heart and peripheral vasculature
DESCRIPTION
Heart and Peripheral Vasculature. N1037. Anatomy and Physiology: Heart. Base @ top Apex @ bottom Pericardium Parietal layer Visceral layer. Anatomy and Physiology: Heart. 4 Chambers of the heart Right and left atria Right and left ventricles Heart valves Atrioventricular (AV) valves - PowerPoint PPT PresentationTRANSCRIPT
Heart and Peripheral Vasculature
N1037
Anatomy and Physiology: Heart• Base @ top• Apex @ bottom• Pericardium
– Parietal layer
– Visceral layer
Anatomy and Physiology: Heart
• 4 Chambers of the heart– Right and left atria
– Right and left ventricles
• Heart valves– Atrioventricular (AV) valves
• Tricuspid
• Mitral (bicuspid)
– Semilunar valves• Pulmonic
• Aortic
Direction of Blood Flow
• Inferior & Superior Vena Cava to Right Atrium (RA), then into Right Ventricle (RV)
• Venous blood flows to Pulmonic Valve to Pulmonary Artery (unoxygenated) to the lungs.
• Lungs oxygenate blood. Pulmonary veins (oxygenated) to Left Atrium (LA).
• Into LA through Mitral Valve to Left Ventricle (LV) and ejected through Aortic Valve into Aorta.
• Aorta delivers oxygenated blood to body.
Neck Vessels
Coronary Circulation
• Left main coronary artery– Left circumflex artery
– Left anterior descending artery
• Right coronary artery
Cardiac Cycle• Systole
– Isovolumic contraction
– Early systole
– Late systole
• Diastole
– Isovolumic relaxation phase
– Early and mid-diastolic filling periods
– Atrial systole (atrial kick)
Cardiac CycleDiastole• Ventricles relax and fill with blood• The AV valves(tricuspid & mitral) are open • During the first rapid filling phase, blood pours rapidly from
the atria into the ventricles (early diastolic filling).• At the end, the atria contract & push the last amount of blood
into the ventricles (presystole = atrial kick).
Systole• After this, the AV valves close and we hear the first heart
sound “S1”. S1”. This is the beginning of Systole.• AV valves close to prevent regurgitation into the atria during
contraction.• Then, the aortic and pulmonic valves (semilunar valves) open
& blood is ejected rapidly into the arteries.• After all the contents are ejected, the semilunar valves close.
This causes the second heart sound, “S2”.“S2”. This is the end of systole.
Excitation of the Heart
• Sinoatrial (SA) node• Atrioventricular node• Bundle of His• Right and left bundle
branches• Purkinje fibers
Conduction Pathway and EKG
• Sinoatrial node (SA Node) initiates an electrical impulse
• It is the “pacemaker” of the heart.
• Travels to the Atrioventricular node (AV Node)
• Then it travels to the “Bundle of His”
• Through the left and right bundle branches.
• And lastly, through the ventricles.
Electrocardiogram (EKG)
• P
• Q
• R
• S
• T
• Isoelectric line
Peripheral Vasculature• Arterial system
– Three layers of arterial walls: tunica intima, media, externa
– Arteries– Arterioles– Capillaries– pulsating flow, no valves
• Venous system– Veins– Venules– steady flow, 1 way
valves,thinner walls , less elastic
Peripheral Vasculature
Health History• Age
– Childhood onset: rheumatic fever– Adult onset: HTN, CAD, MI, CVA, AAA
• Gender– Female– Male
• Race– May predispose to higher risk for CVA, CAD,
HTN, diabetes mellitus
Common Chief Complaints• Chest pain
• Syncope
• Palpitations
• Peripheral edema
• Extremity pain
Characteristics of Chief Complaints– Quality
– Associated manifestations
– Aggravating factors
– Alleviating factors
– Setting
– Timing
Past Health History• Medical
– Cardiac specific: AAA, angina, cardiogenic shock, chest trauma
– Noncardiac specific
• Surgical– Previous cardiovascular procedures
• Common medications– Antianginals or vasodilators
– Antidysrhythmics
– Anticoagulants
– Antihypertensives
– Antilipemics
– Diuretics
– Inotropics
– Thrombolytics
Past Health History
• Communicable diseases
• Childhood illnesses
• Allergies– Aspirin– IVP dye– Seafood
• Injuries and accidents
Family Health History
• Assess for– Aneurysm– CVA– CAD– HTN– MI or sudden cardiac death– MVP
Social History
• Alcohol, drug, or tobacco use
• Sexual practices
• Travel history
• Work and home environment
• Hobbies and leisure activities
• Stress
Health Maintenance Activities
