NURB 3060 Heart and Neck Vessels Chp 19 Jarvis

Palpate only one carotid artery at a time to avoid compromising ________ __________ to the brain.

arterial blood

Although a younger person may tolerate this, an older person with _____________ may experience syncope (fainting or passing out).

cerebrovascular disease

Additional History for Children

Growth: Poor weight gain Activity: Fatigue, record specific limitations Cyanosis

*Serum Cholesterol* High levels of low-density lipoprotein gradually add to the lipid core of thrombus formation in arteries, which results in ____ and ______.

MI stroke

The need to assume a more upright position to breathe. (Note the exact number of pillows used).

Orthopnea

Specifically, they reflect ____________ and ____________.

filling pressure and volume changes.

As the person is raised to a sitting position, these external jugulars _______ and _________, usually at 45 degrees.

flatten disappear

Causes of CVD include an interaction of __________, __________, and _______ factors. However, evidence shows potentially modifiable risk factors attributable to the overwhelming majority of cardiac risk.

genetic environmental lifestyle

The pressure in the atria is *(higher or lower)* than that in the ventricles, so blood pours more *(rapidly or slowly)* into the ventricles.

higher rapidly

With sinus arrhythmia, the rhythm varies with the person's breathing, _____________ at the peak of inspiration and ___________ with expiration.

increasing slowing

To Learn This Phrase: Mo*R*e to the *R*ight heart, *L*ess to the *L*eft

That means that during inspiration, intrathoracic pressure is decreased.

From age ___ to ___ years, the percentages are similar; after age ____ years, women have a much *(higher or lower)* percentage of hypertension than men have.

45 64 64 higher

Once the ventricle is filled with blood the ventricular end diastolic pressure is _____to______ mm Hg, whereas that in the aorta is ______to_______ mm Hg.

5 10 70 80

The _________ components of the jugular venous pulse occur because of events in the _______ side of the heart.

5 right

The age-adjusted prevalence of total cholesterol levels over 200 mg/dL are as follows:

51.1% of Mexican-American men and 49% of Mexican-American women 45% of white men and 48.7% of white women 40.2% of African American men and 41.8% of African American women.

The apical impulse is palpaple in most people, normally at the ____________ intercostal space, ______________ from the _____________.

5th 7 to 9 cm midsternal line

It reaches the adult position when the child reaches age __ years.

7

The _______ wave reflects atrial contraction because some blood flows backward to the vena cava during right atrial contraction.

A

Among racial groups, the prevalence of hypertension in ________ is among the highest in the world and it is rising.

Blacks

__________ or ____________ occurs with myocardial infarction or low cardiac output states as a result of decreased tissue perfusion.

Cyanosis pallor

According to the _______________, the greater the stretch, the *(stronger or weaker)* is the heart's contraction.

Frank-Starling law stronger

Use the _____ __ _____ (_______ _____) as an arbitrary reference point, and compare it with the highest level of the distended vein or venous pulsation.

angle of Louis (sternal angle)

Inside the body, the heart is rotated so that its right side is ____________ and its left side is mostly ___________.

anterior posterior

Evidence from epidemiologic studies shows a strong genetic factor for DM, but no specific _______ type has yet been identified.

antigen

Additional History for the Pregnant Woman

any high blood pressure during this or earlier pregnancies? any associated symptoms such as weight gain, protein in urine, swelling in feet, legs or face? have you had any faintness or dizziness with this pregnancy?

The ________ ascends from the __________ ventricle, arches back at the level of the sternal angle, and __________ behind the heart.

aorta (n) left descends

When the ________ valve closes significantly earlier than the _________ valve, you can hear the two components separately. This is a split ________.

aortic pulmonic S2

And with S2, _______ closure occurs slightly before _________ closure.

aortic (A2) pulmonic (P2)

The _________ component of the second sound slightly precedes the ___________ component.

aortic (A2) pulmonic (P2)

During contraction, the __________ beats against the ___________, producing an _________ impulse.

apex chest wall apical

This used to be called the point of maximal impulse, or PMI. Because some abnormal conditions may cause a maximal impulse to be felt elsewhere on the chest, use the term _______ __________ specifically for the apex beat.

apical impulse

You may not see the _______ __________, the pulsation created as the left ventricle rotates against the chest wall during systole.

apical impulse

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

Toward the end of diastole, the ________ contract and push the last amount of blood (about 25% of stroke volume) into the ventricles.

atria

The current flows in an orderly sequence, first across the ___________ to the ________ low in the ______________.

atria AV node atrial septum

The _________ contract and push blood into a noncompliant ______________.

atria ventricle

Second, the rest of the oxygenated blood is pumped by the right side of the heart out through the pulmonary artery, but it is detoured through the ____________ to the aorta.

ductus arteriosus

The atrial systole occurs _____________ventricular diastole.

during

Avoid ___________ ___________ on the carotid sinus area higher in the neck.

excessive pressure

However, you may use either the ________ or the _________ jugular veins because measurements in both are similar.

external internal

The _______________ vein is more superficial; it lies lateral to the sternomastoid muscle, above the clavicle.

external jugular

After the ventricle's contents are ejected, its pressure _______.

