health assessment lecture 6 denver school of nursing fall 2013 k.hendrickson phd, rn 1

HEALTH ASSESSMENT Lecture 6 Denver School of Nursing Fall 2013 K.Hendrickson PhD, RN 1

CHAPTER 12 Heart and Peripheral Vascular System

Concept Overview: PERFUSION All tissues require perfusion of oxygenated blood. Many physiologic concepts are related to perfusion Oxygenation is foundational to all other processes Blood flow supplies O 2 and nutrients to tissues 3 Perfusion Nutrition Oxygenation Intracranial Regulation Elimination Pain Metabolism Motion Tissue Integrity

Anatomy and Physiology: The Heart and Great Vessels Heart is a pump: Beats 60 to 100 times a minute without rest. Responds to both external and internal demands. Each side has two chambers: Atrium Ventricle Right side: Receives blood from superior and inferior venae cavae. Pumps blood through pulmonary arteries to pulmonary circulation. Left side: Receives blood from pulmonary veins. Pumps blood through aorta into systemic circulation. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 4

Anatomy and Physiology: Heart & Great Vessels Upper part of heart is base. Lower left ventricle is apex. Heart lies behind sternum and above diaphragm in mediastinum. Lies at an angle so right ventricle makes up most of anterior surface and left ventricle lies left and posteriorly. Pulmonary arteries and aorta are termed the great vessels. Aorta curves upward out of left ventricle and bends posteriorly and downward just above the sternal angle. Pulmonary arteries emerge from superior aspect of right ventricle near third intercostal space. 6

Anatomy and Physiology: Pericardium and Cardiac Muscle Heart wall layers: Pericardium, myocardium, & endocardium. Heart encased in pericardium Fibrous pericardium, is fibrous sac of elastic connective tissue shielding heart from trauma and infection. Parietal layer lies next to fibrous pericardium & visceral layer lies next to myocardium. 8

A&P: Blood Flow through the Heart The Cardiac Cycle Four valves govern blood flow through four chambers of heart: Atrioventricular valves (AV) Tricuspid valve on right. Mitral valve on left Semilunar valve Pulmonic valve opens from right ventricle into pulmonary artery Aortic valve opens from left ventricle into aorta. semilunar valves because of their half-moon shape. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 10

A&P: Blood Flow Through the Heart The Cardiac Cycle - Diastole Diastole: Ventricles relax & fill with blood from left & right atria. Movement of blood from atria to ventricles is accomplished when pressure of blood in atria becomes higher than pressure in ventricles. Higher atrial pressures passively open AV valves, allowing blood to fill ventricles. About 80% of blood from atria flows into relaxed ventricles. Contraction of atria forces remaining 20% of blood into ventricles 12

A&P: Blood Flow Through the Heart The Cardiac Cycle Systole Systole: Ventricles contract creating pressure that closes AV valves. Ventricular pressure also forces semilunar valves to open, resulting in ejection of blood into aorta from left ventricle and pulmonary arteries from right ventricle. As blood is ejected ventricular pressure decreases, causing semilunar valves to close. Ventricles relax to begin diastole. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 14

Anatomy and Physiology: Electric Conduction Heart stimulated by electric impulse from SA node and travels in internodal tracts to AV node. SA node usually discharges 60 to 100 impulses per minute. Electric impulses stimulate contractions of both atria Impulses then flow to AV node Impulses are then transmitted through the Bundle of His and Purkinje fibers resulting in ventricular contraction. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 17

A&P: Electric Conduction Failures AV node usually prevents excessive atrial impulses from reaching ventricles. If SA node fails to discharge, AV node can generate ventricular contraction at slower rate of 40 to 60 impulses per minute. If both SA and AV nodes are ineffective, bundle branches may contract, but at very slow rate of 20 to 40 impulses per minute. 19

A&P: Peripheral Vascular System Arteries, Capillaries, and Veins Maintain blood pressure by constricting or dilating in response to stimuli and vascular resistance. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 21

