Week 8- Cardio Vascular Flashcards
Objective data inspection for CVS
-Size, shape, and symmetry of arms, legs, hands and feet
-assess colour of skin and nail beds
-schamroth window test - test for clubbing
-note any edema, brushing, scars, abrasions
Palpation for CVS
ONE at a time
Inspection for CVS
Look at the jugular vein
- jugular distension is a key indicator of heart failure
-whooshing sounds is indicative or coronary artery disease
-hardening of the artery
Auscultation for CVS
-neck in neutral position
-lightly apply bell over each carotid artery while client holds their breath
3 spots
1. Middle of the jaw
2. Midcervical area
3. Base of the neck
Palpation for CVS
-carotid
-brachial
-radial
-+/- ulnar
-+/- femoral
-popliteal
-posterior tibia
-dorsalis pedis
4 point scale - assessing pulse
3+ increased, full, bounding
2+ normal
1+ weak
0 Absent
4 point scale- assessing edema
Grade 1: slightly pitting (2mm depth) no visible distortion that rebounds immediately
Grade 2: somewhat deeper pit (4mm) with no readily detectable distortion that rebounds in fewer than 15 seconds
Grade 3: Noticeably deep put (6mm) with a dependent extremity full and swollen that’s takes up to 30 seconds to rebound
Grade 4: Very deep pit (8mm) with the dependent extremity grossly distorted that takes more than 30 seconds to rebound
What is Grade 1 Edema
Slightly pitting (2mm depth) with no visible distortion that rebounds immediately
What is Grade 2 edema
Somewhat deeper pit (4mm) with no readily detectable distortion that rebounds in fewer than 15 seconds
What is grade 3 edema
Noticeably deep pit (6mm) with the dependent extremity fill and swollen that takes up to 30 seconds to rebound
What is Grade 4 edema
Very deep pit (8mm) with the dependent extremity grossly distorted that takes more than 30 seconds to rebound
Inspection of the heart
- inspection the anterior chest for any lesions, masses, heaves or lifts that appear as a forceful thrusting on the chest
-observe for the apical impulse located at the level of the 4th or 5th ICS
Palpation of the heart
-Gently use the palmar aspect of your four fingers and gently palpate over the apex, left steal border, and the base searching for any pulsations
-normal findings is NO PULSATIONS
-locate the apical impulse using ones finger pad
Auscultation of the heart
-identify rate and rhythm
S1 and S2 with bell and diaphragm of stethoscope
Five areas
1. 2nd right ICS- aortic
2. 2nd left ICS- pulmonic
3. 3rd Left ICS- Erbs point
4. 5th left iCS - tricuspid
5. 5th left ICS- mitral
Unilateral edema occurs with…
Deep vein occlusion
