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Adult CCRN Review ‘23-‘24 > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

First Heart Sound

A

“Lub” the closure of the mitral and tricuspid valves (heard at apex/left ventricular area of the heart).

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2
Q

Second Heart Sound

A

“Dub” the closure of the aortic and pulmonary valves ( heard at the base of the heart).

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3
Q

Systole

A

The time between S1 and S2

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4
Q

Diastole

A

The time between S2 and S1

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5
Q

Ventricular disease

A

Can cause gallops, snaps, or clicks

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6
Q

Stenosis of the valves

A

Failure of the valves to close can cause murmurs.

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7
Q

Pericarditis

A

Can cause a friction rub

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8
Q

Gallop rhythms

A

S3 commonly occurs after S2 in children and young adults but may indicate heart failure or left ventricular failure in older adults ( heard with patient lying on left side). S4 occurs before S1, during the contracting of the atria when there is ventricular hypertrophy, found in coronary artery disease, hypertension, or aortic valve stenosis.

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9
Q

Opening Snap

A

Unusual high-pitched sound occurring after S2 with stenosis of mitral valve from rheumatic heart disease.

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10
Q

Ejection click

A

Brief high-pitched sound after S1; aortic stenosis.

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11
Q

Friction Rub

A

Harsh, grating holosystolic sound; pericarditis

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12
Q

Murmur

A

Sound caused by turbulent blood flow from stenotic or malfunctioning valves, congenital defects, or increased blood flow. Murmurs are characterized by location, timing in the cardiac cycle, intensity (rated from Grade I to Grade VI), pitch (low to high-pitched), quality (rumbling, whistling, blowing) and radiation (to the carotids, axilla, neck, shoulder, or back).

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13
Q

QT Interval

A

The complete time of ventricular depolarization and repolarization, which being with the QRS segment and ends when the Y wave is completed. Typically, duration usually ranges from 0.35 to 0.45 seconds, but this may vary depending on the heart rate. If the heart rate is rapid, the duration is shorter and vice versa. Certain medications can prolong the QT interval, in such cases monitoring this is critical. A prolonged QT interval puts the patient at risk for R-on-T phenomenon, which can result in dangerous arrhythmias.

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14
Q

ST Segment

A

This is an isoelectric period when the ventricles are in a plateau phase, completely depolarized and beginning recovery and repolarization. Deflection is usually isoelectric, but may range from -0.5 to +1mm. If the ST segment is > or = to 0.5mm below the baseline, it is considered depressed and may be an indication of myocardial ischemia. Depression may also indicate digitalis toxicity. If the ST segment is elevated > or = 1mm above baseline, this is an indication of myocardial injury.

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15
Q

MAP

A

(Mean Arterial Pressure) most commonly used to evaluate perfusion as it shows pressure throughout the cardiac cycle. Systole is one-third and diastole two-thirds of the normal cardiac cycle. Normal range for a MAP is 70-100mmHg. A MAP greater than 60mmHg is required to perfuse vital organs, including the heart, brain, and kidneys.

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16
Q

MAP equation

A

MAP = Diastole x 2 + Systole
_____________________
3

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17
Q

Electrocardiogram

A

Records and shows a graphic display of the electrical activity of the heart through a number of different waveforms, complexes, and intervals.

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18
Q

P wave

A

Start of electrical impulse in the sinus node and spreading through the atria, muscle depolarization.

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19
Q

QRS complex

A

Ventricular muscle depolarization and atrial repolarization.

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20
Q

T wave

A

Ventricular muscle repolarization (resting state) as cells regain negative charge.

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21
Q

U wave

A

Repolarization of the Purkinje fibers.

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22
Q

12-Lead ECG Indication

A

Indicated for chest pain, dyspnea, syncope, acute coronary syndrome, pulmonary embolism, and possible MI.

