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nursing fundamentals > Heart/Vasular w/ Breast and Axillae: 5 Questions > Flashcards

Heart/Vasular w/ Breast and Axillae: 5 Questions Flashcards

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1
Q

Central pulses are located where?

A

Carotid and Femoral=Adults

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2
Q

Pediatric central pulses are located where?

A

Brachial pulse under two

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3
Q

What is Cyanosis?

A

Blue lips and lack of oxygen.

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4
Q

What is JVD associated with?

A

Some form of Heart Failure

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5
Q

Adults with under 60 bpm?

A

Bradycardia

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6
Q

Baby under 60 bpm?

A

Is bad

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7
Q

How to assess the heart?

A

Inspect, auscultate, palpate

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8
Q

Heart failure

A

Mechanical Failure

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9
Q

Veins take blood where?

A

To the heart

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10
Q

Arteries take blood where?

A

Pump blood away from the heart

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11
Q

Indications of a patient with low fluid?

A

Cracked lips, skin turgor, and tachycardia

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12
Q

Jugular Vein Distention indicates what ?

A

Right Sided Heart Failure

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13
Q

What elevation do you set the HOB?

A

45-90 degrees

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14
Q

What is located for inspection for the heart?

A

Louis/sternal notch

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15
Q

How do you visualize the JVD?

A

With a flashlight to create shadows that highlight the venous pulse.

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16
Q

Do patient gain weight from acute right sided heart failure?

A

Yes

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17
Q

How do you document the inspection of the JVD?

A

Located the highest point along the vein where you see pulsations.
Measure distance from the sternal notch to the highest point

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18
Q

How do you expand JVD?

A

Chest pain or pressure, SHOB, pallor skin, Bluish coloration of lips or fingernails, profuse sweating, tachypnea, loss of strength

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19
Q

ALL
PIGS
EAT
TOO
MUCH

A

Aortic
Pulmonic
Erb’s Point
Tricuspid
Miteral

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20
Q

Location of the Aortic ?

A

2nd Right Intercostal Space

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21
Q

Location of the Pulmonic ?

A

2nd Left Intercostal Space

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22
Q

Location of the Erb’s Point ?

A

3rd Left Intercostal Space, Left Sternal Border

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23
Q

Location of the Tricuspid?

A

4th Left Intercostal Space, Left Lower Sternal Border

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24
Q

Location of the Mitral Area/Apex?

A

5th Left Intercostal Space, Mid Clavicular Line (Point of Maximum Inpulse)

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25
Q

What pattern do you use for Auscultation?

A

Zig Zag

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26
Q

What heart sounds does S3 sound like?

A

Ken-TUCK-y

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27
Q

Who can have S3 Heart Sounds?

A

Young Children
Adults under the age 40
Trained athletes

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28
Q

What heart sound is irregular for patients over 50 and up?

A

S3 Heart Sounds

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29
Q

What positions do you do for auscultation technique?

A

Supine, HOB 30-45 degrees
Left Side Lying
Sitting up, leaning forward slightly

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30
Q

Small part of the stethoscope ?

A

High frequency

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31
Q

Biggest part of the stethoscope?

A

Low frequency

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32
Q

What heart sounds do “normal” patients have?

A

S1 and S2

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33
Q

What should you check for blood clot possibility ?

A

Extremity Pain

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34
Q

If a patient looks diaphoretic, what is indicated?

A

Patient is SHOB

35
Q

What level is concerning when it comes to hemoglobin levels (HBG) ?

A

Less than 8 can be concern for blood loss

36
Q

What is common with a fever?

A

Tachycardia

37
Q

What happens when the temperature comes down?

A

The heart rate also comes down

38
Q

What side is usually lung issues?

A

Right Side

39
Q

Indicates poor oxygenation and can involve the heart.

A

Clubbed Fingers

40
Q

What should you not do to a fistula?

A

Put a blood pressure cup over it

41
Q

What is the sound of Bruit ?

A

Blowing and Swishing sound

42
Q

Results from turbulent blood flow in the carotid artery.

A

Bruit

43
Q

How many sides should assess for Bruit?

A

One side at a time

44
Q

Where should you place the stethoscope for Bruit ?

A

Lightly place bell over carotid artery

45
Q

What is a Fistula ?

A

Artery and a Vein

46
Q

What is a Thrill ?

