Jarvis Chapter 20: Heart And Neck Vessels

apical impulse: point of maximal impulse; pulsation created as the left ventricle rotates against the chest wall during systole location: normally at the fifth left intercostal space in the midclavicular line duration: systole (short. normally first 1/2 of systole) Size: normally 1 x 2 cm

Obese Thick chest wall Large breast tissue

Cardiac enlargement L Ventricle dilation (volume overload) displaces impulse down and to the left and I ncreases size more than one space. Barrell chest

First heart sound (S1) occurs with closure of the AV valves and this signals the beginning of systole. The mitral component of the first sound slightly precedes the tricuspid component, but you usually hear these two components fused as one sound. You can hear S1 over all the precordium but usually loudest at the apex. Second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. The aortic component of the second sound (A2) slightly precedes the pulmonic component. Although it is heard over all the precordium, S2 is loudest at the base.

Right Side During inspiration blood is pushed into vena cava increasing venous return to R side of heart which increases RV stroke volume. = Prolong RV systole and delay pulmonic valve closure Left side More blood is in the lungs during inspiration which decreased LV stroke volume. = Shortens LV systole and allows the aortic valve to close a bit earlier. When aorotic valve closes earlier than pulmonic valve *More to the Right heart, Less to the left - Can cause a split in s2 - only heard in pulmonic valve area = you can hear the mitral and tricuspid components separately = this is a split S2

S1- "LUB"- Loudest at the apex and softer at the base.

1. Position of AV valve at start of systole--- wide open and no time to drift together. 2. Change in valve structure-- calcification of valve, needs increasing ventricular pressure to close the valve against increased atrial pressure

1. position of AV valve -- delayed conduction from atria to ventricles. Mitral valve drifts shut b4 ventricular contraction closes it 2. Change in valve structure-- extreme calcification, which limits mobility. 3. More forceful atrial contraction into noncompliant ventricle; delays or diminishes ventricular contraction

S2- "Dup"- is the loudest at the base.

1. higher closing pressure (ex systemic hypertension, rining or booming) 2. Exercise and excitement increase pressure in aorta (ex mitral stenosis or heart failure) 3. Pulmonary hypertension (ex aortic or pulmonic stenosis) 4. Semilunar valves calcified but still mobile P488

1. a fall in systemic blood pressure causes a decrease in valve strength (ex shock) 2. Semilunar valves thickened and calcified, decreased mobility (ex. aortic or pulmonic stenosis)

Splitting of the S2 can happen during inspiration. It is heard when the aortic valve closes earlier than the pulmonic valve. Instead of it sounding like "dub" it sounds like "T-Dub". You can hear it only in the pulmonic valve area.

Low pitched sound that occurs in early diastole. You will hear this sound at the apex in the left lateral position. Use the bell of the stethoscope. Normal in children and young adults. It is abnormal when it persists in a person. Usually abnormal in adults over the age of 40 and can be an early sign of heart disease or congested heart failure.

The S3 may be normal (physiological) or abnormal (pathological). The physiological S3 is heard frequently in children and young adults; it occasionally may persist after age 40 years, especially in women. The normal S3 usually disappears when the person sits up. In adults, the S¬3 is usually abnormal. The pathological S3 is also called a ventricular gallop or an S3 gallop, and it persists when sitting up. The S3 indicates decreased compliance of the ventricles, as in heart failure.

The S4 is a ventricular filling sound. It occurs when the atria contract late in diastole. It is heard immediately before S1. This is a very soft sound, of very low pitch. You need a good bell, and you must listen for it. It is heard best at the apex, with the person in left lateral position.

Diastole- AV valves (i.e. tricuspid and mitral) are open Systole- AV valves shut producing S1. Aortic valves open to eject blood rapidly. then some back flow from psi equalizing b/t aorta and ventricles causes aortic valve to shut Diastole again- all 4 valves closed, mitral valve opens and diastolic filling begins again

Venous pressure - the pressure exerted on the walls of the veins by the circulating blood Jugular Venous Pulse - The pulse in the right internal jugular vein at the root of the neck; pressure of right atrium

Venous pressure - the pressure exerted on the walls of the veins by the circulating blood Jugular Venous Pulse - The pulse in the right internal jugular vein at the root of the neck; pressure of right atrium

Chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis or pallor, edema, nocturia, past cardiac history, family cardiac history, personal habits (cardiac risk factors)

A bruit is a blowing, swishing sound indicating blood flow turbulence. Indicated turbulence due to a local vascular cause, such as atherosclerosis narrowing.

A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex.

• S1 is the start if systole and thus serves as the reference point for the timing of all other cardiac sounds; usually you can identify S1 instantly because you hear a pair of sounds close together (lub-dup), and S1 is the first of the pair • S1 is louder than S2¬ at the apex; S2 is louder than S1 at the base • S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel is pulse is S1 • S1 coincides with the R wave (the upstroke of the QRS) complex) if the person is on an ECG monitor

A pulse deficit signals a weak contraction of the ventricle; it occurs with atrial fibrillation, premature beats, and heart failure.

Preload is the venous return that builds during diastole. It is the length to which the ventricular muscle is stretched at the end of diastole just before contraction. When the volume of blood returned to the ventricles is increased (as when exercise stimulates skeletal muscles to contract and force more blood back to the heart), the muscle bundles are stretched beyond their normal resting state to accommodate it. The force for this switch is the preload.

Afterload is the opposing pressure the ventricle must generate to open aortic valve against the higher aortic pressure. It is the resistance against which the ventricle must pump its blood. Once the ventricle is filled with blood, the ventricular end diastolic pressure is 5 - 10 mm Hg, whereas that in the aorta is 70 - 80 mm Hg. To overcome this difference, the ventricular muscle tenses. After the aortic valve opens, rapid ejections occur.

Pattern- crescendo(louder) decrescendo(taper off) crescendo-decrescendo( depends on blood flow/pressure Quality- musical,blowing, harsh, rumbling Location- pmi (best) or valve area, intercostal space on the neck, back or axilla Radiation- heard in the direction of blood flow Posture- may dissapear or enhance with postion Grading of the murmur-- 1-difficult to hear( quiet room needed) 2- audible but faint 3.- easy to hear mod loud 4- loud-thrill palp on chest 5- very loud with part of stethscope lifted off chest 6- loudest with stethscope off chest

innocent murmur: no valvular or other pathologic cause, generally soft (grade ii), midsystolic, short, crescendo-decrescendo, with a vibratory or musical quality ("vooot" sound like fiddle strings). Heard, at 2nd/3rd left ICS and disappears w/ sitting, young person has no associated signs of cardiac dysfunction. functional murmur: due to increased blood flow in the heart (anemia, fever, pregnancy, hyperthyroidism). Force of heart is greater in children, increases blood flow velocity, increased velocity + smaller chest measurement makes an audible murmur