Week 9 - Cardiac & Peripheral Vascular Assessment Content

Where is the point of maximum impulse (PMI) normally located?

At the 5th intercostal space at the left midclavicular line; it should feel like a light tap over an area of 1–2 cm.

What are the four chambers of the heart?

Right atrium, right ventricle, left atrium, and left ventricle.

What are the four heart valves?

Tricuspid, pulmonic, mitral (bicuspid), and aortic valves.

What is the correct pathway of blood through the heart?

Right atrium → tricuspid valve → right ventricle → pulmonic valve → pulmonary artery → lungs → pulmonary veins → left atrium → mitral valve → left ventricle → aortic valve → aorta.

What happens during systole?

The ventricles contract, the AV valves close producing S1, and the semilunar valves open to eject blood.

What happens during diastole?

The ventricles relax, atrial pressure exceeds ventricular pressure, and the AV valves open to allow ventricular filling.

What produces the S1 heart sound?

Closure of the mitral and tricuspid (AV) valves at the beginning of ventricular systole.

Where is S1 heard loudest?

At the apex of the heart, using the diaphragm of the stethoscope.

What produces the S2 heart sound?

Closure of the aortic and pulmonic (semilunar) valves at the end of systole.

Where is S2 heard loudest?

At the base of the heart, using the diaphragm.

What are the ECG intervals represented by one small and one large box?

One small box = 0.04 seconds; one large box = 0.20 seconds.

How many large ECG boxes represent one second?

Five large boxes.

What does normal sinus rhythm (NSR) look like in the presentation?

Small P waves, sharp QRS complexes, slightly larger T waves, even spacing, and a rate that is not excessively fast or slow.

What is the introductory Marsack Method used for?

A simplified assessment of how concerning a rhythm appears, not formal or validated ECG interpretation.

What does Level 1 mean in the Marsack Method?

The rhythm looks good.

What does Level 2 mean in the Marsack Method?

The rhythm is a problem, but not necessarily an immediate emergency.

What does Level 3 mean in the Marsack Method?

An urgent rhythm requiring action.

What does tachy mean?

Fast or rapid.

What is sinus tachycardia?

A faster-than-normal sinus rhythm; its urgency depends partly on the heart rate and clinical situation.

What are premature ventricular contractions (PVCs)?

Early ventricular beats that interrupt the otherwise organized rhythm; excessive PVCs may progress to more serious rhythms.

Why may a patient with a history of PVCs report a skipped heartbeat?

PVCs can create the sensation of a skipped beat; assess the patient's condition and rhythm rather than assuming every episode is harmless.

Why is ventricular tachycardia (V-tach) dangerous?

It can prevent effective blood delivery to organs and may require emergency treatment, including defibrillation when indicated.

What is atrial fibrillation (AFib)?

An irregularly irregular atrial rhythm that reduces effective atrial contraction and increases the risk of clot formation.

Why does AFib increase stroke risk?

Blood may stagnate in the atria, especially the left atrial appendage, allowing clots to form and potentially travel to the brain.

What is AFib with rapid ventricular response (RVR)?

AFib with a very rapid ventricular rate that can impair cardiac output and require urgent intervention.

What is second-degree heart block, Mobitz II?

An electrical conduction disorder in which some atrial impulses fail to conduct to the ventricles, causing dropped QRS complexes.

Which rhythms are listed as Level 3 in the presentation?

Ventricular fibrillation, ventricular tachycardia, asystole, pulseless electrical activity (PEA), AFib with RVR, and torsades de pointes.

What is the purpose of a cardiovascular review of systems?

Assess cardiac symptoms, cardiovascular disease, chronic illness, medications, surgical or diagnostic procedures, and family history.

How should the patient be positioned for a cardiac examination?

Assess in sitting, supine, and left lateral recumbent positions.

Why should both the bell and diaphragm be used during cardiac auscultation?

Different heart sounds have different frequencies; the diaphragm is best for higher-pitched sounds and the bell for lower-pitched sounds.

What should be inspected during cardiac assessment?

Chest wall movement, jugular venous distension, skin color, pallor, cyanosis, respiratory effort, and edema.

What are cardiac heaves or lifts?

Forceful cardiac contractions that cause noticeable movement of the sternum or ribs.

What is a cardiac thrill?

A palpable vibration caused by turbulent blood flow, often associated with a murmur.

