HEART AND

NECK
VESSELS

Chapter 20

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 SUBJECTIVE
DATA

• Chest pain
• Dyspnea
• Orthopnea
• Cough
• Fatigue
Subjective • Cyanosis or pallor
• Edema
Data • Nocturia
• Past cardiac history
• Family cardiac history
• Patient-centered care(cardiac
risk factors)

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 CHEST PAIN QUESTIONS

• onset and location.

• characteristics.
Any chest • precipitating events.
pain or • associated symptoms.
tightness? • relieved by or made worse
Ask about by.
• medication or treatments.

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 DYSPNEA QUESTIONS

• type of activity and

occurrence.
Any • onset and duration.
• affect of positional
shortness changes and
of breath? interruption of sleep.
• presence of
Ask about orthopnea.
• affect ADLs.

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QUESTIONS: COUGH AND FATIGUE

• duration and frequency.

Do you • characteristics of type and productive versus non-

have a productive.
• affect of positional change.
cough? Ask • affect ADLS.
• alleviating factors or precipitating factors.
about • medications or treatments.

Do you
seem to tire • onset and any recent changes in energy level.
• r/t time of day.
easily? Ask
about

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 6

QUESTION:
During a cardiac assessment on a 38-year-old patient in the hospital for “chest
pain,” the nurse practitioner finds the following: jugular vein pulsations 4 cm
above the sternal angle when the patient is elevated at 45 degrees, blood
pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema,
difficulty breathing when supine, and an S3 on auscultation. Which of these
conditions best explains the cause of these findings?

A. Fluid overload

B. Atrial septal defect

C. MI

D. Heart failure

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 ADDITIONAL SUBJECTIVE HISTORY
QUESTIONS

• orthopnea.
Ask about • cyanosis or pallor.
occurrence of •
nocturia.

• Onset and timing

• Amount and location
Edema • Relief of symptoms
• Presence of associated
symptoms

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CARDIAC HISTORY QUESTIONS

• past cardiac history- medical and surgical.

Ask about • diagnostic testing and imaging studies.
• family history.

• Nutrition
Patient-centered care: • Smoking
determine • Alcohol
information relative • Exercise
to patient history for: • Medication

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 ADDITIONAL HISTORY:
INFANTS

• Maternal health: How

was mother’s health
during pregnancy?
• Feeding pattern: Any
Infant cyanotic changes during
nursing or crying?
• Growth and activity:
Meeting developmental
outcomes?

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 ADDITIONAL HISTORY: CHILDREN

• Growth and activity:

Meeting developmental
outcomes?
• Evidence of any chest
pain?
Children • History of respiratory
infections
• Significant family
history—genetic
abnormalities

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 ADDITIONAL HISTORY:
PREGNANT WOMEN

• HTN during
pregnancy?
• Associated clinical
Pregnant symptoms—
women proteinuria, weight
gain, edema?
• Experiencing faintness
or dizziness?

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ADDITIONAL HISTORY FOR AGING ADULT

Medical • Review presence of

history comorbidities.

• Rx or OTC
Medication • Aware of side effects
profile history • Compliance with therapy

Environment • Impact on ADLs

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 OBJECTIVE:
PREPARATION AND EQUIPMENT

• To evaluate carotid arteries,

a person can be sitting.
• To assess jugular veins and
precordium, the person
Preparation should be supine with head
and chest slightly elevated.
• Ensure woman’s privacy by
keeping her breasts draped.

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 OBJECTIVE:
PREPARATION AND EQUIPMENT

• Marking pen
• Small centimeter
ruler
• Stethoscope with
Equipment diaphragm and bell
endpieces
• Alcohol wipe to
clean endpiece

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 NECK VESSELS: INSPECTION

• From jugular veins you can

assess central venous pressure
(CVP) and judge heart’s
Inspect efficiency as a pump.
• Position a person supine
jugular anywhere from a 30- to a 45-
venous degree angle, wherever you can
best see pulsations.
pulse. • Estimate pressure.
• Observe for possible
distention.

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NECK VESSELS: INSPECTION

• location,
• quality,
• respiration,
Characteristics of
jugular versus • palpable,
carotid pulsations
• pressure,
• position of
patient

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NECK VESSELS: PALPATION

• Palpate only one carotid

artery at a time to avoid
compromising arterial
Palpate blood to brain.
• Feel contour and amplitude
carotid of pulse, normal strength
artery 2+.
• Findings should be same
bilaterally

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 NECK VESSELS AUSCULTATION

• Assess for presence of carotid

bruit.
• avoid compressing the artery
Auscultate which can create an artificial
bruit.
carotid • Keep neck in neutral position
artery. and lightly apply stethoscope at
• angle of jaw, mid-cervical
area, and base of neck.

