TEST 2 Flashcards
CULTURE AND GENETICS
NUTRITION
Foods Choices and Eating Patterns are Heavily Influenced by Culture
Newly Arrive Immigrants May be at Increased Nutritional Risk
Religious Dietary Practices- Can affect food choices and eating patterns
types of nutrition screenings
- Admission nutrition screening tool
*If risk is identified complete comprehensive nutritional assessment - 24 hour diet recall
- Food frequency
- Food diaries
- Direct observation
2015-2020 dietary guidelines for americans
*Make small shifts in your daily eating habits to improve health over the long run
*Healthy eating patterns along with regular physical activity has been shown to help people reach and maintain good health and reduce chronic disease risk
healthy eating patterns focus on
◦ Variety of vegetables
◦ Fruits, especially whole fruits.
◦ Grains, primarily whole grains
.◦ Fat-free or low fat dairy
◦ Variety of Protiens
◦ Limit Salt, Saturated and Trans Fats, and Added Sugars
health history questions
nutritional subjective data
- Eating patterns
- Usual weight
- Changes in appetite, taste, smell, chewing, swallowing
- Recent surgery, trauma, burns, infections
- Chronic illness
- Vomiting, diarrhea, constipation
- Food allergies
health history questions
nutritional subjective data- continued
- Medications and/or nutritional supplements
- Self-care behaviors
- Alcohol or illegal drug use
- Exercise and activity patterns
- Family history
clinical signs of malnutrition
◦ Skin- Should be smooth, no bruises, rashes, or flaking
◦ Hair- Should be shiny, scalp intact and without lesions, does not fall out easily
◦ Eyes- corneas clear & shiny, membranes pink and moist, no bumps or sores
◦ Lips- Should be smooth, not chapped, cracked, or swollen
◦ Tongue- Should be red, not swollen or abnormally smooth, no lesions
clinical signs of malnutrition
continued
Gums- Should be pink and moist, no swelling or bleeding
◦ Nails- Smooth, pink
◦ MS- Erect posture, good muscle tone, ambulates without pain
◦ Neuro- Appropriate affect, normal reflexes
derived weight measures
- Body weight as percent of ideal bodyweight
- Percent usual body weight-
- Recent weight change
body mass index
marker of optimal weight for height and indicator for obesity & protein-calorie malnutrition
BMI = weight (kg)/height (m)2
or
BMI = weight (lb)/height (inches)2 x 703
bmi ranges
under 18.5 Underweight
18.5-24.9 Normal weight
25.0-29.9 Overweight
30.0-39.9 Obesity
>40 Extreme obesity
Assessment of body fat distribution and indications of health risks
Waist-to-hip ratio = waist circumference / hip circumference
Indication of upper body obesity “android”:
Ratio of > 1.0 in men or > 0.8 in women* Increased risk for obesity-related diseases & early mortality
total arm span or total arm length
roughly equal to height
what do hemoglobin and hematocrit show
indicators of iron status
what are the indicators of cardiovascular risks
cholesterol with triglycerides, ldl, and hdl levels
malnutrition classifications
obesity
marasmus
kwashiorkor
marasmus
protein calorie malnutrition
kwashiorkor
protein malnutrition
layers of skin
epidermis
dermis
subcutaneous
epidermis
- Replaced every 4 weeks
◦ Outermost layer; thin but tough; houses keratin
dermis
◦ Inner supportive layer; consists of connective tissue (collagen); contains elastic tissue
◦ Nerves, sensory receptors, blood vessels, & lymphatics housed here
subcutaneous
◦ Aka Adipose tissue
◦ Stores fat for energy, provider insulation for temp control, and cushions/protects
FUNCTIONS OF SKIN
protection
perception
temp regulation
identification
communication
wound repair
absorption/excretion
vitamin d production
protection
functions of skin
◦ Thermal
◦ Physical
◦ Chemical
◦ UV
◦ Microorganisms
perception
functions of skin
Houses neurosensory end-organs for touch, pain, temperature, and pressure
temp regulation
functions of skin
Heat dissipation thru sweat glands
Heat storage thru subcutaneous tissue
identification
functions of skin
Facial characteristics, hair, skin color, & fingerprints
communication
functions of skin
blushing, blanching, expressions
vitamin d production
functions of skin
uv light converts cholesterol into vitamin d
infants
developmental care- hair/skin/nails
Lanugo- Fine hair
Vernix caseosa- white, cheesy substance
High risk for fluid loss
Poor thermal regulation
pregnancy
developmental care - hair/skin/nails
◦ Increased sweat and sebaceous glands
◦ Increased fat deposits primarily in buttocks and hips
◦ Linea nigra- mid-abdominal dark line
◦ Melasma (Chloasma)- increased pigment in face
◦Striae gravidarum- aka stretch marks (abd, thighs, breasts)
older adults
developmental care - hair/skin/nails
◦ Thin epidermis, ↓ elasticity, ↑ dryness
◦ Less protective mechanisms (functioning decreases)
melanin
ncreased in Indians and African Americans therefore increased protection from UV rays. Caucasians 20x more likely to develop melanoma (deadliest form of skin cancer)
keloids
scars with increased height and width
pigmentary disorders
increased incidence of pigment problems in african americans
pseudofolliculitis
razor burn/bumps, ingrown hairs
melasma
mask of pregnancy
patchy tan to dark brown discoloration of face
subjective data
hair, skin, nails
Hx skin dz
pigmentation
mole (size color) = ABCDE
Excessive dryness (xerosis) or moisture (seborrhea)
Pruritis
Bruising
subjective data
hair/skin/nails (cont.)
