Assessing the Heart and Vascular System Flashcards
Perfusion
Continuous supply of oxygenated blood through the blood vessels to the vital organs
Systole
Contraction of the ventricles (emptying)
Diastole
Relaxation of the ventricles (filing)
4 Structures of the heart
-Left atrium
-Left ventricles
-Right atrium
-Right ventricles
Hearts positioning
- Under 3,4,5 intercostal space
- Left side
What do you listen for with the heart?
- Cardiac rate
- Cardiac rhythm
- normal/ abnormal sounds
Where do you listen to the heart?
-Atrial
-Pulmonic
-Erb’s point
-Tricuspid
-Mitral
Where is the Aortic Valve auscultation site?
- 2nd intercostal space
- Right side
Where is the Pulmonic auscultation site?
- 2nd intercostal space
- Left side
Where is Erb’s Point auscultation site?
- 3rd intercostal space
- Left side
Where is the Tricuspid auscultation site?
-4th intercostal space
- Left side
Where is the Mitral valve(apical pulse) auscultation site?
- 5th intercostal space
- Mid clavicular line
- Left side
The nurse is preparing to assess a client’s apical impulse, the nurse would palpate at which location?
- 5th intercostal space
- Mid clavicular line
- Left side
S1 Normal “lub”
- Closure of the mitral and tricuspid valves
- Dull, low pitch
- Beginning of systole
S2 Normal “dub”
- Closure of the aortic and pulmonic valve
- Higher in pitch and shorter than “lub”
- Beginning of diastole
S3 extra sounds
- Heard after S2
- Gallop cadence “kenTUCKy”
- Best heard at apical side-lying position
S4 extra sound
- Heard after S1
- Sounds like “FLOrida”
- Best heard at apical using the bell of the stethoscope in side-lying position
Heart Murmur sound
- wind blowing sound
- Can be innocent
CV Subjective data
- Demographic data
- Health history
- Family history
- Cardiovascular history
- Nutrition history
- Lifestyle and Health Promotion Activites
Preparing the client
-Establish rapport
- Alert the patient on what you are doing
- Proper positioning
- Grab proper supplies
Cardiac normal findings
- rate: 60-100bpm
- S1 and S2
- S3 present in children and pregnant women
- S4 present in older adults
Less than 60 bpm
Bradycardia
More than 100 bpm
Tachycardia
Cardiac abnormal findings
- murmurs(location, quality, frequency, intensity, duration)
Cardiac assessment helps
- identify significant factors that influence cardiovascular health
- cardiovascular exam in head-to-toe assessment
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
Arteries
-Carry blood away from the heart
-Artery walls: strong & tough, contain elastic fibers
-high-pressure system
-pulse: systole & diastole
Veins
-Carry blood toward the heart
-parallel to arteries
-low-pressure system
-closer to skin(can see)
The vascular system consists of:
-arteries
-veins
-capillaries
The central vessels
-carotid arteries
-Jugular veins
The peripheral vessels
-arteries
-veins
Carotid Arteries
-Large and close to the heart
-Pulse easily palpable
-Only palpate one side at a time
- Bruit: common in older adults
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
Vascular system assessment purpose
- catch things early as possible
- compare both sides to each other
- identify S & Sof peripheral vascular disease
Vascular system assessment: Inspect
-Skin and mucous membrane color
-cyanosis?
-presence of edema
-general appearance
Vascular system assessment: Palpate
- Pulses
- Skin temp
- Capillary refill
- Edema
- areas of tenderness
Vascular system assessment: Auscultate
- Blood pressure
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
Neck vessel assessment
-inspect/observe
-palpate: rate, rhythm
- Carotids are soft and pliable
Neck vessel abnormal findings
- neck with vein distention: pulsating
- Abnormal rhythm/ strength
- Thrill & Bruit
Thrill
- Vibration felt while checking pulse
Bruit
Audible> sound blood makes as it moves through arteries
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
Arm inspection
-Skin presence/edema
- check skin color
- fingertips for clubbing
- capillary refill time
- radial/ brachial pulses
Leg inspection
- skin color: compare both sides
- no change in pigmentation
- cyanosis/ pallor/ dark colored toes/ blisters
- distribution of hair
Should you compare one side to the other
yes! both legs and arms should appear the same between the two
Normal pulse
- 60-100 bpm
- normal rate
- normal rhythm
- normal amplitude
Pulse strength
0: Absent > use doppler to confirm
1+: Weak
2+: Normal
3+: Strong
4+: Bounding
Pulse sites
- radial
- brachial
- carotid
- temporal
- Dorsalis Pedis
- femoral
- popliteal
pitting edema
edema that doesn’t return back to normal
Newborn pulse
100-160
- very fast!
Young child pulse
70-120
- systolic less than 100
Older child pulse
60-100
- systolic less than 110
Adult pulse
60-90
- bp: less than 120/80
How long do you time apical pulse and where is it?
- Mitral valve
- full 60 seconds
Steps for practicing the system
- Perform hand hygiene
- clean stethoscope
- introduce
- provide privacy
- patient identification
- ASSESSMENT
- return bed to lowest position
- make sure the call light is in reach
- clean stethoscope
- wash hands
- document
