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NUR 212 > 3.1 Heart and Lung Assessment > Flashcards

3.1 Heart and Lung Assessment Flashcards

1
Q

Cardiovascular (CV) System includes

A

Heart

Peripheral vascular
-Arteries, Veins, Capillaries

Hematologic
-Blood – Hemoglobin

Lymphatic
-Lymph, Lymph Nodes, Spleen

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2
Q

The Heart includes

A

4 Chambers

  • Left and Right Atria
  • Left and Right Ventricles

4 Valves

  • AV- tricuspid and mitral
  • Semilunar- pulmonary and aortic

Base at the top
-2nd rib

Apex at the bottom
-5th IC space, midclavicular

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3
Q

Unoxygenated blood flow

A 
Unoxygenated
Inferior and Superior Vena Cava →
Right Atrium →
Tricuspid Valve →
Right Ventricle →
Pulmonic Valve →
Pulmonary Arteries
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4
Q

Oxygenated blood flow

A 
Oxygenated
Pulmonary  Veins →
Left Atrium → 
Mitral Valve →
Left Ventricle →
Aortic Valve →
Aorta
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5
Q

Cardiac Cycle

A

Systole (1/3) + Diastole (2/3)

Systole (Pumping)

  • Semilunar valves open
  • AV valves closed
  • Ventricular contraction

Diastole (Filling)

  • AV valves open
  • Semilunar valves closed
  • Ventricular relaxation
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6
Q

Physical Assessment: Cardiac

A 
Inspection
-Apical Impulse
4th or 5th IC space, midclavicular
-Retraction
-Heaves (lifts)

Palpation

  • Apical impulse
  • Thrills

Percussion

Auscultation

  • Heart Tones
  • Rate and Rhythm
  • Murmurs
  • Gallops

Stethoscope

  • Bell “light low”
  • Diaphragm “high heavy”
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7
Q

Heart Tones S1

A
  • “Lub”
  • Systole
  • Mitral and tricuspid closure
  • Loudest over apex
  • Synchronous w/ carotid pulse
  • Split S1: right bundle branch block (BBB) or premature ventricular contractions (PVC)
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8
Q

Heart Tones S2

A
  • “Dub”
  • Diastole
  • Aortic and pulmonic closure
  • Loudest over the base
  • Split S2: bundle branch block (BBB) or valve disease
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9
Q

Heart Tones: S3

A
  • “Ventricular gallop”
  • Early diastolic sound
  • Loudest over the apex
  • Just after S2 (like Ken-tuc-ky)
  • Due to heart failure (3 syllables)
  • Low-pitch, heard best with the bell
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10
Q

Heart Tones: S4

A
  • “Atrial gallop”
  • Late diastolic sound
  • Loudest over the apex
  • Just before S1, like Ten-nes-see
  • Due to hypertension (4 syllables)
  • Low-pitched, heard best with the bell
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11
Q

MURMURS sounds

A
  • Sounds from turbulent blood flow
  • Most commonly from valve disease
  • Regurgitation- backward flow
  • Stenosis- obstructed forward flow
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12
Q

MURMURS described

A

Described by

  • Location- Listening post
  • Timing- Systole or Diastole
  • Pitch- Low, medium, high
  • Quality- Harsh, blowing
  • Intensity- I – VI
  • Pattern- Crescendo, decrescendo
  • Radiation- Axilla, neck
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13
Q

Jugular Vein Distention (JVD)

A

Assessment of circulatory volume

Normally visible while lying flat

Visible at 45◦ = +JVD

Assess for heart failure

  • Mentation (mental activity)
  • Urine output
  • Skin color and temperature
  • Breath sounds
  • Edema
  • Pulses

Correlates with Central Venous Pressure (CVP)

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14
Q

Oxygen Uptake System

Upper and Lower respiratory

A

Upper Respiratory

  • Nose and Sinuses
  • Pharynx
  • Larynx
  • Trachea

Lower Respiratory

  • Lungs
  • Pleura
  • Bronchi
  • Alveoli
  • Ribcage and -Intercostal Muscles
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15
Q

Oxygen Uptake System alveoli

A
  • Air reaches the alveoli

- The capillary network exchanges CO2 and O2

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16
Q

Physical Assessment: Thoracic

A

Inspection

  • Trachea
  • AP: Transverse ratio
  • Rest rate, depth, pattern
  • Retractions, bulging
  • Expansion

Palpation

  • Expansion
  • Tactile Fremitus

Percussion

Auscultation
-Breath Sounds

17
Q

Tactile Fremitus

A

Tactile Fremitus

  • Open palms, ball of hands at upper back
  • Have patient say “ninety-nine”
  • Move hands down the back and repeat
  • Vibrations should be symmetrical
  • Strongest at the apices, decrease toward the bases
  • Lung consolidations occurs when the air that usually fills the small airways in your lungs is replaced with something else. Depending on the cause, the air may be replaced with: a fluid, such as pus, blood, or water, will increase the intensity
  • Air will decrease the intensity
18
Q

Chest Expansion

A

Chest expansion

  • Thumbs at T9 – T10
  • Have patient take a deep breath
  • -Hands will amplify the movement
19
Q

Normal lung sounds

Bronchial

A

Normal lung sounds
Bronchial: expiratory sounds last longer than inspiratory sounds
-Loud, high-pitched
-Heard over the trachea, upper airways

20
Q

Normal lung sounds Bronchovesicular

A

Bronchovesicular: inspiration and expiration sounds are equal

  • Medium pitch and intensity
  • Heard over the primary bronchi
  • -anterior sternal borders, posterior mid-scapulae
21
Q

Normal lung sounds Vesicular

A

Vesicular: inspiratory sounds last longer than expiratory sounds

  • Soft, low-pitched, breezy
  • Heard over alveoli, all fields except major airways
22
Q

Adventitious and Abnormal Breath sounds Crackles or “Rales”

A

Crackles or “Rales”

  • Short, crackling or bubbling
  • smaller airways
  • fluid in lungs (alveoli)
  • CHF, bronchitis, pneumonia, atelectasis
23
Q

Adventitious and Abnormal Breath sounds Rhonchi

A

Rhonchi

  • Continuous, snoring
  • Large airway congestion
  • obstruction or fluid accumulation in larger airways
  • COPD, pneumonia
24
Q

Adventitious and Abnormal Breath sounds Stridor

A

Stridor

  • High-pitched, tight wheezing
  • Upper airway obstruction
  • over trachea
  • foreign airway obstruction
25
Q

Adventitious and Abnormal Breath sounds Pleural Friction Rub

A

Pleural Friction Rub

  • Harsh, grating
  • Pleural inflammation
26
Q

Adventitious and Abnormal Breath sounds Decreased or absent

A

Decreased or absent

-Pneumothorax, pleural effusion

27
Q

Errors to avoid when listening to lungs and heart

A

Errors to avoid

Listening over clothing

Allowing tubing to rub against rail or clothing

Mistaking chest hair sound for an adventitious sound

Auscultating the convenient places only

Pressing too hard on the bell

28
Q

60 Second Assessment

A

General survey to develop situational awareness

Observe for “60 seconds”

  • ABCs
  • Tubes and lines
  • Respiratory equipment
  • Safety survey
  • Environmental survey
  • Sensory
  • Additional assessment – other questions?
  • Who will you see first? Why?

NUR 212 (22 decks)

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