Chapter 21- Assessing Heart/neck vessels

Tachycardia and Palpitations

-Tachycardia may be seen with weak heart muscles, an attempt by the heart to increase CO. -Palpitations may occur with an abnormality of the heart's conduction system (arrhythmias) or during the heart's attempt to increase CO by increasing the HR. Palpitations may cause the client to feel anxious.

bicuspid valve

2 cusps, between the left atrium and ventricle

tricuspid valve

3 cusps, between the right atrium and ventricle

Auscultate the carotid arteries -if the client is middle-aged or older or if you suspect cardiovascular disease. Place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath for a moment so that breath sounds do not conceal any vascular sounds

A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel, is indicative of occlusive arterial disease. However, if the artery is more than two-thirds occluded, a bruit may not be heard. *Always auscultate the carotid arteries before palpating because palpation may increase or slow the HR, changing the strength of the carotid impulse heard.

lift

A diffuse lifting left during systole at the left lower sternal border, a lift or heave is associated with right ventricular hypertrophy caused by pulmonic valve disease, pulmonic hypertension, and chronic lung disease. You may also see retraction at the apex, from the posterior rotation of the left ventricle caused by the oversized right ventricle.

diminished A2

A diminished A2 is soft or absent over the right, second ICS. This occurs with immobility of the aortic valve in calcific aortic stenosis.

diminished s2

A diminished S2 means that S2 is softer than S1. This occurs in conditions in which the aortic or pulmonic valves have decreased mobility. Examples include: Decreased systemic blood pressure, which weakens the valves, as in shock Aortic or pulmonic stenosis, in which the valves are thickened and calcified, with decreased mobility

normal pulse

A normal pulse, represented in the figure, has a smooth, rounded wave with a notch on the descending slope. The pulse should feel strong and regular. The notch is not palpable. The pulse pressure (the difference between the systolic and diastolic pressure) is 30-40 mmHg. Pulse pressure may be measured in waveforms, which are produced when a pulmonary artery catheter is used to evaluate arterial pressure. The arterial pressure waveform consists of five parts: Anacrotic limb, systolic peak, dicrotic limb, dicrotic notch, and end diastole. The initial upstroke, or anacrotic limb, occurs as blood is rapidly ejected from the ventricle through the open aortic valve into the aorta. The anacrotic limb ends at the systolic peak, the waveform's highest point. Arterial pressure falls as the blood continues into the peripheral vessels and the waveform turns downward, forming the dicrotic limb. When the pressure in the ventricle is less than the pressure in the aortic root, the aortic valve closes and a small notch (dicrotic notch) appears on the waveform. The closing of the aortic notch is the beginning of diastole. The pressure continues to fall in the aortic root until it reaches its lowest point, seen on the waveform as the diastolic peak.

normal (physiologic) split s2

A normal split S2 can be heard over the second or third left ICS. It is usually heard best during inspiration and disappears during expiration. Over the aortic area and apex, the pulmonic component of S2 is usually too faint to be heard and S2 is a single sound resulting from aortic valve closure. In some clients, S2 may not become single on expiration unless the client sits up. Splitting that does not disappear during expiration is suggestive of heart disease.

If you detect an irregular rhythm, auscultate for a pulse rate deficit. This is done by palpating the radial pulse while you auscultate the apical pulse. Count for a full minute.

A pulse deficit (difference between the apical and peripheral/radial pulses) may indicate atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block.

Accentuated Apical Impulse

A sign of pressure overload, the accentuated apical impulse has increased force and duration but is not usually displaced in left ventricular hypertrophy without dilation associated with aortic stenosis or systemic hypertension.

laterally displaced apical impulse

A sign of volume overload, an apical impulse displaced laterally and found over a wider area is the result of ventricular hypertrophy and dilatation associated with mitral regurgitation, aortic regurgitation, or left-to-right shunts. A client with ventricular hypertrophy has an apical impulse that is displaced and found over a large area. Bounding pulses are found in clients with aortic regurgitation or heart block.

diminished p2

A soft or absent P2 sound occurs with an increased anteroposterior diameter of the chest (barrel chest), which is associated with aging, pulmonic stenosis, or COPD (chronic obstructive pulmonary disease).

thrill

A thrill is palpated over the second and third ICS; a thrill may indicate severe aortic stenosis and systemic hypertension. A thrill palpated over the second and third left ICSs may indicate pulmonic stenosis and pulmonic hypertension.