Rash, lesion
Meds
Hair loss
Nails
Environmental/ occupational exposures noteworthy
Self-care behaviors
what should you assess first
hair/skin/nails
hands
what areas must you not forget to assess
hair/skin/nails
intertriginous areas (skin folds)
color
objective assessment of hair/skin/nails
nevus
pallor
erythema
cyanosis
juandice
nevus
mole
abcde
pallor
white, anemia, shock, arterial insufficiency, anxiety, fear, exposure to cold, cigarette smoke
erythema
redness, fever, local inflammation, blushing
cyanosis
blue, low perfusion, unoxygenated hgb
juandice
yellow, excessive bilirubin, sclera and hard and soft palate of mouth
in darker skinned people, where may you be better able to assess color changes
tongue, buccal mucosa, palpebral conjunctiva, sclera
external variable influencing skin color
emotions
environment
physical
emotions
influence on skin color
◦ Fear, anger= peripheral vasoconstriction= pallor
◦ Embarrassment- facial/neck flushing= erythema
environment
influence on skin color
◦ Hot room= vasodilation= erythema
◦ Chilly/air conditioned room= vasoconstriction= pallor
◦ Cigarette smoke= vasoconstriction= pallor
physical
influence on skin color
◦ Prolonged elevation- decreased arterial perfusion= pallor, cool
◦ Dependent position= venous pooling = redness, warmth, distended veins
◦ Immobilization = slowed circulation = pallor, coolness, prolonged capillary filling time
temperature
objective assessment of hair/skin/nails
◦ Dorsa
◦ Hypothermia
◦ Hyperthermia
moisture
objective assessment of hair/skin/nails
◦ Dry vs. diaphoretic
◦ Dehydration- locations: mucous membranes, lips, sunken fontanel, turgor
texture
objective assessment of hair/skin/nails
smooth, firm, even surface
thickness
objective assessment of hair/skin/nails
◦ Mostly thin
◦ Some callus (overgrowth of epidermis)- normal on palms & soles
edema
objective assessment of hair/skin/nails
accumulation of fluid in intercellular space
Most evident dependent parts of body (feet, ankles, sacral)
how to check for edema
place thumbs on ankle malleous or tibia to check
anasarca
generalized edema
edema scale
1+ = mild, 2+ = moderate, 3+ = deep, 4+ = very deep
mobility and turgor
objective assessment of hair/skin/nails
Mobility= how easy the skin rises when pinched
Turgor= how quickly returns to its place when released
◦ Mobility + Turgor= Elasticity
how to check mobility and turgor
objective assessment of hair/skin/nails
Pinch up a large fold of skin on the anterior chest under the clavicle
what are some causes of poor turgor
dehydration, weight loss, change with aging (decreased elasticity)
scleroderma
hard skin
chronic connective tissue disorder
makes it hard to asses turgor
vascularity or bruising
objective assessment of hair/skin/nails
cherry angioma
ecchymosis
tattoo marks
bruising at venous access points (drug use)
cherry angioma
bright red dots
ecchymosis
bruising
lesions
objective assessment of hair/skin/nails
primary vs secondary
hair
objective assessment of hair/skin/nails
Color-Common to gray as we age
*Texture-Shiny and soft
*Distribution-Lesions
profile of the nail bed
objective assessment of nails
◦ 160° = Normal
◦ < 160° = Curved
◦ 180° = Early clubbing- Caused by disrupted pulmonary circulation
◦ > 180°= Late clubbing
◦ Nail base feels spongy (feel your nail bases
consistency
objective assessment of nails
◦ Smooth, regular, firm to palpation
◦ Pits, transverse grooves, or lines= nutrient deficiency or may accompany some acute illnesses
color
objective assessment of nails
even
pink
cyanosis
brown linear streaks- suddent onset could be melanoma
capillary refill
objective assessment of nails
◦ < 3 seconds= normal
◦ > 3 seconds = sluggish refill = CV or pulm prob
What are the skin changes that accompany pregnancy/newborn time period?
