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position & surface landmarks

- Precordium
- Mediastinum
- Apex and base of heart
- Right and left cardiac borders - Great vessels

heart wall: what are the layers

- Pericardium
- Myocardium
- Endocardium


all of the heart & the great vessels

chamber of the heart

- Atria—right and left
- Ventricles—right and left

Valves of the heart

- Atrioventricular
• Tricuspid = right atrium
• Mitral = left atrium
- Semilunar
• Pulmonic = right ventricle
• Aortic = left ventricle

S1: definition & characteristics (9)

= 1st heart sound
• is made by the closing of the mitral and tricuspid valves (from the force of blood leaving ventricles)
• It's the "lubb" in "lubb dubb".
• S1 indicates the start of systole.
• The sound should be heard at all sites.
• S1 is louder than S2 at apex, over tricuspid & mitral valves.
• S1 is usually lower in pitch than S2.
• It is almost synchronous with the carotid pulse.
• Coincides with R wave on EKG.

S2: definition & characteristics (5)

= 2nd heart sound
• is made by the closing of the aortic & pulmonic valves (blood is filling the ventricles)
• It's the "dubb" in "lub dub"
• S2 indicates the start a diastole.
• At the base of the heart S2 is louder than S1.


- extra heart sound
- 3rd heart sound
- may be heard during diastole, when 80% of the blood in the atria rapidly fills the ventricles.
- often heard at the apex
- occurs just after S2
- caused by overstretch, primarily left ventricle = too much fluid (congestive heart failure, sepsis, ↑ cholesterol)
- S3 is normal for children & young adults


- extra heart sound
- 4th heart sound
- is normal in a child or young adult. If heard in someone over 30 it signifies a noncompliant or "stiff" ventricle.
- It occurs at the end of diastole (right before S1), when the atrial contraction completes the filling of the ventricle.
- occurs just the S1 and lasts about the same time as it takes to say "middle"
- caused by hypertension

Murmurs: general

- not an extra heart sound
- turbulent blood flow thru a valve. valve doesn't open (stenosis) or close (regurgitation) or a combination
- mitral sometime easier to hear when laying on one side

Murmur: what characteristics of sound do you note?

- Frequency (pitch) = use bell & diaphragm
- Intensity (loudness)
- Duration = where within systole & diastole
- Timing = where within systole & diastole

murmurs: info to get

• Quality
• Location
• Radiation
• Posture
• Timing
• Loudness
• Pitch
• Pattern


valve doesn't open
narrowing of a passageway


valve doesn't close properly. blood flow goes backward


1. Pressure ventricles must overcome to eject blood into the peripheral blood vessels
2. Amount of resistance is directly related to arterial B/P and the diameter of the blood vessels
3. Impedance: the pressure the heart must overcome to open the aortic valve; amount depends on aortic compliance and total systemic vascular resistance

- if BP is high → after load is high & heart gets big
- to ↓ afterload → ↓BP


1. Degree of myocardial fiber stretch at the end of diastole
2. Determined by left ventricular end-diastolic volume (LVED)
3. Starling's law: the more the heart is filled during diastole the more forcefully it contracts
4. Excessive filling = excessive LVED volume & pressure = ↓ CO (heart failure)
- high fluid, sepsis will ↑ preload

preload stretch

sill heart with a little more fluid. you can stretch the heart but don't want to stretch too much causing overuse. (ex. stretch out a rubber band & it loses its elasticity)

neck vessels

- Carotid artery
- Jugular veins
• Internal
• External
• Venous pulse and pressure

sympathetic system

• Release norepinephrine
↑ HR
↑ AV conduction
↑ Contractility
Vasoconstriction (causes excessive workload)
- heart failure = constant SS

parasympathetic system

• Release acetylcholine
↓ Contractility
↓ Conductivity
↓ SA firing
↓ HR
- stimulate vagus nerve (bowel movement, vomiting, gagging

Health history questions

• Chest pain = location, radiates, constant, palpation, what makes it worse? scale it
• Dyspnea = when? walking, talking, moving
• Orthopnea = how many pillows
• Cough = extra fluid, (pink frothy = heart failure)
• Fatigue = extreme (heart failure) careful of medication b/c many cause fatigue
• Cyanosis or pallor
• Edema
• Nocturia = getting up at night to go to bathroom
• Cardiac history = heart disease, sudden death <50
• Family cardiac history= ↑BP, stroke, diabetes
• Personal habits (cardiac risk factors) = smoking, sedentary, obesity, poor diet, high Na+ diet

in heart failure what color is sputum?

