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CC1 Unit 1&2

Coronary Care I

Where does the right ventricle pump blood to? pulmonary system (aka lungs)
does the right ventricle deliver oxygenated or un-oxygenated blood? un-oxygenated blood from the body to the lungs
what is the approximate thickness of the walls of the right ventricle? 4-5mm in thickness, relatively thin
what are the names of the 2 valves attached to the right ventricle? tricuspid and pulmonic valves
Where does the left ventricle pump blood to? systemic circulation (aka the body)
does the left ventricle deliver oxygenated or un-oxygenated blood? oxygenated blood received from the lungs to the body
what is the approximate thickness of the walls of the left ventricle? 8-15mm thickness, 2-3x that of the right ventricle
what are the names of the 2 valves attached to the left ventricle? mitral and aortic valves
which rib numbers does the heart lie behind? between the 2nd and the 6th ribs
what is the name of the broad portion of the heart (upper right area)? the base
what is the name of the pointed end of the heart (lower left area)? the apex
where is the point of maximum (PMI) impulse heard best at? the apex
what are the names of the 3 inner layers of cardiac tissue? epicardium, myocardium, endocardium
what is the name for the outermost cardiac tissue surrounding the heart? pericardium
where is the pericardial sac located? between the fibrous and serous pericardia
what are the 2 types of pericardial tissue and describe their structure? fibrous pericardium (tough fibrous outer layer) and serous pericardium (thin delicate smooth lining)
which muscle layer forms most of the heart's wall? myocardium
where is an AV (atrio-ventricular) valve located? between an atrium and a ventricle
where is a semilunar valve located? leading from a ventricle to a great vessel
which valve only has 2 cusps? mitral (bicuspid) valve
what is the name of the left sided AV valve? mitral valve
what is the name of the right sided AV valve? tricuspid
what is the name of the valve that leads out of the left ventricle? aortic valve
what is the name of the valve that leads out of the right ventricle? pulmonic
what are the chordae tendoneae? valve leaflets that open and close; strong cords of fibrous tendinous tissue; attached to the cusps of the AV valves and connect to the papillary muscles
what are the papillary muscles? muscles that attach to the ventricles and project into the ventricular cavities; continuous extensions of the chordae tendoneae
what can dysfunction or rupture of a papillary muscle or chordae tendoneae lead to? regurgitation
what is the function of the chordae tendonaea and papillary muscles with respect to blood flow? prevents valves from being pushed backwards, allows the valve to open in the correct position and propel blood in the right direction
what are the 2 phases of the cardiac cycle? diastole and systole
what is another term for diastole? relaxation phase
what is another term for systole? contraction phase
what happens during diastole? chambers are relaxed, filling with blood, tricuspid and mitral valves are open, blood flows from atrium to ventricle
what percentage of ventricular filling occurs during the diastolic phase? 80%
what happens during systole? hearts contracting phase occurs when enough blood has entered the individual chambers to propel blood volume
what are the 2 phases of systole? atrial systole and ventricular systole
what is atrial systole? ventricles are relaxed, atria contract pushing more blood into ventricles
what is the atrial kick? last 20% of blood volume being pushed into the ventricles
what is ventricular systole? ventricles contract and push blood out to the lungs and body
which valves close during ventricular systole? why? tricuspid and mitral valves close to prevent blood flow back into the atria
which valves close after ventricular systole? why? pulmonic and aortic valves close to prevent blood flow back into the ventricles
what does automaticity mean? the ability to initiate electrical impulses
what does conductivity mean? the ability to pass, conduct the impulses along to other cells
what does contractility mean? the ability to cause shortening of cardiac fibers
where do electrical impulses original for normal heart beats? SA node
where is the SA node located? on the endocardial surface of the right atrium
what is the normally the primary pacemaker of the heart? the SA (Sino-Atrial) node
which cells in the heart have automaticity in a normal heart beat? SA node
what is the normal rate of impulses per minute from the SA node? 60-100 times/minute
when would the SA node stop initiating impulses? if another area of the heart originates impulses at a rate more rapid than that of the SA node
where are the intermodal tracts located? between the SA node and the AV node
what is the main role of the intermodal tracts? the main role of the intermodal tracts is to transmit the impulse that has originated in the SA node and conduct it through the RA allowing the RA to contract
where is the inter-atrial tract located? between the two atria
what is the main role of the inter-atrial tract? conducts the impulse from the SA node to the left atria so that the LA can contract
what is another name for the inter-atrial tract? Bachman's Bundle
where is the AV node located? located in the lower right atrium
what is the main property of the AV node? why is this important? its ability to slow/delay the impulse before it reaches the ventricles allowing the atria the time they need to fully contract to fill the ventricles to capacity
what is the AV junction? the pathway that the impulse travels through on its route to reaching the ventricles
what can serve as a backup pacemaker if the SA node were to become ischemic to fail? the AV junction has automaticity meaning that if can initiate impulses if the SA node fails
