Nurse 3

Precordium

area on anterior chest overlying heart and great vessels

great vessels

major arteries and veins connected to the heart

blood vessels aranged in two continuous loops

pulmonary circulation and systemic circulation

pericardium

outer protective layer

myocardium

middle muscular layer

endocardium

inner smooth

atrium

thin wall resevoir for holding blood

ventricle

thick wall muscular chamber

four chambers seperated by valves purpose

to prevent backflow of blood

valves are unidirectional

valves open and close passively in response to pressure gradients in moving blood

four valves in heart

two AV valves

two SL valves

The direcrion of blood

liver to right atrium through inferior vena cava

from RV, venous blood flows through pulmonic valve to pulmonary artery

lungs oxygentate blood

From left atrium, arterial blood travels through mitral valve to left ventricle (LV)

aorta delivers oxygenated blood to body

circulation is continuos loop

systole

heart contraction

blood pumped from ventricles fills pulmonary and systemic arteries

mitral and tricuspid valves close making S1 sound

1/3 of cardiac cycle

diastole

ventricles relax and fill with blood

2/3 of cardiac cycle

• aortic and pulmonic valves close producing the S2 heart sound

auscilation

first heart sound s1-s2

third heart sound (S3)

Occurs when ventricles resistant to filling during early rapid filing phase

fourth heart sound (S4)

Occurs at end of diastole, at presystole, when ventricle resistant to filing

extra heart sounds: murmurs

gentle, blowing, swooshing sound that can be heard on chest wall

conditions that create turbulent blood flow

conditions that can result in murmurs

velocity of blood increases

viscosity of blood decreases

structural defecits in valves

heart has unique ability: automacity

can contract by itself, independent of any signals or stimulation from body

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

specialized cells in sinoatrial (SA) node, near superior bena cava initiate an electric impulse

Because SA node has intrinsic rhythm, it is called the pacemaker

p wave

depolarization of atria

QRS complex

depolarization of ventricles

t wave

repolarization of ventricles

cardiac output

in resting adults, heart normally pumps between 4 and 6 L of blood per min throughout body

CO=hr x SV

heart can alter its cardiac output to adapt to

metabolic needs of body

preload and afterload affect heart’s ability to

increase cardiac output

preload

venous return that builds during diastole

this increased contractility results in an increased volume of blood ejected, increased stroke volume

afterload

opposing pressure ventricle must generate to open aoritc valve against higher aortic pressure

resistance against which ventricle must pump blood

blood volume in pregnancy

increases 30% to 40% during pregnancy despite increased cardiac output, arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation

hemodynamic changes with aging

increase in systolic BP due to thickening of the ateries 

left ventricular wall becomes thicker but the overall size of the heart does not change

no change in resting heart rate or cardiac output at rest

ability of heart to augment cardiac output with increase is decreased

Dysrhythmias

supraventricular and ventricular dysrhythmias increases with age

ectopic beats common in aging people - usually asymptomatic in healthy older people

• may compromise cardiac output and blood pressure

• tachyarrhythmias may not be tolerated as well in older people

electrocardiogram (EKG)

prolonged P-R interval (first degree AV block)

Left axis deviation from age-related mild LV hypertrophy and fibrosis in left bundle branch

increased incidence of bundle branch block

pericardial friction rub

possible cause- rubbing together of inflamed viscera and parietal lining of heart (pericarditis)

characterisitics: high pitched and scratchy

patient position: position patient in sitting position and listen at apex and left lower sternal border (places where pericardium comes in close contact with the chest wall)

location 3rd and 4th ICS

always considered abnormal finding

heart failure

decreased cardiac output occurs when the heart fails as a pump

circulation becomes backed up and congested

acute heart failure

post myocardial infraction when the heart’s contracting ability has been directly damaged

chronic

example hypertension

ventricles pump against chronically increased pressure

systolic dysfunction

the heart cannot contract properly, results in a low ejection fraction

ejection fraction

stroke volumedivided by the end-diastolic volume, normally 60% to 80%

diastolic dysfunction

the heart fails to relax fully between heartbeats

the heart muscle wall is stiff and does not fill properlu

there is low cardiac output but a normal ejection fraction

artery function

supply oxygen and essential nutrients to the cells

ischemia

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

a complete blockage leads to death of the distal tissue

peripheral artery disease

affects noncoronary arteries and usually refers to arteries supply the limbs

caused by artherosclerosis, and less commonly by embolism, hypercoagulable states, or arterial dissection

veins

parallel to arteries

absorb CO2 and waste products from the periphery and carry them back to the heart

closer to the skin surface

low pressure system

PVD

pain occurs when legs are in dependent positons (hanging down) causing pooling of blood at ankles

