Chapter 12 - Lecture - Cardiovascular System

So cardiac, if you think about influences and is influenced by such organs as our kidneys, you know, your kidneys influence our blood pressure. The blood pressure, the blood that our heart pumps out. You will see in this and hopefully we really appreciate that the lungs and the heart are closely related and a lot of the

example that I commonly use, you have a patient, you're working in an ED, and they come in and say, I can't breathe, I can't breathe. So most of you, you know, if not correctly, would say, well, they've got a pulmonary, you know, something's wrong with their lungs. I hope after this class today, you'll see that it could be a cardiac issue. It may not be their lungs at all.

But, you know, the liver is affected by the circulatory system. Everything, you know, has that interaction. So, this is, you know, what obviously fuses live from perfusion. So, perfusion. Remember, perfusion is the ability to take oxygen and include every cell in your body, which is amazing. You know, every day, constantly.

Blood is in pain, it's in every body, it's in oxygen, it's in nutrition, and the process takes CO2 and waste products. CO2 goes to the lungs, we breathe out. And then waste products, we excrete through the kidneys. All these areas are affected by our cardiovascular system, our skin, our brain, our GI tract.

But just keep in mind, so when we have an issue with the cardiac problem or cardiac tissue, the symptoms we see can be very bad. Like respiratory, I can't breathe. Or someone has trouble thinking they're getting a fog in their head. They could just pass out. That's a simple thing. If I can't get it up, I get out of bed, I'm feeling good, I can't get enough blood to my brain, I fall down. So when you guys can do this, work a steady kind of blood pressure.

So it's kind of complex, just, you know, keep that in mind and we're trying to keep it related to how everything else goes. So this we just talked about, here's O2, nutrients, energy cell, picks up which part, the kidneys, which freedom, you said the lungs from CO2. So we need to have that function. If we don't have a function, obviously like the diabetics that have bad feet, we don't get the oxygen nutritional feed.

Those start dying. The nerves start dying. They can't feel their feet. Then they get necrotic toes. They turn black, and then their toes get cut off. And then that's a downward trend for diabetics, when you start losing toes, that's not a good sign. Because then you lose feet. So we need that constantly. There's an old saying, you've probably heard, you can go, what was it, three weeks without food, three days without water, and about three minutes without oxygen.

So, you know, it's obviously a very violent life and we can't go along without it. So, each cell needs that. So, do you have a good history? Is there any chronic illnesses? And again, there's a myriad of illnesses that can affect this. Talk about diabetes. That's obviously one that we're going to talk about a lot. Diabetes has a lot of effects on the body, but one that's cardiovascular.

So again, the peripheral body, like your feet, are the ones that are damaged first. It damages the little capillaries. So remember, you know, from anatomy and physiology, you have these big vessels that go down to this little capillary. So that oxygen and nutrition can be transferred over to that cell, a tiny little cell, on the tips of your toes. And when the diabetes starts affecting that, damaging those.

Tits your toes, but no longer gets oxygen and nutrition. Congestive heart failure, we're talking about what that is today. Hypertension, obviously a big problem today. You see a lot of commercials for medications. For hypertension, no anything over 130, over 130, over 90 is considered hypertension. You know, making that diagnosis, the first time you have someone with 130, over 90, you have to do at least two separate occasions.

So, medications, if you take any medications, you know, again, ask them, I don't have any problems, why are you taking lysiniferol, which is an ACE inhibitor for your heart? Well, okay, they say I have a high blood pressure. Do you? You know, those kind of things. Anything for dysrhythmias, anything for fluid retention. You know, certainly in this area, you see a lot of great parents going, I got to make my water field.

So what is your water field? Probably LASICS or something like that. It's a diuretic. So that pulls water and helps to excrete more water. Why do we even care? Why are we pulling water off a sports body with LASICS? Say it out loud. Say it out loud. Volume, right? So think about the heart. Can you talk about it?

That's the size of your chest, or fist, right in your chest. It's a pump, that's all it is. A muscle that does this. So it's pumping fluid. If I overload the system, what happens to this muscle? It works hard, right? It has to work harder and harder and harder. So one thing we can do, if you have a blood pressure or the heart's working too hard, pull off volume in the system. Make it a little easier to get some of that fluid out of there.

The Lasix has been an old one, an old guy in a radic. Any idea what it stands for? It lasts six hours. Primer, anybody know what a primer is? It's estrogen. It's an estrogen gel that wouldn't be used.

And the name comes from the source of the estrogen was pregnant mares urine. Got it from pregnant horses. So when you see these names, they do sometimes have a meaning, but I don't know. But Lasix was a big diuretic. It was, you know, we used a lot of whole fluid on it. They take that water and peel it. So we try to, you know, decrease the burden on the heart. So that's nice for those kind of names, too.

And anything over the counter know that, you know, those have been its effective cardiovascular system. The easy ones to think about is, you know, when you have that snotty running nose from allergies and you take some decongestant, what is a decongestant? By nature. It's a stimulant, right? You know, remember when they were pseudoephedry, what happened to pseudoephedry? Can't walk up into the pharmacy and buy a pseudoephed any more.

It's taken behind the counter because they use pseudofen to make crack, right? And all those nice stimulant drugs. So it is a stimulant. So when I take pseudofen, what happens to my cardiovascular system? Blood pressure shoots up. It constricts my blood vessels. That's what stimulants do. Blood pressure goes up. So you actually see some leakiness. It's now advertised.

safe for high blood pressure. So they don't have stimulants in them. Saying the same decompressants, you know medications, depress the nervous system and they can lower your blood pressure too. So just be aware there's a lot of herbal medications. When you get a history of drugs always ask them, are you taking anything over the counter? Herbal, those kind of things.

So just get, you know, a good background on all these medications, but we need to know what they're teaching you. One, if they have any effect on the cardiovascular system. Two, it may be, maybe they can tell us the whole truth. You know, people that take aspirin, the parents of you that have grandparents are taking aspirin, that was popular for a long time. There was a lot of older people who were taking aspirin every day. Anyone gets one?

But some people still do it. So that's a good example of where the government said, take it. And then later they go, oh, don't take it. Don't listen to us anymore. It honestly changes. That's why you've got to keep up with your current evidence on this kind of stuff. Past medical history, are there any congenital heart diseases? When you get to Peds, we'll talk about all the congenital heart diseases.

Because that's when you get them. These babies are born with atrial septal defects, or ventral septal defects, or pathology, or flood water, all those things. So they know that, you know, and if they were bad enough, they had heart surgery. You may do an examination to see a scar right in the middle of their chest where they had open-heart surgery. So, you know, those kind of things. If you had any growing pains when you were a kid, and we'll talk about, especially in peds, there's a concern with rheumatic fever.

We treat strep throat because that strep infection can lead to rheumatic fever. Rheumatic fever causes rheumatoid diseases, which actually can cause rheumatoid arthritis and damage to the heart balance. When I was in nursing school, like you guys, I was taking to my OB rehabilitation, had a mom pregnant, listened to her heart, like the good nursing student had a big murmur. I was like shocked.

