Physical Assessment: Cardiovascular

Front 1

Pulmonary/Systemic Circulation

Back 1

pulmonary vein-only oxygenated vein
pulmonary artery-deoxygenated blood

Front 2

Internal Position/Surface Landmarks

Back 2

-heart goes from right side of sternum to the midclavicular line
-apex is at bottom, base at top
-point of max impulse (PMI)-pulse at 5th ICP @ mid clavicular line
-goes from 2nd to 5th ICS
-pericordium
-mediastinum

-

Front 3

Positioning of the atria and ventricles

Back 3

-heart rotated so right ventricle is more anterior
-most of left ventricle is posterior
-->important for valves

Front 4

Great vessels of the heart

Back 4

-superior and inferior vena cava-return blood of body to right atrium
-pulm artery takes deox blood to lungs from right ventricle
-pulm veins take oxy blood lungs to left atrium
-aorta takes ox blood from left ventricle-->rest of body

Front 5

Layers of the heart

Back 5

-mostly connective tissue
-endocardium-CT continuous w inner lining of heart
-myocardium-inner layer
-contracts and pushes blood out of the heart
-pericardium-outter layer of heaer
pericardial cavity-in btw two laters with fluid
-epicardium in btw myo and cavity

Front 6

Passage of blood through heart

Back 6

blood in sup and inferior vena cava-->right atrium-->through atrioventricular valve (tricuspid)-->right ventricle-->heart contract-->trixupsid valve closes and blood out through pulm artery through pulm valve-->lungs
blood into pulm veins-->left atrium-->mitral valve (bicuspid)-->left ventricle-->heart contracts-->mitral valve closes-->blood out aorta through aortic valve

Front 7

Valves

Back 7

atrioventricular-btw artria and ventricles
pulmonic and aortic valves-btw ventricles and vessel

Front 8

Sounds

Back 8

when valves close
S1-when AV valves close-->blood ejected from ventricles
-LUB
S2-when semilunar valves close
-DUB

Front 9

Systole pumping

Back 9

ventricles contract
-right ventricle pumps blood into pulmonary arteries (pulmonic valve open)
-the left ventricle pumps blood into the aorta (aortic valve is open

Front 10

Diastole pumping

Back 10

-blood flows from the right atrium to the right ventricle (tricuspid valve open)
-blood flows from left atrium to left ventricle (mitral valve is open)

Front 11

Cardiac Cycle

Back 11

pressure builds until high enough to open a valve
diastole-ventricles relaxed-->filled with blood-->pressure increases-->aortic valve opens
longer period than systole
-your BP is the pressure needed to open the valve
-the higher the pressure, the more needed to be done/more contraction

Front 12

Blood distribution in heart

Back 12

more to right
less to left
-a little bit less blood in left side of heart during inspiration bc its sequestered in lung picking up O2
--left ventricular side has less volume->not going to take as long to squeeze out during systole

Front 13

Differences in valve closings

Back 13

-aortic valve is going to close quicker than pulmonic
--normal finding when you breathe in ****

Front 14

S3 and S4

Back 14

-if ventricle is tight--doesn't like blood coming in->make bruit, turbulent sound
S3-early diastole when blood is entering the ventricle
S4-at end of diastole when blood is already in ventricle and atria does a little contraction to get the last bit of blood into ventricle-->ventricle kick (atrial systole)
-when ventricle doesnt like this
-turbulent

Front 15

Cardiac Output

Back 15

CO=SVXHR
-btw 4-6 L of blood per min

Front 16

Preload

Back 16

-volume overload
-length at which ventricular muscle stretches at end of diastole
-as blood is pouring in during diastole-->this muscle is going to stretch
-excersize-->more blood return to the heart-->ventricles stretch more than at rest
-greater it stretches--greater the strength of next contraction (starling 4)
-if there is fluid--preload problem
-give diuretic

Front 17

Afterload

Back 17

pressure overload
-the opposing pressure that the ventricle has to generate to open the aortic valve (resistance against which the ventricle has to pump blood
-normally 5-10 mmHg
-if aortic vessel pressure is 80-have to get to 80
-the higher the pressure the harder the ventricle has to work
-pressure problem--an afterload problem

Front 18

Significant subjective data

Back 18

-orthopnea
-how many pillows do you sleep with
-fluid in cough
-dyspnea-hard to breathe
-gender
-men more heart disease until menopause
-race
-blacks 2X likely to have more hypertension

Front 19

Assing the precordium

Back 19

-inspect
-palpate
-auscultate

Front 20

Blood Pressure

Back 20

BP=CO X SVR
Systolic-pressure generated by left ventricle
-when LV ejects blood into aorta and arterial tree
Diastole-pressure generated by blood remaining in arterial tree
-when ventricles are relaxed

Front 21

Assessing Blood Pressure

Back 21

-pumping up high enough to be above systolic-occluded artery-no sound
-->letting air out slowly-->a little like a bruit (turbulent through artery)
diastolic-pressure generated by blood remaining in arterial tree-when ventricles are relaxed
-blood free flowing

