Chapter 19 Heart and Neck Vessels

occurs with closure of the semilunar valves, aortic and pulmonic, and signals the end of systole

Second heart sounds (S2)

Atrial systole occurs

during ventricular diastole

the precordium is..

the area on the anterior chest overlying the heart and great vessels

You will hear a split S2 most clearly in what area?

pulmonic

the tricuspid valve is

the right atriventricular valve

the left semilunar valve separating the left ventricle and te aorta

Aortic valve

cup- shaped endpeice used for soft, low-pitched heart sounds

Bell (of the stethescope)

Which abnormal conditions affect the location of the apical impulse?

Cardiac enlargement, barrel chest

Which abnormal conditions may affect the location of the apical impulse?

Left ventricular dilation (volume overload)

normal variation in S2 heard as two separate components during inspiration

Physiological splitting

Which normal variations may affect the location of the apical impulse?

Rolling patient to the left

Which conditions increase the intensity of S2?

Systemic hypertension, mitral stenosis, heart failure, or aortic or pulmonic stenosis.

Describe the effect of respiration on the heart sounds.

* Sinus arrhythmia-rhythm varies with someone's breathing, increasing at peak of inspiration and slowing with expiration *Holding breath will equalize ejection times in right and left side of heart

Define venous pressure and jugular venous pulse.

...

what conditions decrease the S2 intensity

1 a fall in systemic blood pressure causes a decrease in valve strength (ex shock) 2. Semilunar valves thickened and calcified, decreased mobility (ex. aortic or pulmonic stenosis)

which conditions increase the intensity of S1 ?

1. Position of AV valve at start of systole--- wide open and no time to drift together. 2. Change in valve structure-- calcification of valve, needs increasing ventricular pressure to close the valve against increased atrial pressure

what conditions increase the intensity of the S2?

1. higher closing pressure (ex systemic hypertension, rining or booming) 2. Exercise and excitement increase pressure in aorta (ex mitral stenosis or heart failure) 3. Pulmonary hypertension (ex aortic or pulmonic stenosis) 4. Semilunar valves calcified but still mobile P488

which conditions decrease intensity of S1?

1. position of AV valve -- delayed conduction from atria to ventricles. Mitral valve drifts shut b4 ventricular contraction closes it 2. Change in valve structure-- extreme calcification, which limits mobility. 3. More forceful atrial contraction into noncompliant ventricle; delays or diminishes ventricular contraction

Intensity of S1 depends on what 3 factors weather it is higher or lower intensity?

1. position of AV valve at the start of systole 2. structure of the valve leaflets 3. how quickly pressure rises in the ventricle

Which conditions decrease the intensity of S1?

1st degree heart block, mitral insufficiency, and severe hypertension

Define bruit and discuss what it indicates.

A blowing, swishing sound indicating blood flow turbulence. Can be due to a local vascular cause, such as atherosclerotic narrowing.

Define bruit, and discuss what it indicates.

A bruit is a blowing, swishing sound indicating blood flow turbulence. Indicated turbulence due to a local vascular cause, such as atherosclerosis narrowing.

Define heave or lift, and discuss what it indicates.

A heave or lift is a sustained forceful thrusting of the ventricle during systole. Indicates ventricular hypertrophy.

Define heave or lift, and discuss what it indicates.

A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex.

Define pulse deficit, and discuss what it indicates.

A pulse deficit signals a weak contraction of the ventricle; it occurs with atrial fibrillation, premature beats, and heart failure.

Define afterload.

Afterload is the opposing pressure the ventricle must generate to open aortic valve against the higher aortic pressure. It is the resistance against which the ventricle must pump its blood. Once the ventricle is filled with blood, the ventricular end diastolic pressure is 5 - 10 mm Hg, whereas that in the aorta is 70 - 80 mm Hg. To overcome this difference, the ventricular muscle tenses. After the aortic valve opens, rapid ejections occur.

acute chest pain that occurs when myocardial demand exceeds it's oxygen supply

Angina pectoris

(aortic insufficiencey) incompetent aortic valve that allows backward flow of blood into left ventricle during diastole.

