Term
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Definition
| Area on the chest wall overlying the heart & great vessels |
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Term
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Definition
| Middle 3rd of the thoracic cage |
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Term
| What is the apex of the heart? |
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Definition
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Term
| What is then base of the heart? |
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Definition
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Term
| What are the great vessels? |
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Definition
Located above the base of the heart
Superior/Inferior Vena Cava
Pulmonary Arteries/Veins
Aorta |
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Term
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Definition
– Valves between the atria & ventricles, RAV valve – tricuspid, LAV valve – bicuspid/mitral; AV valves open during diastole, allowing ventricles to fill with blood
Tricuspid/Bicuspid |
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Term
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Definition
Valves between the ventricles and arteries, Rt side – pulmonic, Lt Side – aortic, SL valves open during systole, allowing blood to be ejected from the heart
Location where valves are heard best:
Pulmonic/Aoritic |
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Term
| Where can you hear the Aortic valve best? |
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Definition
| 2nd ICS, right sternal border |
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Term
| Where can you hear the pulmonic valve best? |
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Definition
| 2nd ICS, left sternal border |
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Term
| Where can you hear the tricuspid valve best? |
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Definition
| 5th ICS, left lower sternal border |
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Term
| Where can you hear the mitral valve the best? |
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Definition
| 5th ICS, left midclavicular line |
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Term
| What is the direction of blood flow in the heart? |
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Definition
Blood flows from liver & lower extremities into the inferior vena cava. Blood flows from head & upper extremities into the superior vena cava. Blood flows from the vena cava into the RA. From RA, venous blood travels through the tricuspid valve to the RV.
From RV, venous blood flows through pulmonic valve to the pulmonary artery. The pulmonary artery delivers the unoxygenated blood to the lungs.
Lungs oxygenate the blood. Pulmonary veins return the freshly oxygenated blood to the LA.
From LA, oxygenated blood travels through the mitral valve to the LV. The LV ejects blood through the aortic valve into the aorta.
Aorta delivers the oxygenated blood to the body. |
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Term
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Definition
Relaxation.
Ventricles relax, & fill with blood
- Takes up ⅔ of cardiac cycle
- AV valves are open (tricuspid/mitral), pressure in the atria is higher than in the ventricles, blood pours rapidly into the ventricles |
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Term
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Definition
- Contraction of the heart
- Blood is pumped from ventricles & fills the pulmonary & systemic arteries
- Takes up ⅓ of cardiac cycle
- Ventricular pressure is higher than atrial pressure due to the amount of blood in the ventricles, the AV valves swing shut.
- The closure of the AV valves is the S1 heart sound- signals the beginning of systole.
- The AV valves close to prevent any regurgitation of blood back up into the atria during contraction
- For a brief moment, all valves are closed. Then the ventricular walls contract forcing the blood through the SL valves (aortic/pulmonic), after the ventricle’s contents are ejected, the pressure falls.
- This causes the SL valves to close. This closure causes the S2 heart sound, signalling the end of systole. |
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Term
| What are the events in the L and R side of the heart? |
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Definition
- Same events are happening in the R & L side of the heart
- Pressure in the R side is much lower than in the L
- Events occur slightly later in the R side- due to myocardial depolarization resulting in two distinct components to each of the heart sounds exist.
- With S1, the mitral valve closes just before the tricuspid valve
- With S2, the aortic valve closes just before the pulmonic valve |
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Term
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Definition
1st Heart Sound:
S1 – Beginning of systole
- Heard over the precordium, usually loudest at the apex |
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Term
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Definition
2nd Heart Sound:
S2 – Ending of systole
- Heard over the precordium, usually loudest at the base |
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Term
| What is breaths effect on cardiac sounds? |
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Definition
During inspiration, intrathoracic pressure is ↓d, more blood is pushed into the vena cava, ↑ing venous return to the R side of the heart, → ↑s RV stroke volume, prolonging RV systole and delays pulmonic valve closure
On the L side, a greater amount of blood is sequestered in the lungs during inspiration, momentarily ↓ing the amt of blood returned to the L side, → ↓ing LV stroke volume, ↓d volume shortens LV systole & allows the aortic valve to close a bit earlier resulting in a split S2.
MoRe to the Right heart, Less to the Left |
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Term
| What are the extra heart sounds? |
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Definition
Third heart sound
Fourth heart sound
Murmurs |
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Term
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Definition
S3- vibrations that occur when ventricles are resistant to filling, immediately after S2. The AV valves open and atrial blood first pours into the ventricles. Dull soft sound, low pitch, “distant thunder”. Heard best at the apex with bell with pt on left side.