She saw it on my face, and she goes, oh, I had rheumatic fever as a child. Now I have mitral valve prolapse. So the mitral valves don't fit perfectly anymore. But she says, I'm OK. She's obviously having a baby. But she's been falling for that. And the patient, they have triglycerides, high cholesterol. Another big problem in the country is we eat crappy food.

If they have those kind of issues, again, why is that a problem? Why do I even care if they have high cholesterol and high triglycerides? Think about the process. What did I show you yesterday? This is a nice big vessel and I get this stuff in. What does that stuff come from? Cholesterol and triglycerides, which are fat.

in the system. So for these fatty deposits, your heart has its own arteries. And someone's got to feed your heart muscle with blood, oxygen, and nutrition. So when those vessels get pinched off, what happens? You know, they grab the left and they're out. That's it. So we'll talk about that in a minute. So you want to know if they have these kind of issues. Ever had any surgery on their heart and blood vessels? Those are popular right now. A lot of vascular surgeries are advertised and stuff.

If you've ever had any tests and you have to have an EKG, my heart of perfusion stress tests, I've had one of those done. Echocardiogrids, you may have those done. So, you know, but ask them if they have, why did you have those? There's got to be some reason you had that. So, you know, kind of get that background and be the detective and try to figure out what's going on with them. Because they're not going to be always that open.

Get good history, family history, is there family history? Diabetes, heart disease, one of the best questions you'll always ask is that any men in your family died before the age of 50 of a heart attack. That's a red flag for the men in the family, but there's probably an issue there, especially if you're African-American, because they died twice as many, twice as much, at heart disease or the younger age. So ask them, did your dad and grandfather die before 50?

Any history of hypertension in the family, those kind of things. Do you exercise? You do? How often? Every adult should exercise at least three times a week, vigorously for, you know, at least 30 minutes. At least 30 minutes, you know. Kids now, it's an hour, a day, exercise. So, because of their weeks of doing it.

So, is it aerobic exercise? Is it weight-bearing? It should be a combination of both. You need, especially women, you need weight-bearing for osteoporosis, but we need aerobic exercise. We need to get an heart rate up, break a little sweat, make a little heart, and so on. If you relax, why is that important? Does stress affect our cardiovascular system? Absolutely.

You know, stress can constrict blood vessels. And again, when we're talking about blood vessels constricting, you're thinking arms and legs. Again, remember, your heart has its own blood vessels. So when we start constricting the blood vessels in that heart muscle, it's going to start, too. So we want to relax and kind of dilate the blood vessels. My grandmother, her physician, truly told her, drink wine every day.

She was so happy to have a prescription to drink wine every day. But it is a vasodiline. You know, when you drink wine, you get flushed, you know. So you should just drink a little bit of wine every day. How are you eating? What are you eating? Like we talked about all that junk foods, high cholesterol, high triglycerides. You eat fruits and vegetables, lean meats, not red meats. You know, fish is good. Omega-3 fatty acids, you see that? It's good for your heart health. They sell those pills now.

Krill oil is really good, invited to Walmart. All those things are good for the heart. And alcohol, unfortunately, is not really good for that. We're talking about the wine. But what is, if we talk about this, what is the appropriate amount of alcohol for a man and a woman? For two drinks, for a man and a woman, yeah.

So, if you kept it on that level, but there's still, now there's research coming out that's saying this is probably detrimental to, because of the idea if you're drinking one or two glasses every day of your life, that probably would. Does that change the amount based on like, let's say, if you don't drink for, I don't know, a month or something, and you know how people get drunk on that? It's obviously not good, but you know what I'm saying? It's like, that's...

Different, right? Well, it isn't. It's drinking. Right. It's obviously not good. It's not a good one. Yeah. And it's, you know, keep in mind what they're saying with one drink is typically one can of beer, five ounces of wine, and a thousand and a half of alcohol shot, you know, alcohol. That's a drink. But yeah, I think, you know, I think you're going to see your impression of probably going to find more detrimental results of alcohol use.

chronic alcohol use. We do contribute to fatty liver disease, which can contribute to cirrhosis liver, which results in liver disease. Street drugs, cocaine, IV, all those kind of things, especially if they shoot up. Why? I don't know the concern. Infections, infections. We'll talk about those kind of infections like pericarditis, endocarditis. You get these infections in your heart. As you can imagine, it's horrible.

Gaffey, you know, it's a stimulant. So it's, you know, it's, you just have to keep that in mind. It is a stimulant. Smoking nicotine is a stimulant also. So even though people have smoked, I'm an ex-smoker, I told you guys. You know, we smoked because we thought it relaxed us, but it's actually a stimulant. It constricts blood vessels. I think I told you a plastic surgeon, we've not used plastic surgeries or faces of smokers.

because they know there's not enough perfusion. It doesn't heal well. So it affects also your fingers and toes. Some smokers have radiance disease if you've ever heard about that. They have poor perfusion. Their hands were turned white because the perfusion is so bad and you're really cold. They're trying to get blood flow in their hands and toes. So give those kind of histories, you know, just like, you know. And then help people, you know, if there's smoke, help them with smoking cessation.

Don't jump on them and be that bad nurse. It's like, you need to quit smoking. Have you thought about quit smoking? There's stuff I can do to help you. The smokers, I confess, smokers are horrible. You come after them like, quit smoking. We'll fight back. So it finally took me several tries to quit. And the researchers found that the more you try, the more you'll be successful.

And it's a horrible habit. Please do not ever pick it up. It's a horrible habit. So chest pain, one of the key cardinal symptoms we think of, you know, this is the one that you walk to the ER, which is sad to say, you know, you could, there could be 50 people in the ER, you walk in and go, I got chest pain. You immediately went to the head of the line. You were like, oh, come on in. And then happening before, because I think a lot of people realize it and say, I got chest pain.

But to ask those questions, where are you feeling it? We'll see why that's important in a minute. When did it start? Any other symptoms? Okay, the chest hurts. Is anything else bothering you? We'll see those kinds of symptoms. We'll talk about this. Anything preceded? Yeah, I was cutting the grass. Okay, maybe you're doing some work. Anything may get worse. Yeah, I keep cutting the grass. Anything may get better. I stopped and I sat down.

You know, and rest it, and you kick that. So, these are kind of the common signs and symptoms of MI's. We'll talk about myocardial infarction, which is just a bit of people that have heart attacks. So they have a squeezing pressure in the chest. A lot of people, and this is usually meds, say it felt, literally felt like an elephant sitting on my chest. You'll hear that description. Something sitting on my chest. That pain radiates to the left arm.

