cardiac Flashcards
why is the right side internal jugular more important to check than the left side?
drains directly into the vena cava (directly reflects pressure in right atrium
checks: cardiac function and
volume status- fluid overload in atrium may back up into right internal jugular
what muscle does the internal jugular hide behind?
between sternal and clavicular heads of sternocleidomastoid muscle
what surrounds the heart?
fibrous pericardial sac : Two layers, visceral which attaches to the heart and parietal that attaches to the fibrous membrane. This creates the serous pericardial cavity (potential space).
heart chambers: _____ is the high pressure system and ____ is the low pressure system
left- high pressure
right- low pressure
cardiac cycle: diastole
the period of ventricular relaxation
Aortic valve closed; Pulmonary valve closed
Mitral valve open; Tricuspid valve open
cardiac cycle: systole
the period of ventricular contraction
Aortic valve open; Pulmonary valve open
Mitral valve closed; tricuspid valve closed
At the end of ______ the atrium contracts increasing pressure in both chambers
diastole
Left- as the left ventricle contracts the pressure increases closing the _____ valve and opening the _____valve.
mitral, aortic
As the left ventricle ejects most of its blood the ventricular pressure decreases; the pressure in the ____ exceeds that of the _______ and the ________ closes.
aorta, ventricle, aortic valve
The pressure in the _______increases starting the next diastole.
atrium
what marks the beginning of diastole?
closing of aortic and pulmonary semilunar valves
what are the “final moments” of diastole and the “end” of diastole?
final moments: atrial contraction
end: closure of AV valves (tricuspid and mitral)
opening of aortic and pulmonary valves is during _____
systole
heart sounds are caused by what?
Heart sounds are caused by the valves closing. The sounds arise from the vibrations from the leaflets, the adjacent cardiac structures and the flow of blood.
S1 vs S2
S1 is the sound of the mitral and tricuspid valves closing
S2 is the sound of t
the ____ side sounds of the heart are louder due to _____
left, higher pressure
what causes “split” heart sounds?
The heart sounds are made by the valves closing. When the valves do not close at the same time there is a “splitting” of the sound where each component is heard separately
split S1
S1 is composed of the mitral valve (L) and the tricuspid valve (R) closing.
A split in S1 almost always indicates an abnormality within the heart. Such as a conduction defect.
split S2
Split S2 can be a normal finding. During inspiration there is a drop in intrathoracic pressure causing increased filling of the RV delaying the closure of the pulmonic valve. This is called a physiologic split S2 and goes away with expiration.
Other pathologic reasons can cause a split S2 that will NOT go away with expiration.
opening snap
Heard in early diastole when a stenotic mitral valve opens. “like a bad creaky door”
systolic click
Heard with a prolapse of the mitral valve during systole as the increased ventricular pressure pushes the valve through to the atrium. “like a snapple cap that can’t hold the pressure”
pericardial friction rub
When the pericardial sac becomes inflamed it makes a grating sound as the heart beats.
This sound is in early diastole when the blood passively enters the ventricles and contacts the walls causing them to vibrate.
S3 “ventricular Gallop”
when would someone have an S3?
Can occur in healthy people when cardiac output is elevated (normal high vol. state- e.g. pregnancy)
Most often when ventricular wall is abnormal
is made during the end of diastole when the atria contracts and a bolus of blood is sent into the ventricle.
S4 “atrial gallop”
what sound would immediately precede S1?
S4
loud S4 most often indicates…
Loud S4 most often indicates pathology that involves noncompliance of the ventricular wall
a gallop (S3 or S4 ) rhythm is common in pt’s with….
It is common in patient with heart disease
Volume overload
Noncompliant ventricle
location for heart sound: mitral valve
usually heard best at or around cardiac apex
location for heart sound: tricuspid valve
at or near the lower left sternal border
location for heart sounds: pulmonic valve
2nd and 3rd left interspaces close to sternum; may be higher or lower
location for heart sounds: aortic
right 2nd interspace
4 possible causes of a heart murmur
Caused by:
- Rapid blood flow over a normal valve (physiologic murmur)
- Blood flow over a narrowed valve (stenotic)
- Backflow of blood through an incompetent valve
- Blood flow through an abnormal opening (i.e. ventricular wall defect)
7 things murmurs are evaluated for
- Timing: Systolic, Diastolic, Early, Late, Mid, Pan
- Shape: Crescendo, Decrescendo etc
- Location: Depending on the valve involved it will be heard best at the valves “place”
- Radiation: The sound of the murmur follows the flow of the blood
- Intensity
- Pitch: Low, medium, high pitched murmurs.
