cardiovascular Flashcards
heart chambers
⬤ Four chambers separated by valves, whose
main purpose is to prevent backflow of blood
⮚ Valves are unidirectional
⮚ Valves open and close passively in response to pressure gradients in moving blood
heart valves
⬤ Four valves in heart:
⮚ Two atrioventricular (AV) valves, tricuspid and bicuspid (mitral)
⮚ Two semilunar (SL) valves, pulmonary and aortic
AV valves
⬤ Two AV valves separate atria and ventricles:
⮚ Tricuspid valve: right AV valve
⮚ Bicuspid, or mitral valve: left AV valve
* Valves’ thin leaflets are anchored by collagenous fibers (chordae tendineae) to papillary muscles embedded in ventricle floor
⮚ AV valves open during heart’s filling phase, or diastole, to allow ventricles to fill with blood
⮚ During pumping phase, or systole, AV valves close to prevent regurgitation of blood back up into atria
semilunar valves (exam)
⬤ SL valves are set between ventricles and arteries
⮚ Each valve has three cusps that look like half moons
⮚ Pulmonic valve: SL valve in right side of heart, at the bottom
⮚ Aortic valve: SL valve in left side of heart, at the bottom of the heart
* Open during pumping, or systole, to allow blood to be ejected from heart
⮚ No valves are present between vena cava and right atrium, or between pulmonary veins and left atrium:
* Abnormally high pressure in left side of heart gives a person symptoms of pulmonary congestion
* Abnormally high pressure in right side of heart shows in neck veins and abdomen
blood flow throughout the heart
Blood flows through the heart in the following route: from the vena cava into the right atrium, then through the tricuspid valve to the right ventricle, through the pulmonary valve to the pulmonary artery, to the lungs for oxygenation, back to the heart via the pulmonary veins into the left atrium, through the mitral valve to the left ventricle, and finally through the aortic valve into the aorta, which carries it to the body
heart sounds - the first heart sound (S1)
⬤ First heart sound (S1) -> lub
⮚ Occurs with closure of AV valves—signals beginning of systole
⮚ Mitral component of first sound (M1) slightly precedes tricuspid component (T1)
heart sounds - the second heart sound (S2)
⬤ Second heart sound (S2) -> dub
⮚ Occurs with closure of semilunar valves—signals end of systole
⮚ Aortic component of second sound (A2) slightly precedes pulmonic component (P2)
* S2 loudest at base
extra heart sounds
⬤ Third heart sound (S3)
⮚ Occurs when ventricles resistant to filling during early rapid filling phase (protodiastole)
⮚ Occurs immediately after S2, when AV valves open and atrial blood first pours into ventricles
⬤ Fourth heart sound (S4)
⮚ Occurs at end of diastole, at presystole, when ventricle resistant to filling
⮚ S4 occurs just before S1
murmurs
⬤ Gentle, blowing, swooshing sound that can be heard on chest wall
⬤ Conditions that create turbulent blood flow and collision currents
some common conditions that can result in murmurs
velocity of blood increases
viscosity of blood decreases
structural defects in the valves
conduction of the heart (exam)
⬤ Heart has unique ability: automaticity
⮚ Can contract by itself, independent of any signals or stimulation from body
⮚ Contracts in response to an electrical current conveyed by a conduction system
⮚ Specialized cells in sinoatrial (SA) node, near superior vena cava initiate an electric impulse
⮚ Because SA node has intrinsic rhythm, it is called the pacemaker
what is an ECG
An electrocardiogram (ECG), also known as an EKG, is a medical test that records the electrical activity of the heart. It helps to assess the heart’s rhythm, rate, and electrical conduction pathways
neck vessels
⬤ The Carotid Artery Pulse
⬤ Jugular Venous Pulse and Pressure
⮚ Two jugular veins present on each side of neck -> internal & external jugular
⮚ Empty unoxygenated blood directly into superior vena cava
⮚ Reflect activity/function of right side of heart
developmental competence in pregnant women
⬤ Pregnant woman
⮚ Blood volume increases by 30% to 40% during pregnancy
⮚ Increase in SV, HR & red cell mass
⮚ Despite increased cardiac output, arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation (exam)
developmental competence in infants and children
⬤ Infants and children
⮚ Fetal heart begins to beat after 3 weeks’ gestation
⮚ Lungs nonfunctional 🡪 fetal circulation compensation
⮚ Inflation and aeration of lungs at birth produces circulatory changes
developmental competence in the aging adult
⬤ Aging adult
⮚ Closely interrelated with lifestyle, habits, and diseases
⮚ Lifestyle, smoking, diet, alcohol use, exercise patterns, and stress have
an influence on coronary artery disease
hemodynamic changes with aging -> pressure/pulse changes
⮚ Isolated systolic HTN: Increase in systolic BP due to thickening and stiffening of the arteries
⮚ Pulse pressure increases
* Difference between systolic and diastolic BP
* Reflects cardiovascular health
⮚ No change in resting heart rate or cardiac output at rest
⮚ Ability of heart to augment cardiac output with exercise is decreased
hemodynamic changes with aging - dysrhythmias