Palpate for abnormal pulsations. Use your palmar surfaces to palpate the apex, left sternal border, and base.

A thrill or a pulsation is usually associated with a grade IV or higher murmur.

Listen to S1. Use the diaphragm of the stethoscope to best hear S1

Accentuated, diminished, varying, or split S1 are all abnormal findings

Have you had rheumatic fever?

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) is a significant public health concern around the world (Seckeler & Hoke, 2011). Rheumatic carditis develops after exposure to group A beta-hemolytic streptococci and results in inflammation of all layers of the heart, impairing contraction and valvular function.

S3 (third heart sound)

Also called a ventricular gallop, the S3 has a low frequency and is heard best using the bell of the stethoscope at the apical area or lower right ventricular area of the chest with the patient in the left lateral position. The sound is often accentuated during inspiration and has the rhythm of the word "Ken-tuc-ky." S3 is the result of vibrations caused by the blood hitting the ventricular wall during rapid ventricular filling. The S3 can be a normal finding in young children, people with a high CO, and in the third trimester of pregnancy. It is rarely normal in people older than age 40 years and is usually associated with decreased myocardial contractility, myocardial failure, congestive heart failure, and volume overload of the ventricle from valvular disease.

S4 (fourth heart sound)

Also called an atrial gallop, S4 is a low-frequency sound occurring at the end of diastole when the atria contract. It is caused by vibrations from blood flowing rapidly into the ventricles after atrial contraction. S4 has the rhythm of the word "Ten-nes-see" and may increase during inspiration. It is best heard with the bell of the stethoscope over the apical area with the patient in a supine or left lateral position, and is never heard in the absence of atrial contraction. The S4 can be a normal sound in trained athletes and some older patients, especially after exercise. However, it is usually an abnormal finding and is associated with coronary artery disease, hypertension, aortic and pulmonic stenosis, and acute MI.

S4 heart sound

An S1 may be split along the lower left sternal border, where the tricuspid component of the sound, usually too faint to be heard, can be auscultated. A split S1 heard over the apex may be an S4.

Ask the client to assume a left lateral position. Use the bell of the stethoscope and listen at the apex of the heart.

An S3 or S4 heart sound or a murmur of mitral stenosis that was not detected with the client in the supine position may be revealed when the client assumes the left lateral position.

accentuated A2

An accentuated A2 is loud over the right, second ICS. This occurs with increased pressure, as in systemic hypertension and aortic root dilation because of the closer position of the aortic valve to the chest wall.

accentuated p2

An accentuated P2 is louder than or equal to an A2 sound. This occurs with pulmonary hypertension, dilated pulmonary artery, and atrial septal defect. A wide split S2, heard even at the apex, indicates an accentuated P2.

accentuated s1

An accentuated S1 sound is louder than an S2. This occurs when the mitral valve is wide open and closes quickly. Examples include: Hyperkinetic states in which blood velocity increases such as fever, anemia, and hyperthyroidism Mitral stenosis in which the leaflets are still mobile but increased ventricular pressure is needed to close the valve

accentuated s2

An accentuated S2 means that S2 is louder than S1. This occurs in conditions in which the aortic or pulmonic valve has a higher closing pressure. Examples include: Increased pressure in the aorta from exercise, excitement, or systemic hypertension (a booming S2 is heard with systemic hypertension) Increased pressure in the pulmonary vasculature, which may occur with mitral stenosis or congestive heart failure Calcification of the semilunar valve, in which the valve is still mobile, as in pulmonic or aortic stenosis

Listen to S2. Use the diaphragm of the stethoscope. Ask the client to breathe regularly

Any split S2 heard in expiration is abnormal. The abnormal split can be one of three types: wide, fixed, or reversed.

split s1

As named, a split S1 occurs as a split sound. This occurs when the left and right ventricles contract at different times (asynchronous ventricular contraction). Examples include: Conduction delaying the cardiac impulse to one of the ventricles, as in bundle branch block Ventricular ectopy in which the impulse starts in one ventricle, contracting it first, and then spreading to the second ventricle

pulmonic ejection click

Best heard at the second left ICS during early systole, the pulmonic ejection click often becomes softer with inspiration.

