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Cardio Pulm Eval > Cardiovascular System & Patients > Flashcards

Cardiovascular System & Patients Flashcards

1
Q

Embryonic Development

A

Heart starts out as single ventricle and single atrium
- Truncus arteriosus
- Sinus Venous
- Umbilical Vein (OXYGENATED blood from placenta)

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2
Q

Foramen Secundum

A
  • “Foramen ovale” after birth
  • May form Patent Foramen Ovale or atrial-septal defect (ASD) if open after birth
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3
Q

Inter-ventricular Foramen

A
  • May form Interventricular Septal Defect (VSD) if not closed after 7th week of fetal development
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4
Q

Week 4 of Heart Development

A
  • Partitioning of aorta-ventricular canals
  • Interventricular foramen closes at 7th week IVF (or Ventricular septal defect VSD)
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5
Q

Heart Development at Birth

A
  • Final separation between systemic and pulmonary circulations
  • Septum secundum forms the foramen ovale
  • patient foramen ovale allows oxygenated blood to go to the systemic circulation before birth
  • closes at birth (or ASD)
  • Ductus arteriosus- connects aorta to L pulmonary artery (patent ductus arteriosus PDA)
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6
Q

Congenital CV Defects: Right-Left Shunt

A
  • cyanotic congenital heart disease
  • Examples: Tetralogy of Fallot
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7
Q

What is the Tetralogy of Fallot

A

transposition of great arteries, persistent truncus arteriosus, tricuspid artesia, anomalous pulmonary venous connection

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8
Q

Congenital CV Defects: Left- Right Shunts

A
  • No Cyanosis but pulmonary HTN and pulmonary artery changes
  • Ex: ASD, VSD, PDA
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9
Q

Obstruction

A
  • Stenosis: narrowing
  • Artesia: obstruction
  • Increased resistance causes chamber hypertrophy/dilation
  • Ex: Coarctation of aorta (common), pulmonary stenosis or artesia
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10
Q

Function of heart and blood vessels

A
  • transport nutrients and oxygen
  • endocrine function –> regulation of fluid balance and growth
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11
Q

Elastic Arteries

A
  • “distribution arteries”
  • function: aid in conduction and flow and smooth flow
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12
Q

Muscular Arteries

A
  • Branches of the elastic arteries
  • “resistance” arteries
  • function: regulation of flow, alter resistance
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13
Q

Capillaries (and venules)

A
  • Exchange vessels
  • Function: nutrient and waste exchange between tissues and blood
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14
Q

Veins

A

Capacitance vessels

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15
Q

Structure of Veins

A
  • assist in moving blood by one way valves that prevent back flow
  • located in beds where compression by muscles forces blood toward heart (especially effective in beds in calf and dorsum of foot)
  • negative pressure in thoracic cavity during inhalation assists in venous return
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16
Q

Exchange within the capillary

A

a gradient forms along the length of the capillary, such that
at the beginning, net filtration occurs, and at the end,
absorption. The result is an equilibrium and fluid balance
over the whole length of the capillary

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17
Q

Pericardium

A

– Fibrous outer layer of pericardium
– Inner, smooth layer (parietal and visceral)
– at base, pericardium attaches heart to diaphragm

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18
Q

Myocardium

A

– Cardiomyocytes, fascicles and bundles of fascicles are invested in connective tissue
– Layers of muscle are woven in a complex pattern with a
swirling twist, allowing for a wringing motion during
contraction.

