Unit 3 Flashcards
S1
sound of tricuspid & mitral valves closing = “Lub”
Corresponds to the carotid pulse
Heard as loudest sound at tricuspid & mitral points in all positions & with both the diaphragm & bell
S2
sound of the aortic & pulmonic valves closing- “dub”
S2 should be the loudest sound heard at the aortic & pulmonic area in the supine, left lateral & sitting exam positions with both the diaphragm & bell of the stethoscope
S3
if present, is best heard with the bell of the stethoscope (because it’s low pitched) over the apex of the heart (tricuspid & mitral areas)
Occurs early in early diastole & sounds like the word Ken-tuc-ky.
Best heard in left lying lateral position
OK in young children, people with a high cardiac output or 3rd trimester of pregnancy
Abnormal if heard in people over age 40 & can be caused by myocardial failure, CHF or volume overload from valve disease
S4
if present, is best heard with the bell of the stethoscope (because it’s low pitched) over the apex of the heart (tricuspid & mitral areas in the left lateral position.
Occurs in late diastole, right before S1) & sounds like Ten-nes-see.
Best heard in left lying lateral position
OK in trained athletes & some older patients after exercise
Usually abnormal & associated with HTN, CAD,aortic & pulmonic stenosis & acute MI
Split S1
occurs when the mitral & tricuspid valves close at slightly different times
“Lub Lub Dub”
Does not vary with respiration
OK in Healthy young adults
Abnormal in Middle or older adults & may indicate pulmonary hypertension
Split S2
Split S2 is best heard over the pulmonic area with the client sitting
A split S2 is OK when it is heard only on inspiration. (Ask the patient to hold their breath & see if it goes away)
A split S2 may be abnormal if it is heard during both inspiration & expiration
characterize heart murmurs by intensity
Grade 1: Very faint, heard only after listening carefully,
may not be heard in all positions(supine maybe not heard;
left lying and you hear
Grade 2: Quiet but heard immediately (hear something extra)
Grade 3: Prominent but not loud
Grade 4: Loud; and accompanied by a thrill (vibration)
Grade 5: Very loud
Grade 6: May be heard with stethoscope totally off chest
five traditional auscultatory points of the heart
All Pigs Eat Too Much (mnemonic to remember points-from lab instructor)
- Aortic: 2nd ICS at right sternal border (S2 louder than S1)
- Pulmonic: 2nd ICS at left sternal border (S2 louder than S1)
- Erb’s Point: 3rd ICS at left sternal border (S1 equal to S2)
- Tricuspid: 4th ICS at left sternal border (S1 louder than S2)
- Mitral: 4th-5th ICS in left midclavicular line (S1 louder than S2)
Jugular Vein Distention:
With the head of the bed elevated to 45º & the client’s head turned away from
the side being examined, inspect the jugular vein for distention. There should be none. Distention can be caused by central venous pressure from right ventricular heart failure, pulmonary HTN & pulmonary emboli
apical impulse
apical pulse -felt at mitral point
4th - 5th ICS in left midclavicular line
PMI/Apical Impulse: Palpate over the mitral area to locate the apical impulse. You should be able to feel it. If not have the client turn to the left side to bring the apex of the heart closer to the chest wall.
Document: PMI observed and palpated in 5th left ICS at the MCL. No thrills, heaves & lifts.
Describe the three positions in which to examine the heart and how each position facilitates auscultation.
- Auscultation in supine (on your spine) position. On back with head elevated 45 degrees. Generally how we listen to pts in hospital. Listen at least 1 full cardiac cycle (1 lub-dub). Patient position can influence murmur intensity as well as hear sound splitting. LISTEN WITH DIAPHRAGM AND BELL IN ALL AREAS.
- Auscultate left lateral position - May want to lower HOB to make it easier for pt to turn on to side. In this position it’s easier to hear tricuspid & mitral valves because they are in the apex of the heart and in this position the heart is closer to the skin. Listen specifically for extra heart sounds (S3 & S4) and murmurs related to those two particular valves. Again listen to tricuspid and mitral points for at least 1 full cardiac cycle WITH BELL ONLY because listening for low-pitched sounds & ONLY IN TRICUSPID AND MITRAL AREAS.
- SItting, leaning slightly forward - LISTEN ONLY WITH DIAPHRAGM AND ONLY TO THE AORTIC & PULMONIC AREAS. Only listening for a split S1 or S2 & murmurs. You use the diaphragm of the stethoscope because these are high pitched sounds.
normal capillary refill and the possible causes of delayed capillary refill.
finger & toenails bilaterally. Refill should be immediate.
greater than 2 seconds is abnormal.
