Physical Assessment Chapter 20,21, 12, 13, 14, 17

where is the base of the heart

The “top” of the heart is the broader base

where is the apex of the heart

the “bottom” of the heart is the apex

pericardium

a tough, fibrous, double-walled sac that surrounds and protects the heart

myocardium

is the muscular wall of the heart; it does the pumping.

endocardium

is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves.

Aortic Valve Area

Second right interspace

Where Is The Aortic Valve Best Heard

heard over all the precordium; loudest at the base

Pulmonic valve area

Second left interspace

Where Is The Pulmonic Valve Best Heard

heard over all the precordium; loudest at the base

Tricuspid valve area

Left lower sternal border

Where Is The Tricuspid Valve Best Heard

heard over all the precordium; loudest at the apex

Mitral valve area

Fifth interspace at around left midclavicular line

Where Is The Mitral Valve Best Heard

heard over all the precordium; loudest at the apex

What is the best technique for auscultating the cardiac sounds

Listen with the diaphragm; then switch to the bell, covering all auscultatory areas

what is apical impulse

the pulsation is created as the left ventricle rotates against the chest wall during systole. it is palpable and easier to palpate in children and those with thinner chest walls.

location of the apical impulse

occupies the 4th or 5th intercostal space, at or inside the midclavicular line.

size of the apical impulse

normally 1 × 2 cm, best measured in left lateral position

duration of apical impulse

short; normally occupies only the first half of systole

abnormalities in the apical pulse

Conditions causing cardiac enlargement, such as left ventricular dilation seen in heart failure and cardiomyopathy.

pulse deficit

signals a weak contraction of the ventricles; it occurs with atrial fibrillation, premature beats, and heart failure.

pulse deficit and what it indicates

A pulse deficit is noted by auscultating the apical beat while simultaneously palpating the radial pulse. Count a serial measurement (one after the other) of apical beat and radial pulse. Normally every beat you hear at the apex should perfuse to the periphery and be palpable. The two counts should be identical. If different, subtract the radial rate from the apical and record the remainder as the pulse deficit. A pulse deficit indicates a weak contraction of the ventricles and occurs with atrial fibrillation, premature beats, and heart failure.

What are the Four Chambers of the heart

right ventricle

left ventricle

right atrium

left atrium

What are the valves of the heart

tricuspid

mitral valve.

pulmonic valve

aortic valve

opening and closing of the AV valves

The AV valves open during the heart’s filling phase, or diastole, to allow the ventricles to fill with blood.

The closure of the AV valves contributes to the first heart sound (S 1 ) and signals the beginning of systole.

During the pumping phase or systole, the AV valves close to prevent regurgitation of blood back up into the atria.

opening and closing of the SL valves

The semilunar (SL) valves are set between the ventricles and the arteries. Each valve has three cusps that look like half moons. The SL valves are the pulmonic valve in the right side of the heart and the aortic valve in the left side of the heart. They open during pumping (systole), when blood ejects from the heart.

diastole

the hearts filling phase

systole

the hearts pumping phase

what valves closing signify the beginning of systole

closure of the atrioventricular (AV) valves or S1

what valves closing signify the end of systole

closure of the semilunar valves

which side of the heart pumps to the lungs

is that low or high pressure

the right side of the heart pumps blood into the lungs, low

which side of the heart pumps to the body

is that low or high pressure

left side simultaneously pumps blood into the body; high

what happens in right side heart failure

Because volume and pressure increase when the right side of the heart fails to pump efficiently, the jugular veins reveal this (become distended).

what happens in left side heart failure

the heart’s inability to pump enough blood to the body

what is the order for direction of blood blow

1. From liver to RA through inferior vena cava.

Superior vena cava drains venous blood from the head and upper extremities. From RA venous blood travels through tricuspid valve to RV.

2. From RV venous blood flows through pulmonic valve to pulmonary artery.

Pulmonary artery delivers unoxygenated blood to lungs.

3. Lungs oxygenate blood.

Pulmonary veins return fresh blood to LA.

4. From LA arterial blood travels through mitral valve to LV.

LV ejects blood through aortic valve into aorta.

