Cardiac Sounds: JVP: PICC: SC Flashcards
Cardiac Cycle - mid-late diastole
- assume heart is in complete relaxation
- pressure of heart is Low
- blood is flowing into A & Vs passively from P & Sys circ
- semi-lunar values are closed (Pul & Aortic)
- A-V valves are open
- Atria contract & force blood into Ventricles
Cardiac cycle - Vent systole
- shortly after V contraction begins
- pressure within V rises
- AV valves close & SL valves are forced open (LUB)
- blood rushed thru them from the Vs
- Atria are relaxed & chambers are filling again
Cardiac cycle - early diastole
- at end of systole the Vs relax
- the SL valves snap shut (DUB)
- for a brief moment the Vs are completely closed chambers
- intra-vent pressure drops & AV valves are forced open
- the Vs begin to fill w blood
- this the completing the cycle
Anatomical locations for auscultation
Aortic valve - 2nd R intercostal space on R sternal border
Pulmonic valve - 2nd L intercostal space on L sternal border
Erb’s point - 3rd L intercostal space of L sternal border
Tricuspid valve - 4th L intercostal space on L sternal border
Mitral valve - 5th L intercostal space on mid-clavicular line
Stethoscope pressures
Diaphragm soft - high pitched
- S1, S2 & aortic/pulmonic murmurs
Bell/firm pressure - low pitched sounds
- S3, S4 & mitral stenosis murmur
Tips to differentiate S1 & S2
1- volume of S1 louder over Apex & S2 louder over base
2- concurrently feel carotid pulse & listen over Apex to identify S1
3- connect ECG & watch for R waves whilst listening to Apex: R wave correlates w S1
Auscultating heart sounds General order
- explain & gain consent
- provide privacy
- position sitting or supine
- Diaphragm first: aortic, pulmonic, Erb’s, tricuspid & mitral
- listen for S1 & S2
- position Pt L side down & use extra pressure & repeat [mitral sounds best heard L Lat & listen for S3/S4/murmurs]
- position Pt sitting & leaning forward: ask Pt to exhale & listen over aortic & pulmonic valves w diaphragm - to listen for murmurs in these valves
- thank Pt
- document findings
Additional sounds all/range
S3 - heard after S2 (Lub-Dub-Ta)
S4 - heard before S1 (Ta-Lub-Dub)
Murmurs - blowing/swooshing described by location
Stenosis - valve not opening correctly
Regurgitation - valves not closing properly
Ejection click - occurs after S1 & indicates late opening of stenotic semilunar valve
Opening snap - occurs after S2 & indicates opening of stenotic AV valve
Abnormalities of S1 & S2 loud/soft
Loud S1:
- mitral/tricuspid valve cusps remaining wide open at the end of diastole & shut forcefully w onset of V systole
- mitral stenosis as narrowed valve orifice limits V filling w no reduction in flow towards the end of diastole
- reduced diastolic filling time; tachycardia
Soft S1:
- prolonged diastolic filling time eg; 1 degree HB,
- delayed onset of V systole eg; LBBB
- failure of leaflets to fit together normally eg; mitral valve regurgitation
Loud S2:
- loud aortic component may occur w systemic HTN due to forceful AV closure
- congenital aortic stenosis
- pulmonary component, due to pulmonary HTN
Soft S2:
- soft aortic component due to calcified Aortic valve resulting in reduced leaflet movement
- aortic regurgitation where leaflets cannot fit together properly
Heart murmurs
Continuous sounds caused by turbulent blood flow
- increased turb across normal valves occurs in association w anaemia & thyrotoxicosis
Considering origin:
- associated features?
- timing?
- area of greatest intensity?
- radiation?
- pitch?
- effect of dynamic manoeuvres?
Levine scale murmur grading
Grade 1- hard to hear
Grade 2- faint to hear
Grade 3- easy to hear
Grade 4- loud w a thrill
Grade 5- very loud (can hear as lifting edge of steth off chest)
Grade 6- super loud & very rare (can hear when whole steth is off chest)
Carotid artery auscultation
- using bell/firm diaphragm
Three areas: - just under the angle of the jaw
- mid-cervical area
- base of the neck
JVP info
- use the internal jug vein
- reflects R atrial pressure
- normal waveform has 2 main peaks per cycle
Jug pulsations:
- rapid inward movement
- two peaks of NSR
- impalpable
- pulsation diminished w pressure at root of neck
- height of pulsation: varies w Resps & Pt position; rises w abdominal pressure
Distinct peaks:
- ‘a’ wave is R atrial contraction (just before S1)
- ‘v’ wave caused by atrial filling during V systole when tricuspid valve is closed
- rare ‘c’ wave due to closure of the tricuspid valve (pertinent when CVP measurements taken post central venous cannula placement)
Measuring JVP
- position semi-reclined w head on pillow to relax sternocleidomastoids
- look across Pt’s neck from R side, use light source if req
- identify JV pulsation in suprasternal notch/behind the sternocleidomastoid muscle
- perform abdomino-jugular test to confirm it’s JVP
- identify timing & waveform of pulsation & note any abnormalities
Performing abdomino-jugular reflex test:
- press over abdo or liver firmly for 10secs to increase venous return to R side of heart (temporary) this should increase JVP!
- measure the vertical distance & add 5cms
- performs an indirect estimate of Pt’s CVP
Increased JVP causes: x 7
- R ventricular failure
- tricuspid stenosis/regurgitation
- pericardial effusion
- constrictive pericarditis
- superior vena cava obstruction
- fluid overload
- hyper-dynamic circulation
