Assessment of the heart

• Heart


  The major pumping organ of the body. In resting adult the heart contracts 60 – 100 times while pumping 4 – 5 liters of blood per minute
• Location of the heart

  It is located in the thoracic cavity between the lungs and above the diaphragm in an area known as mediastinum
• Parts of the heart

  • Base - uppermost portion which includes the left and right atria as well as the aorta, pulmonary arteries and superior vena cava and inferior cava
  • Apex – lower portion which extends into the left thoracic cavity covering the heart to appear as if it is lying on the right ventricle
  • Pericardium – heart and roots of the great vessels lie within a sac which is composed of fibrous and serous layers
• Serous layers of the pericardium

  • Parietal – lies close to the fibrous tissue
  • Visceral – lies against the actual heart muscle; epicardium
• Pericardial fluid


  A small space that contains approximately 20 – 50 ml of pericardial fluid; serves to facilitate the movement of the heart muscle and protect it via its lubricant effect
• Chambers of the heart

  • Right and Left atria – interatrial septum
  • Right and Left ventricle – interventricular septum
• Right atria


  The collection point for the blood returning from the systematic circulation for reoxygenation in the lungs
• Left atria


  Receives freshly oxygenated blood via the 4 pulmonary veins which are the only veins in the blood that carry oxygenated blood
• Heart valves


  • Atrioventricular valve (AV valves) – prevent it from prematurely entering the ventricles
  • Tricuspid valve – named from its 3 flaps/cusps; AV valve between the RA and RV
  • Bicuspid/mitral valve – named from its 2 flaps or cusps; AV valve between LA and LV
  • Semilunar valves/outflow valves because blood exists the heart through them
  • Pulmonic valve - the blood flow from the RV to the pulmonary vasculature for oxygenation
• Normal heart


  They open as atrial pressure increases with progressive filling
• Excitation of the heart

  • SA Node – normal pacemaker of the heart and located about 1 mm below the right atrial epicardium
  • AV Node – the intranodal atrial pathways conduct the impulse initiated in the SA node to AV node via the myocardium of the RA
  • Three intranodal pathways: Anterior, Middle and Posterior tract
  • AV node – also known as AV junction which delays the impulse received from the atria before transmitting it to the ventricle
  • Bundle Branch System – composed of: Right bundle branch – carries the impulse down the right side of the interventricular septum into the RV, Left bundle branch – separates into 3 fascicles that relay the impulse to the LV, Purkinje fibers – arising from the distal portions of the bundle branches transmit the impulses into the subendocardial layers of both ventricles
• General Approach to Heart Assessment

  1. Explain to the patient what you are going to do

  2. Ensure that the room is warm, quite and well – lit

  3. Expose the patient's chest only as much as is needed to the assessment

  4. Position the patient in a supine or sitting position

  5. Stand to the patient's right side
• Health History


  • AGE: Childhood onset: rheumatic fever, Adult onset: HTN, CAD, MI, CVA, AAA
  • GENDER: Female and Male
  • RACE: may predispose to higher risk for CVA, CAD, HTN, DM
• Common chief complaints


  • Chest pain
  • Syncope
  • Palpitations
  • Peripheral edema
  • Extremity pain
• Past health history


  • Medical : Cardiac specific: AAA, angina, cardiogenic shock, chest trauma, Non – cardiac specific
  • Surgical: Previous cardiovascular procedures
• Common medications


  • Antianginals/vasodilators, Antihypertensives, Inotropic, Antidysrhythmic, Antilipemic, Thrombolytics, Anticoagulants, Diuretics
• Family health history


  • Aneurysm, HTN, CVA, MI or sudden cardiac death, CAD, MVP
• Social history


  • Alcohol, drug or tobacco use, Sexual practices, Travel history, Work and home environment, Hobbies and leisure activities, Stress
• Health Maintenance Activities


  • Sleep, Stress management, Exercise, use of safety devices, Diet, Health check – ups
• Risk Factors


  • Fixed : age, gender, race, family history, Modifiable: HTN, hyperlipidemia, tobacco use, glucose intolerance, physical inactivity, diet, stress, sedentary lifestyle, obesity
• Gerontological considerations


  Decreased size of heart muscle, Atria and ventricles become fibrotic and sclerotic, Decreased cardiac output, Change in heart position, Obesity, Vessels become fibrotic and rigid
• Assessment of the precordium

  The area on the anterior surface of the body overlying the heart, great vessels, pericardium and some pulmonary tissue
• The 5 cardiac landmarks and its location

  • Aortic area - Second Intercostal space to the right of the sternum
  • Pulmonic area - Second intercostals space to the left of the sternum
  • Erb's Point or Midprecordial area - Third intercostals space to the left of the sternum
  • Tricuspid area or septal area - Fifth intercostals space to the left of the sternum
  • Mitral area or Apical area or Point of Maximal impulse - Fifth intercostals space at the left midclavicular line
• Mitral area


  Correlates anatomically with the apex of the heart
• Aortic and pulmonic area


  Correlates anatomically with the base of the heart
• Assessment of the aortic area

  Lightly place your index finger on the angle of Louis, Move your finger laterally to the right of the sternum to the rib. This is the 2nd rib, Move your finger down beneath the second rib to the ICS. The aortic area is located in the 2nd ICs to the right of the sternum
• Normal aortic area


  No pulsations should be visible
• Abnormal aortic area


  Visible Pulsations
• Assessment of the pulmonic area


  Lightly place your index finger on the left second ICS, The pulmonic area is located at the 2nd ICS to the left of the sternum
• Normal pulmonic area

  No pulsations should be visible
• Abnormal pulmonic area


  Visible Pulsations
• Assessment of the Erb's Point or Midprecordial area


  Lightly place your index finger on the left ICS, Continue to move your finger down the left rib cage counting the 3rd rib and 3rd ICS, The Erb's point is located at the 3rd ICS left sterna border
• Normal Erb's Point or Midprecordial area


  No pulsations should be visible
• Abnormal Erb's Point or Midprecordial area


  Visible Pulsations
• Assessment of the Tricuspid area


  Lightly place your index finger on the left third ICS, Continue to move your finger down the left rib cage counting the 4th rib, the 4th ICS and the 5th rib followed by the 5th ICS, The tricuspid area is located at the 5th ICS left of the sternal border
• Normal


  No pulsations should be visible
• Abnormal


  Visible pulsations
• General approach to auscultation


  Explain to the patient what you are going to do, Expose the chest as much as needed for the assessment, Position the patient in supine or sitting position, Stand to the patient's right side, Use the correct headpiece of the stethoscope, Warm the headpiece in your hands prior to touching the patient, Listen to all 4 valvular cardiac landmarks at least twice, Listen for at least a few cardiac cycles 10 to 15 seconds each area
• Assessment of the Mitral or Apical area


  Lightly place your index finger on the left 5th ICS, Move your finger laterally to the Midclavicular line. This is the mitral area. In a large breasted patient have the patient displace the left breast upward and to the left so you can locate the mitral landmark
• Normal mitral or apical area


  Visibly pulsates during systole since the left ventricle lies close enough to the skin's surface