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Health Assessment > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

How to inspect the anterior chest apical impulse

A

Look for pulsations at the fifth ICS at midclavicular line

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2
Q

Expected finding for anterior chest apical impulse

A

Usually not visible, but seen easier in children and thin adults

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3
Q

If apical impulse is visible in an adult it may indicate ___

A

Ventricular hypertrophy (enlargement)

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4
Q

If a person isn’t orientated x3, they may not be ____

A

Getting enough oxygen to their brain

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5
Q

How to assess jugular vein distention

A

Inspect patient’s neck when they are sitting up at least 45°, and have them turn their neck

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6
Q

Expected finding for jugular vein distention

A

JVD is seen while patient is laying flat, but not seen when patient sitting upright

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7
Q

If you can see JVD when the person is sitting upright, they could have ____

A

Right sided heart failure

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8
Q

Mucous membranes of the eyes

A

Conjunctiva

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9
Q

Lack of oxygen in the blood

A

Hypoxemia

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10
Q

If a patient has pallor, they could be ___

A

Anemic

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11
Q

If patient skin and nail color is as expected, they have ___ ___

A

Adequate perfusion

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12
Q

How to perform apical impulse palpation

A

Turn patient on left side, place hand at the fifth intercostal, ask client to exhale, and feel for pulsation

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13
Q

Expected finding for apical impulse palpation

Not palpable in ___ or ___ people

A

You may feel it.

Not palpable in obese people or in thick chest-walled people

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14
Q

If we are able to feel the apical impulse during palpation, it may indicate what?

A

Enlargement of the heart

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15
Q

Name 7 pulses locations

A

Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial

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16
Q

In the interior of the elbow lies which pulse?

A

Brachial pulse

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17
Q

What pulse is in the wrist closest to the thumb? 

A

Radial

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18
Q

What pulse is behind the knee?

A

Popliteal, and you’re not supposed to be able to feel it

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19
Q

Where does the posterior tibial pulse lie?

A

Inner ankle

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20
Q

Where does the dorsalis pedis pulse lie?

A

On top of the foot

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21
Q

When we are unable to palpate a pulse, we use the __

A

Doppler

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22
Q

When we use a Doppler, we cannot document ___

A

Amplitude

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23
Q

Force or pumping action of the blood

A

Amplitude

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24
Q

What is the number scale for amplitude and each number’s meaning?

A

3+ increased, full, bounding
2+ expected
1+ weak, thread (shock)
0 absent

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25
Q

Expected finding for amplitude?

A

2+

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26
Q

What does an amplitude of 1+ tell me about my patient?

A

May have low blood pressure due to low blood volume or a narrow vessel

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27
Q

What does an amplitude of +3 tell me about my patient? Name 4

A

Patient may have increased blood volume, is anxious, has a fever, or they just exercise

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28
Q

Electrical conduction system of the heart

A

Rhythm

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29
Q

What does rhythm tell me about my patient’s heart rate?

A

If the heart rate is irregular

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30
Q

An irregular heartbeat can be caused by ___ ___, most common is ___ ___

A

Cardiac dysrhythmias; atrial fibrillation

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31
Q

Normal heart rate for an adult is

A

60-100 BPM

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32
Q

____ is an expected finding for the pulse, because we have 2 of each

A

Symmetry

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33
Q

What does symmetry tell me about my patient?

A

Patient’s vessels (vasculature) are the same on both sides, no narrowing on either side

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34
Q

Use backside of hands when assessing persons ___ ___

A

Skin temperature

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35
Q

How do you assess if the patient has good skin turgor?

A

Lightly pinch skin below clavicle, hold for a few seconds and do a quick release

36
Q

What is the expected finding for skin turgor? 

A

Skin should snap back to its normal position

37
Q

Used to test hydration status

A

Skin turgor

38
Q

Patient is dehydrated and has poor skin turgor

A

Tenting

39
Q

Depressing nail bed until it turns white during capillary refill assessment

A

Blanching

40
Q

What tells me the most distal corporal perfusion is intact?

