EXAM 2 PART 1 Flashcards
what is hemoptysis?
coughing up blood
how long does acute cough last?
less than 2-3 weeks
how long does chronic cough last?
over 2 months
a continuous cough throughout the day is indication of a:
acute illness such as respiratory infection
a cough in the afternoon/evening is an indication of:
exposure to irritants
a cough a night could be due to:
postnasal drip, sinusitis
a cough in the early morning could be due to:
chronic bronchial inflammation of smokers
white or clear mucoid sputum is a sign of:
colds, bronchitis, viral infections
yellow or green sputum is a sign of:
bacterial infections
rusted color sputum is sign of:
TB, pnemonoccal pneumonia
pink frothy sputum is a sign of:
pulmonary edema or sympathomimetic medications
How is the thoracic cage defined?
by the sternum, 12 pairs of ribs and 12 thoracic vertebrae
The first 7 ribs attach directly to the _____
sternum via costal cartilage
Ribs 11 and 12 are considered ______
floating ribs
The _____ is the point at which the ribs join their cartilages
costochondral junctions
T/F costochondral junctions are not palpable
True
The suprasternal notch can be felt as a:
hollow U-shaped depression above the sternum, between the clavicles
This structure has 3 parts: the manubrium, the body, and the xiphoid process
sternum
Sternum is also considered as the _________
breastbone
This is often called the angle of louis and is the articulation of the manubrium and body of the sternum
sternal angle
The sternal angle is continous with the:
2nd rib
You can easily palpate down to the:
10th ribs
_________ marks the site of tracheal bifurcation into the right and left main bronchi
angle of louis
The ______ is the right and left coastal margins from an angle where they meet at the xiphoid process
costal angle
The costal angle increases when:
the rib cage is chronically overinflated as in emphysema
When counting ribs and intercoastal spaces on the back start with the:
vertebra prominens and feel for the most prominent bony spur protruding at base of neck (this will be spinous process of c7; if two seem most prominent then the upper one is c7 and lower one is t1
Where is the scapulae located?
symmetrically in each hemithorax
Why do we use reference lines?
to pinpoint a finding vertically on the chest
Midspinal is another name for:
vertebral
The lateral chest is divided by 3 lines:
anterior axillary, posterior axillary and midaxillary
________ is the middle section of the thoracic cavity and contains the esophagus, tracheae, heart and great vessels
mediastinum
Pleural cavities contain which organ:
the lungs
The ______ is the highest point of lung tissue and the ______ is also called the lower border:
apex; base
How many lobes does the right lung have and the left lung have?
3; 2
Lobes of the lung are separated by:
fissures that rub obliquely through the chest
The posterior chest is almost all:
lower lobe
______ is serous membranes that form an envelope between the lungs and the chest wall
Pleurae
________ lines the outside of the lungs and dips down into the fissures
visceral pleura
________ lines the inside of the chest wall and diaphragm and is continous with the visceral pleura
parietal
pleural cavity is filled with lubricating fluid and has ________ which holds lungs tightly against chest wall
negative pressure
Pleurase extend approx. 3 cm below the level of the lungs forming:
the costodiaphragmatic recess
What does the costodiaphragmatic recess do:
is a potential space that compromises lung expansion when abnormally filled with air or fluid
The _______ begins at the cricoid cartilage in the neck and branches just below the sternal angle into the right and left bronchi and lies anterior to the esophagus and is 10-11 cm long in the adult:
trachea
Which bronchus is shorter, wider and more vertical?
the right main bronchus
The _______ and _______ transport gases between the environment and the lung parenchyma
trachea and bronchi
What is the dead space?
space filled with air but is not available for gasesous exchange
What structures constitute the dead space?
trachea and bronchi
What protects alveoli from small particulate matter in the inhaled air?
the bronchial tree
What kind of cells is the bronchi lined with?
goblet cells
_________ secrete mucus that entraps the particles and cilia which sweep particles upward where they can be swallowed and expelled; lined in the bronchi
goblet cells
________ is a functional respiratory unit that consist of the bronchioles, alveolar ducts, alveolar sacs and the alveoli
acinus
Where does gasesous exchange occur?
across the respiratory membrane
Why are alveoli clustered like grapes around each alveolar duct?
to create millions of interalveolar septa walls that increase the working space available for gas exchange (surface area)
What are the major functions of the respiratory system?
supplying o2 to the body for energy production, removing co2 as a waste product of energy reactions, maintaining homeostasis (acid-base balance) of arterial blood and maintaining heat exchange (less important in humans)
How does respiration maintain the pH or the acid-base balance of the blood?
by supplying o2 to the blood and eliminating excess co2
The lungs help to maintain pH balance by:
adjusting the levels of co2 through respiration
What does hypoventilation cause?
co2 to build up in the blood
What does hyperventilation cause?
co2 to be blown off
Our breathing pattern changes without awareness due to:
cellular demands
What mediates the involuntary control of respirations?