Abnormal S3 is called a ventricular gallop or S3 gallop. This indicates decreased compliance of the ventricles_ HF- volume overload. May also be heard in high cardiac output states in the absence of heart disease: hyperthyroidism, anemia, and pregnancy. Slosh ing in. |
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Term
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Definition
| occurs at the end of diastole, at presystole, when the ventricle is resistant to filling. The atria contract and push blood into a noncompliant ventricle. S4 is heard just before S1. Soft low pitch sound, heard best at the apex with the bell, pt on left side. Also called atrial gallop or S4 gallop. Occurs when there is a decreased compliance of the ventricle: coronary artery disease, cardiomyopathy; aortic stenosis, systemic hypertension. A-stiff-wall. |
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Term
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Definition
| gentle blowing, swooshing sound heard on the chest wall. Causes: velocity of blood increase as in exercise; viscosity of blood decreases as in anemia; structural defects in the valves, unusual opening in the chambers- wall defect. |
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Term
| What are the characteristics of sound? |
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Definition
Frequency (pitch)-high/low
Intensity (loudness)-loud/soft
Duration-short heart sounds/longer silent periods
Timing-systole or diastole- S4 end of diastole; S3 early diastole |
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Term
| What is the normal conduction flow of the heart? |
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Definition
| SA node → atria → AV node → Bundle of His → R & L bundle branches → ventricles |
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Term
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Definition
P wave – depolarization of the atria
PR interval – from the beginning of the P wave to the beginning of the QRS complex (time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles)
QRS complex – depolarization of the ventricles
T wave – repolarization of the ventricles |
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Term
| What is the normal amount of blood pumped by the heart? |
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Definition
| Resting adult’s heart normally pumps 4 – 6 L of blood per minute through the body. |
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Term
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Definition
Venous return that builds during diastole. The length to which the ventricular muscle is stretched at the end of diastole just before contraction
When the volume of blood returned to the ventricles is ↑d, muscle bundles are stretched to accommodate (ex. exercise)
Force of ventricular filling is preload.
Frank Starling law states that the greater the stretch, the stronger the heart’s contraction.
↑d contractility results in ↑d volume of blood ejected (↑d SV) |
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Term
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Definition
-Opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure
-The resistance against which the ventricle must pump its blood
-To overcome the difference, the ventricular muscle tenses (isovolumic contraction)
-After the aortic valve opens, rapid ejection occurs |
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Term
| Where is the carotid artery? |
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Definition
| located in the groove between the trachea & the sternomastoid muscle |
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Term
| Where is the jugular veins? |
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Definition
– reflect filling pressure & volume changes in the R side of the heart (JVD)
2 veins – Internal & external |
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Term
| What side of the heart does the jugular vein give information about? |
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Definition
| Jugular Vein dumps un-oxygenated blood right into the Superior vena cava. Can give information about the activity on the right side of the heart. ex.; filling pressure and volume changes because volume and pressure increase when the right side of the heart fails to pump efficiently. |
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Term
| What developmental care is important in infants/chillens? |
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Definition
Heart’s position in the chest is more horizontal in the infant than in the adult. The apex is higher, located 4th ICS.
At age 7, it reaches the adult position (5th ICS, LMCL) |
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Term
| What developmental care is important in preggers? |
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Definition
| Blood volume ↑s 30% - 40% during pregnancy, most rapid expansion occurs during 2nd trimester. ↑s SV & CO, and ↑s pulse rate by 10 – 16 bpm. Despite ↑d CO, BP ↓s as a result of peripheral vasodilation, lowest in 2nd trimester. |
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Term
| What developmental care is important to old people? |
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Definition
| Dysrhythmias ↑ w/aging, tachycardia is not tolerated as well, EKG Δs occur, HTN/CHF incidence ↑s, mostly attributed to lifestyle habits |
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Term
| What are cultural considerations about htn? |
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Definition
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Term
| What are cultural consideration about smoking? |
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Definition
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Term
| What are cultural considerations about cholesterol? |
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Definition
| ↑d in black children & adolescents, reverses in adulthood , High risk mexican-ameican men and women(51%), then white men and women 45-48%. |
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Term
| What are cultural considerations about obesity? |
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Definition
75% Hispanic men, 73% Hispanic women, 73% black men, 77 % black women
72% white men, 58% white women,, 25% Asians |
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Term
| What are cultural considerations about DM? |
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Definition
| 1994 – 2002: prevalence ↑d from 4.8% to 7.3% - occurring in men/women, all ages, all ethnic groups. American Indians rate is 2X that of US adults overall. |
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Term
| What subjective health questions should you ask while doing a cardiac assessment? |
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Definition
Chest pain: Any chest pain or tightness? Edition Change: diaphoresis, pallor, palpitations, dyspnea, nausea, tachycardia, or fatigue should be considered to be equivalent to angina.