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23
Q

12-Lead Placement

A

4 limb leads are placed distally on the wrists and ankles (but may be placed more proximally if necessary).
Precordial leads:
V1: Right sternal border at 4th intercostal space.
V2: Left sternal border at 4th intercostal space.
V3: Midway between V2 and V4.
V4: Left midclavicular line at 5th intercostal space.
V5: Horizontal the V4 at the left anterior axillary line.
V6: Horizontal to V5 at left midaxillary line.

24
Q

Right-sided leads

A

Placed on the right in a mirror image of the left leads, usually to diagnose right ventricular infarction through ST elevation.

25
Q

Cardiac Output (CO)

A

The amount of blood pumped through the ventricles during a specified period. Normal cardiac output is about 5 liters per minute at rest for an adult. Under exercise or stress, this volume may multiply 3 or 4 times with concomitant changes in the heart rate (HR) and stroke volume (SV). The basic formulation for calculating cardiac output id the heart per minute multiplied by the stroke volume, which is the amount of blood pumped through the ventricles with each contraction. The stroke volume is controlled by preload, afterload, and contractibility.

26
Q

Cardiac Output Formula

A

CO(mL|min) = HR(beats|mins) x SV (mL)

27
Q

Heart Rate

A

Controlled by the autonomic nervous system. Normally, if the heart rate decreases, stroke volume increases to compensate. The exception to this would be cardiomyopathies, so bradycardia results in a sharp decline in cardiac output.

28
Q

Cardiac Index (CI)

A

The cardiac output (CO) divided by the body surface area (BSA). This is essentially a measure of cardiac output tailored to the individual, based on height and weight, measured in liters/min per square meter of BSA.
- Normal value: 2.2 - 4.0L/min/m2 (squared)

29
Q

Stroke Volume

A

The amount of blood pumped through the left ventricle with each contraction, minus any blood remaining inside the ventricle at the end of systole.
- Normal values: 60 - 70mL

30
Q

Stroke Volume Formula

A

SV (mL) = CO (mL|min) / HR (beats|min)

31
Q

Pulmonary Vascular Resistance (PVR)

A

The resistance in the pulmonary arteries and arterioles against which the right ventricle has to pump during contraction. It is the mean pressure in the pulmonary vascular bed divided by blood flow. If PVR increases, SV decreases.
- Normal value 1.2 - 3.0 units or 100 - 250 dynes/sec/cm5 (to the 5th)

32
Q

Ejection Fraction

A

The percentage of the total blood volume of the heart that is pumped out with each beat. Dramatically decreased values indicate heart failure.
- Normal value 60 - 70%

33
Q

Preload

A

Refers to the amount of elasticity in the myocardium at the end of diastole when the ventricles are filled to their maximum volume and the stretch of the muscle fibers is the greatest. The preload value is based on the volume in the ventricles. The amount of preload (stretch) affects stroke volume because as stretch increases, the resultant contraction also increases (Frank-Starling Law). Preload may decrease because of dehydration, diuresis, or vasodilation. Preload may increase because of increased venous return, controlling fluid loss, transfusion, or intravenous fluids.

34
Q

Afterload

A

Refers to the amount of systemic vascular resistance to left ventricular ejection of blood and pulmonary vascular resistance to the right ventricular resistance ejection of blood. Determinants of afterload include the size and elasticity of the great vessels and the functioning of the pulmonic and aortic valves. Afterload increases with hypertension, stenotic valves, and vasoconstriction.

35
Q

Minimally/Non-invasive Hemodynamic Monitoring

A

Alternatives to traditional invasive means of hemodynamic monitoring (such as the use of a pulmonary artery catheter) include esophageal doppler, arterial pressure based cardiac output monitoring, and impedance cardiography.

36
Q

Esophageal Doppler

A

A minimally invasive option used in surgical patients to monitor descending aortic blood flow and estimate cardiac output. A probe in inserted into the esophagus and then connected to a monitor, where waveform shapes produced by aortic blood flow are displayed.

37
Q

Arterial Pressure based Cardiac Output Monitors (APCO’s)

A

use an algorithm to estimate cardiac output through the analysis of the arterial pressure waveform. The radial or femoral artery is accessed using a standard arterial catheter and no external calibration is needed.

