Heart and Neck Vessels

Heart and Neck Heart and Neck VesselsVesselsBy InnaKordaBy InnaKorda

Surface AnatomySurface Anatomy

Cardiac AnatomyCardiac Anatomy

Direction of Blood FlowDirection of Blood Flow

Cardiac CycleCardiac Cycle DiastoleDiastole

Ventricles are relaxed, AV valves are openVentricles are relaxed, AV valves are open Pressure in atria are higher than in ventricles Pressure in atria are higher than in ventricles causing causing

blood to pour into the ventriclesblood to pour into the ventricles Atria contract casing more blood to enter the ventricles Atria contract casing more blood to enter the ventricles

“atrial kick”“atrial kick” SystoleSystole

Pressure in ventricles is higher than in atria Pressure in ventricles is higher than in atria causing causing AV valves (mitral and tricuspid) valves to close. First AV valves (mitral and tricuspid) valves to close. First heart sound.heart sound.

Pressure of ventricle begins to become greater than Pressure of ventricle begins to become greater than pressure of aorta and pulmonary artery pressure of aorta and pulmonary artery blood is blood is ejected from the ventriclesejected from the ventricles

When the ventricles’ pressure falls below the pressure of When the ventricles’ pressure falls below the pressure of the aorta (or pulmonary artery), some blood flows the aorta (or pulmonary artery), some blood flows backwards toward the ventricles, causing the semilunar backwards toward the ventricles, causing the semilunar (aortic, pulmonic) valves to close. Second heart sound.(aortic, pulmonic) valves to close. Second heart sound.

Neck VesselsNeck Vessels

Neck MusclesNeck Muscles

Developmental Developmental ConsiderationsConsiderations

Ageing AdultAgeing Adult

Hemodynamic changesHemodynamic changes Systolic pressure tends to increase 20 mm Hg Systolic pressure tends to increase 20 mm Hg

due to arteriosclerosisdue to arteriosclerosis Decreased cardiac output with exerciseDecreased cardiac output with exercise Blacks, Mexicans, and Native Americans have Blacks, Mexicans, and Native Americans have

higher incidence of hypertensionhigher incidence of hypertension ArrhythmiasArrhythmias

Increase with ageIncrease with age ECG changesECG changes

Prolonged P-R interval and prolonged Q-T Prolonged P-R interval and prolonged Q-T intervalinterval

Health HistoryHealth History Chest painChest pain

Onset – When did it start? How long have you had it? Onset – When did it start? How long have you had it? Have you ever had this pain before?Have you ever had this pain before?

Location – Where did it start? Where does it radiate?Location – Where did it start? Where does it radiate? CharacterCharacter Associative and alleviating factors – What brought on Associative and alleviating factors – What brought on

the pain? What relieves it? (nitroglycerinthe pain? What relieves it? (nitroglycerin Associative symptoms – sweating, pale skin, SOB, N&V, Associative symptoms – sweating, pale skin, SOB, N&V,

tachycardia?tachycardia? Dyspnea (shortness of breath)Dyspnea (shortness of breath)

What type of activity brought it on? What type of activity brought it on? DOE – Dyspnea on exertion. Ex: walkingDOE – Dyspnea on exertion. Ex: walking

OnsetOnset DurationDuration PositionalPositional

Nocturnal dyspnea occurs with heart failure.Nocturnal dyspnea occurs with heart failure. Does it awaken you at night?Does it awaken you at night?

Question 1Question 1 A client with no history of cardiovascular A client with no history of cardiovascular

disease presents to the ambulatory clinic disease presents to the ambulatory clinic with flulike symptoms. The client suddenly with flulike symptoms. The client suddenly complains of chest pain. Which of the complains of chest pain. Which of the following questions would best help a following questions would best help a nurse to discriminate pain caused by a nurse to discriminate pain caused by a noncardiac problem?noncardiac problem?

1.1. ““Have you ever had this pain before?”Have you ever had this pain before?”2.2. ““Can you describe the pain to me?”Can you describe the pain to me?”3.3. ““Does the pain get worse when you breathe in?”Does the pain get worse when you breathe in?”4.4. ““Can you rate the pain on a scale of 1 to 10, Can you rate the pain on a scale of 1 to 10,

with 10 being the worst?”with 10 being the worst?”

