Jarvis Chapter 19 - Cardiovascular

dyspnea

difficult, labored breathing

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 AV valves signaling the beginning of systole

second heart sound s2

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

gallop rhythm

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

diastole

the heart's filling phase

systole

the heart's pumping phase

aortic valve

the left semilunar valve separating the left ventricle and the aorta

LVH; left ventricular hypertrophy

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

mitral regurgitation

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

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 in the midclavicular line

pulmonic regurgitation

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

A 45-year-old man is in the clinic for a routine physical. During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be:

ANS: "Do you have any history of problems with your heart?" Paroxysmal nocturnal dyspnea occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air.

The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse. The apical pulse was 118 beats per minute, and the radial pulse was 105 beats per minute. What is the pulse deficit?

ANS: 13 The nurse should count a serial measurement (one after the other) of apical beat and then the radial pulse. Normally every beat heard at the apex should perfuse to the periphery and be palpable. The two counts should be identical. If different, the nurse should subtract the radial rate from the apical and record the remainder as the pulse deficit.

The electrical stimulus of the cardiac cycle follows which sequence?

ANS: AV node SA node bundle of His bundle branches Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly so that the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.

The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for myocardial infarction (MI)? Select all that apply.

ANS: Abnormal lipids Smoking Hypertension Family history Nine modifiable risk factors for MI, as identified by a recent study, include abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, alcohol use, and regular physical activity.

The nurse is preparing for a class on risk factors for hypertension, and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?

ANS: African-Americans According to the American Heart Association, the prevalence of hypertension is higher among African-Americans than in other racial groups.

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

ANS: Fifth left intercostal space at the midclavicular line The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.

The nurse is reviewing anatomy and physiology of the heart. Which statement best describes what is meant by atrial kick?

ANS: The atria contract toward the end of diastole and push the remaining blood into the ventricles. Toward the end of diastole, the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the "atrial kick."

During a cardiac assessment on a 38 year-old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above sternal angle when he is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty in breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings?

ANS: Heart failure Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion; jugular vein distention; and fatigue. The S3 is associated with heart failure and is always abnormal after age 35. The S3 may be the earliest sign of heart failure.

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age?

ANS: Increase in systolic blood pressure With aging, there is an increase in systolic blood pressure. No significant change in diastolic pressure occurs with age. No change in resting heart rate occurs with aging. Cardiac output at rest is not changed with aging.

The nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse?

ANS: Its location may be indicative of heart size. The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle.

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects correct technique?

ANS: Lightly apply the bell of the stethoscope over the carotid artery, and while listening, have the patient take a breath, exhale, and hold it briefly. The nurse should lightly apply the bell of the stethoscope over the carotid artery at three levels; while listening, the nurse should have the patient take a breath, exhale, and hold it briefly. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotids. Examine only one carotid artery at a time to avoid compromising arterial blood flow to the brain. Avoid pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope.

nurse is preparing to auscultate for heart sounds. Which technique is correct?

ANS: Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time.

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?

ANS: Murmur at second left intercostal space when supine Some murmurs are common in healthy children or adolescents and are termed innocent or functional. The innocent murmur is heard at the second or third left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction.

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response?

ANS: No further response is needed because this is normal. The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration, and slowing with expiration.

The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have?

ANS: Presence of dyspnea or diaphoresis when sucking To screen for heart disease in an infant, focus on feeding. Note fatigue during feeding. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic and then falls into exhausted sleep and awakens after a short time hungry again.

The direction of blood flow through the heart is best described by which of these?

ANS: Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. It goes from there to the left ventricle and then out to the body through the aorta.

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

ANS: Smoking, hypertension, obesity, diabetes, high cholestero For major risk factors for coronary artery disease, collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 130 mg/dL or known diabetes mellitus, obesity, cigarette smoking, low activity level.

The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?

ANS: Studies show that percussed cardiac borders do not correlate well with the true cardiac border. Numerous comparison studies have shown that the percussed cardiac border correlates "only moderately" with the true cardiac border. Percussion is of limited usefulness with the female breast tissue or in an obese person, or a person with a muscular chest wall. Chest x-rays or echocardiogram examinations are much more accurate in detecting heart enlargement.

The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings?

ANS: Tetralogy of Fallot Tetralogy of Fallot subjective findings include (1) severe cyanosis, not in the first months of life but developing as the infant grows, and right ventricle outflow (i.e., pulmonic) stenosis gets worse; (2) cyanosis with crying and exertion at first, then at rest; and (3) slowed development. Objective findings include (1) thrill palpable at left lower sternal border; (2) S1 normal, S2 has A2 loud and P2 diminished or absent; and (3) murmur is systolic, loud, crescendo-decrescendo.

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should see which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage?

ANS: The jugular veins will remain elevated as long as pressure on the abdomen is maintained. When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing; however, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained.

Which of these statements describes the closure of the valves in a normal cardiac cycle?

ANS: The tricuspid valve closes slightly later than the mitral valve. Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).

When assessing a newborn infant who is 5 minutes old, the nurse knows that which of these statements would be true?

ANS: There is an opening in the atrial septum where blood can flow into the left side of the heart. First, about two thirds of the blood is shunted through an opening in the atrial septum, the foramen ovale into the left side of the heart, where it is pumped out through the aorta. The foramen ovale closes within the first hour because the pressure in the right side of the heart is now lower than in the left side.

While auscultating heart sounds on a 7-year-old child for a routine physical, the nurse hears an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of these would be a correct interpretation of these findings?

