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Management Of Nursing Care > Cardiovascular System > Flashcards

Cardiovascular System Flashcards

1
Q

Define Apical pulse.

A

The apical pulse is a pulse site on the left side of the chest over the pointed end, or apex, of the heart. Doctors find that taking the apical pulse is the most accurate, noninvasive way of assessing cardiac health.

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2
Q

What are the steps for finding the apical pulse?

A
  1. Explain procedure and gain consent. 2. Ask the client to get changed in a hospital gown. (Ensure privacy). 3. Gather stethoscope. 4. Position patient and inspect the anterior chest 5. Use a systematic palpation of landmarks to find the apical pulsation. 6. auscultate this pulsation using the diaphragm of a stethoscope. 7. Count this for 60 seconds and record.
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3
Q

What are you inspecting for on the anterior chest?

A

Shape, Symmetry, Appearance, colour, landmarks, and apical pulsations)

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4
Q

Define auscultate

A

examine a patient by listening to sounds from (the heart, lungs, or other organs), typically using a stethoscope.

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5
Q

How do you record the apical pulse?

A

The same as recording the radial pulse but draw a small a next to this.

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6
Q

What is involved in a cardiovascular system assessment?

A

Auscultation of the apical pulse, Completing a peripheral Vascular assessment, and explaining the difference between S1 and S2 sounds.

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7
Q

What is an S1 sound?

A

The first heart sound (S1) represents closure of the atrioventricular (mitral and tricuspid) valves as the ventricular pressures exceed atrial pressures at the beginning of systole.

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8
Q

What are all the valves of the heart?

A

tricuspid valve: located between the right atrium and the right ventricle.

pulmonary valve: located between the right ventricle and the pulmonary artery.

mitral valve: located between the left atrium and the left ventricle.

aortic valve: located between the left ventricle and the aorta.

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9
Q

What is an S2 sound?

A

The second heart sound (S2) represents closure of the semilunar (aortic and pulmonary) valves

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10
Q

Define systolic.

A

relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries

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11
Q

Define diastolic.

A

relating to the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood.

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12
Q

What are atrioventricular valves?

A

The atrioventricular valves are those that connect the atrium to the ventricles and include the mitral valve as well as the tricuspid valve

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13
Q

What is the SA node?

A

The SA node (called the pacemaker of the heart) sends out an electrical impulse.

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14
Q

What is the atrium?

A

The atrium is the upper chamber through which blood enters the ventricles of the heart.

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15
Q

What are the landmarks in order that we use to find the apical pulsation?

A

Suprasternal notch, angle of louis, 2nd left intercostal space, 3rd left intercostal space, 4th left intercostal space, 5th left intercostal space, mid clavicular line

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16
Q

True or false, we use the first left intercostal space to locate the apical pulse?

A

False

17
Q

What acronym do we use to do a peripheral vascular assessment?

A

CowsCamp

18
Q

What does cowscamp stand for?

A

Colour, Oedema, Warmth, Sensation, Capillary Refill, Appearance, Movement, Peripheral pulses (posterior tibial, dorsalis pedis).

19
Q

What is important about completing a peripheral vascular assessment?

A

Making sure you are comparing both legs to eachother.

20
Q

What are we looking for in terms of colour?

A

Even and consistent with the rest of the body.

21
Q

What are we looking for in terms of warmth?

A

Even and consistent with the rest of the body. Use back of hands go right from knees to toes. Expect toes to be colder than usual.

22
Q

What are we looking for in terms of appearance?

A

Hair distribution (important indicator of vascular sufficency of the lower limbs)

23
Q

What are we looking for in terms of capillary refill?

A

Blood to return within 2 seconds (might be 3 if its a cold day).

24
Q

What are we looking for in terms of appearance?

A

Hair distribution (important indicator of vascular sufficency of the lower limbs). Look for scars, lumps and lesions.

25
Q

What does adema mean?

A

Swelling, excess fluid in the intercellular space.

26
Q

How do we find a posterior tibial pulse?

A

Dorsiflex the foot and roll hand over ankle towards achilles, find the groove near the tendon and you should be able to feel the foot.

27
Q

How do we find dorsalis pedis pulse?

A

Laterally to the EHL/big toe tendon.

28
Q

What does oedema mean?

A

Swelling, excess fluid in the intercellular space.

29
Q

What do you need to say when taking the dorsalis pedis pulse?

A

You dont want to press to hard as you may occlude the arterial pulse and then you wont be able to feel the pulse.

30
Q

What do you need to say when finding the posterior tibial pulse?

A

Tell the patient to relax the foot and let you hold it back.

31
Q

How do we check for oedema?

A

Press thumb next to ankle and identify if there is pitting or not. We would expect to see no pitting.

32
Q

How would we explain to a teacher what an S1 sound is?

A

The sound which represents the closure of the atrioventricular valves (mitral and tricuspid) at the beginning of the systole. Makes a lub sound.

33
Q

How would we explain to a teacher what an S2 sound is?

A

The sound which represents the closure of the semilunar valves (aortic and pulmonary) at the end of the systole and beginning of the diastole. Makes a dub sound.

34
Q

What influences the rate and rhythm of S1 and S2 sounds?

A

Heart rate.

35
Q

When taking an apical pulse what do you need to do to the bed?

A

Probably elevate it to make taking the pulse easier and more comfortable for the patient.

Management Of Nursing Care (10 decks)

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