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19
Q

Excitation- Contraction Coupling

A
  • AP causes Ca2+ channels to open
  • Extracellular Ca2+ triggers SR release of Ca2+ (Ca-induced Ca-release)
  • Ca2+ binds to troponin, triggering actin-myosin interaction
  • Tension develops
  • Relaxation occurs when Ca sequestered by SR
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20
Q

Innervation of the Heart- Sympathetics

A

– pre-ganglionic cells in lateral gray of upper cervical segments
– post ganglionic cells in cervical, 3rd &4th Thoracic ganglia
– increase strength, rate of contraction, increase rate and extent of
relaxation

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21
Q

Innervation of the Heart- Parasympathetics

A

– pre-ganglionic cells in medulla (N ambiguous, etc…)
– travel in vagus nerve
– decrease rate of contraction, slow conduction, decrease strength
of contraction and slow rate of relaxation

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22
Q

Effects of Aging on CV System

A
  • Decreased vascular elasticity –> increased blood pressure
  • Left ventricular hypertrophy –> decreased ventricular compliance
  • decreased adrenergic responsiveness –> decreased exercise heart rate
  • diastolic dysfunction –> impaired ventricular filling with potential to increase cardiac preload and CHF
  • decreased lean body mass –> decreased muscle strength and peak oxygen consumption
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23
Q

What is arterial blood pressure

A

pressure that results from the rate of flow of blood through and against the resistance of the peripheral arteries

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24
Q

Mean arterial pressure

A

driving force & tissue perfusion P
MAP = [SBP + (2x DBP)] / 3

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25
Q

Pulse Pressure

A

SBP - DP
reflects adaptation to exercise

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26
Q

Orthostatic Hypotension

A

• Delay/ insensitivity in baroreceptor reflex, dehydration or
pooling of blood leads to decreased blood pressure and flow to brain
• Defined as decrease in blood pressure when going from
supine →sitting or sitting →standing

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27
Q

When does orthostatic hypotension occur?

A

after prolonged bed rest, in patients with generalized hypotension, and in Heart failure

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28
Q

What is orthostatic hypotension associated with?

A

• Strongly associated w/ Ca2+-channel blockers (procardia)

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29
Q

Guidelines of orthostatic hypotension

A
  • decrease is SBP of 20 mmHg or DBP of 10 mmHg
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30
Q

Jugular Venous Distension

A
  • Examine pt with head up at 45 degree angle
  • Compress SCM muscle with note if the vein is distended above the level of the clavicle
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31
Q

What does jugular venous dissension indicate?

A

elevated venous pressure and R heart failure

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32
Q

Risk factors of peripheral artery disease

A

smoking, HTN, atherosclerosis, DM, high cholesterol, greater than 60 yo

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33
Q

Signs and symptoms of peripheral artery disease

A

– Intermittent claudication (leg pain with walking gets better with rest)
– Other pain, aches, or cramps with walking
– Muscle atrophy (weakness),
– Hair loss,
– Smooth, shiny skin or skin that is cool,
– Decreased or absent pulses in feet
– Cold or numb toes
– Sores or ulcers in the legs or feet that don’t heal

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34
Q

Medical management of peripheral artery disease

A

– Aspirin or similar antiplatelet, statins and other medications to
reduce atherosclerosis and medication to treat HTN
• Quit smoking
• Surgery may be required (angioplasty, stent or bypass graft)
* PT: Exercise, exercise, exercise!*
– Walking is optimal, but also cycling, other aerobic Ex, HIIT

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35
Q

Radial peripheral pulse

A

compress radial artery under index fingers at distal radius

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36
Q

brachial peripheral pulse

A

compress brachial artery medial to insertion of biceps

37
Q

Carotid Pulse

A
  • slide index and middle fingers lateral from cricoid cartilage on the trachea to jugular groove on either side
  • Feel for pulse and listen with stethoscope for murmur
38
Q

Carotid Bruit

A

“whooshing” or murmur sound heard over
the carotid artery. In most cases, it occurs above the clavicle and indicates a carotid blockage

39
Q

Pedal Pulse

A

anterior surface of foot, between maleoli, just lateral to the extensor Hallicus longus tendon

40
Q

What to feel for when examining pulses

A

texture of artery wall, rhythm, regularity, force:
weak or thready, strong or bounding