falls

Usually, you can identify S1 instantly because you hear a pair of sounds close together (lup-dub), and S1 is the _____ of the pair.

first

The annual rates of ______ CVD event *(increase or decrease)* with age.

first increase

*(Normal Heart Sounds)* The ________________ occurs with closure of the AV valves and thus signals the beginning of systole.

first heart sound (S1)

The foramen ovale closes within the_________ because of the new lower pressure in the right side of the heart than in the left side.

first hour

Both points underscore the need for ____ ______ as an important treatment parameter.

health teaching

The cardiovascular system consists of the __________ and the _______________.

heart (a muscular pump) blood vessels

Certainly, lifestyle habits (smoking, chronic alcohol use, lack of exercise, diet) play a significant role in the acquisition of ____________.

heart disease

Frequency (pitch)

heart sounds are described as high pitched or low pitched, although these terms are relative because all are low-frequency sounds, and you need a good stethoscope to hear them.

The _____ _____ has numerous layers.

heart wall

If venous pressure is elevated of if you suspect heart failure, perform _________ ____________.

hepatojugular reflux p 473

Since there are no valves between the vena cava and the right atrium and no valves between the pulmonary veins and the left atrium, abnormally *(high or low)* pressure in the left side of the heart gives a person symptoms of ___________, and abnormally *(high or low)* pressure in the right side of the heart shows in the _______ and ___________.

high pulmonary congestion high neck veins abdomen

Because volume and pressure *(increase or decrease)* when the right side of the heart fails to pump efficiently, the jugular veins expose this.

increase

(1) With aging, there is an *(increase or decrease)* in the systolic blood pressure (BP). This is due to stiffening of the large arteries, which in turn is due to calcification of vessel walls (_____________). This stiffening creates an increase in pulse wave velocity because the less compliant arteries cannot store the volume __________.

increase arteriosclerosis ejected

This creates an *(increase or decrease)* in stroke volume and cardiac output and an *(increased or decreased)* pulse rate of ____to___ beats per minute.

increase increased 10 15

*(The Aging Adult)* It is difficult to isolate the "aging process" of the cardiovascular system per se because it is so closely interrelated with ___________, _______, and _________.

lifestyle, habits, and diseases

It causes a small rise in the ___________ ventricular pressure.

left

Meanwhile, on the *(right or left)* side, a greater amount of blood is sequestered in the lungs during inspiration.

left

The __________ atrium is located posteriorly, with only a small portion, the left atrial appendages, showing ____________.

left anteriorly

The _______ ventricle lies behind the _________ ventricle and forms the __________ and slender area of the ___________ border.

left (u) right (j) apex (x) left

(3a) Pulmonary veins return fresh blood to the _______ __________ .

left atrium (LA)

Ask the person to take a breath, exhale, and hold it briefly while you listen so that tracheal breath sounds do not mask or mimic a carotid artery bruit. (Holding the breath on inhalation will also tense the _________ ___________ ___________, which makes it hard to hear the carotids.)

levator scapulae muscles

*The Neck Vessels* Palpate the Carotid Artery

located central to the heart, the carotid artery yields important information on cardiac function.

Intensity (loudness)

loud or soft

(2a) Pulmonary artery delivers unoxygenated blood to the __________.

lungs

(3) __________ oxygenates blood.

lungs

Meanwhile, the atria have been filling with blood delivered from the __________.

lungs

The _________ are nonfunctional, but the fetal circulation compensates for this.

lungs

Now the blood is oxygenated through the __________ rather than through the __________.

lungs placenta

The heart and great vessels are located between the __________ in the middle third of the __________.

lungs thoracic cage (mediastinum)

Palpate each carotid artery _______ to the sternomastoid muscle in the neck.

medial

The __________ valve drifts open, and _________ filling begins again.

mitral diastolic

In the first heart sound, the _______ component closes just before the ___________ component.

mitral (M1) tricuspid (T1)

The _________ component of the first sound slightly precedes the ____________ component, but you usually hear these two components fused as one sound.

mitral (M1) tricuspid (T1)

(4) From Left Atrium (LA) arterial blood travels through __________ to __________.

mitral valve (also known as bicuspid valve) left ventricle (LV)

This pushes *(more or less)* blood into the vena cava, *(increasing or decreasing)* venous return to the *(right or left)* side of the heart, which *(increases or decreases)* *(right or left)* ventricular systole and *speeds up or delays)* pulmonic valve closure.

more increasing right increases right delays

These result in a __________, much like a pile of stones or a sharp turn in a stream creates a noisy water flow.

murmur

The _____________ is the muscular wall of the heart; it does the pumping.

myocardium

Structural defects in the valves example

narrowed valves incompentent valve

Some aortic valve murmurs (aortic stenosis) radiate to the ______ and must be distinguished from a local bruit.

neck

Sometimes you can hear normal heart sounds transmitted to the ____; do not confuse these with a bruit.

neck

For example, myocardial infarction (MI) is an important type of CVD. The INTERHEART study covering 52 countries indicated that ______ potentially modifiable risk factors accounted for ____ of the population attributable risk for MI in men and ___ in women!

