Module 6

• due to CHF, kidney disease, peripheral vascular disease or low albumin levels.
• Trace - minimaldepression is noted with pressure
• +1 - 2mm depression, repid return
• +2 - 4 mm, 10-15 sec
• +3 - 6mm, 1-2 min
• +4 - 8mm, 2-3 min

• located at the angle on the left in the 3rd, 4th, 5th ICS.
• atria are contracting(emptying), the ventricle are relaxing(filling)
• Systole - contraction, or emptying, of the ventricles
• Diastole - relaxation, or filling, phase of the ventricles.
• 4 chambers
• 2 thin walled atria - reseives blood
• 2 thick wall ventirlces pump blood out of the heart.
• Base - the widest upper portion of the heart where the antria is.

• 3 Positions: sitting, supine, left lateral recumbent.
• Observe pericardium for visible pulsations. Pulsation at the 5th ICS midclavicular line, the (PMI) point of maximal impulse, is normal
• Heaves and lifts, other visible pulsations, associated with enlarged ventricles.
• Palpate for vibrations - Thrill vibration in any area excpet for PMI. Associated with abnormal blood flow and has murmurs (additional heart sounds)
• Inspect chest from theside for visible vibrations. Cardiac motion is of low amplitude.
• Prominent pulses over aortic, pulmonic and tricuspid areas is abnormal.
• Pulses in the mitral area are normal - its apical impulse or PMI

• Aunt - Aortic Base right, 2nd ICS right sternal border.
• Polly - Pulmanic Base left, 2nd ICS left sternal border
• Takes - Tricuspid Left laterla, 4th ICS left sternal border
• Meds - Mitral Apex, 5th ICL MCL(midlacivular line)

• At the aortic and pulmanic sites the S2 sound is louder than S1
• At erb's point the S1 & S2 sound equal.
• At the tricuspid and mitral valve point S1 sounds louder then S2

• S1 - 1st heart sound (lab) closure of the AV valves the tricuspid and mitral valve. Dull, low-pitched sounds. Loudest over the mitral(5 ICS midclavicular) and tricuspid 5 ICS aress. Begining of systol.
• S2 - dub, closure of the semilunar valves (pulmanic and aortic valve.) Higher in pitch and shorter than S1. Loudest at the aortic(right 2 ICS) and pulmonic(Left 2 ICS) areas. Beginning of diastole.
• S3 - 3rd heart sound heard imediately after S2, has a gallop cadence. Called ventricular gallop. Best herd at the apix with the patient lying on his left side. Normal in young children and in adolescents when they are sitting or lying, but desappears when they stand or sit up. If s3 does not disappear it is abnormal and represents heart failure or volume overload
• S4 - called atrial gallop. heard immediately before S1, heard at the apical site, using the bell of the stethoscope,with the client lying on his left side. Normal in athelets, and abnormal in coronary artery disease, hypertansion and pulmonic stenosis.

• carry blood streight from the heart to the brain. Has turbulent blood fow through the carotid artery producing a whoosing sound known as a Bruit (brui) can asculte it only occurs in in narrowed(stenosis) or atheroscleotic arteries. Ask patient to hold the breath, in there should be no sound in uniteruppted artery.
• Carotid stenosis: narrowing from plaque, causes turbulance, increased cardiacn otuput secondary to fluid overload, use of stimulants or hyperthyroidism. If you hear Bruit,palpate the nekc for thrills(pulsations or vibrations)

return blood from the brain to the hear into superior vena cava. Normaly veins flat when we stand and distend when we lie flat. Juguar vinous distention (JVD) is when the right side of the heart is congested due to inadequate pump function. Best to asses JVD at semi-Fowler's (30-34 degree) Normaly the neck veins are flat at this angle.

