CHAPTER 21 heart assessment Flashcards
a cardiac chest pain described as a sensation of squeezing around the heart
Angina
a pain radiates to left shoulder down to left arm
diaphoresis
palpitations occur with
abnormality of heart conduction system
heart attempt to increase cardiac output by increasing heart rate
cause client to feel anxious
a compromised cardiac output indicates
fatigue
dyspnea may result from
congestive heart failure
pulmonary disorders
coronary artery disease
myocardial ischemia
myocardial infarction
renal perfusion during period at rest /recumbency can cause
nocturia
dizziness indicate
decreased blood flow due to myocardial damage
edema of lower extremities may occur as
a result of heart failure
dyspnea or fatigue may indicate
heart failure
what is taken before intercourse as prophylactic for chest pain
nitroglycerin
what position is needed to auscultate and palpate neck vessels
supine 30 degree with head elevated
what position is required to inspect pulsations
supine with head elevated 30-45 degrees
the apical pulse was originally called
PMI point of maximal impulse
this is a result of left ventricle moving outward during systole
apical impulse
abnormal ventricular impulses
lift
thrill
accentuated apical impulse
laterally displaced apical impulse
a forceful cardiac impulse/pump
lift or heave
palpable vibration of chest / feels ; grade 4 or higher murmur
thrill
in palpating the apical pulse where does the nurse stay
clients right side
where do we palpate the apical impulse
mitral area ; 5th intercostal space at midclavicular line
a not palpable apical impulse may indicate
pulmonary emphysema
locations in palpation of pulse
apex
left sternal border
base
a regularly irregular rhythm indicates
sinus arrhythmia
is sinus arrhythmia an abnormal or normal finding
normal
this indicates when hr increases with inspiration and decreases w expiration
sinus arrhythmia
lesser than 60 bpm indicates
bradycardia
greater than 100 bpm indicates
tachycardia
regular irregular rhythm
PVC/ ATRIAL CONTRACTION
irregular rhythms may indicate
decrease co, heart failure, emboli
if you detect a irregular rhythm, do what
auscultate for a pulse rate deficit (palpating radial pulse while ausculatating)
the difference between apical and peripheral pulse
pulse deficits
this is the quiet sound heard during diastole as ventricl is filled
physiologic s3
physiologic s3 resembles rhthm of
tene-es-see
physiologic s4 sound like
ken-tuc-ky
this is when s3 and s4 sounds together - quadruple rhythm
summation gallop
a harsh, grating sound ; abrasion of inflamed pericardial surfaces
friction rub
abnormal diastolic sounds heard during av opening
opening snaps
result of opening of a rigid and calcified aortic valve
systolic click
gradations of murmur
grade 1, 2, 3, 4, 5, 6
very faint murmur
grade 1
quiet but heard immediately after placing stet
grade 2
moderately loud murmur
grade 3
loud with palpable thrill murmur
grade 4
a very loud with thrill ; stet partly off sa chest
5
a very loud and thrill murmur; heard with stet entirely off sa chest
grade 6
a visible jugular venous plate may indicate
right ventriclar failure
