Heart and Peripheral Vascular

System
Chapter 18
 Anatomy and Physiology:
Cardiac Cycle
• Systole (ventricles contracting)
– Pressure in ventricles greater than atrial pressure,
causing AV valve closure (prevent backflow of
blood)
– Pressure in ventricles greater than pressure in
great vessels, semilunar valves open, allowing
blood to flow into great vessels
• Ejection of blood decreases pressure in ventricles –
semilunar valves close
 Anatomy and Physiology
Cardiac Cycle
• Systole (ventricles contract): mitral/tricuspid
valves close
– First heart sound: S1 (lub)
• Ventricles almost empty: pulmonic/aortic valves
close
– Second heart sound: S2 (dub)
• Ventricular contraction: increased pressure –
aortic pressure increases as blood flows into
aorta
• S1-S2 heard during cardiac cycle; S3-S4 abnormal
 Heart and Peripheral Vascular
System: General Health History
• Present health status
– Chronic illnesses? (describe)
– Taking medications (what/when), side effects; OTC
drugs (aspirin, herbs, cocaine, street drugs; how
often)?
– Exercise: (yes), what/frequency/time?; (no), ever,
what tried, motivated to start/stop?
– Personality type, handle stress? Work factors
(physical/emotional), relaxation (frequency, what?)
– Eating habits (red meat, fat, sodium), whole
grains?
 Heart and Peripheral Vascular
System: General Health History

• Alcohol (type/frequency), caffeine

• Smoke (now/past) what forms, how
long, ever quit (successful?); yes, how
accomplished; no, want to quit?
• Know how smoking affects CV system?
 Heart and Peripheral Vascular
System
• Past medical history
– Congenital heart disease/defect, “growing pains,”
joint pains, recurrent tonsillitis, rheumatic fever,
murmur?
– Increased triglyceride/cholesterol levels, coronary
artery disease (treated, lifestyle changes)?
– Heart/vascular surgery (what/when, success?)
– Heart tests (ECG, stress), when results, any
treatment?
 Heart and Peripheral Vascular
System
• Family history
– History of DM, heart disease, hyperlipidemia,
increased BP, sudden death syndrome
• Problem-based history (symptom analysis)
– Chest pain
• Where feeling, radiate, severity, feel like?
• When started, intermittent or constant?
• Other symptoms?
• What precedes, makes worse or better, what
relieves?
 Health History: Heart and
Peripheral Vascular System
Problem-based history (cont.)
– Shortness of breath
• How long, SOB now, when, how often, lasts how
long?
• Interfere with ADL, walk how many blocks (now or
6 months ago)?
• Other symptoms?
• What makes worse, how many pillows to sleep?
• What makes breathing easier?
 Health History: Heart and
Peripheral Vascular System
• Urinating during the night
– How long, times/night?
– What done to prevent, successful?
• Cough
– When started, frequency, productive, looks
like, any blood?
– Associated with position, anxiety, talking,
activity; what makes worse or relieves?
 Health History: Heart and
Peripheral Vascular System
• Fatigue
– When notice, onset gradual/sudden, worse in am/pm,
work/home, keeping up with friends, too tired to
participate, rest reduce, bed earlier because too tired?
– Vitamins/iron pills, eat foods with iron, heavy menstrual
flow (females)?
– Other symptoms (increased heart rate, HA, pale, sore
tongue/lips, nail changes)
– Unusual feelings in hands, muscle weakness, trouble
thinking
 Health History: Heart and
Peripheral Vascular System
• Fainting
– Last time occurred, doing what before
fainted (dizzy or lose consciousness)?
– Happened before, how often, preceded by
other symptoms?
 Health History: Heart and
Peripheral Vascular System
• Swelling of feet and legs
– First notice, both legs, what makes go away?
– Concomitant symptoms; have pain/sores?
– Female: contraceptives, associated with
period?
• Leg cramps or pain
– Describe, legs feel heavier; location, severity?
– What makes better or worse?
– Changes in skin of legs?
 Examination

• General appearance
– Evaluate general condition; lying supine at
45 degrees
• Peripheral vascular: measure blood
pressure
Examination: Peripheral Vascular

• Upper extremities
– Inspect/palpate for skin turgor or integrity
– Inspect and palpate for appearance, color,
temperature, and capillary refill
– Palpate brachial and radial pulses: rate
rhythm, amplitude, contour
 Examination: Peripheral Vascular
• Lower extremities
– Inspect and palpate for skin turgor/integrity
– Inspect and palpate for appearance, color
temperature, hair distribution, capillary refill,
and superficial veins
– Palpate femoral, popliteal, posterior tibial,
dorsalis pedis pulses for amplitude
– Homan’s Sign
 Examination: Cardiac
• Inspect anterior chest wall for contour,
pulsations, lifts heaves, retractions
• Palpate apical pulse for location
• Palpate precordium for pulsations,
thrills, lifts, heaves
• Percuss heart borders for heart size
• Auscultate S1-S2 heart sounds for rate,
rhythm, pitch, splitting
• Interpret ECG of conduction of heart
 Age-Related Variations: Infants