ANS: These can all be normal findings in a child. Physiologic S3 is common in children. A venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood.

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?

ANS: This is the result of peripheral vasodilatation and is an expected change. Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilatation. The blood pressure drops to its lowest point during the second trimester and then rises after that.

During the cardiac auscultation the nurse hears a sound occurring immediately after S2 at the second left intercostal space. To further assess this sound, what should the nurse do?

ANS: Watch the patient's respirations while listening for effect on the sound. A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the second left interspace. When the split S2 is first heard, the nurse should not be tempted to ask the person to hold his or her breath so that the nurse can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Instead, the nurse should concentrate on the split while watching the person's chest rise up and down with breathing.

During a cardiovascular assessment, the nurse knows that a "thrill" is:

ANS: a vibration that is palpable. A thrill is a palpable vibration. It signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur.

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are:

ANS: aortic and pulmonic. The second heart sound (S2) occurs with closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base of the heart.

A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before S1. The sound is heard only with the bell while the patient is in the left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely a(n):

ANS: atrial gallop. A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle and with systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions. It is heard best at the apex with the patient in the left lateral position.

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:

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

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:

ANS: blood flow turbulence. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present.

When listening to heart sounds, the nurse knows that S1:

ANS: coincides with the carotid artery pulse. S1 coincides with the carotid artery pulse. S1 is the start of systole and is louder than S2 at the apex of the heart; S2 is louder than S1 at the base. The nurse should feel the carotid artery pulse gently while auscultating at the apex; the sound heard as each pulse is felt is S1.

During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:

ANS: displacement of the heart from elevation of the diaphragm. Palpation of the apical impulse is higher and more lateral compared with the normal position because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:

ANS: elevated pressure related to heart failure. Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure.

During inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests:

ANS: enlargement of the right ventricle. Normally, the examiner may or may not see an apical impulse; when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line. 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.

a cardiovascular assessment, the nurse knows that an S4 heart sound is:

ANS: heard at the end of ventricular diastole. An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when the ventricles are resistant to filling. The S4 occurs just before the S1.

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects:

ANS: inflammation of the precordium. Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and scratchy, like sandpaper being rubbed. It is best heard with the diaphragm of the stethoscope, with the person sitting up and leaning forward, and with the breath held in expiration. A friction rub can be heard any place on the precordium but usually is best heard at the apex and left lower sternal border, which are places where the pericardium comes in close contact with the chest wall.

The nurse knows that normal splitting of the second heart sound is associated with:

ANS: inspiration. Normal or physiologic splitting of the second heart sound is associated with inspiration because of the increased blood return to the right side of the heart, delaying closure of the pulmonic valve.

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

ANS: listen with the bell of the stethoscope to assess for bruits. If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults. Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain.

A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding." During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area the nurse also auscultates a blowing, swishing sound right after S1. These findings would be most consistent with:

ANS: mitral regurgitation. Mitral regurgitation subjective findings include fatigue, palpitation, and orthopnea. Objective findings are (1) a thrill in systole at apex, (2) lift at apex, (3) apical impulse displaced down and to the left, (4) S1 diminished, S2 accentuated, S3 at apex often present, and (5) murmur: pansystolic, often loud, blowing, best heard at apex, radiating well to the left axilla.

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:

ANS: normal for this age. The heart rate may range from 100 to 180 beats per minute immediately after birth and then stabilize to an average of 120 to 140 beats per minute. Infants normally have wide fluctuations with activity, from 170 beats per minute or more with crying or being active to 70 to 90 beats per minute with sleeping. Persistent tachycardia is greater than 200 beats per minute in newborns or greater than 150 beats per minute in infants.

The sac that surrounds and protects the heart is called the:

ANS: pericardium. The pericardium is a tough fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid.

The component of the conduction system referred to as the pacemaker of the heart is the:

ANS: sinoatrial (SA) node. Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. Because the SA node has an intrinsic rhythm, it is the "pacemaker."

During an assessment, the nurse notes that the patient's apical impulse is displaced laterally, and it is palpable over a wide area. This indicates:

ANS: volume overload, as in mitral regurgitation. Cardiac enlargement displaces the apical impulse laterally and over a wider area when left ventricular hypertrophy and dilatation are present. This is volume overload, as in mitral regurgitation, aortic regurgitation, or left-to-right shunts.

angina pectoris

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

aortic regurgitation

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

summation gallop

abnormal mid diastolic heart sound heard when both the pathologic s3 and s4 are present

precordium

area of the chest wall overlying the heart and great vessels

base of the heart

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

clubbing

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

aortic stenosis

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

pulmonic stenosis

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

mitral stenosis

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

bell of the stethoscope

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

diaphragm of the stethoscope

flat end piece of the stethoscope used for hearing relatively high pitched heart sounds

pericardial friction rub

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

MCL; midclavicular line

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

mitral valve

left AV valve separating the left atria and ventricle

paradoxical splitting

opposite of a normal split 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 severe heart murmur

tachycardia

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

tricuspid valve

right AV valve separating the right atria 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

Fourth heart sound s4

s4 gallop; atrial gallop; very soft, low pitched ventricular filling sound that occurs in late diastole

coarctation of aorta

severe narrowing of the descending aorta, a congenital heart defeat

bradycardia

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

third heart sound s3

soft, low pitched ventricular filling sound that occurs in early diastole (s3 gallop) and may be an early sign of heart failure

edema

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

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 flood flow (fainting), caused by ventricular systole, pronounced bradycardia, or ventricular fibrillation

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

palpitation

uncomfortable awareness of rapid or irregular heart rate