Dyspnea: Any shortness of breath? Precipitating factors?
Orthopnea: How many pillows do you use when sleeping or lying down?
Cough: Do you have a cough? How long? Productive?
Fatigue: Do you seem to tire easily? Able to keep up with your family and co-workers?
Cyanosis or pallor: Ever noted your facial skin to turn blue or ashen?
Edema: Any swelling of your feet and legs?
Nocturia: Do you awaken at night with an urgent need to urinate? How long has this been occurring? Any recent change?
Cardiac history: Any history of hypertension, elevated blood cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever or unexplained joint pains as child or youth, recurrent tonsillitis, anemia?
Family cardiac history: Any family history of hypertension, obesity, diabetes, coronary artery disease (CAD), sudden death at younger age?
Risk factors for CAD: elevated cholesterol, HTN, elevated BG above 130 mg/dL or DM, smoking, low activity, hormone replacement. |
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Term
| When you are palpating the carotid arteries, should you do both at the same time? |
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Definition
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Term
| When auscultating the carotid arteries, do you use the diaphragm or bell? What are they doing with their breathing at this time? |
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Definition
| Bell. Ask pt to take a breath and exhale, and hold. |
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Term
| When inspecting the jugular veins, what are you looking for? |
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Definition
DISTENTION!
From the patients right side at 30-45 degree angle:
JVP – (CVP) Use the angle of Louis (sternal angle) as a reference point. Hold a vertical ruler on the sternal angle. Align a straight edge on the ruler like a T-square. Adjust the level of the horizontal straight edge to the level of pulsation. Read the level of the intersection on the vertical ruler. Normal JVP is 2 cm or less above the sternal angle. When charting also state the person’s position. Ex: Internal jugular vein pulsations 3 cm above sternal angle when elevated 30 degrees. |
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Term
| What do Full distended external jugular veins above 45 degrees signify? |
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Definition
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Term
| When you inspect the precorium, what are you looking for? |
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Definition
Apical impulse – may be seen or not seen, easier to see in children, adults at the 4 or 5 intercostal space midclavicular line.
Heave/lift – forceful thrusting of the ventricle, seen at apex or sternal border |
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Term
| When you palpate the precordium, what are you looking for? |
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Definition
Palpate:
Apical impulse - Located 4th or 5th ICS, LMCL, 1cm x 2 cm, feels like a short gentle tap
Can be palpate in about 50% of adults, cannot be felt in obese pts, thick chest walls, ask pt to hold breath.
Precordium – feeling for palpations around the area of the heart
Cardiac enlargement due to increased ventricular volume or wall thickness: HTN, CAD, heart failure, and cardiomyopathy
Thrill – palpable vibration, feels like a purr, is turbulent blood flow-Palpate at the apex, left sternal border, and the base |
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Term
| When you percuss to outline the cardiac borders, what are you looking for? |
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Definition
Has been replaced by xrays and echocardiograms, but if not available…
Begin at 5th ICS, L ant axillary line and move toward sternum until you percuss the apex at the L border
Continue moving upward toward the L sternal border, usually percuss the upper R border at the L sternal border
The R sternal border coincides with the R side of the heart |
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Term
| What should note when ausculatating the heart sounds? |
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Definition
1) Note Rate & Rhythm:
60 – 100 bpm rate, regular rhythm
Sinus arrhythmia – occurs w/breathing, especially in young children
Pulse deficit – when apical pulse is not perfusing and a peripheral pulse is different
Auscultate apical pulse and obtain rate. Palpate radial pulse. Should be the same, if different you have pulse deficit- occurs wit weak contraction of ventricles; with atrial fib; premature beats; heart failure. Chart accordingly.