• Arteries: high-pressure system with several palpable pulse sites. Thick elastic walls to allow contraction and relaxation.
• Veins: low-pressure system with valves to preventbackflow due to gravity. Return blood to the heart via the continuing pressure from the arterial system and pumping actionofthe adjacant skeletal muscles. Thinmm muscular, but inelastic walls that collapse easily. Contracts and relax in response to feedback from the sympathetic nervous system.
• All vessels are lined with a smooth endothelial layer that promotes non turbulent bood flow and prevents platelets from sticking to the sides of the walls and beginning a clot.

circulation of blood to al body regions.

in the walls of the heart and blood vessesl are sensitive to pressure changes. the aortic arch and carotid artery baroreceptors are particularl important inteh regulation of heart rate and vascular tone. When baroreceptors sense even a small drap in presure, they send messages to the brain stem centers to stimulate the sympatehtic nervouse system to increase heart rate and induce vasoconstriction. This mechanism matains blood pressure.

ineficient pump. blood is oxygenated but it is not well circulated leading to systemic and pulmonary edema, which further impairs gas exchange

heart muscle disorder - heart enlarges and impairs cardiac contractility

• oxygen requirements of the heart are unmet. Lead to MI and cells die from inadquate oxygen. Angeina pectorie is transient chest paion du to myocardial ischemia. tissue becomes injured but does not necrose.
• Coronary artery disease: leading cause of cardiac ischemia, plaque builds up inside the coronary arteries.
• Dysrhythmias: alterations in heart rate or rhythm, can lower cardiac output and dicrease tissue oxygenation.
• Heart Valve abnormalities: create turbulant flow - murmur in affected mitral and aortic valves.

(tissue swelling with fluid collection) develops with changes in normal hydrostatic pressure differences, such as in patients with right-sided heart failure. In this condition, the volume of blood in the right side of the heart increases greatly because the right ventricle is too weak to pump blood efficiently into the pulmonary blood vessels. As blood backs up into the venous system, venous hydrostatic pressure rises, which causes capillary hydrostatic pressure to rise until it is higher than the hydrostatic pressure in the interstitial space. Then excess filtration of fluid from the capillaries into the interstitial tissue space occurs, forming visible edema.Anascara: generalized edema

• dyspean that appears when he or she lies flat
• a patient with a haert disease can experience that.

• dyspean that is associated with activity, such as climbing staris.
• This is usually an early simptom of heart failure

Developes when a patient has been lying down for several hours. In this position, blood from the lower extermities is redistributed to the venouse system, which increase venous returntothe heart. A diseased heart cannot compensate for the increasedvolume and is ineffective in pumping the additionalfluid into the circulatory sytem. Pulmonary congestion results. Thepatients awakens abruptly,often wih a feeling of suffocation and panic.

brief loss of consciousness.The most common cause is a decreased perfusion to the brain.

• moderate to sever camping sensation(burning) in teir legs or buttocks associated with an activity such as walking.
• related to dicreased arterial tissue perfusion.
• Leg pain from prolonged standing or sitting is realted to venous insufficiency from either incompetent valves or venous obstruciton.

dusky redness. that replaces pallor in a dependent foot sugests arterial insufficiency.

• a weak pulse alternates with a stron pulse despite a regular heart rhythm.
• in patient with severly depressed cardiac function.

• Movement of the chest over the aortic, pulmonic and tricuspid areas
• If a prominent apical pulse is present in more than one ICS and have shifted lateral to the midclavicular line, the patient may have left ventricular hypertrophy.
• S1 - is usually soft, long an low pitched. if it is accentuated or intesified in exercise, hyperthyroidsim and mitral stenosis. If decreasd sound intensity occurs in patients with mitral regurgitation and heart failure.

• Inspection: the cest from side, at the right angle, and donward over areas of the perecardium where vibrations are visible. Note prominent pulses
• Ascultation: evaluates heart rate and rhythm, systol and diastol, vulvar fucntion. Listen with diaphragms from AEP TO MAN then with bell for low - frequency sounds to hear gallops(diastolic filling sounds) and murmurs.

• S1 created by the closure of the mitral and tricuspid valve (atrioventricular valves) softer and longer, markes the beginning of systole.
• S2 - caused mainly by the closing of the aortic and pulmonic valves (semilunra valves). Shorter.

