Quiz #3 Heart and Neck Vessels Flashcards
S1 sound
Occurs with closure of the AV valves- beginning of systole
All over precordium, but loudest at the apex
S2 sound
Occurs with closure of the semilunar valves- end of systole.
Heard all over precordium, but loudest at the base.
S3 sound
Ventricles are resistant to filling during early filling phase- occurs immediately after S2 when AV valve opens. Can be heard at apex or left lower sternal border.
S4 sound
Occurs at the end of diastole when ventricle is resistant to filling. Atria contract and push blood into a noncompliant ventricle- creates vibrations heard as S4.
Could occur in adults older than 40 without cardiovascular disease, especially after exercise.
Causes of heart murmurs
- Velocity of blood flow increases (flow murmor)
- Viscosity of blood decreases (anemia)
- Structural valve defects or unusual openings- eg dilated chamber or septal defect
Blood volume during pregnancy
increases by 30-40%, most rapid expansion during second trimester
Pulse rate in pregnancy
increases by 10-15 bpm
Arterial BP in pregnancy
Decreases due to peripheral vasodilation
foramen ovale
opening in the atrial septum of a fetus through which oxygenated blood enters the heart
ductus arteriosus
Routes oxygenated blood from the pulmonary artery to the aorta.
Heart position in the infant
More horizontal— apex is higher. Reaches adult position at age 7 years
Hemodynamic changes in aging
- Increase in systolic BP due to thickening and stiffening of the arteries (arteriosclerosis).
- Increase in pulse wave velocity
- Left ventricular wall thickness increases.
- Diastolic BP may decrease— pulse pressure increases
- No change in resting HR
- Cardiac output at rest does not change
- Decreased ability to change output with exercise
Dysrhythmias in aging
Presence of supraventricular and ventricular dysrhythmias increases with age.
Ectopic beats are common
Tachydysrhythmias are not tolerated well in older people as myocardium is thicker and less compliant
ECG in older adult
Prolonged PR interval
Prolonged QT interval
QRS interval unchanged
Left axis deviation due to LV hypertrophy and fibrosis
Increased incidence of bundle branch block
9 modifiable factors for CVD prevention
- abnormal lipids
- hypertension
- diabetes
- abdominal obesity
- psychosocial factors
- inadequate consumption of fruits and vegetables
- alcohol use
- smoking
- lack of regular physical activity
Hypertension most common in what group
- Blacks
- American indians
- Whites
- Hispanics
- Asians
Smoking rates
decreased, but still 21.2% of men and 17.5% of women
Serum cholesterol highest in what group
Mexican-Americans
Risk of CVD in DM
2x greater— diabetes damages large blood vessels that nourish brain, heart, and extremities
MI in women
less likely to call 911, pain is more of an ache, women report fatigue, difficulty breathing, radiating pain
Subjective Data for Heart and Neck Vessels
- Chest pain
- Dyspnea
- Orthopnea
- Cough
- Fatigue
- Cyanosis or pallor
- Edema
- Nocturia
- Past cardiac hx
- Family cardiac hx
- Patient centered care
Additional subject hx for aging adult
- Any known heart of lung disease?
- Do you take any medications for your illness?
- Environment- stairs at home?
Non chest-pain symptoms of angina
Diaphoresis, pallor, grayness
Palpitations, dyspnea, nausea, tachycardia, fatigue
Dyspnea characteristics
Paroxysmal?
Constant or intermittent?
Recumbent?
Paroxysmal noctural dyspnea (PND)
Occurs with heart failure. Lying down increases volume of intrathoracic blood- weakened heart can’t accomodate increased load- person awakes after 2 hrs with feeling of needing fresh air
Hemoptysis can signal
mitral stenosis, pulmonary embolism
Fatigue that is worse in the evenings due to
decreased CO
Fatigue all day or worse in the morning due to
anxiety or depression
Cyanosis or pallor occurs with
MI or low CO due to decreased tissue perfusion
Cardiac edema characteristics
Worse in the evening, better in AM after elevating legs. Bilateral.
Nocturia
recumbency at night causes fluid resorption and excretion- occurs with heart failure in pt who ambulates during the day
Risk factors for CAD (7)
- high cholesterol
- hypertension
- blood sugar above 100mg/dL or DM
- obesity
- smoking
- inactivity
- hormone replacement therapy in postmenopausal women
Patient centered care for Heart and Neck Vessels (5)
- Nutrition
- Smoking
- Alcohol
- Exercise
- Drugs
Objective data for the neck vessels
- Palpate carotid
- Auscultate the carotid
- Inspect jugular venous pulse
- Estimate jugular venous pressure
How much blood does the heart pump per minute?