Aortic regurgitation

calcification of aortic valve cusps that restricts forward flow of blood during systole

Aortic stenosis

tip of the heart pointing down toward the 5th left intercoastal space

Apex of the heart

(point of maximal impluse, PMI) pulastion created as the left ventricle rotates against the chest wall during sytole, normally at the 5th left intercostal space in the midclavicular line.

Apical impulse

What is pulse deficit and what does it indicate?

Apical pulse - radial pulse = pulse deficit. Signals irregularity.

thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

endocardium

boarder area of the hearts outline located at the 3rd right and left intercoastal space

Base of the heart

slow heart rate, < 50 beats per min in the adult

Bradycardia

Which ABNORMAL conditions may affect the location of the apical impulse?

CARDIAC ENLARGEMENT: - LEFT VENTRICULAR DILATION (volume overload) displaces impulse down and to the left ans increases size more that one space. -a SUSTAINED impulse wirh increased force and duration but no change in location occurs with LEFT VENTRICULAR HYPERTROPHY and no dilation (pressure overload) - PULMONARY EMPHYSEMA makes it non-palpable from the lung sound overridding heart sound.

Differentiate between the carotid artery pulsation and the jugular vein pulsation.

Carotid - higher and medial to medial to muscle, brisk, localized, one wave per cycle, does not vary, palpable, no pressure changes, unaffected by position change. Jugular - lower, more lateral, under or behind sternomastoid muscle, undulant and diffuse, two visible waves per cycle, varies with respiration. Its level descends during inspiration when intrathoracic pressure is decreased, not palpable, light pressure change at the base of the neck (easily obliterate), level of pulse drops and disappears as person sits up.

Differentiate carotid pulse to jugular vein pulse

Carotid- brisk and localized, doesn't vary with respiration, palpable even with pressure, unaffected by body position. Jugular- diffuse, varies with respiration, impalpable, light pressure obliterates pulse, and it is affected by position.

List the areas of questioning to address during the health history for the cardiovascular system.

Chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis or pallor, edema, nocturia, past cardiac history, family cardiac history, personal habits (cardiac risk factors)

List the areas of questioning to address during the health history of the cardiovascular system.

Chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis or pallor, edema, nocturia, past cardiac history, family cardiac history, personal habits (cardiac risk factors)

Describe the 1st heart sound and how it is produced

Closure of AV valves, beginning of systole, and it is loudest at the apex (bottom of heart)

Describe 2nd heart sound and how it is produced

Closure of semilunar valves (aortic/pulmonic), and is loudest at the base (top) of the heart

bulbous enlargement of the distal phalanges of the fingers and toes that occurs with chronic cyanotic heart and lung conditions

Clubbing

right ventricular hypertrophy and heart failure due to pulmonary hypertension

Cor pulmonale

dusky blue mottling of the skin and mucous membranes due to excessive amount of reduced hemoglbin in the blood

Cyanosis

Define the apical impulse and describe it's normal location, size, and duration.

Defined- the pulsation created as the left ventricle rotates against the chest wall during systole location- occupies only one intercostal space, the 4th or 5th, and at or inside the midclavicular line Size- 1x2 cm duration- short, (1st 1/2 of systole)

the examiner is palpating the apical impulse. the normal size of this impluse is

about 2 cm

flat endpeice of the stethescope used for hearing relatively high-pitched heart sounds

Diaphragm (of the stethescope)

the hearts filling phase

Diastole

Position of valves during each phase of cardiac cycle

Diastole- AV valves (i.e. tricuspid and mitral) are open Systole- AV valves shut producing S1. Aortic valves open to eject blood rapidly. then some back flow from psi equalizing b/t aorta and ventricles causes aortic valve to shut Diastole again- all 4 valves closed, mitral valve opens and diastolic filling begins again

Explain position of valves during each cardiac cycle

Diastole- AV valves open. Systole- AV valves close (S1), Semilunar valves close (S2). Diastole again- mitral valves open.