the pons and medulla (respiratory center in the brainstem)
What is humoral regulation?
change in co2 and o2 levels in the blood and the hydrogen ion level (less important)
What is the normal stimilus to breathe?
hypercapnia
What is hypercapnia?
an increase of co2 in the blood
What is hypoxemia?
decrease of 02 in the blood
______ increases respirations but is less effective then hypercapnia
hypoxemia
Inspiration occurs when:
air rushes into the lungs as the chest size increases
Expiration occurs when:
co2 is expelled from the lungs as the chest recoils
Mechanical expansion and contraction of chest cavity alters the size of the thoracic container in 2 dimensions:
the vertical diameter lengthens or shortens or the anteroposterior diameter increases or decreases
How is the lengthening of the vertical diameter accomplished?
by downward or upward movement of the diaphragm
How is the anteroposterior diameter increased or decreased?
by elevation or depression of the ribs
In ______ increasing the size of thoracic container creates a slightly negative pressure in relation to the atmosphere, therfore air rushes in to fill the partial vacuum
inspiration
Expiration is primarily:
passive
Expiration causes the diaphragm to:
relax
During expiration, the squeezing from the relaxtion of the diaphragm creates a:
relatively positive pressure within the alveoli, allowing air to flow out
Forced inspiration requires the use of:
accessory neck muscles to heave up the sternum and rib cage
In the aging adult, the costal cartilages become _______, making the thorax less mobile
calcified
Respiratory muscle strength _______ after 50 and continues decreasing into the 70s
declines
In the aging adult, there is a decrease in elastic properties within the lungs which makes them less:
distensible and lessens their tendency to collapse and recoil
The aging lung is a more:
rigid structure that is harder to inflate
Older adults experience a increase in small airway closures which yields _______
decreased vital capacity and increased residual volume
What is decreased vital capacity?
Maximum amount of air that can be expelled from the lungs after first filling the lungs to maximum
What is increased residual volume?
the amount of air remaining in the lungs even after the most forceful expiration
With aging, less _______ is available for gas exchange due to ________
surface area; histolic changes
Why do the lung bases in the aging population become less ventilated?
Due to the closing off of a number of airways
A older person is at a greater risk for:
dyspnea and postoperative pulmonary complications such as post-op atelectasis and infection from a decreased abillity to cough, a loss of protective airways refleces and increased secretions (due to histologic changes)
_______ is the 2nd most common diagnosis cancer in men and women and the leading cause of cancer death in the U.S and is primarily caused by _________
lung cancer; smoking
Smoking causes:
a high mutational burden in the DNA genome
Due to complexity of high mutational rates in smokers, finding a _______ against lung cancer is difficult
targeted drug treatment
______ is a airbone lung disease that has infected 1/3 of the worlds population
TB
TB is termed as a ______ due to increased globilazation and air travel
social and migratory disease
TB incidence is stable among US born:
whites and asians
Who are at greater risk for contracting TB?
those with HIV, the homeless, those in shelters, prisons and LTC
Those most at risk for asthma are those living below:
the poverty level
mycoplasma pneumonia has a ______ cough
hacking
early heart failure has a ______ cough
dry
what is croup?
infection of the upper airway
croup has a ______ cough:
barking
colds, bronchitis and pneumonia have a ______ cough
congested
______ is a common burdensome symptom and a predictor of negative outcomes
dyspnea
chronic dyspnea is SOB lasting > 1 month and may have what origin?
neurogenic, respiratory or cardiac
chronic dyspnea can occur with:
anemia, anxiety and deconditioning
what is orthopnea?
Difficulty breathing when supine (state # of pillows needed for comfort)
what is paroxysmal nocturnal dyspnea?
awakening from sleep with SOB and needing to be upright for relief
cyanosis signals:
hypoxia
when may asthma attacks occur?
with a specific allergen, extreme cold or anxiety
how is asthma described?
as chest tightness
for people with a smoking history, dyspnea and cough what tool can you use to identify who should be assessed with spirometry for COPD?
5-item lung function
when does chest pain of the thoracic origin occur?
with muscle soreness from coughing or inflammation of pleura overlying pneumonia
When collecting smoking history, you should:
Assess smoking behavior, ways to modify daily smoking habits, identify triggers and how to manage withdrawal
What increases the risk for allergic rhinitis and asthma?
Traffic related air pollution
What symptoms do carbon monoxide cause?
Dizziness
Headache
Fatigue
What symptoms do sulfur dioxide cause?
Cough
Congestion
The CDC recommends the flu vaccine for everyone:
6 months or olders
Older adults have decreased _________ and less _______ for gas exchange.
vital capacity; surface area
Because older adults have less efficient respiratory systems, they have less tolerance for:
Activity
What may older adults have due to pulmonary function deficits?
reduced exercise capacity
Who is at a greater risk for respiratory dysfunction?
sedentary or bedridden people
Why may an older adults activity levels decrease?