4-6L in a resting adult
Carotid sinus hypersensitivity
Pressure over the carotid sinus leads to decreased HR, decreased BP, cerebral ischemia.
Occurs in older adults with hypertension or occlusion of the carotid artery.
Normal carotid pulse contour
brisk upstroke, slower downstroke, moderate strength. Same bilaterally.
Carotid bruit indicates
turbulence from local vascular cause, atherosclerotic disease. Increases risk of TIA and stroke.
Also occurs in 5% of those age 45-80 with no significant carotid disease
Where to auscultate the thyroid
- angle of the jaw
- midcervical area
- base of the neck
Carotid bruit is audible when
Lumen is occluded by 1/2 to 2/3,
When lumen is completely occluded, bruit disappears—absence of bruit does not indicate absence of carotid lesion
On what side do you assess the central venous pressure?
right side
What do you look for when assessing jugular venous pressure?
Top of the external jugular vein overlying the sternomastoid muscle
pulsation of the internal jugular vein in the sternal notch
Unilateral distention of external jugular veins caused by
local cause- kinking or aneurysm
full distended external jugular veins above 45 degrees caused by
increased CVP with heart failure
Normal jugular venous pulsation
2cm or less above the sternal angle.
Elevated jugular venous pressure
pulsation >3cm above sternal angle.
May indicate heart failure, cardiac tamponade, constrictive pericarditis
If venous pressure is elevated, perform what test?
abdominojugular test
Watch level of jugular pulsation while pushing into right abdomen, pushing blood out of splanchnic vessels. If does not elevate CVP, jugular veins rise then back to normal. If heart failure, jugular veins elevate >4cm and stay as long as you push.
Objective data: the precordium (4 steps)
- Inspect the anterior chest
- Palpate the apical impulse
- Palpate across the precordium
- Auscultation
apical impulse
pulsation created as the left ventricle rotates against the chest wall during systole
occupies 4th or 5th intercostal space at the midclavicular line
easier to see in children/thinner chest walls
heave or lift
sustained forceful thrusting of the ventricle during systole
occurs with ventricular hypertrophy due to increased workload
palpating the apical impulse
use one finger pad, ask pt to exhale and hold it, may need to rotate the person to the left.
4th or 5th interspace @ midclavicular line
Apical impulse in cardiac enlargement
left ventricular dilation displaces impulse down and to the left, increases size to more than one interspace.
Apical impulse with left ventricular hypertrophy
Sustained impulse with increased force and duration but no change in location
Apical impulse in pulmonary emphysema
not palpable due to overriding lungs
Palpating precordium
use palmar aspects of four fingers to palpate apex, left sternal border, and the base, looking for pulsations.
Thrill
palpable vibrations like a purring cat. Indicates turbulent blood flow- look for murmurs.
Valve areas for Auscultation
aortic valve area- second right interspace
pulmonic valve area- second left interspace
tricuspid valve area- left lower sternal border
mitral valve area- fifth interspace at midclavicular line
Auscultation pattern for heart
from base to the apex in zigzag formation
premature beat
isolated beat is early, or pattern of early beats
irregularly irregular
no pattern- beats come rapidly and randomly (eg afib)
sinus arrythmia
occurs regularly in young adults and children
rhythm varies with breathing- increases at inspiration and decreases with expiration
pulse deficit
auscultate apical beat and radial pulse simultaneously. subtract radial from apical to determine deficit.
signifies weak contraction of the ventricles as in afib, premature beats, heart failure
Split S1
normal but rare
split s2
increased on inspiration, normal
midsystolic click
most common extra sound in systole, signals mitral valve prolapse
pathologic S3
ventricular gallop- occurs with heart failure and volume overload
pathologic s4
atrial gallop- occurs with CAD
Describing murmurs
- Timing
- Loudness (Grade 1-6)
- Pitch
- Pattern
- Quality
- Location
- Radiation
- Posture
Murmur of mitral stenosis
low-pitched and rumbling
murmur of aortic stenosis
harsh
innocent murmur
no valvular or other pathologic cause. Normally soft, midsystolic, short, heard at 2nd or 3rd left intercostal space. Disappears with sitting.
functional murmur
caused by increased blood flow in the heart- anemia, fever, pregnancy, hyperthyroidism
soft diastolic murmur of aortic regurgitation heard
when the pt is leaning forward in the sitting position
Objective data for heart and neck in the older adult
Gradual rise in SBP common
Some adults experience orthostatic hypotension
Caution in palpating carotid- could cause HR slowing or compromise circulation when atherosclerosis present
Chest increases in AP diameter- more difficult to palpate apical impise and hear split S2.
S4 occurs with no cardiac disease
Systolic murmurs common
Occasional premature ectopic beats common
S3 in older adult
associated with heart failure and always abnormal over age 35.