Define pulse deficit.

Difference between apical and radial pulse rates.

Explain the mechanism for the normal splitting of S2

Due to respiration, inspiration separates the timing of the closure of the semilunar valves. The aortic valve closes 0.06 seconds before the pulmonic valve creating a split S2. -Only heard in pulmonic valve area.

difficult, labored breathing

Dyspnea

swelling of the legs or dependent body part due to increased interstitial fluid

Edema

Pericardial fluid

Ensures smooth, friction-free movement of the heart muscle

traditional auscultory area in the 3rd left intercoastal space

Erb's point

Which conditions increase the intensity of S1?

Exercise, fever, anemia, hyperthyroidism, and mitral stenosis

Explain the mechanism producing normal first and second heart sounds?

First heart sound (S1) occurs with closure of the AV valves and this signals the beginning of systole. The mitral component of the first sound slightly precedes the tricuspid component, but you usually hear these two components fused as one sound. You can hear S1 over all the precordium but usually loudest at the apex. Second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. The aortic component of the second sound (A2) slightly precedes the pulmonic component. Although it is heard over all the precordium, S2 is loudest at the base.

Describe the mechanism producing normal first and second heart sounds

First heart sound = closure of the AV valves (signaling beging of systole) second heart sound= closure of semilunar valves (signaling end systole) (p460)

occurs with closure of the atrioventricular (AV) valves signaling the begining of systole

First heart sound S1

(S4 gallop; atrial gallop) very soft, low-pitched ventricular filling sound that occurs in late diastole

Fourth heart sound (S4)

the addition of a 3rd or 4th heart sound makes the rhythm sound like the cadence of a galloping horse

Gallop rhythm

Describe the characteristics of the second heart sound and its intensity at the apex of the heart and at the base.

Heard with diaphragm of stethoscope all over pericardium though loudest at base

Define preload.

Preload is the venous return that builds during diastole. It is the length to which the ventricular muscle is stretched at the end of diastole just before contraction. When the volume of blood returned to the ventricles is increased (as when exercise stimulates skeletal muscles to contract and force more blood back to the heart), the muscle bundles are stretched beyond their normal resting state to accommodate it. The force for this switch is the preload.

Is the Dub

S2

technique of moving the stethescope incrementally across the precordium through the auscultatory areas while listening to the heart sounds

Inching

Direction of blood flow to the heart

Inferior vena cava and superior vena cava into RA, then to RV (tricuspid valve), then to Pulmonary artery (pulmonic), to the Lungs, then oxygenated blood is returned to LA, then goes to LV (mitral valve), which ejects blood into the aorta, and oxygenated blood is delivered to the body.

Discuss the characteristics of an innocent and functional murmur

Innocent- no valvular or pathological cause. Functional- increased blood flow to the heart (anemia, pregnancy, fever, hyperthyroidism).

Describe the characteristics of the first heart sounds and its intensity at the apex of the heart and at the base.

Intensity depends on (1) position of AV valve at the start of systole (2) structure of the valve leaflets, and (3) how quickly pressure rises in the ventricle

Define the 3rd heart sound

Is a ventricular filling sound early in diastole during the rapid filling phase. Dull soft sound where as the S2 is a snap. (lightly hold bell against skin) Location- at the Apex or left lower sternal border Respiratory variation- The S3 does not vary in timing w/ respirations the S2 does. Pitch- the S3 is lower pitched than the S2

increase in thickness of myocardial wall that occurs when the heart pumps against chronic outflow obstruction (e.g. aortic stenosis)

LVH (left ventricular hyertrophy)

Briefly relate the route of a blood cell from the liver to tissue in the body

Liver to right atrium via inferior vena cava, to right atrium, through tricuspid valve to right ventricle, through the pulmonic valve to the pulmonary artery, picks up oxygen in the lungs , returns to left atrium, to left ventricle via mitral valve, through aortic valve to aorta, and out to the body.

