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91 Cards in this Set

  • Front
  • Back
Base vs. Apex of heart
Base - top
Apex - bottom
Layers of the pericardium
Fibrous (outer) - connected to diaphragm and sternum, limits stretching of myocardial muscle
Serous (inner)
-parietal - close to fibrous tissues
-visceral (epicardium) - lies against heart muscle
Purpose and amount of pericardial fluid
20-50mL
facilitates movement of heart muscle and protects it with lubricant
AV Valves
Right - tricuspid
Left - bicuspid (mitral)
Semilunar valves
Pulmonic (RV)
Aortic (LV)
Ischemia
local and temporary lack of blood supply to the heart (reversible)
Cardiac injury
beyond ischemia but still reversible
Infarction
necrosis of heart muscle
Coronary circulation
sinus of valsalva -> left and right main coronary arteries -> (L) left anterior descending coronary artery and left circumflex artery
Where does LAD supply blood?
anterior wall and apex of left ventricle, anterior portion of interventricular septum
Where does LCX branch supply arterial blood?
left atrium
lateral and posterior portions of the ventricle (sometimes AV and SA nodes)
Where does the RCA supply blood?
right atrium, right ventricle, inferior wall of LV, usually AV and SA nodes, posterior portion of interventricular septum
What carries venous drainage from the myocardium?
coronary sinus, anterior cardiac veins, thebesian veins
where is venous blood from coronary system taken?
75% RA via coronary sinus
25% in all 4 chambers via thebesian veins
Layers of arterial walls
tunica intima (endothelium +CT)
tunica media (smooth muscle, CT)
tunica externa (fibrous CT)
most common reason for hospitalization in older patients
CHF
amount of patients hospitalized annually for MI over 65
more than half
most common cause of death for patients >65
coronary artery disease
leasing cause of death in women >65
heart disease
What is CHF?
severe progressive decreased ventricular contractility, decreased CO, decreased tissue perfusion, metabolic needs not being met, volume overload
Left sided heart failure
left ventricle cannot pump effectively enough to meet the body's needs (can't move preload, high volume of afterload)
Right sided heart failure
RV cannot pump effectively enough to circulate blood to the lungs to be oxygenated, venous distention
Effects of high afterload in CHF
blood and fluid back up into lungs and organs and cause edema
Symptoms of CHF
cough or crackles (fluid in lungs)
peripheral edema
weight gain
fatigue
SOB, chest pain, tightness
possible decreased urination
dilated pupils
skin pale, grey, or cyanotic
orthopnea
cough - frothy pink or white sputum
decreased BP
nausea and vomiting
ascites
enlarged spleen and liver
anxiety
falling O2
confusion
jugular vein distention
infarct
s2 gallop, tachycardia
weak pulse
cool, moist skin
Angina
partial occlusion of vessels supplying blood to heart muscle
CHF compensation
1) ventricular dilation - muscle stretch, contractility, CO eventually fails
2) ventricular hypertrophy - increased muscle mass, contractility, CO
3) increased sympathetic activity - increased HR, contractility, CO (increased workload)
4) neurohormonal responses - low CO, low RBF - renin-angiotensin system conserve H2O to increase blood volume
MI
complete occlusion of vessels supplying blood to heart muscle
Symptoms of MI AND Angina
pain - squeezing, may radiate to shoulders, arms, neck, jaw, back, may feel like indigestion
Symptoms of angina
may be relieved with rest or medication if stable
MI symptoms in women
pain, pressure or chest discomfort
neck, shoulder, upper back or abdominal discomfort
nausea and vomiting
lightheadedness or diziness
unusual fatigue
Non-modifiable risk factors for CV disease
family hx
age
race
gender
modifiable risk factors for CV disease
hyperlipidemia
Low sat. fats, cholesterol, sodium
learn to manage stress
inactivity
HTN, DM
abdominal obesity
depression
Triggers for angina and MI in at risk persons
exertion
heavy meal
emotions, mental stress
cigarette smoking
stimulants
temperature extremes
Gerontological variations
decreased size of heart muscle
atria and ventricles become fibrotic and sclerotic - decreased CO
vessels become fibrotic and rigid - increase BP
skeletal changes can alter heart position
Health history: age
childhood
-rheumatic fever
adult onset
-HTN
-CAD
-MI
-CVA
-AAA
-Raynaud's
-Mitral valve prolapse
-valve stenosis or regurgitation
-dilated or congestive cardiomyopathy
-arteriosclerosis
Health history: gender
Women
-higher mortality rate after severe MI
-rise in CAD after menopause
-ASD
-Raynauds
Men
-predisposition to CAD, VSD
Health history: Ethnicity
European, S. Asian
-CVD
Chinese
-low rates CVD
Black and aboriginal
-CVD
Health history: chief complaints
chest pain
syncope
palpitations
peripheral edema
extremity pain
orthopnea
Health history: common medications
-antianginals or vasodilators
-antidysrhythmics
-anticoagulants
-antihypertensives (diuretics, calcium channel blockers, ACE inhibitors)
-cholesterol lowering
-inotropics - influence contractility of muscle tissue
-thrombolytics
Health history: communicable diseases
rheumatic fever (valves)
syphilis (aorta)
viral myocarditis
Health history: allergies
aspirin
seafood
imaging dyes
latex
betadine
Health history: Family hx
aneurysm
CVA
CAD
HTN
MI or sudden death
MVP
Characteristics of Cardiac Ischemia pain
-pain is burning, squeezing, heaviness, smothering
-not reproducible by palpation, may be relieved with rest or O2, may or may not be accompanied by ECG changes
Characteristics of aortic dissection pain
-pain: sharp, sudden, tearing, radiates to shoulders, neck, back, abdomen
-neurological complications: hemiplagia, sensory deficits
-may present with new murmur, bruits, or unequal BP in upper extremities
Characteristics of pericarditis pain
pain: positional ache, dyspnea
may also have pericardial friction rub or distended neck veins
Characteristics of pulmonary embolus pain
pain: sudden onset, sharp or stabbing, varies with respiration
Characteristics of pneumothorax pain
-sudden onset, tearing or pleuritic, worsened by breathing
-may also have dyspnea, tachycardia, decreased breath sounds, deviated trachea
Characteristics of pneumonia chest pain
pain: stabbing, exacerbated by coughing and deep breathing
-fever, chills, productive cough, tachypnea
Characteristics of esophageal rupture chest pain
pain: sudden onset upon swallowing or constant retrosternal, epigastric pain
-may mimic signs of pneumothorax
-consider when patient has experienced penetrating trauma, severe epigastric blow, first or second rib fracture
Characteristics of MSK chest pain
pain reproducible by chest palpation
Characteristics of recreational drug use chest pain
cardiac ishemia pain
Cardiac landmarks
aortic area (R2)
pulmonic area (L2)
Erb`s point (L3)
Tricuspid area (L5)
Mitral area (L5, midclavicular)
Inspection of precordium
assess all landmarks for pulsations, apical impulse, point of maximal impulse
Where might the apical impulse be inspected?
