Beruflich Dokumente
Kultur Dokumente
Chapter 19
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Chapter 19: Heart and Neck Vessels
Cardiovascular System
Cardiovascular system consists of heart (a
muscular pump) and blood vessels
Blood vessels are arranged in two continuous
loops
Pulmonary circulation
Systemic circulation
When the heart contracts, it pumps blood
simultaneously into both loops
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Chapter 19: Heart and Neck Vessels
Structure and Function:
Developmental Competence
(cont.)
Infants and children (cont.)
Right and left ventricles equal in weight and
muscle wall thickness and both pumping into
systemic circulation
Inflation and aeration of lungs at birth produces
circulatory changes
Now blood is oxygenated through lungs rather
than through placenta
• Foramen ovale closes within first hour because of new
lower pressure in right side of heart than in left side
• Ductus arteriosus closes within 10 to 15 hours of birth
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Chapter 19: Heart and Neck Vessels
Structure and Function:
Developmental Competence
(cont.)
Infants and children (cont.)
Now, left ventricle has greater workload of
pumping into systemic circulation
• When baby has reached 1 year of age, left ventricle’s
mass increases to reach adult ratio of 2:1, left ventricle to
right ventricle
• Heart’s position in chest is more horizontal in infant than
in adult; thus apex higher, located at fourth left intercostal
space
• Reaches adult position when child is age 7 years
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Chapter 19: Heart and Neck Vessels
Subjective Data
Chest pain Nocturia
Dyspnea Past cardiac history
Orthopnea Family cardiac
Cough history
Fatigue Personal habits
Cyanosis or pallor (cardiac risk factors)
Edema
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Chapter 19: Heart and Neck Vessels
Neck Vessels
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Chapter 19: Heart and Neck Vessels
Objective Data
Precordium
Inspect anterior chest
• Arrange tangential lighting to accentuate any flicker of
movement
• Pulsations: you may or may not see apical impulse,
pulsation created as left ventricle rotates against chest
wall during systole
When visible, it occupies the fourth or fifth intercostal
space, at or inside midclavicular line
Easier to see in children and in those with thinner chest
walls
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Auscultatory Areas
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Chapter 19: Heart and Neck Vessels
Objective Data:
Developmental Competence
Infants
Transition from fetal to pulmonic circulation occurs
in immediate newborn period
• Fetal shunts normally close within 10 to 15 hours but
may take up to 48 hours; thus, you should assess
cardiovascular system during first 24 hours and again in
2 to 3 days
• Note any extracardiac signs that may reflect heart status
(particularly in skin), liver size, and respiratory status
• Skin color should be pink to pinkish brown, depending on
infant’s genetic heritage; if cyanosis occurs, determine
first appearance; at or shortly after birth versus after
neonatal period
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Chapter 19: Heart and Neck Vessels
Objective Data:
Developmental Competence
(cont.)
Infants (cont.)
Normally, the liver is not enlarged, and
respirations are not labored
• Note expected pattern of weight gain throughout infancy
• Palpate apical impulse to fix size and position of heart
• Because infant’s heart has a more horizontal placement,
expect to palpate apical impulse at fourth intercostal
space just lateral to midclavicular line
• Heart rate best auscultated because radial pulses are
hard to count accurately; use small (pediatric size)
diaphragm and bell
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Chapter 19: Heart and Neck Vessels
Objective Data:
Developmental Competence
(cont.)
Infants (cont.)
Heart rate may range from 100 to 180 beats per
minute (bpm) immediately after birth
• Then stabilize to an average of 120 to 140 bpm
• Infants normally have wide fluctuations with activity, from
170 bpm or more with crying or being active to 70 to 90
bpm with sleeping
• Variations are greatest at birth and are even more so
with premature babies
• Expect heart rhythm to have sinus arrhythmia, phasic
speeding up or slowing down with respiratory cycle
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Objective Data:
Developmental Competence
(cont.)
Infants (cont.)
Rapid rates make it more challenging to evaluate
heart sounds
• Expect heart sounds to be louder in infants than in adults
because of infant’s thinner chest wall.
