Angina pectoris
Chest pain of cardiac origin
Apical impulse
Apex Beat
4th to 5th intercostal space, left midclavicular line
-used to be called-PMI-point of maximum impulse
Size: 1 cm. X 2 cm.
Amplitude: short, gentle tap (comes on and off fingers)
Duration: Short, first half of systole only
-Make sure you note if
Apical pulse
Same as Apical Impulse
Pulse felt at Apex
Rate and rhythm, count apical pulse (60 seconds)
Size: 1 cm. X 2 cm.
Amplitude: short, gentle tap (comes on and off fingers)
Duration: Short, first half of systole only
-Make sure you note if only palpable when tu
Atrial gallop
fourth heart sound or S4
-occurs w/decreased compliance of the ventricle & systolic overload, including outflow obstruction to the ventricle & systemic hypertension.
-best heard at Apex
right-sided S4 less common
Bradycardia
A slow pulse; any pulse rate below 50 beats per minute
Bruit
An abnormal blowing or swishing sound heard on auscultation of an artery or an organ.
Orthopnea
SOB laying down
Breathing that is facilitated by sitting up or standing
( Inability to breathe unless in an upright or straight position,
EX:, form of dyspnea associated with asthma and emphysema and angina pectoris)
Orthostatic Hypotension
-Sudden drop in systolic blood pressure when quickly changing from sitting to standing
Pallor
-Paleness, inadequate circulation of blood and subsequent reduction in tissue O2
Palpitation
-Rapid or irregular heart rate,
-Heartbeat that is strong, rapid or irregular enough that the person is aware of it
Paroxysmal nocturnal dyspnea
PND
-happens w/heart failure
-Lying down increases vol. of intrathoracic blood
-Awaking about 2 hours after sleeping w/perception of needing air.
Pericardial friction rub
The sound is high pitched and scratchy
-best heard w/diaphragm, w/person sitting up leaning forward
-best heard at apex and left lower sternal border.
-sandpapper
AV values
Tricuspid (Right)
Mitral (Left)
-allow blood into heart chambers
Open during filling (Diastole)
Close during ejection (Systole
BP
Blood pressure
cm.
Centimeter (s)
CVD or CV Disease
Cardiovascular disease
DM
Diabetes Mellitus
MOst common type 2:
-causes damage large blood vessels that nourish the brain, heart, & extremities;this results in stroke, coronary artery disease
DOE
Dyspnea on Excertion
Clubbing
Nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary disease.
Early:
angle straightens out to 180 an nail beds feel spongy
Late:nail becomes convex as the digit grows
"frog fingers
Cyanosis
Blue color due to lack of O2
Dyspnea
SOB or Shortness of Breath
Edema
Abnormal accumulation of fluid, leading to swelling.
Gallop rhythm
the addition of a 3rd or 4th heart sound makes the rhythm sound like the cadence of a galloping horse
Heart Sounds S1
The start of systole
-Lub sound
-louder that S2, at the apex
-softer at base
-coincides w/the carotid artery pulse
Heart sound S2
Closing of semilunar valves
- signals end of systole (
-heard best at base of Heart
-DUP SOUND
Heart sounds S3
-In early diastole "ventricular filling"
-Low-pitched (heard with bell), at apex or heard in left lateral position
-Physiologic (Normal) or Pathologic (Abnormal)
-Left lateral position best
-Normal S3 could be in CHILDREN and young adults and occasionally
Heart Sounds S4
-Ventricular filling sound
-Occurs when atria contracts late in diastole
-Heard immediately before S1
-Best heard at apex, left lateral position
"End of Diastole
Nocturia
Excessive urination at night
Physiologic Splitting
normal variation in S2 heard as two separate components during inspiration.
Pulse deficit
signals a weak contraction of the ventricles; it occurs w/atrial fibrillation, premature beats, and heart failure.
Pulse Pressure
Difference between systolic and diastolic blood pressure measurements
Summation sound
when both path S3 & S4 are present, a quadruple rythem is heard.
Syncope
a spontaneous loss of consciousness caused by insufficient blood to the brain
Tachycardia
Abnormally fast heartbeat > 90 beats per minute
Thrill
A Palpable vibration.
-It feels like the throat of a purring cat.
-Signifies turbulent blood flow and accompanies loud murmurs.