Because of increasing SOB or pain
Some older adults feel _______ pain less intensely than young adults
pleuritic
In an older adult with precisely localized sharp pain, you should consider:
fractured ribs or muscle injury
When should you begin the respiratory examination?
after palpating the thyroid gland
On the posterior, lateral thorax, and anterior you should go in what order of examination?
- Inspection
- Palpation
- Percussion
- Auscultation
Anteroposterior diameter should be less than the _____ at 1: 2.
transverse diameter
AP to transverse diameter increases with:
age
When AP is equal to transverse diameter, the patient is:
barrel chested
What does it mean to be barrel chested?
the ribs are horizontal and the chest appears as if held in continuous inspiration
Who is more likely to experience a barrel chest?
those with COPD due to hyperinflation of the lungs
Why are neck muscles hypertrophied in those with COPD?
from aiding in forced respirations across the obstructed airways
Why do those with COPD sit in a tripod position?
for leverage so the abdominal, intercostal and neck muscles all can aid in expiration
When does cyanosis occur?
with hypoxia
When does unequal chest expansion occur?
- marked atelectasis
- lobar pneumonia
- pleural effusion
- thoracic trauma
What is tactile fremitus?
a palpable vibration generated by the larynx and transmitted via patent bronchi and the lung parenchyma to the chest wall
What factors affect the intensity of tactile fremitus?
- location: it is most prominent between the scapulae and around the sternum where major bronchi are closest to chest wall
- thin chest wall: thick tissue damps the vibration
- voice: a loud, low pitched voice generates more fremitus than a soft high pitched one
What conditions make for a better conducting medium for sound vibrations and increase tactile fremitus?
those that increase the density of lung tissue
When does decreased fremitus occur?
any barrier that comes between the sound and your palpating hand; obstructed bronchus, pleural effusion or thickening, pneumothorax or emphysema
When does crepitus occur?
in subcutaneous emphysema when air escapes from the lungs and enters subcutaneous tissue
What does a dull note signal?
abnormal density in the lungs (pneumonia, pleural effusion, atelectasis or tumor)
If a patient has a hairy chest, how can you minimize extraneous noises?
by pressing harder on the chest or wetting the hairs with a damp cloth
What are the 3 types of normal breath sounds?
- bronchial
- bronchovesicular
- vesicular
This normal breath sound characteristic is high pitched with a loud amplitude and a harsh hollow tubular quality. It is found in the trachea and larynx
bronchial
This normal breath sound characteristic is moderate pitched with a moderate amplitude and a mixed quality that is found over major bronchi where fewer alveoli are located
bronchovesicular
This normal breath sound characteristic is low pitched with a soft amplitude and a rusting quality. It is located over peripheral lung fields where air flows through smaller bronchioles and alveoli
vesicular
When do decreased or absent breath sounds occur?
- when the bronchial tree is obstructed
- in emphysema
- when theres obstruction of sound between the stethoscope and the lungs
What are increased breath sounds, how do they sound and when do they occur?
sounds are louder than they should be and they are high pitched, tubular quality with prolonged expiratory phase and a pause between inspiration and expiration. they occur when consolidation or compression yields a dense lung area that enhances transmission of sound from the bronchi
Discontinuous popping sounds heard over inspiration. Inspiratory = inhaled air colliding with previously deflated airways and expiratory = sudden airway closing
What are crackles?
Continuous musical sounds heard over expiration normally as a result of acute asthma (high pitched) or chronic emphysema (high pitched) or bronchitis (low pitched)
What are wheezes?
these are non-pathologic sounds that are short, popping crackling sounds lasting only a few breaths
atelectatic crackles
Where are atelectatic crackles heard?
in the periphery of the lung
Where can voice sounds be heard and describe normal voice transmission?
over the chest wall and it is soft, muffled and indistinct
When are voice sounds listened to?
when you suspect lung pathology; you are testing for the presence of bronchophony (99), egophony (eeeeee) and whispered pectoriloquy (1-2-3)
This condition has horizontal ribs and a costal angle of >90 degrees
barrel chest
When does hypertrophy of abdominal muscles occur?
in chronic emphysema
Tense, strained tired facies and purse-lipped breathing accompany what condition?
COPD
Cerebral hypoxia may be reflected by:
excessive drowsiness or anxiety, restlessness and irritability
Clubbing of distal phalanx occurs with ______. Why?
COPD because of growth of vascular connective tissue
Cutaneous angiomas (spider nevi) is associated with ________ and may be evident where?
liver disease or portal hypertension; on the chest
Name the accessory neck muscles and explain when they are used
- scalene
- sternomastoid
- trapezius
Used in acute airway obstruction and massive atelectasis
What does retraction suggest?
obstruction of respiratory tract, when increased inspiratory effort is needed (atelectasis)
What muscles are used to force expiration in COPD?