what is the impulse rate of conduction of the AV junction? 40-60 impulses/minute
what is the pathway of the electrical impulses? SA node -> AV node -> AV junction -> bundle of HIS -> two bundle branches -> Purkinje Fibers
where would electrical impulses be initiated if the SA node and AV junction were to both fail? impulses would be initiated within the ventricles
what would the rate of electrical impulses be if they were initiated in the ventricles? 20-40 impulses/minute
what is the cardiac output? the volume of blood ejected by the left ventricle each minute
what is the normal cardiac output? 3.6-10 litres
what is the equation to determine cardiac output? heart rate x stroke volume
what is the normal stroke volume in ml? 60-100ml
what influences the stroke volume? preload, contractility, afterload
what influences the heart rate? the autonomous nervous system (sympathetic and parasympathetic)
what is another name for preoad (LVEDP)? left ventricular end diastolic pressure
what is left ventricular end diastolic pressure? the amount of stretch, tension, pressure within the LV at the end of diastole aka the amount of wall stretch, caused by the blood volume within the ventricules at the end of distaole
what is preload? the load of blood that establishes the initial muscle length of the cardiac fibers just prior to contraction
what happens if not enough blood is in the left ventricle at the end of diastole before the LV contracts? not enough blood will be ejected by the LV, thereby leading to a decrease in the cardiac output
what influences preload? venous return, status of the LV, atrial kick, status of the mitral valve
how does the status of the mitral valve influence preload? preload decreases with mitral stenosis as blood has difficulty leaving the LA, causing less LV stretch
what is contractility? the muocardial muscles ability to contract which reflect speeds and muscle shortening capacity of the myocardial fibers
what are the major factors affecting contractility? the ability of the muscle fibers to shorten
what happens if the fibers cannot contract effectively? less than optimum amounts of blood are ejected
what is afterload? the amount of stretch, tension, pressure against the LV during peak systole
what influences afterload? status of the aortic valve, blood viscosity, systemic vascular resistance
how does blood viscosity affect afterload? thin blood ejects with more ease than thicker blood
how does vasoconstriction affect afterload? increases afterload as the LV needs more push, energy or pressure to propel its blood volume into the constricted arteries
how does vasodilation affect afterload? afterload is reduced with vasodilatation as blood is easily propelled into the dilated vessels
what influences the heart rate? HR is influenced by the autonomic nervous systems (SNS and PSNS)
what affect does a dominant sympathetic nervous system have on heart rate and CO? HR >100; ventricles have less time to fill because they are contracting too rapidly, preload is decreased = CO decreased
what affect does a dominant parasympathetic nervous system have on heart rate and CO? HR <60; the slow rate allows time to fill but the SV reaches a max and cannot increase more volume = decreased CO
what is the function of coronary arteries? to bring oxygen-rich blood to the myocardium
what are the 2 main coronary arteries? Right and Left coronary arteries
how does coronary artery blood flow through the layers of the heart? from the outside (pericardium) to the inside (endocardium)
what is the pathway of the right coronary artery (RCA)? originates anteriorly off the aorta, lies between the RA and RV then travels posteriorly and descends inferiorly behind the heart
which cardiac muscles are supplied by the RCA? the right atrium, large portion of the RV, most of the inferior wall of the LV, part of the posterior wall of the LV, posterior 1/3 of interventricular septum
what electrical structures are supplies by the RCA? SA node (in about 55% of people), AV node and AV junction (in 90% of people), Bundle of His
what is the pathway of the left coronary artery (LCA)? originates anteriorly off the aorta, divides into 2 braches (LAD artery and circumflex artery)
what are the names of the two branches of the left coronary artery (LCA)? left anterior descending artery (LAD) and the circumflex artery
what is the pathway of the left anterior descending artery (LAD)? travels anteriorly over the interventricular septum, circles around the apex at the bottom of the heart, terminates in the inferior aspect of the cardiac apex
which cardiac muscles are supplies by the LAD artery? anterior walls of both ventricles, anterior 2/3 of interventricular septum
which electrical structures are supplies by the LAD artery? both bundle braches
what is the pathway of the circumflex artery? arises anteriorly from LCA, lies anteriorly between LA and LV, travels posteriorly around to the L side of the heart
which cardiac muscles are supplied by the circumflex artery? LA, lateral wall of LV, part of the posterior wall of LV
which electrical structures are supplied by the circumflex artery? SA node (45% of people), AV node and AV junction (10% of population), proximal bundle branches
what are 6 parts of the assessment of chest pain? location, severity, description, provoking/alleviating factors, type of onset, occurrence and duration
what are other conditions that can cause chest pain that are not cardiac? esophageal asps, hiatus hernia, cholecystitis, peptic ulcer, endocarditis, myocarditis, chest trauma
what are palpitations? awareness or sense of feelings ones own heartbeat
where can palpitations be felt? over the precordium or in the throat
what often causes palpitations? caffeine, alcohol, nicotine, bronchodilators, nasal decongestants