Anatomy and Physiology: Lymph System Works with the PV system to remove fluid from interstitial spaces. During Circulation/Perfusion: O 2 and nutrient-rich fluid is forced out at arterial end of capillary into interstitial space, and then into cells. Waste products from cells flow through interstitial spaces to venous end of capillary. Excess fluid left in interstitial spaces is absorbed by the lymphatic system and carried to lymph nodes 23

A&P: Upper Body Lymph Nodes In the PV system, upper body primary lymph node locations are axilla and arm Axillary nodes drain lymph from the breasts Epitrochlear nodes on medial surface of arm above elbow are palpable. These nodes receive fluid via radial, ulnar, and median lymph vessels. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 26

A&P: Lower Body Lymph Nodes In the PV system, lower body primary lymph node locations are groin and led Inguinal lymph nodes are superficial & receive most of lymph drainage from saphenous lymphatic vessels in legs. In posterior surface of leg, behind knee, are popliteal nodes, which receive lymph from medial portion of lower leg. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 27

Cardiac Assessment 28

General Health History: Present Health Status Do you have any chronic illnesses such as diabetes mellitus, renal failure, chronic hypoxia, or hypertension? Are you taking medications? What are you taking, and when did you start? Have you experienced any side effects? Do you take medications as prescribed? What over-the-counter drugs do you take? Do you take an aspirin on a regular basis to help thin your blood? Do you take herbal medications? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 29

General Health History: Past Medical History Hx of congenital heart disease? During childhood did you have growing pains, unexplained joint pains? Recurrent tonsillitis or strep throat Rheumatic fever? Heart murmur? Have you been told you have high levels of cholesterol or elevated triglycerides? Have you ever had surgery on heart? On blood vessels? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 30

General Health History: Family Health Status Is there anyone in your family with a history of diabetes mellitus, renal failure, chronic hypoxia, or hypertension? If so, who? 31

General Health History: Personal and Psychosocial History Do you use cocaine? Other street drugs? How often do you use drugs? Do you exercise? What kind of exercise? How often? How would you describe your personality type? How do you deal with stress? How often do you take time to relax? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 32

General Health History: Personal and Psychosocial History Describe your usual eating habits: How often do you eat red meat? Do you monitor your fat and salt intakes? Do you eat whole grains each day? http://www.choosemyplate.gov/ Do you drink alcoholic beverages? What type of alcohol do you drink? How much? How often? Do you consume caffeine? Do you smoke, or have you been a smoker in past? Are you interested in quitting smoking? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 33

CV complaints & Problem-based Hx Chest pain SOB Cough Nocturia Syncope Edema in extremities Leg pain Enlarged lymph nodes 34

Problem-Based History: Chest Pain Where are you feeling the chest pain? What does it feel like? Sharp, dull, ache? Does pain radiate to any location? When did pain start? Is pain intermittent or constant? What symptoms have you noticed with pain? Sweating? Turning pale or gray? Heart skipping beats or racing? Shortness of breath? Vomiting? Anxiety? What factors preceded pain? Exercise? Rest? Highly emotional situations? Sexual intercourse? What makes pain worse? What relieves pain? Rest? Nitroglycerin? How many nitroglycerin tablets does it take to relieve chest pain? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 35

Problem-Based History: Shortness of Breath How long have you had shortness of breath? Do you feel short of breath now? When does shortness of breath happen? How often? How long does it last? Does shortness of breath interfere with your daily activities? Do you have other symptoms with shortness of breath (e.g., do your feet swell during day)? What makes shortness of breath worse? Walking upstairs? Lying down? How many pillows do you require when you lie down to sleep? Do you sleep in recliner? When episodes of shortness of breath occur, what do you do to breathe more easily? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 37

Problem-Based History: Cough When did your cough start? How often do you cough? Do you cough up anything? ( What does it look like? Is cough associated with position? More coughing when lying down? With anxiety? Talking or activity? What makes it worse? What actions do you take to relieve cough? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 38

