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NR302 Exam 3 Study Guide Health Assessment I.
Typology: Study notes
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Position and Surface Landmarks Chapter 19 Heart and Neck Vessels o Precordium: area on anterior chest overlying heart and great vessels o During contraction, apex beats against chest wall, producing an apical impulse o Heart has four chambers: atria and ventricles o Great vessels lie bunched above base of heart o Pulmonary veins return freshly oxygenated blood to left side of heart, and aorta carries it out to body Heart Wall, Chambers, and Valves o Heart wall has numerous layers ➢ Pericardium: tough, fibrous, double-walled sac that surrounds and protects heart ➢ Myocardium: muscular wall of heart; it does pumping ➢ Endocardium: thin layer of endothelial tissue that lines inner surface of heart chambers and valves o Heart has two pump systems o Each side of the heart has an atrium and ventricle ➢ Atrium: thin-walled reservoir for holding blood ➢ Ventricle: thick-walled, muscular pumping chamber ➢ Heart Chambers and Valves o Four chambers separated by valves, whose main purpose is to prevent backflow of blood ➢ Valves are unidirectional: can only open one way ➢ Valves open and close passively in response to pressure gradients in moving blood o Four valves in heart ➢ Two atrioventricular (AV) valves ➢ Two semilunar (SL) valves AV Valves o Two AV valves separate atria and ventricles ➢ Tricuspid valve: right AV valve ➢ Bicuspid, or mitral valve: left AV valve
Cardiac Cycle: Systole o Ventricular pressure becomes higher than that in atria, so mitral and tricuspid valves close o Closure of AV valves contributes to first heart sound (S1) and signals beginning of systole ➢ AV valves close to prevent any regurgitation of blood back up into atria during contraction o For a very brief moment, all four valves are closed and ventricular walls contract ➢ Isometric contraction: this contraction against closed system works to build high level pressure in ventricles Events in Right and Left Side of Heart I Systole o Consider left side of heart o When pressure in ventricle finally exceeds pressure in aorta, aortic valve opens and blood is ejected rapidly ➢ After ventricle’s contents are ejected, its pressure falls o When pressure falls below pressure in aorta, some blood flows backward toward ventricle, causing aortic valve to close o This closure of semilunar valves causes second heart sound (S2) and signals end of systole Events in Right and Left Side of Heart II o Diastole again ➢ Now all four valves are closed and ventricles relax
First Heart Sound (S1) ➢ Occurs with closure of AV valves and thus signals beginning of systole ➢ Mitral component of first sound (M1) slightly precedes tricuspid component (T1)
4. the nurse should determine if heart disease runs in the patient’s family and refer him to his primary care physician. Extra Heart Sounds (S4) Fourth heart sound (S4) ➢ Occurs at end of diastole, at presystole, when ventricle resistant to filling ➢ Atria contract and push blood into noncompliant ventricle ➢ This creates vibrations that are heard as S ➢ S4 occurs just before S Extra Heart Sounds: Murmurs o Blood circulating through normal cardiac chambers and valves usually makes no noise o However, some conditions create turbulent blood flow and collision currents o These result in a murmur, much like a pile of stones or a sharp turn in a stream creates a noisy water flow o A murmur is a gentle, blowing, swooshing sound that can be heard on chest wall Conditions Resulting in Murmur o Velocity of blood increases (flow murmur), for example, in exercise, thyrotoxicosis o Viscosity of blood decreases, for example, in anemia o Structural defects in valves, narrowed valve, incompetent valve o Unusual openings occur in chambers, dilated chamber, wall defect Characteristics of Sound o All heart sounds are described by ➢ Frequency or pitch: described as high pitched or low pitched - Although these terms are relative because all are low-frequency sounds and need good stethoscope to hear them ➢ Intensity or loudness: loud or soft ➢ Duration: very short for heart sounds; silent periods are longer ➢ Timing: systole or diastole Conduction I o Heart has unique ability: automaticity ➢ Can contract by itself, independent of any signals or stimulation from body ➢ Contracts in response to an electrical current conveyed by a conduction system ➢ Specialized cells in sinoatrial (SA) node, near superior vena cava initiate an electric impulse ➢ Because SA node has intrinsic rhythm, it is called the pacemaker Conduction II o Current flows in orderly sequence, first across atria to AV node low in atrial septum o There, it is delayed slightly so that atria have time to contract before ventricles are stimulated o Then, impulse travels to bundle of His, right and left bundle branches, and then through ventricles