- Quality: Depending on the type of murmur it will make a different sound
“SLIP RighT Q”
systolic murmur heard on right side
aortic stenosis or backflow through mitral valve in systole (mitral regurgitation)
- sound actually coming from left side
diastolic murmur heard on right side
mitral stenosis or backflow through aortic valve in diastole (aortic regurgitation)
-sound actually coming from left side
systolic murmur heard on left side
pulmonary stenosis or tricuspid regurgitation
-sound actually coming from right side
diastolic murmur heard on left side
tricuspid stenosis or pulmonary regurgitation
-sound actually coming from right side
intensity grading for murmur 1-3 , 4-5
1-3 increasing level of sound
4-5 have thrill (vibration)
6 parts of cardiac PE
- The jugular venous pressure
- Carotid upstroke: any bruits?
- point of max impulse:heaves lifts or thrills?
- S1 and S2
- extra heart sounds?
- murmurs?
4 parts of JVP
A wave
X descent
V wave
Y descent
A wave
– slight rise in atrial pressure that accompanies atrial contraction and occurs just prior to S1 and before the carotid pulse
X descent
– atrial relaxation as right ventricle contracts and pulls floor of atrium downward
V wave
- atrial pressure rises again as it fills with blood from the vena cava
Y descent
– tricuspid valve opens and blood passively flows to the ventricle; early diastole
checking carotid pulse
for information about cardiac function.
- bed elevated at 30 degrees.
- Find carotid pulse, increase pressure until maximal pulsation, then decrease until you can best sense the pressure and contour.
- Avoid pressure on carotid sinus (level of top of thyroid cartilage)
- Do not compress bilateral carotid arteries simultaneously
what to assess for carotid pulse
-Assess the quality of the upstroke, its amplitude, contour and for thrills and bruits.
assessment: amplitude for carotid pulse
Small, thready, weak, bounding?
Correlates with pulse pressure?
Note variations
Beat to beat or with respiration?
assessment: contour for carotid pulse
Speed of upstroke, duration of summit, speed of downstroke
Upstroke = brisk, after S1 and before S2
Summit = smooth and rounded, midsystolic
Downstroke = less abrupt
what is pulsus parodoxus
normal situation in normal people & athletes
carotid pulse: breath in decrease, breath out increase.
or… conditions that impeded ventricular outflow during inspiration (e.g. constrictive pericarditis, COPD, etc)
thrill vs bruit
Thrill- humming vibration over a narrowed artery
Bruits- a murmur like sound of a narrowed artery
Ask patient to ________when assessing for a carotid bruit.
If you feel a thrill or hear a bruit in the carotid artery use the __________ to assess the amplitude and contour of the pulse.
hold their breath , brachial artery
what locations are you palpating on the best for bruits and thrills?
Apex: Confirm the Apical impulse
Thrills and ventricular movements of S3/S4
Subxiphiod area- right ventricle
Lower left sternal border- right ventricle
Left 2nd interspace- pulmonic area
Right 2nd interspace- aortic area
palpating chest wall, First palpate with _______, may feel a ____ due to ventricular impulses.
fingerpads, heave
_______ firmly on the chest to appreciate thrills. These may accompany loud murmurs
ball of the hand
what is the apical impulse and how do you palpate it?
Apical Impulse (PMI) - ventricular contraction as it moves forward and touches the chest wall.
Start with your hand then fine tune with fingers to just one finger.
Can also feel it with the patient in left lateral ducubitus position
4 things to note when palpating apical impulse
- Location- which interspace and distance away from the midline in cm
- Diameter- size of impulse can indicate LV enlargement
- Amplitude- “small” “brisk” “tapping”
- Duration- listen to the heart sounds as you feel the impulse. It should last only about 2/3 of the systole
palpating the left sternal border …
Place fingers in 3rd, 4th, 5th interspaces and feel for the right ventricle impulse. Breathing out and holding it can help.
Palpate the subxiphoid area for right ventricular pulsations
palpating the 2 second interspaces …
Pulmonic area- patient holds expiration, feel for pulsations and possible heart sounds
Aortic area- right second interspace- feel for pulsations and palpable heart sounds
where do you auscultate on the chest?
Right 2nd interspace Left 2nd interspace Left 3rd interspace Left 4th interspace Left 5th interspace Apex -Any areas where you here an abnormality and areas adjacent to murmurs. -Identify S1 and S2
diaphragm vs bell for auscultation
Diaphragm: High-pitched sounds S1, S2, murmurs from regurgitation and friction rubs. Listen to the entire precordium.
Bell: Low-pitched sounds such as S3,S4, murmur of mitral stenosis
Light pressure
what does the left decubitus position do?
Brings the LV closer to the chest wall. S3,S4 Mitral murmurs
what does the leaning forward position do?
Brings out aortic murmurs. Patient exhale completely and stop breathing. Listen along the left sternal border.
what is “inching the stethoscope” ?
auscultation: moving it slowly along to localize a heart sound or murmur