Auscultate HR and rhythm.

Bradycardia (less than 60 beats/min) or tachycardia (more than 100 beats/min) may result in decreased CO. Refer clients with irregular rhythms (i.e., premature atrial contraction or premature ventricular contractions, atrial fibrillation, atrial flutter with varying blocks) for further evaluation. These types of irregular patterns may predispose the client to decreased CO, heart failure, or emboli

heartburn

Cardiac pain may be overlooked or misinterpreted as gastrointestinal problems. Gastrointestinal pain may occur after meals and is relieved with antacids. Cardiac pain may occur anytime, is not relieved with antacids, and worsens with activity.

small, weak pulse

Causes Conditions causing a decreased SV -Heart failure -Hypovolemia -Severe aortic stenosis Conditions causing increased peripheral resistance -Hypothermia -Severe congestive heart failure

Do you experience chest pain? If the client answers yes, use COLDSPA to explore the symptom. Character: Describe your chest pain (stabbing, burning, crushing, squeezing, or tightness).

Chest pain can be cardiac, pulmonary, muscular, or gastrointestinal in origin. Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Diaphoresis and pain worsened by activity are usually related to cardiac chest pain. Other symptoms that may occur include dyspnea, diaphoresis, pallor, nausea, palpitations, or tachycardia. Pain is usually seen in clients with angina. However, some clients may experience these other symptoms without the pain.

venous hum

Common in children, a venous hum is a benign sound caused by turbulence of blood in the jugular veins. It is heard above the medial third of the clavicles, especially on the right, and may radiate to the first and second ICSs. A low-pitched sound, it is often described as a humming or roaring continuous murmur without a silent interval, and is loudest in diastole. A venous hum can be obliterated by putting pressure on the jugular veins.

large, bounding pulse

Conditions that cause an increased SV or decreased peripheral resistance -Fever -Anemia -Hyperthyroidism -Aortic regurgitation -Patent ductus arteriosus Conditions resulting in increased SV due to decreased HR -Bradycardia -Complete heart block -Conditions resulting in decreased compliance of the aortic walls -Aging -Atherosclerosis

Evaluate jugular venous pressure To evaluate jugular vein distention, position the client in a supine position with the head of the bed elevated 30, 45, 60, and 90 degrees. At each increase of the elevation, have the client's head turned slightly away from the side being evaluated. Using tangential lighting, observe for distention, protrusion, or bulging.

Distention, bulging, or protrusion at 45, 60, or 90 degrees may indicate right-sided heart failure. Document at which positions (45, 60, and/or 90 degrees) you observe distention. Clients with obstructive pulmonary disease may have elevated venous pressure only during expiration. An inspiratory increase in venous pressure, called Kussmaul sign, may occur in clients with severe constrictive pericarditis.

dizziness

Dizziness may indicate decreased blood flow to the brain due to myocardial damage. However, there are several other causes for dizziness such as inner ear syndromes, decreased cerebral circulation, and hypotension.

lipid profile test

Dyslipidemia presents the greatest risk for the developing coronary artery disease. Elevated cholesterol levels have been linked to the development of atherosclerosis

Dyspnea, SOB, Orthopnea

Dyspnea may result from congestive heart failure, pulmonary disorders, coronary artery disease, myocardial ischemia, and myocardial infarction (MI). Dyspnea may occur at rest; during sleep; or with mild, moderate, or extreme exertion. Orthopnea is the need to sit more upright to breathe easily due to fluid accumulation in the lungs. Waking up from dyspnea during the night (paroxysmal nocturnal dyspnea) is seen with heart failure due to redistribution of fluid from the ankles to the lungs when one lies down at night.

edema

Edema in both lower extremities at night is seen in heart failure due to a reduction of blood flow out of the heart, causing blood returning to the heart to back up in the organs and dependent areas of the body.