- rectus abdominis
- internal intercostal muscles
What conditions result in a lag in expansion?
- atelectasis
- pneumonia
- post-op guarding
How should you auscultate the lung fields?
over the anterior chest from the apices in the supraclavicular areas down to the 6th rib
What is determined by the number of seconds it takes for the person to exhale from total lung capacity to residual volume; its a screening measure for airflow obstruction
forced expiratory time
What does a handheld spirometer measure?
lung health in chronic conditions such as asthma
_______ is the total volume of air exhaled
forced vital capacity
A normal FEV1/FVC ratio outcome is:
75% or greater meaning no significant obstruction of airflow is present
When does a forced expiration of 6 seconds or more occur?
with obstructive lung disease
An FEV1/FVC ratio of 60% - 70% is a:
mild obstruction of airflow
An FEV1/FVC ratio of 50% - 60% is a:
moderate obstruction of airflow
An FEV1/FVC ratio of <50% is a:
severe obstruction of airflow
SpO2 results must be evaluated in the context of:
- hemoglobin levels
- acid base balance
- ventilatory status
What is a safer, simple, inexpensive clinical measure of functional status in aging adults?
6 minute walk test; they are equipped with a POX
A person who walks >300 meters during a 6 MWT is:
more likely to engage in ADLs
When should the person discontinue the 6 MWT?
If SpO2 is less than 88% or if extreme breathlessness occurs
In older adults, the chest cage commonly shows a increased _______ giving a round barrel shape and kyphosis
AP diameter
In an older person, you may palpate _______ due to decreased subcutaneous fats
marked bony prominences
What may be decreased but symmetric with an older person?
chest expansion
What results in less mobile thorax in an older adult?
costal cartilages becoming calcified
If a older adult becomes dizzy or feels faint during auscultation, what should you do?
Tell them to hold their breath for a few seconds to restore equilibrium
How should you examine the thorax of an acutely ill person?
have a second examiner hold the persons arm and support him in the upright position. If your alone, roll the person from side to side, examining the uppermost half of the thorax (prevents bilateral comparison)
What is the difference between side stream smoke and mainstream smoke?
side stream is the smoke seen from the burning end of a cigarette and mainstream smoke is smoke exhaled from the person smoking
Nonsmokers exposed to SHS increase risk for ______ and ______
heart disease; stroke
What condition is associated with normal aging, chronic emphysema and asthma as a result of hyperinflation of lungs?
barrel chest
This condition is a markedly sunken sternum and adjacent cartilages that is more noticeable on inspiration. It is congenital, usually not symptomatic and may cause embarrassment or negative self-concept; surgery may be indicated
pectus excavatum
This condition is a forward protrusion of the sternum with the ribs sloping back at either side and vertical depressions along costochondral junctions (pigeon breast). It is less common, requires no treatment but if severe, surgery may be indicated.
pectus carinatum
This condition is a lateral S-shaped curvature of the spine that is more prevalent during childhood and in girls. If severe (>45 degree), lung volume may be reduced and cardiopulmonary function may be impaired.
scoliosis
This condition is a exaggerated posterior curvature of the spine that causes significant back pain and limited mobility. It can impair cardiopulmonary function and cause hyperextension of the head to maintain level of vision. It is associated with aging.
kyphosis
Postmenopausal osteoporotic women are likely to get
kyphosis
Rapid shallow breathing, >24 per minute and is a normal response to fever, fear or exercise
tachypnea
This increases in both rate and depth and occurs with extreme exertion, fear or anxiety as well as diabetic ketoacidosis, hepatic coma, salicylate overdose lesions of the midbrain, and alteration in blood gas concentration
hyperventilation
Hyperventilation blows off ______ causing ________
CO2; a decreased level in the blood (alkalosis)
This is slow breathing <10, as in drug induced depression in the medulla, increased intracranial pressure and diabetic coma
Bradypnea
This is irregular shallow pattern caused by an OD of narcotics or anesthetics but may also occur with pro-longed bed rest or splinting of the chest to avoid respiratory pain
Hypoventilation
This is a cycle where respirations gradually wax and wane in a regular pattern increasing in rate and depth and then decreasing. Breathing period last 30-45 seconds with periods of apnea alternating the cycle
Cheyne-stokes respiration
What are some causes of Cheyne-stokes respiration?
- severe heart failure (most common)
- renal failure
- meningitis
- OD
- increased intracranial pressure
(occurs in older adults during sleep)
This condition is similar to Cheyne-stokes respiration but the pattern is irregular and a series of normal respirations are followed by a period of apnea. Cycle can last anywhere from 10 seconds to a minute
biot respiration
This condition causes normal inspiration and prolonged expiration to overcome increased airway resistance
chronic obstructive breathing
Atelectatic crackles develop in:
- aging adults
- bedridden
- persons just aroused from sleep
This is a high-pitched, monophonic, inspiratory crowing sound that is louder in the back and originates from the larynx or trachea
stridor
These conditions result in what kind of breathing?