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 PRECORDIUM

• Arrange tangential lighting to

accentuate any flicker of
movement.
• Observe for any possible
Inspect pulsations.
anterior chest/ • Palpate apical impulse: note
Palpate location, size, amplitude and
precordium duration.
• Palpate across precordium to
assess for any possible
pulsations.

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 PRECORDIUM

• Arrange tangential lighting to

accentuate any flicker of
movement.
• Observe for any possible
Inspect pulsations.
anterior chest/ • Palpate apical impulse: note
Palpate location, size, amplitude and
precordium duration.
• Palpate across precordium to
assess for any possible
pulsations.

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 PRECORDIUM AUSCULTATION

• Sound radiates with blood

flow direction; valve areas
are:
• Second right interspace:
Identify aortic valve area
auscultatory • Second left interspace:
areas pulmonic valve area
associated with • Left lower sternal border:
valves. tricuspid valve area
• Fifth interspace at around
left midclavicular line:
mitral valve area

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 22

PLACEMENT OF STETHOSCOPE

https://www.youtube.com/watch?v=K_BWCw7s1Xo
 PRECORDIUM AUSCULTATION

• Note rate and rhythm: describe

characteristics
• Identify S1 and S2.
• Listen for extra heart sounds: describe
Auscultation: characteristics.
• Listen for murmurs: Timing, loudness,
pitch, pattern, quality, location,
radiation posture and change of
position.

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PROCEDURES FOR ADVANCED PRACTICE

• screening measure
Standing to to detect
squatting: hypertrophic
cardiomyopathy

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PROCEDURES FOR ADVANCED PRACTICE

Estimation
of central • If venous pressure is
venous elevated or heart
pressure failure suspected
(CVP) by perform
assessing abdominojugular
jugular test.
venous
distention

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 EXAMINATION OF THE JUGULAR VENOUS 26

PRESSURE / JVP EXAMINATION PROCEDURE

https://batesvisualguide-com.ezproxy.cdrewu.edu/MultimediaPlayer.aspx?multimediaid=6091270
 DEVELOPMENTAL COMPETENCE:
INFANTS

Transition from fetal to • Heart rate may range from 100 to 180
pulmonic circulation beats per minute (bpm) immediately
occurs in immediate
newborn period after birth

Note any extracardiac • Skin, liver size, and

signs that may reflect
heart status respiratory status

Murmurs in the • Murmurs are usually grade 1 or 2, systolic, no other signs

immediate newborn of heart disease and disappear in 2 to 3 days.
period do not necessarily • Absence of murmurs in the immediate newborn period does
indicate congenital heart not ensure a healthy heart.
• Best to listen frequently and to note and describe any
disease seen due to shunt murmur according to characteristics.
closure.

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DEVELOPMENTAL COMPETENCE:
CHILDREN
Any • Poor weight gain, developmental delay,
extracardiac or persistent tachycardia, tachypnea, dyspnea on
cardiac signs exertion, cyanosis, and clubbing
• Note that clubbing of fingers and toes usually
that may does not manifest until late in first year, even
indicate heart with severe cyanotic defects.
disease

• Be aware of location by age.

• Rhythm remains characterized by sinus
Palpate apical dysrhythmia.
• Physiologic S3 is common in children.
pulse • Venous hum has no pathologic significance.
• Assess for carotid bruit

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DEVELOPMENTAL COMPETENCE:
CHILDREN HEART MURMURS

• Very common through

Innocent
childhood
(or functional) • Some say they have 30%
occurrence, and some say
murmur nearly all children may
demonstrate murmur.

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DEVELOPMENTAL COMPETENCE:
CHILDREN HEART MURMURS

Most innocent • Soft, relatively short systolic ejection murmur

murmurs have • Medium pitch; vibratory
• Best heard at left lower sternal or midsternal border,
these with no radiation to apex, base, or back
characteristics:

• Need to believe that this murmur is just a “noise”

and has no pathologic significance
Patient teaching: • Knowledge through education to prevent
overprotection and limit activity for child

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DEVELOPMENTAL COMPETENCE:
PREGNANT WOMAN AND AGING
ADULT
• Vital signs increase in resting pulse rate of 10 to 15 bpm and drop in BP

Pregnant from normal pre-pregnancy level.

