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Nursing 6410 - Health Assessment > Cardiac Assessment > Flashcards

Cardiac Assessment Flashcards

1
Q

Position of the heart

A 
In mediastinum 
Left of midline
Above diaphragm 
Between medial/lower borders of lungs
3rd-6th ICS
Also called the precordium
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2
Q

Position of heart varies with body build

A

Tall, slender = vertical and positioned centrally

Shorter = more left and horizontal

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3
Q

Factors affecting heart position

A

body build, chest configuration and diaphragm level

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4
Q

Dextrocardia

A

Heart positioned to the right, sometimes rotated or displaced as a mirror image

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5
Q

Situs Inversus

A

Organs flip-flopped

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6
Q

Pericardium

A

Tough, double-walled, fibrous sac encasing and protecting the heart
Several milliliters of fluid are present between inner and outer layer for low-friction

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7
Q

Layers of the heart

A

Epicardium
Myocardium - muscular layer for pumping
Endocardium - innermost layer, lining chambers and covering valves

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8
Q

Anatomy and Physiology of Left Ventricle

A

Bigger in adult heart
higher pressure in systemic circulation requires greater force of contraction (and more muscle mass) in order for blood to be pumped to body
LV contraction and thrust = apical pulse

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9
Q

Atrioventricular Valves

A

Tricuspid (3 leaflets)
Mitral or Bicuspid (2 leaflets)
Close on systole

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10
Q

Semilunar Valves

A

Aortic and Pulmonary (3 cusps)
Open on systole
Close on diastole

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11
Q

What factors influence how much blood volume returns to the heart?

A

Body activity, physical, and metabolic (exercise and fever)

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12
Q

Systole

A 
Pressure raises in ventricles 
AV valves close 
S1 or "lub"
intraventricular pressure > aortic/pulmonic pressure
SL valves open
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13
Q

Diastole

A 
Ventricle pressure < aortic/pulmonic
SL valves close 
S2 or "dub"
A2 is aortic and P2 is pulmonic closure 
Ventricle < atrial pressure
AV valves open
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14
Q

Filling of ventricles = what sound?

A

S3

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15
Q

Atrial contraction = sometimes what sound?

A

S4

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16
Q

S2 Splitting

A

Aortic closes before pulmonic sometimes
A2 before P2
Sounds heard best in area away from the heart because sound is transmitted in the direction of BF

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17
Q

Electrical conductivity pathway

A 
SA wall of RA
AV atrial septum (delayed impulse)
bundle of His 
Purkinje fibers in ventricular myocardium 
Moves from Apex towards the base
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18
Q

ECG records what?

A

Ions moving in and out of the myocardial membranes

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19
Q

PR interval

A 
delay from initial stimulation of atria to stimulation of ventricle
AV node (gatekeeper) responsible for delay 
NO DELAY = possible backflow/insufficient BF
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20
Q

ST segment

A

ST elevation is due to possible MI

Ventricular repolarization

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21
Q

U wave

A

Related to repolarization of purkinje fibers

Also seen in electrolyte abnormalities like severe hypokalemia

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22
Q

QT interval

A

Onset of ventricular depolarization to repolarization

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23
Q

Heart function in infants

A

Patent ductus arteriosis (bypass lungs) and foramen ovale (atrial septum hole) close to allow blood flow to lungs (within 24-48 hours)
RV and LV assume pulmonary and systemic circulation
LV mass increases within first year
Heart lies more horizontal and apex higher
Adult heart position reached at 7 years

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24
Q

Indications for Infants

A 
Tiring during feeding
Breathing changes
Cyanosis 
Weight gain 
Knee-chest position 
Mother's health during pregnancy
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25
Q

Assessment for Infants

A

Examine circulation at 2-3 years of age for birth defects
Include examination of skin, lungs and liver
Inspect color of skin and mucus membranes
Enlargement of heart and position if dyspneic

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26
Q

Heart sounds in infants

A

Difficult to assess (vigor and quality)
Heart rates vary with eating, walking and sleeping
Murmurs are common until 48 hours of age

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27
Q

Indications for Children

A 
Tiring during play 
Naps
Positions at play and rest
Headaches 
Nosebleeds
Unexplained joint pain
Unexplained fever 
Expected height and weight gain 
Expected physical and cognitive development
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28
Q