- croup
- acute epiglottis
stridor
What condition results in the follow?
- airway obstruction
- compression of the lung
- lack of surfactant
Atelectasis
Pneumonia is conditioned by:
swollen alveolar with RBCs and WBCs passing from blood to the alveoli
infection of the trachea and larger bronchi characterized by cough lasting up to 3 weeks…..what condition is this?
Acute bronchitis
proliferation of mucus glands in passageways resulting in excessive mucus secretions….what condition is this?
Chronic bronchitis
destruction of pulmonary connective tissue and characterized by permanent enlargement of air sacs…what condition is this?
Emphysema
free air in pleural space causing partial or complete lung collapse. can be spontaneous, traumatic, or tension…..what condition is this?
Pnemothorax
associated with aids; cysts containing organism and macrophages form in alveolar spaces causing it to thicken and the disease to spread….what condition is this?
Pnemocystis jiroveci pneumonia
inhalation of tubercle bacili into the alveolar wall….what condition is this?
TB
an acute pulmonary insult that damages alveolar capillary membranes leading to increased permeability of pulmonary capillaries and alveolar epithelium and to pulmonary edema….what condition is this?
Acute respiratory distress syndrome (ARDS)
What does the CV system consist of?
The heart (muscular pump) and blood vessels
What area on the anterior chest directly overlies the heart and great vessels?
precordium
What is the mediastinum?
where the heart and great vessels are located between the lungs in the middle third of the thoracic cage
The top of the heart is called the ______ and the bottom of the heart is the ______
base; apex
What continuous loops are the blood vessels arranged in?
pulmonary and systemic circulation
When is an apical impulse produced?
during contraction when the apex beats against the chest wall
Where is the apical pulse palpable?
at the 5th intercostal space 7-9 cm from the mid-sternal line
What is the function of the superior and inferior vena cava?
they return unoxygenated venous blood to the right side of the heart
What is the function of the pulmonary artery?
it leaves the right ventricle, bifurcates and carries the venous blood to the lungs
What is the function of the pulmonary veins?
they return freshly oxygenated blood to the left side of the heart
What is the function of the aorta?
to carry oxygenated blood out to the body
Describe the pericardium
a tough, fibrous double walled sac that surrounds and protects the heart
What ensures smooth, friction free movement of the heart muscles?
pericardial fluid
What is the muscular wall of the heart and its function?
myocardium; it does the pumping
What is the thin layer of endothelial tissue that lines the inner surface of the heart chamber and valves?
endocardium
Which side of the heart pumps blood into the lungs?
right side
Which side of the heart pumps blood into the body?
left side
What is the atrium?
a thin walled reservoir for holding blood
What is the ventricle?
the muscular pumping chamber
What separates the chambers of the heart?
valves
What is the main purpose of valves?
prevent the back flow of blood
Valves are _______ and can open only ________
Unidirectional; one way
What is the right AV valve called?
tricuspid
What is the left AV valve called?
bicuspid; mitral
How many valves are in the heart?
4
Which valves separate the atria and the ventricles?
atrioventricular valves
What is chordae tendineae?
collagen fibers that anchor the AV valves to papillary muscles embedded in the ventricle floor
When do the AV valves open?
during the hearts filling phase (diastole) to allow ventricles to fill with blood
When do the AV valves close?
during the pumping phase (systole) to prevent regurgitation of blood back to atria
These valves are set between the ventricles and the arteries and are considered the pulmonic valve in the right side of the heart and the aortic valve in the left side of the heart
semilunar valve
When do semilunar valves open?
during systole when blood ejects from the heart
What gives a person symptoms of pulmonary congestion?
abnormally high pressure in the left side of the heart
What occurs with high pressure on the right side of the heart?
the neck veins and abdomen distend
What is the cardiac cycle?
rhythmic movement of blood through the heart
Explain the two phases of the cardiac cycle?
In diastole the ventricles relax and fill with blood and in systole the heart contracts and blood is pumped from the ventricles and fills the pulmonary and systemic arteries
What does presystole/atrial systole (atrial kick) cause?
a small rise in the left ventricular pressure
What contributes to the first heart sound and what does it signal?
closure of the AV valves; the beginning of systole
When contraction against a closed system works to build pressure inside the ventricles to a high level, what has occurred?
isometric contraction
What contributes to the second heart sound and what does it signal?
closure of the SL valves; the end of systole
What is isometric or isovolumic relaxation?
when the 4 valves are closed and the ventricles are relaxed
Why is pressure on the right side of the heart lower than the left side?
because less pressure is needed to pump blood to its destination, the pulmonary circulation
Events occur slightly later in the ______ of the heart because of myocardial depolarization
right side
Where is S1 loudest and where is S2 loudest?
apex; base
What is split S2?
when the aortic valves close earlier than the pulmonic valve
When does S3 occur?
when the ventricles are resistant to filling during the early rapid filling phase
When does S4 occur?
at the end of diastole at presystole when ventricle is resistant to filling resulting in decreased compliance of the ventricle and systolic overload
What is a murmur?
a gentle, blowing, swooshing sound
What causes a murmur?