⮚ Presence of supraventricular and ventricular dysrhythmia increases with age
⮚ Ectopic beats common in aging people; usually asymptomatic in healthy older people, may compromise cardiac output and blood pressure when disease present
⮚ Tachyarrhythmias may not be tolerated as well in older people
hemodynamic changes with aging - electrocardiogram
⮚ Occur as result of histologic changes in conduction system; these changes include:
* Prolonged P-R interval (first-degree AV block) and prolonged Q-T interval,
but the QRS interval is unchanged
* Left axis deviation from age-related mild LV hypertrophy and fibrosis in left bundle branch
* Increased incidence of bundle branch block
genetics and the environment - what is the #1 cause of death (exam)
cardiovascular disease, it is a complex interplay between genetics and lifestyle factors
- is an umbrella for multiple other diagnoses
genetics and the environment - cardiovascular and health issues
⮚ Hypertension (HTN) 🡪🡪 ethnicity🡪🡪 accelerates process of
atherosclerosis
⮚ Smoking & Tobacco Use🡪🡪 impacts oxygenation
⮚ Elevated Cholesterol 🡪🡪 LDL adds to plaque formation
⮚ Type 2 Diabetes🡪🡪 need for glycemic control
⮚ Nutrition & Diet 🡪🡪 healthy choices & limit processed/refined foods
⮚ Exercise & Physical Activity🡪🡪 beneficial
⮚ Overweight & Obesity 🡪🡪 caloric restriction & counseling
⮚ Sex & Gender Differences in CVD
chest pain questions
Any chest pain or tightness? Ask about
onset and location
characteristics
precipitating events
associated symptoms
relieved by or made worse by
pain relieved by rest or medication
dyspnea questions
Any shortness of breath? Ask about
type of activity and occurrence
onset and duration
effect of positional changes and interruption of sleep
presence of orthopnea
affect ADLs
questions to ask about a cough
⮚ duration and frequency
⮚ characteristics of type and productive versus non-productive
⮚ effect of positional change
⮚ affect ADLS
⮚ alleviating factors or precipitating factors
⮚ medications or treatments
questions to ask about fatigue
Do you seem to tire easily? Ask about
⮚ onset and any recent changes in energy level
⮚ r/t time of day
additional subjective questions to ask about occurrences
Orthopnea – how many pillows do you use? Cyanosis or pallor
nocturia – do you awaken at night to go to the
bathroom?
have you experienced any edema/swelling in your legs
⮚ Onset and timing
⮚ Amount and location
⮚ Relief of symptoms
⮚ Presence of associated symptoms
cardiac PMH questions
Ask about
⮚ past cardiac history- medical and surgical
⮚ diagnostic testing and imaging studies
⮚ family history
Patient-centered care/lifestyle questions:
⮚ Nutrition
⮚ Smoking
⮚ Alcohol
⮚ Exercise
⮚ Medication
preparation for evaluation of the cardiovascular system
To evaluate carotid arteries, a person can be sitting
⮚ To assess jugular veins and precordium, the person should be supine with head and chest slightly elevated
⮚ Ensure woman’s privacy by keeping her breasts draped
equipment needed for evaluation of the cardiovascular system
⮚ Stethoscope with diaphragm and bell end pieces
⮚ Alcohol wipe to clean endpiece
⮚ Tape measure to measure any edema if warranted
in what order should you assess the cardiovascular system
⮚ Pulse & BP
⮚ Extremities
⮚ Neck vessels
⮚ Precordium
inspecting and palpating the arms
Arms
⮚ Color of skin/nailbeds/clubbing
⮚ Swelling
⮚ Cap refill
⮚ Palpate bilateral radial pulses and grade
* 3+, Increased, full, bounding
* 2+, Normal
* 1+, Weak
* 0, Absent
inspect and palpate the legs
Legs
⮚ Color of skin and hair distribution
⮚ Any sores or lesions
⮚ Swelling – grade edema (see next slide)
⮚ Palpate peripheral arteries/pulses
* Dorsalis pedis
* Doppler to help if pulse is too weak to feel
how to grade lower extremity edema
1+, Mild pitting, slight indentation, no perceptible swelling of the leg
2+, Moderate pitting, indentation subsides rapidly
3+, Deep pitting, indentation remains for a short time, leg looks swollen
4+, Very deep pitting, indentation lasts a long
time, leg is grossly swollen and distorted
inspecting the neck vessels (exam)
Inspect the jugular venous pulse
⮚ From jugular veins you can assess central venous pressure (CVP) and judge heart’s efficiency as a pump
⮚ Position a person supine anywhere from a 30- to a 45- degree angle, wherever you can best see pulsations
⮚ Observe for possible distention
Characteristics of jugular versus carotid pulsations
⮚ Differentiate between location, quality, respiration, palpable, pressure, and position of patient
palpating the carotid artery
⮚ Palpate only one carotid artery at a time to avoid compromising arterial blood to brain
⮚ Feel contour and amplitude of pulse, normal strength 2+
⮚ Findings should be same bilaterally
auscultate the carotid artery (exam)
⮚ Assess for presence of carotid bruit
* avoid compressing the artery which can create an artificial bruit
the technique for assessing for a carotid bruit
⬤ Lightly apply the bell of the stethoscope over the carotid artery at three levels: (1) the
angle of the jaw, (2) the midcervical area, and (3) the base of the neck.
