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Advanced Health Assessment > Quiz 2- Cardiac > Flashcards

Quiz 2- Cardiac Flashcards

1
Q

pathway of blood

A

SVC/IVC

RA

tricuspid valve

RV

pulmonic valve

pulmonary arteries

lungs

pulmonary veins

LA

mitral valve

LV

aortic valve

aorta

body

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2
Q

normal CXR

A

curved ribs/diaphragm

HEART pushing towards L SIDE; normal size

clear lungs

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3
Q

cardiac cycle (rest to rest)

A

SYSTOLE- ventricular contraction

DIASTOLE- ventricular relaxation (need for ventricular filling)

S1- closing of mitral/tricuspid (end of diastole/beginning of systole)

S2- closing of aortic/pulmonic (end of systole/beginning of diastole)

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4
Q

conduction (coordination of muscle contraction)

A

assessment of rate/rhythm/ECG

SINUS NODE- normal pacer, autonomic, 60-100 bpm

AV NODE- at atrial septum, impulse delayed then passes (allows for filling)

bundle of His/bundle branches/perkinje fibers- impulse travels to both ventricles

if muscle damage- will not contract effectively

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5
Q

EKG

A

P WAVE- atrial depolarization (atria contract)

P-R INTERVAL- filling of ventricles

QRS- traveling of impulse thru bundle of His to R/L perkinje fibers; ventricular depolarization (ventricles contract)

T- WAVE- repolarization of ventricles

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6
Q

abnormal QRS

A

wide QRS with left ventricular hypertrophy

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7
Q

cardiac landmarks

A

AORTIC- 2nd ICS RSB, S2>S1

PULMONIC- 2nd ICS LSB, S2>S1

ERB’s- 3rd to 4th ICS LSB, S2=S1; helpful to listen for baseline

TRICUSPID- 5th ICS LSB, S1>S2

MITRAL- 5th ICS L MCL, S1>S2

line from aortic to pulmonic= BASE OF HEART (top)

line from tricuspid to mitral= APEX OF HEART (bottom)

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8
Q

cardiac health history cues

A

SOB

chest pain

syncope- possible dysrhythmia

fatigue

palpitations- consider caffeine intake

claudication- time of ischemia

early satiety/abdominal fullness- CHF

need to obtain a full HPI of CC and rule out cardiac cause with history and physcial exam

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9
Q

child cardiac cues

A

WOB

pallor/cyanosis

limited activity

change in HR

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10
Q

past medical history for cardiac

A

CHILDHOOD ILLNESS- heart murmurs, congenital heart disease, rheumatic fever

surgery- CABG

vaccines

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11
Q

cardiac family history

A

age of onset is very important!

cardiac

endocrine

neuro

vascular

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12
Q

common cardiac presenting symptoms

A

fatigue/activity intolerance

chest pain

shortness of breath

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13
Q

fatigue/activity intolerance

A

most prevalent cardiac symptom

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14
Q

chest pain

A

symptom analysis

stable angina

unstable angina- chest pain at rest; random pattern; no provoking activities

other causes- GERD, coughing trauma, pulmonary

calssifications: CLASS I= angina with strenuous acitvity
CLASS II= angina with ordinary activity, mild limitation of activities
CLASS III= angina with low level of activity, marked restriction of activity
CLASS IV= angina at rest (unstable)

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15
Q

stable angina

A

predictable pattern

rate pressure product (RPP): amount of activity they can do before pain/symptoms; educate pt to stay below this threshold

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16
Q

shortness of breath

A

DOE (how much activity?)

orthopnea

paroxysmal nocturnal dyspnea (wake from sleep with SOB)

talk test- singe happy birthday without SOB

heart failure classification:
CLASS I= no limitation of activity
CLASS II= slight limitation of activity, comfortable at rest but ordinary activity results in fatigue/SOB/palpitations
CLASS III= moderate limitation, comfortable at rest but less than ordinary activity causes fatigue/SOB/palpitation
CLASS IV= unable to carry out any activity without discomfort, symptoms present at rest

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17
Q

non modifiable cardiac risk factors

A

risk reduction

age, gender, genetics (family hx)