• Sleep
• Diet
• Exercise
• Stress management
• Use of safety devices
• Health check-ups
Risk Factors
• Fixed– Age, gender, race, family history
• Modifiable– HTN, hyperlipidemia, tobacco use, glucose
intolerance, physical inactivity, diet, stress, sedentary lifestyle, obesity
Assessment Equipment
• Equipment– Stethoscope– Sphygmomanometer– Watch with second hand– Tape measure
Inspection
Ape To Man• Aortic 2ICS• Pulmonic 2ICS• Midprecordial 3ICS• Tricuspid 5ICS• Mitral 5ICS
N = no visible pulsations except for the PMI in the mitral area
Palpation
• Assess for pulsations, thrills, heaves
• Assess the following areas: aortic, pulmonic, midprecordial, tricuspid, and mitral
N = No pulsations, thrills, or heaves palpated, except in the mitral area, where the apical impulse may be palpated
AuscultationUse diaphragm and bell of
stethoscope• N= Aortic: S2 is louder than S1
• N= Pulmonic: S2 is louder than S1
• N= Tricuspid: S1 is louder than S2
• N=Mitral: S1 is louder than S2
• Remember S1 = Apex, S2 = Base
Auscultation: Normal Findings
• Aortic and Pulmonic– N= physiologoical split of S2
• Mitral and tricuspid:– N= S3 (gallop) may be heard in
children, young adults, and pregnant women
– N= S4 may indicate cardiac decompensation
Auscultation
Abnormal
• Murmurs– Use stethoscope diaphragm over aortic,
pulmonic, mitral, and tricuspid areas
– Use stethoscope bell over mitral and tricuspid areas
• Possible causes
• Characteristics: location, radiation, timing, intensity, quality, pitch, configuration
• Pericardial friction rub– Characteristics: location, radiation,
timing, quality, pitch• Possible cause
Assessment of Peripheral Vasculature• Inspection of jugular venous
pressure– Place pt at 45°angle
– measure vertical distance from sternum to top of distended neck vein
– N= <4cm
Abnormal
> 4 cm indicates R ventricular
pressure, bld vol, or obstruction
Inspection of Hepatojugular Reflux• Position pt at 30 ° in bed, press firmly on RUQ, observe neck for
elevation of JVP
N = no change in jugular veinsAbnormal • A rise of more than 1 cm = right-sided CHF or fluid overload
Assessment of Arterial Pulses
• Palpate temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis for rate, rhythm, amplitude, symmetry
• auscultate with bell carotids, temporal & femoral pulses
N= equal bilaterally, no bruits auscultated at carotids, temporal & femoral
• Abnormal – Presence of bruits = obstruction due to
atherosclerotic plaques, high-output states such as anemia or thyrotoxicosis
Special Techniques
• Assessing for Pulsus paradoxus– take BP while pt supine, note 1st systolic sound heard, note
point where all systolic sounds are not heard
N= paradox should be < or = 10 mmHg
• Abnormal– cardiac tamponade, pericardial effusion, cardiomyopathy,
obstructive lung disease dt blood return to the L ventricle
Assessment of Peripheral Perfusion• Overall …..Evaluate peripheral
pulses, color, clubbing, capillary refill, skin temperature, edema, ulcerations, hair distribution
• Assess Venous system – Inspect fingers, legs, feet & toes
– bend pts knee slightly and dorsiflex each foot - monitor for Homan sign
N= no c/o calf pain
Abnormal + VE Homan sign indicates DVT
or thrombophlebitis
Assessment of Peripheral Perfusion• Assess Arterial system
• Pallor test– Instruct pt to raise extremities – note the time it takes for pallor or lack of color to devlop
N= no pallor develops within 60 secs• Allen test
– ask pt to make fist , – occlude ulnar and radial artery– open hand and release one artery while compressing the other, repeat with
opposite artery
N= + ve Allen test = good blood flow
both arteries in palm of hand
Abnormal – no blood flow dt thrombus or
atherosclerosis
Palpation of Epitrochlear Node
• Place pt in supine position• support pt hand in your hand• plappate behind elbow in btwn biceps & triceps
for epitrochlear node for size, shape, consistency , tenderness, & mobility
N= node not palpable
• Abnormal – enlarged lymph node
Gerontological Variations
• Decreased size of heart muscle
• Atria and ventricles become fibrotic and sclerotic
• Decreased cardiac output
• Change in heart position
• Obesity
• Vessels become fibrotic and rigid