Health HistoryHealth History OrthopneaOrthopnea

Do you need to assume an upright position when Do you need to assume an upright position when sleeping? How many pillows are used?sleeping? How many pillows are used?

CoughCough DurationDuration FrequencyFrequency Type – dry, hacking, congested?Type – dry, hacking, congested? Mucus? Color, odor, blood?Mucus? Color, odor, blood? Associative and alleviative factorsAssociative and alleviative factors

FatigueFatigue Do you tire easily?Do you tire easily?

Fatigue due to decreased cardiac output (CO) is worse in Fatigue due to decreased cardiac output (CO) is worse in eveningevening

Onset – When did fatigue start? Was it sudden or gradual?Onset – When did fatigue start? Was it sudden or gradual? Cyanosis or pallorCyanosis or pallor

Occurs with myocardial infarction (MI) or low CO Occurs with myocardial infarction (MI) or low CO decreased tissue perfusiondecreased tissue perfusion

Health HistoryHealth History Edema (swelling)Edema (swelling)

OnsetOnset FrequencyFrequency

Cardiac edema is worse at evening and better in morningCardiac edema is worse at evening and better in morning Amount - How much swelling occurs normally? Equal on Amount - How much swelling occurs normally? Equal on

both sides?both sides? Associative and alleviative factors – SOB? Before or after leg Associative and alleviative factors – SOB? Before or after leg

swellingswelling NocturiaNocturia

Do you awaken at night with an urgent need to urinate?Do you awaken at night with an urgent need to urinate? More fluid reabsorption and excretion in pt with heart failureMore fluid reabsorption and excretion in pt with heart failure

Past cardiac history Past cardiac history HTN, cholesterol, murmur, congenital heart disease, HTN, cholesterol, murmur, congenital heart disease,

rheumatic feverrheumatic fever How was it treated?How was it treated?

Family historyFamily history

Health HistoryHealth History Personal habitsPersonal habits

Nutrition – Usual diet? Nutrition – Usual diet? Usual weight? Changes Usual weight? Changes in weight?in weight?

Smoking – Cigarettes Smoking – Cigarettes or tobacco? Onset? or tobacco? Onset? Packs per day?Packs per day?

Alcohol – Drinks per Alcohol – Drinks per week/day? week/day?

Exercise – Type, Exercise – Type, durationduration

Drugs – Medication, Drugs – Medication, street drugsstreet drugs

Coronary Heart Disease Risk Factors

4 cig per day = 2x risk for cardio disease20 cig per day = 4x risk for cardio disease

Pack Years =Packs per day X Years smoked

Preparation for Physical Preparation for Physical ExaminationExamination

EnvironmentEnvironment Should be warm. Shivering might interfere with Should be warm. Shivering might interfere with

heart soundsheart sounds PrivacyPrivacy

Make sure the female’s breasts remain draped. When Make sure the female’s breasts remain draped. When auscultating the heart, gently displace the breast or auscultating the heart, gently displace the breast or ask the woman to hold it out of the wayask the woman to hold it out of the way

Order of examOrder of exam Begin with observations peripherally and move Begin with observations peripherally and move

toward the heart.toward the heart.1.1. Pulse and blood pressurePulse and blood pressure

2.2. Extremities – peripheral vascular assessmentExtremities – peripheral vascular assessment

3.3. Neck vesselsNeck vessels

4.4. Precordium – (portion of body over heart and thorax)Precordium – (portion of body over heart and thorax)

General AppearanceGeneral Appearance

General buildGeneral build Chronic HF may appear malnourished, Chronic HF may appear malnourished,

thin, cachecticthin, cachectic SkinSkin

Jaundice and generalized edema in late HFJaundice and generalized edema in late HF LOCLOC

Poor cardiac output and decreased Poor cardiac output and decreased cerebral perfusion may cause mental cerebral perfusion may cause mental confusion, memory loss, slowed verbal confusion, memory loss, slowed verbal responsesresponses

Blood PressureBlood Pressure Normal for adultsNormal for adults

90 to 140 mm Hg systolic90 to 140 mm Hg systolic 60 to 90 mm Hg diastolic60 to 90 mm Hg diastolic Pressure greater than 140/90 is considered Pressure greater than 140/90 is considered

hypertensionhypertension Pressure less than 90/60 is considered hypotension Pressure less than 90/60 is considered hypotension

and may be inadequate to provide oxygenation to cellsand may be inadequate to provide oxygenation to cells Postural blood pressure (orthostatic)Postural blood pressure (orthostatic)