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18
Q

modifiable cardiac risk factos

A

can modify/medicate/change

HTN, HLD, DM

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19
Q

lifestyle cardiac risk factors

A

patient must modify/change

smoking, sedentary lifestyle, diet, obesity, hostility prone behavior

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20
Q

coronary artery calcium score

A

calcium in coronary arteries is a sign of plaque buildup

based on the amount of calcium observed on special CT scan

pts whose 10 year risk is between 5-20% should be tested

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21
Q

ASCVD risk estimator for coronary artery calcium score

A

includes age, gender, race, total/HDL cholesterol, SBP/DBP, HTN, DM, and smoking status to determine 10 year risk

also provides benefits of starting statin/ASA/BP meds

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22
Q

hyperhomocysteinemia

A

high serum homocysteine levels (amino acid from meats) creates a pro coagulaable state

discussed as a risk factor for ATHEROSCLEROSIS, associated with INCREASED RISK OF MI, and linked to higher risk of VTE

associated with low levels of B6, B12, folate, and renal disease

cannot use as a biomarker b/c levels can decrease with B6/B12/folate supplementation, but pt can still have atherosclerosis

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23
Q

CRP

A

reflects ongoing inflammation (not specific to cardiac disease)

inflammation is a known factor in the development of atheroschlerosis and subsequent CVD events- increases vulnerability of an atherosclerotic lesion to erosion/rupture

CRP is not routinely done, but is widely available

scores <1= LOW RISK, 1-2.9= MODERATE RISK, >3= HIGH RISK

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24
Q

CHADS/chads2-vasc

A

model to determine if anticoagulation therapy is needed based on risk

SCORE OF 0= now risk, no anticoags needed

SCORE OF 1= low/moderate risk, consider anticoags

SCORE 2 OR MORE= moderate/high risk, should otherwise be an anticoag candidate (still need to consider the whole patient)

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25
Q

infant cardiac risk factors

A

family history/siblings with congenital heart disease

premature birth, perinatal/prenatal fetal distress

MATERNAL EXPOSURE- ETOH, coxsackie B, CMV, influenza, lithium, mumps, rubella, x-rays, drugs, smoking

CHROMOSAMAL ABNORMALITIES- trisomy 21, 13, 18

maternal age over 40 years

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26
Q

cardiac inspection

A

face, overall color, WOB

CHEST SHAPE AND SIZE- AP/transverse ratio, barrel chest, convex/concave sternum

CHEST MARKINGS- vessel dilation, varicose veins, visible retractions, lesions

VISIBLE PULSATIONS- usually abnormal, but may see aortic pulsation on abdomen of very thin pt

27
Q

extra-cardiac inspection

A

NAILS- capillary refill, clubbing (low perfusion; smokers/COPD/CHF), shape changes, splinter hemorrhages (endocardititis, vasculitis, micro emboli; can be normal in patient who works a lot with hands)

MOUTH- dental hygiene, piercings; high arch in palate often seen with MVP

BMI/PROPORTIONS- waist circumfereance >40 in males of >35 in females; apple vs pear shape= central vs peripheral obesity; higher risk of CVD with apple shape

JANEWAY LESION- seen in acute bacterial andocarditis; flat, on palms/soles, PAINLESS**

OSLER’S NODE- associated with infective endocarditis; PAINFUL** erythametous nodules

MARFAN SYNDROME- often missed; cardiac issues including incompetent valves; tall and slender, long legs/arms/toes, arachnodactyly (long/slender fingers)

XANTHOMAS- lumps containing lipids in periphery; common in older adults and people with high blood lipids; if around the eyes, call XANTHELASMA

ARCUS SENILIS- ring around eye that is lipid deposit; common/normal in older adult, sign of high cholesterol in young adult

28
Q

cardiac palpation

A

symmetrical pattern at all landmarks

PMI 5th intercostal MCL (should be about the size of fingertip/contained, gentle tapping)

THRILL- fine vibration, indicates turbulence in the blood flow (abnormal)

HEAVE- strong outward thrust at PMI, ventricle contracting up into hand (abnormal)

VITAL SIGNS- HR/RHYTHM, strength (weak vs bounding), sites (should assess bilateral pulses), skin temp warm/cold

29
Q

location of thrill

A

aortic area during systole (aortic stenosis), apex during systole (mitral regurgitation), pulmonic area during systole (pulmonic stenosis), LSB 4

30
Q

what may a heave indicate?

