100.jpg)
Auscultate heart sounds
o Alternative areas
o (by chamber)
aortic area
pulmonic area
left atrial area
right atrial area
left ventricular area
right ventricular area
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 100
![Page 101: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/101.jpg)
Auscultation of heart sounds
![Page 102: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/102.jpg)
Auscultate heart rate and rhythm
Traditional areas of
auscultation
Aortic area
Pulmonic area
Erb’s point
Mitral (apical) area
Tricuspid area
“Alternative” areas
Aortic area
Pulmonic area
Left atrial area
Right atrial area
Left ventricular area
Right ventricular area
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 102
![Page 103: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/103.jpg)
Systematically auscultate in each of the five areas
while the patient is breathing regularly and holding
breath for the following: Rate, rhythm S1 ,S2
Splitting
S3 and S4
Extra heart sound snaps, clicks, friction rubs, or murmurs
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 103
![Page 104: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/104.jpg)
Normal findings:
Heart rate and rhythm
60-100 bpm
regular rhythm
regularly irregular rhythm – sinus arrhythmia
when HR increases with inspiration and
decreased with expiration
female – 5 to 10 beats faster than male
do not differ by race or age in adults
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 104
![Page 105: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/105.jpg)
Abnormal findings:
Heart rate and rhythm
bradycardia (‹60 bpm)
tachycardia (›100 bpm)
regular irregular rhythms (i.e., premature
atrial contraction or PVC)
irregular rhythms (i.e., atrial fibrillation,
atrial flutter) – may predispose client to
decreased CO, heart failure, emboli
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 105
![Page 106: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/106.jpg)
If detect irregular rhythm,
auscultate for a pulse rate deficit.
Palpate radial pulse while auscultate apical pulse
Count for a full minute.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 106
![Page 107: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/107.jpg)
Auscultate : pulse rate deficit
Normal findings
radial and apical pulse rates –
identical
Abnormal findings
pulse deficits
difference between apical
and peripheral/radial
pulse
indicate atrial fibrillation,
atrial flutter, PVC, varying
degrees of heart block
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 107
![Page 108: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/108.jpg)
S1 AND S2
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 108
![Page 109: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/109.jpg)
Auscultate to define S1 and S2
Auscultate the first heart sound (S1 or ―lub‖)
and the second heart sound (S2 or ―dub‖).
Remember these two sounds make up the
cardiac cycle of systole and diastole.
S1 starts systole
S2 starts diastole.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 109
![Page 110: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/110.jpg)
Auscultate to identify S1 and S2
o S1- first heart sound
―lub‖
the result of closure of AV valves – indicate start of
systole
best heard – apex of heart; where S1 is louder than
S2
lower in pitch and a bit longer than S2
occurs immediately after diastole
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 110
![Page 111: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/111.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 111
![Page 112: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/112.jpg)
Auscultate to identify S1 and S2
o S2 – second heart sound
―dubb‖
result of closure of semilunar valves- indicate end of
systole, starts diastole
higher in pitch, shorter duration than S1
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 112
![Page 113: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/113.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 113
![Page 114: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/114.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 114
![Page 115: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/115.jpg)
Normal findings:
Auscultation : S1 and S2
o S1 corresponds with each
carotid pulsation and is
loudest at the apex of the
heart
o Note: if have difficulty
differentiating S1 from S2
– palpate carotid pulse
o S1 – harsh sound that
occurs with carotid pulse
.
S2 immediately follows
after S1 and is loudest
at the base of the
heart.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 115
![Page 116: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/116.jpg)
Auscultate to identify S1 and S2
• abnormal findings:
– ventricular impulses
• lift
• thrills
• accentuated apical impulse
• laterally displaced apical impulse
– abnormal heart rhythms
• premature atrial or junctional contractions
• premature ventricular contractions
• sinus arrhythmia
• atrial fibrillation and atrial flutter with varying ventricular response
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 116
![Page 117: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/117.jpg)
S1
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 117
![Page 118: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/118.jpg)
Listen to S1
Use the diaphragm of the stethoscope to best
hear S1.
