heart and peripheral vascular system Flashcards
heart purpose for pumping blood
transport oxygen
transport nutrients
carries metabolic waste products to kidneys and lungs
how does the cardiovascular system adjust to changing demands for blood/ perfusion?
constricting or dilating blood vessels
altering cardiac output
perfusion
the mechanism that either allow or prevent oxygenated blood to reach parts of the body
- all tissues require perfusion of oxygenated blood
what to inspect in a heart assessment
- general appearance
- skin color
- nails (capillary refill)
- edema
- veins, jugular veins
- moisture in the axillae and in skin folds
- diaphoresis
what does brown pigmentation change with
poor circulation
the best place to detect color change
palms soles of feet lips tongue nail beds
pallor
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
cyanosis
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
what does capillary refill asses
circulation
apply firm pressure to nail bed to blanch it
result in brisk return of color
results from aging changes or blood vessel damage
spider angioma
cherry angioma
spider angioma
red center with radiating red legs
cherry angioma
red, round, possibly raised
spider vein
bluish, spider-shaped or linear, up to several inches in size
petechiae/purpura
deep reddish, purple, flat, petechiae
ecchymosis
purple fading to green or yellow over time, variable in size, flat
hematoma
raised ecchymosis
- collection of blood right underskin
jugular veins
inspect when bed is at a 30-40 degree angle
normal: no neck vein distension
insepct anterior chest wall for
contour, pulsations, and retractions
aplical pulse
visible to the left midclavicular line at the fourth or fifth intercostal space
- on a woman have them displace their breast tissue
edema
accumulation of fluid in the tissues
- causes swelling with the skin appearing shiny and tight
- asses for discoloration, location, and tenderness
edema rating
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
pulses should be
symmetrical in quality and quantity on both sides of the body @ the same location
what do you asses to evaluate the adequacy of the vascular system
strength and equality
grade scale for pulsations
0 absent, unable to palpate 1+ diminished, weaker than expected 2+ brisk expected 3+ increased strong 4+ full volume bounding
what will be documented related to pulses
number, quality, strength, location
what do thicker more rigid peripheral blood vessel walls lead to
poor peripheral circulation, higher systolic BP
when listening to heart the nurse hears
heart sounds
lub/dub
S1, S2
what does the beginning of ventricular systole (contraction) produce
s1 sound
- place diaphragm of the stethoscope at the apex to hear “lub”
beginning of ventricular diastole (relaxation) produces
s2 “dub”
3 ways to listen to heart sounds
sitting, leaning forward
lying supine
turned towards the left side
when are murmurs audible
when blood in the heart is increased or its flow is impeded or altered
thrills
palpable vibration that can accompany murmurs
bruits
blowing or swishing sounds that indicate obstructed peripheral blood flow
use the bell to assess
murmurs
thrills
bruits