- congenital and acquired valvular defects *
- velocity of blood increase
- viscosity of blood decreases
- structural defects in the valves or unusual openings occur in the chambers
What initiate an electrical impulse?
specialized cells in the SA near the superior vena cava
What does the ECG waves stand for (PQRST)
- P wave - depolarization of the atria
- PR interval - from beginning of P wave to the beginning of the QRS complex
- QRS complex - depolarization of the ventricles
- T wave - repolarization of the ventricles
In a healthy resting adult, what does the heart normally pump?
4-6 L of blood per minute throughout the body
Formula for cardiac output?
CO = SV x R
What is preload?
volume; of the venous return that builds during diastole; it is a stretch beyond normal resting state
What does the frank starling law state?
the greater the stretch the stronger is the contraction of the heart. this increases contractility results in an increased volume of blood ejected
What is afterload?
pressure; its the opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure
CV assessment includes what vascular structures in the neck?
carotid artery and jugular veins
What do the carotid artery and jugular veins reflect?
Efficiency of cardiac function
Describe the jugular vein
empty unoxygenated blood directly into the superior vena cava. they give information about activity on the right side of the heart and reflect filling pressure and volume changes (i.e when the heart fails to pump efficiently).
______ is caused by a forward propulsion of blood
arterial pulse
_______ results from a backwash, a waveform moving backward caused by events upstream
jugular pulse
What happens to the BP in the aging and what causes the change in BP?
there is an increase in systolic BP (isolated systolic HTN); caused by thickening and stiffening of the large arteries (arteriosclerosis) which is caused by collagen and calcium deposits in vessel walls and loss of elastic fibers
______ creates an increase in pulse wave velocity because the less compliant arteries cant store the volume ejected
arteriosclerosis
What characteristics or functions of the heart do NOT change with aging
- the heart does not increase in size
- no change in the resting heart rate
- cardiac output at rest is not changed
What part of the heart does increase with age? Why or why not
left ventricular wall thickness; it accommodates the vascular stiffening
What increases the pulse pressure in the aging?
a decreasing diastolic pressure and increasing systolic pressure
What happens to the heart of an aging person during exercise?
decreased ability to augment cardiac output shown by a decreased max. heart rate with exercise and diminished sympathetic response
What type of exercise modifies many of the aging changes in CV function?
aerobic exercise
The presence of ______ and ________ increase with age
supraventricular; ventricular dysrhythmias
What is common but usually asymptotic in health older people?
ectopic beats
What may ectopic beats compromise in sickly older people?
cardiac output and BP
Why may tachydysrhythmias not be tolerated well in older people?
the myocardium is thicker and less compliant and early diastolic filling is impaired at rest and the diastole is also shortened
What changes in ECG may occur in older adults?
- prolonged P-R interval and Q-T interbal (QRS interval unchanged)
- left axis deviation
- increased incidence of bundle branch block
What disease increases with age?
CVD is the leading COD in those 65+ (vitamin D deficiency increases risk)
What can older adults do to decrease their chances of getting CVD or respiratory illnesses?
- increasing physical activity (30/min 5/days)
There was an increase in CVD mortality among adults ages:
35-64
What adds to the lipid core of plaque formation in coronary and carotid arteries? What does this result in?
high levels of LDL (bad cholesterol); MI and stoke
What factors does physical activity have good effects on?
- HDL (good cholesterol)
- vitamin D
- apolipoprotein B
- hemoglobin A1c
What is the leading COD in women and why?
CVD because women tend to have smaller coronary arteries compared to men
What are the most common symptoms (and prodromal symptoms) linked to ACS/MI?
- fatigue
- discomfort in the jaw or teeth
- unusual fatigue
- arm pain
- SOB
Chest pain could have origins where else in the body?
- pulmonary
- musculoskeletal
- GI
When does paroxysmal nocturnal dyspnea occur?
with heart failure, normally as the person is lying down and the volume of intrathoracic blood increases. the person typically awakens 2 hours after sleeping with the perception of needing fresh air
______ is the need to assume a more upright position to breathe
orthopnea
When is fatigue worse for those with decreased CO?
in the evening
When is fatigue worse for those with anxiety or depression?
all day or in the morning
_____ is dependent when caused by heart failure. When is this worse and better?
edema; in the evening and its better in the morning after elevating legs all night
Cardiac edema is bilateral. Unilateral swelling has a ________ cause
local vein
_______ is recumbency at night promoting fluid resorption and excretion
nocturia
When does nocturia occur?
with heart failure in those ambulatory during the day
Usage of what medicine could prevent MI?