nine 90% 94%

*Murmurs* Blood circulating through normal cardiac chambers and valves usually makes________ noise.

no

*(Heart Sounds)* Events in the cardiac cycle generate sounds that can be heard through a stethoscope over the chest wall. These include ______________ and, occasionally, _______________ and _______________.

normal heart sounds extra heart sounds murmurs

(5) Cardiac output at rest is *(not changed or changed)* with aging.

not changed

To screen for heart disease in infant

note fatigue during feeding. Infant with heart failure takes fewer ounces each feeding; becomes dyspneic with sucking; may be diaphoretic, then falls into exhausted sleep; awakens after a short time hungry again. Poor weight gain (has the baby grown as expected by growth charts and about the same a siblings or peers?) Activity (motor milestones achieved as expected, is the baby able to play without tiring, how many naps does the baby take each day, how long does the nap last?)

The epidemic of ________ in the United States is well known.

obesity

The most powerful predictor of type 2 DM is ______, with _______ (_________) ____ posing a greater risk than ______ ______ _______ poses.

obesity abdominal (visceral) fat lower body obesity

Systole is _________of the cardiac cycle.

one-third

Oxygenation takes place at the _________, and the arterial blood is returned to the right side of the fetal heart.

placenta

S3 occurs when the ventricles are resistant to filling during the early rapid filling phase ______________.

protodiastole

T wave

repolarization of the ventricles

The __________ valves are set between the ventricles and the arteries.

semilunar

This closure of the ______________ valves causes the second heart sound (__) and signals the end of systole.

semilunar S2

The two pumps are separated by an impermeable wall, the _______.

septum (#14)

The current cut-points for cholesterol risk in adults are the following:

total cholesterol levels of > or equal to 240 mm Hg/dL are high risk levels from 200 to 239 mg/dL are borderline-high risk.

The right AV valve is the ______, and the left AV valve is the _____ or ______ valve.

tricuspid bicuspid mitral

It is the resistance against which the ___________ must pump its blood.

ventricle

Compared with ________, _________ _______ develop HBP earlier in life and their average BPs are much higher.

whites African Americans

_________ jugular veins are present in each side of the neck.

Two

____________ distension of external jugular veins is due to local cause (kinking or aneurysm).

Unilateral

Next, the ________ descent shows atrial relaxation when the right ventricle contracts during systole and pulls the bottom of the atria downward.

X

Finally, the _______ descent reflects passive ventricular filling when the tricuspid valve opens and blood flows from the RA to the RV.

Y

There are ______ valves between the vena cava and the right atrium.

ZERO

There are ________ valves between the pulmonary veins and the left atrium.

ZERO

S4 occurs just before ________.

S1

*Characteristics of Sound* All heart sounds are described by:

(1) Frequency (pitch) (2) Intensity (loudness) (3) Duration (4) Timing

These changes include:

(1) Prolonged P-R interval (first-degree AV block) and prolonged Q-T interval, but the QRS interval is unchanged. (2) Left axis deviation from age-related mild LV hypertrophy and fibrosis in left bundle branch. (3) Increased incidence of bundle branch block.

Other guidelines to distinguish S1 from S2 are:

(1) S1 is louder than S2 at the apex; S2 is louder than S1 at the base. (2) S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1 (3) S1 coincides with the R wave (the upstroke of the QRS complex) if the person is on an ECG monitor

The valve areas are:

(1) Second right interspace--aortic valve area (2) Second left interspace--pulmonic valve area (3) Left lower sternal border --tricuspid valve area (4) Fifth interspace at around left midclavicular line--mitral valve area.

Conditions resulting in a murmur are:

(1) Velocity of blood increases (flow murmur) (2) viscosity of blood decreases (3) Structural defects in the valves (4) Unusual openings occur in the chambers

Keep the neck in a neutral position. Lightly apply the bell of the stethoscope over the carotid artery at three levels:

(1) the angle of the jaw (2) the midcervical area, and (3) the base of the neck

In the past, type 2 DM was diagnosed in adults __ years of age and older, but now we are finding more children with type 2 DM.

40

Now the left ventricle has the greater workload of pumping into the systemic circulation, so that when the baby has reached ________ , the left ventricle's mass increases to reach the adult ratio of _____, left ventricle to right ventricle.

1 year of age 2:1

For example, a ventricular tachycardia produces a ____ to ____ decrease in cerebral blood flow.

40% 70%

A carotid bruit is audible when the lumen is occluded by _____ to _____.

1/2 to 2/3

For women, comparable rates occur _________ years later in life than for men, but this gap narrows with advancing age.

10

The ductus arteriosus closes later, usually within ___________ of birth.

10 to 15 hours

Between ___ and ___ of Mexican Americans have DM, compared with ___ of whites.

11.8% and 13.1% 6.4%

About ____ of African Americans 20 years of age and older have DM.

13%

There is no point in pumping all this freshly oxygenated blood through the lungs, so it is rerouted in _____ ways.

2

But consider that the heart is actually ________ pumps; the right side of the heart pumps blood into the _______, and the left side of the heart simultaneously pumps blood into the __________.