41
Q

Pulse Grading

A

0 - Absent - No perceptible pulse
1+ - Thread - Barely perceptible, easily obliterated with slight pressure
2+ - Weak - Difficult to palpate, slightly stronger than thread, can be obliterated with light pressure
3+ - Normal - Easy to palpate, requires moderate pressure to obliterate
4+ - Bounding - Very Strong, hyperactive

42
Q

Arterial Insufficiency

A

Associated with painful Ulcers, cramps, gangrene, exercise intolerance, CAD,
CVA, etc

43
Q

Venous Insufficiency

A

Associated with infection, Ulcers, VTE, DVT, cramps, leg pain

44
Q

Doppler Assessment of ABI

A
  • Apply US gel and hold Doppler probe 45-70° angel on arm skin as BP
    cuff is deflated –> note first point flow is detected and point where max flow is detected
  • Apply US gel and hold Doppler probe 45-70° angel on posterior tibial
    artery as BP cuff above ankle is deflated –> note first point flow is detected and point where max flow is detected
45
Q

What position should the patient be for the Doppler Assessment of ABI

A

lying flat to decrease the effect of gravity

46
Q

ABI ration

A

LE systolic pressure (ankle) / UE systolic pressure (brachial)

47
Q

ABI 1.0 - 1.2

A

Normal

48
Q

ABI 0.8- 1.0

A
  • Minimal peripheral arterial disease
  • compression for edema is safe
49
Q

ABI 0.5- 0.8

A
  • Moderate peripheral arterial disease
  • possible intermittent claudication
  • Refer to vascular specialist
  • Compression therapy contraindicated if < 0.6
50
Q

ABI < 5.0

A
  • Severe ischemia with resting pain
  • compression therapy contraindicated
51
Q

ABI < 0.2

A

Ischemia and necrosis

52
Q

ABI 1.0-1.3

A

May occur with venous hypertension

53
Q

ABI >1.3

A

Non-reliable in patients with diabetes due to calcification of arteries

54
Q

Peripheral Edema

A
  • Common finding
  • Variable depending on body position (dependent vs. independent)
  • May indicate elevated venous pressure and R HR
55
Q

Pitting Edema Measurement

A
  • Patient in supine with leg/foot in dependent position and then independent position
  • Push down on dorsum of foot for 10 seconds
  • Palpate for depression (30 sec)
  • Compress over medial malleolus
  • keep moving up to determine height of edema
56
Q

Pitting Edema Levels

A
  • 1+ Barely perceptible
  • 2+ easily identified depression (EID) but rebounds < 15 seconds
  • 3+ EID, rebounds 15-30 sec
  • 4+ EID, rebounds in > 30 sec
57
Q

Volume measurements of edema

A
  • Simplest is to use a volumetric tank
  • Fill tank to designated limit, then place the involved extremity in up to an established, reproducible landmark
58
Q

Girth Measurements for edema

A

– Use tape measure around the diameter of the limb crossing designated landmarks
- Compare to previous measurements (tibial tuberosity, medial and lateral malleoli or figure 8 of foot)
- Compare to uninvolved limb (if possible)

59
Q

What does Rubor- Dependency Test indicate?

A

arterial insufficiency

60
Q

Rubor Dependency Test Instructions

A
  1. Patient supine- note the color of plantar aspect of foot
  2. Elevate leg to 45-60° x 1 minute - then note the color of the foot (observe for pallor)
  3. Lower leg to dependent position (back to plinth)
61
Q

What is the normal response of Rubor Dependency Test

A

normal, expected skin color in approximately 15 seconds

62
Q

During Rubor Dependency Test, what does reperfusion in > 30 sec AND dark-red or rubor appearance mean?

A

The test is positive for severe ischemic disease

(rumor results from reactive hyperemia/vasodilation)

63
Q

How to determine how severe PAD is based on Rubor Dependency Test

A

The faster pallor appears in elevated position or longer it takes for
the rubor to appear in the dependent position, the more severe PAD.

