Cardiac Assessment

Question 1

The right atrium receives venous blood from the inferior & superior vena cavae and the coronary sinus

Blood then passes through tricuspid valve into right ventricle

W/each contraction, right ventricle pumps blood through the pulmonic valve into the pulmonary artery & to the lungs

Answer 1

Blood flows from the lungs to the left atrium by way of pulmonary veins

Then passes through the mitral valve & into left ventricle

As heart contracts, blood is ejected through the aortic valve into the aorta and thus enters systemic circulation

Question 2

A visual representation of the cardiac cycle

Answer 2

Cardiac Valves

1. Tricuspid valve
2. Mitral valve
3. Pulmonic valve
4. Aortic valve

Question 3

Cusps of mitral & tricuspid valves are attached to thin strands of fibrous tissue termed chordae tendineae

Chordae are anchored in the papillary muscles of the ventricles

This support system prevents eversion of the leaflets into the atria during ventricular contraction

Answer 3

Pulmonic & aortic valves (also known as semilunar valves) prevent blood from regurgitating into the ventricles @ end of each ventricular contraction

! Perfusion (heart ↔ blood ↔ vessels ↔ lungs)

Question 4

Patient History - Risk Factors

• Smoking, obesity
  > Excess weight (around abdomen?)
• HTN, diabetes
  > Kidney failure?
• Hyperlipidemia
• Age/gender/EO
  > Occupation
• Postmenopausal
  > Post-meno are 2-3x more likely than pre-meno to have CVD

Answer 4

• Family history
  > Domestic partner; other household members; environment; support/support system(s)
• Psychosocial
  > Psychological stress?
• Modifiable vs non-modifiable risk factors
• Specifics of smoking history
  > Age at start; duration of habit; # cigs/day
• A pos fhx for CAD in a first-deg relative is a major risk factor that’s more significant than other factors like HTN, obesity, DM, or sudden cardiac death

Question 5

Cardiovascular System Assessment

• Current health problems
• Pain, discomfort
• Dyspnea, DOE, orthopnea, PND
• Fatigue
• Palpitations
• Edema
• Syncope
• Extremity pain

Answer 5

• General appearance
• Skin/temp, color
  > Skin color can reflect perfusion and if there’s adequate cardiac output (CO); why assessing radial & pedal pulses matters
• Cyanosis, rubor extremities
• Clubbing, edema
• BP
• Hypotension & HTN (if BP too low, CO will be low)
• Postural (orthostatic) hypotension
• Presence or absence of JVD

Question 6

?

Anatomically, this is the area of the anterior chest wall over the heart

Answer 6

Precordium

Question 7

Precordium - Assessment

• Inspection (is the chest uneven or misshapen)
• Palpation (to see what you feel; shouldn’t elicit pain)
• Percussion (normally a dull sound)
• Auscultation
  > Normal heart sounds vs abnormal
  > Gallops & murmurs
  > Pericardial friction rub

Answer 7

• Precordial CP can be an indication of a variety of illnesses like costochondritis & viral pericarditis (vs cardiac CP)

Question 8

Gerontological Consideration

• Age alters the cardiovascular response to physical & emotional stress
• Heart valves become thick & stiff
• Frequent need for pacemakers
• Increase in SBP; decrease or no change in DBP

Answer 8

• With increased age, the amt of collagen in heart increases & elastin decreases
• These changes affect the contractile and distensible properties of the myocardium
• 1 of the major age-associated alterations in cardiovascular response to physical or emotional stress is a decrease in CO & SV caused by decreased contractility & HR response to increased stress

Question 9

Cardiac valves become thicker & stiffer from lipid accumulation, degeneration of collagen, & fibrosis

__ and __ valves are most frequently affected

Answer 9

Aortic, mitral

Question 10

• # of pacemaker cells in SA node dec w/age
• # & function of beta-adrenergic receptors in heart dec w/age (therefore, older adult has dec response to physical & emotional stress)