What are the five cardiac auscultation areas in order?

Aortic, pulmonic, Erb's point, tricuspid, and mitral (APE to Man).

Where is the aortic auscultation area?

Second intercostal space at the right sternal border.

Where is the pulmonic auscultation area?

Second intercostal space at the left sternal border.

Where is Erb's point?

Third intercostal space at the left sternal border.

Where is the tricuspid auscultation area?

Fourth or fifth intercostal space at the left sternal border.

Where is the mitral auscultation area?

Fifth intercostal space at the left midclavicular line.

What sound is assessed at the fifth intercostal space, left midclavicular line?

The apical heart sounds and apical pulse, particularly the mitral area.

What is a physiologic split S2?

A splitting of the aortic and pulmonic components heard during inspiration that disappears during expiration.

How is split S2 assessed?

Use the diaphragm at the pulmonic area with the patient sitting; assess whether the split varies with respiration.

When does S3 occur, and how is it assessed?

Early diastole, just after S2; use the bell over the mitral area with the patient in the left lateral position.

What can a pathologic S3 indicate?

Ventricular failure or volume overload.

When can S3 be a normal finding?

In children, young adults, and during the third trimester of pregnancy.

When does S4 occur, and how is it assessed?

Late diastole, just before S1; use the bell over the mitral area with the patient in the left lateral position.

What can a pathologic S4 indicate?

A stiff, noncompliant ventricle, such as with long-standing hypertension or myocardial infarction.

How can S3 and S4 be remembered by their cadence?

S3 resembles “Ken-tuc-ky”; S4 resembles “Ten-nes-see,” with the extra sound before S1.

What can clicks and snaps indicate?

Valvular disease; an opening snap may occur with mitral stenosis, ejection clicks with damaged aortic or pulmonic valves, and nonejection clicks with mitral valve prolapse.

What causes a heart murmur?

Turbulent blood flow, which may result from increased blood velocity, decreased blood viscosity, valve stenosis or regurgitation, or structural defects.

What is a bruit?

A sound caused by turbulent blood flow over a narrowed or obstructed artery.

What are the six murmur grades?

Grade 1 barely audible; Grade 2 quiet but audible; Grade 3 moderately loud; Grade 4 loud with thrill; Grade 5 very loud with thrill and audible with the stethoscope partly off the chest; Grade 6 very loud with thrill and audible without a stethoscope.

What characteristics should be documented for a murmur?

Location, radiation, duration, pitch, quality, and timing.

How does the infant heart differ in position from the adult heart?

It is more horizontal, with a higher apex located at the fourth intercostal space; adult position is reached around age seven.

How does cardiac output increase in infants?

Primarily through increased heart rate because stroke volume changes are limited.

What cardiovascular changes occur during pregnancy?

Blood and plasma volume increase by approximately 30–50% beginning at 6–8 weeks; S3 may occur, resting pulse may rise 10–15 bpm, and supine hypotension can develop.

What age-related cardiovascular changes occur in older adults?

Large arteries stiffen and calcify, the aorta may dilate and lengthen, the left ventricular wall thickens, and arrhythmias become more common.

Why are calcium, potassium, and sodium monitored in cardiac patients?

Electrolyte imbalances can disrupt the cardiac conduction system and muscle contraction.

What lipid values are listed in the presentation?

Total cholesterol 60 mg/dL; LDL <50 mg/dL.

What does lactate dehydrogenase (LDH) indicate?

LDH is released from damaged tissues; the presentation lists a reference range of 122–222 units/L.

What is creatinine phosphokinase (CPK)?

An enzyme found mainly in the heart, brain, and skeletal muscle that can be released with tissue damage.

What is an ECG or EKG?

A recording of the heart's electrical activity; ECG and EKG mean the same thing.

What is a Holter monitor?

An ambulatory monitor that can record heart rhythm continuously, commonly for 24–48 hours.

What is an event monitor?

A monitor used to capture heart rhythm when symptoms occur, often by activating it during an episode.

What is an echocardiogram?

An ultrasound examination that produces images of the heart and helps assess its structure and function.

What is a transesophageal echocardiogram (TEE)?

A heart imaging study using a probe in the esophagus to obtain closer views of cardiac structures.

What happens during cardiac catheterization?

A catheter is advanced through a blood vessel to the heart to measure pressures and oxygen levels; contrast imaging and interventions such as balloon dilation or stent placement may also be performed.