2)Identify S1 and S2 :
Lub –dub-
S1 is lub and S2 is dup
3) Listen to S1 and S2 separately
Note any differences |
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Term
| Is S1 louder than S2? Where? |
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Definition
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Term
| What does S1 coincide with? |
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Definition
| Carotid artery pulse and R wave on egg |
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Term
| What is the pattern for listening to the heart? |
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Definition
| Sounds produced by the valves may be heard all over the precordium. Use a Z pattern from the base of the heart across and down, then over to the apex. Auscultate in supine position then roll person on left side. Listen with bell at the apex for S3 or S4 sounds. Ask the patient to sit up and lean forward and exhale listen for murmurs. |
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Term
| What are the characteristics of normal heart sounds? |
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Definition
First heart sound
Second heart sound
Splitting of second heart sound |
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Term
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Definition
Split S2- closure of the aortic and pulmonic- inspiration separates the timing of the two valves’ closure= T-DUP
Split S2 – occurs normally in some pts, T-dub instead of dub, heard only in pulmonic area 2nd ICS, LSB, at the end of |
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Term
| How does inspiration affect S2? |
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Definition
Fixed Split S2 – Not affected by resp, always there
Paradoxical Split S2 – not heard on insp, but on exp |
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Term
| What are the grades of loudness for heart sounds? |
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Definition
Loudness – Intensity, based on Grades (i – vi)
Grade i – Barely audible, heard only in a quite room w/difficulty
Grade ii – clearly audible, but faint
Grade iii – moderately loud
Grade iv – Loud, assoc w/a thrill palpable on the chest wall
Grade v – very loud, heard w/one edge of the stethoscope lifted off the chest wall
Grade vi – loudest, still heart with the entire stethoscope lifted just off the chest wall |
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Term
| What are the pitches of heart sounds? |
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Definition
| Pitch – high, medium, low |
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Term
| What are the patterns of heart sounds? |
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Definition
| Pattern – crescendo, decrescendo, crescendo/decrescendo (lots of practice needed to diagnose pattern) |
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Term
| What are the qualities of heart sounds? |
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Definition
| Quality – musical, blowing, harsh, rumbling |
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Term
| What are the radiations of heart sounds? |
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Definition
| Radiation – heard in another area, precordium, neck, back, axilla |
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Term
| What are the postures of heart sounds? |
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Definition
| Posture – may disappear or be enhanced by change in position |
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Term
| What is an innocent mumur? |
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Definition
INNOCENT MURMUR – Pg. 479– heard in healthy children/adolescents, increased blood flow, smaller chest allows for auscultation
Generally – soft (grade ii/vi), midsystolic, short, crescendo/decrescendo, w/vibratory or musical quality, at 2nd or 3rd ICS – L, disappears w/ sitting, no S&S assoc w/it |
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Term
| What are the physical manifestations of CHF? |
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Definition
• Dilated pupils
• Skin pale, grey, cyanotic
• Dyspnea
• Orthopnea
• Crackles/wheeze
• Cough
• Frothy sputum
• Decrease blood pressure
• Nausea/vomiting
• Ascites
• Dependent pitting edema in sacrum, legs
• Anxiety
• Falling O2 sat
• Confusion
• Jugular vein distention
• Infarction
• Fatigue
• S2 Gallop – Tachycardia
• Enlarged spleen and liver
• Decreased urinary output
• Weak pulse
• Cool, moist, skin.
Decreased Perfusion r/t CHF |
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Term
| What are the subjective signs of CHF? |
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Definition
• Weak
• Tired
• Short of Breath
• How many pillows are you sleeping on?
• Have you peed recently?
• Have you gained any weight recently? (3lbs over 2 days) |
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Term
| How do you check the effectiveness of treatment of CHF? |
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Definition
• I+O
• Weight Loss/Gain
• O2 Sat
• HR Decreases
• Edema Decreases
• Electrolytes
• Listen to lungs
• Listen to heart |
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Term
| Why does decreased cardiac output occur with CHF? |
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Definition
| occurs when the heart fails as a pump, & the circulation becomes backed up & congested. |
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Term
| Why are the s/s of CHF what they are? |
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Definition
| – come from 2 main mechanisms: 1) the heart’s inability to pump enough blood to meet the metabolic demands of the body, & 2) the kidney’s compensatory mechanisms of abnormal (abn) retention of sodium (Na) & water (H20) to compensate for the decreased CO. This increases blood volume & venous return, which causes further congestion. |
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Term
| What is the onset of CHF? |
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Definition
| may be 1) acute – following a MI when direct damage to the heat’s contracting ability has occurred, or 2) HTN when the ventricles must pump against chronically increased pressure |
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Term
| What are the core measures to treating CHF? |
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Definition
Document EF or LVF (found on echo)
ACEI or ARB for LVSD
Smoking Cessation
Discharge instructions must include:
Activity,Diet & Follow-up visit
Worsening symptoms
Weight monitoring
List out – must write out home meds |
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Term
You are the nursing supervisor on the night shift in a small community hospital. At the beginning of the shift, you have only one critical care bed available. During your shift, you receive calls for assistance on the following patients: a) Patient A has burns on her face, scalp, and chest and is coughing up sputum with black streaks. b) Patient B has pneumonia but has suddenly become confused. c) Patient C is short of breath and complaining that he can't breathe. His skin is cool and moist, and he is coughing up clear sputum with small bubbles in it.
