Notes Ch: 31 - Assessment Pt. 4

Question 1

S1 and S2 represent…

Answer 1

• The normal heart sounds; lub-dub
• S1 = closure of the semilunar valves
• S2 = closure of the AV valves

Question 2

We should listen for _____ sounds before _____ sounds.

Answer 2

normal, abnormal

Question 3

Where do we auscultate to assess S3, S4 and other abnormal heart sounds?

Answer 3

Apical pulse site; PMI (Point of Maximal Impulse)

Question 4

What is the mneumonic for the auscultation points of the heart?

Answer 4

All Patients Take Medicine

• A = Aortic Valve
• P = Pulmonary Valve
• T = Tricuspid Valve
• M = Mitral Valve/Apex of heart/PMI/Apical pulse

Question 5

Where are the four locations of heart auscultation?

Answer 5

1. Aortic Valve = Right sternal border, 2nd intercostal space
2. Pulmonary Valve = Left sternal border, 2nd intercostal space
3. Tricuspid Valve = Left sternal border, 4th intercostal space
4. Mitral Valve = Midclavicular line, 5th intercostal space

Question 6

What is the S3 sound, when is it heard and what does it sound like?

Answer 6

• Audible filling of the ventricle
• Right after S2
• Lub-Dub-Tss (like a gallop)

Question 7

What is the S4 sound, when is it heard and what does it sound like?

Answer 7

1. Occurs when atria contract harder to overcome resistent ventriclular filling (ventricles not doing their job properly)
2. Prior to S1
3. tuh, lub-dub

Question 8

What are the three basic anomolies we are listening for when auscultating the heart?

Answer 8

1. Dysrhythmia
2. Extra heart sounds
3. Murmurs

Question 9

What three items are we noting when ausculting a heart murmur?

Answer 9

1. Grade
2. Pitch
3. Quality

Question 10

A heart “thrill” is a…

Answer 10

palpable vibration

Question 11

A good heart rythym is documented as…

Answer 11

+S1S2

(positive S1, S2)

Question 12

How many grades of heart murmur are there?

Answer 12

six

Question 13

Describe murmur grades 1-3

Answer 13

Grade 1 = Barely audible in a quiet room (extremely difficult to hear)

Grade 2 = Clearly audible, but quiet

Grade 3 = Moderately loud

Question 14

Describe murmur grades 4-6

Answer 14

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

Question 15

If murmurs are discovered a _____ will be needed for the patient.

Answer 15

referral

Question 16

Blood pressure tends to be higher in which arm?

Answer 16

Right

Question 17

_____ arteries reflect function better than _____ arteries.

Answer 17

Carotid, peripheral

Question 18

Where is a bruit found, what is it, and what does it sound like?

Answer 18

• blood vessels
• narrowed vessel which creates an audible turbulence
• swish

Question 19

How are pulse strengths documented and describe each.

Answer 19

0 = abscent, not palpable

+1 = pulse diminished, barely palpable

+2 = normal/expected

+3 = full pulse, increased

+4 = bounding pulse

Question 20

What are varicosities?

Answer 20

• 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

Question 21

What is peripheral edema?

Answer 21

• 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.

Question 22

What is pitting edema?

Answer 22

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)

Question 23

What is phlebitis?

Answer 23

• means inflammation of a vein.

Question 24

What is thrombophlebitis

Answer 24

• 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.