2 lungs body

The pericardium has _________ layers that contain a few milliliters of ________________ fluid.

2 serous pericardial

This results in 2008 with _____ of men and _____ of women being smokers.

23.1% 18.3%

The heart extends from the _____ to the ____ intercostal space and from the ________border of the ___________ to the _______________.

2nd 5th right sternum left midclavicular line.

Each valve has ______ cusps that look like half moons.

3

*(Developmental Competence)* *Infants and Children* The fetal heart functions early; it begins to beat at the end of ____________ gestation.

3 weeks'

Position the person supine anywhere from a ___ to a ___ degree angle, wherever you can best see the top of the vein or pulsations.

30 45

*(The Pregnant Woman)* Blood volume increases by _____ to ____ during pregnancy, with the most rapid expansion occurring during the __________ trimester.

30% 40% second

The prevalence of hypertension is _____ for African Americans, ____ for American Indians or Alaska natives, ____ for whites, and ____ for Hispanics and Asians.

31.8% 25.3% 23.3% 21%

There are ________ valves in the heart.

4

*Pumping Ability* In the resting adult, the heart normally pumps between _______ and ___________ Liters of blood per ___________ throughout the body.

4 6 minute

*(Diastole Again)* Now all ______ valves are *(open or closed)* and the ventricles relax (called____________ or ____________).

4 closed isometric isovolumic relaxation

Of the heart's ________ chambers, the ______ ventricle forms the greatest area of anterior cardiac surface.

4 right

A higher percentage of men than women have hypertension until age ____ years.

45

In the United States, an estimated __________ people (more than 1 in 3) have one or more forms of cardiovascular heart disease (CVD).

81 million

Among Americans ages 20 years and older, the prevalence of overweight or obesity (body mass index [BMI] of _______for overweight and ____________) is as follows: 74.8% of Mexican-American women 73.7% of African American men 77.7% of African American women 72.4% of white men 57.5% of white women

> or equal to 25 for overweight > or equal to 30 for obesity

_____________ is the opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure.

Afterload

An important cardiac symptom, occurs when the heart's own blood supply cannot keep up with metabolic demand. Chest pain also may have pulmonary, musculoskeletal, or gastrointestinal origin; it is important to differentiate.

Angina

(5) __________ delivers oxygenated blood to body.

Aorta

The ________ wave, or ventricular contraction, is backflow from the bulging upward of the tricuspid valve when it closes at the beginning of ventricular systole (not from the neighboring carotid artery pulsation.)

C

This is described as:

CO = SV x R

*Type 2 Diabetes Mellitus* The risk of _____ is twofold greater among persons with diabetes mellitus (DM) than without DM.

CVD

_______ __________ is worse at evening and better in morning after elevating legs all night.

Cardiac edema

The condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased BP, and cerebral ischemia with syncope. This may occur in older adults with hypertension or occlusion of the carotid artery.

Carotid sinus hypersensitivity

Risk factors for CAD

Collect data regarding elevated cholesterol, elevated blood pressure, blood sugar levels above 130 mg/dL or known diabetes mellitus, obesity, cigarette smoking, low activity level, and length of any hormone replacement therapy for postmenopausal women.

The increased prevalence of ___ in the United States is being followed by increasing prevalence of ___ morbidity and mortality.

DM CVD

A squeezing "clenched fist" sign is characteristic of angina, but the symptoms below may be anginal equivalents in the absence of chest pain.

Diaphoresis, cold sweats, pallor, grayness. Palpitations, dyspnea, nausea, tachycardia, fatigue. Try to differentiate pain of cardiac versus noncardiac origin.

__________ takes up to two thirds of the cardiac cycle.

Diastole

__________ pulse feels small and weak (decreased stoke volume). __________ pulse feels full and strong in hyperkinetic states.

Diminished Increased

Additional History for the Aging Adult

Do you have any known heart or lung disease: Hypertension, CAD, chronic emphysema, or bronchitis? Do you take any medications for your illness such as digitalis? Aware of side effects? Have you recently stopped taking your medication and if so, why? (Noncompliance may be related to side effects; to lack of finances) Environment--Does your home have any stairs? How often do you need to climb them? Does this have any effect on activities of daily living?

_________ is dependent when caused by heart failure.

Edema

What is left to be attributed to the aging process alone?

Hemodynamic changes with aging

________________ is a systolic blood pressure (SBP) of > or equal to 140 mm Hg or diastolic blood pressure (DBP) of > or equal to 90 mm Hg or currently taking _________________ medicine.

Hypertension anithypertensive

______________ (systolic >140 mm Hg and/or diastolic >90 mm Hg) and heart failure also *(increase or decrease)* with age.

Hypertension increase

*Table 19-1* *Characteristics of Jugular Versus Carotid Pulsations*

Internal Jugular Pulse Carotid Pulse 1. Location Lower, more lateral, Higher under of behind the and medial to sternomastoid muscle this muscle 2. Quality Undulant and diffuse, Brisk and two visible waves per localized, one cycle wave per cycle 3. Respiration Varies with respiration; Does not its level descends during vary inspiration when intrathoracic pressure is decreased 4. Palpable No Yes 5. Pressure Light pressure at the No change base of the neck easily obliterates 6. Position of person Level of pulse drops Unaffected disappears as the person is brought to a sitting position

__________ and ___________ of the lungs at birth produces circulatory changes.

Inflation aeration

(4) *(No change or changes)* in resting heart rate occurs with aging.

