Module 2.0 - Advanced Cardiac Assessment Flashcards
What are some cardiovascular system symptoms patients experience?
- Chest Pain
- SOB
- Fatigue
- Cough & Hemoptysis
- Palpitations
- Dizziness
- Weight gain (ankle swelling)
- Voice Changes
- Intermittent Claudication
How might a patient describe chest pain from a cardiac origin?
Descriptors from patients may include “like an elephant sitting on my chest”, “a burning sensation”, “choking sensation”, choking feeling in my throat”, “like a toothache”, “my bra is too tight”, “squeezing”, “feels like a rubber band around my chest”
How might a patient describe fatigue when coming from a cardiac origin?
Is usually constant
How might a patient describe a cough/hemoptysis when coming from a cardiac origin?
- When a cough is related to heart disease it is most often dry, nonproductive, and is noted to be in the recumbent position and nocturnally.
- Hemoptysis may occur if the pulmonary venous pressures are greatly elevated as in severe heart failure or mitral stenosis.
- Pink frothy sputum may be produced with pulmonary edema.
How do patients usually describe palpitations and what can they represent?
- Patients may sense extra, skipped, irregular or rapid heartbeats.
- They may describe fluttering, pounding or racing.
- These may represent PAC’s, PVC’s, Afib, or vTach
What may cause voice changes in a patient experiencing cardiovascular issues?
A hoarse voice may indicate pressure on the laryngeal nerve from an aortic arch aneurysm, a dilated pulmonary artery or an enlarged left atrium
How are pulses graded?
- Bounding +4
- Full +3
- Normal +2
- Diminished +1
- Absent 0
What happens in the heart during systole and what heart sound do you hear?
- the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial pressure, closing the mitral valve.
- Closure of the mitral + tricuspid valves produces the first heart sound, S1
- Occurs almost simultaneously with apical and carotid impulses
- Coincides with R wave on the EKG
- S1 is louder than S2 at the apex
What happens during diastole and what heart sound do you heart?
- As the left ventricle ejects most of its blood, ventricular pressure begins to fall. When left ventricular pressure drops below aortic pressure, the aortic valve closes.
- Aortic + Pulmonic valve closure produces the second heart sound, S2, and another diastole begins.
- The second heart sound, S2, and its two components, A2 and P2, are caused primarily by closure of the aortic and pulmonic valves, respectively
- S2 is usually louder than S1 at the base
What causes a split S2 and where is this best heard?
- S2 heart sound is composed of 2 components: the aortic valve A2 closing and the pulmonic valve closing P2. Since the aortic valve has higher pressure in the valve due to it carrying arterial blood, it is usually louder.
- To hear the pulmonic valve close during the S2 heart sound, it is best heard between the 2nd & 3rd intercostal spaces AND it is heard only on inspiration
What causes an S3 heart sound and what does it sound like?
- S3 sound is produced during ventricular filling when a large amount of blood strikes a very non-compliant left ventricle
- Sounds like “Ken-tuc-ky”
- After age 40, a third heart sound is usually abnormal and correlates with dysfunction or fluid overload of the ventricles.
- Associated with heart failure and: hypertrophic cardiomyopathy, myocarditis, cor pulmonale, or acute valvular regurgitation
When is an S3 heart sound best heard and what part of the stethoscope is used?
Heard early in diastole at the LLSB or Apex with the bell of the stethoscope
What causes an S4 heart sound and what does it sound like?
- S4 is caused by the atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle.
- Occurs commonly due to MI, HTN, left ventricular hypertrophy, and HF
- Sounds like “Ten-ne-ssee“
- It immediately precedes S1 of the next beat and is associated with cardiomyopathy and heart failure
When is an S4 heard sound best heard and what part of the stethoscope should you use?
Heard late in diastole, best at LLSB with bell
What are the 6 grades of murmurs and describe each murmur grade
- Grade I - barely audible
- Grade II - clearly audible but faint
- Grade III - moderately loud, easily heard
- Grade IV - loud, associated with a thrill
- Grade V - very loud; heard with one corner of stethoscope off the chest wall
- Grade VI - loudest; no stethoscope needed
What are some characteristics of the mitral regurgitation heart sound?
- holosystolic high pitched blowing sound
- listen at apex , the sound can radiate to axilla.
- Lateral position can intensify the sound.
- When MR is severe, the murmur is accompanied by an S3 gallop.
When does a midsystolic click occur?
- most common type heart “click” sound and is associated with mitral valve prolapse (MVP).
- A systolic click along with a mid to late systolic murmur or musical “whoop” or “honk” of MR are a classic auscultatory finding of MVP.
What EKG changes are associated with hyperkalemia?
- Increased levels of potassium decrease ventricular depolarization and slow AV conduction leading to:
- Tall peaked T waves
- Widening of the QRS complex
- Prolongation of the P wave/PR interval.
What EKG changes are associated with hypokalemia?
- Increased amplitude and width of the P wave
- Prolongation of the PR interval
- T wave flattening and inversion
- ST depression
- Less common is bradycardia, atrial flutter and AV block.
What EKG changes are associated with hypercalcemia?
- The main ECG abnormality seen with hypercalcaemia is shortening of the QT interval
- In severe hypercalcaemia, Osborn waves (J waves) may be seen
- Ventricular irritability and VF arrest has been reported with extreme hypercalcaemia
What EKG changes are associated with hypocalcemia?
- Hypocalcaemia causes QTc prolongation primarily by prolonging the ST segment.
- The T wave is typically left unchanged.
- Dysrhythmias are uncommon, although atrial fibrillation has been reported.
- Torsades de pointes may occur, but is much less common than with hypokalaemia or hypomagnesaemia.
What EKG changes are associated with hypomagnesemia?
- The primary EKG abnormality seen with hypomagnesemia is a prolonged QTc.
- widened QRS complexes
- Appearance of U wave
What are the cardiovascular changes in the elderly patient?
- Heart valves – become more fibrous and rigid
- Conduction – decreased numbers of cells in the SA node and AV node
- Rhythm – there is a decrease in both the average rate and the maximal rate. The heart rate takes longer to return to normal after periods of stress. Elderly patients tolerate tachyarrhythmias poorly because of reduced compliance in their ventricle.
How would you assess jugular vein distention and what is its significance?
- The internal jugular vein acts as a manometer of right atrial pressure or an indicator of central venous pressure
- The most important first step in measuring jugular venous pressure is to have the patient in the right position - measure when the patient is sitting at a 45-degree angle
- Look for a pulsation in the internal jugular vein
- Measure in centimeters from the angle of Louis – this is 5 cm right of the atrium
- Measure vertically in cm from the angle of Louis to where you see the height of the pulsation
- Add measurement to 5 cm for a total; 7-9 cm is normal
- Greater than 9 cm is an indication of volume overload- the elevation of JVP contributes supporting evidence to the presence of right heart failure due to primary or secondary pulmonary hypertension of lung disease (cor pulmonale), left sided heart failure and tricuspid valve disease
How do you tell the difference between the JVP vs the carotid pulse?
POLICE:
- Palpation: Non-palpable
- Occlusion: Readily occludable
- Location: Between heads of SCM; lateral to carotid
- Inspiration: Drops with inspiration
- Contour: Biphasic Waveform
- Erection/Position: Drops when sitting erect