Pregnancy: Linea nigra, melasma, striae gravidarum, increase in sweat glands, redistribution of fat
Newborn- lanugo, vernix caseosa, very thin skin, more permeable
What are the skin changes that occur with an older adult?
oses elasticity, thinning of the epidermis, wrinkles become more noticeable, fewer sweat/sebaceous glands leads to dryer skin, less collagen makes skin more prone to tearing
* Palpate for temperature and texture
nevus assessment
- ABCDEF
- A-Asymmetry
- B-Border Irregularity
- C-Color Variation
- D-Diameter
- E-Elevation or Evolution
- F-Funny looking
what tool is used to assess risk of skin breakdown in patients
braden scale
This can slow as you age, contributes to constipation and indigestion
GI MOTILITY
Dry flaky skin; dull dry hair; dry cracking lips
MALNUTRITION
Cholesterol that is bad
LDL
Factor that has a huge impact on food choices/accessibility
FINANCES
A form of malnutrition (imbalanced nutrition) arising from excessive intake, leading to accumulation of body fat that impairs health
OVERNUTRITION
Lack of proper nutrition, caused by not having enough food or not eating enough food containing substances necessary for growth and health
UNDERNUTRITION
This value is derived by looking at both height and weight
BMI
This nutrition status means that a person is receiving and using the essential nutrients to maintain health and well-being at the highest possible level
OPTIMAL
his tool can be used to help understand what a patient’s dietary habits are like over a 3 day period
DIARY
This varies from people group to people group, but always influences diet
CULTURE
HgbA1C is a chronic indicator of this disease process
DIABETES
cholesterol that is considered “good”
HDL
STERNUM
consists of 3 parts:
manubrium
body
xiphoid process
ribs
12 pair
1-7 attached to sternum
8-10 attached to costral margin
11-12 floatin
thoracic vertebra
12
diaphragm
a musculotendinous septum
anterior thoracic landmarks
suprasternal notch
sternum
manubriosternal angle (angle of louis)
intercostal spaces
costal angle
posterior thoracic landmarks
vertebra prominens
spinous processes
inferior border of scapula
twelfth rib
reference lines
midsternal
midclavicular
anterior axillary
mid axillary
posterior axillary
scapular
vertebral
mediastinum
thoracic cavity
middle section
contains esophagus, trachea, heart and great vessels
pleural cavities
thoracic cavity
located on either side of the mediastinum
lungs
thoracic cavity
right lung: RUL, RML, RLL
left lung: LUL, LLL (no middle lobe)
pleurae
thoracic cavity
visceral and parietal
where is the trachea located
in the thoracic cavity
bronchial tree
thoracic cavity
right is wider and more vertical
trachea and bronchi transport air
dead space- contains air not involved in gas exchange
acinus
thoracic cavity
functional respiratory unit
includes bronchioles, alveolar ducts, alveolar sacs, and alveoli
the anterior chest contains what
mostly the upper and middle lobe, very little lower lobe and that the apex extends 3-4cm above the inner third of the clavicles.
what does the posterior chest contain
almost all of the lower lobe
what are the functions of respiration
- Supplying oxygen
- Removing carbon dioxide
- Maintaining acid-base balance
- Maintaining heat exchange
hypoventilation
slow, shallow breathing
increased CO2 in the blood
hyperventilation
deep, rapid breathing
decreased co2 in the blood
respiration control
respiration center in the brain stem is the pons and medulla
what is the normal stimulus for breathing
co2, not o2 like you would think
infants and children
respiration developmental considerations
- Foramen ovale closes after birth
- Ductus arteriosus closes hours later
- Smaller & immature resp. system = ↑ of respiratory infections
pregnant female
respiration developmental considerations
effects of increased estrogen
- Elevation of diaphragm (elevates 4cm ↓ vertical diameter of thoracic cage
explain the relaxation of the rib cage in a pregnant female and its relation to respiration
circumference is increased by 2cm with the widening of the costal margin
there is an increaased tidal volume with deeper breathing that may be mistaken as dyspnea
apgar scoring system
used for the newborn’s initial respiratory assessment
* 1-minute score of 7-10: indicates newborn in good condition
* 1-minute score of 3-6: indicates moderately depressed newborn requiring more resuscitation
* 1-minute 0-2: indicates severely depressed newborn requiring full resuscitation
older adults
respiratory considerations
- Decreased mobility of thorax from calcified cartilage
- Decreased muscle strength
- Decreased elasticity of lungs
- Decreased vital capacity (max exhalation)
- Increased residual volume (what’s left over after exhale)
older adults
respiratory considerations (cont)
- Histologic changes with loss of intra
- lveolarseptum & number of alveoli leading to decreased surface area for gas exchange
- Increased risk of dyspnea & pulmonary complications
asthma
most common chronic disease in childhood
tuberculosis TB