No change

Awaken at night with an urgent need to urinate.

Nocturia Recumbency at night promotes fluid reabsorption and excretion; this occurs with heart failure in the person who is ambulatory during the day.

The ECG waves are arbitrarily labeled ______________.

PQRST

Dyspnea on exertion (DOE)---Quantify exactly (e.g. DOE after walking two level blocks).

Paroxysmal (sudden) Constant or intermittent Recumbent (lying down) Paroxysmal nocturnal dyspnea (PND) occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Typically, the person awakens after 2 hours of sleep with the perception of needing fresh air.

_____________and __________ affect the heart's ability to increase cardiac output.

Preload afterload

______ is the venous return that builds during diastole. It is the length to which the ____________ is stretched at the end of diastole just before contraction.

Preload ventricular muscle

*(Culture and Genetics)* __________ is an estimate of how many people in a stated geographic location have a disease at a given point in time.

Prevalence

It is common to use the following abbreviations to refer to the chambers: ______ right atrium, _____ right ventricle, _________left atrium, _______left ventricle.

RA RV LA LV

_________ the pillow to ______ _________ the neck; the head should be in the same plane as the _________.

Remove avoid flexing trunk

The closure of the AV valves contributes to the first heart sound ______ and signals the beginning of ___________.

S1 systole

Although it is heard over all the precordium, ___ is loudest at the base.

S2

This occurs immediately after __, when the _______ valves open and atrial blood first pours into the ventricles.

S2 AV

*(Extra Heart Sounds)* Normally, diastole is a silent event. However, in some conditions, ventricular filling creates vibrations that can be heard over the chest. These vibrations are ____.

S3

This creates vibrations that are heard as ____.

S4

_____________ may not be tolerated as well in older people. The ___________ is thicker and less compliant, and early diastolic filling is impaired at rest. Thus it may not tolerate a __________ as well because of shortened diastole.

Tachydysrhythmias myocardium tachycardia

*The Carotid Artery Pulse* Chapter 9 describes the pulse as a pressure wave generated by each systole pumping blood into the aorta.

The carotid artery is a central artery---that is, it is close to the heart. Its timing closely coincides with ventricular systole.

Direction of Blood Flow

Think of an unoxygenated red blood cell being drained downstream into the vena cava. It is swept along with the flow of venous blood and flows the route illustrated in the photo.

Do not limit your auscultation to only four locations. Sounds produced by the valves may be heard all over the precordium. (For this reason, many experts even discourage the naming of the valve areas.)

Thus learn to inch your 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.

The _______ wave occurs with passive atrial filling because of the increasing volume in the right atria and increased pressure.

V

Characteristics of the carotid artery waveform

a smooth rapid upstroke, a summit that is rounded and smooth, and a downstroke that is more gradual and that has a dicrotic notch caused by closure of the aortic valve.

These nine modifiable risk factors include: _______ _____, _________, _________, ________, ______ _______, ________ _______, _______ of _____ and ______, _______ ___, and ________ _______ ______.

abnormal lipids smoking hypertension diabetes abdominal obesity psychosocial factors consumption of fruits and vegetables alcohol use regular physical activity

The two _______________ valves separate the atria and the ventricles.

atrioventricular (AV)

Each side has an _________ and a _________.

atrium ventricle

The _________ is a thin-walled reservoir for holding blood, and the thick-walled ________ is the muscular pumping chamber.

atrium ventricle

*Conduction* Of all organs, the heart has a unique ability (____________).

automaticity

Turn the person's head slightly _____ from the examined side, and direct a strong light tangentially onto the ____ to highlight pulsations and shadows.

away neck

Although an arterial pulse is caused by a forward propulsion of blood, the jugular pulse is different. The jugular pulse results from a _________, a waveform moving _____ caused by events upstream.

backwash backward

The top of the heart is the broader _________, and the bottom is the ___________, which points down and to the left.

base apex (x)

Cardiac edema is __________; ____________ swelling has a local vein cause.

bilateral unilateral

When the heart contracts, it pumps blood simultaneously into _________________.

both loops (pulmonary circulation and systemic circulation)

A _______ indicates turbulence due to a local vascular cause, such as artherosclerotic narrowing.

bruit

*Auscultate the Carotid Artery* For persons middle-aged or older or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for the presence of a ______. This is a blowing, swishing sound indicating blood flow turbulence; normally none is present.

bruit (pronounced bre'-ee)

Then the impulse travels to the ____________, the right and left _____________, and then through the ________________.

bundle of His bundle branches ventricles

The heart can contract __________, _____________ of any signals or stimulation from the body.

by itself independent

Lifestyle also affects the aging process; _________ once thought to be due to aging are partially due to the _______________ accompanying aging.

cardiac changes sedentary lifestyle

The rhythmic movement of blood through the heart is the ______ ________.

cardiac cycle

A murmur sounds much the same but is caused by a ________ __________.

cardiac disorder

The heart can alter its _________ to adapt to the ___________ of the body.

cardiac output metabolic needs

This ________ equals the volume of blood in each systole (called the ________________) times the number of beats per minute (________).

cardiac output stroke volume rate

Also, increasing the physical activity of older adults---even at a moderate level---is associated with a reduced risk of death from ____________ _________ and ______________ ____________.

cardiovascular disease respiratory illness.

