Chapter 19 Review Questions

Dyspnea

difficult, labored breathing

Atrial systole occurs:

during ventricle diastole

Cyanosis

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

Physiologic splitting

normal variation in S2 heard as two separate components during inspiration

First heart sound (S1)

occurs with closure of the atrioventricular valves signaling the beginning of systole

Second heart sound (S2)

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

The precordium is:

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

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

the bell does not act as a diaphragm

Systole

the hearts pumping phase

Aortic valve

the left semilunar valve separating the left ventricle and the aorta

Aortic regurgitation (aortic insufficiency)

incompetent aortic valve that allows backward flow of blood into left ventricle during diastole

Left ventricular hypertrophy (LVH)

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

State the 4 guidelines to distinguish S1 for S2

1. S1 is the start of 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 (lup-dup), and S1 is the first of the pair 2. S1 is louder than S2 at the apex; S2 is louder than S1 at the base 3. 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 S1 4. S1 coincides with the R wave (the upstroke of the QRS complex) if the person is on an ECG monitor

Discuss the characteristics of an innocent or functional murmur.

30% of children, grade 2 or less, systolic normal split S2, asymptomatic Still's (vibratory) murmur: vibrations from ventricular or mitral structures due to ventricular flow Peripheral pulmonary stenosis murmur: turbulence where main pulmonary artery branches into left and right Venous hum murmur: turbulent flow in superior vena cava and juglar veins (continuous)

Define a bruit, and discuss what it indicates

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

Define a 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

Which of the following cardiac alterations occurs during pregnancy?

An increase in cardiac volume and a decrease in blood pressure Why? During pregnancy the blood volume increases by 30% to 40%; this creates an increase in stroke volume and cardiac output and an increased pulse rate of 10 - 15 beats per minute. The arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation.

Pericardial fluid

ensures smooth, friction-free movement of the heart muscle

Aortic stenosis

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

Differentiate between carotid artery pulsation and jugular vein pulsation

Carotid: higher and 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.

The leaflets of the tricuspid and mitral valves are anchored by __ to the __, which are embedded in the ventricular floor.

Chordae tendineae; papillary muscles Why? the valves are anchored by the collagenous fibers (chordae tendineae) to the papillary muscles, which are embedded in the ventricle floor.

Explain the position of the valves during the cardiac cycle in diastole, isometric contraction, systole, and isometric relaxation.

Diastole- AV vavles (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 between aorta and ventricles causes aortic valve to shut Diastole again - all 4 valves closed, mitral valve opens and diastolic filling begins again

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.

Angina pectoris

acute chest pain that occurs when myocardial demand exceeds its oxygen supply

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

IT is a ventricular filling sound late in diastole when atria contracts right before S1. Heard best at the apex with the patient in left lateral position. (very difficult to hear and need a good bell)

You auscultate a patient to rule out pericardial friction rub. Which assessment technique is most appropriate?

Listen wit the diaphragm, patient sitting up and leaning forward, breath held in expiration

Describe the characteristics of the first heart sound 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. Its intensity is loudest at the apex than 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. S1 is the "lub"

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

Is 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 with respirations the S2 does. The pitch of S3 is lower pitched than S2.

When assessing the carotid artery, the nurse should palpate:

Medial to the sternomastoid muscle, one side at a time.

Myocardium

Muscular wall of the heart

Ventricle

Muscular pumping chamber

explain the physiologic mechanisms for normal splitting of S2 in the pulmonic valve area.

Occurs during inspiration, which separates the timing of the 2 valves (aortic .06 second earlier than pulmonic) closure. So instead of just one Dup, you hear a split T Dup during expiration it returns to normal

The examiner is had estimated the jugular venous pressure. Identify the finding that is abnormal

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

List the characteristics to explore when you hear a murmur, including the grading scale of murmurs.

Pattern- crescendo (louder) decrescendo (taper off). Crescendo-decrescendo depends on blood flow/ pressure. the quality is musical, blowing, harsh, rumbling and location in PMI (best) or valve area, intercostal space on the neck, back, or axilla. Radiation is heard in the direction of blood flow and with posture may disappear or enhance with position. the grading of the murmur: 1. difficult to hear (quiet room needed) 2. Audible but faint 3. easily to hear MOD loud 4. lourd thrill palp on chest 5. very load with part of stethoscope lifted off chest 6. loudest with stethoscope off chest

Differentiate a physiologic S3 from a pathologic S3.

Physio is frequently in children and young adults occasionally may persist after age 40 years especially in women. Usually appears when person sits up. in charts usually S3 is abnormal. Patho is ventricular gallop persists when sitting up and is indicates decreased compliance of ventricles, as in heart failure.

Define preload and after load.

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 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. After load: 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 ejection occurs.

Which description would differentiate a split S2 and S3?

S3 is lower pitches and is heard at the apex

Fourth heart sound (S4)

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

Which of the following is an appropriate position to have the patient assume when auscultating for extra heart sound or murmurs?

Roll toward the left side Why? after auscultation in the supine position, the nurse should have the patient roll onto the left side; the examiner should listen at the apex with the bell for the presence of any diastolic filling sounds (i.e., S3 or S4) of murmurs that may be heard only in this position.

Which of the following guidelines may be used to identify which heart sound is S1?