Moving from lying to sitting or standing positionMoving from lying to sitting or standing position ↑ ↑ in mm Hg by 10 and/or ↑ in pulse by 10 after a in mm Hg by 10 and/or ↑ in pulse by 10 after a

minuteminute May be caused by cardiac drugs or loss of autonomic May be caused by cardiac drugs or loss of autonomic

NS compensatory ability, generally in older adultsNS compensatory ability, generally in older adults Paradoxical blood pressureParadoxical blood pressure

Decrease in systolic BP more than 10 mm Hg during Decrease in systolic BP more than 10 mm Hg during inspirationinspiration

Question 2Question 2 A client is admitted to an emergency room A client is admitted to an emergency room

with chest pain and is being ruled out for with chest pain and is being ruled out for myocardial infarction (MI). Vital signs are as myocardial infarction (MI). Vital signs are as follows: at 11:00 a.m., pulse (P) 92, follows: at 11:00 a.m., pulse (P) 92, respiratory rate (RR) 24, blood pressure (BP) respiratory rate (RR) 24, blood pressure (BP) 140/88 mm Hg; 11:15 a.m., P 96, RR 26, BP 140/88 mm Hg; 11:15 a.m., P 96, RR 26, BP 128/82 mm Hg; 11:30 a.m., P 104, RR 28, BP 128/82 mm Hg; 11:30 a.m., P 104, RR 28, BP 104/68 mm Hg; 11:45 a.m., P 118, RR 32, BP 104/68 mm Hg; 11:45 a.m., P 118, RR 32, BP 88/58 mm Hg. A nurse alerts the physician 88/58 mm Hg. A nurse alerts the physician because these changes are most consistent because these changes are most consistent with:with:1.1. Cardiogenic shockCardiogenic shock2.2. Cardiac tamponadeCardiac tamponade3.3. Pulmonary embolismPulmonary embolism4.4. Dissecting thoracic aortic aneurysmDissecting thoracic aortic aneurysm

Question 3Question 3 A nurse is assessing the blood pressure A nurse is assessing the blood pressure

of a client diagnosed with primary of a client diagnosed with primary hypertension. The nurse ensures hypertension. The nurse ensures accurate measurement by avoiding accurate measurement by avoiding which of the following?which of the following?

1.1. Seating the client with arm bared, supported, Seating the client with arm bared, supported, and at heart leveland at heart level

2.2. Measuring the blood pressure after the client Measuring the blood pressure after the client has been seated quietly for 5 minuteshas been seated quietly for 5 minutes

3.3. Using a cuff with a rubber bladder that Using a cuff with a rubber bladder that encircles at elast 80% of the limbencircles at elast 80% of the limb

4.4. Taking the blood pressure within 30 minutes Taking the blood pressure within 30 minutes after nicotine or caffeine ingestionafter nicotine or caffeine ingestion

Assessing Neck VesselsAssessing Neck Vessels

Carotid ArteryCarotid Artery Palpate the carotid Palpate the carotid

arteryartery Avoid excessive pressure. Avoid excessive pressure.

Excessive vagal Excessive vagal stimulation could slow stimulation could slow down heart rate.down heart rate.

Carotid arteries should be Carotid arteries should be same bilaterallysame bilaterally

AuscultationAuscultation Listen for bruits – blowing, Listen for bruits – blowing,

swishing sounds indicating swishing sounds indicating blood flow turbulence. blood flow turbulence. Caused by atherosclerotic Caused by atherosclerotic narrowing (one half or two narrowing (one half or two thirds of artery).thirds of artery).

Assessing Neck VesselsAssessing Neck Vessels

Jugular VeinsJugular Veins Can be used to assess central venous pressure Can be used to assess central venous pressure

(CVP) and cardiac efficiency(CVP) and cardiac efficiency Distended external jugular veins signify increased CVP, as

with heart failure Position the patient at 30-45 degree angle, Position the patient at 30-45 degree angle,

wherever pulsations can be seen best. Remove wherever pulsations can be seen best. Remove pillow to avoid flexion of head.pillow to avoid flexion of head.

