Assessment of Heart and Neck Vessels Flashcards
What is perfusion
the flow of blood through arteries and capillaries delivering nutrients and oxygen to cells
without the flow of blood oxygen and nutrients what would happen to the cells
the cells could not get nutrients which would result in cell death
what are some causes of decreased perfusion/blood flow (4)
- occlusions (DVT)
- constriction (stenosis)
- disease process (CVD)
- shock
what are some risk factors of decreased perfusion/blood flow
- age
- gender
- race
- occupation
- lifestyle
-genetics - medical history
what is the order that blood flows through the heart
the right ventricle pumps blood to the ______ to collect oxygen
lungs
the left ventricle pumps blood to _____
the rest of the bodies extremities
the ___________ valve is located between the atrium and ventricle
(R = tricuspid; L = bicuspid/mitral)
atrioventricular
the ____ valve is located at the exit of the ventricles and beginning of the great vessels
(R = pulmonic; L = Aortic)
semilunar
what order does blood flow through the heart valves
tricuspid -> pulmonary -> mitral -> aortic
what can happen/be caused if the heart valves don’t work properly
pressure from the ventricle can create backflow of blood in the heart, which can create clotting and a murmur
aortic heart sound
2nd right intercostal space, base of the heart, S2 is heard loudest
pulmonic heart sound
2nd left intercostal space, where S2 is heard loudest
Erb’s Point
3rd left intercostal space, where murmurs are heard
tricuspid heard sound
4th left intercostal space, where S1 sounds are heard
Mitral heart sounds
5th intercostal space, midclavicular line, apex of the heart, where S1 sounds are heard
The ____ heart sound is from the closure of the AV valves
S1 (first heart sound)
With the S1 sound what AV valves are closing
mitral and tricuspid
what sound is S1 usually heard as
lub
S1 corresponds with each carotid pulsation and is loudest at the ____ of the heart
apex
The ____ heart sound is from the closure of the semilunar valves
S2 (second heart sound)
what are the semilunar valves that are closing to cause the S2 heart sound
aortic and pulmonic
S2 is usually heard as a ____ sound
dub
S2 immediately follows the S1 sound and is loudest at the _____ of the heart
base
S3 and S4 are referred to as _____ sounds or extra heart sounds
diastolic
S3 and S4 sounds result from what
ventricular vibration secondary to rapid ventricular filling
S3 (often termed ________) can be heard early in diastole, immediately after S2
ventricular gallop
S3 is best heard using the bell at the ____ area of the heart
apical
When is S3 normal
can be normal in young children and pregnancy (rarely normal in people over 40)
S3 can be associated with that disease processes (3)
- myocardial failure
- CHF
- volume overload
S4 is often termed _______ and can be heard late is diastole, just before S1 (extra beat at the beginning)
atrial gallop
what is an S4 sound usually a sign of
pathologic state, failing left ventricle (associated with CAd, HTN, MI)
S4 is best heard using the bell over the apical area with the patient in what position
supine or left lateral position
a ____ is a swishing sound caused by turbulent blood flow through the heart valves or great valves
murmur
a _____ murmur is not associated with any physiologic abnormality
innoocent
when do innocent murmurs occur
when the ejection of blood into the aorta is turbulent (common in children and young adults)
what are physiologic murmurs caused by
temporary increase in blood flow (can occur with anemia, pregnancy, fever, hypertension)
what is pericardial friction caused by
inflammation of the pericardial sac
(commonly heard during the first week after a MI)
where is pericardial friction best heard
- using the diaphragm over the 3rd intercostal space to the left of the sternum (Erbs point area)
(- have patients sit up, lean forward, exhale, and hold breath for best results)
what does pericardial friction sound like
high pitched, scratchy, scraping sound
where do the internal jugular veins lie
deep and medial to sternocleidomastoid muscle
where do the external jugular veins lie
more superficial than internal, lateral to the sternocleidomastoid muscle above the clavicle
how should a nurse observe the jugular venous pulse
- stand on the right side of the patient
-patient should be in a supine position with their torso elevated 30 degrees, without a pillow