Problem-Based History: Urinating During the Night For how long have you been getting up during night to urinate? How many times a night do you get up to urinate? What have you done to prevent this from happening? How successful have your efforts been? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 39

Problem-Based History: Fatigue When do you notice fatigue? Was onset sudden or gradual? Is it worse in morning or evening? Are you too tired to take part in normal activities? Do you take iron pills? Do you eat foods with iron, such as green leafy vegetables and liver? For women: Do you have heavy menstrual flow? Have you had any other symptoms associated with fatigue? Rapid heart rate? Headache? Pale skin? Have you noticed any unusual feelings in your feet and hands, muscle weakness, or trouble thinking? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 40

Problem-Based History: Fainting What were you doing just before you fainted? Did you feel dizzy? Did you lose consciousness? Has this happened to you before? Was fainting preceded by any other symptoms? Nausea? Chest pain? Headache? Rapid heart rate? Confusion? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 41

Problem-Based History: Swelling of Extremities Where is swelling located? Arms or legs? Unilateral or bilateral? What makes swelling go away? Does elevating your arms or feet reduce swelling? Does swelling disappear after nights sleep? Are there any symptoms associated with swelling? Shortness of breath? Weight gain? Discoloration For women: Is swelling associated with your menstrual period? Copyright 2013 by Mosby, an imprint of Elsevier Inc. 42

Problem-Based History: Leg Cramps or Pain Describe pain and its location. What makes pain worse? What relieves the pain? Have you noticed any changes in skin of your legs? Coldness Pallor Hair loss Sores Redness or warmth over the veins Visible veins Copyright 2013 by Mosby, an imprint of Elsevier Inc. 43

Cardiac Physical Exam INSPECT General appearance, skin color, breathing Anterior chest wall PALPATE The precordium The apical pulse PERCUSS Heart Borders - probably not AUSCULTATE Heart Sounds 45

Peripheral Vascular Physical Exam MEASURE Blood pressure INSPECT Jugular Vein (and estimate pressure) Upper and lower extremities PALPATE Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis pulses Upper and lower extremities Epitrochlear and inguinal lymph nodes AUSCULTATE Carotid artery 46

Physical Exam: General Appearance Measure blood pressure. Auscultate Inspect patient for general appearance, skin color, and breathing effort. Palpate temporal and carotid pulses for amplitude. Inspect jugular vein for pulsations. JVD Copyright 2013 by Mosby, an imprint of Elsevier Inc. 47

Physical Exam: Upper Extremities Inspect and palpate upper extremities for: Symmetry Skin integrity Color and temperature Capillary refill Turgor/Edema Palpate brachial and radial pulses for: Rate Rhythm Amplitude Copyright 2013 by Mosby, an imprint of Elsevier Inc. 48

Physical Exam: Lower Extremities Inspect and palpate lower extremities for: Symmetry Skin integrity Color and temperature Hair distribution Capillary refill, color and angle of nail beds Tenderness Superficial veins. Palpate lower extremities for Pulses: Femoral, Popliteal, Posterior tibial, and dorsalis pedis pulses. Edema (grade) Copyright 2013 by Mosby, an imprint of Elsevier Inc. 49

Locating Pulses 50

Pitting Edema Scale 51

Auscultate Heart Sounds: S1 & S2 53

Auscultate Heart Sounds: S1 & S2 Auscultate S 1 and S 2 heart sounds for: Rate Rhythm Pitch Splitting APE To Man Aortic Pulmonic Erbs Point Tricuspid Mitral Copyright 2013 by Mosby, an imprint of Elsevier Inc.54

Landmarks Aortic: 2 nd ICS at left sternal border Pulmonic: 2 nd ICS at right sternal border Erbs Point: 2 nd ICS at right sternal border Tricuspid: 4 th ICS at left sternal border Mitral: 5 th ICS and left MCL (apex) 55

Abnormal Heart Sounds S 3 : just after S 2 in diastole. Ken-tuck-y S 4 : just before S1 in diastole. Tenn-ess-ee Murmur 56

