Chapter 20 Heart and Neck Vessels

Structure and Function

Position and Surface Landmarks

 The cardiovascular system consists of the heart and the blood vessels.
 Precordium (anterior) area over heart & great vessels (major arteries and veins connected to
heart)
 Heart and great vessels located between lungs in (middle third of thoracic cage area called the
mediastinum)
 Heart extends from 2nd-5th intercostal space from right border of sternum to left midclavicular
line
 Heart positioned so that right side is anterior and left side is posterior
 Hearts four chambers, right ventricle is behind sternum, forms greatest area of anterior cardiac
surface.
 Left ventricle lies behind the right ventricle and forms the apex and slender area of left border
 Blood vessels arranged in two continuous loops (separate but interdependent):
o Pulmonary circulation and systematic circulation: Top of heart is base and bottom is
apex
o During contraction apex beats against chest wall, producing apical impulse (5 th
intercostal space, 7-9cm from midsternal line
o Great vessels lie bunched above base of heart
o Super and inferior venae cavae return unoxygenated venous blood to the right side of
the heart
o Pulmonary artery leaves right ventricle, bifurcates and carries the venous blood to
lungs.
o Pulmonary veins return freshly oxygenated blood to the left side of the heart and aorta
carries it out to the body

Heart Wall, Chambers, and Valves

  Pericardium (outer layer) is tough, fibrous, double walled sac that surrounds and protects heart.
Has two layers of pericardial fluid (ensures smooth friction free movement of the heart muscle-
epicardium)
 Myocardium is the muscular wall of the heart, does the pumping
 Endocardium (interlayer) is the thin layer of endothelial tissue that lines inner surface of the
heart chambers and valves
 Right side of heart pumps blood into the lungs, left side simultaneously pumps blood into body.
 Two pumps separated by impermeable wall, the septum, each side has an atrium and ventricle
 Atrium: reservoir for holding blood; Ventricle: muscular pumping chamber
 Four chambers separated by valves that prevent backflow of blood, open only one way
(unidirectional)
 Valves open and close passively in response to pressure gradients in the moving blood
 4 valves in heart
o 2 Atrioventricular valves (AV) separate the atria and the ventricles
o RIGHT (AV) valve is the tricuspid valve; left (AV) valve is the bicuspid or mitral valve
o AV valves open during hearts filling phase (diastole) to allow ventricles to fill with blood
o During pumping (systole) AV valves close to prevent regurgitation of blood back up into
atria
o Semilunar valves located between the ventricles and the pulmonary arteries; each has 3
cusps that look like half moons
 Open during pumping or systole to allow blood to be ejected from the heart
 Pulmonic valve: right side of heart
 Aortic Valve: left of heart
o Note: no valves between venae cavae, right atrium, between pulmonary veins and the
left atrium. Because of this abnormally high pressure in the left side of heart produces
symptoms of pulmonary congestion, heart failure, HBP, in the right side of heart
manifests as distention of neck veins and abdomen.

Direction of Blood Flow

1. Blood flows from liver to right atrium through inferior vena cava, superior vena cava drains venous
blood from the head and upper extremities, from right atrium venous blood travels through tricuspid
valve to right ventricle.

2. From right ventricle, venous blood flows through pulmonic valve to pulmonary artery, pulmonary
artery delivers unoxygenated blood to lungs.

3. Lungs oxygenate blood, pulmonary veins return fresh blood to left atrium.

4. From left atrium, arterial blood travel through mitral valve to left ventricle, left ventricle ejects blood
through aortic valve into aorta

5. Aorta delivers oxygenated blood to body.

Cardiac Cycle

 Rhythmic movement of blood through heart is the cardiac cycle

  Two phases: Diastole (ventricles relax and fill with blood) and Systole (hearts contraction, blood
is pumped from ventricles and fills the pulmonary and systemic arteries)

Diastole

 Ventricles are relaxed and AV valves (tricuspid and mitral valve) are open
 First passive filling phase is called early and protodiastolic filling
 Toward end of diastole, atria contracts and pushes last amount of blood into ventricles, active
filling phase is called presystole or atrial systole
 Pressure greater in atria than ventricles

Systole

 Ventricular pressure greater than atrial

 Blood has been pumped into ventricles, volume raises ventricular pressure and mitral and
tricuspid valves swing shut.
 Closure of AV vales contributes to the first heart sound (S1)
 All 4 valves closed

Heart Sounds

Normal Heart Sounds

 S1(first heart sound “lub”) occurs with closure of the AV valves; beginning of systole
 (M1) Mitral component of first sound precedes the (T1) tricuspid component but you usually
hear these two as one
 You can hear s1 all over precordium but loudest at apex
 S2(second heart sound “dup”) occurs with closure of the semilunar valves and signals end of
systole
 (A2) Aortic component of the second sound precedes (P2) pulmonic component
 You can hear s2 all over precordium but loudest at the base