abnormal heart sounds

Ejection sounds or clicks (e.g., a mid-systolic click associated with mitral valve prolapse). A friction rub may also be heard during the systolic pause. A pathologic S3 (ventricular gallop) may be heard with ischemic heart disease, hyperkinetic states (e.g., anemia), or restrictive myocardial disease. A pathologic S4 (atrial gallop) toward the left side of the precordium may be heard with coronary artery disease, hypertensive heart disease, cardiomyopathy, and aortic stenosis. A pathologic S4 toward the right side of the precordium may be heard with pulmonary hypertension and pulmonic stenosis. S3 and S4 pathologic sounds together create a quadruple rhythm, which is called a summation gallop. Opening snaps (OSs) occur early in diastole and indicate mitral valve stenosis. A friction rub may also be heard during the diastolic pause While auscultating, keep in mind that development of a pathologic S3 may be the earliest sign of heart failure.

fatigue

Fatigue may result from compromised CO. Fatigue related to decreased CO is worse in the evening or as the day progresses, whereas fatigue seen with depression is ongoing throughout the day.

sputum

Fluid accumulation in the lungs from heart failure can cause one to cough up white- or pink-tinged sputum.

Observe the jugular venous pulse. Inspect the jugular venous pulse by standing on the right side of the client. The client should be in a supine position with the torso elevated 30-45 degrees. Make sure the head and torso are on the same plane. Ask the client to turn the head slightly to the left. Shine a tangential light source onto the neck to increase visualization of pulsations as well as shadows. Next, inspect the suprasternal notch or the area around the clavicles for pulsations of the internal jugular veins.

Fully distended jugular veins with the client's torso elevated more than 45 degrees indicate increased central venous pressure that may be the result of right ventricular failure, pulmonary hypertension, pulmonary emboli, or cardiac tamponade.

intensity of murmur

Grade 1: Very faint, heard only after the listener has "tuned in"; may not be heard in all positions Grade 2: Quiet, but heard immediately on placing the stethoscope on the chest Grade 3: Moderately loud Grade 4: Loud Grade 5: Very loud, may be heard with a stethoscope partly off the chest Grade 6: May be heard with the stethoscope entirely off the chest

aortic ejection click

Heard during early systole at the second right ICS and apex, the aortic ejection click occurs with the opening of the aortic valve and does not change with respiration.

midsystolic click

Heard in middle or late systole, a midsystolic click can be heard over the mitral or apical area and is the result of mitral valve leaflet prolapse during left ventricular emptying. A late systolic murmur typically follows, indicating mild mitral regurgitation.

ejection clicks

High-frequency sounds heard just after S1 (ejection clicks) are produced by a functioning, but diseased, valve. Clicks can occur in early or mid-to-late systole and are best heard through the diaphragm of the stethoscope.

s3

If present, S3 can be heard early in diastole, after S2 S3 is often termed ventricular gallop

s4

If present, S4 can be heard late in diastole, just before S1. vibration is secondary to ventricular resistance (noncompliance) during atrial contraction. S4 is called atrial gallop

nocturia

Increased renal perfusion during periods of rest or recumbent positions may cause nocturia, which occurs with heart failure.

Ask the client to sit up, lean forward, and exhale. Use the diaphragm of the stethoscope and listen over the apex and along the left sternal border

Murmur of aortic regurgitation may be detected when the client assumes this position.

Auscultate for extra heart sounds. Use the diaphragm first, then the bell (Fig. 21-14) to auscultate over the entire heart area. Note the characteristics (e.g., location, timing) of any extra sound heard.