higher incidence in asian americans
peaks in the first 2 months immigrating to the us
cough
respiratory subjective data
sudden or gradual onset, frequency, duration, dry or productive with sputum (color & consistency), hemoptysis, congested, precipitating factors, associated symptoms, any treatment
shortness of breath
respiratory subject data
orthopnea, paroxysmal nocturnal dyspnea, diaphoresis, cyanosis, precipitating factors, any effect on ADLs, increasing, the same or getting better
smoking history
respiratory subjective data
type
packs per day
note in packs per year
other respiratory subjective data
Hx
respiratory infections
asthma
environmental exposure
respiratory subjective data
works in factory, chemical plant, coal mine, farming, in heavy traffic area, x-ray exposure
self care behaviors
respiratory subjective data
last TB test, chest x-ray, pneumonia or flu immunizations
children
subjective respiratory assessment
◦ 4-6 URI per year is acceptable in early childhood
◦ Consider new foods or formula as possible allergens
◦ Child proofing the home to px inhalation/consumption of poisons
◦ Environmental smoke increases risk of ear and respiratory infections
older adults
respiratory subjective data
◦ Decreased functional reserve- takes them longer to recover from activity
◦ Decreased vital capacity
◦ Decreased surface area for gas exchange
◦ Pain response is reduced in older adults- this is a risk factor
respiratory inspection
objective data
thoracic cage
respirations
skin color/condition
position of the person
facial expression
loc
inspection of the thoracic cage
respiratory objective data
for shape and configuration, compare anteroposterior to the transverse diameter (normal ratio is 1:2 or 5:7)
* Abnormal finding: barrel chest (anteroposterior = transverse diameter)
respirations
respiratory objective data
assess rate, depth, effort, use of accessory muscles
normal respiratory pattern of adult
10-20 breaths per minute, even & unlabored, depth of 500-800ml
sigh
respiratory pattern
punctuate the normal breathing pattern; if frequent, can result in hyperventilation & dizziness
tachypnea
rapid, shallow breathing
bradypnea
slow, regular breathing
chyne-strokes respirations
cyclic gradually wax and wane in regular pattern with periods of apnea
hyperventilation
increase in rate and depth
hypoventilation
irregular shallow pattern
biot’s respirations
irregular pattern with periods of apnea
chronic obstructive breathing
normal inspiration with prolonged expiration (from increased airway resistance)
Barrel chest
anteroposterior-to-transverse diameter is equal (with aging, emphysema, asthma)
pectus excavatum
funnel chest
sunken sternum
pectus carinatum
pigeon breast
forward protrusion of sternum
scoliosis
lateral s shaped curvature of the thoracic and lumbar spine
kyphosis
exaggerated posterior curvature of the thoracic spine
humpback
palpate for symmetric expansion of the thorax
note any lag in expansion
* Abnormal finding: unequal chest expansion (present with atelectasis, pneumonia, trauma, or pneumothorax)
palpate the thorax for tactile fremitus
is a palpable vibration, produced by the larynx and transmitted through patent bronchi & lung tissue to the chest wall
decreased fremitis
occurs with any obstruction of vibration (obstructed bronchus, pleural effusion, pneumothorax or emphysema)
increased fremitus
occurs with compression or consolidataion of lung tissue
indicates increased density of lung tissue (must have a patent bronchus)
palpation of the entire chest wall
or tenderness, skin temperature, moisture, superficial lumps, crepitus (indicates air escaping from the lung into the subcutaneous tissue)
pleural friction fremitus
esults from inflammation of the pleura (visceral or parietal) with decrease in the normal lubricating fluid
percussion of the lung fields
percuss in the intercostal spaces, starting at apices, compare from side to side moving down the lung region
* Normal finding: resonance for adult lung; hyperresonance for the young child
what does hyperresonance over an adult lung indicate
emphysema or pneumothorax
diaphragmatic excursion
maps out the lower lung border in inspiration and expiration by use of percussion
* Difference between inspiration and expiration should be equal bilaterally and be 3-5cm (can be 7- 8 in a physically fit person)
auscultate breath sounds
listen to full breath at each location using the diaphragm of the stethoscope
* Compare from side-to-side
characteristics of normal breath sounds
bronchial (tracheal)- at the trachea
bronchovesicular - at the sternum
vesicular- outside of chest
adventitious breath sounds
crackles
rhonchi
friction rub
wheezes
crackles
high pitched popping sounds
rhonchi
long low pitched, coarse, gurgling sounds
friction rub
harsh grating sound
wheezes
high pitched whistling sound
bronchophony
have pt. say “99” (increased transmission of voice sound with increased lungd ensity or consolidation)
egophony
have pt. say “ee” (sounds like “a” with consolidation)
whispered pectoriloquy
