Notes Ch: 31 - Assessment Pt. 4 Flashcards
Heart
S1 and S2 represent…
- The normal heart sounds; lub-dub
- S1 = closure of the semilunar valves
- S2 = closure of the AV valves
We should listen for _____ sounds before _____ sounds.
normal, abnormal
Where do we auscultate to assess S3, S4 and other abnormal heart sounds?
Apical pulse site; PMI (Point of Maximal Impulse)
What is the mneumonic for the auscultation points of the heart?
All Patients Take Medicine
- A = Aortic Valve
- P = Pulmonary Valve
- T = Tricuspid Valve
- M = Mitral Valve/Apex of heart/PMI/Apical pulse
Where are the four locations of heart auscultation?
- Aortic Valve = Right sternal border, 2nd intercostal space
- Pulmonary Valve = Left sternal border, 2nd intercostal space
- Tricuspid Valve = Left sternal border, 4th intercostal space
- Mitral Valve = Midclavicular line, 5th intercostal space
What is the S3 sound, when is it heard and what does it sound like?
- Audible filling of the ventricle
- Right after S2
- Lub-Dub-Tss (like a gallop)
What is the S4 sound, when is it heard and what does it sound like?
- Occurs when atria contract harder to overcome resistent ventriclular filling (ventricles not doing their job properly)
- Prior to S1
- tuh, lub-dub
What are the three basic anomolies we are listening for when auscultating the heart?
- Dysrhythmia
- Extra heart sounds
- Murmurs
What three items are we noting when ausculting a heart murmur?
- Grade
- Pitch
- Quality
A heart “thrill” is a…
palpable vibration
A good heart rythym is documented as…
+S1S2
(positive S1, S2)
How many grades of heart murmur are there?
six
Describe murmur grades 1-3
Grade 1 = Barely audible in a quiet room (extremely difficult to hear)
Grade 2 = Clearly audible, but quiet
Grade 3 = Moderately loud
Describe murmur grades 4-6
Grade 4 = Loud, with associated thrill
Grade 5 = Very loud, thrill easily palpable
Grade 6 = Louder, may be heard w/out stethoscope; thrill palpable and visible
If murmurs are discovered a _____ will be needed for the patient.
referral
Blood pressure tends to be higher in which arm?
Right
_____ arteries reflect function better than _____ arteries.
Carotid, peripheral
Where is a bruit found, what is it, and what does it sound like?
- blood vessels
- narrowed vessel which creates an audible turbulence
- swish
How are pulse strengths documented and describe each.
0 = abscent, not palpable
+1 = pulse diminished, barely palpable
+2 = normal/expected
+3 = full pulse, increased
+4 = bounding pulse
What are varicosities?
- Varicosities are abnormally dilated and tortuous veins that usually appear in the lower extremities.
- Varicosities in general occur as a result of an underlying problem with reverse venous flow, also known as venous insufficiency syndrome
What is peripheral edema?
- Peripheral edema is edema (accumulation of fluid causing swelling) in tissues perfused by the peripheral vascular system, usually in the lower limbs.
- In the most dependent parts of the body (those hanging distally), it may be called dependent edema.
What is pitting edema?
Observable swelling of body tissues due to fluid accumulation that may be demonstrated by applying pressure to the swollen area (such as by depressing the skin with a finger)
What is phlebitis?
- means inflammation of a vein.
What is thrombophlebitis
- Thrombophlebitis is due to one or more blood clots in a vein that cause inflammation.
- Thrombophlebitis usually occurs in leg veins, but it may occur in an arm.
- The thrombus in the vein causes pain and irritation and may block blood flow in the veins.