It affects the left jaw, so it kind of radiates out this way. You know, that pain, they start sweating, and they turn a really unique shade of gray that you'll just have to see one day. You'll see someone in their mind. It is a particular color that's hard to describe, but they really turn gray. Their heart is racing. They will become short of breath. We'll see why in a minute. And they, you know, of course,

I come in, I think I have a heart attack, it's raining now, that's emotionally going to make me want. Scared, anxious, yeah. So what does anxiety do to all this heart attack? Yeah, it just makes it worse. Because anxiety is going to constrict our limits. Fight or flight. We're going to get into fight or flight. So that makes it even worse. Now, know that these are not the symptoms for women. This has been the big issue in health care.

that we've overlooked women who have had heart attacks that we've dismissed them and sent them home. So women don't have these. Typically, their pain is between their shoulder blades behind them. They don't get this elephant on the chest as much. They get nauseous, vomiting, sick to the stomach. They get very tired. So you can see a lot of times, they get dismissed as, oh, you need to see your ass, maybe you're a little anemic or whatever.

that actually have a heart attack. So those symptoms are a little different for women. These are typically from men. Women also have a burning pain. They sweat. They have indigestion kind of pain. And that's probably good to know. A lot of times, these symptoms are initially the person thinks they have indigestion. Because the pain is kind of up in here, the acid indigestion pain.

So they can maybe overlook it and not get the care they need. So make sure you know that. How long have you been short of breath? So short of breath, they come into the hospital and can't breathe. You do respiratory, you do pulmonary, you do x-ray in the chest. They're like, everything's fine. So this is not an issue of the lungs. And we'll see why in a minute. But if you think about what we just talked about, the heart pumps

oxygen right to every part of our body. Our lungs take in the oxygen, but the heart has to pump it, transport it to every area of our body. So it makes sense. If my heart is not working, I'm not getting the oxygen in the parts I need. Know that your body is truly amazing. I think it's always a miracle when you think about it. But under stress or duress, your body

will shut blood away from the parts it doesn't need. So it will shut blood to the core of your body where everything's important and away from your hands and your feet. So you think about if you've ever seen anybody that's had frostbite, what gets cut off? Yeah, the fingers, the toes, the nose, their ears, the things we don't really need. So all the blood goes to the core and your body will do that.

But if they can't even keep up with that, and especially if they can't get the blood to your brain, now the sensation is, I can't breathe. Yeah, they can breathe. They're breathing in and out, but they're not getting the blood in the areas they need. So their brain is kind of, you know, going, this feels like I'm suffocating. Does that make sense? So I can't get my breath, I'm suffocating. I need to breathe more.

And you remember our trigger for breathing is what? CO2. It's not oxygen. When our CO2 levels go up, that's when we breathe more. That's what makes you yawn. When you're tired, you're not breathing. Notice you're not breathing, but your body, your CO2 goes up, and it makes you yawn like this. Makes a point. But it makes you yawn.

So when did this happen? I was cutting the grass, and I started to get short and blessed. Does anybody care about your activities? Yeah, I can't cut the grass. Know that this affects a lot of parts of the life. It does affect sexual relations. Some people will come in and say, this affects my sex life. Because I don't have the stamina to do this. You hear about these little TV shows, yeah, people have heart attacks having sex and die.

That is a strenuous activity, so it is true, those kind of things. But keep that in mind, that is part of quality of life. Any other symptoms, and we'll talk about that, you know, I'll be short of breath. Well, not just saying, I got this pain in my chest and my jaw kind of hurt, you know, and they start going through that. I feel dizzy, I feel like I'm going to pass out, I'm sweating, you know, and they're turning gray in front of me. Do you do anything to relieve the symptoms? Up till now, I'm just quick kind of grasp, I'm quick activities, kind of get a little better, you know, so.

I reduced the demand on the pot, on the heart. Sometimes it would get better, but we'll see eventually. Do you have a cough? This is interesting. Why do you think that's a pain? Why was cough included in cardiovascular? Pulmonary. Pulmonary? Okay. Like what? Can't? Can't? So remember we talked about

Heart and lungs are related. So if I have issues with my heart, is it going to affect my lungs? Yeah. Have you ever heard of pulmonary hypertension? So you can actually have high pressure, it is kind of blood pressure, high blood pressure, but in your lungs. So remember, the lungs, the

They have the chambers of the heart and the knees. And the right ventricle pumps blood to the lungs, right? It has some happens in that heart and it's not getting, it can't get the blood either to the lung or, you know, this blood comes back to here when it's oxygenated.

And then the blood starts backing up, the pressure goes up in there. You get pulmonary hypertension. And then everybody ever heard of pulmonary edema. So when that pressure builds up, you start getting fluid building up in your lungs. Essentially, you're starting to drown in your own lungs. And people won't start coughing. Because they feel like they're drowning in their lungs. They're getting fluid in their lungs.

So they can actually develop, you'll see here, a pink, frothy sputum that comes out of their mouth. Why is it pink? It's blood. They're bleeding, and their lungs are starting to bleed from the inflammation. So if you see that, you know, that indication, you know that the lungs are affected, but this is probably cardiac, this is a cardiac issue, something we're all here. Hemophysis is what?

Coughing up blood, you know, this is the one if you saw Tombstone, you know, with Doc Holliday, you know, he had TB, he's coughing up blood constantly. So that could be another issue. We've got now, we've got in here, you know, these, and we could have blood of the damage in here that started to come back. Does it help where you're at?

So you would think, hey, lay down and this will get better. Will it get better? If you're having cardiac issues, how about just lay down and rest? Why wouldn't it get better if you lay down? So here, I'm having trouble.

We'll just say a heartbeat. My heart is failing. It's not pumping like it should. It's not working. Your engine in your car all of a sudden goes bad. You're on the freeway going 40 miles an hour and you're like, this is the fastest it goes. It's not working the way something has been bad. So when it's not working, it's not circling the blood as well as it should. When I lay down, what happens?

to the blood while I'm laying down. Yeah, pools. And it actually increases the return, which makes sense. That's why a lot of times I have you laid down. You get lightheaded and you're about to faint. You know what they have you do? Lay down. Because I want to make it easier for the blood to get back into my head, right? But if I have heart failure and I lay down, now all this blood is rushing back to my heart, right?

And what does it do to that pump? It overwhelms that pump. The pump now, it's already having trouble pumping. Now it's got a flush of blood coming to it, and it can't pump. It can't pump, it can't pump. So a lot of these times, these patients will lay down and go, I can't breathe. When I lay down, I cannot breathe. It's called dyspnea. So you will ask them, how many pillows do you sleep on? Five.

You're sleeping on five pillows. They have to sleep sitting up. This is the only way they can breathe. They sleep in recliners. Normal is one to two pillows. I have two. Anything over that is suspicious. You need to investigate, why are you sleeping on three or four pillows? I can't breathe when I lay down. I have to sleep up. So they have to elevate their heart and sleep at an angle like this, like this.

Does that make sense? Or thought theater? So you can't breathe when I lay down. I feel like I'm smothering you when I lay down. So I ask them that. You know, is it better or worse when you lay down? Because it's worse. It's worse. I can't. Something is wrong. You're following an heart failure. Your heart is not working like this, really. From nocturia. You heard the term nocturia? Nighttime peeing. So you got to pee at night. So for most of you, young healthy people,

You know, you can go to bed, sleep all night, get up in the morning, and then eat. You don't have to get in and go out and eat. You get older and you have to do that more often. And we found that people that have a heart failure, they're going to have some heart failure, often enough, have to get up more often and write an E more often. Why do you think? The body might be trying to give them an alarm system. You are. I said it might be like that body's alarm system.

