Cardiac Assessment Flashcards
Position of the heart
In mediastinum Left of midline Above diaphragm Between medial/lower borders of lungs 3rd-6th ICS Also called the precordium
Position of heart varies with body build
Tall, slender = vertical and positioned centrally
Shorter = more left and horizontal
Factors affecting heart position
body build, chest configuration and diaphragm level
Dextrocardia
Heart positioned to the right, sometimes rotated or displaced as a mirror image
Situs Inversus
Organs flip-flopped
Pericardium
Tough, double-walled, fibrous sac encasing and protecting the heart
Several milliliters of fluid are present between inner and outer layer for low-friction
Layers of the heart
Epicardium
Myocardium - muscular layer for pumping
Endocardium - innermost layer, lining chambers and covering valves
Anatomy and Physiology of Left Ventricle
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
Atrioventricular Valves
Tricuspid (3 leaflets)
Mitral or Bicuspid (2 leaflets)
Close on systole
Semilunar Valves
Aortic and Pulmonary (3 cusps)
Open on systole
Close on diastole
What factors influence how much blood volume returns to the heart?
Body activity, physical, and metabolic (exercise and fever)
Systole
Pressure raises in ventricles AV valves close S1 or "lub" intraventricular pressure > aortic/pulmonic pressure SL valves open
Diastole
Ventricle pressure < aortic/pulmonic SL valves close S2 or "dub" A2 is aortic and P2 is pulmonic closure Ventricle < atrial pressure AV valves open
Filling of ventricles = what sound?
S3
Atrial contraction = sometimes what sound?
S4
S2 Splitting
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
Electrical conductivity pathway
SA wall of RA AV atrial septum (delayed impulse) bundle of His Purkinje fibers in ventricular myocardium Moves from Apex towards the base
ECG records what?
Ions moving in and out of the myocardial membranes
PR interval
delay from initial stimulation of atria to stimulation of ventricle AV node (gatekeeper) responsible for delay NO DELAY = possible backflow/insufficient BF
ST segment
ST elevation is due to possible MI
Ventricular repolarization
U wave
Related to repolarization of purkinje fibers
Also seen in electrolyte abnormalities like severe hypokalemia
QT interval
Onset of ventricular depolarization to repolarization
Heart function in infants
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
Indications for Infants
Tiring during feeding Breathing changes Cyanosis Weight gain Knee-chest position Mother's health during pregnancy
Assessment for Infants
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
Heart sounds in infants
Difficult to assess (vigor and quality)
Heart rates vary with eating, walking and sleeping
Murmurs are common until 48 hours of age
Indications for Children
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
Assessment in Children
Bulging precordium may be enlargement
Sinus arrythmia is physiologic event
Supraventricular and ventricular ectopic beats rarely require investigation
Heart sounds in children
More variable then adult
Vary with age
Organic murmurs indicative of congential heart disease
Children with known heart disease
weight gain or loss
developmental delays
cyanosis
clubbing of fingers or toes
Innocent murmur
Vigorous expulsion of blood from LV into aorta
increases with activity and diminishes when quiet
Heart changes in pregnant women
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
Indications for Pregnant
Hx of cardiac disease or surgery
Dizziness/fainting on standing
Indications of heart disease during pregnancy
progressive or severe dyspnea progressive orthopnea PND hemoptysis syncope with exertion chest pain with effort or emotion
Heart changes during pregnancy
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
Heart Sounds in pregnant
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
A&P in older adults
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
Q continues to diminish in older due to
fibrosis and sclerosis in region of SA node and in mitral and aortic cusps
Increased vagal tone
Symptoms of CV in older
Confusion and syncope Palpitations Coughs and wheezes Hemoptysis SOB Chest pain and tightness Incontinence and impotence, heat intolerance Fatigue and leg edema
If diagnosed with heart disease in older…
monitor drug reactions
decreased ADLs
coping
orthostatic hypotension
HR and apical pulse in older
slower HR if increased vagal tone
low 40s-100s
ectopic beats common
apical pulse is harder to find with decreased AP chest diameter
More A&P in older
Diaphragm raisesd and heart transverse in obese
S4 is more common, may indicate LV compliance
Murmurs caused by aortic lengthening or scelrotic changes
HPI: Chest pain
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
HPI: Fatigue
Unusual or persistent
Inability to keep up with peers
Associated symptoms
Meds - B-blockers
HPI: Dyspnea
Aggrevated by exertion? On level ground or going up stairs? Worsening or stable? Orthopnea? PND?
