Assessment of Heart Assessment of Heart and Great Vesselsand Great Vessels

Christine M. WilsonChristine M. WilsonViterbo UniversityViterbo University

ObjectivesObjectives

LandmarksLandmarks StructuresStructures Cardiac cycleCardiac cycle Developmental/transcultural Developmental/transcultural Risk factorsRisk factors Subjective dataSubjective data Objective dataObjective data

Position in the ChestPosition in the Chest

Beneath precordium—area on Beneath precordium—area on anterior chest overlying the anterior chest overlying the heart and great vesselsheart and great vessels

Located in mediastinum—Located in mediastinum—middle third of chest—middle third of chest—between the lungsbetween the lungs

Heart is an Heart is an upside down upside down triangle in the triangle in the chestchest

Top of heart isTop of heart is BaseBase, bottom , bottom is is ApexApex

Extends from Extends from 2nd to 5th ICS 2nd to 5th ICS and from Rt and from Rt sternal border sternal border to Lt MCLto Lt MCL

Great vessels Great vessels above base of above base of heartheart

Blood FlowBlood Flow

Inferior vena cavaInferior vena cava Right atriumRight atrium Right ventricleRight ventricle Pulmonary arteryPulmonary artery Pulmonary veinPulmonary vein Left atriumLeft atrium Left ventricleLeft ventricle AortaAorta

Valves of the HeartValves of the Heart Tricuspid valve: Tricuspid valve:

right AVright AV Mitral valve: Mitral valve:

left left AVAV Pulmonic Valve: Pulmonic Valve:

rightright Aortic Valve: Aortic Valve:

leftleft

It is the It is the closure of the closure of the heart valves heart valves that we hear that we hear as heart as heart soundssounds..

Cardiac CycleCardiac CycleDiastoleDiastole Tricuspid/mitral Tricuspid/mitral

valves openvalves open Ventricles relax and Ventricles relax and

fill with bloodfill with blood Ventricular Ventricular

pressures increasespressures increases Tricuspid/mitral Tricuspid/mitral

valves close causing valves close causing first heart sound first heart sound S1S1

LUBLUB dub dub

SystoleSystole Ventricular Ventricular

contraction increases contraction increases pressurepressure

Pulmonic/aortic valves Pulmonic/aortic valves open; blood ejectsopen; blood ejects

Ventricular pressure Ventricular pressure dropsdrops

Pulmonic/aortic valves Pulmonic/aortic valves close causing second close causing second heart sound heart sound S2S2

lub lub DUBDUB

More heart soundsMore heart sounds Events of right heart occur slightly laterEvents of right heart occur slightly later

– S1 Mitral valve closes then tricuspid S1 Mitral valve closes then tricuspid – S2 Aortic valve closes then pulmonicS2 Aortic valve closes then pulmonic

Sound radiates with direction of blood Sound radiates with direction of blood flowflow– S1 heard loudest at apexS1 heard loudest at apex– S2 heard loudest at baseS2 heard loudest at base

Murmurs—turbulent flow through Murmurs—turbulent flow through chambers and valveschambers and valves– Swooshing, blowing soundSwooshing, blowing sound

Pumping abilityPumping ability

Right side pumps blood to lungsRight side pumps blood to lungs Left side pumps blood to bodyLeft side pumps blood to body Cardiac output—volume of blood Cardiac output—volume of blood

pumped per minutepumped per minute– dependent upon volume ejected per dependent upon volume ejected per

stroke and heart rate (CO=SV x rate)stroke and heart rate (CO=SV x rate)– Normal cardiac output 4-6 L per minuteNormal cardiac output 4-6 L per minute

Great Vessels—Neck Great Vessels—Neck

Carotid arteriesCarotid arteries– Central Central

arteries arteries branching branching from aortafrom aorta

Jugular veinsJugular veins– Internal and Internal and

externalexternal– Empty into Empty into

superior vena superior vena cavacava

Developmental Developmental ConsiderationsConsiderations

FetalFetal Fetal heart begins to beat at 3 weeksFetal heart begins to beat at 3 weeks Oxygenation takes place through the Oxygenation takes place through the

placentaplacenta Blood returned to the Right side of the Blood returned to the Right side of the

heart and bypasses lungsheart and bypasses lungs– Foramen ovale-opening between atriumForamen ovale-opening between atrium– Ductus arteriosus-opening b/tw PA and Ductus arteriosus-opening b/tw PA and

Aorta Aorta

Fetal CirculationFetal Circulation

Changes take place at Changes take place at birth!birth!