The _______________ is located in the groove between the trachea and the sternomastoid muscle, medial to and alongside that muscle.

carotid artery

*The Neck Vessels* Cardiovascular assessment includes the survey of vascular structures in the neck the _____________ and the _______________.

carotid artery jugular veins

These vessels reflect the efficiency of cardiac function.

carotid artery jugular veins

*Inspect the Jugular Venous Pulse* From the jugular veins you can assess the _______ ________ _________ (___) and thus judge the heart's efficiency as a pump.

central venous pressure (CVP)

The four _________ are separated by swinging-door-like structures, called ______, whose main purpose is to prevent _________ of blood.

chambers valves backflow

The valves' thin leaflets are anchored by collagenous fibers (______________) to papillary muscles embedded in the ___________ floor.

chordae tendineae (B) ventricle

For a very brief moment, all four valves are __________.

closed

This contraction against a _______ system works to build pressure inside the ventricles to a high level (____________)

closed isometric contraction

Ectopic beats are *(common or rare)* in aging people; although these are usually asymptomatic in healthy older people, they may compromise cardiac output and blood pressure when ________ is present.

common disease

Age-related changes in the ECG occur as a result of histologic changes in the ___________ system.

conduction

Circulation is a ________ _____.

continuous loop

The electrical impulse stimulates the heart to do its work, which is to _______________.

contract

The ventricular walls __________.

contract

We know how that lifestyle is a modifying factor in the development of cardiovascular disease; smoking, diet, alcohol use, exercise patterns, and stress have an influence on __________________ .

coronary artery disease

Sputum production, mucoid or purulent. Hemoptysis (coughing up blood or blood stained sputum) is often a pulmonary disorder but also occurs with mitral stenosis.

cough

*Smoking* In the 40+ years from 1965 to 2004, U.S. smoking rates *(increased or declined)* by 50.4% among adults 18 years of age and older.

declined

When the lumen is completely occluded, the bruit ___________. Thus _________ of a bruit does not ensure _______ of a carotid lesion.

disappears absence absence

(6) There is a *(increased or decreased)* ability of the heart to augment cardiac output with exercise. This is shown by a *(increased or decreased)* maximum heart rate with exercise and *(increased or diminished)* sympathetic response. Noncardiac factors also cause a *(increase or decrease)* in skeletal muscle performance, *(increase or decrease)* in muscle fatigue, *(increased or decreased)* sense of dyspnea. Chronic exercise conditioning will modify many of the aging changes in cardiovascular function.

decreased decreased diminished decrease increase increased

The *(increased or decreased)* volume shortens *(left or right)* ventricular systole and allows the _______ valve to close a bit earlier.

decreased left aortic

This momentarily *(increases or decreases)* the amount returned to the *(right or left)* side of the heart, *(increasing or decreasing)* *(right or left)* ventricular stoke volume.

decreases left decreasing left

There it is ___________slightly so that the atria have time to contract before the ventricles are _________.

delayed stimulated

P wave

depolarization of the atria

QRS complex

depolarization of the ventricles

In _________, the ventricles are relaxed and the AV valves (the tricuspid and the mitral (bicuspid)) are open.

diastole

In __________, the ventricles relax and fill with blood.

diastole

*Fourth Heart Sounds (S4)* S4 occurs at the end of ____________, at _______________, when the ventricle is resistant to filling.

diastole presystole

The AV valves open during the heart's filling phase, or ________, to allow the ____________ to fill with blood.

diastole ventricles

The cardiac cycle has two phases, __________ and __________.

diastole and systole

Unusual openings occur in the chamber example

dilated chamber wall defect

Stand on the person's right side because the veins there have a ________ _________ to the heart.

direct route

This first passive filling phase is called ________ or _______ _________.

early protodiastolic filling

(4a) Left Ventricle ________ blood through _________ into __________.

ejects aortic valve aorta

The heart contracts in response to an _____________ conveyed by a conduction system.

electrical current

A small amount of electricity spreads to the body surface, where it can be measured and recorded on the _____________.

electrocardiograph (ECG)

The _____________ is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves.

endocardium

Fatigue from decreased cardiac output is worse in the _______, whereas fatigue from anxiety or depression occurs _______ or is worse in the _________.

evening all day morning

*High Blood Pressure (HBP)* Although all adults have some potential CVD risk, some groups (defined by race, ethnicity, gender, socioeconomic status, educational level) carry an ______ burden of CVD.

excess

First, about two thirds of it is shunted through an opening in the atrial septum, the ____________, into the left side of the heart, where it is pumped out through the aorta.

foramen ovale

PR interval

from the beginning of the P wave to the beginning of the QRS complex (the time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles.