o Electric impulse stimulates heart to do its work, which is to contract o Small amount of electricity spreads to body surface and can be measured and recorded on electrocardiograph (ECG) Electrocardiograph (ECG) o ECG waves arbitrarily labeled PQRST, which stand for o P wave: depolarization of atria o P-R interval: from beginning of P wave to beginning of ➢ QRS complex (time necessary for atrial depolarization plus time for impulse to travel through AV node to ventricles) o QRS complex: depolarization of ventricles o T wave: repolarization of ventricles o Electrical events slightly precede mechanical events in heart Pumping Ability o In resting adult, heart normally pumps between 4 and 6 L of blood per minute throughout body ➢ This cardiac output equals volume of blood in each systole (called stroke volume) times number of beats per minute (rate) ➢ Heart can alter its cardiac output to adapt to metabolic needs of body ➢ Preload and afterload affect heart’s ability to increase cardiac output Preload o Preload: venous return that builds during diastole ➢ Length to which ventricular muscle stretched at end of diastole just before contraction ➢ When volume of blood returned to ventricles increased
o Note characteristics of its waveform ➢ Smooth rapid upstroke ➢ Summit rounded and smooth ➢ Downstroke more gradual and has a dicrotic notch caused by closure of aortic valve Neck Vessels: Jugular Venous Pulse and Pressure I o Jugular veins empty unoxygenated blood directly into superior vena cava ➢ Because no cardiac valve exists to separate superior vena cava from right atrium, jugular veins give information about activity on right side of heart ➢ Specifically reflect filling pressure and volume changes ➢ Jugular veins expose this because volume and pressure increase when right side of heart fails to pump efficiently Neck Vessels: Jugular Venous Pulse and Pressure II o Two jugular veins present in each side of neck ➢ Larger internal jugular lies deep and medial to sternomastoid muscle ➢ Usually not visible, although diffuse pulsations may be seen in sternal notch when person is supine ➢ External jugular vein is more superficial; lies lateral to sternomastoid muscle, above clavicle Jugular Pulse: 5 Components o The A wave reflects atrial contraction because some blood flows backward to vena cava during right atrial contraction o The C wave, or ventricular contraction, is backflow from bulging upward of tricuspid valve when it closes at beginning of ventricular systole o The X wave descent shows atrial relaxation when right ventricle contracts during systole and pulls bottom of atria downward o The V wave occurs with passive atrial filling because of increasing volume in right atria and increased pressure o Finally, the Y descent reflects passive ventricular filling when tricuspid valve opens and blood flows from RA to RV o Developmental Competence: Infants and Children o Fetal heart begins to beat after 3 weeks’ gestation o Right and left ventricles equal in weight and muscle wall thickness and both pumping into systemic circulation o Inflation and aeration of lungs at birth produces circulatory changes o Now blood is oxygenated through lungs rather than through placenta o Now left ventricle has greater workload of pumping into systemic circulation Developmental Competence: Pregnant Woman Blood volume increases by 30% to 40% during pregnancy o Most rapid expansion occurs during second trimester o Creates an increase in stroke volume and cardiac output and an increased pulse rate of 10 to 15 beats per minute
o Despite increased cardiac output, arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation o Blood pressure drops to lowest point during second trimester, then rises after that o Blood pressure varies with person’s position Developmental Competence: Aging Adult It is difficult to isolate “aging process” of cardiovascular system, per se, because it is so closely interrelated with lifestyle, habits, and diseases o Lifestyle, smoking, diet, alcohol use, exercise patterns, and stress have an influence on coronary artery disease o Lifestyle also affects aging process; cardiac changes once thought to be due to aging are partially due to sedentary lifestyle accompanying aging o What is left to be attributed to aging process alone? Hemodynamic Changes with Aging o With aging, there is an increase