have pt. whisper a phase (one, two, three) normally faint, muffled increased with consolidation)
pulse oximeter
noninvasive procedure
assesses arterial o2 saturation
normal 97-98%
12 or 6 minute distance walk
12 md
- measures functional status of O2 arterial saturation
- used for patients with chronic obstructive pulmonary disease (COPD)
common respiratory disorders
atelectasis
bronchitis
copd
asthma (restrictive airway disease)
pneumothorax
pulmonary embolism
pleural effusion
heart failure
cardiovascular system
heart and blood vessels
2 circulatory types in the body
pulmonary circulation
systemic circulation
the heart is really what
2 pumps, each consisting of an atrium and a ventricle
precordium
region on the anterior chest, over the heart and great vessels
mediastinum
the middle third of the thoracic cavity between the lungs, contains the heart and the great vessels
base of the heart
top
apex of the heart
bottom
great vessels
superior/inferior vena cava
aorta
pulmonary veins
pulmonary artery
4 chambers of the heart
Right atrium
right ventricle
Left atrium
Left ventricle
4 valves of the heart
- Two atrioventricular (AV) valves:
- Tricuspid
- Mitral
- Two semilunar valves:
- Pulmonic valve
- Aortic valve
s1 is the sound of the closure of what
tricuspid and bicuspid
s2 is the sound of the closure of what
pulmonic and aortic valves
p wave
depolarization of the atria
pr interval
from start of p wave to beginning of qrs
qrs
depolarization of ventricles
t wave
repolarization of ventricles
qt interval
electrical systole of the ventricles
effect of respiration of the heart
inspiration –>decreased intrathoracic pressure –>increased venous return to right side of heart–>increased right ventricular stroke volume–>aortic valve closes earlier–> normal split S2
moRe to the Right heart, Less to the Left
more venous return to the right side on inspiration
s3
third heart sound
“ventricular gallop”
- caused by ventricles being resistant to filling during the rapid filling phase (systolic heart failure)
- heard right after S2, sounds like “Kentucky”
s4
fourth heart sound
“atrial gallop”
- present at the end of diastole with resistance of the ventricles to filling (diastolic heart failure)
- sounds like “Tennessee”
murmurs
- Result from turbulent blood flow caused by:
- Increased velocity
- Decreased viscosity
- Structural defects
heart sounds are descibed by
Frequency or pitch
Intensity or loudness
Duration (early, late, pan (continuous))
Timing (systolic or diastolic)
when to use the bell side of the stethoscope
Use the bell for soft, low pitched sounds
(murmurs & extra heart sounds)
cardiac output
is 4-6L/min
* Stroke volume X heart rate = CO
preload
venous return, the volume of blood in the ventricle at the end of diastole
* Amount of stretch prior to systole
* Frank-Starling law: the greater the stretch, the stronger the cardiac contraction
afterload
- The resistance the heart has to pump against
carotid arteries
lies between the trachea and the sternomastoid muscle (medial to this muscle)
jugular venous pulse and pressure
reflect the filling pressure & volume in the right side of heart
internal jugular
larger, located deep & medial to the sternomastoid, generally not visible, diffuse pulsation may be visible in the sternal notch muscle in supine position
external jugular
more superficial, located lateral to the sternomastoid muscle
fetal circulation is rerouted to bypass what
the nonfunctional lungs
foramen ovale
opening in the atrial septum
closes within 1st hour after birth
ductus arteriosus
opening between the aorta and pulmonary artery
closes within 10-15 hrs after birth
describe an infants heart
Heart more horizontal & apex is higher, located at 4th left intercostal space
cardiovascular considerations of a pregnant female
- Increased blood volume by 30%-40%
- Increased stroke volume & cardiac output
- Increased heart rate
when is the arterial blood pressure decreased to its lowest point during pregnancy
during the 2nd trimester
hemodynamic changes
older adults considerations in the vascular system
- Increased systolic BP
- Left ventricule (wall) thickens
- Heart rate: unchanged at rest
- Cardiac output: unchanged at rest
* Decreased adaptation to exercise
dysrhythmias
older adult considerations for the vascular system
supraventricular & ventricular
Increased cardiovascular diseases
CAD
CVD (Cardiovascular Disease) is the number one cause of death worldwide
* influenced by genetics and lifestyle factors
*CAD-Coronary Artery Disease
risk factors of cad
Hypertension
Smoking
Serum cholesterol
Overweight/Obesity
Physical inactivity
Diabetes
Age
Poor nutrition
Family history of premature CAD
chest pain or tightness
vascular subjective data
note onset, character (crushing, stabbing, burning, duration, precipitating factors (activity, emotional upset), associated symptoms (sweating, pallor, SOB, heart beat skipping, N & V, diaphoresis), radiates, relieved by rest or nitroglycerin
* Need to differentiate between cardiac and non cardiac origin!