Try to get them out. Try to get them out. How do they do this? What they found is this. So when they lay down, what happens? They get more blood return, especially to the kidneys. So they get more perfusion in their kidneys. Their kidneys are actually perfusing the blood more and producing more urine.

Which kind of makes sense, I guess. So what we found is these guys tend to at night be more than during the day because what happens in the daytime? When I'm up, like this, what happens? All the blood wants to pull down. Remember, my heart on the left side, that big left ventral is pumping blood to every part of my body. But it's not only pumping the blood to my feet. It's responsible for what?

pumping it all the way back up to my heart. So when I have failure of the heart, what do we see as a symptom? A demon in our legs. I'm going to talk about that in a minute. It makes sense. If I can pump it down, then I can't get it back up. But when I lay down, gravity pulls all this blood up in my kidneys and the heart. So, yeah.

So the things you want to recommend, obviously, just like a kid, don't drink a couple hours before you go to bed. And if you're taking it to the eye and you're ready, don't take it at night. That makes sense, you know, it's going to make you pee more anyway. So you take the eye and you're ready to get a morning night. You have these patients. But that can't be a red flag. It probably could be an armpit or something. Fatigue, obviously. I can't get enough, my heart's not working, can't get enough oxygen to all these cells. My body is going to feel tired.

I can't, you know, I can't test this fatigue. So you need to get, you know, kind of fair that out. If it's sudden or gradual fatigue, if it's sudden fatigue, it could be hemorrhaging. You're losing blood. That's why you're tired. There's not enough blood to circulate around. So you need to, if it's gradual, then it's probably heart disease that is progressing. You're getting more and more tired.

Also don't, you know, we get to rule out is an anemia, too. So make sure, you know, get an H and H and immunoglobulinumatica and see what the human level level is. It could be anemic on top of this. We know this is an issue for women, especially when they menstruate. They lose blood. That's a form of hemorrhage. So they have issues with anemia. So they have to supplement more iron, eat better foods.

Now, there's symptoms, tachycardia. If I'm losing blood, one of the first signs, my heart is going to be faster, right? The pump is going to compensate by pumping faster and constricting the blood vessels to make the pressure higher. So that's something you'll see. We'll talk about, I think, did we mention the pulse pressures? And you can talk about it. We'll talk about it in a minute. So when we did that, your blood pressure went 20 over 80. The difference between that is the pulse pressure.

And that's important, even though it sounds silly. The difference between that is 40, and we need to keep track of it. If that number gets wider, something is happening. And it could be a hemorrhage, actually, if you think about it, because I'm hemorrhaging blood, maybe I've got it stabbed or whatever. My heart is trying to increase the blood pressure to get what's left circulating, so that 120 could go up to 140.

But when the heart's at rest, I've lost so much blood that that 80 drops down to 60, 40. So if you're working ED and you start getting blood pressure, you notice that widening pulse initially. After they run out of fluid, everything's going to crash. Then you have to notice that they could be, because they may not be stabbed, they could rupture their aorta, and they're bleeding internally. You don't even know it. You don't see the blood, but you need to know the images.

Lips, tongues. This is a normal tongue. This is an anemic tongue. This is an anemic tongue. That's a vitamin B12 efficiency. So they can get this red, kind of beaky tongue. So if you notice that, it could actually be anemic. So make sure it's got anemia, and then we're going to go to cardiac arrest for it.

Here's that lower swelling. We just talked about that. So I palm easily with the blood down to my feet, but now I can't get enough pressure or enough strength to get the blood to come back up my legs to my heart. And that interfered me in this game. So what happened, you get these older people, you see them, and they have this edema in their legs. And you will test for that. You know, if you haven't done it yet, when you get in the hospital, you've heard of hitting edema, right?

put your finger in their leg and it leaves a divot in their leg. So I've now got the scale on here. We'll look at that. But that's one of the assessments you're going to do. Obviously, this leg is an issue. Now, if you have cardiac-related edema in the legs, it's always going to be both legs. Makes sense, right? Your heart is up here. Effect that, I guess. What about lymphedema? This actually is lymphedema right there. Lymphedema is going to be one leg.

If it's only in one leg, it's lip edema. So the lymphatic system is holding on to fluids, something that's there or that. Because of its cardiac, both legs are going to get swollen for fluid. So that's a good question. That's how you differentiate between the two. This is actually lip edema because it's only in one leg. So symptoms, we're talking about dyspnea. They're having trouble. They can't lay down, breathe when they lay down.

That's probably heart failure. Weight gain, fluid retention, that is probably heart failure. We'll see why that. If they have some warmth in their leg, now it's infected, red is some warmth, and if there's any discoloration, ischemia, so if it's ischemic, it's going to turn what color? What color? It's pale. It's going to be pallor. So know the difference between pale, pallor, and cyanosis, what cyanosis? Blue.

resulting from lack of oxygen, pallor, ale, results from possibly, the root cause of it is? Yeah, a lack of blood flow. There's no blood flow. So cyanosis, you're seeing the unoxidative blue blood, pallor, you're seeing no blood. There's no blood anymore. So, you know, when we get these diabetics feed,

You know, they're looking pale, you know, you can't get the color. You know, they're not perfusing. There's no blood going to those toes. They're going to die. So, some contraceptives, I don't know why they do this, and you know this, especially as women, that oral contraceptive use does increase the clots on the lips. So, they're actually, oral contraceptive use in smoking is that they

That's the one that's going to get you. So a lot of women that do that had heart attacks, they had heart attacks. And then, of course, for hormonal fluctuations, women who go through menstruation will get food retention. That's the part of that. So pain cramps in your legs. This is from not getting enough blood to the muscles in your legs, and they start cramping. You get those cramps. So just know that, again, what's the cause of it, and how to treat it.

and atrial insufficiency, my heart is not pumping enough blood to my legs to oxygenate or fuse the muscles. Would I want to elevate the legs or just lay them flat? Because on the thought times, remember, we always lay people down and we elevate their feet. We think that's the thing. If you're going into shock, yeah, that's the thing to do.

But in this case, if my heart is not pumping enough blood to my legs in the first place, and I elevate my legs, what's happening? I just made it worse. This pain is getting worse. If it's venous, where it's pumping blood to my feet, but I can't adapt and I have enough strength to pump it back, then if I lean in and elevate my feet, that would probably help. It would help get that blood out of my legs.

So the venous do elevate their feet. And so that's kind of the thing about the cause. And it's going to determine what your intervention is. So if you have atrial inefficient feet, I have a failing heart. And the left side that's not pumping well to my legs, where some of the sides, obviously my feet are going to be pale. We talked about that as a lack of circulation. They're going to be cold.

You can have some sores all day. And you're going to see hair loss. That's one of the assessments you're going to do. If you see, next time you see your grandpa out in the summer in his shorts, look at their legs. And this again, you need to be people watchers. You go to the mall in the summer, and you see these old guys in the shorts, look at their legs. If you see these hairless, shiny kind of legs, and you've seen this in old guys, right?