Examination: Special Circumstances Peripheral vascular system: Auscultate carotid artery for bruits. Estimate jugular venous pressure for pulsations. Palpate epitrochlear lymph nodes for size, consistency, mobility, borders, tenderness, and warmth. Palpate inguinal lymph nodes for size, consistency, mobility, borders, tenderness, and warmth. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 57

Age-Related Variations: Infants, Children, and Adolescents There are several differences in assessment of cardiovascular system for infants and young children: Equipment used to measure blood pressure is smaller, sequence of exam may be different, and findings may differ based on anatomic differences. Assessment of older child and adolescent follows same procedures and reveals similar expected findings. One exception in exam is electrocardiography, which is not typically performed. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 59

Age-Related Variations: Older Adults Assessing cardiovascular status of older adults usually follows same procedures as for all adults. Expected variations may be found in heart rate and blood pressure. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 60

Common Problems and Conditions: Cardiac Disorders Valvular Heart Disease Valvular heart disease (VHD) is an acquired or congenital disorder of heart valve characterized by: Stenotic valve, which does not open completely. Incompetent valve, which does not close completely. Rheumatic fever and endocarditis account for most cases of acquired VHD. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 61

Common Problems and Conditions: Cardiac Disorders Angina Pectoris Angina pectoris is chest pain due to ischemia of myocardium. Usually caused by atherosclerosis within coronary arteries. Can occur during activity, stress, or exposure to intense cold because of an increased demand on heart. Can also occur during rest as result of spasms of coronary arteries. Clinical findings: Patients describe pain as squeezing, suffocating, or constricting. May be significant hypertension, but hypotension may also occur. The duration of angina is important to determine: If precipitated by exertion and patient rests promptly, may last less than 3 minutes. If it follows heavy meal or caused by anger, may last 15 to 20 minutes. Angina lasting more than 30 minutes is unusual, may indicate developing myocardial infarction. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 62

Common Problems and Conditions: Cardiac Disorders Myocardial Infarction Myocardial infarction occurs when myocardial ischemia is sustained, resulting in death of myocardial cells (necrosis). Left ventricle more commonly affected, but right ventricle may also be affected. Clinical findings: Patients describe pain as worst chest pain ever experienced, pain lasts longer than 5 minutes. May radiate to left shoulder, jaw, arm, or other areas of chest; it is not relieved by rest or nitroglycerin. Dysrhythmias are common; heart sounds may be distant with a thready pulse. Women report different symptoms; they report pain or discomfort in center of chest and shortness of breath, cold sweat, nausea, vomiting, or lightheadedness Copyright 2013 by Mosby, an imprint of Elsevier Inc. 63

Common Problems and Conditions: Cardiac Disorders Heart Failure Heart failure occurs when either ventricle fails to pump blood efficiently into aorta or pulmonary arteries. Heart failure may occur in left or right ventricle or both. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 64

Common Problems and Conditions: Left Ventricular Failure Left ventricular failure is caused by : Increased resistance that occurs with aortic stenosis or hypertension, when ventricle can no longer compensate for increased workload, or Weakening of left ventricular contraction occurring after myocardial infarction when death of myocardial cells may result in an ineffective contraction. Because left ventricle cannot pump sufficient blood forward, some blood backs up into left atrium and eventually into pulmonary capillaries, causing pulmonary edema. Clinical findings: Fatigue & SOB, including orthopnea, dyspnea on exertion, and paroxysmal nocturnal dyspnea. Findings may reveal precordial movement, displaced apical pulse, palpable thrill, S 3, and systolic murmur at apex. In acute phase, patient usually has crackles bilaterally from pulmonary edema. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 65

Common Problems and Conditions: Right Ventricular Failure Right ventricular failure caused by hypertrophy from pulmonary hypertension or from necrosis from myocardial infarction. Failure of right ventricle to pump blood into pulmonary arteries causes a backflow of blood into inferior and superior venae cavae. Right ventricular failure caused by pulmonary disease is termed cor pulmonale. Clinical findings: Findings may include precordial movement at xiphoid or left sternal border, elevated jugular venous pressure, dependent peripheral edema, S 3 at lower left sternal border, systolic murmur, and weight gain. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 67