* “Clenched fist” characteristic sign of angina
dyspnea
vascular subjective data
shortness of breath (on exertion or at rest), paroxysmal, constant or intermittent, paroxysmal nocturnal dsypnea “PND” (a sign of heart failure)
orthopnea
vascular subjective data
note how many pillows are needed to improve breathing
cough
vascular system subjective data
Note duration, frequency, dry or productive, mucus (color, odor, blood tinged), hemoptysis, precipitating factors
fatigue
vascular subjective data
onset, sudden or gradual
* From cardiac dysfunction – fatigue worse in evening
* With anxiety or depression - worse in morning or present all day
edema
vascular subjective data
unilateral or bilateral, dependent edema with heart failure (bilateral, increases in the evening, decreases with elevation of legs)
nocturia
vascular subjective data
recumbent position–>increased fluid reabsorption & excretion (with heart failure)
past cardiac Hx
vascular subjective data
HTN, elevated cholesterol levels, rheumatic fever, anemia, recurrent tonsillitis, meds, heart surgery, last ECG, stress test
family cardiac Hx
vascular subjective data
HTN, obesity, diabetes, CAD, sudden death at younger age
personal habits for risk cardiac factors
vascular subjective data
nutrition (diet), smoking, alcoholic intake, exercise, drugs
* Hormonal replacement therapy (HRT) is no longer used for prevention of CAD
infants and children
vascular subjective data
note fatigue, poor weight gain, cyanosis, limitations with exercise, frequent respiratory infections
pregnant female
vascular subjective data
hypertension, protein in urine, swelling (in feet, legs or face), excessive weight gain
aging adult
vascular subjective data
heart or lung disease, HTN, CAD, COPD, meds, noncompliance with meds, limitations with ADLs
order of regional cardiovascular assessment
- Pulse and BP
2. Extremities
3. Neck vessels
4. Precordium
palpate the carotid arteries
cardiovascular objective data
(medial to the sternomastoid muscle): avoid excessive vagal stimulation (decreases heart rate) by using gentle pressure over the lower part of the neck, palpate only one carotid artery at a time (avoids cerebral ischemia with syncope)
* Note contour & amplitude - normal is 2+ and equal bilaterally
* Diminished pulse (small & weak) - decreased stoke volume
* Increased pulse (full & strong) - hyperkinetic states
auscultate the carotid arteries for bruits
cardiovascular objective data
for persons > 40 age or have S/S of CV disease
Use the bell side of the stethoscope for bruits
bruits
Bruit: blowing, swishing sound, indicates turbulent blood flow from a local vascular cause; audible when the lumen is occluded by ½ to 2/3
Absence of bruit does NOT necessarily exclude partial occlusion
unilateral distension of the external jugular veins
cardiovascular objective data
indicates local cause (aneurysm or kinking)
bilateral distension of the external jugular veins
cardiovascular objective data
above 45 degrees indicates increased central venous pressure (CVP) from systemic disorder such as heart failure
estimate the jugular venous pressure
cardiovascular objective data
“reading” the CVP at the highest level of venous pulsations
* Place pt. in supine position with HOB elevated 45 degrees
* Elevated pressure indicated by level of pulsation is > 3 cm with HOB elevated at 45 degrees
*Look at illustration on page 481
inspect the anterior chest
cardiovascular objective data
with tangential lighting
for any pulsations, heaves, liftss
heave or lift
(sustained forceful thrusting of ventricle during systole)
– indicates ventricular hypertrophy from increased workload
palpate the apical pulse
cardiovascular objective data
(for the apex beat) and note its normal characteristics:
- Location: normally at 4 or 5th intercostal space at or medial to midclavicular line & only occupying one intercostal space
- Size: normally 1cm X 2cm
- Amplitude: normally a short, gentle tap
- Duration: normally occupies only one half of systole
left ventricular dilation
cardiovascular objective data
(volume overload) – increases its size, displaces it more laterally, increases its duration & amplitude
palpate across the precordium for a thrill
cardiovascular objective data
(palpable vibration)
* Note its timing if present auscultate or use carotid artery as a guide)
* Thrill: generally indicates a significant murmur
auscultate the precordium
cardiovascular objective data
using the Z pattern technique from the base of the heart and down
Locations of the heart valves:
* Second right interspace – aortic valve
* Second left interspace – pulmonic valve
* Left sternal border – tricuspid valve