Assessment in Children

A

Bulging precordium may be enlargement
Sinus arrythmia is physiologic event
Supraventricular and ventricular ectopic beats rarely require investigation

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29
Q

Heart sounds in children

A

More variable then adult
Vary with age
Organic murmurs indicative of congential heart disease

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30
Q

Children with known heart disease

A

weight gain or loss
developmental delays
cyanosis
clubbing of fingers or toes

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31
Q

Innocent murmur

A

Vigorous expulsion of blood from LV into aorta

increases with activity and diminishes when quiet

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32
Q

Heart changes in pregnant women

A

BV increases 40-50% due to increases in plasma volume, begins after first trimester
Heart works harder to accomodate inreased HR and SV for increased BV
LV increases in thickness and mass
Heart shifts to more horizontal due to enlarged uterus and upward diaphragm shift

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33
Q

Indications for Pregnant

A

Hx of cardiac disease or surgery

Dizziness/fainting on standing

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34
Q

Indications of heart disease during pregnancy

A 
progressive or severe dyspnea
progressive orthopnea 
PND
hemoptysis
syncope with exertion 
chest pain with effort or emotion
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35
Q

Heart changes during pregnancy

A

HR increases gradually
Pulse is 10-30% faster at end of 3rd trimester
apical impulse shifts up and lateral
Q increases by 30-40%
BV and Q return to normal 2-3 weeks after pregnancy

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36
Q

Heart Sounds in pregnant

A

Audible splitting of S1 and S2
S3 heard after 20 weeks of gestation
Systolic ejection murmurs may be heard over pulmonic area in 90% of pregnant

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37
Q

A&P in older adults

A 
heart size decreases (unless HTN or heart disease)
LV wall thickens 
Valves fibrose and calcify
HR slows
SV decreases 
Q declines by 30-40%
Endocardium thickens 
Myocardium becomes less elastic 
Electrical irritability is enhanced
Tachycardia poorly tolerated
Increased O2 is less efficient
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38
Q

Q continues to diminish in older due to

A

fibrosis and sclerosis in region of SA node and in mitral and aortic cusps
Increased vagal tone

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39
Q

Symptoms of CV in older

A 
Confusion and syncope 
Palpitations
Coughs and wheezes
Hemoptysis
SOB 
Chest pain and tightness
Incontinence and impotence, heat intolerance 
Fatigue and leg edema
40
Q

If diagnosed with heart disease in older…

A

monitor drug reactions
decreased ADLs
coping
orthostatic hypotension

41
Q

HR and apical pulse in older

A

slower HR if increased vagal tone
low 40s-100s
ectopic beats common
apical pulse is harder to find with decreased AP chest diameter

42
Q

More A&P in older

A

Diaphragm raisesd and heart transverse in obese
S4 is more common, may indicate LV compliance
Murmurs caused by aortic lengthening or scelrotic changes

43
Q

HPI: Chest pain

A

Onset/duraiton - sudden, gradual, vague, length, activity, rest, eating, coughin, cold temp, trauma, sleep
Character - aching, sharp, tingling, burning, pressure, stabbing, crushing
Location - radiating down arms, to neck, jaws, teeth, scapula, relief with rest?
Severity - 0-10
Associated - anxiety, dyspnea, diaphoresis, dizzy
n/v, fatigue, faintness, cold, clammy, cyanosis, pallor, edmea (constant or at certain times?)
Treatment - rest, position, exercise, NTG
Medications - penicillin

44
Q

HPI: Fatigue

A

Unusual or persistent
Inability to keep up with peers
Associated symptoms
Meds - B-blockers

45
Q

HPI: Dyspnea

A 
Aggrevated by exertion?
On level ground or going up stairs?
Worsening or stable?
Orthopnea?
PND?
46
Q

HPI: Loss of Conciousness (transient syncope)

A

Palpitaiton
Dysrhythmia
Unusual exertion
Sudden turning of neck (carotid sinus effect)
Looking upwards (vertebral artery occlusion)

47
Q

PMHx

A

Cardiac surgery or hospitalization
Congenital heart disease
Rhythm disorder
Acute rheumatic fever, (fever c swollen joints), abd. pain
Chronic illness - HTN, bleeding disorder, HLD, DM, thyroid dysfunction, CAD, obesirty