Extra Heart Sounds

 Normally diastole is silent, sometimes ventricular filling creates vibrations that can be heard
over the chest (S3)
 S3 (third heart sound) occurs when ventricles are resistant to filling during the early rapid filling
phase (protodiastole), occurs immediately after S2, when AV valves open and atrial blood first
pours into ventricles
 S4 (fourth heart sound) occurs at end of diastole, at presystole, when ventricle is resistant to
filling, atria constrict and push blood into a noncompliant ventricle

Murmurs

 Bloor circulating through chambers make no noise

 Some conditions create turbulence in blood flow and collision called murmur (gentle, blowing,
swooshing sound that can be heart on the chest wall)
 What results in a murmur?
o Increases in velocity of blood e.g. exercise
 o Decreases in viscosity of blood e.g. anemia
o Structural defects in valves e.g. narrowed valved, incompetent valve or unusual
openings in chambers e.g. dilated chamber, septal defect

Conduction

 Abilities of cardiac muscle cells

o Automatically (generate impulse), conductivity (transmit pulse), contractility (react to
conduction PQRST = beat)
 Pathway of electrical conduction system of the heart
o Sinoatrial node (SA node) TO atrioventricular node (av node) TO bundle of his TO bundle
branches (L and R) TO Purkinje fibers
 ECG waves are labelled PQRST
o P WAVE= depolarization of atria
o QRS COMPLEX= ventricular depolarization
o T WAVE= ventricular repolarization
o U= FINAL ventricular repolarization

Characteristics of Sound

1. Frequency: (pitch), high or low

2. Intensity: (loudness), loud or soft

3. Duration: very short for heart sounds, silents periods are longer

4. Timing: systole or diastole

Heart sounds

 Split S2 “t-dup” (normal heart sounds and effects of respiration)

 Aortic valve closes earlier than pulmonic
 Due to decrease in intrathoracic pressure during inspiration

o more to the right heart

o less to the left

Pumping Ability

 In resting adult, heart pumps between 4-6L/min throughout body

 Cardiac output is the amount of blood pumped by the ventricles/min
 This cardiac output equals volume of blood in each systole called the stroke volume times the
number of beats per min: CO=SV x R
 Preload is the venous return that builds during diastole; the length to which ventricular muscle
is stretched at the end of diastole just before contraction
 Afterload is the venous opposing pressure that the ventricle must generate to open the aortic
valve against the higher aortic pressure
 Perfusion
 o MAP=mechanical P
o Systolic + diastolic (2)/3
o 70-100 mm hg

The Neck Vessels

 CV assessment includes the survey of vascular structures in neck: carotid artery and jugular
veins

Carotid Artery Pulse

 Carotid artery: close to heart, located in groove between the trachea and sternomastoid muscle
o Smooth rapid upstroke, a summit that is rounded and smooth, downstroke that is more
gradual and has a dicrotic notch caused by closure of the aortic valve
 carotid artery pulse closely coincides with ventricular systole.

Jugular Venous Pulse and Pressure

 Jugular veins empty unoxygenated blood directly into the super vena cava; 2 jugular
o Larger Internal Jugular Vein: not visible, but diffuse pulsations may be seen when
person is supine
o External Jugular Vein: more superficial; lies lateral to sternomastoid muscle

Developmental Considerations

Infants and Children

 Blood is rerouted, shunted through an opening in the atrial septum, the foramen ovale, into left
side of the heart, where it is pumped out through aorta.
 Rest of the oxygenated blood is pumped by the right side of the heart through the pulmonary
artery, but detoured through ductus arteriosus to the aorta.
 Apex is higher in children

Pregnant Women
  Increase in blood volume, causes increase in stroke volume and cardiac output and increase in
pulse rate by 10-15 beats/min
 Arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation

Older Adults

 Lifestyle modifies development of cardiovascular system

 With aging, systolic BP increases and diastolic decreases
 Pulse pressure increases (difference between systolic and diastolic)
 Tachydysrhythmias may not be tolerated well by older adults
 Myocardium is thicker and less compliant and early diastolic filling impaired at rest
 Changes in conduction in the ECG system; prolonged P-R intervals and prolong Q-T intervals

Social Determinants of health

 Increased cardiovascular disease in Canada for men and women

 Influenced by socioeconomic factors like high BP, smoking, serum cholesterol, obesity, diabetes

Subjective Data: Health History Questions

1. Chest Pain: Any chest pain or tightness? OPQRSTU

2. Dyspnea: Any shortness of breath?

3. Orthopnea: How many pillows do you use when sleeping or lying down?

4. Cough: Do you have a cough?

5. Fatigue: Do you tire easily?

6. Cyanosis or Pallor: Ever noted your facial skin turn blue or ashen?

7. Edema: Any swelling of your feet and legs? Note: edema caused by heart failure

8. Nocturia: Do you awaken at night with urgent need to urinate?

9. Cardiac History: Do you have an history of hypertension, cholesterol, murmurs heart disease, heart
attack?

10. Family cardiac history: hypertension, obesity, diabetes, coronary artery disease?

11. Personal habits: nutrition, smoking, alcohol, exercise, medications, stress?

Objective Data

Preparation:

 to evaluate carotid arteries patient can be siting up

 to assess jugular veins and precordium, patient should be supine with the head and chest
elevated
 Perform regional cardiovascular assessment in this order
o 1. Pulse and BP
 o 2. Extremities
o 3. Neck Vessels
o 4. Precordium