• Palpation of apical impulse is higher and lateral compared with normal
position.

woman: • Heart sounds: Changes due to increased volume and workload

• Mammary soufflé: occurs near term or when woman is lactating

• Gradual rise in systolic blood pressure common with aging; widening of

Aging
pulse pressure—be alert for orthostatic hypotension
• Left ventricular wall thickness increase.
• Presence of supraventricular and ventricular dysrhythmias increases with

adult: age.
• Age-related ECG changes occur due to histologic changes in the
conduction system.

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HEALTH PROMOTION AND PATIENT TEACHING

• Appropriate aspirin therapy

• Blood pressure control
Health • Cholesterol control
Promotion • Smoking cessation
• Lifestyle changes
and Patient • Diet
Teaching • Physical activity
• Weight control

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 DIFFERENTIAL DIAGNOSIS OF CHEST
PAIN
• Ischemic: Angina pectoris, Prinzmetal or variant angina, and acute coronary syndrome (ACS)
Cardiovascular • Non-ischemic: Pericarditis, mitral valve prolapse, aortic dissection, and secondary pulmonary HTN

Pulmonary • Pulmonary embolism, pneumonia, and pneumothorax

Gastrointestinal • Gastroesophageal reflux, esophageal spasm, cholecystitis, and pancreatitis

Dermatologic • Herpes Zoster

Musculoskeletal/neurologic • Costochondritis and chest wall muscle strain

Psychogenic • Depression and anxiety

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CLINICAL PORTRAIT OF HEART FAILURE

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VARIATIONS IN HEART SOUNDS

• Loud (accentuated)

S1
• Faint (diminished)
• Varying intensity
• Split

• Accentuated

S2
• Diminished
• Normal splitting
• Fixed split, paradoxical split, and wide split

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 ABNORMAL FINDINGS:
SYSTOLIC AND DIASTOLIC EXTRA
SOUNDS

• Ejection click

Systolic • Aortic prosthetic valve sounds

• Midsystolic click

• Opening snap
• Mitral prosthetic valve sound

Diastolic
• Third heart sound
• Fourth heart sound
• Summation sound
• Pericardial friction rub

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 ABNORMAL FINDINGS:
ABNORMAL PULSATIONS: PRECORDIUM

Thrill at the base

Lift
Pressure (heave) at
overload at the left
the apex sternal
border

Volume overload at
the apex

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 ABNORMAL FINDINGS:
CONGENITAL HEART DEFECTS
Patent
ductus
arteriosus
(PDA)

Atrial
Coarctatio
septal
n of the
defect
aorta
(ASD)

Ventricular
Tetralogy septal
of Fallot defect
(VSD)

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 ABNORMAL FINDINGS:
MURMURS CAUSED BY VALVULAR
DEFECTS
Midsystolic ejection • Aortic stenosis
murmurs • Pulmonic stenosis

Pansystolic regurgitant • Mitral regurgitation

murmurs • Tricuspid regurgitation

Diastolic rumbles of • Mitral stenosis

atrioventricular valves • Tricuspid stenosis

Early diastolic • Aortic regurgitation

murmurs • Pulmonic regurgitation

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 40

QUESTION:
When listening to heart sounds, the student NP knows the valve
closures that can be heard best at the base of the heart are:

A. Mitral and tricuspid.

B. Tricuspid and aortic.

C. Aortic and pulmonic.

D. Mitral and pulmonic.

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 41

DOCUMENTATION AND CRITICAL THINKING

SAMPLE CHARTING

• No chest pain, dyspnea, orthopnea, cough, fatigue, or edema.

• No history of hypertension, abnormal blood tests, heart murmur,
or rheumatic fever in self.
• Last ECG 2 yrs PTA, result normal.
• No stress ECG or other heart tests
• Family history: Father with obesity, smoking, and hypertension,
Subjective: treated diuretic medication.
• No other family history significant for CV disease.
• Personal habits: Diet balanced in 4 food groups, 2 to 3 c. regular
coffee/day; no smoking; alcohol, 1 to 2 beers occasionally on
weekend; exercise, runs 2 miles, 3 to 4 ×/week; no prescription or
OTC medications or street drug

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