The higher the CVP, the higher the position you will needThe higher the CVP, the higher the position you will need Turn the pt’s head away from examiner’s sideTurn the pt’s head away from examiner’s side Distinguish from carotid artery pulsations. Internal Distinguish from carotid artery pulsations. Internal

jugular pulse is lower, varies with respiration, not jugular pulse is lower, varies with respiration, not palpable, and disappears as person is sitting.palpable, and disappears as person is sitting.

Assessing Neck VesselsAssessing Neck Vessels Jugular Venous Pressure EstimateJugular Venous Pressure Estimate

Used to assess heart failureUsed to assess heart failure Position the patient at 30-45 degree angle. Place one Position the patient at 30-45 degree angle. Place one

ruler vertically at the manubriosternal angle. Place a ruler vertically at the manubriosternal angle. Place a second ruler perpendicular to the first and record the second ruler perpendicular to the first and record the height of pulsation of the internal jugular vein.height of pulsation of the internal jugular vein.

Normal pulsation is 2 cm or less above sternal angleNormal pulsation is 2 cm or less above sternal angle Pulsations 3 or more cm above sternal angle while at 45 Pulsations 3 or more cm above sternal angle while at 45

degrees occur with heart failuredegrees occur with heart failure Record height of pulsations and degrees of elevationRecord height of pulsations and degrees of elevation

Question 4Question 4 The examiner has estimated the jugular The examiner has estimated the jugular

venous pressure. Identify the finding that venous pressure. Identify the finding that is abnormal.is abnormal.

1.1. Patient elevated to 30 degrees, internal jugular Patient elevated to 30 degrees, internal jugular vein pulsation at 1 cm above sternal angle.vein pulsation at 1 cm above sternal angle.

2.2. Patient elevated to 30 degrees, internal jugular Patient elevated to 30 degrees, internal jugular vein pulsation at 2 cm above sternal anglevein pulsation at 2 cm above sternal angle



Assessing the HeartAssessing the Heart Apical ImpulseApical Impulse

Apical impulse may or may not be Apical impulse may or may not be seen against the chest wall. (Seen seen against the chest wall. (Seen more in children)more in children)

A A heaveheave or or liftlift is a sustained is a sustained forceful thrusting of ventricle during forceful thrusting of ventricle during systole. Occurs with ventricular systole. Occurs with ventricular hypertrophy. Seen in 4hypertrophy. Seen in 4thth or 5 or 5thth intercostal space, midclavicular line.intercostal space, midclavicular line.

Palpate the apical impulse. May Palpate the apical impulse. May need to ask pt to exhale or to roll to need to ask pt to exhale or to roll to the left.the left.

Location – should occupy only one Location – should occupy only one interspace (4interspace (4thth or 5 or 5thth) and be at or ) and be at or medial to midclavicular linemedial to midclavicular line

Size – normally 1cm x 2cmSize – normally 1cm x 2cm Amplitude – normally a short gentle Amplitude – normally a short gentle

taptap Duration – short, first half of systoleDuration – short, first half of systole

Abnormalities:•Left ventricular dilatation (volume overload) displaces impulse down and left•Left ventricular hypertrophy (pressure overload) increases force and duration but no change in location

Assessing the HeartAssessing the Heart PalpationPalpation

Use the palms of your fingers Use the palms of your fingers to palpate across chest to to palpate across chest to search for any other pulsationssearch for any other pulsations

A A thrillthrill is a palpable vibration. is a palpable vibration. Signifies turbulent blood flow and Signifies turbulent blood flow and accompanies loud murmursaccompanies loud murmurs

PercussionPercussion Used to outline cardiac Used to outline cardiac

bordersborders Not as accurate as X-ray or Not as accurate as X-ray or

echocardiogramechocardiogram Hypertrophy may be due to Hypertrophy may be due to

hypertension, CAD, heart hypertension, CAD, heart failure, cardiomyopathyfailure, cardiomyopathy

AuscultationAuscultation 22ndnd right interspace – right interspace –

Aortic valve areaAortic valve area 22ndnd left interspace – left interspace –

Pulmonic valve areaPulmonic valve area Left lower sternal Left lower sternal

border – Tricuspid border – Tricuspid valve areavalve area

55thth interspace around interspace around midclavicular line- midclavicular line- Mitral valve areaMitral valve area