mitral area
Where is the tricuspid area in infants?
4th ICS
What do you palpate for? (precordium)
masses
pulsations
heaves
thrills
What hand surface is used to palpate for pulsation
fingerpads
What hand surface is used to palpate for thrills
palmar surface of hand
What hand surface is used to palpate for heaves
palmar surface of hand
Where might apical impulse be palpable?
mitral area
Auscultation normal findings at aortic area
s2 (dub)
s2>s1
Auscultation normal findings at pulmonic area
listening for s2
s2>s1 (softer than aortic)
may be splitting of S2
Auscultation normal findings at tricuspid area
s1>s2
s1 softer than in mitral
s1 may be split but disappears when patient holds breath
Auscultation normal findings at mitral area
s1>s2
Auscultation for S3
mitral and tricuspid areas
ventricular diastolic gallop
occurs just after s2
use bell
ausculate for 10-15s
normal in children and young adults, 3rd trimester of pregnancy, abnormal after 30
kentucky
rapid ventricular filling
Auscultation for s4
mitral and tricuspid
use bell 10-15s
usually louder on expiration (L) and inspiration (R)
occurs just before s1
tennessee
may occur with or without evidence of decompensation
Auscultating for murmurs
use diaphragm over aortic, pulmonic, mitral, tricuspid
use bell over mitral and tricuspid
Auscultation components
S1, S2, S3, S4
murmurs
pericardial friction rub
prosthetic heart valves
murmur characteristics
location
radiation
timing
intensity
quality
pitch
configuration
Causes of murmurs
flow across a partial obstruction
increased flow through normal structures
flow into a dilated chamber
backward or regurgitant flow across incompetent valves
shunting of blood out of a high-pressure chamber or artery through an abnormal passageway
Auscultating for pericardial friction rub
from sternum (3rd-5th ICS) to apex (mitral area) with diaphragm
Assessment of peripheral vasculature components
inspection of JVP
inspection of hepatojugular reflex
palpation and auscultation of arterial pulses
inspection and palpation of peripheral perfusion
head elevation during inspection of JVP
30 - 45 deg
normal JVP reading
less than 4cm
most distended when patient is flat
1-2cm above sternal angle when head of bed elevated 30-45
absent when head of bed at 90 deg
Calculating CVP, normal range
add 5 to JVP
normal:3-8cm
What does a JVP of >4cm suggest?
increased RV pressure, increased blood volume or obstruction of RV flow
Cause of increase in JVP during hepatojugular reflex
right-sided CHF
Characteristics of arterial pulses
rate
rhythm
amplitude
symmetry
Warning signs of potential CV problems
pallor, cyanosis
chest pain
diaphoresis, cool
dyspnea
dizziness or syncope
edema
fatigue
feeling of impending doom
palpitations
tingling in extremities
pain that limits self care
pain or numbness in extremities
which arterial pulses should be auscultated? how?
temporal, carotid, femoral
use bell, ask patient to hold breath
Assessment of peripheral perfusion
arterial
-pallor
-allen test

venous
-homan's sign
colour return and venous filling
venous and arterial indications of peripheral perfusion
arterial pulses
colour
clubbing
cap refill
edema
skin temperature
ulcerations
hair distribution
assessing orthostatic hypertension
assess BP supine, sitting, standing (+HR for second 2)
assess weakness or dizziness from position change
abnormal findings: orthostatic hypertension pathologies
hypovolemic
neurological dysfunction
side effects from medications
Performing Homan's sign and possible indication
bend knee slightly and sharply dorsiflex foot
pain may indicate DVT
normal findings: pallor
no pallor develops in 60s
CR and VFT normal findings
CR 10s
VFT 15s
what is a positive allen test?
radial and ulnar arteries can compensate for one another and maintain colour in hand
where should peripheral edema be evaluated?
dorsum of foot, medial malleolus, shin
bilateral comparison starting at malleolus and check how far up the leg the edema goes
where are venous ulcerations common?
around ankles
characteristics of arterial insufficiency in lower limbs
intermittent claudication - pain in calf with exercise
pulses may be decreased or absent
leg colour: dusky red when dependent
skin: thin, shiny, loss of hair over foot and toe, thick ridged nails
ulcers near toes or points of trauma