Cardiac and Vascular Assessment Flashcards
What should be included in focused cardiovascular history?
History, common symptoms, triggers, psychosocial status, PQRST
PQRST Pain Acronym
Provoking, Quality, Region, Severity and Timing
What does the nurse ALWAYS evaluate first on initial survey of patient?
A - airway
B - breathing
C - circulation
Where on the chest does the nurse hear the aortic valve?
2nd and 3rd right interspace
Where on the chest does the nurse hear the pulmonic valve?
2nd and 3rd left interspace
Where on the chest does the nurse hear the tricuspid valve?
left sternal border
Where on the chest does the nurse hear the mitral valve?
apex (just to the right and slightly below left nipple)
Definition of pulse pressure
difference between systolic and diastolic
Definition of orthostatic BP
drop of 20 mmHg in systolic, drop of 10 mmHg in diastolic with standing
Definition of pulse deficit
difference between pulse rate and heart rate seen with arrhythmias
How do you assess pulse deficit
assess apical and radial pulse simultaneously for 1 minute
ankle-brachial index definition
ratio of BP at the ankle and upper arm; normal 0.9-1.3
What does a low ankle brachial index indicate?
occluded arteries caused by PVD
What does a high ankle-brachial index indicate?
abnormally hardened blood vessels
What is a normal range for ankle-brachial index?
0.9-1.3
Prehypertension begins at what systolic range?
120-130
Stage 1 hypertension begins at what systolic and diastolic range?
130-140 systolic, 80-90 diastolic
Stage 2 hypertension beings at what systolic and diastolic range?
140 - 180+ systolic, 90-120+ diastolic
3 categories of Glascow Coma Scale
Eye Opening, verbal response, motor response
PERRLA is assessing what cranial nerves
CN III, IV and VI via pupils
PERRLA acronym
P - pupils
E - equal
R - round
R - react
L - light
A - accommodation
Cranial Nerve I and assessment
Olfactory - have patient close eyes and smell
Cranial Nerve II and assessment
Optic - have patient read and assess periphery
Cranial Nerve III and assessment
Oculomotor - pupil response; follow finger with eyes making an “H”
Cranial Nerve IV and assessment
Trochlear - follow finger moving towards nose to assess downward eye movement
Cranial Nerve V and assessment
Trigeminal - Sensation of forehead, cheeks and jaw - have clench teeth
Cranial Nerve VI and assessment
Abducens - have patient look towards each ear to check sideways eye movement
Cranial Nerve VII and assessment
Facial - assess symmetry of face and puff cheeks
Cranial Nerve VIII and assessment
Vestibulocochlear - assess hearing and equilibrium
Cranial Nerve IX and assessment
Glossopharyngeal - gag reflex check and sour/sweet taste on tongue
Cranial Nerve X and asssessment
Vagus - swallow while speaking, say “ah” (sensory and motor)
Cranial Nerve XI and assessment
Accessory - shrug shoulders and turn head against resistance
Cranial Nerve XII and assessment
Hypoglossal - have patient stick out tongue and move side to side
Mnemonic for cranial nerves
Oh Oh Oh Those Trippy Alien Fruit Vines Generate Visions And Hallucinations
Mnemonic for cranial nerves - motor sensory or both
Some Say Marry Money, But My Brother Says Big Brains Matter More
When percussing lungs, what does the tone indicate?
indicates where lungs are solid and filled with air or fluid
The nurse describes your percussed lung sounds as RESONANT - what does this mean?
normal air-filled lung sounds
What does DULL percussed lung sounds indicate?
fluid/tissue filled cavities - often pneumonia
what does HYPERRESONANT (drum-like) percussed lung sounds indicate?
air filled tissues - seen with emphysema and pneumothorax
Kussmaul breathing and associated state
hyperventilation with deep labored breathing; associated with metabolic acidosis
Cheyne Stokes breathing and associated issue
deep breathing alternating with apnea OR faster rate; associated with L heart failure or sleep apnea
Where are vasicular breath sounds heard?