A

ventricular hypertrophy

31
Q

pulses

A

check temporal, carotid, brachial, radial, femoral, popliteal, post tib, dorsalis pedis

present, grade, symmetry

TWO SCALES (need to indicate which scale you are using)

ABNORMAL PULSES

ALLEN TEST: test for occlusion of the radial/ulnar artery

AORTA PALPATION

BLOOD PRESSURE

32
Q

two scales for pulses

A

3+- 3/3= bounding; 2/3=normal, 1/3=weak, 0/3=absent

4+- 4/4=bounding, 3/4=normal, 2/4=weak, 1/4= thready, 0/4=absent

33
Q

abnormal pulses

A

pulsus magnus- bounding

pulsus parvus- weak

pulsus alterans- alternating

pulsus paradoxus- r/t blood pressure

34
Q

pulsus paradoxus

A

abnormally large decrease in SBP/pulse wave amplitude during inspiration

NORMAL FALL IS <10 MMHG

excessive decline can indicate tamponade, adhesive pericarditits, severe lung disease, advanced heart failure, and other conditions

35
Q

allen test

A

pressure applied to ulnar/radial to occlude both, have pt elevate arm and make fist for 30 seconds, then open (hand should be blanched), release ulnar side

color should return to hand within 7 seconds= +ALLEN (adequate blood flow)

36
Q

aorta palpation

A

identify pulsation if visible

press deeply on either side of the aorta- midline abd, above umbilicus

NORMAL SIZE- 3 cm or less, average 2.5 cm; if >5.5 cm may need surgery

risk factors for AAA*- >65 yo, smoking, male gender, 1st degree relative with AAA, auscultated bruit

37
Q

edema

A

RATE THE DEGREE- 0=no pitting, +1= mild, +2= moderate, +3= severe; +4=severe

also record where edema is located

38
Q

ankle brachial index (ABI)

A

predicts severity of peripheral arterial disease

measurable with doppler ultrasound; perform on each side

right ankle SBP/right arm SBP=ABI (complete bilaterally)

39
Q

right ankle SBP/right arm SBP=ABI

A

normal= 1 or >

at risk= 0.9

borderline ischemia= 0.6-0.8

severe ischemia= <0.5

40
Q

what is the significance of JVP?

A

it is an indication of function of the R side of heart

should see no engorgement of EJ

high level of engorgement=higher RA pressure

41
Q

how to examine R EJ

A

right side of pt, HOB at 45 degrees, pt turn head to left

identify top of venous pulsation in neck (inward pulsation, not palpable), then measure distance between top of pulsation and sternal angle

angle of louis (sternal angle) down to RA= approx 5 cm

your result +5cm=JVP

42
Q

if you get >9cm above RA when examining right EJ, what does this mean?

A

increased RA pressure

right side HF is the most common

constrictive pericarditis, tricuspid stenosis, SVC obstruction, valsalva phenomenon (laughing, coughing)

43
Q

HJR- hepatic jugular reflux

A

apply firm pressure to liver border for 30 seconds

positive test= >4cm JVP risk for >10 seconds

44
Q

what does a positive HJR (hepatic jugular reflux) suggest?

A

suggests CHF

falsely positive if valsalva (pt bearing down, abdominal guarding)

45
Q

normal heart sounds

A

best heard with diaphragm of stethoscope

S1 “LUB”- closing of mitral/tricuspid valves (end of diastole/beginning of systole), loudest at apex (mitral/tricuspid areas), upstroke of pulse/rise of QRS

S2 “DUB”- closing of aortic/pulmonic valves (end of systole/beginning of diastole), loudest at base (aortic/pulmonic areas)

46
Q

abnormal heart sounds

A

best heard with bell of stethoscope

split S2 “lub-d dub”

S3” lub-dub-d” or “ken-tuc-KY”

S4 “d-lub-dub” or “ten-ne-see”

rubs

bruits

47
Q

split s2 “lub-d dub” sound

A

RESPIRATORY EFFECT: normal/physiologic- r/t respirations b/c of volume changes; if and when pt holds breath, stutter goes away= physiological

PARADOXICAL: abnormal/pathologic; sound doesn’t go away with breath hold; seen with LBBB b/c impulse takes longer to get to L ventricle

FIXED: abnormal/pathologic; always there and doesn’t vary; seen with atrial-septal defect and RHF

48
Q

S3 “lub-dub-d” or “ken-tuc-ky”

A

ventricular gallop, best heard at apex (bottom) during early systole (just after s2)

result of blood splashing into ventricles

PATHOLOGIC: seen in CHF, sign of being “wet”