Move stethoscope in a Z pattern, Aortic Pulmonic

Right Left

Erb’s point

AuscultationAuscultation

Tune out any distractionsTune out any distractions Listen to one sound at a timeListen to one sound at a time

1.1. Note rate and rhythmNote rate and rhythm

2.2. Identify S1 and S2Identify S1 and S2

3.3. Assess S1 and S2 separatelyAssess S1 and S2 separately

4.4. Listen for extra heart soundsListen for extra heart sounds

5.5. Listen for murmursListen for murmurs

Rate and RhythmRate and Rhythm Normal 60-100 beats per minute for adults.Normal 60-100 beats per minute for adults. Rhythm should be regularRhythm should be regular

Sinus arrhythmiasSinus arrhythmias occur normally in young adults occur normally in young adults and children and varies with respiration. Rhythm and children and varies with respiration. Rhythm increases at peak of inspiration, slows with increases at peak of inspiration, slows with expiration.expiration.

Premature beatPremature beat – an early beat. May be isolated – an early beat. May be isolated or patterned – occurs every 3or patterned – occurs every 3rdrd or 4 or 4thth beat. beat.

Pulse deficitPulse deficit – the beats at the apex are not the – the beats at the apex are not the same as at a peripheral pulse. May occur with same as at a peripheral pulse. May occur with atrial fibrillation, premature beats, heart failure.atrial fibrillation, premature beats, heart failure.

Apical rate – Radial rate = Pulse deficit

Developmental Developmental Considerations in Considerations in

Assessment - InfantsAssessment - Infants Fetal shunts normally close within 10-15 Fetal shunts normally close within 10-15

hours, but may take up to 48 hours.hours, but may take up to 48 hours. Cyanosis signals oxygen desaturation and Cyanosis signals oxygen desaturation and

congenital heart diseasecongenital heart disease Heart rate may range from 100-180 bpm Heart rate may range from 100-180 bpm

after birth, then stabilize 120-140 bpmafter birth, then stabilize 120-140 bpm Tachycardia – greater than 200 bpm in Tachycardia – greater than 200 bpm in

newborns and greater than 150 bpm in infantsnewborns and greater than 150 bpm in infants Bradycardia – less than 90 in newborns, less Bradycardia – less than 90 in newborns, less

than 60 in older infants and childrenthan 60 in older infants and children Expect sinus arrhythmia – varied Expect sinus arrhythmia – varied

heartbeat with respirationheartbeat with respiration


Assessment - ChildrenAssessment - Children Slowing of heart rateSlowing of heart rate Physiologic S3 is commonPhysiologic S3 is common Innocent heart murmurs are Innocent heart murmurs are

commoncommon Venous hum (turbulence of blood Venous hum (turbulence of blood

flow in jugular venous system) is flow in jugular venous system) is also commonalso common


Assessment - PregnancyAssessment - Pregnancy Increase in pulse rate of 10-15 bpmIncrease in pulse rate of 10-15 bpm Decrease of blood pressure in 2Decrease of blood pressure in 2ndnd

trimester, rise again in 3trimester, rise again in 3rdrd trimester trimester Increase loudness of S1, S3 heardIncrease loudness of S1, S3 heard Possible appearance of heart Possible appearance of heart

murmurs, which disappear after murmurs, which disappear after pregnancypregnancy


Assessment - AgingAssessment - Aging Rise in systolic BP – arteriosclerosis Rise in systolic BP – arteriosclerosis

and atherosclerosis and atherosclerosis Orthostatic hypotensionOrthostatic hypotension Increase in AP diameter of chestIncrease in AP diameter of chest Systolic murmurs become more Systolic murmurs become more

commoncommon Be careful when palpating carotid Be careful when palpating carotid

artery due to the carotid autonomic artery due to the carotid autonomic reflex causing bradycardia!reflex causing bradycardia!

