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Funds > Assessment of Heart and Neck Vessels > Flashcards

Assessment of Heart and Neck Vessels Flashcards

1
Q

What is perfusion

A

the flow of blood through arteries and capillaries delivering nutrients and oxygen to cells

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2
Q

without the flow of blood oxygen and nutrients what would happen to the cells

A

the cells could not get nutrients which would result in cell death

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3
Q

what are some causes of decreased perfusion/blood flow (4)

A
  • occlusions (DVT)
  • constriction (stenosis)
  • disease process (CVD)
  • shock
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4
Q

what are some risk factors of decreased perfusion/blood flow

A
  • age
  • gender
  • race
  • occupation
  • lifestyle
    -genetics
  • medical history
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5
Q

what is the order that blood flows through the heart

A
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6
Q

the right ventricle pumps blood to the ______ to collect oxygen

A

lungs

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7
Q

the left ventricle pumps blood to _____

A

the rest of the bodies extremities

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8
Q

the ___________ valve is located between the atrium and ventricle
(R = tricuspid; L = bicuspid/mitral)

A

atrioventricular

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9
Q

the ____ valve is located at the exit of the ventricles and beginning of the great vessels
(R = pulmonic; L = Aortic)

A

semilunar

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10
Q

what order does blood flow through the heart valves

A

tricuspid -> pulmonary -> mitral -> aortic

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11
Q

what can happen/be caused if the heart valves don’t work properly

A

pressure from the ventricle can create backflow of blood in the heart, which can create clotting and a murmur

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12
Q

aortic heart sound

A

2nd right intercostal space, base of the heart, S2 is heard loudest

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13
Q

pulmonic heart sound

A

2nd left intercostal space, where S2 is heard loudest

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14
Q

Erb’s Point

A

3rd left intercostal space, where murmurs are heard

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15
Q

tricuspid heard sound

A

4th left intercostal space, where S1 sounds are heard

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16
Q

Mitral heart sounds

A

5th intercostal space, midclavicular line, apex of the heart, where S1 sounds are heard

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17
Q

The ____ heart sound is from the closure of the AV valves

A

S1 (first heart sound)

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18
Q

With the S1 sound what AV valves are closing

A

mitral and tricuspid

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19
Q

what sound is S1 usually heard as

A

lub

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20
Q

S1 corresponds with each carotid pulsation and is loudest at the ____ of the heart

A

apex

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21
Q

The ____ heart sound is from the closure of the semilunar valves

A

S2 (second heart sound)

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22
Q

what are the semilunar valves that are closing to cause the S2 heart sound

A

aortic and pulmonic

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23
Q

S2 is usually heard as a ____ sound

A

dub

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24
Q

S2 immediately follows the S1 sound and is loudest at the _____ of the heart

A

base

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25
Q

S3 and S4 are referred to as _____ sounds or extra heart sounds

A

diastolic

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26
Q

S3 and S4 sounds result from what

A

ventricular vibration secondary to rapid ventricular filling

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27
Q

S3 (often termed ________) can be heard early in diastole, immediately after S2

A

ventricular gallop

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28
Q

S3 is best heard using the bell at the ____ area of the heart

A

apical

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29
Q

When is S3 normal

A

can be normal in young children and pregnancy (rarely normal in people over 40)

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30
Q

S3 can be associated with that disease processes (3)

A
  • myocardial failure
  • CHF
  • volume overload
31
Q

S4 is often termed _______ and can be heard late is diastole, just before S1 (extra beat at the beginning)

A

atrial gallop

32
Q

what is an S4 sound usually a sign of

A

pathologic state, failing left ventricle (associated with CAd, HTN, MI)

33
Q

S4 is best heard using the bell over the apical area with the patient in what position

A

supine or left lateral position

34
Q

a ____ is a swishing sound caused by turbulent blood flow through the heart valves or great valves

A

murmur

35
Q

a _____ murmur is not associated with any physiologic abnormality

A

innoocent

36
Q

when do innocent murmurs occur

A

when the ejection of blood into the aorta is turbulent (common in children and young adults)

37
Q

what are physiologic murmurs caused by

A

temporary increase in blood flow (can occur with anemia, pregnancy, fever, hypertension)