what determines the urgency of treatment for palpitations? the presenting clinical picture; can be a symptom of an arrhythmia or can be insignificant
what is syncope? a transient brief loss of consciousness due to cerebral anoxia
what are accompanying symptoms to syncope? pallor, nausea, diaphoresis, slow and shallow respirations, slow and weak peripheral pulses, hypotension
what usually causes syncope? vasodilation or overactivity of the parasympathetic nervous system (PSNS) which results in a slow HR
what is peripheral edema? an abnormal accumulation of fluids in interstitial issues, in the periphery
how does gravity and ambulation affect peripheral edema? ambulatory patients experience edema in legs and feet, bedridden pts develop edema over sacrum
what areas can peripheral edema extend to? abdomen (ascites), torso and face (anasarca)
what is the likely cause of edema of the arm? superior vena cava syndrome or thrombophlebitis
what is the likely cause of edema that develops in one leg only? thrombophlebitis or venous insufficiency
what are some common signs and symptoms that occur with chest pain? dyspnea, cough, decreased breath sounds, diaphoresis, changes in skin colour, weakness/fatigue, dizziness/headache, anxiety/sense of impending doom, nausea, vomiting
what should you examine the chest for on a normal cardiac assessment? symmetry of respiratory movement, presence of intercostal retractions, heaves, pulsations
what are heaves? strong outward thrusts of the chest wall
where is the point of maximum impulses located? at the left 5th intercostal space, medial to the med-clavicular line
what can displace the PMI? can be displaced by lung or rib cage abnormalities (pneumothorax, thoracic scoliosis)
where should the apical pulse be palpated? over the PMI
what can heaves indicate? a hypertrophied left ventricle
what are thrills? vibrations that feel like the throat of a purring cat
what do thrills indicate a heart murmur
what does a murmur result from? turbulent blood flow across a valve
which sounds are best heard using the diaphragm of the stethoscope? used to hear high pitched sounds (S1 and S2)
which sounds are best heard using the bell of the stethoscope? low frequencies (S3, S4, murmurs)
what produces the LUB DUB sounds of the heart? closure of the valves
where is the best place to auscultate the aortic valve? 2nd right intercostal space
where is the best place to auscultate the pulmonic valve? 2nd left intercostal space
where is the best place to auscultate the tricuspid valve? lower left sternal border
where is the best place to auscultate the mitral valve? 5th left intercostal space, just medial to the midclavicular line
what produces the S1 LUB sound? the closure of the mitral and tricuspid valves after atrial contraction; the end of ventricular diastole and the onset of ventricular systole
what produces the S2 DUB sound? closure of the aortic and pulmonic valves that close at the end of ventricular systole
where is S2 heard best? over the base of the heart
what are adventitious heart sounds? vibration-like sounds that occur within the ventricles; S3 and S4
what produces adventitious (S3, S4) heart sounds? these sounds are created by gushes of blood entering stiffened or resistant ventricles; not produced by valve closure
what is another name for heart sounds S3? ventricular gallop
what produces the S3 (ventricular gallop) sound? caused by ventricular filling during atrial diastole in the congested heart (heart failure, pulmonary edema)
what is another name for heart sounds S4? atrial gallop
what produces the S4 (atrial gallop) sound? heard with increased resistance to ventricular filling when the ventricles cannot accommodate the last 20% of blood from the atria
which cardiac complication is commonly associated with the S4 sound? why? commonly heard after MI, because the ventricular damage leads to altered ventricular expansion and compliance
what is a bruit? heard over an artery, usually caused by narrowing of the artery
what is a friction rub? what does it usually indicate? grating leathery sound heard loudest at the left sternal border, that usually indicates pericarditis
what is the first chamber of the heart to receive unoxygenated blood from the body? the internal jugular vein delivers blood into the right atrium
what is used to determine the jugular venous pressure? the pulsation level of the internal jugular vein
what can affect the pulsations in the jugular vein? positioning and breathing; normally the vein is only visible with the patient laying flat not sitting or standing
does position or movement affect the pulsations in the carotid artery? no
how do you observe the JVP? HOB 30-45 degrees, locate suprasternal notched, turn patients head away from examiner
what are elevated JVP? what does this indicate? pulsations visualized higher than 4-5cm above suprasternal notch; indicates distension of the venous system
what cardiac complications are usually associated with elevated JVP? why? right sided heart failure, right sided MI, cor pulmonale; because of higher right sided cardiac pressures as the venous blood is struggling to empty into the RA
what is a systemic approach to assessing arterial pulses? starting at the top of the body and working downward
what is assessed when looking at arterial pulses? compare both sides of the body for rate, rhythm, strength and character
how long should the rate of arterial pulses be counter for? 1 full minute
how is strength of arterial pulses graded? 4+ bounding, 3+ increased strength, 2+ normal, 1+ weak, 0 absent
what can an absent pulse indicate? aortic dissection, atherosclerosis
what is pulsus alternans? what can this indicate? alternating high and low volume beats; left sided heart failure
what is pulsus paradoxuis? what can this indicate? reduction of pulse pressure on inspiration; common in cardiac tamponade
Created by: bveltri



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