Ch. 21 Heart and Neck Vessels
Located on posterior wall of RA generates 60-100 bpm "pacemaker of the heart"
SA node
Electrical pathway through the heart goes:
SA node AV node Bundle of His Bundle branches (right, left) Purkinje fibers
cardiac output calculated by
SV times HR
When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as?
Summation gallop
Where are the heart and great vessels located in the human body?
The mediastinum, between the lungs above the diaphragm
During assessment, the nurse notes an irregular rhythm. What should the nurse do next?
Assess for a pulse deficit.
The atrioventricular valves of the heart are located:
At the entrance to the ventricles
lets blood into ventricle, when ventricle contracts, valves close so blood can't backup
Atrioventricular valves right sided: tricuspid valve left sided: mitral valve
systole
-contraction of the ventricles -AV valves shut -aortic and pulmonic valves open -blood is ejected -aortic and pulmonic (semilunar) valves shut (S2)
diastole
-relaxation of the ventricles -AV valves are open
Closure of the mitral valve is thought to produce the ___ heart sound
1st (S1)
It is thought that the closure of the aortic valve produces the ___ heart sound.
2nd (S2)
The area known as Erb's point is the third site for auscultation on the precordium. Where is it located?
3rd left rib space
a bounding pulse would be rated at
4+
Normal adult cardiac output is ____ L/min.
5-6
Normal stroke volume from LV is _____ mL/beat.
70
-Located in the intraatrial septum -picks up impulses from SA node and slightly delays conduction -relays impulses to AV bundle (Bundle of His) -takes over when SA node fails to initiate impulse -discharges 40-60 bpm
AV node
As the nurse is auscultating a client's heart sounds, she hears the first heart sound, which indicates the beginning of systole. The nurse knows that which structure slightly delays the incoming electrical impulses from the atria before relaying the impulse on to the ventricles, causing them to contract during this phase?
AV node
Areas of auscultation for heart sounds Ape To Man
Aortic (2nd ICS to apex) Pulmonic (2nd and 3rd ICS close to sternum) Erb's (3-5 ICS at left sternal boarder) Mitral (5th ICS near left MCL - the apex of the heart) Tricuspid (4th or 5th ICS at the left lower sternal border
When a patient is obese or has a thick chest wall, what is difficult to palpate?
Apical impulse (Mitral)
How should a nurse assess a client for pulse rate deficit?
Assess for a difference between the apical and radial pulse
The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?
Bruit
-transmits to right and left bundle branches which transmit to Purkinje fibers -has ability to take over when SA and AV nodes fail -discharges 40-60 bpm
Bundle of His
A nurse recognizes that the second heart sound, S2, is produced by which cardiac action?
Closure of the semilunar valves
Route of blood flow
Inferior and Superior vena cava RA tricuspid valve RV pulmonary valve pulmonary artery lungs pulmonary veins LA mitral valve LV aortic valve aorta
A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?
Inflammation of the pericardial sac
Exits RV bifurcates into LPA and RPA carries deoxygenated blood to lungs
Main pulmonary artery
The event producing the first heart sound (S1) is closure of which of the following valves?
Mitral
A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?
Observe for a decrease in jugular venous pressure
exit from ventricles at beginning of great vessels, have 3 cusps and looks like half moon
Semilunar valves right sided: pulmonic valve left sided: aortic valve
A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?
Orthopnea Explanation: Orthopnea, which is dyspnea that occurs when lying down and improves when sitting up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.
A nurse experiences difficulty differentiating S1 from S2 when auscultating a client's heart sounds. What is an appropriate action by the nurse?
Palpate the carotid pulse simultaneously
inferior vena cava drains lower part of body and empties into ____.
RA
superior vena cava drains upper part of body and empties into _____.
RA
The heart sound caused by the closure of the AV valves is
S1
When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound?
S2
A nurse is working with an older client who has decreased left ventricular compliance. The nurse understands that this condition will cause a decrease in the amount of blood pumped from the heart with each contraction, a measure known as which of the following?
Stroke Volume
The client has been diagnosis with severe sepsis. Which finding would indicate the client is experiencing low cardiac output?
Tachycardia; hypotension
Which of the following statements most accurately describes preload?
The amount of blood in the ventricles at the end of diastole
During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's
apex of the heart.