5. Aorta delivers oxygenated blood to body.

what is atrial kick or (presystole) (atrial systole)

Toward the end of diastole the atria contract and push the last amount of blood

describe the S2 splitting

When the aortic valve closes significantly earlier than the pulmonic valve, you can hear the two components separately.

effects of respiration on S2

MoRe to the Right heart,

Less to the Left

During inspiration, decreased intrathoracic pressure increases blood flow to the vena cava, resulting in increased right ventricular stroke volume, prolonging systole and delaying pulmonic valve closure.

During inspiration, increased lung blood sequestration decreases left ventricular stroke volume, shortening left ventricular systole and allowing the aortic valve to close earlier. This results in a split S2 sound, separating the two components.

define the third heart sound

sound occurs in diastole, immediately after S2 when the AV valves open and atrial blood first poors into the ventricles

what are abnormalities of S3

In adults the S 3 is usually abnormal; The S 3 is found in conditions of volume overload and high cardiac output states, disappearing when primary conditions are corrected.

third heart sound intensity, quality, location it is heard, and method of auscultation

To auscultate for the S₃ sound, listen to all auscultatory areas with both the diaphragm and the bell. It is a dull, soft sound; and it is low pitched, like “distant thunder.”

when is it pathological (ventricular group)

A pathologic S3, also known as a ventricular gallop, is an abnormal symptom in adults, indicating decreased ventricle compliance, heart failure, volume overload, or high cardiac output. It disappears when primary condition is corrected.

what is LUB-duppa

It occurs in early diastole during the rapid filling phase.

It is a dull, soft sound; and it is low pitched, like “distant thunder.”

define the 4th heart sound

S4 is a heart sound produced by the atria pushing blood into a noncompliant ventricle, often associated with coronary artery disease (CAD). It occurs just before S1 and can be auscultated at the left lower sternal border and mitral valve area.

Fourth Heart Sound

The S4 is a ventricular filling sound. It occurs when the atria contract late in diastole. It is heard immediately before S1.

what are abnormalities of S4

A right-sided S ₄ is less common. It is heard at the left lower sternal border and may increase with inspiration. It occurs with pulmonary stenosis or pulmonary hypertension.

where is S4 best heard at

You need a good bell, and you must be listening for it. It is heard best at the apex with the person in left lateral position.

pathologic (atrial gallop)

A left-sided S 4 occurs in conditions like coronary artery disease, cardiomyopathy, systolic overload, aortic stenosis, and systemic hypertension, best heard at the apex.

what is daLub dup

heard right before S1

murmur

is a gentle, blowing, swooshing sound that can be heard on the chest wall.

condititions that you would hear a murmur

1. Velocity of blood increases (flow murmur) (e.g., in exercise, thyrotoxicosis)

2. Viscosity of blood decreases (e.g., in anemia)

3. Structural defects in the valves (a stenotic or narrowed valve, an incompetent or regurgitant valve) or unusual openings occur in the chambers (dilated chamber, septal defect)

what is a thrill

is a palpable vibration

electrical impulse

stimulates the heart to do its work, which is to contract.

What is the flow of the current

contracts in response to an electrical current conveyed by a conduction system

Starts at the sinoatrial node (SA or the pacemaker) then where

Specialized cells in the sinoatrial (SA) node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly so the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.

QRS complex

Depolarization of the ventricles

T wave

Repolarization of the ventricles

PR interval

From the beginning of the P wave to the beginning of the QRS complex (the time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles)

P wave

Depolarization of the atria

The R in the wave is the same as

S1 and is the carotid pulse

Cardiac output =

equals the volume of blood in each systole (called the stroke volume) times the number of beats per minute (heart rate).

what are the two ways in which to increase cardiac output are:

preload & afterload

preload

volume affects stroke volume

after load

opposing pressure to overcome the pressure of the aorta

carotid artery

is located in the groove between the trachea and the sternomastoid muscle, medial to and alongside that muscle.

bruit

blowing, swishing sound indicating blood flow turbulence; normally none is present.

when auscultating a bruit which side of the stethoscope is used

bell

what is jugular venous pulse

results from a backwash, a waveform moving backward caused by events upstream.

reflect the health of the right side of the heart

jugular veins give information about activity on the right side of the heart. Specifically they reflect filling pressure and volume changes. Because volume and pressure increase when the right side of the heart fails to pump efficiently, the jugular veins reveal this (become distended).