in systolic BP due to thickening and stiffening of the arteries o Left ventricular wall becomes thicker but the overall size of the heart does not change o Pulse pressure increases o No change in resting heart rate or cardiac output at rest o Ability of heart to augment cardiac output with exercise is decreased Arrhythmias o Presence of supraventricular and ventricular arrhythmias increases with age o Ectopic beats common in aging people; usually asymptomatic in healthy older people, may compromise cardiac output and blood pressure when disease present o Tachyarrhythmias may not be tolerated as well in older people ➢ Myocardium thicker and less compliant, and early diastolic filling impaired at rest ➢ Thus, may not tolerate a tachycardia as well because of shortened diastole Age-Related Changes in ECG o Occur as result of histologic changes in conduction system; these changes include ➢ Prolonged P-R interval (first-degree AV block) and prolonged Q-T interval, but the QRS interval is unchanged ➢ Left axis deviation from age-related mild LV hypertrophy and fibrosis in left bundle branch ➢ Increased incidence of bundle branch block o Although hemodynamic changes associated with aging alone do not seem severe or portentous, incidence of cardiovascular disease increases with age Cardiac Disease and Aging Adult
o Incidence of coronary artery disease increases sharply with advancing age and accounts for about half of deaths of older people ➢ Hypertension and heart failure also increase with age ➢ Lifestyle habits play a significant role in the acquisition of heart disease o Also, increasing physical activity of older adults associated with a reduced risk of death from cardiovascular diseases and respiratory illnesses ➢ Both points underscore need for health teaching as an important treatment parameter Culture and Genetics I Prevalence is an estimate of how many people in a stated geographic location have a disease at a given time ➢ In the U.S., more than 1 in 3 have one or more forms of cardiovascular heart disease (CVD)
o In 2010, 21.2% of men and 17.5% of women were smokers o Nicotine increases risk of myocardial infarction (MI) and stroke by causing ➢ Increase in oxygen demand with a concomitant decrease in oxygen supply ➢ Activation of platelets, activation of fibrinogen; and an adverse change in lipid profile Culture and Genetics: Serum Cholesterol o High levels of low density lipoprotein gradually add to lipid core of thrombus formation in arteries, which results in MI and stroke o Age-adjusted prevalence of LDL cholesterol levels over 130 mg/dL include ➢ 39.9% of Mexican American men and 30.4% of Mexican American women ➢ 30.1% of white men and 29.3% of white women ➢ 33.1% of black men and 31.2% of black women Culture and Genetics: Obesity o Epidemic of obesity in U.S. is well known ➢ Among Americans age 20 or older, prevalence of overweight or obesity
o Edema o Nocturia o Past cardiac history o Family cardiac history o Personal habits (cardiac risk factors) Chest Pain Questions I o Any chest pain or tightness? ➢ Onset: When did it start? How long have you had it this time? Had this type of pain before? How often? ➢ Location: Where did the pain start? Does the pain radiate to any other spot? ➢ Character: How would you describe it? Is it crushing, stabbing, burning, or viselike? (Allow the person to offer adjectives before you suggest them.) (Note if uses clenched fist to describe pain.) ➢ Is pain brought on by activity (what type), rest, emotional upset, eating, sexual intercourse, or cold weather? Chest Pain Questions II o Any associated symptoms, such as sweating, ashen gray or pale skin, heart skipping a beat, shortness of breath, nausea or vomiting, or racing of heart? ➢ Is the pain made worse by moving the arms or neck, breathing, or lying flat? ➢ Is the pain relieved by rest or nitroglycerin? How many tablets? Dyspnea Questions o Any shortness of breath? ➢ What type of activity, and how much brings on shortness of breath? How much activity brought it on 6 months ago? ➢ Onset: Does the shortness of breath come on unexpectedly? ➢ Duration: Is it constant or does it come and go? ➢ Does it seem to be affected by position, such as lying down? ➢ Does it awaken you from sleep at night? ➢ Does the shortness of breath interfere with activities of daily living? Cough Questions o Do you have a cough? ➢ Duration: How long have you had it? ➢ Frequency: Is it related to time of day? ➢ Type: Is it dry, hacking, barky, hoarse, or congested? ➢ Do you cough up mucus? What color is it? Does it have any odor? Is it blood- tinged? ➢ Associated with activity, position (lying down), anxiety, or talking? ➢ Does activity make it better or worse (sit, walk, exercise)? ➢ Is it relieved by rest or medication? Fatigue Questions
