What is Point of Maximal Impulse (PMI)
produced by the tip of the left ventricle
PMI Visualization
@ L midclavicular line,
L 5th intercostal space.
May be obscured by breasts, obesity, or muscularity (habitus).
Should never take up 2 intercostal spaces.
May be enhanced if pt leans forward bringing the L ventricle closer to the chest wall.
PMI Palpation
Find the apical pulse (PMI) with your fingers
Should be palpable in a small radius - no more than 1 cm
Typically gentle & brief
A forceful apical pulse or one that is displaced laterally & ? may indicate ? cardiac output or left ventricular hypertrophy
Aortic valve area auscultation location
2nd R intercostal space, R sternal border
Pulmonic valve area auscultation location
2nd L intercostal space, L sternal border
Second pulmonic area auscultation location
third L intercostal space, L sternal border
Tricuspid area auscultation location
four4th intercostal space, L sternal border
Mitral (or apical) area auscultation location
apex of the heart fifth L intercostal space, miclavicular line
(S1), "lubb
Closure of the mitral and tricuspid valves (which prevents backflow from the ventricles to the atria) produces the first heart sound (S1), "lubb
(S2), "dubb
Closure of the aortic and pulmonic valve produces the second heart sound
split S2
Sometimes the aortic valve closes slightly before the pulmonic valve causing S2 with 2 distinct sounds -
Murmurs definition
Relatively prolonged extra sounds heard during systole of diastole that are caused by some disruption in the flow of the blood into, through, or out of the heart
Causes or murmurs
Diseased valves, a common cause of murmurs, either do not open of do not close well.
When the leaflets are thickened and the passage narrowed, forward blood flow is restricted (stenosis).
Regurgitation Murmur
When valve leaflets, which are intended to fir together snugly, lose competency, the slack openings allow backward flow of blood
Murmur Causes
High output demanding increased speed of flow (pregnancy)
Structural defects, either congenital or acquired, that allow blood to flow through inappropriate pathways (e.g. myocardial septum)
Diminished strength of myocardial contraction
Vigorous left ventr
Pericardial rub:
caused by pericardial sac rubbing against anatomic surfaces
S3
Diastole is a relatively passive interval until ventricular filling is almost complete. This filling sometimes produces a third sound
S4
Then the atria contract to ensure the ejection of any remaining blood. This can sometimes be heard as a fourth heart sound
P wave:
atrial depolarization
PR interval:
time from initial stimulation of atria to initial stimulation of ventricles, usually 0.12 to 0.20 second
QRS complex:
spread of stimulus through ventricles (ventricular depolarization), ? than 0.10 second
ST segment and T wave:
the return of stimulated ventricular muscle to a resting state (ventricular repolarization)
U wave:
a small deflection sometimes seen just after T wave
QT interval:
the time elapsed from onset of ventricular depolarization until completion of ventricular repolarization. Interval varies w/cardiac rate
Arterial blood pressure
Has both systolic & diastolic components. Systolic pressure = pressure exerted against arterial walls when ventricles contract; largely result of cardiac out put, blood volume, & compliance of arterial tree. BP ?est during systole
Diastolic pressure
force exerted against wall of the artery when heart is in filling or relaxed state & is primarily fx of peripheral vascular resistance. During diastole, pressure ? to its lowest point.
Pulse pressure
Difference between systolic & diastolic pressure
Artery Palpation
Palpating for strength/amplitude: graded (4=bounding; 3=full, increased; 2= expected; 1=diminished, barely palpable; 0=absent)
Artery Auscultation
Abnormal sounds (normal blood flow through an artery does not produce sound) - are produced by abnormal blood flow
In arteries these sounds are called bruits (called murmurs in heart sounds)
Need to auscultate over all arteries in a client exam (e.g. caro
Peripheral Vascular Disease Arterial
causes hairless limb (or lower portion of limb
Pulse is weak or absent
Color may be pale
Temperature may be cool as compared to other limbs
Peripheral Vascular Disease Arterial Ulcers
Frequently found at most distal point of arterial perfusion. Tip of toe is common particularly w/pressure from footwear or other trauma.
Often has no edema, unless pt w/pain at rest keeps leg dependent throughout night for comfort.
The clinical appearance
Venous ulcers
Located below knee & primarily on leg inner aspect, just above ankle.
The base is usually red & may be covered w/yellow fibrous tissue or have green or yellow d/c if infected.
Fluid drainage can be significant.
The borders are usually irregularly shaped &