• Anatomy and physiology

– Oxygenation of fetus through placenta
(nonfunctional lungs)
– Foramen ovale: opening between atria; shunts
blood to L side
• Closes from incresed L atrial pressure (first hour)
– Ductus arteriosus: blood pumped from R ventricle
into aorta
• Closes within 10 to 15 hours after birth
 Age-Related Variations: Infants

• Health history
– Mother’s health during pregnancy: rubella,
fever, infections, drugs (OTC, Rx, illicit)?
– Breathing changes: more rapid/heavy
(feeding, bowel movement); feeding, tire
easily, take breaks, turn blue around mouth
(feeding/crying); gaining weight/growing?
– Tire easily while playing; naps—how long?
 Age-Related Variations:
Older Adults
• Health history
– Experienced confusion, dizziness, blackouts,
fainting, palpitations?
– Short of breath, fatigued, confused,
abdominal or back pain, fainter?
• Examination: procedures and techniques
– Same as for younger adult
 Common Problems or
Conditions: Cardiac Disorders
• Angina pectoris: chest pain from ischemia
– Atherosclerosis common cause: occurs during
activity, stress, cold (increased demand on
heart); at rest from coronary artery spasm
– May occur without atherosclerosis:
(hypertrophy, valve disease, increased
metabolic demands)
– Incidence: 6.6 million; more common in
females than males (age adjusted)
 Common Problems or
Conditions: Cardiac Disorders
• Pain: squeezing, suffocating, constricting;
may have HTN (also hypotension)
• Accompanied by gallop rhythm, systolic
murmur, dysrhythmias (supraventricular)
• Duration significant
– Exertion with resting: less than 3 minutes
– Heavy meal or anger: 15 to 20 minutes
– More than 30 minutes: unusual (unstable angina,
developing infarction)
 Common Problems:
Cardiac Disorders
• Severe myocardial ischemia results in necrosis
(infarction)
• MI from coronary artery disease: single leading
cause of death in United States (1 in 5 deaths)
• 1.1 million new or recurrent cases each year;
44% die
• L ventricle most common; may affect R ventricle
 Common Problems or
Conditions: Cardiac Disorders
• Pain described as worse ever, more than 5
minutes; radiate (L shoulder, jaw, arm); not
relieved by nitroglycerin
• Dysrhythmias common; heart sounds distant;
thready pulse
• Women have different symptoms: fatigue, sleep
disturbance, shortness of breath
– Less than 30% reported chest pain before infarction
 Common Problems or
Conditions: Cardiac Disorders
• Heart failure: failure of ventricles to pump
blood efficiently
 Common Problems or
Conditions: Cardiac Disorders
• Thrombus forms where endocardium
damaged
– May break away; become emboli, causing
infarctions or abscesses in lungs, brain
kidneys, spleen, extremities
• Heart sounds normal; in late infection,
murmur if valve damaged
 Common Problems or
Conditions: Vessel Disorders
• Hypertension: based on mean of 2 or more,
BP readings on each of 2 or more
occasions
– Normal values: <120 systolic, <80 diastolic
– Cause unknown; increases workload of heart
– No specific symptoms
 Common Problems or
Conditions: Vessel Disorders
• Venous thrombosis or thrombophlebitis:
development of clot in vein; inflammation
without clot
– Stasis, vein damage, hypercoagulability
predispose to thrombosis or thrombophlebitis
– Lower extremity: deep veins
• Dilated, superficial veins, edema redness, ed
circumference of leg
– Upper extremity: superficial veins
• Redness, warmth tenderness; may be visible or
palpable
 Common Problems or
Conditions: Vessel Disorders

• Involved extremities pale, cold, increased

capillary refill
• Skin ulcers and gangrene fingers or toes
from ischemia
• Symptoms worse with cold or emotional
stress
 Common Problems or
Conditions: Vessel Disorders
• Aneurysm: dilation of artery from weakness in
arterial wall (aorta, iliac vessels)
• Thoracic: asymptomatic; some report deep,
diffuse chest pain
• Aortic or arc: hoarseness (pressure on laryngeal
nerve); dysphagia (esophageal pressure)
• Abdominal aortic: most common; asymptomatic,
discovered on routine exam/ultrasound, CAT scan
– Pulsatile mass in periumbilical area with thrill or bruit