38
Q

Impedance Cardiography

A

A non-invasive method of hemodynamic monitoring in which sensors placed on the body use electrical signals to measure the level of change in impedance in the thoracic fluid. A waveform is generated and id then used to calculate cardiac output and stroke volume, as well as ten additional hemodynamic parameters.

39
Q

Intraarterial Blood Pressure Monitoring

A

Uses a catheter to measure systolic, diastolic, and mean arterial pressures (MAP) continuously. Before catheter insertion, collateral circulation must be assessed by Doppler or the Allen test (radial). Complications include arterial vasospasm, hematoma formation, hemorrhage (accidental disconnect), catheter occlusion, compartment syndrome, retroperitoneal bleed (femoral site), and thrombus/embolus.

40
Q

Intraarterial Blood Pressure Monitoring (setup)

A

The line should be connected to the monitor as well as a pressure bag set at 300mmHg with no longer than 3 feet of stiff, noncompliant tubing to ensure accuracy. The transducer is leveled at the phlebostatic axis of the patient. The line should be kept free of any air or bubbles, and re-zeroed every four hours and with a change of patient position.

41
Q

Intraarterial Blood Pressure Monitoring (waveform)

A

A normal ABP waveform should be smooth and regular, with a dicrotic notch. To test, perform a “square-wave” or “Fast Flush” test; flush the line while watching the monitor. There should be a square shape, followed by two oscillations and a return to normal waves. A missing dicrotic notch indicates a blockage of some kind (thrombus, plaque, and vasospasm) or low pressure in the bag. Too many oscillations or an increased sharpness of the wave indicates under dampening and is caused by increased SVR or too long of tubing.

42
Q

Jugular Venous Pressure (neck-vein)

A

used to assess the cardiac output and pressure in the heart as the pulsations relate to changes in pressure in the right atrium. This procedure is usually not accurate if the pulse rate is >100. This is non-invasive estimation of central venous pressure and waveform. Measurement should be done with the internal jugular if possible; if not, the external jugular may be used.

43
Q

Assessing JVP

A

Elevate the patient’s head 45 degrees (and 90 degrees if necessary) with patient’s head turned to the right. Position a light at an angle to illuminate veins and shadows. Measure the height of the jugular vein pulsation above the sternal joint, using a ruler.

  • Normal height is less than or equal to 4cm above sternal angle.

Increased pressure (>4cm) indicates increased pressure in the right atrium, and right heart failure. It may also indicate pericarditis or tricuspid stenosis. Laughing or coughing may trigger the Valsalva response and also cause an increase in pressure.

44
Q

Stress Test

A

Also called an exercise tolerance test, a commonly used assessment to screen for ischemic heart disease. In this test, the patient is put through exercise with increased rigor, generally on a treadmill, while attached to an ECG to monitor their heart’s rhythm. The patient is assessed for chest pain and dizziness as the rigor level is increased, which is a reflection of the heart’s capacity to handle increasing workloads effectively. The stress test is not a diagnostic on its own, but provides feedback on the direction of additional testing.

45
Q

Water-hammer Pulse

A

Characterized by the alternation between a bounding heartbeat that is strong and forceful, and then collapse. This could be the result of a heightened stroke volume, decreased peripheral resistance, or these two factors together. To assess for this pulse, the patient is seated and one arm is raised vertically. Upon palpation of the radial pulse in the raised arm, the pulse resembles tapping in the muscles of the forearm. This is often an indication of aortic regurgitation.

46
Q

Perfusion Pressure

A

Directly affects coronary blood flow, and coronary perfusion occurs during diastole. Coronary artery perfusion pressure is equal to the diastolic blood pressure minus the pulmonary artery occlusion pressure. Normal values are 60-80mmHg. During the cardiac cycle, aortic pressure causes the coronaries to be perfused, while ventricular pressure compresses the coronaries during systole, decreasing perfusion.