48
Q

FH

A 
Long QT syndrome 
DM 
Heart disease
dyslipidemia 
HTN
congenital heart defects 
morbidity, mortality d/t to CV, age at time of illness or death, sudden death
49
Q

Personal and Social Hx

A

Employment - demanding? hazards?
tobacco
nutrtition - usual diet? fat, salty, hx of diet
weight loss or gain
relaxation hobbies
exercise type/amount/frequency/intensity
use of drugs

50
Q

Apical pulse

A

should be visible at MCL in the 5th ICS
Seen in healthy hearts
Obscured by obesity, breast tissue or muscularity
Sometimes only visible when sitting up, bringing heart closer to anterior chest wall
Examination findings affected by shape and thickness of chest wall and amount of air or fluid through which the impulses are transmitted

51
Q

Signs of CHF

A

crackles in lungs, palpation of a large liver, peripheral edema, barrel chest, xanthelasma, changes of HTN, pitting edema, abdominal aortic bruit

52
Q

Characteristics of cardiac chest pain

A

Substernal; provoked by effort, emotion, eating, relieved by rest and or NTG; often accompanied by diaphoresis, occasionally by nausea

53
Q

Absence/prominence of apical pulse

A

Prominence - readily visible and palpable
Absence - in left lateral recumbent suggests extracardiac problem such as pleural or pericardial fluid
Inspect skin and nails for cyanosis, clubbing, capillary refill or distention

54
Q

Palpation Sequence

A

Apex, up the left sternal border, base, down the right, into the epigastrium or axillae if circumstance dictates

55
Q

PMI

A

Point of Maximal Impulse - where the apical impulse can be seen or felt
5th ICS in adults and 4th in children
Gentle, brief and note diameter

56
Q

Heaves and lifts

A

apical impulse is more vigorous then expected
forceful, widely distributed, fills systole, or is displaced laterally and downward may indicate increased Q or LV hypertrophy
Lift along left sternal border may be caused by RV hypertrophy
Displacement of apical pulse to the right could be dextrocardia, diaphragmatic hernia, distended stomach or a pulmonary abnormality

57
Q

Thrill

A

palpable ,rushing vibration, often felt at base of heart right or left 2nd ICS.
Turbulent or interruption of BF
Defect in aortic or pulm valve - aortic or pulmonary stenosis , pulmonary HTN or atrial septal defect

58
Q

S1 and carotid pulse are both almost…

A

synchronous

59
Q

Percussion

A

Limited value in defining cardiac borders
RV tends to enlarge in the AP diameter rather than lateral allowing diminished percussion of right border
Obesity or muscular development can distort findings
To percuss, start at anterior axillary line and move medially along ICS toward sternum
Resonance to dullness marks cardiac border

60
Q

Auscultation - use diaphragm and bell

Higher pressure for diaphragm and lower c bell

A

Aortic valve area - 2nd right ICS at right sternal border
Pulmonic valve area - 2nd left ICS at left sternal border
Second pulmonic (ERB’s point) 3rd left ICS and left sternal border
Tricuspid area - 4th left ICS at the left sternal border
Mitral (apical) - apex of heart in 5th ICS at MCL

61
Q

Heart sound locations are affected by

A

elevated diaphragm, pregnancy, ascites, intraabdominal condition

62
Q

Ausculatory assessment

A 
rate and rhythm (if irregular compare apical with radial)
frequency 
intensity 
duration 
pathology
63
Q

Listening for S1

A

Hold breath in expiration
Coincides with carotid pulse
Note intensity, variations, effect of respirations or any splitting

64
Q

Systole and diastole is equal in duration when

A

heart rate is rapid

65
Q

Listening for S2

A

inhale deeply

best heard in the pulmonic auscultory area

66
Q

S1

A

closure of mitral and tricuspid
beginning of systole
heard towards apex
Splitting heard best at tricuspid area with deep inspiration

67
Q

S2

A

closure of pulmonary or aortic valves
beginning of diastole
heard towards base

68
Q

Splitting

A

AV or SLV do not close simultaneously
S2 splitting is merging sounds on expiration
A2 louder than P2
Splitting better heard on inspiration and in the young, not in older possible d/t to AP diameter

69
Q

Why is splitting heard better during inspiration?