- aspirin
- vitamin D
What increases the risk for CVD?
- vitamin D deficiency
- advancing age
What is carotid sinus hypersensitivity?
when pressure over the carotid sinus leads to a decreased heart rate, BP and cerebral ischemia with syncope
Who is carotid sinus hypersensitivity more likely to occur in?
older adults with HTN or occlusion of the carotid artery
What is a bruit?
a blowing, swishing sound that indicates blood flow turbulence. it is marked by atherosclerotic diseases
what does a bruit increase the risk for?
transient ischemic attack (TIA) and ischemic stroke
What part of the stethoscope is used to listen to the carotid artery and where is the placement levels on the neck?
the bell
- the angle of the jaw
- midcervical area
- base of the neck
- ask the person to take a breath, exhale and hold it briefly*
What is unilateral distention of external jugular veins caused by?
local causes such as kinking or an aneurysm
What is a heave or lift and when does it occur?
a sustained forceful thrusting of the ventricle during systole it occurs with ventricular hypertrophy from increased workload (PVD, pulmonic HTN, chronic lung disease)
Where is a right ventricle heave seen?
at the sternal border
Where is a left ventricle heave seen?
at the apex
What is the size, amplitude and duration of a apical impulse?
1x2 cm, short gentle tap and short duration normally occupying the first 1/2 of systole
Where or who is the apical impulse not palpable in?
- obese people
- those with thick chest walls
- those with pulmonary emphysema
Left ventricular dilation occurs with:
heart failure and cardiomyopathy
What is a trill?
a palpable vibration that feels like the throat if a purring cat
What do trills signify?
turbulent blood flow and helps you locate loud murmurs (but absence of thrills do not rule out the presence of a murmur)
The valve areas are:
- second right interspace = aortic valve area
- second left interspace = pulmonic valve area
- left lower sternal space border = tricuspid valve area
- fifth interspace at around left midclavicular line = mitral valve area
______ occurs normally in young adults and children and the rhythm varies with the persons breathing, increasing at the peak of inspiration and slowing with expiration
sinus arrhythmia
What does a pulse deficit signal and when does it occur?
it signals a weak contraction of the ventricles and occurs with A Fib, premature bears and heart failure
When may heart sounds be diminished?
in conditions that place an increased amount of tissue b/w the heart and stethoscope ( emphysema, obesity, pericardial fluid)
What is the most common extra sound during systole?
midsystolic click which is associated with mitral valve prolapse
When does S3 (ventricular gallop) occur?
with heart failure and volume overload (mitral/aortic regurgitation and L-R shunts)
When does S4 (atrial gallop) occur?
with CAD
A systolic murmurs may occur with ______ or ______. But a diastolic murmurs always indicates _______
- healthy heart; heart disease
- disease
Grades of a murmur:
1 - barely audible
2- clearly audible but faint
3 - moderately loud and easy to hear
4 - loud; associated with thrills
5 - very loud; associated thrill; one corner os stethoscope lifted off chest wall
6 - loudest; can hear with entire stethoscope off chest wall
A crescendo pattern is:
growing louder
A decrescendo pattern is:
tapering off
A crescendo-decrescendo or diamond shaper:
increases to a peak and then decreases
The murmur of mitral stenosis is:
low pitched and rumbling
The murmur of aortic stenosis is:
harsh
S3 and S4 and the murmur of mitral stenosis may be heard only when on:
the left side
When may the aortic regurgitation be heard?
when the person is leaning forward in the sitting position
What is hypertrophic cardiomyopath?
inherited thickening of the myocardium; men and women equally effected
In older adults, there is a gradual rise in SBP and DBP remains fairly constant resulting in a:
widened pulse pressure
What happens to the chest with aging?
it increases in anteroposterior diameter making it difficult to palpate the apical impulse and hear splitting of S2
What is common in the aging?
- orthostatic hypotension
- S4 esp. after exercise
- systolic murmurs
- premature ectopic beats
A heart healthy diet includes:
- an increase in fruits and vegetables
- avoidance of trans fat and too much salt
This condition can result in pressurelike pain lasting for 3-5 minutes after activity, often resolving with rest. Pain can radiate to the jaw, neck or both arms and usually results in sweating, nausea, vomiting, SOB and fatigue
Angina pectoris
This condition can result in pressurelike discomfort at rest and can radiate to the jaw, neck, left arm or shoulder resulting in palpitations or syncope
Prinzmetal or variant angina
This condition can result in heaviness or crushing pain or pressure that is poorly localized, lasting for 20-30 minutes to hours with no resolve. Pain radiates to the teeth, jaw, neck one or both arms/shoulders but there may be no pain. Symptoms include indigestion, dizziness, flushing, perspiration, etc.
