HA Exam 3

Sanitize stethoscope

70% isopropyl alcohol prep pad on diaphragm and bell

Angi/o

Vessel

Aort/o

Aorta

Arter/o or arteri/o

Artery

Ather/o

Fatty plaque

Atri/o

Atrium

Cardi/o or coron/o

Heart

Phleb/o or ven/o

Vein

Thromb/o

Blood clot

Varic/o

Dilated vein

Vas/o or vascul/o

Vessel

Ventrocul/o

Ventricle

Cardia

Heart condition

Stenosis

Narrowing or stricture

Endo

In, within

Epi

Above, upon

Peri

Around

Diaphragm Sounds

High-pitched acoustic frequencies, including normal respiratory sounds, high-pitched heart sounds (S1 and S2), and standard systolic murmurs.

Bell Sounds

Low-pitched acoustic frequencies, including gallop rhythms (S3 and S4), low-pitched diastolic murmurs, and vascular bruits. Light contact against the skin is mandatory; excessive pressure stretches the underlying skin, turning the bell into a diaphragm and filtering out low-frequency sounds.

Doppler

Amplify arterial blood flow when peripheral pulses are weak, thready, or clinically non-palpable.

How to use Doppler

Apply conductive ultrasound gel over the selected arterial anatomic landmark. Activate the device power, position the transducer probe at a 90° angle perpendicular to the skin surface, and gently maneuver the tip until a distinct, pulsating "whooshing" acoustic signal is localized.

Clock with Second Hand Cardio Assess

Required for accurate measurement of the apical pulse rate by counting beats continuously for one full minute (60 seconds) at the precordium.

Penlight Cardio Assess

Used to direct tangential (side) lighting across the cervical region, enabling visual detection of subtle venous contour variations and arterial pulsations.

Heart Anatomical Location

Muscular organ located in the mediastinum of the central-left chest cavity at an oblique angle.

Base of Heart Location

Broad superior aspect located between the 2nd and 3rd ribs.

Apex of Heart Location

Inferior, pointed tip extending into the 5th intercostal space (ICS), medial to the left midclavicular line.

Point of Maximal Impulse Heart Location

Located precisely at the apex in the 5th ICS at the left midclavicular line (MCL). It represents the location where cardiac contraction forces the left ventricular apex directly against the anterior thoracic wall.

Pericardium

A fibrous, double-layered sac surrounding and protecting the heart from infection and mechanical trauma. The pericardial space contains approximately 10 to 30 mL of serous fluid, which lubricates the visceral and parietal layers to eliminate friction during myocardial contraction and relaxation.

Myocardium

The thick middle muscular layer comprised of specialized cardiac muscle fibers responsible for generating the contractile force needed to pump blood into the pulmonary and systemic circulations.

Endocardium

The smooth, innermost endothelial membrane lining the internal chambers, papillary muscles, and cardiac valves.

Atria Chamber

Superior, thin-walled collecting chambers. The right atrium receives deoxygenated systemic venous return via the Superior Vena Cava (draining upper extremities, head, and neck) and Inferior Vena Cava (draining lower body and viscera). The left atrium receives oxygen-rich blood from the pulmonary circuit via four Pulmonary Veins.

Ventricles

Inferior, thick-walled pumping chambers. The right ventricle propels blood through the low-resistance pulmonary circuit via the Pulmonary Artery. The left ventricle, possessing a muscular wall three times thicker than the right, propels blood under high pressure through the Aorta into the systemic circulation.

Atrioventricular Valves (AV)

Comprise the Tricuspid Valve (separating right atrium and right ventricle) and the Mitral/Bicuspid Valve (separating left atrium and left ventricle). AV valves open during ventricular filling (diastole) and close firmly at the onset of ventricular contraction (systole) to prevent retrograde flow into the atria.

Semilunar Valves (SL)

Comprise the Pulmonic Valve (between right ventricle and pulmonary artery) and the Aortic Valve (between left ventricle and aorta). SL valves open during ejection (systole) and snap shut during relaxation (diastole) as arterial pressure exceeds ventricular pressure.

Right Side of Heart

(low pressure) Receives deoxygenated blood from body and pumps into lungs.

Left Side of Heart

(thicker/high pressure) Receives oxygenated blood from lungs and pumps into entire body.