What is an exercise stress test?

A test that monitors the ECG while the patient exercises on a treadmill or bicycle with gradually increasing difficulty.

What is a stress echocardiogram?

An echocardiogram comparing heart function at rest and after exercise or medication-induced stress.

What does CABG stand for?

Coronary artery bypass graft.

What do MI, STEMI, and NSTEMI mean?

MI = myocardial infarction; STEMI = ST-elevation myocardial infarction; NSTEMI = non-ST-elevation myocardial infarction.

What should be assessed during a peripheral vascular review of systems?

Extremity pain, color, temperature, swelling, smoking, diet, exercise, family history, and diseases such as diabetes and atherosclerosis.

What should be inspected during a peripheral vascular examination?

Extremity color, edema, texture, hair distribution, varicosities, and toenails.

What should be assessed by palpation during a peripheral vascular examination?

Extremity temperature, pulses, Doppler pulses when needed, capillary refill, and edema.

Which peripheral pulses are routinely checked most often?

Radial and dorsalis pedis pulses.

What are the main peripheral pulse sites?

Carotid, temporal, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis.

What is the normal pulse grading scale?

0 = absent; Doppler-only = detected with Doppler; 1+ = weak; 2+ = normal; 3+ = increased/full; 4+ = bounding.

What is the priority when a distal pulse cannot be located with a Doppler after cardiac catheterization?

Perform further assessment, including the popliteal pulse, to determine the extent of perfusion before notifying the provider with the findings.

What is arterial insufficiency?

Inadequate delivery of oxygenated blood to distal extremities, placing the most distal tissues at risk.

What are the common findings of arterial insufficiency?

Absent or diminished pulses, ischemia, hair loss, thick brittle nails, claudication, dependent rubor, pallor with elevation, shiny dry skin, delayed capillary refill, ulcers, and gangrene.

What is claudication?

Lower-leg pain or cramping caused by inadequate muscle blood flow, typically during walking and relieved by rest.

What is venous insufficiency?

Impaired return of blood against gravity to the heart, most commonly affecting the lower extremities.

What are common findings of venous insufficiency?

Brawny thickened skin, edema, varicosities, venous stasis ulcers, usually present pulses, and generally normal nails.

What is deep vein thrombosis (DVT)?

A blood clot in a deep vein, usually of a lower extremity, that can lead to a life-threatening pulmonary embolism.

What are risk factors for DVT?

Prolonged surgery or bed rest, immobility, hormone replacement or oral contraceptives, pregnancy or postpartum status, varicose veins, and obesity.

What are common DVT signs and symptoms?

Intense, sharp, deep lower-extremity pain, warmth, swelling, and redness; these findings require urgent evaluation.

Why is Homan's sign not sufficient to diagnose DVT?

It is not definitive and is no longer used as a reliable diagnostic test.

What is an ankle-brachial index (ABI)?

A noninvasive comparison of ankle and arm blood pressures used to screen for peripheral artery disease; a low value can indicate arterial narrowing or blockage.

What does arterial blood flow testing measure?

Blood pressures at different locations in an extremity using cuffs to help identify arterial blockages.

How can Doppler or venous ultrasonography help assess vascular problems?

They help evaluate blood flow and can be used to investigate suspected vascular obstruction or venous thrombosis.

What platelet range is listed in the presentation?

150,000–300,000/mm³.

How do platelet abnormalities affect bleeding and clotting?

Too few platelets increase bleeding risk; too many may increase clotting risk.

What activated clotting time (ACT) range is listed?

90–130 seconds.

What thrombin time range is listed?

15–23 seconds; it assesses fibrin formation from fibrinogen in plasma.

What prothrombin time (PT) range is listed?

10–12 seconds.

What INR ranges are listed for patients not taking and taking warfarin?

0.8–1.2 when not taking warfarin; 2.5–3.5 when taking warfarin, as listed in the presentation.

What does an INR represent?

A calculation based on the patient's prothrombin time relative to a control prothrombin time.

What does a 15 mmHg systolic blood pressure difference between arms suggest?

An abnormal finding that may indicate obstruction of arterial blood flow to one arm; confirm technique and report the finding appropriately.

What does PAD stand for?

Peripheral artery disease.

What does PVD stand for?

Peripheral vascular disease.