That is, that's not from them shaving their legs. That is from, they have lost the hair on their legs from an eager insufficiency. There's not enough blood flowed to their legs now to feed their hair follicles and they all die. So they have no hair on their legs anymore and they get a shiny appearance to them. When you see that, it's an indication they probably have some chronic heart disease.

You'll see it. You'll see it at the summer when the shorts come out. I have a question about pain and sufficiency. The slide said it's worse with activity. I don't understand why, because if the muscles are moving, it shouldn't stop. That, you know, you're right. Muscle movement will help move that stuff back up. Yeah, this is your exactly right. I think, though, the band, it's also increasing the band on the hard tube, and you're not getting that flow back.

What we'll end up with is a right side heart failure. We'll talk about that. Right side versus left side. But you're right. That's why we want people to move. When you contract muscles, presses on those vessels and pushes through it, I'm going to have to lay. We don't want patients to lay in bed all day in the hospital. That's the problem. That's when they start to come up with blocks. So start your exam. Look at the skin. You're going to do this. You've already done that. It should be pink and perfused.

Should be sweating, should be cold, those kind of things. And what's their breathing effort? You've done that. You walk in, you say, they do not look like they're, they're not seeing signs of distress or discomfort. I do not see signs of respiratory distress or cardiac distress. You would know what those are. If you do, that visit just changed something else. So, look at their skin, look at their, their respirations.

Dismal, we talked about, cytoplasm, cytosis and pallor, you know the difference between those now. And then the use of accessory muscles, we talked about before. If their nostrils are even flaring, flaring out, are they, you know, their neck is straining to get a breath. You see retractions between their ribs, you know, those are the accessory uses of muscles to help them breathe. They will do a thing called tripodia, we'll talk about that, to get down.

lay over a table, trying to stay in their chest and breathe in. So you're going to palpate the temporal, not the temporal, but the corotid pulse. The temporal pulse is easy. You just got to go back from where our eyelashes were when it was right in the ear. That's the one that the new thermometers are using, the temporal artery. But you're going to do the corotid pulse. And you've done this if you've ever been inside. You see people running down, you know, you have to watch and they do this, right? They're like, you get their pulse. This is a corotid pulse. This is what they're after.

So, you know, if you can, you see the sternum and the feet of the mastoid muscle right here. It's going to be between this side of it right next to my throat. So if I just slide this right, you know, inside of my trachea here, it's right there. Not hard to find. You should be able to get it cooking about basic protocols. The biggest thing is don't do it at the same time.

Because carotid arteries are the one that takes all the blood to your brain, and if you're going to clue both of them, they're going to pass out. So you're going to say, I feel a little silly now. But yeah, so if you're going to do that, this is the one that you can also check for bruise. And that's up for just like you did for the alveoliator. We're going to do it for carotid. So we take that bell that says to go place it on there. This one we have to do a little different, because this is right next to our windpipe.

So you have to tell them to stop breathing. Because sometimes the stats could be here that, whoa, whoa, whoa, what sounded like a brulee. So I told you, my doctor, he slaps him and says, stop breathing. Stop breathing for a second. Take a breath, go to the next side, stop breathing for a second. You shouldn't hear anything. But that would be it. You could have a crowded brulee, too. So you'll do those in the exam, too. Quick example. So this is pulses.

You've provided all of them now, you'll know. We always look for a regular rate and rhythms. You can actually put, I used to put that a lot. You know, if you're documenting cardiovascular, you put r-r-r, regular rate and rhythm, with one of their pulses. So what is a regular rate and rhythm? What is the amplitude? So when you're palpating these radial pulses, you need to feel it, and how do you describe it?

And these are the amplitude numbers you need to know for the rest of your nursing life. If it's a zero plus, obviously they have no pulse. It's absolute. They're a bit of a bad shape. One plus is diminished. Often referred to as a threaded pulse. You just barely kind of feel that pulse. It's not really there. Two plus is normal.

So when you describe your partners for the head and toe, when you do these pulses, you can say they are two pulse, or two plus pulses, biolatilate. So when you do the carotid pulses, two plus. Three plus is a little more bounding and four plus is bounding. So, you know, if you just ran 26 miles, get that carotid pulse and boom, boom, boom, you know, just bounding out of your body. That's a bounding kind of pulse.

So that's the amplitude. You always start with, you actually probably do it up here. Two plus, bring the ring rhythm. That's the next thing we're after. What's the rate? We know for an adult, the normal heart rate is $60. So if it's in there, that's a normal rate. And rhythm. And rhythm, you just have to feel or listen to when you're listening to setup. Especially when you're listening to heart, you hear these. I've heard them.

Not regular, really. If you're in kids, theirs will actually be irregular. So young kids listen to their heart. And that's why you have to get a pulse for a full minute. You can't do it for 30 seconds because it's not regular. But if you notice that in an any adult, you also want to do it. But that's regular, two plus regular rate in rhythm.

So that's a good easy way to kind of describe it. This is the awesome thing to do is the jugular veins stench it. So you have the carotid arteries going up, you have the jugular vein coming down. So all these horror movies or slash movies, when they always cut their throats, they're trying to cut the jugular veins that are under our ears. You know, the ear to ear kind of cuts.

That's what they're after. The coronary artery is much deeper. Our bodies protect our arteries, so they're deeper. The veins are a little more superficial. That's what you see. These are veins. So this is, as you can see here, this is a distended jugular vein. And you've probably seen this in people. If you see people exercise weightlifting, I like weightlifting. And I'll see these guys lift these heavy weights.

A lot of times they're holding their breath and their strains are bad. These things will start popping out. You'll see these veins popping out on their neck. Their nose will start bleeding from the pressure. And that's, you know, for them, that's probably normal. But for you and I, or the patients you have, if they're at rest and you see this popping out, that's not a good sign. So what is the cause of that? What do you think is the issue with this? What are these popping out?

Pressure. So the piranha arm is taking all that blood in her head and everything's a circuit and then it needs to come back down through the jugular veins to the superior vena cava on the right side of the heart. If I have an issue with my heart and that blood cannot get in there and there's a back, like on the freeway, it's backing up. This is the backing up part you see right here. This blood is backing up in her head. So they're having a jugular vein extension.

So what you're going to do is you're going to lay these patients back at 45 degrees and turn their head. And when you think of pen light, you flash it across the skin kind of low. Because if you see, when you flash the light here, if you see a shadow back here, you know the jugular vein is elevated. And that's the jugular vein extension. We're good lapsing. But this is what you're looking for.

Pulse pressure, this is what I mentioned earlier. This is that difference between the two. You know, if it's 120 over 80, it's 40. If it's 120 over 90, it's 30. Whatever that difference is. Orthostatic blood pressures, I think we've talked about that. If you know how to do it, get a blood pressure laying down, one sitting up, one standing up. So there's more than 20 millimeters of mercury difference between those. They probably got an orthostatic type of injury. So if they stay there too fast, they'll pass out.