Blood is oxygenated through lungsBlood is oxygenated through lungs Foramen ovale closes in one hourForamen ovale closes in one hour Ductus Arteriosus closes in Ductus Arteriosus closes in

10-15 hours10-15 hours Left ventricle pumps blood to Left ventricle pumps blood to

entire body; by one year, left entire body; by one year, left ventricle twice as large as the ventricle twice as large as the rightright

Pregnant FemalePregnant Female

Blood volume increases by 30-Blood volume increases by 30-40%, mostly during the 2nd 40%, mostly during the 2nd trimestertrimester

Increases Stroke Volume and COIncreases Stroke Volume and CO Rate increases by 10-15 BPMRate increases by 10-15 BPM

Aging AdultAging Adult

Cardiac aging depends on Cardiac aging depends on lifestyle factors lifestyle factors

Stiffening of large arteries due Stiffening of large arteries due to calcification of vessel walls to calcification of vessel walls causes increased workload for causes increased workload for heartheart– BP increases by 25-30%BP increases by 25-30%– LV wall thickness increases by LV wall thickness increases by

25%25%

Aging Adult (con’t)Aging Adult (con’t)

Arrhymias increase with ageArrhymias increase with age Conduction changes are commonConduction changes are common 50% of deaths in elderly due to 50% of deaths in elderly due to

cardiovascular diseasecardiovascular disease Hypertension increases with ageHypertension increases with age

– Systolic greater than 140 and Diastolic Systolic greater than 140 and Diastolic greater than 90greater than 90

Heart failure commonHeart failure common

Transcultural Transcultural ConsiderationsConsiderations

Heart Disease and StrokeHeart Disease and Stroke 1/3 of deaths from culturally diverse 1/3 of deaths from culturally diverse

backgroundsbackgrounds Prevalence higher in blacks, followed Prevalence higher in blacks, followed

by whites, then Mexican Americansby whites, then Mexican Americans Native Americans (<35) CAD 2X Native Americans (<35) CAD 2X

greater than other groupsgreater than other groups Black males 2X more likely to die Black males 2X more likely to die

from stroke as white malesfrom stroke as white males

Transcultural Transcultural ConsiderationsConsiderations

Heart Disease and Stroke (con’t)Heart Disease and Stroke (con’t) Blacks 20-40 yearsBlacks 20-40 years

– Increased # of deaths from CVD Increased # of deaths from CVD compared to whitescompared to whites

– Increased mortality in black Increased mortality in black females over black malesfemales over black males

Black and Mexican American females Black and Mexican American females higher CVD risk factorshigher CVD risk factors

Risk Factors for Heart Risk Factors for Heart Disease, Stroke, and Disease, Stroke, and

HypertensionHypertension SmokingSmoking Increased cholesterol levels Increased cholesterol levels

(LDL)(LDL) ObesityObesity DiabetesDiabetes Oral contraceptivesOral contraceptives Post-menopausePost-menopause

Subjective DataSubjective Data Chest PainChest Pain DyspneaDyspnea OrthopneaOrthopnea CoughCough FatigueFatigue Cyanosis or Cyanosis or

pallorpallor

EdemaEdema NocturiaNocturia Past cardiac Past cardiac

historyhistory Family cardiac Family cardiac

historyhistory Cardiac risk Cardiac risk

factorsfactors

Objective AssessmentObjective Assessment

Order of the examOrder of the exam Pulse and blood pressurePulse and blood pressure Extremities:Peripheral Vascular Extremities:Peripheral Vascular

SystemSystem Neck VesselsNeck Vessels PrecordiumPrecordium

The Neck VesselsThe Neck Vessels

Carotid arteriesCarotid arteries PalpatePalpate

– Individually, with gentle touchIndividually, with gentle touch AuscultateAuscultate

– Angle of jaw, mid-cervical, base Angle of jaw, mid-cervical, base of neckof neck

– Patient to exhale and hold breath Patient to exhale and hold breath

The Precordium The Precordium Inspect for pulsationsInspect for pulsations Palpate the apical pulsePalpate the apical pulse

– 55thth ICS MCL ICS MCL– ““Bump” of the left ventricle Bump” of the left ventricle

against chest wall during systoleagainst chest wall during systole Palpate apex, Lt sternal border, Palpate apex, Lt sternal border,

basebase Percussion not usually donePercussion not usually done

AuscultationAuscultation

Areas to listenAreas to listen Aortic valve area: 2Aortic valve area: 2ndnd Rt. intercostal Rt. intercostal

spacespace Pulmonic area: 2Pulmonic area: 2ndnd Lt. intercostal space Lt. intercostal space Erb’s Point: 3rd Lt. intercostal spaceErb’s Point: 3rd Lt. intercostal space Tricuspid area: 5Tricuspid area: 5thth Lt. intercostal space Lt. intercostal space Mitral area: 5th intercostal space at MCLMitral area: 5th intercostal space at MCL

Heart Ascultation AreasHeart Ascultation Areas

Ascultation tipsAscultation tips

ConcentrateConcentrate Inch diaphragm in Z pattern, base to Inch diaphragm in Z pattern, base to

apexapex– Aortic—pulmonic—Erb’s—tricuspid—mitral Aortic—pulmonic—Erb’s—tricuspid—mitral

Listen to one sound at a timeListen to one sound at a time– RateRate– RhythmRhythm– Identify and assess S1 and S2 separatelyIdentify and assess S1 and S2 separately

Listen for extra soundsListen for extra sounds

REMEMBERREMEMBER

S1 is louder than S1 is louder than S2 at Apex.S2 at Apex.

S2 is louder than S2 is louder than S1 at Base.S1 at Base.

S1 coincides S1 coincides with the Carotid with the Carotid artery pulseartery pulse

Visualize Visualize what’s under what’s under the skinthe skin