S1 coincides with the carotid artery pulse. Why? S1 coincides with the carotid artery pulse is loudest at the apex of the heart, coincides with the C wave of the jugular venous pulse wave, and coincides with the R wave (the upstroke of the QRS complex)

A murmur is heard after S1 and before S2. This murmur would be classified as:

Systolic (possible benign)

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

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

Fill in the blanks 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 wave

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

The pulsation created as the left ventricle orates 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

Pericardium

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

When auscultating the heart of a newborn within 24 hours after birth, the examiner hears a continuous sound that mimics the sound of a machine. This finding most likely indicates:

an expected sound caused by non closure of the ductus arteriosus The murmur of a patent ductus arteriosus is a continuous machinery murmur, which disappears by 2 to 3 days.

Define venous pressure and jugular venous pulse

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

Summation gallop

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

The examiner is palpating the apical impulse. Which is a normal-sized impulse?

approximately 1 x 2 cm

Precordium

area of the chest wall overlying the heart and great vessels

The ability of the hart to contract independently of any signals or stimulation is due to:

automaticity Why? the heart can contract by itself, independent of any signals or stimulation from the body; this property is termed automaticity.

Base of the heart

broader area of heart's outline located at the 3rd right and left intercostal spaces

Clubbing

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

Pulmonic stenosis

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

Mitral stenosis

calcified mitral valves impeded forward flow of blood into left ventricle during diastole

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 and increases size more than one space. - a sustained impulse with increased force and duration but not change in location occurs with Left ventricular hypertrophy and no dilation (pressure overload) - pulmonary emphysema makes it non-palpable fro the lung sound overriding heart sound

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

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

The second heart sound is the result of:

closing of the aortic and pulmonic valves

The first heart sound (S1) is produced by the:

closure of the AV valves Why? S1 occurs with closure of the atrioventricular valves. The second heart sound (S2) occurs with closure of the semilunar valves. Normally opening of the semilunar valves is silent, but in aortic or pulmonic stenosis, and ejection clock may be heard.An ejection click occurs early in systole at the start of ejection because it results from opening of the semilunar valves. A third heart sound (S3) can be heard when the ventricles are resistant to filling during the early rapid filling phase. S3 is heard when the AV valves open and atrial blood first pours into the ventricles.

Bell (of the stethoscope)

cup-shaped end piece used for soft, low-pitched heart sounds

Diaphragm (of the stethoscope)

flat endpeice of the stethoscope used for hearing relatively high0pitched heart sounds.

The jugular venous pressure is an indirect reflection of the:

heart's efficiency as a pump Why? jugular venous pressure is a reflection of the heart's ability to pump blood. IF the pressure is elevated, heart failure is suspected.

Pericardial friction rub

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

When auscultating the heart, your first step is to:

identify S1 and S2

Midclavicular line (MCL)

imaginary vertical line bisecting the middle of the clavicle in early hemithorax

Mitral valve

left atrioventricular valve separating the left atrium and ventricle

Mitral regurgitation

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

Describe the effect of respiration on the heart sounds.

more to the right heart less to the left: during inspiration, more venous blood is able to enter the vena cava due to decreasing thoracic pressure which increases the amount of blood in the right side of the heart thus increasing its volume. Meanwhile on the left side a greater amount of blood is sequestered in the lungs momentarily decreased amount returned to left side and thus volume shortening ventricular systole allowing the aortic to close earlier

Paradoxical splitting

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

Thrill

palpable vibration on the chest wall accompanying sever heart murmur

Apical Impulse

point of maximal impulse (PMI); pulsation created as the left ventricle rotates against the chest wall during systole, normally at the 5th left intercostal space i the midclavicular line

The function of the pulmonic valve it to:

protect the orifice between the right ventricle and the pulmonary artery

You will hear a split S2 most clearly in which area

pulmonic

Pulmonic regurgitation

pulmonic insufficiency; back flow of blood through incompetent pulmonic valve into the right ventricle

Tachycardia

rapid heart rate, greater than 95 beats per minute in the adult

Atrium

reservoir for holding blood

Select the best description of the tricuspid valve.

right atrioventricular valve

Tricuspid valve

right atrioventricular valve separating the right atrium and ventricle

Pulmonic valve

right semilunar valve separating the right ventricle and pulmonary artery

Cor pulmonale

right ventricular hypertrophy and heart failure due to pulmonary hypertension

The nurse auscultates the pulmonic valve area in which region?

second left interspace

Edema

selling of legs or dependent body part due to increased interstitial fluid

Coarctation of aorta

severe narrowing of the descending aorta, a congenital heart defect

Bradycardia

slow heart rate, less than 50 beats per minute in the adult

Third heart sound (S3)

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

Inching

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

Syncope

temporary loss of consciousness due to decreased cerebral blood flow (fainting); caused by ventricular systole, pronounced bradycardia, or ventricular fibrillation

Gallop rhythm

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

Apex of the heart

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

Erb's point

traditional auscultatory area in the 3rd left intercostal space

A bruit heard while auscultating the carotid artery of a 65-year-old patient is caused by:

turbulent blood flow through the carotid artery A carotid bruit is a blowing, swishing sound indicating blood flow turbulence. A bruit indicates atherosclerotic narrowing of the vessel.

Palpitation

uncomfortable awareness of rapid or irregular heart rate

The semilunar valves separate the:

ventricles from the arteries