The QRS complex of the EKG represents:
Ventricular depolarization
During auscultation of the heart, a nurse hears an extra heart sound immediately after S2 at the second left intercostal space. What should the nurse do to further assess this finding?
Watch the client's respirations while listening for effect on the heart sound.
preload
degree of the stretch of the heart muscle preload increases = increase in SV
A thrill or a pulsation is usually associated with
a murmur.
sinus bradycardia
a sinus rhythm with a resting heart rate of 60 beats per minute or less.
sinus tachycardia
a sinus rhythm with a resting heart rate of over 100 beats per minute.
chordae tendineae
anchor the AV valve flaps to papillary muscles within the ventricles
transports oxygenated blood from LV to body
aorta
The area of auscultation located at the second intercostal space at the right sternal border is called the
aortic area
The semilunar valves are located (pulmonic and aortic)
at the exit of each ventricle at the beginning of the great vessels.
P wave
atrial depolarization
While assessing the carotid pulse, the nurse incorporates into the assessment the technique of
ausculating the carotid artery before palpating to avoid changing the heart rate. using the bell of the sthetoscope and having the patient hold his breath for a moment so breath sounds do not conceal vascular sounds. palpating the carotid arteries individually to avoid causing reduced cerebral blood flow.
The bicuspid, or mitral, valve is located
between the left atrium and the left ventricle.
"atrial kick"
during diastole, pressure in ventricles goes up the priming force contributed by atrial contraction immediately before ventricular systole that acts to increase the efficiency of ventricular ejection due to acutely increased preload.
innermost layer of the heart
endocardium
covers outer surface of the heart
epicardium
The nurse knows that when listening to heart sounds, the nurse does not...
have the patient hold his breath because this can cause a split sound to subside.
S4
is a low-frequency gallop sound that results from a forceful atrial contraction during presystole that ejects blood into a ventricle which cannot expand further. S4 occurs ~90 msec before S1. "atrial gallop"
S3
is a rare extra heart sound that occurs soon after the normal two "lub-dub" heart sounds a low-frequency, brief vibration occurring in early diastole at the end of the rapid diastolic filling period of the right or left ventricle associated with heart failure. "ventricular gallop"
In order to palpate an apical pulse (mitral pulse) when performing a cardiac assessment, where should the nurse place the fingers?
left midclavicular line at the fifth intercostal space
Turbulent blood flow may be auscultated as "swooshing" or "blowing" this is called a _____.
murmur
thickest layer of the heart
myocardium
Base of heart located
near 2nd ICS
Apex of the heart located
near 5th ICS, left MCL
The nurse is having difficulty differentiating between S1 and S2. To better differentiate between S1 and S2, the nurse
palpates the carotid pulse, knowing the harsh sound heard from the carotid pulse is S1.
Tough loose filling sack attaches to great vessel and surrounds heart
pericardium
The anterior chest area that overlies the heart and great vessels is called the
precordium.
after load
pressure which heart muscle pumps against after load increases = decrease in SV
Right side of the heart is _______ circulation and left side is _______ circulation.
pulmonary, systemic
What causes S3 sound?
rapid deceleration of blood against the ventricular wall.
JVP is a visible manifestation of the varying pressures in the client's _______.
right atrium
Increased jugular venous pressure is usually the result of...
right-sided heart failure
Cardiac output (CO) is
the amount of blood pumped by the ventricles during a given period of time (usually 1 min) and is determined by the stroke volume (SV) multiplied by the heart rate (HR): SV × HR = CO.
Stroke volume is
the amount of blood pumped from the heart with each contraction.
Where is S2 best heard?
the base of the heart
The AV valves are located at? Name them...
the entrance of the ventricles tricuspid and bicuspid
Semilunar valves are located at? Name them...
the exit of each ventricle at the beginning of the great vessels pulmonic and aortic
The nurse, while assessing heart sounds, hears a swishing sound. The nurse recognizes this sound is a murmur caused by...
turbulant blood flow through the heart valves.
QRS
ventricular depolarization
ST segment, T wave
ventricular recovery
Which symptoms would indicate to the nurse the client may be experiencing a cardiac event? Select all that apply. a) Hypotension b) Diaphoresis c) Chest pain d) Fatigue e) Dyspnea
• Chest pain • Diaphoresis • Dyspnea • Fatigue
