AHA Exam 2 Review / AHA Exam 2 Master Study Guide / NURS 612 AHA Exam 2 Master Study Guide.

AHA Exam 2 Review ● Test consists of cardiac, respiratory, skin, and Neuro (Headaches) ● Make sure that you read the questions before answering- this test will have multiple scenarios, chief complaints, and assessment findings may be given. May be multiple questions within one question so take time to read it. ● Know basic information and don’t go in depth while studying ● This exam covers the course content in weeks 4–7. ● • This exam has 10 multiple choice questions, and 6 short answer questions. *Please note that the multiple choice questions are the first 10 questions and the short answers are questions 11-16. ● • You will have 60 minutes to complete all questions. *Please note the exam will automatically submit at 60 mins. ● • If you want to track your time during the exam, there is an individual student setting while taking the exam. ● • Only one attempt allowed for submission of your final answers. ● • Each multiple choice question is worth 2 points. ● • Each short answer question is worth 2–4 points. ● When formulating differential diagnoses think worse thing first, and then narrow it down by assessing patient and looking at vitals. ● How do you decide whether to do labs or xrays on? Look at symptoms and decide (signs of systemic infection, history) HEART: ● Know how to percuss the chest – what do the findings suggest? ● Normal findings when palpating the chest ● Heart tones- where and what they mean ● Aortic stenosis ● Mitral stenosis ● Pulmonary stenosis ● How do you assess, auscultate, palpate and percuss the chest? ● •What are normal and abnormal findings of your assessment of the chest? ● •What would abnormal findings indicate? ● •What possible differential diagnoses can you think of? ● PVS ● • How to assess chest for cv and pv findings ● • Carotid artery ● • Palpate precordium and what are you assessing for? ● • Auscultate the cardiac system of the chest. What are you looking for. Document nl and abnl ● • How to listen to rate and rhythm of heart? Heart sounds? What is abnl and nl and what do they indicate? ● • S1, S2, S3, S4 ● • What do extra heart sounds indicate? ● • Where are heart murmurs heard and indication ● • Abnormal and normal indications ● • Know ekg strips. ● • Review the sample documentation. May see short answers about it. ● Pearl of Wisdom… ● •When I learned S3 and S4 in undergraduate nursing school, I learned S3 is a gallop and I often heard this in ER and ICU with the bell of my stethoscope. ● •I heard ken tuck EE ken tuck EE ken tuck EE. ● •An S4 I learned in undergraduate nursing school too. This is often in diastolic heart failure, severe left ventricular hypertrophy, active cardiac ischemia. It goes S4, S1 S3. tenUHseetenUHseetenUHsee ● •Go go - It’s a site I like really well for heart sounds. Questions about chest pain and what you should be asking ▪ Subjective Data: o Substernal pain or intense pressure radiating to the neck, jaws, and arms; particularly in the left arm o Often accompanied by shortness of breath, fatigue, diaphoresis, faintness, and syncope ▪ Objective Data: o Are you having current chest pain? o What medicines are you currently taking? o Do you have any comorbidities (other medical dx)? o Is this your 1st time having CP or is this recurrent? o How long has the chest pain been occuring? o Is it constant or intermittent? o Does the pain radiate anywhere? o How long does the chest pain last? o What does the pain feel like (sharp, crushing, dull ache)? o What number would you state it is from 1-10? o Do you have any other symptoms with the chest pain (shortness of breath, nausea, vomiting, dizziness, syncope, palpitations, cough)? o What makes the chest pain worse (activity, intercourse, eating, stress, laying flat)? o What makes the pain better (rest, medications, sitting up)? o Have you had an injury to your chest recently? What are some causes of an increase or decrease in heart sounds ▪ Split S1: o May occur in RBBB and with PVCs ▪ Fixed splitting of S2: o Occurs with ASD and RV failure ▪ Wide splitting of S2: o Associated with delayed closure of the pulmonic valve o Caused by pulmonic stenosis o RBBB o Early closure of aortic