HA - Heart

• CCU

  Coronary Care Unit
• Cardiovascular system


  • Highly complex, consisting of the heart and a closed system of blood vessels
  • To collect accurate data and correctly interpret it, the examiner must have an understanding of the structure and function of the heart, the great vessels, the electrical conduction system of the heart, the cardiac cycle, the production of heart sounds, cardiac output (CO), and the neck vessels
• Heart


  Hollow, muscular, four-chambered (left and right atria, and left and right ventricles) organ located in the middle of the thoracic cavity between the lungs in the space called the mediastinum
• Heart

  • About the size of a clenched fist and weighs approximately 255 g (9 oz) in women and 310 g (10.9 oz) in men
  • Extends vertically from the left second to the left fifth intercostal space (ICS) and horizontally from the right edge of the sternum to the left midclavicular line (MCL)
  • Can be described as an inverted cone, with the upper portion (near the left second ICS) as the base and the lower portion (near the left fifth ICS and the left MCL) as the apex
• Precordium


  The anterior chest area that overlies the heart and great vessels
• Pulmonary circulation


  1. The right side of the heart pumps blood to the lungs for gas exchange by removing CO2 from blood and replenishing oxygen supply

  2. Occurs between alveoli and the blood of lungs
• Systemic circulation


  1. The left side of the heart pumps blood to all other parts of the body

  2. Perfusion occurs when blood flows to tissues and organs promoting the diffusion of oxygen and carbon dioxide
• Great vessels


  The large veins and arteries leading directly to and away from the heart
• Great vessels

  • Superior vena cava
  • Inferior vena cava
  • Pulmonary artery
  • Pulmonary veins
  • Aorta
• Heart chambers and valves

  • The heart consists of four chambers: two upper chambers (right and left atria) and two lower chambers (right and left ventricles)
  • The right and left sides of the heart are separated by a partition called the septum
  • The thin-walled atria receive blood returning to the heart and pump blood into the ventricles
  • The thicker-walled ventricles pump blood out of the heart
  • The left ventricle is thicker than the right ventricle because the left side of the heart has a greater workload
• Heart valves

  • Atrioventricular (AV) valves: Tricuspid valve (between right atrium and right ventricle), Bicuspid (mitral) valve (between left atrium and left ventricle)
  • Semilunar valves: Pulmonic valve (at entrance of pulmonary artery), Aortic valve (at beginning of ascending aorta)
• Function of heart valves

  1. Open AV valves allow blood to flow from the atria into the ventricles

  2. As the ventricles begin to contract, the AV valves snap shut, preventing the regurgitation of blood into the atria

  3. The semilunar valves are open during ventricular contraction and close from the pressure of blood when the ventricles relax, preventing backward flow into the relaxed ventricles
• Heart covering and walls

  • Pericardium: Tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart
  • Epicardium: Serous membrane covering the outer surface of the heart
  • Myocardium: Thickest layer of the heart, made up of contractile cardiac muscle cells
  • Endocardium: Thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels
• Cardiac muscle cells


  Have a unique inherent ability to spontaneously generate an electrical impulse and conduct it through the heart
• Cardiac conduction system

  1. Sinoatrial (SA) node generates impulses that are conducted over both atria, causing them to contract simultaneously and send blood into the ventricles

  2. The impulse is then conducted to the atrioventricular (AV) node, which slightly delays the impulse before relaying it to the AV bundle (bundle of His)

  3. The electrical impulse then travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles, causing them to contract almost simultaneously
• Electrocardiography (ECG/EKG)


  Measures and records the electrical activity generated by the cardiac conduction system and detected on the surface of the skin
• Phases of the ECG

  • P, Q, R, S, and T
• Steps of Health Assessment

  1. Collection of subjective data (Interview and Health History)

  2. Collection of objective data (PE)

  3. Validation of data

  4. Documentation of data
• Subjective (symptoms)


  Sensations or symptoms (ex. Pain, hunger), feelings (happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client
• Objective (signs)


  Information about the client that the nurse directly observes during interaction and information elicited through physical assessment (examination) techniques
• Complete Health History


  • Biographic Data
  • Reason/s for seeking health
  • History of present health concern
  • Past health history
  • Family health history
  • ROS for current health problem
  • Lifestyle and health practices
• Physical Examination

  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Cardiac cycle


  1. Filling and emptying of the heart's chambers

  2. Phases: diastole (relaxation of the ventricles, filling) and systole (contraction of the ventricles, emptying)

  3. Diastole endures for approximately 2/3 s of the cardiac cycle and systole is the remaining 1/3
• Heart sounds

  1. Closure of the AV valves (mitral and tricuspid) produces the first heart sound (S1), which is the beginning of systole

