Blood Flow Through the Heart

The Loop

The fourteen stops bent into a circle: start at stop 1, bottom left, up the blue side, across the lungs, down the red side. The heart is two pumps side by side, in one loop, so they move the same volume with every beat; the left is stronger because it pushes against higher pressure, not because it moves more. (Standard physiology; the deck defines stroke volume and cardiac output but does not compare the two sides.) And the colour changes in exactly two places — red in the lungs, blue in the body — never inside the heart, because the septum keeps the sides apart.

Inside the Heart

The lab worksheet, and very likely the quiz, uses an anatomical outline, so find the same stops on a real shape.

The Word Bank

The only word bank the course has shown you is on the heart lab worksheet, where you labelled the heart and traced the flow in red and blue. Its terms, sorted by whether each is a stop:

The documents disagree on ten blanks or eleven (see the endnote); you cannot predict the subset, so learn the whole chain. Part 2 drills every version.

One Name, Several Labels

A blank that wants “mitral” may sit beside a diagram that says “bicuspid”. A change of label is not a change of answer.

The atrioventricular-and-semilunar terminology is standard anatomy rather than something the cardiac deck spells out; it is how the four valves sort into the two heart sounds in Part 3.

The Quiz, Rehearsed

The quiz as the blueprint describes it: venae cavae given, the rest blank, a word bank with Apex left in to reject. Type into each blank, or click a blank and then a word.

Three versions, because the documents disagree on the count. Eleven is right atrium to aorta with all four valves (the peripheral-vascular prep sheet’s count). Thirteen adds the lungs and the body. Nine drops the two semilunar valves, as the worksheet’s bank does. When you can do all three with the bank hidden, you are ready.

Two Kinds of Valve

The four valves come in two pairs, and the pairing is the key to the heart sounds. Each lets blood through one way only — the Think Conceptually handout’s “Normal Function of the Heart Valves (open and closing)”. (Standard physiology: valves have no muscle; they open and shut passively, on pressure.)

(Standard anatomy, not in the deck: the AV valves are held by chordae tendineae on papillary muscles, which stop the flaps blowing back; semilunar cusps simply fill and seal.)

Lub and Dub

The deck: systole is “myocardial contraction”, diastole the “filling phase”; Jeopardy: the phase “related to relaxing of the heart muscle” is diastole. The two sounds are the borders between the phases.

The clips are played two octaves higher than life so a phone or laptop speaker can carry them; with headphones, open “Original pitch” under each player to hear the true sound a stethoscope gives.

Where Each Valve Is Heard — APETM

The largest block on the Exam 4 blueprint: 8 questions with skeletal figures and locating heart sounds. The five listening posts, top to bottom, spell APETM.

The lab manual words the tricuspid row “S1 > or = S2”; use the deck’s five lines (see the endnote).

Lab manual: normally 1–2 cm and brief, often not palpable in adults, displaced laterally and left in late pregnancy. Slide-16 notes say “4th–5th ICS”; answer fifth, though “4th–5th” is not wrong (endnote).

The technique, in the deck’s order

1. Rate and rhythm first, in one area — “usually apex or Erb’s point”. Regular: count 30 seconds and multiply by 2. Irregular: count a full minute.
2. Then each area: S1, S2 and any extra sounds.

• Erb’s point is the alternative apical-pulse site — “Often easier than Apex for large breasted women.”
• Pulse deficit = apical − radial (Jeopardy), for an irregular pulse: 96 at the apex, 80 at the wrist → 16 beats too weak to make a pulse. (Standard: two nurses, same full minute.)
• Draping: displace breast tissue laterally; expose only the part of the chest being assessed.

Bell or Diaphragm

Equipment: a stethoscope and a watch with a second hand. Lab manual: “Listen with bell (light pressure) and diaphragm (heavy pressure) of stethoscope at all sites.”

Finding the Spaces by the Ribs

On a drawing, the only thing you can count is ribs, so learn each site as a rib address.

Rib addresses: aortic and pulmonic between ribs 2 and 3, Erb’s 3–4, tricuspid 4–5, mitral 5–6 at the midclavicular line.

Labelled

12345

Now find them yourself

Press Start. The unmarked copy has no dots: count down from the sternal angle and click where each site is. Some questions ask by name, some by rib address, some by which sound is louder.

StartShow meStop

Where the Valve Is, and Where You Listen

Two maps of the same four valves. Anatomy: all four bunched behind the sternum, from the pulmonic (highest) to the tricuspid (lowest), where their sounds overlap (standard anatomy). Auscultation — APETM — listens downstream instead.

Extra Sounds

Anything beyond two syllables is an extra sound; the sound strip under Lub and Dub marks where each falls.

S3 and S4 — the gallops

Both are quiet, low thuds in diastole from blood hitting a ventricle that cannot take it. The deck: S3 is “rarely normal in older adults”; S4 comes “late in diastole” from “abnormal resistance to ventricular filling”.

The deck lists children among those in whom S4 can be normal; standard teaching says it is S3 that is normal in children (see the endnote).

Murmurs

A “blowing or swooshing sound”, “audible when blood volume [is] increased in [the] heart or blood flow is impeded or altered”, from “cardiovascular disease or circulatory problems”. Systolic: just after S1. Diastolic: just after S2. The lab manual: graded 1 to 6; “a diastolic murmur or murmur > grade 3/6 is never innocent”; abnormal aortic murmurs are heard best at Erb’s point.

The rest of slide 21

The handout’s sound list adds muffled; in standard teaching that suggests fluid around the heart (pericardial effusion).