PHYSIOLOGIC: increased flow state in someone under 30, pregnancy

49
Q

s4 “d-lub-dub” or “ten-ne-see”

A

always pathologic, atrial gallop, occurs with atrial contraction at the end of diastole (just before s1), found in stiff heart (recent MI, HTN)

50
Q

rubs

A

caused by movement of inflammatory adhesions between visceral/parietal pericardial layers

high pitched/squeaking sound like rubbing leather together

may be systolic or diastolic and systolic

heard at different times depending on cause

components: atrial contraction, ventricular filling, ventricular contraction

best heard with patient leaning forward/breath held on expiration- brings heart closer to chest wall

51
Q

bruits (abnormal vascular sound)

A

caused by turbulent flow in blood vessels

listen for carotid, aortic, renal, iliac, and femoral bruits

biggest risk: HTN

hard to differentiate between carotid bruit and aortic stenosis radiating into neck

52
Q

murmurs

A

sound created by turbulent flow in heart (in periphery=bruit)

TIMING- diastolic (between S2 and S1)= heart disease; systolic (between S1 and S2)= heart disease or can be normal

SHAPE- intensity over time (crescendo, decrescendo, or crescendo-decrescendo)

LOCATION- site of max intensity/loudest (aortic and mitral most common)

RADIATION- can you hear it elsewhere?

PITCH- high, medium, low

QUALITY- blowing, harsh, rumbling, musical

INTENSITY- graded on 1-6 scale

53
Q

intensity of murmur

A

graded on 1-6 scale:

1/6- faint, only heard if you know it’s there

2/6- quiet, but heard immediately

3/6- moderately loud

4/6- loud with PALPABLE THRILL

5/6- very loud, heard with stethoscope partially off of chest wall, PALPABLE THRILL

6/6- loudest, heard with stethoscope completely off of chest wall, PALPABLE THRILL

54
Q

questions to identify valvular disorders

A

where is the loudest?

when does the murmur occur?

what is the valve doing during the cardiac cycle when you hear it?

does it radiate?

possible cause of valve dysfunction?

55
Q

what is the valve doing during the cardiac cycle when you hear the murmur? *systole vs. diastole**

A

systole- tricuspid/mitral CLOSED (regurg); aortic/pulm
OPEN (stenosis)

diastole- tricuspid/mitral OPEN (stenosis); aortic/pulm CLOSED (regurg)

56
Q

mid-systolic murmur

A

heard between S1 and S2

loudest during mid systole (crescendo-decrescendo)

57
Q

holosystolic murmur

A

heard between S1 and S2, does not get louder or softer

58
Q

aortic murmurs

A

radiates into neck

STENOSIS***- mid-systolic, heard in aortic area (2nd ICS-RSB)

INSUFFICIENCY***- diastolic decrescendo, heard in aortic area (2nd ICS-RSB)

59
Q

mitral murmurs

A

radiates into axillary area

STENOSIS***- diastolic murmur, heard in mitral area/apex (5th ICS-MCL)

REGURGITATION ***- systolic murmur, heard in mitral area/apex (5th ICS-MCL)

60
Q

common systolic murmurs: MR PASS MVP

A

Mitral Regurg

Physiologic

Aortic Stenosis

Systolic

Mitral Valve Prolapse

61
Q

common diastolic murmurs: MS ARD

A

Mitral Steosis

Aortic Regurg

Diastolic

62
Q

mitral valve prolapse

A

MID-SYSTOLIC CLICK (from leaflet opening back up)+ LATE MURMUR (2nd half of systole; when valve should be closed)

PRIMARY: familial/non-familial, marfans, or other connective tissue diseases

SECONDARY: CAD, rheumatic heart disease, vegetation, ASD, anorexia, dehydration, straight-back syndrome/pectus excavatum

63
Q

general population aged 60 years or older (recommendations)

A

initiate pharmacologic treatment to lower blood pressure if SBP>150 mmHg or DBP >90 mmHg

treat to a goal of <150/90

older patients with other perfusion issues, can’t lower blood pressure too much or have other issues such as syncope

64
Q

general population <60 years (recommendations)

A

initiate pharmacologic treatment to lower blood pressure if DBP>90 mmHg

treat to goal of DBP <90 mmHg

special recommendations for black and non black patient groups, kidney disease and diabetes

black patients do not do as well on ACE/ARBS- start on CCB/thiazide

Advanced Health Assessment (7 decks)

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