Intensity of S1 depends on
position of mitral valve at start of systole
Structure of valve leaflets
How quickly pressure rises in the ventricles
All these factors influence speed and amount of
closure of the valve
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 118
![Page 119: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/119.jpg)
S1
o Normal finding
distinct sound heard in each area
loudest – apex
may become softer with inspiration
split S1 – young adults; left lateral sternal
border
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 119
![Page 120: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/120.jpg)
S1
Normal variations
Softer at base and louder at apex of heart
May be split along the lower left sternal border,
where tricuspid component of sound, usually too
faint to be heard, can be auscultated
Split S1 heard over apex – may be an S4
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 120
![Page 121: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/121.jpg)
S1
o abnormal finding
Accentuated S1
Diminished S1
Varying S1
Split S1
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 121
![Page 122: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/122.jpg)
S2
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 122
![Page 123: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/123.jpg)
Listen to S2
o use diaphragm of steth
o breathe regularly
o Note: do not ask to hold breath –
breath holding may cause any normal or
abnormal split to subside
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 123
![Page 124: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/124.jpg)
Listen to S2
o normal finding
distinct sound heard in each area
loudest – base
physiologic split
split S2 – two distinct sounds of its
components – A2 and P2
heard at in late inspiration at 2nd or 3rd left
ICS
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 124
![Page 125: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/125.jpg)
Listen to S2
o abnormal finding
Any split S2 heard in expiration is abnormal.
The abnormal split can be one of these three types:
Wide
Fixed
Reversed
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 125
![Page 126: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/126.jpg)
EXTRA HEART SOUNDS
Snaps
Clicks
Friction rubs
Murmurs
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 126
![Page 127: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/127.jpg)
Auscultate for extra heart sounds
o 1st - use diaphragm then bell of steth
o to auscultate over entire heart area
o (1) auscultate during systolic pause
o (2) auscultate during diastolic pause
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 127
![Page 128: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/128.jpg)
Auscultate for extra heart sounds
o systolic pause
space between S1 and S2
short duration
that’s why occur S1 and S2occur very close together
o diastolic pause
space between end of S2 and next S1
longer duration
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 128
![Page 129: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/129.jpg)
Auscultate during the systolic
pause
Auscultate during the systolic pause
space between S1 and S2
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 129
![Page 130: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/130.jpg)
Normal findings:
Auscultation systolic pause
o systolic pause
o no extra heart sounds
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 130
![Page 131: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/131.jpg)
Abnormal findings:
Auscultation systolic pause
extra heart sounds
ejection sounds or clicks
e.g., midsystolic click associated with mitral valve prolapse
friction rub – heard during systolic pause
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 131
![Page 132: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/132.jpg)
Auscultate during the diastolic
pause
Auscultate during the diastolic pause
space heard between end of S2 and S1
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 132
![Page 133: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/133.jpg)
Normal findings:
Auscultation diastolic pause
Normally no sounds are heard.
Other normal findings
Physiologic S3 heart sound
Physiologic S4 heart sound
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 133
![Page 134: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/134.jpg)
Normal findings:
Auscultation diastolic pause
Physiologic S3 benign finding
quiet sound heard during diastole - as ventricle fill form
atria
resembles rhythm of ―Tenn-es-see‖
heard at beginning of diastolic pause
Normal among: children, adolescence, young adults
rare after age 40
usually subsides upon standing or sitting up
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 134
![Page 135: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/135.jpg)
Normal findings:
Auscultation diastolic pause
Physiologic S4 o quiet sound
o sound like ―Ken-tuc-ky‖
o occur in second phase of ventricle filling from atria
o heard near the end of diastole
oNormally heard among:
owell-conditioned athletes
o adults older than 40 or 50 with no evidence of heart dse, esp
after exercise
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 135
![Page 136: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/136.jpg)
Abnormal findings:
Auscultation diastolic pause
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 136
pathologic S3 – (ventricular gallop)
pathologic S4 – (atrial gallop)
summation gallop
snaps
friction rub
![Page 137: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/137.jpg)
Abnormal findings:
Auscultation diastolic pause
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 137
pathologic S3 – (ventricular gallop)
ischemic heart dse, hyperkinetic states (e.g., anemia),
restrictive myocardial dse
![Page 138: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/138.jpg)
Abnormal findings:
Auscultation
pathologic S4 – (atrial gallop)
toward left side of precordium
o coronary artery dse (CAD), hypertensive heart dse,
cardiomyopathy , aortic stenosis
toward right side of precordium
opulmonary HTN, pulmo stenosis
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 138
![Page 139: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/139.jpg)
Abnormal findings:
Auscultation
summation gallop
S3 and S4 pathologic sounds together - creates
quadruple rhythm
friction rub Harsh, grating sound that can be heard in both systole and
