Assessing Clients with Cardiac Disorders I. Background of Anatomy and Physiology A. Heart 1.

Size of adult’s fist, weight < 1 pound 2. Located in mediastinum, between vertebral column and sternum 3. 2/3 of heart mass is left of sternum; upper base is beneath second rib; pointed apex lies approximately with fifth intercostal space, mid-clavicular B. Pericardium 1. Covering of double layered fibroserous membrane, forming pericardial sac 2. Layers of pericardium a. Parietal pericardium: outermost layer b. Visceral pericardium (epicardium) adheres to heart surface 3. Small space between layers is pericardial cavity which contains small amount of serous lubricating fluid that cushions heart as it beats C. Layers of Heart Wall 1. Epicardium: same as visceral pericardium 2. Myocardium: specialized cardiac muscle cells provide bulk of contractile heart muscle 3. Endocardium: sheath of endothelium that is lining inside heart’s chambers and great vessels

Mitral (biscuspid): left side . Four hollow chambers: two upper atria. Tricuspid: right side 2. Right ventricle: receives deoxygenated blood from right atrium and pumps it to lungs for oxygenation via pulmonary artery d. Valves separate each chamber of heart allowing unidirectional blood flow a. Right atrium: receives deoxygenated blood from veins of body 1. Atrioventricular (AV) valves: between atrium and ventricle. Chambers and Valves 1. Coronary sinus: blood from heart b. two lower ventricles. Inferior vena cava: blood from body below diaphragm 3. Superior vena cava: blood from body above diaphragm 2.D. separated lengthwise by interventricular septum a. Left atrium: receives freshly oxygenated blood from lungs via pulmonary veins c. Left ventricle: receives freshly oxygenated blood from left atrium and pumps it to arterial circulation via aorta 2. Flaps of valves anchored to papillary muscles of ventricles by chordae tendineae 1.

b. Heart sounds associated with closure of valves 1. closure of AV valves 2. closure of semilunar valves at onset of relaxation E. Blood pumped out of left ventricle through aorta and major branches to all body tissues F.Systemic Circulation 1.Coronary Circulation (Circulation for heart) 1. Left and right coronary arteries originate at base of aorta and branch out to encircle myocardium . joins right ventricle and pulmonary artery 2. Pulmonary: right side. and blood returns to left atrium through several pulmonary veins 3. Aortic: left side. S1 (“lub”): first heart sound. joins left ventricle and aorta c. oxygen and carbon dioxide are exchanged in capillaries of lungs. Pulmonary circulation begins with right heart: deoxygenated blood from superior and inferior vena cavae is transported to lungs via pulmonary artery and branches 2. S2 (“dub”): second heart sound. In lungs. Semilunar valves: connect ventricles to great vessels 1.

Blood perfuses heart muscle and cardiac veins drain blood into coronary sinus. Cardiac cycle: one heartbeat involving contraction and relaxation of heart 2. During ventricular relaxation coronary arteries fill with oxygen-rich blood 3. Average cardiac output is 4 – 8 liters per minute (L/min) .2. Formula (HR x SV =CO) b. normal ejection fraction is 50% – 70% 7. Systole: phase during which ventricles contract and eject blood into pulmonary and systemic circuits 3. Stroke Volume (SV): volume of blood ejected with each contraction 6. Heart Rate (HR): number of cardiac cycles in a minute (normal 70 –80) 5. atria contract and myocardium is perfused 4. which empties into right atrium G. Cardiac Cycle and Cardiac Output 1. Diastole: phase during which ventricles relax and refill with blood. Cardiac Output (CO): amount of blood pumped by ventricles into pulmonary and systemic circulations in 1 minute a. Ejection Fraction (EF): percentage of total blood in ventricle at the end of diastole ejected from heart with each beat.

Reflex regulation occurs in response to systemic blood pressure through activation of baroreceptors or pressure receptors (located in carotid . Activity level 2. body tissues become ischemic (deprived of oxygen) d. Sympathetic nervous system: increases heart rate 2. Body size e. Cardiac output is influenced by 1. Heart rate: affected by direct and indirect autonomic nervous system stimulation 1.c. Indicator of pump function of heart. Age 5. Cardiac output is determined by interaction of four factors a. Parasympathetic nervous system: decreases heart rate 3. Metabolic rate 3. then cardiac output and tissue perfusion are decreased. Physiologic and psychologic stress responses 4. Cardiac Reserve: ability of heart to respond to body’s changing need for cardiac output 8. if heart is ineffective pump.