47
Q

Pulse Pressure

A

The difference between systolic and diastolic pressures, and this can be an important indicator. For example, with a decrease in cardiac output, vasoconstriction takes place in the body’s attempt to maintain the blood pressure. In this case, the MAP may remain unchanged, but the pulse pressure narrows. Patients should be assessed for changes in pulse pressure that may be precipitated by medications, such as diuretics that alter fluid volume.

48
Q

Lower Extremities Assessment

A

Appearance - includes comparing limbs for obvious differences or changes in skin or nails as well as evaluating for edema, color changes in skin, such as pallor or rubor. Legs that are thin, pale, shiny, and hairless indicate peripheral arterial disease.

Perfusion - should be assessed by checking venous filling time and capillary refill, skin temperature (noting changes in one limb or between limbs), bruits (indicating arterial narrowing), pulses (comparing both sides in a proximal to distal progression), ankle-brachial index and toe-brachial index.

Sensory function - includes the ability to feel pain, temperature, and touch.

Range of motion - of the ankle must be assessed to determine if the joint flexes past 90 degrees because this is necessary for unimpaired walking and aids venous return in the calf.

Pain - is an important diagnostic feature of peripheral arterial disease, so the location, intensity, duration, and characteristics of pain are important.

49
Q

Assessing Pulses

A

The pulses of the lower extremities is an important part of assessment for peripheral arterial disease/trauma. Pulses should be first evaluated with the patient in supine position and then again with the legs dependent, checking bilaterally and proximal to distal to determine if intensity of pulse decreases distally. Pedal pulses should be examined at both the posterior tibialis and the dorsalis pedis. The pulse should be evaluated as to the rate, rhythm, and intensity, which is usually graded on a 0 to 4 scale:

0 = pulse absent
1 = weak, difficult to palpate
2 = normal as expected
3 = full
4 = strong and bounding

Pulses may be palpable or absent with peripheral arterial disease. Absence of pulse on both palpation and Doppler probe does indicate peripheral arterial disease.

50
Q

Bruits

A

May be noted by auscultating over major arteries, such as femoral , popliteal, peroneal, and dorsalis pedis, indicating peripheral arterial disease.

51
Q

Venous Refill Time

A

Begin with the patient laying supine for a few moments and then have the patient sit with the feet dependent. Observe the veins on the dorsum of the foot and count the seconds before normal filling. Venous occlusion is indicated with times greater than 20 seconds.

52
Q

Capillary Refill

A

Grasp the toenail bed between the thumb and index finger and apply pressure for several seconds yo cause blanching. Release the nail and count the seconds until the nail regains normal color. Arterial occlusion is indicated with times of more than 2 to 3 seconds. Check both feet and more than one nail bed.

53
Q

Skin Temperature

A

Using the palm of the hand and fingers, gently palpate the skin, moving distally to proximally and comparing both legs. Arterial disease is indicated by decreased temperature (coolness) or a marked change from proximal to distal. Venous disease is indicated by increased temperature about the ankle.

54
Q

Ankle-Brachial Index (ABI) Examination

A

Done to evaluate peripheral arterial disease of the lower extremities.

55
Q

ABI Exam

A
  1. Apply BP cuff to one arm, palpate brachial pulse, and place conductivity gel over the artery.
  2. Place the tip of the Doppler device at a 45-degree angle into the gel at the brachial artery and listen for the pulse sound.
  3. Inflate the cuff until the pulse sound ceases and then inflate 20mmHg above that point.
  4. Release air and listen for the return of the pulse sound. This reading is the brachial systolic pressure.
  5. Repeat the procedure on the other arm and use the higher reading for calculations.
  6. Repeat the same procedure on each ankle with the cuff applied above the malleoli and the gel over the posterior tibial pulse to obtain the ankle systolic pressure
  7. Divide the ankle systolic pressure by the brachial systolic pressure to obtain the ABI.

Sometimes, reading are taken both before and after 5 minutes of walking on a treadmill.

Adult CCRN Review ‘23-‘24 (1 decks)

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