over the lungs
Wheezing
description, etiology and disease process
- musical-like
- forced air through narrow airway
- COPD, asthma
Rhonchi
description, etiology and disease process
- low pitched, coarse rattles
- secretions in airway
- pneumonia and cystic fibrosis
Stridor
description, etiology and disease process
- high pitched, wheezing sound
- air through UPPER airway is obstructed/narrow
- aspiration or larygnospasm
Rales (crackles)
description, etiology and disease process
- rattling - can be coarse or fine
- fluid in small airways of lung
- pulmonary edema, pneumonia
Pleural Friction Rub
description, etiology and disease process
- grating/creaking sound
- inflamed pleural tissue
- pleuritis/pulmonary embolism
Diminished Lung Sounds
description, etiology and disease process
- decreased intensity due to lack of airflow
- air or fluid in lungs/blocked airway
- pleural effusion, pneumothorax
Egophony
description, etiology and disease process
- “e” sound heard as a “a”
- due to increased resonance of sound traveling across fluid
- pleural effusion, pneumonia
Bronchophony
description, etiology and disease process
- increased volume of spoken voice over area of lung consolidation
- fluid in lungs
- pleural effusion, pneumonia
Whispered Pectoriloquy
description, etiology and disease process
- increased volume of whispered voice over areas of lung consolidation
- fluid in lungs
- pleural effusion, pnuemonia
Patient position to check carotid arteries
position patient at 45 degree angle with head turned away
How to inspect and palpate jugular veins?
relax sternomastoid muscle so pulsation can be seen in internal jugular
Positive JVD = elevated _____?
CVP
Cardiac auscultation mnemonic
A PET Monkey (aortic, pulmonic, Erb’s point, tricuspid, mitral)
Location of PMI
Point of Maximal Intensity = apex of heart (very bottom tip of heart)
Where is the best place to hear the mitral valve?
5th LEFT intercostal space at midclavicular line
Where is the best place to hear the tricuspid valve?
5th intercostal space at LEFT sternal border
Where is the best place to heart the Erb’s Point?
3rd LEFT intercostal space at left sternal border
Where is the best place to hear the pulmonic valve?
2nd LEFT intercostal space at left sternal border
Where is the best place to hear the aortic valve?
2nd RIGHT intercostal space at right sternal border
This sound is caused by the closure of the atrioventricular valves
S1
This sound is caused by the closure of the semilunar valves
S2
Other name for S3 sound and what causes this?
ventricular gallop
rush of blood into ventricles that is normal in children/young adults
What cardiac conditions are related to S3 sounds?
ventricular dysfunction or volume overload in the ventricles
MI, systolic HF, dilated cardiomyopathy, mitral valve regurgitation
What is the other name for S4 sound and what causes this?
atrial gallup; atrial contraction into a noncompliance ventricle
when is S4 heard?
before S1
What cardiac conditions are related to S4 sounds?
decreased ventricular compliance - hypertrophic cardiomyopathy, hypertension, aortic stenosis
What is a carotid bruit?
heard over carotid artery and is caused by turbulent blood flow - indicates carotid artery disease
Where is pericardial friction rub heard and describe sound?
fourth intercostal space with patient leaning forward
high pitched, leathery sound
What cardiac sound is associated with pericarditis?
pleural friction rub
systolic murmur occurs when?
occurs during ventricular contraction
systolic murmur occurs when?
occurs during ventricular contraction
systolic murmur occurs when?
occurs during ventricular contraction
diastolic murmur occurs when?
during ventircular filling
systolic murmur causes
anemia, pregnancy, hyperthyroidism, fever, exercise
Name for loud, rumbling sounds caused by shifting fluid/gas in bowel?
Borborygmi
Do you palpate the painful part of the abdomen FIRST or LAST?
LAST!
Tympanic abdominal percussion indicated what?
air-filled intestines
Dull sounds on percussion of abdomen indicate?
organomegaly, masses or fluid
high pitched bowel sounds can indicate?
early bowel obstruction
term for redness of skin caused by inflammation
Rubor
what causes shiny skin on extremities
peripheral vascular disease
What is hemosiderin staining?
brown skin color caused by iron deposits within cells
seen with venous insufficiency and iron overload
what is clubbing and what causes this?
def: enlargement of tissue at distal phalange which occurs over long periods of time from chronic cardiovascular/respiratory disorders