o Do you seem to tire easily? Able to keep up with your family or co-workers? ➢ Onset: When did it start? Sudden or gradual? Any recent change in energy level? ➢ Fatigue related to time of day? All day? Morning, evening? Assorted Subjective History Questions Orthopnea o How many pillows do you use when sleeping or lying down? Cyanosis or pallor o Have you ever noticed your facial skin turn blue or ashen? Nocturia o Do you awaken at night with an urgent need to void? How long has this been occurring? o Edema Questions o Do you have any swelling of your feet and legs? ➢ Onset: When did you first notice this? Any recent change? ➢ What time of day does the swelling occur? Do your shoes feel tight at the end of day? ➢ How much swelling would you say there is? Are both legs equally swollen? ➢ Does swelling go away with rest, elevation, or after a night’s sleep? ➢ Do you have any associated symptoms, such as shortness of breath? If so, does shortness of breath occur before leg swelling or after? Cardiac History Questions o Do you have a history of hypertension, elevated cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever or unexplained joint pains as child or youth, recurrent tonsillitis, or anemia? o Have you ever had heart disease? When was this? Was it treated by medication or heart surgery? o When was your last ECG, stress ECG, serum cholesterol measurement, or other heart tests? o Any family history of hypertension, obesity, diabetes, coronary artery disease (CAD), sudden death at younger age? Personal Habits (Cardiac Risk Factors) I o Nutrition ➢ Please describe your usual daily diet (Note if this diet is representative of the basic food groups, the amount of calories, cholesterol, and any additives such as salt) ➢ What is your usual weight? Has there been any recent change? o Smoking ➢ Do you smoke cigarettes or use other tobacco products? At what age did you start? How many packs per day? For how many years have you smoked this amount? Have you ever tried quitting? If so, how did this go? (Cardiac Risk Factors) II
o Alcohol ➢ How much alcohol do you usually drink each day or week? When was your last drink? What was the number of drinks that episode? Have you ever been told you had a drinking problem? o Exercise ➢ What is your usual amount of exercise each day or week? What type of exercise (state type or sport)? If a sport, what is your usual activity level (light, moderate, heavy)? o Drugs ➢ Do you take any antihypertensives, beta-blockers, calcium channel blockers, digoxin, diuretics, aspirin/anticoagulants, over-the-counter, or street drugs? ➢ Additional History for Infants o How was mother’s health during pregnancy? Was there any unexplained fever, rubella during first trimester, other infection, hypertension, or drugs taken? ➢ Have you noted any cyanosis while nursing or crying? Is baby able to eat, nurse, or finish bottle without tiring? ➢ Growth: Has this baby grown as expected by growth charts and about same as siblings or peers? ➢ Activity: Were this baby’s motor milestones achieved as expected? Is baby able to play without tiring? How many naps does baby take each day? How long does a nap last? Additional History for Children o Growth: Has this child grown as expected by growth charts? o Activity: Is this child able to keep up with siblings or age mates? o Has the child had any unexplained joint pains or unexplained fever? o Does the child have frequent headaches or nosebleeds? o Does the child have frequent respiratory infections? How many per year? How are they treated? Have any of these been streptococcal infections? o Does child have a sibling with heart defect? Is anyone in child’s family known to have chromosomal abnormalities, such as Down syndrome? Additional History for Pregnant Woman o Have you had any high blood pressure during this or earlier pregnancies? ➢ What was your usual blood pressure level before pregnancy? How has your blood pressure been monitored during the pregnancy? ➢ If high blood pressure, what treatment has been started? ➢ Do you have any associated symptoms, such as weight gain, protein in urine, or swelling in feet, legs, or face? o Have you had any faintness or dizziness with this pregnancy? Additional History for Aging Adult o Do you have any known heart or lung disease, such as hypertension, CAD, chronic emphysema, or bronchitis? o Do you take any medications for your illness, such as digitalis? Are you aware of side effects? Have you recently stopped taking your medication? Why?