aortic arch. Like continuous overstretching of rubber band b. Congestive heart failure 2. Influenced by venous return and ventricular compliance 2. and greater the force with which fibers contract to accomplish emptying 3. Disorders which result in increased preload: 1. Renal disease . Preload: amount of cardiac muscle fiber tension or stretch at the end of diastole (right before contraction of ventricles) 1. Bradycardia decreases cardiac output if stroke volume stays the same b. Starling’s Law of the heart: Greater the volume.sinus. the greater the stretch of cardiac muscle fibers. Physiologic limit to Starling’s Law: overstretching of cardiac muscle fibers results in ineffective contraction a. venae cavae. Very rapid heart rate decreases cardiac output and coronary artery perfusion due to decreased filling time 5. pulmonary veins) 4.

Pressure in arterial system ahead of ventricles a. Afterload: force the ventricles must overcome to eject their blood volume 1. Alterations in vascular tone affect afterload and ventricular work a.3. Vasoconstriction c. work of ventricles increases and consumption of myocardial oxygen increases . eject its volume into lowpressure pulmonary arteries: Pulmonary Vascular Resistance (PVR) b. Decreased circulating blood volume 2. Disorders which result in decreased preload: 1. Left ventricle: ejects load by overcoming pressure behind aortic valve: systemic vascular resistance (SVR). much greater than right ventricle 2. Right ventricle: generates enough tension to open pulmonary valve. As PVR and SVR increase. Hemorrhage 3. Third-spacing c.

Reduces forward flow of blood from heart b. Very low afterload decreases forward flow of blood into systemic and coronary circulation d. Cardiac muscle cells have inherent characteristic of self-excitation: can initiate and transmit impulses independent of stimulus b.b. Increases ventricular pressure from accumulated blood volume c. Conduction System of Heart a. Poor contractility a. Acts as normal pacemaker of heart b. Reduces cardiac output 2. Conduction system 1. Sinoatrial (SA) node: located junction of superior vena cavae and right atrium a. Inherent rate: 60 – 100 times/minute . Increased contractility: overtaxes heart 9. Contractility: inherent capability of cardiac muscles fibers to shorten 1.

creates action (electrical) potential 2. Impulse travels through bundle of His at atrioventricular junction and down interventricular septum through right and left bundle branches out to Purkinje fibers in ventricular muscle walls c. Exchange of sodium. Ion exchange reverses. repolarization (cardiac muscle relaxes) . fibers of AV node slightly delay transmission to ventricles 3. Impulse travels across atria via internodal pathways to Atrioventricular (AV) node: located floor of interatrial septum. cell returns to resting state. potassium.2. and calcium ions across cell membrane. intracellular electrical state: positive charge. electrical state: negative. Path of electrical transmission produces series of changes in ion concentration across membrane of each cardiac muscle cell 1. Electrical stimulus: increases permeability of cell membrane. depolarization (myocardial contraction) 3.

Explore client history for a.10. Cardiac output adjusted for client’s body size. Cardiac Index a. Associated symptoms 3. Severity f. Location b. Timing d. Angina 2. More accurate indicator of ability of heart to effectively circulate blood c. Health assessment interview to collect subjective data 1. Congestive Heart Failure (CHF) .2 L/min/m2 II. Aggravating and relieving factors g.5 – 4. Description of client’s symptoms regarding a. BSA is stated in square meters (m2). which is the Body Surface Area (BSA) b. Quality or character c. Heart disorders 1. Normal CI is 2. Assessing Cardiac Function A. Setting or precipitating factors e. Explore client’s chief complaint 2. Myocardial infarction (Heart attack) 3. Cardiac index calculated by dividing cardiac output by BSA: CI = CO ÷ BSA d.

Congenital heart disease 7. Difficulty breathing. Stroke 4. Scarlet fever 3. Previous heart surgeries or related illnesses 1. Bleeding disorders 3. HTN 3. Fatigue . Shortness of breath c. Client family history for specific heart conditions 1. Palpitations e.4. Hyperlipidemia 5. Endocrine disorders d. Diabetes Mellitus 2. Chest pain b. Recurrent streptococcal throat infection c. Rheumatic fever 2. cough d. Valvular Disease b. Past or present occurrence of cardiac symptoms a. Pertinent other chronic illnesses 1. Sudden death 4. Coronary artery disease (CAD) 2. Hypertension (HTN) 5. Diabetes Mellitus 6.

