HA EXAM 2: heart, vessels, lymphatics

___: area on thew anterior chest overlying the heart and great vessels

3 layers of the heart

____: tough fibrous double walled-sac protecting the heart

____: muscular wall of heart

____: thin endothelial tissue lining inner heart surface

• precordium

• pericardim

• myocardium

• endocardium

5 cardiac auscultation points and where they’re located?

• aortic point @ 2nd ICS

• pulmonic point @ 2nd ICS

• erbs point @ 3rd ICS

• tricuspid point @ 4th ICS

• bicuspid (mitral) aka heart apex @ 5th ICS

lateral displacement of the PMI (point of maximal impulse - aka apex) to the LEFT seen in what conditions?

• cardiomegaly

• right pleural effusion

• right pneumothorax

AV valves

• when do AV valves open?

• when do AV valves close?

SL valves

• each valve has 3 cusps

• abnormally high pressure @ left side of heart causes?

• abnormally high pressure @ right side of heart causes?

• during diastole (filling phase) into ventricles

• during systole (pumping phase) out of ventricles

• pulmonary congestion

• jugular distention

Conduction system and EKG

• flow of conduction?

• flow of EKG?

• what are the positive inflections of a normal EKG?

• what are the positive inflections of a normal EKG?

• what does P wave tell u?

• what does QRS compelx tell u?

• what does T wave tell u?

• SA node > AV node > AV bundle > left/right bundle branches > purkinje fibers

• P-QRS-T

• P R T

• Q R

• atrial contraction

• ventricular contraction (and thus atrial relaxation)

• ventricular relaxation

Normal heart sounds

S1

• start or end of systole?

• closure of what valves?

• opening of what valves?

• where is it loudest?

• coincides with carotid upstroke

S2

• start or end of systole?

• closure of what valves?

• opening of what valves?

• where is it loudest?

Split S1

• quick and non-concerning

• why does this happen?

• heard in people with what heart condition?

Split S2

• why does this happen?

• what does this result in?

• WHEN can u hear this sound (during inhale or exhale?)

• start of ventricular systole

• AV valves

• SL valves

• apex

• end of ventricular diastole

• SL valves

• AV valves

• base of heart

• ventricles contracting at different times bc AV valves contracted separately

• right bundle branch block

• during inhalation, there’s increased venous return > increased right side volume > increased right filling and ejection > delayed pulmonary valve closure bc its gotta wait until all the blood is ejected (and early aortic valve closure)

• inhale

Extra heart sounds

S3

• also called ____

• when does this occur?

• caused by what?

• NORMAL in pregnancy, children, and athletes

• ABNORMAL in heart failure/or dilated/weak ventricle

S4

• also called ____

• when does this occur?

• caused by what?

• isnt uncomomon for elderly, but its still ABNORMAL bc its not a reg sound

• ventricular gallop or “kentucky” sound

• after S2

• new blood from atria clashes with leftover blood sitting inside ventricles due to floppy weak ventricle = creates turbulence and vibration on ventricle walls

• atrial gallop or “tennesse” sound

• before S1

• stiffened ventricular walls (from ppl with hypertension or hypertrophic ventricle) causes turbulent flow bc atria has to contract HARD to force blood into ventricles

____: heart sound caused by turbulent blood flow

Caused by:

• increased speed of bloodflow

• decreased blood viscosity (ex: as seen in anemia)

• closed but leaky valve (aka valve ___)

• open but obstructed valve (aka valve ___)

• aneurysms

• septum defect

• murmurs

• regurgitation

• stenosis

Murmurs cont.

• Systolic murmurs are caused by?

• Diastolic murmurs are caused by?

• aortic stenosis (resulting in mitral regurgitation) OR pulmonary stenosis (resulting in tricuspid regurgitation)

• aortic regurgitation (resulting in mitral stenosis) OR pulmonary regurgitation (resulting in tricuspid stenosis

Neck vessels

• rmb: carotid upstroke coincides with S1 (ventricular contraction)

• palpate carotid artery while listening to heart sounds to check if S1 matches w/carotid pulse

Positioning during cardiac physical assessment

• what position should pt be in while checking for mitral stenosis?

• what position should pt be in while checking for mitral regurgitation?

• laying on side

• sitting position w/back flat to the bed + auscultate left sternal border ***think of laying on ur back and regurgitating throw up****

Carotid bruit

____: “whooshing sound”; indicating turbulent flow caused by narrowed (stenosis) arteries

• what location to auscultate?

• what side of stethoscope to use?

• instructions for pt?

• carotid bruit

• carotid artery

• bell

• hold breath for no longer than 10 secs while i asuculate for bruit sound > press LIGHTLY with stethoscope on carotid artery while listening for whoosing sound

Venous pulse VS Carotid pulse

• venous pulse easily compressed with gentle pressure

• carotid pulse requires harder pressure to compress

• venous pulse descends during inhale and ascends during exhale

• venous pulse (aka venous return) reduced during standing/sitting (bc of gravity pulling blood towards lower extremities)

• carotid unaffected by respirations and sitting/standing changes

Heart palpation

Basic palpation: the 5 basic heart sound areas (aortic, ventricular, erb’s point, tricuspid, bicuspid)

• use the PALMAR aspect of ur 4 fingers

• also: NEED to palpate for point of maximal pulse (PMI) aka the apex at which ICS space?