Name, anatomically locate and palpate the carotid, brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis pulses.
-Count the rate (15 secs. X 4)
-Assess symmetry – rate shouldn’t
vary by more than 2-4 BPM
-Rhythm – should be regular as
opposed to irregular
-Assess the amplitude (Grade
Palpate for edema and describe the degree of edema by grade
Grade Scale of 0-4
1+ 1-2mm indentation, disappears rapidly
2+ 3-5mm indentation, disappears in 10-15 seconds
3+ 6-7mm indentation, lasting 60+ seconds
4+ >8mm indentation, lasts 2-5 min. Extremity grossly distorted
Examine the temperature of the extremities
Temperature should be equal right to left & should become warmer as you move from hands & feet toward trunk with the trunk being the warmest.
Inspection of Peripheral Vascular System:
- clubbing of the fingernails
- hair unevenly distributed on lower extremities
- any lesions or ulcers caused by venous insufficiency
- varicose veins
- The skin temperatures on their extremities should be equal when compared and be warmer as you move distally toward the trunk.
- Capillary refill in the toes and fingers should be immediate, anything over two seconds is abnormal.
Inspection of Lymphatic system
You should not be able to inspect or palpate the inguinal lymph nodes.
If you can feel them and they are hard and immobile this could indicate cancer and should be documented as an abnormal finding.
If you feel them but they are still soft and mobile this is probably just an infection but should still be noted as abnormal.
Analyze findings and plan interventions for the peripheral vascular and lymphatic systems.
Some data used to analyze could include skin temperature differences, capillary refill times, and even comparing the pulse rates in the extremities bilaterally looking for impaired blood flow. The goal should be to restore blood flow to the extremities by finding the source of the problem whether it be high blood sugar in a diabetic or damaged blood vessels due to chronic hypertension. The interventions should all be based upon addressing the chronic health issue at the root of the peripheral vascular disease.
PVD
Peripheral Vascular DIsease
Edema graded scale
0-4+
Grade of Pulses:
0: Absent 1+: Barely palpable, diminished 2+: Normal or expected 3+:Full, increased 4+:Bounding
Skin temperature
warm and equal bilaterally on extremities
Peripheral Pulses:
Rate (BPM), Rhythm (regular), Grade (0,1-4), Symmetry Carotid: Radial Brachial Dorsalis Pedis Posterior Tibial Femoral
Capillary Refill
Refill immediately or delayed refill
Lymphatic
Should be not palpable
RUQ
- Liver
- gallbladder (behind the liver)
- some small intestine (duodenum)
- hepatic flexure of the colo
- head of pancreas
RLQ
- Cecum
- appendix
- ascending colon
- right ovary and fallopian tube (females)
- right kidney/ureter/adrenal gland
LUQ
- Stomach
- spleen
- left lobe of liver
- pancreas
- splenic flexure of colon
- parts of transverse
- descending colon
LLQ
- Part of descending colon
- sigmoid colon
- left ovary and fallopian tube (females)
- left kidney/ureter/adrenal gland
guidelines for palpating the abdomen in assessment
Start with light and moderate palpation. Use fingertips First palpate 0.5-1 cm depth Then palpate 1-3 cm Be sure to palpate all quadrants Deep palpation Use palmar surfaces of fingers Palpate to 5-6 cm depth Be sure to do all four quadrants ** Notice any abnormal firmness (that cannot be attributed to the patient being ticklish), tenderness or masses.
Palpate Liver
Press up, under ribs while pt is exhaling
As pt inhales, liver edge should touch your fingers (should feel like a rubber ball)
Can use pressing up technique or the hook technique
Gallbladder
Use the same technique as liver but on the left side
Spleen should be non-palpable
If it’s palpable, your pt is in trouble and there is something very serious happening
correct sequence of examination for the abdomen
Inspection (Look)
Auscultation (Listen)
Percussion (Feel)
Palpation (Touch)
Abnormal abdominal ausculation
No bowel sounds for a minimum of 1 min. up to 5 min. Associated with peritonitis, paralytic ileus or bowel obstruction. This is an emergency.
Hypoactive – diminished motility common after abdominal surgery or in late bowel obstruction
Hyperactive – increased motility caused by diarrhea or early obstruction
When inspecting joints (Shoulders, Elbows, Wrists, Fingers, Hips, Knees, Ankles, Toes) you are looking for the following things:
symmetry
heat
edema
crepitation
When inspecting muscle you are looking for the following things:
Are they symmetrical in size and shape ---Hypertrophy (increase in muscle mass) ---Atrophy (decrease in muscle mass) Masses tenderness