38
Q

what is pericardial friction caused by

A

inflammation of the pericardial sac

(commonly heard during the first week after a MI)

39
Q

where is pericardial friction best heard

A
  • 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)
40
Q

what does pericardial friction sound like

A

high pitched, scratchy, scraping sound

41
Q

where do the internal jugular veins lie

A

deep and medial to sternocleidomastoid muscle

42
Q

where do the external jugular veins lie

A

more superficial than internal, lateral to the sternocleidomastoid muscle above the clavicle

43
Q

how should a nurse observe the jugular venous pulse

A
  • 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
44
Q

when is it normal to see pulsation of the jugular vein and when is it not normal

A
  • normal when patient is lying flat or at 30 degrees
  • not normal when the patient is elevated to 45 degrees
45
Q

_____ distension or fully distended external jugular veins when a patient’s HOB is elevated at or above 45 degrees is ABNORMAL

A

unilateral

46
Q

jugular vein distension (JVD) indicates __________ that may be the result of right ventricular failure, pulmonary hypertension, pulmonary emboli, cardiac tamponade

A

increased central venous pressure

47
Q

how should you palpate the carotid artery

A

placing pads of the index and middle fingers medial to the sternocleidomastoid muscle

48
Q

normal findings when palpating the carotid artery

A

pulses should be equally strong, 2+, no variation in strength, elastic, no thrills

49
Q

what does a palpable thrill signify

A

turbulent blood flow

50
Q

a nurse should auscultate the carotid arteries if the patient is how old

A

middle-aged or older

51
Q

how should you auscultate the carotid artery

A

place the bell over the artery and have the patient hold their breath

52
Q

normal findings when auscultating the carotid artery

A

equally strong, 2+, no beat variation

53
Q

abnormal findings when auscultating carotid arteries

A

blowing, swishing, other sounds

53
Q

pulse inequity can indicate what

A

arterial constriction, occlusion, narrowing of vessel in one carotid

54
Q

weak pulses can indicate what

A

hypovolemia, shock, decreased cardiac output

55
Q

loss of elasticity of carotid pulse can indicate what

A

arteriosclerosis

56
Q

a bruit (blowing/swishing sound caused by turbulent blood through a narrowed vessel) indicates what

A

occlusive artery disease

  • if the artery is more than 2/3 occluded a bruit may not be heard
57
Q

when inspecting the heart for visible lifts, heaves, and pulsations what position should the client be placed in

A

a supine position with the head of the bed elevated between 30-45 degrees

58
Q

what pulse should be looked for when inspecting the heart

A

the apical pulse

-if seen it will be in the mitral area (normal finding)

59
Q

a _____ is a sustained forceful thrusting of the ventricle during systole

A

heave (or lift)

-occurs due to increased workload

60
Q

where is a right ventricular heave seen

A

at the sternal border (3rd intercostal space)

61
Q

where is a left ventricular heave seen

A

at the apex (5th intercostal space or below)

62
Q

how should you palpate the apical pulse

A
  • 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

63
Q

when palpating the apical impulse in the mitral area what size should it be

A

the size of a nickel

64
Q

what should the amplitude of the apical impulse be

A

small like a gentle tap

65
Q

what should the duration of the apical impulse be

A

brief (lasts through the first 2/3 of systole or less)

66
Q

what does an apical impulse larger than 1-2cm, displaced, forceful, or longer in duration indicate

A

cardiac enlargement

(displacement down and to the left = left ventricular enlargement or volume overload)
(increased force/duration and no location change = left ventricular hypertrophy)

67
Q

how should one auscultate heart rate and rhythm

A
  • 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)

68
Q

the ____ sound corresponds with each carotid pulsation and is loudest at the apex of the heart

A

S1

69
Q

the ___ sound immediately follows S1 and is loudest at the base of the heart

A

S2

70
Q

an irregular heartbeat is called an _____

A

arrhythmia

(caused by: coronary heart disease, electrolyte imbalances in blood, changes in heart muscle, injury from a MI, healing process after heart surgery)

71
Q

how do you check for a pulse deficit

A

auscultate apical pulse then count the radial pulse - the counts should be identical

72
Q

what should you do when the radial pulse and apical heart rate are different

A

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)

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