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HAP FINAL - CK > Week 8 - CV, neck, peripheral and lympatic > Flashcards

Week 8 - CV, neck, peripheral and lympatic Flashcards

1
Q

Common cardiovascular symptoms

A 
Chest pain
Dyspnea, orthopnea, cough
Diaphoresis
Fatigue
Edema
Nocturia
Palpitations
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2
Q

How to check for jugular vein distention

A

Position the patient with the head of the bed at 30-45 degrees to promote visibility of the pulsation.
Right-side is easier to see.

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3
Q

S3 and S4 sounds are commonly called what?

A

Gallops

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4
Q

Extra heart sound: “venous hum”

A

continuous, rough, noisy, occasionally accomp by high-pitched whine. May be louder during diastole. It’s low pitched; heard best w/ bell above the medial third of the clavicles.
Normal in children and pregnancy

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5
Q

Extra heart sound: “Pericardial Friction Rub”

A

Triple phased during midsystole, mid-diastole, and presystole.
A scratchy, leathery quality results from the parietal and visceral pleura rubbing together.

Sound increases on leaning forward and during exhalation. It is heard best in the 3rd left ICS at the sternal border

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6
Q

Extra heart sound: “summation gallop”

A

This is the same as the quadruple rhythm but with a faster rate. S3/S4 merge to create one sound.

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7
Q

Extra heart sound: “opening snap”

A

Indicates mitral valve is mobile & “snaps” during early diastole from high atrial pressure, such as with mitral stenosis

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8
Q

Ejection click

A

results from an open valve that moves during the beg of systole. Heard best w/ diaphragm of stethoscope-audible over the aortic or pulmonic areas

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9
Q

How to describe intensity (loudness) of murmurs (6 levels)

A

I. Faint; heard only with special effort
II. Soft but readily detected
III. Prominent but not loud
IV. Loud; accompanied by thrill
V. Very loud
VI. Loud enough to be heard with stethoscope just removed from contact with the chest wall

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10
Q

edema can cause asymmetry in ONE upper exremity when issue is related to ______

A

Lymph

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11
Q

edema can cause asymmetry in ONE lower exremity when issue is related to ______

A

DVT

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12
Q

when edema is in BOTH lower extremities, issue could be related to

A

kidney or CHF

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13
Q

A radial pulse could be weak and thready due to

A

shock, PAD, hypothyroidism

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14
Q

A radial pulse could be bounding due to

A

exercise, anxiety, fever, anemia, hyperthyroidism

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15
Q

splenomegaly could be related to

A

mono, issues with RBC breaking down, sickle cell patients have blood that can clog up at lymphs

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16
Q

Sinus arrhythmia in children is a NORMAL finding - true/false

A

TRUE

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17
Q

what is sinus arrhythmia

A

HR changes on inspiration (faster) and expiration (slower)

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18
Q

In children, it is NORMAL to have extra S sounds (splitting, S1 S2) - true/false

A

TRUE

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19
Q

In older adults, why might extra S sounds be present?

A

Bc heart isn’t as compliant, doesn’t expand/contract like it used to

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20
Q

in older adults, atherosclerosis can lead to

A

poor perfusion

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21
Q

in older adults, a carotid or abdominal bruit can put organs such as _______ in danger

A

kidneys

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22
Q

Umbilicus appearance:

o Elevated could mean:

A

ascites, hernia

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23
Q

Umbilicus appearance:

-Sunken could mean:

A

this is seen in obese patients

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24
Q

Umbilicus appearance:

-Blueish could mean:

A

cullen sign (internal bleeding)

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25
Q

Umbilicus appearance:

-excessive abdominal aorta pulsations could mean:

A

if very bounding, could indicate aneurysm

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26
Q

In distension d/t FECES, auscultation is ______ and percussion is _______over feces

A

normal, dull

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27
Q

What is a “thrill”

A

palpable, rushing vibration from turbulent blood flow (cat purr) w/incompetent valves, pulmonary HTN, septal defects, AV fistula

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28
Q

the “lub” heart sound indicates:

A

S1, systole (AV valves (mitral and tricuspid) close)

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29
Q

the “dub” heart sound indicates:

A

S2, diastole (SL valves (pulmonic and aortic) close)

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30
Q

S3 heart sound

A

ventricular gallop “Ken-tuck-y”
Causes: fluid overload, HF
May be normal in youth and pregnancy