Blood Flow Through Body

1. Unoxygenated systemic blood returns via the Superior and Inferior Vena Cava into the Right Atrium.

2. Flows through the open Tricuspid Valve during ventricular diastole into the Right Ventricle.

3. Ventricular contraction in systole closes the Tricuspid Valve and ejects blood through the open Pulmonic Valve into the Pulmonary Artery.

4. Blood enters the pulmonary capillary beds where gas exchange diffuses carbon dioxide out and oxygen into red blood cells.

5. Oxygenated blood returns via four Pulmonary Veins into the Left Atrium.

6. Flows through the open Mitral (Bicuspid) Valve during diastole into the Left Ventricle.

7. Left ventricular systole closes the Mitral Valve and propels blood through the open Aortic Valve into the Aorta for systemic arterial delivery.

Sinoatrial Node (SA)

Primary pacemaker located in the upper wall of the right atrium near the superior vena cava inlet; intrinsic automaticity generates 60–100 impulses/min.

Atrioventricular Node (AV)

Located at the lower interatrial septum near the tricuspid valve; delays impulse transmission slightly to allow complete atrial emptying (atrial kick) before generating an intrinsic rate of 40–60 impulses/min if the SA node fails.

Bundle of His & Purkinje Fibers

Electrical pathways descending through the interventricular septum to the Purkinje network in the ventricular myocardium, stimulating coordinated ventricular contraction from apex to base.

Cardiac Output (CO)

The volume of blood ejected by each ventricle in 1 minute (CO = Heart Rate x Stroke Volume). Normal adult resting CO is 4 to 6 L/min, adjusting dynamically to meet metabolic demands.

Cardiopulmonary Disfunction

Manifests in respiratory and integumentary assessment parameters. Left-sided heart failure causes blood to back up into the pulmonary vasculature, resulting in pulmonary edema, exertional dyspnea, orthopnea (quantified by the number of pillows required to elevate the head to sleep without shortness of breath), and paroxysmal nocturnal dyspnea. Cough characteristics yield vital clinical diagnostic data: a persistent cough producing pink, frothy sputum indicates acute pulmonary edema. Furthermore, timing of fatigue provides diagnostic discrimination; fatigue secondary to decreased cardiac output typically worsens in the evening, whereas chronic fatigue present upon waking suggests metabolic or psychiatric etiology. Skin color changes (pallor, cyanosis, or gray slate discoloration) directly signal systemic perfusion failure or chronic tissue hypoxia.

Coronary Arteries

Supply blood to pericardium and cardiac muscles.

Pulmonary Vein

Carries oxygenated blood from lungs to heart. Only vein in the human body that carries oxygen-rich blood.

Aortic Location

2nd Intercostal Space (ICS) at Right Sternal Border (RSB)

Pulmonic Location

2nd Intercostal Space (ICS) at Left Sternal Border (LSB)

Erb’s Point Location

3rd Intercostal Space (ICS) at Left Sternal Border (LSB)

Tricuspid Location

4th Intercostal Space (ICS) at Left Lower Sternal Border (LLSB)

Mitral (Apical) Location

5th Intercostal Space (ICS) at Left Midclavicular Line (MCL)

Aortic Primary Cardiac Value

S2 (second heart sound, caused by the closure of the aortic and pulmonic valves) is loudest here.

Pulmonic Primary Cardiac Value

S2 (second heart sound, dominated by pulmonic valve closure) is loudest here.

Erb’s Point Primary Cardiac Value

Both S1 and S2 are heard with nearly equal intensity; it is also a prime location for listening to heart murmurs like aortic regurgitation.

Tricuspid Primary Cardiac Value

S1 (first heart sound, caused by the closure of the tricuspid and mitral atrioventricular valves) is best heard here.

Mitral (Apical) Primary Cardiac Value

S1 is loudest and clearest here, and it corresponds to the point of maximal impulse (apical pulse).

S1 Heart Sound

("Lub"): Elicited by closure of the AV valves (mitral and tricuspid) at the initiation of ventricular systole. It is a low-pitched, longer sound heard with maximum intensity at the apex.

S2 Heart Sound

("Dub"): Elicited by closure of the SL valves (aortic and pulmonic) at the conclusion of systole / initiation of diastole. It is a higher-pitched, sharper sound heard with maximum intensity at the base.

Systole

The silent interval occurring between S1 and S2.

Diastole

The silent interval occurring between S2 and the subsequent S1.

Tachycardia

Resting apical rate >100 beats/min.