64
Q

What activates the coagulation cascade that causes VTE or DVT

A

Coagulation cascade is activated with surgery or trauma and remains active x 5-6 weeks

65
Q

45 - 80% of symptomatic VTE events occur when?

A

after hospital discharge

66
Q

Factors that predispose to VTE/DVT

A

– Cancer
– Bed rest
– Muscle wasting
– Immobilization
– Burn or other wounds
– Edema
– Heart failure

67
Q

How can diagnosis of VTE or DVT be made?

A

Doppler ultrasound,
venogram or D-Dimer test

68
Q

Best results of VTE

A
  • The best results are found when medication is combined with mobility
  • In a study that examined the combination of ambulation and prophylactic enoxaparin, those who were ambulatory and given medication had a significantly lower rate of VTE
69
Q

Non-Pharmacological Rx for DVT

A

mobilization, exercise, ROM, ambulating, anti-coagulants and anti-thrombosis devices (TED hose, and compression

70
Q

Study the Wells Clinical Decision Rule to Diagnose DVT

A
71
Q

Study Constans Criteria for Risk of UE DVT

A
72
Q

Padua Prediction Score for VTE/DVT

A

recommended for hospitalized patients based on Am Coll of Chest Physicians guidelines
– Useful for patient with cancer, trauma, other serious conditions

73
Q

Khorana Score for VTE/DVT

A
  • recommended for patients with cancer
  • Allocates points based on 5 clinical and pre-chemo Rx lab values: primary tumor site, platelet count, hemoglobin, leukocyte count, BMI
74
Q

Key Phrases VTE/DVT Guidelines

A
  • Advocate for culture of mobility and physical activity
  • Assess for risk of VTW with reduced moility
  • Assess for additional risk factors of VTE in all high-risk patients
  • Establish likelihood of LE DVT when patient presents with symptoms
  • Mobilize patients with LE DVT when therapeutic level of anticoagulation achieved
  • Mobilize individuals with IVC filter
  • Consult medical team to initiate mobility with distal LE DVT not treated with IVC filter or anticoagulant
  • Mobilize pt’s with non-massive PE when therapeutic level of anticoagulation achieved
75
Q

You should not mobilize massive PEs or submissive/intermediate high-risk PEs until what?

A

until they are low risk and hemodynamically stable

76
Q

Auscultation of Aortic Area

A

2nd IC space
R sternum
Aortic value

77
Q

Auscultation of Pulmonic Area

A

2nd IC space
L sternum
Pulmonic valve

78
Q

Auscultation Tricuspid area

A

4-5th IC space
R sternum
tricuspid vavle
sidelying on L

79
Q

Auscultation of Mitral Area

A

5th IC space
L MCL
Mitral valve
sidelying on L

80
Q

S1 Lub

A

closure of mitral and tricuspid valves

81
Q

S2 Dub

A

closure of aortic and pulmonic valves

82
Q

S3 Lub Dub Dub

A
  • low pitched, also called a gallop
  • Normal in young & athletes
  • in > 40: heart failure and cardiac hypertrophy
  • SLOSHing in
83
Q

S4 La Lub Dub

A
  • low pitched, also called atrial gallop
  • abnormal, indicates chronic HTN, cardiomyopathy, hypertrophy
  • “Stiff” wall
84
Q

Murmurs

A
  • Whooshing
  • systolic
  • Lush Dub, valve regurgitation or aortic/pulmonary stenosis (leaky valve)
85
Q

Mitral or tricuspid murmur

A

S1 may be obscured or it occurs between S1 and S2 (systole)

86
Q

Aortic or pulmonic murmur

A

S2 is obscured or it occurs between S2 and S1 (diastole)

87
Q

Parasympathetic Cranial Nerves

A

CN X to SA note, AV node, and ventricles

88
Q

What does sbp reflect

A

Contractility and compliance of arteries

89
Q

What does dbp reflect

A

Total peripheral resistance and heart rate

Cardio Pulm Eval (10 decks)

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