Answer 10

• Arterial & venous blood vessels thicken & become less elastic w/age
  > Arteries inc their sensitivity to vasopressin (ADH); both these changes add to a progressive dec or no change in DBP w/age

HTN guidelines:
Ppl >60 systolic over 150 is considered HTN as opposed to under 60 which is >140 systolic

Question 11

Serum Markers of Myocardial Damage

• Troponin: Troponin T and troponin I
• Creatine kinase (CK)
• Myoglobin
• Serum lipids
• Homocysteine
• Highly sensitive CRP

Answer 11

• Troponin T & I are the most used labs to indicate whether or not someone has had a heart attack; are most heart-specific

Question 12

Lab Assessment

• Microalbuminuria
• Coagulation studies (PT/INR/PTT)
• ABG
• Fluids & electrolytes (F&E)
• Erythrocyte count
• H&H
• Leukocyte count

Answer 12

Diagnostic Assessment

• PA & lateral CXR
• Angiography
• Arteriography
• Cardiac catheterization

Question 13

Cardiac Catheterization

• Typical site accessed via femoral artery but could also be done through a radial artery

Answer 13

Other Diagnostic Assessment

• ECG, aka EKG
• Electrophysiologic study (EPS)
• Stress test
• Echocardiography
  > Pharmacologic stress echo
  > TEE
• Myocardial nuclear perfusion imaging (MNPI)

Question 14

! Best indicator of fluid balance is weight

2.2 lb = 1 kg = 1 L of fluid

Answer 14

If your pt weighs 4 or 5 lbs more than 2 days ago, he/she could have an EXTRA 2 L of fluid retained

Question 15

?

Is the amount of blood pumped from the left ventricle per minute

In adults, ranges from 4-7L/min

Answer 15

Cardiac output (CO)

Question 16

B/c CO requirements vary according to body size, the cardiac index is calculated to adjust for differences in body size

Question 17

The cardiac index can be determined by dividing the __ by the __

Answer 17

CO; body surface area

Question 18

?

Refers to the # of times the ventricles contract each minute

Normal for an adult is between 60-100 bpm

Answer 18

Heart rate (HR)

Question 19

• Increases in rate increase myocardial oxygen demand
• The HR is extrinsically controlled by the ___, which adjusts rapidly when necessary to regulate cardiac output

Answer 19

autonomic nervous system (ANS)

Question 20

The ___ slows the HR, ___ increases the HR

Answer 20

parasympathetic (vagus nerve) system; sympathetic stimulation

Question 21

?

Is the amount of blood ejected by the left ventricle during each contraction

Answer 21

Stroke volume (SV)

Question 22

Dub = S2 = ?

Lub = S1 = ?

Answer 22

Diastole

Systole

Question 23

S1 represents the opening of which valves?

Answer 23

pulmonic, aortic

Question 24

S1 represents the closing of which valves?

Answer 24

tricuspid, mitral

Question 25

S2 represents the closing of which valves?

Answer 25

pulmonic, aortic

Question 26

S2 represents the opening of which valves?

Answer 26

tricuspid, mitral

Question 27

5 areas for listening to the heart *APE* *T*O *M*AN **A**ll **P**eople **E**njoy **T**ime **M**agazine

Question 28

? At the left 2nd ICS

Answer 28

Pulmonic

Question 29

? S1,S2; at the left 3rd ICS

Answer 29

Erb's Point

Question 30

? At the lower left sternal border 4th IC

Answer 30

Tricuspid

Question 31

? At the right 2nd ICS

Answer 31

Aortic

Question 32

? At the left 5th IC, medial to midclavicular line

Answer 32

Mitral

Question 33

S1 Represents ___ __ and __ closes __ and __ open Hear loudest at the apex, mitral, & tricuspid __ pitch - diaphragm

Answer 33

systole mitral, tricuspid aortic, pulmonic High

Question 34

S2 (louder than S1) Represents ___ __ and __ close __ and __ opens Hear best at the base - aortic & pulmonic __ pitch - diaphragm