Bradycardia

Resting apical rate <60 beats/min.

Gallop Rhythms

S3 (ventricular gallop occurring in early diastole during rapid filling, indicating volume overload/heart failure) and S4 (atrial gallop occurring in late diastole during atrial contraction into a non-compliant ventricle, indicating hypertension or hypertrophy).

Murmurs

Blowing or swishing sounds caused by turbulent blood flow across diseased, stenotic, or incompetent valves.

Pericardial Friction Rub

A harsh, high-pitched, double or triple phase sound resembling sandpaper scratching, produced by inflamed visceral and parietal pericardial layers rubbing together during cardiac motion.

P Wave

Atria depolarization (pumping blood into ventricles).

QRS Complex

Ventricle depolarization.

T Wave

Ventricle repolarization.

Pulse Pressure

Difference between systolic and diastolic blood pressure. Low/Narrow: poor cardiac output. Normal: 40-60 mmHg. High/Wide: stiff vessels, narrowing/clogged arteries.

MAP (Mean Arterial Pressure)

Average amount of pressure in the arteries’ walls. Low: poor perfusion to the organs. Normal: around 70-100 mmHg. High: too much pressure.

Preload

Volume in the right aria at the end of diastole.

Afterload

Pressure in the great vessels against which the left ventricle contracts.

Venous System

Returns deoxygenated blood, holds 75% of total blood volume, low pressure, contains valves, and thin walls.

Arterial System

Carries oxygenated blood to body, high pressure, no valves, thicker walls.

Arterioles

Tiny branch of artery.

Venules

Tiny branch of veins.

Capillaries

Fine branching blood vessels that form a network between arterioles and venules.

Aneurysm

Ballooned and weakened area of an artery.

Pulsation Palpation

Use finger pads.

Thrills Palpation

Use padding at the base of fingers.

Heaves/lifts Palpation

Use palm of the hand.

Jugular Veins Assess

Position the client supine with the HOB elevated to a 35° to 45° angle. Instruct the client to rotate their head slightly to the left away from the examiner. Direct tangential lighting across the right cervical region using a penlight. Inspect the internal and external jugular venous contours overlying the sternocleidomastoid muscle.

Expected Jugular Veins

Gentle, soft venous wave pulsations visible without gross venous enlargement.

Unexpected Jugular Veins

Full, bulging, or bounding jugular vein distention (unilateral or bilateral) above a 45° elevation indicates volume overload or Right-Sided Heart Failure resulting from elevated central venous pressure backing up through the superior vena cava into the right atrium.

Carotid Arteries Assess

Position the client supine with the HOB elevated to a 35° to 45° angle. Instruct the client to rotate their head slightly to the left away from the examiner. Direct tangential lighting across the right cervical region using a penlight. Inspect for visible arterial pulsations medial to the sternocleidomastoid muscle.

Carotid Arteries Expected

Smooth, brisk arterial pulse synchronized with S1.

Carotid Arteries Unexpected

Complete absence of pulsation indicates severe obstruction or profound reduction in cardiac output.

Critical Safety Rule

Palpate carotid arteries individually (one at a time). Simultaneous bilateral carotid palpation can compress cerebral blood flow, causing sudden cerebral ischemia, or stimulate carotid sinus baroreceptors, triggering severe vagal bradycardia and syncope.

Pulse Strength Criteria

Expected: 2+ moderate and equal strength bilaterally. Unexpected: 4+ bounding pulse (indicates fluid overload, hyperthyroidism, or severe hypertension); 1+ weak, thready pulse (indicates vascular occlusion, hypovolemia, or shock).

Anterior Chest Inspection Technique

Elevate HOB to 30°–45° with the client supine. Stand on the client's right side to view the anterior thoracic contour and precordium.

Anterior Chest Expected Findings

Symmetrical thoracic expansion during breathing; visible gentle pulsation at the PMI localized within the 5th ICS at the left MCL.

• Expected Variation: PMI pulsation may not be visible in clients who have thick chest walls, large breast tissue, abdominal obesity, or significant muscularity.

Anterior Chest Unexpected Findings

• Lift or Heave: A sustained, forceful thrusting elevation of the precordium observed during systole, secondary to cardiac enlargement or ventricular hypertrophy.

• Thrills: A palpable vascular vibration or buzz feeling over the precordium, indicating severe turbulent blood flow associated with loud cardiac murmurs (Grade IV/VI or higher).