The Neck Vessels (Carotid Artery - sitting up)

 Location: midcervical base of neck, angle of jaw

 Auscultate: at top at angle of jaw, middle, and base of neck, don’t press hard
o Findings: no bruit should be present (blowing, swishing sound indicating blood flow
turbulence)

 Palpate
o palpate only one carotid artery at a time to avoid compromising blood flow to brain
o feel for contour and amplitude
o contour should be smooth with rapid upstroke and slower downstroke and normal
strength is moderate
 Inspect (Jugular Venous) - Supine - 30-45 degrees – no pillow
o Direct a light tangentially onto the neck to highlight pulsations and shadows with
patients head turned away
o External jugular easier to see but internal more reliable for assessment, you cant see the
vein itself but can see pulsations
o External jugular vein: over sternomastoid muscle, in some patients not visible at all, and
some fully visible
o Internal Jugular vein: in suprasternal notch or origin of sternomastoid muscle
The Precordium (Supine with head and chest slightly elevated)

 Inspect the anterior chest: arrange tangential lighting to accentuate any flicker of movement
 Palpate
o Palpate apical impulse; (using one finger pad at apex) located in 4-5 th intercostal space;
midclavicular; may need to roll patient midway to the left to find it, not palpable in
obese patients or thick chest walls
 Findings: Location, size (1 x 2cm), amplitude (short, gentle tap) and duration
(short)
o palpate across precordium (using palmar aspect of fingers): 3 locations: over the apex,
the left sternal border, the base, searching for any other pulsations; normally none are
felt.

Apical Pulse (Auscultation)

Note: Z pattern: NOTE rate and rhythm, identify S1 and S2, listen for extra heart sounds, murmurs

 Apical Pulse: is heard at 5th ICS at left MCL: note location and rhythm
 Aortic Valve: 2nd right interspace at right sternal border
 Pulmonic Valve: 2nd left interspace at left sternal border
 Tricuspid Valve: fourth intercostal space at left lower sternal border
 Mitral Valve Area: fifth interspace at around left midclavicular line
o Findings: identify S1 AND S2 (lub dup pair, first sound is s1, second is s2)
o This guideline does not work with tachyarrhythmia (rates>100 beats/min)
 S1 is louder than S2 at apex
 S2 is louder than S1 at base
 S1 coincides with carotid artery pulse
 Sinus arrythmia: occur in young adults and children, the rhythm varies with patients breathing,
increasing at the peak of inspiration, and slowing with expiration
  Pulse deficit: when you notice any irregularity check for pulse deficit; by auscultating the apical
beat and palpating radial pulse at the same time
o Pulse deficit signals a weak contraction of the ventricles
 Murmurs
o Gentle, blowing, swooshing sound
o NOTE:
 Timing
 Loudness (grading on a scale of 1-6)
 Grade 1: barely audible, heard only in quiet room and with difficulty
 Grade 2: clearly audible but faint
 Grade 3: moderately loud, easy to hear
 Grade 4: loud, associated with a thrill palpable on chest
 Grade 5: very loud, heart with one corner of stethoscope lifted off the chest wall
 Grade 6: loudest, still heard with entire stethoscope lifted just off chest wall

 Posture
 Innocent: No valvar/pathological cause
 Functional: Related to increased blood flow (anemia, fever, pregnancy)

Developmental Considerations

Infants

 Heart rate is best auscultated because radial pulse hard to count

o Heart rate is 100-180 beats/per/min
 May increase when crying
o Murmurs more common in first days

Children

 Position of apical impulse

o 4th intercostal space to the left midclavicular until 4 years
o 4th interspace at the midclavicular line from 4-6 years
o 5th interspace to the right of midclavicular line at age 7
 Venous hum: represents turbulence of blood flow in the jugular venous system and found in
healthy children (low pitches, soft hum heard throughout cycle and loudest at diastole)
 Innocent heart murmurs: very common in childhood

Pregnant Women

 Changes in BP (varies with position)

 Heart sound changes from increased blood volume and workload

Older adult

 Orthostatic hypotension: sudden drop in blood pressure when rising to sit or stand

Abnormal Findings:
 Abnormal pulsations in the precordium
o Thrill murmur: palpable vibration, feels like throat of a purring cat, signifies turbulent
blood flow and accompanies loud murmurs
o Lift aka heave: is a sustained forceful thrusting of the ventricle during systole. Right
ventricular heave seen at sternal border. Left ventricular seen at the apex
o Congenital heart defects
 Patent ductus arteriosus: persistence of the channel joining left pulmonary
artery to aorta
 Atrial septal defect: abnormal opening in the atrial septum, resulting usually in
left to right shunting of blood causing a large increase in pulmonary blood flow
 Ventricular septal defect: abnormal opening in septum between the ventricles,
usually in subaortic area
 Coarctation of the aorta: severe narrowing of descending aorta, usually at the
junction of the ductus arteriosus and the aortic arch