  2. Closure of the semi-lunar valves (pulmonic and aortic valves) produces the 2nd heart sound (S2), which signals the end of the systole
• Normal heart sounds

  Characterized as "lubdubb" (S1 and S2)
• Extra heart sounds

  • Diastolic filling sounds, results from ventricular vibration secondary to rapid ventricular filling
  • S3 (heard early in diastole) is ventricular gallop
  • S4 (heard late in the diastole) is atrial gallop
• Murmurs


  Turbulent blood flow producing swooshing and blowing sound auscultated over the precordium (increased blood velocity, structural valve defects, valve malfunctions, abnormal chamber openings)
• Auscultating Heart Sounds

  • Aortic area – 2nd ICS at the right sternal border – the base of the heart
  • Pulmonic area – 2nd or 3rd ICS at the left sternal border- the base of the heart
  • Erb point – 3rd ICS at the left sternal border
  • Tricuspid area – 4th or 5th ICS at the left lower sternal border
  • Mitral or apical area – 5th ICS at the left sternal border
• The 4 valve areas do not reflect the anatomic location of the valves, rather, they reflect the way in which heart sounds radiate to the chest wall; sounds always travel in the direction of the blood flow
• Other areas to auscultate

  • Aortic area – right 2nd ICS to apex of the heart
  • Pulmonic area – 2nd and 3rd left ICS close to the sternum but may be higher or lower
  • Left atrial area – 2nd to 4th ICS at the left sternal border
  • Right atrial area – 3rd to 5th ICS at the right sternal border
  • Left ventricular area – 2nd to 5th ICS, extending from the left sternal border to the MCL
  • Right ventricular area – 2nd to 5th ICS, centered over the sternum
• How to Auscultate

  1. Position at the client's right side

  2. Client should be supine with the upper trunk elevated 30 degrees

  3. Use the diaphragm of the stethoscope to auscultate all areas of the precordium for high-pitched sounds

  4. Use the bell of the stethoscope to detect (differentiate) low-pitched sounds or gallops

  5. Apply the diaphragm firmly to the chest but apply the bell lightly

  6. Focus on one sound at a time as you auscultate each area of the precordium

  7. Start by listening to the heart's rate and rhythm

  8. Then identify first and the 2nd heart sounds

  9. Concentrate on each heart sound individually

  10. Listen for extra heart sounds

  11. Listen for murmurs

  12. And finally listen with the client in different positions
• The bell is most effective at transmitting lower frequency sounds, while the diaphragm is most effective at transmitting higher frequency sounds
• Cardiac output


  The amount of blood pumped by the ventricles during a given period of time (usually 1 minute) and is determined by the stroke volume (SV, amount of blood pumped from the heart with each contraction) multiplied by the heart rate (HR): CO = SV x HR (normal adult CO is 5-6 L/min)
• Neck Vessels


  • Carotid artery
  • Jugular veins
• Carotid artery


  • Located in the groove between the trachea and the right and left sternocleidomastoid muscles, slightly below the mandible; a centrally located arterial pulse; they supply the neck and head
  • Because it is close to the heart, the pressure wave pulsation coincides closely with ventricular systole
  • Good for assessing the amplitude and contour of the wave pulse; should normally have a smooth, rapid upstroke that occurs in early systole and a more gradual downstroke
• Jugular veins


  • Important in determining the hemodynamics of the right side of the heart
  • Return blood to the heart from the head and neck by way of the superior vena cava
  • The level of the jugular venous pressure reflects right atrial (central venous) pressure, and usually, right ventricular diastolic filling pressure
  • Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure
  • Decreased jugular venous pressure occurs with reduced left ventricular output or reduced blood volume
• History of Present Health Concern (COLDSPA)

  • Chest Pain
  • Tachycardia and palpitations
  • Fatigue
  • Dyspnea
  • Fluid accumulation in the lungs
  • Dizziness
  • Nocturia
  • Edema
  • Heart burns
• Personal Health History

  • Heart defect or a murmur
  • Rheumatic fever
  • Heart surgery or cardiac balloon interventions
  • Previous ECG result
  • Blood test (lipid profile)
  • Compliance with medication
  • Monitoring own HR or BP
• Lifestyles and Health Practices

  • Smoking
  • Stress
  • Diet
  • Alcohol
  • Exercise
  • Performance of daily activities
• Medication non-compliance

  May not take them regularly (diuretics due to urinating frequently, Beta-blockers because of the adverse effects on sexual energy)