Normally no sounds are heard. A physiologic S3 heart sound is a benign finding commonly heard at the beginning of the diastolic pause in children, adolescents, and young adults. It is rare after age 40. The physiologic S3 usually subsides upon standing or sitting up. A physiologic S4 heart sound may be heard near the end of diastole in well-conditioned athletes and in adults older than age 40 or 50 with no evidence of heart disease, especially after exercise.

opening snap

Occurring in early diastole, an opening snap (OS) is heard with the opening of a stenotic or stiff mitral valve. Heard throughout the whole precordium, it does not vary with respirations. Often mistaken for a split S2 or an S3, the OS occurs earlier in diastole and has a higher pitch than an S3

pansystolic murmurs

Occurring when blood flows from a chamber with high pressure to a chamber of low pressure through an orifice that should be closed, pansystolic murmurs are pathologic. Also called holosystolic murmur, these murmurs begin with S1 and continue through systole to S2. -murmur of mitral regurgitation- Occurring when the mitral valve fails to close fully in systole, the murmur of mitral regurgitation is the result of blood flowing from the left ventricle back into the left atrium. Volume overload occurs in the left ventricle, causing dilatation and hypertrophy. -murmur of tricuspid regurgitation- Blood flowing from the right ventricle back into the right atrium over a tricuspid valve that is not fully closed causes the murmur of tricuspid regurgitation. Right ventricular failure with dilation is the most common cause and usually results from pulmonary hypertension or left ventricular failure. -ventricular septal defect- A congenital abnormality in which blood flows from the left ventricle into the right ventricle through a hole in the septum, a ventricular septal defect causes a loud murmur that obscures the A2 sound.

phases of the electrocardiogram

P wave: Atrial depolarization; conduction of the impulse throughout the atria. PR interval: Time from the beginning of the atrial depolarization to the beginning of ventricular depolarization, that is, from the beginning of the P wave to the beginning of the QRS complex. QRS complex: Ventricular depolarization (also atrial repolarization); conduction of the impulse throughout the ventricles, which then triggers contraction of the ventricles; measured from the beginning of the Q wave to the end of the S wave. ST segment: Period between ventricular depolarization and the beginning of ventricular repolarization. T wave: Ventricular repolarization; the ventricles return to a resting state. QT interval: Total time for ventricular depolarization and repolarization, that is, from the beginning of the Q wave to the end of the T wave; the QT interval varies with HR. U wave: May or may not be present; if present, it follows the T wave and represents the final phase of ventricular repolarization.

paradoxical pulse

Palpable decrease in pulse amplitude on quiet inspiration Pulse becomes stronger with expiration You may need a sphygmomanometer to detect the change (the systolic pressure will decrease by more than 10 mmHg during inspiration) Pericardial tamponade Constrictive pericarditis Obstructive lung disease

patent ductus arteriosis

Patent ductus arteriosus (PDA) is a congenital anomaly that leaves an open channel between the aorta and pulmonary artery. Found over the second left ICS, the murmur of PDA may radiate to the left clavicle. It is classified as a continuous murmur because it extends through systole and into part of diastole. It has a medium pitch and a harsh, machinery-like sound. The murmur is loudest in late systole, obscures S2, fades in diastole, and often has a silent interval in late diastole.

Auscultate for murmurs. A murmur is a swishing sound caused by turbulent blood flow through the heart valves or great vessels. Auscultate for murmurs across the entire heart area. Use the diaphragm and the bell of the stethoscope in all areas of auscultation because murmurs have a variety of pitches. Also auscultate with the client in different positions as described in the next section because some murmurs occur or subside according to the client's position.

Pathologic midsystolic, pansystolic, and diastolic murmurs.

have you had heart surgery or cardiac balloon interventions

Previous heart surgery may change the heart sounds heard during auscultation. Surgery and cardiac balloon interventions indicate prior cardiac compromise.

Inspect for any pulsations on anterior chest over heart. With the client in supine position with the head of the bed elevated between 30 and 45 degrees, stand on the client's right side and look for the apical impulse and any abnormal pulsations.

Pulsations, which may also be called heaves or lifts, other than the apical pulsation are considered abnormal and should be evaluated. A heave or lift may occur as the result of an enlarged ventricle from an overload of work.

Palpate the carotid arteries. Palpate each carotid artery alternately by placing the pads of the index and middle fingers medial to the sternocleidomastoid muscle on the neck (Fig. 21-10). Note amplitude and contour of the pulse, elasticity of the artery, and any thrills (which feel similar to a purring cat) *Palpate the carotid arteries individually because bilateral palpation could result in reduced cerebral blood flow. If you detect occlusion during auscultation, palpate very lightly to avoid blocking circulation or triggering vagal stimulation and bradycardia, hypotension, or even cardiac arrest.