Acute coronary syndrome (MI)
This condition has sudden sharp and stabbing pain relieved by sitting or leaning forward but worsens when lying down or inspiration. It can radiate to the trapezius muscle region and symptoms include dry cough, muscle/joint aches and fever
Pericarditis
This condition has sharp pain not associated with activity and chest pain w/o radiation. Symptoms include fatigue, light headedness, SOB, irregular heart beat, palpitations and exercise intolerance
mitral valve prolapse
This condition has sudden severe pain with no change in location or tearing sensation lasting for hours. Pain is in the anterior chest with radiation to the neck, jaw, or intrascapular region of the back. Symptoms include mental status changes, limb pain and weakness and SOB
aortic dissection
This condition has cardiac like chest pain with exertion located in the chest region and symptoms of SOB, low extremity swelling and fatigue
pulmonary hypertension (secondary)
This condition has a sharp, stabbing pain that worsens with deep breaths and is felt in the chest, back, shoulder or upper abdomen. Symptoms include SOB, hemoptysis, and cough
pulmonary embolism
This condition has sharp, stabbing pain associated with cough and is on one side of the chest but can cause upper abdominal pain. Symptoms include cough, fever, SOB, chills, sputum, myalgia and malaise
Pneumonia
This condition has acute/sudden and sharp pain in the lateral region of the chest but it can radiate to the shoulder and cause acute SOB and cough
Pneumothorax
This condition has a burning sensation (angina like) with eating large meals and is worse when laying down but relieved when sitting up. It is in the retrosternal region and symptoms include cough, regurgitation of food and abdominal pain
gastroesophageal reflux
This condition has crushing chest pain that is substernal and results in dysphagia, and a sensation that something is in the throat
Esophageal spasm
This condition has sudden onset of pain that crescendos and last up to 20 minutes after eating fatty meals. It can be in the right upper abdomen and radiate to the right intrascpaular region, shoulder or back resulting in nausea, vomiting, anorexia and fever
cholecystitis
This condition has sudden dull, boring steady pain unrelieved by lying supine but relieved by learning forward or in fetal position. It is periumbilical pain that radiates to the back and causes nausea, vomiting, anorexia and diarrhea
pancreatitis
This condition has it unilateral, burning and borelike pain in the chest region resulting in tingling, itching and burning
herpes zoster
This condition has sharp, pleuritic pain that worsens with deep breathing, palpation or movement and is in the area from 2nd-5th intercostal spaces; can radiate to the arm. Symptoms include chest tightness and warmth at area of pain
costochondritis
This condition has sharp pain with moving, stretching or pushing movements of the arms and is located in the area around the strained muscle, sternum or ribs. Symptoms include muscle spasms, crepitation, swelling and loss of strength
chest wall muscle strain
This condition has heaviness in the chest region and symptoms include fatigue, restlessness, withdrawal and weight gain or loss
depression
This condition has sharp pain in the chest region and symptoms include palpations, dizziness, sweating, shaking, restlessness, fatigue and irritation
Anxiety
This condition has decreased CO, dilated pupils, ascites, jugular vein distention, enlarged spleen and liver, crackles and wheezes, pale, gray or cyanotic skin, decreased BP, urine output and dependent pitting edema in the sacrum/legs
heart failure
______ occurs early in systole at the start of ejection because it results from opening of the SL valve
ejection click
Where is the aortic ejection click heard?
at the 2nd right interspace and apex where it may be loudest at the apex
Where is the pulmonic ejection click heard?
at the 2nd left interspace and often grows softer with inspiration
Where is the midsystolic click best heard?
with the diaphragm and the apex
A deformed valve opens with this sharp, high pitched noise with a snapping quality that sounds after S2 and is best heard with the diaphragm in the 3rd or 4th left interspace at the sternal border
opening snap
Mitral prothetic valve sounds is the:
ball in cage
What is the location, respiratory variation and pitch of S3?
- heard at the apex or left lower sternal border
- does not vary in timing with respiration
- lower pitched
What causes friction rubs? and how do they sound?
inflammation of the pericardium; high pitched like sandpaper that is best heard at the apex and left lower sternal border.
When is friction rub common?
During 1st week after a MI
This condition results in calcification of aortic valve cusps, restricting forward blood flow during systole. LV hypertrophy develops
aortic stenosis
This condition results in calcification of pulmonic valve restricting forward flow of blood
pulmonic stenosis
This condition results in stream of blood regurgitates back into LA during systole via incompetent MV
mitral regurgitation
This condition results in backflow of blood via incompetent tricuspid valve into RA
Tricuspid regurgitation
_____ is caused by backward blood flow from area of high pressure to lower pressure
pansytolic regurgitant murmus
_______ is caused by forward flow through SL valves
midsystolic ejection murmurs
_____ is caused by emilunar valve incompetence
early diastolic murmurs
________ is heard when a backflow of blood via incompetent pulmonic valve from pulmonary artery to RV
pulmonic regurgitation