Describe the characteristics of the second heart sound and its intensity at the apex of the heart and at the base

S2- "Dub"- is the loudest at the base.

imaginary ventrical line bisecting the middle of the clavical in each hemithorax

MCL (midcalvicular line)

Myocardium

Muscular wall of the heart

(mitral insufficiency) incompetent mitral valve allows regurgitation of blood back into left atrium during systole

Mitral regurgitation

calcified mitral valve impedes forward flow of blood into left ventricle during diastole

Mitral stenosis

left AV valve separating left atria and ventricle

Mitral valve

Ventricle

Muscular pumping chamber

Describe location, size, and duration of the apical impulse

Normally located at the 5th left intercostal space on the midclavicular line, is about 1-2 cm in size, and the duration is short (1st half of systole).

Which NORMAL variations may effet the location of the apical impulse?

Obesity, thick chest walls ( with anxiety, fever, hyperthyroidism, anemia) might increase amplitude and duration.

Normal variations that may affect the location of the apical impulse

Obesity, thick chest walls, and large breast tissue

What is the physiological mechanism for normal splitting of S2 in the pulmonic valve area?

Occurs during inspiration, which separates the timing of the 2 valves (aortic 0.06 sec earlier than pulmonic) closure. So instead of just one Dup, you hear a spilt--T-DUP. During expiration it returns to normal.

4th heart sound description

Occurs in late diastole when atria contract immediately before S1. Very soft and low-pitched.

Describe the 3rd heart sound

Occurs when ventricles are resistant to filling during protodiastole (immediately after S2). -Dull, soft sound. & Low-pitched. -Heard at apex.

Define heave or lift, and discuss what it indicates.

Occurs with right ventricular hypertrophy as in pulmonic valve disease, pulmonic hypertension, and chronic lung disease. Feel a diffuse lifting impulse during systole at lower left sternal border.

Afterload

Opposing pressure the ventricle must generate to open aortic valve against the higher aortic pressure.

uncomfortable awareness of rapid or irregular heart rate

Palpitation

opposite of a normal split S2 so that the split is heard in expiration, and in inspiration the sounds fuse to one sound

Paradoxical spliting

the examiner has estimated the jugular venous pressure. describe a normal finding.

Patient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal angle

List the characteristics to explore when you hear a murmor, including the grading scale of murmors.

Pattern: crescendo, decrescendo-depends on blood flow pressure Quality: musical, blowing, harsh, rumbling Location: PMI or valve area, intercostal space, on the neck, back, or axilla Radiation: Heard in the quality of blood flow Posture: may disappear with posture change Grading: 1-difficult, need quiet; 2-audible but faint; 3-easy to hear; 4-loud, thrill palpable on chest; 5-loud with only part of stethoscope off; 6-loud with stethoscope off

high-pitched, scratchy extracardiac sound heard when the precordium is inflamed

Pericardial friction rub

Differentiate a physiologic S3 from a pathologic S3.

Physiologic S3 (normal) disappears when person sits up. Pathologic S3 (abnormal, early sign of heart failure) - aka ventricular gallop - persists when sitting up

Physiological S3 vs Pathological S3

Physiological- ceases when sitting up. Pathological- persists when sitting up.

Differentiate physiological S3 from pathological S3

Physiological- normal in children and young adults. Pathological- abnormal. ventricular gallop-heart failure, anemia, pregnancy, etc.

area of the chest wall overlying the heart and great vessels

Precordium

Make a statement that differentiates a split S2 from S3

S3 is lower pitched and is heard at the apex

Venous pressure

Pressure exerted on the walls of the veins by circulating blood.

calcifiction of pulmonic valve that restricts forward flow of blood during systole

Pulmonic stenosis

right semilunar valve separating the right ventricle and pulmonary artery

Pulmonic valve

Venous pulse

Pulse in the right internal jugular vein at the root of the neck; pressure of right atrium

Atrium

Reservoir for holding blood

How does respiration affect heart sounds?