-could be a murmur, blockage, plaque....ect
(Absence of a thrill does Not necessarily rule out murmur)
ECG (EKG)
electrocardiogram
HTN
Hypertension
>or equal to 140/>or equal 90
ICS
Intercostal Space
MCL
Midclavicular line
PND
Paroxysmal nocturnal dyspnea
-accours w/heart failure
-Lying down increases vol. of intrathoracic blood
-Awaking about 2 hours after sleeping w/perception of needing air.
S1 ( orS2) maybe predominately early_______________?
Apex S1
Base S2
Pulmonary Edema
pink frothy sputum
Mitral stenosis
Calcified mitral valve will not open properly, impedes forward flow of blood in LV during diastole.
-Results in LS enlarged & LA pressure increased
S/S:fatigue, palpitations, DOE, orthopnea
Where is the S4 sound?
End of Diastole
Murmurs
-Blowing, swooshing sound
-Occurs with turbulent blood flow
Characteristics:
(1) Timing:
�Systolic or diastolic
(2) Loudness:
*excessive turbulence
Grade 1 (i) murmur
Barely audible
Grade 2 (ii) murmur
Clearly audible, but faint
Grade 3 (iii) mur
Moderately loud, easy to hear
Grade 4 (iv) mur
Loud, associated w/thrill palpable on chest
Grade 5 (v) murmur
very loud, heard w/one corner of the stethoscope lifted off the chest wall
Grade 6 (vi) murmur
Loudest, still heard w/entire stethescope lifted just off the chest wall
How are murmurs grade?
on a scale to 1-6
Objective Data-exam preparation
-Carotid arteries- sitting
-Jugular veins and precordium- supine with head and chest slightly elevated
-Stand on the person's right side
-Room must be warm- shivering interferes with heart sounds
-Ensure quiet environment
The physical exam ( objective data)
1st ensure privacy
Equipment:
-Tape measure
-Stethoscope
-Pen light
Order of Assessment:
-Pulse and BP
-Extremities
-Neck Vessels
-Precordium
How to ausculate the carotid
-Use bell of stethoscope "lightly"
*
pt. hold breath
*
3 lvls:
1.angle of jaw
2.midcervical area
3.the base of the neck
Normal:
-Absence of bruit
-Normal strength 2+
-Same bilaterally
LOOKING FOR:
Middle Aged and Older
Or Show symptoms or signs of CV dise
Semilunar Valves
Pulmonic (Right)
Aortic (left)
-SL valves allow blood to enter lungs/periphery
Open during ejection (Systole)
Diastole:
Ventricles relaxed (filling)
Systole:
Ventricles contract (ejection)
* Valves respond to
pressure gradients**
A-P-E-TO-MAN
-Aortic Valve-2nd Right ICS
-Pulmonic Valve-2nd Left ICS
-Erb's Point-3rd Left ICS
-Tricuspid Valve-left lower sternal border (4th - 5th ICS)
-Mitral Valve: 5th ICS, left MCL (Apex)
When to auscultate with the bell on the chest
-Over all areas
-Assess for S3 and S4 heart sounds
-Any low-pitched murmurs
(Listen with diaphragm and if you hear extra flip to bell and listen again)
Auscultatory Areas
P. 475
A&P of heart and neck Vessels
p. 456 (19-3), 457 (19-4), p462 (19-10)
List the areas of questioning to address during the health history of the cardiovascular system"subjective
1 Chest pain
2 Dyspnea
3 Orthopnea
4 Cough
5 Fatigue
6 Cyanosis or pallor
7 Edema
8 Nocturia
9 Past cardiac history
10 Family cardiac history
11 Personal habits (cardiac risk factors)
Preparation for Odj. Data Cardio
-Marking pen
-pen light
-Small centimeter tape measure
-Stethoscope with diaphragm and bell endpieces
-Carotid arteries- sitting
-Jugular veins and precordium- supine with head and chest slightly elevated
-ensure privacy
-Stand on the person's right side
Objective Data of heart and neck vessels
1.Pulse and blood pressure (see Chapter 9)
2.Extremities (see Peripheral Vascular Assessment in Chapter 20)
3.Neck vessels
4.Precordium
What are the major risk factors(MRF) associated with heart disease?