Environment ➢ Does your home have any stairs? How often do you need to climb them? Does this have any effect on activities of daily living? Preparation and Equipment Preparation o To evaluate carotid arteries, person can be sitting o To assess jugular veins and precordium, person should be supine with head and chest slightly elevated o Ensure woman’s privacy by keeping her breasts draped Equipment o Marking pen o Small centimeter ruler o Stethoscope with diaphragm and bell endpieces o Alcohol wipe to clean endpiece Neck Vessels: Palpation o Palpate carotid artery ➢ Yields important information on cardiac function ➢ Palpate each carotid artery medial to sternomastoid muscle in neck; palpate gently ➢ Palpate only one carotid artery at a time to avoid compromising arterial blood to brain ➢ Feel contour and amplitude of pulse ➢ Normally contour is smooth with a rapid upstroke and slower downstroke, and the normal strength is 2+ or moderate ➢ Findings should be same bilaterally Neck Vessels: Auscultation I Auscultate carotid artery o For persons middle-aged or older, or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for presence of a bruit ➢ This is a blowing, swishing sound indicating blood flow turbulence; normally none is present o Lightly apply bell of stethoscope over carotid artery at three levels: ➢ Angle of jaw ➢ Midcervical area ➢ Base of neck Neck Vessels: Auscultation II Auscultate carotid artery ➢ Avoid compressing artery because this could create an artificial bruit and could compromise circulation if carotid artery is already narrowed by atherosclerosis ➢ Ask person to take a breath, exhale, and hold it briefly while you listen so that tracheal breath sounds do not mask or mimic a carotid artery bruit
➢ Sometimes you can hear normal heart sounds transmitted to neck; do not confuse these with a bruit Neck Vessels: Inspection I Inspect jugular venous pulse ➢ From jugular veins you can assess central venous pressure (CVP) and judge heart’s efficiency as a pump
Jugular Venous Pressure III Estimate jugular venous pressure ➢ Exert firm sustained pressure for 30 seconds ➢ This empties venous blood out of liver sinusoids and adds its volume to venous system ➢ If heart is able to pump this additional volume (i.e., if no elevated CVP is present), jugular veins will rise for a few seconds, then recede back to previous level Neck Vessels Precordium I Inspect anterior chest ➢ Arrange tangential lighting to accentuate any flicker of movement ➢ Pulsations: you may or may not see apical impulse, pulsation created as left ventricle rotates against chest wall during systole
When you need to search for cardiac enlargement, place your stationary finger in person’s fifth intercostal space over on left side of chest near anterior axillary line Slide your stationary hand toward yourself, percussing as you go, and note change of sound from resonance over lung to dull over heart Precordium Percussion III Normally left border of cardiac dullness at midclavicular line in fifth interspace and slopes in toward sternum as you progress upward, so that by second interspace border of dullness coincides with the left sternal border Right border of dullness normally matches sternal border Precordium Auscultation I Auscultation ➢ Identify auscultatory areas where you will listen; these include four traditional valve “areas”
➢ Consider that at least two, and perhaps three or four sounds may be happening in less than 1 second ➢ You cannot process everything at once ➢ Begin with diaphragm endpiece and use following routine
➢ Occurs in early diastole, just after S2, and is a dull soft sound that is best heard at apex Developmental Competence: Children III Palpate apical impulse ➢ Venous hum, due to turbulence of blood flow in jugular venous system, common in healthy children and has no pathologic significance
o Overall size of the heart does not change but left ventricular wall thickness increases o Presence of supraventricular and ventricular dysrhythmias increases with age o Age-related ECG changes occur as a result of histologic changes in the conduction system o Incidence of CVD increases with age Culture and Genetics o Causes of CVD include an interaction of genetic, environmental, and lifestyle factors o Increased risk factors for CVD attributed to hypertension in terms of certain ethnic, racial, gender groups o Even though smoking has declined, it is still the leading cause of preventable disease, disability, and death in the U.S. o High levels of LDL lead to an increased risk of CVD and are associated with certain ethnic groups o Obesity is also an associated risk factor for CVD as well as other comorbidities o CVD risk is increased twofold greater in those patients who have diabetes o Sex differences still place women with CVD with the highest death rate Sample Charting: Objective and Assessment Abnormal Findings: Systolic Extra Sounds o Ejection click o Aortic prosthetic valve sounds o Midsystolic click Abnormal Findings: Diastolic Extra Sounds o Opening snap o Mitral prosthetic valve sound o Third heart sound o Fourth heart sound o Summation sound o Pericardial friction rub Abnormal Findings: Abnormal Pulsations: Precordium o Thrill at the base o Lift (heave) at the sternal border o Volume overload at the apex o Pressure overload at the apex Abnormal Findings: Congenital Heart Defects o Patent ductus arteriosus o Atrial septal defect o Ventricular septal defect o Tetralogy of Fallot o Coarctation of the aorta Abnormal Findings: Murmurs Due to Valvular Defects o Midsystolic ejection murmurs o Aortic stenosis o Pulmonic stenosis
o Pansystolic regurgitant murmurs o Mitral regurgitation o Tricuspid regurgitation Abnormal Findings: Murmurs Due to Valvular Defects o Diastolic rumbles of atrioventricular valves o Mitral stenosis o Tricuspid stenosis o Early diastolic murmurs o Aortic regurgitation o Pulmonic regurgitation Summary Checklist: Heart and Neck Vessels Examination o Neck o Carotid pulse – observe and palpate o Observe jugular venous pulse o Estimate jugular venous pressure o Precordium o Inspection and palpation ➢ Describe location of apical pulse ➢ Note any heave (lift) or thrill o Auscultation ➢ Identify anatomic areas noting rate and rhythm ➢ Listen in systole and diastole for murmurs ➢ Repeat with bell ➢ Listen at apex and base