Chapter 20
, Chapter 20: Heart & Neck Vessels
●Pericardium: tough, fibrous, double-walled sac that surrounds
and protects heart
● Myocardium: muscular wall of heart
● Endocardium: thin layer of endothelial tissue that lines inner
surface of heart chambers and valves
●Heart extends from the 2nd rib - 5th intercostal space
●Heart Exam:
○Maintain warm room
○Place pt supine to assess precordium
○Have pt sit during carotid assessment
●Aortic valve is most common site of pathology
●A heave/lift is a palpable mass on the chest that is a sign of
ventricular hypertrophy
○Right heave = left sternal border
○Left heave = apex of heart
○Lifting impulse on left sternal border = pulmonic HTN
●AV valves: tricupid & mitral
●Semilunar valves: pulmonic & aortic valves
●Heart Sounds:
○First Heart Sound (S1):
■Closure of AV Valves
■The "lub" sound marks the beginning of systole
■Best heard at the mitral area
■Use diaphragm
○Second Heart Sound (S2):
, ■Closure of Semilunar Valves
■The "dub" sound marks the end of systole
■Loudest at the aortic and pulmonic areas
■Use diaphragm
○Third Heart Sound (S3):
■Ventricular Gallop
■Occurs in early diastole during ventricular filling
■Creates a "Ken-tuc-ky" rhythm pattern.
■S3 is normal until heard in a person aged 40 or older
■Use bell
■Causes of pathological S3: Decreased ventricular
compliance (heart failure) — Volume overload from valve
regurgitation — High cardiac output (anemia, pregnancy,
or thyrotoxicosis)
○Fourth Heart Sound (S4):
■ Atrial Gallop
■Occurs at the end of diastole, just before S1
■Creates a "Ten-nes-see" rhythm pattern
■S4 is always considered abnormal
■Use bell
■Causes of S4: Left ventricular hypertrophy from HTN
or aortic stenosis — Acute MI — CAD — In elderly
patients due to age-related decreased ventricular
compliance.
●Murmurs:
○Always abnormal
○Increased flow velocity: Exercise, fever, hyperthyroidism,
or anxiety
○Decreased blood viscosity: Anemia reduces blood thickness
○Structural abnormalities: Valve stenosis, valve
regurgitation, septal defects, or chamber dilation
○Graded on a scale of 1-6 (1 is most faint)
, ●Cardiac Output: SV x HR — normal is 4-8L/min
●Stroke Volume: amount of blood ejected with each heartbeat —
60-100mL per beat
●Preload: volume of blood filling the ventricles during diastole,
stretching the cardiac muscle fibers.
○Frank-Starling law: increased stretch leads to more
forceful contraction, resulting in increased stroke volume and
cardiac output (i.e. how much vessels must stretch to
accommodate blood, can compensate until it can't no more)
●Afterload: pressure the ventricle must overcome to open the
aortic valve and eject blood.
●The greater the preload, the greater the SV.
●Increased afterload results in decreased SV
●The internal jugular vein provides right atrial pressure making
it valuable for assessing volume status and cardiac function.
●Aging Adult Changes:
○Arterial stiffening
○Left ventricular wall thickness increases
○Pulse pressure widens
○atrial fibrillation
●Patients with DM II must be taught how to manage their BGL
due to the negative effects it has on the heart
●Orthopnea: patients should be asked how many pillows they
require to be able to sleep comfortably
●Nocturia: Patients should be asked if they are awake to urinate
at night. Recumbency at night promotes fluid resorption and
, Chapter 20: Heart & Neck Vessels
●Pericardium: tough, fibrous, double-walled sac that surrounds
and protects heart
● Myocardium: muscular wall of heart
● Endocardium: thin layer of endothelial tissue that lines inner
surface of heart chambers and valves
●Heart extends from the 2nd rib - 5th intercostal space
●Heart Exam:
○Maintain warm room
○Place pt supine to assess precordium
○Have pt sit during carotid assessment
●Aortic valve is most common site of pathology
●A heave/lift is a palpable mass on the chest that is a sign of
ventricular hypertrophy
○Right heave = left sternal border
○Left heave = apex of heart
○Lifting impulse on left sternal border = pulmonic HTN
●AV valves: tricupid & mitral
●Semilunar valves: pulmonic & aortic valves
●Heart Sounds:
○First Heart Sound (S1):
■Closure of AV Valves
■The "lub" sound marks the beginning of systole
■Best heard at the mitral area
■Use diaphragm
○Second Heart Sound (S2):
, ■Closure of Semilunar Valves
■The "dub" sound marks the end of systole
■Loudest at the aortic and pulmonic areas
■Use diaphragm
○Third Heart Sound (S3):
■Ventricular Gallop
■Occurs in early diastole during ventricular filling
■Creates a "Ken-tuc-ky" rhythm pattern.
■S3 is normal until heard in a person aged 40 or older
■Use bell
■Causes of pathological S3: Decreased ventricular
compliance (heart failure) — Volume overload from valve
regurgitation — High cardiac output (anemia, pregnancy,
or thyrotoxicosis)
○Fourth Heart Sound (S4):
■ Atrial Gallop
■Occurs at the end of diastole, just before S1
■Creates a "Ten-nes-see" rhythm pattern
■S4 is always considered abnormal
■Use bell
■Causes of S4: Left ventricular hypertrophy from HTN
or aortic stenosis — Acute MI — CAD — In elderly
patients due to age-related decreased ventricular
compliance.
●Murmurs:
○Always abnormal
○Increased flow velocity: Exercise, fever, hyperthyroidism,
or anxiety
○Decreased blood viscosity: Anemia reduces blood thickness
○Structural abnormalities: Valve stenosis, valve
regurgitation, septal defects, or chamber dilation
○Graded on a scale of 1-6 (1 is most faint)
, ●Cardiac Output: SV x HR — normal is 4-8L/min
●Stroke Volume: amount of blood ejected with each heartbeat —
60-100mL per beat
●Preload: volume of blood filling the ventricles during diastole,
stretching the cardiac muscle fibers.
○Frank-Starling law: increased stretch leads to more
forceful contraction, resulting in increased stroke volume and
cardiac output (i.e. how much vessels must stretch to
accommodate blood, can compensate until it can't no more)
●Afterload: pressure the ventricle must overcome to open the
aortic valve and eject blood.
●The greater the preload, the greater the SV.
●Increased afterload results in decreased SV
●The internal jugular vein provides right atrial pressure making
it valuable for assessing volume status and cardiac function.
●Aging Adult Changes:
○Arterial stiffening
○Left ventricular wall thickness increases
○Pulse pressure widens
○atrial fibrillation
●Patients with DM II must be taught how to manage their BGL
due to the negative effects it has on the heart
●Orthopnea: patients should be asked how many pillows they
require to be able to sleep comfortably
●Nocturia: Patients should be asked if they are awake to urinate
at night. Recumbency at night promotes fluid resorption and