So, you know, they actually get caffeine. Caffeine would be good for them. So, you can't stand it up slowly. This is the pin of edema. This is the scale for this that we talked about. So, you're going to assess for edema of the legs. You can do it any part of the body. If you want to take your finger right over their shin and press into it, your finger goes in. It's dependent on how deep it is.

And how long does it take when you take your finger out for that divot to fill back up, snap back? It gets pretty quick, like almost immediately, that's very, you know, like two millimeters, that's one plus three, a diva. But you can see, this gets deeper and it takes longer for it to come back. Four plus three divas, more than 20 seconds to come back. You can take your finger out, that divot just stays there. That's a penny of diva.

You know, I do cat refill. You know, this is clubbing the fingers. I've never got a picture of it here in a second. But this is, clubbing is from my epoxy, and this is what it looks like. So I saw this picture, and it says all these pictures of me, and I thought, this is a really good representation. What happens is, you see how round the fingers, how wide this is getting.

The other thing that you want to know, because they always ask you a test question, is it's this wideness that it's also, or if you see this, it's also this angle change right here. So you and I, we have our nails, we kind of have a little angle, you know, from the finger down like this. Which is like 160 degrees. Clumbing nails will be the opposite. They'll be greater than 180 degrees. They'll actually go up and down.

So the nails are changed like that. What is the mechanism of hypoxia that makes that happen? They don't know, which is really interesting. They're not sure why it's been damaged from the matrix, I'm guessing. But yeah, I mean, I've seen this in kids with CF. They will even have it. I mean, it has to be a while, you know, with CF kids and all this other stuff. But yeah, they're not really sure why that happened. Unfortunately, and actually, I just found out recently, because I never even thought about it.

Toes could do it, too. They can actually handle it with the toes. So, but usually, if you, obviously, you know, when you see these hands, you won't miss it. So you'll notice. And you see that he's, in adults, these are these COPDers, the old red smokers. You'll see these little tails. That's Columbia and the nails obviously documented that. That is an issue that's positive sometimes.

Pulses, brachial radial pulses, you know how to do this. I'm going to go over this. We've done these already for blood pressures and just getting pulses. So you have to do that. So lower extremities, same thing with the skin trigger. You can do that on their feet. Look at symmetry always with the skin's light, color, temperatures, and warmth. You've done it. You're going to get the temperature of the legs and feet.

You know, is there anything that's lost? They're actually there. Okay, I thought I put it on there. That's clubbing in there, so it is. So, but if you notice that, the hair loss, that's a red flag, shiny skin, it's a red flag, those kind of things. You may see people with varicose veins. I mean, you see them in legs sometimes. That's kind of a red flag if you want to improve it.

And you can do cap refill on the feet. These are pulses that you're going to get. If you're not getting ephemeral pulse, you can do this on yourself at home. But we will get fetal pulses. These are fetal pulses. Hop a deal is not on that assessment, but it's a good one to get. This is one way to get it, is to bend their knee and feel up. It's deep in the back of your knee, so it's hard to get. The other way I like to do it is put them on their stomach, have their leg

at a 90 degree angle and dig down that way. Yeah, a lot of times you have to do a doppler to get that. But we're going to do this, the posterior tibialis and the, this is dorsal fetus, posterior tibialis. The tibia is in the medial side of the foot. It's hard to tell the picture. But you're actually going to feel it at the inside, not the outside foot. Now, we'll get those pulses and labs. These are important. If you're going to work ERPD, someone comes in, gunshot wound in their abdomen.

The surgeons want to know, is their blood flow cut off to their legs? So they're quickly going to ask you, do they have fetal pulses? That's going to tell them, yes or no, blood flow to their legs. So this is a skill you would want to be good at. These are a little tough to feel, so we'll deal with that. And I'll show you how to find this one. Sometimes you get a little tough to feel, but...

Apical pulse, okay, this is the big part of your heart. Apical pulse, I'll show you a minute where it is. It's the most important part. This is the left ventral of the heart. If you give DIG, general guide, you can call it a junction in pharmacology. Big heart med, kids can even get it too. Before you ever give it, you have to get an apical pulse. So you're essentially getting the true pulse of the left ventral of your heart.

This one you have to do the stethoscope. You don't get a radial pulse to give them this medicine. You have to put the stethoscope to the chest and give it two volts. This dead will decrease their heart rate when you give it. It needs to be 50 or higher or you will take them out.

you actually auscultate the order of the valves in the arc. So this is the little mnemonic you can use, A, demand. This is what I've always used. You're very other ones out there. But it's mainly because we want these letters, A, P, E, G, N. So we start over here. This is the secondary cost or race hurdle border. And the way you're going to find that, we're doing it in lab, is

You've got to come down, and if you feel a new chest, you can do it on yourself. As you come down from the notch that's up here, and you work your way down, you'll feel a ridge in your chest. And this ridge is the connection of these two parts of the sternum. The sternum is actually three bones. Remember that from the nano? So this is the new gram and the sternum. And there's a ridge right here. You can feel a little ridge.

And this is an important landmark to always know for nursing, because a lot of things are based off of this. So when you feel that ridge, and you move to the side, it immediately takes you to the second rib right here. And then when you feel that rib, you want to drop right below it. And you'll feel a space in your chest. That is the second intercostal space. And that, when you listen to this, right at the right,

sternum board. We're on the right side of the sternum, right sternum board. Put a set scope there and you're listening to the aortic valve. Then you'll move across to the other side, secondary apostle, and the left sternum board, and you'll be listening to the pulmonic valve. Then you'll go down to the third intercostal space, the left sternum board.

This is Herb's point. This is not a vowel. This is just telling you, this is the middle of these two for the four or five spots you're at. What you notice is up here, these first two, when you listen to Love, Dove, the S2 is louder. Love, Dove. Love, Dove. Love, Dove. So you'll notice the S2 will be louder than these first two. At Herb's point, they're equal. Love, Dove. Love, Dove.

Love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love, love,

And then the last one's a little different. So we come down to the fifth intercostal space, left sternum border, but I'm not here. I'm actually over here. So this is the fourth inter, second, third, fourth, fifth intercostal space, mid-formicular. It's in the middle of your thigh. This is the mitral valve. This is the apex of your heart.

This is the point of maximum intensity, BMI. This is all of it. So this is, when you go to get that med, you have to listen to the apex of the heart, fifth intercostal, mid-climiculum on the left side of the heart, and get that pulse. And it needs to be 50 or higher. This is one of the reasons VSNs save lives.

Because you now know that you just don't give this bed. You have to make sure their heart is a certain level before you give it. This is critical thinking. This is the critical thinking part of this. And we will go through this. And you will, in your, yes, because I always have you say this stuff, you will say this. I'm listening to the secondary cost of right-turn border in the area of the back. This is the secondary cost of left-turn border. And you will go through each of these.

But you'll have these forever. You'll know how to do these. And these will come into play. If you hear something, you're listening, and you hear a murderer up here, yeah, you can tell the provider, a second-air customer, they blessed her in the water, I heard this murmur. And they know immediately where to go to. So these are also the landmarks where they help you chart these defects.