A murmur is a ________, __________, ________ sound that can be heard on the ____________.

gentle blowing swooshing chest wall

The ____________ are the major arteries and veins connected to the heart.

great vessels

The ____________ lie bunched above the base of the heart.

great vessels

The pericardium is adherent to the ________, ____________, ______________, and __________ and is anchored to the _____________.

great vessels esophagus sternum pleurae diaphragm

In general, the _________ the venous pressure is, the _________ the position you need.

higher higher

Atrial pressure is now *(higher or lower)* than the __________ ventricular pressure.

higher relaxed

*(Systole)* Now so much blood has been pumped into the ventricles that ventricular pressure is finally *(higher or lower)* than that in the atria, so the mitral and tricuspid valves swing *(open or shut)*.

higher shut

*Estimate the Jugular Venous Pressure* Think of the jugular veins as a CVP manometer attached directly to the right atrium. You can "read" the CVP at the _______ level of pulsations.

highest

The heart's position in the chest is more _________ in the infant than in the adult; thus the apex is ________, located at the _________ _________ intercostal space.

horizontal higher fourth left

Viscosity of blood decreases example

in anemia

Velocity of blood decreases (flow murmur) example

in exercise thyrotoxicosis

(2) The overall size of the heart does not *(increase or decrease)* with age, but left ventricular wall thickness *(increases or decreases)*. This is an adaptive mechanism to accommodate the vascular stiffening mentioned earlier that creates an *(increased or decreased)* workload on the heart.

increase increases increased

Nicotine increases the risk of MI and stroke by causing the following:

increase in oxygen demand with a concomitant decrease in oxygen supply; an activation of platelets, activation of fibrinogen; and an adverse change in the lipid profile.

Full distended external jugular veins above 45 degrees signify *(increased or decreased)* CVP as with heart failure.

increased

Despite the *(increased or decreased)* cardiac output, arterial blood pressure *(increases or decreases)* in pregnancy as a result of ________________ _____________.

increased decreases peripheral vasodilation

This *(increased or decreased)* contractility results in an *(increased or decreased)* volume of blood ejected *(increased or decreased)* stroke volume).

increased increased increased

When the volume of blood returned to the ventricles is *(increased or decreased)* (as when exercise stimulates skeletal muscles to contract and force more blood back to the heart), the ___________ are stretched beyond their normal resting state to accommodate.

increased muscle bundles

(3) No significant change in diastolic pressure occurs with age. A rising systolic pressure with a relatively constant diastolic pressure *(increases or decreases)* the pulse pressure (the difference between the two).

increases

*Dysrhythmias* The presence of supraventricular and ventricular dysrthythmias *(increases or decreases)* with age.

increases

Although the hemodynamic changes associated with aging alone do not seem severe or portentous (something that seems to be a sign related to a future event), the fact remains that the incidence of cardiovascular disease *(increases or decreases)* with age.

increases

Bruit loudness _________ as the atherosclerosis worsens until the lumen is occluded by 2/3. After that, bruit loudness __________.

increases decreases

The incidence of coronary artery disease *(increases or decreases)* sharply with advancing age and accounts for about _______ of the deaths of older people.

increases half

The larger ____________ lies deep and medial to the sternomastoid muscle.

internal jugular

Traditionally we have been taught to use the _______ ________ _________ pulsations for CVP assessment.

internal jugular vein

You must be able to distinguish _________ _______ ____ pulsation from that of the ______ ______ . It is easy to confuse them because they lie close together.

internal jugular vein carotid artery

The _______________ empty unoxygenated blood directly into the superior vena cava.

jugular veins

Consider first the left side of the heart. When pressure in the ventricle finally exceeds pressure in the aorta, the aortic valve *(opens or closes)* and blood is______ ______.

opens ejected rapidly

Also, hypertension is 2 to 3 times more common women taking ______ ____________ (especially among obese and older women) than in women who do not take them.

oral contraceptives

These children are usually ____________ or ___________, have a family history of DM, and identify with American Indian, African American, Hispanic, or Asian groups.

overweight or obese

Because the SA node has an intrinsic rhythm, it is the __________.

pacemaker

Take care to ________ gently.

palpate

The _______________ contract at this time, so that the _____________ meet and unite to form a perfect seal without turning themselves inside out.

papillary muscles (#18) valve leaflets

The valves open and close __________ in response to pressure gradients in the ___________ blood.

passively moving

The _____________ is a tough, fibrous, double-walled sac that surrounds and protects the heart.

pericardium

The blood pressure varies with the person's _________.

position

Electrical events slightly __________ the mechanical events in the heart.

precede

The ____________ is the area on the anterior chest directly overlying the heart and great vessels.

precordium

You can hear S1 over all the _____________, but usually it is loudest at the apex.

precordium

The force of this switch is the __________.

preload

The blood is kept moving along by continually shifting ______ _________.

pressure gradients

This active filling phase is called _______________ or ______________, or sometimes the "atrial kick".

presystole atrial systole

The _______ ______ leaves the __________ ventricle, bifurcates, and carries the venous blood to the lungs.