valve in MR ▪ Paradoxical splitting of the S2: o Occurs only on expiration o Associated with delayed closure of the aortic valve s/t LBBB ▪ Physiological S3: o Confined to children, young adults, and pregnant women as a result of rapid early ventricular filling ▪ Low pitched at the apex or left sternal border with the bell of the stethoscope ▪ Pathological S3 (aka ventricular gallop): o Heard in adults with decreased myocardial contractility, HF, and volume overload o MR or TR ▪ Same as physiological S3, heard after S2 with pt supine or left lateral recumbent position ▪ The sound is very soft and difficult to hear ▪ S4 (atrial gallop): o Occasionally occurs in normal adults or well-trained athletes o Usually d/t increased resistance to filling of the ventricle o Left sided S4 caused by HTN, CVD, CM, AS o Right sided S4 caused by pulmonic stenosis and pulmonary HTN ▪ Heard just before S1 with the pt supine or in left lateral recumbent position ▪ Sound can be as loud as S1 & S2 ▪ It is not heard in pts with AF due to no atrial kick ▪ Opening snap: o Opening of a stenotic mitral or tricuspid valve ▪ High pitched with the diaphragm of the stethoscope ▪ Friction rub: o Occurs after MI o With pericarditis ▪ High pitched grating, scratching ▪ Increased S3 o Detection: bell at apex; patient in left lateral recumbent position o Timing and description: Early diastole; low pitch ▪ Increased S4 o Bell at apex; patient supine in left lateral recumbent position o Late diastole or early systole; low pitch ▪ Gallops o Bell at apex; patient supine or in left lateral recumbent position o Presystole, intense, easily heard ▪ Mitral valve opening snap o Diaphragm medial to apex, may radiate to base; any position, second left intercostal space o Early diastole briefly, before S3: high pitch, sharp snap or click; not affected by inspiration; easily confused with S2 ▪ Aortic valve ejection click o Apex, base in second right intercostal space; patient sitting or supine o Early systole, intense, high pitch; radiates; not affected by respirations ▪ Pulmonary valve ejection click o Second left intercostal space at sternal border; patient sitting or supine o Early systole, less intense than aortic click; intensifies on expiration, decreased on inspiration ▪ Pericardial friction rub o Widely heard, sound clearest to apex o May occupy all of systole and diastole; intense, grating, machine-like; may have 3 components, may sound like a murmur Mitral Stenosis: heard with bell at apex, patient in left lateral decubitus position Description: ▪ Narrowed valve restricts forward flow; forceful ejection into ventricle ▪ Often occurs with mitral regurgitation ▪ Caused by rheumatic fever or cardiac infection Findings of Exam: ▪ Low-frequency diastolic rumble, more intense in early and late diastole, does not radiate ▪ systole usually quiet ▪ palpable thrill at apex in late diastole common ▪ S1 increased and often palpable at left sternal border ▪ S2 split often with accented P2 ▪ opening snap follows P2 closely ▪ Visible lift in right parasternal area if right ventricle hypertrophied ▪ Arterial pulse amplitude decrease Aortic stenosis: heard over aortic area; ejection sound at second right intercostal border Description: ▪ Calcification of valve cusps restricts forward flow; forceful ejection from ventricle into systemic circulation ▪ Caused by congenital bicuspid (usually tricuspid) valve, rheumatic heart disease, atherosclerosis ▪ May be cause of sudden death, particularly in children and adolescents, either at rest or during exercise; risk apparently related to degree of stenosis Findings of Exam: ▪ Midsystolic (ejection) murmur, medium pitch, coarse, diamond-shaped, crescendo-decrescendo ▪ radiates along the left sternal border (sometimes to the apex) and to carotid with palpable thrill ▪ S1 often heard best at apex, disappearing when stenosis is severe, often followed by ejection click ▪ S2 soft or absent and may not be split ▪ S4 palpable ▪ Ejection sound muted in calcified valves ▪ The more severe the stenosis, the later the peak of the murmur in systole ▪ Apical thrust shifts down and left and is prolonged if left ventricular hypertrophy is also present Subaortic stenosis: heard at apex and along left