A

Abnormal vibration

47
Q

Can you palpate a thrill?

A

No

48
Q

What is normal when assessing carotid vessels ?

A

Regular Rhythm; equal on both sides.
S1 and S2

49
Q

What does Thrill cause ?

A

Valvular Heart Disease, Congenital Heart Defects, Anemia, and Narrowing of the Arteries

50
Q

What sound does an S4 heart sound make?

A

Ten-ne-see or A Stiff Wall

51
Q

What is the frequency of S4?

A

Low-pitched, around 30 Hz

52
Q

Indicates increased resistance to filling of the left or right ventricle.
Myocardial Attack or Ischemia

A

S4

53
Q

What position do auscultate Pericardial Rubs?

A

Patient sits upright, slightly forward

54
Q

What sounds do hear while auscultate pericardial rubs?

A

S1 and S2

55
Q

What does Pericardial Rubs sound like ?

A

Scratchy, rubbing sound

56
Q

How do you differentiate between pericardial and pleural rubs?

A

Ask patient to hold breath
(If it persists then it is pericardial)
(If it ceases then it is pleural)

57
Q

What tool do you use for assessing the vascular system ?

A

Doppler

58
Q

What is a Doppler?

A

An Ultrasonic vascular device to detect weak pulses

59
Q

What is palpation is grading pulse 0?

A

Absent

60
Q

What is palpation is grading pulse 1+?

A

Weak

61
Q

What is palpation is grading pulse 2+?

A

Normal

62
Q

What is palpation is grading pulse 3+?

A

Increased

63
Q

What is palpation is grading pulse 4+?

A

Bounding

64
Q

What finger do you use for palpating for a pulse?

A

Index and Middle Finger

65
Q

Loss of blood flow arterially, Pain out of proportion

A

Compartment Syndrome

66
Q

Petal Pulse at the top of the foot

A

Arterial Insufficiency

67
Q

~Decreased or absent pulses
~Skin cool, pale, shiny, decreased hair in blue spots.
~Pain possible in legs and feet
~Thick Ridged Nails
~Toe Ulcerations
~Deep red when dependent

A

Arterial Insufficiency

68
Q

~Pitting Edema
~Pulses present, difficult to find
~Ankle Ulcerations
~Cyanotic when dependent
~Brown pigmentation

A

Chronic Venous Insufficiency

69
Q

What can edema indicate ?

A

Heart Failure or Venous Insufficiency
Varicosities or Thrombophlebitis

70
Q

How long do you press finger against swollen area of pitting edema?

A

5 seconds

71
Q

Pressure forces fluid into underlying tissues.

A

Pitting Edema

72
Q

What depths measured in centimeters in Pitting edema?

A

1+
2+
3+
4+

73
Q

Skin feels unusually tight and firm, shiny appears.

A

Non-pitting edema

74
Q

“Stasis Ulcer”
Results from Venous HTN
Lower Leg

A

Venous Ulcers

75
Q

~”Ischemic Ulcer”
~Result from progressive atherosclerosis or emboli
~Insufficient blood flow to tissue
~Blue Skin
~Distal ends of arterial branches

A

Arterial Ulcers

76
Q

~Secondary to Lymphedema
~Capillaries are compressed by thickened tissues
~Occludes blood flow to skin

A

Lymphatic Ulcers

77
Q

Why is the right side harder to percuss?

A

Because of the liver

78
Q

~EKG (Usually 12 Lead)
~5 lead/3 lead/2 lead
~Troponin (MI with non-STEMI)
~Cardiac Stress Test
~Ultrasound

A

Cardiac Labs

79
Q

~Blood Pressure Meds (Beta Blockers “olol”
~Diuretics (Fluid meds; Lasix, HCTZ)
~Anti-Dysthymia Meds (Amiodarone, Cardizem, Adenosine)
~Aspirin, Nitroglycerin, Oxygen,Morphine
~TNKase

A

Cardiac Medications

80
Q

Circular
Wedged
Vertical Strip

A

Breast Palpations

81
Q

Breast/Axillary Labs

A

CBC

82
Q

Breast/Axillary Medications

A

Hormone Therapy (ifen/ifene)

83
Q

What should you avoid with a neutropenic fever?

A

Avoid fresh fruits and vegetables

nursing fundamentals (10 decks)

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