HEART AND NECK

• Heart


  Hollow, muscular organ located in mediastinum with four chambers: left atrium and ventricle, right atrium and ventricle; two atrioventricular valves, two semilunar valves; three layers: epicardium, myocardium, endocardium
• The pulmonary artery carries blood to the lungs, not the left atrium
• Cardiac cycle


  Generation and conduction of electrical impulses by cardiac muscle cells that regulates the filling and emptying of the cardiac chambers

  
• Cardiac cycle


  • Sinoatrial node, AV node, AV bundle (bundle of His), Purkinje fibers

  
• Depolarization


  Na channel opens first, Na goes in, less negative charge inner environment, contraction of cardiac muscles (myocardium)
• Repolarization


  K channel opens, K goes out, more negative charge inner environment, relaxation of cardiac muscles (myocardium)
• Electrocardiogram (ECG)


  Records depolarization and repolarization of the heart

  
• Phases of ECG


  • P wave (atrial depolarization)
  • PR interval (beginning of atrial depolarization to beginning of ventricular depolarization)
  • QRS complex (ventricular depolarization)
  • ST segment (period between ventricular depolarization and beginning of ventricular repolarization)
  • T wave (ventricular repolarization)
  • QT interval (total time for ventricular depolarization and repolarization)
  • U wave (final phase of ventricular repolarization)
• Cardiac cycle


  • Diastole (relaxation of ventricles, "filling", 60-80 mmHg, 2/3 of cycle)
  • Systole (contraction of ventricles, "emptying", 100-120 mmHg, 1/3 of cycle)

  
• S1 heart sound


  Closure of AV valves during ventricular contraction, correlates with beginning of systole

  
• S2 heart sound


  Closure of semilunar valves during ventricular relaxation, correlates with beginning of diastole

  
• S3 heart sound


  Early in diastole, ventricular vibration during 2nd rapid ventricular filling, "ventricular gallop"

  
• S4 heart sound


  Ventricular resistance (non compliance) during atrial contraction, "atrial gallop"

  
• Heart murmurs


  Turbulent blood flow with a swooshing or blowing sound, caused by increased blood velocity, structural valve defects, valve malfunction, or abnormal chamber openings

  
• Information to collect in history

  • History of present health concern (chest pain, palpitations)
  • Past health history
  • Family history
  • Lifestyle and health practices
• Physical examination


  Inspect pulsations, palpate apical impulse and abnormal pulsations, auscultate heart rate and rhythm, detect irregular rhythm and pulse rate deficit

  
• Traditional areas of heart auscultation

  • Aortic area (2nd ICS, RSB)
  • Pulmonic area (2nd or 3rd ICS, LSB)
  • Erb's point (3rd ICS, LSB)
  • Mitral (apical) area (5th or 6th ICS, left MCL)
  • Tricuspid area (4th or 5th ICS, left LSB)
• Carotid artery


  Extends from brachiocephalic trunk, supplies oxygenated blood to neck, head and brain, pulse coincides with ventricular systole

  
• Jugular vein


  Internal (deep, medial to sternocleidomastoid, above clavicle), external (superficial, lateral), carries unoxygenated blood from neck, head and brain to SVC

  
• Equipment for heart and neck vessels assessment

  • Stethoscope with bell and diaphragm
  • Small pillow
  • Penlight or movable examination light
  • Watch with second hand
  • Centimeter rulers
• Pulsus alternans has a regular rhythm
• Physiologic murmur is caused by a temporary increase in blood flow, not associated with physical abnormality
• Apical impulse


  Furthest outward and downward point at which the cardiac pulsation is easily palpable

  
• Diastole


  Relaxation of ventricles, known as "filling", endures for approximately two-thirds of the cardiac cycle
• Systole


  Contraction of ventricles, known as "emptying", endures for remaining one-third of the cardiac cycle
• Closure of AV valves produces S1 heart sound, closure of semilunar valves produces S2 heart sound
• Conditions that can create turbulent blood flow and heart murmurs include increased blood velocity, structural valve defects, valve malfunction, and abnormal chamber openings
• In older clients, the apical impulse may be difficult to palpate due to increased anteroposterior chest diameter
• Murmur characteristics

  • Timing
  • Shape
  • Radiation
  • Location
  • Intensity
  • Pitch
  • Quality
• Timing


  Whether the murmur is a systolic or diastolic murmur
• Shape


  The intensity over time; murmurs can be crescendo, decrescendo or crescendo-decrescendo
• Radiation


  Where the sound of the murmur radiates. The general rule of thumb is that the sound radiates in the direction of the blood flow
• Location


  Where the heart murmur is auscultated best. There are 6 places on the anterior chest to listen for heart murmurs

  
• Intensity


  The loudness of the murmur, and is graded on a scale from 0-6/6
• Pitch


  Low, medium or high and is determined by whether it can be auscultated best with the bell or diaphragm of a stethoscope
• Murmur quality

  • Blowing
  • Harsh
  • Rumbling
  • Musical
• Jugular Venous Pressure


  Direct communication with the Right Atrium
• Carotid arteries


  • Carry oxygen-rich blood away from the heart to the head and body
  • Supply the large, front part of the brain, where thinking, speech, personality and sensory and motor functions reside
• Carotid bruit


  An abnormal sound from the heart, in synchronization with the heartbeat, indicating fatty buildup (atherosclerosis) in the carotid artery wall

  
• Thrill


  A vibrating sensation like the purring of a cat or water running through a hose, frequently accompanies a bruit