• reflect turbulent blood flow through normal or abnormal valves. Describe their location based on where thy are best heard.
• Crescendo - increase in intensity
• Decrescendo - decreases in intensity
• Can be harsh, blwoing, whistling, rumbling, sqeaking.
• Pitch high or low

• pg 710 in iggi
• Size of left ventrical increases, it becomes stiff and less distensible
• Aorta and other large arteries thicken and become stiffer and less distensible.
• Systoli BP increase to compensate for the stiff arteries.
• Systemi vascular resistance increase.
• Left ventricular hypertophy
• Baroreceptors become less sensitive.
• Murmurs can be detected before other symptems. Atrial dysrhythmisa
• Heart is less able to meet increased oxygen demands.
• Hypertansion may occur
• Orthostatic (postural) and postprendial changes occur because of ineffective baroreceptors.
• dizziness, fainting.

• Look for distension of Jugular vein
• listen with a bell at carotied artery for Bruits
• Inspect and Palpate the arms
• Skin and nail bed color
• Skin temp, moisute, turgor
• Skin lesion, edema or nail clubbing
• Capillary refill: if greater than 1-2 sec: vasoconstriction, occlusion(zakuporka) or collateral circulation or decreased cardiac otput.
• Symmetri of edema.
• Ask patient if he or he ever have leg cramps when walking? - Intermetent claudication.
• Skin changes
• Swelling in legs (edema)
• Lymph nodes enlarged
• Palpate peripheral pulses: PPPx4 - pedal pulses palpable - dorsales pedis, posterial tibial
• Note rate(60-100), rhythm(regular or irregular), elasticity of vessel wall (countour-ochertanie)smooth or rough, and amplitude (force) - Scale 0-4
• 0 = absent
• 1 = weak
• 2 = normal (ex. Pulse 60, regular, euqal +2, smooth vessels)
• 3 = full
• 4 = bounding

• normal findings: visible carotid pulsations, but no neck vein distention
• anbnormal findings: bruits -wooshing sound - narrowed arteries
• Jugular vein - gives infor about the R side of the heart. Venous distention best noticeable when patient is laing at 45 degree angle.
• Intermettent claudication
• Skin changes, edema, lymph nodes enlarged

• Arteriosclerosis - blood vessels become rigid less elastic
• Atherosclrosis - fatty plaque leading to partial or total arterial occlusion(zakuporka)
• Increased risk of deep vein Thrombosis (DVT) and Pulmonary Embolism (PE)

includes diorders that change the natural flow of lbood through the arteries and veins of theperipheral circulation. Mainly arterial PAD.

develope between or ed of toes, cool/cold foot, secreased or absent pulses, haro loss, shiny thin skin

ankle location, footis warm, discoloration/edema, pulses present, brown pigmentation, chronic non-healing uclers, minimal pain

plantar area of foot, pressure points or metatarsal heads, pulses usually present, reports no pain due to pehripheral neuropathy.

• _Thrombus formation (venous thrombosis) can lead to pulmonary embolism (PE), a life-threatening complication. Venous thromboembolism (VTE) is the current term that includes both deep vein thrombosis and PE.
  _Defective valves lead to venous insufficiency and varicose veins, which are not life threatening but are problematic.
  _Skeletal muscle lacks contractility.

• Thrombophlebitis
• refers to a thrombus that is associated with inflammation. Phlebothrombosis is a thrombus without inflammation. Thrombophlebitis can occur in superficial veins. However, it most frequently occurs in the deep veins of the lower extremities.
• Deep vein thrombophlebitis, commonly referred to as deep vein thrombosis (DVT), not only is most common but also is more serious than superficial thrombophlebitis because it presents a greater risk for pulmonary embolism (PE). In PE, a dislodged blood clot travels to the pulmonary artery. DVT develops most often in the legs but can occur also in the upper arms as a result of increased use of central venous devices.

• Varicose veins - prolonged standing, systemic problem, obesity, family history of varicose veins.
• stasis ulcers - result from edema, minor inury to the limb.
• Thrombophlebitis - mostly in people who undergo surgical procedures., ulcerative colitis, heartt fialure, immobility.