Assessing the Heart and Vascular System Flashcards
1
Q
Perfusion
A
Continuous supply of oxygenated blood through the blood vessels to the vital organs
2
Q
Systole
A
Contraction of the ventricles (emptying)
3
Q
Diastole
A
Relaxation of the ventricles (filing)
4
Q
4 Structures of the heart
A
-Left atrium
-Left ventricles
-Right atrium
-Right ventricles
5
Q
Hearts positioning
A
- Under 3,4,5 intercostal space
- Left side
6
Q
What do you listen for with the heart?
A
- Cardiac rate
- Cardiac rhythm
- normal/ abnormal sounds
7
Q
Where do you listen to the heart?
A
-Atrial
-Pulmonic
-Erb’s point
-Tricuspid
-Mitral
8
Q
Where is the Aortic Valve auscultation site?
A
- 2nd intercostal space
- Right side
9
Q
Where is the Pulmonic auscultation site?
A
- 2nd intercostal space
- Left side
10
Q
Where is Erb’s Point auscultation site?
A
- 3rd intercostal space
- Left side
11
Q
Where is the Tricuspid auscultation site?
A
-4th intercostal space
- Left side
12
Q
Where is the Mitral valve(apical pulse) auscultation site?
A
- 5th intercostal space
- Mid clavicular line
- Left side
13
Q
The nurse is preparing to assess a client’s apical impulse, the nurse would palpate at which location?
A
- 5th intercostal space
- Mid clavicular line
- Left side
14
Q
S1 Normal “lub”
A
- Closure of the mitral and tricuspid valves
- Dull, low pitch
- Beginning of systole
15
Q
S2 Normal “dub”
A
- Closure of the aortic and pulmonic valve
- Higher in pitch and shorter than “lub”
- Beginning of diastole
16
Q
S3 extra sounds
A
- Heard after S2
- Gallop cadence “kenTUCKy”
- Best heard at apical side-lying position
17
Q
S4 extra sound
A
- Heard after S1
- Sounds like “FLOrida”
- Best heard at apical using the bell of the stethoscope in side-lying position
18
Q
Heart Murmur sound
A
- wind blowing sound
- Can be innocent
19
Q
CV Subjective data
A
- Demographic data
- Health history
- Family history
- Cardiovascular history
- Nutrition history
- Lifestyle and Health Promotion Activites
20
Q
Preparing the client
A
-Establish rapport
- Alert the patient on what you are doing
- Proper positioning
- Grab proper supplies
21
Q
Cardiac normal findings
A
- rate: 60-100bpm
- S1 and S2
- S3 present in children and pregnant women
- S4 present in older adults
22
Q
Less than 60 bpm
A
Bradycardia
23
Q
More than 100 bpm
A
Tachycardia
24
Q
Cardiac abnormal findings
A
- murmurs(location, quality, frequency, intensity, duration)
25
Cardiac assessment helps
- identify significant factors that influence cardiovascular health
- cardiovascular exam in head-to-toe assessment
26
Developmental Differences
Infants/children:
-cyanosis when feeding/crying?
-Able to play without tiring?
-Unexpected joint pain?
Older Adults:
-recently stopped taking meds?
-Does illness interfere with ADL's?
-Aren't as active
*Any sign of chest pain should be investigated more*
27
Arteries
-Carry blood away from the heart
-Artery walls: strong & tough, contain elastic fibers
-high-pressure system
-pulse: systole & diastole
28
Veins
-Carry blood toward the heart
-parallel to arteries
-low-pressure system
-closer to skin(can see)
29
The vascular system consists of:
-arteries
-veins
-capillaries
30
The central vessels
-carotid arteries
-Jugular veins
31
The peripheral vessels
-arteries
-veins
32
Carotid Arteries
-Large and close to the heart
-Pulse easily palpable
-Only palpate one side at a time
- Bruit: common in older adults
33
Internal & external jugular veins
-return blood from the vein to the superior vena cava
-veins flat when patient in an upright position and distend when lying flat
34
Vascular system assessment purpose
- catch things early as possible
- compare both sides to each other
- identify S & Sof peripheral vascular disease
35
Vascular system assessment: Inspect
-Skin and mucous membrane color
-cyanosis?
-presence of edema
-general appearance
36
Vascular system assessment: Palpate
- Pulses
- Skin temp
- Capillary refill
- Edema
- areas of tenderness
37
Vascular system assessment: Auscultate
- Blood pressure
38
Prepare client for vascular assessment
- Let the patient know what you are going to do before you do it
- Head of Bed: 30 degrees during auscultation and palpation
39
Neck vessel assessment
-inspect/observe
-palpate: rate, rhythm
- Carotids are soft and pliable
40
Neck vessel abnormal findings
- neck with vein distention: pulsating
- Abnormal rhythm/ strength
- Thrill & Bruit
41
Thrill
- Vibration felt while checking pulse
42
Bruit
Audible> sound blood makes as it moves through arteries
43
Inspect and Palpate skin
- turgor: skin returns to normal position
-Temperature: skin is warm and bilaterally
- Moisture/hydration: skin is warm and dry
- No edemas present
- Capillary refill time <3 secs
44
Arm inspection
-Skin presence/edema
- check skin color
- fingertips for clubbing
- capillary refill time
- radial/ brachial pulses
45
Leg inspection
- skin color: compare both sides
- no change in pigmentation
- cyanosis/ pallor/ dark colored toes/ blisters
- distribution of hair
46
Should you compare one side to the other
yes! both legs and arms should appear the same between the two
47
Normal pulse
- 60-100 bpm
- normal rate
- normal rhythm
- normal amplitude
48
Pulse strength
0: Absent > use doppler to confirm
1+: Weak
2+: Normal
3+: Strong
4+: Bounding
49
Pulse sites
- radial
- brachial
- carotid
- temporal
- Dorsalis Pedis
- femoral
- popliteal
50
pitting edema
edema that doesn't return back to normal
51
Newborn pulse
100-160
- very fast!
52
Young child pulse
70-120
- systolic less than 100
53
Older child pulse
60-100
- systolic less than 110
54
Adult pulse
60-90
- bp: less than 120/80
55
How long do you time apical pulse and where is it?
- Mitral valve
- full 60 seconds
56
Steps for practicing the system
1. Perform hand hygiene
2. clean stethoscope
3. introduce
4. provide privacy
5. patient identification
6. ASSESSMENT
7. return bed to lowest position
8. make sure the call light is in reach
9. clean stethoscope
10. wash hands
11. document