S1 and S2S1 and S2

S1 is the start of systole and is the S1 is the start of systole and is the reference point for other cardiac reference point for other cardiac soundssounds

Distinguishing S1 from S2Distinguishing S1 from S2 11stst sound of the “LUB – dup” except in sound of the “LUB – dup” except in

tachyarrhythmias tachyarrhythmias S1 is louder than S2 at the apex. S2 is S1 is louder than S2 at the apex. S2 is

louder than S1 at the baselouder than S1 at the base Erb’s point – S1 and S2 heard equallyErb’s point – S1 and S2 heard equally

S1 coincides with carotid artery pulseS1 coincides with carotid artery pulse S1 coincides with R wave on ECG monitorS1 coincides with R wave on ECG monitorAuscultation Assistant

http://www.med.ucla.edu/wilkes/intro.html

S1S1 Caused by closure of the AV valvesCaused by closure of the AV valves AbnormalitiesAbnormalities

Accentuated (loud) S1Accentuated (loud) S1 Hyperkinetic states such as exercise, fever, anemia, Hyperkinetic states such as exercise, fever, anemia,

hyperthyroidismhyperthyroidism Calcification of AV valves - requires increasing Calcification of AV valves - requires increasing

ventricular pressure to close valves against increased ventricular pressure to close valves against increased atrial pressureatrial pressure

Diminished S1Diminished S1 First degree heart block – prolonged PR interval on First degree heart block – prolonged PR interval on

ECG due to delayed conduction from atria to ventriclesECG due to delayed conduction from atria to ventricles Extreme calcification of valves, limiting their mobilityExtreme calcification of valves, limiting their mobility

Split S1Split S1 Mitral and tricuspid components are heard separatelyMitral and tricuspid components are heard separately Normal but uncommon Normal but uncommon

S2S2 Caused by closure of semilunar valves (aortic and Caused by closure of semilunar valves (aortic and

pulmonic)pulmonic) AbnormalitiesAbnormalities

Accentuated S2Accentuated S2 Higher closing pressure due to systemic hypertensionHigher closing pressure due to systemic hypertension Pulmonary hypertensionPulmonary hypertension Aortic or pulmonic stenosis – calcification, still mobileAortic or pulmonic stenosis – calcification, still mobile

Diminished S2Diminished S2 Fall in systemic BP – shockFall in systemic BP – shock Aortic and pulmonic stenosis – calcification, decreased mobilityAortic and pulmonic stenosis – calcification, decreased mobility

Split S2Split S2 Normal. Due to the aortic valve closing 0.06 seconds before the Normal. Due to the aortic valve closing 0.06 seconds before the

pulmonic valve during inspirationpulmonic valve during inspiration Heard only in the pulmonic valve areaHeard only in the pulmonic valve area Paradoxical split – opposite of what you’d expect. Split on Paradoxical split – opposite of what you’d expect. Split on

expirationexpiration

S3S3

Physiologic S3Physiologic S3 Heard frequently in children and young adults, Heard frequently in children and young adults,

disappears when the person sits up.disappears when the person sits up. Pathologic S3 (ventricular gallop)Pathologic S3 (ventricular gallop)

Persists when sitting up and heard after age 40Persists when sitting up and heard after age 40 Occurs because the left ventricle is not very Occurs because the left ventricle is not very

compliantcompliant At the beginning of diastole the rush of blood into the left At the beginning of diastole the rush of blood into the left

ventricle causes vibration of the valve leaflets and the ventricle causes vibration of the valve leaflets and the chordae tendinaechordae tendinae

Occurs with heart failure due to volume overload, Occurs with heart failure due to volume overload, such as mitral, aortic, or tricuspid regurgitationsuch as mitral, aortic, or tricuspid regurgitation

KEN - TUCK - YSHLOSH - ING IN

S4S4

Physiologic S4Physiologic S4 May occur in older adults after exerciseMay occur in older adults after exercise

Pathologic S4 (atrial gallop)Pathologic S4 (atrial gallop) Caused by the relatively rapid filling rate Caused by the relatively rapid filling rate

against a relatively stiff ventricle against a relatively stiff ventricle Occurs with:Occurs with:

Decreased compliance of ventricles (coronary artery Decreased compliance of ventricles (coronary artery disease, cardiomyopathy)disease, cardiomyopathy)

Systolic overload (afterload)Systolic overload (afterload) Aortic stenosisAortic stenosis Systemic hypertensionSystemic hypertension

TEN - NES - SEE‘A - STIFF Heart

Extracardiac SoundsExtracardiac Sounds

Pericardial friction rubPericardial friction rub High pitched, scratchy sound as a result of High pitched, scratchy sound as a result of

inflammation of the pericardiuminflammation of the pericardium Heard best at apex and lower sternal borderHeard best at apex and lower sternal border This sound is usually continuous, and heard This sound is usually continuous, and heard

diffusely over the chest. diffusely over the chest. If the rub completely disappears when the If the rub completely disappears when the

patient holds his breath it is more likely due to patient holds his breath it is more likely due to pleural, not pericardial, origin. pleural, not pericardial, origin.