• Also, S2 has a higher pitch and is sharper than S1
• Splitting of S2 just after height of inspiration is common,
not at birth, but beginning a few hours after birth
• Murmurs in immediate newborn period do not
necessarily indicate congenital heart disease
• Murmurs are relatively common in first 2 to 3 days
because of fetal shunt closure
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Objective Data:
Developmental Competence
(cont.)
Infants (cont.)
These murmurs are usually grade i or ii
• They are systolic and accompany no other signs of
cardiac disease, and they disappear in 2 to 3 days
• Murmur of patent ductus arteriosis is continuous
machinery murmur, which disappears by 2 to 3 days
• On other hand, absence of a murmur in immediate
newborn period does not ensure a perfect heart
• Congenital defects can be present that are not signaled
by an early murmur
• Best to listen frequently and to note and describe any
murmur according to characteristics
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Objective Data:
Developmental Competence
(cont.)
Children
Note any extracardiac or cardiac signs that may
indicate heart disease
• Poor weight gain, developmental delay, persistent
tachycardia, tachypnea, dyspnea on exertion, cyanosis,
and clubbing
• Note that clubbing of fingers and toes usually does not
appear until late in 1st year, even with severe cyanotic
defects
• Apical impulse sometimes visible in children with thin
chest walls
• Note any obvious bulge or any heave; these are not
normal
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Objective Data:
Developmental Competence
(cont.)
Children (cont.)
Palpate apical impulse
• Up to age 4: in fourth intercostal space to left of
midclavicular line
• Age 4 to 6: at fourth interspace at midclavicular line
• Age 7: in fifth interspace to right of midclavicular line
• Average heart rate slows as child grows older, although it
is still variable with rest or activity
• Rhythm remains characterized by sinus arrhythmia
• Physiologic S3 is common in children
• Occurs in early diastole, just after S2, and is a dull soft
sound that is best heard at apex
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Objective Data:
Developmental Competence
(cont.)
Children (cont.)
Palpate apical impulse (cont.)
• Venous hum, due to turbulence of blood flow in jugular
venous system, common in healthy children and has no
pathologic significance
Continuous, low-pitched, soft hum heard throughout cycle,
although loudest in diastole
Listen with bell over the supraclavicular fossa at medial
third of clavicle, especially on right, or over upper anterior
chest
• Venous hum is usually not affected by respiration, may
sound louder when the child stands, and is easily
obliterated by occluding jugular veins in neck with fingers
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Objective Data:
Developmental Competence
(cont.)
Children (cont.)
Palpate apical impulse (cont.)
• Heart murmurs that are innocent (or functional) in origin
are very common through childhood
• Some say they have 30% occurrence, and some say
nearly all children may demonstrate murmur
• Most innocent murmurs have these characteristics
Soft, relatively short systolic ejection murmur
Medium pitch; vibratory
Best heard at left lower sternal or midsternal border, with
no radiation to apex, base, or back
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Objective Data:
Developmental Competence
(cont.)
Children (cont.)
Palpate apical impulse (cont.)
• For child whose murmur has been shown to be innocent,
it is very important that parents understand completely
• They need to believe that this murmur is just a “noise”
and has no pathologic significance
• Otherwise, parents may become overprotective and limit
activity for child, which may result in child developing a
negative self-concept
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Objective Data:
Developmental Competence
(cont.)
Pregnant woman
Vital signs usually yield an increase in resting
pulse rate of 10 to 15 bpm and drop in BP from
normal prepregnancy level
• BP decreases to lowest point during second trimester
and then slowly rises during third trimester
• BP varies with position; usually lowest in left lateral
recumbent position, a bit higher when supine, and
highest when sitting
• Inspection of skin often shows a mild hyperemia in light-
skinned women because increased cutaneous blood flow
tries to eliminate excess heat generated by increased
metabolism
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Objective Data:
Developmental Competence
(cont.)
Pregnant woman (cont.)
