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NURS 2910 > Assessing the Heart and Vascular System > Flashcards

Assessing the Heart and Vascular System Flashcards

1
Q

Perfusion

A

Continuous supply of oxygenated blood through the blood vessels to the vital organs

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2
Q

Systole

A

Contraction of the ventricles (emptying)

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3
Q

Diastole

A

Relaxation of the ventricles (filing)

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4
Q

4 Structures of the heart

A

-Left atrium
-Left ventricles
-Right atrium
-Right ventricles

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5
Q

Hearts positioning

A
  • Under 3,4,5 intercostal space
  • Left side
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6
Q

What do you listen for with the heart?

A
  • Cardiac rate
  • Cardiac rhythm
  • normal/ abnormal sounds
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7
Q

Where do you listen to the heart?

A

-Atrial
-Pulmonic
-Erb’s point
-Tricuspid
-Mitral

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8
Q

Where is the Aortic Valve auscultation site?

A
  • 2nd intercostal space
  • Right side
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9
Q

Where is the Pulmonic auscultation site?

A
  • 2nd intercostal space
  • Left side
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10
Q

Where is Erb’s Point auscultation site?

A
  • 3rd intercostal space
  • Left side
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11
Q

Where is the Tricuspid auscultation site?

A

-4th intercostal space
- Left side

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12
Q

Where is the Mitral valve(apical pulse) auscultation site?

A
  • 5th intercostal space
  • Mid clavicular line
  • Left side
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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
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14
Q

S1 Normal “lub”

A
  • Closure of the mitral and tricuspid valves
  • Dull, low pitch
  • Beginning of systole
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15
Q

S2 Normal “dub”

A
  • Closure of the aortic and pulmonic valve
  • Higher in pitch and shorter than “lub”
  • Beginning of diastole
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16
Q

S3 extra sounds

A
  • Heard after S2
  • Gallop cadence “kenTUCKy”
  • Best heard at apical side-lying position
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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
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18
Q

Heart Murmur sound

A
  • wind blowing sound
  • Can be innocent
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19
Q

CV Subjective data

A
  • Demographic data
  • Health history
  • Family history
  • Cardiovascular history
  • Nutrition history
  • Lifestyle and Health Promotion Activites
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20
Q

Preparing the client

A

-Establish rapport
- Alert the patient on what you are doing
- Proper positioning
- Grab proper supplies

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21
Q

Cardiac normal findings

A
  • rate: 60-100bpm
  • S1 and S2
  • S3 present in children and pregnant women
  • S4 present in older adults
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22
Q

Less than 60 bpm

A

Bradycardia

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23
Q

More than 100 bpm

A

Tachycardia

24
Q

Cardiac abnormal findings

A
  • murmurs(location, quality, frequency, intensity, duration)
25
Q

Cardiac assessment helps

A
  • identify significant factors that influence cardiovascular health
  • cardiovascular exam in head-to-toe assessment
26
Q

Developmental Differences

A

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
Q

Arteries

A

-Carry blood away from the heart
-Artery walls: strong & tough, contain elastic fibers
-high-pressure system
-pulse: systole & diastole

28
Q

Veins

A

-Carry blood toward the heart
-parallel to arteries
-low-pressure system
-closer to skin(can see)

29
Q

The vascular system consists of:

A

-arteries
-veins
-capillaries

30
Q

The central vessels

A

-carotid arteries
-Jugular veins

31
Q

The peripheral vessels

A

-arteries
-veins

32
Q

Carotid Arteries

A

-Large and close to the heart
-Pulse easily palpable
-Only palpate one side at a time
- Bruit: common in older adults

33
Q

Internal & external jugular veins

A

-return blood from the vein to the superior vena cava
-veins flat when patient in an upright position and distend when lying flat

34
Q

Vascular system assessment purpose

A
  • catch things early as possible
  • compare both sides to each other
  • identify S & Sof peripheral vascular disease
35
Q

Vascular system assessment: Inspect

A

-Skin and mucous membrane color
-cyanosis?
-presence of edema
-general appearance

36
Q

Vascular system assessment: Palpate

A
  • Pulses
  • Skin temp
  • Capillary refill
  • Edema
  • areas of tenderness
37
Q

Vascular system assessment: Auscultate

A
  • Blood pressure
38
Q

Prepare client for vascular assessment

A
  • Let the patient know what you are going to do before you do it
  • Head of Bed: 30 degrees during auscultation and palpation
39
Q

Neck vessel assessment

A

-inspect/observe
-palpate: rate, rhythm
- Carotids are soft and pliable

40
Q

Neck vessel abnormal findings

A
  • neck with vein distention: pulsating
  • Abnormal rhythm/ strength
  • Thrill & Bruit
41
Q

Thrill

A
  • Vibration felt while checking pulse
42
Q

Bruit

A

Audible> sound blood makes as it moves through arteries

43
Q

Inspect and Palpate skin

A
  • 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
Q

Arm inspection

A

-Skin presence/edema
- check skin color
- fingertips for clubbing
- capillary refill time
- radial/ brachial pulses

45
Q

Leg inspection

A
  • skin color: compare both sides
  • no change in pigmentation
  • cyanosis/ pallor/ dark colored toes/ blisters
  • distribution of hair
46
Q

Should you compare one side to the other

A

yes! both legs and arms should appear the same between the two

47
Q

Normal pulse

A
  • 60-100 bpm
  • normal rate
  • normal rhythm
  • normal amplitude
48
Q

Pulse strength

A

0: Absent > use doppler to confirm
1+: Weak
2+: Normal
3+: Strong
4+: Bounding

49
Q

Pulse sites

A
  • radial
  • brachial
  • carotid
  • temporal
  • Dorsalis Pedis
  • femoral
  • popliteal
50
Q

pitting edema

A

edema that doesn’t return back to normal

51
Q

Newborn pulse

A

100-160
- very fast!

52
Q

Young child pulse

A

70-120
- systolic less than 100

53
Q

Older child pulse

A

60-100
- systolic less than 110

54
Q

Adult pulse

A

60-90
- bp: less than 120/80

55
Q

How long do you time apical pulse and where is it?

A
  • Mitral valve
  • full 60 seconds
56
Q

Steps for practicing the system

A
  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

NURS 2910 (16 decks)

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