Answer 34

diastole aortic, pulmonic mitral, tricuspid High

Question 35

S3 Represents issues with filling into the ventricular __-diastole ___ gallop: lung not compliant; vibrations Seen in HF as pathologic or mitral valve regurgitation, normal w/young adults Hear best in L side lying position - mitral __ pitch - bell S3 may be the earliest sign of ? - Shortly after S2

Answer 35

mid Ventricular Low HF, dilated CM, end-stage ischemic heart disease, valvular heart disease (VHD)

Question 36

S4 Represents issues with filling in __ diastole (before S1) ___ gallop; lung not compliant; vibrations LV hypertrophy, ischemia Hear best L lying side decubitus - mitral __ pitch - bell - Common cause is HTN, AS, cardiomyopathy, ischemic heart disease

Answer 36

late Atrial Low

Question 37

Murmurs - Crescendo (increases in intensity) vs decrescendo (decreases in intensity) - Quality (harsh, blowing, whistling, rumbling, or squeaking) - Pitch (high or low)

Question 38

? Originates from the pericardial sac & occurs w/the movements of the heart during the cardiac cycle

Answer 38

Pericardial friction rub * Usually transient; sign of inflammation, infection, or infiltration * May be heard in pts w/pericarditis resulting from MI, cardiac tamponade, or post-thoracotomy

Question 39

Murmurs Location - where do you hear it loudest? Quality - harsh, blowing, whistling, rumbling, or squeaking Pitch - usually high or low

Question 40

? Refers to the average pressure within the arterial system that is felt by organs in the body Normal 70-110 mmHg Need at least 60-70 to perfuse major organs Under 60 - ! bad

Answer 40

Mean Arterial Pressure (MAP) MAP = [(2 x DBP) + SBP] / 3

Question 41

Example: BP 130/80; SBP = 130; DBP = 80 [(2 x 80) + 130] / 3 = 96.666 or 97 mmHg

Answer 41

Pulse pressure (PP) is the difference between the SBP & DBP <40 >60 * This value can be used as an indirect measure of CO

Question 42

Narrowed PP is rarely normal & results from * increased peripheral vascular resistance or * decreased SV in pts w/HF * hypovolemia * shock; it can also be seen in those w/mitral stenosis or regurgitation

Answer 42

Increased PP may occur in pts w/ * slow heart rates * aortic regurgitation * atherosclerosis * HTN * aging

Question 43

? Is the difference between apical pulse & peripheral pulse A normal finding would be that they're essentially the same

Answer 43

Pulse Deficit ! If they're different, there's a problem. The apical is the SOURCE when it gets to the pulses effectively, it should be the same as at the source

Question 44

Decreased Cardiac Output/Ineffective tissue perfusion Head * Impaired orientation, dizziness, syncope, diaphoresis, lightheadedness, cyanosis, pallor Neck * Carotid, JVD Chest * Pain, dyspnea, PND, orthopnea, palpitations, cough, frothy sputum, blood, murmurs, heart sounds, lung sounds

Answer 44

Abdomen * N/V, nocturia Peripheral * Pain, pulses, hypokinetic?, edema, cyanosis General * Fatigue, anxiety, weight

Question 45

Factors Affecting Cardiac Output * Preload > Volume of blood in ventricles at the end of diastole * Contractility

Answer 45

* Afterload > Peripheral resistance against which the left ventricle must pump

Question 46

**Preload** determines the amount of stretch placed on myocardial fibers

Answer 46

**Contractility** can be increased by *epinephrine* and *norepinephrine* released by the SNS. Increasing contractility raises the SV by increasing ventricular emptying

Question 47

**Afterload** is affected by size of the ventricle, wall tension, and arterial BP

Answer 47

If arterial BP is elevated, ventricles will meet increased resistance to ejection of blood, increasing the work demand. Eventually, this results in *ventricular hypertrophy*, an enlargement of cardiac muscle tissue without an increase in CO or the size of the chambers