Front 22

Assessment of Carotid arteries

Back 22

-palpate medial to sternomastoid muscle in neck
-one carotid at a time
-palpate in lower or upper third of neck, not middle
-if palpate near thyroid cartilage--carotid sinus--causes HR to drop

-auscultate carotid-bruit=carotic stenosis
-hypertension or high cholesterol

Front 23

Jugular Venous Pressure

Back 23

-JVP
-commonly expressed as vertical height (in cm) of column of blood (in head) in relation to the sternal angle (angle of Louis)
-mean height=hydrostatic pressure within right atrium
-6-10cm H2O
-use internal jugular vein
-right side closer and more direct to heart
-can see pulsation in sternal notch when someone is lying down

Front 24

Inspection of the Jugular Venous Pressure

Back 24

If you can't see the head of the pulsating column of blood in int. jug vein
-->because hydrostatic pressure so high head of column disappeared behind angle of jaw
-->increase angle andsit the patient bolt right up
OR
-because hydostratic p in right atrium so low that head lies behind clavicle
-->low reclining angle
-may need to lay down flat
**cite angle of patient when describing height

Front 25

Assessment of the precordium

Back 25

-inspect the anterior chest for lifts of heaves
-palpate across the precordium
-palpate apical pulse
-APT M (aortic, pulmonic, tricuspid, mitral valve)
-percuss around the 5ICS mid clavicular line
-

Front 26

Lifts and Heaves

Back 26

-heart enlarged (ventricle dilation from too much fluid or ventriclar hypertropy)
-lift during systole

Front 27

Thrills

Back 27

-murmur
-turbulent blood flow
-vibration
-feels like a cat purring

Front 28

Hypertrophy

Back 28

-heart bigger
-apex lower and further over
-moves maximal impulse

Front 29

Auscultation routine

Back 29

-hear aorta on right side (hear better)
-hear pulmonic on left
opposite bc heart is twisted in the body
-tricuspid-5 ICS along sternal border
-mitral valve best heard 5ICS MCL (same as PMI)
Herbs-3 ICS where LUB DUB sound same

-listen on left lateral decubitus position

Front 30

Identifying S1 and S2

Back 30

-apex: S1>S2 (LUB)
-base-S2<S1 (DUP)
-S1=R wave on ECG
-S1-carotid artery pulse

Front 31

Physiological Split S2

Back 31

-during inspiration
-aortic valve closes before pulmonic
--->since there is LESS blood on the LEFT it contracts faster

Front 32

S3 Auscultation

Back 32

-ventricular gallop
boom boomboom
Lub dup dup
low pitch
hear with bell
-decreased compliance of ventricle w/ CHF on right side->pathological S3
-lie on side to listen
-pregnant, anemic, hypothyroid
-can be physiological or pathological

Front 33

S4 Auscultation

Back 33

-atrial gallop
boomboom boom
low pitched
-hear through bell
-sound right before S1
-almost always pathological

Front 34

Systolic Clicks/Systolic Extra Sounds

Back 34

-early systolic ejection click
-midsystolic click
-aortic stenosis-calcification of valves-->doesn't open to nicely
--turbulent
--make a noise
-midsystolic click-btw S1 and S2
-valves go backwards-->make a clicking sound

Front 35

Diastolic Extra Sounds

Back 35

-normally opening of AV valves is silent
-stenosis of valves-->open with noise
-sharp and high pitched
-open and snap
-hear in diaphragm or 3/4 ICS at sternal border

Front 36

Murmurs

Back 36

-like a bruit
-bolowing, swishing sound of turbulent blood flow through stenosed or loosely closing valve
-pay attention to timing, location, loudness/intensity (scale 1-6)

Front 37

Types of Murmurs

Back 37

*midsystolic ejection murmurs
-aortic and pulmonic stenosis
*pansystolic regurgitant murmurs
-mitral and tricuspid regurgitation
*diastolic rumbles of AV Valves
-mitral and tricuspid stenosis
*Early diastolic murmurs
-aortic and pulmonic regurg

Front 38

Midsystolic Ejection Murmurs

Back 38

if aorta or pulmonic valves are stenosed (tight)
-open-murmur

Front 39

Pansystolic Rugurgitant Murmurs

Back 39

-in systole
-tricuspid and mitral close improperly
-regurgitation
-blood back
-more common w mitral valve

Front 40

Diastolic Rumbles of AV Valves

Back 40

-valvular defect
-much more serious
-if mitral and tricusp stenosed-->close-->murmur

Front 41

Early Diastolic Murmurs

Back 41

-valvular defect
-much more serious
-aortic and pulmonic do not close properly-->valves go back
-blood back
-can cause syncope

Front 42

Rub

Back 42

painful rubbing sound during systole and diastole

Front 43

Scaling of heart sound intensity

Back 43

1-barely hear
2-louder-normal
3-louder
4-should hear a thrill
5-very loud when part of stethoscope on it--out of chest
6-pretty much hear without stethoscope