Palpation of apical impulse is higher and lateral
compared with normal position
• Enlarging uterus elevates diaphragm and displaces heart
up and to left and rotates it on its long axis
• Auscultation of heart sounds shows changes caused by
increased blood volume and workload
• Heart sounds
Exaggerated splitting of S1 and increased loudness of S1
A loud, easily heard S3
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Objective Data:
Developmental Competence
(cont.)
Pregnant woman (cont.)
Palpation of apical impulse (cont.)
• Heart murmurs
Systolic murmur in 90% which disappears soon after
delivery
Soft, diastolic murmur heard transiently in 19%
Continuous murmur from breast vasculature in 10%
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Objective Data:
Developmental Competence
(cont.)
Pregnant woman (cont.)
Palpation of apical impulse (cont.)
• Last-mentioned murmur termed a mammary souffle,
which occurs near term or when mother is lactating
• Due to increased blood flow through internal mammary
artery
• Murmur is heard in 2nd, 3rd, or 4th intercostal space
• Continuous, although it is accented in systole
• You can obliterate it by pressure with stethoscope or one
finger lateral to murmur
• ECG has no changes except for a slight left axis
deviation due to change in heart’s position
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Objective Data:
Developmental Competence
(cont.)
Aging adult
Gradual rise in systolic blood pressure common
with aging
• Diastolic blood pressure stays fairly constant with a
resulting widening of pulse pressure
• Some older adults experience orthostatic hypotension, a
sudden drop in blood pressure when rising to sit or stand
• Use caution in palpating and auscultating carotid artery
Avoid pressure in carotid sinus area, which could cause a
reflex slowing of heart rate
Also, pressure on carotid artery could compromise
circulation if artery is already narrowed by atherosclerosis
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Objective Data:
Developmental Competence
(cont.)
Aging adult (cont.)
When measuring jugular venous pressure, view
right internal jugular vein
• Aorta stiffens, dilates, and elongates with aging, which
may compress left neck veins and obscure pulsations on
the left side
• Chest often increases in anteroposterior diameter with
aging
• This makes it more difficult to palpate apical impulse and
to hear splitting of S2
• S4 often occurs in older people with no known cardiac
disease
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Objective Data:
Developmental Competence
(cont.)
Aging adult (cont.)
Systolic murmurs common, occurring in over 50%
of aging people
• Occasional premature ectopic beats are common and do
not necessarily indicate underlying heart disease
• When in doubt, obtain an ECG
• However, consider that ECG only records for one
isolated minute in time and may need to be
supplemented by a test of 24-hour ambulatory heart
monitoring
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Chapter 19: Heart and Neck Vessels
Sample charting
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 19-122
Chapter 19: Heart and Neck Vessels
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 19-123
Chapter 19: Heart and Neck Vessels
Abnormal Findings:
Systolic Extra Sounds
Ejection click
Aortic prosthetic valve sounds
Midsystolic click
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 19-124
Chapter 19: Heart and Neck Vessels
Abnormal Findings:
Diastolic Extra Sounds
Opening snap
Mitral prosthetic valve sound
Third heart sound
Fourth heart sound
Summation sound
Pericardial friction rub
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Chapter 19: Heart and Neck Vessels
Abnormal Findings:
Abnormal Pulsations: Precordium
Thrill at the base
Lift (heave) at the sternal border
Volume overload at the apex
Pressure overload at the apex
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Chapter 19: Heart and Neck Vessels
Abnormal Findings:
Congenital Heart Defects
Patent ductus arteriosus
Atrial septal defect
Ventricular septal defect
Tetralogy of Fallot
Coarctation of the aorta
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 19-127
Chapter 19: Heart and Neck Vessels
Abnormal Findings:
Murmurs Due to Valvular Defects
Midsystolic ejection murmurs
Aortic stenosis
Pulmonic stenosis
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 19-128
Chapter 19: Heart and Neck Vessels
Abnormal Findings:
Murmurs Due to Valvular Defects
Diastolic rumbles of atrioventricular valves
Mitral stenosis
Tricuspid stenosis
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 19-129