This is just that ridge up there. You know, tonight when you just feel, here's the notch that you can actually see and just work your way down. And you'll feel, it's that far, you'll feel a ridge right there. And just slide over and you'll be right over the second ridge. So just practice that. If you ever are an ER kind of thing, loves to laugh, they will go over to the secondary costal space.

And you'll take an 18-gauge deep and shave it in there and suck out the air until you play it with the claps of love. So that space is really important. Hard rims, S1, S2. You know those. You're listening to those right now. This is just them. What is the sound? What is love and death? You hear it. You know, this is hard. Love and death. What causes that sound?

So love is the atrial ventricle valves. And then the valves between the atrial and ventricles. So their blood is in the atrial, going to the ventricle, same shot. Love. Then the blood is pumped out of the ventricles. They slam shut through the aortic and pulmonary valves. They slam shut. Go. What's really interesting is you're only hearing both times one sound.

But these are four vowels. So you have love, duh at the same time. Love, duh. If they're not in sync, then you hear extra heart sounds. You'll hear splitting and stuff. There can be la-love to duh. La-love to duh. La-love to duh. Listen to a kitty at five heart sounds. Da-duh, da-duh. Da-duh, da-duh. Da-duh, da-duh. So these vowels are awesome. They are awesome.

But you're hearing two cells with four valves. Should be regular, you know, you should hear those. We talked about the sound differences from where you're listening. Those are the pitches will be different according to where you're at. I already told you that. One will be louder at the top and the other at the bottom. You'll hear in terms of splitting, you'll hear an S1S2 we know.

You can have an S3 and an S4. So again, an S3 comes at the ends, and it follows the sound of Kentucky. Kentucky, love, dump, eat. Love, dump, eat. Love, dump, eat. That's an S3, third sound. S4 comes at the beginning, actually. And it follows Kentucky, or Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee. Tennessee.

But you can have these extra sounds. These two are not valves, actually. They're actually what you're talking about. They're actually blood-eating chambers. So it's a rapid deceleration as well. But if you hear extra sounds, document, if it's an S3 or S4, because those are important to know. These are different sounds to hear. Injection clicks are just that. It's a click.

At least most commonly, if you have an agent that has a new valve, they put artificial valves in ours. They're made out of plastic. So when they close, they click. Click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click, click,

And the sack gets a flame, now the heart is beating against the sack and rubbing against it. And it sounds like leather rubbing together. It's really painful. Murmurs is what I hear the most in kids. And if you hear one, this is what you have to document. What's the timing? Is it a systolic or diastolic murmur? Diastolic murmur is always pathological bad. What's the pitch of it? Is it high-pitched, low-pitched?

What's the quality of it? Is it a blowing murmur? Because a lot of it holds in the heart, so his blood is going through it. There's one called a still murmur. It sounds like a bell. It's actually hitting the chain of the heart, so the chain of the heart vibrates like a bell. So there's different kind of murmur. What's the intensity of it? It's loud, it's soft, and where it's located.

Like I said, is it, you know, secondary consular rights or a board or something like that? That's what you would tell the provider. Where is that problem located? When we get to PEES, you'll get to see all that and you'll see what there's going on. Pulse deficits, this is just, again, in PEES, this is a big deal. Sometime when you're doing an exam, grab a radial pulse and a fetal pulse. They should be about the same. If the heart is pumping blood, normal.

And here you'll see a thing that's called an echosidosis. You don't even know this right now. But they get a narrowing of the aorta over on the left side of the chart. So all the blood above that is good, but the blood below it is really weak. So I have a strong radio pulse and a bad pedal pulse. But if you have to do that, it should be about the same. You can also put your sets with one of the apex of the heart and do the same thing. And they should all be the same.

This is just the EKG or ECU. So this just tells you what the PQRS and TRR are. They're just eight-year-old de-molarization, federal de-molarization, the best. You'll get an update in the order, a lot more about the EKG.

Brewies, we talked about, this is just that brewing on the piranha artery in the bell. This is an ad about the, you know, stop breathing, shouldn't hear anything. This is just another, what those, your elbow issue, the palpate. You're not going to have to do that. Don't worry about that on my nail. Here's your edema, the different edemas, the feet. If it's without any edema, it's low-blade, as you can see there.

As nurses, you would have to measure that. A lot of times you would have to measure the girth of that. Some of what the nurse before you probably would document or put a line with a magic mark on there, so you're measuring the same thing. This ankle break you over the index, don't worry about that. You probably wouldn't be able to do that. Hypertension, we talked about anything over 120 over 80 is considered

120 over 80 to 130 over 90 is that free hypertension? 130 over 90 or 130 over 90 is hypertension. Like I mentioned before, you cannot, you can't diagnose as the first time you take this blood pressure. Oh, it's 130 over 90, you got high blood pressure. Because there could be other factors. You know, going to provide white coat syndrome. Have you ever heard of white coat syndrome? That's real. You know, people see white coats and their blood pressure moves up. So when we do pediatrics, we don't wear white coats.

freaks up the kids. But, you know, adults still get a little anxious about that. So you have to measure it on at least two different occasions. If it's time, two occasions, then they really may be diagnosed with hypertension. We'll talk more about that later. Clots, always a concern.

You know, if you've ever been on a plane, you know, right, you're flying for eight hours, one of the things they tell you, get up and walk around, and you'll sit in the same space for eight hours, take an aspirin or something like that, because we don't want to build quads on the legs. Because what happens is the clock can get up into our lung, and that nice, ripe vegetable, when we talk about blood's coming back, and the ripe vegetable is smoking blood into our lungs, but you get a big clot right there, and that's what?

pulmonary embolism. And this is like death. There was a show, one of the Chicago Hoops or something like that, and they had an actress in that. She was laying in bed, she started coughing, and she rolled over and died from pulmonary embolism. It was that quick. So, in an actress, you know, if you get that clock, it's blocking blood flow to both lungs. That's it. That's it for me.

So we want to prevent this. And what happens, you get the clot down here, my leg, and it warps its way up. Because every, the veins, my feet coming to my heart, get bigger and bigger as they get closer to my heart. So it's easy as you can see, for this clot to work its way up. And then the vessels start getting smaller, and that's when it gets stuck. And then it gets stuck right in there, and you're definitely pulling it, pulling it.

I think, let me tell you about the kid we had in the hospital. The kid that broke his leg in the hospital. You remember that? That was a pulmonary angle. They literally just turned him to take an x-ray. This clock jumped up into his heart and used it. Isn't it? Isn't it? This is why we broke cruel patients. And that's what this is all about. We need to watch the response and prevent these. So you move patients. You move your legs.

They don't need them in one spot. These are just some of the peripheral artery disease. They'll have these sores. They don't heal really well. This is like a pressure ulcer, like this. You can see, having that blood flow in the area, these do not heal very well. And if it's caused by the hospital, the hospital will restore this. And again, you can see that hair loss. It's de-colored. See that shine right there?

