Heart and Neck Vessels

Week 8
The Neck Vessels
1. Conduct an independent review of anatomy & physiology.
2. Identify where to auscultate & palpate carotid arteries.
3. Identify what is considered normal & abnormal in the assessment of the carotid arteries.
4. Outline how to differentiate between carotid & jugular pulses.
5. Identify & describe the jugular venous pulse pressure.
6. Identify significance of central venous pressure.
7. Identify equipment needed for physical examination & safe infection prevention & control practices.

The Precordium
8. Conduct an independent review of anatomy & physiology.
9. Explain how to inspect the anterior chest for heaves/lifts & for the apical impulse.
10. Describe what the apical impulse is & identify its characteristics & how it is assessed.
11. Identify the pulsations/thrills on the precordium & how they are assessed.
12. Describe where to auscultate for the apical pulse & what cardiac characteristic to measure.
13. Identify & explain S1 & S2 heart sounds & characteristics.
14. Define murmurs, characteristics of murmurs & that of an "innocent" & functional murmur.
15. Grading of murmurs.
16. Identify developmental considerations across the lifespan.
17. Identify how to document subjective & objective data.
18. Identify health promotion strategies.
19. Identify equipment needed for physical examination & safe infection prevention & control practices.

Peripheral Vascular System

20. Conduct an independent review anatomy & physiology of upper & lower peripheral vascular systems & regional lymphatics.
21. Outline developmental changes across the lifespan.
22. Describe the relationship between the peripheral vascular/ lymphatic systems & skin integrity.
23. Outline subjective questions & reasons for their consideration.
24. Outline equipment needed & safe infection prevention & control practices.
25. Identify techniques for inspect & palpation of peripheral pulses.
26. Identify the techniques of, & practice using the Doppler Ultrasonic device.
27. Describe abnormalities: identify differences between venous & arterial insufficiency; lymph node enlargement & causes; peripheral edema, how to measure & causes; lymphedema;
Raynaud’s Phenomenon.
28. Identify equipment needed for physical examination & safe infection prevention & control practices.
 Neck Vessels –
Carotid Artery

• Auscultate carotid artery

• Location
• Angle of jaw, midcervical,
base of neck
• Technique
• Findings
• No bruit/bruit
• Palpation of carotid artery
• Location/technique
• Contour & amplitude
 Draping

Approach - positioning
Objective • Carotid artery
Assessment - • Sitting upright
Preparation • Precordium – Heart
• Supine with head & chest slightly
elevated
• Jugular venous pulsation at 30-45°
Auscultating
Carotid Arteries
Ask Ask client to tilt head slightly to one side

Ask Ask client to hold breathe

Start at the angle of the jaw, mid neck and at the

Start base of neck

Use Use the bell of the stethoscope

Remind Remind the client to breathe

Repeat on Repeat on the other side

Inspect -Jugular
Venous Pulsation
Supine position at 30-45 degrees with pillow
removed
Tangential lighting with patient’s head turned away
External jugular veins
Location: Over sternomastoid muscle
Present or full
Internal jugular pulsation
Location: Suprasternal notch or origin of sternomastoid
muscle
Diffuse with two visible waves
 Positioning?
Inspect -
Jugular
Venous
External jugular veins
Pulsation
Internal jugular
pulsation
Assessment of
jugular pulsation
•https://www.youtube.com/watch?v=KDpPRyVE4nI
Inspect Jugular Venous Pulsation
Internal Jugular Carotid Pulse
-lower -higher, medial to
sternomastoid muscle
-undulant, diffuse -brisk, localized with
with 2 visible waves one wave
-varies with R -does not vary with R
-disappears as person -unaffected by position
sits up
https://www.youtube.com/watch?v=LxqK5MgVBmc
 Special considerations for
advanced practice p.504
Inspect -
Jugular Inspecting jugular veins
Venous
Pulsation • Assesses central venous
pressure (heart’s efficiency)
• Right internal vein attached to
superior vena cava
 Heart

