Week 6: Cardiovascular Assessment Flashcards
Describe the flow of blood through the heart (including valves)
Deoxygenated: Vena cava -> R atrium -> Tricuspid valve -> R ventricle -> Pulmonary valve -> Pulmonary artery
Oxygenated: Pulmonary veins -> L atrium -> Mitral valve -> L ventricle -> Aortic valve -> Aorta
Two phases of the cardiac cycle
Systole: Period of contraction
Diastole: Period of relaxation
Heart sounds (4): What’s happening and where is it best heard
S1 “lub”: Both AV valves close. Heard best with the patient in supine with head elevated 30-45°. Loudest at the apex of the heart
S2 “dub”: Semilunar (atrial and ventricle) valves close. Heard best with the patient in supine with head elevated 30-45°. Loudest at the base of the heart
S3: The rapid deceleration of blood against a stiff ventricle. Heard best with the bell of the stethoscope with the patient lying supine and then positioned in the left side-lying position
S4: Atria working hard to contract against a non-compliant and resistant left ventricle that creates vibrations. Heard best with the bell of the stethoscope with the patient lying supine and then positioned in the left side-lying position
Heart murmurs: Definition
Swishing or unusually prolonged sounds indicative of turbulent blood flow in the vascular system
Heart murmurs: Characteristics to document (4)
- Intensity/loudness
- Timing in the cardiac cycle
- Quality of sound (Harsh, rumbling, squeaky, etc)
- Pitch/frequency (High, medium, or low)
Heart murmurs: 6 grades
Grade 1/6: Very soft, requires effort to hear.
Grade 2/6: Soft but immediately audible.
Grade 3/6:Loud and easily audible.
Grade 4/6: Loud with a palpable thrill (always pathologic).
Grade 5/6: Very loud, heard with stethoscope edge on chest.
Grade 6/6: Extremely loud, heard without stethoscope contact.
Heart murmurs: Configurations (4)
Crescendo, decrescendo, crescendo-decrescendo, and plateau
Ejection clicks: Description of sound, when it is heard, implications, how to listen
Description of sound: High-pitched
When: Early diastole
Implications: Reflective of inc. CO
- Dilated aorta or pulmonary artery
- Stenotic aortic or pulmonic valves
How to listen: Use diaphragm of stethescope
Opening snap: Description of sound, when is it heard, what is happening
Description of sound: High-frequency ‘snapping’ sound
When: Diastolic sound heard after S2
Cause: Stenosis reduces the opening of the valve and blood flow through the valve
Pericardial friction rub: Description of sound, when is it heard, what is happening, implications
Description of sound: High-pitched, muffled, grating, and leathery
When: Each heartbeat
Cause: Caused by friction of the visceral and parietal layers of the pericardium
Implications:
- Pericardial sac inflammation (pericarditis)
- Accumulation of fluid between the pericardial layers of the heart (pericardial effusion)
Diagnostic tools and what they do (7)
- Lipid profile: Measure levels of cholesterol in plasma
- Creatinine kinase-MB: Measures levels of an enzyme that is produced in response to cardiac tissue damage
- Troponin test: Measures levels of protein in the cardiac muscle that are released when cardiac tissue is damaged
- EKG: Records the electrical activity of the heart
- Echocardiogram: A noninvasive ultrasound used to capture images of the heart’s structures
- Holter monitor: A 24-hour ambulatory test that records HR and rhythm
- Exercise test: Monitors HR and rhythm while patient exercises on a treadmill. EKG included
Concerning/notable elements of health status (7)
- Chest pain
- Heart palpitations
- Color changes
- Shortness of breath (Dyspnea)
- Edema
- Nocturia
- Fainting
Central vs peripheral cyanosis
Placement of the bluish color (central vs. extremities)
Angina pectoris
Strangling, pressure-like pain caused by cardiac ischemia
Syncope
Brief loss of consciousness (fainting)
Auscultation landmarks: Aortic valve
Second intercostal space, right sternal border (RSB) [2RSB]
Auscultation landmarks: Pulmonic valve
Second intercostal space, left sternal border (LSB) [2LSB]
Auscultation landmarks: Erb’s point
Third intercostal space, left sternal border (LSB) [3LSB]
Auscultation landmarks: Tricuspid valve
Fourth intercostal space, left sternal border (LSB) [4LSB]
Auscultation landmarks: Mitral valve
Fifth intercostal space, left midclavicular line (MCL) [5LMCL]
Order of auscultation
Aortic area -> Pulmonic area -> Erb’s point -> Tricuspid valve -> Mitral valve
Aspects of inspection (4)
- Symmetry!
- Surgical scars
- Pulsations
- Lifts or heaves
Steps of palpation
- Listen to 5 landmarks
- Ask the patient to turn slightly to the left. Using your second and third finger pads of your dominant hand, palpate the apical pulse at the fourth or fifth left intercostal space at the midclavicular line noting the location and amplitude
- While auscultating the apical pulse, use your other hand to palpate the carotid pulse or radial pulse; count and compare the beats per minute, and note amplitude and BPM
Implications of pulsations felt at RSB, 2nd ICS
Aortic aneurysm; a thrill may be indicative of aortic valve stenosis
Implications of pulsations felt at LSB, 2nd ICS
Pulmonary hypertension; a thrill may be indicative of pulmonic valve stenosis
Implications of pulsations felt at LSB, 3rd ICS
Aortic and pulmonic valve anomalies
Implications of pulsations felt at LSB, 4th ICS
Ventricular enlargement and defects
Implications of pulsations felt at LSB, 5th ICS
Mitral valve defects
Possible positions for auscultation (4)
- Supine
- Semi-Fowler’s
- Fowler’s
- Left side-lying position
Steps of auscultation
- Warm stethoscope and have pt in a lying position
- Using the second and third finger pads of your right or left hand, landmark each auscultatory site prior to placing the stethoscope on the skin
- Using the diaphragm of the stethoscope, auscultate S1 and S2 at the 5 landmark sites
- Have pt in a sitting position and ask them to lean forward. Using the diaphragm, auscultate the aortic and pulmonic valves
- Using the bell of the stethoscope, auscultate for low-pitched heart sounds at the 5 landmark sites
- Have pt lie laterally. Using the bell of the stethoscope, auscultate the apical area.
