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Chapter 14

The Cardiovascular System

Anatomy and Physiology


Location of the Heart and Great
Vessels

Anatomy and Physiology


(contd)

Location of the Heart and Great


Vessels

Anatomy and Physiology


(contd)

Cardiac Chambers, Valves, and


Circulation

Anatomy and Physiology


(contd)

The cardiac cycle


Ventricular pressures
Systole: period of
ventricular contraction
Diastole: period of
ventricular relaxation

Anatomy and Physiology


(contd)

The cardiac cycle (contd)


Valve openings and closings

Anatomy and Physiology


(contd)

The cardiac cycle (contd)


Valve openings and closings (contd)

Anatomy and Physiology


(contd)

The splitting of heart sounds


Split S2

Anatomy and Physiology


(contd)

The splitting of heart sounds


Split S1
Earlier mitral and later tricuspid
Heard throughout precordium
Loudest at cardiac apex
Softer tricuspid best at lower left sternal border
Does not vary with respiration

Anatomy and Physiology


(contd)

Heart Murmurs

Anatomy and Physiology


(contd)

Relation of Auscultatory Findings to


the Chest Wall

Anatomy and Physiology


(contd)

Conduction
system
SA node
AV node
Bundle of His
Bundle branches
Purkinje fibers

Anatomy and Physiology


(contd)

Conduction system (contd)

Anatomy and Physiology


(contd)

Conduction system (contd)

Anatomy and Physiology


(contd)

The heart as a pump


Cardiac output: volume of blood ejected from each ventricle in one
minute
Stroke volume: volume of blood ejected with each heartbeat
Preload: the load that stretches the cardiac muscle before
contraction
Myocardial contractility: ability of cardiac muscle when given a
load, to contract or shorten
Afterload: degree of vascular resistance to ventricular contraction

Anatomy and Physiology


(contd)

Arterial pressure
Factors influencing arterial pressure
Left ventricular stroke volume
Distensibility of the aorta and the large arteries
Peripheral vascular resistance, particularly at
the arteriolar level
Volume of blood in the arterial system

Anatomy and Physiology


(contd)

Jugular venous pressure


Reflects right atrial
pressure
Best estimated from right
internal jugular vein
Right external jugular
vein useful for estimating
CVP

Anatomy and Physiology


(contd)

Jugular Venous Pressure (contd)

The Health History


Common or concerning symptoms
Chest pain
Pain or discomfort radiating to the neck, left shoulder or arm, and back
Nausea
Diaphoresis
Arrhythmias: skipped beats, palpitations
Dyspnea
Orthopnea

The Health History


(contd)

Common or concerning symptoms (contd)


Paroxysmal nocturnal dyspnea
Cough
Edema
Nocturia
Fatigue
Cyanosis
Pallor

The Health History


(contd)

Assessing cardiac symptoms


Chest pain
Angina pectoris, coronary artery disease,
myocardial infarction, acute coronary syndrome

Palpitations
Heart skipping, racing, fluttering, pounding

Shortness of Breath
Dyspnea, orthopnea, paroxysmal nocturnal
dyspnea

The Health History


(contd)

Assessing cardiac symptoms (contd)


Cough
Heart failure, fine crackles and rales

Edema
Dependent edema, congestive heart disease,
hypoalbuminemia

Nocturia
Dependent edema, clears at night when patient
supine

The Health History


(contd)

Assessing cardiac symptoms (contd)


Fatigue
Signals heart is not adequately supplying
oxygen

Cyanosis or pallor
Poor oxygenation of body

Past History
Heart problems?
Heart disease?
Murmurs?
Congenital heart disease/defect?
Rheumatic fever?
Hypertension?
Elevated cholesterol or triglycerides?
Diabetes?

Family History

Coronary artery disease?


Hypertension?
Sudden death younger than 60?
Stroke?
Diabetes?
Obesity?

Lifestyle Habits

Nutrition
Smoking
Alcohol
Exercise
Medications, over-the-counter drugs,
herbs, nutritional supplements

Physical Examination
Preparation of the patient
Comfortable and calm
Explain procedure
Examination gown (opened in the front)
Assist to examining table
Cover with drape
Perform examination from patients right side

Physical Examination
(contd)

Equipment
Stethoscope with a bell and diaphragm
Sphygmomanometer
Two 15-cm rulers
Watch with second hand
Examination light for tangential lighting

Physical Examination
(contd)

Blood pressure and heart rate


Review measurements recorded from General Survey and Vital
Signs.
Repeat if needed.
Refer to Table 14-1.

Face
Color: cyanosis, pallor
Orbital edema
Anxiety: occurs during myocardial infarctions

Physical Examination
(contd)

Great vessels of the neck


Carotid artery pulse
Amplitude and contour

Physical Examination
(contd)

Great vessels of the neck


Carotid artery pulse
Thrills and bruits

Brachial artery

Physical Examination
(contd)

Great vessels of the neck


Jugular venous pressure
Head of bed: elevated 30 degrees
Hypovolemic: may need to be flat
Hypervolemic: may need to be higher
Note height of head of bed in record

Physical Examination
(contd)

Jugular venous pressure (contd)


Refer to page 359.