Cardiovascular
System
Blood vessels

• Pulmonary circulation
• Systematic circulation
The Heart: Landmarks

•Precordium
•Mediastinum
•Locating the heart
Positioning
•Apex & Base
•Great Vessels
• Inferior & superior venae cavae
• Pulmonary artery & vein
• Aorta
•Layers of heart
•4 Chambers
• Atria & ventricles
Layers of Heart-Self Review
Pericardium
outermost layer
(covering) of the
heart
Epicardium
(space which
holds 30 mm of
fluid which
prevents friction
between the
layers when heart
pumping)
Myocardium
muscular layer of
the heart
Endocardium
innermost layer of
the heart
Valves- self review
•Atrioventricular
• Tricuspid
• Mitral/bicuspid

•Semilunar
• Pulmonic
• Aortic
Pulmonary & Systematic Circulation- Self Review
What are the 2
phases of the
cardiac cycle?
 •Systole
•&
•Diastole

What are the 2 phases of the cardiac cycle?

https://ca.video.search.yahoo.com/search/video?fr=yfp-t-s-m&p=cardiac+cycle+animation#id=3&vid=898ac50c32d38f8647c9025b25dc0723&
action=vi
 • Diastole
• Pressure is greater in atria
than ventricles
• AV valves open
• Ventricles fill
• Atrial kick
• 25% of stroke volume

The Cardiac Cycle

 • Systole
• Ventricular pressure

greater than atrial

• AV valves close
(sound of S1 “lub”)
• All 4 valves closed
• Pressure builds in
ventricles
• SL valves open &
ventricles contract
• Ventricular pressure falls
below aortic
• SL valves close
Cardiac Cycle (sound of S2 “dup”)
 Normal heart sounds
• S1 “lub” and S2 “dup”
http://depts.washington.edu/physdx/audio/normal.mp3

Normal physiological split

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
• more to the right heart
• less to the left http://www.blaufuss.org/
Conduction- Self Review

• Automaticity
• Electrical current
https://www.youtube.com/watch?v=fZT9vlbL2uA

Current Left side

htthttps://www.youtube.com/watch?
v=fZT9vlbL2uAps://www.youtube.com/watch?
v=fZT9vlbL2uA

Contraction Right side

Electrical conduction system
The Cardiac Cycle
Abilities of cardiac
muscle cells…
automaticity (generate
impulse), conductivity
(transmit impulse),
contractility (react to
conduction PQRST = beat)
The pathway of the
electrical conduction
system of the heart
Sinoatrial node (SA node)
to Atrioventricular node
(AV node) to Bundle of His
to Bundle branches (L and
R) to Purkinje fibers
Cardiac output
• Cardiac output (CO) is the
amount of blood pumped
by the ventricles during 1
min
• Stroke Volume (SV)
(depend preload,
afterload, and
contractility) × HR = CO
• The normal adult cardiac
output is 5 to 6 L/min.

• Perfusion
• MAP=mechanical P
• Systolic+diastolic (2)/3
• 70-100 mm hg
 Developmental Considerations
Infants and children
Foramen ovale
Ductus arteriosus
Position of heart in chest apex higher
Pregnant women
Increase in blood volume
Increase in stroke volume & cardiac output
Older adult
• Influence of lifestyle
• Increase in systolic blood pressure
• Decreased tolerance for tachy-arrhythmias
thicker & less compliant myocardium
• Changes in conductions system on ECG
26
Cultural and Social Considerations
• Increase incidence of
CVD in Canada for men
& women
• Influence of
socioeconomic factors
• High blood pressure
• Smoking
• Serum cholesterol
• Obesity
• Diabetes

27
What are some common reasons for
seeking care in relation to the heart
and neck vessels?

Subjective Data—
Health History Questions
What are some common reasons for seeking care in
relation to the heart & neck vessels?

