Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

health assessment exam 3 > heart and peripheral vascular system > Flashcards

heart and peripheral vascular system Flashcards

1
Q

heart purpose for pumping blood

A

transport oxygen
transport nutrients
carries metabolic waste products to kidneys and lungs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

how does the cardiovascular system adjust to changing demands for blood/ perfusion?

A

constricting or dilating blood vessels

altering cardiac output

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

perfusion

A

the mechanism that either allow or prevent oxygenated blood to reach parts of the body
- all tissues require perfusion of oxygenated blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what to inspect in a heart assessment

A
  • general appearance
  • skin color
  • nails (capillary refill)
  • edema
  • veins, jugular veins
  • moisture in the axillae and in skin folds
  • diaphoresis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what does brown pigmentation change with

A

poor circulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

the best place to detect color change

A 
palms
soles of feet
lips
tongue
nail beds
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

pallor

A

loss of color
black skin tones: change to gray
location: face, conjunctivae, nail beds, palms, lips, buccal mucosa
Indication: could be a problem with the heart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

cyanosis

A

bluish
darker skin tones: palms and soles
location: nail beds, lips, mouth mucosa, skin, palms
indication: hypoxia ( no oxygen in blood) or a problem with circulation due to the heart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

what does capillary refill asses

A

circulation
apply firm pressure to nail bed to blanch it
result in brisk return of color

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

results from aging changes or blood vessel damage

A

spider angioma

cherry angioma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

spider angioma

A

red center with radiating red legs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

cherry angioma

A

red, round, possibly raised

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

spider vein

A

bluish, spider-shaped or linear, up to several inches in size

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

petechiae/purpura

A

deep reddish, purple, flat, petechiae

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

ecchymosis

A

purple fading to green or yellow over time, variable in size, flat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

hematoma

A

raised ecchymosis

- collection of blood right underskin

17
Q

jugular veins

A

inspect when bed is at a 30-40 degree angle

normal: no neck vein distension

18
Q

insepct anterior chest wall for

A

contour, pulsations, and retractions

19
Q

aplical pulse

A

visible to the left midclavicular line at the fourth or fifth intercostal space
- on a woman have them displace their breast tissue

20
Q

edema

A

accumulation of fluid in the tissues

  • causes swelling with the skin appearing shiny and tight
  • asses for discoloration, location, and tenderness
21
Q

edema rating

A

1+ trace, 2 mm, rapid skin response
2+ mild, 4mm, 10- to 15- second skin response
3+ moderate, 6mm prolonged skin response
4+ severe, 8mm prolonged skin response

22
Q

pulses should be

A

symmetrical in quality and quantity on both sides of the body @ the same location

23
Q

what do you asses to evaluate the adequacy of the vascular system

A

strength and equality

24
Q

grade scale for pulsations

A 
0 absent, unable to palpate
1+ diminished, weaker than expected
2+ brisk expected
3+ increased strong
4+ full volume bounding
25
Q

what will be documented related to pulses

A

number, quality, strength, location

26
Q

what do thicker more rigid peripheral blood vessel walls lead to

A

poor peripheral circulation, higher systolic BP

27
Q

when listening to heart the nurse hears

A

heart sounds
lub/dub
S1, S2

28
Q

what does the beginning of ventricular systole (contraction) produce

A

s1 sound

- place diaphragm of the stethoscope at the apex to hear “lub”

29
Q

beginning of ventricular diastole (relaxation) produces

A

s2 “dub”

30
Q

3 ways to listen to heart sounds

A

sitting, leaning forward
lying supine
turned towards the left side

31
Q

when are murmurs audible

A

when blood in the heart is increased or its flow is impeded or altered

32
Q

thrills

A

palpable vibration that can accompany murmurs

33
Q

bruits

A

blowing or swishing sounds that indicate obstructed peripheral blood flow

34
Q

use the bell to assess

A

murmurs
thrills
bruits

health assessment exam 3 (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions