7.7 Cardiovascular & Jugular Flashcards
Which has a higher systemic pressure? Venous or arterial?
ARTERIAL has a higher systemic pressure than venous.
Venous pressure depends on…
Left ventricular contraction
Determinants of venous pressure (4)
o Left ventricular contraction
o Blood volume
o Capactiy of the right heart to eject blood to the pulmonary arterial system
o Cardiac disease (may alter these variables, produce abnormalities)
What effect does failure of the RIGHT heart have on the venous system?
Venous pressure RISES
When left ventricular output or blood volume is reduced, what happens to venous pressure?
Venous pressure falls.
Units of CVP measurements in hospitals (2):
o cm of H2O when using a manometer
o mmHg when using an electronic device
What is normal CVP?
o 0-8 mm Hg or
o 3-8 cm of H20
Venous pressure changes are reflected in…
The height of the venous column of blood in the INTERNAL jugular veins.
What is JVP? What does it reflect?
o Jugular venous pressure.
o It is a reflection of the pressure of the right atrium or central venous pressure
Where is JVP measured? Why?
o The right internal jugular vein
o Because it has a more direct anatomic channel into the right atrium
How do you estimate the level of the JVP?
o Find the highest point of oscillation in the internal jugular vein
o JVP is usually measured in vertical distance above the sternal angle (angle of louis – which is 5cm above the right atrium)
o 5cm + distance of highest oscillation above sternal angle = JVP
What is considered to be an elevated or abnormal JVP?
o A JVP of more than 8-9cm total
o 3 or possibly 4cm above the sternal angle
How do you position a patient for the JVP measurement? 3 scenarios
o Normal/to start: position patient at a 30 degree angle
o A hypovolemic patient may need to lie flat to do measurement
o If JVP is increased, an elevation of up to 60 or 90 degrees may be required
Where should you begin to look for the jugular venous pulsations?
In the suprasternal notch of the neck
What is the precordium?
Area overlying the heart and great vessels
What area is the heart in, in terms of rib count?
2nd to 5th intercostal space
What pulse spot is at the apex? Where is the Apex located?
o PMI
o Left 5th intercostal space
Name the five great vessels of the heart
o Superior vena cava o Inferior vena cava o Pulmonary artery o Pulmonary veins o Aorta
Layers of the heart, from innermost to outermost
o Endocardium (Purkinje fibers connect here) o Myocardium o Epicardium (Visceral pericardium) o Pericardial cavity o Parietal pericardium o Fibrous pericardium
Which side of the heart is high pressure? Which is low?
o Right: Low pressure
o Left: High pressure
What causes valves to open and close?
They open and close PASSIVELY due to changes in pressure.
When do AV valves oen / close?
o OPEN during diastole
o CLOSE during systole (S1 – lub)
When do semilunar valves open / close
o OPEN during systole
o CLOSE during diastole (S2 – dub)
When is S1? When is S2?
o S1: Systole. AV valves close. Lub.
o S2: Diastole. Semilunar valves close. Dub.
What happens during Systole? (4, don’t forget to mention valves)
o S1: Closing of AV valves
o The ventricles contract
o Right ventricle pumps blood into pulmonary arteries (Pulmonary valve is open.)
o left ventricle pumps blood into Aorta. (Aortic valve is open.)
What happens during diastole? (4, don’t forget to mention valves)
o S2: Closing of semilunar valves
o Ventricles relax
o Blood flows from right atrium to right ventricle (Tricuspid valve is open)
o Blood flows from left atrium to left ventricle (Mitral valve is open)
Where is S1 best auscultated?
o 5th intercostal space, at apex
o Tricuspid best heard at left sternal border
o Mitral best heard at right midclavicular line
Where is S2 best auscultated?
o 2nd intercostal space, at base
o Aortic – best heard on right
o Pulmonic – best heard on left
Where are S1 & S2 heard equally well?
o Erb’s point
o 3rd intercostal space
What is a split S2? What causes this? Give a pneumonic.
o When you hear the S2 sounds slightly apart during inspiration
o Occurs because pt has more blood sequestered in the heart picking up oxygen, so you have more blood going into the right ventricle. (Therefore, left AV valve closes first)
o “moRe to the Right and Less to the Left”
Cardiac output equation
o CO = Stroke volume x heart rate
Define stroke volume, give average
o Amount of blood in each systole
o 4-6L per minute
Blood pressure equation
BP = COxSVR
Define preload. When does this occur?
o Volume overload
o Occurs during exercise to give you a stronger contraction
Define afterload. When does this occur?
o Pressure overload
o The ventricle must generate this pressure to open the aortic valve
What is systolic blood pressure? (3)
o Pressure generated by the Left Ventricle during systole
o When the LV ejects blood into the aorta and the arterial tree
o Pressure waves in the arteries create pulses
What is diastolic blood pressure?
o Pressure generated by blood remaining in the arterial tree during diastole, when the ventricles are relaxed
Four manifestations of myocardial ischemia?
o Stable (typical) angina
o Unstable angina
o Variant (Prinzmetal’s) angina
o Myocardial infarction
What is “angina?”
A temporary ischemia
What is “myocardial infarction?”
Total blockage of heart
Three cardiac causes of chest pain (NOT by ischemia)
o Mitral valve prolapse
o Pericarditis
o Dissecting aneurism
What is mitral valve prolapse?
When the mitral valve is not closing well – one or both mitral valve leaflets prolapse back into atria during systole
What is pericarditis? Define. Give 5 causes. Treatment.
o Inflammation of the pericardium
o May be caused by virus, bacteria, uremia, lupus, neoplasm
o May be treated with advil
What is a dissecting aneurism? What does it feel like?
o The tearing of arterial intima. Begins suddenly, tearing quality.
o Sharp pain radiating into back or into neck.
Define “ischemia”
o Inadequate blood supply
Five pulmonary causes of chest pain
o Pulmonary embolism o Pleurisy o Pulmonary hypertension o Pneumothorax o Mediastinal emphysema
What is a pulmonary embolism? What are the symptoms?
o Blood clot travels to the lung
o Dyspnea more common, may be asymptomatic
What is pleurisy? What are the symptoms?
o Pleural inflammation
o Pain worse with breathing, disappears when breath held
Two symptoms of pulmonary hypertension
o Dyspnea more common
o Pain is described as discomfort, nonradiating tight constricting band across chest
How does a pneumothorax occur?
Air in pleural cavity collapses lung
Mediastinal emphysema. What happens? 2 symptoms, 1 sign.
o Free air in the mediastinum produces chest tightness and dyspnea
o Hamman’s sign – crunching sound
Three gastrointestinal causes of chest pain
o Esophageal spasm
o Esophageal reflux
o Gallstone colic
What symptoms occur with esophageal spasm? (3)
o Substernal pain
o Dyspagia
o May mimic angina
What symptoms occur with esophageal reflux? What might this be mistaken for? What relieves it?
o Substernal burning or cramping radiates into arms, neck, jaw
o Can feel like heart attack
o Relieved with antacids
What does gallstone colic feel like?
Right upper quadrant pain radiating to back or right shoulder
Four symptoms / traits of dyspnea
o Shortness of breath
o Uncomfortable awareness of breathing
o Feels smothering
o Causes urgent need to take another breath
For manifestations of dyspnea
o Orthopnea
o Paroxysmal Nocturnal Dyspnea
o Pulmonary edema
o Valvular heart disease
What is orthopnea? What relieves it?
o Dyspnea that occurs soon after patient lies down
o Relieved by sitting or standing up
What is paroxystmal nocturnal dyspnea? What relieves it?
o Dysnpea after lying down for several minutes, or pt awakes short of breath.
o Not relieved immediately after sitting up. May walk around a bit.
Pulmonary edema: What is it, what do symptoms look like?
o Pulmonary congestion (left-sided heart failure)
o Patient is anxious, dyspneic, diaphoretic pink frothy sputum and a fear of impending death.
Valvular heart disease: What is occurring? What is the principle symptom? When in the cardiac cycle does it occur?
o Dyspnea is principal symptom of mitral stenosis
o May occur late in mitral regurgitation or aortic stenosis or regurgitation
Six causes of palpations - gradual acceleration
o Exercise o Anemia o Sexual activity o Postural hypotension o Anxiety o Use of stimulant drug
Four causes of palpations - sudden onset
o Paroxysmal atrial tachycardia
o Ectopic beats
o Extra systoles, or premature atrial or ventricular contractions
o Syncope or seizures may mean asystole, bradycardia
What is syncope?
“Rapid onset, transient loss of consciousness”: blackout, fainting
What is the most common cause of syncope?
“Vasovagal”: Vasomotor response to the vagus nerve
Five cardiovascular causes of syncope
o Arrhythmia o Cardiac outflow tract or obstruction o Ischemia o Carotid sinus syncope (thyroid cartilage) o Decreased blood volume (hypovolemia)
What cardiac issue do you usually think of when you see edema?
Right sided heart failure
______ refers to generalized edema
Anasarca
What is anasarca? (1 def, 3 causes)
Heart failure, liver or nephritic failure
What causes central cyanosis (generally, and 1 pathology)
o Decreased pulmonary venous saturation
o Tetralogy of fallot – most common cause of cyanosis
What causes peripheral cyanosis? (generally, and 2 pathologies
o Decreased cardiac output or reduced rate of blood flow thru capillaries and increased local extraction of oxygen
o CHF, Shock
_______ refers to coughing up blood
Hemoptysis
Four causes of hemoptysis
o Mitral valve stenosis due to increased pulmonary venous congestion
o Ruptured vessel
o Pulmonary infarction
o Pulmonary emboli with infarction
What is the most common cause of hemoptysis? What causes it?
o MITRAL VALVE STENOSIS
o due to increased pulmonary venous congestion
Four causes of orthostatic hypotension
o Vascular volume loss
o Redistribution of blood volume
o Prolonged bed rest (causes simple vasovagal fainting)
o Autonomic nervous system disfunction
What might cause vascular volume loss (5) that could result in hypotension?
o Hemmorrhage o Diarrhea o Vomiting o Dehydration o Excessive diuresis
What might cause a redistribution of blood volume (4) that could result in hypotension?
o Antihypertensives
o Antidepressants
o Alcohol
o Nitrates
• What might cause autonomic nervous system dysfunction (3) that could result in hypotension?
o Diabetic neuropathy
o Adrenal insufficiency
o Parkinson’s disease
When palpating the carotid upstroke, “brisk” is ________
NORMAL
When palpating the carotid upstroke, a delayed stroke suggests ____________
Aortic stenosis
When palpating the carotid upstroke, bounding stroke suggests ___________
Aortic insufficiency
Listen for bruits with the ____ of the stethoscope
BELL
In order to hear a bruit…
The artery must be 70% occluded
What three things do you inspect the neck for distention?
o Inspect the jugular venous pulse
o Estimate the jugular venous pressure
o Hepatojugular reflux
What is the hepatojugular reflex?
When you push un the liver and the right jugular juts out in response, this means the heart is not able to accommodate everything coming its way.
What is a heathe?
Any forceful lifting of the chest wall during systole
What is the mean height of the vertical column of blood when measuring the JVP?
o 6-10 cm
How do you assess the precordium? (4)
o Inspect the anterior chest
o Palpate the apical impulse
o Palpate across the precordium
o Percuss to outline the cardiac borders
How do you assess the PMI? (2 actions)
o Inspect left anterior chest for a visible PMI
o Palpate the apex for the PMI (w fingerpads)
How do you find the PMI?
o Locate PMI by interspace and distance in m from midsternal line
o One interspace, 5th midclavicular line
What two things are you palpating for with PMI?
o Amplitude (short, gentle tap) o Duration (short - first half of systole)
If you don’t feel the PMI, what two reasons might be responsible?
o Left ventricular dilatation (volume overload)
o Left ventricular hypertrophy (pressure overload)
Left Ventricular Dilatation: What does this do to finding the PMI? (2)
o Displaces impulse down and to the left
o Increases size more than one space
Left Ventricular Hypertrophy: What does this do to finding the PMI? (2)
o Increased force & duration
o No change in location
What six places do you listen to in cardiac auscultation?
1) Aortic area
2) Pulmonic area
3) Tricuspid area
4) Mitral area
5) Erb’s Point
6) PMI
Why do you have patient lean forward during cardiac auscultation?
To better listen to aortic and pulmonary valves
Why do you position the patient in left lateral decubitus during auscultation? What part of the stethoscope do you use?
To better listen to the AV valves (listen with bell)
What part of the stethoscope do you use when listening to S1 & S2?
Diaphragm
What part of the stethoscope do you use to listen to the apex of the heart?
The bell
The diaphragm of the stethoscope is best for detecting… (4)
o High pitched sounds like S1, S2
o S4 and most murmurs
The bell of the stethoscope is best used for detecting
o Low-pitched sounds like S3 and the rumble of mitral stenosis
Where is S1 louder than S2?
APEX
Where is S2 louder than S1?
BSE
What coincides with S1?
o Carotid artery pulse
o R wave on ECG
What side would an S3 sound be best auscultated?
Left side
In what position might an S3 heart sound be normal?
Lying down
What does S3 sound like?
Ventricular gallop
“KEN TUC KY”
What does S4 sound like? What is is a reaction to?
Atrial gallop (reaction to the atrial kick) "TEN NESS EE"
What might be responsible for an early systolic ejection click? (2)
o Aortic stenosis
o Pulmonic stenosis
What might be responsible for a Midsystolic Click?
Mitral regurgitatoin
What might be responsible for an opening snap?
Mitral stenosis
What is a summation gallop
All four heart sounds
How do you communicate normal heart sounds on a chart?
ØMRG
No murmurs rubs or gallops
What click might be involved with ejection
Early systolic ejection
Where might you hear extra diastolic sounds?
3 or 4 ICS at sternal border
How do you grade murmurs?
1-6 scale
What would a grade 1 murmur be?
Barely audible. Only audible in completely silent room.
What would a grade 2 murmur be?
Clearly audible but faint
What would a grade 3 murmur be?
Moderately loud. Easy to hear
What would a grade 4 murmur be?
Loud and with a thrill
What would a grade 5 murmur be?
Definite thrill, very loud, can even be auscultated if stethoscope is off the chest.
What would a grade 6 murmur be?
VERY loud. Stethoscope is off chest.
What should you document about a murmur? (5)
o Timing (systolic, diastolic) o Location o Loudness / intensity o Radiation (to neck) o Position of patient
To detect murmurs, what else should you do while auscultating the heart? What does this tell you?
o Palpate the carotid upstroke. Carotid upstroke occurs in systole.
o So, if murmur coincides with the carotid upstroke, it is systolic.
What is the “shape” of a murmur? (4)
o Crecendos up to a heart sound
o Decrecendos down from a heart sound
o Both - crecendos and decrecendos betweween heart sounds
o Plateau
What is responsible for causing a murmur that exhibits BOTH crecendo and decrecendo?
AORTIC STENOSIS
What is responsible for causing a murmur that exhibits plateau?
Holosystolic murmur of mitral regurgitation (between S1 & S2)
If a murmur has a thrill, how would you grade it?
Between a 4-6
How would you describe the sound of mitral regurgitation (5)?
o Harsh o 2/6 o Medium-pitched o Holosystolic murmur o Best heard at apex
How would you describe the sound of aortic regurgitation? (5)
o Soft o Blowing o 3/6 decrescendo o Diastolic murmur o Best heard at the lower left sternal border
What happens to blood going through a stenotic valve?
Only a little blood gets through
What happens to blood going through an incompetent valve?
It can go backwards through the valve
What’s the difference between a bruit and a murmur?
o Bruit: Turbulent bloodflow in VESSEL
o Murmur: Turbulent bloodflow in HEART
During systole, you might hear: (2)
o Tricuspid or mitral regurgitation
o Aortic or pulmonic stenosis
What problems are best auscultated at apex? (2)
o Tricuspid or mitral regurgitation
o Mitral or tricuspid stenosis
What problems are best auscultated at base? (2)
o Aortic or pulmonic stenosis
o Aortic or pulmonic regurgitation
What are midsystolic ejection murmurs? (2)
What is the shape of the sound?
o Aortic stenosis
o Pulmonic stenosis
o Sound crescendoes and decrescendoes between S1&S2
What are pansystolic regurgitant murmurs? (2)
What is the shape of the sound?
o Mitral regurgitation
o Tricuspid regurgitation
o Plateau
Diastolic rumbles of AV valves (2)
o Mitral stenosis
o Tricuspid stenosis
Early diastolic murmurs
o Aortic regurgitation
o Pulmonic regurgitation
What is the shape of diastolic rumbles of AV valves
o Between S2 & S1: Starts out big, goes in a little, ends huge.
What is the shape of early diastolic murmurs
o Starts big after S2, decreases slowly til S1
Where is a rub auscultated?
o Mostly at the apex
When is a ventricular systole rub auscultated?
Before S2
When is a ventricular diastole rub auscultated
Briefly between S2 and S1
When is an atrial systole auscultated?
Leading up to S1