⬤ Ask the person to take a breath, exhale, and hold it briefly while you listen so tracheal breath sounds do not mask or mimic a carotid
artery bruit.
inspecting and palpating the precordium - anterior chest (exam)
⮚ Observe for any possible pulsations
⮚ Palpate apical impulse: note location, size,
amplitude and duration
⮚ Palpate across precordium to assess for any
possible pulsations
⮚ Use palmar aspects of fingers, gently palpate the apex, the left sternal border, & the base, searching for any pulsations
auscultation of the precordium (exam)
Identify auscultatory areas associated with valves
Sound radiates with blood flow direction; valve areas are:
* Second right interspace: aortic valve area
* Second left interspace: pulmonic valve area
* Left lower sternal border: tricuspid valve area
* Fifth interspace at around left midclavicular line: mitral valve area
what to note when auscultating the precordium
⬤ Note rate and rhythm: describe characteristics 🡪🡪 check for pulse deficit
⬤ Identify S1 and S2 🡪🡪 focus on systole, then on diastole & then listen for extra heart sounds/describe characteristics
⬤ Listen for murmurs: Timing, loudness, pitch, pattern, quality, location, radiation posture and change of position
differential diagnosis of the chest - cardiovascular (exam)
⮚ Ischemic: Angina pectoris, Prinzmetal or variant angina, and acute coronary
syndrome (ACS)
⮚ Non-ischemic: Pericarditis, mitral valve prolapse, aortic dissection, and secondary pulmonary HTN
differential diagnosis of the chest - pulmonary
Pulmonary embolism, pneumonia, and pneumothorax
differential diagnosis of the chest - gastro
Gastroesophageal reflux, esophageal spasm, cholecystitis, and pancreatitis
differential diagnosis of the chest - dermatologic
Herpes Zoster
differential diagnosis of the chest - musculoskeletal or neurologic
Costochondritis and chest wall muscle strain
differential diagnosis of the chest - psychogenic
Depression and anxiety
what is a myocardial infarction
Sudden decrease in coronary blood supply
Diagnosed by Dr. with EKG and patient presentation
signs and symptoms of a MI (Exam)
⮚ Heaviness; viselike, squeezing, crushing, tightness; vague, burning, constricting, or pressure
⮚ Women: initial symptom in women is angina, fatigue, indigestion, shortness of breath, and back or jaw pain
⮚ Pale, sweaty, tachycardic, SOB
⮚ Poorly localized pain, can last 20-30 mins to hours
⮚ Does not resolve with rest or nitroglycerin
some treatments of MIs
Tailored to pain management, decreasing the blockage, improve tissue perfusion
abnormal findings of abnormal pulsations of the precordium (exam)
Thrill at the base
Lift (heave) at the left sternal border
Volume overload at the apex
Pressure overload at the apex
midsystolic ejection murmurs
⮚ Aortic stenosis
⮚ Pulmonic stenosis
pansystolic regurgitant murmurs
⮚ Mitral regurgitation
⮚ Tricuspid regurgitation
diastolic rumbles of atrioventricular valves
⮚ Mitral stenosis
⮚ Tricuspid stenosis
early diastolic murmurs
⮚ Aortic regurgitation
⮚ Pulmonic regurgitation
some things that are huge risks for cardiovascular issues (exam)
hypertension
ethnicity
smoking
elevated cholesterol
Type 2 diabetes
obesity
important question to ask about dyspnea (exam)
ask about the effect of positional changes and interruption of sleep
- do they feel better when sitting up or laying down, are they sleeping okay.