border Description: ▪ Fibrous ring, usually 1-4 mm below aortic valve ▪ Most pronounced on ventricular septal side ▪ May become progressively severe with time ▪ Difficult to distinguish from aortic stenosis on clinical grounds alone Findings of Exam: ▪ Murmur fills systole, diamond-shaped, medium pitch coarse ▪ Thrill often palpable during systole at apex and right sternal border ▪ Multiple waves in apical impulses ▪ S2 usually split ▪ S4 often present ▪ Arterial pulse brisk, double wave in carotid common ▪ Jugular venous pulse prominent Pulmonic stenosis: heard over pulmonic area radiating to left and into the neck; thrill in second and third left intercostal spaces Description: ▪ Valve restricts forward flow ▪ Forceful ejection from ventricle into pulmonary circulation ▪ Cause is almost always congenital Findings of Exam: ▪ Systolic (ejection) murmur, diamond-shaped, medium pitch, coarse ▪ Usually with thrill ▪ S1 often followed quickly by ejection click ▪ S2 often diminished, usually wide split ▪ P2 soft or absent ▪ S4 common in right ventricular hypertrophy ▪ Murmur may be prolonged and confused with that of a ventricular septal defect Tricuspid stenosis: heard with bell over tricuspid area Description: ▪ Calcification of valve cusps restricts forward flow; forceful ejection into ventricles ▪ Usually seen with mitral stenosis, rarely occurs alone ▪ Caused by rheumatic heart disease, congenital defect, endocardial fibroelastosis, right atrial myxoma Findings of Exam: ▪ Diastolic rumble accentuated early and late in diastole, resembling mitral stenosis but louder on inspiration ▪ Diastolic thrill palpable over right ventricle ▪ S2 may be split during inspiration ▪ Arterial pulse amplitude decreased ▪ Jugular venous pulse prominent, especially a wave ▪ Slow fall of V wave Mitral regurgitation: heard best at apex; loudest there, transmitted into left axilla Description: ▪ Valve incompetence allows backflow from ventricle to atrium ▪ Caused by rheumatic fever, myocardial infarction, myxoma, rupture of chordae Findings of Exam: ▪ Holosystolic, plateau-shaped intensity, high pitch, harsh blowing quality, often quite loud and may obliterate S2 ▪ Radiates from the apex to base or to left axilla ▪ Thrill may be palpable at apex during systole ▪ S1 intensity diminished ▪ S2 more intense with P2 often accented ▪ S3 often present ▪ S3-S4 gallop common in late disease ▪ If mild, late systolic murmur crescendos ▪ If severe, early systolic intensity crescendos ▪ Apical thrust more to left and down in ventricular hypertrophy Mitral valve prolapse: heard at apex and left lower sternal border; easily missed in supine position; also listen with patient upright Description: ▪ Valve is competent early in systole but prolapses into atrium later in systole ▪ May become progressively severe, resulting in a holosystolic murmur ▪ Often concurrent with pectus excavatum Findings of Exam: ▪ Typically late systolic murmur preceded by midsystolic clicks, but both murmur and clicks highly variable in intensity and timing Aortic regurgitation: heard with diaphragm patient sitting and leaning forward; Austin-Flint murmur heard with bell; ejection click heard in second intercostal space Description: ▪ Valve incompetence allows backflow from aorta to ventricle ▪ Caused by rheumatic heart disease, endocarditis, aortic diseases (like marfan syndrome, medial necrosis), syphilis, ankylosing spondylitis, dissection, cardiac trauma Findings of Exam: ▪ Early diastolic, high pitch blowing, often with diamond-shaped mid-systolic murmur, sounds often not prominent ▪ duration varies with blood pressure ▪ Low-pitched, rumbling murmur at apex common (Austin-Flint) ▪ Early ejection click is sometimes present ▪ S1 soft ▪ S2 split may have drum-like quality ▪ Mitral (M1) and A2 often intensified, S3-4 gallop common ▪ In left ventricular hypertrophy, prominent prolonged apical impulse down and to left ▪ Pulse pressure wide ▪ Water-hammer or Corrigan pulse common in carotid, brachial, and femoral arteries Pulmonic regurgitation Description: ▪ Valve incompetence allows backflow pulmonary artery to ventricle ▪ Secondary to pulmonary hypertension or bacterial endocarditis **************************CONTINUED**********************