pink frothy

what is 1st symptom of coronary artery disease?



short of breath, difficulty breathing
PND = at night person has shortness of breath b/c less sympathetic system and extra fluid recirculates to the lungs. You should have patient sit up on the side of the bed and possibly give them O2

someone is sitting in tripod position, why?

barrel chest, clubbing & brown fingers, pursed lip breathing = shortness of breath


difficulty breathing in any position other than an upright position

routinely performed for cardiac

• Inspect general appearance • Inspect JV pulsations
• Inspect anterior chest
• AUSCULTATE S1 & S2 *****
• Inspect & palpate UE then LE

Carotid arteries: procedure

- Palpate
- Auscultate for bruit, using bell and asking patient to hold their breath (you should hear no sound)
- doppler = looking for plaque, narrowing → can have surgery


- turbulent blood flow thru artery
- swishing sound, low-pitched, usually heard during systole.
Causes = occlusion of the vessel


plaque formation

jugular: procedure

• Inspect the jugular venous pulse
• Estimate the jugular venous pressure

Estimate jugular venous pressure

1. identify highest level of jugular vein pulsation & then locate the manubriosternal joint (angle of Louis).
2. measure the vertical distance btw the sternal angle & the tongue blade
Normal = <1 in. pulsations s/b soft, wavelike,↓ w/inspiration, ↑ in recumbent position
Abnormal = > 1 in. fluttering, oscillating pulsation, irregular rhythms.
Causes = right ventricular failure, pulmonary hypertension, pulmonary valve stenosis

cardiovascular: inspect

inspect the anterior chest → typically don't see anything

cardiovascular: Palpate

1. palpate the apical pulse impulse
2. palpate the precordium (don't typically do this)

cardiovascular: percuss

percuss to outline the cardiac borders
lungs = resonance
heart = dull

cardiovascular: auscultate

- identify auscultatory areas = aortic, pulmonic, erbs, tricuspid, mitral
- note the rate & rhythm
- listen to S1 and S2 separately
- use both the bell and diaphragm
- listen for extra heart sounds & murmurs


large heart

carotid: findings

Normal = HR of 60-100, rhythm regular, amplitude 2+, contour is smooth & rounded
Abnormal = HR >100 or <60, irregular rhythms (regular irregularity or irregular irregularity), pulse that is either weak or bounding

Allen's test

= to ensure adequate ulnar blood flow. typically performed prior to using the radial artery for puncture and collection of blood specimen
1. patient should clench fist. this forces blood out of hand
2. apply pressure to both radial & ulnar artery, hand should lose color
3. still applying pressure, patient loosens hand & blanching should occur
4. release pressure on ulnar artery and within 5-15 seconds blood flow should return to hand. this equals positive test = the ulnar artery is working & you could puncture the radial artery.
- if blood flow doesn't return = negative test & don't puncture the radial artery

manual compression test

= test for competent values on varicose veins
1. firmly compress the lower portion of the varicose vein & place your other hand 6-8 above the first hand
2. feel for a pulsation at your second hand
Normal = no pulsation palpated the valves are competent
Abnormal = pulsations are felt with upper hand = the valves are incompetent

apical impulse

It is the pulse over the apex of the heart (at the 5th intercostal space), as heard through a stethoscope or palpated. This is the point of maximal impulse that corresponds to the left ventricular apex.

3 mechanisms to return blood to the heart

1. valves in each vein keeps blood flowing toward the heart. Doesn't let the pull of gravity drop the blood.
2. Skeletal muscles contracting, compressing the venous valves and helping the blood pump back to the heart.
3. Respiratory system. Inspiration & expiration cause pressure changes which compress veins forcing the blood back to the heart.

Risk factors for venous stasis

Immobility, history of DVT, age, obesity, varicose veins, pregnancy


ventricles are relaxed & fill w/blood from the atria


ventricles contract, creating pressure that closes the AV valves, preventing back flow into the atria. this pressure also forces the semilunar valves to open & blood is ejected out of the ventricles

venous stasis

- slow blood flow in the vein, usually of the legs. Venous stasis is a risk factor for forming blood clots in veins (venous thrombosis), such as in the deep veins of the legs, called deep vein thrombosis (DVT)
- Causes include long periods of immobility that can be encountered from driving[2] flying, bed rest or in orthopedic casts.

Paroxysmal nocturnal dyspnea

at night person has shortness of breath b/c less sympathetic system and extra fluid recirculates to the lungs. You should have patient sit up on the side of the bed and possibly give them O2

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