Right- intrathoracic pressure decreases, venous return increases which increases right ventricular stroke volume and delays pulmonic valve closure. Left- decreased left ventricular stroke volume which leads to the aortic valve closing early creating a split S2

is the Lub

S1

Describe the charecteristics of the 1st heart sound and it's intensity at the apex of the heart and at the base

S1's mitral component (M1) slightly precedes the tricuspid compnent (T1) but u usually hear the 2 as one sound. The S1 can be heard all over the Precodium but loudest at apex. Is associated with the closure of the AV valves and signals the beginning of systole. S1 is lower pitch than S2 so they can be hear as one sometimes.

4 guidelines to distinguish S1 from S2

S1- 1st pair ("lub"-dub), louder than S2 at apex, coincides with carotid pulse, and coincides with R wave.

Describe the characteristics of the first heart sound and its intesity at the apex of the heart and at the base.

S1: louder than S2 at apex S2: louder than S1 at base

Which conditions decrease the intensity of S2?

Shock, aortic or pulmonic stenosis (semilunar valves calcified and thickened with decreased mobility).

abnormal mid-diastolic heart sound heard when both the pathological S3 and S4 are present

Summation Gallop

temporary loss of consciousness due to decreased crebral blood flow (fainting), caused by ventriclular asystole, pronounced bradycardia, or ventricular fibrillation

Syncope

the heart's pumping phase

Systole

rapid heart rate, >90 beats per minute in the adult

Tachycardia

describe the 2nd heart sound

The S2 is associated with the closure of the semilunar valves. You can hear it with the diaphragm, over the entire precordium, although it is loudest at the base.

Define the third heart sound. When in the cardiac cycle does it occur? Describe its intensity, quality, location in which it is heard, and method of auscultation

The S3 is a ventricular filling sound. It occurs in early diastole during the rapid filling phase. Your hearing quickly accommodates to the S3, so it is best heard when you listen initially. It sounds after S2 but later than an opening snap would be. It is heard best at the apex with the bell held lightly (just enough to form a seal) and with the person in the left lateral position.

Differentiate a physiological S3 from a pathological S3.

The S3 may be normal (physiological) or abnormal (pathological). The physiological S3 is heard frequently in children and young adults; it occasionally may persist after age 40 years, especially in women. The normal S3 usually disappears when the person sits up. In adults, the S¬3 is usually abnormal. The pathological S3 is also called a ventricular gallop or an S3 gallop, and it persists when sitting up. The S3 indicates decreased compliance of the ventricles, as in heart failure.

Define the fourth heart sound. When in the cardiac cycle does it occur? Describe its intensity, quality, location in which it is heard, and method of auscultation

The S4 is a ventricular filling sound. It occurs when the atria contract late in diastole. It is heard immediately before S1. This is a very soft sound, of very low pitch. You need a good bell, and you must listen for it. It is heard best at the apex, with the person in left lateral position.

List the major risk factors for heart disease and stroke identified in the text

The major risk factors for heart disease and stroke are hypertension, smoking, high cholesterol, obesity, and diabetes. Physical inactivity, family hist of heart disease, and age are other risk factors.

Define apical impulse

The pulsation created as the left ventricle rotates against the chest wall during systole.

Define the apical impulse and describe its normal location, size, and duration.

The pulsation created as the left ventricle rotates against the chest wall during systole. When visible, it occupies the 4th or 5th intercostal space at or inside the midclavicular line. Should only occupy one intercostal space. Normally a short, gentle tap. Duration: short, normally occupies only first half of systole.

Define the apical impulse and describe its normal location, size, and duration.