-patient should have head turned slightly to the left - light can be used to observe for pulsations
- elevate HOB to 45 degrees and observe for pulsations
when is it normal to see pulsation of the jugular vein and when is it not normal
- normal when patient is lying flat or at 30 degrees
- not normal when the patient is elevated to 45 degrees
_____ distension or fully distended external jugular veins when a patient’s HOB is elevated at or above 45 degrees is ABNORMAL
unilateral
jugular vein distension (JVD) indicates __________ that may be the result of right ventricular failure, pulmonary hypertension, pulmonary emboli, cardiac tamponade
increased central venous pressure
how should you palpate the carotid artery
placing pads of the index and middle fingers medial to the sternocleidomastoid muscle
normal findings when palpating the carotid artery
pulses should be equally strong, 2+, no variation in strength, elastic, no thrills
what does a palpable thrill signify
turbulent blood flow
a nurse should auscultate the carotid arteries if the patient is how old
middle-aged or older
how should you auscultate the carotid artery
place the bell over the artery and have the patient hold their breath
normal findings when auscultating the carotid artery
equally strong, 2+, no beat variation
abnormal findings when auscultating carotid arteries
blowing, swishing, other sounds
pulse inequity can indicate what
arterial constriction, occlusion, narrowing of vessel in one carotid
weak pulses can indicate what
hypovolemia, shock, decreased cardiac output
loss of elasticity of carotid pulse can indicate what
arteriosclerosis
a bruit (blowing/swishing sound caused by turbulent blood through a narrowed vessel) indicates what
occlusive artery disease
- if the artery is more than 2/3 occluded a bruit may not be heard
when inspecting the heart for visible lifts, heaves, and pulsations what position should the client be placed in
a supine position with the head of the bed elevated between 30-45 degrees
what pulse should be looked for when inspecting the heart
the apical pulse
-if seen it will be in the mitral area (normal finding)
a _____ is a sustained forceful thrusting of the ventricle during systole
heave (or lift)
-occurs due to increased workload
where is a right ventricular heave seen
at the sternal border (3rd intercostal space)
where is a left ventricular heave seen
at the apex (5th intercostal space or below)
how should you palpate the apical pulse
- remain on the patient’s right side and have them lay supine
-palpate at the 4th or 5th ICS, MCL with one finger pad
(if it cannot be palpated have the patient roll midway to the left to bring the heart closer to the chest wall)
-may not be palpable in obese patients
when palpating the apical impulse in the mitral area what size should it be
the size of a nickel
what should the amplitude of the apical impulse be
small like a gentle tap
what should the duration of the apical impulse be
brief (lasts through the first 2/3 of systole or less)
what does an apical impulse larger than 1-2cm, displaced, forceful, or longer in duration indicate
cardiac enlargement
(displacement down and to the left = left ventricular enlargement or volume overload)
(increased force/duration and no location change = left ventricular hypertrophy)
how should one auscultate heart rate and rhythm
- patient should be supine w upper trunk elevated 30 degrees
- use diaphragm to auscultate high-pitched sounds and bell to detect low-pitched sounds/gallops
- firmly press stethoscope when auscultating
(Aortic, Pulmonic, Erb’s point, Tricuspid, Mitral)
the ____ sound corresponds with each carotid pulsation and is loudest at the apex of the heart
S1
the ___ sound immediately follows S1 and is loudest at the base of the heart
S2
an irregular heartbeat is called an _____
arrhythmia
(caused by: coronary heart disease, electrolyte imbalances in blood, changes in heart muscle, injury from a MI, healing process after heart surgery)
how do you check for a pulse deficit
auscultate apical pulse then count the radial pulse - the counts should be identical
what should you do when the radial pulse and apical heart rate are different
subtract the radial pulse from the apical and record the remainder as the pulse deficit
(indicates a weak contraction of ventricles; occurs with atrial fibrillation, premature beats, and congestive heart failure)