Pulse inequality may indicate arterial constriction or occlusion in one carotid. Weak pulses may indicate hypovolemia, shock, or decreased cardiac output. A bounding, firm pulse may indicate hypervolemia or increased CO. Variations in strength from beat to beat or with respiration are abnormal and may indicate a variety of problems (Abnormal Findings 21-1). A delayed upstroke may indicate aortic stenosis. Loss of elasticity may indicate arteriosclerosis. Thrills may indicate a narrowing of the artery.

Pulsus alternans

Regular rhythm Changes in amplitude (or strength) from beat to beat Left ventricular failure (usually accompanied by an S3 sound on the left)

Bigeminal Pulse

Regular, irregular rhythm (one normal beat followed by a premature contraction) Alternates in amplitude (one strong pulse followed by a quick, weaker one) premature ventricular contractions

Cardiac Output (CO)

SV × HR = CO The normal adult CO is 5 to 6 L/min.

diminished s1

Sometimes the S1 sound is softer than the S2 sound. This occurs when the mitral valve is not fully open at the time of ventricular contraction and valve closing. Examples include: Delayed conduction from the atria to the ventricles as in first-degree heart block, which allows the mitral valve to drift closed before ventricular contraction closes it Mitral insufficiency in which extreme calcification of the valve limits mobility Delayed or diminished ventricular contraction arising from forceful atrial contraction into a noncompliant ventricle, as in severe pulmonary or systemic hypertension

Stroke Volume (SV)

Stroke volume (SV) is the amount of blood pumped from the heart with each contraction (SV from the left ventricle is usually 70 mL). SV is influenced by several factors: The degree of stretch of the heart muscle up to a critical length before contraction (preload); the greater the preload, the greater the SV. This holds true unless the heart muscle is stretched so much that it cannot contract effectively. The pressure against which the heart muscle has to eject blood during contraction (afterload); increased afterload results in decreased SV. Synergy of contraction (i.e., the uniform, synchronized contraction of the myocardium); conditions that cause an asynchronous contraction decrease SV. Compliance, or distensibility, of the ventricles; decreased compliance decreases SV. Contractility, or the force of contractions, of the myocardium under given loading conditions; increased contractility increases SV.

Palpate the apical impulse. Remain on the client's right side and ask the client to remain supine. Use one or two finger pads to palpate the apical impulse in the mitral area (fourth or fifth ICS at the MCL) (Fig. 21-11A). You may ask the client to roll to the left side to better feel the impulse using your finger pads

The apical impulse may be impossible to palpate in clients with pulmonary emphysema. If the apical impulse is larger than 1-2 cm, displaced, more forceful, or of longer duration, suspect cardiac enlargement.

midsystolic murmurs

The most common type of heart murmurs—midsystolic murmurs—occur during ventricular ejection and can be innocent, physiologic, or pathologic. They have a crescendo-decrescendo shape and usually peak near midsystole and stop before S2. -innocent-occur when the ejection of blood into the aorta is turbulent. Very common in children and young adults -physiologic- Caused by a temporary increase in blood flow, a physiologic murmur can occur with anemia, pregnancy, fever, and hyperthyroidism. -pathologic/ murmur of pulmonic stenosis- occurs from impeded flow across the pulmonic valve and increased right ventricular afterload. Often occurring as a congenital anomaly, the murmur is commonly found in children With severe pulmonic stenosis, the S2 is widely split and P2 is diminished. A right-sided S4 may also be present, and the right ventricular impulse is often stronger and may be prolonged -murmur of hypertrophic cardiopathy- Caused by unusually rapid ejection of blood from the left ventricle during systole, the murmur of cardiac hypertrophy results from massive hypertrophy of the ventricular muscle. There may be a coexisting obstruction to blood flow.

summation gallop

The simultaneous occurrence of S3 and S4 is called a summation gallop. It is brought about by rapid HRs in which diastolic filling time is shortened, moving S3 and S4 closer together, resulting in one prolonged sound. Summation gallop is associated with severe congestive heart disease.