pulmonary artery (#24) right

The blood vessels are arranged in two continuous loops, the _______________ and the _________________.

pulmonary circulation systemic circulation

The _______ _______ return the freshly oxygenated blood to the _________ side of the heart, and the _________ carries it out to the body.

pulmonary veins (q) left aotra (n)

The SL valves are the ________ valve in the right side of the heart and the ______ valve in the left side of the heart.

pulmonic (L) aortic (E)

(2) From the right ventricle (RV), venous blood flows through the _____________ to the _____________.

pulmonic valve pulmonic artery

When you notice any irregularity, check for a __________ ___________ by auscultating the apical beat while simultaneously palpating the radial pulse.

pulse deficit

The common metaphor is to think of the heart as a ______.

pump

After the aortic valve opens, _________ ejection occurs.

rapid

The AV valves close to prevent any ____________ of blood back up into the _________ during contraction.

regurgitation atria

The volume of right and left ventricular systole is just about equal, but this can be affected by ____________.

respiration

Also, events occur just slightly later in the _________ side of the heart because of the route of myocardial depolarization.

right

*(Events in the Right and Left Sides)* The same events are happening at the same time in the right side of the heart, but pressures in the _____ side of the heart are much lower than those of the _____ side because less energy is needed to pump blood to its destination, the _____________ circulation.

right left pulmonary

Because no cardiac valve exists to separate the superior vena cava from the _________ atrium, the jugular veins give information about the activity on the __________ side of the heart.

right right

The ________ atrium lies to the right and above the _________ ventricle and forms the ________ border.

right (#5) right right

(1) From the liver to the ______________ through the ____________.

right atrium (RA) inferior vena cava

The blood pressure drops to its lowest point during the ___________ trimester and then _______ after that.

second rises

The ______________ heart sound occurs with closure of the _____________ valves and signals the end of systole.

second (S2) semilunar

This guideline works, except in the cases of tachydysrhythmias (rates >100 per minute). Then the diastolic filling time is _________, and the beats are ___ ______ together to distinguish.

shortened too close

When ventricle pressure falls below pressure in the aorta, some blood flows backward toward the ventricle, causing the aortic valve to swing *(open or shut)*.

shut

Opening of the normal valve is acoustically __________.

silent

Specialized cells in the ____________ near the superior vena cava initiate an electrical impulse.

sinoatrial node (SA)

The rhythm should be regular, although ______ ________ occurs normally in young adults and children.

sinus arrhythmia

Excessive vagal stimulation here could _______ ________ the heart rate, especially in older adults.

slow down

Serous pericardial fluid ensures _________, __________ movement of the heart muscle.

smooth friction-free

Feel the contour and amplitude of the pulse. Normally the contour is _______ with ______ upstroke and __________ downstroke, and the normal strength is ____ or ________. Your findings should be the same bilaterally.

smooth rapid slower 2+ moderate

It is usually not visible, although its diffuse pulsations may be seen in the ____________ when the person is supine.

sternal notch

You can see the top of the external jugular vein distention overlying the __________ ________ or the pulsation of the internal jugular vein in the ______ __________.

sternomastiod muscle sternal notch

Note the external jugular veins overlying the __________ __________.

sternomastoid muscle

Diabetes causes damage to the large blood vessels that nourish the brain, heart, and extremities; this results in

stroke coronary artery disease peripheral vascular disease.

This results in African Americans having a greater rate of ________, death due to _________ _________ and end-stage __________ __________.

stroke heart disease kidney disease

The ________ and ___________ return unoxygenated venous blood to the __________ side of the heart.

superior (b) inferior vena cava (k) right

In some persons, the veins are not visible at all, whereas in others they are full in the ______ position.

supine

Now look for pulsations of the internal jugular veins in the area of the ____________ _______or around the _________ _________origin of the around the clavicle.

suprasternal notch sternomastoid muscle

A _________ impulse with increased force and duration but no change in location occurs with left ventricular hypertrophy and no dilation (pressure overload).

sustained

Because they are both pumping into the _________________, the right and left ventricles are equal in weight and muscle wall thickness.

systemic circulation

*Identify S1 and S2* This is important because S1 is the start of ________ and thus serves as the reference point for the timing of all other cardiac sounds.

systole

During __________, blood is pumped from the ventricles and fills the pulmonary and systemic arteries.

systole

The heart's contraction is _____________.

systole

During the pumping phase, or ________, the AV valves close to prevent regurgitation of blood back up into the ________.

systole atria

They open during pumping, or ______, to allow blood to be ________ from the heart.

systole ejected

Timing

systole or diastole

Also, ______________ may further compromise a vital organ whose function has already been affected by aging or disease.

tachydysrhythmias

To overcome this difference, the ventricular muscle _________(______________).

tenses isovolumic contraction

(1a) From right atrium (RA) venous blood travels through the _________________ to the ___________________.

tricuspid valve right ventricle (RV)

However, some conditions create ________ blood flow and __________ currents.

turbulent collision

As a result, _____ distinct components to each of the heart sounds exist, and sometimes you can hear them separately.

two

The valves are ________; they can open only one way.

unidirectional

Duration

very short for heart sounds; silent periods are longer