A

Pressure are higher and depolarization occurs earlier on left side of heart
Intrathoracic pressure becomes more negative on inspiration causing increased venous blood return from body into the RA and RV
BV returning from lungs into RV is reduced (blood wants to stay in lungs due to pressure)
Increased BV in RV cauases P2 to stay open longer during systole, while A2 closes earlier d/t reduced BV in left ventricle

70
Q

S1 sound is increased during

A

Blood velocity increase with anemia, fever, hyperthyroidism, anxiety and during exercise
Mitral valve is stenotic

71
Q

S1 sound is diminished during

A

increased overlying tissue like fat, fluid, emphysema
Systemic or pulmonary HTN contributing to forceful atrial contraction
Fibrosis and calcification of a disease mitral valve can result from rheumatic heart disease

72
Q

S2 sound is increased during

A

systemic HTN, syphillis of the aortic valve, exercise or excitement
Pulmonary HTN, mitral stenosis, CHF (accentuates P2)

73
Q

S2 decreases during

A

immobile valve, thickened or calcified
aortic stenosis
pulmonic stenosis
overlying tissue, fat or fluid mutes S2

74
Q

S3 and S4

A

heard better on increased venous return (raising a leg or inhaling) or asking patient to grip and squeeze hand (arterial pressure)

75
Q

Gallop

A

heard when S3 becomes more intense
early diastolic gallop rhythm
heard better on left lateral recumbent

76
Q

S4 is more prominent when

A

presystolic gallop rhythm
heard more in older d/t increased resistance to filling because ventricular walls lost compliance with increased SV or Q
HTN, CAD, pregnancy, anemia

77
Q

Opening snap

A

often of mitral valve

caused by valvular stenosis

78
Q

ejection clicks

A

stenosis of SLV
heard best on expiration in 2nd left ICS
aortic on 2nd right

79
Q

mid to late nonejection systolic clicks

A

mitral prolapse

80
Q

Three causes of murmurs

A

High BF through normal valve
BF through constricted or stenotic valve
Backflow of blood through a regurgitant or insufficient valve

81
Q

What is a murmur?

A

Disruption of BF into, out or through heart

82
Q

Friction Rub

A 
Pericarditis 
rubbing, machiene-like
occupies both systole and diastole
overlies intracardiac sounds
3 components of atrial systole, ventricular systole and ventricular diastole 
heard more towards apex
83
Q

Prosthetic Mitral Valves

A

Can cause clicks early in diastole
Loudest at apex
Pacemakers do not cause sound

84
Q

Causes of murmurs

A

adequacy of valve fxn, size of opening, rate of BF, vigor of myocardium, and thickness and consistency of overlying tissues
Can be harsh, blowing or musical

85
Q

Characteristics of murmurs

A 
timing and duration 
pitch 
intensity 
pattern 
quality 
location 
radiation
variation with respiration
86
Q

Mitral valve stenosis

A

Leaflets are thickened and the passage narrowed, forward BF restricted

87
Q

Mitral valve regurgitation

A

valve incompetence causes blood to leak backwards

88
Q

Other causes of murmurs

A

High output demands that increase BF speed
Structural defects (congenital or acquired)
Diminished strength of myocardial contraction
altered BF in the major vessels near the heart
transmitted murmurs from valvular aortic stenosis, ruptured chordae tendinae of the MV or severe aortic regurgitation
Virgorous LV ejection
Persistence of fetal circulation

89
Q

Increased S3

A

Bell at apex
Patient in left lateral recumbent
early in diastole

90
Q

Increased S4

A

Bell at apex

supine or left lateral recumbent position

91
Q

Gallops

A

bell at apex

supine or left lateral recumbent position

92
Q

mitral valve opening snap

A

diaphragm medial to apex, may radiate to base

any position, 2nd to left ICS

93
Q

aortic valve ejection click

A

apex, base in second right ICS

sitting or supine

94
Q

Pulmonary ejection click

A

second left ICS at sternal border

sitting or supine

95
Q

Pericardial friction rub

A

widely heard

clearest towards ape

96
Q

Grading of Murmurs

A 
I: barely audible
II: quiet but audible
III: Moderate
IV: loud, associated with thrill 
V: very loud, thrill palpable
VI: thrill palpable and visible, very loud, audible w/o contact to chest with stethescope

Nursing 6410 - Health Assessment (16 decks)

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