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31
Q

S4 heart sound

A

atrial gallop, “Ten-nes-see”

Causes: coronary artery disease

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32
Q

Point of maximal impulse (PMI)

A

area where the apical pulsation can be seen or palpated

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33
Q

The amount of blood that is ejected from the heart with each BEAT is the

A

stroke volume

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34
Q

cardiac output =

A

CO=HR x SV

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35
Q

congestion on the LEFT side of heart causes backup into

A

lungs

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36
Q

congestion on the RIGHT side of heart causes backup into

A

body, especially legs and feet

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37
Q

SOB, weight gain, and swollen ankles with decreased cardiac output are s/s of

A

heart failure

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38
Q

Volume in the right atrium at the end of diastole

A

preload (an indicator of how much blood will be forwarded to and ejected from the ventricles)

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39
Q

the amt of pressure the heart has to work against in the wall of the left ventricle during ejection

A

afterload

40
Q

severe SOB and coughing at night (fluid coming to lungs from edematous legs)

A

paroxysmal nocturnal dyspnea (PND)

41
Q

swooshing sound, audible when an artery is partially obstructed

A

bruit

42
Q

hepatojugular reflux test is highly sensitve and specific for

A

right ventricular fluid overload

43
Q

a “venous hum” heart sound is normal in what populations

A

This continuous sound is normal in children and during pregnancy.

44
Q

S1 is louder heard at the _____of the heart

A

apex

45
Q

S2 is louder heard at the ______ of the heart

A

base

46
Q

S3 may be normal in who?

A

children, young adults, pregnant women in 3rd trimester

47
Q

an innocent murmur is

A

a murmur w/ no underlying pathology. Occurs in systole (except for venous hum)

48
Q

an abnormal murmur sounds like

A

a breath sound or is harsh or blowing. Signifies regurgitation and pathology.

49
Q

what is “Coarctation of the aorta”

A

congenital narrowing of aorta (high arm BP and low thigh BP d/t restricted blood supply below the narrowing)

50
Q

What is jugular vein distension indicative of?

A

heart failure (most common), fluid overload, tricuspid regurgitation

51
Q

Orthopnea

A

SOB when lying flat

52
Q

For carotid pulses and bruits, use _____ of stethescope

A

bell

53
Q

Precordium inspection: heaves/lifts/pulsations indicate

A

cardiac hypertrophy of R or L ventricle. The enlarged heart displaces the PMI laterally and inferiorly.

54
Q

A “heave” or “lift” seen on the precordium appears as

A

a forceful thrusting on the chest and is the result of an enlarged ventricle.
A right ventricular heave is observed at the lower left sternal border; a left ventricular heave is observed at the apex.”

55
Q

Erb’s point is where the valves usually are _______ audible; this site is esp effective for taking the _______pulse

A

equally

Apical (but most effective is the mitral area for the apical)

56
Q

For heart auscultation in obese or barrel chested PTs, auscultation is improved by:

A

placing the PT in the left lateral decubitus position or asking the PT to lean forward (this displaces heart more closely to thoracic wall)

57
Q

The difference btwn radial and apical pulse is known as the

A

pulse deficit

58
Q

Pulse deficits are common in:

A

people with irregular heart beats (e.g. with aFib)

59
Q

aortic stenosis

A

thickening of aortic valve leaflets with age (common in older adults–can cause systolic murmurs)

60
Q

The most common diastolic murmurs are

A

aortic insufficiency and mitral stenosis

61
Q

The semilunar valves separate the ______ from the ______

A

The semilunar valves separate the ventricles from the arteries

62
Q

The component of the conduction system referred to as the pacemaker of the heart is the:

A

sinoatrial (SA) node

63
Q

During an assessment of a healthy adult, where would the nurse expect to palpate the apical pulse?

A

Fifth left intercostal space at the midclavicular line

64
Q

During a cardiovascular assessment, the nurse knows that a “thrill” is:

A

vibration that is palpable (like a cat’s purr)

65
Q

Claudication is caused by:

A

arterial insufficiency/obstruction of arteries

66
Q

pain brought on by exertion and relieved by rest is called

A

intermittent claudication

67
Q

How should the nurse document mild, slight pitting edema present at the ankles of a pregnant patient?

A

1+

68
Q

Pacemakers are on which side?