Describe JVD

Because volume and pressure increase when the right side of the heart fails to pump efficiently, the jugular veins reveal this (become distended).

How is JVD measured

Position the person supine anywhere from a 30- to a 45-degree angle, wherever you can best see the top of the vein or pulsations. In general, the higher the venous pressure is, the higher the position you need. Remove the pillow to avoid flexing the neck; the head should be in the same plane as the trunk. Turn the person’s head slightly away from the examined side and direct a strong light tangentially onto the neck to highlight pulsations and shadows.

As the person is raised to a sitting position, these external jugulars flatten and disappear, usually at 45 degrees.

what is an abnormal measurement for JVD

Full distended external jugular veins above 45 degrees signify increased CVP as with heart failure.

internal jugular vein pulsation

Location: Lower, more lateral, under or behind the sternomastoid muscle

Quailty: Undulant and diffuse; two visible waves per cycle

Respiration: Varies with respiration; its level descends during inspiration when intrathoracic pressure is decreased

Palpable: not palpable

Pressure: Light pressure at the base of the neck easily obliterates

Position of person: Level of pulse drops and disappears as the person is brought to a sitting position

Carotid Pulse

Location: Higher and medial to this muscle

Quality: Brisk and localized; one wave per cycle

Respiration: Does not vary

Palpable: Yes

Pressure: no change

Position of person: Unaffected

The aging adult

It is difficult to isolate the “aging process” of the CV system per se because it is so closely interrelated with lifestyle, habits, and diseases

The artery walls

are strong, tough, and tense to withstand pressure demands.

arteries accessible to palpation

Temporal Artery - in front of the ear

Carotid Artery - groove between the sternomastoid muscle and the trachea

Arteries in the Arm - brachial, ulnar and radial

Arteries in the Leg - femoral, popliteal, dorsalis pedis, posterior tibial

what is the function of the arteries

to supply oxygen and essential nutrients to the cells

what is the function of Ischemia

deficient supply of oxygenated arterial blood to a tissue caused by obstruction of a blood vessel

what does PAD stand for

Peripheral artery disease (PAD)

affects noncoronary arteries and usually refers to arteries supplying the limbs

describe veins

Veins drain the deoxygenated blood with its waste products from the tissues and return it to the heart

The _______ is parallels, but direction of the flow is ______ of arteries

course

opposite

Function: Absorbs _______ and _______ from the periphery and carry back to _______

CO2

waste

heart

veins accessible to examination

Jugular Veins

Veins in the Arm - superficial and deep. The superficial veins are in the subcutaneous tissue and are responsible for most of the venous return

Veins in the Leg - femoral and popliteal, great and small saphenous

describe veins in the arm differentiating superficial from deep

The superficial veins are in the subcutaneous tissue and are responsible for most of the venous return.

deep veins run alongside the deep arteries and conduct most of the venous return from the arm.

describe veins in the leg differentiating superficial from deep

deep veins run alongside the deep arteries and conduct most of the venous return from the legs.

Blood flows from the superficial veins into the deep leg veins.

describe venous flow

Veins drain the deoxygenated blood with its waste products from the tissues and return it to the heart.

veins are a low-pressure system

risk factors for venous disease

people who undergo prolonged standing, sitting, or bed rest because they do not benefit from the milking action that walking accomplishes.

Hypercoagulable states and vein wall trauma are other factors that increase risk for venous disease.

what are varicose veins

dilated and tortuous veins with incompetent valves

describe the function of the lymphatic system

retrieves excess fluid and plasma proteins from the interstitial spaces and returns them to the bloodstream

At the arterial end the hydrostatic pressure is caused by the pumping action of the heart and pushes somewhat more fluid out of the capillaries than the venules can absorb.

describe the lymph nodes normal

small, oval clumps of lymphatic tissue located at intervals along the vessels

describe the lymph nodes inflamed

nodes in that area become swollen and tender.

where do Cervical nodes drain

drain the head and neck

where do Axillary nodes drain

drain the breast and upper arm

where do epitrochlear node drain

drains the hand and lower arm