WHo gets a bed? |
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Definition
| This is a difficult question. All of these patients have problems affecting oxygenation that may require admission to a critical care bed. Consider which patient is at immediate risk. When immediate risk is considered, patient C is the correct answer. |
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Term
| What are the mid-diastolic abnormal sounds? |
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Definition
Third heart sound
S3 is a ventricular filling sound
Occurs in early diastole during the rapid filling phase
Occurs after S2, but later than opening snap
Dull, soft, low pitched – like distant thunder
Best heard on initial auscultation, in a quiet room, at apex, w/bell held lightly to chest, w/pt in L lat position |
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Term
| What is a physiologic S3? |
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Definition
Physiologic S3 heard frequently in children & young adults
Occasionally may persist after age 40, especially in women
Normal S3 usually disappears when the pt sits up |
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Term
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Definition
Pathologic S3 called ventricular gallop or S3 gallop.
Persists when sitting up
Indicates decreased compliance of the ventricles (heart failure)
May be earliest sign of CHF
May originate from either LV or RV
L sided S3 heard at apex in L lat position
R sided S3 heard at L lower sternal border in supine position
Louder in inspiration |
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Term
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Definition
S3 occurs w/conditions of volume overload
Mitral regurgitation
Aortic regurgitation
Tricuspid regurgitation |
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Term
| What states does S3 occur at in the absence of heart dz? |
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Definition
HIGH CARDIAC OUTPUT STATES
Hyperthyroidism
Anemia
Pregnancy
When the primary condition is corrected, S3 disappears |
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Term
| What is the late diastolic extra sound? |
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Definition
Fourth heart sound
S4 is a ventricular filling sound
Occurs when the atria contract late in diastole
Heard immediately before S1
Very soft, low pitch sound
Listen w/bell, hard to identify
Best heard at apex w/pt in L lat position |
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Term
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Definition
| Physiologic S4 may occur in adults older than 4o or 50 years w/no evidence of CV dz, especially after exercise |
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Term
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Definition
Pathologic S4 called atrial gallop or S4 gallop. Occurs w/decreased compliance of ventricle (CAD, cardiomyopathy), w/systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) & systemic HTN.
L sided S4 occurs w/these conditions
Heard best at apex, w/pt in L lat position
R sided S4 is less common
Heard best at L lower sternal border, may increase w/inspiration
Occurs w/pulmonary stenosis or pulmonary HTN |
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Term
| What is a diastolic extra sound? |
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Definition
Pericardial friction rub
Inflammation of the precordium
Sound is high pitched & scratchy (sandpaper)
Best heard w/diaphragm, pt sitting up & leaning forward, w/breath held in expiration
Commonly occurs during the 1st week after MI & may last only a few hours. |
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Term
| What is an abnormal pulsation on the precordium? T |
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Definition
Thrill at the base
Located in the 2nd & 3rd R ICS occurs with aortic stenosis & systemic HTN
Located in the 2nd & 3rd L ICS occurs with pulmonic stenosis & pulmonic HTN |
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Term
| WHat is another abnormal pulsation on the precordium? LH |
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Definition
Lift (heave) at the sternal border
Occurs with RV hypertrophy, found in pulmonic valve dz, pulmonic HTN, & chronic lung dz
Felt as a diffuse lifting impulse during systole at the L lower sternal border
May be associated with retractions at the apex because the LV is rotated posteriorly by the enlarged RV |
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Term
| What is another abnormal pulsation on the precordium? V |
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Definition
Volume overload at the apex
Cardiac enlargement displaces the apical impulse laterally & over a wider area when LV hypertrophy & dilatation are present
Volume overload as seen in mitral regurgitation, aortic regurgitation, &
L-to-R shunts. |
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Term
| What is another abnormal pulsation on the precordium? P |
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Definition
Pressure overload at the apex
Apical impulse is increased in force & duration but is not necessarily displaced to the L when LV hypertrophy occurs alone without dilatation
Pressure overload as found in aortic stenosis or systemic HTN |
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