Heave: feels like an abnormally large heartbeat

• which part of hand do you use to palpate for heaves?

• which areas do u palpate?

Thrill: basically feeling the murmur; feels vibratey

• which part of hand do you use to palpate for thrills?

• 5th ICS

• bottom edge of palm

• all over the precordium

• middle third of palm (kinda where ur bony metacarpal bumps are)

• where is S1 loudest?

• where is S2 loudest?

• S1 and S2 heard EQUALLY as loud at what heart sound location = makes it ideal location to listen for murmurs and abnormal sounds (including pericarditis’s friction rub sound)

• apex

• base of heart

• erbs point

Pericardial friction rub

• abnormal heart sound

• due to pericarditis

• high pitched scatchy sound

• where is it best heard?

• 3rd ICS

HEART FAILURE

• Right side heart failure leads to what?

• Left side heart failure leads to what?

• peripheral congestion (peripheral edema lol) + GI tract congestion + Liver congestion

• decreased perfusion + pulmonary congestion (involves impaired breathing, pulmonary edema)

Doppler ultrasonic probe

• used to detect BP from weak peripheral pulse

• how it works: magnifies the weak pulse sound

• how to use: place over pulse site > hold at 45-60 degree angle > use light pressure > listen to what sounds?

whooshing/swishing sounds

Veins pathology

___: inflammed vein

___: clot in vein

___: detatched clot traveling thru blood

Thrombophlebitis

• describe?

• phlebitis

• thrombus

• embolus

• just means vein is inflammed, DOESNT always mean clot is there. BUT requires follow up

Lymphatic system

• 3 main functions of lymphatic system?

• Superficial nodes are large enough to inspect/palpate; described as soft, moveable, non-tender, bean-shaped masses

• what are the 4 superficial lymph nodes we inspect/palpate?

• where to check AFTER noticing the specific lymph node areas are swollen?

• conserve any fluid and plasma fluid that leaked from capillaries → returns it to heart to be circulated + immune function + absorbs lipids from small intestine

• cervical (lower back of neck) + armpit + epitrochlear (above elbow hinge) + inguinal

• if epitrochlear swollen —> check arms/hands

• if cervical swellen —> check under your chin, behind your ears, the back of your head, and above your collarbone

• if axillary swollen —> breasts and chest wall

• is inguinal swollen —> lower abdomen, legs/feet

what is intermittent claudication?

pain in legs caused by walking around/exercise; indicates peripheral artery diseases

Assessing pulse strength

• what does 1+ indicate?

• what does 2+ indicate?

• what does 3+ indicate?

• what does 4+ indicate?

• thready and weak

• normal

• increased pulse

• full bounding

Modified allen test

• a test for upper extremities

• goal is to make sure ur ulnar artery works in case ur radial artery doesnt work

• Steps?

• turn pt’s palm upwards > clench fist and keep it there > press ur fingers on ulnar and radial pulses > have pt clench and unclench fist until palm turns white > let go of radial artery ONLY > watch if the blood returns to palm (turns pink) > GOOD SIGN!

3 stages of Raynaud syndrome

1. Fingertip color is ___ due to lack of bloodflow

2. Fingertip color turns ___ due to vasodilation as attempt to keep blood in tissues

3. Fingertip color turns ___ due as bloodflow returns

• white

• blue

• red

Peripheral artery disease (PAD)

• caused by what main 3 things?

signs/SX

• intermittent claudication (1st appearing SX of PAD)

• burning/aching in feet while resting - especially while laying down at night

• whats the temperature in feet?

• redness of other skin color changes

• repeated infection

• feet sores that wont heal

• atherosclerosis, smoking, genetics

• cool

Intermittent claudication

• first appearing SX of PAD

• pain occurs in legs after walking for period of time

• quickly relieved by resting legs

• older ppl may not have the feeling of intermittent claudication (bc age related sensation loss) but still experience the other SX of PAD

Ankle brachial index (ABI)

• ABI = ratio of ankle systolic BP to brachial systolic BP

• safe range: ___

• if outside of that range = indicates PAD

• use ____ stethoscope to measure ABI

• a specific and accurate measure for PAD

• position: patient lying flat on their back

• use the correct cuff size

• need to rest 5-10 mins before measurement

• 1-1.3 is safe (if its 0.9 or below OR 1.4 or higher = indicates)

• doppler

Position change test for arterial insufficiency (Buerger’s test)

• have pt lay supine > raise legs > if feet become pale = POSITIVE TEST RESULT

• to CONFIRM this: let legs hang > if legs still pale OR feet remain red for long time OR it takes longer than 15 seconds for bloodflow to return > CONFRIMED arterial insufficiency

Arterial ulcer VS venous ulcer

• arterial is cool temp

• person get dry skin, hair loss, thick brittle toenails

• venous is warm temp

• venous creates thick tough brown skin

Varicose veins

• seen in ppl age 50 or above

• more commen in women

Peripheral venous disease

• creates heavy legs

• aching sensation when standing/sitting too long

• leg edema

• varciose veins