Blood clots i. duration. fluids c. Personal habits and nutritional history a. stress 10. efforts to quit 7. Personality type 13. interruptions due to dyspnea. discomfort.f. Light-headedness or fainting g. Perception of health or illness. Body weight b. Apical impulse assessment with abnormal findings a. Physical assessment to collect objective data 1. recreation and relaxation habits 9. Restrictions. Eating patterns: usual intake of fats. Swelling 5. Use of street drugs. urination. Heart murmur h. efforts to quit 8. Psychosocial factors 12. Use of tobacco products. amount. food intolerances d. compliance with treatment B. Use of alcohol and caffeine 6. Activity level and tolerance. type. salt. Pillows used to sleep 11. Positioning lateral to midclavicular line or below fifth left intercostals space: enlarged or displaced heart . type. cough. Sleep patterns.

diaphragmatic hernia. duration of point of maximal impulse (PMI) 1. Thrill (palpable vibration over precordium or artery): severe valve stenosis g. gastric distention. anemia d. chronic lung disease i. Decreased amplitude: dilated heart in cardiomyopathy e. Increased amplitude alone: hyperkinetic states. hyperthyroidism. heave): pulmonary stenosis. Left ventricular volume overload (increased preload): HTN.b. Marked increase in amplitude of PMI at right ventricular area: right ventricular volume overload in atrial septal defect h. pulmonary hypertension. chronic lung disease f. Increased size. amplitude. Increase in amplitude and duration with right ventricular pressure overload (also lift. Palpable thrill: ventricular septal defect 2. Pressure overload (increased afterload): aortic or mitral regurgitation c. aortic stenosis 2. anxiety. Displacement alone: dextrocardia. Subxiphoid area .

Cardiac rate and rhythm with abnormal findings a. atrial septal defect e. Palpable second heart sound (S2 ): systemic HTN 3.a. pulmonary HTN. Increased pulsation at aortic area: aortic aneurysm f. Heart rate< 60: bradycardia c. Pulse deficit (Radial pulse < than apical when checked simultaneously): weak ineffective contractions of left ventricle d. Heart sounds assessment with abnormal findings a. Accentuated pulsation at pulmonary area: hyperkinetic states c. atrial fibrillation e. Gradual increase and decrease in heart rate correlated with respirations: sinus arrhythmia 4. Heart rate > 100: tachycardia b. S1 . Downward pulsation: right ventricular enlargement b. Thrill: aortic or pulmonary stenosis. Irregular rhythm: frequent ectopic beats such as premature ventricular beats. Prominent pulsation: increased flow or dilation of pulmonary artery d.

right ventricular failure b. obesity. conditions of pulmonary HTN (mitral stenosis. hyperthyroidism 2. Splitting: right bundle branch block. Midsystolic: mitral valve prolapse (MVP) . CAD. pulmonary or systemic HTN. CHF. Accentuation: tachycardia. S2 1. emphysema. Extra heart sounds in systole 1. Diminishment: aortic stenosis. Fixed: atrial septal defect. premature ventricular contractions b. excitement. Paradoxical: left bundle branch block c. pulmonary stenosis. increased anterioposterior chest diameter 3. Accentuation: HTN. states of high cardiac output such as fever. exercise. CHF. Diminishment: mitral regurgitation.1. Splitting: a. exercise. shock. pericardial effusion 3. Clicks: aortic and pulmonic stenosis 2. cor pulmonale) 2.

Pericardial friction rub: inflammation of pericardial sac as with pericarditis 5. Extra heart sounds in diastole: Opening snap: opening sound of a stenotic mitral valve e. ventricular septal defect . Murmur assessment with abnormal findings a. Midsystolic murmurs: aortic and pulmonic stenosis. Pansystolic (holosystolic) murmurs: mitral and tricuspid regurgitation. S4 (right-sided): less common. aortic stenosis. Combined S3 and S4 (summation gallop): severe CHF i. CAD.d. S3 (ventricular gallop): myocardial failure and ventricular volume overload (CHF. hypertrophic cardiomyopathy b. mitral or tricuspid regurgitation) f. occurs with pulmonary HTN and pulmonary stenosis h. S4 (atrial gallop): increased resistance to ventricular filling after atrial contraction (HTN. cardiomyopathy) g.

Continuous murmurs throughout systole and all or part of diastole: patent ductus arteriosus . Middiastolic and presystolic murmurs: mitral stenosis f.c. Early diastolic murmur: aortic regurgitation e. Late systolic murmur: MVP d.