The pulsation created as the left ventricle rotates against the chest wall during systole. When visible, it occupies the fourth or fifth intercostal space, at or inside the midclavicular line. Size; normally 1 x 2 cm. Duration; short, normally occupies only first half of systole

Endocardium

Thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

soft, low-pitched ventricular filling sound that occurs in early diastole (S3 gallop) and may be an early sign of heart failure

Third heart sound (S3)

palpable vibration on the chest wall accompanying severe heart murmur

Thrill

Pericardium

Tough, fibrous, double-walled sac that surrounds and protects the heart.

right AV valve separating the right atria and ventricle

Tricuspid valve

Define venous pressure and jugular venous pulse.

Venous pressure - the pressure exerted on the walls of the veins by the circulating blood Jugular Venous Pulse - The pulse in the right internal jugular vein at the root of the neck; pressure of right atrium

Preload

Venous return that builds during diastole

Define the fourth heart sound. When in the cardiac cycle does it occur? Describe its intensity, quality, location in which it is heard, and method of auscultation.

Ventricular filling sound when atria contract late in diastole. Heard immediately before S1. Very soft sound, low pitch. Need good bell. Best heard at apex with person in left lateral position.

Define the third heart sound. When in the cardiac cycle does it occur? Describe its intensity, quality, location in which it is heard, and method of auscultation.

Ventricular filling sound-in early diastole during rapid filling phase. It is a dull, soft sound and it is low pitched, like "distant thunder." It is heard best in a quiet room, at the apex, with bell held lightly, and person in left lateral position.

Define bruit, and discuss what it indicates.

Whooshing, blowing sound heard when auscultating carotid artery with bell. Not normally heard. Occurs with accelerated or turbulent blood flow due to local vascular cause such as atherosclerotic narrowing.

S1 is best heard at the _____ of the heart, whereas S2 is loudest at the _____ of the heart. S1 coincides with the pulse in the _____ and coincides with the ______ wave if the patient is on an ECG monitor.

apex, base, carotid artery, R

reservoir for holding blood

atrium

the second heart sound is the result of

closing of the aortic and pulmonic valves

when ausclutating the heart, your first step is to:

identify S1 and S2

Fourth heart sound

is a ventricular filling sound late in Diastole when atria contracts right b4 S1. heard best at Apex w/ patient in left lateral position. (very difficult to hear need a good bell)

The stethescope bell should be pressed lightly against the skin so that:

it does not act as a diaphragm

When assessing the carotid artery, the examiner should palpate:

medial to the sternomastoid muscle, one side at a time

Describe the effect of respiration on the heart sounds.

more to the Right heart less to the left: during inspiration, more venouse blood is able to enter the vena cava due to decreasing thoracic pressure which ncreases the amt of blood in the right side of heart thus increasign it's volume. Meanwhile on the left side a greater amt of blood is sequestered in the lungs momentarily dec amt returned to left side and thus volume shortening ventricluar systole allowing the aortic to close earlier (p460)

musclular wall of the heart

myocardium

ensures smooth, friction-free movement of the heart muscle

pericardial fluid

tough, fibrous, double-walled sac that surrounds and protects the heart

pericardium

the function of the pukmonic valve is to

protect the orifice b/t the right ventricle and the pulmonary artery

(pulmonic insufficiency) backflow of blood through incompetent pulmonic valve into the right ventricle

pulmonic regurgitation

the examiner wishes to listen in the pulmonic valve area. To do this, the stethoscope would be placed at the:

second left interspace

Coarctation of aorta

severe narrowing of the descending aorta, a congential heart defect

A murmur heard after S1 and before S2 is classified as:

systolic (possibly benign)

Muscular pumping chamber

ventricle

The examiner wants to listen for a pericardial friction rub. What is the best method for this?

with the diaphraghm, patient sitting up and leaning forward, breath held in expiration

State four guidelines to distinguish S1 from S2.

• S1 is the start if systole and thus serves as the reference point for the timing of all other cardiac sounds; usually you can identify S1 instantly because you hear a pair of sounds close together (lub-dup), and S1 is the first of the pair • S1 is louder than S2¬ at the apex; S2 is louder than S1 at the base • S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel is pulse is S1 • S1 coincides with the R wave (the upstroke of the QRS) complex) if the person is on an ECG monitor