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Heart
Personal habits
Diaphoresis
Palpitations
Cardiac Aortic Musculoskeletal Pleural Gastrointestinal Pulmonary Psychoneurotic NOTE: Chest pain in children and adolescents is seldom due to a cardiac problem.
Dyspnea
Interference with ADL Orthopnea
# of pillows
Review of Anatomy
Four chambers
Right atria Right ventricle Left atria Left ventricle Two atrioventricular
Tricuspid Mitral
Four valves
Two semiluunar
Pulmonic Aortic
Circulation
Circulation
Superior and Inferior vena cava Right atrium Tricuspid valve Right ventricle Pulmonic valve Pulmonary arteries Lungs Pulmonary veins Left atrium Mitral valve Left ventricle Aortic valve Aorta Head and Body
Cardiac Cycle
Systole
Blood is ejected
Right ventricle to lungs Left ventricle to aorta
Cardiac Cycle
Systole
Cardiac Cycle
Diastole
Atria contract and ventricles relax As ventricular pressure falls below atrial pressure
Mitral and tricuspid valves open to allow the blood collected in the atria to refill the relaxed ventricles
Cardiac Cycle
Diastole
Equipment
Marking pencil Centimeter ruler Stethoscope with bell and diaphragm Sphygmomanometer Inspection Palpation Percussion Auscultation
Techniques
General Assessment
Color Ease of respirations Signs of distress Blood Pressure
Edema
1+ 2+ 3+ 4+
slight pitting (2 mm), disappears rapidly a little deeper (4 mm), disappears within 10-15 seconds noticeable deep (6 mm), may last more than a minute very deep (8 mm), lasts as long as 2-5 minutes
Varicose Veins
Dilated and swollen Evaluate venous incompetence
Trendelenburg test
person is supine Lift the leg above the level of the heart until the veins empty Then lower the leg quickly An incompetent system will allow rapid filling of the veins
Place person in supine position Gradually raise the head of the bed until jugular venous pulsations are noted
To ensure they are not carotid pulsations, palpate the carotid pulse on the opposite side while you observe the pulsations
Place your cm ruler with its zero point at the sternal angle Extend the level of the JVP horizontally until it intersects with the cm ruler Record the cm height of the the JVP
Should not be > 2 cm.
Chest Landmarks
Costal angle
Lymph Nodes
Epitrochlear Inguinal
Homans sign
Dorsiflexion of the foot with the knee slightly bent Positive sign is calf pain
Peripheral Pulses
Palpate simultaneously so you can compare the right with the left
EXCEPTION: Carotids!
Peripheral Pulses
Assess
Rate (NOT at all sites!) Rhythm
Regular Irregular Regularly irregular
Contour
Smooth
Peripheral Pulses
Assess
Amplitude (strength)
0 Absent +1 Thready or weak +2 Easily felt (normal) +3 Bounding
Peripheral Pulses
Locations:
Carotid Brachial Radial Femoral Popliteal Dorsalis pedis Posterior tibial
Peripheral Vessels
Carotid arteries
Listen for bruits
Bruit: Low-pitched bowing sound over a peripheral vessel Usually indicates a narrowed vessel
Jugular veins
Listen for a venous hum
Venous hum: low to medium-pitched soft hum heard throughout the cycle Common in normal children and has no pathological significance
Peripheral Vessels
PAIN
Arterial After exercise Sharp, stabbing Worse w activity Lowering feet reduces pain Venous With prolonged sitting/standing Aching, heavy Helped by activity Raising feet and legs reduces pain
SKIN
Arterial Cool; cold Hairless Shiny Pallor on elevation Rubor on dangling Venous Warm Thickened Mottled Brown pigmented areas
PULSES
Arterial Often absent Venous Usually present
EDEMA
Infrequent Frequent
Chest Landmarks
Chest Landmarks
Palpate for
Areas
Pulmonic
2nd RICS @ SB 2nd LICS @ SB 3rd-5th LICS @ SB 5th LICS @ MCL Normal location of PMI in an adult
Right ventricle
Apical
Chest Landmarks
Simultaneously palpating the carotid artery will allow you to describe the chest palpation in relation to the cardiac cycle
Carotid pulsation and S1 are practically synchronous
Percuss in anterior axillary line across the intercostal spaces toward the sternum
Change from resonance to dullness marks the cardiac border
Heart Sounds
Sound is transmitted in the direction of blood flow Specific sounds are heard best over areas where the blood flows after it passes through a valve Auscultation should be performed in at least the five cardiac areas
Named for the locations where the valves are best heard Assessment should proceed in an systematic order
From the base of the heart to the apex OR From the apex of the heart to the base
Aortic area Pulmonic area Mitral area
Cardiac Areas
Aortic
Pulmonic
Tricuspid
Mitral
Cardiac Areas
Cardiac Areas
All People Enjoy Their Meals
Heart Sounds
S1
Closure of mitral and tricuspid valves at the beginning of systole Heard loudest at the apex
Mitral area
Heart Sounds
S2
Closure of aortic and pulmonic valves at the beginning of diastole Heard loudest at the base
Upper precordium
S3
Variation during first rapid filling phase during diastole Heard best at apex Sound
Ken-tuc-ky S1 S2 S3
Normal
< 30 yoa Pregnancy
Abnormal
Fluid overload Mitral or tricuspid regurgitation
S4
Variation during 2nd rapid filling phase Heard best at apex Sound
Ten-nes-see S4 S1 S2
Normal
< 30 yoa
Abnormal
Hypertension Mitral or tricuspid regurgitation
Valvular stenosis
Ejection clicks
Semilunar valves
Heart Murmurs
Relatively prolonged extra sounds heard during systole or diastole Causes
Increased blood flow across normal valves Forward flow through a stenosed valve Backward flow through an incompetent valve
Heart Murmurs
Describe
Location Timing and duration
Systolic S1
S1
Heart Murmurs
Describe
Pitch
High Medium Low
Character
Blowing Harsh Rumbling
Intensity
Heart Murmurs
Describe
Intensity: Grade
I II III IV V VI Very faint
Hardly heard
Faint
Clearly audible but quiet
Very loud
Visible heave or lift Heard with stethoscope not in contact with chest
Developmental Variations
Acrocyanosis is normal
Bluish coloration of hands and feet Disappears within a few days after birth
Apical impulse usually in 4th or 5th LICS just medial to the LMCL Murmurs are frequent in the newborn in the first 48 hours
Developmental Variations
Children
Developmental Variations
Pregnancy
BP gradually falls in the first 16-20 weeks then rise to pre-pregnant levels at term May hear an audible S4 Grade II systolic ejection murmurs are heard in 90% of pregnant women Dependent edema is the norm
Decreased venous return
Developmental Variations
Older Adults
S4 is more common in the elderly Soft murmurs are not uncommon Dorsalis pedis and posterior tibial pulses are more difficult to find Heart rate does not respond as readily to exercise Systolic blood pressure may increase
Questions?
Questions?
Questions?
Questions?
An extra heart sound that may be heard as a soft blowing sound during systole is called a:
Murmur
Questions?
Yes
What is this called?
Acrocyanosis