Heart and Neck Vessel

• The cardiovascular system plays an important role in the body
• The cardiovascular system


  • Delivers oxygenated blood
  • Removes waste products
• Autonomic nervous system


  Controls how the heart pumps
• Vascular network


  The arteries, veins, capillaries that carry blood throughout the body, keep the heart filled with blood and maintain blood pressure
• The heart


  • Cone-shaped muscle with four chambers
  • A double pump about the size of a clenched fist (12 cm long and 9 cm wide) 250–390 g (8.8 13.8 oz) in adult males 200–275 g (7.0–9.7 oz) in adult females
  • Pumps blood throughout circulatory system
• Heart Chambers, Valves and Circulatory Flow

  1. RIGHT ATRIUM receives DEOXYGENATED blood from the body via the superior and inferior vena cavae

  2. RIGHT VENTRICLE receives blood from the right atrium and pumps it to the lungs via the pulmonary artery

  3. LEFT ATRIUM receives OXYGENATED blood from the lungs via four pulmonary veins

  4. LEFT VENTRICLE receives OXYGENATED blood from the lungs via the left atrium pumps blood into the systemic circulation via the aorta - the largest and most muscular chamber
• Atrioventricular Valves


  • TRICUSPID VALVE located on the right side of the heart, has three leaflets and prevents backflow of blood from the right ventricle to the right atrium
  • BICUSPID (MITRAL) VALVE located on the left side of the heart, has two leaflets and prevents backflow of blood from left ventricle to the left atrium
• Semilunar Valves


  • PULMONIC SEMILUNAR VALVE lies between the right ventricle and the pulmonary artery and prevents backflow of blood from pulmonary trunk to the right ventricle
  • AORTIC SEMILUNAR VALVE lies between the left ventricle and the Aorta prevents backflow of blood from the aorta into the left ventricle
• Heart Sounds


  Produced by valve closure, therefore, opening of valve is silent
• Normal Heart Sounds


  • S1 - "lub" - the result of closure of the atrioventricular (AV) valves - the TRICUSPID VALVE and the MITRAL VALVE - correlates with the beginning of systole - heard at the base and apex of the heart, softer at the base, louder at the apex (best heard)
  • S2 - "dubb" - results from closure of the semilunar valves - the AORTIC VALVE and the PULMONIC VALVE - correlates with the beginning of DIASTOLE - best heard at the base of the heart
• Extra Heart Sounds


  • S3 & S4 - diastolic filling sounds - result from ventricular vibration secondary to rapid ventricular filling
  • S3 - ventricular gallop - can be heard early in diastole, after S2, when the mitral valve opens
  • S4 - atrial gallop - results from ventricular vibrations secondary to ventricular resistance during atrial contraction - can be heard late in diastole, just before S1
  • Murmurs - Blood NORMALLY flows silently through the heart - In conditions of an audible and prolonged sounds, murmurs are auscultated over the precordium, a swooshing or blowing sound resulting from turbulence created within the vascular system - Conditions that contributes to turbulent blood flow includes increased blood velocity, structural valve defects, valve malfunction, and abnormal chamber opening (septal defect) - increased flow through normal blood vessels, creating frictional, audible sounds flow through constricted blood vessels (e.g., aortic stenosis) - flow of blood into a dilated blood vessel from one of normal size
• Cycles of Heart Sounds
• Auscultating Heart Sounds


  • The Traditional 5 Areas - Aortic Area, Pulmonic Area, Erb's point, Mitral (Apical), Tricuspid Area - the 4 valve areas do not reflect the anatomical position of the valves - sounds always travel in the direction of the blood flow - the areas described in the traditional auscultation overlaps extensively and sounds produced by the valves can be heard all over the precordium
  • The Alternative Areas - AORTIC AREA, PULMONIC AREA, LEFT ATRIAL AREA, RIGHT ATRIAL AREA, LEFT VENTRICULAR AREA, RIGHT VENTRICULAR AREA
• Korotkoff's Sounds


  • Phase I: A faint, clear, rhythmic tapping noise that gradually increases in intensity
  • Phase II: A swishing sound that is heard as the vessel distends with blood
  • Phase III: Sounds become more intense, Vessel is open in systole but not in diastole
  • Phase IV: Sounds begin to muffle, and pressure is closest to diastolic arterial pressure
  • Phase V: Sounds disappear because vessel remains open
• ASSESSMENT PROPER


  1. You will use all four techniques of physical assessment to assess the cardiovascular system - Inspection, Palpation, Percussion, Auscultation

  2. Perform the assessment in 3 positions - sitting, supine, and left lateral
• Inspection - Neck


  • Differentiate carotid arteries and jugular veins - Normal: Carotids have visible pulsation, Jugulars have undulated wave, Carotids have palpable pulsations, Jugulars are obliterated, Carotids not affected by respirations, jugulars are, Carotids not affected by position, Jugulars normally only visible when client is supine - Deviations from normal: Large, bounding visible pulsation in neck of suprasternal notch - HTN, aortic stenosis, or aneurysm, Abnormal venous waveforms - Giant A waves - Tricuspid stenosis, right ventricular hypertrophy - cor pulmonale, Absent A wave - atrial fibrillation
• Inspection - Precordium


  • Look for pulsations on the precordium, paying particular attention to the apex area - Normal: Positive pulsation at apex, May note slight pulsations over base in thin adults and children - Deviations from normal: Pulsations may occur to right of sternum, epigastric area, sternoclavicular areas - AORTIC ANEURYSM, Apical pulsation displaced toward axillary line - left ventricular hypertrophy
• Palpation - Carotid Artery