diastole
caused by abrasion of inflamed pericardial surfaces
(pericarditis)
Heard best with diaphragm of steth, patient sit and
leaning forward
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 139
![Page 140: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/140.jpg)
Abnormal findings:
Auscultation
Note: normally no sound produced when valves
open
Opening snaps: abnormal diastolic sounds heard
during opening of AV valve (mitral stenosis)
Systolic click: result of opening of a rigid and
calcified aortic or pulmonic valve during ventricular
contraction
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 140
![Page 141: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/141.jpg)
MURMURS
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 141
![Page 142: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/142.jpg)
Murmur
o swishing sound caused by turbulent blood flow
thru heart valves or great vessels
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 142
![Page 143: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/143.jpg)
Heart Murmurs
![Page 144: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/144.jpg)
Auscultate for murmurs
o use diaphragm and bell
o bcoz murmurs have diff pitches
o different positions & across entire heart area
o bcoz murmurs occur or subside according to
client’s position
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 144
![Page 145: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/145.jpg)
Auscultate for murmurs
o normal findings:
no murmurs
innocent and physiologic midsystolic murmurs –may
be present
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 145
![Page 146: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/146.jpg)
Auscultate for murmurs
o abnormal findings:
pathologic midsystolic, pansystolic, diastolic
murmurs (p.382)
types of murmur:
systolic: early, mid, late, pansystolic
diastolic: early, mid, late, pandiastolic
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 146
![Page 147: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/147.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 147
![Page 148: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/148.jpg)
AUSCULTATE : DIFFERENT
POSITION
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 148
![Page 149: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/149.jpg)
Auscultate in with the client
assuming other position
o (1) client assume left lateral position
use bell – apex of heart
o (2) client sit up, lean forward, and exhale
use diaphragm – apex, along left sternal border
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 149
![Page 150: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/150.jpg)
Auscultation: Other position
o Normal findings:
S1 and S2 heart sounds present
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 150
![Page 151: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/151.jpg)
Auscultate in with the client assuming
other position
o Abnormal findings:
heard when client assume left lateral position
S3 and S4 or murmur
not detected on supine – indicate mitral stenosis
murmur from aortic regurgitation
May be heard sit up, lean forward, and exhale
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 151
![Page 152: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/152.jpg)
CLINICAL PEARLS
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 152
![Page 153: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/153.jpg)
Heart sounds
It is a common to try to hear all of the sounds in the cardiac
cycle at one time. Take the time to isolate each sound and each
pause in the cardiac cycle, listening separately and selectively for
as many beats as necessary to evaluate the sounds. It takes time
to tune in, so you must not rush. Avoid jumping the stethoscope
from one site to another; instead, inch the endpiece along the
route. This maneuver prevents missing important sounds,
particularly more widely transmitted abnormal sounds, and it
allows tracking of a sound from its loudest point to its farthest
reach (e.g. into the axilla or the back).
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 153
![Page 154: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/154.jpg)
The infant heart and liver
If heart failure is suspected, note that the infants
liver may enlarged before there is any of
moisture in the lungs, and that the left lobe of
the liver may be more distinctly enlarged than
the right.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 154
![Page 155: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/155.jpg)
Chest wall thickness
The heart of an infant or child, particularly a
preschool child, is very close to the chest wall;
thus it is much easier to hear the innocent
sounds cause by the necessary rush of the
cardiovascular system.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 155
![Page 156: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/156.jpg)
DOCUMENTATION
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 156
![Page 157: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/157.jpg)
Sample of subjective data:
No chest pain, dyspnea, dizziness or palpitations. No
previous history of cardiovascular diseases. Denies
rheumatic fever, no current medications or treatment.
Denies family history of hypertension, myocardial
infarction, CAD, high cholesterol levels, or diabetes
mellitus. Has never had an ECG, states he needs to
exercise more and consume less fat. Client does not
monitor own pulse or blood pressure. Denies the use
of tobacco. Sleeps 6-8 hours per night. Feels rested
after sleep. States that job can be somewhat stressful.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 157
![Page 158: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/158.jpg)
Sample of objective data:
Carotid pulse equal bilaterally, 2+, elastic. No bruits
auscultated over carotids. Jugular venous pulsation
disappears when upright. Jugular venous pressure x 2
cm. no visible pulsations, heaves or lifts on
pericardium. Apical impulse palpated in the 5th ICS, at
the left MCL, approximately the size of a nickel, with
no thrill. Apical heart rate auscultated, 70 beats per
min,, regular rhythm, S1 heard best at apex, S2 heard
best at base. No S3 or S4 auscultated. No splitting of
heart sound, snaps, clicks, or murmurs noted
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 158
![Page 159: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/159.jpg)