Subjective Data—
Health History Questions
• Chest pain • Edema
• Dyspnea • Nocturia
• Orthopnea
• Cardiac hx
• Cough
• Fatigue • Family cardiac hx
• Cyanosis or pallor • Personal habits
(cardiac risk factors)
Landmarking
using
imaginary
lines
Objective Data and Physical Exam

Precordium
 Inspect the anterior
chest- can use
tangential light
 Palpate the apical
impulse and pulsations
 heaves or lifts due
to enlarged
ventricle d/t
overload
 Palpate across the
precordium 3 locations
 At 5th ICS at
midclavicular line
 Left Sternal Border
 Base of Heart
 Assessing for Thrills
31
 Palpate precordium for pulsations/thrills
• Using palmar aspects of fingers
• Apex, left sternal border & base
• Normally none felt

Palpate apical impulse (only palpable in ½ the

Precordium - population)
Supine • Using 1 finger pad at apex
• 4th or 5th ICS at/medial to left MCL
• “Exhale and hold it”
• May need to roll patient to the left
• Normal Findings
• Location, size (1 x 2cm), amplitude (short, gentle tap)
and duration (short)
• https://www.youtube.com/watch?v=0_xF2dX8hCM
 Apical pulse
Landmark
5th ICS at left MCL (same location as the mitral
valve)
Auscultation – Note rate & rhythm
Apical Pulse
•https://www.youtube.com/watch?v=kFYvUZsZpkw
Apical Pulse versus Apical Impulse
• What are the differences?
• What are you assessing for each?
• How do they compare and differ?
 Ausculatory Locations of Valves
AV Valves Semilunar Valves
Tricuspid valve Aortic valve
4th ICS at L sternal border 2nd ICS at R sternal border
Mitral Pulmonic valve
5th ICS at L MCL
2nd ICS at L sternal border
 Technique

S1 “lub” & S2 “dup”

• Normal/clear, accentuated, diminished or split

Auscultation • Physiological split – split S2
• Difficult to distinguish with tachyarrhythmia's
of Valves • S1 is louder than S2 at apex
• S2 is louder than S1 at base
• S1 coincides with carotid pulse

Murmurs
Objective Data and Physical Exam
• Auscultate the heart sounds
 With diaphragm and bell
 Rate & rhythm
• Identify auscultatory areas
• Note the rate & rhythm
• Sinus arrhythmia
• Pulse deficit
• Identify S1 and S2
• S1 is louder than S2 at the apex
• S1 coincides with carotid artery pulse
• S1 coincides with R wave on electrocardiogram
• Listen to S1 and S2 separately
• Listen for extra heart sounds
• Listen for murmurs
38
 What are the
assessments for a
murmur?
Murmurs
Distinguish btw
innocent,
functional and
pathological
 • Gentle, blowing, swooshing sound
• Timing
• Loudness (grading 1-6)
• Posture
• Innocent
• No valvar/pathological
cause
Murmurs • Functional
• Related to increased blood
flow (anemia, fever,
pregnancy)
• Pathological
• https://www.youtube.com/watch
?v=Q5-0mSydRR4
Developmental Considerations
• Infants  Pregnant women
• Difference in apical, • Changes in BP (varies
radial pulses with position)
• HR 100-180 bpm • Heart sound changes
• May be in higher range from increased blood
with crying or other volume and workload
activity
• Murmurs more common
 Older adult
in first days • Orthostatic
hypotension
• Children
• Position of apical impulse
• Venous hum
• Innocent heart murmurs

41
Non modifiable and modifiable risk factors

Modifiable risks Non modifiable

Abnormal Findings
• Abnormal pulsations on the
precordium
• Thrill murmur
• Aortic stenosis
• Lift (heave) at the sternal
border
• RV hypertrophy

• Congenital heart defects

• Patent ductus arteriosus (PDA)
• Atrial septal defect (ASD)
• Ventricular septal defect (VSD)
• Coarctation of the aorta

43
Abnormal Findings

44