HPI: Loss of Conciousness (transient syncope)
Palpitaiton
Dysrhythmia
Unusual exertion
Sudden turning of neck (carotid sinus effect)
Looking upwards (vertebral artery occlusion)
PMHx
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
FH
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
Personal and Social Hx
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
Apical pulse
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
Signs of CHF
crackles in lungs, palpation of a large liver, peripheral edema, barrel chest, xanthelasma, changes of HTN, pitting edema, abdominal aortic bruit
Characteristics of cardiac chest pain
Substernal; provoked by effort, emotion, eating, relieved by rest and or NTG; often accompanied by diaphoresis, occasionally by nausea
Absence/prominence of apical pulse
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
Palpation Sequence
Apex, up the left sternal border, base, down the right, into the epigastrium or axillae if circumstance dictates
PMI
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
Heaves and lifts
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
Thrill
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
S1 and carotid pulse are both almost…
synchronous
Percussion
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
Auscultation - use diaphragm and bell
Higher pressure for diaphragm and lower c bell
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
Heart sound locations are affected by
elevated diaphragm, pregnancy, ascites, intraabdominal condition
Ausculatory assessment
rate and rhythm (if irregular compare apical with radial) frequency intensity duration pathology
Listening for S1
Hold breath in expiration
Coincides with carotid pulse
Note intensity, variations, effect of respirations or any splitting
Systole and diastole is equal in duration when
heart rate is rapid
Listening for S2
inhale deeply
best heard in the pulmonic auscultory area
S1
closure of mitral and tricuspid
beginning of systole
heard towards apex
Splitting heard best at tricuspid area with deep inspiration
S2
closure of pulmonary or aortic valves
beginning of diastole
heard towards base
Splitting
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
Why is splitting heard better during inspiration?
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
S1 sound is increased during
Blood velocity increase with anemia, fever, hyperthyroidism, anxiety and during exercise
Mitral valve is stenotic
S1 sound is diminished during
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
S2 sound is increased during
systemic HTN, syphillis of the aortic valve, exercise or excitement
Pulmonary HTN, mitral stenosis, CHF (accentuates P2)
S2 decreases during
immobile valve, thickened or calcified
aortic stenosis
pulmonic stenosis
overlying tissue, fat or fluid mutes S2
S3 and S4
heard better on increased venous return (raising a leg or inhaling) or asking patient to grip and squeeze hand (arterial pressure)
Gallop
heard when S3 becomes more intense
early diastolic gallop rhythm
heard better on left lateral recumbent
S4 is more prominent when
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
Opening snap
often of mitral valve
caused by valvular stenosis
ejection clicks
stenosis of SLV
heard best on expiration in 2nd left ICS
aortic on 2nd right
mid to late nonejection systolic clicks
mitral prolapse
Three causes of murmurs
High BF through normal valve
BF through constricted or stenotic valve
Backflow of blood through a regurgitant or insufficient valve
What is a murmur?
Disruption of BF into, out or through heart
Friction Rub
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
Prosthetic Mitral Valves
Can cause clicks early in diastole
Loudest at apex
Pacemakers do not cause sound
Causes of murmurs
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
Characteristics of murmurs
timing and duration pitch intensity pattern quality location radiation variation with respiration
Mitral valve stenosis
Leaflets are thickened and the passage narrowed, forward BF restricted
Mitral valve regurgitation
valve incompetence causes blood to leak backwards
Other causes of murmurs
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
Increased S3
Bell at apex
Patient in left lateral recumbent
early in diastole
Increased S4
Bell at apex
supine or left lateral recumbent position
Gallops
bell at apex
supine or left lateral recumbent position
mitral valve opening snap
diaphragm medial to apex, may radiate to base
any position, 2nd to left ICS
aortic valve ejection click
apex, base in second right ICS
sitting or supine
Pulmonary ejection click
second left ICS at sternal border
sitting or supine
Pericardial friction rub
widely heard
clearest towards ape
Grading of Murmurs
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