How can these be assessed? (e.g. obesity-BMI [normal and abnormal findings]
MRF:Risk Factors (Habits)
-Nutrition
-Smoking
-Alcohol
-Exercise
-Drugs
Differentiate between the carotid artery pulsation and the jugular vein pulsation. See Table
Page 472
What does finding a bruit indicate?
turbulence to lto local vascular cause, such as atherosclerotic narrowing
How do you assess for a carotid bruit?
Lightly apply the bell of the stethoscope over the carotid artery at three levels:
(1) the angle of the jaw
(2) the midcervical area
(3) the base of the neck
What is the location of the apical impulse as a young child and as an older child/adult?
infant is 4th ICS and child 5th ICS
-you can see their apical impulse
What is an additional position you can use if apical impulse cannot be visualized on inspection or palpated? What does this change of position do to the apical impulse if you find it?
left side, 5th ICS
Is there any other pulsations (besides apical impulse) that should be normally visible and/or palpable?
precordium: the apex, the left sternal border, and the base
What are the auscultation areas where you listen (traditional method) and their locations? In what order do you listen? What is the reason for using this part of the stethoscope?
-Aortic Valve-2nd Right ICS
-Pulmonic Valve-2nd Left ICS
-Erb's Point-3rd Left ICS
-Tricuspid Valve-left lower sternal border (4th - 5th ICS)
-Mitral Valve: 5th ICS, left MCL (Apex)
Listen A P E To Man "z pattern"
diaphragm
What part of the stethoscope is used to assess the different heart sounds?
What is the reason for using this part of the stethoscope?
Diaphragm: relatively high pitched sounds
Bell: low pitched sounds
What causes the heart sounds?
Valves opening and closing to move blood through the heart and body.
Describe the characteristics of the first heart sound and its intensity at the apex of the heart and at the base of the heart. What causes the first heart sound? What is the reason for the different intensity of the first heart sound at the apex and base?
caused by closure of AV valves
-beginging of systole
-can hear diaphragm, over precordium " loudest at Apex"
-LUB
Describe the characteristics of the second heart sound and its intensity at the apex of the heart and at the base of the heart. What is the reason for the different intensity of the second heart sound at the apex and base? What causes the second heart sou
associated w/closure of semilunar values
-can hear diaphragm, over precordium " loudest at Base"
-DUP sound
Explain the physiologic mechanism for normal splitting of S2. In what location on the heart would you expect to hear a split S2?
S2 is heard at BAse
-normal occurs toward the end of inspiration in some
-insperation separates the timing of the two valves closure
AV 0.06 before PV
Describe the location of where you would auscultate the apical pulse in an adult as compared to a infant or very young child. How long should you take to count the apical pulse
Adult left midclavicular line ( supine or pt. on left side)
5th ICS
CHild-
Define the third heart sound. When in the cardiac cycle does it occur?
"intensity, quality, location in which it is heard, and the method of auscultation"
When is an S3 sound normal/abnormal?
Ventricle filling sound
-early diastole during the rapid filling phase.
-can be confused w/ S2
-heard at Apex or left sternal boarder
-does not vary in timing w/respirations
-dull soft sound, low pitch "BELL"
Normal: usually not heard(only children and po
How would you distinguish an S2 physiologic split from an S3 or S4 heart sound?
The S2 doesvary with resperations and s3 does not
S2 is heard at Base while S3 And S$ at Apex
Define the fourth heart sound. When in the cardiac cycle does it occur?
"intensity, quality, location in which it is heard, and method of auscultation"
When is S4 sound normal/abnormal?
Ventricle filling sound
-when atria contract late in diastole
-Heard immediately before S1
-very soft sound
-very low pitch "use bell"
-Apex, left lateral position
List the characteristics to explore when you hear a murmur, including the grading scale of the murmur
(1) Timing:
Systolic or diastolic
(2) Loudness: Note there are 6 grades
What is an innocent or functional murmur?
Common murmur in healthy children or adolescents.
Innocent-having no valvular or other pathologic cause
Functional-due to increased blood flow in the heart.
(anemia, fever, pregnancy, hyperthyroidism)
Look over "Promoting a Healthy Lifestyle"
P. 484
describe the difference between men and women
where is the best place to hear the closing of mitral and tricuspid valves
Apex of the heart