A

can be on L or R side

69
Q

What are normal heart variations in children?

A
  • sinus arrhythmia (very common and normal)

- spliting S1 and S2 (common in young children)

70
Q

Cardiac output

A

amount of blood pumped each minute (typically 4-8 L at rest)

71
Q

The nurse is planning discharge teaching for a PT diagnosed with PVD. It is MOST important for the nurse to address which of the following?

  • the PT drinks socially
  • the PT walks 2 miles/day
  • the PT takes vitamins daily
  • the PT smokes heavily
A

-the PT smokes heavily (a predisposing factor for arterial PVD)

72
Q

The nurse knows which of the following occurrences initiates the changes that take place in the newborn circulatory system after birth?

A

the infant begins pulmonary ventilation

73
Q

The nurse knows that a cyanotic congenital heart defect is associated w/ which symptoms?

A

finger clubbing, costal retractions, and failure to thrive

74
Q

If taking BP on a PT’s lower extremities, place PT in what position?

A

position PT on their abdomen, place BP cuff around thigh, use stethoscope at popliteal artery

75
Q

Average BP for a newborn

A

60-80/40-50mmHg

76
Q

Average BP for child 1-4 yrs

A

90-99/60-65mmHg

77
Q

The nurse cares for the PT being evaluated for aortic stenosis. Which assessment data will the nurse expect to find?

  • dyspnea
  • HTN
  • cyanosis
  • respiratory acidosis
A

dyspnea

78
Q

clients experiencing aortic stenosis are at risk for

A

fluid volume excess as a result of heart failure

79
Q

In aortic stenosis, the PT often experiences:

A

decreased BP, decreased pulse pressure, and has a S4 murmur

80
Q

pulse pressure

A

difference between systolic and diastolic pressure readings

81
Q

characteristic signs of HF include

A

tachycardia and increased respirations

82
Q

heart failure PTs are most comfortable in what position?

A

upright (not laying flat), high fowler’s

83
Q

The nurse cares for a PT diagnosed w/ a recent MI. Which assessment data might alert the nurse that the client is developing left ventricular failure?

A

pulmonary crackles

84
Q

The nurse recognizes that the type of edema r/t cardiac failure is usually

A

dependent edema (seen w/ R-sided heart failure and usually noted in the ankles and in the sacral region)

85
Q

When auscultating heart sounds in the aortic area, where should the nurse place the stethoscope?

A

To the right of the sternum near the manubrium (aortic area)

86
Q

A nurse cares for a PT with an AAA. Which post-op intervention should the nurse include in the PT’s plan of care?

A

perform circulation checks distal to the graft

  • do NOT elevate legs–keep PT flat in bed w/o flexion of extremities to avoid compression of lower extremity arteries
  • low fat diet is indicated for post-op AAA patients
87
Q

The nurse understands that the MOST important factor to maintain adequate circulation is

A

blood volume

88
Q

The nurse cares for a PT with arterial insufficiency. Which s/s should the nurse expect when obtaining the client’s Hx?

A

pain in hip, buttock, thighs, or calf.

Classic symptom of arterial disease is intermittent claudication

89
Q

The nurse understands that the cause of essential HTN is

A

not known

90
Q

The nurse knows that the priority observation for the post-op AAA patient is:

a. BP reading
b. blood chemistry lab report
c. intake/output measurements
d. rectal temp reading

A

-BP reading (patency of the aortic graft can be assured w/ maintenance of an adequate systemic BP

91
Q

True/false: elevation of the leg exacerbates pain of arterial insufficiency

A

true

92
Q

Which short term goal is appropriate for a PT with impaired arterial circulation in lower extremities?

A

The PT will report freedom from muscle pain while walking in the room

93
Q

Over which anatomical area on the chest wall should the nurse place the stethoscope to MOST clearly auscultate the apical pulse?

A

mitral area

94
Q

what are the 6 P’s (signs of acute arterial occlusion)

A

Pain, paresthesia, paralysis, poikilothermia, pallor, and pulselessness

95
Q

A difference of more than ________in BP in limbs may indicate arterial disease

A

10 mmHg

96
Q

Allen test assesses for

A

patency of the collateral circulation of the hands (perform PRIOR to radial cannulation)

97
Q

An ankle-brachial index (ABI) of _______ indicates arterial insufficiency

A

0.90 or less

HAP FINAL - CK (9 decks)

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