Common during the 1Common during the 1stst week following a week following a myocardial infarctionmyocardial infarction

Question 5Question 5

The examiner wishes to listen for a The examiner wishes to listen for a pericardial friction rub. Select the best pericardial friction rub. Select the best method for listening:method for listening:

1.1. With the diaphragm, patient sitting up and With the diaphragm, patient sitting up and leaning forward, breath held in expirationleaning forward, breath held in expiration

2.2. Using the bell with the patient leaning Using the bell with the patient leaning forwardforward

3.3. At the base during normal respirationAt the base during normal respiration

4.4. With the diaphragm, patient turned to the With the diaphragm, patient turned to the left sideleft side

Congenital Heart DefectsCongenital Heart Defects

Listening for MurmursListening for Murmurs LoudnessLoudness

Grade i – barely audibleGrade i – barely audible Grade ii – clearly audible, but faintGrade ii – clearly audible, but faint Grade iii – moderately loud, but easy to hearGrade iii – moderately loud, but easy to hear Grade iv – loud, associated with a thrill palpable on the chest Grade iv – loud, associated with a thrill palpable on the chest

wallwall Grade v – very loud, heard with one corner of stethoscope Grade v – very loud, heard with one corner of stethoscope

lifted offlifted off Grade vi – loudest, heard with entire stethoscope lifted off Grade vi – loudest, heard with entire stethoscope lifted off

the chest wallthe chest wall Pitch – high, medium, low. Depends on pressure and Pitch – high, medium, low. Depends on pressure and

rate of blood flowrate of blood flow PatternPattern Quality – musical, blowing, harsh, rumblingQuality – musical, blowing, harsh, rumbling LocationLocation RadiationRadiation PosturePosture

MurmursMurmurs SystolicSystolic

Occur during the Occur during the ventricular ejection ventricular ejection phase of the cardiac phase of the cardiac cycle cycle

Most caused by Most caused by obstruction of the obstruction of the outflow of the outflow of the semilunar valve semilunar valve (aortic, pulmonic) or (aortic, pulmonic) or by incompetent AV by incompetent AV valves (mitral, valves (mitral, tricuspid). tricuspid).

DiastolicDiastolic Occur in the filling Occur in the filling

phase of the cardiac cyclephase of the cardiac cycle Caused by incompetent Caused by incompetent

semilunar valves or semilunar valves or stenotic AV valves stenotic AV valves

Early diastolic murmurs Early diastolic murmurs usually result from usually result from insufficiency of a insufficiency of a semilunar valve or dilation semilunar valve or dilation of the valvular ring.of the valvular ring.

Mid-and late diastolic Mid-and late diastolic murmurs are generally murmurs are generally caused by narrowed, caused by narrowed, stenosed mitral and stenosed mitral and tricuspid valves that tricuspid valves that obstruct blood flow. obstruct blood flow.

Midsystolic Ejection Midsystolic Ejection MurmursMurmurs

Due to forward flow through semilunar

valves

Midsystolic Ejection Midsystolic Ejection MurmursMurmurs

Pansystolic Regurgitant Pansystolic Regurgitant MurmursMurmurs

Due to backward flow of blood from area of higher pressure to one of lower

pressure

Pansystolic Regurgitation Pansystolic Regurgitation MurmursMurmurs

Diastolic Rumbles of AV Diastolic Rumbles of AV ValvesValves

Filling murmurs at low pressures, best heard

with bell lightly touching skin

Diastolic Rumbles of AV Diastolic Rumbles of AV ValvesValves

Early Diastolic MurmursEarly Diastolic MurmursDue to semilunar

valve incompetence

Early Diastolic MurmursEarly Diastolic Murmurs

Heart and Neck Vessels

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