premature atrial or junctional contractions

These beats occur earlier than the next expected beat and are followed by a pause. The rhythm resumes with the next beat. Auscultation Tip: The early beat has an S1 of different intensity and a diminished S2. S1 and S2 are otherwise similar to normal beats.

premature ventricular contractions

These beats occur earlier than the next expected beat and are followed by a pulse. The rhythm resumes with the next beat. Auscultation Tip: The early beat has an S1 of different intensity and a diminished S2. Both sounds are usually split.

reversed split s2

This is a split S2 that appears on expiration and disappears on inspiration—also known as paradoxical split. It occurs when closure of the aortic valve is abnormally delayed, causing A2 to follow P2 in expiration. Normal inspiratory delay of P2 makes the split disappear during inspiration. An example: Left bundle branch block

fixed split s2

This is a wide splitting that does not vary with respiration. It occurs when there is delayed closure of one of the valves. An example: Atrial septal defect and right ventricular failure, which delay pulmonic valve closing

wide split s2

This is an increase in the usual splitting that persists throughout the entire respiratory cycle and widens on expiration. It occurs when there is delayed electrical activation of the right ventricle. An example: Right bundle branch block, which delays pulmonic valve closing

varying s1

This occurs when the mitral valve is in different positions when contraction occurs. Examples include: Rhythms in which the atria and ventricles are beating independently of each other Totally irregular rhythm such as atrial fibrillation

pericardial friction rub

Usually heard best in the third ICS to the left of the sternum, a pericardial friction rub is caused by inflammation of the pericardial sac. A high-pitched, scratchy, scraping sound, the rub may increase with exhalation and when the patient leans forward. For best results, use the diaphragm of the stethoscope and have the patient sit up, lean forward, exhale, and hold his or her breath. The pericardial friction rub can have up to three components: atrial systole, ventricular systole, and ventricular diastole. These components are associated with cardiac movement. The first two components are usually present. If only one component is present, the rub may be confused with a murmur. Friction rubs are commonly heard during the first week after an MI. If a significant pericardial effusion is present, S1 and S2 sounds will be distant.

Diastolic Murmurs

Usually indicative of heart disease, diastolic murmurs occur in two types. Early decrescendo diastolic murmurs indicate flow through an incompetent semilunar valve, commonly the aortic valve. Rumbling diastolic murmurs in mid- or late diastole indicate valve stenosis, usually of the mitral valve. -murmur of aortic regurgitation- Occurring when the leaflets of the aortic valve fail to close completely, the murmur of aortic regurgitation is the result of blood flowing from the aorta back into the left ventricle. This results in left ventricular volume overload. An ejection sound also may be present. Severe regurgitation should be suspected if an S3 or S4 is also present. -murmur of mitral stenosis- the result of blood flow across a diseased mitral valve. Thickened, stiff, distorted leaflets are usually the result of rheumatic fever. The murmur is loud during mid-diastole as the ventricle fills rapidly, grows quiet, and becomes loud again immediately before systole, as the atria contract. In patients with atrial fibrillation, the second half of the murmur is absent because of the lack of atrial contraction.

sinus arrhythmia

With this dysrhythmia, the HR speeds up and slows down in a cycle, usually becoming faster with inhalation and slower with expiration. Auscultation Tip: S1 and S2 sounds are usually normal. The S1 may vary with the HR.

ATRIAL FIBRILLATION AND ATRIAL FLUTTER WITH VARYING VENTRICULAR RESPONSE

With this dysrhythmia, ventricular contraction occurs irregularly. At times, short runs of the irregular rhythm may appear regularly. Auscultation Tip: S1 varies in intensity.

components of jugular venous pulse

a wave—reflects rise in atrial pressure that occurs with atrial contraction x descent—reflects right atrial relaxation and descent of the atrial floor during ventricular systole v wave—reflects right atrial filling, increased volume, and increased atrial pressure y descent—reflects right atrial emptying into the right ventricle and decreased atrial pressure

atrial kick

blood pushed into the ventricles because of atrial contraction, usually at the end of diastole

Bisferiens pulse

double systolic peak caused by: Pure aortic regurgitation Combined aortic stenosis and regurgitation Hypertrophic cardiomyopathy