Common Problems and Conditions: Infective Endocarditis Infective endocarditis is infection of endothelial layer of heart, including cardiac valves: Develops when endocardial surface is damaged by turbulent blood flow as result of valvular heart disease, congenital lesions, or direct injury from intravenous lines or injections, cardiac catheterization, or artificial valves. Clinical findings: Heart sounds normal during early infection; in late infection, murmur is heard if valve damage occurs. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 69

Common Problems and Conditions: Pericarditis Pericarditis is inflammation of parietal and visceral layers of pericardium and outer myocardium. May be idiopathic or the result of myocardial infarction, uremia, cancer, trauma, infections, cardiac surgery, or autoimmune reaction. Clinical findings: Two classic findings are pericardial friction rub and chest pain. Pericardial friction rub develops as inflamed layers of pericardium move against each other. Friction rub is best heard with patient leaning forward so that heart is closer to chest wall. Listen in second, third, or fourth intercostal spaces at left sternal border or at apex; louder during inspiration. Pain described as sharp pleuritic pain aggravated by deep breathing, lying supine, or coughing. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 71

Common Problems and Conditions: Hypertension Hypertension is diagnosed on the basis of mean of two or more properly measured seated blood pressure readings on each of two or more occasions above 120/80 mm Hg in an adult over 18 years of age. Pressure in arteries can become elevated due to constriction of blood vessels or fluid volume overload or both. Clinical findings: Hypertension Normal blood pressure values are less than 120 mm Hg systolic and less than 80 mm Hg diastolic. Because there are no specific symptoms of hypertension, periodic screening is important. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 73

Common Problems and Conditions: Venous Thrombosis and Thrombophlebitis Venous thrombosis occurs when a thrombus (clot) develops within a vein. Triad of venous stasis, damage to inner layer of veins, and hypercoagulability are usually responsible for both. Either may occur in lower extremity, usually in deep veins. Thrombophlebitis is inflammation of vein that may or may not be accompanied by clot. Clinical findings: Thrombosis Sometimes recognized by dilated superficial veins, edema and redness of involved extremity, and increased circumference of involved leg. In upper extremity, venous thrombosis and thrombophlebitis may occur in superficial veins and are recognized by redness, warmth, and tenderness over affected area. (can happen from IV therapy) Veins may be visible and palpable. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 74

Common Problems & Conditions: Aneurysm Aneurysm is localized dilation of artery caused by weakness in arterial wall. Can occur anywhere along aorta and iliac vessels. Clinical findings: Depend on location of aneurysm. Abdominal aortic aneurysms are most common. Thoracic, usually asymptomatic with deep, diffuse chest pain reported by some patients. Aorta and aortic arch aneurysms can produce hoarseness from pressure on laryngeal nerve or dysphagia from pressure on esophagus. A pulsatile mass may be palpated in periumbilical area. A thrill or bruit may be noted over aneurysm. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 77

Question 1 A patient has been admitted to the medical-surgical unit for exacerbation of congestive heart failure. The nurse notes bilateral +2 pitting edema and dry scaling skin. As the nurse assesses the dorsalis pedis pulse, the nurse is unable to detect it and notes that both feet are warm. What is the best action for the nurse to take? A. Call the physician immediately. B. Assess skin turgor over the clavicle. C. Use a Doppler and assess capillary refill. D. Use a Doppler and assess for renal artery stenosis. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 78

Question 2 In the cardiac unit, a patient awaits surgery for mitral valve repair. As the nurse auscultates the patients heart, the nurse will expect to hear a murmur that is: A. Most pronounced at the base of the heart. B. Most pronounced over the carotid arteries. C. Heard best at the left sternal border. D. Heard best over the left midclavicular line. Copyright 2013 by Mosby, an imprint of Elsevier Inc. 79

health assessment lecture 6 denver school of nursing fall 2013 k.hendrickson phd, rn 1

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