NECK VESSEL ASSESSMENT
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 159
![Page 160: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/160.jpg)
Neck vessel
Observe for jugular venous pulse
Evaluate jugular venous pressure
Auscultate carotid arteries
Palpate carotid arteries
8/14/2017 160 Maria Carmela L. Domocmat, RN, MSN
![Page 161: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/161.jpg)
Observe for jugular venous pulse
o normal findings:
o jugular venous pulse – not visible when sitting
upright; visible on supine
8/14/2017 161 Maria Carmela L. Domocmat, RN, MSN
![Page 162: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/162.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 162
![Page 163: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/163.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 163
![Page 164: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/164.jpg)
Observe for jugular venous pulse
o abnormal findings:
o visible jugular venous pulse – right ventricular
failure, pulmo htn, pulmo emboli, cardiac
tamponade
8/14/2017 164 Maria Carmela L. Domocmat, RN, MSN
![Page 165: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/165.jpg)
Evaluate jugular venous pressure
o normal findings:
jugular vein – not distended, bulging, or protruding
at 45 degrees or greater
8/14/2017 165 Maria Carmela L. Domocmat, RN, MSN
![Page 166: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/166.jpg)
Evaluate jugular venous pressure
o abnormal findings:
distended, bulging, or protruding at 45 degrees or
greater – right sided heart failure
document at which positions you observe distention
elevated venous pressure on expiration – obstructive
pulmonary disease
elevated venous pressure on inspiration –
Kussmaul’s sign – severe constrivtive pericarditis
8/14/2017 166 Maria Carmela L. Domocmat, RN, MSN
![Page 167: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/167.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 167
![Page 168: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/168.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 168
![Page 169: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/169.jpg)
AUSCULTATE & PALPATE
CAROTID ARTERIES
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 169
![Page 170: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/170.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 170
![Page 171: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/171.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 171
![Page 172: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/172.jpg)
Observing Jugular Venous Pulse &
Evaluating Jugular venous pressure
![Page 173: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/173.jpg)
Auscultate carotid arteries
Note: always auscultate first before palpating – palpation
may increase or slow the HR, therefore, changing
strength of impulse
8/14/2017 173 Maria Carmela L. Domocmat, RN, MSN
![Page 174: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/174.jpg)
Auscultate carotid arteries
o normal findings:
no blowing or swishing sound or other sounds
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 174
![Page 175: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/175.jpg)
Auscultate carotid arteries
o abnormal findings:
bruit
blowing or swishing sound; cause- turbulent blood flow
thru narrowed vessel
occlusive arterial disease
no bruit heard – if more than 2/3 artery occluded
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 175
![Page 176: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/176.jpg)
Palpate carotid arteries
o Note: if detect occlusion during auscultation –
palpate very lightly
to avoid blocking circulation or triggering vagal
stimulation and bradycardia, hypotension, or cardiac
arrest
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 176
![Page 177: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/177.jpg)
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 177
![Page 178: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/178.jpg)
Palpate carotid arteries
o normal findings:
pulses – equally strong; 2+; no variation in strength
contour
smooth and rapid on upstroke
slower and less abrupt on down stroke
arteries – elastic and no thrills noted
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 178
![Page 179: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/179.jpg)
Pulse Amplitude Scale
0 = Absent
1+ = Weak
2+ = Normal
3+ = Increased
4+ = Bounding
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 179
![Page 180: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/180.jpg)
Palpate carotid arteries
o abnormal findings:
unequal pulse – arterial constriction or occlusion in 1
carotid
weak pulse – hypovolemia, shock, decreased CO
bounding, firm pulse – hypervolemia or increased CO
variations in strength from beat to beat
delayed upstroke – aortic stenosis
loss of elasticity – arteriosclerosis
thrills – narrowing of artery
180 8/14/2017 Maria Carmela L. Domocmat, RN, MSN
![Page 181: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/181.jpg)
NURSING DIAGNOSES
![Page 182: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/182.jpg)
Wellness
Readiness for enhanced cardiac output
Health seeking behavior: Desired information
on exercise and low fat diet
![Page 183: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/183.jpg)
Risk Diagnoses
Risk for sexual dysfunction related to
misinformation or lack of knowledge regarding
sexual activity and heart disease
Risk for ineffective denial related to smoking
and obesity
![Page 184: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/184.jpg)
Actual Diagnoses
Fatigue related to decreased cardiac output
Activity intolerance related to compromised
oxygen transport secondary to heart failure
Acute pain: Cardiac related to an inequality
between oxygen supply and demand
Ineffective tissue perfusion related to impaired
circulation.
![Page 185: Assessments heart & neck vessel](https://reader031.vdocument.in/reader031/viewer/2022021815/5a66573e7f8b9a5d3d8b493d/html5/thumbnails/185.jpg)
References
Weber J; Kelly J. (2007). Health assessment in
nursing (3rd ed.) Philadelphia: Lippincott Williams
and Wilkins.
National Institute of Health. (n.d.). Heart
Diseases. Retrieved from
www.nlm.nih.gov/medlineplus/heartdiseases.ht
ml - Health Information-MedlinePlus
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 185