A

Assessing capillary refill. Patient is getting circulation all the way down to their fingertips

41
Q

Fluid that seeps into the tissues and doesn’t return to the cardiovascular space

A

Edema

42
Q

Indicates heart failure or liver disease

A

Edema

43
Q

Edema scale 1+ (name 4)

A

Less than 2 mm indentation, slight pitting, no visible swelling, disappears rapidly

44
Q

Edema scale 2+ (name 2)

A

2-4 mm indentation, takes 10-15 seconds to disappear

45
Q

Edema scale 3+ (name 2)

A

4-6 mm indentation, 1 or more minutes to disappear

46
Q

Edema scale 4+ (name 3)

A

6-8 mm indentation, 2-5 minutes or more to go away, grossly distorted

47
Q

An extreme case of edema where the legs are very large, shiny, and taught (tight)

A

Anasarca

48
Q

Extremity inspection (SEE)

A

Skin color/condition, edema, equal

49
Q

Extremity palpation (PEET)

A

Pain, edema, equal, temperature

50
Q

Lack of hair growth indicates what?

A

Lack of arterial blood flow to the hair follicle

51
Q

Lack of arterial blood flow to the hair follicle is caused by what?

A

Narrow blood vessel

52
Q

When assessing carotid bruit, use ___ of stethoscope. Name 3 places to auscultate

A

Bell;

Angle of jaw, mid cervical area, and base of neck just above clavicle

53
Q

Expected finding when auscultating for a carotid bruit

A

NO swishing sounds
You would either hear nothing for a feint heartbeat

54
Q

If you hear a carotid bruit, this means there is a narrowing in the carotid artery, maybe due to ___

A

Atherosclerosis

55
Q

Patient is not getting sufficient blood to the brain and they are more likely to have a stroke if they have ___

A

Atherosclerosis

56
Q

___ is not needed for the cardiac assessment

A

Percussion

57
Q

Name 5 heart sounds

A

Aortic, pulmonic, erb’s point, tricuspid, mitral

58
Q

Use the ___ of the stethoscope when auscultating the heart

A

Diaphragm

59
Q

Systole, lub, loudest at apex

A

S1

60
Q

Diastole, dub, loudest at base

A

S2

61
Q

S1 is the closure of which valves?

A

Mitral and tricuspid

62
Q

S2 is the closure of which valves?

A

Aortic and pulmonary

63
Q

If heart rhythm is irregular, there is a ___ problem

A

Conduction

64
Q

If you hear a swish sound on S1 or S2, this could be a ___ problem 

A

Valve

65
Q

Unexpected findings when auscultating apical heart rate? (Name 3)

A

Bradycardia, tachycardia, or an irregular heartbeat

66
Q

Auscultating the apical heart rate tells us if our patient has ___, ___, or ___

A

Bradycardia, tachycardia, or an irregular heartbeat

67
Q

Stage one hypertension in adults

A

130-139 / 80-89 mmHg

68
Q

Stage two hypertension in adults

A

Anything greater or equal to 140 (systolic) / 90 (diastolic)

69
Q

High blood pressure

A

Hypertension (HTN)

70
Q

Low blood pressure

A

Hypotension

71
Q

Heart rate for infant

A

120 to 160

72
Q

Heart rate for a toddler

A

90 - 140

73
Q

Heart rate of a preschooler

A

80 - 110

74
Q

Heart rate of a school-aged child

A

75 - 100

75
Q

Heart rate of an adolescent

A

60 - 90

76
Q

Heart rate of an adult

A

60 - 100

77
Q

The younger the age, the ____ that the heart rate is

A

Higher

78
Q

The school- aged child is also close to the ___ and the ___ age categories

A

Adolescent; adult

79
Q

The adolescent heart rate range is most like which other age category?

A

Adult

80
Q

When auscultating the apical pulse, which point do you use?

A

Mitral or erb’s point, whichever you hear best

81
Q

Name two reasons a nurse should take an apical pulse

A

When patient is on a cardiac medication and it is mandatory to listen to a full minute and when a patient has an irregular heart rate

82
Q

Left to ___, right to ___

A

Limbs; respiratory

83
Q

If left side of heart is not working, there is a back up in the ____

A

Respiratory system (crackles)

84
Q

If right side of heart is not working, there is a back up in

A

The limbs (edema, JVD)

85
Q

Bilateral edema indicates

A

Heart failure

86
Q

Unilateral edema indicates

A

Lymph edema or a blood clot

Health Assessment (15 decks)

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