Pericardial or Pleural Rub?

Both are a scratchy, grating sound of two membranes rubbing; the difference is what moves them.

Standard teaching: ask for only a brief breath-hold; a pericardial rub is often loudest at the lower left sternal border with the client sitting up and leaning forward.

Bruits and Thrills

Murmur, bruit, thrill: one event found three ways — turbulent flow through a narrowed or damaged opening. Where you find it, and whether you hear or feel it, names it. The Exam IV review: a bruit is “a swishing sound… in the carotid artery or any other artery”.

Standard content: feel a thrill with the palm or base of the fingers; it first appears at murmur grade 4. Lab manual: a bruit can be normal in children and high-output states.

The One Rule: Look One Stop Backwards

The Exam 4 blueprint’s version of the heart lab’s “what happens with abnormalities” adds the clue: “Important to understand blood flow and internal structures to answer these types of questions.” You work the symptoms out from the fourteen stops. Blood is a one-way queue: when a chamber or valve fails, blood waits in whatever comes before it, and whatever comes after it goes short — a backward half (congestion) and a forward half (not enough arriving).

Left- and right-sided failure as named syndromes, and the backward/forward framing, are standard nursing content (Taylor Ch 40; ATI Cardiovascular); this note covers every left-versus-right table in this part.

Left Side Fails — the Lungs Fill

When the left ventricle cannot empty — scarred by an MI, or worn by years of high blood pressure — blood waits in the left atrium, pulmonary veins and lungs, and fluid is pushed into the air spaces: every backward sign is wet lungs.

Standard nursing content: the mechanisms in the “why” column; the cough of pulmonary edema can bring up frothy, pink-tinged sputum; some patients wake suddenly at night short of breath (paroxysmal nocturnal dyspnea).

The forward half: the left ventricle is the only pump that feeds the body, so its failure is decreased cardiac output — see Not Enough Forward, below.

Right Side Fails — the Body Fills

When the right ventricle cannot keep up, blood waits in the right atrium, the venae cavae and every vein that empties into them — neck above; liver, gut and legs below. The lungs are downstream, so they can stay clear.

Standard nursing content: abdominal congestion can cause loss of appetite and nausea; the abdominal fluid is ascites. The lab manual gives the normal finding as no neck vein distention, jugular venous pressure under 3 cm with the patient at 45°.

Standard nursing content: chronic lung disease, raising pulmonary artery pressure, is the other classic cause — one reason the deck’s history slide asks about “Lung disease”.

Why Heart Patients Get Up at Night

The prior-year review: “Nocturia (frequent night urination) and Edema are symptoms of which Heart Condition?” — heart failure. The deck pairs them on its bolded history list and asks “Do you get up during the night to urinate?” right after the pillows question: orthopnea is the lungs’ answer to lying down, nocturia the kidneys’.

The mechanism is standard physiology (Taylor Ch 40). Nocturia has other causes — prostate, diabetes, an evening diuretic, bedtime fluid — so look for it paired with edema.

Not Enough Forward: Decreased Cardiac Output

Cardiac output: Jeopardy’s “how much blood the left ventricle pumps out in a minute”, “a reflection of blood flowing around the body, especially to the brain and other vital organs.”

Standard: resting output is roughly 4–8 litres a minute; the compensating rise in rate costs the heart oxygen.

Standard: on a nitroglycerin drip, like HB, BP is also what the drug can drop.

Left-Sided Versus Right-Sided, Side by Side

Sort a stem’s findings into the columns; whichever fills is the failing side. Both? The left probably went first.

HB’s case gives both “poor capillary refill” and “< 3 seconds”, so build no answer on his refill time. That an anterior-wall MI involves the left ventricle (left anterior descending artery) is standard anatomy, not stated in the case.

Traps

The Exam 4 Blueprint, Mapped

The quiz is one sequence; Exam 4 is the whole unit. The Exam 4 study guide carries this guide’s Parts 1 to 4 and adds the cardiac assessment, peripheral vascular and rest and sleep parts, so the blueprint is mapped line by line there.

One line from it that this guide’s practice quiz asks about: the cardiac deck’s only red line, “Consider all chest pain to be cardiac until cardiac issue is ruled out” — gather data while treating with O₂ and nitroglycerin.

The Week’s Terms

Both preparation sheets’ “Define Terms” lists, in the decks’ words where they give one.

Thrombus and embolism are listed but not defined in the decks; those two lines are standard definitions.

HEENT — Key Points

Lectured in the quiz week but not on the Exam 4 blueprint (the syllabus lists it with Exam 4), so key points only.

Whisper distance and the Rinne ratio follow the lecture; the handout’s figures are in the endnote.

The case (LT): BP 186/108 after ten years of hypertension, out of medication; soft bilateral carotid bruit — a stroke risk; chews tobacco; alcohol-based mouthwash; cerumen blocking both ears.

Define list (standard definitions): amblyopia, lazy eye · myopia, nearsighted · glaucoma, raised eye pressure damaging the optic nerve · cataract, clouded lens · macular degeneration, central vision loss · retinopathy, retinal-vessel damage · dysphagia, difficulty swallowing · halitosis, bad breath · tinnitus, ringing · vertigo, the room spinning · epistaxis, nosebleed · conjunctivitis, pink eye · Eustachian tube, middle ear to nasopharynx · vestibular, inner-ear balance · tympanic membrane, eardrum · maxilla / mandible, upper / lower jaw.

The marked items, one more time

The night before the quiz: the first five rows above are the whole quiz.

Other things worth knowing

Traps, one line each