You see shining skin over the legs. You don't care about it. That is a peripheral vascular disease. Aneurysms, these are what we talked about the other day. Here's your two aneurysms. This is typically what you think of. These are more cerebral aneurysms. The little vessels in your brain will develop this little outcrop right here. And then, of course, you one day get a disruption. And then you're bleeding out of your brain. You have a stroke.

And then they've got to get in there and fix that. We have to die. They are treating this now with a coil. They can put it in, bring it up here, and feed the coil into this pouch. And the coil coils itself. It's just a little metal. So when it gets in there, it's a coil. And it fills this whole pouch up and blocks it off. So it doesn't have blood in it. This is the other one you worry about, especially with this abdominal area.

You start getting into bulging, and then it ruptures. So half the blood flow over, half the blood flow through your heart. It's just pouring out of the vocabulary. So that's why when you listen for those brewies, that's why you're listening. If you're a brewery, they need to get attention quick and see if they have this thing going on. You will hear it. You can actually sometimes feel that. You can feel your abdominal volume, or maybe you were late to have it, feel that pulse, too.

This is in China. I think she talked about this yesterday. So if you think about it, there's two ways to have heart attacks. Do you know that? So you can have one heart attack, then we go grab this AED and come over here and slap it on your chest. That kind of heart attack is caused by one, since I've got an AED. Stop it. It's a rhythm, an electrical issue, because I'm literally going to

Let's attribute this heart to get it going. The other kind is, we talked about, I get that blood vessel, and it starts getting occluded, occluded, occluded, and now the blood vessel in my heart is so occluded, there's no blood going to my heart. And now I get ischemia, and then infarction, which just means the muscle is dying. That's an myocardial infarction. And that's what's with A.J. Agina, pectoris.

So I had that blood vessel from the heart, the outside of the heart, feed the blood to the heart, and it starts getting clotted. So I started getting this ischemia of my heart, and I started getting this pain in my heart. So I cut the grass, do something laborious, and I started getting this pain in my chest. So for, you know, they tell you once, stop doing what you're doing, but the other thing they give you is nitroglycerin.

that she mentioned yesterday. So in the old days, nitroglycerin was in a brown bottle because light affects it, and these guys would carry it in their pockets, pull off the top, and get these little pills of nitroglycerin. Nitroglycerin is, this is the real nitroglycerin, like you think of, you see in the movies. Nitroglycerin comes from dynamite that sweats. So that's when they discovered nitroglycerin. The guys that used to handle dynamite in the old days, when it was in a shed that's hot and sweaty,

They would handle it and get these horrible headaches, just because it vasodilates immediately. Like she said, it was vasodilated immediately. So they realized the nitro does this. So this is why you don't want to touch it. It's a patch, a pill, whatever, wear gloves. You don't want to touch this stuff. But these guys, you get this ischemia, you know, and this pain. Take your macroglycerin, dilates that blood vessel, pain's gone. Yeah, it works great.

So they do this forever and ever and ever. They start having the spasms. And eventually, like you said, the body kind of gets accustomed to it. The damage gets so bad that one day it doesn't work. So that's stable angina. I can stop, rest, take my nitro, pain goes away. That's stable angina. But after a while, in one day, you're going to have unstable angina.

So now I have this chest pain and oh, wait, I wouldn't cut the grass, but I'm getting this chest pain. So I sit down and rest. Oh, it's not getting any better. So I whip out my nitroglycerin, take it, it doesn't get any better. This is an unstable vagina. Now the damage is so bad, the muscle is literally dying in front of you. And this is muscle you don't want to die in your heart. But now it's getting worse.

You know, I didn't do anything before. The nitro is not working, so I'm going to have it in mind. I'm going to die. So these are the ones we rushed into the hospital. That AED will not help us. These are the ones that go in and cath lab, run that cath up and have to get that clot out of that vessel. You know, and get the blood flow back to the heart or the muscle, the heart muscle is dying.

and they die, a couple of myocardial infarction. So now the two ways to die, can be electrical, or it can be this. This is myocardial infarction, this is what we're talking, ischemia in the muscle, that's it. The LAD, the left anterior descending, is called the widow maker. So if you hear that in the hospital, he's got the widow maker. This is the one that feeds the left ventricle, the biggest part of our heart.

And when it goes, that's it. So we talked about these signs over here, the difference between men and women. You can see these a little better. So guys are sweating, just being women. They're dizzy, pains in the back, short of breath. Men and women aren't burned, kind of, they're both. But then women get this kind of, they'll sleep while they're tired of their sleep. So be able to recognize, you know, they may have a heart for them.

This is congestive heart failure, and there's a lot of it. Again, if you think about these, but basically something happens with the heart, you can't keep up with the blood flow. You hear about right-sided heart failure and left-sided heart failure. Right-sided heart failure on the right side of my heart, if this fails, all that blood that's coming back to it, it's congestive. I have edema in my legs. I have that jugular vein distention, because the blood can't get on my head fast enough to get into

the right side of my heart, because there's congestion. Left side, if it's failing, I can't get enough blood out to my body. And then what happens is the backup for this one is where? The lungs. So now I'm getting pulmonary edema. And because my lungs, the blood is backing up my lungs, my left heart can't get it out of the way fast enough. So I'm going to have pulmonary kind of issues. I can't breathe. I've got the frothy.

lua of short breath. There's a thing called core pulmonod, which means it's heart damage caused by lung damage. So the lungs can cause damage to the heart. If there's something wrong with the lungs, you can see it would affect the left heart. So if you hear core pulmonod, they have heart damage that is originally rescued from the pulmonary damage. So you have this left side and right side.

You know, look through it, and really what's important is think about the systems and why these symptoms are happening through the right side versus the left side of the heart. What does the right side do, the left side do? So there's a cold one around here. Last things. I know for writers, none of the interior layer of the heart in this article, it lines the inside of the chambers in the mouth. If you get an infection of that, obviously you've got a lot of problems.

because now we have an infection inside the heart and he's causing inflammation of the valves, they don't work really well. So now they're not opening and shutting as well. So now you have this damage. So the blood flow, like it says here, becomes turbulence. So you'll start hearing that. They may end up even if you can't like this. They're going to have chest pain, short of breath, because the hearts aren't working with them. Fatigue, nice sweats, edema.

than their feet, because it's one of those I'm moving from there. But that's an issue. So we want to avoid these infections if you cause endocarditis. So you'll hear about endocarditis. It's kind of concerning. The other one that you hear about is pericarditis. I can get infections in the outside layer of the heart, too. That sac. So one thing we already talked about, when it gets infected, it starts rubbing against the heart. And that hurts a lot. So you'll hear that friction rub. And they'll get a pain.

And it's floridic pain. So when they breathe, they get a pain in their heart. And that's that rubbing kind of pain, floridic pain. So especially deep breathing. They will cough. They'll cough things up. Laying down, they get short, but they get dizzy. And that's a third part of my eyes. That's it. So a lot of information that I'm going to move over and grab.

what your part would be, but you can see this exam gets a little more detailed.