PAD

patients report leg pain with leg elevation or calf pain during acitivty and disappears with rest

placing legs down help compression will complicate

narrowed arteries reduce blood flow to arms or legs

skin color changes

arterial thrombosis

thrombus (blood clot) adheres to vessel wall

acute arterial thrombi

injury to arterial wall, sluggish flow, or plaque formation secondary to atherosclerotic changes

arterial thrombosis

symtoms depend on what artery is affected

cramping in legs when walking

no edema absence of dorsalis pedal pulse when palpating

varicose veins

elongated, tortuos, dilated veins

primary varicosities believed to be caused by structural defect in the vessel wall

dilation of the bessels lead to incompetant venous valves - causes dilation of vessel

superficial beins are the most affected

venous insufficiency

chronic condition

damaged or againg valves within beins interfere with blood return to heart causing pooling of blood in lower extremities

brown discoloration of leg and foot

modofied allen test

measures arterial competancy- performed before taking an arterial sample

RUQ

liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal gland, hepatic fixture of colon, part of ascending and transverse colon

LUQ

stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal gland, splenic fixture of colon, part of transverse and descending colon

RLQ

cecum, appendix, right ovary and tube, right ureter, right spermatic

LLQ

part of descneding colon

sigmoid colon

left ovary and tube

left ureter

left spermatic cord

umbillicus

normally it is midline and inverted, with no sign of discolation, inflammation or hernia

• protusion of the abdominal viscera through an abnormal opening in the muscle wall

skin

surface smooth and even, with homogenous color

inspect for pigment change and presence of lesions or scars

pulsation or movement of the abdomen

normally you may see/feel pulsations from aorta beneath skin in epigastric area and near the umbilicus

how to assess abdomen

inspect, ausculate, percuss, palpate

normoactive bowel sounds

5-34 clicks/gurgles per min

hyperative bowel sounds

loud >34 clicks/gurgles per minute

-increased motiliy

hypoactive bowel sounds

decreased <5 clicks/ gurgles per minute - can follow abdominal surgry or with inflammation

-absent

absent bowel sounds are uncommon - listen for 3-5 minutes

typanitic (drum-like)

sounds percussing over air filled structures

dull sounds that occur when a solid structure (liver) or fluid (ascites)

tympany

when air in the instenstines risies to the surface when patient supine scattered areas of dullness

costovertebral angle tenderness

positibe finding indicates inflammation of the kidney

indirect fist percussion causes tissues to vibrate instead of producing a sound

to assess kidney, place one hand over 12th rib at costovertebral angle on back

a person normally feels thud but no pain

palpatation of abdomen

light palpatation

approximately 1 cm (0.5'“) with light, gentle, dipping movements keeping fingers together and flat on abdominal 

rovsing’s sign

acute appendicitis

murphy’s sign

hold your fingers beneath the liver border, apply mild pressure, and ask the patient to breathe deeply

should not elicit pain

inflammation of the gall bladder

rebound tenderness at mcburney’s point

apply firm pressure to abdomen then quickly release pressure

a sign of swelling of the lining of the stomach and intestinal wall

peritonitis or appendicitis

ascites

free fluid in the peritoneal cavity

suspect because of distended abdomen, bulging flanks, and an umbilicus that is proturding and displaced downward

• fluid wave 

• stand on the person’s right side

• place the ulnar edge of another examiner’s hand or the patient’s own hand firmly on the abdomen in the midline

• place your left hand on the person’s right flank

• with your right hand reach across the abdomen and give the left flank a firm strike

acute

less pain than one week most common complain in ED

visceral

hollow or solid organs caused by stretching of fibers

parietal

irritation of fibers that innervate the the parietal peritoneum

referred

pain felt in a more distant location from primary/initial site

the aging adult gastric system

may have increased deposits of subcutaneous fat on abdomen and hips- becomes redistributed away from extremities

abdominal musculature is thinner has less tone than that of younger adult - so in absence of obesity you may not peristalsis

abdominal wall

musculature relaxes

changes of the GI system occur with aging- most do

breast is composed of

glandular tissue, fibrous tissue, including suspensory ligaments

adipose tissue

glandular tissue contains 15 to 20 lobes radiating from nipple

breast lymphatics

has extensive lymphatic drainage

four groups of axillary nodes are present 

• central axillary nodes

• pectoral (anterior)

• subscapular (posterior)

• lateral

patient teaching

ask about self-breast exam

monthly just after menses

if no longer menstruating, select the same day of the month

clinical breast exam no longer recomended for breast cancer screening for avaerage-risk women

gynecomastia

benign growth of this breast tissue

distinguishable from other tissues in chest wall

feels like a smooth, firm, movable disk

occurs normally during puberty and is temporary

adolescents very aware of body imahe

reassure this change is normal, common, and temporary