* Fifth interspace near the left midclavicular line – mitral valve
all pigs eat too much
aortic
pulmonic
erb’s point
tricuspid
mitral
at what point does s1 and s2 the same loudness
erb’s point
where is s2 the loudest
base
where is s1 the loudes
apex
With the apical pulse, start with the diaphragm part of the stethoscope and use the following routine
- Note the rate & rhythm
2. Identify S1 and S2
3. Assess S1 and S2 separately
4. Listen for extra heart sounds
5. Listen for murmurs
what does s1 coincide with
the carotid artery pulse
the R wave
the upstroke of the QRS complex on the ecg monitor
s1 sound indicates what
from closure of the AV valves, indicates the beginning of systole
s2 indicates what
from closure of the semilunar valves, indicates beginning of diastole
splitting of the s2
normal physiological split occurs during inspiration only (not during expiration) in some people
what heart sound splits are abnormal
Fixed split (occurs in both inspiration & expiration) or a parodoxical split (occurs with expiration but not with inspiration)
grading murmurs
- Grade I - barely audible
* Grade II - clearly audible– most common
* Grade III - moderately loud
* Grade IV - loud with audible thrill
* Grade V - very loud
* Grade VI - loudest, can hear with stethoscope lifted off the chest
murmurs can be what
*Mid-systolic
*Pan-systolic
*Diastolic rumbles
*Early diastolic murmurs
ins and outs of s3 gallop
- Occurs in early diastole (during rapid filling phase)
- Low pitch, sounds like distant thunder
- Physiologic (normal): in children & some young adults, disappears
when pt. sits up
- Pathologic (abnormal): doesn’t disappear when pt. sits up
- Right ventricular S3 (right sided heart failure): heard at the left
lower sternal border with pt. in supine position
- Left ventricular S3 (left-sided heart failure): heard at the apex with
pt. in left lateral position
- Early sign of heart failure
- Results from volume overload, and also in high cardiac output
states (without cardiac dysfunction) such as with hyperthyroidism,
anemia , and pregnancy
ins and outs of s4 sounds
a ventricular filling sound, referred to as “atrial gallop” or “S4 gallop”
- Heard right before S1 (in late diastole)
- Soft, low-pitched sound
- Listen at the apex with pt. in left lateral position (right sided is less common, heard at the left lower sternal border)
- Results from decreased compliance of the ventricles
- Physiologic: in adults > age 40 or 50, especially after exercise
- Pathologic: from decreased compliance of the ventricles (CAD, cardiomyopathy, or increased afterload)
Patent Ductus Arteriosus (PDA):
congenital heart defects
persistence channel between left pulmonary artery to aorta
Atrial septal defect (ASD):
congenital heart defects
abnormal opening in the atrial septum
ventricular septal defect
vsd
congenital heart defect
abnormal opening in the ventricular septum
tetrology of fallot
congenital heart defect
*Right ventricular outflow obstruction
*VSD
*Right ventricular hypertrophy
*Over-riding aorta
Coarctation of the Aorta
Congenital Heart Defect
vascular system
Job is to circulate blood and lymph throughout the body
Comprised of arteries, veins, and lymphatics
arteries
Arteries-deliver freshly oxygenated blood to body, strong, tough vessels that must withstand high pressure demands, expand and recoil with each heartbeat/pulse
veins
Veins-bring blood back to the heart go to through lungs to be oxygenated, lie closer to the skin surface than arteries, are more elastic/distensible, contain valves so blood cannot flow backwards
lymphatics
Lymphatics-made up of vessels, nodes, ducts, some organs
Bring excess fluid and plasma proteins back to the bloodstream from the interstitial space
Major part of the immune system
Absorb lipids from the small intestine
know location of arteries listed
Temporal artery
Carotid artery
Brachial artery
Radial artery
Ulnar artery
Femoral artery
Popliteal
Posterior tibial
Dorsalis pedis
know the location of the veins listed
Deep veins in the legs:
- Femoral
- Popliteal
Superficial veins in the legs:
- Great saphenous
- small saphenous
know the location of the lymph nodes listed
cervical
axillary
epitrochlear
inguinal
cervical nodes
drain head and neck
axillary nodes
drain breast and upper arm
epitrochlear nodes
drains the hand & lower arm; located in the antecubital fossa
inguinal nodes
drain the lower extremities, the external genitalia, & the anterior abdominal wall
vascular considerations of the pregnant female
increased estrogen levels vasodilation & drop in BP; uterus exerts pressure on iliac veins & inferior vena cava resulting in:
- Edema (diffuse, bilateral, pitting) in the
lower extremities