  Lightly palpate each carotid separately - Note rate, rhythm, amplitude, contour, symmetry, elasticity, thrills
• Palpation - Jugular Veins

  1. Palpate jugular veins and check direction of fill - 3 ways: 1. Occluding under the jaw, the jugular should flatten, but the wave form will become more prominent - Assessing Jugular Flow: Compress jugular below jaw, Jugular vein collapses and jugular wave is more prominent at supraclavicular area

  2. Occluding above the clavicle, the jugular normally distends while the jugular wave diminishes - Checking Jugular Fill: Compress jugular above clavicle, Jugular distends and jugular wave disappears

  3. Test
• Deviations from normal include pulsations to the right of sternum, epigastric area, and sternoclavicular areas
• AORTIC ANEURYSM


  Apical pulsation displaced toward axillary line due to left ventricular hypertrophy
• Palpation of Carotid Artery

  1. Lightly palpate each carotid separately

  2. Note rate

  3. Note rhythm

  4. Note amplitude

  5. Note contour

  6. Note symmetry

  7. Note elasticity
• Palpation of Jugular Veins

  1. Palpate jugular veins and check direction of fill

  2. Occlude under the jaw, the jugular should flatten but the wave form will become more prominent

  3. Occlude above the clavicle, the jugular normally distends while the jugular wave diminishes

  4. Position patient at 45-degree angle, place hands over the midabdominal area and apply 20 to 30 mm Hg of pressure for 15 to 30 sec, look at the jugular veins for increase vein distension and return to normal upon release of pressure
• Deviations from normal cardiac rate

  • Cardiac Rate >100 bpm: Sinus tachycardia, Supraventricular tachycardia (SVT), Paroxsymal tachycardia (PAT), Uncontrolled atrial fibrillation, Ventricular tachycardia
  • Cardiac Rate <60 bpm: Sinus bradycardia, heart block
• Causes of tachycardia include CHF drugs, atropine, nitrates, epinephrine, isoproterenol, nicotine and caffeine
• Causes of bradycardia include MI drugs, digoxin, quinidine, procainamide, and beta-adrenergic inhibitors
• Causes of irregular rhythm

  • Arrhythmia
  • Obstruction or occlusion
  • Right-sided CHF
  • Tricuspid regurgitation
  • Tricuspid stenosis
  • Constrictive pericarditis
  • Cardiac tamponade
  • Inferior vena cava obstruction
  • Hypervolemia
• Precordium


  Area of the chest wall overlying the heart
• Normal Apex (left ventricular area)


  • PMI is 1–2 cm
  • Negative thrills
  • Amplitude may normally be increased in high-output states such as exercise
  • Apical pulsation may not always be palpable
  • Left lateral displacement of PMI may occur during the last trimester of pregnancy
• Normal LLSB (tricuspid area)


  • May not be palpable, although small, nonsustained, systolic impulse may be palpated, especially in thin patients
  • Negative thrills
• Normal Epigastric area


  • Positive slight pulsation may be normal, no diffusion
  • Palpations not palpable at base left (pulmonic area) and base right (aortic area), except in thin patients
• Abnormal precordium findings


  • Enlargement and displacement of PMI to left midaxillary line due to ventricular hypertrophy with dilation
  • Apical impulse located on right side of precordium due to dextrocardia
  • Enlarged apical pulsation without displacement >2–2.5 cm with patient supine or >3 cm with patient in left lateral recumbent position due to ventricular enlargement, HTN, aortic stenosis
  • Sustained pulsation due to hypertrophy, HTN, overload, or cardiomyopathy
• Deviations from normal precordium findings

  • Thrills due to murmur
  • Palpable lifts or heaves due to right ventricular hypertrophy
  • Pulsations felt on the fingertips may come from the right ventricle, indicating right ventricular hypertrophy
  • Large diffuse epigastric pulsation due to abdominal aortic aneurysm
  • Accentuated pulsation in pulmonic area due to pulmonary HTN
  • Accentuated pulsation in aortic area due to HTN or aneurysm
• Percussion of precordium


  • Dullness at 3rd, 4th, and 5th ICS to left of sternum at MCL
  • Left sternal border extends to midaxillary lines in an enlarged, dilated heart
• Auscultation of Neck


  1. Have client hold breath

  2. Auscultate the carotid with the bell portion of the stethoscope for bruits

  3. Auscultate the jugulars with the bell portion of the stethoscope for venous hums
• Normal neck auscultation


  • Positive carotid bruit may be normal in children and is associated with high-output states
  • Negative venous hum
  • Positive venous hum may be normal in children
• Abnormal neck auscultation


  • Bruit suggests carotid stenosis
  • Murmurs can also radiate up to the neck from the heart, as in aortic stenosis
• Auscultation of Precordium


  1. Auscultate at apex

  2. Note rate, rhythm, extra sounds, or murmurs

  3. Auscultate at each site (apex, LLSB, Erb's point, base left and base right)

  4. Note S1, S2, extra sounds, or murmurs

  5. Listen at each site with both the bell and the diaphragm

  6. The diaphragm is best for detecting high-pitched sounds

  7. The bell is best for detecting low-pitched sounds

  8. Use firm pressure with the diaphragm and light pressure with the bell
• Normal Apex (Mitral) auscultation

  • Rate depends on age
  • Rhythm is regular with S1 S2, high-pitched systolic, short duration, no extra sounds
  • Physiological S3 and S4 may be heard in children and young adults without heart disease
• Deviations from normal Apex (Mitral) auscultation

  • Bradycardia rates 60 BPM or tachycardia rates 100 BPM
  • Irregular rhythm: Arrhythmia
  • Quadruple rhythm, S3 S4 with fast rate is called a summation gallop