Physical Examination
(contd)

Hepatojugular reflux
If heart failure is present, jugular
venous pressure will remain
elevated.

Physical Examination
(contd)

The heart
Positioning patient
Supine
Turning to left side
Sitting and leaning forward

Correlate findings with jugular venous


pressure and carotid pulse.

The Physical Examination


(contd)

Sequence of the Cardiac Examination

Physical Examination
(contd)

The heart (contd)


Inspection
Apical pulse
See Table 14-3.
Palpation

Physical Examination
(contd)

Apical Pulse

Physical Examination
(contd)

Apical pulse
(contd)
Location
Diameter

Physical Examination
(contd)

Apical Pulse (contd)

Physical Examination
(contd)

The heart (contd)


Percussion
Rarely used to estimate cardiac size
X-rays, ECG, and echocardiography provide
more accurate measurements

Physical Examination

(contd)
The heart (contd)

Auscultation
Overview
Know your stethoscope

Physical Examination
(contd)

The heart (contd)


Inching your stethoscope
Importance of timing S1 and S2

Physical Examination
(contd)

Physical Examination
(contd)

The heart (contd)


Listening for heart sounds
S1 (see Table 14-4)
S2 (see Table 14-5)
Split S2
Extra sounds in systole (see Table 14-6)
Extra sounds in diastole (see Table 14-7)
Systolic and diastolic murmurs (see Tables 14-8 thorugh 14-11)

Physical Examination
(contd)

The heart (contd)


Correctly identifying heart murmurs
Tips for identifying heart murmurs
Time the murmur.
Locate where it is the loudest
Conduct any necessary maneuvers
Shape
Grade intensity
Associated features

Physical Examination
(contd)

Peripheral edema
Inspect feet, ankles, and legs.
May indicate heart failure
To be covered in detail in Chapter 15

Integrating cardiovascular assessment


Correlate complaints with findings.
Put together information to form hypothesis of patient
complaints.

Recording Your Findings


Structures
Colors
Auscultations
Pulsations
Palpations
Heart sounds

Health Promotion
Topics
Coronary heart disease
Stroke prevention
Hypertension prevention and management
Hyperlipidemia prevention and
management

Health Promotion
(contd)

Key roles for nurse


Screening patients for disease and risk factors
Teaching patients relationship of risk factors to
disease
Educating patients on lifestyle changes to reduce risk
factors
Encouraging patients to adhere to healthy lifestyles
and medical regimens to reduce the incidence of
disease morbidity

Health Promotion
(contd)

Blood Pressure Classification

Health Promotion
(contd)

Risk reduction
Coronary heart disease risk factors
Modifiable risk factors
Diabetes
Systolic and/or diastolic hypertension
Smoking
Obesity
Physical inactivity

Health Promotion
(contd)

Risk reduction (contd)


Coronary heart disease risk factors
(contd)
Nonmodifiable factors
Increasing age
History of cardiovascular disease
Family history of early heart disease

Health Promotion
(contd)

Hypertension risk factors


Modifiable risk factors
Obesity
Physical inactivity
Smoking
Microalbuminuria
Excess dietary sodium
Insufficient intake of potassium
Excess alcohol consumption

Health Promotion
(contd)

Hypertension risk factors (contd)


Nonmodifiable factors
Age
Family history of hypertension or CVD

Health Promotion
(contd)

Risk factors used to assess the 10-year


coronary heart disease risk score
Age
Gender
Height, weight, waist circumference (of BMI)
Smoking
History of cardiovascular disease or diabetes

Health Promotion
(contd)

Risk factors used to assess the 10-year


coronary heart disease risk score (contd)
Systolic and diastolic blood pressure
Total cholesterol, LDL, and HDL cholesterol
Triglycerides
Family history of early heart disease

Health Promotion
(contd)

Health Promotion
(contd)

Healthy Lifestyles

Health Promotion

(contd)
Healthy Lifestyles
(contd)

Health Promotion
(contd)

Healthy eating
Healthy fats
Foods high in monounsaturated fat
Foods high in polyunsaturated fat
Foods high in omega-3

Health Promotion
(contd)

Healthy eating (contd)


Unhealthy Fats
Foods high in trans fat
Foods high in cholesterol
Foods high in saturated fat

Health Promotion
(contd)

Counseling about weight and exercise


Dietary factors are associated with 4 of the 10 leading
causes of death.
Discuss principles of healthy eating.
Encourage exercising, at least 30 minutes on most
days of the week.
Evaluate any cardiovascular, pulmonary, or
musculoskeletal conditions before selecting an
exercise regimen.

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