- Varicose veins
vascular considerations for the aging adult
- Arteriosclerosis from increased rigidity
of the peripheral blood vessels- Increased risk for deep vein thrombosis
- Decreased lymphatic tissue
leg pain or cramps
vascular subjective data
note location, type, precipitating factors, claudication distance, relived by rest walking, rubbing, night pain, recent change in exercise, past history of vascular problems
* Note any sudden worsening of
claudication (decrease in claudication
distance) & pain suddenly not relieved
with rest
skin changes on arms or legs
vascular subjective data
discolorations (redness, pallor, blueness, brownish), varicose veins, coolness, sores or ulcers
swelling in the arms or legs
vascular subjective data
in one side or both, worse in the morning or evening, constant or intermittent, precipitating & relieving factors, associating factors (pain, heat, redness, ulcers, hardened skin)
* Bilateral edema indicates a systemic problem
* Unilateral edema indicates an obstruction or inflammation
lymph node enlargement
vascular subjective data
location, duration, any recent changes, presence of pain or infection
* Enlarged nodes indicate infection, immunologic disease or malignant disease
medications
vascular subjective data
oral contraceptives or hormonal replacement (increased risk for thrombosis)
capillary refill
vascular objective data
index of peripheral perfusion & cardiac output
* Abnormal finding- refill lasting more than 1 or 2 seconds (indicates vasoconstriction or decreased cardiac output)
vascular objective data
temperature
symmetry or presence of edema
Presence of any lesions, scars, needle tracks in antecubital fossa (indicates intravenous drug use)
nailbeds
vascular objective data
for pallor, cyanosis, clubbing (enlargement of
terminal phalanges) indicates chronic hypoxia
* Normal angle is 160 degrees
skin color
vascular objective data
(pale, erythema, cyanosis), texture, turgor
* Pallor with vasoconstriction, erythema with vasodilation
how to assess radial pulse
assess both for rate rhythm and amplitude
palpate the following pulses for amplitude and elasticity
- Radial
- Ulnar (usually not palpated)
- Brachial
- Femoral
- Popliteal
- Posterior tibial
- Dorsalis pedis
Three-point scale for grading the amplitude(Force)
3+ Increased, full, bounding
2+ Normal
1+ Weak
0 Absent
what does a full bounding pulse indicate
hyperkinetic states (exercise, anxiety, fever & hyperthyroidism)
what does a weak thready pulse indicate
shock and peripheral arterial disease
inspect and palpate extremities for
Hair distribution
Venous pattern
Lesions/ulcers
Size, swelling, atrophy
what does an enlarged lymph node indicate
infection of the draining area
assessing edema
- location
- pitting or nonpitting
- measurement
Signs of malnutrition:
thin, shiny, atrophic skin, thick-ridged nails, loss of hair, ulcers, gangrene
signs of arterial insufficiency
pallor, coolness, diminished pulse strength
unilateral vs bilateral swelling
Unilateral swelling signifies a local problem
*If asymmetry of the calves is > 1 cm, refer
the pt. (possible deep vein thrombosis)
Bilateral swelling of legs indicates a systemic
problem
brownish skin discoloration
Brownish discoloration: indicates chronic venous stasis
venous ulcers
generally located on the medial malleolus
location of arterial ulcers
located on tips of toes, metatarsal heads, or lateral malleoli
what does a bruits indicate
turbulent blood flow from partial occlusion
modified allen test
evaluates the adequacy of collateral circulation prior to cannulating the radial artery
* Persistent pallor or sluggish return of color indicates occlusion of collateral circulation
doppler ultrasound stethoscope
use to detect a weak peripheral pulse
* Presence of a swishing, whooshing sound indicates a pulse
Lymphedema
- Impediment of lymph drainage
- Unilateral
- Lymphedema is nonpitting edema, unilateral, overlying skin is indurated and brawny
raynaud’s syndrome
Chronic Arterial Insufficiency:
- deep muscle pain
- pain with walking “claudication”
- coolness, pallor
- diminished pulses
- thin, shinny skin
- absence of hair
- necrotic ulcers on toes, heels, lateral
malleolus
Chronic Venous Insufficiency:
- dull ache, heaviness in lower leg pain
- pulses present
- thick brawney, edematous skin
- brown pigmentation
- weeping ulcers on medial malleolus
Chronic Venous Stasis:
- aching, heaviness, night leg or foot cramps
- dilated, tortuous veins
acute venous thrombosis
- sudden onset pain
- increased warmth, swelling, redness- Homan’s sign – not diagnostic
Grade pitting edema on the following scale:
1+ Mild
2+ Moderate
3+ Deep pitting
4+ Very deep pitting
