Cardiovascular/Peripheral Vascular Assessment Flashcards
List the steps of the arm/leg inspection phase of an assessment
Look at symmetry, size, and shape
Assess colour of skin
Perform Schamroth window test/clubbing
Note any edema, bruising, lesions, scars, lumps, etc. of the arms and hands
Capillary refill of fingers and toes
List the steps of the arm palpation phase of an assessment
Assess CSM bilaterally, simultaneously
Test skin texture and turgor
Palpate brachial, radial, popliteal, posterior tibial, and dorsalis pedis pulses
Describe the 4-point pulse scale
0 - absent pulse, cannot feel or not palpable
1+ - weak or thready pulse, barely palpable, easy to obliterate
2+ - normal pulse, obliterate with slight pressure
3+ - full and bounding pulse, obliterate with firm pressure or unable to obliterate
Describe the 4-point edema scale
Grade 1+ - mild pitting, slight indentation (0-2mm), no perceptible swelling of the leg
Grade 2+ - moderate pitting (3-4mm), indentation subsides rapidly
Grade 3+ - deep pitting (5-6mm), indentation remains for short time, evident swelling of the leg
Grade 4+ - very deep pitting (8mm), indentation lasts a long time, gross swelling and distortion of the leg
What creates bilateral, dependent pitting edema versus unilateral edema?
Bilateral - occurs in heart failure and diabetic neuropathy
Unilateral - occlusion of a deep vein
Describe how to complete a JVD assessment and what point of the assessment it is completed at
Completed during the inspection phase
Put pt. at a 30-45 degree angle, using a pen light inspect the right side of the neck, have the client look slightly away from you
Describe how to auscultate the carotid arteries and what we are looking for? What regions do you auscultate?
Using the bell of the stethoscope, auscultate three regions (angle of the jaw, midcervical area, and base of the neck)
We are looking for bruit sounds - swooshing sounds resulting from turbulent blood flow
Can the apical pulse be inspected?
Not typically, but you may be able to visually inspect in children or thin adults
Where is the apical pulse located?
Between the fourth and fifth ICS
What are the five areas of the heart that should be auscultated? Describe their anatomical placement
- Aortic - right second ICS
- Pulmonic - left second ICS
- Erb’s point (S1/S2) - left third ICS
- Tricuspid - lower left sternal border of 4th intercostal
- Mitral/apical pulse - left 5th intercostal, medial to midclavicular line
Describe a FULL CVS assessment
Inspection
- symmetry of arms and legs
- chest wall pulsations and apical pulse
- skin colour/lesions/scars
- edema
- capillary refill of arms and legs
- clubbing test/Schamroth test
- JVD and carotid arteries
Palpation
- Pulses (carotid, brachial, radial, popliteal, posterior tibial, and dorsalis pedis)
- CSM
- skin turgor/texture
- palpate 5 sites of the heart to ensure no pulsations are present
Auscultation
- Listen to apical pulse for a full minute
- Auscultate carotid (prior to palpation) with bell of stethoscope for bruits at all 3 sites (angle of the jaw, midcervical area, and base of the neck)
- Listen to 5 cardiac sites (aortic, pulmonic, erb’s point, tricuspid, and mitral)
What is dependent edema? When is it not dependent?
Edema is present inn the legs or below the heart
Edema is considered to not be dependent when it evens out across the body upon laying down
When auscultating heart sounds, what should the patient’s breathing be like?
Instruct the patient to take a deep breath in, breath out, and then hold that breath out to reduce additional thoracic cage sounds
What conditions can skew capillary refill?
Cold temperatures, smoking, peripheral edema, anemia
As a result of arteriosclerosis, what changes in BP would you expect as a person ages?
We would expect to see SBP to increase with age