Left-Sided Heart Failure

Left ventricle cannot pump sufficient blood forward, some blood back up into the left atrium and eventually into pulmonary capillaries, causing pulmonary edema.

Left-Sided Heart Failure Causes

• CAD, MI, HTN

• Damaged heart valves (endocarditis)

• Congenital heart defects

• Dysrhythmias

Left-Sided Heart Failure Clinical Manifestations

Left=Lung

• Dyspnea, SOB, tachypnea

• Cough, crackles, cyanosis

• Low O2, restless, confused

• Elevated PAWP

Right-Sided Heart Failure

Failure of the right ventricle to pump blood into the pulmonary arteries causes back flow of blood into the inferior and superior vena cava.

Right-Sided Heart Failure Risk Factors

• HTN, CAD, DM

• Sleep apnea

• Congenital heart defects

• Viruses

• Alcohol/tobacco

• Obesity

• Dysthymias

Right-Sided Heart Failure Clinical Manifestations

Right=Rest of Body

• Blood pools in the body

• Dependent edema

• Ascites, enlarged liver + spleen

• Increased peripheral venous pressure

• JVD, increased weight

Peripheral Vascular System Inspection Criteria

• Symmetry & Skin: Compare upper and lower extremities bilaterally for size, contour, skin pigmentation, and integrity.

• Hair Pattern: Expected: Evenly distributed hair growth corresponding to gender and age. Unexpected: Loss of lower extremity hair, thin shiny skin, or skin scaliness indicating chronic peripheral arterial disease (PAD).

• Ulcerations: Inspect pretibial areas, ankles, and toes. Arterial ulcers appear punched-out, deep, and dry over bony prominences; venous ulcers appear superficial with irregular margins, hyperpigmentation, and exudate over the medial malleolus.

• Veins: Inspect lower legs in dependent positions. Dilated, tortuous varicose veins indicate incompetent venous valves and elevated venous pressure.

• Nails & Clubbing: Inspect nail plate angle. Expected: Smooth nail plate with a normal convex angle of approximately 160°. Unexpected: Pale or cyanotic nail beds; clubbing (flattening of the nail angle > 180° accompanied by spongy enlargement of the distal phalanx), indicating chronic systemic hypoxia.

Peripheral Vascular Palpation Criteria

• Temperature: Assess temperature along extremities using the dorsal (back) aspect of your hands. Unexpected: Asymmetric coolness (arterial insufficiency) or localized warmth/erythema (deep vein thrombosis or cellulitis).

• Turgor: Pinch skin over the sternum or anterior forearm and release. Expected: Immediate elastic recoil. Unexpected: Tenting (persistent skin elevation), signaling fluid volume deficit.

• Moisture: Note excessive diaphoresis. Cold, clammy skin accompanied by nausea and lightheadedness signals acute cardiogenic shock or myocardial infarction.

• Capillary Refill: Depress fingernail or toenail beds until blanched, then release. Expected: Rapid color return in < 2 seconds. Unexpected: Sluggish refill > 2 seconds, indicating peripheral vasoconstriction or reduced cardiac output.

• Edema: Firmly press the thumb over the pretibial surface or medial malleolus for 5 seconds. Unilateral swelling indicates localized venous thrombosis or lymphatic obstruction; bilateral swelling indicates systemic heart failure or fluid retention.

Peripheral Pulse Grading Scale

Grade	Clinical Description	Strength / Amplitude Criteria
0	Absent	Completely impalpable pulse
1+	Weak / Thready	Diminished, easily obliterated with light pressure
2+	Normal	Expected brisk pulse; moderate pressure required to obliterate
3+	Increased	Strong, full volume pulse
4+	Bounding	Hyperdynamic pulse; full volume, cannot be obliterated

Anatomical Pulse Palpation Sites

• Radial: Thumb side of the anterior wrist surface, medial to the radial styloid process.

• Brachial: Antecubital fossa, medial to the biceps tendon.

• Femoral: Inferior to the inguinal ligament, halfway between the anterior superior iliac spine and pubic symphysis (requires firm pressure).

• Popliteal: Deep in the popliteal fossa behind the knee (facilitated by flexing the knee slightly in a prone or supine position).

• Posterior Tibial: Posterior-inferior groove behind the medial malleolus (requires light touch).

• Dorsalis Pedis: Dorsum of the foot, lateral to the extensor tendon of the great toe (requires extremely light touch).